INSTRUMEN SELF ASSESSMENT PERALATAN

KONDISI
NO PERSYARATAN KELAS C KELAS B

JENIS JUMLAH
III. PERALATAN

A. Pelayanan Gawat Darurat

Ruang Triase

1 Kursi Roda/Wheel Chair + + + 3

2 Stretcher/Brankar + + + 5
3 Pocket Pulse Oximetri + + - 0
4 Stethoscope/Stetoskop + + + 1
5 Tensimeter Digital/ Sphygmomanometer Digital + + + 1

6 Tensimeter Anaeroid/ Sphygmomanometer Aneroid + + + 1

7 Termometer Digital + + + 1
8 Timbangan Bayi/Infant Weighting Scale/Baby Weighting Scale + + + 1
9 Timbangan Dewasa + + + 2

9 9 8 15
Resusitasi

1 Defibrilator + + + 1
2 Resusitatir Kit/Resucitation Bay + + + 1
3 Film Viewer + + + 1
4 Lampu Periksa/Examination Lamp/Hanging Lamp + + + 2
5 Laryngoscope + + + 2
6 Nebulizer + + + 4
7 Pulse Oximetry/Portable Pulse Oximetri + + - 0
8 Stethoscope/Stetoskop + + + 1
9 Suction Pump Portable/Aspirator/Vacuum + + + 3
10 Infusion Pump + + + 1
11 Syringe Pump + + + 1
12 Bed Patient Electric/Tempat Tidur Pasien Elektrik + + + 2
13 Bed Patient Manual/Tempat Tidur Pasien Manual + + + 3
14 Sphygmomanometer Digital/Tensimeter Digital + + + 1
15 Sphygmomanometer Aneroid/Tensimeter Aneroid + + + 1
16 Termometer Digital + + - 0
16 16 14 24
Tindakan
1 Gynecological Bed/Obstetric Table/Tempat Tidur Ginekologi + + + 1
2 Head Lamp/Lampu Kepala + + + 1
3 Lampu Periksa/Examination Lamp/Hanging Lamp + + + 1
4 Operating Lamp Mobile - + + 3
5 Minor Surgery Set + + + 4
6 Bed Patient Electric/Tempat Tidur Pasien + + + 1
7 Bed Patient Manual/Tempat Tidur Pasien Manual + + + 1
6 7 7 12
Isolasi
1 Bed Patient Electric/Tempat Tidur Pasien Elektrik + + + 1
2 Bed Patient Manual/Tempat Tidur Pasien Manual + + + 1
3 Bed Side Monitor/Patient Monitor/Pasien Monitor 4 Parameter + + + 1
4 Emergency Trolley/Resucitation Crash Cart + + + 1
5 Oxygen Concentrator Portable + + + 1
6 Stethoscope/Stetoskop + + + 1
7 Sphygmomanometer Digital/Tensimeter Digital + + - 0
8 Sphygmomanometer Aneroid/Tensimeter Anaeroid + + + 1
9 Termometer Digital + + + 0
9 9 8 7
Observasi
1 Stretcher/Brankar + + + 17
2 Bed Side Monitor/Patient Monitor/Pasien Monitor 4 Parameter + + + 3
3 Defibrilator + + + 1
4 ECG/EKG/Electrocardiograph 12 Channels + + + 1
5 Emergency Trolley/ Resucitation Crash Cart + + + 1
6 Infusion Pump + + + 1
 KONDISI
NO 7 Pneumatic Splint Set PERSYARATAN + C KELAS
KELAS + B - 0
8 Resusitator Kit/Resucitation Bay + + - 0
9 Stethoscope/Stetoskop + + + 2
10 Suction Pump Portable/Aspirator/Vacuum + + + 3
11 Syringe Pump + + + 1
12 Sphygmomanometer Digital/Tensimeter Digital + + + 1
13 Sphygmomanometer Aneroid/Tensimeter Anaeroid + + + 1
13 13 11 32
TOTAL PELAYANAN GAWAT DARURAT 53 54 48 90
 KONDISI
B.
NO Pelayanan Penyakit Dalam PERSYARATAN KELAS C KELAS B
Klinik (Rawat Jalan)
1 Film Viewer + + + 1
2 Examination Table/Meja Periksa/Tempat Tidur Periksa + + + 1
3 Medical Flash Light/Pen Light + + + 2
4 Stethoscope/Stetoskop + + + 3
5 Sphygmomanometer Aneroid/ Tensimeter Anaeroid + + + 2
6 Sphygmomanometer Digital/ Tensimeter Digital + + + 1
7 Termometer digital + + + 1
7 7 7 10
Kamar Tindakan
1 Meja Periksa/Tempat tidur periksa/Examination Table + + + 1
2 Tensimeter Digital/Sphygmomanometer Digital + + - 0
3 Tensimeter, Anaeroid/ Sphygmomanometer, Aneroid + + + 2
4 Film Viewer + + + 1
5 Medical Flash light/Pen Light + + - 0
6 Stethoscope/Stetoskop + + + 3
7 Termometer Digital + + + 1
8 Emergency trolley/Resucitation Crash Cart + + - 0
9 Defibrilator + + - 0
10 Minor Surgery Set + + - 0
11 Lever Biopsi Set (Jarum Biopsi khusus) + + - 0
12 Set Aspirasi Sumsum Tulang Belakang (Jarum Khusus) - + - 0
13 Renal Biopsi Set (Jarum Eksplorasi, Jarum Biopsi USG (Tru Cut Needle) - + - 0
14 Suction pump Portable/Aspirator/Vacuum - + - 0
15 ECG/EKG/Electrocardiograph 6 Channels + + - 0
16 Syringe Pump + + - 0
17 Trokar + + - 0
18 Oximeter/Pulse Oximetry/Oksigen Saturasi + + - 0
15 18 5 8
Rawat Inap
1 Bed Side Monitor/ Bed-Patient Monitor/Patient Monitor + + - 0
2 Defibrilator + + - 0
3 ECG/EKG/Electrocardiograph 12 Channels + + + 1
4 Emergency Trolley/Resucitation Crash Cart + + + 3
5 ENT Examination set + + - 0
6 Film Viewer + + + 2
7 Infusion pump + + + 3
8 Lampu Periksa/Examination Lamp/Hanging lamp + + + 1
9 Matras Dekubitus + + + 4
10 Minor Surgery set + + + 2
11 Nebulyzer + + + 7
12 Pen Light / Medical Flash light + + + 3
13 Pulse Oximeter/Pulse Oximetry/Oksigen Saturasi + + - 0
14 Stethoscope / Stetoskop + + + 6
15 Suction Pump Portable/Aspirator/Vacuum + + + 3
16 Syringe Pump + + + 2
17 Bed Patient Electric/Tempat Tidur Pasien Electric + + + 5
18 Bed Patient Manual/Tempat Tidur Pasien Manual + + + 58
19 Sphygmomanometer Aneroid/ Tensimeter Anaeroid + + + 7
20 Sphygmomanometer Digital/ Tensimeter Digital + + + 1
21 Termometer Digital + + + 1
22 Timbangan Pasien + + + 1
22 22 18 110
TOTAL PELAYANAN PENYAKIT DALAM 44 47 30 128
 KONDISI
C.
NOPelayanan Bedah PERSYARATAN KELAS C KELAS B
Klinik (Rawat Jalan)
1 Stethoscope/Stetoskop + + + 1
2 Meja Periksa/ Tempat tidur periksa/Examination Table + + + 1
3 Pen Light/Medical Flash light + + + 1
4 Refleks Hammer + + + 1
5 TCD/Transcranial Doppler + + - 0
6 Sphygmomanometer Aneroid/ Tensimeter Anaeroid + + + 2
7 Sphygmomanometer Digital/ Tensimeter Digital + + - 0
8 Head Lamp/Lampu Kepala + + + 1
9 Lampu Periksa/Examination Lamp /Hanging Lamp + + + 1
10 Termometer Digital + + + 1
11 Film Viewer 2 slides + + + 1
12 Alat pembuka gips (manual dan elektric) + + - 0
13 Suction Pump Portable/Aspirator/Vacuum + + + 1
13 13 10 11
Kamar Tindakan
1 Stethoscope / Stetoskop + + + 1
2 Sphygmomanometer Aneroid/ Tensimeter Anaeroid + + + 1
3 Sphygmomanometer Digital/ Tensimeter Digital + + - 0
4 Meja Periksa/ Tempat tidur periksa/Examination Table + + + 1
5 Lampu Periksa/Examination Lamp/Hanging Lamp + + + 1
6 Minor Surgery Set + + - 0
7 Circumsisi set + + - 0
8 Electrocauter + + - 0
9 Emergency Set + + - 0
10 Hecting set + + - 0
11 Lokal Anestesi Set + + - 0
12 Suction Pump + + + 1
13 Sterilisator kering + + - 0
13 13 5 5
Ruang persiapan (sebelum Operasi)
1 Stethoscope/Stetoskop + + - 0
2 Sphygmomanometer Aneroid/ Tensimeter Anaeroid + + + 1
3 Sphygmomanometer Digital/ Tensimeter Digital + + - 0
4 Bed Side Monitor/Bed-Patient Monitor/Patient Monitor + + + 1
5 Film Viewer 2 slides + + - 0
6 Suction Pump Portable/Aspirator/Vacuum + + + 1
7 Oxygen Saturatie + + + 1
7 7 4 4
Kamar Bedah
1 Operating Table + + + 4
2 Mayo Table + + + 8
3 Operating Lamp Ceiling Type + + + 3
4 Lampu Periksa/Examination Lamp/Hanging Lamp + + - 0
5 ETT, LMA, Nasotracheal, Dewasa dan Pediatric + + -
6 Laringoscope Set (Dewasa Dan Pediatric) + + + 1
7 Fiber Optic + + -
8 Mesin Anesthesi + + + 3
9 Defibrilator + + + 1
10 Ventilator Anesthesi + + -
11 Electro Surgery Unit (ESU) - + + 4
12 Autoklaf + + -
13 Major Surgery Instrument Set Untuk Kepala (Dewasa Dan Pediatric) - + - 0
14 Bor Tulang - + + 2
15 Major Surgery Instrument Set untuk leher (Dewasa dan pediatric) - + + 1
16 Major Surgery Instrument Set untuk thorak cardiac Dewasa - +/- - 0
17 Major Surgery Instrument Set untuk thorak dan cardiac Baby - +/- - 0
18 Major Surgery Instrument Set untuk abdomen Dewasa - + - 0
19 Major Surgery Instrument Set untuk abdomen pediatric - + - 0
20 Major Surgery Instrument Set untuk urologi Dewasa - + - 0
21 Major Surgery Instrument Set untuk urologi pediatric - + - 0
22 Minimal invasive surgery set - +/- - 0
23 Masektomi set + + - 0
24 Operating Microscope - + + 1
25 C-Arm - + -
26 Infusion pump + + + 4
27 Suction pump + + -
28 Patient monitor + + + 3
 KONDISI
NO 29 Patient Stracher PERSYARATAN +/- C KELAS
KELAS + B + 6
 KONDISI
NO 30 Syringe Pump PERSYARATAN +/- C KELAS
KELAS + B + 1
31 Endoscopy THT, Bronchoscopy, gastroscopy, colonoscopy - + + 1
32 Endoscopy THT, Bronchoscopy, gastroscopy, colonoscopy, ERCP - + + 1
33 Microwave - + - 0
34 Harmonic Scalpel - + - 0
35 Caiman seal and cutting device - + - 0
36 USG guided - + - 0
37 Blood Gas Analyzer - + - 0
38 Electrolyte Analyzer - + - 0
39 CCTV For Operation - +/- - 0
17 39 16 44
Recovery Room
1 Bed Side Monitor + + + 3
2 Patient Stracher + + - 0
3 Defibrilator + + + 3
4 Emergency trolley + + + 3
5 Infusion pump + + + 3
6 Suction pump + + + 2
6 6 5 14
Rawat Bedah Umum
1 Hospital Bed + + + 37
2 Stethoscope + + + 2
3 Brandchard + + + 2
4 Infusion pump + + - 0
5 Examination lamp + + + 2
6 Sypgmomanometer + + + 1
7 Film viewer + + + 1
8 Minor Surgery Instrument Set + + + 6
9 Set Perawatan Luka + + + 3
10 Emergency Set + + + 1
10 10 9 55
TOTAL PELAYANAN BEDAH 66 88 49 133
 KONDISI
D.
NOPelayanan Kesehatan Anak PERSYARATAN KELAS C KELAS B
Klinik (Rawat Jalan)
1 ECG + + + 1
2 Infant dan baby pediatric resusitation + + - 0
3 Infant dan baby pediatric Stetoscope + + - 0
4 Examination lamp + + + 2
5 Sypgmomanometer dengan manset untuk bayi dan anak + + - 0
6 Infant dan baby weighting scale + + + 1
7 Termometer rectal + + + 1
8 Termometer axial + + + 1
9 Reflex Hammer + + - 0
10 cold chain : Kulkas Vaksin Termos Portable + + - 0
11 Vena section set + + - 0
12 Baby Suction pump + + - 0
13 Oxygen set dan flow meter + + - 0
14 Nebulizer + + + 1
14 14 6 7
Perawatan Anak
1 Diagnostic Set + + + 2
2 ECG/EKG/Electrocardiograph 3 Channels - - - 1
3 Emergency Trolley/Resucitation Crash Cart + + + 2
4 Film Viewer + + - 0
5 Lampu Periksa/Examination Lamp /Hanging Lamp + + + 2
6 Nebulizer + + + 7
7 Oxygen Concentrator Portable + + + 2
8 Stethoskop Pediatric/Stetoskop Anak + + + 2
9 Pediatric Hospital Bed/Tempat Tidur Anak + + + 21
10 Suction Pump Portable/Aspirator /Vacuum + + + 2
11 Syringe Pump + + + 3
12 Infusion Pump + + + 3
13 Stethoskop Infant/Baby/ Stetoskop Bayi + + - 0
Sphygmomanometer Aneroid/ Tensimeter Anaeroid Dengan Manset
14 Untuk Bayi Dan Anak + - 0
+
Sphygmomanometer Digital/ Tensimeter Digital Dengan Manset Untuk
15 Bayi Dan Anak
+ + + 4
16 Termometer Digital + + - 0
16 16 11 51
Perinatologi
1 Incubator + + + 9
2 Infant Warmer + + + 3
3 Baby Suction pump + + + 1
4 Infant dan baby weighting scale + + + 1
5 Infant stetoscope + + + 2
6 Sypgmomanometer dengan manset untuk bayi dan anak + + + 1
7 Termometer Rectal + + - 0
8 Termometer Axial + + + 2
9 Tongue Spatel + + + 2
10 Photo Therapy + + + 2
11 Baby Resusitasion Set + + + 2
12 Infusion Pump + + + 10
13 Syringe Pump + + + 3
14 Baby Examination table + + + 1
15 Examination lamp + + + 1
16 Bed Side Monitor + + + 1
17 Reflex hammer + + + 1
18 Phono Cardiograph + + - 0
19 Intubation set + + - 0
19 19 16 42
Ruang Bayi
1 Lumbal needle Punction + + + 1
2 Incubator + + - 0
3 Incubator Transpor + + + 1
4 Baby Resusitasion Set + + + 1
5 Baby Suction pump + + + 1
6 Infant Stetoscope + + + 1
7 Sypgmomanometer dengan manset untuk bayi dan anak + + - 0
8 Termometer rectal + + - 0
9 Termometer axial + + + 1
10 Reflex hammer + + + 1
 KONDISI
NO 11 Tongue Spatel PERSYARATAN + C KELAS
KELAS + B + 1
12 Tempat tidur bayi + + + 6
13 Vena section set + + - 0
14 Infant Warmer + + + 1
14 14 10 15
TOTAL PELAYANAN KSEHATAN ANAK 63 63 43 115
 KONDISI
E.
NO Pelayanan Obstetri dan ginekologi
PERSYARATAN KELAS C KELAS B
Klinik (Rawat Jalan)
1 Meja Periksa Kebidanan + + + 1
2 Meja Periksa Ginekologi + + + 1
3 Timbangan Dewasa + + + 1
4 Tensimeter + + + 3
5 Stetoskop + + + 1
6 Doppler + + + 1
7 Examination lamp + + + 1
8 Gynecologycal Examination set + + - 0
9 Pap Smear Kit + + - 0
10 IUD kit + + - 0
11 Implant kit + + - 0
12 USG Transvaginal + + - 0
13 USG 2 dimensi + + - 0
14 Colposcopy + + - 0
15 Forcep Biopsi + + - 0
16 Stetoskop Laenec + + - 0
17 Sterilisator portable + + - 0
18 Cardiotocography + + - 0
19 Minor surgery set + + + 1
20 Office Histeroscopy + + - 0
21 Suction pump + + + 1
22 Utility trolley + + - 0
23 Lemari obat kaca + + + 1
24 bak Instrument kaca + + - 0
25 Tromol kasa + + + 1
26 ECG + + + 1
27 Nierbekhen + + + 1
28 Kursi Dorong + + + 1
29 Standar Infus + + + 1
30 Sonde uterus + + - 0
31 Tampon Tang + + - 0
32 Bak instrument + + + 1
32 32 16 18
Rawat Inap
1 Tempat Tidur + + + 30
2 Termometer + + + 4
3 Lampu Periksa + + + 1
4 Stetoskop + + + 4
5 Suction pump + + + 2
6 Infusion set + + -
7 Infusion pump + + + 1
8 Oxygen Set √ Flow meter + + + 2
9 Recusitation Set + + + 2
10 USG 2 dimensi + + - 0
11 Sterilisator Uap + + - 0
12 Minor surgery instrument set + + - 0
13 Antidecubitus Matras + + + 1
14 Gynecologycal Examination set + + - 0
15 Emergency set + + + 1
16 Film viewer + + - 0
17 Nebulyzer + + - 0
18 Vena section set + + - 0
19 Cardiotocograph + + - 0
20 Food Troly + + + 8
21 Lemari Obat (Kaca) + + + 2
22 Tensimeter + + + 4
23 Lemari Steril + + - 0
24 Bak Catheter + + + 1
25 Meja Suntik Beroda + + + 2
26 Operating Lamp + + - 0
27 Manometer + + - 0
28 Perkakas + + - 0
29 Pinset + + + 6
30 Timbangan Bayi + + + 2
31 Instrument trolley + + + 2
32 Meja Periksa + + + 1
33 Patient monitor + + + 1
 KONDISI
NO 34 EKG Elektro Photo PERSYARATAN + C KELAS
KELAS + B - 0
35 Timbangan Dewasa + + + 2
36 Sterilisator + + - 0
37 Waskom mandi + + + 3
38 Anatomische pinset + + + 4
39 Chirurgical pinset + + + 2
40 Air Viva + + - 0
41 Bak instrument + + + 1
42 Buli-buli panas + + - 0
43 Flow meter O2 + + + 2
44 Gilyserine Spuit + + + 2
45 Irigator + + + 2
46 Korentang + + + 2
47 Lemari obat kaca + + - 0
48 Nierbekhen + + + 3
49 Kursi Dorong + + + 3
50 Standar Infus + + + 22
51 Vena Sectie Set + + - 0
52 Slim Zuiger + + + 1
53 Meja obat + + + 2
54 Gelas takar + + - 0
55 Tabung O2 + + + 2
56 Baby incubator + + - 0
57 Timbangan Dewasa + + - 0
58 Arteri klem + + + 3
59 Bed Skreen/sherm 3 + + + 8
60 Kom Kompres + + + 3
61 Sputum bak + + - 0
62 Standar Waskom + + + 1
63 Pisfot dewasa + + + 6
64 Laser teraphy + + - 0
65 UV Lamp + + + 1
66 Branchard + + + 3
67 Oksigen meter dinding + + - 0
68 Suction pump dinding + + - 0
69 Traffic Light + + - 0
70 droppler + + + 2
71 microscope labophot + + - 0
72 Automatic emergency + + - 0
73 Box baby + + + 25
74 Emergency trolley + + - 0
74 74 46 182
Kamar Tindakan Persalinan (VK)
1 Delivery instrument set + + + 4
2 Curretage instrument set + + + 3
3 Minor surgery set + + + 1
4 Doppler + + + 4
5 Tensimeter + + + 2
6 Suction pump + + + 1
7 Examination lamp + + + 2
8 Timbangan Bayi + + + 1
9 Oxygen Set √ Flow meter + + + 3
10 Sterilisator + + - 0
11 Forceps + + + 1
12 Vacum Ekstraktor + + + 1
13 Cardiotocograph + + - 0
14 Stethoscope + + + 3
15 Recusitation set + + + 1
16 Suction Curetage + + - 0
17 sectio caesarian set + + - 0
18 Anesthesi Machine + + - 0
19 Infusion pump + + + 1
20 Infusion warmer + + - 0
21 Auto tranfusion set + + + 1
22 Embriotomi set + + + 1
23 Operating Lamp + + - 0
24 Utility Troly + + - 0
25 Heacting Set + + + 4
26 Cardiotocography Unit + + - 0
 KONDISI
NO 27 Gynecology Examination PERSYARATAN + C KELAS
KELAS + B + 2
28 Manometer + + - 0
29 Alat Pemanas + + - 0
30 Gunting bengkok + + + 6
31 Pengait IUD + + + 4
32 Spekulum + + + 4
33 Tenakulum + + + 4
34 Pinset + + + 5
35 Korentang + + + 2
36 Tromol kasa + + + 3
37 Pean bengkok + + - 0
38 gagang pisau no. 3 + + + 2
39 Meja Ginekologi + + + 1
40 Lampu ginekolog + + + 1
41 Chirurgical pinset + + + 4
42 Meja obat + + + 1
43 Busi + + + 3
44 Himinoplasti + + - 0
45 Bak instrument + + + 3
46 Bak Korentang + + + 2
47 Nierbekhen + + + 6
48 Sonde uterus + + + 3
49 Sim Utarine Currete Blunt + + + 2
50 Partus instrument set + + - 0
51 Pemecah ketuban + + + 2
52 Sendok kuret + + + 3
53 Tampon Tang + + + 3
54 Metal catheter + + + 1
55 Tabung O2 + + + 6
56 Generator set + + 1
57 Pump suction + + + 1
57 57 43 109
Kamar Operasi Kebidanan
1 Operating table (gynecologi) + + - 0
2 Operating lamp + + - 0
3 Anesthesi Machine + + - 0
4 Ventilator dgn probe pengukur + + - 0
5 Oxygen Set + Flow meter + + - 0
6 Electrosurgical unit + + - 0
7 UV lamp for room sterilization + + - 0
8 Vacum pump + + - 0
9 autoclave + + -
10 Sectio caesarian set + + + 5
11 Laparatomy set + + + 1
12 Histerectomy set + + + 2
13 Laparoscopy set + + + 2
14 Histeroscopy set + + + 2
15 Electro couter bipolar + + - 0
16 Electro couter monopolar + + - 0
17 Monitor Kardiovaskuler - + - 0
18 CVC Set - + - 0
19 Embriotomi set + + + 1
20 Endoskopik Videomonitor - + - 0
21 Incubator bayi + + - 0
22 Micro Surgery set + + - 0
23 Operating Lamp + + - 0
24 Standar Infus + + - 0
25 Standar Waskom + + - 0
26 Utility Troly + + - 0
27 Operating table bedah + + - 0
28 Electric suction pump + + - 0
29 Mayo table stand mobile + + - 0
30 Caesarean section set + + - 0
31 Ventilator internal + + - 0
32 Patient monitor + + - 0
33 Meja obat + + - 0
34 Perkakas + + - 0
35 Ultrasonic cleaner + + - 0
36 DC/AC standar + + - 0
 KONDISI
NO 37 EKG Monitor PERSYARATAN + C KELAS
KELAS + B - 0
38 Fluid management system + + - 0
39 Suction head silicone + + - 0
40 Mesin Anestesi + + - 0
41 Ligasure USAm + + - 0
42 Folley Lab + + - 0
43 Hemodinamic monitoring + + - 0
44 gagang pisau no. 3 + + - 0
45 Monitor Sony + + - 0
46 printer video Sony + + - 0
47 Mini viewer + + - 0
48 Set jahit + + - 0
49 Ring aplikator set + + - 0
50 Kocher + + - 0
51 Chirurgical pinset + + - 0
52 gunting lurus + + - 0
53 Air Viva + + - 0
54 Jarum lumbal + + - 0
55 Bed side monitor + + - 0
56 Lemari obat kaca + + - 0
57 Meja Suntik Beroda + + - 0
58 Nidle holder + + - 0
59 Tromol kasa + + - 0
60 Spatel lidah + + - 0
61 Pean lurus + + - 0
62 Spekulum cocor bebek + + - 0
63 Hak langen beck + + - 0
64 Speculum Shim + + - 0
65 Aligator + + - 0
66 Mini Laparotomy Set + + - 0
67 Laringoscope + + - 0
68 Folding Endurance Tester + + - 0
69 Fenster Klem + + - 0
70 Kromatografi Gas + + - 0
71 Oksigen meter + + - 0
72 Tubing Slip + + - 0
73 Bak bengkok + + - 0
73 73 6 13
ICU Kebidanan
1 Pinset (Pisau Lobang) - + - 0
2 Tensimeter - + - 0
3 Lampu sorot - + - 0
4 Suction pump - + - 0
5 Cardiotocography Unit - + - 0
6 Instrument trolley - + - 0
7 Manometer - + - 0
8 Electric bed matras - + - 0
9 With T bar Handle - + - 0
10 Lambotee Ostiot 24cm - + - 0
11 Halsted Maquito Forceps - + - 0
12 Hoke Chisel 17cm - + - 0
13 Screw Driver Hexaganol - + - 0
0 13 0 0
IGD Kebidanan
1 Stetoscope + + + 3
2 Timbangan Dewasa + + - 0
3 Tabung O2 + + + 6
4 Bak Catheter + + + 1
5 Lampu Sorot + + + 3
6 Pisfot dewasa + + + 2
7 Kursi Dorong + + + 2
8 Standar infus + + + 14
9 Electric Suction pump + + + 1
10 Emergency trolley + + + 1
11 meja periksa + + + 1
12 Manometer + + - 0
13 USG 2 Dimensi + + - 0
14 Utility trolley + + - 0
15 Gynecology examination + + + 1
 KONDISI
NO 16 Timbangan bayi PERSYARATAN + C KELAS
KELAS + B + 1
17 Syringe pump + + + 1
18 X-ray connect teraphy + + - 0
19 Baby bath tube + + + 1
20 Meja rontgen + + - 0
21 Lemari obat kaca + + + 1
22 Sterilisator + + -
23 Branchard + + + 2
23 23 16 41
TOTAL PELAYANAN OBSTETRI DAN GINEKOLOGI 267 272 127 363
 KONDISI
F.
NO Pelayanan Anestesiologi dan Terapi Intensif
PERSYARATAN KELAS C KELAS B
ALAT UNTUK PELAYANAN ANESTESI
Alat Utama Tindakan Anestesi
Circuit System Mesin Anestesi
1 Mesin Anestesi Sederhana + + - 0
2 Mesin Anestesi Standar + + + 3
3 Mesin Anestesi Canggih - + - 0
2 3 1 3
Open System
1 Jackson Rees (Dewasa, Anak dan Neonatus) + + + 3
1 1 1 2
Perlengkapan Life Support Tindakan Anestesi
Airway
1 Laryngoscope Set: Dewasa Anak/Bayi + + + 2
2 Laryngoscope Mc Coy + + - 0
3 Nasopharyngeal tube + + - 0
4 Oropharyngeal tube + + - 0
5 Endotracheal Tube (ETT): Dewasa Anak/Bayi + + - 0
6 Stylet + + - 0
7 Magyl forcep: Dewasa Anak/Bayi + + + 2
8 Mouth spreader + + - 0
9 Suction Apparatus + + - 0
9 9 2 4
Breathing
1 Masker Anes/ BVM (face mask) :Anak – Dewasa Bayi + + + 1
2 Laryngeal Mask/ LMA + + - 0
3 Bag Valve Mask (BVM) bayi, anak, dewasa + + - 0
4 Simple Mask (plastik) dewasa,anak + + + 2
5 Oksigen Tank Transport Small Size + + + 0
5 5 3 3
Circulation
1 Defibrillator + + + 1
2 Syringe pump + + + 1
3 Infusion Pump + + + 4
4 Infusion pressure bag + + - 0
5 Infuse warmer + + - 0
6 Standart infuse + + + 14
7 Timbangan darah + + - 0
7 7 4 20
Monitor Tindakan Anestesi
Bedside Monitor
1 Monitor sederhana + + - 0
2 Monitor standar + + + 6
3 Monitor canggih - + - 0
4 Monitor sangat canggih - + - 0
2 4 1 6
Monitor Saturasi Oksigen
1 Pulse Oxymeter + + + 6
1 1 1 6
Monitor End Tidal CO2
1 Capnometer + + - 0
1 1 0 0
Monitor Tekanan Darah
1 Tensimeter + + + 4
1 1 1 4
Monitor Fungsi Paru (pemeriksaan suara nafas)
1 Stetoscope + + + 3
1 1 1 3
Alat Penunjang Tindakan Anestesi
1 SAB- Doek sterile Set + + - 0
2 Nerve Stimulator + + - 0
3 Spirometer manuil + + - 0
4 Hechting-Set + + - 0
5 Infant Warmer + + - 0
6 Warming (and Cooling) Machine - + - 0
7 BIS- Bispectral Index Score - + - 0
5 7 0 0
Alat Resusitasi dan Emergency
Alat Utama
1 Ventilator Standar + + - 0
 KONDISI
NO 2 Ventilator Canggih PERSYARATAN + C KELAS
KELAS + B - 0
3 CPAP - + - 0
2 3 0 0
Perlengkapan Life Support Resusitasi dan Emergency
Airway
1 Laryngoscope Set: Dewasa Anak/Bayi + + + 1
2 Laryngoscope Mc Coy + + - 0
3 Nasopharyngeal tube + + + 1
4 Oropharyngeal tube + + + 1
5 Endotracheal Tube (ETT): Dewasa, Anak/bayi + + - 0
6 Stylet + + - 0
7 Magyl forcep dewasa dan anak: Dewasa, Anak + + + 2
8 Mouth spreader + + - 0
9 Suction Apparatus + + + 1
9 9 5 6

Breathing
1 Masker Anes/ BVM (face mask) : Anak – Dewasa Bayi + + + 1
2 Laryngeal Mask/ LMA + + - 0
3 Bag Valve Mask (BVM) bayi, anak dan dewasa + + - 0
4 Simple Mask (plastik) dewasa dan anak + + + 1
5 Oksigen Tank Transport Small Size + + + 1
5 5 3 3
Circulation
1 Defibrillator + + + 1
2 Syringe pump + + + 1
3 Infusion Pump + + + 4
4 Infusion pressure bag + + + 1
5 Infuse warmer + + - 0
6 Standart infuse + + + 10
7 Timbangan darah + + + 0
8 Short spine board + + - 0
9 Long spine board + + - 0
9 9 6 17
Alat Monitor Resusitasi dan Emergency
1 Monitor standar + + + 6
2 Monitor canggih + + - 0
3 Pulse Oxymeter + + + 1
4 Capnometer + + - 0
5 Tensimeter + + + 3
6 Stetoscope + + + 3
6 6 4 13
Alat Canggih Resusitasi dan Emergency
1 Alat Pemeriksa Hemoglobin + + - 0
2 Alat Pemeriksa Gula Darah + + - 0
3 Alat Pemeriksa Electrolit + + - 0
4 Alat Pemeriksa lactate Darah + + - 0
5 Menilai kedalaman sedasi (LOC) Level of Consiousness - + - 0
6 Pemeriksaan canggih unt Airway - + - 0
4 6 0 0
ALAT PELAYANAN TERAPI INTENSIF
Alat Utama
1 Ventilator Standar + + + 3
2 Ventilator Canggih + + - 0
3 Ventilator Bayi + + - 0
4 CPAP - + - 0
3 4 1 3
Perlengkapan Life Support Pelayanan Terapi Intensif
Airway
1 Laryngoscope Set: Dewasa Anak/Bayi + + + 3
2 Laryngoscope Mc Coy + + - 0
3 Nasopharyngeal tube + + + 3
4 Oropharyngeal tube + + + 6
5 Endotracheal Tube (ETT) (Dewasa dan anak/bayi) + + + 3
6 Stylet + + - 0
7 Magyl forcep: Dewasa Anak + + - 0
8 Mouth spreader + + - 0
9 Suction Apparatus + + - 0
9 9 4 15
 KONDISI
NO Breathing
PERSYARATAN KELAS C KELAS B
1 Masker Anes/ BVM (face mask)(Anak-Dewasa dan bayi) + + + 3
2 Laryngeal Mask/ LMA + + - 0
3 Bag Valve Mask (BVM) bayi, anak, dewasa + + + 2
4 Simple Mask (plastik) dewasa,anak + + + 9
5 Jackson Rees dewasa,anak + + + 3
6 Oksigen Tank Transport Small Size + + + 2
6 6 5 19
Circulation
1 Defibrillator + + + 1
2 Syringe pump + + + 13
3 Infusion Pump + + + 14
4 Infusion pressure bag + + - 0
5 Infuse warmer + + + 1
6 Standart infuse + + + 12
7 Timbangan darah + + - 0
7 7 5 41
Alat Monitor Pelayanan Terapi Intensif
1 Monitor standar + + + 13
2 Monitor canggih + + - 0
3 Monitor sangat canggih + + - 0
4 Pulse Oxymeter + + + 13
5 Capnometer + + - 0
6 Tensimeter + + + 3
7 Stetoscope + + + 5
7 7 4 34
Alat Penunjang Pelayanan Terapi Intensif
1 Hb-meter + + - 0
2 Gluco-Stick + + + 1
3 Blood Gas Analyzer + + - 0
4 Spirometer manuil + + + 1
5 Hechting-Set + + + 3
6 Doek sterile Set + + - 0
7 TOF guard + + -
8 Infant Warmer + + - 0
9 Untuk penghangat dan Terapi hipotermia - + + 1
10 GlideScope - + -
11 Intubating Laryngeal Mask Airway Fastrach - + - 0
12 Mesin Bulleau Drain + + - 0
9 12 4 6
Alat Canggih Pelayanan Terapi Intensif
1 Alat Pemeriksa Hemoglobin + + - 0
2 Alat Pemeriksa Gula Darah + + + 1
3 Alat Pemeriksa Electrolit + + - 0
4 Alat Pemeriksa lactate Darah + + - 0
5 Menilai kedalaman sedasi (LOC) Level of Consiousness - + - 0
6 Pemeriksaan canggih unt Airway - + - 0
4 6 1 1
TOTAL PELAYANAN ANESTESIOLOGI DAN TERAPI INTENSIF 115 129 57 60
 KONDISI
G. NO
Pelayanan Mikrobiologi PERSYARATAN KELAS C KELAS B
1 Biosafety Cabinet Level 2A + + - 0
2 Biosavety Cabinet Level IIB - + - 0
3 Mikroskop (Binokuler, pembesaran 1000x) + + - 0
4 Mikroskop Lapang Gelap - + - 0
5 Mikroskop Fluoresen - + - 0
6 Sink dan Rak Untuk Pewarnaan + + + 1
7 Bunsen + + + 1
8 Incubator, suhu sd 45 C (Suhu 20-450C) + + - 0
9 Incubator, suhu sampai 80-90 C + + - 0
10 Incubator CO2, Volume 80 liter - + - 0
11 Jar Anaerob (Model Gas Pack) - + - 0
12 Refrigerator suhu 40C (Kapasitas yang besar (600 liter)) - + - 0
13 Freezer -20oC (Kapasitas kapasitas 200 liter) + + - 0
14 Deep Freeze, suhu sampai minus 100 C (Volume 200 liter) + + - 0
15 Sentrifus (Volume tabung sd 15 ml; kecepatan Sampai dengan 10.000 + + - 0
rpm)
16 Refrigerated Centrifuge (Volume tabung sd 15 ml) - + - 0
Refrigerated Micro-centrifuge (Kapasitas sekitar 20 tabung, volume 1,5
17 ml) - + - 0
18 Timbangan Analitik (Kapasitas menimbang di bawah 1 gram) + + - 0
19 Timbangan / Balance untuk Media (Kapasitas sd 1 kilogram) + + - 0
20 pH meter - + - 0
21 Mesin PCR (Satu set) - + - 0
22 Perangkat Elektroforesis, Horizontal - + - 0
23 Mesin Pembaca produk PCR (Contoh: GelDoc Machine) - + - 0
24 Vortex - + - 0
25 Inspisator - + - 0
Mikropipet (Set: di bawah 5 mikroL, 5-20 mikroL, 20-50 mikroL, 50-100
26 mikroL, 100-1000 mikroliter) - + - 0
27 Water Purifier + + - 0
28 Autoklaf (Volume 60 liter) + + - 0
29 ELISA Reader - + - 0
30 Shaking Water bath (Volume air, sekitar 20 liter) - + - 0
31 Spectrophotometer - + - 0
Inkubator Kultur Darah Otomatik, Dengan Optic Sensing (BD atau
32 BactAlert kapasitas 120 tabung) - + - 0
33 Mesin Diagnostik Otomatis Mikrobiologi (Vitek atau Phoenix) - + - 0
34 Mesin Diagnosis M.tuberculosis otomatik, MGIT (MGIT Machine) - + - 0
35 Shaking Incubator (Volume 120 liter) - + + 1
Instrumen Sterilisasi Cairan Menggunakan Filter (Satu set dengan
36 pompoa) - + - 0
37 Alat-alat Gelas (Tabung Reaksi, Petri Dish, Erlenmeyer, Pipet,) + + - 0
14 37 3 3
TOTAL PELAYANAN MIKROBIOLOGI 14 37 3 3
 KONDISI
H. NO
Patologi Anatomi PERSYARATAN KELAS C KELAS B
Ruang Tup (Ruang Pemotongan Jaringan dan Pemeriksaan
Makroskopik)
1 Work Station / Grossing Station + + + 2
2 Autopsi Set + + - 0
3 Pisau Potong (1 set) + + + 1
4 Gunting (lurus,bengkok,kecil) + + - 0
5 Gergaji Listrik + + - 0
6 Pinset, Scalpel + + - 0
7 Alat Pengukur (Penggaris Besi) + + - 0
8 Alat Pengukur Berat (Timbangan) < 1 kg + + + 1
9 Alat pengukur Berat (Timbangan) > 1 kg + + + 1
10 Loop / Kaca Pembesar + + - 0
11 Talenan (Alas Pemotong Jaringan) + + + 1
11 11 5 6
Ruang Pemrosesan Jaringan (Histologi)
1 Automatic Tissue Processing + + - 0
2 Manual Tissue Processing + + - 0
3 Automatic Staining Machine + + - 0
4 Manual Staining + + - 0
5 Embedding Center + + - 0
6 Fully Motorize Rotary Microtome +Waterbath + + - 0
7 Manual Microtome +Waterbath + + - 0
8 Cryostat + + - 0
9 Hotplate + + - 0
10 Peralatan Gelas Untuk Processing Manual + + - 0
11 Timer + + - 0
12 Microscope Binocular + + - 0
13 Virtual Microscope + + - 0
14 Lemari Asam + + - 0
15 Ph Meter + + - 0
16 Alkohol Meter + + - 0
16 16 0 0
Ruang Klinik Sitologi
1 Tempat Tidur Pasien + + - 0
2 Lampu Sorot + + - 0
3 Tempat Tidur Gynekologi + + - 0
4 Lampu Rontgen + + - 0
5 Lemari Penyimpanan Bahan - Bahan FNAB + + - 0
6 Meja Trolly Untuk Alat + + - 0
7 Meja Kerja + + - 0
8 Kursi + + - 0
9 Spekulum (Cocor Bebek) + + - 0
10 Autoclave / Sterillisator Listrik + + - 0
11 Piston Gun + + - 0
12 Microscope Binocular + + - 0
12 12 0 0
Ruang Pemrosesan Cairan (Sitologi)
1 Manual Staining Jar + + - 0
2 Cyto Centrifuge 1500 rpm + + - 0
3 Cyto Spin + + - 0
4 Timer + + - 0
5 Pipet Set (Dari Kecil sd Besar) Masing-Masing + + - 0
6 Microscope Binocular + + - 0
7 Liquid Base Cytology Manual + + - 0
8 Liquid Base Cytology Automatic / Machine + + - 0
9 Vortex + + - 0
10 Lemari Pendingin / Kulkas + + - 0
11 Alkohol Meter + + - 0
12 Hair Dryer + + - 0
13 Rak Slide + + - 0
13 13 0 0
Ruang Immunohistokimia
1 Mesin Standar Automatic Pulasan Immunohistokimia + + - 0
2 Fully Motorize Rotary Microtome √ Waterbath + + - 0
3 Hotplate + + - 0
4 Lemari Pendingin 4°C + + - 0
5 Frezer -20°C + + - 0
6 Timer + + - 0
 KONDISI
NO 7 Microscope Binocular PERSYARATAN + C KELAS
KELAS + B - 0
8 Microscope Double Head + + - 0
8 8 0 0
Ruang Imunofluoresensi
1 Mikroskop Imunofluoresensi Lengkap Dengan Kamera dan Komputer + + + - 0
PC 1 1 0
Ruang Patologi Molekuler
1 PCR (RT dan Convensional) Masing-Masing - + - 0
2 Apparatus Electroforesis - + - 0
3 Gel Doc - + - 0
4 Ph Meter - + - 0
5 Micro Balance - + - 0
0 5 0 0
Ruang Diagnosa
1 Microscope Binocular + + - 0
2 Microscope Double Head + + - 0
3 Five Headed Microscope+Camera Attached+PC + + - 0
4 Meja Untuk Miksroskop + + - 0
5 Kursi Untuk Diagnosis + + - 0
6 Lemari Buku (Build In) + + - 0
6 6 0 0
TOTAL PATOLOGI ANATOMI 67 72 5 6
 KONDISI
I. Pelayanan Patologi Klinik
NO PERSYARATAN KELAS C KELAS B
Peralatan Umum
1 Biosafety cabinet level 2A + + - 0
2 Fume hood (lemari asam) - + - 0
3 Laminary air flow - + - 0
4 Mikroskop + + + 3
5 Sink Laboratorium + + - 0
6 Rak untuk pewarnaan + + - 0
7 Waterbath + + - 0
8 Refrigerator 2-8°C + + + 1
9 Cold room - + - 0
10 Freezer -200C + + - 0
11 Freezer -800C - + - 0
12 Sentrifus + + + 2
13 Mikrosentrifus + + - 0
14 Mikropipet + + - 0
15 Vortex mixer + + - 0
16 Timbangan analitik + + - 0
17 pH meter + + - 0
18 Inkubator + + - 0
19 Autoklaf + + - 0
20 Oven + + - 0
21 EIA sistem + + - 0
22 Rotator + + - 0
23 Bunsen + + - 0
24 Fume hood + + + 1
25 Water purifier + + - 0
26 Sitosentrifus + + - 0
27 Spektrofotometer + + - 0
28 Fotometer + + - 0
29 Flowcitometer - + - 0
30 Peralatan Gelas + + - 0
25 30 4 7
Pelayanan Hematologi
1 Hematology analyzer: Five parts differential (A) + + + 2
2 Coagulometer + + - 0
3 Agregometer - + - 0
4 Spektrofotometer + + - 0
5 Flow Cytometri - + - 0
6 Analisa Hb - + - 0
7 Peralatan Laju Endap Darah (LED) + + + 1
4 7 2 3
Kimia klinik
1 Chemistry analyzer + + + 1
2 Fotometer/spektrofotometer + + + 1
3 Elektroforesis - + - 0
4 Analisa gas darah + + + 1
5 Urine Analyzer + + + 1
4 5 4 4
Imunologi
1 Imunologi analyzer - + + 1
2 Nefelometer - + - 0
3 Enzyme Immunoassay - + + 1
0 3 2 2
Mikrobiologi
1 Mikroskop lapang gelap - + - 0
2 Incubator CO2 - + - 0
3 Jar anaerob - + - 0
4 Inspisator - + - 0
5 Kultur otomatik - + - 0
0 5 0 0
Biologi molekuler
1 Polymerase Chain Rection (PCR) - + + 0
0 1 1 0
TOTAL PELAYANAN PATOLOGI KLINIK 33 51 13 16
 KONDISI
J.
NO Pelayanan Radiologi PERSYARATAN KELAS C KELAS B
Diagnostik
1 Film viewer + + + 4
2 Cassette & Film X-ray semua ukuran + + + 10
3 Film marker + + + 2
4 Film dryer + + - 0
5 MRI - + - 0
6 CT Multislice + + + 1
7 Fluoroskopi - + - 0
8 USG 4D + + + 1
9 Analog X-ray Fixed Unit dan atau Digital - + - 0
10 Mobile x-ray + + + 2
11 Mammography - + - 0
12 Digital Panoramic/ Cephalometri - + + 1
13 Dental X-ray, + + + 1
14 C-arm - + - 0
15 Computed Radiography (CR) - + + 1
16 Picture Archiving Communication System' (PACS) + + - 0
17 Peralatan protektif radiasi + + + 4
18 Perlengkapan proteksi radiasi + + + 26
19 Quality Assurance dan Quality Control - + - 0
20 Emergency Kit + + + 1
21 Viewing box + + + 5
22 Generator set + + + 1
14 22 14 60
TOTAL PELAYANAN RADIOLOGI 14 22 14 60
 KONDISI
K.
NOPelayanan Rehabitasi Medik PERSYARATAN KELAS C KELAS B
Pemeriksaan/Penilaian
1 Meja Periksa / Tempat tidur periksa / Examination Table + + + 1
2 Lampu Periksa/Examination Lamp/Light/Hanging lamp + + + 1
2 2 2 2
Diagnostik
1 Electromyography - + - 0
2 Goniometer + + + 1
3 Handgrip Streght Dynamometer + + - 0
4 Handheld Dynamometer + + + 1
5 Food Trolley Desentralisasi + + - 0
6 Inclinometer + + - 0
7 Nebulizer Jet + + - 0
8 Nebulizer Ultrasound + + - 0
9 Oximeter/Pulse Oximetry/Oksigen Saturasi + + - 0
10 Peak Flow Meter + + - 0
11 Spirometer + + - 0
12 Tensimeter Digital / Sphygmomanometer Digital + + - 0
13 Tensimeter Anaeroid / Sphygmomanometer Anaeroid + + + 1
14 Stetoskop + + + 1
15 Voice Analyzer - + - 0
13 15 4 4
Terapi Psikologi
Peralatan Organis
1 Peralatan Konsultasi dan Terapi + + + 0
1 1 1 0
Fisioterapi Pasif
1 Ankle/Wrist - + - 0
2 Bath Whirl Pool + + - 0
3 Cane, crutch, and walker tips and pads/Cane Set + + - 0
4 Compression Therapy - + - 0
5 Crutches Set + + - 0
6 Electro Stimulation & Analgesia + + + 3
7 Ergocycle + + - 0
8 Examination Table + + - 0
9 Exercise Bicycle + + + 1
10 Exercise Equipment + + - 0
11 Finger Muscle Therapy + + - 0
12 Lampu Infrared + + + 5
13 Laser Therapy + + + 1
14 LF Electro Therapy - + - 0
15 Matras / Mattress cover for medical purposes + + + 1
16 Microwave Diathermy + + + 2
17 Parafin Bath + + + 1
18 Paralell bars - + + 1
19 Platform Walker - + - 0
20 Reciprocal Walker + + - 0
21 Reverse Walker + + - 0
22 Rolling Triceps Walker + + - 0
23 Rolling/Gliding Walker + + - 0
24 Shortwave Diathermy + + + 1
25 Stair-Climbing Walker + + - 0
26 Standar Walker + + - 0
27 Suspention & Pulley Equipment + + + 1
28 TENS - + + 2
29 Therapeutic Position and Equipment Set - + - 0
30 Tilt Table + + - 0
31 Traction Unit + + + 1
32 Treadmill + + + 1
33 Ultrasound Therapy - + + 2
34 Ultraviolet quartz - + - 0
35 Kursi Roda/Wheel Chair + + + 2
36 Wheelchair Elektrik - + + 1
26 36 16 26
Senam (Gymnasium)
1 Perangkat olah raga senam + + - 0
1 1 0 0
Terapi Okupasi
1 Alat Latihan Sensori + + - 0
 KONDISI
NO 2 Alat Terapi Sensori IntegrasiPERSYARATAN
Set + C KELAS
KELAS + B - 0
3 Peralatan Latihan ADL + + - 0
4 Snoozlen Set + + - 0
4 4 0 0
GIP
1 Peralatan Ruang GIP + + - 0
1 1 0 0
Bengkel Halus/Kerja Kayu
1 Peralatan Halus/Kayu Orthotik dan Prostetik/ OP + + - 0
1 1 0 0
Bengkel Kasar/Kerja Pembuatan
1 Peralatan Kasar Orthotik dan Prostetik/ OP - + - 0
0 1 0 0
Jahit/Kulit
1 Peralatan Jahit(Kain & Kulit) - + - 0
0 1 0 0
TOTAL PELAYANAN REHABILITASI MEDIK 49 63 23 32
 KONDISI
L.
NO Pemulasaran Jenazah PERSYARATAN KELAS C KELAS B
1 Body Bags + + + 8
2 Autopsy Table - + - 0
3 Dissection Table + + + 1
4 Autopsi Instrument + + - 0
5 Head Lamp + + - 0
6 Examination Lamp + + + 1
7 Body Trolley + + + 4
8 Preparation table + + - 0
9 Refrigerated Mortuary Cabinet + + + 1
10 Weigthing machine for Weigthing dead bodies - + - 0
11 Weigthing machine for organs - + - 0
12 Body Bags + + + 8
13 Dissection Table + + + 1
10 13 7 24
TOTAL PEMULASARAN JENAZAH 10 13 7 24
 KONDISI
M. NO
Instalasi Gizi PERSYARATAN KELAS C KELAS B
Asuhan Gizi Rawat Inap
Kegiatan asuhan gizi
1 Alat Ukur tinggi badan dan Berat badan + + + 1
2 Alat Ukur Lingkar Lengan Atas + + + 1
3 Knee hight (alat ukur tinggi lutut) + + - 0
4 Food model + + + 1
5 Skinfold + + - 0
6 Timbangan Bayi + + + 1
7 Alat Ukur Panjang badan Bayi + + + 1
8 Bed scale + + - 0
9 Bioelectrical Analisys Impedance + + + 1
10 Chair scale + + - 0
11 Pita Ukur Lingkar Pinggang dan Pinggul + + - 0
11 11 6 6
Kegiatan pelayanan makanan
1 Meja Distribusi Makanan + + + 4
2 Rak Alat Makan + + + 2
3 Lemari alat makan + + + 1
4 Alat Pemanas (kompor) + + + 5
5 Refrigerator Khusus Makanan Cair + + - 0
6 Refrigerator + + + 2
7 Tempat Pencucian Alat + + + 3
8 Food Trolley Sentralisasi + + - 0
9 Food Trolley Desentralisasi + + - 0
10 Trolley Makanan Kelas VIP + + + 1
11 Timbangan Makanan + + + 3
12 Blender + + + 5
13 Alat Makan Khusus Dewasa + + + 159
14 Alat Makan Pasien Anak + + - 0
14 14 10 185
Asuhan Gizi Rawat Jalan (Di Ruang Konseling Gizi)
1 Alat Ukur Tinggi Badan dan Berat Badan (Dewasa dan Anak) + + + 1
2 Alat Ukur Lingkar Lengan Atas + + + 1
3 Food model + + + 1
4 Skinfold + + - 0
5 Lemari Kaca (Untuk Food sample) + + + 1
5 5 4 4
Penyelenggaraan Makanan (Di Ruang Penerimaan)
1 Timbangan Lantai + + - 0
2 Timbangan Duduk + + + 1
3 Timbangan Digital + + - 0
4 Trolley Barang + + + 1
5 Washtafell + + + 2
6 Tempat sampah + + + 1
6 6 4 5
Di Ruang penyimpanan bahan makanan kering
1 Timbangan Digital + + - 0
2 Timbangan Duduk + + - 0
3 Pallet + + + 2
4 Refrigerator + + - 0
5 Tempat Sampah + + + 1
6 Chiller 4 Pintu + + - 0
7 Tangga Lipat + + - 0
8 Hand Lift + + - 0
9 Trolley Barang + + + 1
10 Timbangan Lantai + + - 0
11 Container Bertutup + + + 5
12 AC Split + + + 1
12 12 5 10
Di Ruang penyimpanan bahan makanan segar
1 Timbangan Digital + + - 0
2 Timbangan Duduk + + + 1
3 Refrigerator + + + 2
4 Tempat Sampah + + + 1
5 Chiller 4 Pintu + + - 0
6 Trolley Barang + + + 1
7 Timbangan Lantai + + - 0
8 Timbangan Duduk + + - 0
 KONDISI
NO 9 Container Bertutup PERSYARATAN + C KELAS
KELAS + B + 1
10 Freezer Cabinet + + + 1
11 Cold Room Freezer (Temp -15˚s.d -18˚C) + + + 2
12 Cold Room Chiller (Temp √ 2˚s.d 8˚ C) + + + 1
13 Insect Killer + + + 1
13 13 13 11
Di Ruangan persiapan bahan makanan
1 Timbangan Duduk + + - 0
2 Timbangan Digital + + - 0
3 Mesin Pemotong Daging + + - 0
4 Mesin Pemotong Sayuran + + - 0
5 Bak Cuci + + + 1
6 Penggiling Daging + + + 1
7 Mixer + + - 0
8 Blender + + + 2
9 Penggiling Bumbu + + + 1
10 Talenan + + + 3
11 Food Processor + + - 0
12 Peeler + + + 2
13 Tempat sampah + + + 2
14 Insect Killer + + + 1
15 Pisau + + + 5
15 15 9 18
Di Ruang pengolahan makanan
1 Timbangan + + + 1
2 Cooking Range (tungku) + + - 0
3 Frying Pan + + - 0
4 Gelas Ukur + + + 2
5 Bain Marrie + + - 0
6 Blender + + + 5
7 Boiling Pan + + - 0
8 Boiling Pan + + - 0
9 Oven + + - 0
10 High Pressure Cooker + + + 1
11 Rice Cooker + + + 1
12 Pan Dadar / Ceplok Telur + + + 1
13 Double Sink Heavy + + - 0
14 Tempat Sampah + + + 2
15 Trolley + + + 1
16 Kuali Range + + - 0
17 Refrigerator + + - 0
18 Freezer + + - 0
19 Chiller + + - 0
20 Lemari Alat + + - 0
21 Rak Alat + + + 1
22 Lemari Makanan Matang + + - 0
23 Mesin Wrapping + + - 0
24 Panci set + + - 0
25 Insect Killer + + + 1
26 Meja Persiapan Snack, Makanan Cair + + - 0
27 Cetakan Telur + + + 2
28 Wajan + + + 4
29 Container Tertutup + + - 0
29 29 12 22
Di Ruang distribusi
1 Food Trolley Makanan Dengan Pemanas + + + 2
2 Food Trolley Makanan Tanpa Pemanas + + + 1
3 Timbangan Duduk + + - 0
3 3 2 3
Di Ruang pencuci dan penyimpanan alat
1 Mesin Pencuci Alat + + + 1
2 Bak Pencuci Alat + + + 1
3 Lemari + + + 1
4 Rak Alat + + + 1
5 Tempat Sampah + + + 1
5 5 5 5
Di Ruang Formula
1 Sterilisator + + - 0
2 Tempat Sampah + + + 1
 KONDISI
NO 3 Gelas Ukur PERSYARATAN + C KELAS
KELAS + B + 1
4 Mixer + + - 0
5 Blender + + - 0
6 Kompor Gas + + - 0
7 Tungku + + - 0
8 Cooking Range (tungku) + + - 0
9 Refrigerator + + - 0
10 Mesin Pencuci Botol + + - 0
11 Bain Marrie + + - 0
12 Lemari Bahan Makanan Kering + + + 1
13 Rak Botol Susu + + - 0
14 Trolley + + - 0
15 Rak Alat + + - 0
16 Bak Pencuci Alat + + - 0
16 16 3 3
TOTAL INSTALASI GIZI 120 129 73 272
TOTAL SEMUA INTALASI 915 1040 492 1302
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN JENIS HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN JUMLAH SATUAN (RP)
SATUAN)
KELAS C KELAS B

3 0
3 2
1 -1
1 0
1 0
1 0
1 0
1 0
2 0

14 1 89% 89% 107%

1 0
1 0
1 0
2 0
2 0
4 0
1 -1
2 -1
3 0
2 -1
2 -1
4 -2
4 -1
1 0
1 0
1 -1
32 -8 88% 88% 75%
0
1 0
1 0
1 0
1 2
7 -3
1 0
1 0
13 -1 117% 100% 92%
0
1 0
1 0
1 0
1 0
1 0
1 0
1 -1
1 0
1 -1
9 -2 89% 89% 78%
0
20 -3
1 2
1 0
1 0
1 0
2 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
3 -1
3 0
2 -1
1 0
2 -1
39 -7 85% 85% 82%
107 -17 91% 89% 84%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN 0 SATUAN (RP)
SATUAN)
1 0
1 0
2 0
3 0
1 1
1 0
1 0
9 1 100% 100% 111%
0 Cat : u/ Kamar tindakan Bergabung
1 0
1 -1
1 1
1 0
1 -1
1 2
1 0
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
18 -10 33% 28% 44%

6 -6
3 -3
3 -2
3 0
3 -3
3 -1
9 -6
3 -2
9 -5
6 -4
9 -2
6 -3
3 -3
9 -3
3 0
9 -7
18 -13
58 0
19 -12
3 -2
6 -5
3 -2
194 -84 82% 82% 57%
221 -93 68% 64% 58%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
2 -1
1 0
2 -1
1 0
0 0
2 0
1 -1
1 0
1 0
1 0
1 0
1 -1
1 0
15 -4 77% 77% 73%
Cat : u/Kamar tindakan dgn ruang p
1 0
1 0
1 -1
1 0
1 0
2 -2
1 -1
1 -1
1 -1
1 -1
1 -1
1 0
0 0
13 -8 38% 38% 38%
0
3 -3
2 -1
1 -1
2 -1
1 -1
0 1
2 -1
11 -7 57% 57% 36%

2 2
16 -8
5 -2
0 0
0
6 -5
0
5 -2
2 -1
0
6 -2
0
1 -1
2 0
1 0
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
2 -1
0
5 -1
0
5 -2
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
8 JUMLAH
-2 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
5 JUMLAH
-4 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 0 SATUAN (RP)
SATUAN)
1 0
1 -1
2 -2
1 -1
1 -1
1 -1
1 -1
0 0
88 -44 94% 41% 50%
0
5 -2
1 -1
7 -4
2 1
3 0
2 0
20 -6 83% 83% 70%
0
54 -17
8 -6
4 -2
4 -4
2 0
4 -3
2 -1
6 0
10 -7
2 -1
96 -41 90% 90% 57%
243 -110 74% 56% 55%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
1 0
1 -1
0 0
2 0
0 0
1 0
1 0
2 -1
1 -1
0 0
0 0
0 0
1 -1
1 0
11 -4 43% 43% 64%

2 0
1 0
2 0
1 -1
2 0
7 0
2 0
2 0
21 0
3 -1
3 0
7 -4
1 -1

2 -2

4 0
4 -4
64 -13 69% 69% 80%
0
14 -5
5 -2
2 -1
3 -2
3 -1
1 0
3 -3
3 -1
9 -7
5 -3
3 -1
15 -5
3 0
3 -2
3 -2
2 -1
3 -2
1 -1
1 -1
82 -40 84% 84% 51%

2 -1
2 -2
2 -1
2 -1
2 -1
2 -1
1 -1
1 -1
2 -1
2 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
2 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
8 -2 SATUAN (RP)
SATUAN)
1 -1
2 -1
31 -16 71% 71% 48%
188 -73 68% 68% 61%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
1 0
1 0
1 0
3 0
1 0
1 0
1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 -1
0 0
0 0
1 0
0 0
1 0
1 -1
1 0
0 0
1 0
1 0
1 0
1 0
1 0
0 0
0 0
1 0
20 -2 50% 50% 90%
0
30 0
4 0
1 0
4 0
2 0
0
1 0
1 1
2 0
1 -1
0 0
0 0
1 0
0 0
1 0
0 0
1 -1
0 0
1 -1
8 0
2 0
4 0
2 -2
1 0
2 0
0 0
2 -2
2 -2
6 0
4 -2
2 0
1 0
1 0
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
2 JUMLAH
-2 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 1 SATUAN (RP)
SATUAN)
0 0
4 -1
4 0
2 0
2 -2
1 0
2 -2
1 1
2 0
4 -2
2 0
0
3 0
3 0
8 14
0 0
1 0
2 0
2 -2
1 1
1 -1
0
3 0
8 0
3 0
2 -2
2 -1
6 0
0 0
1 0
3 0
30 -30
30 -30
0 0
2 0
0 0
0 0
25 0
2 -2
252 -70 62% 62% 72%

6 -2
4 -1
1 0
6 -2
6 -4
2 -1
6 -4
2 -1
10 -7
1 -1
2 -1
2 -1
1 -1
6 -3
2 -1
1 -1
2 -2
1 -1
6 -5
0 0
2 -1
2 -1
1 -1
2 -2
6 -2
0 0
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
2 JUMLAH
0 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
1 -1
8 -2
4 0
5 -1
5 -1
6 -1
2 0
4 -1
0
3 -1
2 -1
1 0
6 -2
2 -1
5 -2
1 -1
4 -1
3 -1
8 -2
4 -1
3 -1
0
4 -2
5 -2
4 -1
1 0
12 -6
2 -1
2 -1
190 -81 75% 75% 57%

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
7 -2
3 -2
5 -3
2 0
4 -2
0 0
0 0
0 0
1 -1
1 0
0 0
1 -1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 -1
0 0
0 0
0 0
0 0
0 0
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
62 -49 8% 8% 21%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
13 -13 0% 0%

4 -1
1 -1
12 -6
1 0
5 -2
4 -2
4 -2
16 -2
2 -1
2 -1
2 -1
1 -1
2 -2
1 -1
2 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
2 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
4 -3 SATUAN (RP)
SATUAN)
1 -1
2 -1
0 0
2 -1
0
3 -1
73 -32 70% 70% 56%
610 -247 48% 47% 60%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)

0 0
5 -2
1 -1
6 -3 50% 33% 50%
0
5 -2
1 1 100% 100% 150%
0
0
5 -3
2 -2
0
0 bhp
0 bhp
0 bhp
5 -3
1 -1
2 -2
15 -11 22% 22% 27%
0
5 -4
5 -5
5 -5
2 0
2 -2
19 -16 60% 60% 16%
0
2 -1
5 -4
5 -1
5 -5
5 -5
10 4
0 0
32 -12 57% 57% 63%

0 0
6 0
0 0
2 -2
8 -2 50% 25% 75%

6 0
6 0 100% 100% 100%

2 -2
2 2 0% 0% 0%

6 -2
6 -2 100% 100% 67%
0
1 2
1 2 100% 100% 300%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
7 -7 0% 0% 0%

1 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
3 -3 0% 0% 0%

2 -1
0 0
1 0
1 0
bhp
bhp
2 0
0 0
1 0
7 -1 56% 56% 86%

1 0
0 0
0 0
1 0
1 0
3 0 60% 60% 100%
0
1 0
1 0
4 0
1 0
3 -3
10 0
0 0
0 0
0 0
20 -3 67% 67% 85%

6 0
0 0
1 0
0 0
3 0
3 0
13 0 67% 67% 100%

0 0
0 0
0 0
0 0
0 0
0 0
0 0 0% 0% #DIV/0!

5 -2
6 -6
1 -1
1 -1
13 -10

6 -3
1 -1
8 -5
8 -2
6 -3
1 -1
2 -2
1 -1
3 -3
36 -21
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
6 -3 SATUAN (RP)
SATUAN)
3 -3
6 -4
9 0
6 -3
2 0
32 -13

2 -1
27 -14
18 -4
3 -3
3 -2
18 -6
1 -1
72 -31

13 0
6 -6
3 -3
13 0
1 -1
6 -3
6 -1
48 -14 57% 57% 71%
0
1 -1
1 0
1 -1
2 -1
3 0
8 -8
0
1 -1
3 -2
0
1 -1
1 -1
22 -16 44% 33% 27%

1 -1
1 0
1 -1
1 -1
1 -1
1 -1
6 -5 25% 17% 17%
60 60 50% 44% 100%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
1 -1
1 -1
1 -1
1 -1
2 -1
3 -2
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1

1 -1
1 -1
1 -1
1 0
1 -1
1 -1
40 -37 21% 8% 8%
40 -37 21% 8% 8%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)

3 -1
2 -2
2 -1
5 -5
2 -2
5 -5
2 -2
1 0
1 0
2 -2
1 0
26 -20 45% 45% 23%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
16 -16 0% 0% 0%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
12 -12 0% 0% 0%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
13 -13 0% 0% 0%

1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
8 -8 0% 0% 0%
0
1 -1
1 -1 0% 0% 0%

1 -1
1 -1
1 -1
1 -1
1 -1
5 -5 - 0% 0%
0
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
6 -6 0% 0% 0%
87 -81 7% 7% 7%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
1 -1
1 -1
1 -1
1 2
1 -1
1 -1
1 -1
2 -1
1 -1
1 -1
1 -1
2 0
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
3 -2
1 -1
1 -1
1 -1
1 -1
1 -1
1 -1
34 -27 16% 13% 21%

2 0
1 -1
1 -1
1 -1
1 -1
1 -1
5 -4 + pipet 5
12 -9 50% 29% 25%

1 0
1 0
1 -1
1 0
1 0
5 -1 100% 80% 80%

1 0
1 -1
1 0
3 -1 - 67% 67%

1 -1
1 -1
1 -1
1 -1
1 -1
5 -5 - 0% 0%

1 -1
1 -1 - 100% 0%
60 -44 39% 25% 27%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
4 0
15 -5
4 -2
0 0
0 0
1 0
0 0
1 0
2 -2
2 0
0 0
1 0
1 0
0 0
2 -1
1 -1
1 3
1 25
1 -1
2 -1
5 0
1 0
45 15 100% 64% 133%
45 15 100% 64% 133%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)
2 -1
2 -1
4 -2 100% 100% 50%

2 -2
3 -2
2 -2
3 -2
2 -2
3 -3
2 -2
2 -2
3 -3
3 -3
3 -3
3 -3
3 -2
3 -2
2 -2
39 -35 31% 27% 10%

0 0
0 0 100% 100% #DIV/0!

3 -3
1 -1
2 -2
2 -2
2 -2
5 -2
2 -2
2 -2
3 -2
3 -3
2 -2
5 0
2 -1
3 -3
3 -2
3 -1
2 -1
1 0
3 -3
2 -2
2 -2
3 -3
2 -2
2 -1
2 -2
2 -2
2 -1
4 -2
2 -2
2 -2
1 0
2 -1
4 -2
2 -2
3 -1
1 0
87 -61 62% 44% 30%

1 -1
1 -1 0% 0% 0%

1 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
2 -2 SATUAN (RP)
SATUAN)
2 -2
6 -6 0% 0% 0%

0 0
0 0 0% 0% #DIV/0!

0 0
0 0 0% 0% #DIV/0!

0 0
0 0 #DIV/0! 0% #DIV/0!

0 0
0 0 #DIV/0! 0% #DIV/0!
137 -105 47% 37% 23%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
8 0 SATUAN (RP)
SATUAN)
0 0
1 0
0 0
1 -1
1 0
4 0
0 0
1 0
0 0
0 0
8 0
1 0
25 -1 70% 54% 96%
25 -1 70% 54% 96%
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
JUMLAH ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN SATUAN (RP)
SATUAN)

10 -9
5 -4
0 0
1 0
1 -1
1 0
1 0
8 -8
1 0
0 0
0 0
28 -22 55% 55% 21%

4 0
2 0
2 -1
6 -1
1 -1
3 -1
3 0
0 0
0 0
2 -1
9 -6
5 0
190 -31
15 -15
242 -57

2 -1
1 0
1 0
1 -1
1 0
6 -2

1 -1
1 0
1 -1
1 0
2 0
1 0
7 -2

1 -1
1 -1
3 -1
0 0
1 0
0 0
1 -1
0 0
1 0
1 -1
6 -1
1 0
16 -6

1 -1
1 0
3 -1
1 0
1 -1
1 0
1 -1
1 -1
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
1 JUMLAH
0 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 0 SATUAN (RP)
SATUAN)
2 0
1 0
1 0
16 -5

1 -1
1 -1
0 0
1 -1
1 0
1 0
1 -1
3 -1
2 -1
5 -2
0 0
2 0
2 0
1 0
10 -5
31 -13

2 -1
0 0
0 0
2 0
0 0
5 0
0 0
0 0
0 0
1 0
2 -1
1 0
0 0
2 0
1 0
0 0
1 -1
0 0
0 0
1 -1
1 0
1 -1
1 -1
1 -1
1 0
1 -1
2 0
4 0
1 -1
31 -9

2 0
2 -1
0 0
4 -1

1 0
1 0
2 -1
1 0
1 0
6 -1 100% 100% 83%

1 -1
1 0
 ANALISIS GAP
KEBUTUHAN
STANDAR JUMLAH PERKIRAAN
2 JUMLAH
-1 ANGGARAN (JUMLAH
BERDASARKAN HARGA
KEBUTUHAN KEBUTUHAN*HARGA
KEBUTUHAN
1 -1 SATUAN (RP)
SATUAN)
1 -1
0 0
0 0
0 0
1 -1
1 -1
0 0
2 -1
0 0
1 -1
1 -1
1 -1
13 -10 19% 19% 23%
400 -128 61% 57% 68%
2223 -861 54% 47% 59%
 Nama Unit Standar Kelas C Standar Kelas B Kondisi Gap Kelas CGap Kelas B
IGD
Penyakit Dalam
Bedah
Kesehatan Anak
Obgyn
Anestesi
Mikrobiologi
Patologi Anatomi
Patologi Klinik
Radiologi
Rehabilitasi
Pemulasaran
Jenazah
Gizi
TOTAL
Cat : u/ Kamar tindakan Bergabung dgn ruang periksa dokter
Cat : u/Kamar tindakan dgn ruang periksa, dibutuhkan bangunan/ruang tindakan dipoli bedah
9