Rumah Sakit Siaga Ramania

Samarinda RINCIAN BIAYA OPERASI

No.Registrasi/ID :………………………………………………………….. Jenis kelami : Laki- laki / Perempuan
Nama Pasien :………………………………………………………….. Jenis Operasi : Kecil, Sedang, Besar, Khusus
Alamat :………………………………………………………….. Tanggal Operasi :…………………………………………………………
Umur :………………………………………………………….. Jam :…………………………………………………………
Ruang / Kelas :………………………………………………………….. Jenis Anestesia :…………………………………………………………
Tindakan Operasi :……………………………………………………
I. OBAT-OBATAN RESEP DOKTER
Keterangan Satuan Jumlah No. Keterangan Satuan Jumlah
1 Rp. 16 Rp.
2 Rp. 17 Rp.
3 Rp. 18 Rp.
4 Rp. 19 Rp.
5 Rp. 20 Rp.
6 Rp. 21 Rp.
7 Rp. 22 Rp.
8 Rp. 23 Rp.
9 Rp. 24 Rp.
10 Rp. 25 Rp.
11 Rp. 26 Rp.
12 Rp. 27 Rp.
13 Rp. 28 Rp.
14 Rp. 29 Rp.
15 Rp. 30 Rp.

Subtotal Rp.
…………………………………………………………………………………..
II. OBAT-OBATAN NON RESEP
Keterangan Satuan Jumlah No. Keterangan Satuan Jumlah
1 Rp. 6 Rp.
2 Rp. 7 Rp.
3 Rp. 8 Rp.

Grand Total Rp. …………………………………………………………………………………..

III. Honor Operator : dr. …………………………………………………………… Rp.

:………………………………………………………………………….
Honor Anestator : dr. …………………………………………………………… Rp.
:………………………………………………………………………….
IV. Kamar Operasi : ………………………………………………………………… Rp.
:………………………………………………………………………….
Narcose : ………………………………………………………………… Rp.
:………………………………………………………………………….
Assistensi : ………………………………………………………………… Rp.
:………………………………………………………………………….

1 Assisten I : ………………………………………………………………… 5 Onlope …

I ………………………………………………………
2 Assisten II : ………………………………………………………………… 6 Onlope …………………………………………………………
II
3 Assisten III : ………………………………………………………………… 7 C.S I …………………………………………………………
4 Instrument : ………………………………………………………………… 8 C.S II …………………………………………………………

V. Service : ……………………………………………………………….. Rp.

:………………………………………………………………………….
VI. lain-lain : ………………………………………………………………..
1…………………………………………………………………………… Rp. :…………………………………………
2…………………………………………………………………………… Rp. :…………………………………………
3…………………………………………………………………………… Rp. :…………………………………………
Rp.
:………………………………………………………………………….
Grand Total I + II + III + IV + V + VI ………………………………….. Rp.
:………………………………………………………………………….
Terbilang : (……………..……………………………………………………………………………………………………………………………………….)

Samarinda, ………………………………………
Kepala Kamar Operasi

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