LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

NO: TANGGAL: PELAPORAN BULAN: DESEMBER

NAMA PUSKESMAS: MANGKUNG PENERIMAAN BULAN: JANUARI 2019
KECAMATAN: PRAYA BARAT
KABUPATEN: LOMBOK TENGAH
PROPINSI: NUSA TENGGARA BARAT

PENERIM PERSEDIA PEMAKAI

No. Nama Obat Satuan STOK AWAL
AAN AN AN

Obat PKD dan penunjang -

1 ACT injeksi vial -
2 ACT tablet/ OBAT ANTI MALARIA 24 tablet -
3 Acyclovir 200 mg tablet 100 tablet 200 200
4 Acyclovir krim 5% tube 5 gram -
5 Albendazol tablet 400 mg 30 tablet -
6 Alopurinol tablet 100 mg 100 tablet -
7 Alprazolam 0,5 mg tablet 100 tablet -
8 Ambroxol tablet 100 tablet -
9 Ambroxol sirup 15mg/ml botol 60 ml -
10 Aminofilina injeksi 24 mg / ml-10ml 30 ampul -
11 Aminofilina tablet 200 mg 100 tablet -
12 Amitriptilina tablet 25 mg 100 tablet 100 100
13 Amlodipin 5 mg 30 tablet -
14 Amlodipin 10 mg 30 tablet -
15 Amoksisilina kapsul 500 mg 100 tablet 4,000 5,000 9,000
16 Amoksisilina sirup kering 125 mg/ 5ml botol 60 ml 145 300 445
17 Amoksisilina sirup kering 250 mg/ 5ml botol 60 ml -
18 Ampisilina injeksi 10 vial -
19 Antasida DOEN tablet 100 tablet -
20 Antasida DOEN suspensi btl 60 ml 30 30
21 Antibakteri DOEN salep kombinasi 25 tube@5 gr -
22 Antifungi DOEN kombinasi 24 pot@30 gr -
23 Antihemaroid DOEN kombinasi 10 supp -
24 Aqua Pro injeksi steril bebas pirogen 10 vial @ 20 ml -
25 Aquadest steril 500 ml -
26 Asam Mefenamat tablet 500 mg 100 tablet 1,400 1,400
27 Asam Askorbat (Vit. C) tablet 50 mg 1000 tablet 2,400 2,400
28 Asam Tranexamat 500mg/5 ml injeksi 10 ampul 8 8
29 Asam Tranexamat 500mg 100 tablet -
30 Asering cairan infus botol 500 ml -
31 Asetosal tablet 100 mg 100 tablet -
32 Asetosal tablet 500 mg 100 tablet -
33 Attalpulgite 600mg - New Antides 100 tablet 100 100
34 Atropin Sulfat injeksi 0,25 mg / ml-1 ml 30 ampul 10 10
35 Benzatin Benzil Penisillin 2,4 juta IU 10 vial -
36 Betametason krim 0,1 % 25 tube@5 gr 75 75
37 Calsium Glukonas Injeksi 24 ampul 24 24
38 Captopril tablet 25 mg 100 tablet 100 100
39 Cefadroxil 500 mg 100 kapsul -
40 Cyproploxasin tablet 100 tablet 1,000 1,000
41 Deksametason inj. 5 mg /ml-1 ml 100 ampul -
42 Deksametason tablet 0,5 mg 100 tablet -
43 Diazepam injeksi 5 mg/ ml- 2 ml 30 ampul -
44 Diazepam rectal tube (stesolid rectal) 5 tube 5 5
45 Diazepam tablet 2 mg 100 tablet 100 100
46 Diazepam tablet 5 mg 100 tablet -
47 Difenhidramina injeksi 10 mg/ ml- 1 ml 30 ampul -
48 Digoksin tablet 0,25 mg 100 tablet -
49 Domperidon tablet 10 mg 100 tablet 100 100
50 Doxycyklin tablet 100 mg 100 tablet -
51 Dulcolax 5mg supp 6 supp 12 12
52 Efedrina HCl. tablet 25 mg 250 tablet -
53 Ekstrak Belladona tablet 10 mg 1000 tablet -
54 Epinefrin injeksi 0,1 % - 1 ml 30 ampul 30 30
55 Eritromisin kapsul 500 mg 100 kapsul -
56 Etakridina (Rivanol) larutan 0,1 % btl 300 ml 10 10
57 Etanol 70 % btl 1000 ml 9 9
58 Fenobarbital injeksi 50 mg / ml-2 ml 30 ampul -
59 Fenobarbital injeksi 50 mg / ml-1 ml 31 ampul -
60 Fenobarbital tablet 30 mg 100 tablet -
61 Fenoksimetil Penisilina tablet 250 mg 100 tablet -
62 Fenoksimetil Penisilina tablet 500 mg 100 tablet -
63 Fenolgliserol tetes telinga 10 % 24 btl @ 5 ml -
64 Fitomenadion (Vit. K) injeksi 10 mg / ml-1 ml 30 ampul 90 90
65 Fitomenadion (Vit. K) tablet salut 10 mg 100 tablet -
66 Furosemida tablet 40 mg 100 tablet 160 160
67 Garam Oralit untuk 200 ml air 100 bungkus -
68 Garam oralit new ORS FORMULA 25 saset -
69 Gentamycin injeksi 5 ampul -
70 Gentian Violet larutan 1 % 10 ml -
71 Glibenklamida tablet 5 mg 100 tablet 300 300
72 Glimepiride tablet 1 mg 50 tablet 150 150
73 Gliseril Guayakolat tablet 100 mg 1000 tablet -
74 Glukosa infus 5 % btl 500 ml 100 100
 75 Glukosa infus 10 % btl 500 ml -
76 Glukosa infus 40 % 10 amp @ 25 ml -
77 Griseofulvin tablet 125 mg Mikronized 100 tablet 100 100
78 Haloperidol tablet 1,5 mg 100 tablet 100 500 600
79 Haloperidol tablet 5 mg 100 tablet -
80 Haloperidol injeksi 5mg/ml (LODOMER 5) kotak@12ampul -
81 Hidroklortiazide (HCT) tablet 25 mg 1000 tablet -
82 Hidrokortison krim 2,5 % 24 tube @ 5 gr -
83 Hyoscine N Butilbromide/ Scopma 100 tablet 100 100
84 Ibuprofen tablet 200 mg 100 tablet -
85 Ibuprofen tablet 400 mg 100 tablet 500 500
86 Isoniazid ( INH ) 100mg 1000 tablet -
87 Isosorbid Dinitrat (ISDN) Sub Lingual tablet 5 mg 100 tablet -
88 Kalsium Laktat tablet 500 mg btl 1000 tablet 1,000 1,000
89 Karbamazepin 200 mg 100 tablet 100 100
90 Ketokonazole tablet 200 mg 50 tablet -
91 Kloramfenikol injeksi vial -
92 Kloramfenikol kapsul 250 mg 100 kapsul -
93 Kloramfenikol suspensi 125mg/5 ml botol 60 ml -
94 Kloramfenikol salep mata 1 % tube 5 gram -
95 Kloramfenikol tetes mata 0,5 % botol 60 ml -
96 Kloramfenikol tetes telinga 1 % 24 botol -
97 Kloramfenikol tetes telinga 3 % botol -
98 Klorfeniramin Maleat (CTM) tablet 4 mg 1000 tablet 600 600
99 Klorpromazina injeksi 25 mg / ml-2 ml 30 ampul -
100 Klorpromazina tablet 25 mg 1000 tablet -
101 Klorpromazina tablet 100 mg 250 tablet -
102 Kotrimoksazol dewasa tablet 100 tablet 100 100
103 Kotrimoksazol pediatrik tablet 100 tablet -
104 Kotrimoksazol suspensi btl 60 ml -
105 Kuinin ( Kina ) tablet 200 mg 60 tablet 80 80
106 Lidokain Kompositum injeksi 30 ampul -
107 Lidokain 2% injeksi (tunggal) 100 ampul -
108 Magnesium Sulfat injeksiI (IV) 20 %-25 ml 10 vial -
109 Magnesium Sulfat injeksiI (IV) 40 %-25 ml 10 vial -
110 Metformin HCL 500 mg tablet 100 tablet -
111 Metilergometrin Maleat tablet 0,125 mg 100 tablet 200 200
112 Metilergometrin Maleat injeksi 0,2 mg / ml ktk 30 ampul 10 10
113 Metoclopramide 10 mg 100 tablet 100 100
114 Metocloperamide inj ampul -
115 Metronidazol tablet 250 mg 100 tablet -
116 Metronidazol tablet 500 mg 100 tablet -
117 Miconazol krim tube 10 gram -
118 Misoprotol tab 200 mcg 30 tablet -
119 Multivitamin ibu hamil 100 tablet -
120 Na diklofenak 25mg 50 tablet -
121 Na diklofenak 50mg 50 tablet -
122 Natrium Klorida infus 0,9 % botol 500 ml 45 45
Nebules kombinasi : ipatropium br 0.5 mg+
123
salbutamol 2.5 mg (COMBIVENT) 20 vial 25 25
124 Nebules salbutamol 2,5 mg (VENTOLIN) 20 vial -
125 Nifedipin tablet 100 tablet 300 300
126 Nistatin tablet salut 500.000 IU 100 tablet -
127 Nistatin tablet vaginal 100.000 IU 100 tablet -
128 Obat Batuk Hitam (OBH) cairan botol 100 ml -
129 Obat Anti Tuberkulosis FDC kategori 1/3 paket -
130 Obat Anti Tuberkulosis FDC kategori 2 paket -
131 Obat Anti Tuberkulosis FDC kategori anak paket -
132 Obat Anti Tuberkulosis FDC kategori sisipan paket -
133 Obat Anti Tuberkulosis Kombipak kategori 1 paket -
134 Obat Anti Tuberkulosis Kombipak kategori anak paket -
135 Oksitetrasiklin HCl. injeksi IM 50 mg / ml- 10 ml 10 vial -
136 Oksitetrasiklin salep kulit 3 % 25 tube @ 5 gr -
137 Oksitetrasiklin salep mata 1 % 25 tube @ 3,5 gr -
138 Oksitosin injeksi 10 IU / ml - 1 ml 100 ampul 200 200
139 Omeprazole kapsul 30 kapsul -
140 Papaverin injeksi 100 ampul -
141 Papaverin tablet 1000 tablet -
142 Parasetamol drop 100 mg/ml @ 15 ml botol 15 ml -
143 Parasetamol sirup 120 mg / 5 ml botol 60 ml -
144 Parasetamol tablet 100 mg 100 tablet -
145 Parasetamol tablet 500 mg 100 tablet -
146 Paracetamol suppo 125mg/ Pamol 125 suppo kotak@12 suppo -
147 Paracetamol suppo 250 mg/ Pamol 250 suppo kotak@12 suppo -
148 Perhidrol ( Lar H2O2 ) botol 800 ml -
149 Piridoksina HCl. tablet 10 mg 100 tablet 200 200
150 Piroksikam kapsul 10 mg 120 tablet -
151 Polikresulen 10 ml -
152 Povidon Iodida 10 % , 300 ml botol 300 ml 10 10
153 Povidon Iodida 10 % , 30 ml botol 30 ml 14 10 24
154 Prednison tablet 5 mg 100 tablet 900 900
155 Primakuin tablet 15 mg 1000 tablet -
156 Prokain Penisilin inj 3jt IU 30 vial -
157 Propiltiourasil tablet 100 mg 100 tablet -
158 Propanolol 10 mg 100 tablet -
159 Propranolol tablet 40 mg 100 tablet -
160 Pyrantel Pamoat tablet 125 mg 100 tablet -
161 Ranitidin tablet 150 mg 100 tablet -
162 Ranitidine injeksi 25 ampul 70 70
163 Retinol (Vitamin A) kapsul 100.000 IU 50 kapsul -
164 Retinol (Vitamin A) kapsul 200.000 IU 50 kapsul -
165 Ringer Laktat larutan infus steril botol 500 ml 160 200 360
166 Risperidon 2 mg tablet 50 tablet -
167 Sabu Polivalen 5 ml (ABU I) vial 1 1
168 Salbutamol tablet 2 mg 100 tablet -
169 Salbutamol tablet 4 mg 100 tablet 800 800
170 Salep 2-4 Kombinasi 24 pot @ 30 gr -
171 Salisil Bedak 2 % 50 gr -
172 Scabicid/Scabimid cream (Permetrin 5%) tube @ 50 ml -
173 Serum Anti Tetanus injeksi 1.500 IU / ampul (ATS) ampul 1 ml 1 1
174 Sianokobalamin (Vit. B 12) injeksi 500 mcg / ml 100 ampul -
175 Simvastatin 10mg 30 tablet -
176 Sikzonoate injeksi ampul -
177 Sulfasetamida tetes mata 15 % 24 botol @ 5 ml 5,100 5,100
178 Tablet Tambah Darah kombinasi 100 sase @ 30 tablet 21,600 21,600
179 Tetrasiklina HCl. kapsul 250 mg 1000 tablet -
180 Tetrasiklina HCl. kapsul 500 mg 100 tablet -
181 Thiamfenikol tablet 500 mg 100 tablet -
182 Tiamine HCl. (Vit. B-1) injeksi 100 mg / ml-1 ml 30 ampul -
183 Tiamine HCl. Mononitrat (Vit. B-1) tablet 50 mg 100 tablet -
184 Triheksifenidil HCl. tablet 2 mg 100 tablet 400 400
185 Vitamin B Komplek tablet 100 tablet -
186 Xylamidone injeksi 10 vial -
187 Zinc tablet 20 mg 100 tablet -
Bahan Medis Habis Pakai -
188 Alat Suntik sekali pakai 1 ml 100 set -
189 Alat Suntik sekali pakai 3 ml 100 set -
190 Alat Suntik sekali pakai 5 ml 100 set -
191 Alat Suntik sekali pakai 10 ml 100 set -
192 Alat Suntik sekali pakai 20 ml 50 set -
193 Alkohol Swab box -
194 Catgut / Benang Bedah No. 2/0 24x70 cm -
195 Catgut / Benang Bedah No. 3/0 24x70 cm -
196 Catgut Chromic Caset 3/0-100 m set -
197 Foley cathether No. 16 set -
198 Foley cathether No. 18 set -
199 Foley cathether No. 20 set -
200 Feeding Tube 40cm No. 8 set -
201 Hand Rub 500ml botol -
202 Infusion Set anak-anak set -
203 Infusion Set dewasa set -
204 IV Cathether No. 18 G set -
205 IV Cathether No. 20 G set -
206 IV Cathether No. 22 G set -
207 IV Cathether No. 24 G set -
208 Jarum hecting kombinasi set -
209 Jelly Dopler botol -
210 Kapas Pembalut / Adsorben 500 gram bungkus -
211 Kapas Pembalut / Adsorben 250 gram bungkus -
212 Kasa Pembalut 40 yd x 80 cm rol -
213 Kasa Pembalut 4x10 cm rol -
214 Kasa Pembalut 4x15 cm rol -
215 Kasa hidrofil DRC 35 m x 80 rol -
216 Kertas EKG 58mm X 30 mm rol -
217 Kertas EKG 63mm X 30 mm rol -
218 Masker surgical set -
219 Pembalut gibs rol -
220 Plester 5 yard x 2 inchi rol -
221 Plester Kertas 1" (Surgical tape) rol -
222 Regulator Oksigen SET -
223 Sarung tangan non steril uk.M pasang 200 200
224 Sarung tangan non steril uk L pasang 200 200
225 Sarung tangan steril NO.6,5 pasang -
226 Sarung tangan steril NO.7 pasang -
227 Sarung tangan steril NO.7,5 pasang -
228 Sarung tangan obgin No. 6,5 pasang -
229 Sarung tangan obgin No. 7 pasang -
230 Sarung tangan obgin No. 7,5 pasang -
231 Sarung tangan obgin No. 8 pasang -
232 Silk 3/0 + 1/2 GT 35MM set -
233 Silk 2/0 + 1/2 GT 35MM set -
234 Surgical mess 11 set -
235 Surgical mess 20 set -
236 Umbilical cord klem set -
237 Urine bag pcs -
Bahan Gigi -
238 Air Raksa dental use 100 gram -
239 Arsen Septodont Rapid botol -
240 Bur set high speed kotak -
241 Cavit botol -
242 Cresophene botol -
243 Etil klorida semprot 100 ml -
244 Euginol cairan dus 12 btl -
245 Glass Ionomer cement (GC IX) set -
246 Jarum exterpatie set -
247 Jarum reaming file set -
248 Kalsium Hidroksida pasta 2 tube -
249 Klorfenol Kamper Menthol ( CHKM ) 10 ml -
250 Mummifying pasta botol -
251 Semen Seng Pospat serbuk dan cairan set @ 30 gr -
252 Silver Amalgam 1 oz -
253 Spon Gelatin Cubicles 1 x 1 x 1 cm 24 buah -
254 Temperory Stoping Fletcher serbuk & cair set @ 100 gr -
TAMBAHAN -
255 Camabion 1,000 9,000 10,000
256 Gentamycin Salep mata 10 10
257 Betahistin 100 100
258 iliadin dewasa -
259 Omeprazol injeksi 40 40
260 Setrizin syr 60 300 360
261 Alprazolam 1 mg -
262 glimepiride 2 mg -
Mengetahui/Menyetujui
Kepala UPT Farmasi Yang Menyerahkan

LALU SUDIRMAN
NIP. 196912311990031049 Lalu Mustaid
AN OBAT (LPLPO) DANA DAK

ESEMBER
ANUARI 2019

TERIMA TANGGAL VERIFIKASI TANGGALPENYERAHAN OBAT TANGGAL

PEMBERIAN
SISA PERMINTA STOK
NON KET
STOK AN OPTIMUM BS PROV DAK 15 DAK 16 PROGRAM
KAPITASI
 Yang Menerima Yang Melaporkan
Pengelola Obat Puskesmas, UPT. Puskesmas MANGKUNG

( MUHAMMAD RUM S.Kep.) )

NIP : 197112311991031017