DATA PASIEN UMUM POLI GIGI

KLINIK VITA MEDIKA

TGL NO. NAMA NO RM DIAGNOSA TERAPI TARIF Ket.

hiperemi pulpa gigi 36,
6/25/2018 1 Ny.Wulandari 3058 gangren radiks 25 T.komposit kecil, tunda exo R/ Rp 150,000
2. Tn.Imam W 5444 period.akut 47,48 R/ amox,kaditic Rp 40,000
3. Tn.Khusnul 5275 gangren radiks 11,21 Exo 11,21 Rp 150,000
4. Tn.Agus Irawan 5436 pulpitis 46 (tambalan cuil) T.komposit kecil Rp 125,000
6/29/2018 5. Ny.Zumroh 5630 period.apikalis akut R/metro,kaditic,dexa Rp 40,000 apotek
6. Ny.Isa komariyah 5609 GP+gingival polip gigi 28 R/kaditic Rp 30,000 apotek
7. Tn.Misnu 4146 partial edentulus 2 gigi Valplas 2 gigi Rp 950,000 on process
7/3/2018 8. Ny.Zumroh 5630 nekrosis pulpa gigi 37 open bur, R/ asmef, caviplex Rp 50,000
9. Tn.Khusnul 5273 gangren radiks 25 exo 25 Rp 150,000
10. Ny.Mila 5792 pulpitis 14 eug+TS Rp 40,000

11. Tn.Wardi 5786 pulpitis irever gigi 27 devital, R/amox,kaditic,caviplex Rp 50,000

7/4/2018 12. Ny.Eni 573 pulpitis irever gigi 46 devital, R/ dexa Rp 50,000
7/5/2018 13. Ny.Sri Rahayu 5878 crown lepas konsultasi, luting gi Rp 80,000

Rp 1,835,000
 DATA KUNJUNGAN PASIEN POLI GIGI
KLINIK VITA MEDIKA

TGL NO. NAMA NO RM DIAGNOSA TERAPI TARIF Ket.

7/9/2018 1 ny.Oktora 1481 abses periapikal R/ amox, pct BPJS
2 tn.Khusnul 5275 pulpitis rev.24 T.komposit Rp200,000
3 ny.Zumroh 5630 nekrosis pulpa 37 exo, R/asmef,caviplex Rp250,000

4 tn.Subagyo abses periapikal dgn sinusitis pro refer BPJS

5 tn.Paijan 5671 karies dentin 21 T.komposit kecil Rp150,000
7/10/2018 6 ny.Elis 1911 period.kronis exo, R/nadik,caviplex BPJS
7 ny.Sumirah 3593 period.kronis 23 exo, R/asmef BPJS
8 an.Inara 3713 abses gingiva R/amox syr BPJS
9 tn.Choirus saleh 6035 gingivitis ra rb scalling ra rb BPJS
10 ny.Ef 6039 hiperemi pulpa 25 T.komposit BPJS

11 ny.Sriamah 6032 pulpitis 25 + gingivitis akut R/amox,metro,asmef BPJS

12 tn.Sutikno nekrosis pulpa 37 pro refer BPJS
7/11/2018 13 ny.Rima 6089 nekrosis pulpa 21 psa + labial wall komposit Rp250,000
14 an.Diah siwi 6087 persistensi 61 exo, R/ibuprofen syr Rp100,000
15 an.Galang 6088 fr.ellis klas III konsultasi BPJS
16 ny.Sakini 6082 period.akut 26 R/amox,asmef,caviplex BPJS
17 an.Relief 6077 persistensi 54 , GP 46 exo 54,R/amox, dexa,asmef Rp100,000
18 ny.Oktora 1481 period.kronis 45 exo 45, R/asmef, caviplex BPJS
19 an.Sandy 6781 gangren radiks 62 konsultasi BPJS
7/12/2018 20 ny.Yeti 6135 pulpitis 27 rop Rp40,000
21 ny.Rini 6133 abses gingiva 16 R/amox,asmef,nadik Rp40,000
22 ny.nur kholifah 6132 pulpitis 11 rop, pro foto ronsen Rp40,000
23 ny.Suparmi 5273 resesi gingiva r/ BPJS
24 tn.Yasin 4419 pulpitis 36 rop BPJS
25 tn.Sabar 228 gingivitis akut 27 scalling 27, R/ BPJS

pulpitis rev.21, nekrosis t.komposit 21,

26 ny.Puji 6128 pulpa 11 ektirpasi+labial wall 11 BPJS
7/13/2018 27 tn.Misnu 4146 partial edent 2 gigi insersi valplas Rp0 LUNAS
28 tn.Suharsono 6168 abses periodontal 47 R/ amox, metro, asmef BPJS
7/16/2018 29 nn.Dewi Novita 3182 nekrosis pulpa 11 sterilisasi chkm BPJS
30 ny.Sumirah 3595 period. kronis 21 22 exo, R/asmef BPJS

31 ny.Elis 1911 GP 46 exo, R/amox,asmef,nadik BPJS

32 tn.Endra 4577 period. apikalis kronis 37 pro refer BPJS

7/17/2018 33 nn.Septina 6284 GP 36 exo, R/asmef, kaditic Rp200,000
34 tn.Suko 4794 abses gingiva 16 R/amox,asmef BPJS
35 ny.Endang 3162 period.apikalis akut 36 R/amox,asmef,dexa BPJS
7/18/2018 36 nn.Triska ayu 6265 gingivitis kronis scalling RA-RB Rp300,000
cek GDA=225, R/gliben 1-
37 tn.Mujito 6325 period.kronis 12 11 dg DM 1/2-0 Rp50,000

38 tn.Sutrisno 6335 perikoronitis akut 38 irigasi, R/ amox,metro,nadik Rp50,000

openbur,
39 nn.Dewi Maya 709 period.apikalis kronis 16 R/amox,metro,nadik BPJS
40 nn.Vio sindi 6345 pulpitis rev.21 t.komposit BPJS

7/19/2018 41 ny.Suparmi 6367 abses palatina 16 R/ amox,metro,asmef, dexa Rp50,000

42 nn.Aprilia 6121 pulpitis ireversbl 46 ROP, R/ amox,metro,kaditic Rp50,000

43 ny.Yusiana 4071 npp 47 mumifkasi+basis GI BPJS
44 sdr.Bagus 6370 trismus R/ dexa, kaditic Rp50,000
7/20/2018 45 an.Mareta 6376 abses gingiva 51 R/ amox,ibuprofen syr Rp50,000
 46 nn.Dewi Maya 709 nekrosis pulpa 16 pro refer BPJS
47 tn.Rizki 6318 nekrosis pulpa 11 t.komposit+sterilisasi Rp200,000
GDA=132, exo 12,
7/23/2018 48 tn.Mujito 6325 period.kronis 12 dg DM R/asmef,caviplex Rp150,000
49 tn.nur mahfudi 908 karies dentin 21 t.komposit BPJS
50 ny.Nunuk 3239 period.apikalis akut 27 R/amox, asmef,dexa BPJS
7/24/2018 51 tn.Rizki 6318 nekrosi pulpa 11 psa Rp100,000
52 tn.Surateman 6531 period.kronis 25 26 exo , R/asmef,caviplex Rp300,000
53 ny.Sumirah 3595 period.kronis 11 12 exo, R/dexa, caviplex BPJS
54 tn.Suko 4794 abses gingiva 16 R/amox,metro,asmef BPJS

TOTAL Rp2,720,000

PENGELUARAN
7/9/2018 Asiadent (cotton roll, caviton, matabur) Rp176,000
7/9/2018 Lab. Tn.Misnu Rp290,000
7/14/2018 Cobra
servicedental pameran halbilsyringe,
scaller,suction,3way pdgi (GIC, mikrobrush)
highspeed (teknisi pak Rp524,300
7/23/2018 yanto) Rp300,000
TOTAL Rp1,290,300

SISA UANG Rp1,429,700

NB : uang yang dibawa drg.Sintha.. Karena pembuatan gigi tiruan pasien belum selesai
pasien a.n : tn.Khusnul 5275 partial edent 4 gigi gts akrilik, cetak ra-rb Rp850,000 LUNAS

DATA KUNJUNGAN PASIEN POLI GIGI KLINIK VITA MEDIKA

TGL NO. NAMA NO RM DIAGNOSA TERAPI TARIF Ket.

7/25/2018 1 sdr.Jamaludin 6568 gingivitis ra-rb, period.akut 17 scalling, R/amox,metro,asmef BPJS

2 ny.Ria 6520 abses periapikal 11 openbur, R/amox,metro,asmef BPJS

3 tn.Mardiono 5437 period.kronis 16 exo BPJS
4 ny.Nunuk 3239 period.kronis 27 exo BPJS
5 an.Abid 6571 abses gingiva R/amox syr,ibuprofen syr Rp50,000
7/26/2018 6 sdr.Wahyu 595 hiperemi pulpa 34,37 T.GIC BPJS

7 tn.Nur khojin 3901 pulpitis 16 caoh+TS, R/amox,asmef,dexa BPJS

8 ny.Suparmi 6367 period.kronis 16 R/amlodipin Rp40,000
9 tn.Sabar 228 gingivitis akut 27,28 scalling, R/mixalgin BPJS
7/27/2018 10 ny.Winarti 974 pulpitis 24 pulpcapping BPJS
11 ny.Efrina 2836 p.apikalis akut 38 R/amox,metro,hufamag,mixalgin Rp50,000
12 tn.Munadi 3243 pulpitis 27 ROP,R/amox,asmef,dexa BPJS
13 ny.Sriama 6032 karies dentin 27 T.GIC BPJS
7/28/2018 14 ny.Ninik 6750 gingivitis ra-rb scalling Rp300,000
15 tn.Khusnul 5275 partial edent GTS akrilik 5gigi Rp850,000
16 ny.Sumirah 3595 period.kronis 14 exo,R/asmef BPJS
17 an.Seviq 6741 ulkus decubitus 51 konsultasi, R/ibuprfn syr Rp50,000
7/31/2018 18 ny.Winarti 974 post pulpcapping T.GIC BPJS
19 tn.Suliono 6810 pulpitis ire 48 ROP,R/amox,asmef,nadik BPJS
20 ny.Naning 6524 gingivitis RA scalling BPJS
21 ny.Supinatun 2201 gangren pulpa 37 R/amox,asmef,nadik BPJS
22 ny.Sunarmi 6800 period.kronis 31,42 exo,R/asmef,caviplex Rp250,000
23 ny.Watini 121 nekrosis pulpa 12 psa Rp100,000
 24 ny.Patemi 1971 abses vestibular R/amox,metro,dexa,asmef BPJS
8/1/2018 25 ny.Siti Kamsiah 4273 resesi gingiva 27, HP 36 T.Gic, R/mixalgin BPJS
26 tn.Pujiono 6827 pulpitis 36 t.komposit Rp200,000
27 ny.Kusniyatul 942 pulpitis akut 37 Rop, R/amox,metro,asmef BPJS

28 tn.Irfan 2757 period.apikalis akut 45 R/amox,metro,hufamag,dexa BPJS

29 ny.Naning 6524 gingivitis Rb scalling Rb BPJS
8/2/2018 30 an.Sandika 6868 persistensi 51 exo ce, R/caviplex syr Rp100,000
31 nn.Puspita 6863 abses bukal 45 R/ amox,metro,kaditic Rp50,000
32 ny.farida 3373 Gangren pulpa 18 exo, R/asmef,caviplex BPJS
8/6/2018 33 ny.heni 4340 atrisi 31,41 t.komposit BPJS
34 an.Ariel 7023 period.akut 85 R/ibuprofen,amox Rp50,000
35 tn.Agus 7026 period.akut 26 R/amox,metro,asmef Rp50,000
36 ny.Watini 121 nekrosis pulpa 12 guttap+ts Rp50,000
37 nn.Puspita 6863 nekrosis pulpa 45 sterilisasi chkm Rp50,000
8/7/2018 38 ny.siti fatimah 7089 pulpitis 27, karies servikal rop,R/asmef, t.gic BPJS
39 ny.Khusniyatul 942 period.akut 37 R/amox,metro,mixalgin BPJS
40 ny.Sunarmi 6800 period.kronis 12,11 exo, R/asmef,vitBC Rp200,000
41 ny.Rahamah 7083 period.akut 46 R/amox,metro,dexa BPJS
42 ny.Umi 7081 pulpitis akut 37 rop,R/amox,metro,dexa BPJS
nekrosis pulpa 33, hiperemi psa+sterilisasi chkm, t.komposit
43 ny.Sugiyem 7065 pulpa 22 kecil Rp200,000
44 sdr.Ahmad Septi 7092 hiperemi pulpa 11 t.komposit kecil Rp135,000
8/8/2018 45 an.Davi 7141 pulpitis 36 R/amox syr BPJS
46 ny.Naning 6524 nekrosis pulpa 26 sterilisasi chkm BPJS
47 nn.Clara 7142 nekrosis pulpa+polip devital, R/asmef BPJS
48 ny.Reni 7143 hiperemi pulpa 23 t.komposit BPJS
scalling, exo
49 sdr.M.Yos setiaji 7139 gingivitis ra rb, period.kronis 36 R/amox,asmef,dexa BPJS

8/9/2018 50 an.Keisya 1312 pulpitis 36, persistensi 74 rop, exo 74, R/amox,asmef,dexa BPJS
51 ny.Sugiati 4714 sus.abses submandibula R/amox,metro,amlo BPJS
52 tn.Tedy 7183 nekrosis pulpa 25 psa+sterilisasi chkm, t.komposit k Rp100,000
8/10/2018 53 ny.Sugiyem 7065 period.apikalis iodotin+ts Rp50,000
54 nn.Puspita 6863 nekrosis pulpa 45 sterilisasi cresophene Rp50,000
55 ny.Khusniyatul 7084 pulpitis konsultasi,R/mixalgin BPJS

56 tsakilul 4571 abses vestibular openbur, R/amox,metro,asmef BPJS

57 sdr.Safroni 7174 abses gingiva scalling 16,R/amox,metro,asmef Rp50,000

TOTAL Rp3,025,000
PENGELUARAN
7/15/2018 LAB.P.Khusnul (GTS) Rp175,000

SISA Rp2,850,000