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IN PATIENT INVOICE

Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE

:
:
:
:
:
:
:
:
:
:
:

24/04/2014
SHDP-BILL-1404-07175
SHDP-IPD-1404-0000252
22/04/2014
24/04/2014
GATOT SISWANDONO
21/11/1949
5030
dr. I Made Junior Rina Artha Sp. JP
-

ITEM

QTY

UOM

DISC
(%)

Amount
(Rp)

Hospital Facility
24/04/14

INLACIN 100mg

Printed By : I Kadek Ari Sudana

56,332.00

Sub Total - (Rp) :

56,332.00

[24/04/2014 19:40:14]

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IN PATIENT INVOICE
Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE

:
:
:
:
:
:
:
:
:
:
:

24/04/2014
SHDP-BILL-1404-07175
SHDP-IPD-1404-0000252
22/04/2014
24/04/2014
GATOT SISWANDONO
21/11/1949
C1A
5030
dr. I Made Junior Rina Artha Sp. JP
-

ITEM

QTY

UOM

DISC
(%)

Amount
(Rp)

Administration Fee
24/04/14

ADMINISTRATION
FEE

399,938.52

Cardiology
23/04/14

ECG

140,000.00

24/04/14

ECG

140,000.00

30,000.00

30,000.00

320,000.00

160,000.00

30,000.00

160,000.00

160,000.00

Consultation
22/04/14
23/04/14
23/04/14
23/04/14
24/04/14
24/04/14
24/04/14

TARIF VISIT RAWAT


INAP RMO ()
TARIF VISIT RAWAT
INAP RMO ()
TARIF VISIT RAWAT
INAP ()
TARIF VISIT RAWAT
INAP ()
TARIF VISIT RAWAT
INAP RMO ()
TARIF VISIT RAWAT
INAP ()
TARIF VISIT RAWAT
INAP ()

Drugs
22/04/14

Cedocard - 5 mg
tablet

22/04/14

Norvask - 5 mg tablet

Printed By : I Kadek Ari Sudana

TAB

1,819.00

10

TAB

105,060.00

[24/04/2014 19:40:14]

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IN PATIENT INVOICE
Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE
22/04/14
24/04/14
24/04/14
24/04/14

:
:
:
:
:
:
:
:
:
:
:

24/04/2014
SHDP-BILL-1404-07175
SHDP-IPD-1404-0000252
22/04/2014
24/04/2014
GATOT SISWANDONO
21/11/1949
C1A
5030
dr. I Made Junior Rina Artha Sp. JP
-

ITEM
NovoRapid - 100 u/1
mL x 3 mL FlexPen
Lipanthyl Penta 145 145 mg film-coated
tablet
Stator - 20 mg filmcoated tablet
Urdahex - 250 mg
capsul

UOM

DISC
(%)

VIAL

232,120.00

TAB

168,812.00

TAB

147,378.00

CAPSUL

94,325.00

QTY

Amount
(Rp)

Laboratories

22/04/14

COMPLETE BLOOD
COUNT (HB, HT, E,
LEUKOCYTE,
PLATELET, MCV,
MCH, MCHC)

105,000.00

22/04/14

POTASIUM

119,000.00

22/04/14

SODIUM

119,000.00

22/04/14

CREATININE

61,000.00

22/04/14

UREUM

61,000.00

22/04/14

SGOT-SGPT

119,000.00

22/04/14

GLYCO HB (HBA1C)

308,000.00

23/04/14

URINE LENGKAP /
COMPLETE
URINALYSIS(CHEM&S
ED)

82,000.00

Printed By : I Kadek Ari Sudana

[24/04/2014 19:40:14]

Page 3 of 6

IN PATIENT INVOICE
Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE
24/04/14
24/04/14

:
:
:
:
:
:
:
:
:
:
:

24/04/2014
SHDP-BILL-1404-07175
SHDP-IPD-1404-0000252
22/04/2014
24/04/2014
GATOT SISWANDONO
21/11/1949
C1A
5030
dr. I Made Junior Rina Artha Sp. JP
-

ITEM
HDL-CHOLESTEROL
DIRECT
LDL-CHOLESTEROL
DIRECT

QTY

UOM

DISC
(%)

Amount
(Rp)

89,000.00

138,000.00

24/04/14

TOTAL CHOLESTEROL

72,000.00

24/04/14

TRIGLISERIDA

73,000.00

24/04/14

URIC ACID

62,000.00

Medical Supplies
23/04/14
23/04/14

23/04/14

23/04/14
23/04/14
23/04/14

INFUSOMAT
SPACELINE TRANSF
SET
NACL OTSU 0.9% X
500 ML
TEGADERM IV
DRESSING (SOFT
CLOTH +
ADDITIONAL
PLASTER) 6 x 7 cm
TM1633
DISCOFIX C 3-WAY
STOPCOCK + TUBING
25 cm
PEN NEEDLE 32G X
4MM
TERUMO SYRINGE W/
NEEDLE 10ML

Printed By : I Kadek Ari Sudana

PCS

111,650.00

BAG

13,650.00

PCS

16,581.00

PCS

46,255.00

PCS

4,374.00

PCS

7,673.00

[24/04/2014 19:40:14]

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IN PATIENT INVOICE
Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE
23/04/14
23/04/14

:
:
:
:
:
:
:
:
:
:
:

24/04/2014
SHDP-BILL-1404-07175
SHDP-IPD-1404-0000252
22/04/2014
24/04/2014
GATOT SISWANDONO
21/11/1949
C1A
5030
dr. I Made Junior Rina Artha Sp. JP
-

ITEM

UOM

DISC
(%)

PCS

9,963.00

BAG

13,650.00

112,000.00

896,000.00

820,000.00

820,000.00

50.00

410,000.00

QTY

TEGADERM IV
DRESSING 7 x 7 cm
TM1623
NACL OTSU 0.9% X
500 ML

Amount
(Rp)

Nursing Procedure
23/04/14

NUR- GLUCOSE

Radiologies
23/04/14

COMPLETE ABDOMEN
USG

Treatment Room
22/04/14
23/04/14
24/04/14

General Room
Charges
General Room
Charges
General Room
Charges

Sub Total - C1A (Rp) :

Printed By : I Kadek Ari Sudana

[24/04/2014 19:40:14]

7,009,248.52

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IN PATIENT INVOICE
SUB TOTAL (Rp) :

7,065,580.52

DISCOUNT 0.00% :

.00

7,065,581.00

ROUNDOFF (+) :

419.00

TOTAL (Rp) :

7,066,000.00

DEPOSIT (Rp) :

0.00

BALANCE (Rp) :

7,066,000.00

Denpasar, 24-04-2014

Siloam Hospitals Bali


CASHIER

Printed By : I Kadek Ari Sudana

[24/04/2014 19:40:14]

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