Bidan Neng Uma Akromah, AM. Keb

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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 RINCIAN BIAYA KET TOTAL

1 Pertolongan Bidan Rp 500.000 Rp 2 Perawatan Ibu&Bayi Rp 50.000 Rp 3 Pemakaian Alkes Rp 40.000 Rp 4 Handscoen&FaceMask Rp 5.000 Rp 5 Syringe Rp 5.000 Rp 6 Iodine/Alkohol Rp 15.000 Rp 7 Kassa/Tamponade Rp 10.000 Rp 8 UnderPad/Pampers Rp 20.000 Rp 9 Oxytocin inj. 10 IU Rp 20.000 Rp 10 Phytomenadion inj. Rp 5.000 Rp 11 Methylergometrin inj. Rp 10.000 Rp

12 Vaksin Hep-B inj. Rp 25.000 Rp

13 Amoxicillin tab. Rp 5.000 Rp

14 Ferum tab. Rp 5.000 Rp

15 As. Mefenamat tab. Rp 5.000 Rp

16 Vit. A Cap. Rp 5.000 Rp 17 Abocath No. 20 Rp 10.000 Rp 18 Infus/Blood Set Rp 20.000 Rp 19 Cairan Elektrolit 500 ml Rp 15.000 Rp 20 Intervensi Ibu: Rp 50.000 Rp 21 Intervensi Bayi: Rp 50.000 Rp 22 Lain2 Rp TOTAL Rp Karawang, ... Penolong Persalinan,

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IKATAN BIDAN INDONESIA

(IBI)

SURAT KETERANGAN LAHIR

No.

Yang bertanda tangan di bawah ini, menerangkan bahwa:

Nama : ... ( thn ) Nama Suami : ... ( thn ) Alamat : ...

Telah melahirkan seorang anak yang bernama:

... Anak ke- : ...

Jenis Kelamin : ... Hari, tanggal/jam lahir : ...

Berat Badan Lahir : ... gram, PB : ... cm, LK : ... cm

Sidik

Ibu jari Kiri

Ibu

Sidik Kaki Kiri Bayi Sidik Kaki Kanan Bayi

Sidik

Ibu jari Kanan

Ibu

Demikian surat keterangan lahir ini dibuat dengan penuh tanggung jawab. Saksi-saksi:

1. ... 2. ...

Karawang, ... Penolong Persalinan,

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No.

Telah diterima dari : ... Uang sejumlah : ... : ... Untuk pembayaran : ... : ... : ... Karawang, 00 September 2013 Terbilang Rp.

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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

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

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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

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

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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

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

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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

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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

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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. Tgl.

Nama : ... Umur : ...

Semoga Lekas Sembuh

X

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

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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

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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