RSUD DR.

SOEDARSO PONTIANAK
Jl. dr. Soedarso No.1 Pontianak
BUKTI PELAYANAN PASIEN RSUD dr.SOEDARSO

No. RM : 00174281 No. SEP : 1501R0011122V002919 RAWAT INAP

Nama Pasien : Margareta Saini
Alamat : DUSUN SETABAR Umur : 50 th 24 hr
Dokter
Poliklinik Tujuan : 1. ICCU
2. ........................................................................... INFAN KETAREN, DR, SP.JP
Kode ICD-X Dokter
Diagnosa Utama : 1. Acute subendocardial myocardial infarcti I21.4 ...................................
2. Non-insulin-dependent diabetes mellitus E11.9 ...................................
3. ........................................................................... ................................... ...................................
Kode ICD 9 CM Dokter
Prosedur/ Tindakan : 1. PCI Dengan Stent 00.41 ...................................
2. ........................................................................... 00.46 ...................................
3. ........................................................................... 00.66 ...................................

Penunjang : 1. HBsAg (hasil negatif)

2. Anti HCV (hasil negatif)
3. Anti HIV (Kromatografi)

Biaya INA-CBGs : .........................

Pasien Pontianak, 08 November 2022
Petugas RSUD dr. Soedarso

( ................................... ) ( ................................... )

SURAT ELEGIBILITAS PESERTA

RSUD Dr. SOEDARSO

No. SEP : 1501R0011122V002919

Tgl. SEP : 08-11-2022
No. Kartu : 0000049771664 No.MR : 00174281
Nama Peserta : MARGARETA SAINI Peserta : PNS DAERAH
Tgl. Lahir : 15-10-1972 COB : 0
Jenis Kelamin : Perempuan Jenis Rawat : Rawat Inap
No. Telepon : 0815228398 Kelas Hak : I
Poli/ Ruangan Tujuan : ICCU Kelas Rawat : I
Faskes Perujuk : NGABANG Penjamin :
Diagnosa Awal : Z03.8 Observation for other suspected diseases Pasien/
and conditions Keluarga Pasien
Catatan : -
______________
*Saya Menyetujui BPJS Kesehatan menggunakan informasi Medis Pasien jika diperlukan.
*SEP bukan sebagai bukti penjaminan peserta.
Cetakan Ke - 1

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 RSUD DR. SOEDARSO PONTIANAK
Jl. dr. Soedarso No.1 Pontianak, KOTA PONTIANAK - 78124 Telp. (0561) 737701
rsuddrsoedarso.kalbarprov.go.id, rsud@kalbarprov.go.id

No Pendaftaran : 2211080525 Ruangan Terakhir : ICCU

No. CM : Tgl. Pendaftaran : 08-11-2022 16:15:43
00174281
Nama Pasien : Ny. Margareta Saini Tgl. Pulang : 12-11-2022 09:23:45
Umur : 50 th 24 hr/ 15-10-1972 Jenis Pasien : JKN
Alamat : DUSUN SETABAR Penjamin : BPJS(0000049771664)
No. Surat Jaminan : 1501R0011122V002919
Diagnosa : nstemi , dm tipe 2 Jenis Peserta : PNS DAERAH
Kelas Rawat KELAS I Kelas Dijamin : KELAS I

RINCIAN BIAYA PELAYANAN

No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

ICCU

Pelayanan Instalasi Gawat Darurat

1 08-11-2022 Pemakaian Monitor Vital Sign / Hari : INFAN KETAREN, DR, SP.JP Intens 1.00 40,000.00 0.00 40,000.00
(T) ive

Pelayanan Rawat Inap

2 08-11-2022 Paket Pelayanan Kamar Rawat Intensive : INFAN KETAREN, DR, Intens 1.00 450,000.00 0.00 450,000.00
SP.JP (T) ive

Pelayanan Instalasi Gawat Darurat

3 09-11-2022 Pemakaian Monitor Vital Sign / Hari : INFAN KETAREN, DR, SP.JP Intens 1.00 40,000.00 0.00 40,000.00
(T) ive

4 09-11-2022 ECG / Kali : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 53,000.00 0.00 53,000.00
ive

Pelayanan Rawat Inap

5 09-11-2022 Paket Pelayanan Kamar Rawat Intensive : INFAN KETAREN, DR, Intens 1.00 450,000.00 0.00 450,000.00
SP.JP (L) ive

Pelayanan Instalasi Gawat Darurat

6 10-11-2022 Pemakaian Monitor Vital Sign / Hari : INFAN KETAREN, DR, SP.JP Intens 1.00 40,000.00 0.00 40,000.00
(T) ive

7 10-11-2022 ECG / Kali : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 53,000.00 0.00 53,000.00
ive

Pelayanan Rawat Inap

8 10-11-2022 Paket Pelayanan Kamar Rawat Intensive : INFAN KETAREN, DR, Intens 1.00 450,000.00 0.00 450,000.00
SP.JP (T) ive

Tindakan Medik Non Operatif

9 10-11-2022 GDS Strip (Ruangan) : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 25,000.00 0.00 25,000.00
ive

10 10-11-2022 Pasang Kateter : INFAN KETAREN, DR, SP.JP (L) Intens 1.00 20,000.00 0.00 20,000.00
ive

Pelayanan Instalasi Gawat Darurat

11 11-11-2022 Pemakaian Monitor Vital Sign / Hari : INFAN KETAREN, DR, SP.JP Intens 1.00 40,000.00 0.00 40,000.00
(L) ive

12 11-11-2022 ECG / Kali : INFAN KETAREN, DR, SP.JP (L) Intens 1.00 53,000.00 0.00 53,000.00
ive

13 11-11-2022 Injeksi Subcutan : INFAN KETAREN, DR, SP.JP (L) Intens 3.00 7,500.00 0.00 22,500.00
ive

Tindakan Medik Non Operatif

14 11-11-2022 GDS Strip (Ruangan) : INFAN KETAREN, DR, SP.JP (L) Intens 1.00 25,000.00 0.00 25,000.00
ive
No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

Pelayanan Rawat Inap

15 11-11-2022 Paket Pelayanan Kamar Rawat Intensive : INFAN KETAREN, DR, Intens 1.00 450,000.00 0.00 450,000.00
SP.JP (L) ive

Tindakan Medik Non Operatif

16 11-11-2022 Vulva Higiene : INFAN KETAREN, DR, SP.JP (L) Intens 1.00 20,000.00 0.00 20,000.00
ive

Pelayanan Instalasi Gawat Darurat

17 11-11-2022 Injeksi Subcutan : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 7,500.00 0.00 7,500.00
ive

18 12-11-2022 Injeksi Intravena : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 7,500.00 0.00 7,500.00
ive

19 12-11-2022 Pemakaian Monitor Vital Sign / Hari : INFAN KETAREN, DR, SP.JP Intens 1.00 40,000.00 0.00 40,000.00
(T) ive

20 12-11-2022 ECG / Kali : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 53,000.00 0.00 53,000.00
ive

Tindakan Medik Non Operatif

21 12-11-2022 Vulva Higiene : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 20,000.00 0.00 20,000.00
ive

Pelayanan Instalasi Gawat Darurat

22 12-11-2022 Injeksi Subcutan : INFAN KETAREN, DR, SP.JP (T) Intens 1.00 7,500.00 0.00 7,500.00
ive

Pelayanan Rawat Inap

23 12-11-2022 Paket Pelayanan Kamar Rawat Intensive : INFAN KETAREN, DR, Intens 1.00 450,000.00 0.00 450,000.00
SP.JP (L) ive

Sub Total Gawat Darurat 2,817,000.00

Gawat Darurat

Pelayanan Instalasi Gawat Darurat

1 08-11-2022 Konsultasi/pemeriksaan oleh Dokter Umum : DAVID RAINER II 1.00 40,000.00 0.00 40,000.00
IRIANTO HUTAJULU, DR (L)

2 08-11-2022 Pemakaian Monitor Vital Sign / Hari : DAVID RAINER IRIANTO II 1.00 40,000.00 0.00 40,000.00
HUTAJULU, DR (T)

3 08-11-2022 ECG / Kali : DAVID RAINER IRIANTO HUTAJULU, DR (T) II 1.00 53,000.00 0.00 53,000.00

Sub Total Cath Lab 133,000.00

Cath Lab

Pelayanan Kateterisasi Jantung

1 10-11-2022 PCI Dengan Stent : INFAN KETAREN, DR, SP.JP (L) Intens 1.00 18,398,000.00 0.00 18,398,000.00
ive

Sub Total Laboratorium Klinik 18,398,000.00

Laboratorium Klinik

Pelayanan Dan Pemeriksaan Bank Darah

1 08-11-2022 Anti HIV (Kromatografi) : IKA RIDLAWATI, DR, M.SC, SP.PK (L) II 1.00 59,900.00 0.00 59,900.00

Pelayanan Dan Pemeriksaan Laboratorium Klinik

2 08-11-2022 HBsAg (hasil negatif) : IKA RIDLAWATI, DR, M.SC, SP.PK (L) II 1.00 36,892.00 0.00 36,892.00

3 08-11-2022 Anti HCV (hasil negatif) : IKA RIDLAWATI, DR, M.SC, SP.PK (L) II 1.00 213,500.00 0.00 213,500.00

4 09-11-2022 Kreatinin Automatic : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 25,612.00 0.00 25,612.00
ive

5 09-11-2022 Urea Automatic : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 16,204.00 0.00 16,204.00
ive
No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

6 09-11-2022 Kalium : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 20,600.00 0.00 20,600.00
ive

7 09-11-2022 Kalsium : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 15,600.00 0.00 15,600.00
ive

8 09-11-2022 Klorida : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 16,100.00 0.00 16,100.00
ive

9 09-11-2022 Natrium Manual : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 81,600.00 0.00 81,600.00
ive

10 09-11-2022 Gula Darah Sewaktu : IKA RIDLAWATI, DR, M.SC, SP.PK (L) Intens 1.00 19,888.00 0.00 19,888.00
ive

Sub Total Depo Rawat Inap A 505,896.00

Depo Rawat Inap A

Tablet
1 08-11-2022 Aspilets 80mg Tab / Cartylo / Miniaspi II 3.00 106.00 0.00 318.00

2 08-11-2022 CPG (Clopidogrel) 75mg Tab II 3.00 682.00 0.00 2,046.00

3 08-11-2022 Isosorbid Dinitrat (ISDN)/Farsorbid 5mg Tab II 10.00 117.00 0.00 1,170.00

4 08-11-2022 Ramipril 2.5 Mg Tab II 3.00 284.00 0.00 852.00

5 08-11-2022 Concor 2,5mg Tab / bisoprolol 2,5mg II 3.00 159.00 0.00 477.00

Injeksi
6 08-11-2022 Novorapid/ Apidra II 1.00 106,118.00 0.00 106,118.00

7 08-11-2022 Ranitidin 50mg Inj (25mg/2mL) II 5.00 1,797.00 0.00 8,985.00

BHP
8 08-11-2022 DISP SPUIT 5 CC (A) II 5.00 1,137.00 0.00 5,685.00

9 08-11-2022 BD MICRO FINE PEN NEEDLE (A) II 1.00 1,992.00 0.00 1,992.00

Injeksi
10 09-11-2022 Arixta/Fondaparinuks Inj (2.5mg/0.5ml) (A) Intens 1.00 289,931.00 0.00 289,931.00
ive

BHP
11 09-11-2022 DISP SPUIT 3 CC (A) Intens 5.00 1,034.00 0.00 5,170.00
ive

Injeksi
12 10-11-2022 Arixta/Fondaparinuks Inj (2.5mg/0.5ml) (A) Intens 1.00 289,931.00 0.00 289,931.00
ive

Tablet
13 10-11-2022 Atorvastatin 20 Mg Tab Intens 4.00 529.00 0.00 2,116.00
ive

BHP
14 10-11-2022 IV. CATH 22 POT (A) Intens 1.00 8,609.00 0.00 8,609.00
ive

Sub Total Depo Cath Lab 723,400.00

Depo Cath Lab

Injeksi
1 10-11-2022 Diphenhidramin Inj Intens 1.00 978.00 0.00 978.00
ive

2 10-11-2022 Xolmetras Inj 100 ml Intens 1.00 663,988.00 0.00 663,988.00

ive

Obat dan Bahan Baku

3 10-11-2022 NaCl 0,9% 500ml Inf (A) Intens 2.00 8,037.00 0.00 16,074.00
ive
No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

Injeksi
4 10-11-2022 Deksametason Inj (5mg/mL) Intens 1.00 1,148.00 0.00 1,148.00
ive

5 10-11-2022 HEPARIN INJ @5 VIAL (A) Intens 0.50 54,796.00 0.00 27,398.00
ive

BHP
6 10-11-2022 TRANFUSI SET (A) Intens 1.00 9,870.00 0.00 9,870.00
ive

7 10-11-2022 UNIFLEX 3" Intens 1.00 36,425.00 0.00 36,425.00

ive

8 10-11-2022 Opsite Post OP 9.5 X 8.5cm Intens 1.00 18,512.00 0.00 18,512.00
ive

9 10-11-2022 Underpad 60X90cm Intens 1.00 4,071.00 0.00 4,071.00

ive

10 10-11-2022 PERFORMA ANGIOGRAPHIC CATETHER 5F TLTIMATE 4-T40 Intens 1.00 373,490.00 0.00 373,490.00
ive

11 10-11-2022 PRELUDE+NEEDLE SHEATH PSI-6F-11-018 Intens 1.00 592,840.00 0.00 592,840.00

ive

12 10-11-2022 INQWIRE GUIDEWIRE IQ35F150J3 Intens 1.00 186,152.00 0.00 186,152.00

ive

13 10-11-2022 NUGRA GUIDE WIRE 0.035 X 180CM Intens 1.00 452,375.00 0.00 452,375.00
ive

14 10-11-2022 SELANG OKSIGEN DEWASA (A) Intens 1.00 6,786.00 0.00 6,786.00
ive

Injeksi
15 11-11-2022 Xolmetras Inj 100 ml Intens 1.00 663,988.00 0.00 663,988.00
ive

16 11-11-2022 Lidokain Inj Intens 1.00 1,047.00 0.00 1,047.00

ive

BHP
17 11-11-2022 HANDSCOEN POWDER FREE NO. 7,5 (A) Intens 1.00 16,081.00 0.00 16,081.00
ive

18 11-11-2022 HANDSCOEN POWDER FREE NO. 8 Intens 1.00 16,081.00 0.00 16,081.00
ive

19 11-11-2022 Disp Spuit 1 CC Nipro Intens 1.00 1,434.00 0.00 1,434.00

ive

20 11-11-2022 DISP SPUIT 3 CC (A) Intens 2.00 1,034.00 0.00 2,068.00

ive

21 11-11-2022 DISP SPUIT 5 CC (A) Intens 2.00 1,137.00 0.00 2,274.00

ive

22 11-11-2022 DISP SPUIT 10 CC (A) Intens 2.00 1,512.00 0.00 3,024.00

ive

23 11-11-2022 Disp Spuit 20 CC Intens 1.00 2,893.00 0.00 2,893.00

ive

24 11-11-2022 Bisturi No 11 Intens 1.00 3,442.00 0.00 3,442.00

ive

Injeksi
25 11-11-2022 Vascon / Levosol / Norepineprin Inj Inj Intens 1.00 7,841.00 0.00 7,841.00
ive

26 11-11-2022 Atropin Sulfat Inj (A) Intens 2.00 2,019.00 0.00 4,038.00
ive

BHP
27 11-11-2022 Silk 2/0 C /Ss 685/ Hr 26 Intens 1.00 43,593.00 0.00 43,593.00
ive

Sub Total Depo Rawat Inap A 3,157,911.00

No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

Depo Rawat Inap A

Injeksi
1 11-11-2022 Ranitidin 50mg Inj (25mg/2mL) Intens 3.00 1,797.00 0.00 5,391.00
ive

Syrup
2 11-11-2022 Laxadine/ Kompolax Syr Intens 1.00 6,580.00 0.00 6,580.00
ive

Tablet
3 11-11-2022 Aspilets 80mg Tab / Cartylo / Miniaspi Intens 1.00 106.00 0.00 106.00
ive

4 11-11-2022 CPG (Clopidogrel) 75mg Tab Intens 1.00 682.00 0.00 682.00
ive

5 11-11-2022 Isosorbid Dinitrat (ISDN)/Farsorbid 5mg Tab Intens 5.00 117.00 0.00 585.00
ive

6 11-11-2022 Ramipril 5 Mg Tab Intens 1.00 187.00 0.00 187.00

ive

Injeksi
7 11-11-2022 Novorapid/ Apidra Intens 1.00 106,118.00 0.00 106,118.00
ive

8 11-11-2022 Lantus/ Levemir Flexpen (A) Intens 1.00 104,575.00 0.00 104,575.00
ive

BHP
9 11-11-2022 BD MICRO FINE PEN NEEDLE (A) Intens 5.00 1,992.00 0.00 9,960.00
ive

Tablet
10 11-11-2022 Atorvastatin 20 Mg Tab Intens 4.00 529.00 0.00 2,116.00
ive

BHP
11 11-11-2022 URINE BAG (A) Intens 1.00 6,292.00 0.00 6,292.00
ive

12 11-11-2022 BALON CATHETER 16 (A) Intens 1.00 10,857.00 0.00 10,857.00

ive

13 11-11-2022 IV. CATH 22 POT (A) Intens 1.00 8,609.00 0.00 8,609.00
ive

14 11-11-2022 DERMAFIX/LEUKOMED IV FILM (DINKES)(T) Intens 1.00 0.00 0.00 0.00

ive

15 11-11-2022 Three Way With Tube (A) Intens 1.00 4,010.00 0.00 4,010.00
ive

16 11-11-2022 AQUAPACK Intens 1.00 44,962.00 0.00 44,962.00

ive

Tablet
17 11-11-2022 Lansoprazole 30mg Intens 2.00 327.00 0.00 654.00
ive

18 12-11-2022 Aspilets 80mg Tab / Cartylo / Miniaspi Intens 10.00 106.00 0.00 1,060.00
ive

19 12-11-2022 CPG (Clopidogrel) 75mg Tab Intens 10.00 682.00 0.00 6,820.00
ive

20 12-11-2022 Isosorbid Dinitrat (ISDN)/Farsorbid 5mg Tab Intens 30.00 117.00 0.00 3,510.00
ive

21 12-11-2022 Ramipril 5 Mg Tab Intens 5.00 187.00 0.00 935.00

ive

22 12-11-2022 Concor 2,5mg Tab / bisoprolol 2,5mg Intens 10.00 159.00 0.00 1,590.00
ive
 No Tanggal Deskripsi Layanan Kelas Qty Biaya Satuan CITO Total

23 12-11-2022 Atorvastatin 20 Mg Tab Intens 20.00 529.00 0.00 10,580.00

ive

24 12-11-2022 Lansoprazole 30mg Intens 10.00 327.00 0.00 3,270.00

ive

Sub Total Depo Cath Lab 339,449.00

Depo Cath Lab

Implant
1 14-11-2022 PROMUS PREMIER SELECT 2,25 X 16 MM (VIBRASA) Intens 1.00 7,166,071.00 0.00 7,166,071.00
ive

2 14-11-2022 PROMUS PREMIER SELECT 2,75 X 24 MM (VIBRASA) Intens 1.00 7,166,071.00 0.00 7,166,071.00
ive

Sub Total Depo Cath Lab 14,332,142.00

Terbilang Harus Dibayar:

Kota Pontianak, 09 Desember 2022 Total Biaya Pelayanan : Rp. 40,406,798.00

Tanggungan Penjamin : Rp. 20,450,200.00

Top UP : Rp. 14,607,300.00

Selisih Bayar : Rp. 0.00

Deposit : Rp. 0.00

Tanggungan RS : Rp. 5,349,298.00

Harus Dibayar : Rp. 0.00

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 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA JKN
Berkas Klaim Individual Pasien 12/11/2022

Kode Rumah Sakit : 6171011 Kelas Rumah Sakit : A

Nama RS : RSUD DR SUDARSO Jenis Tarif : TARIF RS KELAS A PEMERINTAH

Nomor Peserta : 0000049771664 Nomor SEP : 1501R0011122V002919

Nomor Rekam Medis : 00174281 Tanggal Masuk : 08/11/2022
Umur Tahun : 50 Tanggal Keluar : 12/11/2022
Umur Hari : 18286 Jenis Perawatan : 1 - Rawat Inap
Tanggal Lahir : 15/10/1972 Cara Pulang : 1 - Atas Persetujuan Dokter
Jenis Kelamin : 2 - Perempuan LOS : 5 hari
Kelas Perawatan : 1 - Kelas 1 Berat Lahir : -

Diagnosa Utama : I21.4 Acute subendocardial myocardial infarction

Diagnosa Sekunder : E11.9 Non-insulin-dependent diabetes mellitus without complications

Prosedur : 00.41 Adjunct vascular system procedures, procedure on two vessels

00.46 Adjunct vascular system procedures,Insertion of two vascular stents
00.66 Parcutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy
36.07 Insertion of drug-eluting coronary artery stent(s)
57.94 Insertion of indwelling urinary catheter
89.52 Electrocardiogram

ADL Sub Acute : - ADL Chronic : -

Hasil Grouping

INA-CBG : I-1-40-I PROSEDUR KARDIOVASKULAR PERKUTAN (RINGAN) Rp 20,450,200.00

Sub Acute : - - Rp 0.00
Chronic : - - Rp 0.00
Special CMG : YY-02-III PCI Rp 14,607,300.00

Total Tarif : Rp 35,057,500.00

Generated : E-Klaim 5.7.2.202211140657 @ 2022-12-09 15:35:15 Lembar 1 / 1

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RSUD dr. Soedarso PONTIANAK
Jl. dr. Soedarso No. 1 Pontianak, KOTA PONTIANAK Kode Pos 78124 Telp. (0561) 737701
rsuddrsoedarso.kalbarprov.go.id, rsud@kalbarprov.go.id

RINGKASAN PASIEN PULANG

Ruangan : ICCU

No. MR 00174281 Tanggal Masuk : Selasa, 8 November 2022

Ny. Margareta Saini Tanggal Keluar : Sabtu, 12 November 2022
Perempuan / Umur : 50 th 1 bl 24 hr

Diagnosa Waktu Dirawat :

Diagnosa Terakhir : nstemi , dm tipe 2

Indikasi Pasien Rawat Inap : kateterisasi jantung

Hasil Operasi : PCI 2 DES DI LAD

Ringkasan Riwayat Penemuan Fisik Penting

Riwayat Penyakit Pemeriksaan Fisik

dm ttv td 134/80 hr 75 rr 19 spo2 99%

Riwayat Alergi

Hasil-hasil Laboratorium, Rontgent dan Konsultasi (yang penting) :

Laboratorium Patalogi Anatomi

echo ef 76,5% troponim + -

Rontgent

Pengobatan / Obat yang diberikan

Saat Masuk /dirawat di RS : Saat Keluar RS :

Arixta/Fondaparinuks Inj (2.5mg/0.5ml) (A) , Aspilets 80mg Tab / Aspilets 80mg Tab / Cartylo / Miniaspi , Atorvastatin 20 Mg Tab ,
Cartylo / Miniaspi , Atorvastatin 20 Mg Tab , Atropin Sulfat Inj (A) , Concor 2,5mg Tab / bisoprolol 2,5mg , CPG (Clopidogrel) 75mg Tab
Concor 2,5mg Tab / bisoprolol 2,5mg , CPG (Clopidogrel) 75mg Tab , Isosorbid Dinitrat (ISDN)/Farsorbid 5mg Tab , Lansoprazole 30mg
, Deksametason Inj (5mg/mL) , Diphenhidramin Inj , HEPARIN INJ , Ramipril 5 Mg Tab
@5 VIAL (A) , Isosorbid Dinitrat (ISDN)/Farsorbid 5mg Tab ,
Lansoprazole 30mg , Lantus/ Levemir Flexpen (A) , Laxadine/
Kompolax Syr , Lidokain Inj , NaCl 0,9% 500ml Inf (A) ,
Novorapid/ Apidra , Ramipril 2.5 Mg Tab , Ramipril 5 Mg Tab ,
Ranitidin 50mg Inj (25mg/2mL) , Vascon / Levosol / Norepineprin
Inj Inj , Xolmetras Inj 100 ml

Prognosis : membaik

Keadaan Pasien Waktu Pulang : Membaik

Anjuran / Edukasi

1. Kontrol Kembali : poli jantung 4. Dirujuk Ke :

2. Rehab Medis : 5. Diet :

Page 1/2
 3. Lain-lain (Sebutkan) :

Pontianak,...........................
Pasien / Keluarga Pasien Dokter yang merawat / DPJP

(....................................................) (INFAN KETAREN, DR, SP.JP)

Page 2/2

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