of KEMENTERIAN KESEHATAN REPUBLIK INDONESIA. JKN Berkas Klaim Individual Pasien 23/03/2022 Kode Rumah Sakit 3175610 Kelas Rumah Sakit c Nama RS RUMAH SAKIT UMUM PEKERJA —_Jenis Tarif TARIF RS KELAS C SWASTA Nomor Peserta 001609415462 Nomor SEP 0116R0340322v002173 Nomor Rekam Medis : 00042269 Tanggal Masuk 16/03/2022 mur Tahun 52 Tanggal Keluar 23/03/2022 mur Har 19036 denis Perawatan 1 = Rawat tnap Tanggal Lahir 01/02/1970 Cara Pulang 4 = Meninggal Dunia Jenis Kelarin 1 Lak-laki Los 8 hari Kelas Perawatan 3 - Kelas 3 Berat Lahir - Diagnosa Utama Diagnosa Sekunder Prosedur RS7.2 Septic shock 381 Pulmonary oedeme 112.0 Hypertensive renal disease with renal failure 87.6 Hypokalaemia 120.0 Unstable angina 96,71 Continuous invasive mechanical ventilation for less than 96 consecutive hours 38.97 Central venous catheter placement with guidance 38.95 Venous catheterization for renal dialysis 99.18 Injection or infusion of electrolytes 99.29 Injection or Infusion of other therapeutic or prophylactic substance 99.21 Injection of antibiotic 90,59 Microscopic examination of blood, Other microscopic examination 87.44 Routine chest x-ray, so described 89.65 Measurement of systemic arterial blood gases 39.95 Hemodialysis ADL Sub Acute - ADL Chronic - Hasil Grouping INA-CBG J-1-20-1II__ PROSEDUR SISTEM PERNAFASAN NON-KOMPLEKS (BERAT) Rp 19,210,900.00, SSub acute - Rp 0.00 Chronic - Rp 0.00 Special CMG - Rp 0.00 Total Tarif Rp 19,210,900.00 Ganered E-Minim 5,67 20220a2AITI © 2002-08-08 DSTA Tene