INPATIENT INVOICE DE

Room Rent
No
From Date
1
02/03/2011
2
02/03/2011
3
11/03/2011
4
01/04/2011
5
03/04/2011

To Date
13:09
02/03/2011
18:03
11/03/2011
22:28
01/04/2011
13:40
03/04/2011
19:45
06/04/2011

Bed Type
CLASS
18:03 2
CLASS
22:28 2
CLASS
13:40 2
CLASS
19:45 2
CLASS
9:55 2

Bed No
327-ICU
329-ICU
821(5)
821(6)
821(6)

Ancillary Service
No
Trans Date
Service(s)
Investigations
BLOOD BANK
1
02/03/2011
CROSSMATCH + BLOOD TYPE &
RHESUS
BLOOD BANK
BLOOD CHEMISTRY / KIMIA DARAH
2
02/03/2011
BILIRUBIN TOTAL-DIRECT
3
03/03/2011
GLUCOSE POCT
4
03/03/2011
GLUCOSE POCT
5
03/03/2011
GLUCOSE POCT
6
04/03/2011
GLUCOSE POCT
7
04/03/2011
GLUCOSE POCT
8
04/03/2011
GLUCOSE POCT
9
05/03/2011
GLUCOSE POCT
10
05/03/2011
GLUCOSE POCT
11
05/03/2011
GLUCOSE POCT
12
06/03/2011
GLUCOSE POCT
13
07/03/2011
GLUCOSE POCT
14
08/03/2011
GLUCOSE POCT
15
09/03/2011
GLUCOSE POCT
16
09/03/2011
GLUCOSE POCT
17
10/03/2011
GLUCOSE POCT
18
4/4/2011
ELECTROLYTE PACKAGE
19
4/1/2011
ELECTROLYTE PACKAGE
20
29/03/2011
ELECTROLYTE PACKAGE
21
03/03/2011
BLOOD GAS ANALYSIS
22
03/03/2011
BLOOD GAS ANALYSIS
23
04/03/2011
BLOOD GAS ANALYSIS
24
04/03/2011
BLOOD GAS ANALYSIS
25
04/03/2011
BLOOD GAS ANALYSIS
26
05/03/2011
BLOOD GAS ANALYSIS
27
06/03/2011
BLOOD GAS ANALYSIS
28
07/03/2011
BLOOD GAS ANALYSIS

29
30
31
32
33
34
35
36
37
38
39
40
41

42
43
44
45
46
47
48

49

50
51
52
53

54

08/03/2011
09/03/2011
09/03/2011
10/03/2011
11/03/2011
02/03/2011
3/29/2011
4/2/2011
3/31/2011
03/03/2011
02/03/2011
07/03/2011
11/03/2011

BLOOD GAS ANALYSIS

BLOOD GAS ANALYSIS
BLOOD GAS ANALYSIS
BLOOD GAS ANALYSIS
BLOOD GAS ANALYSIS
LACTIC ACID
PANEL FUNGSI GINJAL (UR,CR,UR
PANEL FUNGSI GINJAL (UR,CR,UR
PANEL PROFIL LIPID (TOTAL
PANEL ICU II(ICU I, PT,
PANEL ICU III(ICU II, OT, PT)
PANEL ICU III(ICU II, OT, PT)
PANEL ICU III(ICU II, OT, PT)
(NAT,KAL,CHLO)
(NAT,KAL,CHLO)
(NAT,KAL,CHLO)
ACID)
ACID)
APTT,D-D,UR,CR)
CHOL,HDL,LDL,TRIG)
BLOOD CHEMISTRY / KIMIA DARAH
CONVENTIONAL
02/03/2011
THORAX AP/PA
03/03/2011
THORAX AP/PA
04/03/2011
THORAX AP/PA
04/03/2011
THORAX AP/PA
07/03/2011
THORAX AP/PA
09/03/2011
THORAX AP/PA
10/03/2011
THORAX AP/PA
CONVENTIONAL
DUAL SOURCE CT SCAN - NON CONTRAST
02/03/2011
DS CT CRANIAL / HEAD SCREENING
NON CONTRAST
DUAL SOURCE CT SCAN - NON CONTRAST
HEMATOLOGY
14/03/2011
FULL BLOOD COUNT (HB, WBC, DIFF, E,
HT, PLATELET)
19/03/2011
FULL BLOOD COUNT (HB, WBC, DIFF, E,
HT, PLATELET)
3/28/2011
FULL BLOOD COUNT (HB, WBC, DIFF, E,
HT, PLATELET)
4/1/2011
TAT-PLATELET AGGREGATION TEST
HEMATOLOGY
MICROBIOLOGY
02/03/2011
BLOOD, CULTURE & SENSITIVITY TEST

55

02/03/2011

56
57

03/03/2011
03/03/2011

58
59

03/03/2011
3/31/2011

60

SEROLOGY
3/30/2011

61

URINE
14/03/2011

62

19/03/2011

(AEROB)
BLOOD, CULTURE & SENSITIVITY TEST
(ANAEROB)
SPUTUM, DIRECT PREPARAT GRAM
SPUTUM, CULTURE & SENSITIVITY TEST
(AEROB)
SPUTUM, FUNGI CULTURE
SCREENING MRSA
MICROBIOLOGY
PROCALCITONIN
SEROLOGY
URINE LENGKAP / COMPLETE
URINALYSIS(CHEM&SED)
URINE LENGKAP / COMPLETE
URINALYSIS(CHEM&SED)
URINE

Operation Theatre
No
Trans Date
1
02/03/2011

Service(s)
OT RENT 5 - PER 15 MIN

OP/IP Procedure
No
Trans Date
1
02/03/2011
2
02/03/2011
3
05/03/2011
4
02/03/2011
5
02/03/2011
6
10/03/2011
7
06/03/2011
8
02/03/2011
9
17/03/2011
10
12/03/2011
11
12/03/2011
12
13/03/2011
13
14/03/2011
14
14/03/2011
15
15/03/2011
16
16/03/2011
17
16/03/2011
18
17/03/2011

Doctor's Name
Surgery & Procedure
Dr EKA J.W. Team Bedah Saraf
Dr ISMAEL
INTUBATION
CVP
SCC (ARTERI LINE)
ECHOCARDIOGRAM PACKAGE
ECG - BEDSIDE PROCEDURE
DOCTOR PROCEDURE-OT
CHEST PHYSIOTHERAPY
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE

19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63

18/03/2011
18/03/2011
19/03/2011
20/03/2011
21/03/2011
21/03/2011
22/03/2011
22/03/2011
23/03/2011
24/03/2011
24/03/2011
25/03/2011
25/03/2011
26/03/2011
26/03/2011
27/03/2011
28/03/2011
28/03/2011
29/03/2011
29/03/2011
30/03/2011
31/03/2011
01/04/2011
02/04/2011
03/04/2011
04/04/2011
05/04/2011
3/29/2011
14/03/2011
16/03/2011
17/03/2011
18/03/2011
19/03/2011
20/03/2011
21/03/2011
22/03/2011
24/03/2011
04/03/2011
05/03/2011
05/03/2011
06/03/2011
06/03/2011
07/03/2011
07/03/2011
08/03/2011

ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
ADVANCE EXERCISE
NEBULIZER TREATMENT
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
TILTING TABLE
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY

64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107

08/03/2011
09/03/2011
09/03/2011
10/03/2011
10/03/2011
11/03/2011
11/03/2011
11/03/2011
12/03/2011
13/03/2011
14/03/2011
15/03/2011
16/03/2011
17/03/2011
18/03/2011
19/03/2011
20/03/2011
21/03/2011
22/03/2011
23/03/2011
24/03/2011
25/03/2011
26/03/2011
27/03/2011
28/03/2011
29/03/2011
30/03/2011
31/03/2011
01/04/2011
02/04/2011
03/04/2011
04/04/2011
05/04/2011
3/29/2011
3/30/2011
3/31/2011
4/1/2011
4/2/2011
4/3/2011
4/4/2011
4/5/2011
18/03/2011
11/03/2011
11/03/2011

ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
ICU PHYSIOTHERAPHY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
OCCUPATIONAL THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
DYSPHAGIA THERAPY
NMES
PENGGUNAAN ALAT DOKTER
PENGGUNAAN ALAT DOKTER

INPATIENT INVOICE DETAIL

Qty
1.0
9.0
21.0
2.0
3.0

Patient Amount

13,500,000
11,550,000
1,100,000
1,650
Total:

Qty

1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Asli
0
4,500,000
2,730,000
260,000
390,000
7,880,000

Price

302,000

26,151,650
SUB Total:

26,151,650

Amount

1,208,000

408,000

Total:

1,208,000

408,000

101,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
540,000
540,000
540,000
387,000
387,000
387,000
387,000
387,000
387,000
387,000
387,000

101,000
44,000
44,000
44,000
88,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
44,000
540,000
540,000
540,000
387,000
387,000
387,000
387,000
387,000
387,000
387,000
387,000

71,000
25,000
25,000
25,000
50,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
196,000
196,000
196,000
277,000
277,000
277,000
277,000
277,000
277,000
277,000
277,000

1
1
1
1
1
1
1
1
1
1
1
1
1

387,000
387,000
387,000
387,000
387,000
732,000
830,000
830,000
487,000
2,978,000
3,044,000
3,044,000
3,044,000

Total:
1
1
1
1
1
1
1

215,000
215,000
215,000
215,000
215,000
215,000
215,000
Total:
1,595,000

387,000
387,000
387,000
387,000
387,000
732,000
830,000
830,000
487,000
2,978,000
3,044,000
3,044,000
3,044,000

277,000
277,000
277,000
277,000
277,000
332,000
100,000
100,000
167,000
978,000
1,044,000
1,044,000
1,044,000

22,445,000

9,469,000

215,000
215,000
215,000
215,000
215,000
215,000
215,000

165,000
165,000
165,000
165,000
165,000
165,000
165,000
1,155,000

1,505,000

1,595,000

1,275,000

Total:

1,595,000

1,275,000

116,000

116,000

61,000

116,000

116,000

61,000

116,000

116,000

61,000

515,000
Total:

515,000

215,000
398,000

609,000

609,000

863,000

409,000

609,000

609,000

409,000

1
1

98,000
609,000

98,000
609,000

42,000
409,000

1
1

504,000
754,000
Total:

504,000
754,000
3,183,000

304,000
254,000
1,827,000

838,000
Total:

838,000

538,000

838,000

72,000

72,000

47,000

72,000

72,000

47,000

Total:

144,000

94,000

SUB Total:

31,781,000

Amount

3,665,000
Total:

3,665,000
SUB Total:

1,665,000
1,665,000
3,665,000

Amount

PACKAGE

28,000,000
8,000,000
750,000
740,000
700,000
694,000
109,000
96,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000

24,000,000
7,000,000
600,000
510,000
500,000
592,000
79,000
0
66,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000

300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
225,000
132,000
132,000
132,000
132,000
132,000
132,000
132,000
132,000
132,000
128,000
128,000
128,000
128,000
128,000
128,000
128,000
128,000

147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
105,000
92,000
92,000
92,000
92,000
92,000
92,000
92,000
92,000
92,000
82,000
82,000
82,000
82,000
82,000
82,000
82,000
82,000

128,000
128,000
128,000
128,000
128,000
128,000
128,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
300,000
250,000
250,000
250,000
250,000
250,000
250,000
250,000
250,000
90,000
6,000,000
7,500,000
Total:

76,612,000

82,000
82,000
82,000
82,000
82,000
82,000
82,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
147,000
162,000
162,000
162,000
162,000
162,000
162,000
162,000
162,000
60,000
5,500,000
6,600,000
58,080,000

SUB Total:

76,612,000

7,880,000

4,000,000

15,164,000

1,665,000

8,080,000

58,080,000