住院费用清单模板

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1、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:10ml100ml500ml100ml200ug×3片30

2、mg:1ml10mg:1ml37.5mg:5ml500mg:2ml0.5mg:1ml500ml100IU0.75g22814119211112614150.250.600.170.240.200.802.604.905.202.431.064.01.920.170.902.603.2038.50.501.21.360.240.800.802.6044.1010.402.431.064.901.924.420.9010.403.20192.50.501.21.360.240.800.802.6044.1010.402.431.064.901.924.420.9010.403.20192

3、.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45﹡65120﹡220肝功能生化ssssAS_E10﹡151:41:9小3111212115121513121613.001.085.400.866.483.2454.0012.967.560.8619.871.9423.760.6521.602.704.1042.120.975.401.709.001.085.400.8612.963.24

4、108.0012.967.564.3019.873.8823.763.2521.608.104.1084.240.9732.401.709.001.085.400.8612.963.24108.0012.967.564.3019.873.8823.763.2521.608.104.1084.240.9732.401.70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AB

5、O血型鉴定（微柱法）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

6、男第1页其2页住院费用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Ⅰ级护理Ⅱ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

7、表检查会阴冲洗小换药宫颈注射新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）7710.0020.007