PEMERINTAH KOTA BANDAR LAMPUNG

RUMAH SAKIT DAERAH (RSD)

Dr. A. DADI TJOKRODIPO
Jalan Basuki rahmat No. 73 Teluk Betung – Bandar Lampung, Telp. 0721-471723, 470177, Fax. 0721-486480

RINCIAN BIAYA PELAYANAN RUMAH SAKIT DAERAH

DR. A. DADI TJOKRODIPO KOTA BANDAR LAMPUNG

NAMA : …......................................................... DPJP : ….............................................

TGL LAHIR : …......................................................... RUANG : ….............................................
NO RM : …......................................................... DIAGNOSA : ….............................................
TGL MASUK : …........................ JAM : ……............ ……...................................................................
TGL KELUAR : …........................ JAM : ……............ ……...................................................................
JAMINAN : …......................................................... ……...................................................................

A PROSEDUR NON BEDAH : ................................................................................ Rp. ….................

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B PROSEDUR BEDAH : ................................................................................ Rp. ….................
C KONSULTASI Rp. ….................
VISITE DR RUANGAN ...................................................................................
VISITE DR POLI ...................................................................................
KONSUL VIA TELP/WA VISITE DR SPESIALIS
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D TENAGA AHLI : ................................................................................ Rp. ….................
E KEPERAWATAN : ................................................................................ Rp. ….................
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F PENUNJANG : ................................................................................ Rp. ….................
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G RADIOLOGI : ................................................................................ Rp. ….................
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H LABORATORIUM : ................................................................................ Rp. ….................
I PELAYANAN DARAH : ................................................................................ Rp. ….................
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J REHABILITASI : ................................................................................ Rp. ….................
K KAMAR/AKOMODASI Rp. ….................
HARI RAWAT ...................................................................................
SKRINING GIZI ...................................................................................
JENIS DIIT ...................................................................................
AMBULANCE/JENAZAH ...................................................................................
L RAWAT INTENSIF : ................................................................................ Rp. ….................
M OBAT : ................................................................................ Rp. ….................
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N OBAT KRONIS : ................................................................................ Rp. ….................
O OBAT KEMOTERAPI : ................................................................................ Rp. ….................
P ALKES : ................................................................................ Rp. ….................
Q BMHP : ................................................................................ Rp. ….................
R SEWA ALAT : ................................................................................ Rp. ….................
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JUMLAH Rp. ….................

Bandar Lampung,
Dokter Yang Merawat Peserta/Pasien Koordinator Ruangan