Laporan BPJS bulan Juli 2019

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 0001131767998 Cahyo Darmawan 01 1-Jul-19 Amoxicillin N 10 437 4,370
Furosemide N 5 200 1,000
Embalase 600
Total 5,970

2 dr. Adi Surija 0002765286033 Pelangi Indrayana 02 1-Jul-19 Salep 2-4 N 1 4500 4,500
Embalase 300
Total 4,800

3 dr. Adi Surija 0001623284008 Carissa Alya Salsabila 03 2-Jul-19 Amoxicillin N 6 437 2,622
Ambroxol N 6 217 1,302
Paracetamol N 5 250 1,250
Embalase 900
Total 6,074

4 dr. Adi Surija 0002247559659 M. Asyifa Caesar Darmawan 04 3-Jul-19 Amoxicillin R 3,75 437 1,639
Paracetamol R 3,75 250 938
Vit. B comp R 3 115 345
Ctm R 3 100 300
Embalase 500
Total 3,722

5 dr. Adi Surija 0000198682121 Antyestie Anissaufa 05 5-Jul-19 Dimenhydrinate N 10 242 2,420
Mefenamic Acid N 10 350 3,500
Vit. B6 N 5 130 650
Embalase 900
Total 7,470

6 dr. Adi Surija 0001535361671 Yuwati 06 8-Jul-19 Na. diklofenak 50 N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715
7 dr. Adi Surija 0001452412708 Sarmini 07 9-Jul-19 Antalgin N 10 400 4,000
Diazepam 2 N 3 300 900
Vit. B Comp N 5 115 575
Embalase 900
Total 6,375

8 dr. Adi Surija 0000121379073 Slamet, Drs 08 9-Jul-19 Ctm N 10 100 1,000
Antasida N 10 137 1,370
Vit. B Comp N 5 115 575
Embalase 900
Total 3,845

9 dr. Adi Surija 0001463201651 Galih Teguh Wibowo 09 9-Jul-19 Amoxicillin N 6 437 2,622
Ambroxol N 6 217 1,302
Paracetamol N 6 250 1,500
Embalase 900
Total 6,324

10 dr. Adi Surija 0002071120882 Daffa Naufal Mahardika 10 9-Jul-19 Amoxicillin R 3,6 150 1,573
Paracetamol R 3 250 750
Ctm R 2 100 200
Embalase 500
Total 3,023

11 dr. Adi Surija 0001879583409 Angel Dwi Kartika 11 9-Jul-19 Amoxicillin R 5 437 2,185
Paracetamol R 4 250 1,000
Ambroxol R 4 217 868
Embalase 500
Total 4,553

12 dr. Adi Surija 0002294195916 Ayuatiningrum 12 11-Jul-19 Amlodipin 5 N 10 500 5,000

Antalgin N 10 400 4,000
Embalase 600
Total 9,600
13 dr. Adi Surija 0001163323664 Brian Aditama S 13 11-Jul-19 Vit. B comp N 10 115 1,150
Embalase 300
Total 1,450

14 dr. Adi Surija 0001743413409 Soepardi 14 11-Jul-19 Amlodipin 5 N 6 500 3,000

Antalgin N 10 400 4,000
Embalase 600
Total 7,600

15 dr. Adi Surija 0001868586399 Ester Sriningsih 15 12-Jul-19 Ranitidin N 10 280 2,800
Demacolin N 10 425 4,250
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 9,950

16 dr. Adi Surija 0001844760532 Owen Christopher Kurniawan 16 13-Jul-19 Amoxicillin R 4,8 437 2,097
Paracetamol R 4,2 250 1,050
Ctm R 3 100 300
Embalase 500
Total 3,947

17 dr. Adi Surija 0001287115468 Lilik Suprapti 17 13-Jul-19 Na. Diclofenac N 10 388 3,880
Diazepam 2 N 4 300 1,200
Embalase 600
Total 5,680

18 dr. Adi Surija 0001905034419 Sudarsih 18 15-Jul-19 Na. Diclofenac 50 N 10 388 3,880
Vit. B1 N 5 447 2,235
Diazepam 2 N 3 300 900
Embalase 900
Total 7,915

19 dr. Adi Surija 0001379808483 Sri Indiyah 19 17-Jul-19 Amoxicillin N 10 437 4,370
Antalgin N 10 400 4,000
Vit. B Comp N 5 115 575
Embalase 900
 Total 9,845

20 dr. Adi Surija 0001905034487 Erina Martaningtyas 20 17-Jul-19 Na. Diclofenac N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715

21 dr. Adi Surija 0001908303941 Rahma ayudia 21 19-Jul-19 Amoxicillin R 4,2 437 1,835
Ambroxol R 4 217 868
Ctm R 4 100 400
Dexamethasone R 4 200 800
Embalase 500
Total 4,403

22 dr. Adi Surija 0001541350855 Sri Rahayu 22 20-Jul-19 Cetirizine N 4 365 1,460
Prednison N 10 240 2,400
Calc. Lact N 4 190 760
Embalase 900
Total 5,520

23 dr. Adi Surija 0002055454593 Liliek Sugiati 23 20-Jul-19 Antalgin N 10 400 4,000
Vit. B Comp N 6 115 690
Embalase 600
Total 5,290

24 dr. Adi Surija 0001379808483 Sri Indiyah 24 22-Jul-19 Ciprofloxacin N 10 676 6,760
Antalgin N 10 400 4,000
Embalase 600
Total 11,360

25 dr. Adi Surija 0001146719463 Soedjarwoto 25 22-Jul-19 Na. Diclofenac N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715

26 dr. Adi Surija 000108429096 Sudjoko 26 23-Jul-19 Amlodipin 5 N 9 500 4,500

 Diazepam 2 N 2 300 600
Embalase 600
Total 5,700

27 dr. Adi Surija 0001542729341 Diah Ayu W 27 24-Jul-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
Vit. B comp N 5 115 575
Embalase 900
Total 8,345

28 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 28 25-Jul-19 Antasida N 10 137 1,370
Ranitidin N 8 280 2,240
Embalase 600
Total 4,210

29 dr. Adi Surija 0001874250674 Soegihartiwie 29 25-Jul-19 Amoxicillin N 10 437 4,370

Paracetamol N 10 250 2,500
Ambroxol N 10 217 2,170
Embalase 900
Total 9,940

30 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 30 27-Jul-19 Antasida N 10 137 1,370
Diazepam 2 N 3 300 900
Embalase 600
Total 2,870

31 dr. Adi Surija 0002211634989 Lutfiana Saputri 31 29-Jul-19 Na. Diclofenac N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715

32 dr. Adi Surija 0002201729771 Khanza Ceiesta Meara Azzahra 32 26-Jul-19 Amoxicillin R 6 437 2,622
Paracetamol R 5 250 1,250
Neodiaform R 3 540 1,620
Embalase 500
Total 5,992
33 dr. Adi Surija 0002223586462 Muhammad Kenzho Naulandro Fadilah 33 30-Jul-19 Amoxicillin R 5 437 2,185
Paracetamol R 4 250 1,000
Ambroxol R 4 217 868
Embalase 500
Total 4,553

34 dr. Adi Surija 0002201728724 Ririn Retnoningsih 34 30-Jul-19 Paracetamol N 10 250 2,500
Vit. B Comp N 5 115 575
Embalase 600
Total 3,675

35 dr. Adi Surija 0001163323653 Fadilla Rifa A 35 30-Jul-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
GG N 10 200 2,000
Embalase 900
Total 9,770

36 dr. Adi Surija 0001134840126 Adi Kurniawan 36 31-Jul-19 Paracetamol N 10 250 2,500
Vit. B comp N 5 115 575
Embalase 600
Total 3,675

TOTAL 220,306

KEDIRI, 07 AGUSTUS 2019

(ANIEK SURYANI)
 Laporan BPJS bulan SEPTEMBER 2019

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 0002623871441 Muhammad Gauyn Isma'il Syahrul Anam 01 2-Sep-19 Amoxicillin R 3 437 1,311
Paracetamol R 2.7 250 675
Ambroxol R 1.5 217 326
Embalase 500
Total 2,812

2 dr. Adi Surija 000108268986 Girang Murjito 02 2-Sep-19 Demacolin tab N 10 425 4,250
Glyceril Guaicolat N 10 200 2,000
Vit. B comp N 10 115 1,150
Embalase 900
Total 8,300

3 dr. Adi Surija 0000108163034 Umi Sulistyani 03 2-Sep-19 Paracetamol N 10 250 2,500
Ambroxol N 10 217 2,170
Vit. B comp N 5 115 575
Embalase 900
Total 6,145

4 dr. Adi Surija 0001199200239 Dwi R 04 4-Sep-19 Amoxicillin N 10 437 4,370

Paracetamol N 10 250 2,500
Ambroxol N 10 217 2,170
Embalase 900
Total 9,940

5 dr. Adi Surija 0002214525958 Irawan Adrianto 05 5-Sep-19 Vit. B comp N 10 115 1,150
Embalase 300
Total 1,450

6 dr. Adi Surija 0001835157778 Lakeswara Evan Mahardika Prasetyo 06 7-Sep-19 Amoxicillin R 6 437 2,622
Paracetamol R 5 250 1,250
Domenhydrinate R 3 242 726
Embalase 500
 Total 5,098

7 dr. Adi Surija 0001169810201 Reza Dian Faiz 07 10-Sep-19 Antalgin N 10 400 4,000
Amoxicillin N 10 437 4,370
Embalase 600
Total 8,970

8 dr. Adi Surija 0001430122184 Ulfa Catur Dewi Kustianti 08 11-Sep-19 Amoxicillin N 10 437 4,370
Ambroxol N 10 217 2,170
Antalgin N 10 400 4,000
Embalase 900
Total 11,440

9 dr. Adi Surija 0001383566152 Kuncoro 09 11-Sep-19 Na. Diclofenac 50 N 10 388 3,880
Diazepam 2 (Valisanbe) N 3 300 900
Embalase 600
Total 5,380

10 dr. Adi Surija 0002220276723 Muhammad Noah Isma'il Syahrul Anam 10 11-Sep-19 Amoxicillin R 3.6 437 1,573
Antalgin R 4 400 1,600
Ambroxol R 4 217 868
Embalase 500
Total 4,541

11 dr. Adi Surija 0002623871441 Muhammad Gavyn Isma'il Syahrul Anam 11 11-Sep-19 Amoxicillin R 2 437 874
Ambroxol R 2 217 434
Vit. B comp R 2 115 230
Embalase 500
Total 2,038

12 dr. Adi Surija 0001908303941 Rahma Ayudia 12 12-Sep-19 Amoxicillin R 4.2 437 1,835
Paracetamol R 3.6 250 900
Ambroxol R 4 217 868
Embalase 500
Total 4,103
13 dr. Adi Surija 0001826847347 Farel Rido Ariyadana 13 13-Sep-19 Antasida Sy N 1 4500 4,500
Embalase 300
Total 4,800

Amoxicillin R 8 437 3,496

Domperidon R 5 465 2,325
Embalase 600
Total 6,421

14 dr. Adi Surija 0001315411727 Sukarwatik 14 14-Sep-19 Na. Diclofenac N 10 388 3,880
Vit. C N 5 100 500
Embalase 600
Total 4,980

15 dr. Adi Surija 0002766255074 Jessica Yunita Wiguna 15 14-Sep-19 Antasida N 10 137 1,370
Na. Diclofenac 50 N 10 388 3,880
Embalase 600
Total 5,850

16 dr. Adi Surija 0001896050294 Purnomo 16 16-Sep-19 Amoxicillin N 10 437 4,370

Ambroxol N 10 217 2,170
Antalgin N 6 400 2,400
Embalase 900
Total 9,840

17 dr. Adi Surija 0001163324046 Jeffry Prayoga 17 16-Sep-19 Cotrimoxazole N 12 230 2,760
Neodiaform N 10 540 5,400
Embalase 600
Total 8,760

18 dr. Adi Surija 0001865457426 Marc Maxwell Putra Cakra 18 18-Sep-19 Amoxicillin R 6 437 2,622
Paracetamol R 5 250 1,250
CTM R 4 100 400
Embalase 500
 Total 4,772

19 dr. Adi Surija 0001169810212 Mochmad Fai'zal Fanani 19 18-Sep-19 Antalgin N 10 400 4,000
Amoxicillin N 10 437 4,370
Embalase 600
Total 8,970

20 dr. Adi Surija 0002623871441 Muhammad Gavyn Isma'il Syahrul Anam 20 18-Sep-19 Paracetamol R 2 250 500
Ambroxol R 2 217 434
Embalase 500
Total 1,434

21 dr. Adi Surija 000220276723 Muhammad Noah Isma'il Syahrul Anam 21 18-Sep-19 Amoxicillin R 4.2 437 1,835
Antalgin R 4 400 1,600
GG R 4 200 800
Embalase 500
Total 4,735

22 dr. Adi Surija 0002755380104 Andyk Fran Manofri 22 20-Sep-19 Amodipin 5 N 5 400 2,000
Simvastatin 20 N 5 1000 5,000
Embalase 600
Total 7,600

23 dr. Adi Surija 0002295352517 Dessy Christina Natalia Yuanita 23 20-Sep-19 Amoxicillin N 10 437 4,370
Demcolin N 10 425 4,250
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 11,520

24 dr. Adi Surija 0001898449086 Rachmawati Dwi Septianingrum 24 20-Sep-19 Ctm N 5 100 500
Prednison N 10 240 2,400
Vit. B comp N 5 115 575
Embalase 900
Total 4,375
25 dr. Adi Surija 0002457019045 Sri Wiyati 25 21-Sep-19 Na. Diclofenac N 10 388 3,880
Vit. B comp N 5 115 575
Embalase 600
Total 5,055

26 dr. Adi Surija 0000171865721 Desi Natalia Trimayasari 26 23-Sep-19 Antalgin N 10 400 4,000
Embalase 300
Total 4,300

27 dr. Adi Surija 0001134840126 Adi Kurniawan 27 23-Sep-19 Cetirizine N 4 400 1,600
Antalgin N 10 400 4,000
Embalase 600
Total 6,200

28 dr. Adi Surija 0002888298988 Niniek Srimulyani 28 23-Sep-19 Amoxicillin N 10 437 4,370
Ambroxol N 10 217 2,170
Embalase 600
Total 7,140

29 dr. Adi Surija 0002278722734 Dhirgam Pramana Ksatria Putera 29 24-Sep-19 Amoxicillin R 3.6 437 1,573
Ambroxol R 3 217 651
Antalgin R 3 400 1,200
Embalase 500
Total 3,924

30 dr. Adi Surija 0002295352719 Cecilia Yohana Prasetya 30 24-Sep-19 Amoxicillin N 10 437 4,370
Ambroxol N 10 217 2,170
Antalgin N 6 400 2,400
Embalase 900
Total 9,840

31 dr. Adi Surija 0002055454593 Liliek Sugiati 31 25-Sep-19 Amoxicillin N 10 437 4,370
Dimenhydrinate N 6 242 1,452
Ranitidin N 6 280 1,680
Embalase 900
 Total 8,402

32 dr. Adi Surija 0002294195916 Ayuatiningrum 32 26-Sep-19 Ranitidin N 6 280 1,680

Amoxicillin N 10 437 4,370
Embalase 600
Total 6,650

33 dr. Adi Surija 0002888299405 Fatchi Nisa'ul Karima Millenia 33 26-Sep-19 Demacolin N 10 425 4,250
Prednison N 10 240 2,400
Embalase 600
Total 7,250

34 dr. Adi Surija 0002379360767 Marimbi 34 28-Sep-19 Na. Diclofenac 50 N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715

TOTAL 219,751

KEDIRI, 07 OKTOBER 2019

(ANIEK SURYANI)
 Laporan BPJS bulan Agustus 2021

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 0001898153998 Tri Widayati 01 2-Aug-21 Amoxicillin N 10 500 5,000
Paracetamol N 10 300 3,000
Ambroxol N 10 300 3,000
Embalase 600
Total 11,600
2 dr. Adi Surija 0002435630613 Mei Rina Ikasari 02 5-Aug-21 Amoxicillin N 10 500 5,000
Paracetamol N 10 300 3,000
Glyceril Guaicolat N 10 150 1,500
Embalase 600
Total 10,100
3 dr. Adi Surija 0002321643262 Sulastri 03 5-Aug-21 Antalgin N 10 137 1,370
Vit B1 N 6 280 1,680
Embalase 600
Total 3,650
4 dr. Adi Surija 0001123797295 Sutaman 04 9-Aug-21 Amoxicillin N 10 550 5,500
Paracetamol N 10 300 3,000
Ambroxol N 10 300 3,000
Embalase 600
Total 12,100
5 dr. Adi Surija 0001315411727 Sukarwatik 05 9-Aug-21 Antalgin N 10 200 2,000
Na.Diclofenak N 10 400 4,000
Vit B Complex N 5 150 750
Embalase 600
Total 7,350
6
dr. Adi Surija 0001146794455 Gideon Sony 06 10-Aug-21 Amoxicillin N 10 550 5,500
Antalgin N 10 200 2,000
Glyceril Guaicolat N 10 150 1,500
Embalase 600
Total 9,600

7 dr. Adi Surija 000163807493 Luckman 07 18-Aug-21 Amoxicillin N 10 550 5,500

Antalgin N 10 200 2,000
Glyceril Guaicolat N 10 150 1,500
Embalase 600
Total 9,600
8 dr. Adi Surija 0001825330882 Carolee 08 19-Aug-21 Antalgin N 10 200 2,000
Vit. B comp N 5 150 750
Embalase 600
Total 3,350
9 dr. Adi Surija 0000088816252 Erni Akhir 09 24-Aug-21 Amoxicillin N 10 550 5,500
Antalgin N 10 200 2,000
Vit B Complex N 5 150 750
Embalase 600
Total 8,850
10 dr. Adi Surija 0002202810614 Adi Kurniawan 10 27-Aug-21 Vit. B1 N 5 150 750
 Embalase 600
Total 1,350
11 dr. Adi Surija 0001616478333 Merry Ekawati 11 30-Aug-21 Antalgin N 10 200 2,000
Vit B Complex N 5 150 750
Embalase 600
Total 3,350

12 dr. Adi Surija 0001163324046 Jeffy Prayoga 12 31-Aug-21 Paracetamol N 10 300 3,000
Glyceril Guaicolat N 10 150 1,500
Amoxicillin N 10 550 5,500
Embalase 600
Total 10,600

TOTAL 91,500

KEDIRI, 08 SEPTEMBER 2021

(ANIEK SURYANI)
 Laporan BPJS bulan OKTOBER 2019

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 0001327073995 Masini 01 1-Oct-19 Antalgin N 10 400 4,000
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,835

2 dr. Adi Surija 0001446338924 Adib Al Muhktari 02 1-Oct-19 Amoxicillin N 6 437 2,622
Paracetamol N 5 250 1,250
Glyceril Guaicolat N 6 200 1,200
Embalase 900
Total 5,972

3 dr. Adi Surija 0001859189951 Sujarwo 03 2-Oct-19 Amlodipin 5 N 10 400 4,000

Embalase 300
Total 4,300

4 dr. Adi Surija 0001383263392 Ruddy Wibowo 04 2-Oct-19 Na. Diclofenac N 10 388 3,880
Embalase 300
Total 4,180

5 dr. Adi Surija 0002755380104 Andyk Fran Manofri 05 3-Oct-19 Amlodipin 5 N 5 400 2,000
Simvastatin 10 N 5 600 3,000
Embalase 600
Total 5,600

6 dr. Adi Surija 0001383569684 Anis Meliani Kuncoro 06 4-Oct-19 Ranitidin N 10 280 2,800
Antasida N 10 137 1,370
Embalase 600
Total 4,770

7 dr. Adi Surija 0002052641259 Jon Welli Eka Sandra 07 4-Oct-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
Glyceril Guaicolat N 10 200 2,000
 Embalase 900
Total 9,770

8 dr. Adi Surija 000178999655 Soetidjab 08 5-Oct-19 Amoxicillin N 12 437 5,244

Ambroxol N 12 217 2,604
Embalase 600
Total 8,448

9 dr. Adi Surija 0001544364393 Setiawan Putro Samudera 09 8-Oct-19 Antalgin N 10 400 4,000
Diazepam 2 (da Valisanbe) N 2 300 600
Embalase 600
Total 5,200

10 dr. Adi Surija 0001908303941 Rahma Ayudia 10 8-Oct-19 Amoxicillin R 4.2 437 1,835
Paracetamol R 3.6 250 900
Ambroxol R 4 217 868
Embalase 500
Total 4,103

11 dr. Adi Surija 0001905986687 Bobby Kristiawan 11 14-Oct-19 Amoxicillin N 10 437 4,370
Antalgin N 10 400 4,000
Vit. B comp N 5 115 575
Embalase 900
Total 9,845

12 dr. Adi Surija 0001134569013 Frengki Jefrianis Oerna 12 15-Oct-19 Na. Diclofenac 50 N 10 388 3,880
Vit. B comp N 5 115 575
Embalase 600
Total 5,055

13 dr. Adi Surija 0002756337895 Stevan Edward Ong 13 16-Oct-19 Vit. B Comp R 6 115 690
Glyceril Guaicolat R 6 200 1,200
Embalase 500
Total 2,390
14 dr. Adi Surija 0001865457426 Marc Maxwell Putra Cakra 14 18-Oct-19 Paracetamol tab R 4.5 250 1,125
CTM R 2 100 200
Embalase 500
Total 1,825

15 dr. Adi Surija 0002070991236 Suryanto 15 21-Oct-19 Vit. B Comp N 10 115 1,150
Embalase 300
Total 1,450

16 dr. Adi Surija 0001721516319 Rosalina Novita 16 23-Oct-19 Omeprazole N 3 600 1,800
Domperidone N 6 465 2,790
Antasida N 10 137 1,370
Embalase 900
Total 6,860

17 dr. Adi Surija 0001842373394 Raka Satria Dharma 17 23-Oct-19 Amoxicillin N 6 437 2,622
Paracetamol N 5 250 1,250
Antasida N 5 137 685
Embalase 900
Total 5,457

18 dr. Adi Surija 0001743413409 Soepardi 18 23-Oct-19 Amoxicillin N 10 437 4,370

Paracetamol N 10 250 2,500
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 9,770

19 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 19 25-Oct-19 Antalgin N 10 400 4,000
Embalase 300
Total 4,300

20 dr. Adi Surija 0001475879038 Dimas Irhan Suryaputra 20 25-Oct-19 Prednison N 5 240 1,200
Vit. B Comp N 5 115 575
Embalase 600
Total 2,375
21 dr. Adi Surija 0002294283159 Astrid Renita Tambahani 21 25-Oct-19 Ichtyol Zalf N 1 5500 5,500
Embalase 300
Total 5,800

22 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 22 28-Oct-19 Omeprazole N 3 600 1,800
CTM N 5 100 500
Embalase 600
Total 2,900

23 dr. Adi Surija 0001643519632 Andri Wicahyo 23 28-Oct-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 9,770

24 dr. Adi Surija 0002467792102 Aneesa Nareswara Dharna 24 28-Oct-19 Amoxicillin R 5.25 437 2,294
Paracetamol R 4.5 250 1,125
CTM R 3 100 300
Embalase 500
Total 4,219

25 dr. Adi Surija 0002278200161 Aura Latisha Ardyanti 25 28-Oct-19 Amoxicillin R 3.6 437 1,573
Antalgin R 3 400 1,200
Ambroxol R 3 217 651
CTM R 1.5 100 150
Embalase 500
Total 4,074

26 dr. Adi Surija 0001163324024 Suprapti 26 29-Oct-19 Antalgin N 10 400 4,000

Vit. B comp N 5 115 575
Embalase 600
Total 5,175

27 dr. Adi Surija 0001743413433 Ivo Victor Merdioke Adam 27 29-Oct-19 Demacolin N 10 425 4,250
 Glyceril Guaicolat N 10 200 2,000
Embalase 600
Total 6,850

28 dr. Adi Surija 0001613807515 Ahmad Azzan Nugroho 28 30-Oct-19 Amoxicillin R 4.2 437 1,835
Paracetamol R 3.6 250 900
Ambroxol R 3 217 651
CTM R 3 100 300
Embalase 500
Total 4,186

29 dr. Adi Surija 0002062876702 Antok Kurniawan Winarno 29 30-Oct-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
Ambroxol N 10 217 2,170
Embalase 900
Total 9,940

30 dr. Adi Surija 0001865456998 Jenny 30 30-Oct-19 Amoxicillin N 10 437 4,370

Demacolin N 10 425 4,250
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 11,520

TOTAL 172,940

KEDIRI, 07 NOVEMBER 2019

(ANIEK SURYANI)
 Laporan BPJS bulan NOVEMBER 2019

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 000186545998 Jenny 01 2-Nov-19 Ambroxol N 10 217 2,170
Prednison N 10 240 2,400
Embalase 600
Total 5,170

2 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 02 2-Nov-19 Antasida N 10 137 1,370
Antalgin N 10 400 4,000
Embalase 600
Total 5,970

3 dr. Adi Surija 0001146719463 Soedjarwoto 03 5-Nov-19 Omeprazole N 3 600 1,800

Vit. B Comp N 5 115 575
Embalase 600
Total 2,975

4 dr. Adi Surija 0001829754191 Moh. Yusron 04 5-Nov-19 Omeprazole N 3 600 1,800
Antasida N 10 137 1,370
Embalase 600
Total 3,770

5 dr. Adi Surija 0002073472018 Khaizuran Asyraaf Rabbani 05 5-Nov-19 Omeprazole N 3 600 1,800
Antasida N 10 137 1,370
Embalase 600
Total 3,770

6 dr. Adi Surija 0001875213707 Nurhadi 06 6-Nov-19 Amoxicillin N 10 437 4,370

Antalgin N 10 400 4,000
Embalase 600
Total 8,970

7 dr. Adi Surija 0001284034454 Susilowati 07 8-Nov-19 Asam Mefenamad N 15 340 5,100
Vit. B Comp N 10 115 1,150
 Embalase 600
Total 6,850

8 dr. Adi Surija 0002231167241 Fiolin Dara Vista 08 11-Nov-19 Antasida Doen N 10 137 1,370
Omeprazole N 3 600 1,800
Embalase 600
Total 3,770

9 dr. Adi Surija 0001794651254 Sri Rahayu 09 11-Nov-19 Na. Diclofenac 50 N 10 388 3,880
Embalase 300
Total 4,180

10 dr. Adi Surija 0001424361666 Anisa Zuliatin 10 12-Nov-19 Antasida Doen N 10 137 1,370
Omeprazole N 3 600 1,800
Embalase 600
Total 3,770

11 dr. Adi Surija 0001134589013 Frengki Jefrianis Oeina 11 12-Nov-19 Glyceril Guaicolat N 10 200 2,000
Na. Diclofenac N 10 388 3,880
Embalase 600
Total 6,480

12 dr. Adi Surija 0001543998644 Arga Ramadhani 12 14-Nov-19 Amoxicillin N 6 437 2,622
Antalgin N 5 400 2,000
Embalase 600
Total 5,222

13 dr. Adi Surija 0002274227537 Khamim Muntohari 13 15-Nov-19 Na. Diclofenac 50 N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
Total 6,715

14 dr. Adi Surija 0001127294774 Bambang Supriyanto 14 18-Nov-19 Na. Diclofenac 50 N 10 388 3,880
Vit. B1 N 5 447 2,235
Embalase 600
 Total 6,715

15 dr. Adi Surija 0001616478355 Egi Dwi Oktavian 15 19-Nov-19 Amoxicillin N 10 437 4,370
Paracetamol N 10 250 2,500
Glyceril Guaicolat N 10 200 2,000
Embalase 900
Total 9,770

16 dr. Adi Surija 0001636473317 Baliska Allya Shalsabella 16 21-Nov-19 Ciprofloxacin N 6 676 4,056
Paracetamol N 10 250 2,500
Neodiaform N 6 640 3,840
Embalase 900
Total 11,296

17 dr. Adi Surija 0001812093963 Sunarno 17 22-Nov-19 Omeprazole N 5 600 3,000

Diazepam (da Valisanbe) N 3 300 900
Amoxicillin N 10 437 4,370
Embalase 900
Total 9,170

18 dr. Adi Surija 0001792796905 Caesilya Ratna Dewantari 18 22-Nov-19 Vit. B Comp N 6 115 690
Embalase 300
Total 990

19 dr. Adi Surija 0001868586399 Ester Sriningsih 19 23-Nov-19 Antalgin N 10 400 4,000
Doazepam (da Valisanbe) N 3 300 900
Embalase 600
Total 5,500

20 dr. Adi Surija 0002756338841 Michael Edward Ong 20 25-Nov-19 Amoxicillin R 6 437 2,622
Paracetamol tab R 5.5 250 1,375
Dimenhydrinate R 4 242 968
Embalase 500
Total 5,465
21 dr. Adi Surija 0001657911609 Bondan Sasongkowarno 21 25-Nov-19 Antalgin N 10 400 4,000
Prednison N 5 240 1,200
Embalase 600
Total 5,800

22 dr. Adi Surija 0002294195916 Ayuatiningrum 22 21-Nov-19 Neodiaform N 6 640 3,840

Cotrimoxazole 480 N 12 230 2,760
Embalase 600
Total 7,200

23 dr. Adi Surija 0001875215351 Anggraini 23 28-Nov-19 Vit. B Comp N 5 115 575
Na. Diclofenac 50 N 6 388 2,328
Embalase 600
Total 3,503

24 dr. Adi Surija 0000171865912 Dimas Putra Manggiharto 24 30-Nov-19 Amoxicillin N 10 437 4,370
Paracetamol N 8 250 2,000
Embalase 600
Total 6,970

CTM R 5 100 500

Prednison R 5 240 1,200
Embalase 500
Total 2,200

TOTAL 142,191

KEDIRI, 09 DESEMBER 2019

(ANIEK SURYANI)
 Laporan BPJS bulan DESEMBER 2019

No Nama dokter No BPJS Nama pasien No. R/ Tanggal R/ Nama Obat R/ - Non R/ Jumlah Obat Harga Satuan
1 dr. Adi Surija 0001484747291 Gapemu Sentina Hasugian 01 2-Dec-19 Amoxicillin 500 N 10 437 4,370
Antalgin N 10 400 4,000
GG N 10 200 2,000
Embalase 900
Total 11,270

2 dr. Adi Surija 0001898153998 Tri Widayati 02 2-Dec-19 Amoxicillin 500 N 10 437 4,370
Paracetamol N 10 250 2,500
Dimenhydrinate N 6 242 1,452
Embalase 900
Total 9,222

3 dr. Adi Surija 0001616478344 Arcella Elsawati 03 2-Dec-19 Amoxicillin 500 N 10 437 4,370
Paracetamol N 10 250 2,500
Domperidone N 5 465 2,325
Embalase 900
Total 10,095

4 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 04 2-Dec-19 Vit B complex N 8 115 920
Embalase 300
Total 1,220

5 dr. Adi Surija 0001962902935 Marikem 05 2-Dec-19 Amoxicillin N 10 437 4,370

Paracetamol N 10 250 2,500
Omeprazole 20 N 3 600 1,800
Embalase 900
Total 9,570

6 dr. Adi Surija 0001865457426 Marc Maxwell Putra Cakra 06 2-Dec-19 Amoxicillin R 4.8 437 2,098
Paracetamol R 4.2 250 1,050
Ambroxol R 4 217 868
Embalase 500
Total 4,516
7 dr. Adi Surija 0001269220318 Adnan Putra A 07 3-Dec-19 Ambroxol 30 N 10 217 2,170
Vit. B Comp N 5 115 575
Embalase 600
Total 3,345

8 dr. Adi Surija 0001721816943 Elmira Wahyu Pusparatih 08 6-Dec-19 Amoxicillin 500 N 5 437 2,185
Antalgin N 5 400 2,000
Ambroxol 30 N 5 217 1,085
Embalase 900
Total 6,170

9 dr. Adi Surija 0001134792066 Moch. Zaenal Fanani 09 7-Dec-19 Antalgin N 10 400 4,000
Vit. B Comp N 5 115 575
Embalase 600
Total 5,175

10 dr. Adi Surija 0001896451997 Joko Pamilih 10 9-Dec-19 Amoxicillin 500 N 10 437 4,370
Antalgin N 10 400 4,000
Embalase 600
Total 8,970

11 dr. Adi Surija 0001721516319 Rosalina Novita 11 9-Dec-19 Omeprazole 20 N 3 600 1,800
Embalase 300
Total 2,100

12 dr. Adi Surija 0001812097203 Ary Ardiyansyah 12 9-Dec-19 Amoxicillin N 6 437 2,622
Antasida doen N 5 137 685
Embalase 600
Total 3,907

13 dr. Adi Surija 0001898449086 Rachmawati Dwi Septianingrum 13 9-Dec-19 Amoxicillin 500 N 10 437 4,370
Paracetamol tab N 10 250 2,500
Ambroxol N 10 217 2,170
Embalase 900
Total 9,940

14 dr. Adi Surija 0001865457189 Kimberly Putri Cakra 14 11-Dec-19 Amoxicillin 500 R 6 437 2,622
 Paracetamol tab R 5.4 250 1,350
GG R 4 200 800
Embalase 500
Total 5,272

15 dr. Adi Surija 0001789995655 Soetidjab 15 11-Dec-19 Cotrimoxazole 480 N 12 230 2,760
Neo diaform N 6 640 3,840
Embalase 600
Total 7,200

16 dr. Adi Surija 0001535612714 Mariyati 16 11-Dec-19 Hydrocortison Cr 1% N 1 6000 6,000

Embalase 300
Total 6,300

17 dr. Adi Surija 0002457404627 Muhammad Rafa Azka P 17 12-Dec-19 Amoxicillin 500 R 4.5 437 1,967
Demacolin tab R 3 425 1,275
GG R 3 200 600
Embalase 500
Total 4,342

18 dr. Adi Surija 0002882082429 Devy Amellia 18 12-Dec-19 Amoxicillin 500 N 10 437 4,370
CTM N 10 100 1,000
Prednison 5 N 10 240 2,400
Embalase 900
Total 8,670

19 dr. Adi Surija 0001373625718 Mohammad Ali supriyono Y 19 12-Dec-19 Amoxicillin 500 N 10 437 4,370
Paracetamol N 10 250 2,500
GG N 10 200 2,000
Embalase 900
Total 9,770

20 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 20 3-Dec-19 Valisanbe 2 N 2 300 600
Embalase 300
Total 900

21 dr. Adi Surija 0001178868104 Endrawan Joko Purwanto 21 16-Dec-19 Vit. B Comp N 10 115 1,150
 Embalase 300
Total 1,450

22 dr. Adi Surija 0000108608747 Prawito 22 16-Dec-19 CTM N 8 100 800

Embalase 300
Total 1,100

23 dr. Adi Surija 0001544364393 Setiawan Putro Samudra 23 16-Dec-19 Amoxicillin N 10 437 4,370
Antalgin N 10 400 4,000
Vit. B Comp N 5 115 575
Embalase 900
Total 9,845

24 dr. Adi Surija 0002137569513 Sri Yuliani 24 16-Dec-19 Simvastatin 10 N 3 600 1,800
Metformin 500 N 3 250 750
Vit. B Comp N 3 115 345
Embalase 900
Total 3,795

25 dr. Adi Surija 0002910659128 By Ny Suci Setya M 25 16-Dec-19 Vit. B Comp R 1 115 115
Embalase 500
Total 615

26 dr. Adi Surija 0001300839129 Nadhifa Aina Zahra 26 17-Dec-19 Amoxicillin 500 R 4.2 437 1,835
Paracetamol R 3.6 250 900
CTM R 3 100 300
Embalase 900
Total 3,935

27 dr. Adi Surija 0001535622052 Eko Suyanto 27 17-Dec-19 Amoxicillin 500 N 10 437 4,370
Demacolin N 10 425 4,250
GG N 10 200 2,000
Embalase 900
Total 11,520

28 dr. Adi Surija 0001287115468 Lilik Suprapti 28 17-Dec-19 Piroxicam 20 N 10 300 3,000
Prednison 5 N 10 250 2,500
 Embalase 600
Total 6,100

29 dr. Adi Surija 0001629305471 Yosafat Setyawan Go 29 20-Dec-19 Amoxicillin 500 N 10 437 4,370
Nat. Diklofenac N 10 388 3,880
Embalase 600
Total 8,850

30 dr. Adi Surija 0001264664193 Ida Rusdiana 30 20-Dec-19 Amoxicillin 500 N 12 437 5,244
Antalgin N 10 400 4,000
CTM N 5 100 500
Embalase 900
Total 10,644

31 dr. Adi Surija 0001743413411 Marie Rahayu 31 20-Dec-19 Amoxicillin 500 N 10 437 4,370
Paracetamol N 10 250 2,500
GG N 10 200 2,000
Embalase 900
Total 9,770

32 dr. Adi Surija 0001865457189 Kimberly Putri Cakra 32 24-Dec-19 Amoxicillin 500 R 6 437 2,622
Demacolin R 6 425 2,550
GG R 6 200 1,200
Embalase 500
Total 6,872

33 dr. Adi Surija 0001890801843 Kevin Mattew Yang 33 24-Dec-19 Amoxicillin 500 R 4.8 437 2,098
Demacolin R 4 425 1,700
Ambroxol R 4 217 868
Embalase 500
Total 5,166

34 dr. Adi Surija 0001847740509 Bagoes Priyo Aris Hendradi 34 24-Dec-19 Furosemide N 5 200 1,000
Embalase 300
Total 1,300

35 dr. Adi Surija 0001284935815 Eny Dwi Komalawati 35 21-Dec-19 Amoxicillin N 10 437 4,370
 Paracetamol N 10 250 2,500
GG N 10 200 2,000
Embalase 900
Total 9,770

36 dr. Adi Surija 0001543998611 Kardjiati 36 27-Dec-19 Amoxicillin N 10 437 4,370

Antalgin N 10 400 4,000
Embalase 600
Total 8,970

37 dr. Adi Surija 0001432827011 Soni Dwi Tjaksono 37 28-Dec-19 Acyclovir Cr N 1 4000 4,000
Antalgin N 10 400 4,000
Embalase 600
Total 8,600

38 dr. Adi Surija 0001163324024 Suprapti 38 28-Dec-19 Antalgin N 10 400 4,000

Antasida doen N 10 137 1,370
Embalase 600
Total 5,970

39 dr. Adi Surija 0001879583409 Angel Dwi Kartika 39 28-Dec-19 Amoxicillin R 5.4 437 2,360
Paracetamol R 4.8 250 1,200
Ambroxol R 4 217 868
Embalase 500
Total 4,928

40 dr. Adi Surija 0001200909352 Ani fatati 40 30-Dec-19 Amoxicillin N 12 437 5,244
Paracetamol N 12 250 3,000
Embalase 600
Total 8,844

TOTAL 255,997

KEDIRI, 8 September 2021

(ANIEK SURYANI)