PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH

Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO
1
1
2
3

NAMA
2
Ny. Marice Rumere
An. Samuel Simopiaref
Ny. Yunita Y. Manggaprouw

:
:
:
:
:
:
:

SEPTEMBER 2014
RSUD BIAK

22 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

TANGGAL

No. MR

04 Sept 2014
08 Sept 2014
09 Sept 2014

3
2/201378/14
1/174733/13
1/177821/13

UMUR
THN
BLN HARI
4
5
47
9
24

P/L

DKTR

DIAGNOSA

ICD

TINDAKAN

6
P
L
P

7
dr. Syukri, M.kes
dr Benny Ap
dr Delly

8
TB. Paru
KP
TB. Paru

9
A15.0

10

A15.0

Kontrol
Kontrol
Kontrol

An. Aurel Mansnandifu

12 Sept 2014

2/184134/14

dr Lato

TB. Paru

A15.0

Lab
Lab
Kontrol

Ny. Rini Rumaropen

12 Sept 2014

1/110824/11

27

dr I Gede s

TB. Paru

A15.0

Lab
Kontrol
Lab
Kontrol

Tn. Nelson Ofahe

13 Sept 2014

1/210556/14

22

dr Lia Y

TB. Paru

A15.0

7
8
9

Ny. Bastalina Rumaropen

Ny. Merry Rumaropen
An. Aurel Mansnandifu

15 Sept 2014
15 Sept 2014
17 Sept 2014

2/132671/12
1/129538/12
2/184134/14

27
27
2

P
P
P

dr I Gede s
dr I Gede s
dr. Reni R

TB. Paru
TB. Paru
TB. Paru

A15.0
A15.0
A15.0

17 Sept 2014

1/207939/14

26

dr. Reni R

TB. Paru

A15.0

10 Tn. Aser Nap

Lab
Kontrol
Kontrol
Kontrol
Ro
Kontrol

11 An. Donbosco Titirlolobi

12 Tn. Nelson Ofahe

18 Sept 2014
18 Sept 2014

1/200915/14
1/210556/14

7
22

L
L

dr Jonatan
dr Jonatan

Malaria Klinis
Bronchitis Cronis

B54

Kontrol
Kontrol
Ro

13 Ny. Merry Rumaropen

19 Sept 2014

1/129538/12

27

dr Michael

TB. Paru

A15.0

Kontrol

14 An. Jessica W. Lengkong

18 Sept 2014

1/116266/11

dr Jonatan

Mal. Klinis+ISPA

15
16
17
18
19
20

23
23
23
25
26
27

2014
2014
2014
2014
2014
2014

2/178468/13
1/163965/13
1/174733/13
1/111793/11
1/103355/10
1/212111/14

5
3
9
49
21
24

L
L
L
L
L
P

dr Jonatan
dr Jonatan
dr Delly
dr Lato
dr Lia Y
dr Jonatan

GEA
GEA
TB. Paru
TB. Paru
TB. Paru
Bronchopneumonia

29 Sept 2014
30 Sept 2014

2/184134/14
2/208735/14

2
67

P
P

dr Benny Ap
dr. Reni R

TB. Paru
TB. Paru

An. Epafras Noriwari

An. Yosia Noriwari
An. Samuel Simopiaref
Tn. Dominggus Kaisiri
Tn. Damani Kafiar
Ny. Pona Rumsowek

21 An. Aurel Mansnandifu

22 Ny. Persila Manggaprouw

Sept
Sept
Sept
Sept
Sept
Sept

Lab
Kontrol

A15.0
A15.0
A15.0

A15.0
A15.0

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Ro
Kontrol
Kontrol

TOTAL

01 November 2014
Direktur

dr. Iras B.P Rumbiak, M.K

Nip. 19681014 200012

ICD
11

BIAYA
12
27,500
27,500
27,500
18,000
18,000
27,500
18,000
27,500
18,000
27,500
18,000
27,500
27,500
27,500
25,500
27,500

JUMLAH

KETERANGAN

13
14
27,500 P. DOTS
27,500

63,500
45,500
45,500
45,500
27,500
27,500
53,000
27,500

27,500
27,500
25,500
27,500
18,000
27,500

27,500
27,500
27,500
27,500
27,500
27,500
25,500
27,500
27,500

27,500
53,000
45,500
27,500

27,500
27,500
27,500
27,500
27,500
53,000
27,500
27,500
789,500

01 November 2014
Direktur

as B.P Rumbiak, M.Kes, SpPK

p. 19681014 200012 2 002

PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

NO

: OKTOBER 2014
: RSUD BIAK
:
:
:
32 PASIEN
: dr. IRAS B.P RUMBIAK, M Kes,SpPK
: RAWAT JALAN TINGKAT LANJUT

NAMA

TANGGAL

No. MR

UMUR
THN BLN HARI
4
5
25
37

P/L

DKTR

DIAGNOSA

ICD

6
P
P

7
dr Delly
dr Benny Ap

8
TB. Paru
Bronchiolitis

9
A15.0
J21,9

A15.0
A15.0

1
1
2

2
Ny. Yulinda Sroyer
Ny. Yuliana Bisay

01 Okt 2014
03 Okt 2014

3
1/212478/14
2/156183/12

3
4
5
6

Ny.
Ny.
Tn.
Tn.

03
04
04
07

2014
2014
2014
2014

1/174491/13
2/153534/12
2/210910/14
1/126093/12

26
48
32
41

P
P
L
L

dr Benny Ap
dr Jonatan
dr Jonatan
dr. Ricardo M

KP
TB. Paru
TB. Paru
Faringitis

7
8
9

Ny. Welmina Maninemwarba

Tn. Sem Manggombrab
Tn. Metusale Konyonan

07 Okt 2014
09 Okt 2014
10 Okt 2014

1/210896/14
2/210910/14
1/212931/14

34
32
57

P
L
L

dr Lato
dr Delly
dr Benny Ap

TB. Paru
TB. Paru
Bronchitis Non Specific

An. Aurel Mansnandifu

Tn. Herry Sasia

10 Okt 2014
10 Okt 2014

2/184134/14
2/122747/12

2
32

L
L

dr Benny Ap
dr. Reni R

KP
TB. Paru

10
11

Rika Rumbiak
Ruth Marandof
Sem Manggombrab
Ruben Urbasa

Okt
Okt
Okt
Okt

A15.0
A15.0

A15.0

12
13

Tn. Makmeser Kafiar

Tn. Herry Sasia

13 Okt 2014
13 Okt 2014

1/212271/14
2/122747/12

25
32

L
L

dr Lato
dr. Syukri, M.kes

Bronchitis
TB. Paru

J40
A15.0

14
15

Ny. Fransina Awom

Ny. Agustina Burdam

14 Okt 2014
15 Okt 2014

1/116161/11
2/122154/14

28
52

P
P

dr Lato
dr Delly

TB. Paru
TB. Paru

A15.0
A15.0

16

Nn. Ruth Rumbekwan

20 Okt 2014

1/211738/14

19

dr Lato

TB. Paru

A15.0

17
18
19
20
21
22

Ny.
Ny.
Tn.
Ny.
Ny.
Tn.

20
22
22
23
24
27

Okt
Okt
Okt
Okt
Okt
Okt

2014
2014
2014
2014
2014
2014

1/143347/12
1/143347/12
1/213094/14
1/210896/14
1/143347/12
1/209545/14

26
26
26
34
27
26

P
P
L
P
P
L

dr Lato
dr Jonatan
dr Lato
dr Lato
dr Lato
dr. Dewi P

HIV
TB. Paru
TB. Paru
TB. Paru
HIV
Susp. TB. Paru Aktif

B20
A15.0
A15.0
A15.0
B20

23
24
25
26

An. Aurel Mansnandifu

An. Ance Rumere
Nn. Dessi Miokbun
Ny. Desi Mirino

27
28
28
28

Okt
Okt
Okt
Okt

2014
2014
2014
2014

2/184134/14
2/213637/14
1/213122/14
1/143347/12

2
9
16
26

L
P
P
P

dr. Dewi P
dr. Windhy, SpA
dr Jonatan
dr Jonatan

TB. Paru Aktif

TB. Paru
HIV

A15.0
B20

27

Tn. Charlie J. Rumbiak

29 Okt 2014

1/212928/14

36

dr Jonatan

TB. Paru

A15.0

28

Tn. Otto Wabiser

29 Okt 2014

1/202268/14

38

29
30
31
32

Tn. Zakarias Wakum

An. Maya Esterlin dedifu
Tn. Naftali Rouw
Tn. Zakarias Wakum

30
31
31
31

1/213652/14
1/214557/14
1/213094/14
1/213652/14

54
1
26
54

L
P
L
L

dr. Reni R
dr. Reni R
dr Lato
dr Lato

TB. Paru
TB. Paru
TB. Paru

A15.0
A15.0
A15.0

Desi Mirino
Desi Mirino
Naftali Rouw
Welmina Maninemwarba
Desi Mirino
Edison Mayor

Okt
Okt
Okt
Okt

2014
2014
2014
2014

33

Tn. Demetrius Simbiak

31 Okt 2014

1/102809/10

45

dr Lato

Bronchitis

J40

TOTAL

01 Novembe
Direkt

dr. Iras B.P Rumbia

Nip. 19681014 2

FOR

47 BIAK PAPUA

TINDAKAN

ICD

10
Kontrol
Kontrol
Ro
Kontrol
Kontrol
Kontrol
Kontrol
Lab
Lab
Kontrol
Kontrol
Kontrol
Ro
Kontrol
Kontrol
Ro

11

BIAYA
12
27,500
27,500
25,500
27,500
27,500
27,500
27,500
18,000
18,000
27,500
27,500
27,500
25,500
27,500
27,500
25,500

JUMLAH

KETERANGAN

13
14
27,500 P. DOTS
53,000
27,500
27,500
27,500

63,500
27,500
27,500
53,000
27,500
53,000

Kontrol
Kontrol

27,500
27,500

27,500

Lab
Kontrol
Kontrol

18,000
27,500
27,500

45,500
27,500
27,500

Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Ro
Kontrol
Kontrol
Kontrol
Kontrol
Lab
Kontrol
Lab
Kontrol
Ro
Kontrol
Kontrol
Kontrol
Kontrol
Lab
Lab
Ro

27,500
18,000
27,500
27,500
27,500
27,500
27,500
27,500
25,500
27,500
27,500
27,500
27,500
18,000
27,500
18,000
27,500
25,500
27,500
27,500
27,500
27,500
18,000
18,000
25,500

45,500
27,500
27,500
27,500
27,500
27,500
53,000
27,500
27,500
27,500
45,500
45,500
53,000
27,500
27,500
27,500

89,000

Kontrol

27,500

27,500
1,204,500

01 November 2014
Direktur

dr. Iras B.P Rumbiak, M.Kes, SpPK

Nip. 19681014 200012 2 002

PEMERINTAH KABUPATEN BIAK NUMFOR

RUMAH SAKIT UMUM DAERAH
Jl. Sriwijaya Ridge I Tlp ( 0981 ) 21294 Fax ( 0981 ) 22747 BIAK PAPUA

FORM KLAIM KARTU PAPUA SEHAT

Bulan Pelayanan
Nama RS
Kode RS
Kelas RS
Jumlah Pasien
Nama Direktur RS
Jenis Perawatan

:
:
:
:
:
:
:

NO

NAMA

1
1
2
3
4
5
6
7
8
9

2
An. Ricardo T
Ny. Desi Mirino
Ny. Ruth Marandof
Ny. Ruth Rumbekwan
Tn. Sem Manggombrab
An. Beatriks Wambrauw
An. Daud Manggara
By. Bastian Msen
Tn. Donatus Chamas

10 Tn. Edison Mayor

11 Ny. Welmina Maninemwarba
12 An. Samuel Simopiaref

NOVEMBER 2014
RSUD BIAK

45 PASIEN
dr. IRAS B.P RUMBIAK, M Kes,SpPK
RAWAT JALAN TINGKAT LANJUT

TANGGAL

No. MR

2014
2014
2014
2014
2014
2014
2014
2014
2014

3
2/101888/10
1/143347/12
2/153534/12
1/211738/14
2/210910/14
2/104637/10
1/214404/14
2/213370/14
1/214644/14

04 Nov 2014
04 Nov 2014
04 Nov 2014

1/209545/14
1/210896/14
1/174733/13

01
01
01
01
03
03
03
03
04

Nov
Nov
Nov
Nov
Nov
Nov
Nov
Nov
Nov

UMUR
THN BLN HARI
4
5
14
26
60
16
32
8
13
5
48

26
34
9

P/L

DKTR

DIAGNOSA

ICD

TINDAKAN

ICD

6
L
P
P
P
L
P
L
P
L

7
dr Delly
dr Delly
dr Delly
dr Delly
dr. Reni R
dr. Reni R
dr. Reni R
dr. Reni R
dr. Syukri, M.kes

8
Bronchitis
Candidiasis Oral
TB. Paru
TB. Paru
TB. Paru
TB. Paru
TB. Paru
TB. Paru
Bronchitis

9
J40

11

A15.0
A15.0
A15.0
A15.0
A15.0
A15.0
J40

L
P
L

dr. Syukri, M.kes

dr. Syukri, M.kes
dr. Syukri, M.kes

TB. Paru
TB. Paru
Bronchitis

A15.0
A15.0
J40

10
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Lab
Lab
Ro
Kontrol
Kontrol
Kontrol
Ro

13 Nn. Itha Haluk

04 Nov 2014

1/214726/14

23

dr. Syukri, M.kes

TB. Paru

A15.0

14 Ny. Suslin Mampioper

04 Nov 2014

2/144898/12

45

dr. Syukri, M.kes

TB. Paru

A15.0

Kontrol
Lab
Kontrol

15 Tn. Zakarias Wakum

16 Ny. Desi Mirino
17 Tn. Yakob Rumbin

05 Nov 2014
07 Nov 2014
07 Nov 2014

1/213652/14
1/143347/12
1/140450/12

54
27
56

L
P
L

dr Benny Ap
dr. Edo S
dr. Edo S

TB. Paru
TBC
TB. Paru

A15.0
B20
A15.0

Kontrol
Kontrol
Kontrol

18 An. Aurel Mansnandifu

19 Tn. Sem Manggombrab

08 Nov 2014
08 Nov 2014

2/184134/13
2/210910/14

2
32

P
L

dr Delly
dr Delly

TB. Paru
TB. Paru

A15.0
A15.0

20 Ny. Sila Mofu

10 Nov 2014

2/184629/13

25

dr Delly

AIDS

21
22
23
24
25
26
27
28
29
30

Ny. Yuliana Marandof

Tn. Charlie J. Rumbiak
Tn. Korneles Rumbrawer
Ny. Fransina Awom
Ny. Yuliana Marandof
An. Beatriks Wambrauw
An. Derek Deki Baransano
By. Bastian Msen
Tn. Hendrik Boseren
Ny. Fransina Awom

10
10
11
11
12
13
13
14
15
15

Nov
Nov
Nov
Nov
Nov
Nov
Nov
Nov
Nov
Nov

2014
2014
2014
2014
2014
2014
2014
2014
2014
2014

1/197963/14
1/212928/14
1/124586/12
1/116161/11
1/197763/14
2/104637/10
2/164195/12
2/213370/14
1/215507/14
1/116161/11

32
36
36
28
32
8
3

dr Delly
dr Delly
dr. Edo S
dr. Edo S
dr. Benny AP
dr. Syukri, M.kes
dr. Syukri, M.kes
dr Jonatan
dr Delly
dr Delly

TB. Paru
TBC
TBC
TB. Paru
TB. Paru
Limfadenopati TB
TB. Paru
Bronchopneumonia
TBC

A15.0
B20
B20
A15.0
A15.0

52
28

P
L
L
P
P
P
L
P
L
P

31
32
33
34
35
36

Tn. Naftali Rou

Ny. Suslin Mampioper
An. Samuel Simopiaref
Ny. Welmina Maninemwarba
Tn. Edison Mayor
Ny. Virgo N

17
17
18
18
18
19

Nov
Nov
Nov
Nov
Nov
Nov

2014
2014
2014
2014
2014
2014

1/213094/14
2/144898/12
1/174733/13
1/210896/14
1/209545/14
1/112177/11

26
45
9
34
26
42

L
P
L
P
L
P

dr Michael
dr Michael
dr. Syukri, M.kes
dr. Syukri, M.kes
dr. Syukri, M.kes
dr Jonatan

TB. Paru
TB. Paru
TB. Paru
TB. Paru
Bronchopneumonia
Goutr A

A15.0
A15.0
A15.0
A15.0

Kontrol
Kontrol
Lab
Kontrol
Lab
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Lab
RO
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Kontrol
Lab

A15.0
B20

37 Tn. Hendrik Boseren

20 Nov 2014

1/215507/14

52

dr. Edo S

TB. Paru
TB. Paru

A15.0
A15.0

dr. Reni R
dr. Dewi P
dr. Dewi P
dr Michael

TB.
TB.
TB.
TB.

Paru
Paru
Paru
Paru

A15.0
A15.0
A15.0
A15.0

dr Michael
dr Jonatan
dr. Reni R
dr. Reni R
dr. Syukri, M.kes

TB.
TB.
TB.
TB.
TB.

Paru
Paru
Paru
Paru
Paru

A15.0
A15.0
A15.0
A15.0
A15.0

Kontrol
Kontrol
Kontrol
Kontrol
Kontrol

24 Nov 2014
25 Nov 2014

2/184134/13
2/215795/14

2
56

P
L

dr. Benny AP
dr. Edo S

40
41
42
43

An. Roy Abraham Mayor

Nn. Eta Korwa
An. Aski Rumere
Tn. Mihel Orboy

26
27
27
28

Nov
Nov
Nov
Nov

2014
2014
2014
2014

1/214916/14
1/216564/14
1/214686/14
2/214413/14

10
18
8
23

L
P
L
L

44
45
46
47
48

By. Bastian Msen

Tn. Naftali Rou
Tn. Otniel Otis Djitman
Tn. Otniel Otis Djitman
Tn. Otniel Otis Djitman

28
29
01
03
04

Nov
Nov
Nov
Nov
Nov

2014
2014
2014
2014
2014

2/213370/14
1/213094/14
1/214600/14
1/214600/14
1/214600/14

P
L
L
L
L

26
27
27
27

B20

Lab
Lab
Lab
Kontrol
Kontrol
Lab
RO
Kontrol
Kontrol
Kontrol
Kontrol

38 An. Aurel Mansnandifu

39 Tn. Marthen Korwa

HIV+TB. Paru

Lab
Lab
Kontrol

TOTAL

01 Desember 2014
Direktur

dr. Iras B.P Rumbiak, M.Kes, Sp

Nip. 19681014 200012 2 002

BIAYA
12
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
18,000
18,000
25,500
27,500
27,500
27,500
25,500

JUMLAH

KETERANGAN

13
14
27,500 P. DOTS
27,500
27,500
27,500
27,500
27,500
27,500
27,500

89,000
27,500
27,500
53,000

27,500
18,000
27,500

45,500
27,500

27,500
27,500
27,500

27,500
27,500
27,500

27,500
27,500
18,000
27,500
18,000
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
18,000
25,500
27,500
27,500
27,500
27,500
27,500
27,500
18,000

27,500
45,500
45,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500
27,500

71,000
27,500
27,500
27,500
27,500
27,500

18,000
18,000
27,500
18,000
18,000
18,000
27,500
27,500
18,000
25,500
27,500
27,500
27,500
27,500

27,500
27,500
27,500
27,500
27,500

1 Desember 2014
Direktur

P Rumbiak, M.Kes, SpPK

681014 200012 2 002

81,500

81,500
27,500

71,000
27,500
27,500
27,500
27,500

27,500
27,500
27,500
27,500
27,500
1,656,000