RUTIN I
Nama Pasien : _______________________________
NO. RM : __________ - ___________ - _______
FORMULIR PERMINTAAN Jenis Kelamin : Laki-laki / Perempuan
PEMERIKSAAN Tgl Lahir : ______ - ______________ - ________
RSUD PASAR MINGGU (001/ FORM/ LAB/ IV/ 2015) Umur : _________ Thn / Bln / Hr
JL. TB. Simatupang No.1 Jakarta Selatan
Telepon : 021-78841672, Fax : 021-78841672
E-mail : [Link]@[Link]
Diagnosa : NO. Lab :
Tanggal Penerimaan Sampel : Jam :
Dokter Pengirim :
Beri tanda ( X ) pada pemeriksaan yang diminta
KODE JENIS PELAYANAN TARIF KODE JENIS PELAYANAN TARIF
HEMATOLOGI KIMIA DARAH
Hema Rutin (Hb,Ht,Lekosit, Trombosit) 55,000 FUNGSI HATI
Hematologi Lengkap (Hema I+hj+E+NER+LED) 65,000 Protein Total 35,000
Eosinofil 30,000 Albumin 35,000
Retikulosit 35,000 Globulin 35,000
o
LED 25,000 SGOT / ASAT 37 C 35,000
Hitung Jenis 35,000 SGPT / ALAT 37 o C 35,000
Malaria 35,000 Bilirubin Total/Direct/Indirect 35,000
Filaria 35,000 Alkali Phosphatase 37 o C 45,000
o
Golongan darah + Rhesus 30,000 GAMMA GT 37 C 45,000
IT Ratio 50,000 Amylase 85,000
SEL LE 50,000 Lypase 150,000
Gambaran Darah Tepi 80,000 PROFIL LIPID
Gambaran Sumsum Tulang *** 250,000 Kolesterol Total* 35,000
HEMOSTASIS Trigliserida* 35,000
Masa Perdarahan 25,000 HDL Direct/LDL* 50,000
Fibrinogen 125,000 DIABETES
PT/INR 100,000 Glukosa Darah Puasa * 25,000
APTT 100,000 Glukosa Darah 2 jam PP 25,000
D- Dimer 150,000 Glukosa Sewaktu 25,000
Agregrasi Trombosit * 125,000 Glukosa Rapid 25,000
URINALISA Toleransi Glukosa Oral * 50,000
Urinalisis Lengkap 30,000 HBA1C 175,000
Urinalisis Rutin 20,000 Kurva Harian 75,000
Protein Kuantitatif 24 Jam 60,000 ENZIM JANTUNG
β HCG Urine rapid (25 IU) 50,000 LDH 60,000
FESES CK-NAC (TOTAL ) 75,000
Feses Rutin 30,000 CK-MB 75,000
Darah Samar 50,000 FUNGSI GINJAL
Feses Lengkap 60,000 Ureum 35,000
Analisa Feses/Gastroenterologi 225,000 Kreatinin 35,000
TEST KETERGANTUNGAN OBAT Asam urat 35,000
Benzodiazepin 60,000 Ureum Urine 24 Jam** 35,000
Amphetamin 60,000 Kreatinin Urine 24 Jam** 35,000
Morfin/Opiat 60,000 Asam urat Urine 24 Jam** 35,000
Mariyuana 60,000 Bersihan Kreatinin Urine 24 Jam ** 60,000
Cocaine 60,000 Microalbumin (Urine 24 Jam)** 125,000
IMUNOLOGI/SEROLOGI ELEKTROLIT
Widal 60,000 Elektrolit (Na, K, Cl) 125,000
Salmonella Typhi IgM 125,000 Natrium 75,000
CRP Kualilatif 60,000 Kalium 75,000
CRP Kuantitatif 100,000 Chlorida 75,000
HBsAg (ELISA) 125,000 Calcium Total 45,000
HBsAg Rapid 60,000 Magnesium 45,000
Anti HBsAg (ELISA) 150,000 Phosphor 50,000
Anti HCV (ELISA) 200,000 Phosphor Urine ** 50,000
Anti HIV 1-2 (ELISA) 200,000 Magnesium Urine ** 50,000
DHF IgG & IgM Rapid 150,000 Calcium Urine ** 50,000
Dengue NS-1 Antigen 225,000 Elektrolit Urine (Na, K, Cl) ** 225,000
ASTO 60,000 MIKROBIOLOGI
Rhematoid Faktor (RF) 60,000 Sediaan Gram 50,000
Auto Serum 45,000 Sediaan BTA 3X (Sputum) 50,000
HORMON Sediaan BTA MH 60,000
T3 150,000 Sediaan GO 80,000
T4 150,000 Sediaan Jamur (KOH) 30,000
TSH 150,000 LAIN-LAIN
Analisa Sperma 80,000
* Puasa 10 s.d. 12 Jam
** Urine Tampung 24 Jam
*** Pengambilan oleh klinisi