LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( L P L P O

NAMA PUSKESMAS :
KAB/KOTA : Lombok Barat
LAPORAN BULAN :
PERMINTAAN BULAN :

PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)

BAHAN MEDIS HABIS PAKAI (BMHP)

1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set

0 0 0
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set
0 0 0
3 Alat Suntik Sekali Pakai - 5 cc x 22G x 1 1/4" Set
0 0 0
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set
0 0 0
5 Alat Suntik Sekali Pakai - 20 cc Set
0 0 0
6 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set
0 0 0
Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35
7 Set
mm 0 0 0
8 Benang Operasi - Catgut Plain 3/0 + jarum 1/2 GT 35 mm Set
0 0 0
Benang Operasi - Catgut Chromic 3/0 + jarum 1/2 GT 35
9 Set
mm 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
10 Benang Operasi - Silk 2/0 + jarum 1/2 GT 35 mm Set
0 0 0
11 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set
0 0 0
12 Cover Glass 24 x 24 mm Pcs
0 0 0
13 Hand Scound Steril No 7 Pasang
0 0 0
14 Hand Scound Steril No 7,5 Pasang
0 0 0
15 Hand Scound Non Steril Ukuran L Lembar
0 0 0
16 Hand Scound Non Steril Ukuran M Lembar
0 0 0
17 Hand Scound Non Steril Ukuran S Lembar
0 0 0
18 Hand scound Obgyn Pasang
0 0 0
19 HYPAFIX 10 x 5 CM (pharmaplast) Pasang
0 0 0
20 Infus Set, IV, Wing needle - Infusion Set Pediatric (60 set
drops/ml) 0 0 0
21 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 set
drops/ml) 0 0 0
22 Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 mm buah
0 0 0
23 Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 1/4 " buah
0 0 0
24 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah
0 0 0
25 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah
0 0 0
26 Infus Set, IV, Wing needle - I.V Catheter No. 26 G x 1/2 " buah
0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
27 Infus Set, IV, Wing needle - Wing Needle 21G set
0 0 0
28 Infus Set, IV, Wing needle - Wing Needle 23G set
0 0 0
29 Infus Set, IV, Wing needle - Wing Needle 25G set
0 0 0
30 Infus Set, IV, Wing needle - Wing Needle 27G set
0 0 0
31 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll
0 0 0
32 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll
0 0 0
33 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm Lembar
0 0 0
34 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar
0 0 0
35 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 3 cm Roll
0 0 0
36 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 Roll
cm 0 0 0
37 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 15 Roll
cm 0 0 0
38 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 cm Roll
0 0 0
39 Mess 11 pcs
0 0 0
40 Mess 21 pcs
0 0 0
41 Mess 22 pcs
0 0 0
42 Nasal Kanula bayi pcs
0 0 0
43 Nasal Kanula anak pcs
0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
44 Nasal Kanula dewasa pcs
0 0 0
45 Nebulizer with mask anak pcs
0 0 0
46 Nebulizer with mask dewasa pcs
0 0 0
47 Pembalut Gips 3 Inci buah
0 0 0
48 PLESTER 5 YARDS X 2 INCHI Roll
0 0 0
49 Surgical Mask - 3 ply Tie on (tali) pcs
0 0 0
50 Surgical Mask - 3 ply Earloop (karet) pcs
0 0 0
51 Underpad 60 cm x 90 cm pcs
0 0 0
52 Urologi - Folley Catheter 2 way No. 16
pcs 0 0 0
53 Urologi - Folley Catheter 2 way No. 18
pcs 0 0 0
54 Urologi - Urine Bag Standard Steril 2 Lt (T Valve)
pcs 0 0 0
55 Jarum Jahit Bedah
Pcs 0 0 0

TABLET DAN SERBUK ORAL

56 Asam Asetilsalisilat (asetosal) tablet 80 mg

Tablet 0 0 0
57 Asam Asetilsalisilat (asetosal) tablet 100 mg
Tablet 0 0 0
58 Asetil N sistein 5 mg tablet
Tablet 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
59 Albendazol tablet/kapsul/kaplet 400 mg
Tablet 0 0 0
60 Alopurinol tablet/kapsul/kaplet 100 mg
Tablet 0 0 0
61 Alprazolam Tablet 1 mg
Tablet 0 0 0
62 Aminofilin tablet scored 200 mg
Tablet 0 0 0
63 Amitriptilin tablet salut 25 mg (HCl)
Tablet 0 0 0
64 Amlodipin tablet 5 mg
Tablet 0 0 0
65 Amoksisilin kapsul/kaplet/tablet scored 500 mg
Kaplet 0 0 0

66 Antasida DOEN I tablet kunyah, kombinasi : Aluminium

Hidroksida 200 mg Magnesium Hidroksida 200 mg
Tablet 0 0 0
67 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg
Tablet 0 0 0
68 Asam Askorbat (Vitamin C) tablet 250 mg
Tablet 0 0 0
69 Asam Askorbat (Vitamin C) tablet 50 mg
Tablet 0 0 0
70 Asam Folat tablet/kapsul/kaplet 1 mg
Tablet 0 0 0
71 Asam Mefenamat 500 mg tab
Kaplet 0 0 0
72 Asam Valproat 250 mg
Tablet 0 0 0
73 Asiklovir tablet/kapsul/kaplet 400 mg
Tablet 0 0 0
74 Attapulgit Tablet 600 mg
Tablet 0 0 0
75 Betahistin Mesilat Tablet 6 mg
Tablet 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
76 Bisakodil 5 mg (dulkolax)
Tablet 0 0 0
77 Bisoprolol 5 mg tab
Tablet 0 0 0
78 Clozapine 25 mg tab
Tablet 0 0 0
79 Clozapine 100 mg tab
Tablet 0 0 0
80 D H P TAB
Tablet 0 0 0
81 Deksametason tablet 0,5 mg
Tablet 0 0 0
82 Diazepam 2 mg tab
Tablet 0 0 0
83 Diazepam 5 mg tab
Tablet 0 0 0
84 Digoksin tablet 0,25 mg
Paket 0 0 0
85 Dimenhidrinat tablet 50 mg
Tablet 0 0 0
86 Domperidon tablet 10 mg
Tablet 0 0 0
87 Doksisiklin tablet/kapsul/kaplet 100 mg
Tablet 0 0 0
88 Efedrin Hcl 25 Mg tab
Tablet 0 0 0
89 Erythromycin 500 mg
Tablet 0 0 0
90 Fenitoin kapsul/kaplet 100 mg
Tablet 0 0 0
91 Fenitoin Natrium 30 mg kapsul
Kapsul 0 0 0
92 Fenobarbital tablet/kapsul/kaplet 100 mg
Kapsul 0 0 0
93 Fenobarbital tablet/kapsul/kaplet 30 mg
Kapsul 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
94 Fitomenadion (Vit.K1) tablet salut gula 10 mg
Tablet 0 0 0
95 Furosemid tablet 40 mg
Tablet 0 0 0
Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g
96 kalium klorida 0,30 g Trinatrium sitrat dihidrat 0,58 g
Glukosa Anhidrat 2,70 g
Sachet 0 0 0
97 Glibenklamid tablet 5 mg
Tablet 0 0 0
98 Glimepiride tablet 1 mg
Tablet 0 0 0
99 Glimepiride tablet 2 mg
Tablet 0 0 0
100 Griseofulvin tablet 125 mg
Tablet 0 0 0
101 Haloperidol tablet 1,5 mg
Tablet 0 0 0
102 Haloperidol tablet 5 mg
Tablet 0 0 0
103 Hidroklorotiazide tab 25 mg
Tablet 0 0 0
104 Hyocina N Butilbromid 10 mg tab
Tablet 0 0 0
105 Ibuprofen tablet 400 mg
Tablet 0 0 0
106 Isoniazid 100 mg (INH)
Tablet 0 0 0
107 Isosorbid Dinitrat Sub Lingual 5 mg
Tablet 0 0 0
108 Kalsium Laktat 500 mg
Tablet 0 0 0
109 Kaptopril tablet scored 12,5 mg
Tablet 0 0 0
110 Kaptopril tablet scored 25 mg
Tablet 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
111 Karbamazepin tablet 200 mg
Tablet 0 0 0
112 Ketokonzol Tablet 200 mg
Tablet 0 0 0
113 Kloramfenikol tablet/kapsul/kaplet 250 mg
Tablet 0 0 0
114 Klorfeniramini maleat tab 4 mg( ctm )
Tablet 0 0 0
115 Klorpromazin 100 mg tab (hcl)
Tablet 0 0 0
116 Kodeina 10 mg tab
Tablet 0 0 0
117 Kombinasi tablet salut : Besi (II) Fumarat 180 mg Asam
folat 0,4 mg (TTD) Tablet 0 0 0
118 Kotrimoksazol DOEN I (dewasa) kombinasi :
Sulfametoksazol 400 mg Trimetoprim 80 mg Tablet 0 0 0
119 Kotrimoksazol DOEN I (dewasa) Forte
Tablet 0 0 0
120 Kuinine tab salut selaput 222 mg
Tablet 0 0 0
121 Loratadin tablet 10 mg
Tablet 0 0 0
122 Metformin hcl tablet 500 mg
Tablet 0 0 0
123 Metilergometrin Maleat (Metilergometrin) tablet salut
0,125 mg Tablet 0 0 0
124 Metoklopramide tablet 10 mg
Tablet 0 0 0
125 Metronidazole 500 mg tab
Sachet 0 0 0
126 Natrium diklofenak 50 mg tab
Paket 0 0 0
127 Nifedipin tablet/kapsul 10 mg
Paket 0 0 0
128 Nistatin tablet salut 500.000 IU/ g
Paket 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
129 Oat Kat Anak FDC
Paket 0 0 0
130 Oat Kat Anak Komb
Paket 0 0 0
131 Oat Kat I Komb
Paket 0 0 0
132 Oat Kat I.3 FDC
kaplet 0 0 0
133 Oat Kat Ii FDC
Tablet 0 0 0
134 Oat Kat Sisipan FDC
Tablet 0 0 0
135 Omeprazol kapsul/kaplet 20 mg
Tablet 0 0 0
136 Parasetamol tablet 500 mg
Tablet 0 0 0
137 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl)
Tablet 0 0 0
138 Prednison tablet/kapsul/kaplet 5 mg
Tablet 0 0 0
139 Primakuin tablet 15 mg
Tablet 0 0 0
140 Propanolol 40 mg tab (hcl)
Tablet 0 0 0
141 Propiltiourasil 100 mg tab
Tablet 0 0 0
142 Ranitidin tablet 150 mg
Tablet 0 0 0
143 Risperidon Tablet 2 mg
Tablet 0 0 0
144 Retinol 100 000 iu kapsul (vit a biru) Kapsul
Lunak 0 0 0
145 Retinol 200 000 iu cap (vit a merah) Kapsul
Lunak 0 0 0
146 Salbutamol 4 mg tab
Tablet 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
147 Setirizin tablet 10 mg
Tablet 0 0 0
148 Simvastatin tablet 20 mg
Tablet 0 0 0
149 Siprofloksasin tablet 500 mg (sebagai HCl)
Tablet 0 0 0
150 Tetrasiklin 500 kapsul
Kapsul 0 0 0
151 Thiamin hcl 50 mg tab ( vit b1 )
Tablet 0 0 0
152 Triheksifenidil hcl 2 mg tab
Tablet 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
153 Vit b komplek tab
Tablet 0 0 0
154 Zinc tab 20 mg
Tablet 0 0 0

SYRUP

155 Amoksisilin sirup kering 125 mg/ 5 ml

Botol 0 0 0
156 Amoksisilin sirup kering forte 250 mg/5 ml
Botol 0 0 0
Antasida DOEN II suspensi, kombinasi : Aluminium
157 Hidroksida 200 mg/5 ml Magnesium Hidroksida 200 mg/5
ml
Botol 0 0 0
158 Domperidon syrup
Botol 0 0 0
159 Ferosulfat Syrup
Botol 0 0 0
160 Ibuprofen Suspensi 100 mg/ 5ml
Botol 0 0 0
161 Kaolin Pectin Syrup
Botol 0 0 0
162 Kloramfenikol suspensi 125 mg/ 5 ml
Botol 0 0 0

163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg +

Trimetoprim 40 mg / 5 ml Botol 0 0 0
164 Metoklopramide sirup 5 mg/ 5 ml
Botol 0 0 0
165 Metronidazol suspensi
Botol 0 0 0
166 Nistatin suspesi
Botol 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)

167 Parasetamol drop 100 mg/ml btl @15ml (60mg/0,6ml)

Botol 0 0 0
168 Parasetamol sirup 120 mg / 5 ml
Botol 0 0 0

INJEKSI

169 Aminofilin injeksi 24 mg/ml

Ampul 0 0 0
170 Ampisilin serbuk injeksi i.v. 1000 mg/vial
Vial 0 0 0
171 Artemeter Injeksi 80 Mg (artemeter injeksi 1 ml)

172 Artesunate Cairan Injeksi 60 Mg

173 Aqua Pro Inj steril

Vial 0 0 0
174 Deksametason injeksi i.v./i.m. 5 mg/ml
Ampul 0 0 0
175 Diazepam injeksi i.v./i.m 5 mg/ml
Ampul 0 0 0
176 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl)
Ampul 0 0 0
177 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml
Ampul 0 0 0
178 Fenitoin injeksi 50 mg/ml
Ampul 0 0 0
179 Fenobarbital injeksi i.m./i.v. 50 mg/ml
Ampul 0 0 0
180 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml
Ampul 0 0 0
181 Flufenazin decanoate injeksi 5 mg/ml
Ampul 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
182 Furosemid Inj Iv/Im 10 mg/Ml
Ampul 0 0 0
183 Gentamisin injeksi 40 mg/ ml
Ampul 0 0 0
184 Haloperidol Injeksi IV/IM 10 mg/ml
Ampul 0 0 0
185 Hyocina N Butilbromid Inj 20 mg
Ampul 0 0 0
186 Kalsium Glukonas Inj 100 mg/ml
Ampul 0 0 0
187 Kloramfenikol serb inj 1000 mg/mL
Vial 0 0 0
188 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml
Ampul 0 0 0
189 Lidokain injeksi 2% (HCL)
Ampul 0 0 0
190 Magnesium Sulfat 40 % Inj 25 ml
Vial 0 0 0
191 Metoklopramide INJ 5 mg/ml
Ampul 0 0 0
192 Metilergometrin Maleat injeksi 0,200 mg-1 ml
Ampul 0 0 0
193 Oksitosin injeksi 10 IU/ml
Ampul 0 0 0
194 Ranitidin inj 25 mg/2 ml
Ampul 0 0 0
195 Sianokobalamin (vitamin B12) injeksi 500 mcg
Ampul 0 0 0

OBAT KHUSUS
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)

196 Antihemoroid, kombinasi: bismut subgalat 150 mg

heksaklorofen 2,5 mg lidokain 10 mg seng oksida 120 mg
SUPP 0 0 0
197 Bisacodyl supp (dulcolax) 10 mg / Stolax supp
SUPP 0 0 0

198 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal)

TUBE 0 0 0
199 Microlax
TUBE 0 0 0
200 Nistatin Vaginal tab 100 000 iu/gr
TABLET 0 0 0
201 SABU I 5 ml
VIAL 0 0 0
202 Salbutamol (as sulphate) 2,5 mg/2,5 ml nebuls
Ampul 0 0 0
203 Serum ATS 1 500 IU
VIAL 0 0 0
204 Serum ATS 20.000 IU
VIAL 0 0 0

CAIRAN

205 Glukosa larutan infus 10 % steril

Botol 0 0 0
206 Glukosa larutan infus 40 % steril
Botol 0 0 0
207 Glukosa larutan infus 5 % steril
Botol 0 0 0
208 Nacl 0,9%
Botol 0 0 0
209 Ringer Laktat larutan infus
Botol 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)

OBAT LUAR

210 Antiseptik dan Disinfektan - alkohol 70% 100 ml

Botol 0 0 0
211 Antiseptik dan Disinfektan - alkohol 70% 1 liter
Botol 0 0 0
212 Bedak salisil serbuk 2%
Tube 0 0 0
213 Betametason Cream 0,1 %
Tube 0 0 0
214 Fenol Gliserol TT 10%
TUBE 0 0 0
215 Gentamicin SK 0,1%
Botol 0 0 0
216 Gentamicin Salep Mata 0,3%
Tube 0 0 0
217 Gentamisin Sulfat Tetes Mata
Tube 0 0 0
218 Hidrogen Peroksida Larutan 3%
Botol 0 0 0
219 Hidrokortison Cream 2,5 %
Tube 0 0 0
220 Ketokonazol Krim 2%
Tube 0 0 0
221 Kloramfenikol salep mata 1 %
Tube 0 0 0
222 Kloramfenikol teter telinnga 3 %
Botol 0 0 0
223 Oksimetazolin tetes hidung
Botol 0 0 0
224 Permetrin Cream 5%(anti scabies)
tube 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
225 Povidon Iodida larutan 10% 30 ml
Botol 0 0 0
226 Povidon Iodida larutan 10% 300 ml
Botol 0 0 0

227 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang

endap 4% Botol 0 0 0
228 Sulfadiazin Silver Salep
Kotak 0 0 0

OBAT GIGI

229 Devitalisasi Pasta ( non arsen )

Pot 0 0 0
230 Etil Klorida Spray
Botol 0 0 0
231 Eugenol Cairan
Botol 0 0 0
232 Glass Ionomer Cement Art
Botol 0 0 0
233 Kalsium Hidroksida Pasta
Pot 0 0 0
234 Klorfenol Kamfer Menthol (CHKM)
Botol 0 0 0

BAHAN LABORATORIUM

235 Carik Celup / Urin Tes 3 GPH

Stik 0 0 0
236 Carik Celup / Urin Tes 11 GPH
Stik 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
237 Hb Test Kit
Set 0 0 0
238 Kit Gol Darah
Set 0 0 0
239 Lart As Acetat
Botol 0 0 0
240 Lart Asam Klorida 0,1 N
Botol 0 0 0
241 Lart Barium Chlorida 10 %
Botol 0 0 0
242 Lart Benedict
Botol 0 0 0
243 Lart E D T A 10 %
Botol 0 0 0
244 Lart Etanol Asam
Botol 0 0 0
245 Lart Koh 10 %
Botol 0 0 0
246 Lart Nacl 0,9 %
Botol 0 0 0
247 Lart Natrium Citrat 3,8 %
Botol 0 0 0
248 Lart Rees Ecker
Botol 0 0 0
249 Lart Turk
Botol 0 0 0
250 Oil Emersi
Botol 0 0 0
251 PP Test
Stik 0 0 0
252 RDT Test Malaria
Stik 0 0 0
253 Stik Gula Darah
Stik 0 0 0
254 Stik Asam Urat
Stik 0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
255 Stik Kolesterol
Stik 0 0 0
256 Stik HBSAG
Stik 0 0 0
257 Stik HBSAG
Stik 0 0 0
258 widal Test
Set 0 0 0

TABLET DAN SERBUK ORAL

259 Ambroxol 30 mg tablet

Tablet 0 0 0
260 Haloperidol tablet 0,5 mg
Tablet 0 0 0
261 Kloramfenikol tablet/kapsul/kaplet 500 mg
Tablet 0 0 0
262 Mineral mix serbuk
Tablet 0 0 0
263 Multi micro nutrien
Tablet 0 0 0
264 Piroksikam 20 mg tab
Tablet 0 0 0
265 Thiampenikol kapsul 250 mg
Kapsul 0 0 0
266 Thiampenikol kapsul 500 mg
Kapsul 0 0 0

SIRUP
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
267 Ambroxol syrup 15 mg/ml
Botol 0 0 0
268 Multivitamin syrup
Botol 0 0 0
269 OBH Syrup
Botol 0 0 0

OBAT LUAR

270 Gentian violet larutan 1 %

Tube 0 0 0
271 Hexachlorocyclohexane 0,5% ((Peditox)
Botol 0 0 0
272 Ictyol salep hitam
Pot 0 0 0
273 Oksitetrasiklin sm 1%
Tube 0 0 0

OBAT KHUSUS

274 Parasetamol supp 80 mg

Suup 0 0 0
275 Parasetamol supp 125 mg
Suup 0 0 0
276 Parasetamol supp 160 mg
0 0 0
277 Parasetamol supp 250 mg
0 0 0
 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)
OBAT GIGI

278 Polikresulen (albotyl)

Botol 0 0 0
279 Semen seng fosfat serbuk +cairan
Pot 0 0 0
280 Temporary stopping fketcher serbuk+cairan (caviton)
Pot 0 0 0
281 Trikkresol formalin (TKF)
Botol 0 0 0

TAMBAHAN OBAT FORNAS

TAMBAHAN OBAT NON FORNAS

 PENERIMAAN
STOK TOTAL ED /
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SATUAN PEMAKAIAN SISA STOK
AWAL SUMBER DANA RUSAK
IFK PKM LAIN-LAIN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11)

UMUM
TIDAK BAYAR
JUMLAH KUNJUNGAN RESEP BAYAR
JKN UKS

Mengetahui Yang Menyerahkan Yang Menerima/ Melap

Kepala Dinas Kesehatan Kab. Lobar Kepala UPTD IFK Lobar Pemimpin UPT BLUD Puske

Drs. H Rachman Sahnan Putra M. Kes Hj. Bq. Endang Suprihartini, Msi.,Apt. ..................................
NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP.

KETERANGAN :
LEMBAR PERTAMA (ASLI) : IFK
LEMBAR KEDUA : DIKES LOBAR
LEMBAR KETIGA : ARSIP / PUSKESMAS
NOMOR 56 s/d 232 : OBAT FORNAS
TAMBAHAN FORNAS DAN NON FORNAS : URUTAN SESUAI ABJAD
LAIN-LAIN : DILUAR IFK DAN PKM
BAT ( L P L P O )
NO DOC :
TAHUN :
TANGGAL :

RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

0
 RATA-RATA PEMBERIAN
PEMBELIAN
PEMAKAIAN STOK OPT PERMINTAAN
SUMBER DANA PKM
PER BULAN JML
DAK DAU PROG
12 13 14=(13-11) 15 16 17 18 19

JUMLAH
S LAIN-LAIN
0

Yang Menerima/ Melapor Yang Menerima

Pemimpin UPT BLUD Puskesmas Pengelola Obat Puskesmas

................................... ..............................
NIP. NIP.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( L P L P O )
NAMA PUSKESMAS : APOTIK
KAB/KOTA : LOMBOK BARAT
LAPORAN BULAN : MEI
PERMINTAAN BULAN : JUNI

PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12

BAHAN MEDIS HABIS PAKAI (BMHP)

1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x Set

1/2" 0 0 0 0 0
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set
0 0 0 0 0
3 Alat Suntik Sekali Pakai - 5 cc x 22G x 1 1/4" Set
0 0 0 0 0
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set
0 0 0 0 0
5 Alat Suntik Sekali Pakai - 20 cc Set
0 0 0 0 0
6 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 Set
GT 35 mm 0 0 0 0 0
7 Benang Operasi - Catgut Chromic 2/0 + jarum
1/2 GT 35 mm Set
0 0 0 0 0
Benang Operasi - Catgut Plain 3/0 + jarum 1/2
8 GT 35 mm Set
0 0 0 0 0
9 Benang Operasi - Catgut Chromic 3/0 + jarum Set
1/2 GT 35 mm 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
Benang Operasi - Silk 2/0 + jarum 1/2 GT 35
10 mm Set
0 0 0 0 0
11 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 Set
mm 0 0 0 0 0
12 Blood Lancet Botol
0 0 0 0 0
13 Cover Glass 24 x 24 mm Pcs
0 0 0 0 0
14 Hand Scound Steril No 7 Pasang
0 0 0 0 0
15 Hand Scound Steril No 7,5 Pasang
0 0 0 0 0
16 Hand Scound Non Steril Ukuran L Lembar
0 0 0 0 0
17 Hand Scound Non Steril Ukuran M Lembar
0 0 0 0 0
18 Hand Scound Non Steril Ukuran S Lembar
0 0 0 0 0
19 Hand scound gynaecology non steril
0 0 0 0 0
20 Hand scound Obgyn Steril Pasang
0 0 0 0 0
21 Non Woven Dressing for Fixation 10 cm X 5 m Pasang
(hypafix) 0 0 0 0 0
Infus Set, IV, Wing needle - Infusion Set
22 Pediatric (60 drops/ml) set
0 0 0 0 0
23 Infus Set, IV, Wing needle - Infusion Set set
Dewasa (20 drops/ml) 0 0 0 0 0
24 Infus Set, IV, Wing needle - I.V Catheter No. 18 buah
G x 32 mm 0 0 0 0 0
25 Infus Set, IV, Wing needle - I.V Catheter No. 20 buah
G x 1 1/4 " 0 0 0 0 0
26 Infus Set, IV, Wing needle - I.V Catheter No. 22 buah
Gx1" 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
Infus Set, IV, Wing needle - I.V Catheter No. 24
27 G x 3/4 " buah
0 0 0 0 0
28 Infus Set, IV, Wing needle - I.V Catheter No. 26 buah
G x 1/2 " 0 0 0 0 0
29 Infus Set, IV, Wing needle - Wing Needle 21G set
0 0 0 0 0
30 Infus Set, IV, Wing needle - Wing Needle 23G set
0 0 0 0 0
31 Infus Set, IV, Wing needle - Wing Needle 25G set
0 0 0 0 0
32 Infus Set, IV, Wing needle - Wing Needle 27G set
0 0 0 0 0
Kasa, Verband, Kapas - Kasa Pembalut /
33 absorben 250 gr Roll
0 0 0 0 0
34 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 Roll
cm 0 0 0 0 0
35 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 Lembar
x 16 cm 0 0 0 0 0
36 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 Lembar
x 22 cm 0 0 0 0 0
37 Kasa, Verband, Kapas - Kasa Pembalut Roll
Hydrophil 4 x 3 cm 0 0 0 0 0
38 Kasa, Verband, Kapas - Kasa Pembalut Roll
Hydrophil 4 x 10 cm 0 0 0 0 0
Kasa, Verband, Kapas - Kasa Pembalut
39 Hydrophil 4 x 15 cm Roll
0 0 0 0 0
40 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 Roll
cm 0 0 0 0 0
41 Mess 11 pcs
0 0 0 0 0
42 Mess 21 pcs
0 0 0 0 0
43 Mess 22 pcs
0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
44 Nasal Kanula bayi pcs
0 0 0 0 0
45 Nasal Kanula anak pcs
0 0 0 0 0
46 Nasal Kanula dewasa pcs
0 0 0 0 0
47 Nebulizer with mask anak pcs
0 0 0 0 0
48 Nebulizer with mask dewasa pcs
0 0 0 0 0
49 Pembalut Gips 3 Inci buah
0 0 0 0 0
50 PLESTER 5 YARDS X 2 INCHI Roll
0 0 0 0 0
51 Surgical Mask - 3 ply Tie on (tali) pcs
0 0 0 0 0
52 Surgical Mask - 3 ply Earloop (karet) pcs
0 0 0 0 0
53 Underpad 60 cm x 90 cm pcs
0 0 0 0 0
54 Urologi - Folley Catheter 2 way No. 16
pcs 0 0 0 0 0
55 Urologi - Folley Catheter 2 way No. 18
pcs 0 0 0 0 0
Urologi - Urine Bag Standard Steril 2 Lt (T
56 Valve)
pcs 0 0 0 0 0
57 Jarum Jahit Bedah
Pcs 0 0 0 0 0

0 0
TABLET DAN SERBUK ORAL
0 0

0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
58 Asam Asetilsalisilat (asetosal) tablet 80 mg
Tablet 0 0 0 0 0
59 Asam Asetilsalisilat (asetosal) tablet 100 mg
Tablet 0 0 0 0 0
60 Asetil N sistein 5 mg tablet
Tablet 154 980 980 1134 490 644
61 Albendazol tablet/kapsul/kaplet 400 mg
Tablet 44 0 44 1 43
62 Alopurinol tablet/kapsul/kaplet 100 mg
Tablet 50 100 100 150 50 100
63 Alprazolam Tablet 1 mg
Tablet 40 100 100 140 70 70
64 Aminofilin tablet scored 200 mg
Tablet 0 0 0 0 0
65 Amitriptilin tablet salut 25 mg (HCl)
Tablet 90 0 90 0 90
66 Amlodipin tablet 5 mg
Tablet 145 0 145 30 115
67 Amoksisilin kapsul/kaplet/tablet scored 500 mg
Kaplet 491 1000 1000 1491 1024 467
Antasida DOEN I tablet kunyah, kombinasi :
68 Aluminium Hidroksida 200 mg Magnesium
Hidroksida 200 mg Tablet 502 400 400 902 585 317
69 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50
mg Tablet 0 0 0 0 0
70 Asam Askorbat (Vitamin C) tablet 250 mg
Tablet 0 0 0 0 0
71 Asam Askorbat (Vitamin C) tablet 50 mg
Tablet 415 300 300 715 80 635
72 Asam Folat tablet/kapsul/kaplet 1 mg
Tablet 35 100 100 135 25 110
73 Asam Mefenamat 500 mg tab
Kaplet 821 300 300 1121 520 601
74 Asam Valproat 250 mg
Tablet 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
75 Asiklovir tablet/kapsul/kaplet 400 mg
Tablet 119 0 119 35 84
76 Attapulgit Tablet 600 mg
Tablet 666 0 666 120 546
77 Betahistin Mesilat Tablet 6 mg
Tablet 134 0 134 10 124
78 Bisakodil 5 mg (dulkolax)
Tablet 30 0 30 0 30
79 Bisoprolol 5 mg tab
Tablet 0 0 0 0 0
80 Clozapine 25 mg tab
Tablet 0 0 0 0 0
81 Clozapine 100 mg tab
Tablet 0 0 0 0 0
82 D H P TAB
Tablet 4 0 4 0 4
83 Deksametason tablet 0,5 mg
Tablet 381 200 200 581 190 391
84 Diazepam 2 mg tab
Tablet 0 0 0 0 0
85 Diazepam 5 mg tab
Tablet 0 0 0 0 0
86 Digoksin tablet 0,25 mg
Paket 94 0 94 0 94
87 Dimenhidrinat tablet 50 mg
Tablet 126 0 126 0 126
88 Domperidon tablet 10 mg
Tablet 203 0 203 26 177
89 Doksisiklin tablet/kapsul/kaplet 100 mg
Tablet 0 0 0 0 0
90 Erythromycin 500 mg
Tablet 0 0 0 0 0
91 Fenitoin kapsul/kaplet 100 mg
Tablet 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
92 Fenitoin Natrium 30 mg kapsul
Kapsul 0 0 0 0 0
93 Fenobarbital tablet/kapsul/kaplet 100 mg
Kapsul 0 0 0 0 0
94 Fenobarbital tablet/kapsul/kaplet 30 mg
Kapsul 0 0 0 0 0
95 Fitomenadion (Vit.K1) tablet salut gula 10 mg
Tablet 47 100 100 147 45 102
96 Furosemid tablet 40 mg
Tablet 200 0 200 10 190
Garam Oralit I serbuk, kombinasi : Natrium
97 klorida 0,52 g kalium klorida 0,30 g Trinatrium
sitrat dihidrat 0,58 g Glukosa Anhidrat 2,70 g Sachet 123 100 100 223 116 107
98 Glibenklamid tablet 5 mg
Tablet 293 500 500 793 290 503
99 Glimepiride tablet 1 mg
Tablet 0 0 0 0 0
100 Glimepiride tablet 2 mg
Tablet 250 0 250 0 250
101 Griseofulvin tablet 125 mg
Tablet 180 0 180 0 180
102 Haloperidol tablet 0,5 mg
0 0 0 0 0
103 Haloperidol tablet 1,5 mg
Tablet 0 0 0 0 0
104 Haloperidol tablet 5 mg
Tablet 60 0 60 30 30
105 Hidroklorotiazide tab 25 mg
Tablet 0 0 0 0 0
106 Hyocina N Butilbromid 10 mg tab
Tablet 129 0 129 20 109
107 Ibuprofen tablet 400 mg
Tablet 0 0 0 0 0
108 Isoniazid 100 mg (INH)
Tablet 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
109 Isosorbid Dinitrat Sub Lingual 5 mg
Tablet 60 0 60 0 60
110 Kalsium Laktat 500 mg
Tablet 170 100 100 270 90 180
111 Kaptopril tablet scored 12,5 mg
Tablet 380 0 380 50 330
112 Kaptopril tablet scored 25 mg
Tablet 234 200 200 434 145 289
113 Karbamazepin tablet 200 mg
Tablet 90 0 90 0 90
114 Ketokonzol Tablet 200 mg
Tablet 110 0 110 10 100
115 Kloramfenikol tablet/kapsul/kaplet 250 mg
Tablet 0 0 0 0 0
116 Kloramfenikol tablet/kapsul/kaplet 500 mg
Tablet 495 0 495 40 455
117 Klorfeniramini maleat tab 4 mg( ctm )
Tablet 317 600 600 917 782 135
118 Klorpromazin 100 mg tab (hcl)
Tablet 0 0 0 0 0
119 Kodeina 10 mg tab
Tablet 0 0 0 0 0
120 Kombinasi tablet salut : Besi (II) Fumarat 180
mg Asam folat 0,4 mg (TTD) Tablet 70 300 300 370 145 225
Kotrimoksazol DOEN I (dewasa) kombinasi :
121 Sulfametoksazol 400 mg Trimetoprim 80 mg
Tablet 0 0 0 0 0
122 Kotrimoksazol DOEN I (dewasa) Forte
Tablet 0 0 0 0 0
123 Kuinine tab salut selaput 222 mg
Tablet 0 0 0 0 0
124 Loratadin tablet 10 mg
Tablet 0 0 0 0 0
125 Mineral mix serbuk
Tablet 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
126 Metformin hcl tablet 500 mg
Tablet 130 500 500 630 400 230
127 Metilergometrin Maleat (Metilergometrin)
tablet salut 0,125 mg Tablet 0 0 0 0 0
128 Metoklopramide tablet 10 mg
Tablet 273 0 273 66 207
129 Metronidazole 500 mg tab
Sachet 0 0 0 0 0
130 Natrium diklofenak 50 mg tab
Paket 260 0 260 30 230
131 Nifedipin tablet/kapsul 10 mg
Paket 267 0 267 20 247
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
132 Nistatin tablet salut 500.000 IU/ g
Paket 0 0 0 0 0
133 Oat Kat Anak FDC
Paket 0 0 0 0 0
134 Oat Kat Anak Komb
Paket 0 0 0 0 0
135 Oat Kat I Komb
Paket 0 0 0 0 0
136 Oat Kat I.3 FDC
kaplet 0 0 0 0 0
137 Oat Kat Ii FDC
Tablet 0 0 0 0 0
138 Oat Kat Sisipan FDC
Tablet 0 0 0 0 0
139 Omeprazol kapsul/kaplet 20 mg
Tablet 226 300 300 526 106 420
140 Parasetamol tablet 500 mg
Tablet 467 2000 2000 2467 1783 684
141 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10
mg (HCl) Tablet 156 0 156 101 55
142 Prednison tablet/kapsul/kaplet 5 mg
Tablet 244 0 244 0 244
143 Primakuin tablet 15 mg
Tablet 64 0 64 0 64
144 Propanolol 40 mg tab (hcl)
Tablet 0 0 0 0 0
145 Propiltiourasil 100 mg tab
Tablet 0 0 0 0 0
146 Ranitidin tablet 150 mg
Tablet 174 0 174 50 124
147 Risperidon Tablet 2 mg
Tablet 175 0 175 70 105
148 Retinol 100 000 iu kapsul (vit a biru) Kapsul
Lunak 49 0 49 0 49
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
149 Retinol 200 000 iu cap (vit a merah) Kapsul
Lunak 21 0 21 4 17
150 Salbutamol 4 mg tab
Tablet 47 300 300 347 105 242
151 Setirizin tablet 10 mg
Tablet 0 0 0 40 -40
152 Simvastatin tablet 20 mg
Tablet 165 0 165 0 165
153 Siprofloksasin tablet 500 mg (sebagai HCl)
Tablet 245 0 245 110 135
154 Tetrasiklin 500 kapsul
Kapsul 0 0 0 0 0
155 Thiamin hcl 50 mg tab ( vit b1 )
Tablet -35 0 -35 55 -90
156 Triheksifenidil hcl 2 mg tab
Tablet 100 0 100 0 100
157 Vit B Komplek tab
Tablet 430 500 500 930 579 351
158 Zinc tab 20 mg
Tablet 392 0 392 90 302

0 0
SYRUP
0 0

0 0
159 Amoksisilin sirup kering 125 mg/ 5 ml
Botol 48 0 48 40 8
160 Amoksisilin sirup kering forte 250 mg/5 ml
Botol 0 0 0 0 0
Antasida DOEN II suspensi, kombinasi :
161 Aluminium Hidroksida 200 mg/5 ml
Magnesium Hidroksida 200 mg/5 ml Botol 6 14 14 20 8 12
162 Domperidon syrup
Botol 15 0 15 4 11
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
163 Ferosulfat Syrup
Botol 0 0 0 0 0
164 Ibuprofen Suspensi 100 mg/ 5ml
Botol 4 50 50 10 3 7
165 Kaolin Pectin Syrup
Botol 0 0 0 0 0
166 Kloramfenikol suspensi 125 mg/ 5 ml
Botol 0 0 0 0 0
167 Kotrimoksazol Suspensi komb: Sulfametoksazol
200 mg + Trimetoprim 40 mg / 5 ml Botol 47 0 47 10 37
168 Metoklopramide sirup 5 mg/ 5 ml
Botol 6 0 6 7 -1
169 Metronidazol suspensi
Botol 0 0 0 0 0
170 Nistatin suspesi
Botol 0 0 0 0 0
171 Parasetamol drop 100 mg/ml btl @15ml
(60mg/0,6ml) Botol 0 0 0 0 0
172 Parasetamol sirup 120 mg / 5 ml
Botol 48 70 70 118 93 25

0 0
INJEKSI
0 0

0 0
173 Aminofilin injeksi 24 mg/ml
Ampul 0 0 0 0 0
174 Ampisilin serbuk injeksi i.v. 1000 mg/vial
Vial 0 0 0 0 0
175 Artemeter Injeksi 80 Mg (artemeter injeksi 1
ml) Ampul 0 0 0 0 0
176 Artesunate Cairan Injeksi 60 Mg
Ampul 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
177 Atropin 0,25 mg/ml injeksi
Ampul 0 0 0 0 0
178 Aqua Pro Inj steril
Vial 0 0 0 0 0
179 Deksametason injeksi i.v./i.m. 5 mg/ml
Ampul 0 0 0 0 0
180 Diazepam injeksi i.v./i.m 5 mg/ml
Ampul 0 0 0 0 0
181 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl)
Ampul 0 0 0 0 0
182 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1
mg/ml Ampul 0 0 0 0 0
183 Fenitoin injeksi 50 mg/ml
Ampul 0 0 0 0 0
184 Fenobarbital injeksi i.m./i.v. 50 mg/ml
Ampul 0 0 0 0 0
185 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml
Ampul 0 0 0 0 0
186 Flufenazin decanoate injeksi 5 mg/ml
Ampul 0 0 0 0 0
187 Furosemid Inj Iv/Im 10 mg/Ml
Ampul 0 0 0 0 0
188 Gentamisin injeksi 40 mg/ ml
Ampul 0 0 0 0 0
189 Haloperidol Injeksi IV/IM 10 mg/ml
Ampul 0 0 0 0 0
190 Hyocina N Butilbromid Inj 20 mg
Ampul 0 0 0 0 0
191 Kalsium Glukonas Inj 100 mg/ml
Ampul 0 0 0 0 0
192 Ketorolax Injeksi 30 mg/ ml
Ampul 0 0 0 0 0
193 Kloramfenikol serb inj 1000 mg/mL
Vial 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000
194 - 2ml
Ampul 0 0 0 0 0
195 Lidokain injeksi 2% (HCL)
Ampul 0 0 0 0 0
196 Magnesium Sulfat 20 % Inj 25 ml
0 0 0 0 0
197 Magnesium Sulfat 40 % Inj 25 ml
Vial 0 0 0 0 0
198 Metamizol inj 500 mg/ml
Ampul 0 0 0 0 0
199 Metoklopramide INJ 5 mg/ml
Ampul 0 0 0 0 0
200 Metilergometrin Maleat injeksi 0,200 mg-1 ml
Ampul 0 0 0 0 0
201 Oksitosin injeksi 10 IU/ml
Ampul 0 0 0 0 0
202 Ranitidin inj 25 mg/2 ml
Ampul 0 0 0 0 0
203 Sianokobalamin (vitamin B12) injeksi 500 mcg
Ampul 0 0 0 0 0

0 0
OBAT KHUSUS
0 0

0 0
Antihemoroid, kombinasi: bismut subgalat 150
204 mg heksaklorofen 2,5 mg lidokain 10 mg seng
oksida 120 mg SUPP 0 3 3 3 3 0
205 Bisacodyl supp (dulcolax) 5 mg / Stolax supp
SUPP 0 0 0 0 0
206 Bisacodyl supp (dulcolax) 10 mg / Stolax supp
SUPP 0 0 0 0 0
207 Diazepam larutan rektal 5 mg/2,5 mL (stesolit
rectal) TUBE 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
208 Nistatin Vaginal tab 100 000 iu/gr
TABLET 0 0 0 0 0
209 SABU I 5 ml
VIAL 0 0 0 0 0
210 Salbutamol (as sulphate) 2,5 mg/2,5 ml nebuls
Ampul 0 0 0 0 0
211 Serum ATS 1 500 IU
VIAL 0 0 0 0 0
212 Serum ATS 20.000 IU
VIAL 0 0 0 0 0
213 Vaksin Rabies Inj 2,5 IU
0 0 0 0 0

0 0
CAIRAN
0 0

0 0
214 Glukosa larutan infus 10 % steril
Botol 0 0 0 0 0
215 Glukosa larutan infus 40 % steril
Botol 0 0 0 0 0
216 Glukosa larutan infus 5 % steril
Botol 0 0 0 0 0
217 Nacl 0,9%
Botol 0 0 0 0 0
218 Ringer Laktat larutan infus
Botol 0 0 0 0 0

0 0
OBAT LUAR
0 0

0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
Antiseptik dan Disinfektan - alkohol 70% 100
219 ml
Botol 0 0 0 0 0
220 Antiseptik dan Disinfektan - alkohol 70% 1 liter
Botol 0 0 0 0 0
221 Bedak salisil serbuk 2%
Tube 0 0 0 0 0
222 Betametason Cream 0,1 %
Tube 36 0 36 6 30
223 Fenol Gliserol TT 10%
TUBE 1 0 1 1 0
224 Gentamicin SK 0,1%
Botol 8 40 40 48 30 18
225 Gentamicin Salep Mata 0,3%
Tube 18 0 18 2 16
226 Gentamisin Sulfat Tetes Mata
Tube 25 0 25 8 17
227 Hidrogen Peroksida Larutan 3%
Botol 0 0 0 0 0
228 Hidrokortison Cream 2,5 %
Tube 6 0 6 0 6
229 Ketokonazol Krim 2%
Tube 9 0 9 2 7
230 Kloramfenikol salep mata 1 %
Tube 24 0 24 7 17
231 Kloramfenikol teter telinnga 3 %
Botol 8 10 10 18 2 16
232 Oksimetazolin tetes hidung
Botol 0 0 0 0 0
233 Permetrin Cream 5%(anti scabies)
tube 0 0 0 0 0
234 Povidon Iodida larutan 10% 30 ml
Botol 0 0 0 0 0
235 Povidon Iodida larutan 10% 300 ml
Botol 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
Salep 2-4 , Kombinasi : Asam Salisilat 2% +
236 Belerang endap 4%
Botol 13 0 13 3 10
237 Sulfadiazin Silver Salep
Kotak 0 0 0 0 0

0 0
OBAT GIGI
0 0

0 0
238 Devitalisasi Pasta ( non arsen )
Pot 0 0 0 0 0
239 Etil Klorida Spray
Botol 0 0 0 0 0
240 Eugenol Cairan
Botol 0 0 0 0 0
241 Glass Ionomer Cement Art
Botol 0 0 0 0 0
242 Kalsium Hidroksida Pasta
Pot 0 0 0 0 0
243 Klorfenol Kamfer Menthol (CHKM)
Botol 0 0 0 0 0
244 Polikresulen (albotyl)
Botol 0 0 0 0 0
245 Semen seng fosfat serbuk +cairan
Pot 0 0 0 0 0
246 Temporary stopping fketcher serbuk+cairan
(caviton) Pot 0 0 0 0 0
247 Trikkresol formalin (TKF)
Botol 0 0 0 0 0

0 0
BAHAN LABORATORIUM
0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12

0 0
248 Carik Celup / Urin Tes 3 GPH
Stik 0 0 0 0 0
249 Carik Celup / Urin Tes 11 GPH
Stik 0 0 0 0 0
250 Hb Test Kit
Set 0 0 0 0 0
251 Kartu golongan darah
Lembar 0 0 0 0 0
252 Kit Gol Darah
Set 0 0 0 0 0
253 Lart As Acetat
Botol 0 0 0 0 0
254 Lart asam klorida 0,1%
Botol 0 0 0 0 0
255 Lart Asam Klorida 0,1 N
Botol 0 0 0 0 0
256 Lart Barium Chlorida 10 %
Botol 0 0 0 0 0
257 Lart Benedict
Botol 0 0 0 0 0
258 Lart E D T A 10 %
Botol 0 0 0 0 0
259 Lart Etanol Asam
Botol 0 0 0 0 0
260 Lart Koh 10 %
Botol 0 0 0 0 0
261 Lart Nacl 0,9 %
Botol 0 0 0 0 0
262 Lart Natrium Citrat 3,8 %
Botol 0 0 0 0 0
263 Lart Rees Ecker
Botol 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
264 Lart Turk
Botol 0 0 0 0 0
265 Oil Emersi
Botol 0 0 0 0 0
266 PP Test
Stik 0 0 0 0 0
267 Reagen ABX Minidil Lmg
Paket 0 0 0 0 0
268 Reagen ABC Minilyse Lmg
Paket 0 0 0 0 0
269 Reagen ABX Miniclean
Paket 0 0 0 0 0
270 Reagen ABX Minotrol
Paket 0 0 0 0 0
271 Stik Gula Darah
Stik 0 0 0 0 0
272 Stik Asam Urat
Stik 0 0 0 0 0
273 Stik Kolesterol
Stik 0 0 0 0 0
274 Stik HBSAG
Stik 0 0 0 0 0
275 Stik HBSAG
Stik 0 0 0 0 0
276 widal Test
Set 0 0 0 0 0

0 0
OBAT NON FORNAS
0 0

0 0
277 Ambroxol 30 mg tablet
Tablet 0 0 0 10 -10
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
278 Asam tranexamat tablet 500 mg
Tablet 0 0 0 0 0
279 Gliseryl guaiakolat 100 mg tab
Tablet 89 200 200 289 249 40
280 Loperamid tab 2 mg
Tablet 0 0 0 0 0
281 Multi micro nutrien
Tablet 0 0 0 0 0
282 Piroksikam 20 mg tab
Tablet 123 0 123 56 67
283 Thiampenikol kapsul 250 mg
Kapsul 0 0 0 0 0
284 Thiampenikol kapsul 500 mg
Kapsul 0 0 0 0 0

0 0
SIRUP
0 0

0 0
285 Ambroxol syrup 15 mg/ml
Botol 26 20 20 46 23 23
286 Multivitamin syrup
Botol 17 0 17 17 0

0 0
IJNEKSI
0 0

0 0
287 Asam tranexamat injeksi 50 mg / ml
Ampul 0 0 0 0 0
288 Ondansetron Injeksi 2 mg/ ml (4 mg/2 ml)
Ampul 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12

0 0
OBAT LUAR
0 0

0 0
289 Asiklovir krim 5 %
Tube 31 0 31 2 29
290 Bedak Salisil serbuk 2 %
12 0 12 0 12
291 Gentian violet larutan 1 %
Tube 0 0 0 0 0
292 Hexachlorocyclohexane 0,5% ((Peditox)
Botol 0 0 0 0 0
293 Ictyol salep hitam
Pot 0 0 0 0 0
294 Oksitetrasiklin SK 3%
Tube 46 0 46 3 43
295 Oksitetrasiklin sm 1%
Tube 25 0 25 0 25
296 Salep luka bakar ( bioplacenton )
Tube 1 0 1 0 1

0 0
OBAT KHUSUS
0 0

0 0
297 Parasetamol supp 80 mg
Suup 0 0 0 0 0
298 Parasetamol supp 125 mg
Suup 2 0 2 0 2
299 Parasetamol supp 160 mg
Suup 0 0 0 0 0
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12
300 Parasetamol supp 250 mg
Suup 0 0 0 0 0

0 0

TAMBAHAN OBAT FORNAS 0 0

CAVIPLEK 68 100 68 30 38

CAMABION 258 0 258 170 88

OBH SIRUP 0 0 0 5 -5

KLORAMFENICOL SALEP KULIT 24 0 24 0 24

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0

TAMBAHAN OBAT NON FORNAS 0 0

0 0
Kasa, Verband, Kapas - Kasa Hydrophil 40 x 40
1 cm 0 0 0 0 0

2 Baby Cough Syrup 60 ml 8 0 8 2 6

3 Demacolin Tablet 70 0 70 0 70
 PENERIMAAN RATA-RATA
SATUA STOK TOTAL PEMAKAIA ED / PEMAKAIA
PENERIMAAN PERSEDIAAN
NO NAMA OBAT SISA STOK
N AWAL SUMBER DANA N RUSAK N PER
IFK PKM LAIN-LAIN BULAN
1 2 3 4 5 6 7 8=(5+6+7) 9=(4+7) 10 11 12=(9-10-11) 12

4 Rohto Tetes Mata 8 0 8 0 8

UMUM
TIDAK BAYAR
JUMLAH KUNJUNGAN RESEP BAYAR
JKN UKS
292 414 5

Mengetahui Yang Memberi Yang Menerima dan Mel

pemimpin UPT Puskesmas petugas gudang obat puskesmas Petugas Apotek

NS.Akhmad juaini S.kep lalu syarif hidayatullah,Amd. Far lalu syarif hidayatullah,Amd. Fa
NIP. 197221231 199203 1 026 NIP :19881023 201001 1 006 NIP :19881023 201001 1 006

KETERANGAN :
LEMBAR PERTAMA (ASLI) : IFK
LEMBAR KEDUA : DIKES LOBAR
LEMBAR KETIGA : ARSIP / PUSKESMAS
NOMOR 58 s/d 247 : OBAT FORNAS
TAMBAHAN FORNAS DAN NON FORNAS : URUTAN SESUAI ABJAD
LAIN-LAIN : DILUAR IFK DAN PKM
LPLPO)
NO DOC :
TAHUN :2019
TANGGAL : 24 MEI 2019

PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0 0

0 0

870.7 227

1.8 -41

88.8 100

124.4 100

0.0 0

0.0 -90

53.3 -62

1819.6 1353

1039.5 500

0.0 0

0.0 0

142.2 500

44.4 100

924.0 323

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

62.2 -22

213.2 200

17.8 -106

0.0 -30

0.0 0

0.0 0

0.0 0

0.0 -4

337.6 200

0.0 0

0.0 0

0.0 -94

0.0 -126

46.2 -131

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

80.0 200

17.8 -172

206.1 100

515.3 500

0.0 0

0.0 -250

0.0 -180

0.0 0

0.0 0

53.3 23

0.0 0

35.5 -73

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 -60

159.9 -20

88.8 -241

257.7 -31

0.0 -90

17.8 -82

0.0 0

71.1 -384

1389.6 1255

0.0 0

0.0 0

257.7 33

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

710.8 481

0.0 0

117.3 -90

0.0 0

53.3 -177

35.5 -211
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

188.4 -232

3168.3 2484

179.5 200

0.0 -244

0.0 -64

0.0 0

0.0 0

88.8 -35

124.4 100

0.0 -49
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

7.1 -10

186.6 500

71.1 111

0.0 -165

195.5 60

0.0 0

97.7 200

0.0 -100

1028.8 678

159.9 -142

0.0 0

0.0 0

0.0 0

71.1 63

0.0 0

14.2 20

7.1 -4
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

5.3 -2

0.0 0

0.0 0

17.8 -19

12.4 13

0.0 0

0.0 0

0.0 0

165.3 140

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

5.3 5

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

10.7 -19

1.8 2

53.3 35

3.6 -12

14.2 -3

0.0 0

0.0 -6

3.6 -3

12.4 -5

3.6 -12

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

5.3 -5

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

17.8 28
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

442.5 402

0.0 0

0.0 0

99.5 33

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

40.9 18

30.2 30

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

3.6 -25

0.0 -12

0.0 0

0.0 0

0.0 0

5.3 -38

0.0 -25

0.0 -1

0.0 0

0.0 0

0.0 0

0.0 0

0.0 -2

0.0 0
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 0

0.0 0

0.0 0

53.3 15

302.1 214

8.9 14

0.0 -24

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

0.0 0

3.6 -2

0.0 -70
 PEMBERIAN
PEMBELIA
STOK OPT PERMINTAAN
SUMBER DANA N PKM
JML
DAK DAU PROG
13 14=(13-11) 15 16 17 18 19

0.0 -8

JUMLAH
LAIN-LAIN
15 726

Yang Menerima dan Melaporkan

Petugas Apotek

syarif hidayatullah,Amd. Far

:19881023 201001 1 006
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS : EYAT MAYANG

KAB / KOTA : LOMBOK BARAT
LAPORAN PERIODE / BULAN : MEI
PERMINTAAN PERIODE / BULAN : JUNI

N0 NAMA OBAT SATUAN STOK AWAL

24 25 26 27 28 29

ALAT KESEHATAN

Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set

1
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set
3 Alat Suntik Sekali Pakai - 5 cc x 22G x 1 1/4" Set
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set
5 Alat Suntik Sekali Pakai - 20 cc Set
Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 Set
6 mm
Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT Set
7 35 mm
Benang Operasi - Catgut Plain 3/0 + jarum 1/2 GT 35 Set
8 mm
Benang Operasi - Catgut Chromic 3/0 + jarum 1/2 GT Set
9 35 mm
10 Benang Operasi - Silk 2/0 + jarum 1/2 GT 35 mm Set
11 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set
12 Blood Lancet Botol
13 Cover Glass 24 x 24 mm Pcs
14 Hand Scound Steril No 7 Pasang
15 Hand Scound Steril No 7,5 Pasang
16 Hand Scound Non Steril Ukuran L Lembar
17 Hand Scound Non Steril Ukuran M Lembar
18 Hand Scound Non Steril Ukuran S Lembar
19 Hand scound gynaecology non steril
20 Hand scound Obgyn Steril Pasang
Non Woven Dressing for Fixation 10 cm X 5 m Pasang
21 (hypafix)
Infus Set, IV, Wing needle - Infusion Set Pediatric (60 set
22 drops/ml)
Infus Set, IV, Wing needle - Infusion Set Dewasa (20 set
23 drops/ml)
Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 buah
24 mm
Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 buah
25 1/4 "

Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah
26
Infus Set, IV, Wing needle - I.V Catheter No. 24 G x buah
27 3/4 "
Infus Set, IV, Wing needle - I.V Catheter No. 26 G x buah
28 1/2 "
29 Infus Set, IV, Wing needle - Wing Needle 21G set
30 Infus Set, IV, Wing needle - Wing Needle 23G set
31 Infus Set, IV, Wing needle - Wing Needle 25G set
32 Infus Set, IV, Wing needle - Wing Needle 27G set
Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 Roll
33 gr
 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll
34
Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 Lembar
35 cm
Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 Lembar
36 cm
Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 3 Roll
37 cm
Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x Roll
38 10 cm
Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x Roll
39 15 cm
40 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 cm Roll
41 Mess 11 pcs
42 Mess 21 pcs
43 Mess 22 pcs
44 Nasal Kanula bayi pcs
45 Nasal Kanula anak pcs
46 Nasal Kanula dewasa pcs
47 Nebulizer with mask anak pcs
48 Nebulizer with mask dewasa pcs
49 Pembalut Gips 3 Inci buah
50 PLESTER 5 YARDS X 2 INCHI Roll
51 Surgical Mask - 3 ply Tie on (tali) pcs
52 Surgical Mask - 3 ply Earloop (karet) pcs
53 Underpad 60 cm x 90 cm pcs
54 Urologi - Folley Catheter 2 way No. 16 pcs
55 Urologi - Folley Catheter 2 way No. 18 pcs
56 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs
57 Jarum Jahit Bedah Pcs
 TABLET DAN SERBUK ORAL

58 Asam Asetilsalisilat (asetosal) tablet 80 mg Tablet

59 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet
60 Asetil N sistein 5 mg tablet Tablet 30 50 30 30 30
61 Albendazol tablet/kapsul/kaplet 400 mg Tablet
62 Alopurinol tablet/kapsul/kaplet 100 mg Tablet 40
63 Alprazolam Tablet 1 mg Tablet 20
64 Aminofilin tablet scored 200 mg Tablet
65 Amitriptilin tablet salut 25 mg (HCl) Tablet
66 Amlodipin tablet 5 mg Tablet 20
67 Amoksisilin kapsul/kaplet/tablet scored 500 mg Kaplet 45 99 22 88 57
Antasida DOEN I tablet kunyah, kombinasi :
Aluminium Hidroksida 200 mg Magnesium Hidroksida
68
200 mg Tablet 20 30 30 40

Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg

69 Tablet
70 Asam Askorbat (Vitamin C) tablet 250 mg Tablet
71 Asam Askorbat (Vitamin C) tablet 50 mg Tablet 20 2 10
72 Asam Folat tablet/kapsul/kaplet 1 mg Tablet 15 10
73 Asam Mefenamat 500 mg tab Kaplet 60 30 60 30
74 Asam Valproat 250 mg Tablet
75 Asiklovir tablet/kapsul/kaplet 400 mg Tablet
76 Attapulgit Tablet 600 mg Tablet 10 10
77 Betahistin Mesilat Tablet 6 mg Tablet
78 Bisakodil 5 mg (dulkolax) Tablet
79 Bisoprolol 5 mg tab Tablet
80 Clozapine 25 mg tab Tablet
81 Clozapine 100 mg tab Tablet
82 D H P TAB Tablet
83 Deksametason tablet 0,5 mg Tablet 32 33 20 5 10
84 Diazepam 2 mg tab Tablet
85 Diazepam 5 mg tab Tablet
86 Digoksin tablet 0,25 mg Paket
87 Dimenhidrinat tablet 50 mg Tablet
88 Domperidon tablet 10 mg Tablet 6
89 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet
90 Erythromycin 500 mg Tablet
91 Fenitoin kapsul/kaplet 100 mg Tablet
92 Fenitoin Natrium 30 mg kapsul Kapsul
93 Fenobarbital tablet/kapsul/kaplet 100 mg Kapsul
94 Fenobarbital tablet/kapsul/kaplet 30 mg Kapsul
95 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet
96 Furosemid tablet 40 mg Tablet
Garam Oralit I serbuk, kombinasi : Natrium klorida
0,52 g kalium klorida 0,30 g Trinatrium sitrat dihidrat
97
0,58 g Glukosa Anhidrat 2,70 g Sachet 11
98 Glibenklamid tablet 5 mg Tablet 30 60
99 Glimepiride tablet 1 mg Tablet
100 Glimepiride tablet 2 mg Tablet
101 Griseofulvin tablet 125 mg Tablet
102 Haloperidol tablet 0,5 mg
103 Haloperidol tablet 1,5 mg Tablet
104 Haloperidol tablet 5 mg Tablet 30
105 Hidroklorotiazide tab 25 mg Tablet
106 Hyocina N Butilbromid 10 mg tab Tablet
107 Ibuprofen tablet 400 mg Tablet
108 Isoniazid 100 mg (INH) Tablet
109 Isosorbid Dinitrat Sub Lingual 5 mg Tablet
110 Kalsium Laktat 500 mg Tablet 10 30 10
111 Kaptopril tablet scored 12,5 mg Tablet 10
112 Kaptopril tablet scored 25 mg Tablet 10 15 20 10
113 Karbamazepin tablet 200 mg Tablet
114 Ketokonzol Tablet 200 mg Tablet
115 Kloramfenikol tablet/kapsul/kaplet 250 mg Tablet
116 Kloramfenikol tablet/kapsul/kaplet 500 mg Tablet
117 Klorfeniramini maleat tab 4 mg( ctm ) Tablet 34 76 28 18 36
118 Klorpromazin 100 mg tab (hcl) Tablet
119 Kodeina 10 mg tab Tablet
Kombinasi tablet salut : Besi (II) Fumarat 180 mg
120 Asam folat 0,4 mg (TTD) Tablet 10 20 10 15
Kotrimoksazol DOEN I (dewasa) kombinasi :
121 Sulfametoksazol 400 mg Trimetoprim 80 mg Tablet
122 Kotrimoksazol DOEN I (dewasa) Forte Tablet
123 Kuinine tab salut selaput 222 mg Tablet
124 Loratadin tablet 10 mg Tablet
125 Mineral mix serbuk Tablet
126 Metformin hcl tablet 500 mg Tablet 30 30 30 30
Metilergometrin Maleat (Metilergometrin) tablet
127 salut 0,125 mg Tablet
128 Metoklopramide tablet 10 mg Tablet 10
129 Metronidazole 500 mg tab Sachet
130 Natrium diklofenak 50 mg tab Paket
131 Nifedipin tablet/kapsul 10 mg Paket
132 Nistatin tablet salut 500.000 IU/ g Paket
133 Oat Kat Anak FDC Paket
134 Oat Kat Anak Komb Paket
135 Oat Kat I Komb Paket
136 Oat Kat I.3 FDC kaplet
137 Oat Kat Ii FDC Tablet
138 Oat Kat Sisipan FDC Tablet
139 Omeprazol kapsul/kaplet 20 mg Tablet 5 10
140 Parasetamol tablet 500 mg Tablet 74 165 45 103 80
Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg
141 (HCl) Tablet 26 10 15
142 Prednison tablet/kapsul/kaplet 5 mg Tablet
143 Primakuin tablet 15 mg Tablet
144 Propanolol 40 mg tab (hcl) Tablet
145 Propiltiourasil 100 mg tab Tablet
146 Ranitidin tablet 150 mg Tablet 6
147 Risperidon Tablet 2 mg Tablet 20
148 Retinol 100 000 iu kapsul (vit a biru) Kapsul Lunak
149 Retinol 200 000 iu cap (vit a merah) Kapsul Lunak
150 Salbutamol 4 mg tab Tablet 2 12 5 10 10
151 Setirizin tablet 10 mg Tablet 10 10
152 Simvastatin tablet 20 mg Tablet
153 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 10 20
154 Tetrasiklin 500 kapsul Kapsul
155 Thiamin hcl 50 mg tab ( vit b1 ) Tablet 10
156 Triheksifenidil hcl 2 mg tab Tablet
157 Vit B Komplek tab Tablet 20 35 25 30 40
158 Zinc tab 20 mg Tablet 10

SYRUP

159 Amoksisilin sirup kering 125 mg/ 5 ml Botol 5 1 2 1 1

160 Amoksisilin sirup kering forte 250 mg/5 ml Botol
 Antasida DOEN II suspensi, kombinasi : Aluminium
Hidroksida 200 mg/5 ml Magnesium Hidroksida 200
161
mg/5 ml Botol
162 Domperidon syrup Botol
163 Ferosulfat Syrup Botol
164 Ibuprofen Suspensi 100 mg/ 5ml Botol
165 Kaolin Pectin Syrup Botol
166 Kloramfenikol suspensi 125 mg/ 5 ml Botol
Kotrimoksazol Suspensi komb: Sulfametoksazol 200
167 mg + Trimetoprim 40 mg / 5 ml Botol 2
168 Metoklopramide sirup 5 mg/ 5 ml Botol 1
169 Metronidazol suspensi Botol
170 Nistatin suspesi Botol
Parasetamol drop 100 mg/ml btl @15ml
171 (60mg/0,6ml) Botol
172 Parasetamol sirup 120 mg / 5 ml Botol 3 4 5 4 1

INJEKSI

173 Aminofilin injeksi 24 mg/ml Ampul

174 Ampisilin serbuk injeksi i.v. 1000 mg/vial Vial
175 Artemeter Injeksi 80 Mg (artemeter injeksi 1 ml) Ampul
176 Artesunate Cairan Injeksi 60 Mg Ampul
177 Atropin 0,25 mg/ml injeksi Ampul
178 Aqua Pro Inj steril Vial
179 Deksametason injeksi i.v./i.m. 5 mg/ml Ampul
180 Diazepam injeksi i.v./i.m 5 mg/ml Ampul
181 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul
182 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul
183 Fenitoin injeksi 50 mg/ml Ampul
184 Fenobarbital injeksi i.m./i.v. 50 mg/ml Ampul
185 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul
186 Flufenazin decanoate injeksi 5 mg/ml Ampul
187 Furosemid Inj Iv/Im 10 mg/Ml Ampul
188 Gentamisin injeksi 40 mg/ ml Ampul
189 Haloperidol Injeksi IV/IM 10 mg/ml Ampul
190 Hyocina N Butilbromid Inj 20 mg Ampul
191 Kalsium Glukonas Inj 100 mg/ml Ampul
192 Ketorolax Injeksi 30 mg/ ml Ampul
193 Kloramfenikol serb inj 1000 mg/mL Vial

Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml

194 Ampul
195 Lidokain injeksi 2% (HCL) Ampul
196 Magnesium Sulfat 20 % Inj 25 ml
197 Magnesium Sulfat 40 % Inj 25 ml Vial
198 Metamizol inj 500 mg/ml Ampul
199 Metoklopramide INJ 5 mg/ml Ampul
200 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul
201 Oksitosin injeksi 10 IU/ml Ampul
202 Ranitidin inj 25 mg/2 ml Ampul
203 Sianokobalamin (vitamin B12) injeksi 500 mcg Ampul

OBAT KHUSUS

Antihemoroid, kombinasi: bismut subgalat 150 mg

heksaklorofen 2,5 mg lidokain 10 mg seng oksida 120
204
mg SUPP
205 Bisacodyl supp (dulcolax) 5 mg / Stolax supp SUPP
206 Bisacodyl supp (dulcolax) 10 mg / Stolax supp SUPP
 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal)
207 TUBE
208 Nistatin Vaginal tab 100 000 iu/gr TABLET
209 SABU I 5 ml VIAL
210 Salbutamol (as sulphate) 2,5 mg/2,5 ml nebuls Ampul
211 Serum ATS 1 500 IU VIAL
212 Serum ATS 20.000 IU VIAL
213 Vaksin Rabies Inj 2,5 IU

CAIRAN

214 Glukosa larutan infus 10 % steril Botol

215 Glukosa larutan infus 40 % steril Botol
216 Glukosa larutan infus 5 % steril Botol
217 Nacl 0,9% Botol
218 Ringer Laktat larutan infus Botol

OBAT LUAR

219 Antiseptik dan Disinfektan - alkohol 70% 100 ml Botol

220 Antiseptik dan Disinfektan - alkohol 70% 1 liter Botol
221 Bedak salisil serbuk 2% Tube
222 Betametason Cream 0,1 % Tube 1 1
223 Fenol Gliserol TT 10% TUBE
224 Gentamicin SK 0,1% Botol 3 3 2 4
225 Gentamicin Salep Mata 0,3% Tube 1
226 Gentamisin Sulfat Tetes Mata Tube 1
227 Hidrogen Peroksida Larutan 3% Botol
228 Hidrokortison Cream 2,5 % Tube
229 Ketokonazol Krim 2% Tube 1
230 Kloramfenikol salep mata 1 % Tube 1
231 Kloramfenikol teter telinnga 3 % Botol 1
232 Oksimetazolin tetes hidung Botol
233 Permetrin Cream 5%(anti scabies) tube
234 Povidon Iodida larutan 10% 30 ml Botol
235 Povidon Iodida larutan 10% 300 ml Botol
Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang
236 endap 4% Botol
237 Sulfadiazin Silver Salep Kotak

OBAT GIGI

238 Devitalisasi Pasta ( non arsen ) Pot

239 Etil Klorida Spray Botol
240 Eugenol Cairan Botol
241 Glass Ionomer Cement Art Botol
242 Kalsium Hidroksida Pasta Pot
243 Klorfenol Kamfer Menthol (CHKM) Botol
244 Polikresulen (albotyl) Botol
245 Semen seng fosfat serbuk +cairan Pot

Temporary stopping fketcher serbuk+cairan (caviton)

246 Pot
247 Trikkresol formalin (TKF) Botol

BAHAN LABORATORIUM

248 Carik Celup / Urin Tes 3 GPH Stik

249 Carik Celup / Urin Tes 11 GPH Stik
250 Hb Test Kit Set
251 Kartu golongan darah Lembar
252 Kit Gol Darah Set
253 Lart As Acetat Botol
254 Lart asam klorida 0,1% Botol
255 Lart Asam Klorida 0,1 N Botol
256 Lart Barium Chlorida 10 % Botol
257 Lart Benedict Botol
258 Lart E D T A 10 % Botol
259 Lart Etanol Asam Botol
260 Lart Koh 10 % Botol
261 Lart Nacl 0,9 % Botol
262 Lart Natrium Citrat 3,8 % Botol
263 Lart Rees Ecker Botol
264 Lart Turk Botol
265 Oil Emersi Botol
266 PP Test Stik
267 Reagen ABX Minidil Lmg Paket
268 Reagen ABC Minilyse Lmg Paket
269 Reagen ABX Miniclean Paket
270 Reagen ABX Minotrol Paket
271 Stik Gula Darah Stik
272 Stik Asam Urat Stik
273 Stik Kolesterol Stik
274 Stik HB Stik
275 Stik HBSAG Stik
276 widal Test Set

OBAT NON FORNAS

277 Ambroxol 30 mg tablet Tablet 10

278 Asam tranexamat tablet 500 mg Tablet
279 Gliseryl guaiakolat 100 mg tab Tablet 8 24 6 15
280 Loperamid tab 2 mg Tablet
281 Multi micro nutrien Tablet
282 Piroksikam 20 mg tab Tablet 10
283 Thiampenikol kapsul 250 mg Kapsul
284 Thiampenikol kapsul 500 mg Kapsul

SIRUP

285 Ambroxol syrup 15 mg/ml Botol 2 1 1 2

286 Multivitamin syrup Botol 1 1 1

IJNEKSI

287 Asam tranexamat injeksi 50 mg / ml Ampul

288 Ondansetron Injeksi 2 mg/ ml (4 mg/2 ml) Ampul

OBAT LUAR

289 Asiklovir krim 5 % Tube

290 Bedak Salisil serbuk 2 %
291 Gentian violet larutan 1 % Tube
292 Hexachlorocyclohexane 0,5% ((Peditox) Botol
293 Ictyol salep hitam Pot
294 Oksitetrasiklin SK 3% Tube 1
295 Oksitetrasiklin sm 1% Tube
296 Salep luka bakar ( bioplacenton ) Tube

OBAT KHUSUS
297 Parasetamol supp 80 mg Suup
298 Parasetamol supp 125 mg Suup
299 Parasetamol supp 160 mg Suup
300 Parasetamol supp 250 mg Suup

TAMBAHAN OBAT FORNAS

301 CAVIPLEK 15
302 CAMABION 30 30
303 OBH SIRUP
304
305
306
307
308
309
TAMBAHAN OBAT NON FORNAS

Kasa, Verband, Kapas - Kasa Hydrophil 40 x 40 cm

400
401 Baby Cough Syrup 60 ml
402 Demacolin Tablet
403 Rohto Tetes Mata
AAN OBAT (LPLPO)

PEMAKAIAN
30 31 1 2 3 4 5 6 7 8 9 10 11 12 13
 40 10 20 20 40 10 10 20

10

10
40 120 15 22 25 30 75 27 40 55 65

10 50 40 10 10 30 20 45 20 20

3 10 3

40 30 40 20 10 20 10 10 30 30

5
10 10 10 10 20
 11 13 12 10 6 3 1 13

10

5 10 10
10

11 6 6 6 6 12 17
40 30 10 30

10
 10 20
10 20 10
10 10 10 20 10

20 20
13 98 23 30 2 16 34 41 12 40 22

40 10

30 30 10 30 30

10 10 10 10

10 10
10 10
5 5 10 15 10 16
45 158 52 52 34 30 90 82 26 85 80

10 5 5

10 6

3 1
11 10 10 2 7 12
10

10 20 20

10 5 5 5 10 10

35 50 15 25 25 15 5 40 15 10 12
10 10 10 10

1 2 2 1 1 3 1 3 1
 1 1 1
1

1 1

1 1 2
1 1 1 1 1

4 9 1 1 4 6 7 5 3 4
1 2
 1
1
2 1 2 1 1 1 1 1

1 1 2
 1
1

1
12 21 2 8 6 14 17 9 12 12

10 10

3 1 2
3 1 1 1

2
 5 10
10 10 60 10
2 1 2

1 1
 /X/2015

KET
14 15 16 17 18 19 20 21 22 23 JML

0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0

0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 0
0
0
0
0
50 30 20 10 20 10 10 490
1 1
50
20 20 10 70
0
0
30
12 15 95 35 12 30 1024

40 20 30 20 30 10 20 40 585

0
0
15 3 2 12 80
25
10 40 20 30 520
0
30 35
20 10 10 120
10 10
0
0
0
0
 0
10 3 2 6 190
0
0
0
0
10 26
0
0
0
0
0
0
10 10 45
10

17 12 6 6 116
30 30 30 290
0
0
0
0
0
30
0
10 20
0
0
0
 10 90
50
10 10 10 145
0
10 10
0
40
46 28 43 17 10 9 36 35 35 782
0
0

10 30 145

0
0
0
0
0
30 30 90 400

0
10 6 66
0
10 30
20
0
0
0
0
0
 0
0
10 5 5 5 5 106
111 50 63 32 60 50 55 45 116 1783

30 101
0
0
0
0
12 6 10 50
20 30 70
0
4
10 2 2 105
10 40
0
20 10 110
0
55
0
36 25 30 5 10 25 6 45 579
40 90
0
0
0
1 6 2 1 2 1 2 40
0
 1 1 1 2 8
1 2 4
0
1 3
0
0

1 1 1 1 10
1 7
0
0

0
2 3 2 3 6 4 2 10 93
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
0
0

3
0
0
 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1 1 1 6
1
2 2 2 1 1 30
1 2
1 1 1 8
0
0
1 2
3 2 7
2
0
0
0
0

1 1 3
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
0
4 18 13 4 8 7 11 3 15 249
0
0
6 10 10 56
0
0
0
0
0
2 2 4 1 2 23
3 1 1 3 17
0
0
0
0
0
0
0
0
1 2
0
0
0
0
3
0
0
0
0
0
 0
0
0
0
0
0
30
20 170
5
0
0
0
0
0
0
0
0

0
2
0
0