LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS ………………………………..
KODE PUSKESMAS :
PUSKESMAS : ……………………………
KECAMATAN : …………………………….
KAB./KOTA : BARITO SELATAN BULAN : Hal. 1
PROPINSI : KALIMANTAN TENGAH TAHUN : 2 0 1 9 LB2

NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
I OBAT dan BAHAN OBAT
1 ACT (Artesunat tab.50 mg+Amodiaquine tab.200mg) Tablet 0 0 0 0 0 0
2 Acetyl Cysteine Kapsul 200 mg Kapsul 0 0 0 0 0 0
3 Acyclovir tablet 400 mg Tablet 0 0 0 0 0 0
4 Acyclovir salep kulit 5 gram Tube 0 0 0 0 0 0
5 Albendazol tablet 400 mg Tablet 0 0 0 0 0 0
6 Alopurinol tablet 100 mg Tablet 0 0 0 0 0 0
7 Alprazolam tablet 1 mg Tablet 0 0 0 0 0 0
8 Ambroxol tablet 30 mg Tablet 0 0 0 0 0 0
9 Aminofilin injeksi 24 mg/ml - 10 ml Ampul 0 0 0 0 0 0
10 Aminofilin tablet scored 200 mg Tablet 0 0 0 0 0 0
11 Amlodipin tablet 5 mg Tablet 0 0 0 0 0 0
12 Amlodipin tablet 10 mg Tablet 0 0 0 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 0 0 0 0 0 0
14 Amoksisilin kapsul 250 mg Kapsul 0 0 0 0 0 0
15 Amoksisilin kaplet 500 mg Kaplet 0 0 0 0 0 0
16 Antasida DOEN suspensi 400 mg/5 mL Botol 0 0 0 0 0 0
17 Antasida doen tablet 400 mg, kombinasi Tablet 0 0 0 0 0 0
18 Antibakteri doen salep kombinasi Tablet 0 0 0 0 0 0
19 Antihemoroid doen kombinasi Suppo 0 0 0 0 0 0
20 Antifungi doen kombinasi Pot 0 0 0 0 0 0
21 Antimigrain doen tablet kombinasi (Ergotamin+Cafein) Tablet 0 0 0 0 0 0
22 Antiparkinson doen tablet kombinasi Tablet 0 0 0 0 0 0
23 Aqua pro injeksi steril,bebas pirogen Ampul 0 0 0 0 0 0
24 Aquadest steril Botol 0 0 0 0 0 0
25 Artesunate injeksi 60 mg Vial 0 0 0 0 0 0
26 Asam askorbat ( Vit. C) tablet 250 mg Tablet 0 0 0 0 0 0
27 Asam askorbat ( Vit. C) tablet 50 mg Tablet 0 0 0 0 0 0
28 Asam Mefenamat tablet 500 mg Tablet 0 0 0 0 0 0
29 Asam Mefenamat tablet 250 mg Tablet 0 0 0 0 0 0
30 Asam Folat tablet 1 mg Tablet 0 0 0 0 0 0
31 Asetosal tablet 100 mg Tablet 0 0 0 0 0 0
32 Asetosal tablet 80 mg Tablet 0 0 0 0 0 0
33 Atapulgit tab 630 mg (Akita) Tablet 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
34 Atropin sulfat injeksi 0,25 mg/ml - 1 ml Ampul 0 0 0 0 0 0
35 Atropin sulfat tablet 0,5 mg Tablet 0 0 0 0 0 0
36 Atropin sulfat tetes mata 0,5 % Botol 0 0 0 0 0 0
37 Betahistin Mesilat tablet 6 mg Tablet 0 0 0 0 0 0
38 Betametason krim 0,1 % Tube 0 0 0 0 0 0
39 Betason-N cream Tube 0 0 0 0 0 0
40 Bisakodil tablet salut selaput 5 mg Tablet 0 0 0 0 0 0
41 Bisoprolol tablet 5 mg Tablet 0 0 0 0 0 0
42 Calcii Gluconas 10 mg/ml Ampul 0 0 0 0 0 0
43 Captopril tablet 12,5 mg Tablet 0 0 0 0 0 0
44 Captopril tablet 25 mg Tablet 0 0 0 0 0 0
45 Cefadroksil kapsul 500 mg /Dexadrox Kapsul 0 0 0 0 0 0
46 Cefotaxime injeksi 1 gr/vial Vial 0 0 0 0 0 0
47 Ceftriaxon injeksi 1 gr/vial Vial 0 0 0 0 0 0
48 Cimetidin tablet 200 mg Tablet 0 0 0 0 0 0
49 Ciprofloksasin tablet 500 mg / Licoprox Tablet 0 0 0 0 0 0
50 Clozapine tablet 25 mg Tablet 0 0 0 0 0 0
51 Combivent UDV (Komb. Ipra.bromida+salbutamol) Vial 0 0 0 0 0 0
52 Dapson tablet 100 mg Tablet 0 0 0 0 0 0
53 Deksametason inj. 5 mg/ml - 1 ml Ampul 0 0 0 0 0 0
54 Deksametason tablet 0,5 mg Tablet 0 0 0 0 0 0
55 Dekstran 70-larutan infus 6 % steril Botol 0 0 0 0 0 0
56 DHP-Frimal tablet (Anti Malaria) Tablet 0 0 0 0 0 0
57 Diazepam inj. 5 mg/ml - 2 ml Ampul 0 0 0 0 0 0
58 Diazepam tablet 2 mg Tablet 0 0 0 0 0 0
59 Diazepam tablet 5 mg Tablet 0 0 0 0 0 0
60 Dietilkarbamazin sitrat tablet 100 mg Tablet 0 0 0 0 0 0
61 Difenhidramin HCl inj. 10 mg/ml - 1 ml Ampul 0 0 0 0 0 0
62 Digoksin tablet 0,25 mg Tablet 0 0 0 0 0 0
63 Diltiazem tablet 30 mg Tablet 0 0 0 0 0 0
64 Dimenhidrinat Tab 50 mg Tablet 0 0 0 0 0 0
65 Domperidon tablet 10 mg Tablet 0 0 0 0 0 0
66 Domperidon suspensi 5 mg/ml Botol 0 0 0 0 0 0
67 Dulcolax Suppo 5 mg (Bisakodil) Suppo 0 0 0 0 0 0
68 Efedrin HCl tablet 25 mg Tablet 0 0 0 0 0 0
69 Elizac tablet 20 mg (Fluoxetine HCL 20 mg) Kapsul 0 0 0 0 0 0
70 Epinefrin HCl /bitartrat (adrenalin) inj. 0,1 % - 1 ml Ampul 0 0 0 0 0 0
71 Eritromisin kapsul 250 mg Kapsul 0 0 0 0 0 0
72 Etambutol HCl tablet 250 mg Tablet 0 0 0 0 0 0
73 Etil klorida semprot Botol 0 0 0 0 0 0
74 Fenitoin natrium injeksi 50 mg/ml Ampul 0 0 0 0 0 0
75 Fenitoin natrium kapsul 100 mg Kapsul 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
76 Fenitoin natrium kapsul 30 mg Kapsul 0 0 0 0 0 0
77 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul 0 0 0 0 0 0
78 Fenobarbital tablet 100 mg Tablet 0 0 0 0 0 0
79 Fenobarbital tablet 30 mg Tablet 0 0 0 0 0 0
80 Fenofibrat kapsul 100 mg Kapsul 0 0 0 0 0 0
81 Fenol gliserol tetes telinga 10 % Botol 0 0 0 0 0 0
82 Fitomenadion (Vit. K 1) injeksi 10 mg/ml - 1 ml Ampul 0 0 0 0 0 0
83 Fitomenadion (Vit. K 1) tablet salut 10 mg Tablet 0 0 0 0 0 0
84 Furosemid inj.iv/im.10 mg/ml Ampul 0 0 0 0 0 0
85 Furosemid tablet 40 mg Tablet 0 0 0 0 0 0
86 Garam oralit untuk 1000 ml air Sachet 0 0 0 0 0 0
87 Garam oralit untuk 200 ml air Sachet 0 0 0 0 0 0
88 Gentamisin tetes mata 0,3% Botol 0 0 0 0 0 0
89 Gemfibrozil kapsul 300 mg / Hypofil Kapsul 0 0 0 0 0 0
90 Gentian violet larutan 1 % Botol 0 0 0 0 0 0
91 Glibenklamid tablet 5 mg Tablet 0 0 0 0 0 0
92 Gliseril guayakolat tablet 100 mg Tablet 0 0 0 0 0 0
93 Gliserin Botol 0 0 0 0 0 0
94 Glukosa larutan infus 10 % steril Botol 0 0 0 0 0 0
95 Glukosa larutan infus 40 % steril Botol 0 0 0 0 0 0
96 Glukosa larutan infus 5 % steril Botol 0 0 0 0 0 0
97 Griseofulvin tablet 125 mg, micronizet Tablet 0 0 0 0 0 0
98 Haloperidol injeksi 5 mg/ 1 ml-i.m (Iodomer) 0
99 Haloperidol tablet 0,5 mg Tablet 0 0 0 0 0 0
100 Haloperidol tablet 1,5 mg Tablet 0 0 0 0 0 0
101 Hidroklorotiazid (HCT) tablet 25 mg Tablet 0 0 0 0 0 0
102 Hidrokortison krim 2,5 % Tube 0 0 0 0 0 0
103 Ibuprofen tablet 400 mg Tablet 0 0 0 0 0 0
104 Ibuprofen suspensi 100 mg/ 5 ml Botol 0 0 0 0 0 0
105 Isoniazid tablet 300 mg Tablet 0 0 0 0 0 0
106 Isosorbid dinitrat tablet sublingual 5 mg Tablet 0 0 0 0 0 0
107 Kalium permanganat serbuk Botol 0 0 0 0 0 0
108 Kalsium hidroksida pasta Tube 0 0 0 0 0 0
109 Kalsium laktat (kalk) tablet 500 mg Tablet 0 0 0 0 0 0
110 Kandesartan tablet 8 mg Tablet 0 0 0 0 0 0
111 Kandesartan tablet 16 mg Tablet 0 0 0 0 0 0
112 Karbamazepin tablet 200 mg Tablet 0 0 0 0 0 0
113 Karbogliserin Tetes Telinga 10% Botol 0 0 0 0 0 0
114 Ketokonazole tablet 200 mg Tablet 0 0 0 0 0 0
115 Ketokonazole krim 2 % Tube 0 0 0 0 0 0
116 Kloramfenikol kapsul 250 mg Kapsul 0 0 0 0 0 0
117 Kloramfenikol suspensi 125 mg/5 mL Botol 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
118 Kloramfenikol salep kulit 2% (Bufacetine) Tube 0 0 0 0 0 0
119 Kloramfenikol salep mata 1 % Tube 0 0 0 0 0 0
120 Kloramfenikol tetes mata 0,5 % (Erlamycetin) Botol 0 0 0 0 0 0
121 Kloramfenikol tetes telinga 3 % Botol 0 0 0 0 0 0
122 Klorfeniramin maleat (CTM) tablet 4 mg Tablet 0 0 0 0 0 0
123 Klorokuin fosfat tablet 250 mg Tablet 0 0 0 0 0 0
124 Klorpromazin HCl inj. 25 mg/ml- 1 ml Ampul 0 0 0 0 0 0
125 Klorpromazin HCl inj. 5 mg/ml- 2 ml Ampul 0 0 0 0 0 0
126 Klorpromazin HCl tablet salut 100 mg Tablet 0 0 0 0 0 0
127 Klorpromazin HCl tablet salut 25 mg Tablet 0 0 0 0 0 0
128 Kodein HCl tablet 10 mg Tablet 0 0 0 0 0 0
129 Kombinasi pirimetamin 25 mg + sulfadoksin 500 mg Tablet 0 0 0 0 0 0
130 Kotrimoksazol pediatrik tablet Tablet 0 0 0 0 0 0
131 Kotrimoksazol suspensi Botol 0 0 0 0 0 0
132 Kotrimoksazol 480 mg (dewasa) tablet Tablet 0 0 0 0 0 0
133 Kuinin dihidroklorida inj. 25 % - 2 ml Ampul 0 0 0 0 0 0
134 Kuinin tablet salut selaput 200 mg Tablet 0 0 0 0 0 0
135 Lidocain inj. 2% - 2 ml (murni) Ampul 0 0 0 0 0 0
136 Lidokain HCl 2% Compositum inj. (Pehacain) Ampul 0 0 0 0 0 0
137 Lisol Botol 0 0 0 0 0 0
138 Loperamid tablet 2 mg Tablet 0 0 0 0 0 0
139 Loratadin tab 10 mg Tablet 0 0 0 0 0 0
140 Lorazepam tablet 2 mg Tablet 0 0 0 0 0 0
141 Magnesium sulfat injeksi (iv) 20 % - 25 ml Vial 0 0 0 0 0 0
142 Magnesium sulfat injeksi (iv) 40 % - 25 ml Vial 0 0 0 0 0 0
143 Mebendazol sirup tablet 100 mg/5 ml Botol 0 0 0 0 0 0
144 Mebendazol tablet 100 mg Tablet 0 0 0 0 0 0
145 Metanol Botol 0 0 0 0 0 0
146 Metformin Hcl Tab 500 mg Tablet 0 0 0 0 0 0
147 Metilergometrin maleat tablet salut 0,125 mg Tablet 0 0 0 0 0 0
148 Metilergometrin maleat inj. 0,200 mg - 1 ml Ampul 0 0 0 0 0 0
149 Metilprednisolon tablet 4 mg Tablet 0 0 0 0 0 0
150 Metronidazol tablet 500 mg Tablet 0 0 0 0 0 0
151 Metronidazol suspensi 125 mg/ 5 ml Botol 0 0 0 0 0 0
152 Mikonazol krim 2 % Tube 0 0 0 0 0 0
153 Natrium Diklofenak Tab 25 mg Tablet 0 0 0 0 0 0
154 Natrium klorida larutan infus 0,9 % steril Botol 0 0 0 0 0 0
155 Natrium tiosulfat injeksi 25% - 10 ml Ampul 0 0 0 0 0 0
156 Neurodex tablet Tablet 0 0 0 0 0 0
157 Nifedipin tablet 10 mg Tablet 0 0 0 0 0 0
158 Nistatin 100.000 iu/ g tablet vaginal Tablet 0 0 0 0 0 0
159 Nistatin 500.000 iu tablet salut Tablet 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
160 Obat anti tuberkolusis kategori 1 Paket 0 0 0 0 0 0
161 Obat anti tuberkolusis kategori 2 Paket 0 0 0 0 0 0
162 Obat batuk hitam (O.B.H.) cairan 100 ml Botol 0 0 0 0 0 0
163 Obat batuk hitam (O.B.H.) cairan 200 ml Botol 0 0 0 0 0 0
164 Oksitetrasiklin HCl inj. i.m. 50 mg/ml - 10 ml Vial 0 0 0 0 0 0
165 Oksitetrasiklin HCl salep kulit 3 % Tube 0 0 0 0 0 0
166 Oksitetrasiklin HCl salep mata 1 % Tube 0 0 0 0 0 0
167 Oksitosin injeksi 10 iu/ml - 1 ml Ampul 0 0 0 0 0 0
168 Omeprazole kapsul 20 mg Kapsul 0 0 0 0 0 0
169 Parasetamol sirup 120 mg/5 ml Botol 0 0 0 0 0 0
170 Parasetamol tablet 100 mg Tablet 0 0 0 0 0 0
171 Parasetamol tablet 500 mg Tablet 0 0 0 0 0 0
172 Petidin HCl injeksi 50 mg/ml - 2 ml Ampul 0 0 0 0 0 0
173 Pirantel pamoat tablet 125 mg Tablet 0 0 0 0 0 0
174 Piridoksin HCl tablet 10 mg (Vit. B6) Tablet 0 0 0 0 0 0
175 Piroksikam tablet 10 mg Tablet 0 0 0 0 0 0
176 Prazikuantel tablet 600 mg Tablet 0 0 0 0 0 0
177 Prednison tablet 5 mg Tablet 0 0 0 0 0 0
178 Primakuin tablet 15 mg Tablet 0 0 0 0 0 0
179 Propiltiurasil (PTU) tablet 100 mg Tablet 0 0 0 0 0 0
180 Propanolol HCl tablet 40 mg Tablet 0 0 0 0 0 0
181 Rabies immune globulin (human) 150 iu/ml Vial 0 0 0 0 0 0
182 Ranitidin injeksi 25 mg/2 mL Ampul 0 0 0 0 0 0
183 Ranitidin Tab 150 mg Tablet 0 0 0 0 0 0
184 Reserpin tablet 0,10 mg Tablet 0 0 0 0 0 0
185 Reserpin tablet 0,25 mg Tablet 0 0 0 0 0 0
186 Retinol (Vitamin A) kapsul 200.000 iu Kapsul 0 0 0 0 0 0
187 Rifampisin kaplet 600 mg Kaplet 0 0 0 0 0 0
188 Rifampisin kapsul 300 mg Kapsul 0 0 0 0 0 0
189 Rifampisin kapsul 450 mg Kapsul 0 0 0 0 0 0
190 Ringer laktat larutan infus steril Botol 0 0 0 0 0 0
191 Salbutamol tablet 2 mg Tablet 0 0 0 0 0 0
192 Salep 2- 4 kombinasi Pot 0 0 0 0 0 0
193 Salisil bedak 2 % Kotak 0 0 0 0 0 0
194 Sefiksim kapsul 100 mg Kapsul 0 0 0 0 0 0
195 Sefiksim suspensi 100 mg/ 5 ml Botol 0 0 0 0 0 0
196 Serum anti bisa ular polivalen inj 5 ml (ABU I) Vial 0 0 0 0 0 0
197 Serum anti bisa ular polivalen inj 50 ml (ABU II) Vial 0 0 0 0 0 0
198 Serum anti difteri inj. 20.000 iu/ vial (a.d.s.) Vial 0 0 0 0 0 0
199 Serum anti tetanus inj. 1.500 iu/ ampul ( a.t.s.) Ampul 0 0 0 0 0 0
200 Serum anti tetanus inj. 20.000 iu/ ampul ( a.t.s.) Vial 0 0 0 0 0 0
201 Sianokobalamin (Vit. B12) inj. 500 mcg/ml Ampul 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
202 Sianokobalamin (Vit. B12) tablet 50 mcg Tablet 0 0 0 0 0 0
203 Simvastatin tablet 10 mg Tablet 0 0 0 0 0 0
204 Spironolakton tablet 25 ml Tablet 0 0 0 0 0 0
205 Stesolid 5 mg (Diazepam) enema 5 mgh/2,5 ml Suppo 0 0 0 0 0 0
206 Stesolid 5 mg (Diazepam) enema 10 mgh/2,5 ml Suppo 0 0 0 0 0 0
207 Streptomisin sulfat serbuk inj 1000 mg/ vial Vial 0 0 0 0 0 0
208 Streptomisin sulfat serbuk inj 1500 mg/ vial Vial 0 0 0 0 0 0
209 Tablet tambah darah (komb. Ferro Fumarat+as.folat) Tablet 0 0 0 0 0 0
210 Tiamin HCl (Vit. B1) inj. 100 mg/ ml - 1 ml Ampul 0 0 0 0 0 0
211 Tiamin HCl monitrat (Vit. B1) tablet 50 mg Tablet 0 0 0 0 0 0
212 Tramadol kapsul 50 mg Kapsul 0 0 0 0 0 0
213 Triheksifenidil hidroklorida tablet 2 mg Tablet 0 0 0 0 0 0
214 Vaksin rabies vero Set 0 0 0 0 0 0
215 Vitamin B kompleks tablet Tablet 0 0 0 0 0 0
216 Vitamin-mineral kombinasi (Livron B-Plex) Tablet 0 0 0 0 0 0
217 Vitamin syrup anak (Biovitan) Botol 0 0 0 0 0 0
218 Zinc tablet 20 mg Tablet 0 0 0 0 0 0
II ALAT KESEHATAN BAHAN MEDIS HABIS PAKAI
1 Alat suntik sekali pakai 1 ml Pcs 0 0 0 0 0 0
2 Alat suntik sekali pakai 3 ml Pcs 0 0 0 0 0 0
3 Alat suntik sekali pakai 5 ml Pcs 0 0 0 0 0 0
4 Alat suntik sekali pakai 20 ml Pcs 0 0 0 0 0 0
5 Alkohol Swab Pcs 0 0 0 0 0 0
6 Alkohol/Etanol 70 % 100 ml Botol 0 0 0 0 0 0
7 Alkohol/Etanol 70 % 1000 ml Botol 0 0 0 0 0 0
8 Antiseptic Gel 500 cc + Dispenser Botol 0 0 0 0 0 0
9 Aximed Examination Gloves S Pcs 0 0 0 0 0 0
10 Aximed Examination Gloves M Pcs 0 0 0 0 0 0
11 Aximed Examination Gloves L Pcs 0 0 0 0 0 0
12 Cat gut/benang bedah No. 2/0-3/0 (plain & Cromic) Set 0 0 0 0 0 0
13 Dermafix T 5 x 7 cm Pcs 0 0 0 0 0 0
14 Etakridin (rivanol) larutan 0,1 % Botol 0 0 0 0 0 0
15 Feeding Tube FR 6 Pcs 0 0 0 0 0 0
16 Feeding Tube FR 8 Pcs 0 0 0 0 0 0
17 Folley Catheter 2 Way FR - 8 Set 0 0 0 0 0 0
18 Folley Catheter 2 Way FR - 12 Set 0 0 0 0 0 0
19 Folley Catheter 2 Way FR - 16 Set 0 0 0 0 0 0
20 Folley Catheter 2 Way FR - 18 Set 0 0 0 0 0 0
21 Handscoon No. 7,5 Pasang 0 0 0 0 0 0
22 Infusion set anak Set 0 0 0 0 0 0
23 Infusion set dewasa Set 0 0 0 0 0 0
24 Intravenous Catheter No. 18 Set 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
25 Intravenous Catheter No. 20 Set 0 0 0 0 0 0
26 Intravenous Catheter No. 22 Set 0 0 0 0 0 0
27 Intravenous Catheter No. 24 Set 0 0 0 0 0 0
28 Intravenous Catheter No. 26 Set 0 0 0 0 0 0
29 Jarum jahit (bedah) no.9 s/d 14 Biji 0 0 0 0 0 0
30 Kapas Berlemak 500 gram Roll 0 0 0 0 0 0
31 Kapas Pembalut/Absorben 50 gram Roll 0 0 0 0 0 0
32 Kapas Pembalut/Absorben 250 gram Roll 0 0 0 0 0 0
33 Kapas Pembalut/Absorben 500 gram Roll 0 0 0 0 0 0
34 Kasa Kompres 16/16 steril Ktk 0 0 0 0 0 0
35 Kasa Kompres 40/40 steril Roll 0 0 0 0 0 0
36 Kasa Pembalut Hidrofil 2 m x 80 cm Roll 0 0 0 0 0 0
37 Kasa Pembalut Hidrofil 4 m x 3 cm Roll 0 0 0 0 0 0
38 Kasa Pembalut Hidrofil 4 m x 15 cm Roll 0 0 0 0 0 0
39 Kasa Pembalut Hidrofil 4 m x 5 cm Roll 0 0 0 0 0 0
40 Kasa Steril 40 x 80 Roll 0 0 0 0 0 0
41 Lancet Set 0 0 0 0 0 0
42 Lisol (Kresol tersabun 50%) 1000 ml Botol 0 0 0 0 0 0
43 Masker Lembar 0 0 0 0 0 0
44 Masker N 95 Lembar 0 0 0 0 0 0
45 Nelaton Catheter CH 14 Pcs 0 0 0 0 0 0
46 Object Glass Pcs 0 0 0 0 0 0
47 Object Glass Cover Pak 0 0 0 0 0 0
48 Papsmear Kit S Set 0 0 0 0 0 0
49 Papsmear Kit M Set 0 0 0 0 0 0
50 Papsmear Kit L Set 0 0 0 0 0 0
51 Pembalut Gips Roll 0 0 0 0 0 0
52 Plester 5 yards x 2 inch Roll 0 0 0 0 0 0
53 Plester 2,5 cm x 4,5 m Roll 0 0 0 0 0 0
54 Plester Non Woven 5 cm x 5 m Roll 0 0 0 0 0 0
55 Polifix 5 cm x 5 m Roll 0 0 0 0 0 0
56 Povidon larutan 10 % 30 ml Botol 0 0 0 0 0 0
57 Povidon larutan 10 % 300 ml Botol 0 0 0 0 0 0
58 Povidon larutan 10 % 1000 ml Botol 0 0 0 0 0 0
59 Pregnancy Test (tes kehamilan) Set 0 0 0 0 0 0
60 Sabun Anti Bakteri 500 ml + dispenser Botol 0 0 0 0 0 0
61 Silk (Benang Bedah Sutra No. 3/0) Set 0 0 0 0 0 0
62 Spiritus 1000 ml Botol 0 0 0 0 0 0
63 Sputum Pot Dahak Pot 0 0 0 0 0 0
64 Sterile Surgical Blades No. 11 Pcs 0 0 0 0 0 0
65 Sterile Surgical Blades No. 15 Pcs 0 0 0 0 0 0
66 Sterile Surgical Blades No. 20 Pcs 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
67 Stomach Tube FR 14 Pcs 0 0 0 0 0 0
68 Suction Catether FR 10 Pcs 0 0 0 0 0 0
69 Suction Catether FR 14 Pcs 0 0 0 0 0 0
70 Suction Catether FR 6 Pcs 0 0 0 0 0 0
71 Suction Conneting Tube (SCT) 3 M Pcs 0 0 0 0 0 0
72 Sofratulle Pcs 0 0 0 0 0 0
73 Tangkai Penjepit Surgical Blades Pcs 0 0 0 0 0 0
74 Urine Bag (Onemed) Set 0 0 0 0 0 0
III BAHAN GIGI
1 Alveogyl Kotak 0 0 0 0 0 0
2 Anastesi Gel Kotak 0 0 0 0 0 0
3 Bahan pembersih plak dan karang gigi Set 0 0 0 0 0 0
4 Caviton Set 0 0 0 0 0 0
5 CHKM (Chlorphenol Kamfer Menthol) Set 0 0 0 0 0 0
6 Composite set (Bahan, Bonding + Etching) Set 0 0 0 0 0 0
7 Devitalisasi pasta (non arsen) Botol 0 0 0 0 0 0
8 Eugenol cairan Botol 0 0 0 0 0 0
9 Gameksan emulsi 1 % Botol 0 0 0 0 0 0
10 Glass Ionomer Cement (GIC IX) Set 0 0 0 0 0 0
11 Hidrogen Peroksida (H2O2) cairan 3% Botol 0 0 0 0 0 0
12 Kalsium Hidroksit Set 0 0 0 0 0 0
13 Mummifying pasta Botol 0 0 0 0 0 0
14 Semen seng fosfat serbuk dan cairan Set 0 0 0 0 0 0
15 Silver amalgam serbuk 65 - 75 % Botol 0 0 0 0 0 0
16 Spongostan Kotak 0 0 0 0 0 0
17 Spons gelatin cubicles 1 x 1 x 1 cm Set 0 0 0 0 0 0
18 Temporary stopping Flecher serbuk dan cairan Set 0 0 0 0 0 0
19 Tricresilformalin 10 ml (TKF) Set 0 0 0 0 0 0
IV REAGENSIA
1 Larutan Amonium Oxalat 1% Btl/100 ml 0 0 0 0 0 0
2 Larutan Turk Btl/100 ml 0 0 0 0 0 0
3 Reagen Glukosa 4x100 ml 0 0 0 0 0 0
4 Reagen Drabkins / Hemoglobin 10x500 ml 0 0 0 0 0 0
5 Reagen Kolestrol 4x100 ml 0 0 0 0 0 0
6 Reagen Trigliserida 4x100 ml 0 0 0 0 0 0
7 Reagen Gol. Darah : A Kit/10 ml 0 0 0 0 0 0
8 Reagen Gol. Darah : anti D (Rhesus) Kit/10 ml 0 0 0 0 0 0
9 Reagen Gol. Darah : B Kit/10 ml 0 0 0 0 0 0
10 Reagen Malbin Btl/100 ml 0 0 0 0 0 0
11 Reagen untuk tes asam urat 4x100 ml 0 0 0 0 0 0
12 Reagen Rees Ecker 1x500 ml 0 0 0 0 0 0
13 Reagen Pewarna MDT 3x100 ml 0 0 0 0 0 0
14 Reagen Benedict 1x500 ml 0 0 0 0 0 0
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18
15 Reagen EDTA 10% 1x500 ml 0 0 0 0 0 0
16 Reagen HCL 0,1 N 100 ml Btl/100 ml 0 0 0 0 0 0
17 Reagen Pewarna Giemsa 1x100 ml 0 0 0 0 0 0
18 Reagen Zielh Neelsen Botol 0 0 0 0 0 0
V BAHAN LABORATORIUM
1 Strip Asam Urat (Nesco) Tube/25 pcs 0 0 0 0 0 0
2 Strip Glukosa (Nesco) Tube/25 pcs 0 0 0 0 0 0
3 Strip Cholesterol (Nesco) Tube/10 pcs 0 0 0 0 0 0
4 Strip Asam Urat (Easy Touch) Tube/25 pcs 0 0 0 0 0 0
5 Strip Glukosa (Easy Touch) Tube/25 pcs 0 0 0 0 0 0
6 Strip Cholesterol (Easy Touch) Tube/10 pcs 0 0 0 0 0 0
7 Strip Asam Urat (Dr Family) Tube/25 pcs 0 0 0 0 0 0
8 Strip Glukosa (Gluco Dr) Tube/50 pcs 0 0 0 0 0 0
9 Strip Cholesterol (Dr Family) Tube/10 pcs 0 0 0 0 0 0
10 Strip Urine 3 parameter (Verify) Tube/100 strip 0 0 0 0 0 0
11 Stik DHF (Ig-G dan Ig-M) / Diagnostic Box/20 pcs 0 0 0 0 0 0
12 Strip Urine 10 Parameter (Verify) Tube/100 pcs 0 0 0 0 0 0
13 Deck Glass 18x18 cm (Supperior) Kotak/100 pcs 0 0 0 0 0 0
14 Strip HBsAg (Answer) Box/50 pcs 0 0 0 0 0 0
15 Widal Test AO-BO-O-H (Fortress) Set 0 0 0 0 0 0
16 Stik RDT Malaria Box/ 40 pcs 0 0 0 0 0 0
V OBAT PROGRAM
1 Obat Anti Tuberculosis/FDC KAT I PAKET 0 0 0 0 0 0
2 Obat Anti Tuberculosis/FDC KAT II PAKET 0 0 0 0 0 0
3 Obat Anti Tuberculosis/FDC KAT. ANAK PAKET 0 0 0 0 0 0
4 Obat Anti Tuberculosis/FDC KAT. SISIPAN PAKET 0 0 0 0 0 0

UMUM ASKES/PHB ASKESKIN/ LAIN-LAIN*) KET.

BAYAR TIDAK BAYAR JAMKESMAS LANSIA
SKTM GRATIS
L P L P L P L P L P L P

JUMLAH KUNJUNGAN RESEP 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 0 0 0 0 0 0

*) = pengeluaran obat atau alkes BHP Puskesmas di luar kegiatan pelayanan kesehatan dasar yang utama (misalnya kegiatan UKS, pengobatan massal, dll).

(misalnya kegiatan UKS, pengobatan massal, dll) dan dicantumkan nama kegiatan tersebut.
L = Laki - Laki

P = Perempuan
NO. NAMA OBAT/ALKES BHP SATUAN SISA/STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBERIAN JUMLAH KET.
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN APBN ASKES APBD I APBD II BUFFER LAIN-LAIN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11 12 13 14 15 16 17=11+12+13+14+15+16 18

Mengetahui / Menyetujui, Yang Menyerahkan, Yang Menerima /Melapor Yang Menerima,

Kepala Dinkes Kab./Kota Kepala GFK/ Kasi. Kefarmasian Kepala Puskesmas Petugas Puskesmas

( ………………………………………………….. ) (…………………………………………………………) (…………………………..………………………) (……………………………………)

NIP. NIP. NIP. NIP.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSTU / POSKESDES …………………..

BULAN :
TAHUN : 2 0 1 6

STOK PENERI- PERSE- PEMA- SISA/STOK EXPIRED

NO. NAMA OBAT/ALKES BHP SATUAN PEMBERIAN KET
AWAL MAAN DIAAN KAIAN AKHIR DATE

1 2 3 4 5 6=4+5 7 8=6-7 9 10 11
I Obat dan Bahan Obat
1 ACT (Artesunat tab.50 mg+Amodiaquine tab.200mg) Tablet 0 0 0 0 0
2 Acyclovir tablet 400 mg Tablet
3 Alopurinol tablet 100 mg Tablet
4 Ambroxol tablet 30 mg Tablet
5 Aminofilin injeksi 24 mg/ml - 10 ml Ampul
6 Aminofilin tablet scored 200 mg Tablet
7 Amlodipin tablet 10 mg Tablet
8 Amoksisilin sirup kering 125 mg/5 ml Botol
9 Amoksisilin kaplet 500 mg Kaplet
10 Antalgin injeksi 250 mg/ml - 2 ml Ampul
11 Antasida DOEN suspensi 400 mg/5 mL Botol
12 Antasida doen tablet, kombinasi Tablet
13 Antihemoroid doen kombinasi Suppo
14 Antimigrain doen kombinasi Tablet
15 Aqua pro injeksi steril,bebas pirogen Ampul
16 Asam askorbat ( Vit. C) tablet 50 mg Tablet
17 Asam Mefenamat tablet 500 mg Tablet
18 Asam Mefenamat tablet 250 mg Tablet
19 Asam Folat Tablet
20 Asetosal tablet 100 mg Tablet
21 Atapulgit tab 630 mg Tablet
22 Betahistin Mesilat tablet 6 mg Tablet
23 Betametason krim 0,1 % Tube
24 Betason-N cream Tube
25 Captopril tablet 12,5 mg Tablet
26 Captopril tablet 25 mg Tablet
27 Cefadroksil kapsul 500 mg /Dexadrox Kapsul
28 Cimetidin tablet 200 mg Tablet
29 Ciprofloksasin tablet 500 mg / Licoprox Tablet
30 Deksametason inj. 5 mg/ml - 1 ml Ampul
31 Deksametason tablet 0,5 mg Tablet
32 Diazepam inj. 5 mg/ml - 2 ml Ampul
33 Diazepam tablet 2 mg Tablet
34 Difenhidramin HCl inj. 10 mg/ml - 1 ml Ampul
35 Digoksin tablet 0,25 mg Tablet
36 Dimenhidrinat Tab 50 mg Tablet
37 Domperidon tablet 10 mg Tablet
38 Epinefrin HCl /bitartrat (adrenalin) inj. 0,1 % - 1 ml Ampul
39 Etakridin (rivanol) larutan 0,1 % Botol
40 Etanol 70 % Botol
41 Etil klorida semprot Botol
42 Fenobarbital tablet 30 mg Tablet
43 Fenol gliserol tetes telinga 10 % Botol
44 Fitomenadion (Vit. K 1) injeksi 10 mg/ml - 1 ml Ampul
45 Fitomenadion (Vit. K 1) tablet salut 10 mg Tablet
46 Furosemid inj.iv/im.10 mg/ml Ampul
47 Furosemid tablet 40 mg Tablet
48 Garam oralit untuk 200 ml air Sachet
49 Gemfibrozil kapsul 300 mg / Hypofil Kapsul
50 Glibenklamid tablet 5 mg Tablet
51 Gliseril guayakolat tablet 100 mg Tablet
52 Glukosa larutan infus 10 % steril Botol
53 Glukosa larutan infus 5 % steril Botol
54 Griseofulvin tablet 125 mg, micronizet Tablet
55 Haloperidol tablet 1,5 mg Tablet
56 Hidroklorotiazid (HCT) tablet 25 mg Tablet
57 Hidrokortison krim 2,5 % Tube
58 Ibuprofen tablet 400 mg Tablet
59 Isosorbid dinitrat tablet sublingual 5 mg Tablet
60 Kalsium laktat (kalk) tablet 500 mg Tablet
61 Karbogliserin Tetes Telinga 10% Botol
62 Ketokonazole tablet 200 mg Tablet
 STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBE-
NO. NAMA OBAT/ALKES BHP SATUAN
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN RIAN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11
63 Ketokonazole krim 2 % Tube
64 Kloramfenikol kapsul 250 mg / Novachlor Kapsul
65 Kloramfenikol suspensi 125 mg/5 mL Botol
66 Kloramfenikol salep mata 1 % Tube
67 Kloramfenikol tetes mata 0,5 % / Reco Botol
68 Klorfeniramin maleat (CTM) tablet 4 mg Tablet
69 Klorpromazin HCl tablet salut 25 mg Tablet
70 Kodein HCl tablet 10 mg Tablet
71 Kotrimoksazol suspensi Botol
72 Kotrimoksazol 480 mg (dewasa) tablet Tablet
73 Lidocain inj. 2% - 2 ml (murni) Ampul
74 Lidokain HCl 2% Comp. inj. / Pehacain Ampul
75 Lisol Botol
76 Loperamid tablet 2 mg Tablet
77 Loratadin tab 10 mg Tablet
78 Metformin Hcl Tab 500 mg Tablet
79 Metilergometrin maleat tablet salut 0,125 mg Tablet
80 Metilergometrin maleat inj. 0,200 mg - 1 ml Ampul
81 Metronidazol tablet 500 mg Tablet
82 Mikonazol krim 2 % Tube
83 Natrium Diklofenak Tab 25 mg Tablet
84 Natrium klorida larutan infus 0,9 % steril Botol
85 Nistatin 500.000 iu tablet salut Tablet
86 Obat batuk hitam (O.B.H.) cairan 100 ml Botol
87 Oksitetrasiklin HCl salep kulit 3 % Tube
88 Oksitosin injeksi 10 iu/ml - 1 ml Ampul
89 Omeprazole kapsul 20 mg Kapsul
90 Papaverin tablet 40 mg Tablet
91 Parasetamol sirup 120 mg/5 ml Botol
92 Parasetamol tablet 500 mg Tablet
93 Pirantel pamoat tablet 125 mg Tablet
94 Piridoksin HCl tablet 10 mg Tablet
95 Piroksikam tablet 10 mg Tablet
96 Prednison tablet 5 mg Tablet
97 Primakuin tablet 15 mg Tablet
98 Propiltiurasil tablet 100 mg Tablet
99 Propanolol HCl tablet 40 mg Tablet
100 Ranitidin Tab 150 mg Tablet
101 Ringer laktat larutan infus steril Botol
102 Salbutamol tablet 2 mg Tablet
103 Salisil bedak 2 % Kotak
104 Sianokobalamin (Vit. B12) inj. 500 mcg/ml Ampul
105 Sianokobalamin (Vit. B12) tablet 50 mcg Tablet
106 Simvastatin tablet 10 mg Tablet
107 Syrup Vitamin Anak / Livitan Botol
108 Tablet tambah darah kombinasi Tablet
109 Tiamin HCl monitrat (Vit. B1) tablet 50 mg Tablet
110 Triheksifenidil hidroklorida tablet 2 mg Tablet
111 Vitamin B kompleks tablet Tablet
112 Vitamin-mineral kombinasi / Livron B-Plex Tablet
113 Yodium Povidon larutan 10 % 30 ml Botol
114 Yodium Povidon larutan 10 % 300 ml Botol
115 Zinc tablet 20 mg Tablet
II Alat Kesehatan Habis Pakai
SATUAN STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBE-
NO. NAMA OBAT/ALKES BHP
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN RIAN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11
1 Alat suntik sekali pakai 1 ml Set
2 Alat suntik sekali pakai 3 ml Set
3 Alat suntik sekali pakai 5 ml Set
4 Alkohol Swab Pcs
5 Aximed Examination Gloves S Pcs
6 Aximed Examination Gloves M Pcs
7 Aximed Examination Gloves L Pcs
8 Cat gut/benang bedah No. 2/0-3/0 (plain & Cromic) Set
9 Folley Catheter 2 Way FR - 8 Set
10 Handscoon No. 7,5 Pasang
11 Infusion set anak Set
12 Infusion set dewasa Set
13 Intravenous Catheter No. 18 Set
14 Intravenous Catheter No. 20 Set
15 Intravenous Catheter No. 22 Set
16 Intravenous Catheter No. 24 Set
17 Intravenous Catheter No. 26 Set
18 Kapas Pembalut/Absorben 50 gram Rol
19 Kapas Pembalut/Absorben 500 gram Rol
20 Kasa Kompres 16/16 steril Ktk
 STOK PENERI- PERSE- PEMA- SISA/STOK STOK PERMIN- PEMBE-
NO. NAMA OBAT/ALKES BHP SATUAN
AWAL MAAN DIAAN KAIAN AKHIR OPTIMUM TAAN RIAN
1 2 3 4 5 6=4+5 7 8=6-7 9 10 11
21 Kasa Kompres 40/40 steril Rol
22 Kasa Pembalut Hidrofil 2 m x 80 cm Rol
23 Kasa Pembalut Hidrofil 4 m x 5 cm Rol
24 Kasa Steril 40 x 80 Rol
25 Lancet Set
26 Masker Lembar
27 Pembalut Gips Rol
28 Plester 5 yards x 2 inch Rol
29 Pregnancy Test (tes kehamilan) Set
30 Silk (Benang Bedah Sutra No. 3/0) Set
31 Sofratulle Pcs
32 Tangkai Penjepit Surgical Blades Pcs
33 Urine Bag (Onemed) Set

UMUM ASKES/PHB ASKESKIN/ LAIN-LAIN*)

BAYAR TIDAK BAYAR JAMKESMAS
SKTM GRATIS
L P L P L P L P L P L P

JUMLAH KUNJUNGAN RESEP

TOTAL

*) = pengeluaran obat atau alkes BHP Puskesmas di luar kegiatan pelayanan kesehatan dasar yang utama (misalnya kegiatan UKS, pengobatan massal, dll).
(misalnya kegiatan UKS, pengobatan massal, dll) dan dicantumkan nama kegiatan tersebut.
L = Laki - Laki
P = Perempuan

Mengetahui / Menyetujui, Yang Menyerahkan, Yang Menerima,

Kepala Puskesmas Pendang Pengelola Obat Puskesmas Pendang Petugas Pustu/Poskesdes ………………..

ANDUNG, A. Md. Kep RENI SULASTRI, A.Md. Farm (…………………………..)

NIP. 19660517 198802 1 005 NIP. NIP.
KET.
 LAPORAN PEMAKAIAN OBAT
PR O G RAM
Puskesmas :
Kecamatan :
Kab./Kota : Barito Selatan
Propinsi : Kalimantan Tengah

NO. NAMA OBAT SATUAN STOK AWAL PENERIMAAN PEMAKAIAN SISA STOK E.D KET
1 Artesunat Anak Tablet Blister/ 6 Tab 0 0 0 0
2 Artesunat Remaja Tablet Blister/ 12 Tab 0 0 0 0
3 Artesunat Dewasa Tablet Blister/ 24 Tab 0 0 0 0
4 Artesunat Injeksi Kotak/ 8 vial 0 0 0 0
5 Arterakine Tablet Kotak / 8 Tab 0 0 0 0
6 Arsuamoon Tablet Kotak / 3 Blister ( 24 Tab) 0 0 0 0
7 Kuinin Injeksi Ampul 0 0 0 0
8 Primaquin Tablet Tablet 0 0 0 0
9 Garam Oralit 200 Saccet 0 0 0 0
10 Zinc Tablet Tablet 0 0 0 0
11 Antacida Doen Tablet Tablet 0 0 0 0
12 Amoxycillin Syrup Botol 60 ml 0 0 0 0
13 CTM Tablet Tablet 0 0 0 0
14 Doksisilin Tablet Tablet 0 0 0 0
15 Kotrimoksazol Syrup Botol 60 ml 0 0 0 0
16 Kotrimoksazol 480 mg Tablet Tablet 0 0 0 0
17 Paracetamol 500 mg Tablet Tablet 0 0 0 0
18 Pyridoxin Tablet Tablet 0 0 0 0
19 Albendazole 400 mg Tablet Tablet 0 0 0 0
20 Dietylkarbamezepin 100 mg tablet Tablet 0 0 0 0
21 Pyrantel Tablet Tablet 0 0 0 0
22 Oseltamivir 75 mg tablet Tablet 0 0 0 0
23 OAT FDC Kat 1 & 3 Paket 0 0 0 0
24 OAT Kat II Paket 0 0 0 0
25 OAT Katagori Anak Paket 0 0 0 0
26
27
 LAPORAN PEMAKAIAN OBAT JANUARI 2016

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JANUARI 2016 JANUARI 2016 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
I Obat dan Bahan Obat
1 Acyclovir tablet 400 mg Tablet
2 Acyclovir salep Tube
3 Albendazol tablet 400 mg Tablet
4 Alopurinol tablet 100 mg Tablet
5 Aminofilin injeksi 24 mg/ml - 10 ml Ampul
6 Aminofilin tablet scored 200 mg Tablet
7 Amlodipin tablet 10 mg Tablet
8 Amoksisilin sirup kering 125 mg/5 ml Botol
9 Amoksisilin kapsul 250 mg Kapsul
10 Amoksisilin kaplet 500 mg Kaplet
11 Ampisilin kaplet 500 mg Kaplet
12 Ampisilin sirup kering 125 mg/5 ml Botol
13 Antalgin (metampiron) tablet 500 mg Tablet
14 Antalgin injeksi 250 mg/ml - 2 ml Ampul
15 Antalgin-Pyramidon-Lidocain kombinasi inj. (Xylomidon) Vial
16 Antasida DOEN suspensi 400 mg/5 mL Botol
17 Antasida doen tablet, kombinasi Tablet
18 Antibakteri doen salep kombinasi Tablet
19 Antihemoroid doen kombinasi Suppo
20 Antifungi doen kombinasi Pot
21 Antimigrain doen kombinasi Tablet
22 Antiparkinson doen tablet kombinasi Tablet
23 Aqua pro injeksi steril,bebas pirogen Ampul
24 Aquadest steril Botol
25 Asam askorbat ( Vit. C) tablet 250 mg Tablet
 STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK
NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
26 Asam askorbat ( Vit. C) tablet 50 mg Tablet
27 Asam Mefenamat tablet 500 mg Tablet
28 Asam Folat Tablet
29 Asetosal tablet 100 mg Tablet
30 Asetosal tablet 500 mg Tablet
31 Atapulgit tab 600 mg Tablet
32 Atropin sulfat injeksi 0,25 mg/ml - 1 ml Ampul
33 Atropin sulfat tablet 0,5 mg Tablet
34 Atropin sulfat tetes mata 0,5 % Botol
35 Betahistin Mesilat tablet 6 mg Tablet
36 Betametason krim 0,1 % Tube
37 Captopril tablet 12,5 mg Tablet
38 Captopril tablet 25 mg Tablet
39 Cefadroksil kapsul 500 mg Kapsul
40 Cefotaxime injeksi 1 g/vial Vial
41 Cimetidin tablet 200 mg Tablet
42 Ciprofloksasin tablet 500 mg Tablet
43 Dapson tablet 100 mg Tablet
44 Deksametason inj. 5 mg/ml - 1 ml Ampul
45 Deksametason tablet 0,5 mg Tablet
46 Dekstran 70-larutan infus 6 % steril Botol
47 Diazepam inj. 5 mg/ml - 2 ml Ampul
48 Diazepam tablet 2 mg Tablet
49 Diazepam tablet 5 mg Tablet
50 Dietilkarbamazin sitrat tablet 100 mg Tablet
51 Difenhidramin HCl inj. 10 mg/ml - 1 ml Ampul
52 Digoksin tablet 0,25 mg Tablet
53 Diltiazem tablet 30 mg Tablet
54 Dimenhidrinat Tab 50 mg Tablet
 STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK
NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
55 Domperidon tablet 10 mg Tablet
56 Efedrin HCl tablet 25 mg Tablet
57 Epinefrin HCl /bitartrat (adrenalin) inj. 0,1 % - 1 ml Ampul
58 Etakridin (rivanol) larutan 0,1 % Botol
59 Etambutol HCl tablet 250 mg Tablet
60 Etanol 70 % Botol
61 Etil klorida semprot Botol
62 FDC Kategori I Paket
63 FDC Kategori Anak Paket
64 Fenitoin natrium injeksi 50 mg/ml Ampul
65 Fenitoin natrium kapsul 100 mg Kapsul
66 Fenitoin natrium kapsul 30 mg Kapsul
67 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul
68 Fenobarbital tablet 100 mg Tablet
69 Fenobarbital tablet 30 mg Tablet
70 Fenol gliserol tetes telinga 10 % Botol
71 Fitomenadion (Vit. K 1) injeksi 10 mg/ml - 1 ml Ampul
72 Fitomenadion (Vit. K 1) tablet salut 10 mg Tablet
73 Fluor tablet 0,5 mg Tablet
74 Furosemid inj.iv/im.10 mg/ml Ampul
75 Furosemid tablet 40 mg Tablet
76 Garam oralit untuk 1000 ml air Sachet
77 Garam oralit untuk 200 ml air Sachet
78 Gemfibrozil kapsul 300 mg Kapsul
79 Gentian violet larutan 1 % Botol
80 Glibenklamid tablet 5 mg Tablet
81 Gliseril guayakolat tablet 100 mg Tablet
82 Gliserin Botol
83 Glukosa larutan infus 10 % steril Botol

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
84 Glukosa larutan infus 40 % steril Botol
85 Glukosa larutan infus 5 % steril Botol
86 Griseofulvin tablet 125 mg, micronizet Tablet
87 Haloperidol tablet 0,5 mg Tablet
88 Haloperidol tablet 1,5 mg Tablet
89 Hidroklorotiazid (HCT) tablet 25 mg Tablet
90 Hidrokortison krim 2,5 % Tube
91 Ibuprofen tablet 400 mg Tablet
92 Isoniazid tablet 300 mg Tablet
93 Isosorbid dinitrat tablet sublingual 5 mg Tablet
94 Kalium permanganat serbuk Botol
95 Kalsium hidroksida pasta Tube
96 Kalsium laktat (kalk) tablet 500 mg Tablet
97 Karbamazepin tablet 200 mg Tablet
98 Karbogliserin Tetes Telinga 10% Botol
99 Ketokonazole tablet 200 mg Tablet
100 Ketokonazole krim 2 % Tube
101 Kloramfenikol kapsul 250 mg Kapsul
102 Kloramfenikol suspensi 125 mg/5 mL Botol
103 Kloramfenikol salep mata 1 % Tube
104 Kloramfenikol tetes mata 0,5 % Botol
105 Kloramfenikol tetes telinga 3 % Botol
106 Klorfeniramin maleat (CTM) tablet 4 mg Tablet
107 Klorokuin fosfat tablet 250 mg Tablet
108 Klorpromazin HCl inj. 25 mg/ml- 1 ml Ampul
109 Klorpromazin HCl inj. 5 mg/ml- 2 ml Ampul
110 Klorpromazin HCl tablet salut 100 mg Tablet
111 Klorpromazin HCl tablet salut 25 mg Tablet
112 Kodein HCl tablet 10 mg Tablet

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
113 Kombinasi pirimetamin 25 mg + sulfadoksin 500 mg Tablet
114 Kotrimoksazol pediatrik tablet Tablet
115 Kotrimoksazol suspensi Botol
116 Kotrimoksazol dewasa tablet Tablet
117 Kuinin dihidroklorida inj. 25 % - 2 ml Ampul
118 Kuinin sulfat tablet 222 mg (7H2O) Tablet
119 Lidocain inj. 2% - 2 ml (murni) Ampul
120 Lidokain HCl 2% + Epinefrin (Compositum/kombinasi) inj. Ampul
121 Lisol Botol
122 Loperamid tablet 2 mg Tablet
123 Loratadin tab 10 mg Tablet
124 Magnesium sulfat injeksi (iv) 20 % - 25 ml Vial
125 Magnesium sulfat injeksi (iv) 40 % - 25 ml Vial
126 Mebendazol sirup tablet 100 mg/5 ml Botol
127 Mebendazol tablet 100 mg Tablet
128 Metanol Botol
129 Metformin Hcl Tab 25 mg Tablet
130 Metilergometrin maleat tablet salut 0,125 mg Tablet
131 Metilergometrin maleat inj. 0,200 mg - 1 ml Ampul
132 Metronidazol tablet 500 mg Tablet
133 Mikonazol krim 2 % Tube
134 Natrium Diklofenak Tab 25 mg Tablet
135 Natrium klorida larutan infus 0,9 % steril Botol
136 Natrium tiosulfat injeksi 25% - 10 ml Ampul
137 Nifedipin tablet 10 mg Tablet
138 Nistatin 100.000 iu/ g tablet vagina Tablet
139 Nistatin 500.000 iu tablet salut Tablet
140 Obat anti tuberkolusis kategori 1 Paket
141 Obat anti tuberkolusis kategori 2 Paket

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
142 Obat batuk hitam (O.B.H.) cairan 100 ml Botol
143 Obat batuk hitam (O.B.H.) cairan 200 ml Botol
144 Oksitetrasiklin HCl inj. i.m. 50 mg/ml - 10 ml Vial
145 Oksitetrasiklin HCl salep kulit 3 % Tube
146 Oksitetrasiklin HCl salep mata 1 % Tube
147 Oksitosin injeksi 10 iu/ml - 1 ml/ Pitogin Ampul
148 Omeprazole kapsul 20 mg Kapsul
149 Papaverin tablet 40 mg Tablet
150 Parasetamol sirup 120 mg/5 ml Botol
151 Parasetamol tablet 100 mg Tablet
152 Parasetamol tablet 500 mg Tablet
153 Petidin HCl injeksi 50 mg/ml - 2 ml Ampul
154 Pirantel pamoat tablet 125 mg Tablet
155 Piridoksin HCl tablet 10 mg Tablet
156 Piroksikam tablet 10 mg Tablet
157 Prazikuantel tablet 600 mg Tablet
158 Prednison tablet 5 mg Tablet
159 Primakuin tablet 15 mg Tablet
160 Propiltiurasil tablet 100 mg Tablet
161 Propanolol HCl tablet 40 mg Tablet
162 Rabies immune globulin (human) 150 iu/ml Vial
163 Ranitidin injeksi 25 mg/2 mL Ampul
164 Ranitidin Tab 150 mg Tablet
165 Reserpin tablet 0,10 mg Tablet
166 Reserpin tablet 0,25 mg Tablet
167 Retinol (Vitamin A) kapsul 200.000 iu Kapsul
168 Rifampisin kaplet 600 mg Kaplet
169 Rifampisin kapsul 300 mg Kapsul
170 Rifampisin kapsul 450 mg Kapsul

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
171 Ringer laktat larutan infus steril Botol
172 Salbutamol tablet 2 mg Tablet
173 Salep 2- 4 kombinasi Pot
174 Salisil bedak 2 % Kotak
175 Serum anti bisa ular polivalen inj 5 ml (ABU I) Vial
176 Serum anti bisa ular polivalen inj 50 ml (ABU II) Vial
177 Serum anti difteri inj. 20.000 iu/ vial (a.d.s.) Vial
178 Serum anti tetanus inj. 1.500 iu/ ampul ( a.t.s.) Ampul
179 Serum anti tetanus inj. 20.000 iu/ ampul ( a.t.s.) Vial
180 Sianokobalamin (Vit. B12) inj. 500 mcg/ml Ampul
181 Silk (benang bedah sutera) no. 3/0 Set
182 Simvastatin tablet 10 mg Tablet
183 Streptomisin sulfat serbuk inj 1000 mg/ vial Vial
184 Streptomisin sulfat serbuk inj 1500 mg/ vial Vial
185 Tablet tambah darah kombinasi Tablet
186 Tetrakain HCl tetes mata Botol
187 Tetrasiklin HCl kapsul 250 mg Kapsul
188 Tetrasiklin HCl kapsul 500 mg Kapsul
189 Tiamin HCl (Vit. B1) inj. 100 mg/ ml - 1 ml Ampul
190 Tiamin HCl monitrat (Vit. B1) tablet 50 mg Tablet
191 Tramadol kapsul 50 mg Kapsul
192 Triheksifenidil hidroklorida tablet 2 mg Tablet
193 Vaksin rabies vero Set
194 Vitamin B kompleks tablet Tablet
 195 Vitamin-mineral kombinasi untuk lansia (Greavita) Tablet
196 Yodium Povidon larutan 10 % 30 ml Botol
197 Yodium Povidon larutan 10 % 300 ml Botol
198 Zinc tablet 20 mg Tablet

II Alat Kesehatan Habis Pakai

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK
NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
1 Alat suntik sekali pakai 1 ml Set
2 Alat suntik sekali pakai 3 ml Set
3 Alat suntik sekali pakai 5 ml Set
4 Cat gut/benang bedah No. 2/0-3/0 (plain & Cromic) Set
5 Folley Catheter 2 Way FR - 12 Set
6 Folley Catheter 2 Way FR - 16 Set
7 Folley Catheter 2 Way FR - 18 Set
8 Handscoon No. 7,5 Pasang
9 Infusion set anak Set
10 Infusion set dewasa Set
11 Intravenous Catheter No. 18 Set
12 Intravenous Catheter No. 20 Set
13 Intravenous Catheter No. 22 Set
14 Intravenous Catheter No. 24 Set
15 Intravenous Catheter No. 26 Set
16 Jarum jahit (bedah) no.9 s/d 14 Biji
17 Kapas Berlemak 500 gram Rol
18 Kapas Pembalut/Absorben 250 gram Rol
19 Kasa Kompres 40/40 steril Rol
20 Kasa Pembalut Hidrofil 2 m x 80 cm Rol
21 Kasa Pembalut Hidrofil 4 m x 3 cm Rol
22 Kasa Pembalut Hidrofil 4 m x 15 cm Rol
 23 Kasa Pembalut Hidrofil 4 m x 5 cm Rol
24 Lancet Set
25 Masker Lembar
26 Pembalut Gips Rol
27 Plester 5 yards x 2 inch Rol
28 Pregnancy Test (tes kehamilan) Set

STOK PENERI- PERSE- KELUAR SISA/STOK STOK/CHECK

NO. NAMA OBAT/ALKES BHP SATUAN SELISIH
AWAL MAAN DIAAN JAN S/D DES'14 PER 31 DES'14 FISIK
1 2 3 4 5 6=4+5 7 8=6-7 9 10
29 Silk (Benang Bedah Sutra No. 3/0) Set
30 Sterile Surgical Blades No. 11 Pcs
31 Sterile Surgical Blades No. 15 Pcs
32 Sterile Surgical Blades No. 20 Pcs
33 Tangkai Penjepit Surgical Blades Pcs
34 Urine Bag (Onemed) Set
III Bahan Gigi
1 Bahan pembersih plak dan karang gigi Set
2 Caviton Set
3 CHKM Set
4 Composite set (Bahan, Bonding + Etching) Set
5 Devitalisasi pasta (non arsen) Botol
6 Eugenol cairan Botol
7 Gameksan emulsi 1 % Botol
8 Glass ionomer cement (gc ix) Set
9 Mummifying pasta Botol
10 Semen seng fosfat serbuk dan cairan Set
11 Silver amalgam serbuk 65 - 75 % Botol
12 Spons gelatin cubicles 1 x 1 x 1 cm Set
13 Temporary stopping Flecher serbuk dan cairan Set
14
IV Tambahan Lainnya
1 Multivitamin Tablet / Livron B- Plex Tablet
2 Syrup Vitamin Anak / Livitan Botol
3 Tiamphenicol Caps 500 mg Kapsul
4
5
6
7