RS NU BANYUWANGI
Jl. Raya Mangir Rogojampi
Website : [Link] | Email. info@[Link]
REKENING PASIEN SEMENTARA
NO RM : 03.78.58 REGISTER [Link]
:
NAMA : DINA MAHARANI, Nn UMUR 018T: 03B 01H
L/P : P JENIS Asuransi
: Kesehatan
ALAMAT : KRAJAN 03/01 SINGOLATREN Kec. Singojuruh PERUSAHAN BPJS:Kesehatan
Kabupaten Banyuwangi
KETERANGAN/DETAILS JUMLAH (Rp)
Biaya Sewa Kamar 900,000
ADENIUM - VVIP 5 X 3 20/11/2017 11:29:30 s.d 22/11/2017 19:30:49 @ Rp. 300,000 900,000
Biaya Visit Dokter 200,000
DR. ODE SP, An 21/11/2017 07:52:45 100,000
DR. NOLLY KIKI ADITYA, [Link] 22/11/2017 14:45:52 100,000
Biaya Radiologi 243,000
THORAXS AP/PA X 1 DR. LUKMAN DANU SAPUTRA 20/11/2017 85,000
FEMUR AP/[Link]/SIN X 1 DR. LUKMAN DANU SAPUTRA 21/11/2017 158,000
Biaya Laboratorium 204,050
Darah Lengkap X 1 20/11/2017 60,000
PPT/Appt X 1 20/11/2017 31,050
SGOT (AST) X 1 20/11/2017 17,500
SGPT (ALT) X 1 20/11/2017 17,500
BUN X 1 20/11/2017 20,000
Creatinin Serum X 1 20/11/2017 20,000
Bleeding Time X 1 20/11/2017 10,000
Clothing Time X 1 20/11/2017 10,000
Gula Darah Acak X 1 20/11/2017 15,000
D 3CC X 1 20/11/2017 1,500
EDTA & SWAB ALCOHOL X 1 20/11/2017 1,500
Biaya Tindakan/Perawatan 177,680
BAGI DIET X 1 20/11/2017 2,380
GANTI CAIRAN X 1 20/11/2017 4,000
INJEKSI BOLUS X 3 20/11/2017 10,800
INJEKSI IC X 1 20/11/2017 3,600
BAGI SEKA X 1 20/11/2017 2,400
TTV X 3 20/11/2017 Poli Orthopedi 11,000
BAGI DIET X 3 21/11/2017 7,140
GANTI CAIRAN X 3 21/11/2017 12,000
INJEKSI BOLUS X 7 21/11/2017 25,200
BAGI SEKA X 2 21/11/2017 4,800
TTV X 2 21/11/2017 8,000
Jasa Konsultasi Gizi X 1 21/11/2017 2,400
ASUHAN KEPERAWATAN X 1 21/11/2017 15,000
AFF INFUS X 1 22/11/2017 9,000
BAGI DIET X 2 22/11/2017 4,760
GANTI CAIRAN X 2 22/11/2017 8,000
INJEKSI BOLUS X 3 22/11/2017 10,800
BAGI SEKA X 1 22/11/2017 2,400
TTV X 1 22/11/2017 4,000
ASUHAN KEPERAWATAN X 2 22/11/2017 30,000
24/11/2017 8:26:22 Page 1/2
RS NU BANYUWANGI
Jl. Raya Mangir Rogojampi
Website : [Link] | Email. info@[Link]
REKENING PASIEN SEMENTARA
NO RM : 03.78.58 REGISTER [Link]
:
NAMA : DINA MAHARANI, Nn UMUR 018T: 03B 01H
L/P : P JENIS Asuransi
: Kesehatan
ALAMAT : KRAJAN 03/01 SINGOLATREN Kec. Singojuruh PERUSAHAN BPJS:Kesehatan
Kabupaten Banyuwangi
KETERANGAN/DETAILS JUMLAH (Rp)
Biaya Operasi 6,525,000
INSISI 20/11/2017 6,525,000
Biaya Penunjang 82,500
Paketan IRNA 1 2017-11-21 82,500
Biaya Obat 1,405,099
Pembelian Obat
20723 20/11/2017 DR. NOLLY KIKI ADITYA, [Link] 91,308
20795 20/11/2017 77,467
20807 21/11/2017 897,046
20819 21/11/2017 878
20982 22/11/2017 DR. ODE SP, An 26,690
21071 22/11/2017 DR. ODE SP, An 311,710
Biaya Administrasi 145,000
LOKET RI Poli Orthopedi 20/11/2017 10,000
JASA DOKTER SPESIALIS Poli Orthopedi 20/11/2017 50,000
STATUS RAWAT INAP Poli Orthopedi 20/11/2017 20,000
ADM RAWAT INAP Poli Orthopedi 20/11/2017 15,000
SEWA KAMAR IGD Poli Orthopedi 20/11/2017 50,000
Biaya Gizi 210,000
NASI ADENIUM - VVIP 5 2017-11-21 105,000
NASI ADENIUM - VVIP 5 2017-11-22 105,000
Total Biaya Pelayanan 10,092,329
Tanggungan Penjamin 4,141,000
Dibuat Oleh
AGOES
24/11/2017 8:26:22 Page 2/2