« (aps Kesehatan | SURAT ELEGIBILITAS PESERTA eusaeniegua irae’ RUMAH SAKIT MATA UNDAAN. No.SEP o217Roze0220V003383, ToL.SEP 2020-02-18 No.kariy (0002241366175 ( MR. 079029 ) Nama Peserta SUTIN Tal.Lahir 1963-06-02 Kelamin :Perempuan No.Telepon 082331733687 Sub/Spesiais * PASIEN OPERASI KATARAK Peseta: Pl (APBD) cos : Jns.Rawat ; Rlnap Kis.Rawat :Kolas 3 Penjamin Faskes Perujuk = RUMAH SAKIT MATA UNDAAN, H40.9- Glaucoma, unspecified OD PE ECCE 10 aaa EAN Serer tte tetera tern |_Mstraaare | See See PasiovKelyarga Pasion TeustiganRUMAH SAKIT MATA UNDAAN D4. undoan kulon 19 Surabaya 60274 FORMULIR CASE MIX Telp 5343806, 5319619, Fax 5317503 No RM ama Pasien SUT NY canon Wee DgN BROMBONG RF 03 RW, TULUNGAGUNG No Kartu BAS ‘Aamat No kM / SEP” Tel Masuk TehKeluae ‘OPemerianan dan i Darust Mata ‘Oemeriinan dn i Speak =a ‘RROSERUN PINCHES ea PAMERNSAAN DIAGNOSTIC Pemerasan Rela (Toner eos (OTonomet Alone (Toomer Nan contact ‘ophtaimocopyOrect ‘ophinimaceyndrect, Foto ands ova Pen. 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Kwitanei 47190200201000005 DETAIL BIAYA RAWATINAP No, Medical Revor!: 0779029 Tanggal Masuk =18-02-2020 0840 Name Pasien — :SUTINI, NY Tanggal Kelvar 19-02-2000 08:23 Feraruan Kelomaok Pasien: BPS KESEHATAN ris P Kelas / Ruang Dokter Operator :Sohata PHN, Spi Dokter Penghim :Sahata PHN, SpM TANGGAL, DRAIN, [ary Tarr [—Torac_] Fael__Tae, oo] __ 2505089 SUBTOTAL! 250.0 INDAKAN RAWATINAP i 000-010 or [ix] sano) —co.c00 2000-02-18 § Cae Text —ton.o00 { 2020021 [eiomeui TX] 720,004 SUB TOTAL! 270,005) RRO : | i 2000-02-18 [aya Operas Praca el TR { [SAYA ADMINISTRAST x [aa of a0) i 2: PAKET OPERAS | is40 900] 5540.00 3. JASA NEOIS OPERAST 1.400.900] 10.00 [= Sahata PHN, ST 7 { (cate 5 ES EST) t SUBTOTAL! —6110,000 RESEPOBAT i { DIETS Baie Reses Oo | i ai if ETHYL PREDHSOTOREPHGERIS [5 | aaol a ROSON MO OPIS {ax Taal 3,004 200 117,000) SUBTOTAL! 158,000! t t i FS GIFLOX MD BPS {(BIAVA OBAT & ALKES RAWATINAP — f IsPUiT 306 GNEMED Tsk se] a0 i [DEXAMETHASONE 5 GL [3x 2.687] _€.009) 2020-02518 JOEFTAZIOINE 1 GRAM Tax} too.sa7}so2.000) Spa0-02-18 “ID BAND PIN DEWASA OM Tix [IO BAND YELLOW ( FALL RISK) x | ‘ { { 2020-00-16 i Bc 220.0318 {sPurr 10co ONEMED Text 20-02-16 [ALCOROL SWABBD 5x BORE. FNS 700M [osx aoe INENFLON 22 5D PRO SAFETY [x 2000-0218 [TEGADERM TH 162307 [ix 2020:02-48 HANSAPLAST PLESTER. 2x 2020-02-78 {SPUN 70S ONEMED, ix BODES “ET SENST GLOVES NONSTERES Tox Tea SUS TOTAL| 47.006) JUNTA | €,904,000} Sisa yang harus dibayar : Rp. 6,904,000 Terbilang : enam juta sembilan raius empai ribu rupi ‘Surabaya, 19-02-2020 08:23 (SUTIN, NY)KEMENTERIAN KESEHATAN REPUBLIK INDONESIA, Berkas Kiaim Individual Pasien 18/02/2020 Kode Rumah Sakt —: 3578202 Kelas Rumah salet 8 Noma Rs RS MATA UNOAAN denis Tat TARIF RS KELAS & SWASTA NomrPeserta 0002241366175 Nomar SEP (021720260220V009383, NomerRekam Mesks : 0779029 Tanggal Masuk 19/02/2020, UUmur Tohun 56 “Tanggal Ketuar 19/02/2020, mor Har 20715 denis Perawatan = Rawat Inap Tanggal hie 02/06/1963 Care Puieng 11 Alas Persotujuan Dokter Jens Kelamin 2 Pererpuan Los hari Kelas Perawatan 3 Kalas 3 erat Lahir Diagnose Utama 126.2 Complicated cataract Diagnose Sekunder HS4.4 Blindness, one eve 40.5 Glaucoma sacondary to ether eye digorders 59.9 Postprocedural disorder af eve and adnexa, unspecnied Prosedur 13.41 Phacoemulsifcation and aspiration of cataract 13.71 Insertion of intraceuar lens prosthesis atte of eatarect extract ‘ADL Sub Acute ADL Chronic : INA-cag PROSEDUR LENSA DAN INTRA OKULER (RINGAN) Rp 7,454,300.00 Subaate 2 = Ro 0.00 hone : : o 0.00 Special CHG : fp 0.00 “otal Tant Re 7.454,300.00, coraed Tin Sa RISOADOOTRE B ROROGE RE ORE Tear