PERMINTAAN FORMULIR REKAM MEDIS 2022

RINCIAN PERHITUNGAN
NO NAMA FORMULIR JUMLAH
KOEFISIEN SATUAN HARGA PPN
1 Form triage IGD 300 lembar x 12 bulan lembar Rp700 Rp252,000 Rp2,772,000
2 Form Assesmen IGD 300 lembar x 12 bulan lembar Rp700 Rp252,000 Rp2,772,000
3 Form Resume rawat jalan 3 ply 12 buku x 12 bulan buku Rp30,480 Rp438,912 Rp4,828,032
4 Form persetujuan-penolakan tindakan medis 500 lembar x 12 bulan lembar Rp700 Rp420,000 Rp4,620,000
5 Form catatan dan evaluasi keperawatan 500 lembar x 12 bulan lembar Rp700 Rp420,000 Rp4,620,000
6 Form pemberian komunikasi informasi dan edukasi 500 lembar x 12 bulan lembar Rp700 Rp420,000 Rp4,620,000
7 Form pemberian komunikasi informasi dan edukasi covid-19 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
8 Form asesmen rawat jalan umum 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
9 Form asesmen rawat jalan khusus gigi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
10 Form konsul umum 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
11 Form catatan perkembangan pasien terintegrasi rawat jalan 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
12 Form asesmen fisioterapi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
13 Form CPPT fisioterapi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
14 Form hasil tindakan uji fungsi KFR 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
15 Form layanan kedokteran fisik 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
16 Kartu fisioterapi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
17 Form pengantar laboratorium 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
18 Form pengantar radiologi 200 lembar x 12 bulan lembar Rp700 Rp168,000 Rp1,848,000
19 Resep 2 ply 13 buku x 12 bulan buku Rp30,480 Rp475,488 Rp5,230,368
20 Form skrining covid-19 500 lembar x 12 bulan lembar Rp700 Rp420,000 Rp4,620,000
21 Form pengkajian rawat inap anak 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
22 Form general consent 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
23 Form catatan perkembangan pasien terintegrasi rawat inap 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
24 Form permintaan DPJP 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
25 Form discharge summary 3 ply 13 buku x 12 bulan buku Rp30,480 Rp475,488 Rp5,230,368
26 Form asesmen pra transfer 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
27 Form asesmen gizi anak 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
28 Form menajemen nyeri 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
29 Form asesmen humphty-dumphty 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
30 Form surat pengantar rawat inap 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
31 Form laporan pemberian obat 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
32 Form monitoring TTV 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
33 Form asesmen gizi dewasa 200 lembar x 12 bulan lembar Rp700 Rp168,000 Rp1,848,000
34 Form asesmen morse 200 lembar x 12 bulan lembar Rp700 Rp168,000 Rp1,848,000
35 Form asesmen geriatri ontario 200 lembar x 12 bulan lembar Rp700 Rp168,000 Rp1,848,000
36 Form pengkajian rawat inap dewasa dan lansia 400 lembar x 12 bulan lembar Rp700 Rp336,000 Rp3,696,000
37 Form catatan persalinan 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
38 Form patograf 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
39 Form pengkajian obgyn 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
40 Form pengkajian bayi baru lahir 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
41 Form identifikasi bayi baru lahir 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
42 Form surat kelahiran bayi baru lahir 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
43 Form asesmen pra bedah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
44 Form laporan operasi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
45 Form penandaan lokasi operasi pada wanita 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
46 Form penandaan lokasi operasi pada pria 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
47 Form ceklist keselamatan pasien 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
48 Form konsultasi dan asesmen pra anestesi dan pra sedasi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
49 Form cek list kesiapan anestesi sedasi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
50 Form evaluasi pra anestesi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
51 Form serah terima preoperasi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
52 Form serah terima post operasi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
53 Form askep perioperatif 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
54 Form laporan operasi urologi 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
55 Form persetujuan tindakan bedah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
56 Form penolakan tindakan bedah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
57 Form pemberian transfusi darah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
58 Form permintaan darah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
59 Form APS pasien covid 50 lembar x 12 bulan lembar Rp700 Rp42,000 Rp462,000
60 Form persetujuan tindakan transfusi darah 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
61 Form persetujuan umum rawat inap covid 100 lembar x 12 bulan lembar Rp700 Rp84,000 Rp924,000
62 Form resep mata 5 buku x 12 bulan buku Rp30,480 Rp182,880 Rp2,011,680
63 Form bukti pelayanan ambulance 40 lembar x 12 bulan lembar Rp700 Rp33,600 Rp369,600
64 Form surat kematian 25 lembar x 12 bulan lembar Rp700 Rp21,000 Rp231,000
65 Map rekam medis 150 pcs x 12 bulan pcs Rp8,600 Rp1,548,000 Rp17,028,000
TOTAL Rp146,271,048

Mengetahui Atasan Langsung

Yang Mengajukan Kepala Seksi Penunjang Medis dan Non Medis RSUD Kota Manado

TRIJUMARDI, A.Md.RMIK BERTJE B. WOWILING, SKM

NIP. 19980307 202203 1 007 NIP. 19650918 198603 2 016