DAFTAR KLAIM RAWAT INAP PASIEN JAMKESDA RSUD TANAH BUMBU

PROPINSI : KALIMANTAN SELATAN
KABUPATEN : TANAH BUMBU

BULAN : Desember
TAHUN : 2013

Umur (Thn)
NO

NAMA PASIEN

NO.REKOMENDASI JAMKESDA

TANGGAL
LOS

Alamat
L

Jl. Raya BTL Gg. Matoangin rt 003,
kampung baru, simpan empat

1

Tn. Nasar

6310092801780003

2

An. Taufik Rahman

6310092612080002

3

Tn. Abdullah

6310021207510001

4

Tn. Kamberun

6310021202470001

5

An. Putri andien

6310016704120001

6

Ny. Mardiana

6310035008870003

7

Ny. Asnah

6310025503600001

8

Ny. Pasinah

6310026302790001

9

An. Putri maulida

6310026002110002

Jl. Mjara pagatan rt 004, kusan hilir

10

Tn. Suraidi

6310022906870003

Jl. Tepian kusan rt 006, penylongan,
kusan hilir

11

An. Lina herliani

6310025810080001

Jl. SMPN 2 rt 008, batuah kusan hilir

12

Tn. Agus setiawan

6310100903920003

13

tn. Dasmin

6310052907630001

14

Tn. Mamiq mulyadi

6310030707440001

15

Tn. Yusran

6310090107690151

16

ny. Masriah

6310104107700077

Jl. Ins gub Gg. Pelita II rt 004 Ds.
Kampung baru, simpang empat
Ds. Rantau panjang hulu, rt 001,
kusan hilir
jl. Jati no 109 rt 003, kota pagatan
kusan hilir
Jl. Dharma praja rt 003 ds. Gunun
tinggi, BTL
Jl. Propinsi rt 004 ds. Sebamban
lama, sungai loban
Ds. Muara pagatan tengah rt 003,
kusan hilir
Jl. Raya btl rt 003 ds. Sepunggur,
kusan hilir

Jl. Raya transmigrasi dusun I rt 002,
ds dukuh rejo, mantewe
Ds. Wonorejo rt 007, kusan hulu
Sebamban I blok A rt 007 ds. Sari
mulya, sungai loban
jl. Andika rt 008 ds. Sari gadung,
simpang empat

Masuk

Keluar

35

08 Nopember 2013

13 Nopember 2013

5 (Hari

5

08 Nopember 2013

10 Nopember 2013

2 (Hari)

Diare cair akut tanpa dehidrasi

62

07 Nopember 2013

24 Nopember 2013

17 (Hari)

Anorexia

66

08 Nopember 2013

20 Nopember 2013

12 (Hari)

Hematemesis melena

1

18 Nopember 2013

20 Nopember 2013

2 (Hari)

26

17 Nopember 2013

30 Nopember 2013

13 (Hari)

Ascites

53

09 Nopember 2013

20 Nopember 2013

11 (Hari)

Dyspepsia

35

09 Nopember 2013

12 Nopember 2013

3 (Hari)

Colic abdomen

2

08 Nopember 2013

09 Nopember 2013

1 (Hari)

KDS, Diare akut dehidrasi tak berat

08 Nopember 2013

16 Nopember 2013

8 (Hari)

09 Nopember 2013

12 Nopember 2013

3 (Hari)

typhoid fever

21

12 Nopember 2013

19 Nopember 2013

7 (Hari)

Susp hepatitis

53

14 Nopember 2013

25 Nopember 2013

11 (Hari)

Fisbula

68

07 Nopember 2013

22 Nopember 2013

15 (Hari)

CHF Nyha I-II

44

07 Nopember 2013

12 Nopember 2013

5 (Hari)

colic abdomen

16 Nopember 2013

21 Nopember 2013

5 (Hari)

CHF

37

15 Nopember 2013

19 Nopember 2013

4 (Hari)

Acute abdomen d/d ISK

47

17 Nopember 2013

19 Nopember 2013

2 (Hari)

Obs. Abdominal pain

63

12 Nopember 2013

17 Nopember 2013

5 (Hari)

26
5

43

Jl. Kodeco KM 42 rt 003, mantewe
SP.I rt 005 Ds. Batulicin irigasi,
Karang Bintang
jl. Raya kampung baru rt 031 Ds.
Bersujud, simpang empat
Jl. Transmigrasi KM. 37 Dusun II rt
007 Ds. Bulu rejo, mantewe

P

DIAGNOSA

17

Tn. M. Hanafi

6310080302760001

18

Tn. H. Syahruni

6310090909660006

19

Tn. Paiman

6310100107500026

20

ny. Masrudah

6310046711830005

Ds. Bukit baru rt 001, satui

30

18 Nopember 2013

25 Nopember 2013

7 (Hari)

Obs dispneu, susp TB paru

21

Ny. Hati

6310024107650240

Jl. Andi iwang rt 005 Ds. Kampung
baru, kusan hilir

48

18 Nopember 2013

23 Nopember 2013

5 (Hari)

Gastritis acute

22

Tn. Teguh

6310071210500991

23

Ny. Jumantan

6310044107590011

24

Tn. Suyanto

6310030107410006

25

Ny. Nadiah

6310014107500024

26

An.Merda Amalia

6310094103030009

27

Ny.Sunarmi

6310016002560001

Ds. Manunggal rt 016, karang
bintang
Ds. Bukit baru rt 002, satui
Sebamban I blok B1 001/001 Ds.
Sari utama, sungai loban
Gg. Mudding 009/002 Ds. Kersik
putih, BTL
Jl.Rahayu Rt 06 Desa Bersujud
Simpang Empat
Jl .Mutiara Rt 12 Batulicin

28

Ny.Rahawati

6310045001780009

Jl .Kuripan Rt 01 Sinar Bulan Satui

29

Tn.Joko Wakidi

631010040472002

30

Tn.Suryanto

6310051302700004

31

An.Bernadito

6310092005080004

32

Tn.M.H.Sayuti

6310092104450004

33

Tn.Adenan

6310082912560001

34

Tn.Masri

6310020107530041

Jl.Transmigrasi Km37 Dusun II rt 05
Bulu Rejo Mantewe
Jl.Tapus Rt 05 Tapus Kusan Hulu
perumahan Bumi Datarlaga rt 12
Desa Sarigadung simpang empat
Gang Suka damai rt 03 desa
bersujud simpang empat
Desa Manunggal dusun III rt 24
Karang Bintang
Jl.Cempaka rt 06 batuah Kusan Hilir

63

20 Nopember 2013

23 Nopember 2013

3 (Hari)

CHF Nyha III-IV

20 Nopember 2013

23 Nopember 2013

3 (Hari)

Dispepsia

19 Nopember 2013

23 Nopember 2013

4 (Hari)

PPOK

60

21 Nopember 2013

26 Nopember 2013

5 (Hari)

Colic abdomen

10

12 November 2013

18 November 2013

6 (Hari)

57

12 November 2013

20 November 2013

8 (hari)

syndrom Dyspepsia

35

12 November 2013

14 November 2013

2 (Hari)

Sups KAD

41

12 November 2013

19 November 2013

7 (Hari)

43

11 November 2013

27 November 2013

16 (Hari)

negheted distal sinistra

5

11 November 2013

13 November 2013

2 (Hari)

GEA

70

04 November 2013

19 November 2013

15 (Hari)

ASHD DESOMP

56

01 November 2013

05 November 2013

4 (Hari)

Hipertensy Emergency

60

13 November 2013

18 November 2013

5 (Hari)

Ruptur flexn tendon of the lept hand zere V

15 November 2013

19 November 2013

4 (Hari)

Hiperemesis

14 November 2013

18 November 2013

4 (Hari)

20 November 2013

02 Desember 2013

12 (hari)

SNH

19 November 2013

27 November 2013

8 (hari)

Vesikolitungngis

54
72

Jl.Transmigrasi Km37 Dusun II rt 06
Bulu Rejo Mantewe
Jl.Brigjen H.Hasan Basri Rt 1
11 ( Bulan)
Pagaruyung Kusan hilir
Jl.H.M.Amin Rt 02 Mudalang Kusan
Hilir
Jl.Lasumpung Rt 03 Muara Pagatan
47
Tengah kusan Hilir

35

Ny.Rohimah

6310105508760002

36

An.M.Fikrih

6310020701130001

37

Ny.Mahnah

6310024107500176

38

Tn.Pandang

6310021207670002

39

Tn.Kasmad

6310091412590004

Jl.Kebanjiran no 34 rt 2 Tungkaran
pangeran simpang empat

53

21 November 2013

24 November 2013

3 (Hari)

Hil D Repanable

40

Tn.Duhammang

6310020305560001

Desa Rantau Panjang Hilir Rt02
Kusan Hilir

57

22 November 2013

26 November 2013

4 (Hari)

Kohile Abdomen

41

An. Tanti putri santika

6310096410000001

Jl. Simpang sari 1 rt 015 Ds.
Tungkaran pangeran, simpng empat

13

20 Nopember 2013

29 Nopember 2013

9 (Hari)

Obs febris hari ke v

42

Ny. Muthia Hijriani

6310026608870003

Jl. Annur no. 58 rt 005 Ds. Pasar
baru, kusan hilir

27

18 Nopember 2013

20 Nopember 2013

2 (Hari)

43

Ny. Noor halimah

6310094101700018

Jl. Raya serongga KM 5,5 rt 004 Ds.
Gunung besar, simpang empat

43

19 Nopember 2013

21 Nopember 2013

2 (Hari)

Ulkus peptikum

44

Tn. Aliansyah

6310020212940002

16

18 Nopember 2013

21 Nopember 2013

3 (Hari)

Chest paru

45

Tn. Mahrawi

6310021012630001

50

18 Nopember 2013

21 Nopember 2013

3 (Hari)

Kista

46

Ny. St. nortas

6310055004660001

47

19 Nopember 2013

21 Nopember 2013

2 (Hari)

Susp Tumor paru

47

An. Yulia Nur Asyifa

6310095104130001

7 (Bulan)

21 Nopember 2013

23 Nopember 2013

2 (Hari)

48

Tn. Darmansyah

6310020109550002

20 Nopember 2013

24 Nopember 2013

4 (Hari)

CHF

49

Ny. Ita

631004410690001

21 Nopember 2013

23 Nopember 2013

2 (Hari)

Sind. Dispepsia

jl. H.M. Badri rt 003 Ds. Pasar Baru,
kusan hilir
Jl. Tepian sungai kusan rt 002 Ds.
Salimuran, kusan hilir
Ds. Bakarangan rt 002, kusan hulu
Jl. Transmigrasi rt 005 Ds. Sari
gadung, simpang empat
Jl. H.M. amin rt 001 Ds. Mudalang,
kusan hilir
Jl. PLN Lama rt 007 Ds. Sungai
Danau, satui

37

63

58
44

50

Ny. Nurliana

6310054201920001

Ds. Bakarangan rt 002, kusan hulu

51

Tn. Sholihin Z

6310071708480001

Ds. Indra loka jaya 006/004 , kuranji

52

Ny. Dawiyah/Diwi

6310095012730003

Jl. PLN Gg. Tridaya 006/002 Ds.
Kampung baru, simpang empat

53

By. Nur Asyifa. F

6310067103130002

Jl. Kodeco KM 2,5 rt 011 Ds. Gunung
antasari, simpang empat

54

Ny. Suryani

6310054107670105

55

By. Aria

6310031812120001

56

An. Ahmad Dafa

6310022505090001

57

Tn. Syahmudin

6310080107370008

58

Tn. Mahmutu

6310021103520002

59

An. Kenzie

6310022505120001

60

Tn. Mawardi

6310090708870005

61

Tn. Samsul hadi

6310030404680001

62

An. Gadis

6310094608100002

Jl. Raya serongga KM 5,5 rt 004 Ds.
Gunung besar, simpang empat

63

Ny. Fujiati

6310074704820001

64

Ny. Sugatin

6310084107690047

65

Ny. Satiah

66

Ny. Norhaniah

21

22 Nopember 2013

24 Nopember 2013

2 (Hari)

20 Nopember 2013

22 Nopember 2013

2 (Hari)

38

21 Nopember 2013

24 Nopember 2013

3 (Hari)

CKR

7 (Bulan)

22 Nopember 2013

25 Nopember 2013

3 (Hari)

GEA

45

20 Nopember 2013

23 Nopember 2013

3 (Hari)

Tumor mammae sinistra

22 Nopember 2013

25 Nopember 2013

3 (Hari)

DCA dg dehidrasi ringan sedang

23 Nopember 2013

26 Nopember 2013

3 (Hari)

DF/DHF

22 Nopember 2013

27 Nopember 2013

5 (Hari)

Susp Goat

20 Nopember 2013

23 Nopember 2013

3 (Hari)

Obs LBP osteogenik

21 Nopember 2013

23 Nopember 2013

2 (Hari)

Eroup

22 Nopember 2013

26 Nopember 2013

4 (Hari)

GEA

22 Nopember 2013

27 Nopember 2013

5 (Hari)

Obs. Dispneu, susp efusi pleura

3

20 Nopember 2013

22 Nopember 2013

2 (Hari)

CKS

Ds. Karang intan 005/0002, kuranji

31

24 Nopember 2013

30 Nopember 2013

6 (Hari)

Obs Febris

Jl. Melati 008/004 Ds. Pandan sari,
karang bintang

44

23 Nopember 2013

26 Nopember 2013

3 (Hari)

Unstable Angina

6310027112580006

Ds. Penyolongan Rt 006, kusan hilir

55

22 Nopember 2013

28 Nopember 2013

6 (Hari)

Ginggivites dd paralisis

6310024107710026

Jl. Anugrah Rt 006 Ds. Batuah, kusan
hilir

42

22 Nopember 2013

30 Nopember 2013

8 (Hari)

Anemia gravi, susp gastritis erosif

65

Ds. Pacakan 004/002, kusan hilir
Ds. Sebamban lama 004/002, sungai
11 (Bulan)
loban
Jl.A. yani rt 001 Ds. Pejala, kusan
4
hilir
Ds. Manunggal dusun II Rt 011,
76
karang bintang
Jl. Propinsi rt 006 Ds. Betung, kusan
61
hilir
Jl. Brigjen H. hasan basri rt 001 Ds.
1
Pagaruyung, kusan hilir
Jl. Transmigrasi Km. 3 Rt 005 Ds
26
barokah, simpang empat
Dusun widya mandala 003/008 Ds.
44
Batu meranti, sungai loban

FAM Dekstra

Pelayanan Kesehatan Dan Besaran Tarif sesuai PERDA (Rp)

Akomodasi

Jasa Medis
Spesialis

Jasa Medis
Umum

Jasa Keperawatan
Tindakan Kecil

Tindakan
Sedang

Tindakan
Intensif

Konsultasi
medis gigi

Tindakan di UGD
Jasa Apoteker

Berkas RM
Sederhana

Sederhana Poli
Umum

Kecil

Sedang

Besar

Rp

250,000 Rp

60,000

Rp

120,000 Rp

320,000

Rp

150,000 Rp

270,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000 Rp

60,000

Rp

20,000 Rp

60,000

Rp

90,000 Rp

135,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

850,000 Rp

210,000

Rp

200,000 Rp

800,000

Rp

450,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

600,000 Rp

300,000

Rp

140,000 Rp

600,000

Rp

120,000 Rp

180,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000 Rp

60,000

Rp

20,000 Rp

60,000

Rp

90,000 Rp

135,000

Rp

10,000

Rp

200,000

Rp

650,000 Rp

270,000

Rp

140,000 Rp

680,000

Rp

450,000 Rp

585,000

Rp

10,000

Rp

200,000

Rp

550,000 Rp

210,000

Rp

120,000 Rp

600,000

Rp

450,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

150,000

Rp

40,000 Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

10,000

Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

50,000 Rp

60,000

Rp

20,000 Rp

40,000

Rp

Rp

400,000 Rp

270,000

Rp

20,000 Rp

180,000

Rp

150,000 Rp

60,000

Rp

40,000 Rp

80,000

Rp

350,000 Rp

150,000

Rp

80,000 Rp

400,000

Rp

550,000 Rp

330,000

Rp

240,000

Rp

5,000 Rp

10,000

Rp

750,000 Rp

240,000

Rp

80,000 Rp

600,000

Rp

225,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

60,000

Rp

60,000 Rp

320,000

Rp

90,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

120,000

Rp

60,000 Rp

240,000

Rp

90,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

200,000 Rp

90,000

Rp

40,000 Rp

280,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000 Rp

60,000

Rp

20,000 Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

150,000

Rp

20,000 Rp

120,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

350,000 Rp

150,000

Rp

60,000 Rp

440,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

120,000

Rp

60,000 Rp

240,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

Rp

Rp

60,000 Rp

120,000 Rp

90,000

180,000

540,000

30,000
Rp

405,000

Tindakan Penyakit Dalam

Rp

150,000 Rp

60,000

Rp

40,000 Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

150,000 Rp

120,000

Rp

40,000 Rp

160,000

Rp

Rp

5,000 Rp

10,000

Rp

200,000

Rp

200,000 Rp

90,000

Rp

80,000 Rp

240,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

120,000

Rp

40,000 Rp

240,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

300,000 Rp

210,000

Rp

140,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

400,000 Rp

240,000

Rp

80,000 Rp

320,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000 Rp

30,000

Rp

60,000 Rp

160,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

350,000 Rp

60,000

Rp

140,000 Rp

400,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

800,000 Rp

420,000

Rp

340,000

Rp

5,000 Rp

10,000

Rp

150,000 Rp

60,000

Rp

60,000

Rp

200,000

Rp

750,000 Rp

330,000

Rp

180,000 Rp

720,000

Rp

200,000 Rp

60,000

Rp

60,000 Rp

Rp

250,000 Rp

150,000

Rp

200,000 Rp

60,000

Rp

200,000 Rp

Rp

Rp

Rp

90,000

135,000

90,000 Rp

135,000

Rp

5,000 Rp

10,000

Rp

675,000

Rp

5,000 Rp

10,000

320,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

60,000 Rp

240,000

Rp

5,000 Rp

10,000

Rp

200,000

60,000

Rp

60,000 Rp

100,000

600,000 Rp

480,000

Rp

60,000 Rp

640,000

Rp

200,000

Rp

400,000 Rp

300,000

Rp

Rp

150,000 Rp

90,000

Rp

200,000 Rp

90,000

Rp

450,000 Rp

240,000

Rp

100,000 Rp

120,000

Rp

100,000 Rp

30,000

Rp

150,000 Rp

60,000

Rp

150,000 Rp

90,000

Rp

100,000 Rp

30,000

Rp

100,000 Rp

Rp
Rp

Rp

50,000

Rp

135,000

150,000 Rp

225,000

Rp

10,000

Rp

270,000

Rp

10,000

Rp

5,000 Rp

10,000

Rp

5,000 Rp

10,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

200,000

220,000
Rp

Rp

Rp

100,000

100,000

Rp

80,000

Rp

80,000 Rp

360,000

Rp

40,000 Rp

200,000

Rp

60,000

Rp

5,000 Rp

10,000

Rp

40,000 Rp

160,000

Rp

5,000 Rp

10,000

Rp

40,000 Rp

200,000

Rp

5,000 Rp

10,000

Rp

80,000

Rp

5,000 Rp

10,000

Rp

40,000 Rp

120,000

Rp

90,000

Rp

5,000 Rp

10,000

90,000

Rp

20,000 Rp

60,000

Rp

90,000 Rp

135,000

Rp

10,000

Rp

200,000

200,000 Rp

210,000

Rp

100,000 Rp

240,000

Rp

180,000

Rp

5,000 Rp

10,000

Rp

200,000

100,000 Rp

60,000

Rp

40,000 Rp

160,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

60,000

Rp

300,000 Rp

Rp

450,000

135,000

Rp

100,000 Rp

150,000

Rp

60,000

Rp

5,000 Rp

10,000

Rp

100,000 Rp

90,000

Rp

60,000

Rp

5,000 Rp

10,000

Rp

150,000 Rp

270,000

Rp

60,000 Rp

80,000

Rp

Rp

5,000 Rp

10,000

Rp

200,000

Rp

150,000 Rp

60,000

Rp

20,000 Rp

80,000

Rp

120,000 Rp

180,000

Rp

10,000

Rp

200,000

Rp

150,000 Rp

60,000

Rp

60,000 Rp

80,000

5,000 Rp

10,000

Rp

150,000 Rp

60,000

Rp

20,000 Rp

80,000

Rp

120,000 Rp

180,000

Rp

10,000

Rp

200,000

Rp

150,000 Rp

90,000

Rp

80,000

Rp

120,000 Rp

180,000

Rp

10,000

Rp

250,000 Rp

120,000

20,000 Rp

480,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

150,000 Rp

150,000

Rp

200,000

Rp

5,000 Rp

10,000

Rp

100,000 Rp

90,000

Rp

140,000

Rp

5,000 Rp

10,000

Rp

200,000 Rp

90,000

Rp

40,000 Rp

360,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

250,000 Rp

120,000

Rp

40,000 Rp

320,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

100,000 Rp

120,000

Rp

20,000 Rp

40,000

Rp

5,000 Rp

10,000

Rp

200,000

Rp

300,000 Rp

90,000

Rp

100,000 Rp

280,000

Rp

10,000

Rp

200,000

Rp

150,000 Rp

60,000

Rp

20,000

Rp

160,000

5,000 Rp

10,000

Rp

300,000 Rp

210,000

Rp

40,000

Rp

320,000

Rp

10,000

Rp

200,000

Rp

400,000 Rp

150,000

Rp

80,000

Rp

400,000

Rp

10,000

Rp

200,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp

60,000

Rp

Rp

120,000

Rp

Rp

135,000

135,000
Rp

Rp

90,000

Rp

100,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp

10,000
10,000

Tindakan Operasi Bedah
Sederhana

Kecil

Sedang

Rp

Rp

Besar

1,750,000

Rp

2,187,500

1,750,000

Khusus

Sederhana

Kecil

Sedang

Rp

Rp

Rp

Rp

Pemakaian
Oksigen

Anastesi

600,000

750,000

4,000,000

4,000,000

Besar

Rontgen

USG

EKG

Khusus

Rp

400,000

Rp

60,000

Rp

400,000

Rp

100,000

Rp

400,000

Rp

520,000

Rp

400,000

Rp

180,000

Rp

Rp

Rp

60,000

Rp

60,000

300,000
Rp

120,000

Rp 1,400,000

Rp

600,000

Rp 1,400,000
Rp

Rp

400,000

20,000

Rp 1,080,000

Pemeriksaan
Darah Untuk
Tranfusi dan
Kantong

260,000

Rp 1,300,000

Laboratorium

Rp

225,500

Rp

185,000

Rp

180,000

Rp

619,500

Rp

308,000

Rp

95,000

Rp

170,500

Rp

128,000

Rp

345,000

Rp

214,500

Rp

222,500

Rp

187,000

Rp

60,000

Rp

130,000

Rp

60,000

Rp

130,000

Rp

120,000

Rp

430,000

Rp

100,000

Rp

60,000

Rp

244,000

Rp

120,000

Rp

70,000

Rp

78,000

Rp

60,000

Rp

235,000

Rp

100,000

Rp

235,000

Rp

Rp

120,000

60,000

Rp

Rp

Rp

5,000,000

400,000

Rp

60,000

130,000
Rp

160,000

Rp

150,000

Rp

60,000

Rp

120,000

Rp

120,000

Rp

200,000

Rp

100,000

Rp 3,600,000

Rp

Rp

6,562,500

500,000

Rp

180,000

Rp

135,000

Rp

62,000

Rp

250,000

Rp

500,000

Rp

95,000

Rp

610,000

Rp

100,000

Rp

295,000

Rp

180,000

Rp

234,500

Rp

17,000

Rp

158,000

Rp

231,500

Rp

158,000

Rp

175,000

Rp

379,000

Rp

200,000

Rp

180,000

Rp

60,000

Rp 2,250,000

Rp

60,000

Rp

120,000

Rp

4,000,000

Rp 1,400,000

Rp

170,500

Rp

4,000,000

Rp 1,400,000

Rp

170,500

Rp

306,500

Rp

495,000

Rp

170,500

Rp

180,000

Rp

140,000

Rp

170,500

Rp

135,000

Rp

45,000

Rp

Rp

4,000,000

120,000

Rp

60,000

Rp 1,400,000
Rp
Rp

1,750,000

184,500

Rp 1,750,000

Rp 10,500,000

Rp

Rp

Rp

200,000

600,000

Rp

60,000

300,000

Rp

60,000

Rp

80,000

Rp

60,000

Rp

60,000

Rp

367,500

Rp

60,000

Rp

185,000

Rp

1,750,000

Rp

4,000,000

Rp 1,400,000

Rp

4,000,000

Rp 1,400,000

Rp

Rp

60,000

Rp

90,000

Rp

60,000

600,000

Rp

Rp

147,500

Rp

169,500

Rp

440,000

Rp

65,000

Rp

22,500

Rp

90,000

Rp

120,000

Rp

309,500

Rp

300,000

Rp

195,000

Rp

45,000

Rp

197,000

Rp

295,000

Rp

362,000

Rp

242,000

Rp

243,000

300,000

200,000

Rp

Rp

Rp

60,000

Rp

70,000

Rp

100,000

60,000

Rp

60,000

Rp

60,000

Rp

60,000

Rp

780,000

TOTAL KLAIM

3497500
15000
3512500

Obat, alat suntik,
alat infus dan
cairan infus
selama dirawat
dan atau operasi

Tindakan Medis

Lepas Infus

Rp

591,000

Rp

30,000

Rp

144,000

Rp

5,000

Rp

1,475,000

Rp

90,000

Rp

2,416,000

Rp

65,000

Rp

261,000

Rp

5,000

Rp

2,671,000

Rp

55,000

Rp

2,113,000

Rp

Rp

265,000

Rp

Injeksi IV

Injeksi IM

Pasang Infus

Rp

Rp

Rp

200,000

Rp

450,000

Rp

325,000

Rp

150,000

Rp

150,000

Rp

125,000

120,000

Rp

300,000

Rp

15,000

Rp

100,000

81,000

Rp

5,000

Rp

50,000

Rp

3,161,000

Rp

5,000

Rp

450,000

Rp

143,000

Rp

5,000

Rp

200,000

Rp

914,000

Rp

Rp

1,835,000

Rp

600,000

Rp

3,965,000

Rp

Rp

300,000

Rp

170,000

20,000

Rp

25,000

35,000

Rp

175,000

Rp

35,000

Rp

175,000

652,000

Rp

30,000

Rp

150,000

Rp

713,000

Rp

15,000

Rp

75,000

Rp

432,000

Rp

25,000

Rp

125,000

Rp

500,000

Rp

15,000

Rp

75,000

Rp

536,000

Rp

5,000

Rp

612,000

Rp

90,000

Rp

110,000

Rp

225,000

Rp

615,000

Rp

30,000

Rp

60,000

Rp

150,000

Rp

60,000

Observasi Igd

Pasang OGT

Pemberian
Transfusi
Darah

Nebulisasi

Nebulizer

Inkubator

Jahit luka

Angkat jahitan Rawat Luka OP Rehab Medik

150,000

30,000
Rp

Observasi

Rp

200,000

Rp

250,000
Rp

Rp

80,000

300,000

Rp

462,000

Rp

25,000

Rp

264,000

Rp

10,000

Rp

125,000

Rp

50,000

Rp

1,465,000

Rp

10,000

Rp

20,000

Rp

50,000

Rp

469,000

Rp

15,000

Rp

60,000

Rp

75,000

Rp

493,500

Rp

5,000

Rp

25,000

Rp

861,000

Rp

371,000

Rp

40,000

Rp

100,000

Rp

30,000

Rp

75,000

Rp

40,000

Rp

350,000

Rp

613,000

Rp

35,000

Rp

175,000

3,614,000

Rp

15,000

Rp

50,000

Rp

114,000

Rp

2,917,000

Rp

75,000

Rp

375,000

Rp

673,500

Rp

30,000

Rp

150,000

Rp

1,561,000

Rp

5,000

Rp

714,000

Rp

50,000

Rp

125,000

Rp

192,000

Rp

5,000

Rp

25,000

Rp

1,612,000

Rp

125,000

Rp

375,000

Rp

2,436,000

Rp

25,000

Rp

550,000

Rp

451,000

Rp

5,000

Rp

25,000

Rp

200,000

Rp

371,500

Rp

15,000

Rp

75,000

Rp

542,000

Rp

450,000

Rp

765,000

Rp

5,000

Rp

50,000

Rp

Rp

316,000

Rp

15,000

Rp

75,000

Rp

311,000

Rp

40,000

Rp

100,000

Rp

965,000

Rp

5,000

Rp

25,000

Rp

191,500

Rp

5,000

Rp

25,000

Rp

106,000

Rp

5,000

Rp

835,000

Rp

50,000

Rp

60,000

Rp

125,000

Rp

271,000

Rp

5,000

Rp

40,000

Rp

100,000

20,000

Rp

Rp

160,000

60,000

150,000
Rp

29,000

Rp

39,000

Rp 1,350,000

Rp

Rp

Rp

Rp

850,000

Rp

100,000

Rp

250,000

Rp

250,000

Rp

Rp

Rp

600,000

Rp

75,000

50,000

150,000

Rp

525,000

150,000

Rp

75,000

Rp

150,000

Rp

75,000

Rp

50,000

Rp

416,000

Rp

5,000

Rp

25,000

Rp

150,000

Rp

467,000

Rp

10,000

Rp

25,000

Rp

150,000

Rp

391,000

Rp

5,000

Rp

50,000

Rp

250,000

Rp

113,000

Rp

5,000

Rp

200,000

Rp

231,000

Rp

5,000

Rp

150,000

Rp

135,000

Rp

5,000

Rp

200,000

Rp

194,000

Rp

5,000

Rp

25,000

Rp

50,000

Rp

431,000

Rp

30,000

Rp

150,000

Rp

317,500

Rp

25,000

Rp

125,000

Rp

135,000

Rp

458,000

Rp

15,000

Rp

75,000

Rp

1,906,000

Rp

30,000

Rp

150,000

Rp

266,000 Rp

5,000

Rp

100,000

Rp

1,160,500 Rp

15,000

Rp

70,000 Rp

75,000 Rp

100,000

Rp

267,000 Rp

15,000

Rp

40,000 Rp

50,000

Rp

612,500

Rp

15,000

Rp

80,000

Rp

75,000

1,030,500 Rp

30,000

Rp

100,000 Rp

125,000

Rp

Rp
Rp

Rp

Rp

25,000

10,000

50,000

80,000

Rp

75,000

JUMLAH
Suction

Psikologi

Heacting

Konseling

Penyimpanan
Jenazah

Biaya
Pemeriksaan
poliklinik

Rp

300,000

TAGIHAN

UPF

Interna

Rp

5,451,500

Kes. Anak

Rp

1,179,000

Interna

Rp

5,685,000

Interna

Rp

6,901,000

Kes. Anak

Rp

1,121,000

Interna

Rp

10,863,000

Interna

Rp

5,506,000

Interna

Rp

1,080,000

Kes. Anak

Rp

916,000

Bedah

Rp

10,571,500

Kes. Anak

Rp

1,366,000

Interna

Rp

2,664,000

Bedah

Rp

12,134,500

Interna

Rp

7,157,500

Interna

Rp

2,074,000

Interna

Rp

2,538,000

Interna

Rp

1,811,000

Interna

Rp

1,305,000

Bedah

Rp

1,854,000

Interna

Rp

4,032,000

Interna

Rp

2,135,000

Interna

Rp

2,071,500

Interna

Rp

1,169,000

Interna

Rp

2,755,000

Interna

Rp

1,706,000

Bedah

Rp

8,638,500

Interna

Rp

2,910,000

Interna

Rp

3,236,000

Interna

Rp

2,383,000

Orthopedhi

Rp

21,218,500

Kesehatan Anak

Rp

1,011,000

Interna

Rp

7,005,000

Interna

Rp

2,120,000

Orthopedhi

Rp

11,576,500

Interna

Rp

2,224,000

Kesehatan Anak

Rp

1,527,000

Syaraf

Rp

5,630,000

Bedah

Rp

10,141,500

Bedah

Rp

6,646,500

Interna

Rp

1,893,000

Kes. Anak

Rp

3,442,000

Bedah

Rp

6,910,500

Interna

Rp

1,191,000

Interna

Rp

1,391,000

Bedah

Rp

4,135,500

Interna

Rp

891,500

Kes. Anak

Rp

911,000

Interna

Rp

2,942,500

Interna

Rp

1,236,000

Bedah

Rp

6,468,500

Bedah

Rp

6,606,500

Bedah

Rp

2,061,000

Kes. Anak

Rp

1,203,000

Bedah

Rp

3,223,500

Kes. Anak

Rp

1,170,000

Kes. Anak

Rp

994,000

Interna

Rp

2,125,500

Syaraf

Rp

1,527,500

Kes. Anak

Rp

645,000

Interna

Rp

1,650,000

Interna

Rp

3,901,000

Bedah

Rp

866,000

Interna

Rp

2,957,500

Interna

Rp

1,207,000

Interna

Rp

2,164,500

Interna

Rp

3,798,500

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Sepunggur ,

Rp
Rp

10,000
10,000

Rp

251,737,000

Januari 2014

Mengetahui
Direktur RSUD Tanah Bumbu

Bendahara Jamkesmas

dr.H.Daru Dewa, M.Kes
NIP.19680710 199803 1 011

M. Adhi Sulaiman, SKM
NIP.19840415 200908 1 001

DAFTAR KLAIM RAWAT INAP PASIEN KEBIDANAN JAMKESDA RSUD TANAH BUMBU
PROPINSI : KALIMANTAN SELATAN
KABUPATEN : TANAH BUMBU

BULAN : Desember
TAHUN : 2013

Umur (Thn)
NO

NAMA PASIEN

NO.REKOMENDASI
JAMKESDA

LOS

Alamat

6310095705690001

Ny. Eni puryanti

6310055602860001

Ny. Siti hajarani

6310095204790006

Ny. Isare

6310024104690004

Ny. Misnah

6310026504790007

Ny. Hamidah

6310044805860002

By. Ny. Hamidah

6310044805860002

Ny. Saenah

6310046707760003

Ny. Nasimas Shabah

6310096912830004

Ny. Ria suprihartini

6310076605730001

Ny. Helda Hariyani

6310026409940003

Ny. Megawati

6310044511790002

Ny. Tasmiati

6310045507840005

DIAGNOSA
Akomodasi

L
Ny. Rumiyati

TANGGAL

Gg. Amandit rt 001 ds. Barokah,
simpang empat
Ds. Ringkit rt 005, kuranji
Jl. Transmigrasi rt 010 Ds.
Barokah, simpang empat
Ds. Saring sungai bubu rt 005,
kusan hilir
Ds. Serdangan rt 001, kusan hilir
Jl. Raja wali rt 007 Ds. Sumber
makmur, satui
Jl. Raja wali rt 007 Ds. Sumber
makmur, satui
Jl. Propinsi rt 009 Ds. Sungai
Danau, satui
Jl. Veteran rt 007 Ds. Barokah,
simpang empat
Ds, manunggal dusun III rt 023,
karang bintang
Jl. Raya batulicin rt 001 Ds.
Sepunggur, Kusan hilir
Jl. Propinsi KM. 170 rt 007 Ds.
Satui barat, satui
Ds. Sumber arum rt 011, satui
Jl. Sentosa rt 001 Ds. Batuah,
kusan hilir
Jl. Hasta karya I rt 005 Ds.
Pagaruyung, kusan hilir

Jasa Medis
Spesialis

P

Masuk

Keluar

45

13 Nopember 2013

23 Nopember 2013

10 (Hari)

G4p3a0 dg mola idatidosa

Rp

500,000

Rp

420,000

27

17 Nopember 2013

18 Nopember 2013

1 (Hari)

Retensio placenta

Rp

50,000

Rp

90,000

34

08 Nopember 2013

09 Nopember 2013

1 (Hari)

G3p2a0 hamil 12 minggu dgn blighted ovum

Rp

50,000

Rp

60,000

45

08 Nopember 2013

13 Nopember 2013

5 (Hari)

Kista ovarium+mioma

Rp

250,000

Rp

210,000

34

19 Nopember 2013

30 Nopember 2013

11 (Hari)

Kista ovarium

Rp

550,000

Rp

450,000

27

11 Nopember 2013

15 Nopember 2013

4 (Hari)

G2p1a0 hamil aterm inpartu kala 1 fase laten

Rp

200,000

Rp

150,000

12 Nopember 2013

15 Nopember 2013

3 (Hari)

Bayi Baru Lahir

Rp

75,000

Rp

120,000

37

19 Nopember 2013

21 Nopember 2013

2 (Hari)

G3p2a0 H 11 Mg dg B.O

Rp

100,000

Rp

150,000

29

20 Nopember 2013

21 Nopember 2013

1 (Hari)

G2p1a0 hamil 12-13 minggu dengan abortus

Rp

50,000

Rp

90,000

40

19 Nopember 2013

21 Nopember 2013

2 (Hari)

Missed abortion

Rp

100,000 Rp

150,000

19

21 Nopember 2013

21 Nopember 2013

G1p0a0 abortus susp KET

Rp

50,000 Rp

60,000

34

21 Nopember 2013

23 Nopember 2013

2 (Hari)

G3p1a0 H. 14-15 minggu dg dead conseptus

Rp

100,000 Rp

120,000

29

21 Nopember 2013

23 Nopember 2013

2 (Hari)

g3p2a0 Uk 12 minggu dgn susp abortus incomplite

Rp

100,000 Rp

120,000

36

23 Nopember 2013

25 Nopember 2013

2 (Hari)

G3p1a0 H. 16 minggu dg missed abortion

Rp

100,000 Rp

150,000

30

24 Nopember 2013

28 Nopember 2013

4 (Hari)

P2A0 dg retensi urine

Rp

200,000 Rp

150,000

40

24 Nopember 2013

26 Nopember 2013

2 (Hari)

G4p2a1 H 11 minggu dg Ab. Incomplite

Rp

100,000 Rp

150,000

26

25 Nopember 2013

27 Nopember 2013

2 (Hari)

g2p1a0 dg ab. Incomplite

Rp

100,000 Rp

150,000

48

25 Nopember 2013

27 Nopember 2013

2 (Hari)

Tumor uterus

Rp

100,000 Rp

90,000

31

28 Nopember 2013

30 Nopember 2013

2 (Hari)

P3a0 post partum

Rp

100,000 Rp

90,000

35

28 Nopember 2013

29 Nopember 2013

1 (Hari)

G7p6a0 H. 16 minggu dg susp PID

Rp

50,000 Rp

90,000

0 (Hari)

Ny. Mala

6310024507770002

Ny. Syarifah Fatimah

6310025812850001

Ny. Ni Nyoman Wistri

6310034204730001

Ny. Miniarti

6310026605860002

Ny. Arbainah

6310085810650001

Ny. Siti Kholifah

6310084212820002

Ny. Hariani

6310024707780007

Ny. Hasidah

6310025206940004

Ds. Sepunggur rt 002, kusan hilir

19

28 Nopember 2013

30 Nopember 2013

2 (Hari)

g1p0a0 dg susp abortus incomplite

Rp

100,000 Rp

90,000

Ny. Eliyani

6310047112940007

Jl. Angkasa rt 002 Ds. Sungai
danau, satui

19

19 Nopember 2013

02 Desember 2013

3 (Hari)

G2p0a1, hamil 9 minggu dgn Ab. Inkomplit

Rp

150,000 Rp

90,000

Sebamaban 1 blok G rt 014/003
Ds. Sari utama, sungai loban
Jl. Raya batulicin rt 001 Ds.
Sepunggur, Kusan hilir
Ds. Karang bintang rt 004/002
Ds. Manunggal dusun I Rt 003,
karang bintang
Jl. Cempaka rt 005 Ds. Batuah,
kusan hilir

T O T A L

Jasa Medis
Umum

Rp

Rp

Jasa Keperawatan
Tindakan Kecil

Tindakan
sedang

60,000

20,000

Rp

160,000

Rp

Jasa keperawatan Nifas
Tindakan
intensif

Tindakan Kecil

Tindakan
sedang

Rp

700,000

Rp

90,000

Rp

80,000

Rp

20,000

Rp

280,000

Rp

180,000

Rp

20,000

Rp

30,000

Rp

80,000

Rp

90,000

Jasa Keperawatan VK
Tindakan
intensif

Rp

180,000

Rp

45,000

Tindakan kecil

Rp

Rp

Rp

20,000

Tindakan
sedang

Tindakan
Intensif

Berkas RM
Apoteker

100,000

Rp

40,000

Rp

80,000

Rp

Rp

45,000

Rp

5,000

Rp

10,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

10,000

Rp

125,000

Rp

10,000

Rp

125,000

Rp

10,000

20,000
Rp

30,000

Rp

45,000

Rp

5,000

Rp

30,000
Rp

20,000

Rp

Sedang

30,000

20,000

30,000

Kecil

Sederhana

Rp

120,000
Rp

Tindakan di UGD

Jasa

100,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

30,000

Rp

45,000 Rp

5,000

Rp

10,000

Rp

125,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

60,000

Rp

30,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

60,000

Rp

30,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

60,000

Rp

30,000

Rp

45,000

Rp

5,000

Rp

10,000

Rp

125,000

Rp

260,000

Rp

5,000

Rp

10,000

Rp

60,000

Rp

10,000

Rp

125,000

Rp

60,000

Rp

10,000

Rp

125,000

Rp

20,000

Rp

10,000

Rp

80,000

Rp

10,000

Rp

125,000

Rp

60,000

Rp

10,000

Rp

125,000

Rp

20,000

Rp

10,000

Rp

125,000

Rp

120,000

Rp

10,000

Rp

125,000

Rp

10,000

Rp

Rp

30,000

20,000

Rp

40,000

Rp

90,000

Rp

40,000

Rp

90,000
Rp

Rp
Rp

45,000

Rp

40,000

Rp

60,000

Rp

45,000

30,000

Rp
Rp

40,000

Rp

60,000

Rp

5,000

45,000

5,000

Rp

100,000

Besar

Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp
Rp

10,000
10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000

Pelayanan Kesehatan Dan Besaran Tarif sesuai PERDA (Rp)

GD

Tindakan di VK
Tindakan
Penyakit Dalam

Sederhana

Kecil

Sedang

Tindakan Persalinan & Kebidanan
Besar Laminarta

Persalinan
Normal

Persalinan Sulit

Persalinan Sulit
VK

Persalinan Sulit
VK Bersalin

Persalinan Sulit
VK III

Resusitasi Bayi
Baru Lahir

RJPO

Rp

Kuretasi +
Anastesi

Kuretasi +
Anastesi VK

Kuretasi Sulit +
Anastesi

200,000
Rp

1,750,000

Rp

1,750,000

Rp

1,750,000

Rp

1,750,000

Rp

1,750,000

Rp

2,050,000

Rp

2,050,000

Rp

2,050,000

Rp

2,050,000

Rp

2,050,000

Rp

2,050,000

Rp

2,050,000

Tindakan Operasi Bedah
Kuretasi sulit +
Anastesi VK

Manual Plasenta Manual Plasenta
+ Anastesi VK
+ Anastesi

Sederhana

Kecil

Sedang

Anastesi

Besar

Khusus

Sederhana

Kecil

Sedang

Rp 4,000,000
Rp

Pemakaian
Oksigen
Besar
Rp

Rontgen

USG

Khusus

1,400,000

Rp

600,000

Rp

60,000

Rp

100,000

1,625,000
Rp 2,187,500

Rp

Rp 5,000,000

750,000

Rp

10,500,000

Rp

3,600,000

Rp

100,000

Rp

5,250,000

Rp

1,800,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

100,000

Rp

1,750,000

Rp

100,000

EKG

Rp 60,000

Rp 60,000

Pemeriksaan
Darah Untuk
Tranfusi dan
Kantong

Laboratorium

Obat, alat suntik,
alat infus dan
cairan infus
selama dirawat
dan atau operasi

Lepas Infus

Lepas Infus
Nifas

Lepas Infus VK

Injeksi IV

Injeksi IV Nifas Injeksi IV (VK)

Injeksi IV VK III

Injeksi IM

Injeksi IM (VK)

Rp

520,000

Rp

410,000

Rp

641,000

Rp

20,000

Rp

260,000

Rp

178,000

Rp

153,000

Rp

5,000

Rp

30,000

Rp

5,000

Rp

168,000

Rp

128,500

Rp

5,000

Rp

20,000

Rp

5,000

Rp

185,000

Rp

561,000

Rp

5,000

Rp

100,000

Rp

425,000

Rp

1,613,000

Rp

10,000

Rp

280,000

Rp

185,000

Rp

191,000

Rp

5,000

Rp

140,000

Rp

1,300,000

Rp

Injeksi IV VK
Bersalin

200,000

Rp

Rp

260,000

Rp

198,000

Rp

211,000

Rp

5,000

Rp

30,000

Rp

192,500

Rp

166,000

Rp

5,000

Rp

30,000

Rp

215,000

Rp

178,500

Rp

5,000

Rp

30,000

Rp

175,500 Rp

151,500

Rp

20,000

Rp

175,000 Rp

143,000

Rp

5,000

Rp

30,000

Rp

210,000 Rp

157,000

Rp

5,000

Rp

30,000

Rp

143,000 Rp

237,000

Rp

5,000 Rp

Rp

40,000

Rp

158,000 Rp

243,000

Rp

5,000

Rp

158,000 Rp

173,500

Rp

5,000

Rp

30,000

Rp

183,000 Rp

Rp

30,000

Rp

40,000

Rp

20,000

Rp

30,000

193,000

Rp

5,000

Rp

30,000

Rp

194,000

Rp

5,000

Rp

230,500

Rp

196,000

Rp

5,000

Rp

193,000

Rp

136,000

Rp

5,000

Rp

175,500

Rp

184,000

Rp

5,000

Rp

175,500

Rp

318,000

Rp

5,000

10,000

Rp

30,000

10,000

Injeksi IM VK
III

Injeksi IM VK
Bersalin

Injeksi IM
Nifas

Tindakan Medis

Pasang Infus

Pasang Infus
Nifas

Rp

Rp

Rp

Pasang Infus
VK

Observasi

75,000

25,000

50,000

Rp

Rp

50,000

Observasi Nifas

Observasi VK

Rp

500,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

100,000

Rp

150,000

Rp

50,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

100,000

Rp

50,000 Rp

100,000

Rp

50,000 Rp

100,000

Rp

50,000 Rp

200,000

Rp

50,000 Rp

50,000

Rp

200,000 Rp

200,000

Rp

200,000

Rp

50,000

Rp

50,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

50,000

Rp

100,000

Rp

50,000

50,000

Observasi VK III

Observasi VK
Bersalin

Observasi IGD

Pasang OGT

Nebulizer

Inkubator

Jahit luka

Jahit Luka VK

Rp

100,000

Jahit Luka VK
Bersalin

Angkat
jahitan

JUMLAH

Rawat Luka OP

Rawat Luka OP
Nifas

Rawat Luka OP
Ruang Bedah

Suction

CPAP

Heacting

Perawatan
Jenazah

Perawatan
Jenazah
Perinatalogi

TAGIHAN
Konseling

Poli

UPF

Obstetri

Rp

10,846,000

Ginekologi

Rp

2,986,000

Ginekologi

Rp

3,749,000

Rp

75,000

Ginekologi

Rp

16,336,000

Rp

75,000

Ginekologi

Rp

12,243,000

Rp

75,000

Obstetri

Rp

8,431,000

Perinatalogi

Rp

825,000

Ginekologi

Rp

2,939,000

Ginekologi

Rp

2,688,500

Ginekologi

Rp

2,903,500

Ginekologi

Rp

2,942,000

Ginekologi

Rp

3,178,000

Ginekologi

Rp

3,227,000

Ginekologi

Rp

3,130,000

Ginekologi

Rp

1,231,000

Ginekologi

Rp

3,191,500

Ginekologi

Rp

3,366,000

Ginekologi

Rp

604,000

Ginekologi

Rp

3,526,500

Ginekologi

Rp

1,004,000

Ginekologi

Rp

3,084,500

Ginekologi

Rp

3,093,500

Ginekologi

Rp

10,000

Rp 10,000

Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp
Rp

10,000
10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp

10,000

Rp

10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000
10,000

Rp
Rp
Rp
Rp
Rp

Mengetahui
Direktur RSUD Tanah Bumbu

Sepunggur,

Januari 2014

Bendahara Jamkesmas

dr.H.Daru Dewa, M.Kes
NIP.19680710 199803 1 011

M.Adhi Sulaiman
NIP.19840415 200908 1 001

10,000
10,000
10,000
10,000
97,595,000