SURAT BUKTI BARANG KELUAR (SBBK)

No : ..................................................

PUSKESMAS : UJUNG BATU III

KECAMATAN : HUTARAJA TINGGI
KABUPATEN : PADANG LAWAS
UNTUK : APOTEK

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
I. OBAT
1 Albendazole tablet 400 mg Tablet
2 Allopurinol 100 mg tablet Tablet
3 Allopurinol 300 mg tablet Tablet
4 Ambroxol 30 mg tablet Tablet
5 Ambroxol syrup Botol
6 Aminofilin tablet 200 mg Tablet
7 Amitriptilin tablet 25 mg Tablet
8 Amlodipin 10 mg Tablet
9 Amoksisilin kaplet 250 mg Kaplet
10 Amoksisilin kaplet 500 mg Kaplet
11 Amoksisilin syrup kering 125 mg/5 ml Botol 5
12 Amoksisilin syrup kering forte 250 mg/5 ml Botol
13 Ampisilin kaplet 500 mg Tablet
14 Ampisilin syrup kering 125 mg/5 ml Botol
15 Ampisilin serbuk injeksi Vial
16 Antalgin (Methampiron) inj 250 mg Ampul
17 Antalgin (Methampiron) inj 500 mg Ampul
18 Antalgin (Methampiron) tablet 500 mg Tablet
19 Antalgin tablet 500 mg (Lexagin 500 mg) Tablet
20 Antasida Doen suspensi kombinasi Botol 5
21 Antasida Doen tablet kunyah Tablet
22 Anti Bakteri Basitrasin Doen salep Tube
23 Anti Fungi Doen Kombinasi Pot
24 Anti Hemoroid kombinasi Bismut Subgalat Supp
25 Anti Migrain tablet komb Ergotamin Tartrat+Kafein Tablet
26 Anti parkinson Doen tab Tablet
27 Aqua Pro Injeksi steril bebas pirogen 20 ml Vial
28 Artesunate injeksi Ampul
29 Asam Ascorbat 50 mg tablet Tablet
30 Asam Asetilsalisilat tablet 80 mg (Miniaspi) Tablet
31 Asam Asetilsalisilat tablet 100 mg Tablet
32 Asam Asetilsalisilat tablet 500 mg Tablet
33 Asam Folat tablet 0,4 mg Tablet
34 Asam Mefenamat 500 mg tablet Tablet 300
35 Asam Mefenamat (Benostan tab 500 mg) Tablet
36 Asam Traneksamat inj 100 mg/ml Ampul
37 Asam Pipemidat 400 mg kapsul Kapsul
38 Asiklovir 400 mg tablet Tablet
39 Attapulgit tablet 600 mg Tablet
40 Attapulgit tablet 630 mg Tablet
41 Atropin Sulfat injeksi 0,25 mg/ml - 1 ml Vial
42 Atropin Sulfat tetes mata 0,5% Botol
43 Azitromisin tablet 500 mg Tablet
44 Betahistin Mesilat 6 mg Tablet
45 Betamethason krim 0,1% 1,2 mg Tube
46 Bisakodil suppositoria 10 mg Supp
47 Bisakodil suppositoria 5 mg Supp 6
48 Bisoprolol tablet 5 mg Tablet
49 Bromhexin sirup 60 ml (HUSTAB) Botol
50 Clozapine tablet 25 mg Tablet
51 Co-Amoksiklav tablet 625 mg Tablet
52 Dexamethason injeksi 5 mg/ml Ampul
53 Dexamethason tablet 0,5 mg Tablet
54 Dextromethorpan syrup 10 mg/5 ml Botol
55 Dextromethorpan tablet 15 mg Tablet
56 Diazepam injeksi 5 mg/ml - 2 ml Ampul
57 Diazepam tablet 2 mg Tablet
58 Diazepam tablet 5 mg Tablet
59 Dietilkarbamazin (DEC) tablet Tablet
60 Difenhydramin injeksi 10 mg/ml Ampul
61 Digoksin Tablet 0,25 mg Tablet
62 Dihydroartemisin Piperaquin (OAM) Tablet
63 Dihidroartemisin (D-Artep) Tablet
64 Doksisiklin tablet 100 mg Tablet
65 Domperidone suspensi 5 mg/5 ml Botol 10
66 Domperidone Tablet 10 mg Tablet
67 Dopamet Metildopa 250 mg Tablet
68 Ekstrak belladona tablet Tablet
69 Epinefrin (Adrenalin) Injeksi Ampul
70 Eritromisin 500 mg Tablet
71 Eritromisin syrup kering 200 mg/5 ml Botol
72 Fenitoin injeksi 50 mg/ml Ampul
73 Fenobarbital injeksi 50 mg/ml Ampul
74 Fenobarbital Tablet 30 mg Tablet
75 Fitomenadion (vit K) Injeksi 2 mg/ml Ampul
76 Fitomenadion (vit K) tablet salut 10 mg Tablet
77 Flufenazin Decanoate inj.25 mg/ml - 1 ml Ampul
78 Flukonazol 150 mg Tablet
79 Fluoksetin tablet 10 mg Tablet
80 Furosemid 40 mg Tablet
81 Garam Oralit Serbuk, Kombinasi Sachet
82 Gentamisin sulfat Injeksi 40 mg/ml Ampul
83 Gentamisin sulfat tetes mata 0,3% Botol
84 Gentamisin salep kulit 0,1% Tube
85 Gentian Violet 1% Botol
86 Glibenklamid tablet 5 mg (RENABETIC) Tablet
87 Glimepiride tablet 2 mg Tablet

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
88 Glimepiride tablet 4 mg Tablet
89 Gliseril Guaiakolat 100 mg Tablet
90 Glukonas Kalsikus 10% Ampul
91 Glukosa larutan infus 5% Botol
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 Haloperidol inj 5 mg/ml ampul
96 Haloperidol inj 50 mg/ml ampul
97 Hidroklorotiazid 25 mg Tablet
98 Hidrokortison krim 2,5% Tube
Human Tetanus Imunoglobulin injeksi IM 250 IU - 1 ML Syringe
99 (TETAGAM P)
100 Ibuprofen 400 mg Tablet
101 Ibuprofen suspensi 100 mg/5 ml Botol 6
102 Ibuprofen suspensi 200 mg/5 ml Botol
103 Ibuprofen tablet 200 mg Tablet
104 Isoniazid tablet 100 mg Tablet
105 Isosorbid Dinitrat tablet sublingual 5 mg Tablet
106 Isosorbid Dinitrat tablet sublingual 10 mg (Farsorbid) Tablet
107 Kalium Diklofenak Tablet 25 mg Tablet
108 Kalium Diklofenak Tablet 50 mg Tablet
109 Kalsium Glukonat inj 10 mg
110 Kalsium Laktat tablet 500 mg Tablet
111 Kaptopril Tablet 12,5 mg Tablet
112 Kaptopril Tablet 25 mg Tablet 300
113 Karbamazepin tablet 200 mg (BAMGETOL) Tablet
114 Karbogliserin Tetes Telinga 10% (Fenolgliserol) Botol
115 Ketokonazol krim 2% 10 g Tube 10
116 Ketokonazol tablet 200 mg Tablet
117 Ketorolac injeksi 30 mg/ml Ampul
118 Kina tablet 222 mg Tablet
119 Klindamysin kapsul 150 mg Kapsul
120 Klindamysin kapsul 300 mg Kapsul
121 Kloramfenikol Kapsul 250 mg Tablet
122 Kloramfenikol salep mata 1% Tube
123 Kloramfenikol salep mata (ERLAMYCETIN 3%) Tube
124 Kloramfenikol suspensi 125 mg/5 ml Botol
125 Kloramfenikol tetes telinga 3% Botol
126 Klorfeniramin Maleat tablet 4 mg Tablet 200
127 Kloroquin injeksi 8 ml Vial
128 Klorpromazin tablet 25 mg Tablet
129 Klorpromazin tablet 100 mg Tablet
130 Kodein tablet 10 mg Tablet
131 Kombinasi Bromhexin, Difenhidramin, Parasetamol Tablet
(HUSTAB)
132 Kombinasi Dextromethorpan, Dexklorfeniramin maleat, Botol
Fenilepinefrin (DEXTROFEN Syrup) 5
133 Kombinasi tablet salut: Besi (II) Sulfat + Asam Folat Tablet
134 Kotrimoksazol Doen I (dewasa) tab 480 mg Tablet
135 Kotrimoksazol Doen II (anak) tab 240 mg Tablet
136 Kotrimoksazol suspensi Botol 8
137 Laktulosa sirup 3,335 g/5 ml Botol
138 Lansoprazole Kapsul 30 mg Kapsul 120
Fls
Larutan mengandung Karbohidrat + elektrolit (Larutan
Nutrisi kombinasi infus per L: Na 100 mEq, K 18 mEq, Ca 4
139 mEq, Mg 6 mEq, Cl 90 mEq, Asetat 3 mEq, Sorbitol 50 mg
140 Levofloksasin 500 mg Tablet
141 Lidokain injeksi 2% Ampul
142 Lidokain injeksi 2% + Epinefrin 1% ampul
143 Lidokain injeksi 2% + Epinefrin 1:80.000 Ampul
144 Lidokain injeksi 2% + Epinefrin (PEHACAIN INJ) Ampul
145 Loperamid 2 mg Tablet
146 Loratadin 10 mg Tablet
147 MDT MB Dewasa Blister
148 MDT MB Anak Blister
149 Meloksikam Tablet 15 mg Tablet
150 Meloksikam Tablet 7,5 mg Tablet
151 Metformin 500 mg tablet Tablet
152 Metilprednisolon tablet 4 mg Tablet
153 Metilergometrin Maleat injeksi 0,2 mg/ml Ampul
154 Metilergometrin Maleat tablet 0,125 mg Tablet
155 Metildopa (Dopamet) Tablet
156 Metoklopramid drop 2 mg (GAVISTAL) Botol
157 Metoklopramid HCl 0,1% (Mepramid drop) Botol
158 Metoklopramid injeksi 5 mg/ml Ampul
159 Metoklopramid inj (SOTATIC INJ) Ampul
160 Metoklopramid tablet 5 mg Tablet
161 Metoklopramid tablet 10 mg Tablet
162 Metronidazole 250 mg Tablet
163 Metronidazole 500 mg Tablet
164 Metronidazole infus 500 mg/100 ml Fls
165 Metronidazole sirup 125 mg/5 ml Botol
166 Magnesium Sulfat injeksi 20% (MgSO4 20%) Fls
167 Magnesium Sulfat injeksi 40% (MgSO4 40%) Fls
168 Mikonazol krim 2% Tube
169 Mineral Mix Sachet
170 Multivitamin (RECOVIT SYRUP) Botol
171 Multivitamin ibu hamil dan ibu menyusui (BUNDAVIN) Tablet
172 Multivitamin dan mineral (HEMAFORT) Tablet
173 N-Asetil Sistein tablet 200 mg Tablet
174 Natrium Bicarbonat tablet 500 mg Tablet
175 Natrium diklofenak 25 mg Tablet
176 Natrium diklofenak 50 mg Tablet
177 Natrium Fusidat salep 20 mg/g (FUCILEX) Tube
178 Natrium Klorida larutan infus 0,9% Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
 1 2 3 4 5 6
179 Natrium Tiroksin tablet (Levotiroksin) 100 µg EUTHYROX Tablet
180 Nifedipin tablet 10 mg Tablet
181 Nystatin Vaginal tablet 100.000 ui/g Tablet
182 Obat Batuk Hitam (OBH) Tropica Botol
183 OBH Indo Plus Botol
184 Obat FDC Kategori anak Paket
185 Obat FDC Kategori I Paket
186 Obat FDC Kategori II Paket
187 Obat FDC Kategori sisipan Paket
188 Ofloksasin 400 mg Kapsul
189 Ofloksasin tetes telinga 3% (Tarivid Otic Solution) Botol
190 Oksimetazolin tetes hidung 0,025% (Iliadin drops) Botol
191 Oksitetrasiklin injeksi Vial
192 Oksitetrasiklin Salep mata 1% Tube
193 Oksitosin injeksi 10 IU/ml Ampul
194 Omeprazol 20 mg kapsul Kapsul
195 Omeprazol injeksi 40 mg/10 ml Ampul
196 Papaverin 40 mg Tablet
197 Paracetamol drip (infus) 1000 mg/ml Botol
198 Parasetamol drop Botol
199 Parasetamol syrup 120 mg/5 ml Botol 5
200 Parasetamol Tablet 500 mg Tablet
201 Pethidin injeksi 50 mg/ml - 2 ml Ampul
202 Piracetam injeksi 3 g - 15 ml Ampul
203 Pirantel sirup 125 mg/5 ml Botol
204 Pirantel Tablet 125 mg Tablet
205 Piridoksin (Vit B6) inj 100 mg/ml Ampul
206 Piridoksin (Vit B6) 10 mg Tablet
207 Piroksikam Tablet 20 mg Tablet
208 Piroksikam tablet (Benoxicam 20 mg) Tablet
209 Prednison tablet 5 mg Tablet
210 Primakuin tablet 15 mg Tablet
211 Prokain Benzil Penicillin G Inj 3 jt IU Vial
212 Propanolol HCl Tablet 10 mg Tablet
213 Propanolol HCl Tablet 40 mg Tablet
214 Propil Thiuracil tablet 100 mg Tablet
215 Ranitidine Injeksi 25 mg/ml Ampul
216 Ranitidine tablet 150 mg Tablet
217 Retinol (Vitamin A) 100.000 IU kapsul lunak Kapsul
218 Retinol (Vitamin A) 200.000 IU kapsul lunak Kapsul
219 Ringer Laktat larutan infus Botol
220 Risperidone tablet 1 mg Tablet
221 Salbutamol sirup 2 mg/5 ml Botol
222 Salbutamol 2 mg Tablet
223 Salbutamol 4 mg Tablet
224 Salep 2-4 kombinasi Asam Salisilat + Sulfur Pot
225 Salisil Bedak 2% Kotak
226 Sefadroksil Kapsul 500 mg Kapsul
227 Sefadroksil sirup kering 125 mg/5 ml Botol 10
228 Sefaleksin 500 mg Tablet
229 Sefiksim 100 mg Tablet
230 Sefotaksim injeksi 500 mg/2 ml Ampul
231 Sefotaksim injeksi 1000 mg/2 ml Ampul
232 Septriaxone injeksi 1000 mg/2 ml Ampul
233 Setirizine sirup 5 mg/5 ml Botol
234 Setirizine tablet 10 mg Tablet
235 Serum Anti Bisa Ular Polivalen (Kuda) Injeksi 5 ml BIOSAVE Vial
236 Serum Anti Tetanus inj 1500 IU Ampul
237 Sianokobalamin (Vit B12) inj 500 mcg Ampul
238 Sianokobalamin (Vit B12) tablet 50 mcg Tablet
239 Simetidin Tablet 200 mg Tablet
240 Simvastatin tablet 10 mg Tablet
241 Simvastatin tablet 20 mg Tablet
242 Siprofloksasin tablet 500 mg Tablet
243 Siprofloksasin tablet (Etaflox 500 mg) Tablet
244 Streptomisin Sulfat serbuk inj. 1,0 g/ml (OAT FDC Kat.II) Vial
245 Sukralfat suspensi 500 mg/5 ml Botol
246 Sukralfat tablet 500 mg Tablet
247 Suplemen mata (Ocugard) Kapsul
 248 Tetrasiklin HCl kapsul 250 mg Kapsul
249 Tetrasiklin HCl kapsul 500 mg Kapsul
250 Thiamfenikol 500 mg Kapsul
251 Thiamin HCl injeksi 100 mg/ml Vial
252 Thiamin HCl tablet 100 mg Tablet
253 Thiamin HCl tablet 50 mg Tablet 100
254 Tramadol injeksi Ampul
255 Tramadol kapsul 50 mg Tablet
256 Triheksifenidil 2 mg Tablet
257 Vaksin BCG Vial
258 Vaksin Campak Vial
259 Vaksin DPT HB Hib Vial
260 Vaksin Hepatitis B Hip Vial
261 Vaksin Polio (b0PV) Vial
262 Vaksin Td Vial
263 Vaksin TT Vial
264 Valproat sirup 250 mg/ml (Depakene) Botol
265 Valproat tab SR 250 mg (Depakote) Tablet
266 Valproat tab SR 500 mg (Depakote) Tablet
267 Vaksin Rabies Vero injeksi (Verorab) Set/kur
268 Vitamin B Kompleks injeksi 25 ml Ampul
269 Vitamin B Kompleks tablet Tablet
270 Vitamin Dewasa (Rovital Dragee) Tablet
271 Zinc pro drops 10 mg/ml (Zinc Elemental) Botol
272 Zinc 20 mg Tablet Tablet
273 Zinc tablet 20 mg (Zink Kid) Tablet
274 Zinc sirup 10 mg/5 ml Botol
275 Zinc sirup 20 mg/5 ml Botol 10

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
II. BAHAN MEDIS HABIS PAKAI
1 Alat Suntik Sekali pakai 1 ml Stera Pcs
2 Alat Suntik Sekali pakai 2,5 ml Stera Pcs
3 Alat Suntik Sekali pakai 3 ml Stera Pcs
4 Alat Suntik Sekali pakai 5 ml Stera Pcs
5 Alat Suntik Sekali pakai 0,05 ml (Medeco Syringe) Pcs
6 Alat Suntik Sekali pakai 0,5 ml (Medeco Syringe) Pcs
7 Alkohol Swab Pcs
8 Ballon Chateter 2 Way FR 16 (Chroma) Pcs
9 Ballon Chateter 2 Way FR 18 (Chroma) Pcs
10 Baju Pelindung Pcs
11 Blood Lancet Box
12 Box Slide Buah
13 Catgut chromic No. 2/0 + Jarum Pcs
14 Catgut chromic No. 3/0 + Jarum Pcs
15 Etakridin (Rivanol) 0,1% 300 ml Botol
16 Etanol 70% 1000 ml Botol
17 Etanol 70% 300 ml Botol
18 Examination Glove Size S, M, L (Safeglove) Pcs
19 Examination Glove Size S, M, L (Mas) Pcs
20 Folley Chateter 2 way No. 16 (Urocare) Pcs
21 Folley Chateter Ped No. 10 (Urocare) Pcs
22 Folley Chateter Ped No. 6 (Urocare) Pcs
23 Folley Chateter Ped No. 8 (Urocare) Pcs
24 Handscoon Non Steril Lembar
25 Hospital Product Suction Chateter FR 8 Pcs
26 Hospital Product Suction Chateter FR 10 Pcs
27 Infusion Set Anak Pcs
28 Infusion Set Anak 60 drops/ml Stera Pcs
29 Infusion Set Dewasa pcs
30 Infusion Set Dewasa 20 drops/ml Pcs
31 IV Chateter No. 22 G (IV Cannula) Pcs
32 IV Chateter No. 24 G (IV Cannula) Pcs
33 IV Chateter No. 20 G (IV Cannula) Pcs
34 Kaca Slide Box
 35 Kantong Plastik Berklip Lembar
36 Kapas Pembalut 100 gram Bungkus
37 Kapas Pembalut 250 gram Onemed Bungkus
38 Kapas Pembalut 500 gram Onemed Bungkus
39 Kasa Hidrofil Steril uk. 16 x 16 cm Onemed Kotak
40 Kasa Pembalut Hidrofil 4 m x 5 cm Onemed Roll
41 Kasa Kompres Steril 40 x 40 cm Onemed Lembar
42 Kasa Pembalut Hydrophil 4 m x 10 cm Roll
43 Kertas Perkamen Pcs
44 Lab Kit Malaria Kit
45 Masker (Face Masker) Lembar
46 Mikrotois Pcs
47 Nald Hecting Pcs
48 Oral/Nasal Tracheal Tube Cuffles I.D 2,5 mm Pcs
49 Oral/Nasal Tracheal Tube Cuffles I.D 3,0 mm Pcs
50 Oral/Nasal Tracheal Tube Cuffles I.D 4,0 mm Pcs
51 Plester 5 Yard x 2 inchi Pcs
52 Plester 5 cm x 4,5 m Roll
53 Povidon larutan iodine 10% 300 ml Botol
54 Povidon larutan iodine 10% 60 ml Botol
55 Povidon larutan iodine 10% 30 ml Botol
56 Reagen Kit
57 Safety Box Pcs
58 Sarung Tangan steril 6,5 (Surgical Gloves Sterile) Pasang
59 Sarung Tangan steril 7 (Surgical Gloves Sterile) Pasang
60 Sarung Tangan steril 7,5 (Surgical Gloves Sterile) Pasang
61 Sarung Tangan Non Steril Lembar
62 Silk No. 3/0 + Jarum Pcs
63 Silk No. 3/0 + Jarum 1/2 GT 35 mm Pcs
64 Silk No. 2/0 + Jarum 1/2 GT 35 mm Pcs
65 Sputum pot Pcs
66 Surgical Mask 3 Ply Ear Loop Pcs
67 Surgical Mask 3 Ply Tie On Pcs
68 Umbilical Cord Klem Steril Onemed Pcs
69 Urine Bag Standard Steril 2 Lt Onemed Pcs
70 Wing Needle 23 G Onemed Pcs
III. PERBEKALAN KESEHATAN
1 Hand Rub 500 ml Botol
2 Lysol 1 Liter Botol

Ujung Batu III, Juni 2018

Yang Menerima : Yang Menyerahkan :

JUWARIYAH JUWARIYAH
NIP. 19860504 201101 2 030 NIP. 19860504 201101 2 030

Mengetahui / Menyetujui :
Kepala Puskesmas

H. KHAIRUL MUSLIM, S.Sos

NIP. 19640831 198703 1 003
AH PENGELUARAN
IV TOTAL KET
7 8 9

5
200 200

300

6
 10

AH PENGELUARAN
IV TOTAL KET
7 8 9

300

10
 200

200 320

AH PENGELUARAN
IV TOTAL KET
 7 8 9

90 90

10

200 200
 100

10

AH PENGELUARAN
IV TOTAL KET
7 8 9
Ujung Batu III, Juni 2018

Yang Menyerahkan :

JUWARIYAH
60504 201101 2 030
 SURAT BUKTI BARANG KELUAR (SBBK)
No : ..................................................

PUSKESMAS : UJUNG BATU III

KECAMATAN : HUTARAJA TINGGI
KABUPATEN : PADANG LAWAS
UNTUK : PUSTU

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
I. OBAT
1 Albendazole tablet 400 mg Tablet
2 Allopurinol 100 mg tablet Tablet
3 Allopurinol 300 mg tablet Tablet
4 Ambroxol 30 mg tablet Tablet
5 Ambroxol syrup Botol
6 Aminofilin tablet 200 mg Tablet
7 Amitriptilin tablet 25 mg Tablet
8 Amlodipin 10 mg Tablet
9 Amoksisilin kaplet 250 mg Kaplet
10 Amoksisilin kaplet 500 mg Kaplet
11 Amoksisilin syrup kering 125 mg/5 ml Botol
12 Amoksisilin syrup kering forte 250 mg/5 ml Botol
13 Ampisilin kaplet 500 mg Tablet
14 Ampisilin syrup kering 125 mg/5 ml Botol
15 Ampisilin serbuk injeksi Vial
16 Antalgin (Methampiron) inj 250 mg Ampul
17 Antalgin (Methampiron) inj 500 mg Ampul
18 Antalgin (Methampiron) tablet 500 mg Tablet
19 Antalgin tablet 500 mg (Lexagin 500 mg) Tablet
20 Antasida Doen suspensi kombinasi Botol
21 Antasida Doen tablet kunyah Tablet
22 Anti Bakteri Basitrasin Doen salep Tube
23 Anti Fungi Doen Kombinasi Pot
24 Anti Hemoroid kombinasi Bismut Subgalat Supp
25 Anti Migrain tablet komb Ergotamin Tartrat+Kafein Tablet
26 Anti parkinson Doen tab Tablet
27 Aqua Pro Injeksi steril bebas pirogen 20 ml Vial
28 Artesunate injeksi Ampul
29 Asam Ascorbat 50 mg tablet Tablet
30 Asam Asetilsalisilat tablet 80 mg (Miniaspi) Tablet
31 Asam Asetilsalisilat tablet 100 mg Tablet
32 Asam Asetilsalisilat tablet 500 mg Tablet
33 Asam Folat tablet 0,4 mg Tablet
34 Asam Mefenamat 500 mg tablet Tablet
35 Asam Mefenamat (Benostan tab 500 mg) Tablet
36 Asam Traneksamat inj 100 mg/ml Ampul
37 Asam Pipemidat 400 mg kapsul Kapsul
38 Asiklovir 400 mg tablet Tablet
39 Attapulgit tablet 600 mg Tablet
40 Attapulgit tablet 630 mg Tablet
41 Atropin Sulfat injeksi 0,25 mg/ml - 1 ml Vial
42 Atropin Sulfat tetes mata 0,5% Botol
43 Azitromisin tablet 500 mg Tablet
44 Betahistin Mesilat 6 mg Tablet
45 Betamethason krim 0,1% 1,2 mg Tube
46 Bisakodil suppositoria 10 mg Supp
47 Bisakodil suppositoria 5 mg Supp
48 Bisoprolol tablet 5 mg Tablet
49 Bromhexin sirup 60 ml (HUSTAB) Botol
50 Clozapine tablet 25 mg Tablet
51 Co-Amoksiklav tablet 625 mg Tablet
52 Dexamethason injeksi 5 mg/ml Ampul
53 Dexamethason tablet 0,5 mg Tablet
54 Dextromethorpan syrup 10 mg/5 ml Botol
55 Dextromethorpan tablet 15 mg Tablet
56 Diazepam injeksi 5 mg/ml - 2 ml Ampul
57 Diazepam tablet 2 mg Tablet
58 Diazepam tablet 5 mg Tablet
59 Dietilkarbamazin (DEC) tablet Tablet
60 Difenhydramin injeksi 10 mg/ml Ampul
61 Digoksin Tablet 0,25 mg Tablet
62 Dihydroartemisin Piperaquin (OAM) Tablet
63 Dihidroartemisin (D-Artep) Tablet
64 Doksisiklin tablet 100 mg Tablet
65 Domperidone suspensi 5 mg/5 ml Botol
66 Domperidone Tablet 10 mg Tablet
67 Dopamet Metildopa 250 mg Tablet
68 Ekstrak belladona tablet Tablet
69 Epinefrin (Adrenalin) Injeksi Ampul
70 Eritromisin 500 mg Tablet
71 Eritromisin syrup kering 200 mg/5 ml Botol
72 Fenitoin injeksi 50 mg/ml Ampul
73 Fenobarbital injeksi 50 mg/ml Ampul
74 Fenobarbital Tablet 30 mg Tablet
75 Fitomenadion (vit K) Injeksi 2 mg/ml Ampul
76 Fitomenadion (vit K) tablet salut 10 mg Tablet
77 Flufenazin Decanoate inj.25 mg/ml - 1 ml Ampul
78 Flukonazol 150 mg Tablet
79 Fluoksetin tablet 10 mg Tablet
80 Furosemid 40 mg Tablet
81 Garam Oralit Serbuk, Kombinasi Sachet
82 Gentamisin sulfat Injeksi 40 mg/ml Ampul
83 Gentamisin sulfat tetes mata 0,3% Botol
84 Gentamisin salep kulit 0,1% Tube
85 Gentian Violet 1% Botol
86 Glibenklamid tablet 5 mg (RENABETIC) Tablet
87 Glimepiride tablet 2 mg Tablet

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
88 Glimepiride tablet 4 mg Tablet
89 Gliseril Guaiakolat 100 mg Tablet
90 Glukonas Kalsikus 10% Ampul
91 Glukosa larutan infus 5% Botol
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 Haloperidol inj 5 mg/ml ampul
96 Haloperidol inj 50 mg/ml ampul
97 Hidroklorotiazid 25 mg Tablet
98 Hidrokortison krim 2,5% Tube
99 Human Tetanus Imunoglobulin injeksi IM 250 IU - 1 ML Syringe
(TETAGAM P)
100 Ibuprofen 400 mg Tablet
101 Ibuprofen suspensi 100 mg/5 ml Botol
102 Ibuprofen suspensi 200 mg/5 ml Botol
103 Ibuprofen tablet 200 mg Tablet
104 Isoniazid tablet 100 mg Tablet
105 Isosorbid Dinitrat tablet sublingual 5 mg Tablet
106 Isosorbid Dinitrat tablet sublingual 10 mg (Farsorbid) Tablet
107 Kalium Diklofenak Tablet 25 mg Tablet
108 Kalium Diklofenak Tablet 50 mg Tablet
109 Kalsium Glukonat inj 10 mg
110 Kalsium Laktat tablet 500 mg Tablet
111 Kaptopril Tablet 12,5 mg Tablet
112 Kaptopril Tablet 25 mg Tablet
113 Karbamazepin tablet 200 mg (BAMGETOL) Tablet
114 Karbogliserin Tetes Telinga 10% (Fenolgliserol) Botol
115 Ketokonazol krim 2% 10 g Tube
116 Ketokonazol tablet 200 mg Tablet
117 Ketorolac injeksi 30 mg/ml Ampul
118 Kina tablet 222 mg Tablet
119 Klindamysin kapsul 150 mg Kapsul
120 Klindamysin kapsul 300 mg Kapsul
121 Kloramfenikol Kapsul 250 mg Tablet
122 Kloramfenikol salep mata 1% Tube
123 Kloramfenikol salep mata (ERLAMYCETIN 3%) Tube
124 Kloramfenikol suspensi 125 mg/5 ml Botol
125 Kloramfenikol tetes telinga 3% Botol
126 Klorfeniramin Maleat tablet 4 mg Tablet
127 Kloroquin injeksi 8 ml Vial
128 Klorpromazin tablet 25 mg Tablet
129 Klorpromazin tablet 100 mg Tablet
130 Kodein tablet 10 mg Tablet
131 Kombinasi Bromhexin, Difenhidramin, Parasetamol Tablet
(HUSTAB)
132 Kombinasi Dextromethorpan, Dexklorfeniramin maleat, Botol
Fenilepinefrin (DEXTROFEN Syrup)
133 Kombinasi tablet salut: Besi (II) Sulfat + Asam Folat Tablet
134 Kotrimoksazol Doen I (dewasa) tab 480 mg Tablet
135 Kotrimoksazol Doen II (anak) tab 240 mg Tablet
136 Kotrimoksazol suspensi Botol
137 Laktulosa sirup 3,335 g/5 ml Botol
138 Lansoprazole Kapsul 30 mg Kapsul
139 Fls
Larutan mengandung Karbohidrat + elektrolit (Larutan
Nutrisi kombinasi infus per L: Na 100 mEq, K 18 mEq, Ca 4
mEq, Mg 6 mEq, Cl 90 mEq, Asetat 3 mEq, Sorbitol 50 mg
140 Levofloksasin 500 mg Tablet
141 Lidokain injeksi 2% Ampul
142 Lidokain injeksi 2% + Epinefrin 1% ampul
143 Lidokain injeksi 2% + Epinefrin 1:80.000 Ampul
144 Lidokain injeksi 2% + Epinefrin (PEHACAIN INJ) Ampul
145 Loperamid 2 mg Tablet
146 Loratadin 10 mg Tablet
147 MDT MB Dewasa Blister
148 MDT MB Anak Blister
149 Meloksikam Tablet 15 mg Tablet
150 Meloksikam Tablet 7,5 mg Tablet
151 Metformin 500 mg tablet Tablet
152 Metilprednisolon tablet 4 mg Tablet
153 Metilergometrin Maleat injeksi 0,2 mg/ml Ampul
154 Metilergometrin Maleat tablet 0,125 mg Tablet
155 Metildopa (Dopamet) Tablet
156 Metoklopramid drop 2 mg (GAVISTAL) Botol
157 Metoklopramid HCl 0,1% (Mepramid drop) Botol
158 Metoklopramid injeksi 5 mg/ml Ampul
159 Metoklopramid inj (SOTATIC INJ) Ampul
160 Metoklopramid tablet 5 mg Tablet
161 Metoklopramid tablet 10 mg Tablet
162 Metronidazole 250 mg Tablet
163 Metronidazole 500 mg Tablet
164 Metronidazole infus 500 mg/100 ml Fls
165 Metronidazole sirup 125 mg/5 ml Botol
166 Magnesium Sulfat injeksi 20% (MgSO4 20%) Fls
167 Magnesium Sulfat injeksi 40% (MgSO4 40%) Fls
168 Mikonazol krim 2% Tube
169 Mineral Mix Sachet
170 Multivitamin (RECOVIT SYRUP) Botol
171 Multivitamin ibu hamil dan ibu menyusui (BUNDAVIN) Tablet
172 Multivitamin dan mineral (HEMAFORT) Tablet
173 N-Asetil Sistein tablet 200 mg Tablet
174 Natrium Bicarbonat tablet 500 mg Tablet
175 Natrium diklofenak 25 mg Tablet
176 Natrium diklofenak 50 mg Tablet
177 Natrium Fusidat salep 20 mg/g (FUCILEX) Tube
178 Natrium Klorida larutan infus 0,9% Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
 1 2 3 4 5 6
179 Natrium Tiroksin tablet (Levotiroksin) 100 µg EUTHYROX Tablet
180 Nifedipin tablet 10 mg Tablet
181 Nystatin Vaginal tablet 100.000 ui/g Tablet
182 Obat Batuk Hitam (OBH) Tropica Botol
183 OBH Indo Plus Botol
184 Obat FDC Kategori anak Paket
185 Obat FDC Kategori I Paket
186 Obat FDC Kategori II Paket
187 Obat FDC Kategori sisipan Paket
188 Ofloksasin 400 mg Kapsul
189 Ofloksasin tetes telinga 3% (Tarivid Otic Solution) Botol
190 Oksimetazolin tetes hidung 0,025% (Iliadin drops) Botol
191 Oksitetrasiklin injeksi Vial
192 Oksitetrasiklin Salep mata 1% Tube
193 Oksitosin injeksi 10 IU/ml Ampul
194 Omeprazol 20 mg kapsul Kapsul
195 Omeprazol injeksi 40 mg/10 ml Ampul
196 Papaverin 40 mg Tablet
197 Paracetamol drip (infus) 1000 mg/ml Botol
198 Parasetamol drop Botol
199 Parasetamol syrup 120 mg/5 ml Botol
200 Parasetamol Tablet 500 mg Tablet
201 Pethidin injeksi 50 mg/ml - 2 ml Ampul
202 Piracetam injeksi 3 g - 15 ml Ampul
203 Pirantel sirup 125 mg/5 ml Botol
204 Pirantel Tablet 125 mg Tablet
205 Piridoksin (Vit B6) inj 100 mg/ml Ampul
206 Piridoksin (Vit B6) 10 mg Tablet
207 Piroksikam Tablet 20 mg Tablet
208 Piroksikam tablet (Benoxicam 20 mg) Tablet
209 Prednison tablet 5 mg Tablet
210 Primakuin tablet 15 mg Tablet
211 Prokain Benzil Penicillin G Inj 3 jt IU Vial
212 Propanolol HCl Tablet 10 mg Tablet
213 Propanolol HCl Tablet 40 mg Tablet
214 Propil Thiuracil tablet 100 mg Tablet
215 Ranitidine Injeksi 25 mg/ml Ampul
216 Ranitidine tablet 150 mg Tablet
217 Retinol (Vitamin A) 100.000 IU kapsul lunak Kapsul
218 Retinol (Vitamin A) 200.000 IU kapsul lunak Kapsul
219 Ringer Laktat larutan infus Botol
220 Risperidone tablet 1 mg Tablet
221 Salbutamol sirup 2 mg/5 ml Botol
222 Salbutamol 2 mg Tablet
223 Salbutamol 4 mg Tablet
224 Salep 2-4 kombinasi Asam Salisilat + Sulfur Pot
225 Salisil Bedak 2% Kotak
226 Sefadroksil Kapsul 500 mg Kapsul
227 Sefadroksil sirup kering 125 mg/5 ml Botol
228 Sefaleksin 500 mg Tablet
229 Sefiksim 100 mg Tablet
230 Sefotaksim injeksi 500 mg/2 ml Ampul
231 Sefotaksim injeksi 1000 mg/2 ml Ampul
232 Septriaxone injeksi 1000 mg/2 ml Ampul
233 Setirizine sirup 5 mg/5 ml Botol
234 Setirizine tablet 10 mg Tablet
235 Serum Anti Bisa Ular Polivalen (Kuda) Injeksi 5 ml BIOSAVE Vial
236 Serum Anti Tetanus inj 1500 IU Ampul
237 Sianokobalamin (Vit B12) inj 500 mcg Ampul
238 Sianokobalamin (Vit B12) tablet 50 mcg Tablet
239 Simetidin Tablet 200 mg Tablet
240 Simvastatin tablet 10 mg Tablet
241 Simvastatin tablet 20 mg Tablet
242 Siprofloksasin tablet 500 mg Tablet
243 Siprofloksasin tablet (Etaflox 500 mg) Tablet
244 Streptomisin Sulfat serbuk inj. 1,0 g/ml (OAT FDC Kat.II) Vial
245 Sukralfat suspensi 500 mg/5 ml Botol
246 Sukralfat tablet 500 mg Tablet
247 Suplemen mata (Ocugard) Kapsul
 248 Tetrasiklin HCl kapsul 250 mg Kapsul
249 Tetrasiklin HCl kapsul 500 mg Kapsul
250 Thiamfenikol 500 mg Kapsul
251 Thiamin HCl injeksi 100 mg/ml Vial
252 Thiamin HCl tablet 100 mg Tablet
253 Thiamin HCl tablet 50 mg Tablet
254 Tramadol injeksi Ampul
255 Tramadol kapsul 50 mg Tablet
256 Triheksifenidil 2 mg Tablet
257 Vaksin BCG Vial
258 Vaksin Campak Vial
259 Vaksin DPT HB Hib Vial
260 Vaksin Hepatitis B Hip Vial
261 Vaksin Polio (b0PV) Vial
262 Vaksin Td Vial
263 Vaksin TT Vial
264 Valproat sirup 250 mg/ml (Depakene) Botol
265 Valproat tab SR 250 mg (Depakote) Tablet
266 Valproat tab SR 500 mg (Depakote) Tablet
267 Vaksin Rabies Vero injeksi (Verorab) Set/kur
268 Vitamin B Kompleks injeksi 25 ml Ampul
269 Vitamin B Kompleks tablet Tablet
270 Vitamin Dewasa (Rovital Dragee) Tablet
271 Zinc pro drops 10 mg/ml (Zinc Elemental) Botol
272 Zinc 20 mg Tablet Tablet
273 Zinc tablet 20 mg (Zink Kid) Tablet
274 Zinc sirup 10 mg/5 ml Botol
275 Zinc sirup 20 mg/5 ml Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
II. BAHAN MEDIS HABIS PAKAI
1 Alat Suntik Sekali pakai 1 ml Stera Pcs
2 Alat Suntik Sekali pakai 2,5 ml Stera Pcs
3 Alat Suntik Sekali pakai 3 ml Stera Pcs
4 Alat Suntik Sekali pakai 5 ml Stera Pcs
5 Alat Suntik Sekali pakai 0,05 ml (Medeco Syringe) Pcs
6 Alat Suntik Sekali pakai 0,5 ml (Medeco Syringe) Pcs
7 Alkohol Swab Pcs
8 Ballon Chateter 2 Way FR 16 (Chroma) Pcs
9 Ballon Chateter 2 Way FR 18 (Chroma) Pcs
10 Baju Pelindung Pcs
11 Blood Lancet Box
12 Box Slide Buah
13 Catgut chromic No. 2/0 + Jarum Pcs
14 Catgut chromic No. 3/0 + Jarum Pcs
15 Etakridin (Rivanol) 0,1% 300 ml Botol
16 Etanol 70% 1000 ml Botol
17 Etanol 70% 300 ml Botol
18 Examination Glove Size S, M, L (Safeglove) Pcs
19 Examination Glove Size S, M, L (Mas) Pcs
20 Folley Chateter 2 way No. 16 (Urocare) Pcs
21 Folley Chateter Ped No. 10 (Urocare) Pcs
22 Folley Chateter Ped No. 6 (Urocare) Pcs
23 Folley Chateter Ped No. 8 (Urocare) Pcs
24 Handscoon Non Steril Lembar
25 Hospital Product Suction Chateter FR 8 Pcs
26 Hospital Product Suction Chateter FR 10 Pcs
27 Infusion Set Anak Pcs
28 Infusion Set Anak 60 drops/ml Stera Pcs
29 Infusion Set Dewasa pcs
30 Infusion Set Dewasa 20 drops/ml Pcs
31 IV Chateter No. 22 G (IV Cannula) Pcs
32 IV Chateter No. 24 G (IV Cannula) Pcs
33 IV Chateter No. 20 G (IV Cannula) Pcs
34 Kaca Slide Box
 35 Kantong Plastik Berklip Lembar
36 Kapas Pembalut 100 gram Bungkus
37 Kapas Pembalut 250 gram Onemed Bungkus
38 Kapas Pembalut 500 gram Onemed Bungkus
39 Kasa Hidrofil Steril uk. 16 x 16 cm Onemed Kotak
40 Kasa Pembalut Hidrofil 4 m x 5 cm Onemed Roll
41 Kasa Kompres Steril 40 x 40 cm Onemed Lembar
42 Kasa Pembalut Hydrophil 4 m x 10 cm Roll
43 Kertas Perkamen Pcs
44 Lab Kit Malaria Kit
45 Masker (Face Masker) Lembar
46 Mikrotois Pcs
47 Nald Hecting Pcs
48 Oral/Nasal Tracheal Tube Cuffles I.D 2,5 mm Pcs
49 Oral/Nasal Tracheal Tube Cuffles I.D 3,0 mm Pcs
50 Oral/Nasal Tracheal Tube Cuffles I.D 4,0 mm Pcs
51 Plester 5 Yard x 2 inchi Pcs
52 Plester 5 cm x 4,5 m Roll
53 Povidon larutan iodine 10% 300 ml Botol
54 Povidon larutan iodine 10% 60 ml Botol
55 Povidon larutan iodine 10% 30 ml Botol
56 Reagen Kit
57 Safety Box Pcs
58 Sarung Tangan steril 6,5 (Surgical Gloves Sterile) Pasang
59 Sarung Tangan steril 7 (Surgical Gloves Sterile) Pasang
60 Sarung Tangan steril 7,5 (Surgical Gloves Sterile) Pasang
61 Sarung Tangan Non Steril Lembar
62 Silk No. 3/0 + Jarum Pcs
63 Silk No. 3/0 + Jarum 1/2 GT 35 mm Pcs
64 Silk No. 2/0 + Jarum 1/2 GT 35 mm Pcs
65 Sputum pot Pcs
66 Surgical Mask 3 Ply Ear Loop Pcs
67 Surgical Mask 3 Ply Tie On Pcs
68 Umbilical Cord Klem Steril Onemed Pcs
69 Urine Bag Standard Steril 2 Lt Onemed Pcs
70 Wing Needle 23 G Onemed Pcs
III. PERBEKALAN KESEHATAN
1 Hand Rub 500 ml Botol
2 Lysol 1 Liter Botol

Ujung Batu III, Juni 2018

Yang Menerima : Yang Menyerahkan :

SITI HOTMAIDA NASUTION JUWARIYAH

NIP. NIP. 19860504 201101 2 030

Mengetahui / Menyetujui :
Kepala Puskesmas

H. KHAIRUL MUSLIM, S.Sos

NIP. 19640831 198703 1 003
AH PENGELUARAN
IV TOTAL KET
7 8 9

10 10

100 100

100 100

10 10
 30 30

10 10

AH PENGELUARAN
IV TOTAL KET
7 8 9
 100 100

10 10

AH PENGELUARAN
IV TOTAL KET
 7 8 9

10 10
100 100

100 100

10 10
100 100
 100 100

AH PENGELUARAN
IV TOTAL KET
7 8 9

10 10
 20 20

Ujung Batu III, Juni 2018

Yang Menyerahkan :

JUWARIYAH
60504 201101 2 030
 SURAT BUKTI BARANG KELUAR (SBBK)
No : ..................................................

PUSKESMAS : UJUNG BATU III

KECAMATAN : HUTARAJA TINGGI
KABUPATEN : PADANG LAWAS
UNTUK : POLI GIGI

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
I. OBAT
1 Albendazole tablet 400 mg Tablet
2 Allopurinol 100 mg tablet Tablet
3 Allopurinol 300 mg tablet Tablet
4 Ambroxol 30 mg tablet Tablet
5 Ambroxol syrup Botol
6 Aminofilin tablet 200 mg Tablet
7 Amitriptilin tablet 25 mg Tablet
8 Amlodipin 10 mg Tablet
9 Amoksisilin kaplet 250 mg Kaplet
10 Amoksisilin kaplet 500 mg Kaplet
11 Amoksisilin syrup kering 125 mg/5 ml Botol
12 Amoksisilin syrup kering forte 250 mg/5 ml Botol
13 Ampisilin kaplet 500 mg Tablet
14 Ampisilin syrup kering 125 mg/5 ml Botol
15 Ampisilin serbuk injeksi Vial
16 Antalgin (Methampiron) inj 250 mg Ampul
17 Antalgin (Methampiron) inj 500 mg Ampul
18 Antalgin (Methampiron) tablet 500 mg Tablet
19 Antalgin tablet 500 mg (Lexagin 500 mg) Tablet
20 Antasida Doen suspensi kombinasi Botol
21 Antasida Doen tablet kunyah Tablet
22 Anti Bakteri Basitrasin Doen salep Tube
23 Anti Fungi Doen Kombinasi Pot
24 Anti Hemoroid kombinasi Bismut Subgalat Supp
25 Anti Migrain tablet komb Ergotamin Tartrat+Kafein Tablet
26 Anti parkinson Doen tab Tablet
27 Aqua Pro Injeksi steril bebas pirogen 20 ml Vial
28 Artesunate injeksi Ampul
29 Asam Ascorbat 50 mg tablet Tablet
30 Asam Asetilsalisilat tablet 80 mg (Miniaspi) Tablet
31 Asam Asetilsalisilat tablet 100 mg Tablet
32 Asam Asetilsalisilat tablet 500 mg Tablet
33 Asam Folat tablet 0,4 mg Tablet
34 Asam Mefenamat 500 mg tablet Tablet
35 Asam Mefenamat (Benostan tab 500 mg) Tablet
36 Asam Traneksamat inj 100 mg/ml Ampul
37 Asam Pipemidat 400 mg kapsul Kapsul
38 Asiklovir 400 mg tablet Tablet
39 Attapulgit tablet 600 mg Tablet
40 Attapulgit tablet 630 mg Tablet
41 Atropin Sulfat injeksi 0,25 mg/ml - 1 ml Vial
42 Atropin Sulfat tetes mata 0,5% Botol
43 Azitromisin tablet 500 mg Tablet
44 Betahistin Mesilat 6 mg Tablet
45 Betamethason krim 0,1% 1,2 mg Tube
46 Bisakodil suppositoria 10 mg Supp
47 Bisakodil suppositoria 5 mg Supp
48 Bisoprolol tablet 5 mg Tablet
49 Bromhexin sirup 60 ml (HUSTAB) Botol
50 Clozapine tablet 25 mg Tablet
51 Co-Amoksiklav tablet 625 mg Tablet
52 Dexamethason injeksi 5 mg/ml Ampul
53 Dexamethason tablet 0,5 mg Tablet
54 Dextromethorpan syrup 10 mg/5 ml Botol
55 Dextromethorpan tablet 15 mg Tablet
56 Diazepam injeksi 5 mg/ml - 2 ml Ampul
57 Diazepam tablet 2 mg Tablet
58 Diazepam tablet 5 mg Tablet
59 Dietilkarbamazin (DEC) tablet Tablet
60 Difenhydramin injeksi 10 mg/ml Ampul
61 Digoksin Tablet 0,25 mg Tablet
62 Dihydroartemisin Piperaquin (OAM) Tablet
63 Dihidroartemisin (D-Artep) Tablet
64 Doksisiklin tablet 100 mg Tablet
65 Domperidone suspensi 5 mg/5 ml Botol
66 Domperidone Tablet 10 mg Tablet
67 Dopamet Metildopa 250 mg Tablet
68 Ekstrak belladona tablet Tablet
69 Epinefrin (Adrenalin) Injeksi Ampul
70 Eritromisin 500 mg Tablet
71 Eritromisin syrup kering 200 mg/5 ml Botol
72 Fenitoin injeksi 50 mg/ml Ampul
73 Fenobarbital injeksi 50 mg/ml Ampul
74 Fenobarbital Tablet 30 mg Tablet
75 Fitomenadion (vit K) Injeksi 2 mg/ml Ampul
76 Fitomenadion (vit K) tablet salut 10 mg Tablet
77 Flufenazin Decanoate inj.25 mg/ml - 1 ml Ampul
78 Flukonazol 150 mg Tablet
79 Fluoksetin tablet 10 mg Tablet
80 Furosemid 40 mg Tablet
81 Garam Oralit Serbuk, Kombinasi Sachet
82 Gentamisin sulfat Injeksi 40 mg/ml Ampul
83 Gentamisin sulfat tetes mata 0,3% Botol
84 Gentamisin salep kulit 0,1% Tube
85 Gentian Violet 1% Botol
86 Glibenklamid tablet 5 mg (RENABETIC) Tablet
87 Glimepiride tablet 2 mg Tablet

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
88 Glimepiride tablet 4 mg Tablet
89 Gliseril Guaiakolat 100 mg Tablet
90 Glukonas Kalsikus 10% Ampul
91 Glukosa larutan infus 5% Botol
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 Haloperidol inj 5 mg/ml ampul
96 Haloperidol inj 50 mg/ml ampul
97 Hidroklorotiazid 25 mg Tablet
98 Hidrokortison krim 2,5% Tube
99 Human Tetanus Imunoglobulin injeksi IM 250 IU - 1 ML Syringe
(TETAGAM P)
100 Ibuprofen 400 mg Tablet
101 Ibuprofen suspensi 100 mg/5 ml Botol
102 Ibuprofen suspensi 200 mg/5 ml Botol
103 Ibuprofen tablet 200 mg Tablet
104 Isoniazid tablet 100 mg Tablet
105 Isosorbid Dinitrat tablet sublingual 5 mg Tablet
106 Isosorbid Dinitrat tablet sublingual 10 mg (Farsorbid) Tablet
107 Kalium Diklofenak Tablet 25 mg Tablet
108 Kalium Diklofenak Tablet 50 mg Tablet
109 Kalsium Glukonat inj 10 mg
110 Kalsium Laktat tablet 500 mg Tablet
111 Kaptopril Tablet 12,5 mg Tablet
112 Kaptopril Tablet 25 mg Tablet
113 Karbamazepin tablet 200 mg (BAMGETOL) Tablet
114 Karbogliserin Tetes Telinga 10% (Fenolgliserol) Botol
115 Ketokonazol krim 2% 10 g Tube
116 Ketokonazol tablet 200 mg Tablet
117 Ketorolac injeksi 30 mg/ml Ampul
118 Kina tablet 222 mg Tablet
119 Klindamysin kapsul 150 mg Kapsul
120 Klindamysin kapsul 300 mg Kapsul
121 Kloramfenikol Kapsul 250 mg Tablet
122 Kloramfenikol salep mata 1% Tube
123 Kloramfenikol salep mata (ERLAMYCETIN 3%) Tube
124 Kloramfenikol suspensi 125 mg/5 ml Botol
125 Kloramfenikol tetes telinga 3% Botol
126 Klorfeniramin Maleat tablet 4 mg Tablet
127 Kloroquin injeksi 8 ml Vial
128 Klorpromazin tablet 25 mg Tablet
129 Klorpromazin tablet 100 mg Tablet
130 Kodein tablet 10 mg Tablet
131 Kombinasi Bromhexin, Difenhidramin, Parasetamol Tablet
(HUSTAB)
132 Kombinasi Dextromethorpan, Dexklorfeniramin maleat, Botol
Fenilepinefrin (DEXTROFEN Syrup)
133 Kombinasi tablet salut: Besi (II) Sulfat + Asam Folat Tablet
134 Kotrimoksazol Doen I (dewasa) tab 480 mg Tablet
135 Kotrimoksazol Doen II (anak) tab 240 mg Tablet
136 Kotrimoksazol suspensi Botol
137 Laktulosa sirup 3,335 g/5 ml Botol
138 Lansoprazole Kapsul 30 mg Kapsul
139 Fls
Larutan mengandung Karbohidrat + elektrolit (Larutan
Nutrisi kombinasi infus per L: Na 100 mEq, K 18 mEq, Ca 4
mEq, Mg 6 mEq, Cl 90 mEq, Asetat 3 mEq, Sorbitol 50 mg
140 Levofloksasin 500 mg Tablet
141 Lidokain injeksi 2% Ampul
142 Lidokain injeksi 2% + Epinefrin 1% ampul
143 Lidokain injeksi 2% + Epinefrin 1:80.000 Ampul
144 Lidokain injeksi 2% + Epinefrin (PEHACAIN INJ) Ampul
145 Loperamid 2 mg Tablet
146 Loratadin 10 mg Tablet
147 MDT MB Dewasa Blister
148 MDT MB Anak Blister
149 Meloksikam Tablet 15 mg Tablet
150 Meloksikam Tablet 7,5 mg Tablet
151 Metformin 500 mg tablet Tablet
152 Metilprednisolon tablet 4 mg Tablet
153 Metilergometrin Maleat injeksi 0,2 mg/ml Ampul
154 Metilergometrin Maleat tablet 0,125 mg Tablet
155 Metildopa (Dopamet) Tablet
156 Metoklopramid drop 2 mg (GAVISTAL) Botol
157 Metoklopramid HCl 0,1% (Mepramid drop) Botol
158 Metoklopramid injeksi 5 mg/ml Ampul
159 Metoklopramid inj (SOTATIC INJ) Ampul
160 Metoklopramid tablet 5 mg Tablet
161 Metoklopramid tablet 10 mg Tablet
162 Metronidazole 250 mg Tablet
163 Metronidazole 500 mg Tablet
164 Metronidazole infus 500 mg/100 ml Fls
165 Metronidazole sirup 125 mg/5 ml Botol
166 Magnesium Sulfat injeksi 20% (MgSO4 20%) Fls
167 Magnesium Sulfat injeksi 40% (MgSO4 40%) Fls
168 Mikonazol krim 2% Tube
169 Mineral Mix Sachet
170 Multivitamin (RECOVIT SYRUP) Botol
171 Multivitamin ibu hamil dan ibu menyusui (BUNDAVIN) Tablet
172 Multivitamin dan mineral (HEMAFORT) Tablet
173 N-Asetil Sistein tablet 200 mg Tablet
174 Natrium Bicarbonat tablet 500 mg Tablet
175 Natrium diklofenak 25 mg Tablet
176 Natrium diklofenak 50 mg Tablet
177 Natrium Fusidat salep 20 mg/g (FUCILEX) Tube
178 Natrium Klorida larutan infus 0,9% Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
 1 2 3 4 5 6
179 Natrium Tiroksin tablet (Levotiroksin) 100 µg EUTHYROX Tablet
180 Nifedipin tablet 10 mg Tablet
181 Nystatin Vaginal tablet 100.000 ui/g Tablet
182 Obat Batuk Hitam (OBH) Tropica Botol
183 OBH Indo Plus Botol
184 Obat FDC Kategori anak Paket
185 Obat FDC Kategori I Paket
186 Obat FDC Kategori II Paket
187 Obat FDC Kategori sisipan Paket
188 Ofloksasin 400 mg Kapsul
189 Ofloksasin tetes telinga 3% (Tarivid Otic Solution) Botol
190 Oksimetazolin tetes hidung 0,025% (Iliadin drops) Botol
191 Oksitetrasiklin injeksi Vial
192 Oksitetrasiklin Salep mata 1% Tube
193 Oksitosin injeksi 10 IU/ml Ampul
194 Omeprazol 20 mg kapsul Kapsul
195 Omeprazol injeksi 40 mg/10 ml Ampul
196 Papaverin 40 mg Tablet
197 Paracetamol drip (infus) 1000 mg/ml Botol
198 Parasetamol drop Botol
199 Parasetamol syrup 120 mg/5 ml Botol
200 Parasetamol Tablet 500 mg Tablet
201 Pethidin injeksi 50 mg/ml - 2 ml Ampul
202 Piracetam injeksi 3 g - 15 ml Ampul
203 Pirantel sirup 125 mg/5 ml Botol
204 Pirantel Tablet 125 mg Tablet
205 Piridoksin (Vit B6) inj 100 mg/ml Ampul
206 Piridoksin (Vit B6) 10 mg Tablet
207 Piroksikam Tablet 20 mg Tablet
208 Piroksikam tablet (Benoxicam 20 mg) Tablet
209 Prednison tablet 5 mg Tablet
210 Primakuin tablet 15 mg Tablet
211 Prokain Benzil Penicillin G Inj 3 jt IU Vial
212 Propanolol HCl Tablet 10 mg Tablet
213 Propanolol HCl Tablet 40 mg Tablet
214 Propil Thiuracil tablet 100 mg Tablet
215 Ranitidine Injeksi 25 mg/ml Ampul
216 Ranitidine tablet 150 mg Tablet
217 Retinol (Vitamin A) 100.000 IU kapsul lunak Kapsul
218 Retinol (Vitamin A) 200.000 IU kapsul lunak Kapsul
219 Ringer Laktat larutan infus Botol
220 Risperidone tablet 1 mg Tablet
221 Salbutamol sirup 2 mg/5 ml Botol
222 Salbutamol 2 mg Tablet
223 Salbutamol 4 mg Tablet
224 Salep 2-4 kombinasi Asam Salisilat + Sulfur Pot
225 Salisil Bedak 2% Kotak
226 Sefadroksil Kapsul 500 mg Kapsul
227 Sefadroksil sirup kering 125 mg/5 ml Botol
228 Sefaleksin 500 mg Tablet
229 Sefiksim 100 mg Tablet
230 Sefotaksim injeksi 500 mg/2 ml Ampul
231 Sefotaksim injeksi 1000 mg/2 ml Ampul
232 Septriaxone injeksi 1000 mg/2 ml Ampul
233 Setirizine sirup 5 mg/5 ml Botol
234 Setirizine tablet 10 mg Tablet
235 Serum Anti Bisa Ular Polivalen (Kuda) Injeksi 5 ml BIOSAVE Vial
236 Serum Anti Tetanus inj 1500 IU Ampul
237 Sianokobalamin (Vit B12) inj 500 mcg Ampul
238 Sianokobalamin (Vit B12) tablet 50 mcg Tablet
239 Simetidin Tablet 200 mg Tablet
240 Simvastatin tablet 10 mg Tablet
241 Simvastatin tablet 20 mg Tablet
242 Siprofloksasin tablet 500 mg Tablet
243 Siprofloksasin tablet (Etaflox 500 mg) Tablet
244 Streptomisin Sulfat serbuk inj. 1,0 g/ml (OAT FDC Kat.II) Vial
245 Sukralfat suspensi 500 mg/5 ml Botol
246 Sukralfat tablet 500 mg Tablet
247 Suplemen mata (Ocugard) Kapsul
 248 Tetrasiklin HCl kapsul 250 mg Kapsul
249 Tetrasiklin HCl kapsul 500 mg Kapsul
250 Thiamfenikol 500 mg Kapsul
251 Thiamin HCl injeksi 100 mg/ml Vial
252 Thiamin HCl tablet 100 mg Tablet
253 Thiamin HCl tablet 50 mg Tablet
254 Tramadol injeksi Ampul
255 Tramadol kapsul 50 mg Tablet
256 Triheksifenidil 2 mg Tablet
257 Vaksin BCG Vial
258 Vaksin Campak Vial
259 Vaksin DPT HB Hib Vial
260 Vaksin Hepatitis B Hip Vial
261 Vaksin Polio (b0PV) Vial
262 Vaksin Td Vial
263 Vaksin TT Vial
264 Valproat sirup 250 mg/ml (Depakene) Botol
265 Valproat tab SR 250 mg (Depakote) Tablet
266 Valproat tab SR 500 mg (Depakote) Tablet
267 Vaksin Rabies Vero injeksi (Verorab) Set/kur
268 Vitamin B Kompleks injeksi 25 ml Ampul
269 Vitamin B Kompleks tablet Tablet
270 Vitamin Dewasa (Rovital Dragee) Tablet
271 Zinc pro drops 10 mg/ml (Zinc Elemental) Botol
272 Zinc 20 mg Tablet Tablet
273 Zinc tablet 20 mg (Zink Kid) Tablet
274 Zinc sirup 10 mg/5 ml Botol
275 Zinc sirup 20 mg/5 ml Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
II. BAHAN MEDIS HABIS PAKAI
1 Alat Suntik Sekali pakai 1 ml Stera Pcs
2 Alat Suntik Sekali pakai 2,5 ml Stera Pcs
3 Alat Suntik Sekali pakai 3 ml Stera Pcs
4 Alat Suntik Sekali pakai 5 ml Stera Pcs
5 Alat Suntik Sekali pakai 0,05 ml (Medeco Syringe) Pcs
6 Alat Suntik Sekali pakai 0,5 ml (Medeco Syringe) Pcs
7 Alkohol Swab Pcs
8 Ballon Chateter 2 Way FR 16 (Chroma) Pcs
9 Ballon Chateter 2 Way FR 18 (Chroma) Pcs
10 Baju Pelindung Pcs
11 Blood Lancet Box
12 Box Slide Buah
13 Catgut chromic No. 2/0 + Jarum Pcs
14 Catgut chromic No. 3/0 + Jarum Pcs
15 Etakridin (Rivanol) 0,1% 300 ml Botol
16 Etanol 70% 1000 ml Botol
17 Etanol 70% 300 ml Botol
18 Examination Glove Size S, M, L (Safeglove) Pcs
19 Examination Glove Size S, M, L (Mas) Pcs
20 Folley Chateter 2 way No. 16 (Urocare) Pcs
21 Folley Chateter Ped No. 10 (Urocare) Pcs
22 Folley Chateter Ped No. 6 (Urocare) Pcs
23 Folley Chateter Ped No. 8 (Urocare) Pcs
24 Handscoon Non Steril Lembar
25 Hospital Product Suction Chateter FR 8 Pcs
26 Hospital Product Suction Chateter FR 10 Pcs
27 Infusion Set Anak Pcs
28 Infusion Set Anak 60 drops/ml Stera Pcs
29 Infusion Set Dewasa pcs
30 Infusion Set Dewasa 20 drops/ml Pcs
31 IV Chateter No. 22 G (IV Cannula) Pcs
32 IV Chateter No. 24 G (IV Cannula) Pcs
33 IV Chateter No. 20 G (IV Cannula) Pcs
34 Kaca Slide Box
 35 Kantong Plastik Berklip Lembar
36 Kapas Pembalut 100 gram Bungkus
37 Kapas Pembalut 250 gram Onemed Bungkus 1
38 Kapas Pembalut 500 gram Onemed Bungkus
39 Kasa Hidrofil Steril uk. 16 x 16 cm Onemed Kotak
40 Kasa Pembalut Hidrofil 4 m x 5 cm Onemed Roll
41 Kasa Kompres Steril 40 x 40 cm Onemed Lembar
42 Kasa Pembalut Hydrophil 4 m x 10 cm Roll
43 Kertas Perkamen Pcs
44 Lab Kit Malaria Kit
45 Masker (Face Masker) Lembar
46 Mikrotois Pcs
47 Nald Hecting Pcs
48 Oral/Nasal Tracheal Tube Cuffles I.D 2,5 mm Pcs
49 Oral/Nasal Tracheal Tube Cuffles I.D 3,0 mm Pcs
50 Oral/Nasal Tracheal Tube Cuffles I.D 4,0 mm Pcs
51 Plester 5 Yard x 2 inchi Pcs
52 Plester 5 cm x 4,5 m Roll
53 Povidon larutan iodine 10% 300 ml Botol
54 Povidon larutan iodine 10% 60 ml Botol
55 Povidon larutan iodine 10% 30 ml Botol
56 Reagen Kit
57 Safety Box Pcs
58 Sarung Tangan steril 6,5 (Surgical Gloves Sterile) Pasang
59 Sarung Tangan steril 7 (Surgical Gloves Sterile) Pasang
60 Sarung Tangan steril 7,5 (Surgical Gloves Sterile) Pasang
61 Sarung Tangan Non Steril Lembar
62 Silk No. 3/0 + Jarum Pcs
63 Silk No. 3/0 + Jarum 1/2 GT 35 mm Pcs
64 Silk No. 2/0 + Jarum 1/2 GT 35 mm Pcs
65 Sputum pot Pcs
66 Surgical Mask 3 Ply Ear Loop Pcs
67 Surgical Mask 3 Ply Tie On Pcs
68 Umbilical Cord Klem Steril Onemed Pcs
69 Urine Bag Standard Steril 2 Lt Onemed Pcs
70 Wing Needle 23 G Onemed Pcs
III. PERBEKALAN KESEHATAN
1 Hand Rub 500 ml Botol
2 Lysol 1 Liter Botol

Ujung Batu III, Juni 2018

Yang Menerima : Yang Menyerahkan :

drg. FADIL PRADANA JUWARIYAH

NRPK. NIP. 19860504 201101 2 030

Mengetahui / Menyetujui :
Kepala Puskesmas

H. KHAIRUL MUSLIM, S.Sos

NIP. 19640831 198703 1 003
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
 1

Ujung Batu III, Juni 2018

Yang Menyerahkan :

JUWARIYAH
60504 201101 2 030
 SURAT BUKTI BARANG KELUAR (SBBK)
No : ..................................................

PUSKESMAS : UJUNG BATU III

KECAMATAN : HUTARAJA TINGGI
KABUPATEN : PADANG LAWAS
UNTUK : KIA

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
I. OBAT
1 Albendazole tablet 400 mg Tablet
2 Allopurinol 100 mg tablet Tablet
3 Allopurinol 300 mg tablet Tablet
4 Ambroxol 30 mg tablet Tablet
5 Ambroxol syrup Botol
6 Aminofilin tablet 200 mg Tablet
7 Amitriptilin tablet 25 mg Tablet
8 Amlodipin 10 mg Tablet
9 Amoksisilin kaplet 250 mg Kaplet
10 Amoksisilin kaplet 500 mg Kaplet
11 Amoksisilin syrup kering 125 mg/5 ml Botol
12 Amoksisilin syrup kering forte 250 mg/5 ml Botol
13 Ampisilin kaplet 500 mg Tablet
14 Ampisilin syrup kering 125 mg/5 ml Botol
15 Ampisilin serbuk injeksi Vial
16 Antalgin (Methampiron) inj 250 mg Ampul
17 Antalgin (Methampiron) inj 500 mg Ampul
18 Antalgin (Methampiron) tablet 500 mg Tablet
19 Antalgin tablet 500 mg (Lexagin 500 mg) Tablet
20 Antasida Doen suspensi kombinasi Botol
21 Antasida Doen tablet kunyah Tablet
22 Anti Bakteri Basitrasin Doen salep Tube
23 Anti Fungi Doen Kombinasi Pot
24 Anti Hemoroid kombinasi Bismut Subgalat Supp
25 Anti Migrain tablet komb Ergotamin Tartrat+Kafein Tablet
26 Anti parkinson Doen tab Tablet
27 Aqua Pro Injeksi steril bebas pirogen 20 ml Vial
28 Artesunate injeksi Ampul
29 Asam Ascorbat 50 mg tablet Tablet
30 Asam Asetilsalisilat tablet 80 mg (Miniaspi) Tablet
31 Asam Asetilsalisilat tablet 100 mg Tablet
32 Asam Asetilsalisilat tablet 500 mg Tablet
33 Asam Folat tablet 0,4 mg Tablet
34 Asam Mefenamat 500 mg tablet Tablet
35 Asam Mefenamat (Benostan tab 500 mg) Tablet
36 Asam Traneksamat inj 100 mg/ml Ampul
37 Asam Pipemidat 400 mg kapsul Kapsul
38 Asiklovir 400 mg tablet Tablet
39 Attapulgit tablet 600 mg Tablet
40 Attapulgit tablet 630 mg Tablet
41 Atropin Sulfat injeksi 0,25 mg/ml - 1 ml Vial
42 Atropin Sulfat tetes mata 0,5% Botol
43 Azitromisin tablet 500 mg Tablet
44 Betahistin Mesilat 6 mg Tablet
45 Betamethason krim 0,1% 1,2 mg Tube
46 Bisakodil suppositoria 10 mg Supp
47 Bisakodil suppositoria 5 mg Supp
48 Bisoprolol tablet 5 mg Tablet
49 Bromhexin sirup 60 ml (HUSTAB) Botol
50 Clozapine tablet 25 mg Tablet
51 Co-Amoksiklav tablet 625 mg Tablet
52 Dexamethason injeksi 5 mg/ml Ampul
53 Dexamethason tablet 0,5 mg Tablet
54 Dextromethorpan syrup 10 mg/5 ml Botol
55 Dextromethorpan tablet 15 mg Tablet
56 Diazepam injeksi 5 mg/ml - 2 ml Ampul
57 Diazepam tablet 2 mg Tablet
58 Diazepam tablet 5 mg Tablet
59 Dietilkarbamazin (DEC) tablet Tablet
60 Difenhydramin injeksi 10 mg/ml Ampul
61 Digoksin Tablet 0,25 mg Tablet
62 Dihydroartemisin Piperaquin (OAM) Tablet
63 Dihidroartemisin (D-Artep) Tablet
64 Doksisiklin tablet 100 mg Tablet
65 Domperidone suspensi 5 mg/5 ml Botol
66 Domperidone Tablet 10 mg Tablet
67 Dopamet Metildopa 250 mg Tablet
68 Ekstrak belladona tablet Tablet
69 Epinefrin (Adrenalin) Injeksi Ampul
70 Eritromisin 500 mg Tablet
71 Eritromisin syrup kering 200 mg/5 ml Botol
72 Fenitoin injeksi 50 mg/ml Ampul
73 Fenobarbital injeksi 50 mg/ml Ampul
74 Fenobarbital Tablet 30 mg Tablet
75 Fitomenadion (vit K) Injeksi 2 mg/ml Ampul
76 Fitomenadion (vit K) tablet salut 10 mg Tablet
77 Flufenazin Decanoate inj.25 mg/ml - 1 ml Ampul
78 Flukonazol 150 mg Tablet
79 Fluoksetin tablet 10 mg Tablet
80 Furosemid 40 mg Tablet
81 Garam Oralit Serbuk, Kombinasi Sachet
82 Gentamisin sulfat Injeksi 40 mg/ml Ampul
83 Gentamisin sulfat tetes mata 0,3% Botol
84 Gentamisin salep kulit 0,1% Tube
85 Gentian Violet 1% Botol
86 Glibenklamid tablet 5 mg (RENABETIC) Tablet
87 Glimepiride tablet 2 mg Tablet

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
88 Glimepiride tablet 4 mg Tablet
89 Gliseril Guaiakolat 100 mg Tablet
90 Glukonas Kalsikus 10% Ampul
91 Glukosa larutan infus 5% Botol
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 Haloperidol inj 5 mg/ml ampul
96 Haloperidol inj 50 mg/ml ampul
97 Hidroklorotiazid 25 mg Tablet
98 Hidrokortison krim 2,5% Tube
99 Human Tetanus Imunoglobulin injeksi IM 250 IU - 1 ML Syringe
(TETAGAM P)
100 Ibuprofen 400 mg Tablet
101 Ibuprofen suspensi 100 mg/5 ml Botol
102 Ibuprofen suspensi 200 mg/5 ml Botol
103 Ibuprofen tablet 200 mg Tablet
104 Isoniazid tablet 100 mg Tablet
105 Isosorbid Dinitrat tablet sublingual 5 mg Tablet
106 Isosorbid Dinitrat tablet sublingual 10 mg (Farsorbid) Tablet
107 Kalium Diklofenak Tablet 25 mg Tablet
108 Kalium Diklofenak Tablet 50 mg Tablet
109 Kalsium Glukonat inj 10 mg
110 Kalsium Laktat tablet 500 mg Tablet
111 Kaptopril Tablet 12,5 mg Tablet
112 Kaptopril Tablet 25 mg Tablet
113 Karbamazepin tablet 200 mg (BAMGETOL) Tablet
114 Karbogliserin Tetes Telinga 10% (Fenolgliserol) Botol
115 Ketokonazol krim 2% 10 g Tube
116 Ketokonazol tablet 200 mg Tablet
117 Ketorolac injeksi 30 mg/ml Ampul
118 Kina tablet 222 mg Tablet
119 Klindamysin kapsul 150 mg Kapsul
120 Klindamysin kapsul 300 mg Kapsul
121 Kloramfenikol Kapsul 250 mg Tablet
122 Kloramfenikol salep mata 1% Tube
123 Kloramfenikol salep mata (ERLAMYCETIN 3%) Tube
124 Kloramfenikol suspensi 125 mg/5 ml Botol
125 Kloramfenikol tetes telinga 3% Botol
126 Klorfeniramin Maleat tablet 4 mg Tablet
127 Kloroquin injeksi 8 ml Vial
128 Klorpromazin tablet 25 mg Tablet
129 Klorpromazin tablet 100 mg Tablet
130 Kodein tablet 10 mg Tablet
131 Kombinasi Bromhexin, Difenhidramin, Parasetamol Tablet
(HUSTAB)
132 Kombinasi Dextromethorpan, Dexklorfeniramin maleat, Botol
Fenilepinefrin (DEXTROFEN Syrup)
133 Kombinasi tablet salut: Besi (II) Sulfat + Asam Folat Tablet
134 Kotrimoksazol Doen I (dewasa) tab 480 mg Tablet
135 Kotrimoksazol Doen II (anak) tab 240 mg Tablet
136 Kotrimoksazol suspensi Botol
137 Laktulosa sirup 3,335 g/5 ml Botol
138 Lansoprazole Kapsul 30 mg Kapsul
139 Fls
Larutan mengandung Karbohidrat + elektrolit (Larutan
Nutrisi kombinasi infus per L: Na 100 mEq, K 18 mEq, Ca 4
mEq, Mg 6 mEq, Cl 90 mEq, Asetat 3 mEq, Sorbitol 50 mg
140 Levofloksasin 500 mg Tablet
141 Lidokain injeksi 2% Ampul
142 Lidokain injeksi 2% + Epinefrin 1% ampul
143 Lidokain injeksi 2% + Epinefrin 1:80.000 Ampul
144 Lidokain injeksi 2% + Epinefrin (PEHACAIN INJ) Ampul
145 Loperamid 2 mg Tablet
146 Loratadin 10 mg Tablet
147 MDT MB Dewasa Blister
148 MDT MB Anak Blister
149 Meloksikam Tablet 15 mg Tablet
150 Meloksikam Tablet 7,5 mg Tablet
151 Metformin 500 mg tablet Tablet
152 Metilprednisolon tablet 4 mg Tablet
153 Metilergometrin Maleat injeksi 0,2 mg/ml Ampul
154 Metilergometrin Maleat tablet 0,125 mg Tablet
155 Metildopa (Dopamet) Tablet
156 Metoklopramid drop 2 mg (GAVISTAL) Botol
157 Metoklopramid HCl 0,1% (Mepramid drop) Botol
158 Metoklopramid injeksi 5 mg/ml Ampul
159 Metoklopramid inj (SOTATIC INJ) Ampul
160 Metoklopramid tablet 5 mg Tablet
161 Metoklopramid tablet 10 mg Tablet
162 Metronidazole 250 mg Tablet
163 Metronidazole 500 mg Tablet
164 Metronidazole infus 500 mg/100 ml Fls
165 Metronidazole sirup 125 mg/5 ml Botol
166 Magnesium Sulfat injeksi 20% (MgSO4 20%) Fls
167 Magnesium Sulfat injeksi 40% (MgSO4 40%) Fls
168 Mikonazol krim 2% Tube
169 Mineral Mix Sachet
170 Multivitamin (RECOVIT SYRUP) Botol
171 Multivitamin ibu hamil dan ibu menyusui (BUNDAVIN) Tablet
172 Multivitamin dan mineral (HEMAFORT) Tablet
173 N-Asetil Sistein tablet 200 mg Tablet
174 Natrium Bicarbonat tablet 500 mg Tablet
175 Natrium diklofenak 25 mg Tablet
176 Natrium diklofenak 50 mg Tablet
177 Natrium Fusidat salep 20 mg/g (FUCILEX) Tube
178 Natrium Klorida larutan infus 0,9% Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
 1 2 3 4 5 6
179 Natrium Tiroksin tablet (Levotiroksin) 100 µg EUTHYROX Tablet
180 Nifedipin tablet 10 mg Tablet
181 Nystatin Vaginal tablet 100.000 ui/g Tablet
182 Obat Batuk Hitam (OBH) Tropica Botol
183 OBH Indo Plus Botol
184 Obat FDC Kategori anak Paket
185 Obat FDC Kategori I Paket
186 Obat FDC Kategori II Paket
187 Obat FDC Kategori sisipan Paket
188 Ofloksasin 400 mg Kapsul
189 Ofloksasin tetes telinga 3% (Tarivid Otic Solution) Botol
190 Oksimetazolin tetes hidung 0,025% (Iliadin drops) Botol
191 Oksitetrasiklin injeksi Vial
192 Oksitetrasiklin Salep mata 1% Tube
193 Oksitosin injeksi 10 IU/ml Ampul
194 Omeprazol 20 mg kapsul Kapsul
195 Omeprazol injeksi 40 mg/10 ml Ampul
196 Papaverin 40 mg Tablet
197 Paracetamol drip (infus) 1000 mg/ml Botol
198 Parasetamol drop Botol
199 Parasetamol syrup 120 mg/5 ml Botol
200 Parasetamol Tablet 500 mg Tablet
201 Pethidin injeksi 50 mg/ml - 2 ml Ampul
202 Piracetam injeksi 3 g - 15 ml Ampul
203 Pirantel sirup 125 mg/5 ml Botol
204 Pirantel Tablet 125 mg Tablet
205 Piridoksin (Vit B6) inj 100 mg/ml Ampul
206 Piridoksin (Vit B6) 10 mg Tablet
207 Piroksikam Tablet 20 mg Tablet
208 Piroksikam tablet (Benoxicam 20 mg) Tablet
209 Prednison tablet 5 mg Tablet
210 Primakuin tablet 15 mg Tablet
211 Prokain Benzil Penicillin G Inj 3 jt IU Vial
212 Propanolol HCl Tablet 10 mg Tablet
213 Propanolol HCl Tablet 40 mg Tablet
214 Propil Thiuracil tablet 100 mg Tablet
215 Ranitidine Injeksi 25 mg/ml Ampul
216 Ranitidine tablet 150 mg Tablet
217 Retinol (Vitamin A) 100.000 IU kapsul lunak Kapsul
218 Retinol (Vitamin A) 200.000 IU kapsul lunak Kapsul
219 Ringer Laktat larutan infus Botol
220 Risperidone tablet 1 mg Tablet
221 Salbutamol sirup 2 mg/5 ml Botol
222 Salbutamol 2 mg Tablet
223 Salbutamol 4 mg Tablet
224 Salep 2-4 kombinasi Asam Salisilat + Sulfur Pot
225 Salisil Bedak 2% Kotak
226 Sefadroksil Kapsul 500 mg Kapsul
227 Sefadroksil sirup kering 125 mg/5 ml Botol
228 Sefaleksin 500 mg Tablet
229 Sefiksim 100 mg Tablet
230 Sefotaksim injeksi 500 mg/2 ml Ampul
231 Sefotaksim injeksi 1000 mg/2 ml Ampul
232 Septriaxone injeksi 1000 mg/2 ml Ampul
233 Setirizine sirup 5 mg/5 ml Botol
234 Setirizine tablet 10 mg Tablet
235 Serum Anti Bisa Ular Polivalen (Kuda) Injeksi 5 ml BIOSAVE Vial
236 Serum Anti Tetanus inj 1500 IU Ampul
237 Sianokobalamin (Vit B12) inj 500 mcg Ampul 10
238 Sianokobalamin (Vit B12) tablet 50 mcg Tablet
239 Simetidin Tablet 200 mg Tablet
240 Simvastatin tablet 10 mg Tablet
241 Simvastatin tablet 20 mg Tablet
242 Siprofloksasin tablet 500 mg Tablet
243 Siprofloksasin tablet (Etaflox 500 mg) Tablet
244 Streptomisin Sulfat serbuk inj. 1,0 g/ml (OAT FDC Kat.II) Vial
245 Sukralfat suspensi 500 mg/5 ml Botol
246 Sukralfat tablet 500 mg Tablet
247 Suplemen mata (Ocugard) Kapsul
 248 Tetrasiklin HCl kapsul 250 mg Kapsul
249 Tetrasiklin HCl kapsul 500 mg Kapsul
250 Thiamfenikol 500 mg Kapsul
251 Thiamin HCl injeksi 100 mg/ml Vial
252 Thiamin HCl tablet 100 mg Tablet
253 Thiamin HCl tablet 50 mg Tablet
254 Tramadol injeksi Ampul
255 Tramadol kapsul 50 mg Tablet
256 Triheksifenidil 2 mg Tablet
257 Vaksin BCG Vial
258 Vaksin Campak Vial
259 Vaksin DPT HB Hib Vial
260 Vaksin Hepatitis B Hip Vial
261 Vaksin Polio (b0PV) Vial
262 Vaksin Td Vial
263 Vaksin TT Vial
264 Valproat sirup 250 mg/ml (Depakene) Botol
265 Valproat tab SR 250 mg (Depakote) Tablet
266 Valproat tab SR 500 mg (Depakote) Tablet
267 Vaksin Rabies Vero injeksi (Verorab) Set/kur
268 Vitamin B Kompleks injeksi 25 ml Ampul
269 Vitamin B Kompleks tablet Tablet
270 Vitamin Dewasa (Rovital Dragee) Tablet
271 Zinc pro drops 10 mg/ml (Zinc Elemental) Botol
272 Zinc 20 mg Tablet Tablet
273 Zinc tablet 20 mg (Zink Kid) Tablet
274 Zinc sirup 10 mg/5 ml Botol
275 Zinc sirup 20 mg/5 ml Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
II. BAHAN MEDIS HABIS PAKAI
1 Alat Suntik Sekali pakai 1 ml Stera Pcs
2 Alat Suntik Sekali pakai 2,5 ml Stera Pcs
3 Alat Suntik Sekali pakai 3 ml Stera Pcs 17
4 Alat Suntik Sekali pakai 5 ml Stera Pcs
5 Alat Suntik Sekali pakai 0,05 ml (Medeco Syringe) Pcs
6 Alat Suntik Sekali pakai 0,5 ml (Medeco Syringe) Pcs
7 Alkohol Swab Pcs 100
8 Ballon Chateter 2 Way FR 16 (Chroma) Pcs
9 Ballon Chateter 2 Way FR 18 (Chroma) Pcs
10 Baju Pelindung Pcs
11 Blood Lancet Box
12 Box Slide Buah
13 Catgut chromic No. 2/0 + Jarum Pcs
14 Catgut chromic No. 3/0 + Jarum Pcs
15 Etakridin (Rivanol) 0,1% 300 ml Botol
16 Etanol 70% 1000 ml Botol
17 Etanol 70% 300 ml Botol
18 Examination Glove Size S, M, L (Safeglove) Pcs
19 Examination Glove Size S, M, L (Mas) Pcs
20 Folley Chateter 2 way No. 16 (Urocare) Pcs
21 Folley Chateter Ped No. 10 (Urocare) Pcs
22 Folley Chateter Ped No. 6 (Urocare) Pcs
23 Folley Chateter Ped No. 8 (Urocare) Pcs
24 Handscoon Non Steril Lembar
25 Hospital Product Suction Chateter FR 8 Pcs
26 Hospital Product Suction Chateter FR 10 Pcs
27 Infusion Set Anak Pcs
28 Infusion Set Anak 60 drops/ml Stera Pcs
29 Infusion Set Dewasa pcs
30 Infusion Set Dewasa 20 drops/ml Pcs
31 IV Chateter No. 22 G (IV Cannula) Pcs
32 IV Chateter No. 24 G (IV Cannula) Pcs
33 IV Chateter No. 20 G (IV Cannula) Pcs
34 Kaca Slide Box
 35 Kantong Plastik Berklip Lembar
36 Kapas Pembalut 100 gram Bungkus
37 Kapas Pembalut 250 gram Onemed Bungkus
38 Kapas Pembalut 500 gram Onemed Bungkus
39 Kasa Hidrofil Steril uk. 16 x 16 cm Onemed Kotak
40 Kasa Pembalut Hidrofil 4 m x 5 cm Onemed Roll
41 Kasa Kompres Steril 40 x 40 cm Onemed Lembar
42 Kasa Pembalut Hydrophil 4 m x 10 cm Roll
43 Kertas Perkamen Pcs
44 Lab Kit Malaria Kit
45 Masker (Face Masker) Lembar
46 Mikrotois Pcs
47 Nald Hecting Pcs
48 Oral/Nasal Tracheal Tube Cuffles I.D 2,5 mm Pcs
49 Oral/Nasal Tracheal Tube Cuffles I.D 3,0 mm Pcs
50 Oral/Nasal Tracheal Tube Cuffles I.D 4,0 mm Pcs
51 Plester 5 Yard x 2 inchi Pcs
52 Plester 5 cm x 4,5 m Roll
53 Povidon larutan iodine 10% 300 ml Botol
54 Povidon larutan iodine 10% 60 ml Botol
55 Povidon larutan iodine 10% 30 ml Botol
56 Reagen Kit
57 Safety Box Pcs
58 Sarung Tangan steril 6,5 (Surgical Gloves Sterile) Pasang
59 Sarung Tangan steril 7 (Surgical Gloves Sterile) Pasang
60 Sarung Tangan steril 7,5 (Surgical Gloves Sterile) Pasang
61 Sarung Tangan Non Steril Lembar
62 Silk No. 3/0 + Jarum Pcs
63 Silk No. 3/0 + Jarum 1/2 GT 35 mm Pcs
64 Silk No. 2/0 + Jarum 1/2 GT 35 mm Pcs
65 Sputum pot Pcs
66 Surgical Mask 3 Ply Ear Loop Pcs
67 Surgical Mask 3 Ply Tie On Pcs
68 Umbilical Cord Klem Steril Onemed Pcs
69 Urine Bag Standard Steril 2 Lt Onemed Pcs
70 Wing Needle 23 G Onemed Pcs
III. PERBEKALAN KESEHATAN
1 Hand Rub 500 ml Botol
2 Lysol 1 Liter Botol

Ujung Batu III, Juni 2018

Yang Menerima : Yang Menyerahkan :

JUWARIYAH
NIP. 19860504 201101 2 030

Mengetahui / Menyetujui :
Kepala Puskesmas

H. KHAIRUL MUSLIM, S.Sos

NIP. 19640831 198703 1 003
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9

10
AH PENGELUARAN
IV TOTAL KET
7 8 9

17

100
Ujung Batu III, Juni 2018

Yang Menyerahkan :

JUWARIYAH
60504 201101 2 030
 SURAT BUKTI BARANG KELUAR (SBBK)
No : ..................................................

PUSKESMAS : UJUNG BATU III

KECAMATAN : HUTARAJA TINGGI
KABUPATEN : PADANG LAWAS
UNTUK : POLI UMUM

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
I. OBAT
1 Albendazole tablet 400 mg Tablet
2 Allopurinol 100 mg tablet Tablet
3 Allopurinol 300 mg tablet Tablet
4 Ambroxol 30 mg tablet Tablet
5 Ambroxol syrup Botol
6 Aminofilin tablet 200 mg Tablet
7 Amitriptilin tablet 25 mg Tablet
8 Amlodipin 10 mg Tablet
9 Amoksisilin kaplet 250 mg Kaplet
10 Amoksisilin kaplet 500 mg Kaplet
11 Amoksisilin syrup kering 125 mg/5 ml Botol
12 Amoksisilin syrup kering forte 250 mg/5 ml Botol
13 Ampisilin kaplet 500 mg Tablet
14 Ampisilin syrup kering 125 mg/5 ml Botol
15 Ampisilin serbuk injeksi Vial
16 Antalgin (Methampiron) inj 250 mg Ampul
17 Antalgin (Methampiron) inj 500 mg Ampul
18 Antalgin (Methampiron) tablet 500 mg Tablet
19 Antalgin tablet 500 mg (Lexagin 500 mg) Tablet
20 Antasida Doen suspensi kombinasi Botol
21 Antasida Doen tablet kunyah Tablet
22 Anti Bakteri Basitrasin Doen salep Tube
23 Anti Fungi Doen Kombinasi Pot
24 Anti Hemoroid kombinasi Bismut Subgalat Supp
25 Anti Migrain tablet komb Ergotamin Tartrat+Kafein Tablet
26 Anti parkinson Doen tab Tablet
27 Aqua Pro Injeksi steril bebas pirogen 20 ml Vial
28 Artesunate injeksi Ampul
29 Asam Ascorbat 50 mg tablet Tablet
30 Asam Asetilsalisilat tablet 80 mg (Miniaspi) Tablet
31 Asam Asetilsalisilat tablet 100 mg Tablet
32 Asam Asetilsalisilat tablet 500 mg Tablet
33 Asam Folat tablet 0,4 mg Tablet
34 Asam Mefenamat 500 mg tablet Tablet
35 Asam Mefenamat (Benostan tab 500 mg) Tablet
36 Asam Traneksamat inj 100 mg/ml Ampul
37 Asam Pipemidat 400 mg kapsul Kapsul
38 Asiklovir 400 mg tablet Tablet
39 Attapulgit tablet 600 mg Tablet
40 Attapulgit tablet 630 mg Tablet
41 Atropin Sulfat injeksi 0,25 mg/ml - 1 ml Vial
42 Atropin Sulfat tetes mata 0,5% Botol
43 Azitromisin tablet 500 mg Tablet
44 Betahistin Mesilat 6 mg Tablet
45 Betamethason krim 0,1% 1,2 mg Tube
46 Bisakodil suppositoria 10 mg Supp
47 Bisakodil suppositoria 5 mg Supp
48 Bisoprolol tablet 5 mg Tablet
49 Bromhexin sirup 60 ml (HUSTAB) Botol
50 Clozapine tablet 25 mg Tablet
51 Co-Amoksiklav tablet 625 mg Tablet
52 Dexamethason injeksi 5 mg/ml Ampul
53 Dexamethason tablet 0,5 mg Tablet
54 Dextromethorpan syrup 10 mg/5 ml Botol
55 Dextromethorpan tablet 15 mg Tablet
56 Diazepam injeksi 5 mg/ml - 2 ml Ampul
57 Diazepam tablet 2 mg Tablet
58 Diazepam tablet 5 mg Tablet
59 Dietilkarbamazin (DEC) tablet Tablet
60 Difenhydramin injeksi 10 mg/ml Ampul
61 Digoksin Tablet 0,25 mg Tablet
62 Dihydroartemisin Piperaquin (OAM) Tablet
63 Dihidroartemisin (D-Artep) Tablet
64 Doksisiklin tablet 100 mg Tablet
65 Domperidone suspensi 5 mg/5 ml Botol
66 Domperidone Tablet 10 mg Tablet
67 Dopamet Metildopa 250 mg Tablet
68 Ekstrak belladona tablet Tablet
69 Epinefrin (Adrenalin) Injeksi Ampul
70 Eritromisin 500 mg Tablet
71 Eritromisin syrup kering 200 mg/5 ml Botol
72 Fenitoin injeksi 50 mg/ml Ampul
73 Fenobarbital injeksi 50 mg/ml Ampul
74 Fenobarbital Tablet 30 mg Tablet
75 Fitomenadion (vit K) Injeksi 2 mg/ml Ampul
76 Fitomenadion (vit K) tablet salut 10 mg Tablet
77 Flufenazin Decanoate inj.25 mg/ml - 1 ml Ampul
78 Flukonazol 150 mg Tablet
79 Fluoksetin tablet 10 mg Tablet
80 Furosemid 40 mg Tablet
81 Garam Oralit Serbuk, Kombinasi Sachet
82 Gentamisin sulfat Injeksi 40 mg/ml Ampul
83 Gentamisin sulfat tetes mata 0,3% Botol
84 Gentamisin salep kulit 0,1% Tube
85 Gentian Violet 1% Botol
86 Glibenklamid tablet 5 mg (RENABETIC) Tablet
87 Glimepiride tablet 2 mg Tablet

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
 1 2 3 4 5 6
88 Glimepiride tablet 4 mg Tablet
89 Gliseril Guaiakolat 100 mg Tablet
90 Glukonas Kalsikus 10% Ampul
91 Glukosa larutan infus 5% Botol
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 Haloperidol inj 5 mg/ml ampul
96 Haloperidol inj 50 mg/ml ampul
97 Hidroklorotiazid 25 mg Tablet
98 Hidrokortison krim 2,5% Tube
99 Human Tetanus Imunoglobulin injeksi IM 250 IU - 1 ML Syringe
(TETAGAM P)
100 Ibuprofen 400 mg Tablet
101 Ibuprofen suspensi 100 mg/5 ml Botol
102 Ibuprofen suspensi 200 mg/5 ml Botol
103 Ibuprofen tablet 200 mg Tablet
104 Isoniazid tablet 100 mg Tablet
105 Isosorbid Dinitrat tablet sublingual 5 mg Tablet
106 Isosorbid Dinitrat tablet sublingual 10 mg (Farsorbid) Tablet
107 Kalium Diklofenak Tablet 25 mg Tablet
108 Kalium Diklofenak Tablet 50 mg Tablet
109 Kalsium Glukonat inj 10 mg
110 Kalsium Laktat tablet 500 mg Tablet
111 Kaptopril Tablet 12,5 mg Tablet
112 Kaptopril Tablet 25 mg Tablet
113 Karbamazepin tablet 200 mg (BAMGETOL) Tablet
114 Karbogliserin Tetes Telinga 10% (Fenolgliserol) Botol
115 Ketokonazol krim 2% 10 g Tube
116 Ketokonazol tablet 200 mg Tablet
117 Ketorolac injeksi 30 mg/ml Ampul
118 Kina tablet 222 mg Tablet
119 Klindamysin kapsul 150 mg Kapsul
120 Klindamysin kapsul 300 mg Kapsul
121 Kloramfenikol Kapsul 250 mg Tablet
122 Kloramfenikol salep mata 1% Tube
123 Kloramfenikol salep mata (ERLAMYCETIN 3%) Tube
124 Kloramfenikol suspensi 125 mg/5 ml Botol
125 Kloramfenikol tetes telinga 3% Botol
126 Klorfeniramin Maleat tablet 4 mg Tablet
127 Kloroquin injeksi 8 ml Vial
128 Klorpromazin tablet 25 mg Tablet
129 Klorpromazin tablet 100 mg Tablet
130 Kodein tablet 10 mg Tablet
131 Kombinasi Bromhexin, Difenhidramin, Parasetamol Tablet
(HUSTAB)
132 Kombinasi Dextromethorpan, Dexklorfeniramin maleat, Botol
Fenilepinefrin (DEXTROFEN Syrup)
133 Kombinasi tablet salut: Besi (II) Sulfat + Asam Folat Tablet
134 Kotrimoksazol Doen I (dewasa) tab 480 mg Tablet
135 Kotrimoksazol Doen II (anak) tab 240 mg Tablet
136 Kotrimoksazol suspensi Botol
137 Laktulosa sirup 3,335 g/5 ml Botol
138 Lansoprazole Kapsul 30 mg Kapsul
139 Fls
Larutan mengandung Karbohidrat + elektrolit (Larutan
Nutrisi kombinasi infus per L: Na 100 mEq, K 18 mEq, Ca 4
mEq, Mg 6 mEq, Cl 90 mEq, Asetat 3 mEq, Sorbitol 50 mg
140 Levofloksasin 500 mg Tablet
141 Lidokain injeksi 2% Ampul
142 Lidokain injeksi 2% + Epinefrin 1% ampul
143 Lidokain injeksi 2% + Epinefrin 1:80.000 Ampul
144 Lidokain injeksi 2% + Epinefrin (PEHACAIN INJ) Ampul
145 Loperamid 2 mg Tablet
146 Loratadin 10 mg Tablet
147 MDT MB Dewasa Blister
148 MDT MB Anak Blister
149 Meloksikam Tablet 15 mg Tablet
150 Meloksikam Tablet 7,5 mg Tablet
151 Metformin 500 mg tablet Tablet
152 Metilprednisolon tablet 4 mg Tablet
153 Metilergometrin Maleat injeksi 0,2 mg/ml Ampul
154 Metilergometrin Maleat tablet 0,125 mg Tablet
155 Metildopa (Dopamet) Tablet
156 Metoklopramid drop 2 mg (GAVISTAL) Botol
157 Metoklopramid HCl 0,1% (Mepramid drop) Botol
158 Metoklopramid injeksi 5 mg/ml Ampul
159 Metoklopramid inj (SOTATIC INJ) Ampul
160 Metoklopramid tablet 5 mg Tablet
161 Metoklopramid tablet 10 mg Tablet
162 Metronidazole 250 mg Tablet
163 Metronidazole 500 mg Tablet
164 Metronidazole infus 500 mg/100 ml Fls
165 Metronidazole sirup 125 mg/5 ml Botol
166 Magnesium Sulfat injeksi 20% (MgSO4 20%) Fls
167 Magnesium Sulfat injeksi 40% (MgSO4 40%) Fls
168 Mikonazol krim 2% Tube
169 Mineral Mix Sachet
170 Multivitamin (RECOVIT SYRUP) Botol
171 Multivitamin ibu hamil dan ibu menyusui (BUNDAVIN) Tablet
172 Multivitamin dan mineral (HEMAFORT) Tablet
173 N-Asetil Sistein tablet 200 mg Tablet
174 Natrium Bicarbonat tablet 500 mg Tablet
175 Natrium diklofenak 25 mg Tablet
176 Natrium diklofenak 50 mg Tablet
177 Natrium Fusidat salep 20 mg/g (FUCILEX) Tube
178 Natrium Klorida larutan infus 0,9% Botol 10 10

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
179 Natrium Tiroksin tablet (Levotiroksin) 100 µg EUTHYROX Tablet
180 Nifedipin tablet 10 mg Tablet
181 Nystatin Vaginal tablet 100.000 ui/g Tablet
182 Obat Batuk Hitam (OBH) Tropica Botol
183 OBH Indo Plus Botol
184 Obat FDC Kategori anak Paket
185 Obat FDC Kategori I Paket
186 Obat FDC Kategori II Paket
187 Obat FDC Kategori sisipan Paket
188 Ofloksasin 400 mg Kapsul
189 Ofloksasin tetes telinga 3% (Tarivid Otic Solution) Botol
190 Oksimetazolin tetes hidung 0,025% (Iliadin drops) Botol
191 Oksitetrasiklin injeksi Vial
192 Oksitetrasiklin Salep mata 1% Tube
193 Oksitosin injeksi 10 IU/ml Ampul
194 Omeprazol 20 mg kapsul Kapsul
195 Omeprazol injeksi 40 mg/10 ml Ampul
196 Papaverin 40 mg Tablet
197 Paracetamol drip (infus) 1000 mg/ml Botol
198 Parasetamol drop Botol
199 Parasetamol syrup 120 mg/5 ml Botol
200 Parasetamol Tablet 500 mg Tablet
201 Pethidin injeksi 50 mg/ml - 2 ml Ampul
202 Piracetam injeksi 3 g - 15 ml Ampul
203 Pirantel sirup 125 mg/5 ml Botol
204 Pirantel Tablet 125 mg Tablet
205 Piridoksin (Vit B6) inj 100 mg/ml Ampul
206 Piridoksin (Vit B6) 10 mg Tablet
207 Piroksikam Tablet 20 mg Tablet
208 Piroksikam tablet (Benoxicam 20 mg) Tablet
209 Prednison tablet 5 mg Tablet
210 Primakuin tablet 15 mg Tablet
211 Prokain Benzil Penicillin G Inj 3 jt IU Vial
212 Propanolol HCl Tablet 10 mg Tablet
213 Propanolol HCl Tablet 40 mg Tablet
214 Propil Thiuracil tablet 100 mg Tablet
215 Ranitidine Injeksi 25 mg/ml Ampul
216 Ranitidine tablet 150 mg Tablet
217 Retinol (Vitamin A) 100.000 IU kapsul lunak Kapsul
218 Retinol (Vitamin A) 200.000 IU kapsul lunak Kapsul
219 Ringer Laktat larutan infus Botol
220 Risperidone tablet 1 mg Tablet
221 Salbutamol sirup 2 mg/5 ml Botol
222 Salbutamol 2 mg Tablet
223 Salbutamol 4 mg Tablet
224 Salep 2-4 kombinasi Asam Salisilat + Sulfur Pot
225 Salisil Bedak 2% Kotak
226 Sefadroksil Kapsul 500 mg Kapsul
227 Sefadroksil sirup kering 125 mg/5 ml Botol
228 Sefaleksin 500 mg Tablet
229 Sefiksim 100 mg Tablet
230 Sefotaksim injeksi 500 mg/2 ml Ampul
231 Sefotaksim injeksi 1000 mg/2 ml Ampul
232 Septriaxone injeksi 1000 mg/2 ml Ampul
 233 Setirizine sirup 5 mg/5 ml Botol
234 Setirizine tablet 10 mg Tablet
235 Serum Anti Bisa Ular Polivalen (Kuda) Injeksi 5 ml BIOSAVE Vial
236 Serum Anti Tetanus inj 1500 IU Ampul
237 Sianokobalamin (Vit B12) inj 500 mcg Ampul
238 Sianokobalamin (Vit B12) tablet 50 mcg Tablet
239 Simetidin Tablet 200 mg Tablet
240 Simvastatin tablet 10 mg Tablet
241 Simvastatin tablet 20 mg Tablet
242 Siprofloksasin tablet 500 mg Tablet
243 Siprofloksasin tablet (Etaflox 500 mg) Tablet
244 Streptomisin Sulfat serbuk inj. 1,0 g/ml (OAT FDC Kat.II) Vial
245 Sukralfat suspensi 500 mg/5 ml Botol
246 Sukralfat tablet 500 mg Tablet
247 Suplemen mata (Ocugard) Kapsul
248 Tetrasiklin HCl kapsul 250 mg Kapsul
249 Tetrasiklin HCl kapsul 500 mg Kapsul
250 Thiamfenikol 500 mg Kapsul
251 Thiamin HCl injeksi 100 mg/ml Vial
252 Thiamin HCl tablet 100 mg Tablet
253 Thiamin HCl tablet 50 mg Tablet
254 Tramadol injeksi Ampul
255 Tramadol kapsul 50 mg Tablet
256 Triheksifenidil 2 mg Tablet
257 Vaksin BCG Vial
258 Vaksin Campak Vial
259 Vaksin DPT HB Hib Vial
260 Vaksin Hepatitis B Hip Vial
261 Vaksin Polio (b0PV) Vial
262 Vaksin Td Vial
263 Vaksin TT Vial
264 Valproat sirup 250 mg/ml (Depakene) Botol
265 Valproat tab SR 250 mg (Depakote) Tablet
266 Valproat tab SR 500 mg (Depakote) Tablet
267 Vaksin Rabies Vero injeksi (Verorab) Set/kur
268 Vitamin B Kompleks injeksi 25 ml Ampul
269 Vitamin B Kompleks tablet Tablet
270 Vitamin Dewasa (Rovital Dragee) Tablet
271 Zinc pro drops 10 mg/ml (Zinc Elemental) Botol
272 Zinc 20 mg Tablet Tablet
273 Zinc tablet 20 mg (Zink Kid) Tablet
274 Zinc sirup 10 mg/5 ml Botol
275 Zinc sirup 20 mg/5 ml Botol

JUMLAH PENGELUARAN
NO NAMA OBAT SATUAN
I II III
1 2 3 4 5 6
II. BAHAN MEDIS HABIS PAKAI
1 Alat Suntik Sekali pakai 1 ml Stera Pcs
2 Alat Suntik Sekali pakai 2,5 ml Stera Pcs
3 Alat Suntik Sekali pakai 3 ml Stera Pcs
4 Alat Suntik Sekali pakai 5 ml Stera Pcs
5 Alat Suntik Sekali pakai 0,05 ml (Medeco Syringe) Pcs
6 Alat Suntik Sekali pakai 0,5 ml (Medeco Syringe) Pcs
7 Alkohol Swab Pcs
8 Ballon Chateter 2 Way FR 16 (Chroma) Pcs
9 Ballon Chateter 2 Way FR 18 (Chroma) Pcs
10 Baju Pelindung Pcs
11 Blood Lancet Box
12 Box Slide Buah
13 Catgut chromic No. 2/0 + Jarum Pcs
14 Catgut chromic No. 3/0 + Jarum Pcs
15 Etakridin (Rivanol) 0,1% 300 ml Botol
16 Etanol 70% 1000 ml Botol 1
17 Etanol 70% 300 ml Botol
18 Examination Glove Size S, M, L (Safeglove) Pcs 100
19 Examination Glove Size S, M, L (Mas) Pcs 100
20 Folley Chateter 2 way No. 16 (Urocare) Pcs
21 Folley Chateter Ped No. 10 (Urocare) Pcs
22 Folley Chateter Ped No. 6 (Urocare) Pcs
23 Folley Chateter Ped No. 8 (Urocare) Pcs
24 Handscoon Non Steril Lembar
25 Hospital Product Suction Chateter FR 8 Pcs
26 Hospital Product Suction Chateter FR 10 Pcs
27 Infusion Set Anak Pcs
28 Infusion Set Anak 60 drops/ml Stera Pcs
29 Infusion Set Dewasa pcs
30 Infusion Set Dewasa 20 drops/ml Pcs
31 IV Chateter No. 22 G (IV Cannula) Pcs
32 IV Chateter No. 24 G (IV Cannula) Pcs
33 IV Chateter No. 20 G (IV Cannula) Pcs
34 Kaca Slide Box
35 Kantong Plastik Berklip Lembar
36 Kapas Pembalut 100 gram Bungkus
37 Kapas Pembalut 250 gram Onemed Bungkus
38 Kapas Pembalut 500 gram Onemed Bungkus
39 Kasa Hidrofil Steril uk. 16 x 16 cm Onemed Kotak 8 6
40 Kasa Pembalut Hidrofil 4 m x 5 cm Onemed Roll
41 Kasa Kompres Steril 40 x 40 cm Onemed Lembar
42 Kasa Pembalut Hydrophil 4 m x 10 cm Roll
43 Kertas Perkamen Pcs
44 Lab Kit Malaria Kit
45 Masker (Face Masker) Lembar
46 Mikrotois Pcs
47 Nald Hecting Pcs
48 Oral/Nasal Tracheal Tube Cuffles I.D 2,5 mm Pcs
49 Oral/Nasal Tracheal Tube Cuffles I.D 3,0 mm Pcs
50 Oral/Nasal Tracheal Tube Cuffles I.D 4,0 mm Pcs
51 Plester 5 Yard x 2 inchi Pcs
52 Plester 5 cm x 4,5 m Roll
53 Povidon larutan iodine 10% 300 ml Botol
54 Povidon larutan iodine 10% 60 ml Botol
55 Povidon larutan iodine 10% 30 ml Botol
 56 Reagen Kit
57 Safety Box Pcs
58 Sarung Tangan steril 6,5 (Surgical Gloves Sterile) Pasang 10
59 Sarung Tangan steril 7 (Surgical Gloves Sterile) Pasang 5
60 Sarung Tangan steril 7,5 (Surgical Gloves Sterile) Pasang
61 Sarung Tangan Non Steril Lembar
62 Silk No. 3/0 + Jarum Pcs
63 Silk No. 3/0 + Jarum 1/2 GT 35 mm Pcs
64 Silk No. 2/0 + Jarum 1/2 GT 35 mm Pcs
65 Sputum pot Pcs
66 Surgical Mask 3 Ply Ear Loop Pcs 50
67 Surgical Mask 3 Ply Tie On Pcs
68 Umbilical Cord Klem Steril Onemed Pcs
69 Urine Bag Standard Steril 2 Lt Onemed Pcs
70 Wing Needle 23 G Onemed Pcs
III. PERBEKALAN KESEHATAN
1 Hand Rub 500 ml Botol
2 Lysol 1 Liter Botol 1

Ujung Batu III, Juni 2018

Yang Menerima : Yang Menyerahkan :

SANGKOT HARAHAP JUWARIYAH

NIP. NIP. 19860504 201101 2 030

Mengetahui / Menyetujui :
Kepala Puskesmas

H. KHAIRUL MUSLIM, S.Sos

NIP. 19640831 198703 1 003
AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
 10 30

AH PENGELUARAN
IV TOTAL KET
7 8 9
AH PENGELUARAN
IV TOTAL KET
7 8 9
 1

100
100

14
 10
5

50 100

Ujung Batu III, Juni 2018

Yang Menyerahkan :

JUWARIYAH
60504 201101 2 030