Lampiran 3
2
FORM PEMERIKSAAN LABORATORIUM Jl. Raya Rajeg No.1 Tangerang Banten, Indonesia 15540 Tlp : 021- 5578946, FAX : 021- 5576894, Email : [email protected] Nama : .......... ................................ ......... Dr. Patologis : ........ ................................ ... Umur : .......... ................................ ......... Rumah sakit : ........... ................................ Jenis Kelamin : ..................... .............................. No. Rekam Medis : .................... ...................... Alamat : ........... ................................ ......... .... ................................ ................ No. Tlp : .............. ................................ ...... HEMATOLOGI KIMIA KLINIK IMUNOSEROLOGI LED Darah Rutin (Hb, Ht, Leukosit, Eritrosit, Trombosit) Darah lengkap (Hb, Ht, Leukosit, Trombosit, Eritrosit, Indeks Glukosa Darah Puasa * Glukosa Darah Sewaktu Glukosa Darah 2 jam pp* Kolesterol total Kolesterol HDL Golongan Darah Widal** HBs Ag (Hepatitis B ) Anti HBs DATA DIRI PASIEN JENIS PEMERIKSAAN
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Transcript of Lampiran 3
FORM PEMERIKSAAN LABORATORIUM
Jl. Raya Rajeg No.1 Tangerang Banten, Indonesia 15540Tlp : 021- 5578946, FAX : 021- 5576894, Email : [email protected]
Nama : ................................................... Dr. Patologis : ...........................................Umur : ................................................... Rumah sakit : ...........................................Jenis Kelamin : ................................................... No. Rekam Medis : ..........................................Alamat : .................................................... ....................................................No. Tlp : ....................................................
HEMATOLOGI KIMIA KLINIK IMUNOSEROLOGI
LED
Darah Rutin (Hb, Ht, Leukosit, Eritrosit, Trombosit)
Darah lengkap (Hb, Ht, Leukosit, Trombosit, Eritrosit, Indeks Eritrosit (MCV, MCH, MCHC), Hitung Jenis Leukosit.
Faktor pembekuan darah (PT, aPTT, TT, Kadar Fibrinogen, D-Dimer)
Glukosa Darah Puasa*
Glukosa Darah Sewaktu
Glukosa Darah 2 jam pp*
Kolesterol total
Kolesterol HDL
Kolesterol LDL
Trigliserida*
PAKET LIPID (Koloesterol, HDL, LDL, Trigliserida)
SGOT
SGPT
Asam Urat
Ureum*
Kreatinin
Golongan Darah
Widal**
HBs Ag (Hepatitis B )
Anti HBs
Keterangan :
* pasien diwajibkan puasa terlebih dahulu 10 – 12 jam
** pemeriksaan dilakukan 4 – 7 hari setelah demam
DATA DIRI PASIEN
JENIS PEMERIKSAAN
