REALISASI CAPEX PELAYANAN MEDIK TAHUN …………..

I. PERBAIKAN DAN PENGEMBANGAN FISIK

PRIORIT HARGA HARGA SATUAN JML TOTAL RUANG BULAN

NO JENIS QTY TOTAL
AS SATUAN 2020 2021 USULAN 2021
RNP RJL VK OK ICU …DLL JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
Ruang rehat drg+perawat (untuk sholat,
1 1 1 15,000,000 16,500,000 16,500,000 1 16,500,000 16,500,000
makan dsb)
Ganti walpaper+internit untuk poli
2 2 4 8,000,000 8,800,000 35,200,000 4 35,200,000 35,200,000
242,244,249,250
3 Perbaikan fisik+plapon (poli mata) 2 1 10,000,000 11,000,000 11,000,000 1 11,000,000 11,000,000
Pengecatan ruangan (JBC & Koridor poli
4 3 2 2,000,000 2,200,000 4,400,000 4,400,000 4,400,000
paru)
5 Penggantian walpaper (143 &146) 2 2 6,000,000 6,600,000 13,200,000 2 13,200,000 13,200,000
6 Jaringan komputer (JDC) 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000

Pengecatan ruang VIP B (6 kamar) &

7 klas I (6 kamar) dan koridor lily yasmin 1 14 2,000,000 2,200,000 30,800,000 14 30,800,000 30,800,000
(merk jotun/ Nippon cat adukan)

Pengecatan lemari pasien Lily & Yasmin

8 1 35 1,000,000 1,100,000 38,500,000 35 38,500,000 38,500,000
(kls vip A, vip B & I)
Perbaikan Kamar Mandi &WC kls VIP A
9 1 11 30,000,000 33,000,000 363,000,000 11 363,000,000 363,000,000
(11 Kamar 308-318)
Perbaikan Kamar Mandi &WC kls VIP B
10 (6 Kamar) 1 6 30,000,000 33,000,000 198,000,000 6 198,000,000 198,000,000

Penggantian toilet perawat ruang yasmin

11 1 1 6,000,000 6,600,000 6,600,000 1 6,600,000 6,600,000
( toilet rusak )
Penggantian arm chair ruang VIP A, 11
12 1 22 2,000,000 2,200,000 48,400,000 22 48,400,000 48,400,000
kamar (1 kamar 2 kursi)
Gudang linen & kamar ganti pria untuk di
13 2 1 10,000,000 11,000,000 11,000,000 1 11,000,000 11,000,000
cat dan perbaiakan internit
Penggantian bel kmr
14 359,354,360,361,364 krn sdh kendur / 1 5 3,000,000 3,300,000 16,500,000 5 16,500,000 16,500,000
rusak (Kisan)
Pengecatan kamar 2121,2122, 2117,
15 1 7 2,000,000 2,200,000 15,400,000 7 15,400,000 15,400,000
2116, 2115, 2114, dan 2113 (Anyelir)
16 Pengecatan tempat tidur anak (Anyelir) 1 13 2,000,000 2,200,000 28,600,000 13 28,600,000 28,600,000

17 Pengecatan kamar 227 & 228 (Dahlia) 1 2 2,000,000 2,200,000 4,400,000 2 4,400,000 4,400,000

18 Pengecatan kamar mandi 227,228 & VK 1 3 1,500,000 1,650,000 4,950,000 3 4,950,000 4,950,000

19 Renovasi kamar bayi (Anyelir) 1 1 10,000,000 11,000,000 11,000,000 1 11,000,000 11,000,000

20 Penggantian bel kmr 318 karena kendur. 1 1 3,000,000 3,300,000 3,300,000 1 3,300,000 3,300,000
Kabel bel kamar 333, 334, 337, 339,
21 1 9 3,000,000 3,300,000 29,700,000 7 29,700,000 29,700,000
338,327,328, 316, dan 310.
22 Perbaikan krey ruang lily 24 kmr (Lily) 2 24 3,000,000 3,300,000 79,200,000 24 79,200,000 79,200,000
TOTAL 156,500,000 172,150,000 975,150,000 22,000,000 45,100,000 80,300,000 363,000,000 198,000,000 59,400,000 37,950,000 41,800,000 48,400,000 79,200,000 - - 975,150,000

II. PERALATAN DAN PERLENGKAPAN

A. PERLENGKAPAN ALAT KESEHATAN NON INSTRUMENT >Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL RUANG BULAN

NO JENIS PRIORITASQTY 2021 USULAN 2021 TOTAL
SATUAN 2020 DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Mesin rotari merk denstply 1 1 30,000,000 33,000,000 33,000,000 1 33,000,000 33,000,000
2 Ligh box ( Orthopedi LED) 1 3 4,000,000 4,400,000 13,200,000 3 13,200,000 13,200,000
3 Shage guide merk Vita (JDC) 1 2 2,500,000 2,750,000 5,500,000 2 5,500,000 5,500,000
4 Rubber dam (JDC) 1 1 3,000,000 3,300,000 3,300,000 1 3,300,000 3,300,000
5 Apron radiasi (JDC) 1 1 3,000,000 3,300,000 3,300,000 1 3,300,000 3,300,000
6 Smoke Evakuator (JBHC) 2 1 30,000,000 33,000,000 33,000,000 1 33,000,000 33,000,000
7 Doppler merk Huntleigh (obsgyn) 1 1 10,000,000 11,000,000 11,000,000 1 11,000,000 11,000,000
8 Tempat tidur gyn (obsgyn) 1 1 60,000,000 66,000,000 66,000,000 1 66,000,000 66,000,000
9 Tayu Set (THT) 1 1 250,000,000 275,000,000 275,000,000 1 275,000,000 275,000,000
10 Lampu Kepala (THT) 1 1 4,000,000 4,400,000 4,400,000 1 4,400,000 4,400,000
11 Tympanometri (THT) 1 1 30,000,000 33,000,000 33,000,000 1 33,000,000 33,000,000
12 Kursi tindakan elektrik (THT) 1 1 50,000,000 55,000,000 55,000,000 1 55,000,000 55,000,000
13 DC Shock (Treadmil) 1 1 350,000,000 385,000,000 385,000,000 1 385,000,000 385,000,000
14 Alat treadmil (Treadmil) 1 1 600,000,000 660,000,000 660,000,000 1 660,000,000 660,000,000
15 Tensimeter elektrik (Treadmil) 1 1 1,000,000 1,100,000 1,100,000 1 1,100,000 1,100,000
16 Tensimeter standing (JDC, Orthopedi) 2 3 1,500,000 1,650,000 4,950,000 3 4,950,000 4,950,000
Tensimeter air raksa merk Riester (BRC,
17 1 2 1,100,000 1,210,000 2,420,000 1 1 2,420,000 2,420,000
Dahlia)
Stetoscope merk lietmen (Poli:
18 2 7 1,000,000 1,100,000 7,700,000 1 5 1 7,700,000 7,700,000
(Int,umum,ort); BRC; Dahlia)
19 Lampu sorot merk Dyna (Orto,Obsgyn) 2 3 1,000,000 1,100,000 3,300,000 3 3,300,000 3,300,000
20 Tempat tidur elektric (JBC) 1 1 60,000,000 66,000,000 66,000,000 1 66,000,000 66,000,000
21 Kabel pasien EKG (246) 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
22 Troly Obat (Liyas 2 & Krisan 1) 1 3 40,000,000 44,000,000 132,000,000 1 2 132,000,000 132,000,000
Oksigen flowmeter (Timeter/puritan
23 1 4 5,000,000 5,500,000 22,000,000 4 22,000,000 22,000,000
bennett) Krisan
Lampu emergency merk Maspion
24 1 2 1,000,000 1,100,000 2,200,000 2 2,200,000 2,200,000
(krisan)
Vacutron Suction merk puritan bennet
25 1 5 1,500,000 1,650,000 8,250,000 5 8,250,000 8,250,000
(Krisan)
26 Wall Mounted (Krisan) 1 2 1,000,000 1,100,000 2,200,000 2 2,200,000 2,200,000
27 Oxcyon II (SPO2) merk Bionet (anyelir) 2 1 20,000,000 22,000,000 22,000,000 1 22,000,000 22,000,000
Neo puff merk Fisher & Paykel Health
28 1 1 37,000,000 40,700,000 40,700,000 1 40,700,000 40,700,000
care (anyelir)
29 Rak Stenlis pispot & urinal stenlis 1 2 7,000,000 7,700,000 15,400,000 2 15,400,000 15,400,000
TOTAL 1,609,600,000 1,770,560,000 1,916,420,000 660,000,000 418,000,000 123,970,000 93,500,000 275,000,000 33,550,000 66,000,000 55,000,000 59,400,000 132,000,000 0 0 1,916,420,000

B. PERLENGKAPAN ALAT KESEHATAN NON INSTRUMENT < Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL RUANG BULAN

NO JENIS PRIORITASQTY 2021 USULAN 2021 TOTAL
SATUAN 2020 DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Pen light merk riester 1 5 500,000 385,000 1,925,000 5 1,925,000 1,925,000
Ear thermometer merk Microlife (poli
2 1 6 900,000 990,000 5,940,000 1 2 2 1 5,940,000 5,940,000
Anak2, BRC 1, Anyelir1, Lily2)
Thermometer elektrik non kontac
3 2 7 900,000 990,000 6,930,000 7 6,930,000 6,930,000
(Counter Poli)
4 Meteran (JBC) 2 1 100,000 110,000 110,000 1 110,000 110,000
5 Bel Panggil merk Himawari (poli) 2 5 500,000 550,000 2,750,000 5 2,750,000 2,750,000
Thermometer digital merk microlife (ily
6 2 13 50,000 110,000 1,430,000 13 1,430,000 1,430,000
13)
7 Spuit glicerin 100 CC (lily) 2 1 300,000 330,000 330,000 1 330,000 330,000
8 Ligh box (JDC 3 portble) 2 3 650,000 715,000 2,145,000 2,145,000 2,145,000
TOTAL 3,900,000 4,180,000 21,560,000 2,145,000 5,940,000 6,930,000 4,675,000 110,000 1,430,000 330,000 - - - - - 21,560,000

C. PERLENGKAPAN ALAT KESEHATAN INSTRUMENT > Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL RUANG BULAN

NO JENIS PRIORITASQTY 2021 USULAN 2021 TOTAL
SATUAN 2020 DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Citoject merk Hareus (JDC) 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
2 Cartridge syiringe (Osung/Yunex) JDC 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
3 Tang gigi tetap (Osung/Yunex) JDC 1 6 1,000,000 1,100,000 6,600,000 6 6,600,000 6,600,000
4 Bone file (Osung/Yunex) JDC 1 2 1,000,000 1,100,000 2,200,000 2 2,200,000 2,200,000
Gunting aff hecthing (Osung/Yunex)
5 1 6 1,500,000 1,650,000 9,900,000 9,900,000 9,900,000
JDC 6
6 Periodontal probe (osung/Yunex) JDC 1 3 1,000,000 1,100,000 3,300,000 3 3,300,000 3,300,000
7 Crown rectraktor (Osung/Yunex) JDC 1 3 1,000,000 1,100,000 3,300,000 3 3,300,000 3,300,000
8 Set ODC (Osung/Yunex) JDC 1 3 2,000,000 2,200,000 6,600,000 3 6,600,000 6,600,000
9 Set Heacting (Obsgyn) 1 2 2,000,000 2,200,000 4,400,000 2 4,400,000 4,400,000
10 Sonde Uterus (Obsgyn) 1 2 2,000,000 2,200,000 4,400,000 2 4,400,000 4,400,000
11 Spekulum kecil (Obsgyn) 1 4 1,000,000 1,100,000 4,400,000 4 4,400,000 4,400,000
12 Spekulum sedang (Obsgyn) 1 4 1,250,000 1,375,000 5,500,000 4 5,500,000 5,500,000
Set GV : (Pincet anatomi 1, Pincet
13 cirurgis 1, gunting jaringan 1, arteri klem 1 10 2,000,000 2,200,000 22,000,000 22,000,000 22,000,000
1) Poli Bedah&Ortho 10
14 Gunting verban (Poli: ortho,bedah, mata) 1 5 1,000,000 1,100,000 5,500,000 5,500,000 5,500,000
5
15 Gunting aff heacting (JBHC) 1 3 1,000,000 1,100,000 3,300,000 3 3,300,000 3,300,000
16 Jarum electrocauter (JBHC) 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
17 Pinset anatomis (Liyas) 2 5 1,000,000 1,100,000 5,500,000 5 5,500,000 5,500,000
18 Pinset cirurgis (Liyas) 2 5 1,000,000 1,100,000 5,500,000 5 5,500,000 5,500,000
TOTAL 34,750,000 38,225,000 108,900,000 5,500,000 12,100,000 22,000,000 12,100,000 12,100,000 11,000,000 17,600,000 11,000,000 5,500,000 - - - 108,900,000

D. PERLENGKAPAN ALAT KESEHATAN INSTRUMENT < Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL BULAN

NO JENIS PRIORITASQTY TOTAL
SATUAN 2020 2021 USULAN 2021
DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Bein Lurus merk martin (JDC) 1 10 650,000 715,000 7,150,000 10 7,150,000 7,150,000
2 Box ODC merk Labora (JDC) 1 3 500,000 550,000 1,650,000 3 1,650,000 1,650,000
3 Aligator merk eartek (Poli THT) 1 2 700,000 770,000 1,540,000 2 1,540,000 1,540,000
4 Cerumen hak (THT) 1 3 800,000 880,000 2,640,000 3 2,640,000 2,640,000
 5 Suction kecil (lurus) THT 1 2 500,000 550,000 1,100,000 2 1,100,000 1,100,000
6 Suction besar (lurus) THT 1 2 500,000 550,000 1,100,000 2 1,100,000 1,100,000
7 Gunting kecil lurus THT 1 2 500,000 550,000 1,100,000 2 1,100,000 1,100,000
8 Lampu spiritus merk standar (JDC) 1 2 100,000 110,000 220,000 2 220,000 220,000
9 Bowl+spatula merk standar (JDC) 1 2 100,000 110,000 220,000 2 220,000 220,000
10 Plastis filling merk hanz (JDC) 1 10 50,000 55,000 550,000 10 550,000 550,000
11 Semen spatel merk hanz (JDC) 1 5 35,000 38,500 192,500 5 192,500 192,500
12 Nierbeken sedang merk hanz (JDC) 1 4 250,000 275,000 1,100,000 4 1,100,000 1,100,000
13 Nierbeken besar merk hanz (Otho) 1 4 250,000 275,000 1,100,000 4 1,100,000 1,100,000
14 Minesota merk Osung (JDC) 1 3 400,000 440,000 1,320,000 3 1,320,000 1,320,000
TOTAL 5,868,500 20,982,500 0 7,150,000 2,750,000 2,640,000 3,740,000 440,000 742,500 2,200,000 1,320,000 0 0 0 20,982,500

E.PERLENGKAPAN ALAT NON MEDIK > Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL RUANG BULAN

NO JENIS PRIORITASQTY TOTAL
SATUAN 2020 2021 USULAN 2021
DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Troly Pakaian kotor tertutup (BRC) 1 1 .- 5,000,000 5,000,000 1 5,000,000 5,000,000
Tempat tidur pasien elektrik (Liyas) merk
2 2 4 50,000,000 55,000,000 220,000,000 4 220,000,000 220,000,000
paramount
3 Nakas (Liyas) 2 5 4,000,000 4,400,000 22,000,000 5 22,000,000 22,000,000
4 TV USG kamar dokter (Poli Obsgyn) 1 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
5 Kursi + Meja dokter (Poli Mata) 2 1 3,500,000 3,850,000 3,850,000 1 3,850,000 3,850,000
6 AC Split (Poli 246&249) 1 2 5,000,000 5,500,000 11,000,000 2 11,000,000 11,000,000
Kursi untuk ps rongsent dental (JDC)
7 1 1 1,500,000 1,650,000 1,650,000 1 1,650,000 1,650,000
merk diploma
8 Asisten atole/kursi asisten (JDC) 1 2 1,000,000 1,100,000 2,200,000 2 2,200,000 2,200,000
9 Perbaikan sofa (JDC) 1 10 3,000,000 3,300,000 33,000,000 10 33,000,000 33,000,000
DVD Player + TV ( untuk lihat hasil ro via
10 1 1 7,500,000 8,250,000 8,250,000 1 8,250,000 8,250,000
disc) JDC
11 Kulkas Vaksin (Poli anak ) 1 1 20,000,000 22,000,000 22,000,000 1 22,000,000 22,000,000
12 Komputer (poli 248) 1 1 25,000,000 27,500,000 27,500,000 1 27,500,000 27,500,000
13 TV 32" inchi Toshiba (Poli Paru) 2 1 5,000,000 5,500,000 5,500,000 1 5,500,000 5,500,000
14 Troly stenlis 2 1 5,000,000 5,500,000 5,500,000 5,500,000 5,500,000
TOTAL 135,500,000 154,050,000 372,950,000 3,850,000 10,500,000 33,000,000 220,000,000 22,000,000 12,100,000 11,000,000 22,000,000 27,500,000 11,000,000 0 0 372,950,000

F.PERLENGKAPAN ALAT NON MEDIK < Rp 1.000.000

HARGA HARGA SATUAN JML TOTAL BULAN

NO JENIS PRIORITASQTY 2021 USULAN 2021 TOTAL
SATUAN 2020 DAH ANY POLI KRI LIYAS BRC JNR FBR MRT APR MEI JUN JUL AGT SPT OKT NVR DSR
1 Telepon (Poli 144 &JDC IV) 1 2 800,000 880,000 1,760,000 2 1,760,000 1,760,000
2 Jam dinding (Poli 144 & JDC IV) 1 4 200,000 220,000 880,000 4 880,000 880,000
3 Senter LED (poli Umum) 1 2 150,000 165,000 330,000 2 330,000 330,000
4 Timbangan portable (Poli 146) 1 1 250,000 275,000 275,000 1 275,000 275,000
Box plastik kotak (Poli JDC, Ortho, THT,
5 2 10 50,000 55,000 550,000 10 550,000 550,000
Obsyn
6 Botol spray (Poli JDC & THT) 2 6 50,000 55,000 330,000 6 330,000 330,000
7 Meja Komputer (Poli JDC) 1 1 900,000 990,000 990,000 1 990,000 990,000
8 Ember Plastik sedang (Krisan) 2 4 50,000 55,000 220,000 4 220,000 220,000
9 Gayung (Krisan) 2 5 20,000 22,000 110,000 5 110,000 110,000
10 Gelas ukur plastik (Krisan) 2 6 150,000 165,000 990,000 6 990,000 990,000
11 Kom Plastik (Krisan) 2 10 20,000 22,000 220,000 10 220,000 220,000
12 Urinal Plastik (Krisan) 2 6 100,000 110,000 660,000 6 660,000 660,000
13 Pispot stenlis ceper (Krisan) 2 3 800,000 880,000 2,640,000 3 2,640,000 2,640,000
14 Troly kayu (Liyas) 2 2 900,000 990,000 1,980,000 2 1,980,000 1,980,000
15 Timbangan digital dewasa (Liyas) 2 1 990,000 1,089,000 1,089,000 1 1,089,000 1,089,000
16 Rak formulir kayu (Liyas) 2 1 500,000 550,000 550,000 1 550,000 550,000
17 Timbangan digital bayi (Liyas) 2 1 990,000 1,089,000 1,089,000 1 1,089,000 1,089,000
18 Lemari untuk berkas formulir (BRC) 2 1 800,000 880,000 880,000 1 880,000 880,000
Lemari untuk tempat hasil-hasil film
19 2 1 800,000 880,000 880,000 1 880,000 880,000
radiologi (BRC)
TOTAL 8,520,000 9,372,000 16,423,000 1,760,000 1,210,000 2,805,000 2,409,000 880,000 2,959,000 2,640,000 880,000 880,000 0 0 0 16,423,000

TOTAL ANGGARAN :
3,432,385,500

Jakarta, ………………………………..
Manager……………………………….