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  • Formulir Ina-Cbgs Rawat Jalan

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    Adhitya Kurniawan Putra
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    This document is a form for inpatient claims at the Sangkulirang Public Hospital in Kutai Timur Regency. It includes fields to provide information such as the patient's name, date of birth, diagnosis codes, medical procedures performed, and the INA-CBGs tariff for the treatment. The form is to be filled out and signed by both the patient or family member and the head of the outpatient clinic.

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    Formulir Ina-cbgs Rawat Jalan

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    This document is a form for inpatient claims at the Sangkulirang Public Hospital in Kutai Timur Regency. It includes fields to provide information such as the patient's name, date of birth, diagnosis codes, medical procedures performed, and the INA-CBGs tariff for the treatment. The form is to be filled out and signed by both the patient or family member and the head of the outpatient clinic.

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    8 views1 page

    Formulir Ina-Cbgs Rawat Jalan

    Uploaded by

    Adhitya Kurniawan Putra
    This document is a form for inpatient claims at the Sangkulirang Public Hospital in Kutai Timur Regency. It includes fields to provide information such as the patient's name, date of birth, diagnosis codes, medical procedures performed, and the INA-CBGs tariff for the treatment. The form is to be filled out and signed by both the patient or family member and the head of the outpatient clinic.

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    © All Rights Reserved
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    of 1

    PEMERINTAH KABUPATEN KUTAI TIMUR

    RUMAH SAKIT UMUM DAERAH SANGKULIRANG


    Jalan Wana Bhakti Desa Benua Baru Ulu Kec. Sangkulirang 75384
    Telpon: 0852-4828-4818 Email : rsu.sangkulirang@gmail.com

    FORMULIR INA-CBGs RAWAT JALAN


    KHUSUS BPJS
    POLIKLINIK/ IGD : …………………………………….

    1. Nama RS : RSUD SANGKULIRANG


    2. Nomor Kode RS : 6404051
    3. Kelas RS : Tipe D
    4. Nomor SEP : ……………………………………..
    5. Nomor Rekam Medis : ……………………………………..
    6. Nama Pasien : …………………………………………………………………….............
    7. Jenis Perawatan : Rawat Jalan
    8. Tanggal Lahir : ……………………………………………………………………..………
    9. Usia dalam tahun : …………………………………………………………………………..…
    10. Usia dalam hari : ………………………………………………………………………..……
    11. Jenis Kelamin : ……………………………………………………………………….…....
    12. Berat Lahir (gram) : …………………………………………………………………………..…
    13. Diagnosis Utama : …………………………………………………………………………..…
    ………………………………………………… Kode : ……………….
    14. Diagnosis Sekunder : ………………………………………………… Kode : ……………….
    ………………………………………………... Kode : ……………….
    ………………………………………………... Kode : ……………….
    ………………………………………………... Kode : ……………….
    15. Tindakan/ Prosedur : ………………………………………………... Kode : ……………….
    ………………………………………………... Kode : ……………….
    …………………………………………….….. Kode : ……………….
    ………………………………………………... Kode : ……………….
    16. Alat bantu kesehatan
    Yang diberikan : …………………………………………………………………………..…
    17. Tarif INA-CBGs : ………………………………………………………………………..……

    Sangkulirang, ………………….20........
    Pasien/ Keluarga, Kepala/ Penanggung Jawab Poliklinik,

    (…………………………………..) (………………...……………………..…)
    NPK:

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