RUMAH SAKIT UMUM MITRA MEDIKA
Jl. Medan - Batang Kuis Dusun XI Emplasmen
Bandar Klippa
Kec. Percut Sei Tuan, Kab. Deli Serdang
Telp (061) 73381822
PERINCIAN BIAYA RAWAT INAP
No. Pendaftaran : 121050128192 Tgl Masuk : 27.05.2021 16:35:37
Nama Pasien : DINI ANITA ANGGRAINI Tgl Keluar : 31.05.2021 12:14:32
Tgl. Lahir : 28.01.1997 Ruang Rawat / Kelas : 409C / KELAS 3
No. Rekam Medis : 040331 Penjamin : BPJS KESEHATAN / -
Alamat : DUSUN V GG. DAMAI BANDAR KHALIPAH No. ID/ BPJS : -
Dokter : [Link] Rama Darya, [Link]
No. Keterangan Tanggal Qty Tarif (Rp) Subtotal (Rp)
Klinik Obgyn - Administrasi
1 Administrasi Pelayanan Rawat Inap 27.05.2021 1 50.000 50.000
Total : 50.000
Diskon : 0
Klinik Obgyn - Pelayanan/Tindakan
1 USG Kebidanan dan Kandungan 2 Dimensi [[Link] Rama 27.05.2021 1 150.000 150.000
Darya, [Link]]
Total : 150.000
Diskon : 0
Klinik Obgyn - Laboratorium
1 Golongan Darah - A,B,O dan Rhesus D 27.05.2021 1 80.000 80.000
2 HIV Rapid Test 27.05.2021 1 90.000 90.000
3 Darah Lengkap 27.05.2021 1 106.000 106.000
4 Rapid Antigen SARS CoV-2 27.05.2021 1 275.000 275.000
5 Test Koagulasi - Masa Perdarahan (BT) 27.05.2021 1 17.500 17.500
6 Test Koagulasi - Masa Pembekuan (CT) 27.05.2021 1 17.500 17.500
7 HBs Ag 27.05.2021 1 189.000 189.000
8 Glukosa Ad Random 27.05.2021 1 39.000 39.000
Total : 814.000
Diskon : 0
Klinik Obgyn - Visit Dan Konsultasi
1 Konsultasi Dokter Specialis Rawat Jalan [[Link] Rama 27.05.2021 1 100.000 100.000
Darya, [Link]]
Total : 100.000
Diskon : 0
Rawat Inap - Pelayanan/Tindakan
1 Tindakan Ruangan - Pemasangan Kateter 28.05.2021 1 30.000 30.000
2 Tindakan Ruangan - Pemasangan Infus IV Perifer 28.05.2021 1 20.000 20.000
Total : 50.000
Diskon : 0
Rawat Inap - Laboratorium
1 Test Koagulasi - Masa Thrombin (TT) 27.05.2021 1 408.000 408.000
Dicetak oleh ADMIN SOFTMEDIX, 31.05.2021 21:06:22
2 Test Koagulasi - APTT 27.05.2021 1 233.000 233.000
3 Test Koagulasi - Masa Prothrombin (PT) 27.05.2021 1 350.000 350.000
4 Test Koagulasi - Masa Perdarahan (BT) 28.05.2021 1 17.500 17.500
5 Test Koagulasi - Masa Pembekuan (CT) 28.05.2021 1 17.500 17.500
6 Darah Lengkap 29.05.2021 1 106.000 106.000
Total : 1.132.000
Diskon : 0
Rawat Inap - Bahan Medis Habis Pakai
1 INFUS SET MAKRO 27.05.2021 1 9.180 9.180
2 THREE WAY 27.05.2021 1 7.140 7.140
3 TEGADERM DEWASA 27.05.2021 1 8.540 8.540
4 BLOOD TRANSFUSION SET 27.05.2021 1 10.560 10.560
5 SPUIT 1 CC 27.05.2021 1 3.080 3.080
6 GILLETTE GOAL 27.05.2021 1 11.480 11.480
7 BLOOD TRANSFUSION SET 27.05.2021 1 10.560 10.560
8 SPUIT 10 CC 27.05.2021 1 3.900 3.900
9 ABBOCATH NO. 18 28.05.2021 2 11.760 23.520
10 BLOOD TRANSFUSION SET 28.05.2021 1 10.560 10.560
11 SPUIT 10 CC 28.05.2021 2 3.900 7.800
12 SPUIT 3 CC 28.05.2021 2 2.340 4.680
13 ALKOHOL SWAB 28.05.2021 2 580 1.160
14 HANDSCOON NON STERIL 28.05.2021 1 4.620 4.620
15 GROUNDING PLATE 28.05.2021 1 112.280 112.280
16 FOLEY CATHETER NO. 14 BARDIA 28.05.2021 1 40.040 40.040
17 KASA TUPER 35 X35 CM 28.05.2021 10 700 7.000
18 KASA PROPAX 35 X 35 CM 28.05.2021 30 3.360 100.800
19 SPUIT 5 CC TERUMO 28.05.2021 1 8.680 8.680
20 GILLETTE GOAL 28.05.2021 1 11.480 11.480
21 APRON 28.05.2021 3 8.820 26.460
22 SPUIT 3 CC TERUMO 28.05.2021 1 7.140 7.140
23 BENANG ASSUCRYL 1 TAPER (43437H) 28.05.2021 1 88.900 88.900
24 BENANG ASSUCRYL 1 TAPER (43417H) 28.05.2021 1 88.900 88.900
25 BENANG ASSUCRYL 3/0 CUTTING (4564) 28.05.2021 1 76.300 76.300
26 URINE BAG 28.05.2021 1 10.200 10.200
27 ELECTROSURGERY CAUTER 28.05.2021 1 112.280 112.280
28 ALKOHOL SWAB 28.05.2021 2 580 1.160
29 ALKOHOL 70% 28.05.2021 100 140 14.000
30 LOMATUELL 10 X 10 CM 28.05.2021 1 20.020 20.020
31 HYPAFIX 10 CM X 5 M 28.05.2021 20 420 8.400
32 HANDSCOON STERIL GAMMEX NO. 8 28.05.2021 2 19.740 39.480
33 HANDSCOON STERIL GAMMEX NO. 6,5 28.05.2021 2 19.740 39.480
34 HANDSCOON STERIL GAMMEX NO. 7 28.05.2021 1 19.740 19.740
35 SPINOCAN NO. 25 28.05.2021 1 49.280 49.280
36 MASKER KARET (EARLOOP) 28.05.2021 5 2.100 10.500
37 TOPI OPERASI PERAWAT (NURSE CAP) 28.05.2021 5 560 2.800
38 POVIDONE IODINE 60 ML 28.05.2021 2 27.020 54.040
39 HANDSCOON NON STERIL 28.05.2021 5 4.620 23.100
40 BLADE AESCULAP NO. 23 28.05.2021 1 5.180 5.180
41 ALKOHOL SWAB 28.05.2021 4 580 2.320
42 SPUIT 10 CC 28.05.2021 3 3.900 11.700
43 SPUIT 3 CC 28.05.2021 4 2.340 9.360
44 SPUIT 3 CC 29.05.2021 3 2.340 7.020
Dicetak oleh ADMIN SOFTMEDIX, 31.05.2021 21:06:22
45 ALKOHOL SWAB 29.05.2021 2 580 1.160
46 HANDSCOON NON STERIL 29.05.2021 1 4.620 4.620
47 SPUIT 5 CC 29.05.2021 1 2.940 2.940
48 SPUIT 10 CC 29.05.2021 2 3.900 7.800
49 LOMATUELL 10 X 10 CM 30.05.2021 1 20.020 20.020
Total : 1.161.360
Diskon : 0
Rawat Inap - Obat-Obatan
1 DEXAMETHASONE 5 MG/ML INJEKSI 27.05.2021 2 11.000 22.000
2 NACL 0,9% 500 ML 27.05.2021 1 15.840 15.840
3 DEXAMETHASONE 5 MG/ML INJEKSI 27.05.2021 1 11.000 11.000
4 CEFTRIAXONE 1 G INJEKSI 27.05.2021 1 26.400 26.400
5 RINGER LACTAT 500 ML 27.05.2021 1 14.820 14.820
6 DEXAMETHASONE 5 MG/ML INJEKSI 28.05.2021 1 11.000 11.000
7 NACL 0,9% 500 ML 28.05.2021 1 15.840 15.840
8 CEFTRIAXONE 1 G INJEKSI 28.05.2021 1 26.400 26.400
9 RANITIDINE 50 MG/2 ML INJEKSI 28.05.2021 1 10.150 10.150
10 OXYTOCIN 10 IU/ML INJEKSI 28.05.2021 1 9.520 9.520
11 ONDANSETRON 4 MG/2 ML INJEKSI 28.05.2021 1 13.650 13.650
12 RINGER LACTAT 500 ML 28.05.2021 1 14.820 14.820
13 KETOROLAC 30 MG/ML INJEKSI 28.05.2021 1 10.560 10.560
14 KETOPROFEN 100 MG SUPP 28.05.2021 1 18.480 18.480
15 ASAM TRANEKSAMAT 500 MG/5 ML INJEKSI 28.05.2021 1 15.580 15.580
16 AQUABIDEST 25 ML 28.05.2021 1 7.700 7.700
17 ASAM TRANEKSAMAT 500 MG/5 ML INJEKSI 28.05.2021 1 15.580 15.580
18 RINGER LACTAT 500 ML 28.05.2021 1 14.820 14.820
19 CEFTRIAXONE 1 G INJEKSI 28.05.2021 1 26.400 26.400
20 KETOPROFEN 100 MG SUPP 28.05.2021 1 18.480 18.480
21 ONDANSETRON 4 MG/2 ML INJEKSI 28.05.2021 1 13.650 13.650
22 OXYTOCIN 10 IU/ML INJEKSI 28.05.2021 1 9.520 9.520
23 KETOROLAC 30 MG/ML INJEKSI 28.05.2021 1 10.560 10.560
24 RANITIDINE 50 MG/2 ML INJEKSI 28.05.2021 1 10.150 10.150
25 KETOROLAC 30 MG/ML INJEKSI 28.05.2021 1 10.560 10.560
26 OXYTOCIN 10 IU/ML INJEKSI 28.05.2021 2 9.520 19.040
27 ONDANSETRON 4 MG/2 ML INJEKSI 28.05.2021 1 13.650 13.650
28 ETANYL 0,1 MG/2 ML INJEKSI 28.05.2021 1 61.600 61.600
29 EPHEDRINE HCL 50 MG/ML INJEKSI 28.05.2021 1 38.500 38.500
30 RINGER LACTAT 500 ML 28.05.2021 2 14.820 29.640
31 AQUABIDEST 25 ML 28.05.2021 3 7.700 23.100
32 REGIVELL 20 MG/4 ML INJEKSI 28.05.2021 1 107.800 107.800
33 PETHIDINE HCL INJEKSI 28.05.2021 1 35.040 35.040
34 METHYLERGOMETRINE 0,2 MG/ML INJEKSI 28.05.2021 2 10.440 20.880
35 KETOROLAC 30 MG/ML INJEKSI 28.05.2021 1 10.560 10.560
36 CEFTRIAXONE 1 G INJEKSI 28.05.2021 1 26.400 26.400
37 AQUABIDEST 25 ML 28.05.2021 1 7.700 7.700
38 RINGER LACTAT 500 ML 28.05.2021 1 14.820 14.820
39 RANITIDINE 50 MG/2 ML INJEKSI 28.05.2021 1 10.150 10.150
40 ASAM TRANEKSAMAT 500 MG/5 ML INJEKSI 28.05.2021 1 15.580 15.580
41 KETOPROFEN 100 MG SUPP 28.05.2021 1 18.480 18.480
42 PARACETAMOL 500 MG TABLET 28.05.2021 1 480 480
43 ETANYL 0,1 MG/2 ML INJEKSI 29.05.2021 1 61.600 61.600
44 KETOROLAC 30 MG/ML INJEKSI 29.05.2021 1 10.560 10.560
Dicetak oleh ADMIN SOFTMEDIX, 31.05.2021 21:06:22
45 RINGER LACTAT 500 ML 29.05.2021 1 14.820 14.820
46 ASAM TRANEKSAMAT 500 MG/5 ML INJEKSI 29.05.2021 1 15.580 15.580
47 KETOPROFEN 100 MG SUPP 29.05.2021 1 18.480 18.480
48 RANITIDINE 50 MG/2 ML INJEKSI 29.05.2021 1 10.150 10.150
49 ASAM MEFENAMAT 500 MG TABLET 29.05.2021 1 280 280
50 RAMABION CAPSUL (ETABION) 29.05.2021 1 720 720
51 RINGER LACTAT 500 ML 29.05.2021 1 14.820 14.820
52 AQUABIDEST 25 ML 29.05.2021 1 7.700 7.700
53 CEFTRIAXONE 1 G INJEKSI 29.05.2021 1 26.400 26.400
54 RAMABION CAPSUL (ETABION) 29.05.2021 1 720 720
55 CEFADROXYL 500 MG CAPSUL 29.05.2021 1 1.820 1.820
56 ASAM MEFENAMAT 500 MG TABLET 29.05.2021 1 280 280
57 ASAM MEFENAMAT 500 MG TABLET 30.05.2021 1 280 280
58 RAMABION CAPSUL (ETABION) 30.05.2021 1 720 720
59 CEFADROXYL 500 MG CAPSUL 30.05.2021 1 1.820 1.820
60 ASAM MEFENAMAT 500 MG TABLET 30.05.2021 1 280 280
61 ASAM MEFENAMAT 500 MG TABLET 30.05.2021 1 280 280
62 RAMABION CAPSUL (ETABION) 30.05.2021 1 720 720
63 CEFADROXYL 500 MG CAPSUL 30.05.2021 1 1.820 1.820
64 RAMABION CAPSUL (ETABION) 30.05.2021 10 720 7.200
65 GENTAMYCIN 0,1% SALEP KULIT 30.05.2021 1 6.720 6.720
66 ASAM MEFENAMAT 500 MG TABLET 30.05.2021 10 280 2.800
67 CEFADROXYL 500 MG CAPSUL 30.05.2021 10 1.820 18.200
Total : 1.051.670
Diskon : 0
Rawat Inap - Operasi
1 Sewa Kamar Operasi Regional Spinal Anastesi Block Besar 28.05.2021 1 1.600.000 1.600.000
2 Jam Pertama
2 Ruang Pemulihan [] 28.05.2021 1 195.000 195.000
3 Sectio Cesaria [[Link] Rama Darya, [Link]] 28.05.2021 1 3.000.000 3.000.000
4 Jasa Perawat OK 28.05.2021 1 300.000 300.000
5 Honor Dokter Anestesi [dr. Arna Fransisca Purba, [Link]] 28.05.2021 1 990.000 990.000
Total : 6.085.000
Diskon : 0
Rawat Inap - Transfusi Darah
1 Transfusi Darah Packed Red Cell (PRC) / Bag 27.05.2021 1 360.000 360.000
2 Transfusi Darah Packed Red Cell (PRC) / Bag 28.05.2021 1 360.000 360.000
Total : 720.000
Diskon : 0
Rawat Inap - Visit Dan Konsultasi
1 Visite Dokter Specialis [dr. Arna Fransisca Purba, 27.05.2021 1 100.000 100.000
[Link]]
2 Visite Dokter Specialis [dr. Hasbi Murdhani, [Link]] 28.05.2021 1 100.000 100.000
3 Visite Dokter Specialis [[Link] Rama Darya, [Link]] 29.05.2021 1 100.000 100.000
Total : 300.000
Diskon : 0
Rawat Inap - Kamar Perawatan
1 405 [KELAS 2] 27.05.2021 1 295.000 295.000
2 410 [KELAS 3] 28.05.2021 2 195.000 390.000
3 412 [KELAS 3] 29.05.2021 0 195.000 0
4 411 [KELAS 3] 29.05.2021 1 195.000 195.000
5 409 [KELAS 3] 29.05.2021 2 195.000 390.000
Dicetak oleh ADMIN SOFTMEDIX, 31.05.2021 21:06:22
6 Jasa Perawat Ruangan 31.05.2021 1 127.000 127.000
Total : 1.397.000
Diskon : 539.000
Total : Rp. 13.011.030
Total Diskon : Rp. 539.000
Grand Total (Total - Diskon) : Rp. 12.472.030
Plafon Perawatan : Rp. 0
Plafon Hak Kelas : Rp. 0
Selisih : Rp. 0
Simpanan Awal / Angsuran : Rp. 0
PEMBAYARAN : Rp. 0
COPY RINCIAN REKENING
Bandar Klippa, 31 Mei 2021
Penanggung Jawab Pasien
Kasir
( )
EVITA ANDRIANI SILAEN
Dicetak oleh ADMIN SOFTMEDIX, 31.05.2021 21:06:22