RINCIAN TAGIHAN PASIEN

NO.RM : 005656
NAMA PASIEN : TEGUH KURNIAWAN. TN
JENIS KELAMIN : LAKI -LAKI
ALAMAT : LEGUNDI RT 1 RW 1,DRIYOREJO,GRESIK
TGL MRS : 17/03/2023
TGL KRS : 20/03/2023
PENJAMIN : UMUM
KELAS RAWAT INAP : 3
RUANG RAWAT INAP : URANUS D 2

JENIS LAYANAN JUMLAH NILAI

TGL JENIS TINDAKAN HARGA JMLH KET
(RANAP,LAB.,RAD/IGD BIAYA JAMINAN

RANAP Jasa Pelayanan Keperawatan Rp 35.000 4 Rp 140.000

BAHP Dasar Rp 17.500 4 Rp 70.000
Biaya Makan
Konsultasi dr. Spesialis Via Telpon dr Rp 24.500 3 Rp 73.500
Trixie Sp.OT Rp 17.500 1 Rp 17.500
17/03/2023
Visite Dokter Umum Rp 24.500 1 Rp 24.500
s/d
Visite dokter spesialis dr Trixie Sp.OT Rp 38.500 2 Rp 77.000
20/03/2023
Rp 10.500 1 Rp 10.500
Visite Nutrisionis Devi Arum, A.Md.Gz
Sewa Kamar Rp 28.000 3 Rp 84.000
Visite Apoteker sri ermawati,S.Si, Apt Rp 14.000 1 Rp 14.000

FARMASI RL 500 Rp 8.854 2 Rp 17.708

KETOROLAC Rp 974 3 Rp 2.922
CEFAZOLIN
K-WIRE HOLD AND POINTED 1,0 X Rp 7.338 3 Rp 22.014
310MM (ORTHO TIMUR) Rp 337.483 1 Rp 337.483
ELEKTRODE
HMEF DEWASA
1000 VIRAL (ONEMED)
FILTER (VR Rp 1.288 5 Rp 6.440
MEDICAL)
RINGER LAKTAT INFUS 500 ML Rp 19.202 1 Rp 19.202
(SATORIA) Rp 8.854 2 Rp 17.708
NACL 0.9% INFUS 500 ML (EMJEBE) Rp 7.891 1 Rp 7.891
SPUIT 3 ML (TERUMO) Rp 1.321 1 Rp 1.321
SPUIT 10 MLMOUNT
CATHETER (NIPRO)DEWASA AL- Rp 1.506 1 Rp 1.506
17300 V001 (ALTECH)
PROPOFOL 1% INJEKSI I.V. 20 ML Rp 26.111 1 Rp 26.111
(NOVELL) 0.1 MG/2 ML INJEKSI 2ML
FENTANIL Rp 11.476 1 Rp 11.476
(MAHAKAM BETA)
KETOROLAC 30 MG/ML INJEKSI 1 ML Rp 31.249 1 Rp 31.249
(DEXA MEDICA) Rp 974 1 Rp 974
DOUBLE SPIKE
UNDERPAD (ONESTERIL
(U-PAD) MED) 60X90 Rp 2.553 1 Rp 2.553
(ONE MED)
KASA STERIL 7.5 X 7.5 CM 8 PLY Rp 8.680 2 Rp 17.360
(ONEMED)CONECTING TUBE
SUCTION Rp 12.881 6 Rp 77.286
(ONEMED) Rp 13.912 1 Rp 13.912
17/03/2023 HANDSCOON
COUTER PENCIL (ONEMED)
STERIL 8.0 Rp 55.702 1 Rp 55.702
s/d (SENTRAMED) Rp 7.276 4 Rp 29.104
20/03/2023 HANDSCOON STERIL 7.5 (MEDIGRIP) Rp 11.782 5 Rp 58.910
HANDSCOON STERIL 7.0 (SKIFA) Rp 11.782 4 Rp 47.128
MESS 15 (ONE MED) Rp 648 1 Rp 648
SPUIT 10 ML (NIPRO)
FRAMISETIN SULFAT TULLE 1% Rp 1.506 1 Rp 1.506
(DARYA VARIA)
ELASTOMUL LEUKOPLAST 8CMX Rp 16.417 1 Rp 16.417
4CM (BSN) Rp 54.626 1 Rp 54.626
NACL 0.9% INFUS 500 ML (EMJEBE) Rp 7.891 2 Rp 15.782
GYPSONA4/0
DAFILON POPB 3.5BLUE
DS 19 MX1075CM(B(BSN) Rp 32.493 1 Rp 32.493
BRAUN) Rp 34.602 1 Rp 34.602
HANDSCOON STERIL 6.5 (MEDIGRIP) Rp 11.782 2 Rp 23.564
KETOROLAC Rp 974 6 Rp 5.844
CEFAZOLIN Rp 7.338 3 Rp 22.014
NACL 500 SATORIA Rp 8.824 2 Rp 17.648
CEFIXIME 200 MG Rp 869 2 Rp 1.738
CEFIXIME 200 MG Rp 869 14 Rp 12.166
KALSIUM LAKTAT Rp 70 15 Rp 1.050
VITAMIN D 5000 Rp 4.170 7 Rp 29.190
BIONICOM ZINK Rp 2.196 7 Rp 15.372
ANALTRAM Rp 10.438 15 Rp 156.570

RETUR KETOROLAC -Rp 974 1 -Rp 974

Open Reduction Of Fracture With Internal

BEDAH CENTRAL 18/03/2023 Fixation - Phalanges Of Hand - Simple Rp 5.406.100 1 Rp 5.406.100
Implant
Debridement of open fracture site,
Rp 3.378.900 1 Rp 3.378.900
unspecified site

TOTAL Rp 10.542.216
TOTAL TAGIHAN PASIEN Rp 10.542.216
TOTAL BAYAR
BAYAR Rp 10.542.216
STATUS LUNAS

SIDOARJO, 20 MARET 2023

PETUGAS KASIR

NILA