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Form Hasil Lab

The document is a laboratory test result form containing information about a patient's hematology, clinical chemistry, and urine test results. It includes the patient's name, age, gender, doctor/referring physician, and test results for items like hemoglobin, leukocytes, cholesterol, uric acid, and pregnancy test. The form contains the test results in a table format with the test name, unit of measure, patient result, and reference range.

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Aditya Megananda
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as XLSX, PDF, TXT or read online on Scribd
21 views3 pages

Form Hasil Lab

The document is a laboratory test result form containing information about a patient's hematology, clinical chemistry, and urine test results. It includes the patient's name, age, gender, doctor/referring physician, and test results for items like hemoglobin, leukocytes, cholesterol, uric acid, and pregnancy test. The form contains the test results in a table format with the test name, unit of measure, patient result, and reference range.

Uploaded by

Aditya Megananda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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FORMULIR HASIL PEMERIKSAAN LABORATORIUM FORMULIR HASIL PEMERIKSAAN LABORATORIUM

Dokter / pengirim : .............................................. Dokter / pengirim : ..............................................


Pasien Pasien
No. Rekam Medis : ............ No. Reg Lab ............. No. Rekam Medis : ............ No. Reg Lab .............
Nama : .............................................. Nama : ..............................................
Umur : ............... Jenia Kelamin : L/P Umur : ............... Jenia Kelamin : L/P
Alamat : .............................................. Alamat : ..............................................
JENIS NILAI NILAI
SATUAN HASIL KET JENIS PEMERIKSAAN SATUAN HASIL KET
PEMERIKSAAN RUJUKAN RUJUKAN

HEMATOLOGI HEMATOLOGI
L: L:
Hemoglobin g/dL Hemoglobin g/dL
P: P:
L: L:
Hematokrit ％ Hematokrit ％
P: P:
5.000 - 5.000 -
Leukosit /mm3 Leukosit /mm3
10.000 10.000
Trombosit mm3 Trombosit mm3
Eritrosit Juta/mm 3
Eritrosit Juta/mm3
MCV (fl) MCV (fl)
MCH Pg/sel MCH Pg/sel
MCHC g/dL MCHC g/dL
Golongan Darah - - Golongan Darah - -
KIMIA KLINIK KIMIA KLINIK
Gula Darah Gula Darah
Sewaktu mg/dL Sewaktu mg/dL
Puasa mg/dL Puasa mg/dL
2 Jam PP mg/dL 2 Jam PP mg/dL
Cholesterol mg/dL < 200 Cholesterol mg/dL < 200
L: 3,4 - 7,0 L: 3,4 - 7,0
Asam Urat mg/dL Asam Urat mg/dL
P : 2,4 - 5,7 P : 2,4 - 5,7
URINE URINE
Protein Urin - Negatif Protein Urin - Negatif
Tes Kehamilan - Negatif Tes Kehamilan - Negatif
LAIN - LAIN LAIN - LAIN
Sputum (A) - Negatif Sputum (A) - Negatif
Sputum (B) - Negatif Sputum (B) - Negatif

FORMULIR HASIL PEMERIKSAAN LABORATORIUM FORMULIR HASIL PEMERIKSAAN LABORATORIUM


Dokter / pengirim : .............................................. Dokter / pengirim : ..............................................
Pasien Pasien
No. Rekam Medis : ............ No. Reg Lab ............. No. Rekam Medis : ............ No. Reg Lab .............
Nama : .............................................. Nama : ..............................................
Umur : ............... Jenia Kelamin : L/P Umur : ............... Jenia Kelamin : L/P
Alamat : .............................................. Alamat : ..............................................
JENIS NILAI NILAI
SATUAN HASIL KET JENIS PEMERIKSAAN SATUAN HASIL KET
PEMERIKSAAN RUJUKAN RUJUKAN

HEMATOLOGI HEMATOLOGI
L: L:
Hemoglobin g/dL Hemoglobin g/dL
P: P:
L: L:
Hematokrit ％ Hematokrit ％
P: P:
5.000 - 5.000 -
Leukosit /mm 3
Leukosit /mm 3
10.000 10.000
Trombosit mm3 Trombosit mm3
Eritrosit Juta/mm3 Eritrosit Juta/mm3
MCV (fl) MCV (fl)
MCH Pg/sel MCH Pg/sel
MCHC g/dL MCHC g/dL
Golongan Darah - - Golongan Darah - -
KIMIA KLINIK KIMIA KLINIK
Gula Darah Gula Darah
Sewaktu mg/dL Sewaktu mg/dL
Puasa mg/dL Puasa mg/dL
2 Jam PP mg/dL 2 Jam PP mg/dL
Cholesterol mg/dL < 200 Cholesterol mg/dL < 200
L: 3,4 - 7,0 L: 3,4 - 7,0
Asam Urat mg/dL Asam Urat mg/dL
P : 2,4 - 5,7 P : 2,4 - 5,7
URINE URINE
Protein Urin - Negatif Protein Urin - Negatif
Tes Kehamilan - Negatif Tes Kehamilan - Negatif
LAIN - LAIN LAIN - LAIN
Sputum (A) - Negatif Sputum (A) - Negatif
Sputum (B) - Negatif Sputum (B) - Negatif
UPT PUSKESMAS KEDATON UPT PUSKESMAS KEDATON
Jl. Sunan Gunung Jati Kapetakan Cirebon Jl. Sunan Gunung Jati Kapetakan Cirebon
FORMULIR HASIL PEMERIKSAAN LABORATORIUM FORMULIR HASIL PEMERIKSAAN LABORATORIUM
Dokter / pengirim : .............................................. Dokter / pengirim : ..............................................
Pasien : .............................................. Pasien : ..............................................
No. Rekam Medis : ............ No. Reg Lab ............. No. Rekam Medis : ............ No. Reg Lab .............
Nama : .............................................. Nama : ..............................................
Umur : ............... Jenia Kelamin : L/P Umur : ............... Jenia Kelamin : L/P
Alamat : .............................................. Alamat : ..............................................
JENIS NILAI JENIS NILAI
SATUAN HASIL KET SATUAN HASIL KET
PEMERIKSAAN RUJUKAN PEMERIKSAAN RUJUKAN

HEMATOLOGI HEMATOLOGI

L : 14 - 18 L : 14 - 18

Hemoglobin g% P : 12 – 16 Hemoglobin g% P : 12 – 16

A : 10 - 16 A : 10 - 16

Golongan Darah Golongan Darah

KIMIA KLINIK KIMIA KLINIK

Gula Darah Gula Darah

Sewaktu mg/dL < 200 Sewaktu mg/dL < 200

Puasa mg/dL < 120 Puasa mg/dL < 120

2 Jam PP mg/dL < 140 2 Jam PP mg/dL < 140

Cholesterol mg/dL < 200 Cholesterol mg/dL < 200

L: 3,4 - 7,0 L: 3,4 - 7,0


Asam Urat mg/dL Asam Urat mg/dL
P : 2,4 - 5,7 P : 2,4 - 5,7

URINE URINE

Protein Urin - Negatif Protein Urin - Negatif

Tes Kehamilan Tes Kehamilan


LAIN - LAIN LAIN - LAIN
Sputum (BTA) - Negatif Sputum (BTA) - Negatif

UPT PUSKESMAS KEDATON UPT PUSKESMAS KEDATON


Jl. Sunan Gunung Jati Kapetakan Cirebon Jl. Sunan Gunung Jati Kapetakan Cirebon
FORMULIR HASIL PEMERIKSAAN LABORATORIUM FORMULIR HASIL PEMERIKSAAN LABORATORIUM
Dokter / pengirim : .............................................. Dokter / pengirim : ..............................................
Pasien : .............................................. Pasien : ..............................................
No. Rekam Medis : ............ No. Reg Lab ............. No. Rekam Medis : ............ No. Reg Lab .............
Nama : .............................................. Nama : ..............................................
Umur : ............... Jenia Kelamin : L/P Umur : ............... Jenia Kelamin : L/P
Alamat : .............................................. Alamat : ..............................................
JENIS NILAI JENIS NILAI
SATUAN HASIL KET SATUAN HASIL KET
PEMERIKSAAN RUJUKAN PEMERIKSAAN RUJUKAN
HEMATOLOGI HEMATOLOGI
L : 14 - 18 L : 14 - 18

Hemoglobin g% P : 12 – 16 Hemoglobin g% P : 12 – 16

A : 10 - 16 A : 10 - 16

Golongan Darah Golongan Darah

KIMIA KLINIK KIMIA KLINIK

Gula Darah Gula Darah

Sewaktu mg/dL < 200 Sewaktu mg/dL < 200

Puasa mg/dL < 120 Puasa mg/dL < 120

2 Jam PP mg/dL < 140 2 Jam PP mg/dL < 140

Cholesterol mg/dL < 200 Cholesterol mg/dL < 200

L: 3,4 - 7,0 L: 3,4 - 7,0


Asam Urat mg/dL Asam Urat mg/dL
P : 2,4 - 5,7 P : 2,4 - 5,7

URINE URINE

Protein Urin - Negatif Protein Urin - Negatif

Tes Kehamilan Tes Kehamilan


LAIN - LAIN LAIN - LAIN
Sputum (BTA) - Negatif Sputum (BTA) - Negatif
FORMULIR PERMINTAAN FORMULIR PERMINTAAN
PEMERIKSAAN LABORATORIUM PEMERIKSAAN LABORATORIUM
No. Rekam Medis : .................... Jaminan : U / BPJS / KIS No. Rekam Medis : .................... Jaminan : U / BPJS / KIS

Nama : ............................................................... Nama : ...............................................................

Umur : ............................ Jenis Kelamin : L / P Umur : ............................ Jenis Kelamin : L / P

Alamat : ............................................................... Alamat : ...............................................................

Tgl/ Jam Pengambilan sp : ............................................................... Tgl/ Jam Pengambilan sp : ...............................................................

JENIS PEMERIKSAAN LABORATORIUM JENIS PEMERIKSAAN LABORATORIUM


HEMATOLOGI KIMIA KLINIK HEMATOLOGI KIMIA KLINIK
● Hemoglobin ● Gula darah sewaktu ● Hemoglobin ● Gula darah sewaktu

● Golongan Darah ● Gula darah Puasa ● Golongan Darah ● Gula darah Puasa

● Gula Darah 2 jam PP ● Gula Darah 2 jam PP

● Cholesterol ● Cholesterol

● Asam Urat ● Asam Urat

URIN LAIN - LAIN URIN LAIN - LAIN


● Protein Urin ● Protein Urin
● Sputum (BTA) ● Sputum (BTA)
● Tes Kehamilan ● Tes Kehamilan
Puasa (10 - 12 jam) Dokter / pengirim Puasa (10 - 12 jam) Dokter / pengirim
Hasil dikirim kepada dokter Hasil dikirim kepada dokter

Hasil diserahkan kepada pasien (............................) Hasil diserahkan kepada pasien (............................)

FORMULIR PERMINTAAN FORMULIR PERMINTAAN


PEMERIKSAAN LABORATORIUM PEMERIKSAAN LABORATORIUM
No. Rekam Medis : .................... Jaminan : U / BPJS / KIS No. Rekam Medis : .................... Jaminan : U / BPJS / KIS

Nama : ............................................................... Nama : ...............................................................

Umur : ............................ Jenis Kelamin : L / P Umur : ............................ Jenis Kelamin : L / P

Alamat : ............................................................... Alamat : ...............................................................

Tgl/ Jam Pengambilan sp : ............................................................... Tgl/ Jam Pengambilan sp : ...............................................................

JENIS PEMERIKSAAN LABORATORIUM JENIS PEMERIKSAAN LABORATORIUM


HEMATOLOGI KIMIA KLINIK HEMATOLOGI KIMIA KLINIK
● Hemoglobin ● Gula darah sewaktu ● Hemoglobin ● Gula darah sewaktu

● Golongan Darah ● Gula darah Puasa ● Golongan Darah ● Gula darah Puasa

● Gula Darah 2 jam PP ● Gula Darah 2 jam PP

● Cholesterol ● Cholesterol

● Asam Urat ● Asam Urat

URIN LAIN - LAIN URIN LAIN - LAIN


● Protein Urin ● Protein Urin
● Sputum (BTA) ● Sputum (BTA)
● Tes Kehamilan ● Tes Kehamilan
Puasa (10 - 12 jam) Dokter / pengirim Puasa (10 - 12 jam) Dokter / pengirim
Hasil dikirim kepada dokter Hasil dikirim kepada dokter

Hasil diserahkan kepada pasien (............................) Hasil diserahkan kepada pasien (............................)

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