LAPOR

PUSKESMAS PELAPORAN
KECAMATAN : PERMINTAAN
KAB/KOTA :
PROPINSI :

KODE
NO OBAT NAMA OBAT SATUAN STOK AWAL PENERIMAAN
1 2 3 4 5

1 A.B.U. I (khusus ular dari luar Papua) inj (i.m./i.v.) vial 0 0

2 A.B.U.II (khusus ular dari Papua) inj (i.m./i.v.) vial 0 0
3 Air untuk injeksi amp 25 mL ampul 0 0
4 Albendazol tab 400 mg tablet 0 0
5 Albendazol susp 200 mg/5 mL botol 0 0
6 Alopurinol tab 100 mg tablet 7064 0
7 Alopurinol tab 300 mg tablet 0 0
8 Amilorid tab 5 mg tablet 0 0
9 Aminofilin tab 150 mg tablet 0 0
10 Aminofilin tab 200 mg tablet 0 0
11 Aminofilin inj 24 mg/mL vial 0 0
tablet
12 Amitriptilin tab sal 25 mg salut 270 0
13 Amlodipin tab sal 5 mg tablet 2255 4500
14 Amlodipin tab 10 mg tablet 0 0
15 Amoksisilin tab 500 mg tablet 19106 1000
16 Amoksisilin sir forte 250 mg/5 mL botol 0 0
17 Ampisilin serb inj 1000 mg/vial vial 0 0
18 Ampisilin serb inj 250 mg/vial vial 0 0
Anestetik lokal gigi kombinasi : lidokain HCl
vial
19 2% + epinefrin 1 : 80.000 inj 2 mL 0 0
Antasida, kombinasi : aluminium hidroksida 200 tablet
20 mg + magnesium hidroksida 200 mg kunyah 1274 7200
Antasida, kombinasi :aluminium hidroksida 200
botol
21 mg + magnesium hidroksida 200 mg 50 50
Antifungi salep, kombinasi : asam benzoat 6%
tube
22 + asam salisilat 3% 0 0
Antihemoroid, kombinasi: bismut subgalat 150
mg + heksaklorofen 2,5 mg + lidokain 10 mg + supp
23 seng oksida 120 mg, sup ad 2 g 1030 0
Antimalaria kombinasi : sulfadoksin 500 mg +
kapsul
24 pirimetamin 25 mg 0 0
 Antiparkinson kombinasi : benserazid 25 mg +
25 levodopa 100 mg kapsul 0 0
26 Artemether inj 80 mg/mL vial 0 0
27 Artesunat serb inj 60 mg/mL (i.v./i.m.) vial 0 0

kertas
warna
penanda
28 Articulating paper oklusi 0 0

29 Asam asetilsalisilat (asetosal) / Miniaspi tab 80 mg tablet 401 200

30 Asam askorbat (vitamin C) tab 50 mg tablet 24758 0
31 Asam askorbat (vitamin C) tab 250 mg tablet 0 0
32 Asam folat tab 0,4 mg tablet 0 0
33 Asam folat tab 1 mg tablet 8562 10000
34 Asam folat tab 5 mg tablet 0 0
35 Asam mefenamat kaps 250 kapsul 0 0
36 Asam mefenamat kaps 500 kapsul 1656 2000
37 Asam salisilat 5% salep 0 0
38 Asam salisilat 0,1% larutan 0 0
39 Asiklovir tab 200 mg tablet 2307 0
40 Asiklovir tab 400 mg tablet 2310 0
41 Atapulgit tablet 0 0
42 Atenolol tab 50 mg tablet 0 0
43 Atropin tab 0,5 mg tablet 0 0
44 Atropin inj 0,25 mg/mL (i.v./i.m./s.k.) vial 0 0
45 Bahan tumpatan sementara lar, serb botol 0 0
46 Bedak salisil serb 2% serbuk 189 300
47 Benzatin penisilin inj 1,2 juta UI/mL (i.m.) vial 0 0
48 Benzatin penisilin inj 2,4 juta UI/mL (i.m.) vial 0 0
49 Betametason krim 0,5 mg/g krim 149 125
50 Betametason tts mata 1 mg/mL botol 0 0
Bisakodil sup 10 mg tab salut
51 146 0
52 Bisakodil sup 5 mg supp 1 0
53 Bisakodil tab salut 5 mg supp 57 0
54 Coal tar lar 5 % botol 0 0
Copper T set/buah
55 0 0
tab
Dapson tab scored 100 mg
56 scored 0 0
57 Deksametason inj 5 mg/mL (i.v./i.m.) vial 38 0
58 Deksametason tab 0,5 mg tablet 8023 10000
59 Diazepam inj 5 mg/mL (i.v./i.m.) vial 0 0
Diazepam lar rektal 10 mg/2,5 mL lar rektal
60 0 0
 Diazepam lar rektal 5 mg/2,5 mL lar rektal
61 38 0
62 Diazepam tab 2 mg tablet 66 0
63 Diazepam tab 5 mg tablet 0 0
64 Dietilkarbamazin tab 100 mg tablet 0 0
65 Difenhidramin inj 10 mg/mL (i.v./i.m.) vial 30 0
66 Digoksin tab 0,25 mg tablet 0 0
67 Diltiazem HCl tab 30 mg tablet 0 0
68 Dimenhidrinat tab 50 mg tablet 0 0
69 Doksisiklin kaps 100 mg kapsul 5781 0
70 Domperidon tab 10 mg tablet 7507 2000
71 Epinefrin (adrenalin) inj 0,1% (i.v./s.k./i.m.) ampul 0 0
72 Epinefrin (adrenalin) inj 1 mg/mL ampul 0 0
73 Ergokalsiferol (vitamin D2) kaps 50.000 UI kapsul 0 0
74 Ergokalsiferol (vitamin D2) susp 10.000 UI/mL botol 0 0
75 Ergotamin tab 1 mg tablet 0 0
76 Eritromisin kaps 250 mg kapsul 0 0
77 Eritromisin sir 200 mg/5 mL botol 0 0
78 Etambutol tab 250 mg tablet 0 0
79 Etambutol tab 400 mg tablet 0 0
80 Etambutol tab 500 mg tablet 0 0
81 Etanol botol 70% botol 2 0
82 Etil klorida semprot 100 mL botol 0 0
83 Etonogestrel implan 68 mg implan 0 0
84 Eugenol botol 0 0
85 Fenitoin Na kaps 50 mg kapsul 0 0
86 Fenitoin Na kaps 100 mg kapsul 0 0
87 Fenitoin Na inj 100 mg/2 ampul 0 0
88 Fenitoin Na inj 50 mg/mL ampul 0 0
89 Fenobarbital tab 30 mg tablet 798 0
90 Fenobarbital tab 100 mg tablet 0 0
Fenoksimetil penisilin (penisilin V) tab 250 mg tablet
91 0 0
Fenoksimetil penisilin (penisilin V) tab 500 mg tablet
92 0 0
Fenoksimetil penisilin (penisilin V) serb inj 3
vial
93 juta UI/vial (i.m.) 0 0
kaps.
Ferro fumarat kaps lunak 300 mg
94 Lunak 0 0
tablet
Ferro sulfat tab salut 300 mg
95 salut 0 0
96 Ferro sulfat sir. 15 mg/5 mL botol 0 0
tab.
Fitomenadion (vitamin K 1) tab sal 10 mg
97 Salut 348 0
Fitomenadion (vitamin K 1) inj 2 mg/mL (i.m.) vial
98 98 0
 99 Fluor tab 0,5 mg tablet 0 0
100 Fluor kapl 1 mg kapsul 0 0
101 Fluor sediaan topikal tube 0 0
102 Fluoresein tts mata 2,5 mg/mL botol 0 0
103 Formokresol botol 0 0
104 Furosemid tab 40 mg tablet 0 0
105 Furosemid inj 10 mg/mL (i.v./i.m.) ampul 0 0
Galactose microparticle200- 400 mg
gel
106 micropart/mL 0 0
Garam oralit kombinasi : natrium klorida 0,52 g
+ kalium klorida 0,30 g + trinatrium sitrat
sachet
dihidrat 0,58 g+ glukosa anhidrat 2,7 g serbuk
107 untuk 200 ml air 413 0
Glass ionomer ART (Atraumatic Restorative
sachet
108 Treatment) 0 0
Glass ionomer ART (Atraumatic Restorative
botol
109 Treatment) 0 0
Glass ionomer ART (Atraumatic Restorative cocoa
110 Treatment) cocoa butter 5 g butter 0 0
111 Glibenklamid tab 2,5 mg tablet 0 0
112 Glibenklamid tab 5 mg tablet 4480 0
113 Glimepirid tab 1 mg tablet 0 0
114 Glimepirid tab 2 mg tablet 808 0
115 Glipizid tab 5 mg tablet 0 0
tablet
Gliseril trinitrat tab sublingual 0,5 mg
116 sub. 0 0
117 Gliserin tts 10 mg/mL botol 0 0
118 Gliserin tts 100 mg/mL botol 0 0
119 Griseofulvin (micronized ) tab 125 mg tablet 2058 0
tablet
Griseofulvin (micronized ) tab scored 250 mg
120 score 0 0
121 Gutta percha dan paper points 15 - 40 mm roll 0 0
122 Gutta percha dan paper points 45 - 80 mm roll 0 0
123 Haloperidol tab 0,5 mg tablet 100 0
124 Haloperidol tab 1,5 mg tablet 90 0
125 Haloperidol tab 2 mg tablet 0 0
126 Haloperidol tab 5 mg tablet 0 0
127 Haloperidol tts 2 mg/mL botol 0 0
128 Haloperidol inj 5 mg/mL (i.m.) vial 0 0
Hepatitis B imunoglobulin (human) inj 0,5 mL vial
129 0 0
130 Hidrogen peroksida botol 3% botol 0 0
131 Hidrogen peroksida lar. konsentrat 3% botol 0 0
132 Hidroklorotiazid tab 25 mg tablet 278 0
133 Hidrokortison serb inj 100 mg/vial vial 0 0
134 Hidrokortison krim 2,5% krim 25 144
135 Hiosina butilbromida tab 10 mg tablet 0 0
Human tetanus imunoglobulin inj 250 UI(i.m) vial
136 0 0
Human tetanus imunoglobulin inj 500 UI (i.m.) vial
137 0 0
138 Ibuprofen tab 200 mg tablet 0 0
139 Ibuprofen tab 400 mg tablet 0 0
140 Ibuprofen sir 100 mg/5 mL botol 69 0
141 Ibuprofen sir 200 mg/5 mL botol 0 0
142 Ipratropium bromida ih padat 20 mg botol 0 0
143 Ipratropium bromida nebulizer 0,025% botol 0 0
144 Isoniazid tab 100 mg tablet 0 0
145 Isoniazid tab 300 mg tablet 0 0
146 Isosorbid dinitrat tab 5 mg tablet 606 1000
147 Kalamin botol 0 0
148 Kalsium glukonat inj 100 mg/mL ampul 0 0
149 Kalsium hidroksida pasta 0 0
150 Kalsium karbonat tab 500 mg tablet 0 0
151 Kalsium laktat (kalk) tab 500 mg tablet 6227 8400
152 Kaptopril tab 12,5 mg tablet 10059 0
153 Kaptopril tab 25 mg tablet 10151 3500
154 Karbamazepin tab 200 mg tablet 0 0
155 Karbamazepin sir 100 mg/5 mL botol 0 0
156 Karbo adsorben tab 0,5 g tablet 0 0
157 Karbogliserin tts telinga 10 % botol 0 0
158 Ketamin inj 50 mg/mL ampul 0 0
159 Ketamin inj 100 mg/mL (i.v.) ampul 0 0
160 Ketokonazol tab 200 mg tablet 64 0
161 Klofazimin, micronizedkaps 100 mg kapsul 0 0
162 Kloramfenikol kaps 250 mg kapsil 3836 0
163 Kloramfenikol susp 125 mg/5 mL botol 0 0
164 Kloramfenikol salep kulit 2% pot 0 0
165 Kloramfenikol tts mata 0,5% botol 0 0
166 Kloramfenikol tts mata 1% botol 0 0
167 Kloramfenikol salep mata 1% pot 0 0
168 Klorfeniramin maleat tab 4 mg tablet 277391 0
169 Klorfenol kamfer mentol (CHKM) botol 0 0
170 Klorheksidin lar 15% botol 0 0
171 Klorheksidin lar 0,2% botol 0 0
tablet
Klorpromazin tab sal 25 mg
172 salut 0 0
tablet
Klorpromazin tab sal 100 mg
173 salut 0 0
174 Klorpromazin inj 5 mg/mL (i.m.) vial 0 0
175 Klorpromazin inj 25 mg/mL vial (i.m.) vial 0 0
176 Klortalidon tab 50 mg tablet 0 0
177 Kodein tab 10 mg tablet 130 0
178 Kodein tab 20 mg tablet 0 0
Kombinasi untuk anak : Paduan dalam bentuk
dosis tetap (KDT/FDC) Rifampisin kaplet 75 mg Paket
179 + isoniazid tablet 50 mg 0 0
kombinasi (kombipak) : artesunat tab 50 mg +
Tablet
180 amodiakuin tab 200 mg 0 0
kombinasi : tablet salut ferro sulfat 200 mg + Tablet
181 asam folat 0,25 mg / SF Tambah darah salut 391 5000
Kombinasi : artemeter 20 mg + lumefantrin 120
Tablet
182 mg 0 0

kombinasi untuk anak : (Paduan dalam bentuk

Kombipak) Rifampisin kaplet 75 mg + isoniazid Paket
tablet 100 mg + pirazinamid tablet 200 mg
183 0 0
kombinasi untuk anak : (Paduan dalam bentuk
kombipak) Rifampicin kaplet75 mg + isoniazid
tablet
100 mg
184 Paket 0 0
Kombinasi untuk anak : Paduan dalam bentuk
dosis tetap (KDT/FDC) Rifampisin kaplet 75 mg
+ isoniazid tablet 50 mg + pirazinamid tablet
185 150 mg Paket 0 0
Kombinasi untuk dewasa : Paduan dalam
bentuk kombipak Rifampisin kaplet 450 mg +
186 isoniazid tablet 300 mg Paket 0 0

kombinasi untuk dewasa: (Paduan

dalam bentuk Kombipak) Rifampisin
kaplet 450 mg + isoniazid tablet 300
mg + pirazinamid tablet 500 mg +
etambutol tablet 250 mg dan 500 mg
187 Paket 0 0
kombinasi untuk dewasa: Paduan dalam
bentuk dosis tetap (KDT/FDC) Rifampisin
kaplet 150 mg + isoniazid tablet 75 mg +
pirazinamid tablet 400 mg + etambutol tablet
188 275 mg Paket 0 0

kombinasi untuk dewasa: Paduan dalam bentuk

dosis tetap (KDT/FDC) Rifampisin kaplet 150 mg + Paket
189 isoniazid tablet 150 mg 0 0

190 Kombinasi: kaolin 550 mg + pektin 20 mg / diaform tablet 1003 2500

kombinasi: ipratropium Br 0,5 mg + salbutamol 2,5
191 mg botol 0 0
192 Komposit resin set 0 0

Kontrasepsi oral kombinasi tablet : levonorgestrel

193 150 mcg + etinilestradiol 30 mcg tablet 0 0
Kotrimoksazol 240 mg : sulfametoksazol 200 mg +
194 trimetoprim 40 mg botol 166 50
Kotrimoksazol (dewasa) 480 mg : sulfametoksazol
195 400 mg + trimetoprim 80 tablet 4800 0

Kotrimoksazol forte kombinasi 960 mg:

196 sulfametoksazol 800 mg + trimetoprim 160 mg tablet 0 0
197 Kuinin tab 200 mg tablet 0 0
198 Kuinin tab 222 mg tablet 0 0
199 Kuinin tab 250 mg tablet 0 0
200 Kuinin inj 25% (i.v.) vial 0 0

201 Levonorgestrel implan 2 rods, 75 mg (3-4 tahun) implan 0 0

202 Lidokain inj 1 % (infltr) ampul 0 0
203 Lidokain inj 2% (infiltr/p.v.) ampul 110 0
204 Lidokain gel 2% gel 0 0
205 Lidokain semprot 10% botol 0 0
206 Lidokain pasta 5% (HCl) tube 0 0
207 Lidokain semprot 15% (HCl) botol 0 0
208 Loratadin tab 10 mg tablet 738 2000
209 Lugol botol 0 0
210 Magnesium sulfat serb, ktg 30 g sachet 0 0
211 Magnesium sulfat inj 20% ampul 0 0
212 Magnesium sulfat inj 40% ampul 0 0
213 Mebendazol tab 100 mg tablet 0 0
214 Mebendazol tab 500 mg tablet 0 0
215 Mebendazol sir 50 mg/mL botol 0 0
Medroksi progesteron asetat inj depo 150 mg vial
216 0 0
Metenamin mandelat (heksamin mandelat) tab tablet
217 salut enterik 500 mg salut 0 0
218 Metformin tab 500 mg tablet 5362 0
219 Metformin tab 850 mg tablet 0 0
220 Metilergometrin tab salut 0,125 mg tablet 0 0
221 Metilergometrin inj 0,2 mg/Ml ampul 0 0
222 Metoklopramid tab 5 mg tablet 0 0
223 Metoklopramid tab 10 mg tablet 1484 0
224 Metronidazol tab 250 mg tablet 0 0
225 Metronidazol tab 500 mg tablet 2225 0
226 Metronidazol sir 125 mg/5 mL botol 0 0
227 Metronidazol lar inf 5 mg/mL botol 0 0
228 Metronidazol ovula 500 mg supp 0 0
229 Mikonazol serb 2% vial 0 0
230 Mikonazol krim 2% krim 356 48
231 Natrium bikarbonat tab 500 mg tablet 0 0
232 Natrium diklofenak tab 25 mg tablet 0 0
tab 50
233 Natrium diklofenak tab 50 mg mg 13909 1500
234 Natrium hipoklorit botol konsentrat 5% botol 0 0
235 Natrium tiosulfat inj 25% (i.v.) vial 0 0
236 Nifedipin kaps 10 mg kapsul 133 0
237 Nikotinamid tab 5 mg tablet 0 0
238 Nikotinamid tab 20 mg tabet 0 0
239 Nikotinamid tab 100 mg tablet 0 0
tablet
240 Nistatin tab salut 500.000 UI salut 0 0
241 Nistatin susp 100.000 UI/mL botol 0 0
242 Nistatin tab vaginal 100.000 UI/tab supp 73 0
243 Nitrofurantoin tab 50 mg tablet 0 0
244 Norepinefrin inj 1 mg/mL ampul 0 0
245 Oksigen ih, gas dlm tabung botl 0 0
246 Oksimetazolin tts hidung 0,025% botol 0 0
247 Oksimetazolin tts hidung 0,05% botol 0 0
248 Oksitosin inj 10 UI/mL ampul 0 0
249 Olopatadin tts mata 0,1% botol 0 0
250 Omeprazol kaps 20 mg kapsul 1551 0
251 Omeprazol inj 40 mg/10 mL ampul 0 0
252 Paraformaldehid tab 1 g tablet 0 0
253 Parasetamol tab 500 mg tablet 37641 10000
254 Parasetamol sir 120 mg/5 mL botol 0 150
255 Parasetamol tts 60 mg/0,6 mL botol 0 0
256 Pasta devitalisasi (non arsen) tube 0 0
257 Pasta pengisi saluran akar tube 0 0
258 Perak nitrat lar 20% botol 0 0
259 Perak sulfadiazin krim 1% pot 0 0
260 Permetrin krim 5 % pot 0 0
tablet
261 Pirantel pamoat tab scored 125 mg score 493 0
tablet
262 Pirantel pamoat tab scored 250 mg score 0 0
263 Pirantel pamoat tab 500 mg tablet 0 0
264 Pirantel pamoat susp 125 mg/5 mL botol 3 0
265 Pirazinamid tab 500 mg tablet 0 0
266 Piridoksin (vitamin B6) tab 10 mg tablet 11828 50000
267 Piridoksin (vitamin B6) tab 25 mg tablet 0 0
268 Piridoksin (vitamin B6) inj 100 mg/mL ampul 0 0
269 Povidon iodin lar 1000 mg/mL botol 0 0
 tablet
Prazikuantel tab scored 300 mg
270 score 0 0
tablet
Prazikuantel tab scored 600 mg
271 score 0 0
272 Prednison 5 mg tablet 10614 0
273 Primakuin 15 mg tablet 0 0
274 Probenesid 500 mg tablet 0 0
Prokain benzilpenisilin inj 1 juta UI/vial (i.m.) vial
275 0 0
Prokain benzilpenisilin serb inj 3 juta UI/vial
vial
276 (i.m.) 0 0
277 Propiltiourasil 100 mg tablet 0 0
278 propranolol 10 mg tablet 0 0
279 Ranitidin 150 mg tablet 5200 0
kapsul
Retinol (vitamin A) kaps lunak 100.000 UI
280 lunak 36 0
kaps
Retinol (vitamin A) kaps lunak 200.000 UI
281 lunak 89 0
282 Rifampisin 300 mg kapsul 0 0
283 Salbutamol 2 mg tablet 1778 0
284 Salbutamol 4 mg tablet 0 0
285 Salbutamol lar ih 0,5 % botol 0 0
286 Salbutamol botol ih 0,1% botol 0 0
Salep 2-4, kombinasi : asam salisilat 2% + belerang tube
287 endap 4% 111 0
288 Serum antidifteri (A.D.S) i.m 10.000 UI/vial vial 0 0
289 Serum antidifteri (A.D.S) i.m 20.000 UI/vial vial 0 0
290 Serum antirabies inj 200 UI/mL vial 0 0
291 Serum antirabies inj100 UI/mL vial 0 0
Serum antitetanus (A.T.S) inj 1500 UI/amp
ampul
292 (i.m.) 0 0
Serum antitetanus (A.T.S) inj 10.000 UI/vial
vial
293 (i.m /i.v.) 0 0
Serum antitetanus (A.T.S) inj 20.000 UI/vial
vial
294 (i.m /i.v.) 0 0
295 Setirizin 5 mg/5 mL botol 0 0
296 Sianokobalamin (vitamin B12) 50 mcg tablet 17834 0
297 Sianokobalamin (vitamin B12) 500 mcg/mL ampul 84 0
tablet
Simvastatin 10 mg
298 salut 2406 1100
tabet
Simvastatin 20 mg
299 salut 0 0
tablet
Siprofloksasin 500 mg
300 scored 4936 0
301 Spironolakton 25 mg tablet 0 0
302 Streptomisin 1000 mg/vial vial 0 0
303 Surgical ginggival pack pasta 0 0
304 Tetanus toxoid vial 0 0
305 Tetrakain 0,5% botol 0 0
306 Tetrasiklin 250 mg kapsul 577 0
307 Tetrasiklin 500 mg kapsul 0 0
308 Tiamin (vitamin B1) 50 mg tablet 3035 0
309 Triheksifenidil 2 mg tablet 10 0
Tuberkulin protein purified derivative 1:10 (i.k.) ampul
310 0 0
311 Vaksin BCG vial 0 0
312 Vaksin campak vial 0 0
313 Vaksin jerap difteri tetanus pertusis (DTP) vial 0 0
314 Vaksin jerap difteri tetanus (DT) vial 0 0

vial
315 Vaksin jerap tetanus (tetanus adsorbed toxoid 0 0
316 Vaksin kombinasi DPT + hepatitis B vial 0 0
317 Vaksin polio botol 0 0
318 Vaksin rabies, untuk manusia vial 0 0
tablet
319 Valproat 250 mg salut 0 0
tablet
320 Valproat 500 mg salut 0 0
321 Valproat 250 mg/5 mL botol 0 0
322 Vitamin B kompleks tablet 48769 0
323 Zinc 10 mg/mL botol 0 0
tablet
324 Zinc 20 mg disp 4715 0
325 Zinc 20 mg/5 mL botol 119 0
326 Zinc 10 mg sachet 0 0

UMUM
BPJS
JUMLAH KUNJUNGAN RESEP BAYAR TDK

Mengetahui
Kepala

.....
NIP
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
BULAN :

: AGUSTUS 2017 DOKUMEN

DINKES
IF KAB/KOTA
PUSKESMAS

PEMBERIAN
PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPTIMUM PERMINTAAN APBD I APBD II
6=4+5 7 8=6-7 9 10 11 12

0 0 0
0 0 0
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7064 215 6849
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20106 5487 14619
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8474 4935 3539

100 52 48

0 0 0

1030 72 958

0 0 0
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601 470 131

24758 13460 11298
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18562 6000 12562
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3656 3656 0
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18023 5309 12714
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413 413 0

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3503 1681 1822

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2738 1860 878
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15409 8400 7009

0 0 0
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47641 21076 26565
150 35 115
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493 0 493

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3 1 2
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10614 3961 6653
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5200 3568 1632

36 0 36

89 0 89
0 0 0
1778 0 1778
0 0 0
0 0 0
0 0 0

111 7 104
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0

0 0 0
0 0 0
17834 4910 12924
84 0 84

3506 1036 2470

0 0 0

4936 702 4234

0 0 0
0 0 0
 0 0 0
0 0 0
0 0 0
577 0 577
0 0 0
3035 1536 1499
10 0 10

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
48769 8196 40573
0 0 0

4715 547 4168

119 39 80
0 0 0

JUMLAH
 NOMOR TGL

PEMBERIAN TIDAK MAMPU

DAK PROGRAM LAIN-LAIN JUMLAH DILAPORKAN KETERANGAN
13 14 15 16=11+12+13+14

0
Yang
Petugas

.....
NIP
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS PELAPORAN
KECAMATAN : PERMINTAAN
KAB/KOTA :
PROPINSI :

KODE
NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN
OBAT

1 2 3 4 5
1 Akarbose tab 100 mg Tablet 0 0
2 Alprazolam tab 0,5 mg Tablet 0 0
3 Alprazolam tab 1 mg Tablet 0 0
Alumunium Hidroksida, Magnesium Hidroksida,
4 Botol 0 0
Simethicone
5 Ambroksol Drop 7.5 Mg/ml Botol 0 0
6 Ambroksol Syr 15mg/5ml 60 Ml Botol 0 300
7 Ambroksol Syr 30mg/5ml 60 Ml Botol 53 100
8 Ambroksol Tablet 30 Mg Tablet 487 4000
9 Amiodaron tab 200 mg Tablet 0 0
10 Amiodaron inj 150 mg/3 ml Ampul 0 0
11 Amoksisilin drop 100 mg/ml Botol 0 0
12 Amoksisilin kaps. 250 mg Kapsul 1604 1500
13 Amoksisilin sirup kering 125mg/5ml Botol 0 200
Amoksisilin 125 mg + Kalium Klavulanat 31,25 mg
14 Botol 0 0
sirup
Amoksisilin 250 mg + Kalium Klavulanat 62,5 mg
15 Botol 0 0
sirup

16 Amoksisilin 500 mg + Kalium klavulanat 125 mg Tablet 0 0

17 Ampisilin tablet 500 mg Tablet 0 0

18 Ampisilin 1 gram + Sulbaktam 500 mg injeksi Vial 0 0
19 Ampisilin 500 mg + Sulbaktam 250 mg Vial 0 0
Amylase, protease, lipase, desoxycholic acid,
20 dimethylpolysiloxane, vit B1, vit B2, vit B6, vit B12, Tablet 0 0
niacinamide, Ca pantothenate tablet
21 Antalgin Tablet 500 Mg Tablet 1000 0
22 Antalgin injeksi Ampul 0 0
Antibakteri, kombinasi : basitrasin 500 UI/g+
23 Tube 0 0
Polimiskin B 10.000 UI/g

24 Antimigrain DOEN kombinasi : Ergotamin + Caffein Tablet 0 0

25 Aquadest steril 500 ml Botol 4 0

26 Antidulafungin 100 mg injeksi Ampul 0 0
27 Aripiprazol 10 mg tablet Tablet 0 0
28 Asam asetilsalisilat tab 500 mg Tablet 0 0
29 Asam asetilsalisilat tab 100 mg Tablet 0 0
30 Asam askorbat (vitamin C) tab 100 mg Tablet 0 0
31 Asam askorbat (vitamin C) tab 25 mg Tablet 0 0

As.Folat, ß-Carotene, Vit.B1, B2, B6,

32 Ca.Pantothenate, Ca carbonate, vitamin D3, vitamin Tablet 0 0
K1, biotin, besi glukonat, IPC, DHA, ARA

33 Asam Risedronic tablet 35 mg Tablet 0 0

34 Asam pipemidat 400 mg Tablet 0 0
35 Asam traneksamat tab 500 mg Tablet 0 0
36 Asam traneksamat injeksi Ampul 0 0
37 Asefillin Piperazine injeksi 500 mg/5 ml Ampul 0 0
38 Asetazolamide tab 250 mg (glaucon) Tablet 0 0
39 Asiklovir injeksi Vial 0 0
40 Asiklovir Krim 5 % Tube 52 50
41 Astasantin kapsul Kapsul 0 0
42 Atorvastatin 10 Mg Tab Tablet 0 0
43 Atorvastatin 20mg tab Tablet 0 0
44 Azitromisin tab 500 mg Tablet 0 0
45 Azitromisin tab 250 mg Tablet 0 0
46 Azitromisin 500mg inj Vial 0 0

47 Besi II Sulfat , Folic acid, Magnesium, Vit A, Copper, botol 0 0

vit B
48 Betahistine tablet 6 mg Tablet 0 0
Beta karoten 6000 IU, Extract billberry 80 mg,
49 Vitamin C 100 mg, Vitamin E 25 mg, Lutein 3 mg, Tablet 0 0
Lycopene 2 mg, Zn 10 mg

50 Betametason valerat 0,1 % + neomisin sulfat 0,5 % Tube 0 0

Betamethasone valerate 0.1% + Gentamicin sulfate

51 0.1% Tube 0 0

52 Bisoprolol 1.25 mg tablet 620 0

53 Bisoprolol 5 mg Tablet 0 0
54 Borak Glyserol 5 % larutan Botol 6 60
55 Bromheksin HCl 4 mg/2ml injeksi Ampul 0 0
56 Bromheksin HCl Elixir 4 Mg/5 Ml 60 Ml Botol 0 0
57 Bromheksin HCl Sol 2mg/ml 50 Ml Botol 0 0
58 Bromheksin HCl Tablet 8 Mg Tablet 0 0
59 Celecoxib 100 mg Tablet 0 0
60 Celecoxib 200 mg Tablet 0 0
61 Chlorhexidine Botol 0 0
62 Clidinium Br 2.5 Mg, Chlordiazepoxide 5 Mg. Tablet 0 0
63 Curcuma Root Sirup / Curviplex Botol 66 216
64 Curcumaminoid, B1, B2, B6, B12, B caroten Tablet 0 0
65 Deksketoprofen injeksi 50 mg Ampul 0 0
66 Deksketoprofen tablet 25 mg Tablet 0 0
67 Dekspanthenol krim 5 % Tube 0 0
68 Desonide Krim 0,05 % Tube 0 0
69 Dextromethorphan, maleate, phenylephrine Botol 0 0
sirup
70 Diazepam 2 mg + Metampiron 500 mg Tablet 20 0
Dibasic Ca phosphate 200 mg, Ca lactate 100
71 mg, vit B6 20 mg, vit C 25 mg, vit D3 100 IU Tablet 0 0
tablet
72 Dibekacin Vial 100 mg/2 ml Ampul 0 0
73 Dibekacin vial 50 mg/ 2 ml Ampul 0 0
74 Diosmin 450 mg + hesperidin 50 mg tablet Tablet 0 0
75 Domperidone Suspensi Botol 79 100
76 Dopamine HCL Injeksi. Ampul 0 0
Drop per ml : Isothipendyl HCl 1 mg,
77 acetaminophen 120 mg, phenylephrine HCl 1 Botol 0 0
mg
78 Efedrin HCl tablet 25 mg Tablet 0 0
79 Ekstrak Belladona tab 10 mg Tablet 0 0
80 Ekstrak plasenta 10 %, neomisin sulfat 0.5 % Tube 0 0
Gel
Ekstrak plasenta 15 mg, Vitamin B12 20 mcg, dan
81 Tablet 0 0
tribasic calcium phosphate 12 mcg. 
82 Elemen Besi + Asam Folat oral drop 15 mg/ml Botol 0 0
83 Entecavir 0.5 mg Tablet 0 0
84 Eperisone Tablet Tablet 0 0
85 Erdosteine sirup 175 mg/5 ml Botol 0 0
86 Eritromisin tab 500 mg Tablet 434 0
87 Estazolam Tablet 2 Mg Tablet 0 0
88 Ethamsilat injeksi 250 mg Ampul 0 0
89 Etoricoxib tab 60 mg Tablet 0 0
90 Famotidin tab 40 mg Tablet 0 0
91 Fenilbutazon tab 200 mg Tablet 0 0
92 Fenobarbital inj. 50 mg/ml Ampul 0 0
93 Flavoxate hidroklorida 200 mg Tablet 0 0

94 Florometolon 1 mg + Neomisin sulfat 3.5 mg/ml Botol 0 0

fludrocortisone, lidocaine, neomysin, polymiksin B

95 tetes telinga Botol 0 0

96 Fluphenazine dekanoat injeksi 25 mg/ml Ampul 0 0

97 Flukonazole kaps 150 mg Kapsul 0 0
98 Flunarizin tablet 10 mg Tablet 0 0
 99 Flunarizin tablet 5 mg Tablet 0 0
100 Fluorometolon tts mata 0,1% Botol 0 0
101 Fluoxetine tab tablet 0 0
102 Fosfomisin Vial 2 G Vial 0 0
Fradiomisin Sulfat 2,5 mg, Gramisidin-S HCl 1 mg
103 Tablet 0 0
tablet
104 Framisetin sulfat kassa steril Lembar 0 0
105 Fructus schizandrae extract siccum 7,5mg Kapsul 0 0
106 Gatifloxacin tetes mata Botol 0 0
107 Gemfibrozil tab 300 mg tablet 61 1000
108 Gentamisin injeksi 40 mg/ml Ampul 0 0
109 Gentamisin sulfat salep mata Tube 0 0
110 Gentamisin tts mata 0,3% Botol 0 0
111 Gentamisin Salep Kulit Tube 179 288
112 Gentian Violet Larutan 1 % Botol 0 0
113 Gliseril guaiakolat 100 mg Tablet 9236 4000
114 Glikuidon tablet Tablet 0 0

115 Glucosamin Hcl 500 Mg + Kondroitin Sulfat 400 Mg Kaplet 0 0

116 Glucosamin Tablet 250 Mg Tablet 0 0

117 Glucosamin tablet 500 mg Tablet 0 0

Glucosamine sulphate 500 mg, chondroitin sulfate

118 400 mg, vit C 50 mg, manganese 0.5 mg, Mg 10 mg, Tablet 0 0
selenium 10 mcg, Zn 5 mg, MSM 350 mg tablet

119 Glukosa 70% (Dextran 70) larutan steril Botol 0 0

120 Glukosa 40% larutan infus Botol 0 0
121 Glukosa 10% larutan infus Botol 0 0
122 Glukosa 5% larutan infus Botol 0 0
123 Granisetron injeksi 3 mg Ampul 0 0
124 Hidrokortison krim 0,5% Tube 0 0
125 Hidrokortison krim 1% Tube 0 0
Hidrokortison 0.5 % + Kloramfenikol 0.2 % salep
126 mata 3,5 g Tube 0 0

Hyoscine-N-butylbromide 10 mg, Paracetamol 500

127 Tablet 0 0
mg
128 Hyoscine-N-butylbromide 20 mg/ml injeksi Ampul 0 0
129 Ibuprofen Supp 125mg Suppos 0 0
130 Ichtyol salep ( salep hitam ) pot 1 24
131 Ilberry extract, gliserin, gelatin, minyak sayur Botol 0 0
132 Imipenem Cilastatin Vial 1 G Vial 0 0
Ion Natrium & Kalium dengan Benzalkonium Cl tetes
133 Botol 0 0
mata
134 Isoksuprine Hcl Injeksi Ampul 0 0
135 Isoksuprine Tablet 20 Mg Tablet 0 0
136 Itraconazole Kapsul 100 Mg Kapsul 0 0
137 Kalium Diklofenak 25 mg tablet Tablet 0 0
138 Kalium Diklofenak 50 Mg Tablet Tablet 0 0
139 Kalium Permanganat ( PK ) pot 47 0
140 Kalium L-Aspartat tab 300 mg Tablet 0 0
141 Kanamisin Inj. 1 G Vial 0 0
142 Kaolin + Pektin Sirup / Novadiar Botol 168 0
Kaplet mengandung:Acetaminofen 500 mg, Gliseril
143 guaiacolat 50 mg, Fenilpropanolamin HCl 15 mg, Kaplet 0 0
Dekstrometorfan HBr 15 mg, Chlorfeniramine
maleat
144 Kaptopril tablet 50 mg Tablet 0 0
145 Karbazochrom Na. Inj. Ampul 0 0
146 Karboksimetilselulosa 5 mg tetes mata Botol 0 0
147 Ketoacid essensial Tablet 0 0
148 Ketokonazole krim Tube 0 0
149 Ketoprofen Injeksi Ampul 0 0
150 Ketoprofen Suppos Suppos 0 0
151 Ketoprofen Tablet 100 Mg Tablet 0 0
152 Ketorolac injeksi 10 mg/ml Ampul 0 0
153 Ketorolac tablet 10 mg Tablet 0 0
154 Ketotifen sirup 0,2 mg/ml Botol 0 0
155 Ketotifen tablet 1 mg Tablet 0 0
156 Klindamisin kaps. 150 mg Kapsul 0 0
157 Klindamisin kaps. 300 mg Kapsul 50 0
158 Klobazam tab 10 mg Tablet 0 0
159 Klobetasol 10 G Krim Tube 0 0
160 Klobetasol Propionat Salep Tube 0 0
161 Klopidogrel tab 75 mg Tablet 0 0
162 Kloramfenikol kaps. 500 mg Kapsul 0 0
163 Kloramfenikol 2% + Hydrokortison 2,5% krim Tube 0 0
164 Kloramfenikol Basa + Prednisolone krim Tube 0 0
165 Kloramfenikol tetes telinga 3 % Botol 0 0
166 Klozapine tab 25 mg Tablet 0 0
167 Kodein 30 mg + feniltoloksamin 10 mg Botol 0 0
Setiap tablet tambah darah SEKURANGNYA
mengandung Zat besi setara dengan 60 mg besi
168 Tablet 0 0
elemental (dalam bentuk sediaan Ferro) Asam folat
0,400 mg

Kombinasi : MedroksiprogesteronAsetat 50 mg,

169 Vial 25 240
Estradiol Sipinoat 10 mg (Cyclofem Inj.)

Kombinasi Larutan Infus Per L : Ca++ 3 mEq, Na+ 130

Botol 0 0
mEq, Cl- 109 mEq, Asetat 28 mEq (Asering Infus)
 Kombinasi Larutan Infus Per L: NaCl 1,75 g, KCL 1,5 g,
Na. Laktat 2, 24 g, Dekstrosa Anhidrat 27 g (KAEN Botol 0 0
3B)
170 Kombinasi Fe, Asam folat, Vitamin B Kapsul 0 0
171 Kombinasi Metampiron 500 mg + Vit B tablet Tablet 0 0

172 Kombinasi Suspensi Parafin+Gliserin+Fenolftalein Botol 0 0

173 Kortison Acetat Inj 5 ml Vial 0 0

174 Lactobacillus serbuk Sachet 0 0
175 Lansoprazole kaps. 40 mg Kapsul 0 0
176 Levofloxacin tab 500 mg Tablet 0 0
177 Levofloxacin Tetes Mata Botol 0 0
178 Larutan mengandung Lipid (Emulsi lemak 20%) Botol 0 0
Lecithin 100 mg + Serratiopeptidase 5 mg +
179 Kapsul 0 0
pancreatin 25 mg kapsul
180 Lincomycin 500 MG Kapsul 0 0
181 Linezolid infus 600 mg Botol 0 0
182 Lisinopril tab 10 mg Tablet 0 0
183 Loperamide tab 2 mg Tablet 0 0
184 Losartan tab 50 mg Tablet 0 0

185 Loratadine 5 mg, pseudoephedrine sulfate 120 mg Tablet 0 0

186 L-Ornithine-L-Aspartate injeksi 500 mg/ml Ampul 0 0

187 Mekobalamin 500 Mcg Kapsul 0 0
188 Mekobalamin 250 Mcg Kapsul 0 0
189 Mekobalamin Injeksi Ampul 0 0
190 Meloksikam Tablet 15 Mg Tablet 0 0
191 Meloksikam Tablet 7,5 Mg Tablet 0 0
192 Menadion ( Vit K 3) Amp 10 mg/ml Ampul 0 0
Metampiron 500 mg + Thiamin HCl50 mg + Pridoksin
193 HCl 10 mg + Sianokobalamin HCl 10 mcg + Tablet 0 0
Trimetilsantin 50 mg tablet (Neuralgin)
194 Methildopa tablet 250 mg Tablet 0 0
195 Methil prednisolone tab 4 mg Tablet 0 0
196 Methil prednisolone tab 8 mg Tablet 0 0
197 Methil prednisolone tab 16 mg Tablet 0 0
198 Methisoprinol 250 mg/5 ml sirup 60 ml Botol 0 0
199 Methisoprinol Tablet 500 Mg Tablet 0 0
Methyl salicylate 102 mg, menthol 54.4 mg, eugenol
200 13.6 mg krim Tube 0 0

201 Metoklopramide injeksi 5 mg/5 ml Ampul 0 0

202 Metoklopramide 5 mg/5ml sirup 60 ml Botol 0 0

203 Metronidazole 500 mg + nystatin 100.000 iu ovula Ovula 0 0

 Micobacterium Tuberculosisi 0,4 mcg + disodium
204 fosfat 7,6 mg+Potasium fosfat 1,45 mg +sodium Vial 0 0
klorida 4,8 mg (PPD RT23)
205 Milrinone injeksi Vial 0 0
206 Misoprostol Tablet 200 Mcg Tablet 0 0
207 Moksifloksasin tts mata 0,5% Botol 0 0
208 Multivitamin + Lysine Drop botol 0 0
209 Multivitamin + Lysine Sirup Anak / Biovitan Botol 30 150
211 Mupirosin Krim Tube 0 0
212 Na Hyaluronat 0.1% tetes mata Botol 0 0

Na lauril sulfoasetat 45 mg, Na sitrat 450 mg, asam

213 Tube 0 0
sorbat 5 mg, PEG-400 625 mg, sorbitol 4.465 mg

214 NaCL 0,9% 100 ml Botol 0 0

215 NaCL 0,9% 500 ml botol 4 20
216 Naftidrofuryl Oxalate tablet 100 mg Tablet 0 0
217 Natium diklofenak tetes mata 1 mg Botol 0 0
218 Natrium diklofenak gel 1% Tube 0 0
219 Natrium dokusate tetes telinga 5 mg Botol 0 0

Neomisin 3,5 mg + Polimiksin 16.250 IU + Fenilefrin

220 Botol 0 0
1,2 mg + asam borat 1,769 mg/ ml tetes mata 

221 Neomisin sulfat 3,5 mg + polimiksin B sulfat 10000 iu Botol 0 0

+ deksametason sodium fospat 1 mg tetes mata

neomycin sulfate setara dengan neomycin base 3.5

222 mg polymixin b sulfate 10000 iu dan dexamethason Botol 0 0
sodium phosphate 1 mg
223 Nifuroksazide sirup 250 mg/5 ml Botol 0 0
224 Nitrogliserin injeksi 10 mg Ampul 0 0
225 Norephineprine injeksi Ampul 0 0
226 Noretisteron tab 5 mg Tablet 0 0
Obat Batuk Pilek Sirup Anak (Mengandung
227 Pseudoefedrin, Tanpa Parasetamol) / zentra Botol 0 0

Obat Batuk Pilek Sirup Anak (Mengandung

228 Botol 0 0
Parasetamol) / coldrexin
229 Obat Batuk Hitam (OBH) sirup Botol 83 0
230 Ofloksasin 2 Mg/ml Infus 100 Ml bag 0 0
231 Ofloksasin 3 mg tetes mata mini dose 0.6 ml strip 0 0
232 Ofloxacin 3mg/ml tetes telinga Botol 0 0
233 Oksitetrasiklin Salep Kulit 3 % Tube 0 0
234 Ondansetron injeksi Ampul 14 0
235 Ondansetron tab 8 mg Tablet 0 0

236 Ossein hydroxyapatite compound tablet 800 mg Tablet 0 0

237 Otilonium Br Tablet 0 0
238 Oxytetrasiklin salep Kulit Tube 0 0
239 Oxytetrasiklin salep mata Tube 10 50
240 Pantoprazole Injeksi 40 Mg Vial 0 0
241 Pantoprazole kapsul 20 mg Kapsul 0 0
242 Papaverin injeksi Ampul 0 0
243 Papaverin 40 mg tablet Tablet 5288 0

244 Paracetamol 500mg, Phenylpropanolamine HCl Tablet 0 0

12,5mg, chlorpheniramine maleate 2mg

245 Parasetamol 500 mg + n-asetilsitein 200 mg tablet Tablet 0 0

246 Parasetamol supp 80 mg Suppos 0 0

247 Parasetamol supp 125 mg Suppos 0 12
248 Parasetamol supp 160 mg Suppos 0 0
249 Parasetamol supp 240 mg Suppos 0 0
250 Parasetamol supp 250mg Suppos 0 0
251 Parekoksib injeksi 40 mg/2 ml Ampul 0 0
252 Piperacillin 4 g, tazobactam 500 mg injeksi Vial 0 0
253 PIRASETAM 12gr 60ml infus Vial 0 0
254 PIRASETAM 1gr injeksi Ampul 0 0
255 Pirasetam Amp 3 G Ampul 0 0
256 Pirasetam tablet 800 mg Tablet 0 0
257 Pirasetam tablet 1200 mg Tablet 0 0
258 Pirenoxin Sodium 0.05 mg/ml tts mata Botol 0 0
259 Piroksikam 15 mg gel Tube 0 0
260 Piroksikam Tablet 10 Mg Tablet 0 0
261 Piroksikam Tablet 20 Mg Tablet 0 0

Polimiksin B sulfat 10.000 UI, Neomisin sulfat 5 mg,

262 Ampul 0 0
Fludokortison asetat 1 mg, Lidokain HCl 40 mg

Polikresulen 10 ml (Albothyl) Botol 0 0

263 Polivinilpirolidon 20 mg tetes mata Botol 0 0
Polymixin b-sulfat 1.000.000 IU, Neomisin sulfat 0.5
264 mg, Fludokortison asetat 100 mg, Lidokain HCl 4 g, Botol 0 0
PEG, Gliserin Tetes telinga
265 Povidon Iodine Gargle 1% Botol 0 0
266 Pregabalin kapsul 150 mg Kapsul 0 0
267 Pregabalin kapsul 75 mg Kapsul 0 0
268 Preparat optalmik tetes mata Botol 0 0
Propanolol tab 40 mg Tablet 0 0
269 Pseudoefedrin 7,5 mg Drop Botol 0 0
Pseudoefedrin HCL 15 mg + Terfenadine HCl 20
270 Botol 0 0
mg/ml sirup
271 Pseudoefedrin HCl 30 mg + Terfenadin 40 mg Tablet 0 0
272 Pseudoefedrin Hcl 60 mg + Loratadin 5 mg Tablet 0 0
 Pseudoephedrine Hcl 15 mg + klorfeniramin maleat
273 Botol 0 0
1 mg sirup

274 Pseudoephedrine HCl 30 mg + Brompheniramine Botol 0 0

maleat 2 mg/5 ml sirup

275 Pseudoephedrine Hcl 30 mg, Triprolidine 2,5 mg tab Tablet 0 0

Pulmicort Respules 0,25 mg/ml (anak) @ 2 ml Ampul 0 0

Pulmicort Respules 0,50 mg/ml (dewasa) @ 2 ml Ampul 0 0

Pure lecithin (PPC 95%) 300 mg, vit B1 6 mg, vit B2 6

276 mg, vit B6 6 mg, vit B12 6 mcg, vit E 10 mg, Kapsul 0 0
nicotinamide 30 mg kapsul
277 Ramipril tab 5 mg Tablet 0 0
278 Ranitidin injeksi Ampul 14 0
279 Ranitidin sirup 75 mg/5 ml Botol 0 0
280 Rebamipide 100 Mg Tablet Tablet 0 0
Recombinan hepatitis B inj 10 mcg/0.5 mL (syringe)
281 Ampul 0 0
0.5 mL
282 Reserpin tab 0,25 mg Tablet 0 0
283 Retinol (Vitamin A) 6000 UI Kapsul 0 0
284 Rifampisin kaps. 600 mg Kapsul 0 0
285 Rifampisin kaps. 450 mg Kapsul 0 0
286 Ringer Laktar (RL) Larutan Infus Botol 24 0
287 Risperidone tab 2 mg Tablet 0 0
288 Rivanol (ETAKRIDIN) Botol 0 0
289 Rocuronium Bromide Vial 0 0
290 Ropivacain hidroklorida injeksi 2 mg/ml Vial 0 0
291 Salbutamol sulfat rotacaps 200 mcg Kapsul 0 0
Salbutamol sulfat injeksi 2,5 mg/ml (Ventolin
292 Ampul 30 40
Nebules)
293 Sefadroksil kaps. 500 mg Kapsul 6289 1500
294 Sefadroksil kaps. 250 mg Kapsul 0 0
295 Sefadroksil sirup kering Botol 57 40
296 Sefaleksin kaps. 500 mg Kapsul 0 0
297 Sefiksim kapsul/kaplet 200 mg Kapsul 0 0
298 Sefiksim kapsul/kaplet 100 mg Kapsul 0 0
299 Sefiksim sirup kering 100 mg/5ml Botol 0 0
300 Sefoperazone + Sulbactam Vial 1 G Vial 0 0
301 Sefotiam dihidroklorida 1 gram injeksi Vial 0 0
302 Sefotaksim serbuk injeksi 1 G Vial 0 0
303 Seftriaksone serbuk injeksi 1 G Vial 0 0
304 Septocain Inj. (Articane HCL dan Epinephrine) Ampul 0 0
305 Setirizine tablet 10 mg Tablet 0 0
306 Setirizine drop Botol 0 0
307 Sianokobalamin (vitamin B12) tab 50 mcg Tablet 21036 0
308 Simetidine tab 200 mg Tablet 1375 1000
309 Siprofloksasin 3 mg/ml tetes mata Botol 0 0
310 Sitikolin Amp 1000 mg/8 ml Ampul 0 0
311 Sitikolin Amp 500 mg/4 ml Ampul 0 0
312 Sitikolin Amp 125mg/ml 2ml Ampul 0 0
313 Sitikolin Tablet 1000 Mg Tablet 0 0
314 Sitikolin Tablet 500 Mg Tablet 0 0
315 Sodium Klorida Semprot Hidung Botol 0 0
Monoammonium glycyrrhizinate (sebagai
glycyrrhizin) 4 mg
316 Ampul 0 0
Aminoacetic acid 40 mg
L-cystein hydrochloride 2 mg Injeksi
317 Sulpirida tablet 200 mg Tablet 0 0
318 Sulpirida tablet 50 mg Tablet 0 0
Tablet Flu Batuk Bromheksin, Difenhidramin,
319 Parasetamol Tablet 0 0

Tetes Mata : CaCl2 anhidrat 0.075 gr, Kalium iodida

320 0.075 gr, Na Tiosulfat 0.005 gr, Fenilmerkuri nitrat Strip 0 0
0.3 mg Mini Dose

Tetes Mata : CaCl2 anhidrat 0.075 gr, Kalium iodida

321 0.075 gr, Na Tiosulfat 0.005 gr, Fenilmerkuri nitrat Botol 0 0
0.3 mg

Tetes Mata : Dexamethasone/Deksametason 0,1 %,

322 Neomisin sulfat 3,5 mg/mL, Polimiksin B sulfat 6000 Strip 0 0
iu/mL. Mini Dose

323 Tetes Mata : Deksametason 0,1%, Neomisin sulfat Botol 0 0

3,5 mg, Polimiksin-B-Sulfat 6000 UI
Tetes Mata : HPMC 5 mg, Dextran (70) 1 mg
324 Strip 0 0
Minidose

325 Tetes Mata : HPMC 5 mg, Dextran (70) 1 mg Tetes Botol 0 0

mata
tetesMata :Tobramisin 3 mg + Deksametason 1 mg
326 Strip 0 0
mini dose/ml.
tetes Mata : Tobramisin 3 mg + Dexamethason 1
327 Botol 0 0
mg/ml.
328 Thiamphenicol sirup 125/5ml Botol 0 0
329 Tiamfenikol kapsul 500 mg Kapsul 2793 0
Tiap 100 gram mengandung Heparin sodum 20.000
330 Tube 0 0
IU
331 Tigesiklin injeksi 50 mg/5ml Vial 0 0
332 Tizanidine tablet 2 mg Tablet 0 0
333 Tramadol 37,5 mg + Parasetamol 325 mg Tablet 0 0
334 Tramadol injeksi Ampul 0 0
335 Tramadol Kapsul 50 Mg Kapsul 24 0
336 Tramadol Supp 100 mg Suppos 0 0
337 Terbutaline sulfat injeksi Ampul 0 0

338 Terbutaline sulfat tab 2,5 mg / Molasma / terasma Tablet 3889 0

339 Trifluoperazine tab 2 mg Tablet 200 0

340 Trifluoperazine tab 5 mg Tablet 0 0
341 Trimetazidine hidroklorida tablet 35 mg Tablet 0 0
Tripolidin HCl 2mg,Pseudoefedrin HCl 30 mg,
342 Tablet 0 0
Parasetamol 500 mg tablet
343 Valsartan tab 160 mg Tablet 0 0
344 Valsartan tab 80 mg Tablet 0 0
345 Vekuronium bromida Vial 10 Mg Vial 0 0
346 Vekuronium bromida Vial 4 Mg Vial 0 0
347 Vit A palmitate, karbomer gel 10 gram Tube 0 0
348 Vit B1 100 mg, B6 200 mg, B12 200 mcg injeksi Ampul 0 0
Vit B1 100 Mg, Vit B6 50 Mg, Vit B12 100 Mcg, Vit E
349 30 Iu. Tablet 0 0

350 Vit B1 100 mg,vit B6 100 mg, vit B12 5000 mcg Ampul 0 0
Vit B1 100mg + Vit B6 100mg + Vit B12 5000ug
351 Tablet 0 0
tablet

352 Vit B1 100mg + Vit B6 200mg + Vit B12 200ug tablet Tablet 0 0

Vit B1, B2, B6, B12, Vit C 500Mg, Ca Pantotenate

353 Tablet 0 0
tablet

354 Vit B1, B2, B3, B6, B12, Vit C 500Mg, Ca Pantotenate, Tablet 0 0
Tocopherol Vit E) tablet

Vitamin A 4000 IU, C 50 mg, D 400 IU, E 10 mg, B1

3mg, B2 3 mg, B6 2 mg, B12 2 mcg, B3 20 mg, Ca
355 pantotenat 5 mg, Asam folat 1 mg, Biotin 0.1 mg, Fe Tablet 0 0
fumarat 20 mg, Ca 100 mg, Cu 0.5 mg, Mn 0.5 mg,
Mg 1 mg, Zn 0.25 mg tablet

356 Vitamin B1 100 Mg Tab (Thiamin/Aneurin Hcl) Tablet 0 0

357 Vitamin C injeksi 200 mg/ ml Ampul 0 0
358 Vitamin C injeksi 500 mg/5 mL Ampul 0 0
359 YAL JELLY SOLUTION Botol 0 0
304 Parasetamol 125 mg rectal tube tube 10 25
305 Omneuron Tablet 535 0
306 bisolvon drop Botol 3 0
307 Medroksiprogresteron 50 mg inj /Depogeston Vial 347 0
308 FG Troches Tablet 70 0
310 PonFlu Tablet 0 0
311 Enervon C Tablet 0 0
312 Benoson G Tube 0 0
313 Benoson M Tube 2 0
314 Dulcolax Sirup Botol 3 0
315 Levertran Tube 0 0
316 Scopamin Injeksi Ampul 1 0
317 Mersibion Tablet 210 150
318 Phenol Gliseril Tetes Telinga Botol 0 0
319 Noza Tablet 0 100
320 Korason N Tube 0 0
321 Supratulle / Daryantulle pcs 0 20
322 Bioplacenton Tube 52 0
325 Counterpain Tube 0 0
326 Bexicom Tablet 135 500
328 Thrombopob Tube 0 0
329 Camidryl Botol 0 0
330 Scabisid Tube 10 0
331 Povidone Iodine 60 ml Botol 7 0
332 Co-Amoxiclav Tablet 392 0
333 0 0
334 0 0
335 0 0
336 0 0
337 0 0
338 0 0
339 0 0
340 0 0

UMUM
JUMLAH KUNJUNGAN RESEP BPJS
BAYAR TDK

Mengetahui
Kepala

.....
NIP
: AGUSTUS 2017 DOKUMEN
DINKES
IF KAB/KOTA
PUSKESMAS

PEMBERIAN
PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPTIMUM PERMINTAAN
APBD I APBD II

6=4+5 7 8=6-7 9 10 11 12
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0
300 253 47
153 32 121
4487 3459 1028
0 0 0
0 0 0
0 0 0
3104 325 2779
200 139 61

0 0 0

0 0 0

0 0 0

0 0 0
0 0 0
0 0 0

0 0 0

1000 761 239

0 0 0

0 0 0

0 0 0

4 0 4
 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
102 29 73
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

620 235 385

0 0 0
66 58 8
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
282 152 130
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
20 0 20

0 0 0

0 0 0
0 0 0
0 0 0
179 56 123
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
434 45 389
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

0 0 0
0 0 0
0 0 0
1061 101 960
0 0 0
0 0 0
0 0 0
467 124 343
0 0 0
13236 9106 4130
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
25 11 14
0 0 0
0 0 0

0 0 0

0 0 0
0 0 0
 0 0 0
0 0 0
0 0 0
47 43 4
0 0 0
0 0 0
168 0 168

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 0 50
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

265 214 51

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

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
0 0 0

0 0 0
 0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
180 116 64
0 0 0
0 0 0

0 0 0

0 0 0
24 10 14
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

83 83 0
0 0 0
0 0 0
0 0 0
0 0 0
14 3 11
0 0 0

0 0 0
 0 0 0
0 0 0
60 31 29
0 0 0
0 0 0
0 0 0
5288 1035 4253

0 0 0

0 0 0

0 0 0
12 2 10
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

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
14 1 13
0 0 0
0 0 0

0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
24 0 24
0 0 0
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70 30 40

7789 1776 6013

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97 48 49
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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
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21036 4910 16126
2375 686 1689
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

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0 0 0

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0 0 0
2793 199 2594

0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
24 0 24
0 0 0
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3889 470 3419

200 0 200
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
0 0 0
0 0 0
0 0 0
35 25 10
535 0 535
3 0 3
347 256 91
70 0 70
0 0 0
0 0 0
0 0 0
2 1 1
3 0 3
0 0 0
 1 0 1
360 250 110
0 0 0
100 100 0
0 0 0
20 10 10
52 0 52
0 0 0
635 200 435
0 0 0
0 0 0
10 0 10
7 0 7
392 0 392
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

JUMLAH
 NOMOR TGL

PEMBERIAN
TIDAK MAMPU
KETERANGAN
DILAPORKAN
DAK PROGRAM LAIN-LAIN JUMLAH

13 14 15 16=11+12+13+14
Yang
Petugas

.....
NIP