PEMERINTAH KABUPATEN KUTAI TIMUR

DINAS KESEHATAN
UPT
PUSKESMAS SANGATTA UTARA
Jalan Cut Nyak Dien No. 01 Sangatta, Telp.0549-2029778, email:
pkmsangattautara@gmail.com

FORMULIR HASIL PEMERIKSAAN LABORATORIUM PUSKESMAS

Dokter pengirim .....................
Nama Pasien :..............................
Umur :...........................................
Jenis Kelamin :.............................
Alamat :........................................
Jenis Pemeriksaan Hasil Nilai Normal (satuan)
HEMATOLOGI
Hemoglobin P (14-18), W (12-14) gr%
Leukosit 5.000 – 10.000 /mm³
Trombosit 150.000 – 450.000 /mm³
IMUNOLOGI
 Tes kehamilan
 Golongan Darah
 Widal O (negatif)
AO (negatif)
BO (negatif)
H (negatif)
 HbsAg Non Reaktif
 Anti HIV Non Reaktif
URINALISA
MAKROSKOPIK
 Warna .......................................
 Kejernihan .......................................
 Berat jenis .......................................
 Ph ......................................
 Protein .......................................
 Glukosa ......................................
 Billirubin ......................................
 Urobilinogen ......................................
 Keton .....................................
 Nitrit ......................................
 Lekosit .....................................
 Eritrosit .....................................
 Sedimen :
- lekosit .....................................
- eritrosit .....................................
- epitel .....................................
- bakteri .....................................
- kristal .....................................
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Dokter/Penanggung Jawab Tgl...................

pemeriksa

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