住院费用清单模板

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甘二纳注射液20mg:2ml20.250.500.50开塞露20ml20.601.21.2维生素b6注射液100mg:2ml80.171.361.360.9%氯化钠注射液10ml10.240.240.24地塞米松磷酸钠注射液5mg:1ml40.200.800.80盐酸利多卡因注射液200mg:10ml10.800.800.8010%葡萄糖注射液（可立袋）100ml12.602.602.605%葡萄糖注射液（可立袋）500ml94.9044.1044.10

2、0.9%氯化钠注射液（可立袋）100ml25.2010.4010.40米索前列醇片200ug切片12.432.432.43盐酸麻黄碱注射液30mg:1ml11.061.061.06盐酸吗啡注射液10mg:1ml14.04.904.90盐酸布比卡因注射液37.5mg:5ml11.921.921.92维生素c注射液500mg:2ml260.174.424.42硫酸阿托品注射液0.5mg:1ml10.900.900.90复方氯化钠注射液500ml42.6010.4010.40注射用铺本酶a100iu13.203.203.201注射用头抱他咤0.75g538.5192.5192.5西药合计283.73

3、283.73吸引连接管33.009.009.00一次性备皮刀11.081.081.08产腹带15.405.405.40一次性枕套45 6510.860.860.86一次床单120 22026.4812.9612.96留置针贴膜13.243.243.24爱惜康254.00108.00108.00幕丝线112.9612.9612.96一次性便盆17.567.567.56一次性采血管肝功能生化50.864.304.30留置针119.8719.8719.87一次性氧管ssss21.943.883.88一次性导尿管123.7623.7623.76电极板50.653.253.25一次性麻醉包as_e121

4、.6021.6021.60肝素帽32.708.108.10无菌敷贴10 1514.104.104.10一次性引流瓶242.1284.2484.24抗凝采血管1:4 1:910.970.970.97缓排空型一次性输液器65.4032.4032.401一次性婴儿吸痰器小11.701.701.70材料费合计369.23369.23围产保健访视45.0020.0020.00住院诊查费54.0020.0020.00诊查费合计40.0040.00血常规（五分类）218.003636尿常规检查（尿十一项）19.009.009.00尿常规（手工法）13.003.003.00葡萄糖测定14.004.004.00

5、肝功能常规检查155.0055.0055.00肾功能常规检查118.0018.0018.00乙肝三对检测125.0025.0025.00输血前常规检查180.0080.0080.00abo血型鉴定（微柱法）127.0027.0027.001rh血型鉴定（微柱法）127.0027.0027.00检验费合计284.00284.00输卵管结扎术0.5240.00120.00120.00剖宫产术1800.00800.00800.00肠粘连松解术0.5800.00400.00400.00经腹子宫肌痛剔除术0.5720.00360.00360.00精品资料制表：邓美男第1页其2页住院费用清单精品资料衡南县

6、人民医院单位：元项目规格数量单价金额自负金额镇痛泵体内置入木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9.00119.00新生儿油浴护理55.0025.0025.00i级护理113.0013.0013.00口级护理47.0028.0028.00新生儿护理59.0045.0045.00新生儿抚触护理920.00180.00180.00新生儿呼吸道清理护理15.005.005.00动静脉置管护理35.0015.0015.00护理合计311.00311.00产前检查28.0016.0016.00胎心监测523.00115.00

7、115.00新生儿量表检查118.0018.0018.00会阴冲洗84.0032.0032.00小换药17.007.007.00宫颈注射118.0018.0018.00新生儿经皮胆红素测定59.0045.0045.00心电监测62.0012.0012.00血氧饱和度监测61.006.006.00治疗费合计 269.00 269.00住院床位费婴儿床（母婴同室双人间）710.0070.0075.00普通病房床位费（单人间）720.00140.00125.00床位费合计210.00210.00肌肉注射32.006.006.00皮试13.003.003.00皮下注射22.004.004.00静脉注射

8、53.0015.0015.00静脉输液134.0052.0052.00连续输液第二组起每组加收111.0011.0011.00静脉穿刺置管术120.0020.0020.00注射费合计111.00111.00低流量吸氧32.57.50 7.50输氧合计7.57.5椎管内麻醉1250.00250.00250.00术后镇痛185.0085.0085.00麻醉中监测415.0060.0060.00麻醉合计395.0011395.00常规心电图检查19.009.009.00常规心电图检查（12导联加收）110.0010.0010.00频谱心电图123.0023.0023.00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 100.00 100.00凝血常规检测170.0070.001170.00血凝全套合计70.00 70.00病房空调费（单人间）71070.0