form sp laborat
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8/16/2019 Form SP Laborat
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PERMI NTAAN
PEM
ERI K S AAN
L AB ORAT O
RI UM
No RM : Umur : bl / th
Nama Pasien : ________________________ L / P
Alamat : _______________________________
Diagnosa / Ket klinik : _______________________________
RS. OR!OPA"D# PUR$OK"RO RUAN% : ________________ &am Sam'ling :OR!OPA"D# ( RAUMAOLO%# ( R"!A)#L#AS# M"D#K
anggal : _____/_____/_____
PAKET PEMERIKSAAN KIMIA KIMIA
Pre O' )P&S GLUKOSA FUNGSI GINJAL
Pre O' *% %lukosa Puasa Ureum
Pre O' UMUM + ( +, h %lukosa , &am PP Kreatinin
Pre O' UMUM +- ( , h %lukosa Seaktu 0%DS1 Asam Urat
Pre O' UMUM ,+ ( 2 h %DS Rutin - Kali ELEKTROLIT
Pre O' UMUM 3 2 h %DS Rutin 2 kali Kalium 0K41
Post O'erasi !bA+5 Natrium 0Na41
HEMATOLOGI FUNGSI HATI *lori6a 0*l(1!ematologi Lengka' S%O *al5ium 0*a,41
!emoglobin S%P IMUN-SEROLOGI
Lekosit )ilirubin otal !)sAg
!itung &enis Lekosit )ilirubin Direk Anti !)s
La7u "n6a' Darah 0L"D1 Alkali 8os9at Anti !A
"ritrosit %amma(% Anti !*
!ematokrit 0!t1 Protein otal Anti !#
M* Albumin / %lobulin )(#*
M*! LEMAK $i6al
M*!* Kolesterol otal Reumatoi6 8aktor
rombosit rigliseri6a URINE / FAECES
$aktu Pen6arahan 0)1 Kolesterol !DL Urine Lengka' 0UL1
$aktu Pembekuan 0*1 Kolesterol LDL Se6imen Urine
#NR FUNGSI JANTUNG 8ae5es Rutin
Prothrombin ime 0P1 *K KULTUR & RESISTENSI
AP *K M) Pus / Nanah
%olongan Darah A ) O ro'onin *airan Sen6i
LD! PEMERIKSAAN LAIN
Status Pasien __________________________
__________________________
Paraf & Naa !"#ter __________________________
Umum BPJS
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