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Sub Total: 800,000 0: Kamar / Ruang Perawatan

1. This document provides a billing detail for inpatient treatment of Bambang S. at RS Mitra Medika hospital from April 4 to April 8, 2016. 2. The total billing before discounts was Rp4,374,072 including room charges, medical procedures, medications, and laboratory tests. 3. After a return of Rp50,902 for unused medications and no other discounts, the final amount due was Rp4,323,170 to be paid by PERUM PERHUTANI KPH BONDOWOSO as the insurer.

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55 views4 pages

Sub Total: 800,000 0: Kamar / Ruang Perawatan

1. This document provides a billing detail for inpatient treatment of Bambang S. at RS Mitra Medika hospital from April 4 to April 8, 2016. 2. The total billing before discounts was Rp4,374,072 including room charges, medical procedures, medications, and laboratory tests. 3. After a return of Rp50,902 for unused medications and no other discounts, the final amount due was Rp4,323,170 to be paid by PERUM PERHUTANI KPH BONDOWOSO as the insurer.

Uploaded by

Uis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
You are on page 1/ 4

Hal.

1 dari 4

Rincian ke : Perusahaan / Asuransi


Dicetak Oleh : muchlis, Sabtu, 09 April 2016, 08:45:22
RS MITRA MEDIKA
JL. HOS COKROAMINOTO no.98 BONDOWOSO - JAWA TIMUR Telp: 0332,421981

Fax:

RINCIAN BIAYA RAWAT INAP PASIEN PERUM PERHUTANI KPH BONDOWOSO


: PraBilling
Status
:
Tanggal
No. Medical Record : 00-02-93-43
Tanggal Rawat : 04/04/2016 - 08/04/2016

No. Transaksi : 160404-0042


Penjamin
:PERUM PERHUTANI KPH BONDOWOSO
Nama Pasien
: BAMBANG S., TN
Dr Pen Jawab : Yahya Amar, Dr. Sp. PD
No #

Layanan

Biaya Tunai

By Jaminan

0
0
0
0

200,000
200,000
200,000
200,000

800,000

Team Perawat IGD 10.00

15,000

2. 04/04/16 TARIF DOKTER IGD

Adkhiatul, dr

1.00

60,000

3. 04/04/16 SpO2 RJ

Team Perawat IGD

1.00

62,500

4. 04/04/16 Ambil Darah

Team Perawat IGD

1.00

31,250

5. 04/04/16 Injeksi/Intramusculer/Intracutan/SCTeam Perawat


IGD
1.00

45,000

6. 04/04/16 Pasang Kateter IGD

Team Perawat IGD

1.00

91,250

7. 04/04/16 Observasi <6 jam

Team Perawat IGD

1.00

46,250

8. 04/04/16 Pasang Venflon Infus

Team Perawat IGD

1.00

56,250

9. 04/04/16 BS Stik IGD

Team Perawat IGD

1.00

18,750

10. 04/04/16 ECG - IGD

Team Perawat IGD

1.00

81,250

11. 04/04/16 ECG - IGD

Team Perawat IGD

1.00

81,250

12. 04/04/16 PASANG O2

Team Perawat IGD

1.00

31,250

13. 04/04/16 Konsul Dokter Spesialis


per-telepon

Nur Wahyudi.,
Dr. Sp JP

1.00

75,000

695,000

Kamar / Ruang Perawatan :


1. 04/04/16 TULIP
2. 05/04/16 TULIP
3. 06/04/16 TULIP
4. 07/04/16 TULIP
Sub Total

Tindakan :
INSTALASI GAWAT DARURAT
1. 04/04/16 GAS O2 PER KG/CM2

Sub Total :
TULIP
1. 04/04/16 Buka Kateter

Team Perawat RI

1.00

42,188

2. 04/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

3. 04/04/16 Partial Care (4-6 Jam/24


Jam)

Team Perawat RI

1.00

35,156

4. 04/04/16 Pasang O2 RI

Team Perawat RI

1.00

42,188

5. 04/04/16 SpO2

Team Perawat RI

1.00

75,000

6. 04/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.


Sp. PD

1.00

150,000

7. 04/04/16 PAKET KEBERSIHAN RUANGAN & Team Kebersihan


LOUNDRE

1.00

75,000

8. 05/04/16 Barang Habis Pakai

RUMAH SAKIT

1.00

25,000

9. 05/04/16 Materai

RUMAH SAKIT

1.00

7,500

10. 05/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

11. 05/04/16 Partial Care (4-6 Jam/24


Jam)

Team Perawat RI

1.00

35,156

12. 05/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.


Sp. PD

1.00

150,000

Hal. 2 dari 4

Rincian ke : Perusahaan / Asuransi


Tindakan :
TULIP
13. 06/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

14. 06/04/16 Partial Care (4-6 Jam/24


Jam)

Team Perawat RI

1.00

35,156

15. 06/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.


Sp. PD

1.00

150,000

16. 07/04/16 GAS O2 PER PSI RI

RUMAH SAKIT

200,000

17. 07/04/16 Observasi < 6 Jam

Team Perawat RI

1.00

42,188

18. 07/04/16 Partial Care (4-6 Jam/24


Jam)

Team Perawat RI

1.00

35,156

19. 07/04/16 Visite Dokter Spesialis

Yahya Amar, Dr.


Sp. PD

1.00

150,000

20. 07/04/16 PAKET PELAYANAN GIZI 4

Team Gizi

1.00

140,000

1,516,252

Sub Total :
LABORATORIUM
1. 04/04/16 Creatinine

Adkhiatul, dr

1.00

23,750

2. 04/04/16 Asam Urat

Adkhiatul, dr

1.00

25,000

3. 04/04/16 BUN

Adkhiatul, dr

1.00

23,750

4. 04/04/16 SGOT

Adkhiatul, dr

1.00

23,750

5. 04/04/16 SGPT

Adkhiatul, dr

1.00

23,750

6. 04/04/16 Darah Lengkap

Adkhiatul, dr

1.00

60,000

7. 04/04/16 CK-MB

Yahya Amar, Dr.


Sp. PD

1.00

220,000

8. 04/04/16 Troponin I

Yahya Amar, Dr.


Sp. PD

1.00

106,250

9. 04/04/16 Cholesterol Total

Adkhiatul, dr

1.00

20,000

10. 04/04/16 Urine Lengkap

Yahya Amar, Dr.


Sp. PD

1.00

37,500

11. 07/04/16 Cholesterol Total

Yahya Amar, Dr.


Sp. PD

1.00

20,000

583,750

45,000

45,000

179,852

Sub Total :
Pemakaian Obat :
TULIP
1. 04/04/16 PAKET RUANGAN
Sub Total

1.00
:

Biaya Resep :
1. 04/04/16

A160400137
INTRAFIX SAFESET
VENFLON NO 20
URINE BAG
FOLLEY CATH GOLDRUSCH NO.16
HANSAPLAST SILVER CARE
AQUABIDEST 25 ML
HANDSCOON STERIL MAXTER 7
OXYFLOW DWS
SPUIT 10 CC TERUMO
SPUIT 3 CC TERUMO
ULCERANIN INJ
FUROSEMIDE INJ
RING AS SP 500 ML

1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
3.00
1.00
1.00
1.00

Hal. 3 dari 4

Rincian ke : Perusahaan / Asuransi


Biaya Resep :
2. 04/04/16

D160400063

D160400064

D160400076

D160400087

D160400088

D160400104

D160400144

36,393

21,929

95,587

165,253

690,762

5.00
5.00
1.00
5.00
5.00

SIBERID 10
FUNDAMIN E TAB
SPUIT 3 CC TERUMO
SIMVASTATIN TAB 20MG
EXFORGE 10/160 MG
Sub Total

1.00
1.00
1.00
1.00
2.00
1.00

SIBERID 10
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN RL SP
INFUSAN D5 500 SP
EXFORGE 10/160 MG
8. 07/04/16

75,430

1.00

EXFORGE 10/160 MG
7. 06/04/16

2.00

TWYNSTA 40/5
6. 05/04/16

5,318

1.00
1.00
1.00
1.00
1.00
1.00

TWYNSTA 40/5
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN D5 500 SP
INFUSAN RL SP
SIBERID 10
5. 05/04/16

0
1.00

SPUIT 10 CC TERUMO
4. 05/04/16

111,000

2.00
1.00
2.00
1.00
2.00
1.00

INFUSAN D5 500 SP
SIBERID 10
TWYNSTA 40/5
FASTOR 20 MG
FUNDAMIN E TAB
INFUSAN RL SP
3. 04/04/16

Hal. 4 dari 4

Rincian ke : Perusahaan / Asuransi


Total Transaksi

Rp.

Biaya Administrasi

Rp.

0
0

4,330,764
43,308

Total Biaya

Rp.

4,374,072

Pengurangan :- Return Obat


- Discount

Rp.
Rp.

0
0

50,902
0

Total Biaya Setelah Return dan Discount

Rp.

4,323,170

Pembayaran : - Uang Muka


- Billing Partial

Rp.

Rp.

Saldo Pembayaran ( sblm pembulatan )


Pembulatan

Rp.
Rp.

0
0

4,323,170
0

Saldo Pembayaran ( stlh pembulatan )

Rp.

4,323,170

TERBILANG : # EMPAT JUTA TIGA RATUS DUA PULUH TIGA


RUPIAH #

RIBU SERATUS TUJUH PULUH

KA.SIE ADM.PASIEN
RS MITRA MEDIKA

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