KEMENTERIAN KESEHATAN REPUBLIK INDONESIA JKN

Berkas Klaim Individual Pasien 26/01/2021

Kode Rumah Sakit : 3273015 Kelas Rumah Sakit : A

Nama RS : RSU DR. HASAN SADIKIN Jenis Tarif : TARIF RS KELAS A PEMERINTAH

Nomor Peserta : 0001936606 Nomor SEP : 19892993802

Nomor Rekam Medis : 0001210024 Tanggal Masuk : 26/01/2021
Umur Tahun : 0 Tanggal Keluar : 26/01/2021
Umur Hari : 22 Jenis Perawatan : 1 - Rawat Inap
Tanggal Lahir : 04/01/2021 Cara Pulang : 1 - Atas Persetujuan Dokter
Jenis Kelamin : 1 - Laki-laki LOS : 1 hari
Kelas Perawatan : 3 - Kelas 3 Berat Lahir : 0 gram

Diagnosa Utama : T29.3 Burns multi regions at least one burn of third degree mentioned

Diagnosa Sekunder : T31.3 Burns involving 30-39% of body surface

R77.0 Abnormality of albumin

Prosedur : 99.21 Injection of antibiotic

93.57 Application of other wound dressing
93.59 Other immobilization, pressure, and attention to wound
86.22 Excisional debridement of wound, infection, or burn
86.28 Nonexcisional debridement of wound, infection, or burn
86.91 Excision of skin for graft
86.69 Other skin graft to other sites
86.71 Cutting and preparation of pedicle grafts or flaps
86.74 Attachment of pedicle or flap graft to other sites

ADL Sub Acute : - ADL Chronic : -

Hasil Grouping

INA-CBG : L-1-20-I PEMINDAHAN KULIT PADA LUKA BAKAR (RINGAN) Rp 26,121,700.00

Sub Acute : - - Rp 0.00
Chronic : - - Rp 0.00
Special CMG : - - Rp 0.00

Total Tarif : Rp 26,121,700.00

Generated : E-Klaim 5.4.11.202106120705 @ 2021-01-26 12:31:51 Lembar 1 / 1