PAKET SC BPJS PAKET SC BPJS (ERACS)

NAMA PASIEN/NO CM: NAMA PASIEN/NO CM:

NO NAMA BARANG JUMLAH KET NO NAMA BARANG
1 urin bag 1 1 urin bag
2 paket benang sc 1 2 paket benang sc
3 t chromic 27 1 3 t chromic 27
4 paket blood set 20 1 4 paket blood set 20
5 cuticell 1 5 cuticell
6 nasal oxygen adult 1 6 nasal oxygen adult
7 sarung tangan steril no 7 2 7 sarung tangan steril no 7
8 sarung tangan steril no 7,5 2 8 sarung tangan steril no 7,5
9 povidone iodine 60 ml 1 8 povidone iodine 60 ml
10 spuit 1 1 9 spuit 1
11 spuit 3 2 10 spuit 5
12 spuit 5 1 11 spuit 10
13 spuit 10 1 12 spuit 20
14 spuit 20 1 13 fol cath 14
15 fol cath 14 1 14 suction catheter no 8
16 suction catheter no 8 1 15 spinocan 27 bbraun
17 spinocan 27 bbraun 1 16 pisau 20
18 pisau 20 1 17 hansaplast
18 VITADION INJ
19 hansaplast 1 21 bunascan inj / regivell inj
20 umbilical cord clamp 1 22 ondansentron 4 mg inj
21 aqua 25 ml 1 23 ranitidine inj
22 vitadion inj 1 24 oxyla inj
23 bunascan inj / regivell inj 1 25 metvell inj
24 ondansentron 4 mg inj 2 26 nacl 500 ml wida
25 ranitidine inj 1 27 rl sp
26 oxyla inj 4 28 Pct inf 1000
27 metvell inj 1 29 ketorolac inj
28 ketorolac inj 1 30 tramadol inj
29 tramadol inj 1 31 kaltrofen supp
30 kaltrofen supp 1 32 dexametason inj
31 nacl 500 ml wida 1 33 lidocain inj
32 rl sp 2 SERAH TERIMA
regivell inj : senin- kamis
bunascan inj : jumat - minggu

PAKET BPJS KISTEKTOMY/ TINDAKAN

SELAIN HT
PAKET BPJS HISTEREKTOMY NO NAMA BARANG
NAMA PASIEN/NO CM: 1 urin bag
NO NAMA BARANG JUMLAH KET 2 paket benang sc
1 urin bag 1 4 paket blood set 20
2 paket benang sc 1 5 cuticell
3 t mono m 48 1 6 nasal oxygen adult
4 paket blood set 20 1 7 sarung tangan steril no 7
5 cuticell 1 8 sarung tangan steril no 7,5
6 nasal oxygen adult 1 9 povidone iodine 60 ml
7 sarung tangan steril no 7 2 10 spuit 1
8 sarung tangan steril no 7,5 2 11 spuit 3
9 povidone iodine 60 ml 1 12 spuit 5
10 spuit 1 1 13 spuit 10
11 spuit 3 2 14 spuit 20
12 spuit 5 1 15 fol cath 14
13 spuit 10 1 16 spinocan 27 bbraun
14 spuit 20 1 17 pisau 20
15 fol cath 14 1 18 hansaplast
16 spinocan 27 bbraun 1 19 aqua 25 ml
17 pisau 20 1 20 bunascan / regivell
18 hansaplast 1 21 ondansentron 4 mg inj
19 aqua 25 ml 1 22 ranitidine inj
20 bunascan / regivell 1 23 ketorolac inj
21 ondansentron 4 mg inj 2 24 tramadol inj
22 ranitidine inj 1 25 kaltrofen supp
23 ketorolac inj 1 26 nacl 500 ml wida
24 tramadol inj 1 27 rl sp
25 kaltrofen supp 1 SERAH TERIMA
26 nacl 500 ml wida 1 cat :
27 rl sp 2 regivell inj : senin- kamis
SERAH TERIMA bunascan inj : jumat - minggu
cat :
regivell inj : senin- kamis
bunascan inj : jumat - minggu
PAKET APPENDICTOMY
NAMA PASIEN/NO CM:
PAKET HERNIATOMY NO NAMA BARANG
NAMA PASIEN/NO CM: 1 urin bag
NO NAMA BARANG JUMLAH KET 2 paket benang appendictomi
1 urin bag 1 3 paket blood set 20
2 paket benang herniatomi 1 4 cuticell
3 paket blood set 20 1 5 nasal oxygen adult
4 cuticell 1 6 sarung tangan steril no 7,5
5 nasal oxygen adult 1 7 povidone iodine 60 ml
6 sarung tangan steril no 7,5 4 8 spuit 1
7 povidone iodine 60 ml 1 9 spuit 3
8 spuit 1 1 10 spuit 5
9 spuit 3 2 11 spuit 10
10 spuit 5 2 12 spuit 20
11 spuit 10 1 13 fol cath 14 / 16
12 spuit 20 1 14 spinocan 27 bbraun
13 fol cath 16 1 15 hansaplast
14 spinocan 27 bbraun 1 16 aqua 25 ml
15 hansaplast 1 17 tramadol inj
16 aqua 25 ml 1 18 bunascan / regivell
19 bunascan / regivell 1 19 ondansentron4 mg inj
20 ondansentron4 mg inj 2 20 ranitidine inj
22 ranitidine inj 1 21 kaltrofen supp
23 ketorolac inj 1 22 nacl 500 ml wida
20 tramadol inj 1 23 RL SP
23 kaltrofen supp 1 SERAH TERIMA
24 nacl 500 ml wida 1 cat :
21 RL SP 2 regivell inj : senin- kamis
SERAH TERIMA bunascan inj : jumat - minggu
cat :
regivell inj : senin- kamis
bunascan inj : jumat - minggu

PAKET KATARAK (dr. Deddy, SpM)

NAMA PASIEN/NO CM:
PAKET KATARAK (dr. Erika, SpM) NO NAMA BARANG
NAMA PASIEN/NO CM: 1 spuit 5
NO NAMA BARANG JUMLAH KET 2 spuit 10
1 spuit 5 1 3 spuit 20
2 spuit 10 1 4 sarung tangan steril 7,5
3 spuit 20 1 5 rl sp
4 sarung tangan steril no 6,5 2 6 gentamicin inj
5 rl sp 1 7 lidocain inj
6 gentamicin inj 1 8 deksamethason inj
7 lidocain inj 1 9 asmef 500 mg tab (3x 1 tab)
8 deksamethason inj 1 10 ciprofloxacin tab (2x 1 tab)
9 lfx minidose (1 tetes tiap 1 jam) 5 11 eyefreshplus md (6x 1 tetes)
10 eyefresh plus md (6x 1 tetes) 5 12 xitrol minidose (6x 1 tetes)
11 xitrol minidose (6x 1 tetes) 5 SERAH TERIMA
SERAH TERIMA

MEMO

MEMO
DARI : FARMASI
UNTUK : FARMASI
TANGGAL : 13 - 06 – 2022
PERIHAL : PERMINTAAN MASKER

DIMOHON UNTUK MEMBERIKAN MASKER SEJUMLAH 50.

ATAS PERHATIANNYA TERIMAKASIH.

S) PAKET ANESTESI SPINAL (URS/ TURP/ HEMOROID/
TINDAKAN SELAIN OBGYN) PAKET ANASTES
JUMLAH KET NAMA PASIEN/NO CM: NAMA PASIEN/N
1 NO NAMA BARANG JUMLAH KET NO
1 1 urin bag 1 1
1 2 paket blood set 20 1 2
1 3 hansaplast 1 3
1 4 nasal oxygen adult 1 4
1 5 sarung tangan steril no 7,5 4 5
2 6 povidone iodine 60 ml 1 6
1 7 spinocan 27 bbraun 1 7
1 8 spuit 1 1 8
1 9 spuit 3 2 9
1 10 spuit 5 2 10
1 11 spuit 10 1 11
1 12 spuit 20 1 12
1 13 aqua 25 ml 1 13
1 14 bunascan / regivell 1 14
1 15 ondansentron4 mg inj 2 15
1 16 ranitidine inj 1 16
1 17 ketorolac inj 1 17
1 18 tramadol inj 1
1 19 nacl 500 ml wida 1 18
2 20 rl sp 2 19
1 SERA
4
1
1
2 cat :
1 regivell inj : senin- kamis
1 bunascan inj : jumat - minggu
1
1 1
2
2

OMY/ TINDAKAN OBGYN PAKET FAM PAKET DNC

NAMA PASIEN/NO CM: NAMA PASIEN/N
JUMLAH KET NO NAMA BARANG JUMLAH KET NO
1 1 paket benang fam 1 1
1 2 paket blood set 20 1 2
1 3 nasal oxygen adult 1 3
1 4 sarung tangan steril no 7,5 4 4
1 5 povidon iodine 60 ml 1 5
 2 6 spuit 3 2 6
2 7 spuit 5 2 7
1 8 spuit 10 1 8
1 9 proanes inj 1 9
2 10 ondansentron4 mg inj 2 10
1 11 ketorolac inj 1 11
1 12 nacl 500 ml wida 1 12
1 13 RL 1 13
1 SERAH TERIMA 14
1 15
1 16
1 SERAH TERIMA
1
1
2
1
1
1
1
1
2

Y PAKET CIMINO/CDL DAFTAR PAKET

NAMA PASIEN/NO CM: HERMINA TANG
JUMLAH KET NO NAMA BARANG JUMLAH KET 1
1 1 paket benang cimino/CDL 1 2
1 2 ecare iv dressing 6x7 1 3
1 3 sarung tangan steril no 7,5 1 4
1 4 spuit 3 1 5
1 5 spuit 5 1
4 6 spuit 10 1 6
1 7 povidone iodine 60 ml 1 7
1 8 nacl 500 ml wida 1
2 9 transofix 1 8
2 10 lidocain inj 8 9
1 SERAH TERIMA 10
1 11
1 12
1 13
1 14
1 15
3
1
2
1
1
 1
2

Deddy, SpM) PAKET KATARAK (dr. Suminto, SpM)

NAMA PASIEN/NO CM:
JUMLAH KET NO NAMA BARANG JUMLAH KET
1 1 spuit 5 1
1 2 spuit 10 1
1 3 spuit 20 1
2 4 sarung tangan steril 7,5 2
1 5 rl sp 1
1 6 gentamicin inj 1
1 7 lidocain inj 1
1 8 deksamethason inj 1
12 9 tobroson md (1 tetes tiap 3 jam) 5
10 10 floxa md (1 tetes tiap 3 jam) 5
5 SERAH TERIMA
5
PAKET ANASTESI UMUM
NAMA PASIEN/NO CM:
NAMA BARANG JUMLAH KET
paket blood set 20 1
nasal oxygen adult 1
sarung tangan steril no 7 2
sarung tangan steril no 7,5 2
povidone iodine 60 ml 1
spuit 1 1
spuit 3 2
spuit 5 2
spuit 10 1
aqua 25 ml 1
nacl 25 ml 1
ondansentron4 mg inj 2
ranitidine inj 1
proanes inj 1
ketorolac inj 1
tramadol inj 1
kaltrofen supp 1

nacl 500 ml wida 1

rl sp 2
PAKET ANESTESI SPINAL (URS/ TURP/ HEMOROID/ TINDAKAN SELAIN OBGYN)

PAKET DNC
NAMA PASIEN/NO CM:
NAMA BARANG JUMLAH KET
paket blood set no 20 1
nasal oxygen adult 1
spuit 3 1
spuit 5 1
spuit 10 1
 proanes inj 1
metvell inj 1
ondansentron4 mg inj 2
rl sp 1
nacl 500 ml wida 1
povidone iodine 60 ml 1
kaltropen supp 1
clindamicin 300 mg kapsul 10
asam mefenamat 500mg 10
Metil ergometrin tab 10
sarung tangan steril no 7 1
SERAH TERIMA

DAFTAR PAKET OPERASI PASIEN JKN RS

HERMINA TANGERANG PER OKTOBER 2021
PAKET SC BPJS
PAKET SC BPJS (ERACS)
PAKET BPJS HISTEREKTOMY
PAKET ANESTESI UMUM
PAKET ANESTESI SPINAL (URS/ TURP/
HEMOROID/ TINDAKAN SELAIN OBGYN)
PAKET BPJS HISTEREKTOMY
PAKET BPJS KISTEKTOMY/ TINDAKAN
OBGYN SELAIN HT
PAKET FAM
PAKET DNC
PAKET HERNIATOMY
PAKET APPENDICTOMY
PAKET CIMINO / CDL
PAKET KATARAK (dr. Erika, SpM)
PAKET KATARAK (dr. Deddy, SpM)
PAKET KATARAK (dr. Suminto, SpM)
PAKET SC BPJS PAKET SC BPJS (ERACS) PAKET BPJS HISTEREKTOMY PAKET ANESTESI UMUM
NO NAMA BARANG JUMLAH HPP BIAYA NO NAMA BARANG JUMLAH HPP BIAYA NO NAMA BARANG JUMLAH HPP BIAYA NO NAMA BARANG JUMLAH HPP BIAYA
1 urin bag 1 Rp6,700 Rp6,700 1 urin bag 1 Rp6,700 Rp6,700 1 urin bag 1 Rp6,700 Rp6,700 1 paket blood set 20 1 Rp16,190 Rp16,190
2 paket benang sc 1 Rp192,512 Rp192,512 2 paket benang sc 1 Rp192,512 Rp192,512 2 paket benang sc 1 Rp192,512 Rp192,512 2 nasal oxygen adult 1 Rp6,600 Rp6,600
3 t chromic 27 1 Rp64,000 Rp64,000 3 t chromic 27 1 Rp64,000 Rp64,000 3 t mono m 48 1 Rp98,827 Rp98,827 3 sarung tangan steril no 7 4 Rp19,000 Rp76,000
4 paket blood set 20 1 Rp16,190 Rp16,190 4 paket blood set 20 1 Rp16,190 Rp16,190 4 paket blood set 20 1 Rp16,190 Rp16,190 4 povidone iodine 60 ml 1 Rp6,400 Rp6,400
5 cuticell 1 Rp12,815 Rp12,815 5 cuticell/ bactigras 1 Rp12,815 Rp12,815 5 cuticell 1 Rp12,815 Rp12,815 5 spuit 1 1 Rp1,116 Rp1,116
6 nasal oxygen adult 1 Rp6,600 Rp6,600 6 nasal oxygen adult 1 Rp6,600 Rp6,600 6 nasal oxygen adult 1 Rp6,600 Rp6,600 6 spuit 3 2 Rp1,185 Rp2,370
7 sarung tangan steril no 7 4 Rp19,000 Rp76,000 7 sarung tangan steril no 7 4 Rp19,000 Rp76,000 7 sarung tangan steril no 7 4 Rp19,212 Rp76,848 7 spuit 5 2 Rp1,451 Rp2,902
8 povidone iodine 60 ml 1 Rp6,400 Rp6,400 8 povidone iodine 60 ml 1 Rp6,400 Rp6,400 8 povidone iodine 60 ml 1 Rp6,400 Rp6,400 8 spuit 10 1 Rp1,580 Rp1,580
9 spuit 1 1 Rp1,400 Rp1,400 9 spuit 1 1 Rp1,400 Rp1,400 9 spuit 1 1 Rp1,400 Rp1,400 9 aqua 25 ml 1 Rp2,634 Rp2,634
10 spuit 3 2 Rp2,000 Rp4,000 10 spuit 3 2 Rp2,000 Rp4,000 10 spuit 3 2 Rp2,000 Rp4,000 10 nacl 25 ml 1 Rp4,815 Rp4,815
11 spuit 5 1 Rp1,451 Rp1,451 11 spuit 5 1 Rp1,451 Rp1,451 11 spuit 5 1 Rp1,451 Rp1,451 11 ondansentron4 mg inj 2 Rp3,700 Rp7,400
12 spuit 10 1 Rp1,580 Rp1,580 12 spuit 10 1 Rp1,580 Rp1,580 12 spuit 10 1 Rp1,580 Rp1,580 12 ranitidine inj 1 Rp1,700 Rp1,700
13 spuit 20 1 Rp1,700 Rp1,700 13 spuit 20 1 Rp1,700 Rp1,700 13 spuit 20 1 Rp1,700 Rp1,700 13 proanes inj 1 Rp70,258 Rp70,258
14 fol cath 14 1 Rp15,400 Rp15,400 14 fol cath 14 1 Rp15,400 Rp15,400 14 fol cath 14 1 Rp15,400 Rp15,400 14 ketorolac inj 1 Rp2,100 Rp2,100
15 suction catheter no 8 1 Rp6,000 Rp6,000 15 suction catheter no 8 1 Rp6,000 Rp6,000 15 spinocan 27 bbraun 1 Rp33,600 Rp33,600 15 nacl 500 ml wida 1 Rp6,800 Rp6,800
16 spinocan 27 bbraun 1 Rp33,600 Rp33,600 16 spinocan 27 bbraun 1 Rp33,600 Rp33,600 16 pisau 20 1 Rp3,800 Rp3,800 16 rl sp 2 Rp7,629 Rp15,258
17 pisau 20 1 Rp3,800 Rp3,800 17 pisau 20 1 Rp3,800 Rp3,800 17 hansaplast 1 Rp250 Rp250 TOTAL BIAYA Rp224,123
18 hansaplast 1 Rp250 Rp250 18 hansaplast 1 Rp250 Rp250 18 aqua 25 ml 1 Rp2,634 Rp2,634
19 umbilical cord clamp 1 Rp4,000 Rp4,000 19 umbilical cord clamp 1 Rp4,000 Rp4,000 19 bunascan / regivell 1 Rp61,600 Rp61,600
20 aqua 25 ml 1 Rp2,700 Rp2,700 20 aqua 25 ml 1 Rp2,700 Rp2,700 20 ondansentron 4 mg inj 2 Rp3,700 Rp7,400
21 vitadion inj 1 Rp10,956 Rp10,956 21 vitadion inj 1 Rp10,956 Rp10,956 21 ranitidine inj 1 Rp1,700 Rp1,700 PAKET ANESTESI SPINAL (URS/ TURP/ HEMOROID/
22 bunascan inj / regivell inj 1 Rp61,600 Rp61,600 22 bunascan inj / regivell inj 1 Rp61,600 Rp61,600 22 ketorolac inj 1 Rp2,100 Rp2,100 TINDAKAN SELAIN OBGYN)
23 ondansentron 4 mg inj 2 Rp3,700 Rp7,400 23 ondansentron 4 mg inj 2 Rp3,700 Rp7,400 23 nacl 500 ml wida 1 Rp6,800 Rp6,800 NO NAMA BARANG JUMLAH HPP BIAYA
24 ranitidine inj 1 Rp1,700 Rp1,700 24 ranitidine inj 1 Rp1,660 Rp1,660 24 rl sp 2 Rp7,629 Rp15,258 1 urin bag 1 Rp6,700 Rp6,700
25 oxyla inj 4 Rp10,120 Rp40,480 25 oxyla inj 4 Rp10,120 Rp40,480 TOTAL BIAYA Rp577,565 2 paket blood set 20 1 Rp16,190 Rp16,190
26 metvell inj 1 Rp7,589 Rp7,589 26 metvell inj 1 Rp7,589 Rp7,589 cat : 3 hansaplast 1 Rp250 Rp250
27 ketorolac inj 1 Rp2,100 Rp2,100 27 nacl 500 ml wida 1 Rp6,800 Rp6,800 regivell inj : senin- kamis 4 nasal oxygen adult 1 Rp6,600 Rp6,600
28 nacl 500 ml wida 1 Rp6,800 Rp6,800 28 rl sp 2 Rp7,629 Rp15,258 bunascan inj : jumat - minggu 5 sarung tangan steril no 7,5 4 Rp19,000 Rp76,000
29 rl sp 2 Rp7,629 Rp15,258 29 Pct inf 1000 1 Rp9,800 Rp9,800 6 povidone iodine 60 ml 1 Rp6,400 Rp6,400
TOTAL BIAYA Rp610,981 30 ketorolac inj 1 Rp2,100 Rp2,100 7 spinocan 27 bbraun 1 Rp33,600 Rp33,600
cat : 31 dexametason inj 2 Rp1,200 Rp2,400 8 spuit 1 1 Rp1,116 Rp1,116
PAKET BPJS KISTEKTOMY/ TINDAKAN OBGYN SELAIN HT
regivell inj : senin- kamis TOTAL BIAYA Rp623,141 9 spuit 3 2 Rp2,000 Rp4,000
bunascan inj : jumat - minggu cat : NO NAMA BARANG JUMLAH HPP BIAYA 10 spuit 5 2 Rp1,451 Rp2,902
regivell inj : senin- kamis 1 urin bag 1 Rp6,700 Rp6,700 11 spuit 10 1 Rp1,580 Rp1,580
bunascan inj : jumat - minggu 2 paket benang sc 1 Rp192,512 Rp192,512 12 spuit 20 1 Rp1,689 Rp1,689
PAKET DNC 4 paket blood set 20 1 Rp16,190 Rp16,190 13 aqua 25 ml 1 Rp2,700 Rp2,700
NO NAMA BARANG JUMLAH HPP BIAYA 5 cuticell 1 Rp12,815 Rp12,815 16 bunascan / regivell 1 Rp61,600 Rp61,600
1 paket blood set no 20 1 Rp16,190 Rp16,190 6 nasal oxygen adult 1 Rp6,600 Rp6,600 17 ondansentron4 mg inj 2 Rp3,625 Rp7,250
2 nasal oxygen adult 1 Rp6,600 Rp6,600 PAKET FAM 7 sarung tangan steril no 7 4 Rp19,212 Rp76,848 19 ranitidine inj 1 Rp1,700 Rp1,700
3 spuit 3 1 Rp1,185 Rp1,185 NO NAMA BARANG JUMLAH HPP BIAYA 8 povidone iodine 60 ml 1 Rp6,400 Rp6,400 20 ketorolac inj 1 Rp2,100 Rp2,100
4 spuit 5 1 Rp1,451 Rp1,451 1 paket benang fam 1 Rp137,500 Rp137,500 9 spuit 1 1 Rp1,400 Rp1,400 21 nacl 500 ml wida 1 Rp6,800 Rp6,800
5 spuit 10 1 Rp1,580 Rp1,580 2 paket blood set 20 1 Rp16,190 Rp16,190 10 spuit 3 2 Rp2,000 Rp4,000 22 rl sp 2 Rp7,629 Rp15,258
6 proanes inj 1 Rp70,258 Rp70,258 3 nasal oxygen adult 1 Rp6,600 Rp6,600 11 spuit 5 1 Rp1,451 Rp1,451 TOTAL BIAYA Rp254,435
7 metvell inj 1 Rp7,589 Rp7,589 4 sarung tangan steril no 7 4 Rp19,000 Rp76,000 12 spuit 10 1 Rp1,580 Rp1,580 cat :
8 ondansentron4 mg inj 2 Rp3,625 Rp7,250 5 povidon iodine 60 ml 1 Rp6,400 Rp6,400 13 spuit 20 1 Rp1,700 Rp1,700 regivell inj : senin- kamis
9 rl sp 1 Rp7,629 Rp7,629 6 spuit 3 2 Rp1,185 Rp2,370 14 fol cath 14 1 Rp15,400 Rp15,400 bunascan inj : jumat - minggu
10 nacl 500 ml wida 1 Rp6,800 Rp6,800 7 spuit 5 2 Rp1,451 Rp2,902 15 spinocan 27 bbraun 1 Rp33,600 Rp33,600
11 povidone iodine 60 ml 1 Rp6,400 Rp6,400 8 spuit 10 1 Rp1,580 Rp1,580 16 pisau 20 1 Rp3,800 Rp3,800 PAKET CIMINO / CDL
12 kaltropen supp 1 Rp10,725 Rp10,725 9 proanes inj 1 Rp70,258 Rp70,258 17 hansaplast 1 Rp250 Rp250 NO NAMA BARANG JUMLAH HPP BIAYA
13 clindamicin 300 mg kapsul 10 Rp900 Rp9,000 10 ondansentron4 mg inj 2 Rp3,700 Rp7,400 18 aqua 25 ml 1 Rp2,634 Rp2,634 1 paket benang cimino/CDL 1 Rp377,685 Rp377,685
14 asam mefenamat 500mg 10 Rp216 Rp2,160 11 ketorolac inj 1 Rp2,100 Rp2,100 21 bunascan / regivell 1 Rp61,600 Rp61,600 2 ecare iv dressing 1 Rp2,300 Rp2,300
15 Metil ergometrin tab 10 Rp330 Rp3,300 12 nacl 500 ml wida 1 Rp6,800 Rp6,800 22 ondansentron 4 mg inj 2 Rp3,700 Rp7,400 3 sarung tangan steril no 7,5 1 Rp8,153 Rp8,153
16 sarung tangan steril no 7 1 Rp19,212 Rp19,212 13 RL 1 Rp7,629 Rp7,629 24 ranitidine inj 1 Rp1,700 Rp1,700 4 spuit 3 1 Rp1,185 Rp1,185
TOTAL BIAYA Rp177,329 TOTAL BIAYA Rp343,729 25 ketorolac inj 1 Rp2,100 Rp2,100 5 spuit 5 1 Rp1,451 Rp1,451
26 nacl 500 ml wida 1 Rp6,800 Rp6,800 6 spuit 10 1 Rp1,580 Rp1,580
27 rl sp 2 Rp7,629 Rp15,258 7 povidone iodine 60 ml 1 Rp6,400 Rp6,400
TOTAL BIAYA Rp478,738 8 nacl 500 ml wida 1 Rp6,800 Rp6,800
cat : 9 transofix 1 Rp4,200 Rp4,200
regivell inj : senin- kamis 10 lidocain inj 8 Rp850 Rp6,800
bunascan inj : jumat - minggu TOTAL BIAYA Rp416,554
PAKET HERNIATOMY PAKET APPENDICTOMY PAKET KATARAK (dr. Erika, SpM) DAFTAR PAKET OPERASI PASIEN JKN RS HERMINA
NO NAMA BARANG JUMLAH HPP BIAYA NO NAMA BARANG JUMLAH HPP BIAYA NO NAMA BARANG JUMLAH HPP BIAYA TANGERANG PER OKTOBER 2021
1 urin bag 1 Rp6,700 Rp6,700 1 urin bag 1 Rp6,700 Rp6,700 1 spuit 5 1 Rp1,451 Rp1,451
2 paket benang herniatomi 1 Rp414,700 Rp414,700 2 paket benang appendictomi 1 Rp244,200 Rp244,200 2 spuit 10 1 Rp1,580 Rp1,580 1 PAKET SC BPJS
3 paket blood set 20 1 Rp16,190 Rp16,190 3 paket blood set 20 1 Rp16,190 Rp16,190 3 spuit 20 1 Rp1,689 Rp1,689 2 PAKET SC BPJS (ERACS)
4 cuticell 1 Rp7,000 Rp7,000 4 cuticell 1 Rp12,815 Rp12,815 4 sarung tangan steril no 7 2 Rp19,000 Rp38,000 3 PAKET BPJS HISTEREKTOMY
5 nasal oxygen adult 1 Rp6,600 Rp6,600 5 nasal oxygen adult 1 Rp6,600 Rp6,600 5 rl sp 1 Rp7,629 Rp7,629 4 PAKET BPJS KISTEKTOMY/ TINDAKAN OBGYN SELAIN
6 sarung tangan steril no 7,5 4 Rp19,000 Rp76,000 6 sarung tangan steril no 7 4 Rp19,000 Rp76,000 6 gentamicin inj 1 Rp7,714 Rp7,714 HT
7 povidone iodine 60 ml 1 Rp6,400 Rp6,400 7 povidone iodine 60 ml 1 Rp6,400 Rp6,400 7 lidocain inj 1 Rp450 Rp450 5 PAKET ANESTESI UMUM
8 spuit 1 1 Rp1,116 Rp1,116 8 spuit 1 1 Rp1,116 Rp1,116 8 deksamethason inj 1 Rp1,090 Rp1,090 6 PAKET ANESTESI SPINAL (URS/ TURP/ HEMOROID/
9 spuit 3 2 Rp2,000 Rp4,000 9 spuit 3 2 Rp2,000 Rp4,000 9 lfx minidose (1 tetes tiap 1 jam) 5 Rp13,708 Rp68,540 TINDAKAN SELAIN OBGYN)
10 spuit 5 2 Rp1,451 Rp2,902 10 spuit 5 2 Rp1,451 Rp2,902 10 eyefresh plus md (6x 1 tetes) 5 Rp6,905 Rp34,525 7 PAKET DNC
11 spuit 10 1 Rp1,580 Rp1,580 11 spuit 10 1 Rp1,580 Rp1,580 11 xitrol ed (6x 1 tetes) 1 Rp26,977 Rp26,977 8 PAKET FAM
12 spuit 20 1 Rp1,689 Rp1,689 12 spuit 20 1 Rp1,689 Rp1,689 TOTAL BIAYA Rp189,645 9 PAKET CIMINO / CDL
13 fol cath 16 1 Rp15,400 Rp15,400 13 fol cath 14 / 16 1 Rp15,400 Rp15,400 10 PAKET HERNIATOMY
14 spinocan 27 bbraun 1 Rp33,600 Rp33,600 14 spinocan 27 bbraun 1 Rp33,600 Rp33,600 PAKET KATARAK (dr. Deddy, SpM) 11 PAKET APPENDICTOMY
15 hansaplast 1 Rp250 Rp250 15 hansaplast 1 Rp250 Rp250 NO NAMA BARANG JUMLAH HPP BIAYA 12 PAKET KATARAK (dr. Erika, SpM)
16 aqua 25 ml 1 Rp2,700 Rp2,700 16 aqua 25 ml 1 Rp2,700 Rp2,700 1 spuit 5 1 Rp1,451 Rp1,451 13 PAKET KATARAK (dr. Deddy, SpM)
19 bunascan / regivell 1 Rp61,600 Rp61,600 17 tramadol inj 3 Rp3,575 Rp10,725 2 spuit 10 1 Rp1,580 Rp1,580 14 PAKET KATARAK (dr. Suminto, SpM)
20 ondansentron4 mg inj 2 Rp3,700 Rp7,400 18 bunascan / regivell 1 Rp61,600 Rp61,600 3 spuit 20 1 Rp1,689 Rp1,689
22 ranitidine inj 1 Rp1,700 Rp1,700 19 ondansentron4 mg inj 2 Rp3,700 Rp7,400 4 sarung tangan steril 7,5 2 Rp19,000 Rp38,000
23 ketorolac inj 1 Rp2,100 Rp2,100 20 ranitidine inj 1 Rp1,700 Rp1,700 5 rl sp 1 Rp7,629 Rp7,629
24 nacl 500 ml wida 1 Rp3,564 Rp3,564 21 kaltrofen supp 1 Rp10,725 Rp10,725 6 gentamicin inj 1 Rp7,714 Rp7,714
25 RL SP 2 Rp7,629 Rp15,258 22 nacl 500 ml wida 1 Rp6,800 Rp6,800 7 lidocain inj 1 Rp450 Rp450
TOTAL BIAYA Rp688,449 23 RL SP 2 Rp7,629 Rp15,258 8 deksamethason inj 1 Rp1,090 Rp1,090
cat : TOTAL BIAYA Rp546,350 9 asmef 500 mg tab (3x 1 tab) 12 Rp216 Rp2,592
regivell inj : senin- kamis cat : 10 ciprofloxacin tab (2x 1 tab) 10 Rp342 Rp3,420
bunascan inj : jumat - minggu regivell inj : senin- kamis 11 eyefreshplus md (6x 1 tetes) 5 Rp6,905 Rp34,525
bunascan inj : jumat - minggu 12 xitrol ed (6x 1 tetes) 1 Rp26,977 Rp26,977
TOTAL BIAYA Rp127,117

PAKET KATARAK (dr. Suminto, SpM)

NO NAMA BARANG JUMLAH HPP BIAYA
1 spuit 5 1 Rp1,451 Rp1,451
2 spuit 10 1 Rp1,580 Rp1,580
3 spuit 20 1 Rp1,689 Rp1,689
4 sarung tangan steril 7,5 2 Rp19,000 Rp38,000
5 rl sp 1 Rp7,629 Rp7,629
6 gentamicin inj 1 Rp7,714 Rp7,714
7 lidocain inj 1 Rp450 Rp450
8 deksamethason inj 1 Rp1,090 Rp1,090
9 tobroson md (1 tetes tiap 3 jam) 5 Rp5,742 Rp28,710
10 floxa md (1 tetes tiap 3 jam) 5 Rp5,296 Rp26,480
TOTAL BIAYA Rp114,793

Dibuat di Tangerang, 08 Oktober 2021

Mengetahui, Mengetahui, Menyetujui,

dr. Uswah Muslim dr. Christiansen W Ns. Lanawati, S.Kep dr. Anggraina W Ria Herdarwulan, S.E., MARS dr. Nienne Aridayanthi H., MARS., M.H
(Man. Yanmed) (Man. Jangmed) (Man. Keperawatan) (Wadirmed) (Wadir Umum) (Direktur)
PAKET BPJS KATARAK VACO DR ERIKA

NO NAMA BARANG JUMLAH KETERANGAN NO

1 Povidone iodine 60 ml
2 syring 5/10/20
3 sarung tangan steril no 7
4 sarung tangan steril 7,5
5 rl sp
6 nacl 25 ml
7 gentamicin inj
8 lidocain inj
9 deksamethason inj
10 lfx minidose
11 eyefresh plus md
12 xitrol ed
PAKET BPJS KATARAK DR DEDDY
NO NAMA BARANG
1 Povidone iodine 60 ml
2 spuit 5/10/20
3 sarung tangan steril no 7
4 sarung tangan steril 7,5
5 RL SP
6 nacl 25 ml
7 sagestam inj
8 lidocain inj
9 deksamethason inj
10 mefenamat asam 500 mg tab
11 ciprofloxacin tab
12 eyefreshplus md
13 xitrol ed
PAKET BPJS KATARAK DR SUMINTO
1 10 pasien 1 botol 1
1'/1'/1' 2
2 3
1 4
1 5
1 6
1 7
1 8
1 9
5 ampul tiap jam 1 tetes 10
5 ampul 6 x sehari 1 tetes 11
1 6 x sehari 1 tetes 12
13
14
15
16
JUMLAH KETERANGAN 17
1 10 pasien 1 botol 18
1'/1'/1' 19
2 20
1 21
1 22
1 23
1 24
1 25
1 26
12 3 x sehari 1 tablet 27
10 2 x sehari 1 tablet 28
1 6 x sehari 1 tetes
1 6 x sehari 1 tetes cat :
regivell inj : senin- kamis
bunascan inj : jumat - minggu

NO NAMA BARANG JUMLAH KETERANGAN

1 Povidone iodine 60 ml 1 10 pasien 1 botol
2 spuit 5/10/20 1'/1'/1'
3 sarung tangan steril no 7 2
4 sarung tangan steril 7,5 1
5 RL SP 1
6 nacl 25 ml 1
7 sagestam inj 1
8 lidocain inj 1
9 deksamethason inj 1
10 tobroson md 5 ampul tiap 3 jam 1 tetes PAKET BPJS DNC
11 floxa md 5 ampul tiap 3 jam 1 tetes
NO
1
PAKET CIMINO / CDL 2
NAMA BARANG 3
NO paket benang cimino/CDL JUMLAH KETERANGAN 4
1 opsite iv 3000 1 5
2 sarung tangan steril no 7 1 6
3 sarung tangan steril no 7,5 1 7
4 spuit 3/5/10 1 8
5 povidone iodine 60 ml 1'/1'/1' 9
6 nacl 25 ml 1 10
7 lidocain inj 3 11
12

PAKET BPJS APPENDICTOMI

NO
NO NAMA BARANG JUMLAH KETERANGAN 1
1 urin bag 1 2
2 paket benang appendictomi 1 3
3 paket blood set 20 1 4
4 cuticell/ bactigras 1 5
5 nasal oxygen adult 1 6
6 sarung tangan steril no 7 4 7
7 povidone iodine 60 ml 1 8
8 spuit 1/3/5/10/20 1/2/2/1/1 9
9 fol cath 14 / 16 1 10
10 spinocan 27 bbraun 1 11
11 hansaplast 1 12
12 aqua 25 ml 1 13
13 nacl 25 ml 1 14
 14 ceftriaxon inj 2 15
15 tramadol inj 1 16
16 bunascan inj / regivell inj 1 17
17 ondansentron 8 mg inj 1 18
18 ranitidine inj 1 19
19 kaltrofen supp 1 20
20 nacl 500 ml wida 1 21
21 RL SP 2
cat :
cat : regivell inj : senin- kamis
regivell inj : senin- kamis bunascan inj : jumat - minggu
bunascan inj : jumat - minggu

NO
ANASTESI UMUM 1
2
NO NAMA BARANG JUMLAH KET 3
1 paket blood set 20 1 4
2 nasal oxygen adult 1 5
3 sarung tangan steril no 7 4 6
4 povidone iodine 60 ml 1 7
5 spuit 1/3/5/10 1/2/2/1 8
6 aqua 25 ml 1 9
7 nacl 25 ml 1 10
8 ceftriaxon inj 2 11
9 tramadol inj 1 12
10 ondansentron 8 mg inj 1 13
11 ranitidine inj 1 14
12 proanes inj 1 15
13 kaltrofen supp 1 16
14 nacl 500 ml wida 1 17
15 rl sp 2 18
19

cat :
regivell inj : senin- kamis
bunascan inj : jumat - minggu
 PAKET SC BPJS

NAMA BARANG JUMLAH KET NO

urin bag 1 1
paket benang sc 1 2
t chromic 27 1 3
paket blood set 20 1 4
cuticell/ bactigras 1 5
nasal oxygen adult 1 6
sarung tangan steril no 7 4 7
povidone iodine 60 ml 2 8
spuit 1/3/5/10/20 1/2/2/1/1 9
fol cath 14 1 10
suction catheter no 8 1 11
spinocan 27 bbraun 1 12
pisau 20 1 13
hansaplast 1 14
umbilical cord clamp 1 15
aqua 25 ml 1 16
nacl 25 ml 1 17
vitadion inj 1 18
ceftriaxon inj 1 19
tramadol inj 1 20
bunascan inj / regivell inj 1 21
ondansentron 8 mg inj 1 22
ranitidine inj 1 23
oxyla inj 4
metvell inj 1 cat :
kaltrofen supp 1 regivell inj : senin- kamis
nacl 500 ml wida 1 bunascan inj : jumat - minggu
rl sp 2 0p

cat :
regivell inj : senin- kamis
bunascan inj : jumat - minggu p
PAKET BPJS DNC

NAMA BARANG JUMLAH

KETERANGAN
paket blood set no 20 1
nasal oxygen adult
spuit 3/5/10 2'/2'/1'
proanes inj 1 NO
metvell inj 1 1
ondansentron 8 mg inj 1 2
rl sp 1 3
nacl 500 ml wida 1 4
povidone iodine 60 ml 1 5
kaltropen supp 1 6
clindamicin 150 mg kapsul 10 2X1 7
ASAM MEFENAMAT 10 8

PAKET BPJS FAM

PAKET HERNIATOMI
NAMA BARANG JUMLAH KET NO
urin bag 1 1
paket benang herniatomi 1 2
paket blood set 20 1 3
cuticell/ bactigras 1 4
nasal oxygen adult 1 5
sarung tangan steril no 7 4 6
povidone iodine 60 ml 1 7
spuit 1/3/5/10/20 1/2/2/1/1 8
fol cath 16 1 9
spinocan 27 bbraun 1 10
hansaplast 1 11
aqua 25 ml 1
nacl 25 ml 1
ceftriaxon inj 2
 tramadol inj 1
bunascan inj / regivell inj 1
ondansentron 8 mg inj 1
ranitidine inj 1
kaltrofen supp 1
nacl 500 ml wida 1
RL SP 2

regivell inj : senin- kamis

bunascan inj : jumat - minggu

PAKET ANASTESI SPINAL

NAMA BARANG JUMLAH KET

urin bag 1
paket blood set 20 1
hansaplast 1
nasal oxygen adult 1
sarung tangan steril no 7 4
povidone iodine 60 ml 1
spuit 1/3/5/10/20 1/2/2/1/1
fol cath 14 / 16 1
spinocan 27 bbraun 1
aqua 25 ml 1
nacl 25 ml 1
ceftriaxon inj 2
tramadol inj 1
bunascan inj / regivell inj 1
ondansentron 8 mg inj 1
ranitidine inj 1
kaltrofen supp 1
nacl 500 ml wida 1
rl sp 2

regivell inj : senin- kamis

bunascan inj : jumat - minggu
pP
 PAKET BPJS NON SC

NAMA BARANG JUMLAH KET

urin bag 1
paket benang sc 1
t mono m 48 1
paket blood set 20 1
cuticell/ bactigras 1
nasal oxygen adult 1
sarung tangan steril no 7 4
povidone iodine 60 ml 1
spuit 1/3/5/10/20 1/2/2/1/1
fol cath 14 1
spinocan 27 bbraun 1
pisau 20 1
hansaplast 1
aqua 25 ml 1
nacl 25 ml 1
ceftriaxon inj 2
tramadol inj 1
bunascan / regivell 1
ondansentron 8 mg inj 1
ranitidine inj 1
kaltrofen supp 1
nacl 500 ml wida 1
rl sp 2

regivell inj : senin- kamis

bunascan inj : jumat - minggu
p
 PAKET KAUTER
NAMA BARANG
lidocain inj JUMLAH KETERANGAN
asam traneksamat in 500 mg 2
aqua 25 ml 1
spuit 10 cc 1
spuit 5 cc 1
amoxicilin 500 mg kaplet 1
mefenamat asam 500 mg tab 10 3 x sehrai 1 tablet
asam traneksamat 500 mg tba 10 3 x sehrai 1 tablet

KET BPJS FAM

NAMA BARANG JUMLAH KET

paket benang fam 1
paket blood set 20 1
nasal oxygen adult 1
sarung tangan steril no 7 4
povidon iodine 60 ml 1
spuit 3/5/10 2'/2'/1'
proanes inj 1
ondansentron 8 mg inj 1
kaltrofen supp 1
nacl 500 ml wida 1
RL 1