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]
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
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]
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
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]
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
Sub Total - C1A (Rp) :
Printed By : I Kadek Ari Sudana
[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
Siloam Hospitals Bali
CASHIER
Printed By : I Kadek Ari Sudana
[24/04/2014 19:40:14]
Page 6 of 6
