KWITANSI
Bukti Pembayaran
Invoice No. : RF16-0154939/F16-1406347 Page : 1 of 1
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI
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Date Item Code Description Quantity Amount (Rp)
Admin Fee
24/10/20 ADM002 ADM PASIEN 1 50,000
Extemp Items
24/10/20 MCU002 MEDICAL CHECKUP PACKAGE - FEMALE (dr. Suwendi, SpPD)1 1,600,000
Medication
OP-Consultation
24/10/20 DCR001 KONSULTASI DOKTER SPESIALIS (dr. Suwendi, SpPD) 1 250,000
Medical Room
24/10/20 CBR003 RUANG MCU 1 0
TOTAL : 1,900,000
DEPOSIT : 0
PATIENT ROUNDING : 0
-----------
NET PAYABLE : 1,900,000
PAID BY :
CASH/CREDIT 1,900,000
Reference : SELF
ONE MILLION NINE HUNDRED THOUSAND RUPIAH.
Tangerang Selatan, 24-OCT-2020
_______________ ____________ NIA NURJANAH
Tanda Tangan pasien/Penanggung Jawab Cashier
Patien Sign/Guarantor
1. Invoice ini merupakan tanda terima pembayaran resmi, setelah di stempel oleh kasir
This is an official payment receipt, upon cashier stamp
2. Barang yang sudah di beli tidak dapat ditukar/dikembalikan
Change or return after purchase are not allowed
3. Untuk Barang kena pajak, harga termasuk PPN
VAT is included for taxable goods N.P.W.P : 02.275.900.5-411.000
PT. PELITA RELIANCE INTERNATIONAL HOSPITAL
Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 1 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 1 Of 3
Blood Type : O
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_________________________________________
Detail
_________________________________________
Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan
HEMATOLOGI
HEMOGLOBIN 14.8 14.0-18.0 g/dl
LED 1 0.101 mm
LEKOSIT 6800 5.000-10.000 /uL
HITUNG JENIS
BASOFIL 0 0-1 %
EOSINOFIL 3 1-3 %
BATANG 2 2-6 %
SEGMEN 51 50-70 %
LIMFOSIT 23 21-40 %
MONOSIT 4 2-8 %
HEMATOKRIT 52 42-52 VOL%
TROMBOSIT 367.000 150.000-450.000 /uL
ERITROSIT 5.27 4.50-5.50 juta/uL
M C V, M C H, M C H C
MCV 81 81-92 fL
MCH 32 27-31 pg
MCHC 31 32-36 %
KOAGULASI
MASA PENDARAHAN 3.1 1.0-6.0 menit
MASA PEMBEKUAN 12.2 10.0-15.0 menit
KIMIA
FUNGSI HATI
SGOT 32 0-35 u/L
SGPT 33 0-45 u/L
GAMMA GT 19 15-85 u/L
FUNGSI GINJAL
UREUM 25 15-39 mg/dL
PT. PELITA RELIANCE INTERNATIONAL HOSPITAL
Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 2 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 2 Of 3
Blood Type : O
_________________________________________
_________________________________________
Detail
_________________________________________
Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan
.
CREATININ 1.2 0.6-1.3 mg/dl
ASAM URAT 3.6 3.5-7.2 mg/dl
DIABETES
GLUKOSA PUASA
BAIK : 80-109
GLUKOSA DARAH PUASA 122 mg/dl SEDANG : 110-125
BURUK : >=126
HBA1C 7.8 % BAIK : 4-5.9
SEDANG : 6-8
BURUK : >8
LEMAK BAIK : <200
CHOLESTEROL TOTAL 241 mg/dl SEDANG : 200-239
BURUK : >=240
BAIK : <130
LDL CHLOSTEROL DIREK 162 mg/dl SEDANG : 130-159
BURUK : >=160
HDL CHLOSTEROL DIREK 47 mg/dl BAIK : <45
SEDANG : 36-44
BURUK : >=45
TRIGLISERIDA 215 mg/dl BAIK : <150
SEDANG : 150-199
URINALISA BURUK : >=200
WARNA KUNING JENUH KUNING JENUH
BJ 1.050 1.005-1.030
pH 64 5.0-8.5
KETON NEGATIVE NEGATIVE
PROTEIN/ALBUMIN NEGATIVE NEGATIVE
GLUKOSA NEGATIVE NEGATIVE
BILIRUBIN NEGATIVE NEGATIVE
BP 139/90
PT. PELITA RELIANCE INTERNATIONAL HOSPITAL
Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
Invoice No. : RF16-0154939/F16-1406347 Page : 3 of 3
Visit No. : BS0072294359 Location : BSD_KSR01
Patient : ANITA DEWI LESTARI Date/Time : 24-OCT-2020 12:47
PRN : 0072294882 Admission Date : 24-OCT-2020 14:02
Payer : ANITA DEWI LESTARI Lab : 3 Of 3
Blood Type : O
_________________________________________
_________________________________________
Detail
_________________________________________
Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan
.
DARAH SAMAR NEGATIVE NEGATIVE
NITRAT NEGATIVE NEGATIVE
UROBILINOGEN 1.0 0.2-1.0
SEDIMEN URINE
LEKOSIT 0-1 0-5 /LPB
ERITROSIT 0-1 0-2 /LPB
SILINDER NEGATIVE NEGATIVE
EPITEL POSITIVE POSITIVE
BAKTERI NEGATIVE NEGATIVE
KRISTAL NEGATIVE NEGATIVE
LAIN-LAIN NEGATIVE NEGATIVE
PT. PELITA RELIANCE INTERNATIONAL HOSPITAL
Central Business District Lot IX, BSD City, Tangerang. 15321. Phone : (021) 3100 928 | Fax : (021) 3100 929
Email : infobsd@ekahospital.com
