Bidan Neng Uma Akromah, AM. Keb

Bidan Neng Uma Akromah, AM. Keb Jl. Jend. Sudirman Dsn. Sukamulya No.34 RT 02/09 Ds. Pucung Kec. Kotabaru Kab. Karawang 41373, Telp. 082110222081

RINCIAN BIAYA PERSALINAN Atas Nama: NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

RINCIAN Pertolongan Bidan Perawatan Ibu&Bayi Pemakaian Alkes Handscoen&FaceMask Syringe Iodine/Alkohol Kassa/Tamponade UnderPad/Pampers Oxytocin inj. 10 IU Phytomenadion inj. Methylergometrin inj. Vaksin Hep-B inj. Amoxicillin tab. Ferum tab. As. Mefenamat tab. Vit. A Cap. Abocath No. 20 Infus/Blood Set Cairan Elektrolit 500 ml Intervensi Ibu: Intervensi Bayi: Lain2

Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp TOTAL

BIAYA 500.000 50.000 40.000 5.000 5.000 15.000 10.000 20.000 20.000 5.000 10.000 25.000 5.000 5.000 5.000 5.000 10.000 20.000 15.000 50.000 50.000

KET

TOTAL Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp Rp

Rp

Karawang, .................................... Penolong Persalinan,

Neng Uma Akromah, AM. Keb

IKATAN BIDAN INDONESIA (IBI) SURAT KETERANGAN LAHIR No. Yang bertanda tangan di bawah ini, menerangkan bahwa: Nama Nama Suami Alamat

: ...................................................................................... ( : ...................................................................................... ( : ......................................................................................

thn ) thn )

Telah melahirkan seorang anak yang bernama: .................................................................................................................................. Anak ke: Jenis Kelamin : Hari, tanggal/jam lahir : Berat Badan Lahir :

Sidik

...................................................................................... ...................................................................................... ...................................................................................... .................. gram, PB : ............. cm, LK : .............. cm

Sidik Kaki Kiri Bayi

Sidik Kaki Kanan Bayi

Sidik

Ibu jari Kiri

Ibu jari Kanan

Ibu

Ibu

Demikian surat keterangan lahir ini dibuat dengan penuh tanggung jawab. Saksi-saksi: 1. .......................................... 2. .......................................... Karawang, .................................... Penolong Persalinan,

Neng Uma Akromah, AM. Keb

No. Telah diterima dari

: ..................................................................................................................................................................................

Uang sejumlah

: .................................................................................................................................................................................. : ..................................................................................................................................................................................

Untuk pembayaran

: .................................................................................................................................................................................. : .................................................................................................................................................................................. : .................................................................................................................................................................................. Karawang,

Terbilang Rp.

00 September 2013

DAFTAR OBAT

1 Albendazol tablet 400 mg ktk 5 x 6 tablet 15.888 2 Alopurinol tablet 100 mg ktk 10 x 10 tablet 21.520 3 Amilorida tablet 5 mg (HCI) ktk 10 x 10 tablet 13.416 4 Aminofilin injeksi 24 mg/ml ktk 30 ampul @ 10 ml 50.034 5 Aminofilin tablet 200 mg btl 100 tablet 10.439 6 Amitriptilin tablet salut 25 mg (HCI) ktk 10 x 10 tablet salut 15.015 7 Amoksisilin Anhidrat tablet 500 mg ktk 10 x10 tablet 41.954 8 Amoksisilin Anhidrat kapsul 250 mg ktk 12 x 10 kapsul 33.977 ktk 10 x 10 kapsul 28.392 9 Amoksisilin sirup kering 125 mg/ 5 ml btl 60 ml 4.310 10 Ampisilin serbuk injeksi i.m./i.v. 1000 mg/ml ktk 10 vial 74.100 11 Ampisilin serbuk injeksi i.m./i.v. 500 mg/vial ktk 10 vial 49.400 12 Antasida DOEN I tablet kunyah, kombinasi : btl 1000 tablet kunyah 64.766 Aluminium Hidroksida 200 mg ktk 10 x 10 tablet kunyah 11.859 magnesium Hidroksida 200 mg 13 Antasida DOEN II suspensi, kombinasi : btl 60 ml 4.550 Aluminium Hidroksida 200 mg/5 ml Magnesium Hidroksida 200 mg/5 ml 14 Antihemoroid DOEN kombinasi : ktk 10 supp 20.639 Bismut subgalat 150 mg Heksaklorofen 2,5 mg 15 Antimalaria DOEN kombinasi : ktk 10 x 10 tablet 61.490 Pirimetamin 25 mg Sulfadoksin 500 mg 16 Antiparkinson DOEN tablet kombinasi : ktk 10 x 10 tablet 134.589 Karbidopa 25 mg Levodova 250 mg 17 Asam Asetilsalisilat tablet 500 mg (Asetosal) ktk 10 x 10 tablet 13.728 18 Asam Asetilsalisilat tablet 100 mg (Asetosal) ktk 10 x10 tablet 8.198 19 Asam Askorbat (Vitamin C) tablet 50 mg btl 1000 tablet 25.679 20 Asam Folat tablet 1 mg btl 100 tablet 4.550 21 Asiklovir tablet 400 mg ktk 10 x 10 tablet 132.678 ktk 50 tablet 83.693 ktk 3 x 10 tablet 50.193 22 Asiklovir tablet 200 mg ktk 50 tablet 47.775 ktk 10 x 10 tablet 87.165 ktk 3 x 10 tablet 28.964 23 Asiklovir krim 5% tube 2 gram 4.583 24 Atropin injeksi i.m./i.v/s.k. 0,25 mg/ml (Sulfat) ktk 30 amp @ 1 ml 41.600 25 Atropin tetes mata 0,5% (sulfat) btl 5 ml 3.932 26 Benzatin benzil Penisilin 2,4 juta IU/vial ktk 10 vial @ 20 ml 70.200 27 Benzatin benzil Penisilin 1,2 juta IU/vial ktk 10 vial @ 20 ml 49.433 28 Besi (II) sulfat 7 H2O tablet salut 300 mg btl 1000 tablet salut 31.460 29 Betametason krim 0,1% (sebagai valerat) tube 5 gram 3.414 30 Deksametason injeksi i.v. 5 mg/ml ktk 100 amp @ 1 ml 152.945 31 Deksametason tablet 0,5 mg btl 1000 tablet 44.044 ktk 10 x 10 tablet 12.146 32 Dekstrometorfan sirup 10 mg/5 ml (HBr) btl 60 ml 4.056

33 Dekstrometorfan tablet 15 mg (HBr) btl 1000 tablet 86.125 ktk 10 x 10 tablet 12.870 34 Diazepam injeksi 5 mg/ml ktk 30 amp @ 2 ml 36.754 35 Diazepam tablet 5 mg btl 1000 tablet 45.198 btl 250 tablet 11.300 36 Diazepam tablet 2 mg btl 1000 tablet 18.190 37 Difenhidramin injeksi i.m. 10 mg/ml (HCI) ktk 30 amp @ 1 ml 23.053 38 Digoksin tablet 0,25 mg ktk 10 x 10 tablet 13.309 39 Dikloksalisin kapsul 250 mg ktk 25 x 4 kapsul 52.884 40 Diltiazem HCI tablet 30 mg ktk 10 x 10 tablet 23.350 41 Dimenhidrinat tablet 50 mg btl 100 tablet 13.241 42 Doksisiklin kapsul 100 mg ktk 10 x 10 tablet 40.950 43 Efedrin tablet 25 mg (HCI) btl 1000 tablet 55.809 44 Ekstrak Belladona tablet 10 mg btl 1000 tablet 27.121 45 Epinefrin (Adrenalin) injeksi 0,1 % (sebagai HCI) ktk 30 amp @ 1 ml 14.560 46 Eritromisin kapsul 500 mg ktk 10 x 10 kapsul 128.700 47 Eritromisin kapsul 250 mg ktk 12 x 10 kapsul 68.130 ktk 10 x 10 kapsul 65.520 48 Eritromisin sirup 200 mg/ 5 ml btl 60 ml 10.920 49 Etambutol tablet salut 500 mg (HCI) ktk 10 x 10 tablet salut 53.196 50 Etambutol tablet 250 mg (HCI) ktk 20 x 10 tablet 55.640 51 Fenilbutason tablet 200 mg btl 1000 tablet 104.520 52 Fenobarbital tablet 30 mg btl 1000 tablet 27.599 53 Fenobarbital injeksi i.m./i.v. 50 mg/ml ktk 30 amp @ 1 ml 28.220 54 Fenoksimetil Penisilin tablet 500 mg ktk 10 x 10 tablet 55.120 55 Fenoksimetil Penisilin tablet 250 mg ktk 10 x 10 tablet 31.688 56 Fitomenadion (Vitamin K) injeksi 10 mg/ml ktk 30 amp @ 1 ml 40.300 57 Fitomenadion (Vitamin K) tablet salut 10 mg btl 100 tablet salut 93.347 58 Flour tablet 0,5 mg btl 100 tablet 4.550 59 Furosemid injeksi i.v./i.m. 10 mg/ml ktk 25 amp @ 2 ml 49.400 60 Furosemid tablet 40 mg ktk 20 x 10 tablet 23.810 ktk 10 x 10 tablet 10.319 61 Garam Oralit I serbuk, kombinasi : ktk 100 sachet 44.759 Natrium 0,70 g ktk 25 sachet 11.440 Kalium klorida 0,30 g tiap sachet untuk Trinatrium sitrat dihidrat 0,58 g 200 ml air Glukosa Anhidrat 4 g 62 Gentamisin injeksi 80 mg/ml (sebagai Sulfat) ktk 1 vial @ 2 ml 4.875 63 Gentamisin salep kulit tube 5 gram 2.535 64 Glibenklamida tablet 5 mg ktk 10 x 10 tablet 21.704 65 Gliseril guaiakolat tablet 100 mg btl 1000 tablet 39.273 66 Glukosa larutan infus 10 % btl 500 ml 6.370 67 Glukosa larutan infus 5 % btl 500 ml 6.045 68 Griseofulvin tablet 125 mg, Micronized ktk 10 x 10 tablet 19.448 69 Haloperidol tablet 5 mg ktk 10 x 10 tablet 21.255 70 Haloperidol tablet 1,5 mg ktk 10 x 10 tablet 13.813 71 Haloperidol tablet 0,5 mg ktk 10 x 10 tablet 9.362 72 Hidroklorotiazida tablet 25 mg btl 1000 tablet 23.452

73 Hidrokortison krim 2 % (Asetat) tube 5 g 3.673 74 Ibuproten tablet 400 mg ktk 10 x 10 tablet 25.350 75 Ibuproten tablet 200 mg btl 100 tablet 11.700 76 Isoniazid tablet 300 mg btl 1000 tablet 104.000 77 Isoniazid tablet 100 mg btl 1000 tablet 36.816 78 Isosorbid Dinitrat tablet sublingual 5 mg ktk 10 x 10 tablet 13.650 79 Kalsium Laktat (Kalk) tablet 500 mg btl 1000 tablet 60.915 80 Kaptropil tablet 25 mg ktk 10 x 10 tablet 26.618 ktk 6 x 10 tablet 16.478 81 Kaptropil tablet 12,5 mg ktk 10 x 10 tablet 18.590 ktk 6 x 10 tablet 11.154 82 Ketamin injeksi 10 mg ktk 10 vial @ 20 ml 273.542 83 Kloramfenikol kapsul 250 mg btl 1000 kapsul 246.740 btl 250 kapsul 69.615 ktk 12 x 10 kapsul 33.410 84 Kloramfenikol suspensi 125 mg/ 5 ml btl 60 ml 6.890 85 Kloramfenikol tetes telinga 3 % btl 5 ml 3.349 86 Klorfeniramina Maleat (CTM) tablet 4 mg btl 1000 tablet 25.381 87 Klorokuin tablet 150 mg btl 1000 tablet 109.200 88 Klorpromazin injeksi i.m. 25 mg/ml (HCI) ktk 30 amp @ 2 ml 16.943 89 Klorpromazin injeksi i.m. 5 mg/ml (HCI) ktk 30 amp @ 1 ml 16.285 90 Klorpromazin tablet salut 100 mg (HCI) btl 1000 tablet salut 123.833 91 Klorpromazin tablet salut 25 mg (HCI) btl 1000 tablet salut 33.696 92 Kotrimoksazol DOEN I (dewasa) kombinasi : ktk 10 x 10 tablet 21.320 Sulfametoksazol 400 mg Trimetoprim 20 mg 93 Kotrimoksazol DOEN II (pediatrik) kombinasi : ktk 10 x10 tablet 8.320 Sulfametoksazol 100 mg Trimetoprim 20 mg 94 Kuinin injeksi i.v. 25% (sebagai 2 HCI) ktk 100 amp @ 2 ml 197.605 95 Kuinin tablet 222 mg (H2SO4.7H2O) btl 1000 tablet 316.774 96 Lidokain injeksi 2% (HCI) + Epinefrin 1 : 80.000 - 2 ml ktk 30 vial @ 2 ml 23.774 97 Lidokain injeksi 2% (HCI) ktk 100 amp @ 2 ml 43.680 98 Mebendazol tablet 100 mg ktk 5 x 6 tablet 6.919 99 Metampiron tablet 500 mg btl 1000 tablet 91.741 ktk 10 x 10 tablet 14.456 100 Metampiron injeksi 250 mg ktk 30 amp @ 2 ml 17.690 101 Metformin tablet salut 500 mg ktk 10 x 10 tablet salut 40.950 102 Metilergometrin tablet salut 0,125 mg (Maleat) ktk 10 x 10 tablet 18.018 103 Metronidazol tablet 500 mg ktk 10 x 10 tablet 21.107 104 Mertonidazol tablet 250 mg ktk 10 x 10 tablet 13.786 105 Mikonazol krim/salep 2% (Nitrat) tube 10 g 4.862 106 Natrium Bikarbonat tablet 500 mg btl 1000 tablet 18.308 107 Natrium Klorida larutan infus 0,9 % btl 500 ml 6.126 108 Natrium Thiosulfat injeksi i.v. 25% ktk 10 amp @ 10 ml 27.435 109 Nifedifin tablet 10 mg ktk 10 x 10 tablet 39.000 110 Nistatin tablet salut 500.000 IU/ g ktk 10 x 10 tablet salut 66.950

111 Nistatin vaginal tablet 100.000 IU/ g ktk 10 x10 tablet vaginal 42.250 112 Oksitetrasiklin injeksi i.v. 50 mg/ml (HCI) ktk 10 vial @ 10 ml 58.378 113 Oksitetrasiklin salep mata 1% (HCI) tube 3,5 gram 1.764 114 Parasetamol sirup 120 mg / 5 ml btl 60 ml 3.088 115 Parasetamol tablet 500 mg btl 1000 tablet 67.997 ktk 10 x 10 tablet 11.050 116 Parasetamol tablet 100 mg btl 100 tablet 5.210 117 Perfenazin tablet 4 mg (HCI) btl 100 tablet 5.513 118 Pilokarpin tetes mata 2 % (HCI/ Nitrat) btl 5 ml 6.777 119 Pirazinamid tablet 500 mg ktk 10 x 10 tablet 51.901 120 Pirantel tab. Score (base) 125 mg ktk 25 x 4 tablet score 28.145 ktk 30 x 2 tablet score 22.520 121 Piridoksin (Vitamin B6) tablet 10 mg (HCI) btl 1000 tablet 22.136 122 Primakuin tablet 15 mg btl 1000 tablet 129.532 123 Podivon lodida larutan 10% btl 1000 ml 54.600 btl 300 ml 20.358 btl 60 ml 4.290 btl 30 ml 2.808 124 Prazikuantel tablet 600 mg btl 100 tablet 208.000 125 Prazosin tablet 1 mg (HCI) btl 100 tablet 32.136 126 Frednison tablet 5 mg btl 1000 tablet 122.863 127 Prokain Benzil Penisilin G. injeksi 3 jt IU/vial ktk 30 vial @ 15 ml 234.780 128 Propanolol tablet 40 mg (HCI) ktk 10 x 10 tablet 18.720 129 Propanolol tablet 10 mg (HCI) ktk 10 x 10 tablet 9.360 130 Propiltiourasil tablet 100 mg btl 100 tablet 44.096 131 Ranitidin tablet 150 mg ktk 10 x 10 tablet 58.500 ktk 3 x 10 tablet 18.233 132 Reserpin tablet 0,25 mg btl 1000 tablet 100.984 133 Reserpin tablet 0,10 mg btl 250 tablet 16.250 134 Retinol (Vitamin A) 200.000 IU kapsul lunak btl 50 kapsul lunak 21.801 135 Retinol (Vitamin A) 100.000 IU kapsul lunak btl 50 kapsul lunak 16.575 136 Retinol (Vitamin A) tablet 50.000 IU btl 1000 tablet 208.000 137 Rifampisin kaplet 600 mg ktk 10 x 10 kaplet 159.120 138 Rifampisin tablet salut 450 mg ktk 10 x 10 tablet salut 127.257 139 Rifampisin kapsul 300 mg ktk 12 x 10 kapsul 93.600 ktk 10 x 10 kapsul 92.560 140 Ringer Laktat larutan infus btl 500 ml 7.319 141 Salbutamol tablet 4 mg (sebagai Sulfat) ktk 10 x 10 tablet 15.600 142 Salbutamol tablet 2 mg (sebagai Sulfat) ktk 10 x 10 tablet 13.780 143 Sianokobalamin (Vitamin B 12) injeksi 500 mcg ktk 100 amp @ 1 ml 91.000 144 Siprofloksasin tablet 500 mg (sebagai HCI) ktk 5 x 10 tablet 56.162 145 Streptomisin serbuk injeksi i.v. 1500 mg/ml ktk 30 vial @ 15 ml 71.292 146 Sulfadimidin tablet 500 mg btl 1000 tablet 133,078 147 Tetrasiklin kapsul 500 mg ktk 10 x 10 kapsul 32.512

148 Tetrasiklin kapsul 250 mg btl 1000 kapsul 153.371 149 Tiamin (Vitamin B1) injeksi 100 mg/ml ktk 30 amp @ 1 ml 22.198 150 Tiamin (Vitamin B1) tablet 50 mg (HCI/ Nitrat) btl 1000 tablet 42.208 151 Triheksifenidil tablet 2 mg ktk 10 x 10 tablet 7.410 152 Verapamil tablet 80 mg (HCI) ktk 10 x 10 tablet 65.280 153 Vitamin B Kompleks tablet btl 1000 tablet 30.592 NAMA ALAT PARTUS SET 1 Braun Stadler. Episiotomy Scissor 14 cm 2 Busch. Umbilical Scissor 16 cm 3 Standard Operating Scissor STR - Sh / Bl 14 cm 4 Mayo Hegar. Needle Holder 14 cm 5 Thumb Dressing Forsep. 14 cm 6 Tissue Forsep. (1x2 teeth) 14 cm 7 Kocher. Haemostatic Forsep STR 14 cm 8 Rochester. Pean Haemostatic Forsep STR 14 cm 9 Beacham. Amniotic Membrane Perforator (1/2 Kocher) 16 cm 10 Female Catheter Metal Fr. 12 11 Needle Case (50x30x6 mm) 12 Measuring Tape. For Baby (Reactable Type) 1,5 m 13 Umbilical Cord Clamp 14 Alcohol

Bidan NENG UMA AKROMAH, AM.Keb


Jl. Jend. Sudirman Dsn. Sukamulya No.34 RT 02/09 Ds. Pucung Kec. Kotabaru Kab. Karawang, Telp.082110222081


No. Nama : .............. Umur : ..............

Tgl.

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X

Bidan NENG UMA AKROMAH, AM.Keb Jl. Jend. Sudirman Dsn. Sukamulya No.34 RT 02/09 Ds. Pucung Kec. Kotabaru Kab. Karawang, Telp.082110222081

No. Nama : .............. Umur : ..............

Tgl.

X

Sebelum / Sesudah Makan

X



Semoga Lekas Sembuh

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NO

DAFTAR OBAT

KET

Abocath No.20 Alcohol 70%300 ml ACEVIT/VITALENE Vit A 10.000 IU

Dos 3 x 10 kaplet 40.000

Amoksisilin tablet 500 mg

Ktk 10 x10 tablet 41.954

ANDALAN pil kombinasi ANDALAN LAKTASI pil Antasida tablet kunyah, kombinasi: Aluminium Hidroksida 200 mg Magnesium Hidroksida 200 mg

Btl 1000 tablet kunyah 64.766 Ktk 10 x 10 tablet kunyah 11.859

ANTIMO Dimenhidrinat tab Asam Askorbat (Vitamin C)

Tablet 50 mg btl 1000 tablet 25.679

Asam Mefenamat tablet 500 mg Baby Kit (Dress & Soap) Bag Midwife Kit Besi (II) sulfat 7 H2O tablet salut 300 mg

Btl 1000 tablet salut 31.460

CALADRYL/CALAREX/CALAMEC lotion Calsium Lactate (Calc) tablet 500 mg

Btl 1000 tablet 60.915

CAPTOPRIL tablet 25 mg Catheter nelaton small CAVIPLEX/VIFFERON

Dos 10 x 10 30.000

Chromic Catgut No.2 in&out CYCLOFEM 0,5 ml Deksametason tablet 0,5 mg

Btl 1000 tablet 44.044 Ktk 10 x 10 tablet 12.146

DEPO Progestin 1 ml DEXTRAL tablet DIANE/YASMIN pil KB ERLACYCLIN salep mata Fenobarbital tab

Tablet 30 mg btl 1000 tablet 27.599

Fitomenadion (Vitamin K) injeksi 10 mg/ml

Ktk 30 amp @ 1 ml 40.300

Gentamisin cream

Tube 5 gram 2.535

Glukosa larutan infus 10 %

Btl 500 ml 6.370

Handscoen

Steril per pasang Box

Infus Set Kapas Kasa steril

Box Gulung

KOMPOLAX syrup Kotrimoksazol kombinasi: Sulfametoksazol 100 mg Trimetoprim 20 mg

Ktk 10 x10 tablet 8.320 Btl sirup (pediatrik)

Lidokain injeksi 2% (HCI)

Ktk 100 amp @ 2 ml 43.680

MELAXAN/LAXAMEX tab Methylergometrin tablet salut 0,125 mg POSPARGIN/METHOVIN

Ktk 10 x 10 tablet 18.018

Metoclopramide tab METSOCRIM Desoksimetason cream MICROLAX

Tube

MILNA Toddler Biscuit Balita Molagit tab MOMILEN Baby Care Diaper Rash cream

Tube 15gr

MOMILEN Intensive Tummy

Tube 15gr

MOMILEN Maternity Care Nursing cream

Tube 15gr

Needle Hecting: skin&muscle Syringe: No 25 – 23 – 20 NELICORT/OTOPAIN tetes telinga

Botol 10 ml 9.000

NEOCENTA/CENTABIO gel Oksitetrasiklin salep mata 1% (HCI)

Tube 3,5 gram 1.764

Oksitosin inj 10 IU Parasetamol tablet 100 mg

Btl 100 tablet 5.210

Podivon lodine larutan 10%

Btl 300 ml 20.358 Btl 30 ml 2.808

POSTINOR-2 Progestin 0,75mg/tab PREGNABION Allylestrenol 5 mg Provenit supp (analgetik manual plasenta) REMCO sirup anak Retinol (Vitamin A) 200.000 IU kapsul lunak

Btl 50 kapsul lunak 21.801

Ringer Laktat larutan infus

Btl 500 ml 7.319

Salbutamol tablet 4 mg

Ktk 10 x 10 tablet 15.600

Syringe 1cc 3cc 6cc Test Blood Indicator (pro/glu/cho) Test Lakmus Blue/Red Test Urine Indicator (pro/glu/uric) Test Urine Hcg pack Timbangan Bayi meja&gantung THROMBOPHOB Heparin gel TRANEXAMIC tab 250gr TRANEC tab 500gr Umbilical Cord Clamp disposible Under Pad Vaccine BCG Vaccine Campak Vaccine DPT Vaccine Hep-B Uniject Vaccine TT Vaccine Polio Zinc tab

Bidan Neng Uma Akromah, AM. Keb

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