FORMULIR RESEP PAKET BEDAH

RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET SC DOKTER YOHANES

PAKET SC PAKET PRO SC IBU + BAYI
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No.7 2     1 Aquadest 25 mL 1
2 Handscoon No. 7,5 1     2 Spuit 1 cc 1
3 PGA 1 (Tapper) 1     3 Spuit 10 cc 1
4 PGA 3/0 (Cutting) 1     4 Urine bag 1
5 Chromic 1 (Tapper) 1     5 Catheter No. 16 1
6 Lommatule 1     6 Neo-K inj/phytomenadion 1
7 Pencil Couter 1     7 Penjepit tali pusar 1
8 Apron 3     8 Bisturi No. 10 / 20 1
9 Bisturi no 20 1     9 Suction No.8 1
10 10 Handscoon No. 7 1
PAKET ANESTESI PAKET OBAT PULANG SC
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Spinocain 26 1 1 Cefadroxil (2x1) 10
2 Spinocain 25 1 2 As. Mefenamat (3x1) 15
3 Handscoon No.6,5 1 3 Hufabion (1x1) 5
4 Handscoon No.7 1 4 Metronidazol (3X1) 15
5 Handscoon No. 7,5 1 5
6 Spuit 3 cc 2 6
7 Spuit 10 cc 1 TAMBAHAN DAN LAIN LAIN
8 RL 3     NO NAMA BARANG JML CEK 1 CEK 2
9 Bupivacaine inj 1     1 Tramadol inj 1  
10 Santocyn (Umum) 2     2 NaCL 500 mL 1  
11 Oxytocin (BPJS) 2     3 Aquadest 25 mL 1  
12 Bledstop inj 1     4 Midazolam 1  
13 AsamTranexamat inj 2     5 Propofol 1  
14 Fentanyl inj 1     6 Underpad 2  
15 Ketorolac inj 1     7 Spuit 3 cc 2  
16 Ondansetron inj 1     8 Spuit 5 cc 2  
17 Ephedrin inj 2 9 Spuit 10 cc 2
18 Masker earloop 8 10 Atropin Sulfat inj 2
19 Nasal Canul dewasa 1 11 Metoclopramide inj 1
 FORMULIR RESEP PAKET BEDAH
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET SC DOKTER HERMAN

PAKET SC PAKET PRO SC IBU + BAYI
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No.7 2     1 Aquadest 25 mL 1
2 Handscoon No. 7,5 1     2 Spuit 1 cc 1
3 PGA 1 (Tapper) 1     3 Spuit 10 cc 1
4 PGA 3/0 (Cutting) 1     4 Urine bag 1
5 Chromic 2/0 (Tapper) 1     5 Catheter No. 16 1
6 Lommatule 1     6 Neo-K inj/phytomenadion 1
7 Pencil Couter 1     7 Penjepit tali pusar 1
8 Apron 3     8 Bisturi No. 10 / 20 1
9 Bisturi no 20 1     9 Suction No.8 1
10 10
PAKET ANESTESI PAKET OBAT PULANG SC
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Spinocain 26 1 1 Cefadroxil (2x1) 10
2 Spinocain 25 1 2 As. Mefenamat (3x1) 15
3 Handscoon No.6,5 1 3 Hufabion (1x1) 5
4 Handscoon No.7 1 4
5 Handscoon No. 7,5 1 5
6 Spuit 3 cc 2 6
7 Spuit 10 cc 1 TAMBAHAN DAN LAIN LAIN
8 RL 3     NO NAMA BARANG JML CEK 1 CEK 2
9 Bupivacaine inj 1     1 Tramadol inj 1  
10 Santocyn (Umum) 2     2 NaCL 500 mL 1  
11 Oxytocin (BPJS) 2     3 Aquadest 25 mL 1  
12 Bledstopinj 1     4 Midazolam 1  
13 AsamTranexamat inj 1     5 Propofol 1  
14 Fentanyl inj 1     6 Underpad 2  
15 Ketorolac inj 1     7 Spuit 3 cc 2  
16 Ondansetron inj 1     8 Spuit 5 cc 2  
17 Ephedrin inj 2 9 Spuit 10 cc 2
18 10 Atropin Sulfat inj 2
19 11 Metoclopramide inj 1

FORMULIR RESEP PAKET BEDAH

RSIA BUNDA SEJATI
NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET SC DOKTER SAIFUL

PAKET SC PAKET PRO SC IBU + BAYI
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No.7 2     1 Aquadest 25 mL 1
2 Handscoon No. 7,5 1     2 Spuit 1 cc 1
3 PGA 1 (Tapper) 2     3 Spuit 10 cc 1
4 PGA 2/0 (Tapper) 1     4 Urine bag 1
5 Lommatule 1     5 Catheter No. 16 1
6 Pencil Couter 1     6 Neo-K inj/phytomenadion 1
7 Apron 3     7 Penjepit tali pusar 1
8 Bisturi no 20 1     8 Bisturi No. 10 / 20 1
9     9 Suction No.8 1
10 10 Handscoon no.7 1
PAKET ANESTESI PAKET OBAT PULANG SC
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Spinocain 26 1 1 Cefadroxil (2x1) 10
2 Spinocain 25 1 2 As. Mefenamat (3x1) 15
3 Handscoon No.6,5 1 3 Hufabion (1x1) 5
4 Handscoon No.7 1 4
5 Handscoon No. 7,5 1 5
6 Spuit 3 cc 2 6
7 Spuit 10 cc 1 TAMBAHAN DAN LAIN LAIN
8 RL 3     NO NAMA BARANG JML CEK 1 CEK 2
9 Bupivacaine inj 1     1 Tramadol inj 1  
10 Santocyn (Umum) 2     2 NaCL 500 mL 1  
11 Oxytocin (BPJS) 2     3 Aquadest 25 mL 1  
12 Bledstopinj 1     4 Midazolam 1  
13 AsamTranexamat inj 2     5 Propofol 1  
14 Fentanyl inj 1     6 Underpad 2  
15 Ketorolac inj 1     7 Spuit 3 cc 2  
16 Ondansetron inj 1     8 Spuit 5 cc 2  
17 Ephedrin inj 2 9 Spuit 10 cc 2
18 Selang O2 dewasa 1 10 Atropin Sulfat inj 2
19 Masker earloop 8 11 Metoclopramide inj 1
 FORMULIR RESEP PAKET BEDAH
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET SC DOKTER EFFENDY

PAKET SC PAKET PRO SC IBU + BAYI
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No.6,5 2     1 Aquadest 25 mL 1
2 Handscoon No.7 1     2 Spuit 1 cc 1
3 PGA 1 (Tapper) 2     3 Spuit 10 cc 1
4 PGA 2/0 (Tapper) 1     4 Urine bag 1
5 Lommatule 1     5 Catheter No. 16 1
6 Pencil Couter 1     6 Neo-K inj/ phytomenadion 1
7 Apron 3     7 Penjepit tali pusar 1
8 Bisturi no 20 1     8 Bisturi No. 10 / 20 1
9     9 Suction No.8 1
10 10
PAKET ANESTESI PAKET OBAT PULANG SC
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Spinocain 26 1 1 Cefadroxil (2x1) 10
2 Spinocain 25 1 2 As. Mefenamat (3x1) 15
3 Handscoon No.6,5 1 3 Hufabion (1x1) 5
4 Handscoon No.7 1 4
5 Handscoon No. 7,5 1 5
6 Spuit 3 cc 2 6
7 Spuit 10 cc 1 TAMBAHAN DAN LAIN LAIN
8 RL 3     NO NAMA BARANG JML CEK 1 CEK 2
9 Bupivacaine inj 1     1 Tramadol inj 1  
10 Santocyn (Umum) 2     2 NaCL 500 mL 1  
11 Oxytocin (BPJS) 2     3 Aquadest 25 mL 1  
12 Bledstopinj 1     4 Midazolam 1  
13 AsamTranexamat inj 1     5 Propofol 1  
14 Fentanyl inj 1     6 Underpad 2  
15 Ketorolac inj 1     7 Spuit 3 cc 2  
16 Ondansetron inj 1     8 Spuit 5 cc 2  
17 Ephedrin inj 2 9 Spuit 10 cc 2
18 10 Atropin Sulfat inj 2
19 11 Metoclopramide inj 1
 FORMULIR RESEP PAKET KURET
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET KURET LAIN LAIN

NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 RL 1     1    
2 Atropininj 2     2    
3 Propofol/Proanesinj 1     3    
4 Bledstopinj 1     4    
5 Fentanyl inj 1     5    
6 Spuit 3 cc 1     6    
7 Spuit 5 cc 1     7    
8 Spuit 10 cc 1     8    
9 Blood Set 1
10 Venflon No. 18 1
11 Underpad 1
 FORMULIR RESEP PAKET BEDAH
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET ANESTESI BEDAH UMUM PAKET BEDAH UMUM

NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Propofol/Proanesinj 2     1 Handscoon 6.5 2    
2 Fentanyl 1     2 Handscoon 7 1    
3 Ketamine 1     3 Pencil couter 1    
4 Miloz 1     4 Benang PGA 3/0 Tapper 1    
5 Ondancentron 1     5 Benang PGA 4/0 Tapper 1    
6 Ketorolac 1     6 Lomatule 1    
7 ParasetamolInfus 1     7 Bisturi No 10 1    
8 Spuit 10 cc 2     8    
9 Spuit 5 cc 2 9
10 Spuit 3 cc 2 10
11 11
12 12
13 13
 FORMULIR RESEP PAKET BEDAH
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET ANESTESI BEDAH DOKTER SUTOMO PAKET BEDAH DOKTER SUTOMO

NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No. 7 2     1 Handscoon No. 7 2    
2 Handscoon No. 7.5 1     2 Handscoon No. 7.5 1    
3 Propofol/Proanes inj 2     3 Pencil couter 1    
4 Fentanyl inj 1     4 Benang PGA 2/0 Tapper 1    
5 Ketamine inj 1     5 Benang PGA 3/0 Tapper 1    
6 Lidocain inj 2     6 Lomatule 1    
7 Ondancentron inj 1     7 Bisturi No 10 1    
8 Ketorolac inj 1     8 Guedel No. 3(dewasa) 1    
9 Pehacain inj 1 9 Guedel No. 2 (anak) 1
10 Spuit 1 cc 3 10 LMA No. 3 (dewasa) 1
11 Spuit 5 cc 3 11 LMA No. 2 (anak) 1
12 Spuit 3 cc 3 12 Underpad 2
13 Spuit 10 cc 3 13 Apron 3
14 NaCl 25 cc 1 14 Bisturi No. 11 1
15 Aquabidest 25 cc 1 15 Masker Anestesi 1
16 RL 2 16 Selang Oksigen Anak/Dewasa 1
17 NaCL 500 cc 1 17 Masker earloop 8
18 Atropin Sulfat inj 2 18 Masker oksigen anak/Dewasa 1
Tensocrepe 15cm, 7.5cm,
19 Tramadol inj 1 19
10cm
20 Dexamethason inj 1 20. Chromic 2-0 tapper 1
PAKET INFUS
1 Vasofix 18 1
2 Blood Set 1
3 RL 1
 FORMULIR RESEP PAKET BEDAH
RSIA BUNDA SEJATI

NAMA PASIEN : PROGRAM :

TTL : VERIFIKASI BILLING :

NO. RM :

PAKET SC DOKTER DEWI KARTIKA DJ

PAKET SC PAKET PRO SC IBU + BAYI
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Handscoon No.7 2     1 Aquadest 25 mL 1
2 Handscoon No. 6.5 1     2 Spuit 1 cc 1
3 PGA 1 (Tapper) 2     3 Spuit 10 cc 1
4 PGA 3/0 (Cutting) 1     4 Urine bag 1
5 Chromic 2/0 (Tapper) 1     5 Catheter No. 16 1
6 Lommatule 1     6 Neo-K inj/phytomenadion 1
7 Pencil Couter 1     7 Penjepit tali pusar 1
8 Apron 3     8 Bisturi No. 10 / 20 1
9 Bisturi no 20 1     9 Suction No.8 1
10 10
PAKET ANESTESI PAKET OBAT PULANG SC
NO NAMA BARANG JML CEK 1 CEK 2 NO NAMA BARANG JML CEK 1 CEK 2
1 Spinocain 26 1 1 Cefadroxil (2x1) 10
2 Spinocain 25 1 2 As. Mefenamat (3x1) 15
3 Handscoon No.6,5 2 3 Hufabion (1x1) 5
4 Handscoon No.7 1 4
5 Spuit 3 cc 2 5
6 Spuit 10 cc 1 6
7 RL 3 TAMBAHAN DAN LAIN LAIN
8 Bupivacaine inj 1     NO NAMA BARANG JML CEK 1 CEK 2
9 Santocyn (Umum) 2     1 Tramadol inj 1  
10 Oxytocin (BPJS) 2     2 NaCL 500 mL 1  
11 Bledstopinj 1     3 Aquadest 25 mL 1  
12 AsamTranexamat inj 2     4 Midazolam 1  
13 Fentanyl inj 1     5 Propofol 1  
14 Ketorolac inj 1     6 Underpad 2  
15 Ondansetron inj 1     7 Spuit 3 cc 2  
16 Ephedrin inj 2     8 Spuit 5 cc 2  
17 Masker Earloop 8 9 Spuit 10 cc 2
18 Selang O2 dewasa 1 10 Atropin Sulfat inj 2
19 11 Metoclopramide inj 1