'清单编号 '${listNo}' 结算期间 '${period}' 患者 '${patientName}
| '清单编号 / LIST NO.' | ${listNo} | '结算期间 / PERIOD' | ${period} |
| '患者姓名 / 病案号' | ${patientName} | '医疗机构 / 科室' | ${hospitalName} |
| '医保类型' | ${insuranceType} | '费用总额' | ${totalFee} |
| '统筹支付' | ${fundPay} | '个人自付' | ${selfPay} |
| '清单页数' | ${pageInfo} | '打印日期 / 打印人' | ${printInfo} |
| ' ' | '药品与耗材明细' |
| '序号' | '药品 / 耗材名称' | '规格 / 剂型' | '数量' | '单价' | '金额' | '医保类别' |
|---|---|---|---|---|---|---|
| ${itemName1} | ${itemSpec1} | ${itemUnit1} | ${itemQty1} | ${itemPrice1} | ${itemAmount1} | ${itemTax1} |
| ${itemName2} | ${itemSpec2} | ${itemUnit2} | ${itemQty2} | ${itemPrice2} | ${itemAmount2} | ${itemTax2} |
| ${itemName3} | ${itemSpec3} | ${itemUnit3} | ${itemQty3} | ${itemPrice3} | ${itemAmount3} | ${itemTax3} |
| ${itemName4} | ${itemSpec4} | ${itemUnit4} | ${itemQty4} | ${itemPrice4} | ${itemAmount4} | ${itemTax4} |
| ${itemName5} | ${itemSpec5} | ${itemUnit5} | ${itemQty5} | ${itemPrice5} | ${itemAmount5} | ${itemTax5} |
| ${itemName6} | ${itemSpec6} | ${itemUnit6} | ${itemQty6} | ${itemPrice6} | ${itemAmount6} | ${itemTax6} |
| ${itemName7} | ${itemSpec7} | ${itemUnit7} | ${itemQty7} | ${itemPrice7} | ${itemAmount7} | ${itemTax7} |
| ${itemName8} | ${itemSpec8} | ${itemUnit8} | ${itemQty8} | ${itemPrice8} | ${itemAmount8} | ${itemTax8} |
| '药品耗材合计' | '—' | '—' | '—' | '—' | '￥'${totalAmount} | '—' |
| '药品耗材金额合计' | ${totalLine} |
| '备注 / REMARKS' | ${remark} |
| '本联次加盖印章后有效，扫码可验真' | '（医疗机构公章 / 财务专用章占位）' '（骑缝章 / 二维码占位）' |
| ' ' | '医疗机构：'${hospitalName} '骑缝章沿右边线骑缝加盖' |
| ' ' | '出具日期：'${period} '二维码打印于右上角方框内' |
| ' ' | '制表人：'${preparer} | '药剂科核对：'${pharmacist} | '医保办审核：'${insuranceOfficer} |