Professional Documents
Culture Documents
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
56,332.00
56,332.00
[24/04/2014 19:40:14]
Page 1 of 6
IN PATIENT INVOICE
Invoice Date
Invoice No
Registration No
Admission Date
Discharge Date
Patient
DOB Patient
Class
Bed No
Doctor
Payer
DATE
:
:
:
:
:
:
:
:
:
:
:
24/04/2014
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
Drugs
22/04/14
Cedocard - 5 mg
tablet
22/04/14
Norvask - 5 mg tablet
TAB
1,819.00
10
TAB
105,060.00
[24/04/2014 19:40:14]
Page 2 of 6
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
[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
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]
Page 4 of 6
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
[24/04/2014 19:40:14]
7,009,248.52
Page 5 of 6
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
[24/04/2014 19:40:14]
Page 6 of 6