住院费用清单模板.docx

1、住院费用清单模板住院费用清单*医院 单位：元 住院号： 姓名： 科室： 床位： 类别：自费总费用： 预交金额： 尚欠： 住院天数：天项目规格数量单价金额自负金额保险金额三磷酸腺苷二纳注射液开塞露维生素B6注射液0.9%氯化钠注射液地塞米松磷酸钠注射液盐酸利多卡因注射液10%葡萄糖注射液（可立袋）5%葡萄糖注射液（可立袋）0.9%氯化钠注射液（可立袋）米索前列醇片盐酸麻黄碱注射液盐酸吗啡注射液盐酸布比卡因注射液维生素C注射液硫酸阿托品注射液复方氯化钠注射液注射用铺本酶A注射用头孢他啶20mg:2ml20ml100mg:2ml10ml5mg:1ml200mg:10ml100ml500ml100ml

2、200ug3片30mg:1ml10mg:1ml37.5mg:5ml500mg:2ml0.5mg:1ml500ml100IU0.75g22814119211112614150.250.600.170.240.200.802.604.905.202.431.064.01.920.170.902.603.2038.50.501.21.360.240.800.802.6044.1010.402.431.064.901.924.420.9010.403.20192.50.501.21.360.240.800.802.6044.1010.402.431.064.901.924.420.9010.403.2

3、0192.5西药合计283.73283.73吸引连接管一次性备皮刀产腹带一次性枕套一次床单留置针贴膜爱惜康幕丝线一次性便盆一次性采血管留置针一次性氧管一次性导尿管电极板一次性麻醉包肝素帽无菌敷贴一次性引流瓶抗凝采血管缓排空型一次性输液器一次性婴儿吸痰器4565120220肝功能 生化ssssAS_E10151:4 1:9小3111212115121513121613.001.085.400.866.483.2454.0012.967.560.8619.871.9423.760.6521.602.704.1042.120.975.401.709.001.085.400.8612.963.2410

4、8.0012.967.564.3019.873.8823.763.2521.608.104.1084.240.9732.401.709.001.085.400.8612.963.24108.0012.967.564.3019.873.8823.763.2521.608.104.1084.240.9732.401.70材料费合计369.23369.23围产保健访视住院诊查费455.004.0020.0020.0020.0020.00诊查费合计40.0040.00血常规（五分类）尿常规检查（尿十一项）尿常规（手工法）葡萄糖测定肝功能常规检查肾功能常规检查乙肝三对检测输血前常规检查ABO血型鉴定（微

5、柱法）Rh血型鉴定（微柱法）211111111118.009.003.004.0055.0018.0025.0080.0027.0027.00369.003.004.0055.0018.0025.0080.0027.0027.00369.003.004.0055.0018.0025.0080.0027.0027.00检验费合计284.00284.00输卵管结扎术剖宫产术肠粘连松解术经腹子宫肌痛剔除术0.510.50.5240.00800.00800.00720.00120.00800.00400.00360.00120.00800.00400.00360.00制表：邓美男 第1页其2页住院费用

6、清单衡南县人民医院 单位：元 项目规格数量单价金额自负金额保险金额镇痛泵体内置入术1720720720 手术费合计2400.002400.00超声计算机图文报告19.009.009.00计算机图文合计9.009.00新生儿油浴护理级护理级护理新生儿护理新生儿抚触护理新生儿呼吸道清理护理动静脉置管护理51459135.0013.007.009.0020.005.005.0025.0013.0028.0045.00180.005.0015.0025.0013.0028.0045.00180.005.0015.00护理合计311.00311.00产前检查胎心监测新生儿量表检查会阴冲洗小换药宫颈注射新

7、生儿经皮胆红素测定心电监测血氧饱和度监测2518115668.0023.0018.004.007.0018.009.002.001.0016.00115.0018.0032.007.0018.0045.0012.006.0016.00115.0018.0032.007.0018.0045.0012.006.00治疗费合计269.00269.00住院床位费婴儿床（母婴同室双人间）普通病房床位费（单人间）7710.0020.0070.00140.0075.00125.00床位费合计210.00210.00肌肉注射皮试皮下注射静脉注射静脉输液连续输液第二组起每组加收静脉穿刺置管术3125131112

8、.003.002.003.004.001.0020.006.003.004.0015.0052.0011.0020.006.003.004.0015.0052.0011.0020.00 注射费合计111.00111.00低流量吸氧32.57.507.50 输氧合计7.57.5椎管内麻醉术后镇痛麻醉中监测114250.0085.0015.00250.0085.0060.00250.0085.0060.00 麻醉合计395.00395.00常规心电图检查常规心电图检查（12导联加收）频谱心电图1119.0010.0023.009.0010.0023.009.0010.0023.00心电图合计42.0042.00临床操作的彩色多普勒超声引导1100.00100.00100.00 彩超合计100.00100.00凝血常规检测170.0070.0070.00 血凝全套合计70.0070.00病房空调费（单人间）71070.0070.00 其他合计70.0070.00静脉采血23.006.006.00 抽血费合计 6.006.00总计4947.464947.46制表： 保险金额：0 第2页共2页