PERMINTAAN FORMULIR REKAM MEDIS 2023

RINCIAN PERHITUNGAN
NO NAMA FORMULIR JUMLAH
KOEFISIEN SATUAN HARGA PPN
1 Form triage IGD 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
2 Form Assesmen IGD 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
3 Form Resume rawat jalan 20 buku x 16 bulan buku Rp30,480 Rp975,360 Rp10,728,960
4 Form persetujuan-penolakan tindakan medis 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
5 Form catatan dan evaluasi keperawatan 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
6 Form pemberian komunikasi informasi dan edukasi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
7 Form pemberian komunikasi informasi dan edukasi covid-19 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
8 Form asesmen rawat jalan umum 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
9 Form asesmen rawat jalan khusus gigi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
10 Form konsul umum 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
11 Form catatan perkembangan pasien terintegrasi rawat jalan 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
12 Form asesmen fisioterapi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
13 Form CPPT fisioterapi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
14 Form hasil tindakan uji fungsi KFR 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
15 Form layanan kedokteran fisik 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
16 Kartu fisioterapi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
17 Form pengantar laboratorium 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
18 Form pengantar radiologi 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
19 Resep 20 buku x 16 bulan buku Rp30,480 Rp975,360 Rp10,728,960
20 Form skrining covid-19 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
21 Form pengkajian rawat inap anak 500 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
22 Form general consent 501 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
23 Form catatan perkembangan pasien terintegrasi rawat inap 502 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
24 Form permintaan DPJP 503 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
25 Form discharge summary 504 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
26 Form asesmen pra transfer 505 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
27 Form asesmen gizi anak 506 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
28 Form menajemen nyeri 507 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
29 Form asesmen humphty-dumphty 508 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
30 Form surat pengantar rawat inap 509 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
31 Form laporan pemberian obat 510 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
32 Form monitoring TTV 511 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
33 Form asesmen gizi dewasa 512 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
34 Form asesmen morse 513 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
35 Form asesmen geriatri ontario 514 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
36 Form pengkajian rawat inap dewasa dan lansia 515 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
37 Form catatan persalinan 516 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
38 Form patograf 517 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
39 Form pengkajian obgyn 518 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
40 Form pengkajian bayi baru lahir 519 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
41 Form identifikasi bayi baru lahir 520 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
42 Form surat kelahiran bayi baru lahir 521 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
43 Form asesmen pra bedah 522 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
44 Form laporan operasi 523 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
45 Form penandaan lokasi operasi pada wanita 524 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
46 Form penandaan lokasi operasi pada pria 525 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
47 Form ceklist keselamatan pasien 526 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
48 Form konsultasi dan asesmen pra anestesi dan pra sedasi 527 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
49 Form cek list kesiapan anestesi sedasi 528 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
50 Form evaluasi pra anestesi 529 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
51 Form serah terima preoperasi 530 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
52 Form serah terima post operasi 531 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
53 Form askep perioperatif 532 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
54 Form laporan operasi urologi 533 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
55 Form persetujuan tindakan bedah 534 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
56 Form penolakan tindakan bedah 535 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
57 Form pemberian transfusi darah 536 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
58 Form permintaan darah 537 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
59 Form APS pasien covid 538 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
60 Form persetujuan tindakan transfusi darah 539 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
61 Form persetujuan umum rawt inap covid 540 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
62 Form resep mata 20 buku x 16 bulan buku Rp30,480 Rp975,360 Rp10,728,960
63 Form bukti pelayanan ambulance 542 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
64 Form surat kematian 543 lembar x 16 bulan lembar Rp700 Rp560,000 Rp6,160,000
65 Map rekam medis 150 pcs x 16 bulan pcs Rp8,600 Rp2,064,000 Rp22,704,000
TOTAL Rp430,650,880

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