RUMAH SAKIT BENYAMIN GULUH

Jl. Mekongga Indah, Kelurahan. Tahoa, Kolaka, Kabupaten Kolaka, Sulawesi Tenggara 93511

RINCIAN BIAYA PASIEN

Registrasi / No MR : 20230906-095654244-002 / 12-97-01 Nama Pasien : Ny. MEGAWATI SILVIA
Penjamin : JASA RAHARJA Alamat : JL.AHMAD MUSTIN KEL LALOEHA KEC KOLAKA
No Peserta :-
Tgl/Jam Masuk : 12-08-2023 / 20:40:45 Ruangan : INSTALASI GAWAT DARURAT - KELAS I KAMAR 7 (KELAS 1)
Tgl/Jam Keluar : 17-08-2023 / 10:29:00 Sex / Umur : Perempuan / 36.366 th
Diagnosa :-

RINCIAN BIAYA PERAWATAN

NO LAYANAN TGL KETERANGAN QTY NILAI KLAIM TERBAYARKEKURANGAN
12- Kamar dan Gizi Kelas 1
1 1 180,000 180,000 180,000 0
Aug - -
Askep Keperawatan
12-
2 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Health Education/hari
12-
3 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 10,000 10,000 10,000 0
Aug
- Abigail Ury,AMK
Assesment Nyeri (Skor Vas)
12-
4 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 15,000 15,000 15,000 0
Aug
- Abigail Ury,AMK
Perawatan
12-
5 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Visite Dokter Spesialis
12-
6 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Tindakan Suntik/Injeksi
12-
7 - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 13,000 13,000 13,000 0
Aug
- Abigail Ury,AMK
13- Kamar dan Gizi Kelas 1
8 KELAS I KAMAR 7 (KELAS I) 1 180,000 180,000 180,000 0
Aug - -
Perawatan
13-
9 KELAS I KAMAR 7 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Visite Dokter Spesialis
13-
10 KELAS I KAMAR 7 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Tindakan Suntik/Injeksi
13-
11 KELAS I KAMAR 7 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 13,000 13,000 13,000 0
Aug
- Abigail Ury,AMK
RI Konsultasi Antar Spesialis
13-
12 KELAS I KAMAR 7 (KELAS I) - dr. Tamsil, Sp. An 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
13 CEFTRIAXONE POWDER INJ 1 G @ 100 VIAL (BERNO/TSJ) 2 8,750 17,500 17,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
14 OMEPRAZOLE SODIUM INJ IV 40 MG @ 1 VIAL (BERNO/TSJ) 2 15,250 30,500 30,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
15 AQUA PRO INJ (OTSU-WATER) @ 25 ML (OTSUKA/MRP) 1 4,500 4,500 4,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 13- DEXTO (DEXKETOPROFE TROMETAMOL) I.M/I.V 50 MG/2ML INJ @ 5
16 3 49,700 149,100 149,100 0
RAWAT INAP Aug AMP (AAA)
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
17 DISPOSABLE SYRINGE 10 ML @100 (ONEMED/BIS) 4 2,125 8,500 8,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
18 DISPOSABLE SYRINGE 3 ML (ONEMED/BIS) @100 3 1,500 4,500 4,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 13-
19 DISPOSABLE SYRINGE 1 ML LUER @100 (GIDCARE/HMM) 2 1,500 3,000 3,000 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 14-
20 CHLODINE SWAB @100 (INFION/AAA) 3 500 1,500 1,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 14-
21 I.V CATHETER NO. 22 (TERUMO/MBS) @50 2 8,750 17,500 17,500 0
RAWAT INAP Aug
KELAS I KAMAR 7 (KELAS I) - DEPO 14-
22 INFUSION SET Y-TYPE STANDARD (AKSAMED/BIS) @ 50 1 12,000 12,000 12,000 0
RAWAT INAP Aug
Kamar dan Gizi Kelas 1
14-
23 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 180,000 180,000 180,000 0
Aug
- Abigail Ury,AMK
 Perawatan
14-
24 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Visite Dokter Spesialis
14-
25 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Tindakan Suntik/Injeksi
14-
26 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 13,000 13,000 13,000 0
Aug
- Abigail Ury,AMK
Skrining Gizi
14-
27 KELAS I KAMAR 8 (KELAS I) - dr. Rohani Ramang, Sp.GK 1 15,000 15,000 15,000 0
Aug
- Dian Pravita Sari. S.Tr.Gz
KELAS I KAMAR 8 (KELAS I) - DEPO 14-
28 CEFTRIAXONE POWDER INJ 1 G @ 10 VIAL (DEXA/AAM) 2 4,000 8,000 8,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 14- DEXTO (DEXKETOPROFE TROMETAMOL) I.M/I.V 50 MG/2ML INJ @ 5
29 3 49,700 149,100 149,100 0
RAWAT INAP Aug AMP (AAA)
KELAS I KAMAR 8 (KELAS I) - DEPO 14-
30 DISPOSABLE SYRINGE 3 ML (AXIMED/BIS) @100 3 1,700 5,100 5,100 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 14-
31 DISPOSABLE SYRINGE 10 ML @100 (ONEMED/BIS) 4 2,125 8,500 8,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 14-
32 OMEPRAZOLE SODIUM INJ IV 40 MG @ 10 VIAL (PHAPROS/KF) 2 16,250 32,500 32,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 14-
33 AQUA PRO INJ (OTSU-WATER) @ 25 ML (OTSUKA/MRP) 1 4,500 4,500 4,500 0
RAWAT INAP Aug
15- Kamar dan Gizi Kelas 1
34 KELAS I KAMAR 8 (KELAS I) 1 180,000 180,000 180,000 0
Aug - -
TRANSFUSI DARAH
15-
35 UTD - dr. hj Sri Noviati 1 350,000 350,000 350,000 0
Aug
- Andi Rahayu, AMK
Perawatan
15-
36 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Visite Dokter Spesialis
15-
37 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Tindakan Suntik/Injeksi
15-
38 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 13,000 13,000 13,000 0
Aug
- Abigail Ury,AMK
Foto Shoulder Joint
15-
39 RADIOLOGI - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 110,400 110,400 110,400 0
Aug
- Amelia Kadir, A.Md.Rad
Operasi (OK) Khusus
15-
40 OK ORTHOPEDI - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 4,400,000 4,400,000 4,400,000 0
Aug
- Muh. Misrajuddin Syaf, S.Kep.,Ns
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
41 SAGESTAM 40 I.M/I.V (2ML) INJ @ 5 AMP (SANBE/BSP) 3 10,000 30,000 30,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
42 CEFTRIAXONE POWDER INJ 1 G @ 100 VIAL (BERNO/TSJ) 2 8,750 17,500 17,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
43 OMEPRAZOLE 40MG INJ VIAL (BERNO/TSJ) 2 15,250 30,500 30,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
44 DISPOSABLE SYRINGE 3 ML (ONEMED/BIS) @100 6 1,350 8,100 8,100 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
45 FOLLEY CATHETER 2 WAY CH 16 (NORTA/AAM) @10 1 31,000 31,000 31,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
46 OXYGEN NASAL CANNULA DEWASA (ONEMED/BIS) 1 12,500 12,500 12,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
47 RINGER LAKTATE @ 500 ML INF (OTSUKA/MRP) 3 10,850 32,550 32,550 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
48 DISPOSABLE SYRINGE 10 ML @100 (ONEMED/BIS) 5 2,100 10,500 10,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
49 SANMOL 500 MG INF @ 100 ML (SANBE) 3 32,200 96,600 96,600 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
50 URINE BAG WITH ANTI-REFLUX 2000 ML (ONEMED/BIS) 1 16,000 16,000 16,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15-
51 AQUA PRO INJ (OTSU-WATER) @ 25 ML (OTSUKA/MRP) 3 4,000 12,000 12,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 15- DEXTO (DEXKETOPROFE TROMETAMOL) I.M/I.V 50 MG/2ML INJ @ 5
52 3 49,700 149,100 149,100 0
RAWAT INAP Aug AMP (AAA)
16- Kamar dan Gizi Kelas 1
53 KELAS I KAMAR 8 (KELAS I) 1 180,000 180,000 180,000 0
Aug - -
 Perawatan
16-
54 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Visite Dokter Spesialis
16-
55 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
Tindakan Suntik/Injeksi
16-
56 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 13,000 13,000 13,000 0
Aug
- Abigail Ury,AMK
Pasang infuse dewasa
16-
57 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 20,000 20,000 20,000 0
Aug
- Abigail Ury,AMK
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
58 CEFTRIAXONE POWDER INJ 1 G @ 10 VIAL (DEXA/AAM) 2 4,000 8,000 8,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
59 INFUSION SET Y-TYPE STANDARD (AKSAMED/BIS) @ 50 1 12,000 12,000 12,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16- DEXTO (DEXKETOPROFE TROMETAMOL) I.M/I.V 50 MG/2ML INJ @ 5
60 3 49,700 149,100 149,100 0
RAWAT INAP Aug AMP (AAA)
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
61 FIXOMULL STRETCH 15 CM X 5 M NEW (BSN/AAM) 10 550 5,500 5,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
62 RINGER LAKTATE @ 500 ML INF (OTSUKA/MRP) 3 10,850 32,550 32,550 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
63 SAGESTAM 40 I.M/I.V (2ML) INJ @ 5 AMP (SANBE/BSP) 3 10,000 30,000 30,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
64 SANMOL 500 MG INF @ 100 ML (SANBE) 3 32,200 96,600 96,600 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
65 DISPOSABLE SYRINGE 10 ML @100 (ONEMED/BIS) 4 2,125 8,500 8,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
66 OMEPRAZOLE 40MG INJ VIAL (BERNO/TSJ) 2 15,250 30,500 30,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
67 CHLODINE SWAB @100 (INFION/AAA) 4 500 2,000 2,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
68 DISPOSABLE SYRINGE 3 ML (AXIMED/BIS) @100 6 1,500 9,000 9,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 16-
69 I.V CATHETER NO. 22 @ 50 (TERUMO/HMM) 1 20,000 20,000 20,000 0
RAWAT INAP Aug
17- Kamar dan Gizi Kelas 1
70 KELAS I KAMAR 8 (KELAS I) 1 180,000 180,000 180,000 0
Aug - -
Formulir asuransi
17-
71 OK ORTHOPEDI - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 50,000 50,000 50,000 0
Aug
- Tri Saktiawan, AMD.Kom
Perawatan
17-
72 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 25,000 25,000 25,000 0
Aug
- Abigail Ury,AMK
Pemberian obat oral, tetes mata, tetes telinga, topikal
17-
73 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 10,000 10,000 10,000 0
Aug
- Abigail Ury,AMK
Ganti Verban Sedang
17-
74 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 40,000 40,000 40,000 0
Aug
- Abigail Ury,AMK
KELAS I KAMAR 8 (KELAS I) - DEPO 17-
75 CIPROFLOXACIN HCL 500 MG @ 100 TABLET (NOVA/BIS) 10 700 7,000 7,000 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 17-
76 MELOXICAM 7,5 MG @ 100 TAB (HJ/PPG) 10 350 3,500 3,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 17-
77 OMEPRAZOLE 20 MG @ 200 KAP (HJ/TSJ) 10 550 5,500 5,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 17-
78 CUTICELL CLASSIC 10 CM X 10 CM (BSN/AAM) @100 1 11,500 11,500 11,500 0
RAWAT INAP Aug
KELAS I KAMAR 8 (KELAS I) - DEPO 17-
79 FIXOMULL STRETCH 10 CM X 5 M NEW (BSN/AAM) 50 330 16,500 16,500 0
RAWAT INAP Aug
Visite Dokter Spesialis
18-
80 KELAS I KAMAR 8 (KELAS I) - dr Ahmad Perdana Asy'arie. B., Sp. OT 1 30,000 30,000 30,000 0
Aug
- Abigail Ury,AMK
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
81 ELECTROSURGICAL PENCILS (LIFERESOURCES/AMU) 1 118,500 118,500 118,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
82 CUTICELL CLASSIC 10 CM X 10 CM (BSN/AAM) @100 2 11,250 22,500 22,500 0
SENTRAL Aug
18-
83 OK ORTHOPEDI - DEPO RAWAT INAP STOMACH TUBE (MAAG SLANG) NO. 16 (TERUMO/MBS) 1 17,500 17,500 17,500 0
Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
84 ARM SLING SIZE L (WELDACO/HMM) 1 41,500 41,500 41,500 0
SENTRAL Aug
 OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
85 ELASTIS VERBAN FM CREPE 10 CM x 4.55 M (SNA MEDIKA/RN) 2 62,250 124,500 124,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
86 SANBE INFUSAN-NS SODIUM CHLORIDE @ 500 ML (BSP) 2 10,000 20,000 20,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
87 N32 T - NYLON 3 - 0 76 CM (TRITON/MPI) @12 1 61,000 61,000 61,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
88 VICRYL PLUS SUTURE 3 - 0 JVCP316H 70 CM (ETHICON/APL) @36 2 177,250 354,500 354,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
89 LIDOCAINE 2 % (40MG/2ML) INJ @ 100 AMP (BERNO/TSJ) 5 2,200 11,000 11,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
90 RECOFOL-N 10MG/ML (20ML) INJ @ 5 (PRIMEX/AAM) 1 106,000 106,000 106,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
91 FENTANYL 0,05MG/ML, 2ML INJ @ 5 AMP (KF) 3 37,500 112,500 112,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
92 KETOROLAC TROMETAMOL 30 MG INJ @ 10 AMP (BERNO/AAA) 1 7,000 7,000 7,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
93 DISPOSABLE SYRINGE 10 ML @100 (ONEMED/BIS) 5 2,100 10,500 10,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
94 DISPOSABLE SYRINGE 5 ML @100 (ONEMED/BIS) 3 1,500 4,500 4,500 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18-
95 FIXOMULL STRETCH 15 CM X 5 M NEW (BSN/AAM) 60 500 30,000 30,000 0
SENTRAL Aug
OK ORTHOPEDI - DEPO INSTALASI BEDAH 18- DEXAMETHASONE SODIUM PHOSPHATE 5 MG/ML INJ I.M/I.V @100
96 2 2,500 5,000 5,000 0
SENTRAL Aug AMP (BERNO/TSJ)
TOTAL 8,952,3008,952,300 8,952,300 0

RINCIAN PEMBAYARAN
KETERANGAN TOTAL , 18 October 2023
Bill Dalam Perawatan 8,952,300
TUNAI 8,952,300
Total Tagihan 0 Teguh Prasojo
Terbilang : ( Delapan Juta Sembilan Ratus Lima Puluh Dua Ribu Tiga Ratus Rupiah )