j8his Keselmatan SURAT ELEGIBILITAS PESERTA
wen Peomerena enon ses Klinik Utama Budi Mulia
No.SEP (014080020623¥000011 (BACKDATE)
TolSEP 2023-06-02 Peserta
No.Kartu 0002655963347 ( MR. 5938/0623 )
Nama Peserta RIVANTI FARRAH ALMAHYRA Jns Rawat
TolLahir 2016-02-06 Kelamin :Perempuan ns. Kunjungan
No.Telepon 082256783214
SubiSpesialis : Poli Perujuk
Dokter dr. Ahmad Hadiwiiaya, Sp.A, M.Kes Kis Hak
Faskes Perujuk ——: Klinik Utama Budi Mulia Kis Rawat
Diagnose Awal ‘AGS - Diarrhoea and gastoentertis of presum ——_Penjamin
Catatan
+ Saye menyetu BPUS Kesehatan menggunakan inlomas! medis pasion a iparskan
+, SEP Buran sebopa but peniaminan peseria
Dengan tampa karan SEP elsrons ny maropakan hast vas! tahadep elites Pasian sacra elektro
(vaidos rigor pont tau Bomelrk astm vases an)
dan selayunya Pasion dapat mengatsespelayanan Kesehatan ryckan sous Kelontan Drak
Kebenaran dan keasian alas formas data Pasion meric arggung jawab porch FART.
(Cotnan ke 1 03.08.2023 173603 wt
PBI (APBD)
Riinap
- Konsultasi dokter (pertama)
Kelas 3
Kelas 3
RIVANTI FARRAH ALMAHYRA, KEMENTERIAN KESEHATAN REPUBLIK INDONESIA akN
+ Se cerkas Kiaim individual Pasien 03/06/2023
Kode Rumah Sakit 6401002 Kelas Rumah Sakit_ :
Nama RS KLINIK UTAMA BUDI MULIA Jenis Tarif ‘TARIF RS KELAS D SWASTA
Nomor Peserta + 0002655963347 Nomor SEP : 0140S0020623v000011
Nomor Rekam Medis : 5938/0623 Tanggal Masuk = 02/06/2023,
Umur Tahun 7 Tanggal Keluar 03/06/2023
Umur Hari : 2673 Jenis Perawatan 1 - Rawat Inap
Tanggat Lahir 96/02/2036 Cara Pulang 1 - Atas Persetujuan Dokter
Jenis Kelamin 2 2+ Perempuan Los 2 hari
Kelas Perawatan —:3- Kelas 3 Berat Lahir :
Diagnosa Utama: A09.9 Gastroenteritis and colitis of unspecified origin
Diagnosa Sekunder : £86 Volume depletion
Prosedur -
ADL Sub Acute - ADL Chronic pe
Hasil Grouping
INA-CBG + K-4-17-1 _NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (RINGAN) Rp 1,298,900.00
Subacute: = . Ro 0.00
Chronic - : Rp 0.00
Special CMG: : Rp 0.00
Total Tarif Rp 1,298,900.00
oy =
loi 5.8.6 202307080847 @ 20D
13 15.0052 Temberiyt KLINIK UTAMA BUDI MULIA
JL. R.A Kartini No.1 Tanah Grogot Kab. Paser Kaltim
Telp: 0543-22173 / 0852 4968 5918 (Emergency Call)
a i RESUME MEDIS _ Ee
Nama: fn. Ratacts Farrah A No.RM: 5926 /oczs
Alamat : Loreyec uc Umur: Wan
Tanggal Masuk 62 gant pous | Tonggal keluar: 0% suas s6u3
Keluhan utama a
VA cree yee
Riwayat medis
Hasil pemeriksaan Feecen. > bk si |
Diagnosa Dew ty Ft Nt Acsg
| | B86
Terapi/ pengobatan
wy 4 Buy ine,
Komplikasi op
Prognosis
Vb |
Keadaan waktu keluar klinik / RB
Whee
Rekomendas
Sebab meninggal
ee
Tana Paser,
Dokter Yang Merawat. KLINIK UTAMA BUDI MULIA
TANA PASER
Jalan Kartin No.1 Tana Paser Telp 0543-22173 Hp 0852-4968-5918,
[Untuk Pembayaran Blaya perawatan dari
Nama Pasien : An Riyanti Farrah A
+765 /8PIS/BMK/VI/23
Nama Dokter —: Dr A.Hadiwijaya SpA,,M.Kes
rt
+02 Juni 2023
203 Juni 2023
"Rdrministrast
+ Sarana dan Prasarana 1.165.000,
Jasa Pelayanan 390,000
Dokter Spesialis Anak 675.000
+ Obat dan bahan habis pakai
(Terlampir)
820.000
Tana Paser, 03 Juni 2023,
Administrasi
Keterangan (Rangkap 2)
Lembar 1. Pasien
Lembar 2 Arsip No yas BHP Jumiah Pemakaian_ Harga
(1 Senne i Rp.
Pa tsct We iis Tp
3_| D5% Rp.
4_| INFUS SET Et z Rp.
_5_| ABOCATH20G 94 (0 \ 71 ~_ | Rp.
6 | SLYMSEVHER Rp.
("7 | CATETHER 16G718G Rp. =
8_| URINE BAG Rp. a
9 _|PEMPERS Rp.
[10 TUNDERPADS Rp.
11 |PENENG BAYT 7 Rp. 4
12 | UMBILICAL CORD Rp.
13_| BETHADINE (CC) _ Rp.
14 | ALKOHOL SWAB. Rp.
1s | HANDSCONE STERIL UK Rp.
16 | SPUIT 10CC : I Rp.
17 | SPUIT SCC Rp.
18 | SPUIT3CC 1 Rp.
19 | SPUIT ICC I Rp.
20_[HYPAPIX X 400 Rp.
21 | TABUNG EDTHA t Rp. a
[22 |CROMIC CUT GUT. Rp.
23 | LIDOCAIN Rp.
24 | VIT-KIND Rp.
25 | FETIK SUPP Rp.
26_| INDUXIN INI I [Rp.
(ar “Salah 0 Rp.
128 | intertinc 1 Ry
[29 T wex qo Cw a
30. Onde Tir Rp.
3 (mm 1 Rp.
32 i 1 Rp.
te Sa ie
4 | [Rp
s Rp.
pe I Ry
TOTAL R
Bidan ifinik soypuy ‘Pury “YyelnguE
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