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    Blanko Permintaan Pemeriksaan Radiologi

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    joko suhartono
    This document is a request form for radiology examinations at a medical office located on Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi. It includes sections for the patient's name, medical record number, clinical diagnosis, and department. The following sections list various radiology tests available including x-rays of different body parts, ultrasounds, CT scans, and available laboratory tests such as blood tests and urine analysis. The form provides the doctor with a way to request specific radiology and laboratory examinations.

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    © All Rights Reserved
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    Blanko Permintaan Pemeriksaan Radiologi

    Uploaded by

    joko suhartono
    115 views4 pages
    This document is a request form for radiology examinations at a medical office located on Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi. It includes sections for the patient's name, medical record number, clinical diagnosis, and department. The following sections list various radiology tests available including x-rays of different body parts, ultrasounds, CT scans, and available laboratory tests such as blood tests and urine analysis. The form provides the doctor with a way to request specific radiology and laboratory examinations.

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    BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

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    This document is a request form for radiology examinations at a medical office located on Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi. It includes sections for the patient's name, medical record number, clinical diagnosis, and department. The following sections list various radiology tests available including x-rays of different body parts, ultrasounds, CT scans, and available laboratory tests such as blood tests and urine analysis. The form provides the doctor with a way to request specific radiology and laboratory examinations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    115 views4 pages

    Blanko Permintaan Pemeriksaan Radiologi

    Uploaded by

    joko suhartono
    This document is a request form for radiology examinations at a medical office located on Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi. It includes sections for the patient's name, medical record number, clinical diagnosis, and department. The following sections list various radiology tests available including x-rays of different body parts, ultrasounds, CT scans, and available laboratory tests such as blood tests and urine analysis. The form provides the doctor with a way to request specific radiology and laboratory examinations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 4

    Jl. Prof. H.M. Yamin No.

    17 Tebing Tinggi
    Telepon : (0621) 3950222
    Fax : (0621) 3950221
    Email : rschevani175@gmail.com

    BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

    Nama : BPJS
    No. RM : Perusahaan
    Klinis/Diagnosa : Umum
    Ruang/Poli :

    PEMERIKSAAN RONTGEN

    MANUS L/R LUMBAL AP/LAT


    WRIST JOINT L/R PELVIC
    ANTEBRACHI L/R DENTAL
    ELBOW JOINT L/R THORAX PA/AP
    HUMERUS L/R BNO
    SHOULDER JOINT L/R POLOS ABDOMEN
    CRURIS L/R CLAVICULA L/R
    ANGKLE JOINT L/R HIP JOINT L/R
    PEDIS L/R FEMUR L/R
    SCHEDEL L/R KNEE JOINT L/R
    MASTOID L/R CALCANEUS
    SPN WATER/LAT BNO IVP
    MANDIBULLA APPENDICOGRAM
    TMJ L/R HSG
    NASAL OESOPHAGUS
    CERVICAL AP/LAT COLON IN LOOP
    THORACAL AP/LAT ………………………

    Ket: L = Kiri
    R = Kanan
    Tebing Tinggi, ………………….. 20……
    Dokter Pengirim
    Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
    Telepon : (0621) 3950222
    Fax : (0621) 3950221
    Email : rschevani175@gmail.com

    BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

    Nama : BPJS
    No. RM : Perusahaan
    Klinis/Diagnosa : Umum
    Ruang/Poli :

    PEMERIKSAAN USG

    USG UPPER ABDOMEN USG SOFT TISSUE


    USG LOWER ANDOMEN USG PROSTAT
    USG UPPER + LOWER ABDOMEN USG THYROID
    USG THORAX USG MAMAE
    USG EXTREMITAS USG TESTIS
    USG SOFT TISSUE USG APPENDIX
    USG EXTREMITAS ………………………..

    Tebing Tinggi, ………………….. 20……


    Dokter Pengirim
    Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
    Telepon : (0621) 3950222
    Fax : (0621) 3950221
    Email : rschevani175@gmail.com

    BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

    Nama : BPJS
    No. RM : Perusahaan
    Klinis/Diagnosa : Umum
    Ruang/Poli :

    PEMERIKSAAN CT SCAN

    CT SCAN KEPALA C/NC CT SCAN SPINE CERVICAL C/NC


    CT SCAN ORBITA C/NC CT SCAN SPINE THORACAL C/NC
    CT SCAN SELLA TURSICA C/NC CT SCAN SPINE LUMBAL C/NC
    CT SCAN MANDIBULLA C/NC CT SCAN MAXILLA C/NC
    CT SCAN NASOPHARINX C/NC CT SCAN LARYNX C/NC
    CT SCAN EXTREMITAS ATAS C/NC CT SCAN THORAX C/NC
    CT SCAN EXTREMITAS BAWAH C/NC CT SCAN PELVIS C/NC
    CT SCAN UPPER ABDOMEN C/NC CT SCAN SPN C/NC
    CT SCAN LOWER ABDOMEN C/NC CT SCAN FACIAL BONE C/NC
    CT SCAN ABDOMEN UPP/LOW C/NC ………………………………..
    CT SCAN CONE BEAM DENTAL C/NC ………………………………..

    Ket: C = Kontras
    NC = Non Kontras
    Tebing Tinggi, ………………….. 20……
    Dokter Pengirim
    Jl. Prof. H.M. Yamin No. 17 Tebing Tinggi
    Telepon : (0621) 3950222
    Fax : (0621) 3950221
    Email : rschevani175@gmail.com

    BLANKO PERMINTAAN PEMERIKSAAN RADIOLOGI

    Nama : BPJS
    No. RM : Perusahaan
    Klinis/Diagnosa : Umum
    Ruang/Poli :

    PEMERIKSAAN LABORATORIUM

    DARAH RUTIN URINE ANALYSA FUNGSI HATI


    Haemoglobine Urine Rutin SGOT
    Leucocyte Test Kehamilan SGPT
    Eritrocyt Beta HCG Serum Alkali Pospatase
    Thrombocyt Bilirubin Total Direct
    Hematocryt PROFILE TIROIT Albumin/GL
    MCV, MCH, MCHC T3 Globulin
    T4 Protein Total
    FUNGSI GINJAL TSH HBe Antigen
    Ureum Anti HBs
    Creatinin LIPID PROFILE Anti HCV
    Urid Acid Cholesterol Total IgG Anti HAV
    HDL Cholesterol IgM Anti HAV
    TEST KOAGULASI LDL Cholesterol Anti HBe
    Masa Perdarahan Trigleserida HBs Ag
    Masa Pembekuan
    ELEKTROLIT
    PARASIT DARAH Natrium
    Malaria Kalium
    Micro Filaria Clorida

    Tebing Tinggi, ………………….. 20……


    Dokter Pengirim

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