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    ROBIYATUL ADAWIYAH
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    This document appears to be a laboratory test form from a public health center in Baru Ulu, Balikpapan. It includes sections to record a patient's personal information and the results of hematology, clinical chemistry, serology/immunology, urinalysis, and parasitology tests. Normal reference ranges are provided for each test parameter. The form is signed by the responsible doctor and testing staff.

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    FORM PX LAB

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    This document appears to be a laboratory test form from a public health center in Baru Ulu, Balikpapan. It includes sections to record a patient's personal information and the results of hematology, clinical chemistry, serology/immunology, urinalysis, and parasitology tests. Normal reference ranges are provided for each test parameter. The form is signed by the responsible doctor and testing staff.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    5 views2 pages

    Form PX Lab

    Uploaded by

    ROBIYATUL ADAWIYAH
    This document appears to be a laboratory test form from a public health center in Baru Ulu, Balikpapan. It includes sections to record a patient's personal information and the results of hematology, clinical chemistry, serology/immunology, urinalysis, and parasitology tests. Normal reference ranges are provided for each test parameter. The form is signed by the responsible doctor and testing staff.

    Copyright:

    © All Rights Reserved
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    of 2

    PUSAT KESEHATAN MASYARAKAT BARU ULU WAKTU PUSAT KESEHATAN MASYARAKAT BARU ULU WAKTU

    Jl. Wolter Monginsidi RT.047 No. 85 Kelurahan Baru Ulu Datang : Jl. Wolter Monginsidi RT.047 No. 85 Kelurahan Baru Ulu Datang :
    Telp. (0542)-740021 Balikpapan Barat 76133 Selesai: Telp. (0542)-740021 Balikpapan Barat 76133 Selesai:

    FORMULIR PEMERIKSAAN LABORATORIUM FORMULIR PEMERIKSAAN LABORATORIUM


    Nama : No Kartu Nama : No Kartu
    Umur : (BPJS/KIS/Jamkesmas) : Umur : (BPJS/KIS/Jamkesmas) :
    Jenis Kelamin : Tanggal : Jenis Kelamin : Tanggal :
    Alamat : Dokter/Poli : Alamat : Dokter/Poli :
    JENIS PEMERIKSAAN HASIL SATUAN NILAI NORMAL JENIS PEMERIKSAAN HASIL SATUAN NILAI NORMAL
    HEMATOLOGI HEMATOLOGI
    -Hemoglobine : gr% L: 14-18 P:12-14 -Hemoglobine : gr% L: 14-18 P:12-14
    -Hematokrit : Vol% L: 40-54 P: 38-48 -Hematokrit : Vol% L: 40-54 P: 38-48
    -Eritrosit : juta/mmk L: 4-7 P: 4-5 -Eritrosit : juta/mmk L: 4-7 P: 4-5
    -Leokosit : /mmk 5000-10.000 -Leokosit : /mmk 5000-10.000
    -Trombosit : /mmk 150.000-400.000 -Trombosit : /mmk 150.000-400.000
    -LED : mm/jam L: 0-10 P: 0-20 -LED : mm/jam L: 0-10 P: 0-20
    KIMIA KLINIK KIMIA KLINIK
    -Glukosa Darah Puasa : mg/dl 70-110 -Glukosa Darah Puasa : mg/dl 70-110
    -Glukosa Darah Sewaktu : mg/dl <180 -Glukosa Darah Sewaktu : mg/dl <180
    -Asam Urat : mg/dl L<7 P<6 -Asam Urat : mg/dl L<7 P<6
    -Cholesterol : mg/dl <200 -Cholesterol : mg/dl <200
    -Trigliseride : mg/dl <150 -Trigliseride : mg/dl <150
    SEROLOGI / IMUNOLOGI SEROLOGI / IMUNOLOGI
    A.Golongan Darah : - - A.Golongan Darah : - -
    B.Tes Kehamilan : - - B.Tes Kehamilan : - -
    C.Widal C.Widal
    *Typi O : - Negatif *Typi O : - Negatif
    *Typi H : - Negatif *Typi H : - Negatif
    *Para Typi AO : - Negatif *Para Typi AO : - Negatif
    *Para Typi BO : - Negatif *Para Typi BO : - Negatif
    D.Test Dengue Ag D.Test Dengue Ag
    *NS 1.Ag : - Negatif *NS 1.Ag : - Negatif
    E. Hepatitis E. Hepatitis
    *Hbs Ag Rapid Test : - Non Reaktif *Hbs Ag Rapid Test : - Non Reaktif
    F.HIV test F.HIV test
    *HIV Rapid Test : - Non Reaktif *HIV Rapid Test : - Non Reaktif
    G.Syphilis test G.Syphilis test
    *Syphilis Rapid Test : - Non Reaktif *Syphilis Rapid Test : - Non Reaktif
    URINALISA URINALISA
    A.Urine Rutin/Lengkap A.Urine Rutin/Lengkap
    *PH : *Sedimen Urine *PH : *Sedimen Urine
    *Albumin : -Leokosit :………………./LPB *Albumin : -Leokosit :………………./LPB
    *Reduksi : -Eritrosit :………………./LPB *Reduksi : -Eritrosit :………………./LPB
    *Warna : -Kristal :……………….. *Warna : -Kristal :………………..
    *Kekeruhan : -Bakteri :……………….. *Kekeruhan : -Bakteri :………………..
    *Bau : -Silinder :………………./LPK *Bau : -Silinder :………………./LPK
    *Leokosit : -Epitel :………………./LPK *Leokosit : -Epitel :………………./LPK
    *Nitrit : *Nitrit :
    *Urobilinogen : *Urobilinogen :
    *Blood : *Blood :
    *BJ : *BJ :
    *Keton : *Keton :
    *Bilirubin : *Bilirubin :
    PARASITOLOGI PARASITOLOGI
    -Malaria : - Negatif -Malaria : - Negatif
    Penanggung Jawab Pemeriksa Penanggung Jawab Pemeriksa
    (dr. Ummi Sartika) (Robiyatul Adawiyah) (dr. Ummi Sartika) (Robiyatul Adawiyah)
    NIP.19780120 200604 2 017 NIP.19760525 200112 2 005 NIP.19780120 200604 2 017 NIP.19760525 200112 2 005

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