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RUMAH SAKIT BAPTIS BATU

KEU 01

Jl. Raya Tlekung No. 1 Batu Tromol Pos 100


Tlp. (0341) 594161, 598192, 598193 Fax. (0341) 598911

LEMBAR PELAYANAN PASIEN INSTALASI RAWAT JALAN / IGD


RAWAT JALAN PAGI RAWAT JALAN SORE IGD Tanggal :...........................................
No. MR
: ..................................... Baru Lama
Status Px : Umum

Asuransi : ..................................
Nama Pasien : .........................................................................L/P Umur :
Th.
Alamat
: .....................................
Dokter
: Umum
: .....................................
Diagnosa :
1. .....................................
Spesialis
: .....................................
2. .....................................
Gigi
: .....................................
3. .....................................

JENIS PELAYANAN / TINDAKAN MEDIS


I.

Tindakan Dokter / Perawat / Bidan ( ).


EKG
Nebulizer
Ganti Verban
USG
Enema
Kompres :
Pasang Catheter
Ambil Jahitan Rendam :
Pasang Gips
Tindik
Cuci :
Pasang IUD
Suntik :
Irigasi
Pasang IV
Biopsi
Evakuasi Benda Asing :
Pasang SL
Microcuret
Evakuasi Kolesteatoma :
Buka Gips :
FNA / Aspirasi Evakuasi Serumen
Lepas Drain
Pap Smear
...................................
Operasi :
Snellen
...................................
I & D Abses
Tonometer
...................................
Jahit Luka : cm
Refraksi
...................................

III.
Alat / Obat yang dipakai Saat Tindakan ()
Gouse :
Kasa Husada :
Jarum :
ABD :
Folley Cath. No. :
Spuit :

II. Lain-lain ()
Adm. Kartu Hijau Px. Baru
Adm. Rawat Jalan / IGD Jam Dinas
Adm. IGD Luar Jam Dinas
Adm. Klinik Gigi Sore
Adm. Pembelian Obat / Alkes
Konsul Gizi :
Ambulance / Mobil ke :
...................................
...................................
...................................
...................................
...................................

...................................
...................................

IV.
Rehabilitasi Medik ()
Alat A-1 (Pulley/Pararel/Stair Case/Icing/Shoulder Wheel*)
Akunpuntur (<10 titik/>10 titik*)
Alat A-2 (Sepeda Statik/Home Gym/Body Fitness/Treatmill*)
Latihan Terapeutik (LE/GE*)
Alat B-1 (Infra Red/Polar Care/Nebulizer/Ozon*)
Massage Terapeutik (Local/General
Massage*)
Alat B-2 (Chair Massage/Heating Blanket/SWD*)
Okupasi Terapi (OT-A/OT-B/OT-C)
Alat C-1 (US/TENS/ES/Traksi/MWD*)
Terapi Wicara (Sederhana/General*)
Injeksi Obat
...................................
Laser (<10 titik/> 10 titik)
................................... Sub Total :

Cabut Gigi Tetap (Posterior/Anterior/Komplikasi*)


Pembersihan Karang Gigi
Cabut Gigi Sulung (Tidak/Pakai Suntik/Komplikasi*)
Pengobatan Radang / Incisi Abscess
Tumpat Sementara (ROM, ROP/Trimix+TS, Pulpcaping*)
RE Foto Periapikal :
Tumpat GIC/Komposit Aduk (Fuji I, IX, Trimix + Fuji*)
Kontrol Ulangan / Check
Fissure Sealant/Wave
: Kelas :
Kontrol Ortho Cekat
: Kelas :
...................................
Komposit Preparasi
: Kelas :
...................................
: Kelas :
...................................
Sub Total :

CBC
LDL
SGOT
LED
BTA
Urine Lengkap
Triglycerides SGPT
Golongan Darah
Malaria
B.U.N
Protein Total Alk, Phospatase
Hbs Ag
Preg Test
(GDP/GDS/GD-2JPP*)
Albumin
Uric Acid
IgM Salmonella
...................................
Creatinin
Globulin
Calcium
Tb Rapid Test
...................................
Cholesterol Total
Bill Total
Na+, K+, Cl
Dengue Blood
HDL
Bill D/I
PPT/APTT
Widal
Sub Total :

Ossa Manus
Pedis
Skoliosis Standar
Waters
Colon In Loop
Wrist
Ankle
Cervical 2 Posisi
Mandibula
Urethrogram
Anthebarchi
Cruris :
Cervical 4 Posisi
TMJ
...................................
Elbow
Genu
Thoraco Lumbal
Thorax Dewasa
...................................
Humerus
Femur
Lumbo Sacral
Thorax Anak
...................................
Shoulder
Hip Joint
Sacrum
BOF / BNO / KUB
Clavicula
Pelvis
Skull
IVP
Sub Total :

Total Biaya Yang Harus Dibayar Pasien


Catatan : *) Coret Yang Tidak Perlu

Rp.
Instalasi Farmasi

Kasir IRJ

Pendaftaran

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