Evaluasi Cost of Illness Pasien di Kamar Bedah Emergency Instalasi Gawat Darurat dan Instalasi Bedah Pusat RSUP. H. Adam Malik Medan

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September 2016 RSUP.H.Adam Malik Medan

Total tarif

klaim

(Rp)

Total Tari Rs

(Rp)

Selisih Tarif

(Rp)

1 G-1-10-I Prosedur

kraniotomi ringan

68.42.xx KS PR 5 3 20.343.700 21.272.901 -929.201 pernafasan non kompleks ringan

67.92.xx MBRS PR 27 3 15.093.800 35.556.210 -20.462.410

4 J-1-20-II Prosedur sistem pernafasan non kompleks sedang

68.01.xx MA PR 36 3 19.009.200 24.380.123 -5.370.923

5 K-1-10-II Prosedur non kompleks usus halus & usus besar (sedang)

61.25.xx AJS LK 4 3 12.387.700 19.055.930 -6.668.230

66.25.xx HT LK 31 3 12.387.700 20.442.789 -8.055.089

67.89.xx RP PR 66 3 12.387.700 19.348.188 -6.960.488

6 K-1-13-III Prosedur appendik berat

68.35.xx HM LK 36 3 8.719.500 14.258.147 -7.281.920

7 K-1-20-I Prosedur intestinal

kompleks (ringan)

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Lampiran 1. (Lanjutan)

67.65.xx AP LK 19 3 20.475.000 27.614.761 -7.139.761

66.84.xx BS LK 67 3 20.475.000 20.549.403 -74.403

57.36.xx TH PR 38 3 20.475.000 27.702.042 -7.227.042

9 K-1-20-III Prosedur intestinal

kompleks (berat)

68.20.xx T LK 52 3 35.803.100 51.155.834 -15.352.734

54.97.xx AM LK 50 3 35.803.100 38.334.771 -2.531.671

10 K-1-40-II Prosedur sistem pencernaan lain-lain (sedang)

68.51.xx P PR 66 3 10.663.500 24.382.152 -13.718.652

11 K-1-40-III Prosedur sistem pencernaan lain-lain (berat)

67.52.xx VW PR 43 2 26.556.200 48.891.405 -22.335.205

12 K-1-50-I Prosedur anal ringan

67.86.xx S PR 55 3 7.390.200 7.647.051 -256.851

13 K-4-18-I Diagnosis sistem pencernaan lain-lain

(ringan)

66.39.xx AH LK 0 2 4.395.600 8.440.729 -4.045.129

67.15.xx HB LK 3 1 5.128.100 8.167.884 -3.039.784

67.56.xx MS PR 63 1 5.128.100 7.837.175 -2.709.075

14 M-1-02-II Prosedur

amputasi sedang

68.54.xx J LK 27 3 6.360.500 11.827.535 -5.467.035

15 M-1-20-I Prosedur paha dan sendi panggul selain sendi mayor ringan

67.58.xx PPDA LK 31 3 15.340.000 30.428.355 -15.088.355

16 M-1-20-II Prosedur paha dan sendi panggul selain sendi

67.34.xx AA PR 16 3 21.516.900 41.884.910 -20.368.010

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mayor sedang 67.73.xx SS LK 48 3 21.516.900 74.789.928 -53.273.028 17 M-1-50-I Prosedur jaringan

lunak ringan

66.67.xx JWM LK 13 1 8.987.200 11.524.453 -2.537.253

66.98.xx DS PR 20 3 6.418.800 10.444.768 -4.025.968

18 M-1-60-II Prosedur sistem muskuloskletal dan jaringan penghubung lain-lain (sedang)

67.94.xx KMRS PR 23 3 12.463.400 43.203.027 -30.739.627

19 M-1-80-I Prosedur anggota tubuh atas ringan

66.73.xx K PR 43 3 15.080.700 27.094.309 -12.013.609

20 O-6-10-I Prosedur operasi pembedahan caesar ringan

67.22.xx AAS PR 27 3 5.300.400 12.772.733 -7.472.333

67.40.xx MS PR 27 3 5.300.400 21.062.983 -15.762.583

67.27.xx M PR 29 2 6.360.500 12.170.517 -5.810.017

67.39.xx SBRS PR 30 1 7.420.500 14.980.946 -7.560.446

67.26.xx DM PR 34 3 5.300.400 11.599.001 -6.298.601

67.34.xx EP PR 35 3 5.300.400 12.317.203 -7.016.803

67.30.xx MAS PR 36 3 5.300.400 19.470.407 -14.170.007

67.23.xx MES PR 38 3 5.300.400 11.433.113 -6.132.713

67.48.xx BS PR 27 2 6.360.500 18.728.161 -12.367.661

66.95.xx DS PR 20 3 5.300.400 8.722.454 -3.422.054

67.46.xx DP PR 23 3 2.747.800 4.746.725 -1.998.925

65.21.xx ESP PR 31 2 6.360.500 15.122.937 -8.762.437

67.49.xx ETMS PR 33 3 5.300.400 10.705.841 -5.405.441

67.72.xx EG PR 37 2 6.360.500 12.909.946 -6.549.446

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Lampiran 1. (Lanjutan)

67.49.xx ETMS PR 33 3 5.300.400 10.705.841 -5.405.441

67.72.xx EG PR 37 2 6.360.500 12.909.946 -6.549.446

67.91.xx GS PR 36 3 5.300.400 13.936.782 -8.636.382

67.79.xx HS PR 21 3 5.300.400 9.941.636 -4.641.236

67.76.xx LN PR 36 1 7.420.500 9.405.821 -1.985.321

67.94.xx NG PR 28 2 6.360.500 10.621.042 -4.260.542

67.90.xx RS PR 31 3 5.300.400 11.995.000 -6.694.600

67.71.xx SR PR 25 3 5.300.400 10.856.887 -5.556.487

67.73.xx SW PR 31 2 6.360.500 14.527.787 -8.167.287

67.78.xx SBRS PR 21 3 5.300.400 11.248.428 -5.948.028

67.99.xx ESN PR 28 3 5.300.400 9.889.107 -4.588.707

46.03.xx E PR 33 3 5.300.400 7.184.606 -1.884.206

67.96.xx ILS PR 30 3 5.300.400 11.540.485 -6.240.085

68.03.xx M PR 42 2 6.360.500 11.770.107 -5.409.607

68.00.xx NT PR 22 3 5.300.400 6.502.960 -1.202.560

67.91.xx TDA PR 32 1 7.420.500 9.904.102 -2.483.602

67.98.xx TH PR 40 1 7.420.500 13.783.219 -6.362.719

68.54.xx FNP PR 39 2 3.600.600 8.108.137 -4.507.537

21 U-1-20-I Prosedur tenggorokan, mulut, hidung dan telinga lain-lain (ringan)

67.12.xx S LK 57 3 7.452.700 16.175.855 -8.723.155

68.46.xx K LK 51 1 10.433.800 13.525.373 -3.091.573

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22 W-1-20-I Prosedur pada rahim dan adneksa ringan

67.13.xx YRH PR 28 2 12.310.000 19.287.066 -6.977.066

67.38.xx LA PR 31 3 10.258.300 11.244.681 -986.381

23 W-1-20-II Prosedur pada rahim dan adneksa sedang

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Lampiran 2.

Demografi Pasien, Biaya Terapi Pasien di Instalasi Bedah Pusat Periode April 2016 – September 2016 RSUP. H.

Adam Malik Medan

Total tarif

klaim

(Rp)

Total tarif rs

(Rp)

Selisih Tarif

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4 J-1-20-II Prosedur sistem pernafasan non kompleks sedang

64.65.xx HM PR 16 3 19.009.200 89.596.401 -70.587.201

68.07.xx HJR PR 80 1 26.612.800 29.338.752 -2.725.952

67.92.xx EN PR 0 3 19.009.200 32.002.620 -12.993.420

5 K-1-10-II Prosedur non kompleks usus halus dan usus besar (sedang)

66.32.xx DS PR 50 1 17.344.500 21.663.093 - 4.318.593

6 K-1-13-III Prosedur appendik Berat

68.28.xx RH LK 18 3 8.719.500 15.882.780 -7.163.280

7 K-1-20-I Prosedur intestinal kompleks (ringan)

63.78.xx W LK 52 3 14.658.800 15.117.209 - 458.409

8 K-1-20-II Prosedur intestinal kompleks (sedang)

64.04.xx S PR 40 3 20.475.000 30.012.524 - 9.537.524

64.28.xx RS PR 61 1 28.662.100 48.839.366 - 20.177.266

67.57.xx CI PR 38 2 24.567.500 52.390.702 - 27.823.202

67.73.xx JO LK 7 3 20.475.000 50.011.018 - 29.536.018

67.50.xx M PR 45 3 20.475.000 29.978.231 - 9.503.231

67.65.xx M LK 55 3 20.475.000 32.323.241 -11.848.241

67.84.xx SRTR G

LK 74 1 28.662.100 34.915.090 - 6.252.990)

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Lampiran 2. (Lanjutan)

67.75.xx TS LK 62 1 28.662.100 39.721.395 - 11.059.295

9 K-1-20-III Prosedur intestinal kompleks (berat)

67.24.xx BYN W

PR 0 3 35.803.100 36.984.405 -1.181.305

67.05.xx OS LK 51 3 35.803.100 77.754.116 -41.951.016

29.31.xx TW LK 13 3 35.803.100 37.659.370 - 1.856.270

67.18.xx T LK 50 3 35.803.100 51.840.440 -16.037.340

67.10.xx DS PR 67 3 35.803.100 80.238.532 - 44.435.432

67.28.xx PK PR 59 1 50.119.300 115.891.951 -65.772.651

10 K-1-40-II Prosedur sistem pencernaan lain-lain (sedang)

68.25.xx S LK 62 3 10.663.500 30.109.744 -19.446.244

11 K-1-40-III Prosedur sistem pencernaan lain-lain (berat)

67.66.xx DO PR 3 3 22.132.400 24.423.470 - 2.291.070

12 K-1-50-I Prosedur anal ringan

54.77.xx NS PR 3 3 7.390.200 11.601.366 -4.211.166

13 K-4-18-I Diagnosis sistem pencernaan lain-lain (ringan)

67.26.xx DBS LK 2 2 4.395.600 8.649.995 -4.254.395

67.62.xx BS LK 58 1 5.128.100 9.655.050 - 4.526.950

14 M-1-02-II Prosedur amputasi sedang

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15 M-1-20-I Prosedur paha dan sendi panggul selain sendi mayor ringan

47.87.xx A PR 50 1 21.476.000 25.340.986 -3.864.986

65.65.xx AR PR 23 3 15.340.000 18.980.968 -3.640.968

16 M-1-20-II Prosedur paha dan sendi panggul selain sendi mayor sedang

67.14.xx J LK 41 3 21.516.900 55.722.016 -34.205.116

67.21.xx KS PR 28 3 21.516.900 47.538.233 -26.021.333

66.39.xx RWA LK 31 3 21.516.900 26.461.116 - 4.944.216

17 M-1-50-I Prosedur jaringan lunak ringan

67.17.xx NABR PR 68 3 6.418.800 15.374.300 -8.955.500

67.23.xx NI LK 21 3 6.418.800 11.058.301 - 4.639.501

54.22.xx MS LK 59 1 8.987.200 10.260.562 -1.273.362

67.92.xx R PR 57 3 6.418.800 15.047.396 -8.628.596

67.91.xx AA PR 12 3 6.418.800 15.668.274 - 9.249.474

18 M-1-60-II Prosedur sistem muskulosklet al dan jaringan penghubung lain-lain (sedang)

67.73.xx M LK 47 3 12.463.400 63.878.822 -51.415.422

19 M-1-80-I Prosedur anggota tubuh atas ringan

37.96.xx S PR 63 1 21.115.000 29.461.882 -8.346.882

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Lampiran 2. (Lanjutan) 20 O-6-10-I Prosedur

operasi pembedahan caesar ringan

58.62.xx A PR 40 3 5.300.400 13.210.705 -7.910.305

52.86.xx NHP PR 33 3 5.300.400 8.150.795 -2.850.395

66.66.xx SAT PR 33 3 5.300.400 8.533.433 -3.233.033

67.24.xx YS PR 24 3 5.300.400 6.209.154 - 908.754

63.31.xx RES PR 42 3 5.300.400 11.483.703 -6.183.303

67.50.xx M PR 28 3 5.300.400 8.761.923 -3.461.523

67.51.xx N PR 32 2 6.360.500 8.402.447 -2.041.947

67.86.xx S PR 37 1 7.420.500 10.740.548 -3.320.048

68.00.xx EM PR 33 3 5.300.400 8.981.981 -3.681.581

68.38.xx SM PR 29 3 5.300.400 7 7.0186.36 -1.718.236/

68.55.xx ALR PR 30 3 5.300.400 10.947.867 -5.647.467

21 U-1-20-I Prosedur tenggorokan, mulut, hidung dan telinga lain-lain (ringan)

63.05.xx I LK 53 1 10.433.800 14.060.377 -3.626.577

66.73.xx LS LK 59 3 7.452.700 20.163.420 -12.710.720

67.20.xx MH LK 66 1 10.433.800 10.778.649 -344.849

67.16.xx N LK 48 3 7.452.700 12.022.382 -4.569.682

67.26.xx AE LK 54 3 7.452.700 8.561.584 -1.108.884

68.0.7.xx PPA PR 13 2 8.942.300 28.898.804 -19.956.504

59.77.xx RH LK 58 1 10.433.800 23.156.092 -12.722.292

68.10.xx SI LK 57 3 7.452.700 8.138.957 - 686.257

68.20.xx AS LK 52 1 10.433.800 12.548.594 -2.114.794

68.28.xx IC LK 52 3 7.452.700 11.915.417 -4.462.717

67.85.xx JS LK 50 2 8.942.300 15.189.605 - 6.247.305

68.23.xx MM LK 72 2 8.942.300 15.483.544 -6.541.244

67.90.xx SY LK 40 3 7.452.700 9.528.884 -2.076.184

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67.43.xx AS LK 53 3 7.452.700 9.251.726 -1.799.026

68.61.xx PS LK 54 3 7.452.700 12.577.051 -5.124.351

22 W-1-20-I Prosedur pada rahim dan adneksa ringan

66.66.xx ED PR 50 3 10.258.300 11.669.142 -1.410.842

67.13.xx LA PR 27 3 10.258.300 12.018.355 -1.760.055

58.73.xx MPS PR 40 1 14.360.200 18.204.872 -3.844.672

66.55.xx N PR 54 1 14.360.200 18.280.004 -3.919.804

48.90.xx R PR 48 1 14.360.200 16.554.968 -2.194.768

66.56.xx YS PR 55 3 10.258.300 15.102.283 -4.843.983

67.16.xx RSG PR 59 3 10.258.300 12.231.082 -1.972.782

66.75.xx RS PR 41 3 10.258.300 13.822.946 -3.564.646

67.18.xx SG PR 28 3 10.258.300 14.808.486 -4.550.186

23 W-1-20-II Prosedur pada rahim dan adneksa sedang

67.28.xx N PR 48 3 12.757.900 14.251.623 -1.493.723

67.42.xx NSRP PR 38 3 12.757.900 14.364.957 -1.607.057

67.42.xx NAS PR 25 3 12.757.900 14.429.313 -1.671.413

67.28.xx AR PR 22 2 15.311.000 24.324.079 -9.013.079

67.19.xx F PR 51 2 15.311.000 17.171.778 -1.860.778

68.38.xx R PR 51 1 17.862.800 19.472.851 -1.610.051

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Lampiran 3. Biaya Terapi Pasien Meliputi Biaya Penunjang di Kamar Bedah

Emergency Instalasi Gawat Darurat Periode April 2016 –

September 2016 RSUP. H. Adam Malik Medan

No Kode

INA-CBG’s

Inisial

Pasien

Biaya Langsung

Medis

Jumlah

(Unit)

Total

Biaya

(Rp)

Dijamin

(Rp)

1

G-1-10-I KS Laboratorium 7 217.000 206.522

Radiologi 3 940.000 898.941

Obat/barang medis 10,2 294.945 282.061

2

G-1-10-II J Laboratorium 7 217.000 131.502

Radiologi 3 900.000 545.397

Obat/barang medis 152 6.478.829 3.926.147

TJB Laboratorium 7 411.000 234.965

Radiologi 5 1.115.000 855.872

Obat/barang medis 107 437.946 3.252.696

3

J-1-20-I MBRS Laboratorium 16 1.242.000 1007.146

Radiologi - - -

Obat/barang medis 66 1.907.824 809.881

4

J-1-20-II MA Laboratorium 11 1.137.000 780.480

Radiologi - - -

5

K-1-10-II AJS Laboratorium 9 666.000 517.376

Radiologi 2 280.000 182.020

Obat/barang medis 128,5 321.412 208.94.07

HT Laboratorium 9 425.000 230.269

Radiologi 2 280.000 169.671

RP Laboratorium 7 217.000 138.935

Radiologi 2 280.000 179.270

6

K-1-13-III

HM Laboratorium 11 390.000 302.718

Radiologi 1 80.000 48.924

7

K-1-20-I S Laboratorium 15 1.069.000 939.718

(13)

8

K-1-20-II RA Laboratorium 12 1.048.500 503.381

Radiologi 2 280.00 250.563

RS Laboratorium 8 224.500 208.461

Radiologi 1 100.000 74.492

MH Laboratorium 12 562.500 537.456

Radiologi 2 280.000 267.296

FSP Laboratorium 10 617.000 497.513

Radiologi 3 80.000 59.316

AP Laboratorium 11 495.500 367.018

Radiologi 2 280.000 207.426

Obat/barang medis 58 2713.335 2.011.806

BS Laboratorium 7 217.000 158.275

Radiologi 2 280.000 278.986

TH Laboratorium 10 474.000 350.371

Radiologi 2 280.000 206.952

9

K-1-20-III

T Laboratorium 11 495.000 346.443

Radiologi 2 280.000 195.967

AM Laboratorium 13 1.066.000 1.066.000

Radiologi 1 80.000 80.000

10

K-1-40-II P Laboratorium 7 217.000 94.905

Radiologi 2 280.000 122.458

Obat/barang medis 179,5 4.273.680 1.869.088

11

K-1-40-III

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Lampiran 3. (Lanjutan)

Radiologi - - -

Obat/barang medis 53 649.090 352.564

12

K-1-50-I S Laboratorium 11 305.000 294.755

Radiologi 1 80.000 77.313

13

K-4-18-I AH Laboratorium 11 479.000 207.848

Radiologi - - -

HB Laboratorium 12 468.500 294.455

Radiologi 1 125.000 78.480

MS Laboratorium 13 267.000 174.700

Radiologi 2 205.000 134.138

14

M-1-02-II J Laboratorium 7 217.000 176.082

Radiologi 3 255.000 206.917

15

M-1-20-I PPDA Laboratorium 10 650.000 209.718

Radiologi 3 260.000 131.075

16

M-1-20-II AA Laboratorium 10 468.000 252.907

Radiologi 11 1.660.000 852.767

DS Laboratorium 10 466.000 237.897

Radiologi 2 155.000 91.878

Farmasi 163 4.617.626 2.737.146

SS Laboratorium 16 795.000 228.720

Radiologi 8 1.475.000 424.354

17

M-1-50-I JWM Laboratorium 10 468.000 364.423

Radiologi 5 525.000 417.213

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18

M-1-60-II KMRS Laboratorium 8 253.000 101.836

Radiologi 7 575.000 165.789

19

M-1-80-I K Laboratorium 14 468.000 260.0.489

Radiologi 4 330.000 183.678

Obat/barang medis 109 5119518 2.849.525

20

O-6-10-I AAS Laboratorium 10 414.000 171.801

Radiologi - - -

MYS Laboratorium 14 1.022.000 257.162

Radiologi - - -

M Laboratorium 13 841.000 366.483

Radiologi - - -

Obat/barang medis 109,5 1.747.667 761.269

SBRS Laboratorium 13 1.081.000 545.031

Radiologi - - -

DM Laboratorium 13 740.500 740.500

Radiologi - - -

EP Laboratorium 14 1.106.00 475.939

Radiologi - - -

MAS Laboratorium 13 769.500 209.479

Radiologi - - -

MES Laboratorium 14 794.500 188.331

Radiologi - - -

BS Laboratorium 14 1.021.000 346.754

Radiologi - - -

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Lampiran 3. (Lanjutan)

Radiologi - - -

DP Laboratorium 14 862.000 343.830

Radiologi - - -

ESP Laboratorium 16 1.121.000 526.083

Radiologi - - -

ETMS Laboratorium 11 495.000 374.738

Radiologi - - -

FG Laboratorium 5 523.000 285.318

Radiologi - - -

HYM Laboratorium 14 1.298.000 422.503

Radiologi - - -

M Laboratorium 16 1.165.000 556.316

Radiologi 1 80.000 35.500

NA Laboratorium 10 468.000 107.678

Radiologi - - -

SMN Laboratorium 14 1.231.000 347.209

Radiologi - - -

YW Laboratorium 16 629.000 388.462

Radiologi - - -

DLN Laboratorium 2 81.000 38.726

Radiologi - - -

(17)

EBRT Laboratorium 13 883.000 490.946

Radiologi - - -

EG Laboratorium 7 217.000 106.642

Radiologi - - -

GS Laboratorium 10 468.000 177.989

Radiologi - - -

HS Laboratorium 10 1.779.989 264.443

Radiologi - - -

LN Laboratorium 7 217.000 171.224

Radiologi - - -

NG Laboratorium 1 59.000 27.082

Radiologi - - -

RS Laboratorium 7 217.000 128.240

Radiologi - - -

SR Laboratorium 15 1.165.999 568.760

Radiologi - - -

SW Laboratorium 14 1.106.000 484.224

Radiologi - - -

SBRS Laboratorium 10 423.000 390.165

Radiologi - - -

ESN Laboratorium 11 495.000 265.303

Radiologi - - -

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Lampiran 3. (Lanjutan)

Radiologi - - -

ILS Laboratorium 14 991.000 610.852

Radiologi - - -

M Laboratorium 14 1.106.000 597.675

Radiologi - - -

NT Laboratorium 6 668.000 560.772

Radiologi - - -

TDA Laboratorium 12 824.000 617.364

Radiologi - - -

TH Laboratorium 14 932.000 501.766

Radiologi - - -

FNP Laboratorium 13 855.000 619.512

Radiologi - - -

21

U-1-20-I S Laboratorium 8 362.000 173.850

Radiologi 1 80.000 36.858

K Laboratorium 8 410.000 316.283

Radiologi - - -

HPP Laboratorium 12 324.000 194.024

Radiologi 2 205.000 122.762

22

W-1-20-I YRH Laboratorium 11 438.500 279.473

Radiologi - - -

LA Laboratorium 12 554.000 505.402

(19)

23

W-1-20-II E Laboratorium 7 217.000 144.605

Radiologi 1 80.000 71.744

(20)

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67.05.xx OS 130 4.945.756,00 2.277.205 29.31.xx TW 183,0 3.120.256 3.545.361 67.18.xx T 302,0 5.543.083 3.828.277 67.10.xx DS 194,0 3.714.784 1.657.568 67.28.xx PK 69,2 1.728.815 747.653

10

K-1-40-II 68.25.xx S 40 3.556.576 1.259.578

11

K-1-40-III

67.66.xx DO 26 1.329.993 1.205.232

12

K-1-50-I 54.77.xx NS 27,2 1.378.539 878.144

13

K-4-18-I 67.26.xx DBS 109,8 1.201.672 610.644 67.62.xx BS 30,0 1.261.886 670.227

14

M-1-02-II

68.67.xx MM 30 1.744.238,07 1687661

15

M-1-20-I 47.87.xx A 58 2.441.961 2.069.515

65.65.xx AR 115 4.502.639 3.638.935

16

M-1-20-II

67.14.xx J 364 4.745.557,15 2.177.930 67.21.xx KS 365 25.236.507 11.422.625 66.39.xx RWA 341,6 6.255.699 4.909.830

17

M-1-50-I 67.17.xx NABR 98,4 1.881.974 785.728

67.23.xx NI 51 2.413.702 1.401.035

54.22.xx MS 33 1.408.013,00 1233275

67.92.xx R 30,0 1.470.232 627.160

67.91.xx AA 32 1.373.479 567.671

18

M-1-60-II

67.73.xx M 164 5.264.510,00 1.027.159

19

M-1-80-I 37.96.xx S 37 19.558.932 14.017.667

67.63.xx YS 50 21.654.922,64 13.957.408

20

O-6-10-I 58.62.xx A 133,2 3.104.890 1.245.744

52.86.xx NHP 126 2.990.420 1.944.647 66.66.xx SAT 129,2 1.926.762 1.196.776

67.24.xx YS 15 97.774 83.464

63.31.xx RES 149 1.311.070 605.135

67.50.xx M 156 3.513.970 2.125.726

67.51.xx N 70 1.779.433 1.346.998

67.86.xx S 40 1.631.031 1.126.857

68.00.xx EM 113 3.613.091 2.132.139

68.38.xx SM 32 1.278.855 965.778

68.55.xx ALR 44 3.463.404 1.676.804

21

U-1-20-I 63.05.xx I 120,0 1.113.671 826.423

(22)

Lampiran 4. (Lanjutan)

67.16.xx

N

107

1.850.455

1.146.558 67.26.xx

AE

114,4

1.925.086

1.675.752 68.0.7.xx

PPA

39

1.246.471

385.702 59.77.xx

RS

23

863.353

473.973 68.10.xx

SI

7

677.719

620.575 68.20.xx

ASR

25

1.700.686

1.414.072 68.28.xx

IC

34 1665043

1049463

67.85.xx

JS

22

1.590.840

936.546 68.23.xx

MM

35 1.600.561,55

924.381 67.90.xx

SY

12 927032

958;340

55.68.xx

SD

29

1.486.380

1.158.147 67.43.xx

AS

45

2.876.968

772.223 67.90.xx

SY

12 927032

958;340

55.68.xx

SD

29

1.486.380

1.158.147 67.43.xx

AS

45

2.876.968

772.223 68.61.xx

PS

93,2

1.983.098

1.175.111

22 W-1-20-I

66.66.xx

ED

119,6

1.856.392

1.631.947 67.13.xx

LA

123,6

2.091.568

1.785.264 58.73.xx

MPS

148,7

1.615.783

1.274.547 66.55.xx

N

158,6

2.361.850

1.855.396 48.90.xx

R

136,6

2.450.245

2.125.405 66.56.xx

YS

174,6

1.642.832

1.795.157 67.16.xx

RSG

119

2.033.408

1.705.434 66.75.xx

RS

149,2

1.583.954

1.175.486 67.18.xx

SG

50,0

4.332.646

3.001.359

23 W-1-20-II

67.28.xx

N

51

3.978.190

3.561.233 67.42.xx

NSRP

72

2.678.091

2.378.848 67.42.xx

NAS

54

3.265.595

2.887.327 67.28.xx

AR

114

4.944.576

3.112.406 67.19.xx

F

43

2.100.363

1.872.762 68.38.xx

R

49

2.956.673

2.712.210

(23)

Medan

Obat/Barang Medis

Rp

(%)

(24)

(25)

(26)

(27)

20 O-6-10-I

AAS

5.300.400

414.000 SBRS

7.420.500

1.081.000

(28)

(29)

(30)

(31)

(32)

Lampiran 6.

Diagram Persentase Penggunaan Biaya Pelayanan Penunjang dari

Total Klaim INA-CBG’s di KBE RSUP. H. Adam Malik Medan

6% 1%

23%

10% 60%

Diagram Persentase Penggunaan Biaya Pelayanan Penunjang

dari Total Biaya Klaim INA-CBG's di KBE RSUP. H. Adam

Malik Medan

laboratorium

radiologi

obat/barang medis

biaya penunjang selain di KBE

(33)

PeriodeApril 2016 – September 2016 RSUP. H. Adam Malik

Medan

No Nama Obat

Satuan

Jumlah

Total Biaya

(Rp)

1

Ringer Laktat Lar infus botol

500 ml

Botol

305 2.351.233,00

2

Nacl 0,9% 100 ml

Botol

299 2.293.621,20

3

Fentanil injeksi 0,05 mg/ml (Sebagai Sitrat) 2 ml

Ampul

229 10.515.460,00

4

Otsu Water injeksi ampul @ 25 ml

Botol

127 345.840,00

5

Oxytoxin injeksi 10 IU/ml

Botol

120 410.160,00

6

Asam Traneksamat injeksi 250

mg/ 5 ml ampul

Ampul

102 373..053,60

7

ketorolac injeksi 30 mg / ml ampul 1 ml

Ampul

100 220.109,00

8

Deksametason injeksi 5mg/ml (Sebagai Natrium F)

Ampul

98 `95098,40

9

Epinefrine injeksi 0,1 % ( sebagai HCL / Bitartrat

Ampul

98 566.435,00

10

Atropin Sulfas 0,25 % injeksi

Ampul

95 450.148,00

11

Ranitidine injeksi 50mg/ 2 ml

@ampul 2 ml

Ampul

93 235.774,42

12

Propofol - Fresofol 1 % MCT/ LCT

Ampul

79 1.168.048,00

13

Metilergometrin injeksi 0,200 mg/ml ampul @1ml

Ampul

74 244.200,00

14

Lidokain Hcl 2 % (HCL)

Vial

66 69.469,80

15

Neostigmin injeksi 0,5mg/ml Hameln

Vial

50

570.630

16

Roculax injeksi 5 ml

Ampul

50 4.295.480,00

17

Efedrin - Vasodrin injeksi

Ampul

44 1.662.600,00

18

Rokuronium - Esmeron injeksi

50 mg / ml

Vial

44

2.189.096

19

Otsu - MGSO4 injeksi 20% ampul 20 ml

Ampul

42 196.315,20

20

Seftazidim injeksi 1000 mg/vial

Vial

42 899.905,60

21

Asam Traneksamat injeksi 500

mg

Ampul

39 113.497,40

22

Ketamin injeksi 50 mg / ml - Ketamin Hameln

Vial

35 2.783,220

23

Gentamycin injeksi 40mg/2ml

Vial

34 136.954,80

24

Furosemid injeksi 10mg/ml

(34)

Lampiran 7. (Lanjutan)

27

Gelofusine infus 100 ml

Kantong

25 1.714.376,00

28

Sefazolin 1 gram

Vial

25 536.490,00

29

Petidin injeksi 50 mg/ml (HCL) ampul @2ml

33

Sotatic injeksi 5mg/ml

(Metoclopramide)

Ampul

20 73.920,00

34

Fitomenadion injeksi 2g/ml

Ampul

19 76.947,80

35

Marcain 0,5% Heavy (Marcain

Spinal)

Ampul

19 631.508,27

36

Ringer Soluition botol 500 ml

Botol

19 265.666,74

37

Alkohol 70 % 300 ml RS

Botol

18 972.384,44

38

Nifedipin tablet 10 mg

Tablet

18 2.376,00

39

Metronidazol larutan infus 5mg/ml botol 100

Botol

17 206.968,80

40

Seftriakson serbuk injeksi 1000 mg / vial

Vial

15 81.000,00

41

Atrakurium - Notrixum injeksi 25mg/2,5 ml

Vial

14 211.524,00

42

Naropin 7,5 mg

Vial

14 1.362.149,60

43

Stesolid injeksi 10 mg ampul/2 ml

Ampul

14

67.200

44

Norepinefrin injeksi 1mg/ml – Levosol

Ampul

13 805.805,00

45

Aminofilin injeksi 24mg/ml ampul @10ml

Ampul

12 51.407,60

46

Paracetamol infus 10mg/ml @10 ml

Botol

12 223.154,00

47

Sefotaksim serbuk injeksi 1000 mg /vial

Vial

12 142.583,60

48

Epinephrine

Ampul

11 45.578,20

49

Povidone Iodine 300 cc

Botol

11 463.307,06

50

Bupivakain /Recain injeksi 4mg 5ml

Vial

10 270.000,00

51

Atropin Sulfas 0,25 mg

Tablet

9

13.960

52

Dobutamin injeksi 50mg/ml – Doburan

Ampul

9 308.736,00

53

Alkohol 70 % 100 ml

Botol

8 35.874,31

54

Atropin injeksi 0,25ml/ampul @1ml

Ampul

6

9.360

55

Bupivakain injeksi 0,50% Marcain

(35)

56

Noveron (Rokuronium)

64

Kalsium Glukonat -C4 Glukonas 100ml

Vial

2 23.892,00

65

Larutan Asam Amino - Aminofluid 500 ml

Botol

2

149.477

66

Otsu - D4040 infus 40% ampul 25 ml

Ampul

2 7.677,60

67

Pethidin Hcl injeksi 2 ml

Ampul

2

36.538

68

Albumin - Albure Injeksi 20% 100ml

Vial

1

900.900

69

Aquadest Non Steril

Botol

1

3.000

70

Bupivacain Spinal injeksi 4 ml

Ampul

1 32.254,46

71

Dobutamin injeksi 250mg/ml –

Doburan

76

Kombinasi Iprat 0,5+sal - Combivent UDV

Vial

1 5.994,00

77

Larutan Lipid - Lipofudin MCT/LCT100 ml

Vial

1 121325

78

Manitol larutan infus 5mg/ml botol 100

Botol

1 71.300,00

79

Manitol Larutan Infus 20% botol 500 ml

Botol

1 52.800,00

80

Natrium Bikarbonat 8,4% - Myelon

Botol

1

7.440

81

Propanolol Tablet 10 mg

Buah

1

8.400

(36)

Lampiran 8.

Rekapitulasi Penggunaan Barang Medis di Kamar Bedah

Emergency Periode April 2016 – September 2016 RSUP. H.

Adam Malik Medan

No

Nama Obat

Satuan Jumlah

Total Biaya

Pasang

251 1.929.595,00

5

Sarung Tangan Steril No. 7,5 Trge

Pasang

221 1.748.994,00

6

Celemek Plastik / Apron

Buah

219 612.791,52

7

Disp. Syringe / Spuit 5 cc

Buah

205 2.344.677,66

8

Topi (Nurse Cup) One

Buah

184 73.725,12

9

Cuticell Classic 10cmx10cm

Buah

171 1.179.853,16

10

Sikat Operasi/ Scrub Brush

Steril

Buah

152 1.627.740,00

11

Sarung Tangan NS M Ax

Pasang

151 83.714,00

12

Sarung Tangan Steril No. 6,5

Trge

Pasang

133 1.054.531,00

13

Sarung Tangan Steril No. 8,0 Trge

Pasang

132

1.277.554

14

Silk Peters 2/0 S25339 TP25

Buah

129 6.106.959,20

15 Buah

118 232.930,00

16

Sarug Tangan Karet Pjg

Pasang

110 2.395.800,00

17

Cover A ll Flu Burung UK XI

Buah

101 2.044.563.315,00

18

Kaca Mata Clear

Buah

100 4.321.176,02

19

Masker Karet

Buah

96 38.016,00

20

Optime 1 18S40G TP 48mm

Buah

85 8.620.012,46

21

Electroda Adult FSTFA (43 x

51)

25

Cauther/ Goldline Pencil

Buah

61 8.900.583,35

(37)

31

Polysorb 1CL 925 RB

Buah

39 4.209.108,31

32

Urine Bag T Type

Buah

39 573.546,00

33

Abbocath Safety Plus No 18

Buah

38 784.388.944,00

34

Celelemek / Plastik Putih 25

Micron

Buah

38 92.293,60

35

Celemek/ Apron Surg

Buah

38

502.199

36

Sarung Tangan Nitile M

Pasang

38 26.063,20

37

Suction Connection 300 cm

Buah

37 980.214,74

38

Safil No. 1 HR48

Buah

36 4.268.538,36

39

Optime 3/0 18S20K RC 24mm

Buah

34 2.803.313,20

40

Kaus kaki /shoe cover Non

Moven

Pasang

33 39.204,00

41

C Gut Chromic 2 HR50

Buah

26 1.022.280,00

42

Koloid HES BM13000 6%- Voluven

Buah

26 1.029.600,00

43

Silk Peters 3/0 S5266 TP25

Buah

26 1.281.463,20

44

Spinocan No.25

Buah

26 1.036.636,24

45

Suction Catheter No. 6 Ax

Buah

26 238.788,00

46

Tranfusi Set

Buah

24 119.999.327,80

47

Masker - Surgical Respiratot N95

Buah

23 468.000,00

48

C Gut Chromic 2/0 HR26

Buah

21 881.590,22

49

C.Gut Plain 2/0 210

Buah

21 927.489,00

50

Daryan - Tulle Kasa Steril 10 x 10 cm

Buah

21 642.982,12

51

ETT With Cup No 7.5

Buah

20 580.800,00

52

Sarung Tangan / Gloves Steril No. 7,5 Trge

Pasang

20 182.400,00

53

Sarung Tangan NS UK M

Pasang

20 7.800,00

54 Buah

19 154.339,92

55

UT

Buah

19 391.635,60

56

Silk Black 2/0 HR26

Buah

19

252.000

57 Buah

18 28.104,00

58

Elastis Verban / FM Crepe 4

Buah

18 950.118,40

59

Urine Bag With Hanger

Buah

16 101.376,00

60

Askina Soft Clear 9 x 25cm

Buah

15 377.491,20

61 Buah

15 148.960,00

62

Optime 3/0 18S20FE RB26

Buah

15 1.180.468,55

63

Abbocath Pjg No. 16

Buah

14 120.322.052,00

64

Abbocath Safety Sine No 18

Buah

14 429.727,01

65

ETT With Cup No 7

Buah

14 380.984,00

(38)

Lampiran 8. (Lanjutan)

67

Perifix Paed /Epidural Set 400 G18 x 3

Buah

14 4.774.000,00

68

Selang Oxygen Dws

Buah

14 92.400,00

69 Buah

14 123.616,00

70

CVC DBL Lumen 7F

(702-20Y)

Buah

13 1281858,,60

71

Infus Set Ped Term

Buah

13 231.358,85

72

C.Gut Plain 0 HR37

Buah

12 349.027,20

73

C.Gut Plain 0 TP 35mm

Buah

12 739.585,30

74

Corolene2/0 20S30B RC26

Buah

12 1.070.460,00

75

Gybs (Polygips ) 4

Buah

12 303.552,00

76

Optime 2/0 18S20E RB26mm

Buah

12 105.949,28

77

Piasu Operasi No.20

Buah

12 43.200,00

78

Selang Oxygen Bayi be

Buah

12 72.600,00

79

Silk Black 3/0 HR26

Buah

12

196.070

80 Buah

12 106.128,00

81

Corolene 3/0 S20E RB26

Buah

11 1.550.618,08

82

Electroda FS - TC1 PED

Buah

11 28.418,28

83

Polysorb 3/0 SL693

Buah

11 1.125.158,58

84 Buah

10 277.200,00

85

C.Gut Plain 1 225

Buah

10 561.216,00

86

Colostomy Bag No. 3 OM

Buah

10 34.782,00

87

Corolene 2/0 20S30B RC26

Buah

10 891.825,00

88

Corolene 3/020S2OH RC19

Buah

10 1.093.955,00

89

Onescrub 500 cc

Buah

10 724.063,00

90

Polysorb 2/0 GL-123

Buah

10 713.547,40

91

Sarung Tangan NS S Ax

Pasang

10 5.544,00

92

Sarung Tangan NS L Ax

Pasang

10 5.544,00

93

Sarung Tangan NS UK S

Pasang

10

6.996

94

Silk Peters 1 TC35mm S25509

Buah

10 543.066,78

95 Buah

10 88.440,00

96

Suction Catheter No.6

Buah

10 52.140,00

97

Tranfusi Set / Sangofix ES

Buah

10 601.147,78

98

Camelux

Buah

9 190.080,00

99

Foley Cath 2Way No.18

Buah

9 118.800,00

100

Optime 1 S40FE RB40

Buah

9 819.176,05

101

Optime 2/0 18S30GE TP36mm

Buah

9 510.656,93

102

Pisau Operasi No.15

Buah

9 32.400,00

103

Pisau Opperasi No.11

Buah

9 32.400,00

104

Clipper Blade 9660

Buah

8 582.864,65

(39)

106

Disp. Syringe / Spuit 100 cc UT

Buah

8

172.704

107

Foley catheter 2Way Fr16

Buah

8 105.474,80

108

Rectal Tube No.28 - 40 cm

Buah

8 63.360,00

109

Vicryl No. 1 VCP519 TC36

Buah

8 1.027.053,52

110

Bone Wax

Buah

7 416.990,00

111 Buah

7 248.799,60

112

C.Gut Plain 2/0 180S TS24

Buah

7 312.346,40

113 Buah

7 27.447,60

114

Foley catheter No.18 Bard

Buah

7 139.524,00

115

Infus Set Y

Buah

7 620.880,00

116

NGT N0.12

Buah

7 89.620,55

117 Buah

6

581.171

118

C.Gut Plain 0 TP 35mm

Buah

6 354.832,50

119

Corolene 4/0 20S15K RC19

Buah

6 573.804,00

120 Buah

6 4.976,00

121

Disp. Syringe / Spuit 50 cc UP

Buah

6 36.744,40

122

Ecosorb 2/0 E29RH260

Buah

6 406.824,00

123

Electroda Red Dot 2228

Buah

6 67.709,00

124

Filapeau 2/0 F87499 RC25

Buah

6 360.112,20

125

Selang Oxygen O2 Size L

Buah

6 47.520,00

126

Silkam 2/0 NNS 13 x 60 cm

Buah

6 217.021,17

127

Suction Catheter No 6.Ax

Buah

6 53.064,00

128 Buah

6 31.284,00

129

Suprasorb C20481

Buah

6 649.363,00

130

Three Way With Extentiom

Buah

6 12.540,00

131

Vicryl No. 2/0 VCP339H

Buah

6 559.921,20

132

C.Gut Plain 2/0 HR26

Buah

5

321.310

133

Cauter / Harum Pen

Buah

5

552.000

134

Corolene 5/0 SG 20S10H TP18

Buah

5 649.071,50

135

Disp. Syringe / Spuit 10cc

Buah

5 7.812,00

136

ETT No. 7.0

Buah

5 198.000,00

137

ETT No. 2,5

Buah

5 167.400,20

138

Infus Set Adult Ax

Buah

5 28.800,00

139

NGT N0.14 Med

Buah

5 89.100,00

140

Premilene 6/0 DS12

Buah

5 328.815,75

141

Silk Black 3/0 DS24 SMI

Buah

5

92.982

142

Three Way (3Way)

Buah

5 58.080,00

143

Vicryl No. 3/0 W9890

Buah

5 300.953,80

144

Corolene 6/0 20AS07D

Buah

4

812.889

(40)

Lampiran 8. (Lanjutan)

146

Optime 3/0 18S20EE TP22

Buah

4 337.276,60

147

Perfusor Tub. White 150cm

Buah

4

168.000

148

Pharmafix 10 cm x 5cm

Buah

4 182.033,00

149

Polysorb 4/0 SL5629 Cut

Buah

4 451.605,00

150

Safil No. 1 HR40S

Buah

4 432.285,00

151

Safil No. 2/0 HRT 37S

Buah

4 459.540,00

152

Surgipro 3/0 C-14 TS684

Buah

4 303.600,00

153

Umbilical Catheter PVC 3,5

mtr

Buah

4 197.485,00

154

Underpad Adult

Buah

4 22.176,00

155

Vicryl No. 3/0 VCP311H RB22

Buah

4 366.219,80

156

Abbocath Safety Sine No 24

Buah

3 79,894,80

157

C.Gut Plain 0 224 HRG38

Buah

3 168.364,80

158 Buah

3 133.927,00

159

Corolene N0 2/0 20S308B

RC26

Buah

3 268.523,85

160

Disp. Syringe /Spuit 20 cc

Buah

3 7.034,40

161

Elastis Verban / Pro Crepe

15cmx 4,55m

Buah

3 150.876,00

162

Infus Set Adult Term

Buah

3 53.627,58

163

Infusion Set Med

Buah

3 19.611,00

164

Medifix Line 90cm With Intrafix

Buah

3 416.057,20

165

NGT Levin No.18 -125 cm

Buah

3

19.800

166

NGT N0.18

Buah

3 144.147,00

167

NGT No. 8 100cm

Buah

3 31.831,64

168

Safil No. 1 HR49

Buah

3 343.447,50

169

Safil No.4/ 0 HR22

Buah

3 314.122,50

170

Selang Oxygen Anak BE

Buah

3 19.800,00

171

Selang Oxygen Baby / Infant

Buah

3 19.800,00

172

Silkam 1 HR37S

Buah

3 128.261,81

173

Steinman PIN DIA 4,5 mm

Buah

3

724.500

174 Buah

3

26.532

175

Suction Catheter No. 8Ax

Buah

3 26.532,00

176

Suction Catheter T No.14

Buah

3 15.552,00

177

Suction Connecting Tube

Buah

3 71.280,00

178

Surgical Skin Marker

Buah

3 231.115,50

179

Surgicel W 1913T

Buah

3 249.995,60

180

Abbocath No. 20G

Buah

2 23.562,00

181

Abbocath No. 24 Ter

Buah

2 24.052,00

(41)

184

C Gut Chromic 1 HS37

Buah

2 75.892,80

185

C Gut Chromic 0 HR 40

Buah

2 68.317,92

186 Buah

2 68.317,92

187

C.Gut Plain 3/0 180S HR26

Buah

2 112780

188 Buah

2 56.858,40

189

C.Gut Plain No 3/0 HR271804

Buah

2 89.284,80

190

Colostomy Bag No.2 OM

Buah

2

36.300

191

Corolene 2/0 20S30A TP26

Buah

2 207.556,60

192

Corolene 5/0 20S5K RC16

Buah

2 191.987,90

193

CV Certofix Duo V720

Buah

2 1.155.000,00

194

UT

Buah

2 84.000,00

195

Disp. Syringe / Spuit100 ml UT

Buah

2 88.704,00

196

Disp. Syringe / Spuit 1000 cc UT

Buah

2

86.352

197

Disp. Syringe / Spuit 50 ml Cath Tip UT

Buah

2

58.080

198

Ecolene 3/0 R37CD240

Buah

2 153.824,00

199

Ecosorb 4/0 E47CD190

Buah

2 144.716,00

200

G.Cut Chromic 1 HR48

Buah

2

7.186

201

Infus Set Luer Slip

Buah

2 12.196,80

202

Infusion Set Adult

Buah

2 17.570,40

203

Medifix Line 100 cm

Buah

2 163.269,00

204

Medifix Monometer

Buah

2 529.668,15

205

NGT N0. 18

Buah

2

24.024

206

NGT N0.10 Med

Buah

2

35.904

207

NGT N0.16

Buah

2 24.022,02

208

NGT No. 14

Buah

2

24.024

209

Plastik Klip35 x 25cm

Buah

2 2.042,40

210

Polyhesive II Ret Elect E7507

Buah

2 311.949,00

211

Pot Plastik 100cc

Buah

2 3.828,00

212

Premilene 2/0 DS24 Cut

Buah

2 119.597,08

213

Premilene 3/0 DS24 Cut

Buah

2 119.574,08

214

Premilene 4/0 DS19

Buah

2 175.899,40

215

Rectal Tube No.30

Buah

2

33.000

216

Safil No.1 HR48

Buah

2 28.965,00

217

Silk Peters 1TC35mm

Buah

2 99.266,40

218

Softband (Padding) 4 SNA

Buah

2 34.622,40

219

Softsilk 2/0 GS833 RB

Buah

2

103.200

220 Buah

2 10.428,00

(42)

Lampiran 8. (Lanjutan)

222

Vicryl No. 5/0 VCP303H

RB17

Buah

2 153.381,26

223

Vicryl No. 6/0 J544G TG - 100 G

Buah

2 708.736,60

224

Abbocath Intocan Safety No 20BB

Buah

1 26.400,00

225

Abbocath Intocan Safety No 22B

Buah

1 26.400,00

226

Abbocath No. 18 Ter

Buah

1

28.050

227

Abbocath Pjg No. 14

Buah

1 10.026,00

228

Abbocath Pjg No. 18

Buah

1 10.026,00

229 Buah

1

27.720

230

Abbocath/ Port No. 24 Ter

Buah

1 25.278,00

231

Asering infus

Buah

1

11.130

232

Askina Sorb 10 x 10

Buah

1

80.500

233 Buah

1 37.946,40

234

C.Gut Plain No. 1 HR 48 BB

Buah

1 56.249,21

235

C.Gut Plain3/0 HR26

Buah

1 56.390,4

236

Colostomy Bag No. 2 pho

Buah

1

18.150

237

Colostomy Bag No. 3 pho

Buah

1

18.150

238

CVC DBL Lum 5Fr x 13cm

Buah

1 925.903,65

239

CVC Double No 5 FV2564

Buah

1

380.424

240 Buah

1 996,00

241

Disp. Syringe /Spuit 10 cc UT

Buah

1 44.352,00

242

Disp. Syringe /Spuit 10 ml

Term

Buah

1 2.148,00

243

Disp. Syringe /Spuit 100 cc UT

Buah

1 42.000,00

244

ETT No. 7.5

Buah

1 39604,80

245

ETT Non Cup 3,5Fr

Buah

1 22.800,00

246

ETT No. 3,5 Rusch

Buah

1 58.544,20

247

ETT No. 4,5mm

Buah

1 32.036,40

248

ETT With Cup No 3

Buah

1 29.040,00

249

ETT With Cup No 4.5

Buah

1

29.040

250

ETT With Cup No.3

Buah

1 29.040,00

251

ETT With Cup No.4

Buah

1

29.040

252

Fixomull Transparent 5 x 10m

Buah

1 81.538,45

253 Buah

1 13.200,00

254 Buah

1

13.200

(43)

259

Foley catheter No.6 Norta

Buah

1 55.977,60

260

Foley catheter No.8 Norta

Buah

1 47.671,20

261

Foley Catheter Silicon No.22

Buah

1 66.320,50

262

Guedel Airway 0/60mm

Buah

1 15.089,26

263

Infusi Set Adult Term

Buah

1 8.785,20

264

Infusion Set Y

Buah

1 5.970,00

265

LMA Supreme Size 3

Buah

1 525.769,20

266

Medifix Anometer

Buah

1 277.414,50

267

Medifix Line

Buah

1 148.384,50

268

Medifix Mnometer

Buah

1 277414,5

269

Mersilk N0, 2/0 W213 (13x60cm)

Buah

1 63.091,88

270

NGT (Feeding Tube) N0. 10 -100cm

Buah

1

9.240

271

NGT Tube CH16

Buah

1 16.919,76

272

NGT Levin No.14 - 125 cm

Buah

1 9.900,00

273

NGT N0.10

Buah

1 19.008,00

274

NGT/ Stomach Tube Fr16

Buah

1 4.461,60

275

Rectal Tube No.32

Buah

1

13.860

276

Safil Qui 3/0 DS24

Buah

1 104.029,00

277

Selang Oxygen Adult Hosp

Buah

1 112.924,98

278

Selang Oxygen O2 Size XS

Buah

1 7.920,00

279

Senter / Pen Light

Buah

1 42.000,00

280

Silk Black No. 1 HR26

Buah

1 16339,20

281

Silk Black No. 1 HR37

Buah

1 24.840,00

282

Softban/Polyban (Padding) 6

Buah

1 23.226,00

283

Softban/Polyban (Padding) 6

Buah

1 23.226,00

284

Softband (Padding) 6 SNA

Buah

1 23.226,00

285

Softband / Polyband (Padding)

4

Buah

1 17.310,00

286

Spuit 10 cc Med

Buah

1 74.247,73

287

Stylet 2,0mm (2,5 - 4,5)

Buah

1 73.053,75

288 Buah

1 5877,96

289

Suction Catheter No 16

Buah

1 5.214,00

290

Suction Catheter No 6

Buah

1 5.124,00

291

Suction Catheter No.16 Ax

Buah

1 8.844,00

292

Suction Catheter T No.16

Buah

1 5.214,00

293

Thoracic Trocar dan Cannula

CH-32

Buah

1 150.965,10

294

Tracheostomy Tube W/Cup No.7

Buah

1 570.858,75

295

Umbilical Catheter PVC 3,5Fr

Buah

1 47.604,48

(44)

Lampiran 9. Daftar Obat sesuai dengan Formularium Nasional di Kamar Bedah

Emergency

Periode April 2016 – September 2016 RSUP. H.

Adam Malik Medan

No

Nama Obat

1 Albumin - Albure Injeksi 20% 100ml

2 Alkohol 70 % 100 ml

3 Alkohol 70 % 300 ml RS

4 Aminofilin injeksi 24mg/ml ampul @10ml

5 Aqudest Non Steril

6 Asam Traneksamat injeksi 500 mg

7 Atropin injeksi 0,25ml/ampul @1ml

8 Atropin Sulfas 0,25 % injeksi

9 Atropin Sulfas 0,25 mg

10 Bupivacain Spinal injeksi 4 ml

11 Bupivakain injeksi 0,50% Marcain

12 Deksametason injeksi 5mg/ml (SebagaiNatrium F)

13 Dobutamin injeksi 50mg/ml – Doburan

14 Efedrin injeksi

15 Efedrin - Vasodrin injeksi

16 Epinefrine injeksi 0,1 % ( Sebagai HCL / Bitartrat)

17 Epinephrine

18 Fentanil injeksi 0,05 mg/ml (Sebagai Sitrat) 2 ml

19 Fitomenadion injeksi 2g/ml

20 Furosemid injeksi 10mg/ml amp@ 2 ml

21 Gentamycin injeksi 40mg/2ml

22 Glukosa 10 % infus 10% botol 500 ml

23 Glukosa 5% infus 5% botol 500 ml

24 Isofluran 250 ml – Terrel

25 Kalsium Glukonat -C4 Glukonas 100ml

26 Kamadol Injeksi

27 Ketamin injeksi 100 mg / ml – KTM

28 Ketamin injeksi 50 mg / ml - Ketamin Hameln

29 ketorolac injeksi 30 mg / ml ampul 1 ml

30 LarutamAsam Amino - Amnofluid 500 ml

31 Larutan Lipid - Lipofudin MCT/LCT100 ml

32 Lidokain Hcl 2 % (HCL)

33 Manitol Larutan Infus 20% botol 500 ml

34 Meropenem 1000 mg

35 Metilergometrin injeksi 0,200 mg/ml ampul @1ml

36 Midazolam - Fortanest 1 mg / 5 ml

(45)

39 Natrium Bikarbonat 8,4% - Myelon

40 Nifedipin Tablet 10 mg

41 Neostigmin injeksi 0,5mg/ml Hameln

42 Norepinefrin injeksi 1mg/ml – Levosol

43 Otsu - D40 infus 40% ampul 25 ml

44 Otsu - D4040 infus 40% ampul 25 ml

45 Otsu - MGSO4 injeksi 20% ampul 20 ml

46 Otsu Water injeksi ampul @ 25 ml

47 Paracetamol infus 10mg/ml @100 ml

48 Pethidin Hcl injeksi 2 ml

49 Pethidin injeksi 50 mg/ml (HCL) ampul @2ml

50 Propofol - Fresofol 1 % MCT/ LCT

51 Ranitidine injeksi 50mg/ 2 ml @ampul 2 ml

52 Ringer Laktat Larutan infus botol 500 ml

53 Ringer Soluition botol 500 ml

54 Sefazolin 1 gram

55 Sefotaksim serbuk injeksi 1000 mg /vial

56 Seftazidim injeksi 1000 mg/vial

(46)

Lampiran 10. Daftar Obat yang Tidak Sesuai dengan Formularium Nasional di

Kamar Bedah Emergency Periode April 2016 – September 2016

RSUP. H. Adam Malik Medan

No

Nama Obat

1 Asam Traneksamat injeksi 250 mg/ 5 ml ampul

2 Atrakurium - Notrixum injeksi 25mg/2,5 ml

3 Bupivakain /Recain injeksi 4mg/5ml

4 Dobutamin inj 250mg/ml – Doburan

5 Farsix Injkesi

6 Gelofusine infus 100 ml

7 Genoit tetes mata 0,3% botol 5 ml

8 Isodine/ Betadine Sol 100 ml

9 Kombinasi Iprat 0,5+sal - Combivent UDV

10 Manitol larutan infus 5mg/ml botol 100ml

11 Marcain 0,5% Heavy (Marcain Spinal)

12 Naropin 7,5 mg

13 Neo – K (Potasium Klorida 500 mg)

14 Noveron (Rokuronium) 50mg/ml

15 Oxytetracyclin SM

16 Oxytoxin inj 10 IU/ml

17 Ozid 40 mg injeksi

18 Pehacain injeksi

19 Povidone Iodine 300 cc

20 Propanolol Tablet 10 mg

21 Roculax inj 5 ml

22 Rokuronium - Esmeron inj 50 mg / ml

23 Sevorane 250 ml(Sevoflurane)

(47)

(48)

(49)

(50)