DOKUMEN

DINKES KABUPATEN

PUSKESMAS
PUSKESMAS : SIDAMULIH
KECAMATAN : SIDAMULIH .
KABUPATEN : PANGANDARAN PELAPORAN BULAN/PERIODE : SEPTEMBER
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : OKTOBER

STOK STOK HARGA JUMLAH HARGA PEMBERIAN

NO NAMA OBAT SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN PERMINTAAN
AWAL AKHIR KEMASAN RP (8x9) DAK APBD
1 2 3 4 5 6 7 8 9 10 11 12 13
A. APBD / DAK
1 Allopurinol tablet 100 mg Tablet 0 200 200 0 200 99 19,800
2 Albendazol suspensi 200mg/5 mL Botol 0 10 10 0 10 3,849 38,490
3 Albendazol suspensi 200mg/5 mL Botol 0 0 0 4,000 -
4 Ambroksol sirup 15 mg Botol 0 0 0 3,553 -
5 Ambroksol sirup 15 mg Botol 42 50 92 24 68 3,230 219,640.00 50
6 Ambroksol tablet 30 mg Tablet 0 0 0 161.7 -
7 Ambroksol tablet 30 mg Tablet 0 0 0 147 - 500
8 Aminofilin injeksi 24 mg/ml ampul 0 0 0 2,998 -
9 Aminofillin injeksi 25 mg/ml Ampul 30 30 0 30 3,822 114,660.00
10 Aminofilin tablet 200mg Tablet 0 0 0 89
11 Amlodipin tablet 5 mg Tablet 139 139 4 135 70 9,450.00
12 Amlodipin tablet 10 mg Tablet 0 1500 1500 20 1480 93 137,640.00
13 Amoksisilin kapsul 250 mg Kapsul 0 0 0 180 -
14 Amoksisilin kapsul 250 mg Kaplet 4460 4460 20 4440 195 865,800.00
15 Amoksisilin kaplet 500 mg Kaplet 10160 10160 480 9680 232 2,245,760.00
16 Amoksisilin kaplet 500 mg Kaplet 0 0 0 190 -
17 Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml 0 0 0 2000 -
18 Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml 479 479 29 450 1881 846,450.00
19 Analgesik Krim (Molakrim) Tube 10 24 34 2 32 13860 443,520.00
 Antasida DOEN I tablet kunyah, kombinasi :
20 Aluminium Hidroksida 200 mg + Magnesium Tablet 54
Hidroksida 200 mg 0 0 0 -
Antasida DOEN I tablet kunyah, kombinasi :
21 Aluminium Hidroksida 200 mg + Magnesium Tablet 62
Hidroksida 200 mg 8060 8060 746 7314 453,468.00
Antasida DOEN II suspensi, kombinasi : Aluminium
22 Btl 60 ml
Hidroksida 200 mg + Magnesium Hidroksida 200 mg
0 0 0 1,995 - 100
Anti Bakteri DOEN salep kombinasi : Basitrasin 500
23 Tube 3,035
IU/g + polimiksin 10.000 IU/g 0 0 0 -
Antifungi DOEN Kombinasi : Asam Benzoat 6% +
24 Pot 2,750.0
Asam Salisilat 3% 21 21 6 15 41,250.00
Antifungi DOEN Kombinasi : Asam Benzoat 6% +
25 Pot 4,158.0
Asam Salisilat 3% 0 0 0 -
Antihemoroid DOEN kombinasi : Bismut Subgalat
26 Supp 3,167
150 mg + Heksaklorofen 250 mg 0 0 0 - 10
27 Antimigren : Ergotamin tartrat 1mg + Kofein 50mg tablet 0 0 0 173 -
28 Asam Asetil Salisilat / Asetosal tablet 80mg Tablet 0 0 0 99 -
29 Asam Askorbat (vitamin C) tablet 50 mg Tablet 0 0 0 104.0 - 1000
30 Asam Folat Tablet 0,4mg tablet 0 0 0 52.0 - 300
31 Asam Mefenamat 500mg Tablet 6414 6414 144 6270 103.0 645,810.00
32 Asam pipemidat 400 mg (Urotractin) kapsul 0 0 0 1,400 -
33 Asam Traneksamat 50 mg/ml inj Vial 0 0 0 1,748 -
34 Asam Traneksamat 500mg Tablet 0 0 0 2,915 - 50
35 Asering Infus bag 0 0 0 9,646 -
36 Asiklovir tablet 200 mg Kaplet 0 0 0 240.0 -
37 Asiklovir tablet 200 mg tablet 1000 1000 60 940 249.0 234,060.00
38 Asiklovir tablet 400 mg Tablet 0 500 500 20 480 365.0 175,200.00
39 Asiklovir krim 5% Tube 0 0 0 3,080 -
40 Atapulgit 600 mg (New Antides) Tablet 0 0 0 136 -
41 Atropin Inj 0,25 mg/ml Ampul 0 0 0 1,540 -
42 Betahistin Tablet Tablet 0 0 0 110.0 -
43 Betametason krim 0,1 % Tube 0 0 0 1,340 -
44 Betametason krim 0,1 % Tube 0 25 25 25 1,349 33,725.00
45 Bisakodil Suppositoria (Dulcolax) Supp 0 12 12 12 5,370 64,440.00
46 Deksametason tablet 0,5 mg Tablet 0 0 0 32 -
47 Deksametason tablet 0,5 mg Tablet 0 0 0 41 -
48 Deksametason tablet 0,5 mg Tablet 3506 3506 280 3226 44 141,944.00
49 Desoksimetason krim 0,25% tube 0 0 0 10,400 -
50 Diazepam enema 5 mg/2,5ml tube 0 0 0 12,573 -
51 Diazepam inj 5 mg/ml Ampul 0 0 0 1,735 -
52 Diazepam tablet 2 mg Tablet 0 0 0 86 - 100
53 Diazepam tablet 2 mg Tablet 0 0 0 110 -
54 Difenhidramin Injeksi I.M. 10 mg/ml (HCL) Ampul 0 0 0 1,095 - 50
55 Digoksin tablet 0,25 mg Tablet 100 100 100 104 10,400.00
56 Dimenhidrinat tablet 50 mg Tablet 1307 1307 41 1266 99 125,334.00
57 Doksisiklin kapsul 100 mg Kapsul 0 0 0 264 -
58 Domperidon Suspensi Btl 50 50 2 48 2,700 129,600.00
59 Domperidon Tablet 10 mg Tablet 0 0 0 85 -
60 Domperidon Tablet 10 mg Tablet 898 898 30 868 95 82,460.00
61 Epinefrin (adrenalin) injeksi 0,1% (sebagai HCl) Ampul 0 90 90 90 1,749 157,410.00
62 Epinefrin (adrenalin) injeksi 0,1% (sebagai HCl) ampul 0 0 0 1,408
63 Eugenol Btl 0 0 0 18,100
64 Fenol Gliserol tetes telinga 10% (Carbo Gliseril) Botol 0 0 0 2,590 - 48
65 Fitomenadion (Vit. K1) injeksi 10 mg/ml Ampul 0 0 0 6,490
66 Fitomenadion (Vit. K1) injeksi 10 mg/ml Ampul 27 27 27 3,550 95,850.00
67 Fitomenadion (Vit. K1) injeksi 2 mg/ml Ampul 0 0 0 5,900 -
68 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet 0 0 0 710 -
69 Furosemid tablet 40 mg Tablet 0 500 500 500 78 39,000.00
70 Furosemid tablet 40 mg Tablet 0 0 0 77 -
71 Garam Oralit Serbuk Kombinasi Sachet 0 0 0 257 -
72 Gemfinrozil 300mg Tablet 0 0 0 371 - 300
73 Gentamisin Injeksi Ampul 0 0 0 3,509 -
74 Gentamisin Sulfat Injeksi Ampul 0 0 0 3,386 -
75 Gentamisin Salep Kulit 0,1% tube 0 0 0 3,520 - 50
76 Gentamisin Salep Mata 0,3% tube 3 3 2 1 2,960 2,960.00 50
77 Glibenklamida tablet 5 mg Tablet 0 0 0 119 - 500
78 Glimepiride 2 mg Kotak 0 500 500 500 207 103,500.00
 79 Gliseril Gualakolat tablet 100 mg Tablet 0 0 0 176.00 - 1000
80 Glukosa Larutan Infus 10% btl 500 ml 0 0 0 7,500 -
81 Glukosa Larutan Infus 5% btl 500 ml 0 0 0 6,900 -
82 Griseofulvin tablet 125 mg, micronized Tablet 0 0 0 210.0 -
83 Haloperidol tablet 1,5 mg Tablet 0 0 0 61 -
84 Hidroklortiazid tab 25 mg tablet 0 0 0 155 -
85 Hidrokortison krim 2,5% Tube 0 0 0 2,475 -
86 Hidrokortison krim 2,5% Krim 36 48 84 36 48 2,639 126,672.00 48
87 Hiosin Butil bromida inj 20 mg/ml Ampul 0 0 0 9,790 -
88 Hiosin Butil bromida tab 20 mg Tablet 0 0 0 1,727 -
89 Ibuprofen suspensi 100 mg/5ml Btl 60ml 93 93 53 40 2,365 94,600.00 50
90 Ibuprofen tablet 400 mg Tablet 0 0 0 111 - 1000
91 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 0 0 0 89 -
92 KA EN 3B - Larutan Karbohidrat + elektrolit kantong 0 0 0 10,696 -
93 KA EN 3B - Larutan Karbohidrat + elektrolit Softbag 0 0 0 10,285 -
94 Kalium Klorida 600 mg / KSR tablet 0 0 0 1,755 -
95 Kalsium Glukonat Injeksi 100mg/ml (Ecosol Ca.Gluconas) Ampul 0 0 0 9,955 -
96 Kalsium Glukonat Injeksi 100mg/ml Ampul 24 24 24 7,800 187,200.00
97 Kalsium glukonat inj i.v 10% Ampul 0 0 0 10,351 -
98 Kanamisin Inj 1000 mg Ampul 0 0 0 12,100 -
99 Kaptopril 12,5 mg Tablet 5712 5712 476 5236 59 308,924.00
100 Kaptopril tablet 12,5 mg Tablet 0 0 0 62 -
101 Kaptopril tablet 25 mg Tablet 4908 4908 40 4868 80 389,440.00
102 Kaptopril tablet 25 mg Tablet 0 0 0 68 -
103 Ketokonazol Krim Tube 0 0 0 2,518 -
104 Ketokonazol Cream Tube 0 0 0 2,595 -
105 Ketokonazol Cream 2% tube 42 42 17 25 2,545 63,625.00
106 Ketorolak Inj 30 mg/ml Ampul 0 0 0 1,045 -
107 Klindamisin 300 mg Kapsul Kapsul 0 0 0 578 -
108 Kloramfenikol Salep Mata 1% tube 27 24 51 4 47 1,810 85,070.00
109 Kloramfenikol Salep Mata 1% tube 0 0 0 1,881 -
110 Kloramfenikol Salep Kulit 1% (Bufacetin SK) tube 0 0 0 3,091 - 48
111 Kloramfenikol suspensi 125 mg/5 ml Botol 60 ml 0 0 0 4,700 -
112 Kloramfenikol sirup 125 mg/5 ml Botol 60 ml 0 0 0 4,700 -
113 Kloramfenikol kapsul 250 mg (Chloramex) Kapsul 0 0 0 1,090 - 1000
114 Klorfeniraniramina Maleat (CTM) tablet 4 mg Tablet 0 0 0 22 -

Kotrimosakzol Suspensi Kombinasi :

115 botol 60 ml 2,120
Sulfametoksazol 200 mg + Trimetoprim 40 mg/ 5 ml
31 31 4 27 57,240.00

Kotrimosakzol Suspensi Kombinasi :

116 botol 60 ml 2,052
Sulfametoksazol 200 mg + Trimetoprim 40 mg/ 5 ml
0 100 100 100 205,200.00
Kotrimosakzol DOEN I (dewasa) Kombinasi :
117 Tablet 125
Sulfametoksazol 400 mg, Trimetoprim 80 mg 0 0 0 - 1000
118 Laktulosa sirup 3,335 g/5 mL botol 0 0 0 15,060 - 50
119 Lansoprazole capsul 30mg Kapsul 0 0 0 303 - 1500
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
120 Ampul 1,937
ml 0 0 0 -
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
121 Ampul 1,845
ml 0 270 270 2 268 494,460.00
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
122 Ampul 1,152
ml 0 0 0 -
123 Lidocain inj 2 % Ampul 0 0 0 1,144 -
124 Lidocain inj 2 % Ampul 0 0 0 1,111 -
125 Lidocain inj 2 % Ampul 0 0 0 860 -
126 Loperamide tablet Tablet 0 0 0 80 - 500
127 Loratadin tablet 10 mg Tablet 546 546 227 319 123 39,237.00 500
128 Magnesium Sulfat inj (IV) 20 %-25 ml vial 0 0 0 3,200 -
129 Metformin HCl tablet 500 mg tablet 0 0 0 96 - 500
130 Metildopa tab 250 mg tablet 0 0 0 946 - 200
131 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 0 0 0 2,959 -
132 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 164 164 164 2,684 440,176.00
133 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 0 0 0 2,849 -
134 Metilprednisolon tablet 4 mg Tablet 0 0 0 134 -
135 Metoklopramid tablet 10 mg tablet 0 0 0 80 -
136 Metoklopramid tablet 10 mg Tablet 0 0 0 87 -
137 Metronidazol infus 500 mg/100 ml Botol 0 0 0 8,110 -
138 Metronidazol infus 500 mg/100 ml Infus 0 0 0 9,200 -
139 Metronidazol Sirup Botol 0 0 0 3,950 -
140 Metronidazol Sirup 125mg Botol 65 65 65 3,800 247,000.00
141 Metronidazol Tablet 500 mg Tablet 0 0 0 124 -
142 Mikonazole krim / salep 2% (nitrat) tube 0 0 0 3,414 -
143 Mikonazole krim / salep 2% (nitrat) Tube 48 48 1 47 3,250 152,750.00
144 Misoprostol tablet 200mg Tablet 0 0 0 6,900 -
145 N-asetil sistein 200 mg tablet 0 0 0 358 -
146 N-asetil sistein 100 mg nebules inj (Fluimucil) ampul 0 0 0 12,535 -
147 Natrium Diklofenak 50 mg Tablet 0 0 0 115 - 1000
148 Natrium Klorida larutan infus 0,9 % Botol 0 0 0 6,410 -
149 Nifedifin 10 mg Tablet 50 50 50 104 5,200.00

150 Nifedifin 10 mg Tablet 99

0 0 0 -
151 Nistatin Tablet Tablet 0 0 0 790 - 100
152 Nistatin Vaginal tablet salut 100.000 IU/g Tablet 0 0 0 560 -
153 OAT Kategori 2 Paket 0 0 0 1,297,889 -
Obat Batuk Pilek Kombinasi Syrup (Tiap 5ml
154 mengandung: Difenhidramin 5mg, Dekstrometorfan Btl 7,350
10mg, Amonium Klorida 62,5mg ,Na.Sitrat
25mg/5ml ) (Samcodryl) 19 50 69 23 46 338,100.00 50
Obat Batuk Pilek Kombinasi Kaplet (Tiap Kaplet:
155 Parasetamol 250mg, Dextromethorphan HBr 15mg, Tablet 850
Penylephrine HCl 2mg, Glyseril Guaiakolat 50mg,
Klorfeniramin maleat 1mg) (Lodecon) 0 1000 1000 150 850 722,500.00 500
156 Oksitosin injeksi 10 UI/ml-1 ml Ampul 11 11 5 6 1900 11,400.00 10
157 Oksitosin injeksi 10 UI/ml-1 ml Ampul 0 0 0 1,199.00 -
158 Omeprazole kapsul 10 mg Kapsul 0 0 0 130 - 1000
159 Ondansetron Inj 4 mg/2ml Ampul 30 30 30 1070 32,100.00
160 Parasetamol Drop Btl 0 0 0 6,649.00 - 50
161 Parasetamol syrup Btl 223 223 48 175 1,107.00 193,725.00
162 Parasetamol tablet 500 mg Tablet 0 1000 1000 10 990 53.00 52,470.00
163 Perak Sulfadiazin krim 1% Tube 0 0 0 20,700 -
164 Permetrin krim 5% tube 0 0 0 12,155 -
165 Piridoksin HCl (Vit B6) tablet 25 mg Tablet 0 0 0 118 -
166 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 0 0 0 53 -
167 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet 0 0 0 123 -
168 Polikresulen cairan Btl 0 0 0 19,250 -
169 Povidon Iodida larutan 10 % Botol 30 ml 0 0 0 2,893 -
170 Prednison tablet 5 mg Tablet 0 500 500 500 68 34,000.00
171 Propanolol tablet 10 mg (HCL) Tablet 0 0 0 54.0 -
172 Ranitidin injeksi 25 mg/ 2ml Ampul 99 99 99 1,155.0 114,345.00
173 Ranitidin tablet 150 mg tablet 1500 1500 784 716 98 70,168.00
174 Ranitidin tablet 150 mg tablet 0 0 0 105 -
175 Ringer Laktat larutan infus Botol 500 ml 798 798 8 790 7,150 5,648,500.00
176 Salbutamol Cairan Inhalasi (Fartolin) Botol Inh 0 20 20 2 18 15,700 282,600.00
177 Salbutamol sirup botol 49 49 49 4,446 217,854.00
178 Salbutamol tablet (sebagai sulfat) 4 mg Tablet 0 300 300 10 290 70 20,300.00
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
179 Pot
endap 4% 0 0 0 2,527 -
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
180 Pot 2,621
endap 4% 0 0 0 -
181 Salisil bedak 2% Kotak 50 gram 0 0 0 5,610 - 20
182 Salisil bedak 2% Kotak 50 gram 0 0 0 1,020 -
183 Sefadroksil kapsul 500 mg kapsul 0 0 0 478 -
184 Sefadroksil Sirup Botol 112 112 34 78 3,980 310,440.00
185 Sefadroksil Sirup Botol 0 0 0 3,922 -
186 Sefiksim Kapsul 100mg Kapsul 0 0 0 750 -
187 Sefiksim Sirup Botol 0 0 0 5,530 -
188 Sefotaksim injeksi 1 gram Vial 0 0 0 4,200 -
189 Seftriakson Inj Vial 0 0 0 4,483 -
190 Setirizin tablet Tablet 0 0 0 90 - 1000
191 Setirizin Sirup Btl 0 0 0 2,850 - 50
192 Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU I) Vial 0 0 0 479,996 -
193 Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU I) Vial 2 2 2 462,000 924,000.00
194 Serum Anti Tetanus Injeksi 1.500 IU/ampul (A.T.S.) Vial 2 10 12 2 10 176,800 1,768,000.00
195 Simvastatin 10mg tablet 0 0 0 110 -
196 Siprofloksasin tablet 500 mg Tablet 0 500 500 500 240 120,000.00
197 Siprofloksasin 500mg Tablet 0 0 0 265 -
198 Sukralfat Suspensi Btl 21 100 121 43 78 8,338 650,364.00 100
199 Terbutalin Sulfat 1,5 mg/5 mL (Tebas Syr) botol 0 0 0 6,459 -
200 Tiamin (vitamin B1) tablet 50 mg (HCL/Nitrat) Tablet 396 1000 1396 54 1342 82 110,044.00
201 Tiamin (vitamin B1) tablet 50 mg (HCL/Nitrat) Tablet 0 0 0 85.0 -
202 Ursodeoksiholik 250 mg tablet 0 0 0 2,139 -
203 Vitamin B Kompleks tablet Tablet 0 0 0 156.2 - 2000
204 Zink Tablet Dispersible 20mg Tablet 0 0 0 524 -
205 Zink Tablet Dispersible 20mg Tablet 1068 1068 160 908 508 461,264.00
206 Zink Sirup 20 mg/ml Btl 60ml 108 108 10 98 4,789 469,322.00
207 Zink Sirup 20 mg/ml Btl 60ml 0 0 0 2,972 -
Alat Kesehatan 0 -
208 Alat suntik sekali pakai 1 ml Ktk 100 0 1,614 -
209 Alat suntik sekali pakai 5 ml pcs 4100 4100 4100 0 750 - 800
210 Alkohol Swab 100 pcs/box 13 13 5 8 10,000 80,000.00
211 Alkohol 70% 1 L Botol 36 36 1 35 21,500 752,500.00
212 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 0 0 0 2,295 -
213 Aquasonic 250 ml Gel Botol 3 3 3 186,867.75 560,603.25
214 Aquasonic Jelly Botol 4 4 4 156,640 626,560.00
215 Aseptik Gel Btl 9 9 2 7 22,000 154,000.00
216 Bisturi No 11 (Aesculap) box 0 0 0 300,000 -
217 Blood Lancet box 0 0 0 14,564 -
218 Catgut Cromic No. 2/0 Kotak 1 1 1 134,000 134,000.00
219 Catgut Cromic No. 3/0 Kotak 1 1 1 134,000 134,000.00
220 Catgut Plain No. 2/0 Kotak 2 2 2 134,000 268,000.00
221 Catgut Plain No. 3/0 Kotak 1 1 1 134,000 134,000.00
222 Cervical colar unit 0 0 0 121,000 -
223 Celemek Lengan Panjang (Apron non Steril waterproff) 0 0 0 25,256 -
224 Cuticell Classic 10cm x 10cm sachet 0 0 0 5,198 -
225 Folley Catheter 2 Way No. 16 Pcs 9 9 9 13,090 117,810.00
226 Folley Catheter 2 Way No. 18 Pcs 0 0 0 13,090 -
227 Gluco Protein (One Med) pcs 0 0 0 1,045 -
228 Guedel Airway 80mm steril Pcs 0 0 0 12,574 -
229 Guedel Airway 90mm steril Pcs 0 0 0 12,574 -
230 HCG Strip pcs 0 100 100 100 1,939 193,900.00
231 Infusion set anak (Aximed Pediatric Set) Set /kantong 0 0 0 5,100 -
232 Infusion set anak (Terumo) Set /kantong 0 0 0 5,100 -
233 Infusion set Y dws pcs 0 0 0 6,287 -
234 Infusion set dewasa / Aximed Infuset Set /kantong 100 100 100 4,800 480,000.00
235 IV Catheter No. 18 G (Aximed) 50 buah / kotak 0 0 0 7,000 -
236 IV Catheter No. 18 G 50 buah / kotak 0 0 0 7,700 -
237 IV Catheter No. 18 G 50 buah / kotak 0 0 0 8,700 -
238 IV Catheter No. 20 G 50 buah / kotak 0 0 0 7,700 -
239 IV Catheter No. 22 G 50 buah / kotak 50 50 50 7,700 385,000.00
240 IV Catheter No. 24 G 50 buah / kotak 0 0 0 7,700 -
241 IV Catheter No. 26 G (Jayamas Steracath) Pcs 0 0 0 4,100 -
242 Kapas Pembalut / Absorben 250 gram Bungkus 26 26 26 12,500 325,000.00
243 Kasa Hidrofil DRC 36m x 80 cm rol 1 1 1 130,000 130,000.00
244 Kasa Kompres 40/40 steril Bungkus 100 100 100 1,600 160,000.00
245 Kasa Pembalut 2 m x 80 cm Rol 34 34 34 7,700 261,800.00
246 Kasa Pembalut Hidrofil 4 m x 15 cm elastic Rol 0 0 0 2,100 -
247 Kasa Pembalut Hidrofil 4 m x 15 cm elastic roll 80 80 6 74 2,090 154,660.00
248 Kasa Steril 16x16 cm Bungkus 0 0 0 8,000 -
249 Leukomed IV Film 6cm x 8cm streil box 0 0 0 123,056 -
250 Leukomed IV Film 6cm x 8cm streil pcs 0 0 0 2,461.12 -
251 Masker kotak @50pcs 1 1 1 16,500 16,500.00
252 Masker ties on / tali dus 0 10 10 10 24,000 240,000.00
253 Masker Nebulizer Set Dewasa pcs 0 0 0 22,000 -
254 Masker Nebulizer Set Anak pcs 24 24 24 22,000 528,000.00
255 Mucus Extractor 25 mL pcs 0 0 0 7,040 -
256 Object Glass pax 0 0 0 144,605.50 -
257 Pro Crepe Pembalut Elastis Ukuran 10 cm X 4,55 M roll 0 0 0 33,272 -
258 Pro Crepe Pembalut Elastis Ukuran 10 cm X 4,55 M roll 0 0 0 33,000.00 -
259 Pro Crepe Pembalut Elastis Ukuran 15 cm X 4,55 M roll 0 0 0 41,910.00 -
260 Plester 7,5 x 4,5cm (Leukoplast) roll 67 67 44 23 35,532 817,236.00
261 Plester Bulat pcs 0 0 0 30,800 -
262 Plester 7,5 x 4,5cm (Hospital) roll 0 0 0 35,532 -
263 Sarung Tangan Examination S (Aximed) box/100 8 8 1 7 46,200 323,400.00
264 Sarung Tangan Examination M (Aximed) box/100 0 10 10 10 46,200 462,000.00 10
265 Sarung Tangan L (Sensi Gloves) kotak 12 12 12 46,200 554,400.00
266 Sarung Tangan Examination L (Aximed) box/100 0 0 0 46,200 -
267 Sarung Tangan Powder Free Steril No.7 pasang 0 0 0 12,925 -
268 Sarung Tangan Powder Free Steril No.7,5 pasang 0 0 0 12,925 -
269 Sarung Tangan Powder Free Steril (Mas DHD) pasang 0 0 0 13,101 -
270 Sarung Tangan Obgyn Steril pasang 0 0 0 19,360 -
271 Simple Oxygen Mask Dewasa / Masker O2 box/50 0 0 0 19,800 -
272 Selang Oksigen Anak (Canula Nasal O2 Anak) Pcs 0 0 0 5,500 -
273 Selang Oksigen Anak (Besmed Oxyflow Nasal O2) Pcs 0 0 0 5,500 -
274 Selang Oksigen Dewasa (Besmed Oxyflow Nasal O2) Pcs 0 0 0 5,500 -
275 Silk No. 2/0 Kotak 0 3 3 3 110,000 330,000.00 1
276 Silk No. 3/0 Kotak 0 3 3 3 110,000 330,000.00 1
277 Spalk kayu pcs 4 4 4 61,600 246,400.00
278 Tapping (Self Tapping Vertebral Screw) roll 0 0 0 151,800 -
279 Water Fuchsin / Water One 1 L btl 0 0 0 14,960 -
280 Underpad 60x90 cm pcs 190 190 190 7626.15 1,448,968.50
281 Urine Bag pcs 1 20 21 21 3,000 63,000.00 20
282 Umbilical Cord Klem Pcs 40 40 40 1,000 40,000.00
Reagensia 0 -
283 Reagen Gol. Darah Anti A (Lorne Lab) vial 0 70,575 -
284 Reagen Gol. Darah Anti AB (Lorne Lab) vial 0 94,885 -
285 Reagen Gol. Darah Anti B (Lorne Lab) vial 0 70,575 -
286 Reagen Gol. Darah Anti D (Lorne Lab) vial 0 116,445 -
287 Widal Test Salmonella Paratyphi AH (Lorne Lab) vial 0 69,035 -
288 Widal Test Salmonella Paratyphi AO (Lorne Lab) vial 0 69,035 -
289 Widal Test Salmonella Paratyphi BH (Lorne Lab) vial 0 69,035 -
290 Widal Test Salmonella Paratyphi BO (Lorne Lab) vial 0 69,035 -
291 Widal Test Salmonella Paratyphi CH (Lorne Lab) vial 0 69,035 -
292 Widal Test Salmonella Paratyphi CO (Lorne Lab) vial 0 69,035 -
293 Widal Test Salmonella Paratyphi H (Lorne Lab) vial 0 69,035 -
294 Widal Test Salmonella Paratyphi O (Lorne Lab) vial 0 69,035 -
 0 JUMLAH RP 33,377,648.75
B. PROGRAM 0
I. TB PARU (OAT FDC) 0
1 OAT kategori 1 Paket 0 - 0 359,980 -
2 OAT kategori 2 Paket 0 - 0 1,199,985 - 3
3 OAT anak Paket 4 4 4 214,985 859,940
4 Pot Dahak (Pot Sputum) Pcs 600 600 600 5,800 3,480,000
5 Reagen ziehl nielsen (Indo reagen ZN) Kit 10 10 10 276,500 2,765,000
II. DIARE 0 -
1 Garam oralit / Oralit Granula Sachet 0 - 0 260 -
2 Zinc Tab 20 mg Tablet 0 - 0 508 -
III. KECACINGAN 0 -
1 Albendazol tablet 400 mg Tablet 270 270 70 200 1,356 271,200
2 Albendazol tablet kunyah 400 mg Tablet 0 1800 1,800 180 1620 403 652,860
IV. GIZI 0 -
1 Tablet Fe (Ferro Fumarat) 200mg Kotak 0 - 36,700 -
2 Vitamin A 100.000 IU Kapsul Botol 4 4 1 3 14,400 43,200
3 Vitamin A 200.000 IU Kapsul Botol 0 - 22,950 -
V. IMUNISASI 0 -
1 Vaksin BCG Vial 10 10 5 5 61,996 309,980
2 Vaksin boPv (Polio Oral) Vial 42 42 13 29 19,954 578,666
3 Vaksin Campak Bias Vial 13 13 0 13 28,204 366,652
4 Vaksin DPT-HB/Hib (Pentabio) Vial 52 52 13 39 76,285 2,975,115
5 Vaksin DPT-HB/Hib (Pentabio) Vial 0 - 0 78,991 -
6 Vaksin HB Uniject (Hepatitis B Rekombinan) Pouch 38 38 5 33 20,900 689,700
7 Vaksin Measles Rubella (MR) Vial 37 37 6 31 149,820 4,644,420
8 Vaksin Measles Rubella (MR) / MMR II Vial 0 - 0 155,813 -
9 Vaksin Polio IPV 5 ds (Poliomyelitis) Vial 5 5 3 2 158,994 317,988
10 Vaksin Td (Vaksin Jerap) Vial 0 - 0 16,995 -
11 Vaksin Td (Vaksin Jerap) Vial 64 64 5 59 16,500 973,500
12 Vaksin Td Bias (Vaksin Serap) Vial 0 - 0 16,500 -
VI. MALARIA 0 -
1 Artesunat Cairan injeksi 60mg Ampul 0 0 39,000 -
 2 Primakuin Tablet 15 mg Tablet 0 0 109 -
3 RDT Test Malaria combo Test 0 0 105,600 -
4 RDT Test Malaria Test 0 0 5,271 -
0 0 -
VII. HIV/AIDS 0 0 -
1 Efavirenz tablet 600mg tablet 0 0 191,250 -
2 Flukonazol tablet 150mg tablet 0 0 1,800 -
3 INH tablet 300mg tablet 0 0 173 -
4 Lamivudine Tablet salut Selaput 150mg tablet 0 0 90,000 -
5 Needle holder (Marwa Needle Holder) pcs 0 0 295 -
6 Nevirapine Kaplet 200mg Kaplet 0 0 168,000 -
7 Rapid HIV 2 / Fokus Test 0 0 14,470 -
8 Rapid Test HIV 1/2 Biometric/Vikia Test 0 0 22,475 -
9 Rapid Test Syphillis (Sensatest One-step Diagnostic) Test 254 254 106 148 26,527 3,925,996
10 Rapit Test HIV 1/2 Elisa Test 267 267 106 161 22,330 3,595,130
11 RPR Siphyllis / Fokus Test 0 0 0 4,150 -
12 Tabung Eppendrof pcs 0 0 0 750 -
13 Tenofovir tablet 300mg tablet 0 0 0 243,000 -
Tenofovir-Lamivudin-Efavirens (TDF-3TC-EFV) 0 0
14
tablet 300mg-300mg-600mg (FDC TDF-3TC-EFV) tablet 0 356,829 -
15 Zidovudine - Lamivudine Kaplet 0 0 0 222,000 -
0 0 0 -
VIII. KEJIWAAN 0 0 0 -
1 Haloperidol Injeksi Ampul 0 0 0 6,250 -
0 0 0 -
IX. RABIES 0 0 0 -
1 Vaksin Anti Rabies (Verorab) Kuur 0 3 3 1 2 165,000 330,000
0 0 -
X. KUSTA 0 0 -
1 MB Dewasa (MDT Combi MB Adult) Blister 0 0 31,570 -
2 MB Anak (MDT Combi MB Child) Blister 0 0 19,800 -
3 PB Anak (MDT Combi PB Child) Blister 0 0 8,712 -
0 0 -
XI. Vaksin Haji 0 0 -
1 Vaksin Meningitis (Remel Neisseria Meningitis) Paket 0 0 214,500 -
2 Vaksin Meningitis (Slidex) Paket 0 0 214,500 -
26,779,347
JUMLAH RP
C. OBAT TAMBAHAN Diluar JKN
1 Allopurinol tablet 100 mg Tablet 535 535 145 390 89.0 34,710.00
2 Allopurinol tablet 300 mg Tablet 100 100 100 220.00 22,000.00
3 Amlodipin tablet 5 mg Tablet 870 870 170 700 85 59,500.00
4 Amlodipin tablet 10 mg Tablet 30 30 30 0 104 -
5 Amitripiline 25 mg Tablet 0 0 0 143 -
Analgesik-Psikotropik (mengandung Diazepam
6 2mg+Metamizol 500mg) (Metaneuron)
Tablet 37 1,045
307 307 270 282,150.00
Anti Bakteri DOEN salep kombinasi : Basitrasin 500 IU/g
7 + polimiksin 10.000 IU/g
tube 2,516
15 15 15 37,740.00
Antihemoroid DOEN kombinasi : Bismut Subgalat 150 mg
8 + Heksaklorofen 250 mg
Supp 3 3,045
13 13 10 30,450.00
9 Antispasmodik-Analgetik tablet (Spasminal) Tablet 55 55 29 26 581.90 15,129.40
10 Antimigren : Ergotamin tartrat 1mg + Kofein 50mg Tablet 100 100 100 167 16,700.00
11 Asam Asetil Salisilat / Asetosal tablet 80mg Tablet 130 130 130 114 14,820.00
12 Asiklovir tablet 200 mg Tablet 15 15 15 0 237 -
13 Betametason krim 0,1 % tube 57 57 22 35 1,380 48,300.00
14 Bisakodil Suppositoria (Dulcolax) Supp 8 8 8 5,789.784 46,318.27
15 Diazepam tablet 2 mg Tablet 100 100 100 0 45.000 -
16 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet 90 90 5 85 686.000 58,310.00
17 Furosemid injeksi Ampul 8 8 8 0 1,829.000 -
18 Flukonazol tablet 150mg Tablet 10 10 10 0 18,000.000 -
19 Garam Oralit Serbuk Kombinasi Tablet 569 569 27 542 260.000 140,920.00
20 Glukosa Larutan Infus 10% Botol 500 ml 50 50 50 5,700.000 285,000.00
21 Glukosa Larutan Infus 5% Botol 500 ml 19 19 19 5,200.000 98,800.00
22 Hidroklortiazid tab 25 mg Tablet 700 700 1 699 149.000 104,151.00
23 Hystolan 20 mg Tablet 50 50 50 4,900.500 245,025.00
24 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 260 260 4 256 88.000 22,528.00
25 Kalsium Laktat (Kalk) tablet 500 mg Tablet 710 710 10 700 52.000 36,400.00
26 Kalsium Laktat (Kalk) tablet 500 mg Tablet 0 0 0 63.000 -
27 Kaporit Pail 1 1 1 418,000.000 418,000.00
28 Kloramfenikol sirup 125 mg/5 ml Botol 60 ml 15 15 2 13 3,955 51,415.00
29 Klorfeniraniramina Maleat (CTM) tablet 4 mg Tablet 5360 5360 265 5095 37 188,515.00
Kotrimosakzol DOEN I (dewasa) Kombinasi :
30 Sulfametoksazol 400 mg, Trimetoprim 80 mg
Tablet 20 149.000
500 500 480 71,520.00
31 Lansoprazole capsul 30mg Tablet 0 0 0 319.000 -
32 Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2 ml Ampul 6 6 6 0 3,109.000 -
33 Lisol Botol 15 15 15 55,000.000 825,000.00
34 Magnesium Sulfat inj (IV) 20 %-25 ml Vial 36 36 36 3,650.000 131,400.00
35 Metformin HCl tablet 500 mg Tablet 465 465 216 249 94.000 23,406.00
36 Metilergometrin Maleat tablet salut 0,125 mg Tablet 68 68 68 154.000 10,472.00
37 Metilprednisolon tablet 4 mg Tablet 460 460 460 0 150.000 -
38 Metronidazol tablet 250 mg Tablet 100 100 15 85 94.000 7,990.00
39 Metronidazol Tablet 500 mg Tablet 3812 3812 2 3810 113.000 430,530.00
40 Mikonazole krim / salep 2% (nitrat) tube 0 0 0 3,000.000 -
41 Mikonazole serbuk (Mycorine) Botol 13 13 2 11 25,500.000 280,500.00
Multivitamin Sirup (Per 5 mL sir Vit A 2,000 iu, vit B1 1
mg, vit B2 0.5 mg, vit B6 1 mg, vit B12 1 mcg, vit C 10
42 mg, vit D 400 iu, Ca pantothenate 5 mg, Ca gluconate 50 Botol 26 11,847.000
mg, DHA 8 mg, lysine HCl 100 mg, colostrum bovine 250
mg.) (Truvit)
101 101 75 888,525.00 50
43 N-asetil sistein 100 mg nebules inj (Fluimucil) Ampul 15 15 15 13,175.000 197,625.00
44 Natrium Bikarbonat tablet 500 mg Tablet 10 10 10 0 44.000 - 1000
45 Natrium Diklofenak 50 mg Tablet 1180 1180 206 974 159.000 154,866.00
46 Nistatin Vaginal tablet salut 100.000 IU/g Tablet 25 25 0 25 523.000 13,075.00
Obat Flu Kombinasi Syrup (Tiap 5ml mengandung:
Paracetamol 120mg, Glyseril Guaiakolat 25mg,
47 Klorfeniramin maleat 1mg, Phenylephrine HCL 5mg)
Botol 12,000.000
(Solaflu)
0 0 0 -
Obat Untuk Saluran Cerna (Tablet kombinasi: Pancreatin
48 170mg, simethicone 80mg) (Flazymec)
Tablet 1,002.100
160 160 160 160,336.00
49 Omeprazole kapsul 10 mg Kapsul 445 445 125 320 140.000 44,800.00
50 Omeprazole kapsul 10 mg Kapsul 0 0 0 0 160.000 -
51 Parasetamol tablet 500 mg Tablet 5090 5090 1390 3700 167.000 617,900.00
52 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet 520 520 230 290 45.000 13,050.00
53 Povidon Iodida larutan 10 % Botol 30 ml 33 33 0 33 2,163.000 71,379.00
54 Prednison tablet 5 mg Tablet 1280 1280 80 1200 76.000 91,200.00
55 Salbutamol cairan IH 0,5% (Ventolin Nebule) Ampul 0 0 0 0 4,000.000 -
56 Salbutamol sirup Botol 21 21 2 19 4,275.000 81,225.00
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
57 endap 4%
Pot 0 2,000.000
24 24 24 48,000.00
58 Salisil bedak 2% Kotak 50 gram 5 5 5 0 1,025.000 -
59 Sefadroksil kapsul 500 mg Kapsul 3250 3250 798 2452 450 1,103,400.00
60 Setirizin tablet Tablet 115 115 115 0 96 -
61 Simvastatin 10mg Tablet 1170 1170 280 890 111.000 98,790.00
62 Siprofloksasin 500mg Tablet 590 590 70 520 281.000 146,120.00
63 Tramadol injeksi 50 mg/ml Ampul 15 15 0 15 2,395 35,925.00
Alat Kesehatan 0
1 Alat suntik sekali pakai 2,5 ml Set /kantong 4000 4000 4000 0 650 - 1600
2 Alkohol Swab 100 pcs/box 22 22 0 22 11,000 242,000.00
3 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 3 3 0 3 2,475 7,425.00
4 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 10 10 0 10 2,302 23,020.00
5 Bisturi No 11 (Aesculap) Buah 103 103 3 100 3,150 315,000.00
6 HCG Strip pcs 70 70 13 57 1,936 110,352.00
7 Infusion set anak Set /kantong 114 114 7 107 3,500 374,500.00
8 Infusion set dewasa Set /kantong 48 48 7 41 3,200 131,200.00
9 IV Catheter No. 18 G pcs 13 13 1 12 3,800 45,600.00
10 IV Catheter No. 20 (Adsyte 20) pcs 47 47 5 42 3,800 159,600.00
11 IV Catheter No. 22 G wings 50 buah / kotak 17 17 0 17 12,342 209,814.00 50
12 IV Catheter No. 24 G Pcs 6 6 1 5 3,800 19,000.00
13 IV Catheter No. 24 G wings 50 buah / kotak 98 98 0 98 7,000 686,000.00
14 Kasa Kompres 40/40 steril Bungkus 53 53 1 52 1,800 93,600.00
15 Object Glass Buah 100 100 0 100 290 29,000.00
16 Plester 7,5 x 4,5cm (Hansaplast) Rol 29 29 1 28 31,265 875,420.00
17 Pot Dahak (Pot Sputum) Buah 500 500 10 490 1,700 833,000.00
IMUNISASI 0
 1 Vaksin Anti Rabies (Verorab) Kuur 2 2 2 0 78,500 -
2 Vaksin BCG Vial 31 31 0 31 59,950 1,858,450.00
3 Vaksin DT Vial 3 3 0 3 17,798 53,394.00
4 Vaksin Polio IPV 5 ds (Poliomyelitis) Vial 5 5 0 5 139,760 698,800.00
5 Ads 0,5 ml pcs 600 600 600 0 1,086.00 -
6 Ads 0,05 ml Oneject Buah 100 100 0 100 1,590.00 159,000.00
7 Ads 0,05 ml Oneject/2018 Buah 1600 1600 0 1600 1,195.00 1,912,000.00
8 Ads 5 ml Buah 200 200 0 200 1,640.00 328,000.00
9 Safety Box Pcs 25 25 0 25 24,122.00 603,050.00
10 Safety Box Pcs 25 25 0 25 22,433.00 560,825.00
11 Ads 0,5 oneject Buah 400 400 0 400 1,185.00 474,000.00
TB PARU (OAT FDC) 0
1 OAT kategori 1 Paket 12 12 2 10 359,900 3,599,000.00
2 Kaca Slide Kotak 5 5 0 5 19,700 98,500.00
GIZI 0
1 Iodine Test 4 4 0 4 5,806 23,224.00
2 Tablet Fe (Ferro Fumarat) 200mg Kotak @100 tab 2760 2760 360 2400 376 902,400.00
KEJIWAAN 0
1 Amitriptillin Tablet Salut 25mg Tablet 200 200 0 200 102.00 20,400.00
2 Clozapine Tablet 25mg Tablet 100 100 0 100 1,550.00 155,000.00
3 Haloperidol Inj. 5 mg/ml Ampul 0 0 0 0 6,250.00 -
4 Haloperidol Tablet 5 mg Tablet 100 100 0 100 69.00 6,900.00
5 Haloperidol Tablet 5 mg Tablet 50 50 0 50 58.00 2,900.00
6 Klorpromazine Hcl Tablet Salut 100mg Tablet 0 0 0 0 162.00 -
7 Risperidol Tablet 2mg Tablet 1500 1500 50 1450 1,008.00 1,461,600.00
8 Triheksifenidil Tablet Tablet 0 0 0 0 88.00 -
KIA 0
1 Ca Glukonas Injeksi 10 ml Ampul 44 44 0 44 7800.00 343,200.00
2 Gentamicin injeksi 40 mg Ampul 0 0 0 0 5900.00 -
3 Magnesium Sulfate Injeksi 20 % Botol 26 26 0 26 3650.00 94,900.00
4 Metil ergometrin maleat inj 0,3 mg Ampul 0 0 0 0 2175.00 -
5 Onemed Glucose + Protein Test Ampul 30 30 30 0 1045.00 -
6 U-PAD (U-PAD 60x90) Pcs 0 0 0 0 7626.15 -
 DBD 0
1 Bactivec Botol 24 24 0 24 18,945 454,680.00
2 RDT DBD Combo ( IgG dan NS1 ) Test 30 30 0 30 110,089 3,302,670.00
HIV -
1 Jarum Lanset Dus 0 1 1 0 1 52,800 52,800.00
2 Kasa Alkohol/HIV Box 0 1 1 0 1 40,700 40,700.00
3 Label Pack 0 1 1 0 1 4,400 4,400.00
4 Lampu Spirtus Buah 0 1 1 0 1 179,300 179,300.00
5 Mikro Pipet 5-50 ul Buah 0 1 1 0 1 1,749,000 1,749,000.00
6 Pen Lanset Buah 0 1 1 0 1 73,700 73,700.00
7 Rapid Test Syphilis Monotest Box 0 1 1 0 1 1,050,500 1,050,500.00
8 Tabung Vacutrimer/HIV Box 0 1 1 0 1 292,600 292,600.00
9 Tip Kuning/2018 Box@100pcs 0 1 1 0 1 224,400 224,400.00
10 Torniquett Buah 0 1 1 0 1 49,500 49,500.00
JUMLAH RP 32,788,239.67
D. JKN/BPJS
1 Donperidone Syr 60 ml Botol 7 0 7 7 0 3,333.00 0.00
2 Gentamicin injeksi Ampul 2 0 2 0 2 3,399.00 6,798.00
3 Ketorolac inj 30 mg Ampul 6 0 6 0 6 1,290.00 7,740.00
4 Amoksisilin 125 mg Botol 35 0 35 0 35 2,445.00 85,575.00
5 Erythromicyne Kaplet 500 mg Tablet 0 0 0 0 0 730.00 0.00
6 Furosemid 40 mg Tablet 2062 0 2,062 38 2024 78.00 157,872.00
7 Lidokain injeksi 2% Ampul 206 0 206 7 199 860.00 171,140.00
8 Ondansentron 4 mg Injeksi 2 ml Ampul 20 0 20 0 20 1,650.00 33,000.00
9 Accu check Performa Strip 400 0 400 0 400 4,200.00 1,680,000.00
10 Blood Lancet 26G Onemed Dus 0 0 0 0 14,564.00 0.00
11 One Scrub Botol 0 0 0 0 62,491.00 0.00
12 Oxyflow (Oxygen Nasal) Buah 23 23 0 23 5,500.00 126,500.00
13 Natrium Clorida Botol 155 155 43 112 6,410.00 717,920.00
14 Gentamisin Salep Kulit Tube 0 0 0 0 3,080.00 0.00
15 L-BIO Sachet 0 0 0 0 6,600.00 0.00
16 Thiampenicol 500 mg Tablet 0 0 0 0 921.10 0.00
17 Meloxicam 7,5 mg Tablet 0 0 0 0 629.00 0.00
18 Piroxicam 10 mg Tablet 28 28 28 0 115.00 0.00
19 Ambroxol Tablet 0 0 0 0 143.68 0.00

20 Hyosin n buthylbromide 10 mg, Paracetamol (SCOPMA) Tablet

8 8 0 8 1,795.20 14,361.60
21 Stesolid/Diazepam Tube 1 1 0 1 23,760.00 23,760.00
22 Metronidazole Syp 200mg Botol 25 25 0 25 20,240.00 506,000.00
23 Neo K inj Ampul 50 50 0 50 6,600.00 330,000.00
24 Lodecon Tablet 0 0 0 0 869.00 0.00
25 Paracetamol 500 mg Tablet 1600 1,600 0 1600 169.00 270,400.00
26 Antasida Tablet 1300 1,300 0 1300 113.00 146,900.00
27 Solaflus Botol 0 0 0 0 12,100.00 0.00
28 Salbutamol Tablet 1428 1,428 28 1400 89 124,600.00

JUMLAH RP 4,402,566.60
 JUMLAH TOTAL 97,347,802.022

UMUM
TIDAK BPJS JUMLAH
BAYAR
BAYAR
JUMLAH RESEP

Mengetahui / Menyetujui : Yang Menyerahkan : Yang Melaporkan Dokter Puskesmas,

An. Kepala Dinas Kesehatan Kab.Pangandaran Kepala UPT Farmasi Plt UPTD Kesehatan Puskesmas Sidamulih,
Bidang Sumber Daya Kesehatan,
Ub/Seksi Kefarmasian

Tuti Perwitasari, S.Si., Apt., MM. dr. Eka Suprijana, S.Ked. Tati Haryati, Am. Keb Indri Noviyanti, dr
NIP. 19800227 200901 2 004 NIP. 189641023 200212 1 002 NIP. 19680313 199003 2 007 NIP. 19851103 201503 2 001
 FORM : LPLPO
NOMOR TANGGAL

PEMBERIAN
KET.
BUFFER LAIN JML
14 15 16 17
ex.date
ex.date
ex.date
9,347

ex.date

ex.date

ex.date
ex.date
97,347,802.022

Sidamulih , September 2018

Yang Menerima
Petugas Pengelola
Obat Puskesmas

Hj. N Minarni
NIP. 19690604 199303 2 005
 FORM PEMANTAUAN KETERSEDIAAN OBAT DAN VAKSIN INDIKATOR
DI PUSKESMAS
Periode Pelaporan: September 2018

Nama Puskesmas : Sidamulih Penanggung Jawab Farmasi: Hj. N. Minarni

Alamat : Jl. Karang Sari No. 139 No. HP:
Email : ciosmulih@gmail.com
Kabupaten: Pangandaran
Provinsi : Jawa barat

Ketersediaan Ada
No Nama Obat Satuan (1) / Tidak (0)
1 2 3 4
1 Albendazol tab tablet 1
2 Amoxicillin 500 mg tab tablet 1
3 Amoxicillin syrup botol 1
4 Deksametason tab tablet 1
5 Diazepam inj 5 mg/mL injeksi 0
6 Epinefrin (Adrenalin) Injeksi 0,1% (Sebagai HCl) injeksi 1
7 Fitomenadion (Vitamin K) injeksi injeksi 1
8 Furosemid tablet 40 mg/Hidroklortiazid (HCT) tablet 1
9 Garam Oralit serbuk 1
10 Glibenklamid/Metformin tablet 1
11 Kaptopril tab tablet 1
12 Magnesium Sulfat Injeksi injeksi 1
13 Metilergometrin Maleat 0,200 mg - 1 mL injeksi 1
14 OAT Dewasa tablet 1
15 Oksitosin injeksi 1
16 Parasetamol 500 mg tab tablet 1
17 Tablet tambah darah tablet 1
18 Vaksin BCG injeksi 1
19 Vaksin DPT - HB- Hib injeksi 1
20 Vaksin Td injeksi 1

Pangandaran, September 2018

Mengetahui Yang Melaporkan,
Plt UPTD Kesehatan Puskesmas Sidamulih Pengelola Obat

Tati Haryati, Am.Keb Hj. N Minarni

NIP. 19680313 199003 2 007 NIP. 19690604 199303 2 005

Nb. Isi Kolom keterangan dengan X bila puskesmas tidak membutuhkan obat tersebut
 Keterangan

aran, September 2018

ang Melaporkan,
Pengelola Obat

Hj. N Minarni
9690604 199303 2 005