Lplpo Tahun 2019

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( L P L P O )
NAMA PUSKESMAS : Puskesmas Dasan Tapen NO DOC :

KAB/KOTA : Lombok Barat TAHUN : 2017
LAPORAN PERIODE/BULAN : Juli 2017 TANGGAL : 3 Agustus 2017
PERMINTAAN PERIODE/BULAN : Agustus 2017
STOK PENERIM PERSEDIA PEMAKAI SISA PEMBERIAN

STOK OPT PERMINT KET
NO NAMA OBAT SATUAN AWAL AAN AN AN STOK AAN APBD APBN PROG LAIN JML
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set 100 200 300 163 137 261 200
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set 200 700 900 178 722 285 0
3 Alat Suntik Sekali Pakai - 5 cc x 22G x 1 1/4" Set 6 600 606 44 562 70 0
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set 60 0 60 11 49 18 0
5 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set 0 0 0 0 0 - 48
6 Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Set 0 0 0 0 0 - 0
7 Benang Operasi - Catgut Plain 3/0 + jarum 1/2 GT 35 mm Set 0 24 24 24 0 38 48
8 Benang Operasi - Catgut Chromic 3/0 + jarum 1/2 GT 35 mm Set 0 0 0 0 0 - 0
9 Benang Operasi - Silk 2/0 + jarum 1/2 GT 35 mm Set 88 0 88 4 84 6 0
10 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set 18 0 18 3 15 5 0
11 HAND SCOUND STERIL NO 7 Pasang 200 50 250 122 128 195 100
12 HAND SCOUND STERIL NO 7,5 Pasang 77 70 147 105 42 168 100
13 HAND SCOUND NON STERIL UK L Lembar 0 0 0 0 0 - 0
14 HAND SCOUND NON STERIL UK S 0 200 200 200 0 320 300
15 HAND SCOUND NON STERIL UK M Lembar 0 200 200 200 0 320 300
16 HYPAFIX 10 x 5 CM Pasang 0 0 0 0 0 - 5
17 Infus Set, IV, Wing needle - Infusion Set Pediatric (60 drops/ml) set 10 50 60 1 59 2 0
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set 43 200 243 60 183 96 0
19 Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 mm buah 60 200 260 41 219 66 0
20 Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 1/4 " buah 10 50 60 24 36 38 2
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah 3 50 53 6 47 10 0
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah 31 20 51 5 46 8 0
STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
23 Infus Set, IV, Wing needle - I.V Catheter No. 26 G x 1/2 " buah 4 0 4 0 4 - 50
24 Infus Set, IV, Wing needle - Wing Needle 21G set 0 0 0 0 0 - 0
28 Jarum Jahit Bedah 0 0 0 0 0 - 0
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll 10 0 10 3 7 5 0
30 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll 7 4 11 2 9 3 0
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar 40 40 40 0 64 50
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar 0 0 0 0 0 - 0
33 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 3 cm Roll 0 0 0 0 0 - 0
34 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 cm Roll 50 50 100 47 53 75 0
35 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 15 cm Roll 0 0 0 0 0 - 0
36 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 cm Roll 4 0 4 0 4 - 0
37 MESS 11 pcs 60 0 60 5 55 8 100
38 MESS 21 pcs 100 0 100 0 100 - 0
39 MESS 22 pcs 0 0 0 0 0 - 0
40 PEMBALUT GIPS 3 INCI buah 0 0 0 0 0 - 0
41 PLESTER 5 YARDS X 2 INCHI Roll 8 24 32 6 26 10 0
42 Surgical Mask - 3 ply Tie on (tali) pcs 250 100 350 147 203 235 0
43 Surgical Mask - 3 ply Earloop (karet) pcs 200 0 200 80 120 128 0
44 Urologi - Folley Catheter 2 way No. 16 pcs 0 20 20 2 18 3 0
45 Urologi - Folley Catheter 2 way No. 18 pcs 5 0 5 2 3 3 10
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs 17 0 17 10 7 16 0
TABLET DAN SERBUK ORAL
47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet 0 0 0 0 0 - 100

48 Asam Asetilsalisilat (asetosal) tablet 500 mg Tablet 100 0 100 0 100 - 0
49 Albendazol tablet/kapsul/kaplet 400 mg Tablet 24 0 24 0 24 - 0
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet 0 0 0 0 0 - 0
51 ALPRAZOLAM TABLET 1 MG Tablet 0 0 0 0 0 - 0
52 AMBROXOL 30 MG TAB Tablet 500 2000 2500 2500 0 4,000 4000
53 Aminofilin tablet scored 200 mg Tablet 0 0 0 0 0 - 0
54 Amitriptilin tablet salut 25 mg (HCl) Tablet 234 400 634 34 600 54 0
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
55 Amlodipin tablet 5 mg Tablet 0 0 0 0 - 0
56 Amoksisilin kapsul/kaplet/tablet scored 500 mg Kaplet 0 16000 16000 8177 7823 13,083 10000
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksida 2 Tablet 11600 0 11600 2233 9367 3,573 0
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet 20 0 20 0 20 - 100
59 Asam Askorbat (Vitamin C) tablet 250 mg Tablet 12600 0 12600 440 12160 704 0
60 Asam Askorbat (Vitamin C) tablet 50 mg Tablet 11100 0 11100 232 10868 371 0
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet 0 0 0 0 - 0
62 ASAM MEFENAMAT 500 MG TAB Kaplet 3000 700 3700 2814 886 4,502 4000
63 ASAM TRANEXAMAT TABLET 500 MG Tablet 0 0 0 0 0 - 0
64 ASAM VALPROAT 250 MG Tablet 362 0 362 0 362 - 0
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet 0 500 500 100 400 160 0
66 ATTAPULGIT TABLET 600 MG Tablet 1300 0 1300 430 870 688 0
67 BETAHISTIN MESILAT TABLET 6 MG Tablet 0 0 0 0 - 0
68 Bisakodil 5 mg (dulkolax) Tablet 0 0 0 0 0 - 0
69 D H P TAB Tablet 81 0 81 0 81 - 0
70 Deksametason tablet 0,5 mg Tablet 0 3500 3500 1587 1913 2,539 2000
71 DIAZEPAM 2 MG TAB Tablet 0 0 0 0 0 - 0
72 DIAZEPAM 5 MG TAB Tablet 0 0 0 0 0 - 0
73 Digoksin tablet 0,25 mg Paket 200 0 200 0 200 - 0
74 Dimenhidrinat tablet 50 mg Tablet 290 0 290 0 290 - 0
75 Domperidon tablet 10 mg Tablet 200 300 500 70 430 112 300
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet 0 0 0 0 0 - 0
77 EFEDRIN HCL 25 MG TAB Tablet 0 0 0 0 0 - 0
78 ERYTHROMYCIN 500 MG Tablet 0 0 0 0 0 - 0
79 Fenitoin kapsul/kaplet 100 mg Tablet 0 0 0 0 0 - 0
80 FENITOIN NATRIUM 30 MG KAPSUL Kapsul 0 0 0 0 0 - 0
81 Fenobarbital tablet/kapsul/kaplet 100 mg Kapsul 0 0 0 0 0 - 0
82 Fenobarbital tablet/kapsul/kaplet 30 mg Kapsul 1000 0 1000 42 958 67 0
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet 300 200 500 30 470 48 0
84 Furosemid tablet 40 mg Tablet 0 0 0 0 0 - 0
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium klorid Sachet 300 1000 1300 291 1009 466 500
86 Glibenklamid tablet 5 mg Tablet 0 0 0 0 0 - 0
87 Glimepiride tablet 1 mg Tablet 450 0 450 200 250 320 200
88 Glimepiride tablet 2 mg Tablet 0 0 0 0 0 - 0
89 Glimepiride tablet 4 mg
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
90 GLISERYL GUAIAKOLAT 100 MG TAB Tablet 0 0 0 0 0 - 0
91 Griseofulvin tablet 125 mg Tablet 0 0 0 0 0 - 0
92 Haloperidol tablet 0,5 mg Tablet 32 500 532 76 456 122 0
93 Haloperidol tablet 1,5 mg Tablet 1030 0 1030 98 932 157 0
94 Haloperidol tablet 5 mg Tablet 200 800 1000 132 868 211 0
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet 9800 0 9800 1285 8515 2,056 0
96 Ibuprofen tablet 400 mg Tablet 0 0 0 0 0 - 0
97 ISOSORBID DINITRAT SUB LINGUAL 5 MG Tablet 0 0 0 0 0 - 0
98 KALSIUM LAKTAT 500 MG Tablet 900 200 1100 360 740 576 500
99 Kaptopril tablet scored 12,5 mg Tablet 0 0 0 0 0 - 0
100 Kaptopril tablet scored 25 mg Tablet 1000 1500 2500 1651 849 2,642 2000
101 Karbamazepin tablet 200 mg Tablet 400 0 400 60 340 96 0
102 KETOKONZOL TABLET 200 MG Tablet 0 0 0 0 0 - 0
103 Kloramfenikol tablet/kapsul/kaplet 250 mg Tablet 0 0 0 0 0 - 0
104 Kloramfenikol kapsul 500 mg Tablet 2140 0 2140 0 2140 - 0
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet 25000 0 25000 4217 20783 6,747 0
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet 0 0 0 0 0 - 0
107 KODEINA 10 MG TAB Tablet 0 0 0 0 0 - 0
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0,25 Tablet 11400 18000 29400 5570 23830 8,912 12000
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 mg Tablet 0 2500 2500 190 2310 304 0
110 KUININE TAB SALUT SELAPUT 222 MG Tablet 0 0 0 0 0 - 0
111 LOPERAMID TAB 2 MG Tablet 0 1000 1000 690 310 1,104 1000
112 LORATADIN TABLET 10 MG Tablet 0 0 0 0 0 - 0
113 METFORMIN HCL TABLET 500 MG Tablet 1000 0 1000 0 1000 - 0
114 Metilergometrin Maleat (Metilergometrin) tablet salut 0,125 mg Tablet 0 0 0 0 0 - 0
115 Metoklopramide tablet 5 mg Tablet 0 0 0 0 0 - 0
116 Metoklopramide tablet 10 mg Tablet 0 500 500 210 290 336 0
117 METRONIDAZOLE 250 MG TAB Tablet 0 0 0 0 0 - 0
118 METRONIDAZOLE 500 MG TAB Tablet 500 0 500 215 285 344 300
119 MINERAL MIX SERBUK Tablet 0 0 0 0 0 - 0
120 MULTI MICRO NUTRIEN Sachet 0 0 0 0 0 - 0
121 MULTIVITAMIN ANAK TABLET HISAP T ablet hisap 0 0 0 0 0 - 0
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet 300 2000 2300 350 1950 560 0
123 Nifedipin tablet/kapsul 10 mg Tablet 239 0 239 0 239 - 0
124 Nistatin tablet salut 500.000 IU/ g Tablet 100 0 100 0 100 - 0
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
125 OAT KAT ANAK FDC Paket 0 0 0 0 0 - 0
126 OAT KAT ANAK KOMB Paket 0 0 0 0 0 - 0
127 OAT KAT I KOMB Paket 0 0 0 0 0 - 0
128 OAT KAT I.3 FDC Paket 0 8 8 4 4 6 7
129 OAT KAT II FDC Paket 0 1 1 1 0 2 0
130 OAT KAT SISIPAN FDC Paket 0 0 0 0 0 - 0
131 Omeprazol kapsul/kaplet 20 mg kaplet 1890 0 1890 40 1850 64 0
132 Parasetamol tablet 100 mg Tablet 0 0 0 0 0 - 0
133 Parasetamol tablet 500 mg Tablet 5200 15000 20200 10893 9307 17,429 10000
134 PERFENAZIN TAB 4 MG Tablet 0 0 0 0 0 - 0
135 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 50 2000 2050 517 1533 827 1000
136 PIROKSIKAM 10 MG TAB Tablet 200 0 200 0 200 - 0
137 PIROKSIKAM 20 MG TAB Tablet 0 1000 1000 140 860 224 0
138 Prednison tablet/kapsul/kaplet 5 mg Tablet 900 500 1400 333 1067 533 500
139 PRIMAKUIN TABLET 15 MG Tablet 0 0 0 0 0 - 0
140 PROPANOLOL 40 MG TAB (HCL) Tablet 0 0 0 0 0 - 0
141 PROPILTIOURASIL 100 MG TAB Tablet 60 0 60 0 60 - 0
142 PYRANTEL SCORE (BASE) 125 MG TAB Tablet 20 0 20 0 20 - 0
143 Ranitidin tablet 150 mg Tablet 600 0 600 570 30 912 1000
144 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak 0 400 400 0 400 - 0
145 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak 0 4350 4350 38 4312 61 0
146 SALBUTAMOL 4 MG TAB Tablet 700 2000 2700 1032 1668 1,651 1000
147 Setirizin tablet 10 mg Tablet 228 0 228 20 208 32 0
148 Simvastatin tablet 20 mg Tablet 580 0 580 0 580 - 0
149 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 100 1500 1600 450 1150 720 500
150 SPIRONOLAKTON TABLET 25 MG Tablet 0 0 0 0 0 - 0
151 TETRASIKLIN 500 KAPSUL Kapsul 0 0 0 0 0 - 0
152 THIAMPENICOL KAPSUL 250 MG Kapsul 0 0 0 0 0 - 0
153 THIAMPENICOL KAPSUL 500 MG Kapsul 0 0 0 0 0 - 0
154 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet 2500 3000 5500 2952 2548 4,723 3000
155 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet 0 0 0 0 0 - 1000
156 VIT B KOMPLEK TAB Tablet 0 5000 5000 3402 1598 5,443 8000
157 ZINC TAB 20 MG Tablet 1300 500 1800 810 990 1,296 500
SYRUP
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
158 AMBROXOL SYR 15 mg/ml Botol 100 0 100 49 51 78 100

159 Amoksisilin sirup kering 125 mg/ 5 ml Botol 192 240 432 167 265 267 96
160 Amoksisilin sirup kering forte 250 mg/5 ml Botol 0 0 0 0 0 - 100
161 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 200 m Botol 0 0 0 0 0 - 0
162 DOMPERIDON SYRUP Botol 50 50 100 60 40 96 50
163 Kloramfenikol suspensi 125 mg/ 5 ml Botol 150 0 150 5 145 8 0
164 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetoprim Botol 100 100 200 72 128 115 50
165 Metoklopramide sirup 5 mg/ 5 ml Botol 0 0 0 0 0 - 0
166 METRONIDAZOL SUSPENSI Botol 0 0 0 0 0 - 0
167 MULTIVITAMIN SYR Botol 240 60 300 68 232 109 0
168 NISTATIN SUSPESI Botol 0 0 0 0 0 - 0
169 O B H SYR Botol 80 40 120 32 88 51 120
170 Parasetamol drop 100 mg/ml btl @15ml (60mg/0,6ml) Botol 0 0 0 0 0 - 0
171 Parasetamol sirup 120 mg / 5 ml Botol 4500 0 4500 266 4234 426 0
INJEKSI
172 Aminofilin injeksi 24 mg/ml Ampul 28 0 28 1 27 2 0

173 Ampisilin serbuk injeksi i.v. 1000 mg/vial Vial 63 0 63 13 50 21 0
174 ASAM TRANEXAMAT INJEKSI 50 MG / ML Ampul 0 10 10 0 10 - 0
175 AQUA PRO INJ STERIL Vial 12 50 62 16 46 26 0
176 CEFTRIAXON 1 GR INJ Vial 0 0 0 0 0 - 0
177 Deksametason injeksi i.v./i.m. 5 mg/ml Ampul 150 0 150 1 149 2 0
178 Diazepam injeksi i.v./i.m 5 mg/ml Ampul 0 0 0 0 0 - 0
179 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul 30 0 30 6 24 10 0
180 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul 14 0 14 8 6 13 30
181 Fenitoin injeksi 50 mg/ml Ampul 0 0 0 0 0 - 0
182 Fenobarbital injeksi i.m./i.v. 50 mg/ml Ampul 0 0 0 0 0 - 0
183 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul 0 0 0 0 0 - 0
184 FUROSEMID INJ IV/IM 10 MG/ML Ampul 0 0 0 0 0 - 0
185 Gentamisin injeksi 40 mg/ ml Ampul 0 0 0 0 0 - 0
186 HYOCINA N BUTILBROMID INJ 20 MG Ampul 0 0 0 0 0 - 0
187 KALSIUM GLUKONAS INJ 100 MG/ML Ampul 18 0 18 0 18 - 0
188 Kloramfenikol serb inj 1000 mg/mL Vial 0 0 0 0 0 - 0
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
189 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Ampul 955 0 955 7 948 11 0
190 Lidokain injeksi 2% (HCL) Ampul 490 0 490 25 465 40 0
191 MAGNESIUM SULFAT 20 % INJ 25 ML Vial 20 0 20 0 20 - 0
192 MAGNESIUM SULFAT 40 % INJ 25 ML Vial 40 0 40 5 35 8 0
193 Metoklopramide INJ 5 MG/ML Ampul 20 20 40 0 40 - 0
194 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul 43 0 43 3 40 5 0
195 Oksitosin injeksi 10 IU/ml Ampul 303 0 303 82 221 131 0
196 OXYTETRACIKLIN HCL INJ IM 50 MG/ML 10 ML Vial 0 0 0 0 0 - 0
197 RANITIDIN INJ 25 MG/2 ML Ampul 280 0 280 5 275 8 0
198 Sianokobalamin (vitamin B12) injeksi 500 mcg Ampul 0 0 0 0 0 - 0
199 THIAMIN INJ ( VIT BI ) 100 MG/ML Ampul 0 0 0 0 0 - 0
OBAT KHUSUS
200 Antihemoroid, kombinasi: bismut subgalat 150 mg heksaklorofen 2,5 SUPP 320 0 320 2 318 3 0
201 BISACODYL SUPP (DULCOLAX) 10 MG / Stolax supp SUPP 77 0 77 6 71 10 0
202 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal) TUBE 26 0 26 0 26 - 0
203 MICROLAX 29 0 29 0 29 - 0
204 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET 78 0 78 9 69 14 0
205 PARASETAMOL SUPP 80 MG SUPP 0 0 0 0 0 - 0
206 PARASETAMOL SUPP 125 MG SUPP 0 0 0 0 0 - 0
207 SABU I 5 ML VIAL 0 0 0 0 0 - 0
208 SALBUTAMOL (AS SULPHATE) 2,5 MG/2,5 ML NEBULS Ampul 29 60 89 22 67 35 40
209 SERUM ATS 1 500 IU VIAL 0 0 0 0 0 - 0
210 Serum ATS 20.000 IU 0 0 0 0 0 - 0
CAIRAN
211 Glukosa larutan infus 10 % steril Botol 0 0 0 0 0 - 5

214 Nacl 0,9% Botol 0 60 60 29 31 46 20
215 Ringer Laktat larutan infus Botol 1000 0 1000 57 943 91 0
OBAT LUAR
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
216 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g Polimiksin 10. Tube 0 0 0 0 0 - 100
217 ANTI FUNGI DOEN KOMB Pot 0 0 0 0 0 - 0
218 ASIKLOVIR CREAM 5% Tube 0 0 0 0 0 - 100
219 BETAMETASON CREAM 0,1 % Tube 14 0 14 14 0 22 100
220 FENOL GLISEROL TT 10% TUBE 0 0 0 0 0 - 0
221 GENTAMICIN SK 0,1% Botol 0 0 0 0 - 0
222 GENTAMICIN SALEP MATA 0,3% Tube 576 0 576 26 550 42 0
223 GENTAMISIN SULFAT TETES MATA Tube 0 0 0 0 0 - 0
224 GENTIAN VIOLET LART 1% Botol 0 0 0 0 0 - 48
225 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol 8 0 8 0 8 - 0
226 HIDROGEN PEROKSIDA LARUTAN 3% Botol 0 0 0 0 0 - 0
227 HIDROKORTISON CREAM 2,5 % Tube 0 0 0 0 - 0
228 ICHTIOL SALEP HITAM Pot 7 24 31 7 24 11 0
229 KALIUM PERMANGANAT SERBUK Pot 20 0 20 2 18 3 0
230 KETOKONAZOL KRIM 2% Tube 20 0 20 11 9 18 50
231 Kloramfenikol salep mata 1 % Tube 0 0 0 0 0 - 48
232 Kloramfenikol teter telinnga 3 % Botol 0 0 0 0 - 48
233 MICONAZOLE CREAM 2% Tube 0 0 0 0 0 - 0
234 OKSITETRASIKLIN SK 3% Tube 0 0 0 0 0 - 25
235 OKSITETRASIKLIN SM 1% Tube 0 0 0 0 0 - 0
236 Povidon Iodida larutan 10% 30 ml Botol 17 0 17 3 14 5 10
238 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang endap 4% Botol 96 0 96 3 93 5 0
239 SALEP LUKA BAKAR (bioplacenton) Pot 0 0 0 0 0 - 5
240 Bedak salisil serbuk 2% Tube 50 0 50 23 27 37 0
241 Scabicid / Scabimite Cream Tube 20 0 20 0 20 - 0
242 SULFASETAMID NATRIUM TM 15 % Kotak 0 0 0 0 0 - 0
OBAT GIGI
243 DEVITALISASI PASTA ( NON ARSEN ) Pot 0 0 0 0 0 - 1

244 ETIL KLORIDA SPRAY Botol 0 4 4 0 4 - 0
245 EUGENOL CAIRAN Botol 0 0 0 0 0 - 0
246 GLASS IONOMER CEMENT ART Botol 0 0 0 0 0 - 0
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
247 KALSIUM HIDROKSIDA PASTA Pot 0 0 0 0 0 - 0
248 KLORFENOL KAMFER MENTHOL (CHKM) Botol 2 0 2 0 2 - 0
249 MUMMIFYING PASTA Pot 0 0 0 0 0 - 1
250 POLIKRESULEN (ALBOTYL) Botol 0 0 0 0 0 - 3
251 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot 0 0 0 0 0 - 1
252 SPONGOSTAN Kotak 0 0 0 0 0 - 0
253 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot 2 0 2 0 2 - 0
254 TRIKRESOL FORMALIN (TKF) Botol 0 0 0 0 0 - 0
BAHAN LABORATORIUM
255 CARIK CELUP / URIN TES 3 GPH Stik 0 100 100 0 100 - 100
256 CARIK CELUP / URIN TES 11 GPH Stik 0 0 0 0 0 - 100
257 Antiseptik dan Disinfektan - alkohol 70% 100 ml Botol 0 0 0 0 0 - 0
258 Antiseptik dan Disinfektan - alkohol 70% 1 liter Botol 29 0 29 6 23 10 0
259 GLISERIN Botol 0 0 0 0 0 - 0
260 HB TEST KIT Set 0 0 0 0 0 - 0
261 KIT GOL DARAH Set 0 0 0 0 0 - 0
262 LART AS ACETAT Botol 0 0 0 0 0 - 0
263 LART ASAM KLORIDA 0,1 N Botol 0 0 0 0 0 - 0
264 LAR ASAM KLORIDA 0,1% Botol 0 0 0 0 0 - 0
265 LART BARIUM CHLORIDA 10 % Botol 0 0 0 0 0 - 0
266 LART BENEDICT Botol 0 0 0 0 0 - 0
267 LART E D T A 10 % Botol 0 0 0 0 0 - 0
268 LART ETANOL ASAM Botol 0 0 0 0 0 - 0
269 LART KOH 10 % Botol 0 0 0 0 0 - 0
270 LART NACL 0,9 % Botol 0 0 0 0 0 - 0
271 LART NATRIUM CITRAT 0,38 % Botol 0 0 0 0 0 - 0
272 LART ASAM CITRAT 3,8% Botol 0 0 0 0 0 - 0
273 LART REES ECKER Botol 0 0 0 0 0 - 0
274 LART SCHLESINGER Botol 0 0 0 0 0 - 0
275 LART TURK Botol 0 0 0 0 0 - 0
276 OIL EMERSI Botol 0 0 0 0 0 - 0
277 PP TEST Stik 200 0 200 50 150 80 0
278 RDT TEST MALARIA Stik 0 0 0 0 0 - 0
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
279 STIK GULA DARAH Stik 0 0 0 0 0 - 0
280 STIK ASAM URAT Stik 0 0 0 0 0 - 0
281 STIK KOLESTEROL Stik 0 0 0 0 0 - 0
282 STIK HBSAG Stik 0 0 0 0 0 - 0
283 STIK HBSAG Stik 0 0 0 0 0 - 0
284 WIDAL TEST Set 0 0 0 0 0 - 0
REAGEN
285 REAGEN ABX MINIDIL LMG PAKET 0 0 0 0 0 - 0

286 REAGEN ABC MINILYSE LMG PAKET 0 0 0 0 0 - 0
287 REAGEN ABX MINICLEAN PAKET 0 0 0 0 0 - 0
288 REAGEN ABX MINOTROL PAKET 0 0 0 0 0 - 0
TAMBAHAN
289 HALOPERIDOL INJ 5 Mg/Ml Ampul 0 0 0 0 0 - 0

290 Cover Glass 24x24 MM BUAH 0 0 0 0 0 - 0
291 DASABION KAPSUL 9000 0 9000 270 8730 432 0
292 KETOROLAC INJ AMPUL 14 0 14 0 14 - 0
293 ONDANCETRON INJ AMPUL 25 0 25 0 25 - 0
294 METAMIZOLE INJ AMPUL 300 0 300 0 300 - 0
295 BISOPROLOL 5 MG TABLET 200 0 200 0 200 - 0
TIDAK BAYAR
BAYAR JUMLAH
JUMLAH KUNJUNGAN RESEP BPJS UKS LAIN
704 2556 39 3299
STOK OPT KET
3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
Mengetahui Yang Menyerahkan Yang Menerima/ Melapor Yang Menerima
Kepala Dinas Kesehatan Kab. Lombok Barat Kepala UPTD IFK Lobar Pemimpin UPT BLUD Puskesmas Pengelola Obat Puskesmas,
Drs. H. Rachman Sahnan Putra M. Kes Hj. Bq. Endang Suprihartini, Msi.,Apt. Ns. H. Hasmuni Budiawan, S.Kep. Dyah Noor Hidayati
NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
LEMBAR PERTAMA (ASLI) : IFK
LEMBAR KEDUA : DIKES LOBAR
LEMBAR KETIGA : ARSIP / PUSKESMAS
97.8
106.8
26.4
6.6
0
0
14.4
0
2.4
1.8
73.2
63
0
120
120
0
0.6
36
24.6
14.4
3.6
3
0
0
0
0
0
0
1.8
1.2
24
0
0
28.2
0
0
3
0
0
0
3.6
88.2
48
1.2
1.2
6
0
0
0
0
0
0
0
0
1500
0
20.4
0
4906.2
1339.8
0
264
139.2
0
1688.4
0
0
60
258
0
0
0
952.2
0
0
0
0
42
0
0
0
0
0
0
25.2
18
0
174.6
0
120
0
0
0
45.6
58.8
79.2
771
0
0
216
0
990.6
36
0
0
0
2530.2
0
0
3342
114
0
414
0
0
0
0
126
0
129
0
0
0
210
0
0
0
0
0
2.4
0.6
0
24
0
6535.8
0
310.2
0
84
199.8
0
0
0
0
342
0
22.8
619.2
12
0
270
0
0
0
0
1771.2
0
2041.2
486
0
0
0
29.4
100.2
0
0
36
3
43.2
0
0
40.8
0
19.2
0
159.6
0
0
0
0.6
7.8
0
9.6
0
0.6
0
3.6
4.8
0
0
0
0
0
0
0
0
4.2
15
0
3
0
1.8
49.2
0
3
0
0
0
0
0
1.2
3.6
0
0
5.4
0
0
0
13.2
0
0
0
0
0
0
0
0
17.4
34.2
0
0
0
0
0
0
8.4
0
0
15.6
0
0
0
0
0
4.2
1.2
6.6
0
0
0
0
0
1.8
2.4
1.8
0
13.8
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
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
30
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
162
0
0
0
0
LAPORAN PERIODE/BULAN : Agustus 2017 TANGGAL : 4 September 2017
PERMINTAAN PERIODE/BULAN : September 2017

NAMA OBAT SATUAN STOK OPT KET
NO AWAL AAN AN AN STOK AAN APBD APBN PROG LAIN JML
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set 137 2,300 2,437 195 2,242 312 -
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set 722 2,900 3,622 180 3,442 288 -
3 Alat Suntik Sekali Pakai - 5 cc x 22G x 1 1/4" Set 562 - 562 77 485 123 -
5 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set - 48 48 12 36 19 48
6 Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Set - - - - - - -
7 Benang Operasi - Catgut Plain 3/0 + jarum 1/2 GT 35 mm Set - 48 48 37 11 59 48
9 Benang Operasi - Silk 2/0 + jarum 1/2 GT 35 mm Set 84 - 84 11 73 18 -
10 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set 15 - 15 5 10 8 72
12 HAND SCOUND STERIL NO 7,5 Pasang 42 100 142 100 42 160 50
13 HAND SCOUND NON STERIL UK L Lembar - - - - - - -
14 HAND SCOUND NON STERIL UK S - 300 300 300 - 480 500
15 HAND SCOUND NON STERIL UK M Lembar - 300 300 300 - 480 500
16 HYPAFIX 10 x 5 CM Pasang - 5 5 1 4 2 -
17 Infus Set, IV, Wing needle - Infusion Set Pediatric (60 drops/ml) set 59 - 59 5 54 8 -
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set 183 1,100 1,283 48 1,235 77 -
19 Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 mm buah 219 450 669 62 607 99 -
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah 47 - 47 7 40 11 -
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah 46 - 46 - 46 - -
23 Infus Set, IV, Wing needle - I.V Catheter No. 26 G x 1/2 " buah 4 - 4 4 - 6 50
24 Infus Set, IV, Wing needle - Wing Needle 21G set - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
28 Jarum Jahit Bedah - - - - - - -
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll 7 - 7 5 2 8 5
30 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll 9 76 85 1 84 2 -
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar - - - - - -
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar - 336 336 - 336 - -
33 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 3 cm Roll - - - - - - -
34 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 cm Roll 53 - 53 22 31 35 -
36 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 cm Roll 4 - 4 - 4 - -
37 MESS 11 pcs 55 100 155 14 141 22 -
38 MESS 21 pcs 100 - 100 - 100 - -
39 MESS 22 pcs - - - - - - -
40 PEMBALUT GIPS 3 INCI buah - - - - - - -
41 PLESTER 5 YARDS X 2 INCHI Roll 26 - 26 5 21 8 -
42 Surgical Mask - 3 ply Tie on (tali) pcs 203 - 203 91 112 146 -
43 Surgical Mask - 3 ply Earloop (karet) pcs 120 - 120 120 - 192 -
44 Urologi - Folley Catheter 2 way No. 16 pcs 18 - 18 14 4 22 -
45 Urologi - Folley Catheter 2 way No. 18 pcs 3 10 13 7 6 11 -
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs 7 - 7 7 - 11 -
47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet - 100 100 - 100 - -

48 Asam Asetilsalisilat (asetosal) tablet 500 mg Tablet 100 - 100 - 100 - -
49 Albendazol tablet/kapsul/kaplet 400 mg Tablet 24 - 24 - 24 - 10,000
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet - - - - - - -
51 ALPRAZOLAM TABLET 1 MG Tablet - 500 500 61 439 98 -
52 AMBROXOL 30 MG TAB Tablet - 4,000 4,000 2,905 1,095 4,648 8,000
53 Aminofilin tablet scored 200 mg Tablet - - - - - - -
54 Amitriptilin tablet salut 25 mg (HCl) Tablet 600 - 600 86 514 138 -
55 Amlodipin tablet 5 mg Tablet - - - - - - -
56 Amoksisilin kapsul/kaplet/tablet scored 500 mg Kaplet 7,823 10,000 17,823 8,264 9,559 13,222 5,000
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksida 200 Tablet 9,367 - 9,367 3,328 6,039 5,325 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet 20 100 120 74 46 118 100
59 Asam Askorbat (Vitamin C) tablet 250 mg Tablet 12,160 - 12,160 460 11,700 736 -
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet - - - - - - 1,000
62 ASAM MEFENAMAT 500 MG TAB Kaplet 886 4,000 4,886 2,846 2,040 4,554 4,000
63 ASAM TRANEXAMAT TABLET 500 MG Tablet - - - - - - -
64 ASAM VALPROAT 250 MG Tablet 362 - 362 - 362 - -
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet 400 - 400 - 400 - -
66 ATTAPULGIT TABLET 600 MG Tablet 870 - 870 870 - 1,392 -
67 BETAHISTIN MESILAT TABLET 6 MG Tablet - - - - - - 300
68 Bisakodil 5 mg (dulkolax) Tablet - - - - - - 80
69 D H P TAB Tablet 81 - 81 81 - 130 27
70 Deksametason tablet 0,5 mg Tablet 1,913 1,000 2,913 2,740 173 4,384 3,000
71 DIAZEPAM 2 MG TAB Tablet - - - - - - -
72 DIAZEPAM 5 MG TAB Tablet - - - - - - -
73 Digoksin tablet 0,25 mg Paket 200 - 200 - 200 - -
74 Dimenhidrinat tablet 50 mg Tablet 290 - 290 - 290 - -
75 Domperidon tablet 10 mg Tablet 430 200 630 100 530 160 -
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet - - - - - - 100
77 EFEDRIN HCL 25 MG TAB Tablet - - - - - - -
78 ERYTHROMYCIN 500 MG Tablet - - - - - - 200
79 Fenitoin kapsul/kaplet 100 mg Tablet - 500 500 43 457 69 -
80 FENITOIN NATRIUM 30 MG KAPSUL Kapsul - - - - - - -
81 Fenobarbital tablet/kapsul/kaplet 100 mg Kapsul - - - - - - -
82 Fenobarbital tablet/kapsul/kaplet 30 mg Kapsul 958 - 958 130 828 208 -
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet 470 - 470 39 431 62 -
84 Furosemid tablet 40 mg Tablet - - - - - - 200
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium klorida 0 Sachet 1,009 500 1,509 454 1,055 726 500
86 Glibenklamid tablet 5 mg Tablet - - - - - - 1,000
87 Glimepiride tablet 1 mg Tablet 250 - 250 250 - 400 1,000
88 Glimepiride tablet 2 mg Tablet - - - - - - 1,000
89 Glimepiride tablet 4 mg - - 1,000
90 GLISERYL GUAIAKOLAT 100 MG TAB Tablet - - - - - - 6,000
91 Griseofulvin tablet 125 mg Tablet - - - - - - 500
92 Haloperidol tablet 0,5 mg Tablet 456 - 456 68 388 109 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
94 Haloperidol tablet 5 mg Tablet 868 - 868 368 500 589 -
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet 8,515 - 8,515 1,528 6,987 2,445 -
96 Ibuprofen tablet 400 mg Tablet - - - - - - 5,000
97 ISOSORBID DINITRAT SUB LINGUAL 5 MG Tablet - - - - - - -
98 KALSIUM LAKTAT 500 MG Tablet 740 500 1,240 490 750 784 500
99 Kaptopril tablet scored 12,5 mg Tablet - - - - - - 2,000
100 Kaptopril tablet scored 25 mg Tablet 849 2,000 2,849 2,164 685 3,462 2,000
101 Karbamazepin tablet 200 mg Tablet 340 - 340 156 184 250 200
102 KETOKONZOL TABLET 200 MG Tablet - - - - - - 500
103 Kloramfenikol tablet/kapsul/kaplet 250 mg Tablet - - - - - - -
104 Kloramfenikol kapsul 500 mg Tablet 2,140 - 2,140 200 1,940 320 -
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet 20,783 - 20,783 5,696 15,087 9,114 -
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet - 500 500 91 409 146 -
107 KODEINA 10 MG TAB Tablet - - - - - - -
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0,25 mg Tablet 23,830 12,000 35,830 5,980 29,850 9,568 9,000
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 mg Tri Tablet 2,310 - 2,310 135 2,175 216 -
110 KUININE TAB SALUT SELAPUT 222 MG Tablet - - - - - - -
111 LOPERAMID TAB 2 MG Tablet 310 1,000 1,310 661 649 1,058 500
112 LORATADIN TABLET 10 MG Tablet - - - - - - 500
113 METFORMIN HCL TABLET 500 MG Tablet 1,000 - 1,000 140 860 224 -
114 Metilergometrin Maleat (Metilergometrin) tablet salut 0,125 mg Tablet - - - - - - 500
115 Metoklopramide tablet 5 mg Tablet - - - - - - -
116 Metoklopramide tablet 10 mg Tablet 290 - 290 185 105 296 -
117 METRONIDAZOLE 250 MG TAB Tablet - - - - - - -
118 METRONIDAZOLE 500 MG TAB Tablet 285 - 285 130 155 208 500
119 MINERAL MIX SERBUK Tablet - - - - - - -
120 MULTI MICRO NUTRIEN Sachet - - - - - - -
121 MULTIVITAMIN ANAK TABLET HISAP T ablet hisap - - - - - - -
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet 1,950 - 1,950 600 1,350 960 -
123 Nifedipin tablet/kapsul 10 mg Tablet 239 - 239 53 186 85 -
124 Nistatin tablet salut 500.000 IU/ g Tablet 100 - 100 - 100 - -
125 OAT KAT ANAK FDC Paket - - - - - - -
126 OAT KAT I KOMB Paket - - - - - - -
128 OAT KAT II FDC Paket - - - - - - -
129 OAT KAT SISIPAN FDC Paket - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
130 Omeprazol kapsul/kaplet 20 mg kaplet 1,850 - 1,850 190 1,660 304 -
131 Parasetamol tablet 100 mg Tablet - - - - - - -
132 Parasetamol tablet 500 mg Tablet 9,307 10,000 19,307 11,957 7,350 19,131 10,000
133 PERFENAZIN TAB 4 MG Tablet - - - - - - -
134 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 1,533 500 2,033 529 1,504 846 2,000
135 PIROKSIKAM 10 MG TAB Tablet 200 - 200 - 200 - -
136 PIROKSIKAM 20 MG TAB Tablet 860 - 860 350 510 560 -
137 Prednison tablet/kapsul/kaplet 5 mg Tablet 1,067 500 1,567 503 1,064 805 500
138 PRIMAKUIN TABLET 15 MG Tablet - - - - - - -
139 PROPANOLOL 40 MG TAB (HCL) Tablet - - - - - - 100
140 PROPILTIOURASIL 100 MG TAB Tablet 60 - 60 30 30 48 100
141 PYRANTEL SCORE (BASE) 125 MG TAB Tablet 20 - 20 2 18 3 -
142 Ranitidin tablet 150 mg Tablet 30 - 30 30 - 48 1,000
143 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak 400 - 400 393 7 629 -
144 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak 4,312 - 4,312 3,412 900 5,459 -
145 SALBUTAMOL 4 MG TAB Tablet 1,668 1,000 2,668 848 1,820 1,357 -
146 Setirizin tablet 10 mg Tablet 208 - 208 40 168 64 -
147 Simvastatin tablet 20 mg Tablet 580 - 580 - 580 - -
148 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 1,150 500 1,650 600 1,050 960 500
149 SPIRONOLAKTON TABLET 25 MG Tablet - - - - - - -
150 TETRASIKLIN 500 KAPSUL Kapsul - - - - - - -
151 THIAMPENICOL KAPSUL 250 MG Kapsul - - - - - - -
153 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet 2,548 2,000 4,548 2,718 1,830 4,349 3,000
154 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet - 1,000 1,000 304 696 486 500
155 VIT B KOMPLEK TAB Tablet 1,598 - 1,598 1,598 - 2,557 8,000
156 ZINC TAB 20 MG Tablet 990 500 1,490 870 620 1,392 -
SYRUP

159 Amoksisilin sirup kering forte 250 mg/5 ml Botol - - - - - - 100
160 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 200 mg/5 Botol - - - - - - 50
161 DOMPERIDON SYRUP Botol 40 50 90 27 63 43 -
162 Kloramfenikol suspensi 125 mg/ 5 ml Botol 145 - 145 7 138 11 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetoprim 40 Botol 128 50 178 31 147 50 -
164 Metoklopramide sirup 5 mg/ 5 ml Botol - - - - - - -
165 METRONIDAZOL SUSPENSI Botol - - - - - - -
166 MULTIVITAMIN SYR Botol 232 - 232 98 134 157 -
167 NISTATIN SUSPESI Botol 50 - 50 - 50 - -
168 O B H SYR Botol 88 50 138 70 68 112 120
169 Parasetamol drop 100 mg/ml btl @15ml (60mg/0,6ml) Botol - - - - - - -
170 Parasetamol sirup 120 mg / 5 ml Botol 4,234 - 4,234 392 3,842 627 -
INJEKSI
171 Aminofilin injeksi 24 mg/ml Ampul 27 - 27 - 27 - -

172 Ampisilin serbuk injeksi i.v. 1000 mg/vial Vial 50 - 50 9 41 14 -
173 ASAM TRANEXAMAT INJEKSI 50 MG / ML Ampul 10 - 10 - 10 - -
174 AQUA PRO INJ STERIL Vial 46 - 46 15 31 24 -
175 CEFTRIAXON 1 GR INJ Vial - - - - - - -
176 Deksametason injeksi i.v./i.m. 5 mg/ml Ampul 149 - 149 3 146 5 -
177 Diazepam injeksi i.v./i.m 5 mg/ml Ampul - 30 30 - 30 - -
178 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul 24 - 24 6 18 10 -
179 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul 6 30 36 7 29 11 -
180 Fenitoin injeksi 50 mg/ml Ampul - - - - - - -
181 Fenobarbital injeksi i.m./i.v. 50 mg/ml Ampul - - - - - - -
182 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul - - - - - - -
183 FUROSEMID INJ IV/IM 10 MG/ML Ampul - - - - - - -
184 Gentamisin injeksi 40 mg/ ml Ampul - - - - - - -
185 HYOCINA N BUTILBROMID INJ 20 MG Ampul - - - - - - -
186 KALSIUM GLUKONAS INJ 100 MG/ML Ampul 18 - 18 - 18 - -
187 Kloramfenikol serb inj 1000 mg/mL Vial - - - - - - -
188 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Ampul 948 - 948 14 934 22 -
189 Lidokain injeksi 2% (HCL) Ampul 465 - 465 22 443 35 -
190 MAGNESIUM SULFAT 20 % INJ 25 ML Vial 20 - 20 - 20 - -
191 MAGNESIUM SULFAT 40 % INJ 25 ML Vial 35 - 35 1 34 2 -
192 Metoklopramide INJ 5 MG/ML Ampul 40 - 40 5 35 8 -
193 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul 40 - 40 6 34 10 -
194 Oksitosin injeksi 10 IU/ml Ampul 221 - 221 73 148 117 -
195 OXYTETRACIKLIN HCL INJ IM 50 MG/ML 10 ML Vial - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
196 RANITIDIN INJ 25 MG/2 ML Ampul 275 - 275 8 267 13 -
197 Sianokobalamin (vitamin B12) injeksi 500 mcg Ampul - - - - - - -
198 THIAMIN INJ ( VIT BI ) 100 MG/ML Ampul - - - - - - -
OBAT KHUSUS
199 Antihemoroid, kombinasi: bismut subgalat 150 mg heksaklorofen 2,5 mg SUPP 318 - 318 17 301 27 -
200 BISACODYL SUPP (DULCOLAX) 10 MG / Stolax supp SUPP 71 - 71 8 63 13 -
201 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal) TUBE 26 - 26 - 26 - -
202 MICROLAX 29 - 29 - 29 - -
203 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET 69 - 69 - 69 - -
204 PARASETAMOL SUPP 80 MG SUPP - - - - - - -
206 SABU I 5 ML VIAL - - - - - - -
208 SERUM ATS 1 500 IU VIAL - - - - - - -
209 Serum ATS 20.000 IU - - - - - - -
CAIRAN
210 Glukosa larutan infus 10 % steril Botol - 20 20 - 20 - -

211 Glukosa larutan infus 40 % steril Botol - - - - - - 10
212 Glukosa larutan infus 5 % steril Botol - 20 20 6 14 10 -
213 Nacl 0,9% Botol 31 20 51 7 44 11 -
214 Ringer Laktat larutan infus Botol 943 - 943 44 899 70 -
OBAT LUAR
215 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g Polimiksin 10.000 Tube - - - - - - 100
216 ANTI FUNGI DOEN KOMB Pot - - - - - - -
217 ASIKLOVIR CREAM 5% Tube - - - - - - 100
218 BETAMETASON CREAM 0,1 % Tube - - - - - - 100
219 FENOL GLISEROL TT 10% TUBE - - - - - - 96
220 GENTAMICIN SK 0,1% Botol - - - - - - 200
221 GENTAMICIN SALEP MATA 0,3% Tube 550 - 550 58 492 93 -
222 GENTAMISIN SULFAT TETES MATA Tube - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
223 GENTIAN VIOLET LART 1% Botol - - - - - - 48
224 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol 8 - 8 2 6 3 -
225 HIDROGEN PEROKSIDA LARUTAN 3% Botol - - - - - - 3
226 HIDROKORTISON CREAM 2,5 % Tube - - - - - - -
227 ICHTIOL SALEP HITAM Pot 24 - 24 5 19 8 24
228 KALIUM PERMANGANAT SERBUK Pot 18 - 18 1 17 2 -
229 KETOKONAZOL KRIM 2% Tube 9 - 9 9 - 14 50
230 Kloramfenikol salep mata 1 % Tube - - - - - - 48
231 Kloramfenikol teter telinnga 3 % Botol - - - - - - 48
232 MICONAZOLE CREAM 2% Tube - - - - - - -
233 OKSITETRASIKLIN SK 3% Tube - - - - - - 25
234 OKSITETRASIKLIN SM 1% Tube - - - - - - -
235 Povidon Iodida larutan 10% 30 ml Botol 14 50 64 16 48 26 -
237 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang endap 4% Botol 93 - 93 26 67 42 48
238 SALEP LUKA BAKAR (bioplacenton) Pot - 5 5 - 5 - 5
239 Bedak salisil serbuk 2% Tube 27 - 27 27 - 43 30
240 Scabicid / Scabimite Cream Tube 20 - 20 - 20 - -
241 SULFASETAMID NATRIUM TM 15 % Kotak - - - - - - -
OBAT GIGI
242 DEVITALISASI PASTA ( NON ARSEN ) Pot - - - - - - 1

243 ETIL KLORIDA SPRAY Botol 4 - 4 - 4 - -
244 EUGENOL CAIRAN Botol - - - - - - -
245 GLASS IONOMER CEMENT ART Botol - - - - - - 2
246 KALSIUM HIDROKSIDA PASTA Pot - - - - - - -
247 KLORFENOL KAMFER MENTHOL (CHKM) Botol 2 - 2 - 2 - -
248 MUMMIFYING PASTA Pot - - - - - - 1
249 POLIKRESULEN (ALBOTYL) Botol - 3 3 - 3 - -
250 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot - 1 1 - 1 - 1
251 SPONGOSTAN Kotak - - - - - - -
252 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot 2 - 2 1 1 2 -
253 TRIKRESOL FORMALIN (TKF) Botol - - - - - - -
BAHAN LABORATORIUM
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
254 CARIK CELUP / URIN TES 3 GPH Stik 100 - 100 30 70 48 200
255 CARIK CELUP / URIN TES 11 GPH Stik - - - - - - 100
256 Antiseptik dan Disinfektan - alkohol 70% 100 ml Botol - - - - - - -
257 Antiseptik dan Disinfektan - alkohol 70% 1 liter Botol 23 67 90 3 87 5 -
258 GLISERIN Botol - - - - - - -
259 HB TEST KIT Set - - - - - - -
260 KIT GOL DARAH Set - - - - - - 6
261 LART AS ACETAT Botol - - - - - - -
262 LART ASAM KLORIDA 0,1 N Botol - - - - - - -
263 LAR ASAM KLORIDA 0,1% Botol - - - - - - -
264 LART BARIUM CHLORIDA 10 % Botol - - - - - - -
265 LART BENEDICT Botol - - - - - - -
266 LART E D T A 10 % Botol - - - - - - -
267 LART ETANOL ASAM Botol - - - - - - -
268 LART KOH 10 % Botol - - - - - - -
269 LART NACL 0,9 % Botol - - - - - - -
270 LART NATRIUM CITRAT 0,38 % Botol - - - - - - -
271 LART ASAM CITRAT 3,8% Botol - - - - - - -
272 LART REES ECKER Botol - - - - - - -
273 LART SCHLESINGER Botol - - - - - - -
274 LART TURK Botol - - - - - - -
275 OIL EMERSI Botol - - - - - - -
276 PP TEST Stik 150 - 150 - 150 - -
277 RDT TEST MALARIA Stik - - - - - - -
278 STIK GULA DARAH Stik - - - - - - -
279 STIK ASAM URAT Stik - - - - - - -
280 STIK KOLESTEROL Stik - - - - - - -
281 STIK HBSAG Stik - - - - - - -
282 STIK HBSAG Stik - - - - - - -
283 WIDAL TEST Set - - - - - - -
REAGEN
284 REAGEN ABX MINIDIL LMG PAKET - - - - - - -

285 REAGEN ABC MINILYSE LMG PAKET - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
286 REAGEN ABX MINICLEAN PAKET - - - - - - -
287 REAGEN ABX MINOTROL PAKET - - - - - - -
TAMBAHAN
288 HALOPERIDOL INJ 5 Mg/Ml Ampul - - - - - - -

289 Cover Glass 24x24 MM BUAH - - - - - - -
290 DASABION KAPSUL 8,730 - 8,730 1,270 7,460 2,032 -
291 KETOROLAC INJ AMPUL 14 - 14 - 14 - -
292 ONDANCETRON INJ AMPUL 25 - 25 5 20 8 -
293 METAMIZOLE INJ AMPUL 300 - 300 6 294 10 -
294 BISOPROLOL 5 MG TABLET 200 - 200 - 200 - -
295 OXYFLOW ANAK BUAH 45 - 45 - 45 - -
TIDAK BAYAR
BAYAR JUMLAH
841 2919 40 3800

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
LAPORAN PERIODE/BULAN : September 2017 TANGGAL : 2 Oktober 2017
PERMINTAAN PERIODE/BULAN : Oktober 2017

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set 2,242 - 2,242 220 2,022 352 -
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set 3,442 30 3,472 326 3,146 522 -
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set 12 - 12 12 - 19 100
5 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set 36 48 84 2 82 3 -
10 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set 10 72 82 6 76 10 -
12 HAND SCOUND STERIL NO 7,5 Pasang 42 100 142 100 42 160 -
13 HAND SCOUND NON STERIL UK L Lembar - - - - - - -
14 HAND SCOUND NON STERIL UK S - 500 500 350 150 560 500
15 HAND SCOUND NON STERIL UK M Lembar - 500 500 370 130 592 500
16 HYPAFIX 10 x 5 CM Pasang 4 - 4 1 3 2 -
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set 1,235 5 1,240 41 1,199 66 -
19 Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 mm buah 607 - 607 30 577 48 -
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah 40 - 40 11 29 18 50
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah 46 - 46 5 41 8 -
23 Infus Set, IV, Wing needle - I.V Catheter No. 26 G x 1/2 " buah - - - - - - 50
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll 2 5 7 4 3 6 4
30 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll 84 - 84 4 80 6 -
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar - 5 5 5 - 8 -
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar 336 - 336 - 336 - -
34 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 cm Roll 31 - 31 29 2 46 -
37 MESS 11 pcs 141 - 141 - 141 - -
38 MESS 21 pcs 100 - 100 - 100 - -
39 MESS 22 pcs - - - - - - -
42 Surgical Mask - 3 ply Tie on (tali) pcs 112 - 112 70 42 112 300
43 Surgical Mask - 3 ply Earloop (karet) pcs - - - - - - 300
44 Urologi - Folley Catheter 2 way No. 16 pcs 4 - 4 4 - 6 10
45 Urologi - Folley Catheter 2 way No. 18 pcs 6 - 6 2 4 3 10
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs 7 - 7 7 - 11 10

49 Albendazol tablet/kapsul/kaplet 400 mg Tablet 24 6,000 6,024 2,900 3,124 4,640 -
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet - - - - - - 1,000
51 ALPRAZOLAM TABLET 1 MG Tablet 439 - 439 46 393 74 -
52 AMBROXOL 30 MG TAB Tablet 1,095 8,000 9,095 4,617 4,478 7,387 8,000
53 Aminofilin tablet scored 200 mg Tablet - - - - - - -
54 Amitriptilin tablet salut 25 mg (HCl) Tablet 514 - 514 - 514 - -
55 Amlodipin tablet 5 mg Tablet - 900 900 - 900 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksi Tablet 6,039 - 6,039 2,756 3,283 4,410 -
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet 46 100 146 64 82 102 100
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet - 1,000 1,000 265 735 424 1,000
62 ASAM MEFENAMAT 500 MG TAB Kaplet 2,040 4,000 6,040 2,610 3,430 4,176 4,000
63 ASAM TRANEXAMAT TABLET 500 MG Tablet - - - - - - 300
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet 400 - 400 210 190 336 1,000
66 ATTAPULGIT TABLET 600 MG Tablet - 500 500 160 340 256 1,000
67 BETAHISTIN MESILAT TABLET 6 MG Tablet - 600 600 160 440 256 300
69 D H P TAB Tablet - 27 27 - 27 - -
70 Deksametason tablet 0,5 mg Tablet 173 4,000 4,173 2,667 1,506 4,267 4,000
71 DIAZEPAM 2 MG TAB Tablet - - - - - - 200
74 Dimenhidrinat tablet 50 mg Tablet 290 - 290 168 122 269 500
75 Domperidon tablet 10 mg Tablet 530 - 530 58 472 93 -
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet - 100 100 - 100 - -
79 Fenitoin kapsul/kaplet 100 mg Tablet 457 - 457 69 388 110 -
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet 431 - 431 114 317 182 200
84 Furosemid tablet 40 mg Tablet - - - - - - 200
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium kl Sachet 1,055 500 1,555 542 1,013 867 300
86 Glibenklamid tablet 5 mg Tablet - - - - - - 1,000
87 Glimepiride tablet 1 mg Tablet - 1,000 1,000 620 380 992 1,000
89 Glimepiride tablet 4 mg - 500 500 - 500 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
94 Haloperidol tablet 5 mg Tablet 500 - 500 214 286 342 500
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet 6,987 - 6,987 970 6,017 1,552 -
96 Ibuprofen tablet 400 mg Tablet - 5,000 5,000 2,866 2,134 4,586 5,000
98 KALSIUM LAKTAT 500 MG Tablet 750 500 1,250 440 810 704 500
99 Kaptopril tablet scored 12,5 mg Tablet - 2,000 2,000 - 2,000 - -
100 Kaptopril tablet scored 25 mg Tablet 685 2,000 2,685 2,685 - 4,296 4,000
102 KETOKONZOL TABLET 200 MG Tablet - - - - - - -
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet 15,087 - 15,087 6,100 8,987 9,760 -
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet 409 - 409 91 318 146 -
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0, Tablet 29,850 9,000 38,850 22,020 16,830 35,232 12,000
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 Tablet 2,175 100 2,275 159 2,116 254 -
111 LOPERAMID TAB 2 MG Tablet 649 - 649 640 9 1,024 1,000
113 METFORMIN HCL TABLET 500 MG Tablet 860 - 860 115 745 184 -
116 Metoklopramide tablet 10 mg Tablet 105 - 105 105 - 168 500
118 METRONIDAZOLE 500 MG TAB Tablet 155 - 155 155 - 248 500
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet 1,350 - 1,350 840 510 1,344 1,000
123 Nifedipin tablet/kapsul 10 mg Tablet 186 - 186 37 149 59 100
125 OAT KAT ANAK FDC Paket - - - - - - 2
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
127 OAT KAT I.3 FDC Paket 5 3 8 1 7 2 -
130 Omeprazol kapsul/kaplet 20 mg kaplet 1,660 - 1,660 475 1,185 760 -
134 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 1,504 2,000 3,504 598 2,906 957 2,000
135 PIROKSIKAM 10 MG TAB Tablet 200 - 200 - 200 - 1,000
136 PIROKSIKAM 20 MG TAB Tablet 510 - 510 510 - 816 1,000
137 Prednison tablet/kapsul/kaplet 5 mg Tablet 1,064 600 1,664 588 1,076 941 1,000
140 PROPILTIOURASIL 100 MG TAB Tablet 30 100 130 60 70 96 100
141 PYRANTEL SCORE (BASE) 125 MG TAB Tablet 18 - 18 12 6 19 -
142 Ranitidin tablet 150 mg Tablet - - - - - - 1,000
143 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak 7 - 7 - 7 - -
144 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak 900 - 900 20 880 32 -
145 SALBUTAMOL 4 MG TAB Tablet 1,820 - 1,820 1,518 302 2,429 2,000
146 Setirizin tablet 10 mg Tablet 168 - 168 100 68 160 300
147 Simvastatin tablet 20 mg Tablet 580 - 580 150 430 240 -
148 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 1,050 500 1,550 320 1,230 512 500
153 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet 1,830 5,000 6,830 2,653 4,177 4,245 -
154 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet 696 500 1,196 224 972 358 -
155 VIT B KOMPLEK TAB Tablet - - - - - - 8,000
156 ZINC TAB 20 MG Tablet 620 - 620 430 190 688 -
SYRUP
157 AMBROXOL SYR 15 mg/ml Botol 22 50 72 72 - 115 100

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
159 Amoksisilin sirup kering forte 250 mg/5 ml Botol - 50 50 - 50 - -
160 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 20 Botol - 50 50 15 35 24 50
161 DOMPERIDON SYRUP Botol 63 - 63 53 10 85 50
163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetop Botol 147 - 147 71 76 114 -
165 METRONIDAZOL SUSPENSI Botol - 50 50 - 50 - -
166 MULTIVITAMIN SYR Botol 134 - 134 134 - 214 240
167 NISTATIN SUSPESI Botol 50 - 50 3 47 5 -
168 O B H SYR Botol 68 120 188 50 138 80 -
INJEKSI

176 Deksametason injeksi i.v./i.m. 5 mg/ml Ampul 146 - 146 - 146 - -
177 Diazepam injeksi i.v./i.m 5 mg/ml Ampul 30 - 30 1 29 2 -
178 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul 18 - 18 3 15 5 -
179 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul 29 240 269 8 261 13 -
182 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul - 540 540 - 540 - -
185 HYOCINA N BUTILBROMID INJ 20 MG Ampul - - - - - - -
186 KALSIUM GLUKONAS INJ 100 MG/ML Ampul 18 144 162 - 162 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
193 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul 34 100 134 - 134 - -
OBAT KHUSUS
199 Antihemoroid, kombinasi: bismut subgalat 150 mg heksaklorofen 2 SUPP 301 - 301 14 287 22 -
201 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal) TUBE 26 - 26 1 25 2 -
202 MICROLAX 29 - 29 2 27 3 -
203 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET 69 - 69 3 66 5 -
206 SABU I 5 ML VIAL - - - - - - -
208 SERUM ATS 1 500 IU VIAL - - - - - - -
209 Serum ATS 20.000 IU - - - - - - -
CAIRAN
210 Glukosa larutan infus 10 % steril Botol 20 - 20 7 13 11 -

212 Glukosa larutan infus 5 % steril Botol 14 - 14 1 13 2 20
213 Nacl 0,9% Botol 44 - 44 16 28 26 -
214 Ringer Laktat larutan infus Botol 899 10 909 46 863 74 -
OBAT LUAR
215 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g Polimiksin Tube - - - - - - 100
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
218 BETAMETASON CREAM 0,1 % Tube - 2,100 2,100 - 2,100 - -
221 GENTAMICIN SALEP MATA 0,3% Tube 492 96 588 60 528 96 -
222 GENTAMISIN SULFAT TETES MATA Tube - - - - - - 50
224 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol 6 - 6 2 4 3 5
227 ICHTIOL SALEP HITAM Pot 19 24 43 9 34 14 -
229 KETOKONAZOL KRIM 2% Tube - 300 300 - 300 - -
235 Povidon Iodida larutan 10% 30 ml Botol 48 - 48 6 42 10 -
236 Povidon Iodida larutan 10% 300 ml Botol 4 5 9 2 7 3 -
238 SALEP LUKA BAKAR (bioplacenton) Pot 5 5 10 1 9 2 -
239 Bedak salisil serbuk 2% Tube - - - - - - 30
OBAT GIGI
242 DEVITALISASI PASTA ( NON ARSEN ) Pot - 1 1 1 - 2 1

243 ETIL KLORIDA SPRAY Botol 4 1 5 5 - 8 8
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
249 POLIKRESULEN (ALBOTYL) Botol 3 - 3 - 3 - -
250 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot 1 - 1 - 1 - 1
252 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot 1 - 1 1 - 2 2
BAHAN LABORATORIUM
254 CARIK CELUP / URIN TES 3 GPH Stik 70 100 170 170 - 272 200
257 Antiseptik dan Disinfektan - alkohol 70% 1 liter Botol 87 - 87 4 83 6 -
259 HB TEST KIT Set - - - - - - -
260 KIT GOL DARAH Set - 1 1 - 1 - -
266 LART E D T A 10 % Botol - - - - - - -
268 LART KOH 10 % Botol - - - - - - -
269 LART NACL 0,9 % Botol - - - - - - -
274 LART TURK Botol - - - - - - -
276 PP TEST Stik 150 - 150 63 87 101 50
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
281 STIK HBSAG Stik - - - - - - -
282 STIK HBSAG Stik - - - - - - -
283 WIDAL TEST Set - - - - - - -
REAGEN

TAMBAHAN

290 DASABION KAPSUL 7,460 - 7,460 920 6,540 1,472 -
291 KETOROLAC INJ AMPUL 14 - 14 6 8 10 -
292 ONDANCETRON INJ AMPUL 20 - 20 - 20 - -
TIDAK BAYAR
BAYAR JUMLAH
812 3173 48 4033
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15

NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
LAPORAN PERIODE/BULAN : Oktober 2017 TANGGAL : 2 November 2017
PERMINTAAN PERIODE/BULAN : November 2017

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set 3,146 - 3,146 198 2,948 317 -
4 Alat Suntik Sekali Pakai - 10 cc x 21G x 1 1/2" Set - 100 100 19 81 30 -
5 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set 82 - 82 19 63 30 24
6 Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Set - - - - - -
12 HAND SCOUND STERIL NO 7,5 Pasang 42 - 42 - 42 - -
13 HAND SCOUND NON STERIL UK L Lembar - - - - - - 500
14 HAND SCOUND NON STERIL UK S 150 400 550 550 - 880 800
15 HAND SCOUND NON STERIL UK M Lembar 130 200 330 330 - 528 500
16 HYPAFIX 10 x 5 CM Pasang 3 - 3 2 1 3 6
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set 1,199 - 1,199 33 1,166 53 -
20 Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 1/4 " buah 90 20 110 16 94 26 -
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah 29 30 59 7 52 11 -
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah 41 - 41 2 39 3 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll 3 4 7 7 - -
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar - - - - - - 320
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar 336 - 336 36 300 58 -
34 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 cm Roll 2 - 2 2 - 3 100
37 MESS 11 pcs 141 - 141 2 139 3 -
38 MESS 21 pcs 100 - 100 - 100 - -
39 MESS 22 pcs - - - - - - -
42 Surgical Mask - 3 ply Tie on (tali) pcs 42 100 142 142 - 227 300
43 Surgical Mask - 3 ply Earloop (karet) pcs - 100 100 100 - 160 300
44 Urologi - Folley Catheter 2 way No. 16 pcs - 10 10 9 1 14 10
45 Urologi - Folley Catheter 2 way No. 18 pcs 4 10 14 1 13 2 -
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs - 10 10 3 7 5 -

49 Albendazol tablet/kapsul/kaplet 400 mg Tablet 3,124 - 3,124 2,869 255 4,590 -
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet - 400 400 - 400 - 1,000
53 Aminofilin tablet scored 200 mg Tablet - - - - - - 200
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
54 Amitriptilin tablet salut 25 mg (HCl) Tablet 514 - 514 - 514 - -
55 Amlodipin tablet 5 mg Tablet 900 5,010 5,910 420 5,490 672 -
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksid Tablet 3,283 - 3,283 3,128 155 5,005 -
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet 82 - 82 - 82 - 100 ED
59 Asam Askorbat (Vitamin C) tablet 250 mg Tablet 11,260 - 11,260 785 10,475 1,256 -
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet 735 200 935 561 374 898 1,000
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet 190 800 990 113 877 181 -
66 ATTAPULGIT TABLET 600 MG Tablet 340 200 540 280 260 448 1,000
67 BETAHISTIN MESILAT TABLET 6 MG Tablet 440 90 530 60 470 96 300
69 D H P TAB Tablet 27 - 27 - 27 - -
70 Deksametason tablet 0,5 mg Tablet 1,506 2,000 3,506 3,506 - 5,610 6,000
74 Dimenhidrinat tablet 50 mg Tablet 122 200 322 - 322 - 300
75 Domperidon tablet 10 mg Tablet 472 - 472 242 230 387 -
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet 100 - 100 - 100 - -
79 Fenitoin kapsul/kaplet 100 mg Tablet 388 - 388 168 220 269 100
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet 317 200 517 24 493 38 200
84 Furosemid tablet 40 mg Tablet - 3,000 3,000 121 2,879 194 -
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium klo Sachet 1,013 300 1,313 692 621 1,107 1,000
86 Glibenklamid tablet 5 mg Tablet - 1,000 1,000 155 845 248 500
87 Glimepiride tablet 1 mg Tablet 380 1,000 1,380 650 730 1,040 1,000
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
89 Glimepiride tablet 4 mg 500 - 500 200 300 320 500
92 Haloperidol tablet 0,5 mg Tablet 350 - 350 - 350 - -
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet 6,017 - 6,017 6,017 - 9,627 - ED
96 Ibuprofen tablet 400 mg Tablet 2,134 2,000 4,134 3,665 469 5,864 5,000
98 KALSIUM LAKTAT 500 MG Tablet 810 - 810 350 460 560 1,000
99 Kaptopril tablet scored 12,5 mg Tablet 2,000 - 2,000 150 1,850 240 -
100 Kaptopril tablet scored 25 mg Tablet - 4,000 4,000 2,793 1,207 4,469 3,000
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet 8,987 - 8,987 5,204 3,783 8,326 5,000
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet 318 - 318 77 241 123 -
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0, Tablet 16,830 6,000 22,830 5,851 16,979 9,362 12,000
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 Tablet 2,116 - 2,116 217 1,899 347 -
111 LOPERAMID TAB 2 MG Tablet 9 - 9 9 - 14 1,000
113 METFORMIN HCL TABLET 500 MG Tablet 745 - 745 415 330 664 600
116 Metoklopramide tablet 10 mg Tablet - 500 500 175 325 280 500
118 METRONIDAZOLE 500 MG TAB Tablet - - - - - - 500
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet 510 1,000 1,510 970 540 1,552 1,000
123 Nifedipin tablet/kapsul 10 mg Tablet 149 100 249 27 222 43 100
125 OAT KAT ANAK FDC Paket - 2 2 - 2 - -
127 OAT KAT I.3 FDC Paket 7 - 7 5 2 8 8
130 Omeprazol kapsul/kaplet 20 mg kaplet 1,185 - 1,185 413 772 661 900
134 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 2,906 - 2,906 670 2,236 1,072 2,000
135 PIROKSIKAM 10 MG TAB Tablet 200 200 400 400 - 640 1,000
136 PIROKSIKAM 20 MG TAB Tablet - - - - - - 1,000
137 Prednison tablet/kapsul/kaplet 5 mg Tablet 1,076 - 1,076 588 488 941 1,000
140 PROPILTIOURASIL 100 MG TAB Tablet 70 100 170 100 70 160 100
141 PYRANTEL SCORE (BASE) 125 MG TAB Tablet 6 - 6 - 6 - -
143 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak 7 - 7 7 - 11 -
144 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak 880 - 880 24 856 38 -
145 SALBUTAMOL 4 MG TAB Tablet 302 2,000 2,302 1,433 869 2,293 2,000
147 Simvastatin tablet 20 mg Tablet 430 - 430 300 130 480 600
148 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 1,230 - 1,230 540 690 864 500
153 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet 4,177 - 4,177 2,639 1,538 4,222 4,000
154 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet 972 - 972 169 803 270 -
155 VIT B KOMPLEK TAB Tablet - - - - - - 8,000
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
156 ZINC TAB 20 MG Tablet 190 - 190 190 - 304 1,500
SYRUP
157 AMBROXOL SYR 15 mg/ml Botol - 100 100 81 19 130 100

159 Amoksisilin sirup kering forte 250 mg/5 ml Botol 50 - 50 7 43 11 50
160 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 20 Botol 35 50 85 31 54 50 -
161 DOMPERIDON SYRUP Botol 10 50 60 44 16 70 -
163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetopr Botol 76 - 76 76 - 122 200
165 METRONIDAZOL SUSPENSI Botol 50 - 50 - 50 - -
166 MULTIVITAMIN SYR Botol - 300 300 85 215 136 -
168 O B H SYR Botol 138 - 138 53 85 85 -
INJEKSI

177 Diazepam injeksi i.v./i.m 5 mg/ml Ampul 29 - 29 - 29 - -
178 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul 15 - 15 - 15 - -
179 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul 261 - 261 13 248 21 -
182 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul 540 - 540 - 540 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
185 HYOCINA N BUTILBROMID INJ 20 MG Ampul - - - - - - 20
193 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul 134 - 134 - 134 - -
OBAT KHUSUS
202 MICROLAX 27 - 27 27 - 43 - ED
203 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET 66 - 66 - 66 - -
206 SABU I 5 ML VIAL - - - - - - -
208 SERUM ATS 1 500 IU VIAL - - - - - - -
209 Serum ATS 20.000 IU - - - - - - -
CAIRAN
210 Glukosa larutan infus 10 % steril Botol 13 - 13 - 13 - -

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
212 Glukosa larutan infus 5 % steril Botol 13 20 33 2 31 3 -
213 Nacl 0,9% Botol 28 - 28 15 13 24 -
OBAT LUAR
218 BETAMETASON CREAM 0,1 % Tube 2,100 - 2,100 - 2,100 - -
222 GENTAMISIN SULFAT TETES MATA Tube - 50 50 2 48 3 50
224 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol 4 - 4 4 - 6 5
227 ICHTIOL SALEP HITAM Pot 34 - 34 4 30 6 -
229 KETOKONAZOL KRIM 2% Tube 300 - 300 30 270 48 -
236 Povidon Iodida larutan 10% 300 ml Botol 7 - 7 3 4 5 3
238 SALEP LUKA BAKAR (bioplacenton) Pot 9 - 9 - 9 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
OBAT GIGI
242 DEVITALISASI PASTA ( NON ARSEN ) Pot - 1 1 1 - 2 1

243 ETIL KLORIDA SPRAY Botol - 8 8 2 6 3 -
250 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot 1 1 2 - 2 - -
252 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot - - - - - - 2
BAHAN LABORATORIUM

259 HB TEST KIT Set - - - - - - -
260 KIT GOL DARAH Set 1 - 1 - 1 - -
266 LART E D T A 10 % Botol - - - - - - -
268 LART KOH 10 % Botol - - - - - - -
269 LART NACL 0,9 % Botol - - - - - - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
274 LART TURK Botol - - - - - - -
276 PP TEST Stik 87 50 137 - 137 - 50
281 STIK HBSAG Stik - - - - - - -
282 STIK HBSAG Stik - - - - - - -
283 WIDAL TEST Set - - - - - - -
REAGEN

TAMBAHAN

290 DASABION KAPSUL 6,540 - 6,540 870 5,670 1,392 -
291 KETOROLAC INJ AMPUL 8 - 8 5 3 8 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
TIDAK BAYAR
BAYAR JUMLAH
884 2975 30 3889

NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
LAPORAN PERIODE/BULAN : November 2017 TANGGAL : 2 Desember 2017
PERMINTAAN PERIODE/BULAN : Desember 2017

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
2 Alat Suntik Sekali Pakai - 2.5 cc x 23G x 1 1/4" Set 2,948 - 2,948 196 2,752 314 -
6 Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Set - - - - - -
10 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set 75 - 75 - 75 - -
11 HAND SCOUND STERIL NO 7 Pasang 7 275 282 161 121 258 -
12 HAND SCOUND STERIL NO 7,5 Pasang 42 - 42 10 32 16 -
13 HAND SCOUND NON STERIL UK L Lembar - - - - - - 500
14 HAND SCOUND NON STERIL UK S - 1,000 1,000 500 500 800 300
15 HAND SCOUND NON STERIL UK M Lembar - 700 700 500 200 800 600
16 HYPAFIX 10 x 5 CM Pasang 1 6 7 1 6 2 -
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set 1,166 - 1,166 47 1,119 75 -
20 Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 1/4 " buah 94 - 94 25 69 40 50
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah 52 - 52 14 38 22 50
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah 39 - 39 9 30 14 50
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll 7 - 7 3 4 5 5
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar - 1,600 1,600 84 1,516 134 -
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar 300 - 300 132 168 211 -
34 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 10 cm Roll - 100 100 72 28 115 100
37 MESS 11 pcs 139 - 139 4 135 6 -
38 MESS 21 pcs 100 - 100 - 100 - -
39 MESS 22 pcs - - - - - - -
42 Surgical Mask - 3 ply Tie on (tali) pcs - 600 600 435 165 696 200
43 Surgical Mask - 3 ply Earloop (karet) pcs - - - - - - 200
44 Urologi - Folley Catheter 2 way No. 16 pcs 1 - 1 1 - 2 10
45 Urologi - Folley Catheter 2 way No. 18 pcs 13 - 13 3 10 5 -
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs 7 - 7 5 2 8 20

49 Albendazol tablet/kapsul/kaplet 400 mg Tablet 255 - 255 3 252 5 -
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet 400 1,000 1,400 - 1,400 - -
53 Aminofilin tablet scored 200 mg Tablet - - - - - - 200
54 Amitriptilin tablet salut 25 mg (HCl) Tablet 514 - 514 64 450 102 -
55 Amlodipin tablet 5 mg Tablet 5,490 - 5,490 1,130 4,360 1,808 -
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksi Tablet 155 - 155 155 - 248 8,000
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet 82 - 82 82 - 131 200
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet 374 500 874 601 273 962 700
64 ASAM VALPROAT 250 MG Tablet 362 - 362 362 - 579 - ED
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet 877 - 877 277 600 443
66 ATTAPULGIT TABLET 600 MG Tablet 260 1,300 1,560 390 1,170 624 1,000
67 BETAHISTIN MESILAT TABLET 6 MG Tablet 470 - 470 171 299 274 300
69 D H P TAB Tablet 27 - 27 - 27 - -
70 Deksametason tablet 0,5 mg Tablet - 7,000 7,000 3,693 3,307 5,909 3,000
74 Dimenhidrinat tablet 50 mg Tablet 322 300 622 - 622 -
75 Domperidon tablet 10 mg Tablet 230 - 230 174 56 278 500
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet 100 - 100 - 100 - -
79 Fenitoin kapsul/kaplet 100 mg Tablet 220 200 420 80 340 128 100
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet 493 - 493 68 425 109 -
84 Furosemid tablet 40 mg Tablet 2,879 - 2,879 45 2,834 72 -
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium kl Sachet 621 3,100 3,721 1,268 2,453 2,029 -
86 Glibenklamid tablet 5 mg Tablet 845 - 845 460 385 736 1,000
87 Glimepiride tablet 1 mg Tablet 730 650 1,380 380 1,000 608 600
89 Glimepiride tablet 4 mg 300 - 300 90 210 144 300
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet - - - - - - -
96 Ibuprofen tablet 400 mg Tablet 469 6,700 7,169 4,148 3,021 6,637 4,000
98 KALSIUM LAKTAT 500 MG Tablet 460 - 460 100 360 160 1,000
99 Kaptopril tablet scored 12,5 mg Tablet 1,850 - 1,850 125 1,725 200 -
100 Kaptopril tablet scored 25 mg Tablet 1,207 4,400 5,607 2,139 3,468 3,422 1,000
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet 3,783 6,600 10,383 6,762 3,621 10,819 7,000
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet 241 - 241 91 150 146 300
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0, Tablet 16,979 114,681 131,660 16,773 114,887 26,837 -
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 Tablet 1,899 - 1,899 205 1,694 328 -
111 LOPERAMID TAB 2 MG Tablet - - - - - - 1,000
113 METFORMIN HCL TABLET 500 MG Tablet 330 600 930 345 585 552 600
116 Metoklopramide tablet 10 mg Tablet 325 200 525 143 382 229 -
118 METRONIDAZOLE 500 MG TAB Tablet - - - - - - 500
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet 540 1,000 1,540 940 600 1,504 1,000
123 Nifedipin tablet/kapsul 10 mg Tablet 222 100 322 21 301 34 -
125 OAT KAT ANAK FDC Paket 2 - 2 2 - 3 4
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
130 Omeprazol kapsul/kaplet 20 mg kaplet 772 9,000 9,772 523 9,249 837 -
134 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet 2,236 - 2,236 575 1,661 920 500
135 PIROKSIKAM 10 MG TAB Tablet - 1,040 1,040 460 580 736 1,000
136 PIROKSIKAM 20 MG TAB Tablet - - - - - - 1,000
137 Prednison tablet/kapsul/kaplet 5 mg Tablet 488 1,000 1,488 747 741 1,195 1,000
139 PROPANOLOL 40 MG TAB (HCL) Tablet - 500 500 - 500 - -
140 PROPILTIOURASIL 100 MG TAB Tablet 70 - 70 10 60 16 -
141 PYRANTEL SCORE (BASE) 125 MG TAB Tablet 6 - 6 6 - 10 -
143 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak - - - - - - -
144 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak 856 2,700 3,556 20 3,536 32 -
145 SALBUTAMOL 4 MG TAB Tablet 869 2,000 2,869 1,438 1,431 2,301 1,500
147 Simvastatin tablet 20 mg Tablet 130 600 730 130 600 208 -
148 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet 690 500 1,190 460 730 736 500
153 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet 1,538 4,000 5,538 2,481 3,057 3,970 2,000
154 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet 803 - 803 307 496 491 300
155 VIT B KOMPLEK TAB Tablet - 17,000 17,000 17,000 - -
156 ZINC TAB 20 MG Tablet - 1,500 1,500 1,235 265 1,976 2,000
SYRUP
159 Amoksisilin sirup kering forte 250 mg/5 ml Botol 43 - 43 7 36 11 200
160 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 20 Botol 54 - 54 54 - 86 50
161 DOMPERIDON SYRUP Botol 16 - 16 16 - 26 200
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetop Botol - 200 200 102 98 163 50
165 METRONIDAZOL SUSPENSI Botol 50 - 50 1 49 2 -
166 MULTIVITAMIN SYR Botol 215 - 215 164 51 262 300
168 O B H SYR Botol 85 - 85 56 29 90 120
INJEKSI

174 AQUA PRO INJ STERIL Vial 9 - 9 9 - 14 -
177 Diazepam injeksi i.v./i.m 5 mg/ml Ampul 29 - 29 - 29 - -
178 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul 15 - 15 15 - 24 -
179 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul 248 - 248 12 236 19 -
182 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul 540 - 540 12 528 19 -
185 HYOCINA N BUTILBROMID INJ 20 MG Ampul - 20 20 - 20 - -
192 Metoklopramide INJ 5 MG/ML Ampul 26 - 26 - 26 - -
193 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul 134 - 134 4 130 6 -
194 Oksitosin injeksi 10 IU/ml Ampul 17 - 17 17 - 27 -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
OBAT KHUSUS
200 BISACODYL SUPP (DULCOLAX) 10 MG / Stolax supp SUPP 61 - 61 - 61 - -
202 MICROLAX - - - - - - -
203 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET 66 - 66 6 60 10 -
205 PARASETAMOL SUPP 125 MG SUPP - - - - - -
206 SABU I 5 ML VIAL - 10 10 - 10 - -
208 SERUM ATS 1 500 IU VIAL - 20 20 - 20 - -
209 Serum ATS 20.000 IU - - - - - - -
CAIRAN

213 Nacl 0,9% Botol 13 - 13 13 - 21 20
OBAT LUAR
218 BETAMETASON CREAM 0,1 % Tube 2,100 - 2,100 55 2,045 88 -
222 GENTAMISIN SULFAT TETES MATA Tube 48 - 48 - 48 - -
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
224 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol - - - - - - 5
227 ICHTIOL SALEP HITAM Pot 30 - 30 7 23 11 -
228 KALIUM PERMANGANAT SERBUK Pot 15 - 15 - 15 - -
229 KETOKONAZOL KRIM 2% Tube 270 - 270 33 237 53 -
236 Povidon Iodida larutan 10% 300 ml Botol 4 - 4 2 2 3 3
237 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang endap 4% Botol 72 24 96 17 79 27 -
238 SALEP LUKA BAKAR (bioplacenton) Pot 9 - 9 1 8 2 -
240 Scabicid / Scabimite Cream Tube 20 - 20 2 18 3 -
OBAT GIGI
242 DEVITALISASI PASTA ( NON ARSEN ) Pot - - - - - - 1

243 ETIL KLORIDA SPRAY Botol 6 - 6 3 3 5 2
250 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot 2 - 2 - 2 - -
252 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot - - - - - - 2
BAHAN LABORATORIUM
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15

259 HB TEST KIT Set - - - - - - -
260 KIT GOL DARAH Set 1 - 1 - 1 - -
266 LART E D T A 10 % Botol - - - - - - -
268 LART KOH 10 % Botol - - - - - - -
269 LART NACL 0,9 % Botol - - - - - - -
274 LART TURK Botol - - - - - - -
276 PP TEST Stik 137 - 137 - 137 - -
281 STIK HBSAG Stik - - - - - - -
282 STIK HBSAG Stik - - - - - - -
283 WIDAL TEST Set - - - - - - -
REAGEN

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
-
TAMBAHAN -
-
290 DASABION KAPSUL 5,670 - 5,670 2,370 3,300 3,792 -
291 KETOROLAC INJ AMPUL 3 - 3 3 - 5 -
TIDAK BAYAR
BAYAR JUMLAH
986 3280 68 4334

NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
1,845
2,948
333
81
63
-
70
-
66
75
7
42
-
-
-
1
49
1,166
548
94
52
39
-
-
-
-
-
-
7
78
-
300
-
-
-
4
139
100
-
-
16
-
-
1
13
7
100
100
255
400
324
2,745
-
514
5,490
3,638
155
82
10,475
9,396
374
2,741
-
362
877
260
470
-
27
-
-
-
200
322
230
100
-
-
220
-
-
706
493
2,879
621
845
730
-
300
-
-
350
704
280
-
469
-
460
1,850
1,207
359
-
-
1,570
3,783
241
-
16,979
1,899
-
-
-
330
-
-
325
-
-
-
-
-
540
222
100
2
-
2
-
-
772
-
8,669
-
2,236
-
-
488
-
-
70
6
-
-
856
869
268
130
690
-
-
-
-
1,538
803
-
-
19
88
43
54
16
128
-
-
50
215
43
85
-
2,932
27
20
10
9
-
146
29
15
248
-
-
540
-
-
-
162
-
823
419
20
25
26
134
17
-
264
-
-
270
61
24
-
66
-
-
-
92
-
-
13
-
31
13
811
-
-
-
2,100
-
-
455
48
-
-
-
-
30
15
270
-
-
-
-
-
34
4
72
9
-
20
-
-
6
-
-
-
2
-
3
2
-
-
-
-
-
-
78
-
-
1
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
137
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
5,670
3
18
286
200
45
121,138
LAPORAN PERIODE/BULAN : Desember 2017 TANGGAL : 2 Januari 2018
PERMINTAAN PERIODE/BULAN : Januari 2018

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
ALAT KESEHATAN
1 Alat Suntik Sekali Pakai - 1 cc Tuberculin 27G x 1/2" Set

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 Benang Operasi - Catgut Plain 2/0 + jarum 1/2 GT 35 mm Set
6 Benang Operasi - Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Set
7 Benang Operasi - Catgut Plain 3/0 + jarum 1/2 GT 35 mm Set
8 Benang Operasi - Catgut Chromic 3/0 + jarum 1/2 GT 35 mm Set
9 Benang Operasi - Silk 2/0 + jarum 1/2 GT 35 mm Set
10 Benang Operasi - Silk 3/0 + jarum 1/2 GT 35 mm Set
11 HAND SCOUND STERIL NO 7 Pasang
12 HAND SCOUND STERIL NO 7,5 Pasang
13 HAND SCOUND NON STERIL UK L Lembar
14 HAND SCOUND NON STERIL UK S
15 HAND SCOUND NON STERIL UK M Lembar
16 HYPAFIX 10 x 5 CM Pasang
17 Infus Set, IV, Wing needle - Infusion Set Pediatric (60 drops/ml) set
18 Infus Set, IV, Wing needle - Infusion Set Dewasa (20 drops/ml) set
19 Infus Set, IV, Wing needle - I.V Catheter No. 18 G x 32 mm buah
20 Infus Set, IV, Wing needle - I.V Catheter No. 20 G x 1 1/4 " buah
21 Infus Set, IV, Wing needle - I.V Catheter No. 22 G x 1 " buah
22 Infus Set, IV, Wing needle - I.V Catheter No. 24 G x 3/4 " buah
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
23 Infus Set, IV, Wing needle - I.V Catheter No. 26 G x 1/2 " buah
24 Infus Set, IV, Wing needle - Wing Needle 21G set
28 Jarum Jahit Bedah
29 Kasa, Verband, Kapas - Kasa Pembalut / absorben 250 gr Roll
30 Kasa, Verband, Kapas - Kasa Hydrophil 40 x 80 cm Roll
31 Kasa, Verband, Kapas - Kasa Hydrophil Steril 16 x 16 cm lembar
32 Kasa, Verband, Kapas - Kasa Hydrophil Steril 18 x 22 cm Lembar
33 Kasa, Verband, Kapas - Kasa Pembalut Hydrophil 4 x 3 cm Roll
36 Kasa, Verband, Kapas - Kasa Pembalut 2 x 80 cm Roll
37 MESS 11 pcs
38 MESS 21 pcs
39 MESS 22 pcs
40 PEMBALUT GIPS 3 INCI buah
41 PLESTER 5 YARDS X 2 INCHI Roll
42 Surgical Mask - 3 ply Tie on (tali) pcs
43 Surgical Mask - 3 ply Earloop (karet) pcs
44 Urologi - Folley Catheter 2 way No. 16 pcs
45 Urologi - Folley Catheter 2 way No. 18 pcs
46 Urologi - Urine Bag Standard Steril 2 Lt (T Valve) pcs
47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet

48 Asam Asetilsalisilat (asetosal) tablet 500 mg Tablet
49 Albendazol tablet/kapsul/kaplet 400 mg Tablet
50 Alopurinol tablet/kapsul/kaplet 100 mg Tablet
51 ALPRAZOLAM TABLET 1 MG Tablet
52 AMBROXOL 30 MG TAB Tablet
53 Aminofilin tablet scored 200 mg Tablet
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
54 Amitriptilin tablet salut 25 mg (HCl) Tablet
55 Amlodipin tablet 5 mg Tablet
56 Amoksisilin kapsul/kaplet/tablet scored 500 mg Kaplet
57 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Hidroksi Tablet
58 Antimigren: Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet
59 Asam Askorbat (Vitamin C) tablet 250 mg Tablet
60 Asam Askorbat (Vitamin C) tablet 50 mg Tablet
61 Asam Folat tablet/kapsul/kaplet 1 mg Tablet
62 ASAM MEFENAMAT 500 MG TAB Kaplet
63 ASAM TRANEXAMAT TABLET 500 MG Tablet
64 ASAM VALPROAT 250 MG Tablet
65 Asiklovir tablet/kapsul/kaplet 400 mg Tablet
66 ATTAPULGIT TABLET 600 MG Tablet
67 BETAHISTIN MESILAT TABLET 6 MG Tablet
68 Bisakodil 5 mg (dulkolax) Tablet
69 D H P TAB Tablet
70 Deksametason tablet 0,5 mg Tablet
71 DIAZEPAM 2 MG TAB Tablet
72 DIAZEPAM 5 MG TAB Tablet
73 Digoksin tablet 0,25 mg Paket
74 Dimenhidrinat tablet 50 mg Tablet
75 Domperidon tablet 10 mg Tablet
76 Doksisiklin tablet/kapsul/kaplet 100 mg Tablet
77 EFEDRIN HCL 25 MG TAB Tablet
78 ERYTHROMYCIN 500 MG Tablet
79 Fenitoin kapsul/kaplet 100 mg Tablet
80 FENITOIN NATRIUM 30 MG KAPSUL Kapsul
81 Fenobarbital tablet/kapsul/kaplet 100 mg Kapsul
82 Fenobarbital tablet/kapsul/kaplet 30 mg Kapsul
83 Fitomenadion (Vit.K1) tablet salut gula 10 mg Tablet
84 Furosemid tablet 40 mg Tablet
85 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium kl Sachet
86 Glibenklamid tablet 5 mg Tablet
87 Glimepiride tablet 1 mg Tablet
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
88 Glimepiride tablet 2 mg Tablet
89 Glimepiride tablet 4 mg
90 GLISERYL GUAIAKOLAT 100 MG TAB Tablet
91 Griseofulvin tablet 125 mg Tablet
92 Haloperidol tablet 0,5 mg Tablet
93 Haloperidol tablet 1,5 mg Tablet
94 Haloperidol tablet 5 mg Tablet
95 HYOCINA N BUTILBROMID 10 MG TAB Tablet
96 Ibuprofen tablet 400 mg Tablet
97 ISOSORBID DINITRAT SUB LINGUAL 5 MG Tablet
98 KALSIUM LAKTAT 500 MG Tablet
99 Kaptopril tablet scored 12,5 mg Tablet
100 Kaptopril tablet scored 25 mg Tablet
101 Karbamazepin tablet 200 mg Tablet
102 KETOKONZOL TABLET 200 MG Tablet
103 Kloramfenikol tablet/kapsul/kaplet 250 mg Tablet
104 Kloramfenikol kapsul 500 mg Tablet
105 KLORFENIRAMINI MALEAT TAB 4 MG( CTM ) Tablet
106 KLORPROMAZIN 100 MG TAB (HCL) Tablet
107 KODEINA 10 MG TAB Tablet
108 Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg Asam folat 0, Tablet
109 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 Tablet
110 KUININE TAB SALUT SELAPUT 222 MG Tablet
111 LOPERAMID TAB 2 MG Tablet
112 LORATADIN TABLET 10 MG Tablet
113 METFORMIN HCL TABLET 500 MG Tablet
114 Metilergometrin Maleat (Metilergometrin) tablet salut 0,125 mg Tablet
115 Metoklopramide tablet 5 mg Tablet
116 Metoklopramide tablet 10 mg Tablet
117 METRONIDAZOLE 250 MG TAB Tablet
118 METRONIDAZOLE 500 MG TAB Tablet
119 MINERAL MIX SERBUK Tablet
120 MULTI MICRO NUTRIEN Sachet
121 MULTIVITAMIN ANAK TABLET HISAP T ablet hisap
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
122 NATRIUM DIKLOFENAK 50 MG TAB Tablet
123 Nifedipin tablet/kapsul 10 mg Tablet
124 Nistatin tablet salut 500.000 IU/ g Tablet
125 OAT KAT ANAK FDC Paket
126 OAT KAT I KOMB Paket
127 OAT KAT I.3 FDC Paket
128 OAT KAT II FDC Paket
129 OAT KAT SISIPAN FDC Paket
130 Omeprazol kapsul/kaplet 20 mg kaplet
131 Parasetamol tablet 100 mg Tablet
132 Parasetamol tablet 500 mg Tablet
133 PERFENAZIN TAB 4 MG Tablet
134 Piridoksin (Vitamin B6) tablet/kapsul/kaplet 10 mg (HCl) Tablet
135 PIROKSIKAM 10 MG TAB Tablet
136 PIROKSIKAM 20 MG TAB Tablet
137 Prednison tablet/kapsul/kaplet 5 mg Tablet
138 PRIMAKUIN TABLET 15 MG Tablet
139 PROPANOLOL 40 MG TAB (HCL) Tablet
140 PROPILTIOURASIL 100 MG TAB Tablet
141 PYRANTEL SCORE (BASE) 125 MG TAB Tablet
142 Ranitidin tablet 150 mg Tablet
143 RETINOL 100 000 IU KAPSUL (VIT A BIRU) Kapsul Lunak
144 RETINOL 200 000 IU CAP (VIT A MERAH) Kapsul Lunak
145 SALBUTAMOL 4 MG TAB Tablet
146 Setirizin tablet 10 mg Tablet
147 Simvastatin tablet 20 mg Tablet
148 Siprofloksasin tablet 500 mg (sebagai HCl) Tablet
149 SPIRONOLAKTON TABLET 25 MG Tablet
150 TETRASIKLIN 500 KAPSUL Kapsul
151 THIAMPENICOL KAPSUL 250 MG Kapsul
152 THIAMPENICOL KAPSUL 500 MG Kapsul
153 THIAMIN HCL 50 MG TAB ( VIT B1 ) Tablet
154 TRIHEKSIFENIDIL HCL 2 MG TAB Tablet
155 VIT B KOMPLEK TAB Tablet
156 ZINC TAB 20 MG Tablet
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
SYRUP
157 AMBROXOL SYR 15 mg/ml Botol

158 Amoksisilin sirup kering 125 mg/ 5 ml Botol
159 Amoksisilin sirup kering forte 250 mg/5 ml Botol
160 Antasida DOEN II suspensi, kombinasi : Aluminium Hidroksida 20 Botol
161 DOMPERIDON SYRUP Botol
162 Kloramfenikol suspensi 125 mg/ 5 ml Botol
163 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Trimetop Botol
164 Metoklopramide sirup 5 mg/ 5 ml Botol
165 METRONIDAZOL SUSPENSI Botol
166 MULTIVITAMIN SYR Botol
167 NISTATIN SUSPESI Botol
168 O B H SYR Botol
169 Parasetamol drop 100 mg/ml btl @15ml (60mg/0,6ml) Botol
170 Parasetamol sirup 120 mg / 5 ml Botol
INJEKSI
171 Aminofilin injeksi 24 mg/ml Ampul

172 Ampisilin serbuk injeksi i.v. 1000 mg/vial Vial
173 ASAM TRANEXAMAT INJEKSI 50 MG / ML Ampul
174 AQUA PRO INJ STERIL Vial
175 CEFTRIAXON 1 GR INJ Vial
176 Deksametason injeksi i.v./i.m. 5 mg/ml Ampul
177 Diazepam injeksi i.v./i.m 5 mg/ml Ampul
178 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Ampul
179 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul
180 Fenitoin injeksi 50 mg/ml Ampul
181 Fenobarbital injeksi i.m./i.v. 50 mg/ml Ampul
182 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul
183 FUROSEMID INJ IV/IM 10 MG/ML Ampul
184 Gentamisin injeksi 40 mg/ ml Ampul
185 HYOCINA N BUTILBROMID INJ 20 MG Ampul
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
186 KALSIUM GLUKONAS INJ 100 MG/ML Ampul
187 Kloramfenikol serb inj 1000 mg/mL Vial
188 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Ampul
189 Lidokain injeksi 2% (HCL) Ampul
190 MAGNESIUM SULFAT 20 % INJ 25 ML Vial
191 MAGNESIUM SULFAT 40 % INJ 25 ML Vial
192 Metoklopramide INJ 5 MG/ML Ampul
193 Metilergometrin Maleat injeksi 0,200 mg-1 ml Ampul
194 Oksitosin injeksi 10 IU/ml Ampul
195 OXYTETRACIKLIN HCL INJ IM 50 MG/ML 10 ML Vial
196 RANITIDIN INJ 25 MG/2 ML Ampul
197 Sianokobalamin (vitamin B12) injeksi 500 mcg Ampul
198 THIAMIN INJ ( VIT BI ) 100 MG/ML Ampul
OBAT KHUSUS
199 Antihemoroid, kombinasi: bismut subgalat 150 mg heksaklorofen 2 SUPP

200 BISACODYL SUPP (DULCOLAX) 10 MG / Stolax supp SUPP
201 Diazepam larutan rektal 5 mg/2,5 mL (stesolit rectal) TUBE
202 MICROLAX
203 NISTATIN VAGINAL TAB 100 000 IU/GR TABLET
204 PARASETAMOL SUPP 80 MG SUPP
205 PARASETAMOL SUPP 125 MG SUPP
206 SABU I 5 ML VIAL
207 SALBUTAMOL (AS SULPHATE) 2,5 MG/2,5 ML NEBULS Ampul
208 SERUM ATS 1 500 IU VIAL
209 Serum ATS 20.000 IU
CAIRAN
210 Glukosa larutan infus 10 % steril Botol

213 Nacl 0,9% Botol
214 Ringer Laktat larutan infus Botol
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
OBAT LUAR
215 Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g Polimiksin Tube
216 ANTI FUNGI DOEN KOMB Pot
217 ASIKLOVIR CREAM 5% Tube
218 BETAMETASON CREAM 0,1 % Tube
219 FENOL GLISEROL TT 10% TUBE
220 GENTAMICIN SK 0,1% Botol
221 GENTAMICIN SALEP MATA 0,3% Tube
222 GENTAMISIN SULFAT TETES MATA Tube
223 GENTIAN VIOLET LART 1% Botol
224 HEXACHLOROCYLOHEXANE 0,5% (Peditox) Botol
225 HIDROGEN PEROKSIDA LARUTAN 3% Botol
226 HIDROKORTISON CREAM 2,5 % Tube
227 ICHTIOL SALEP HITAM Pot
228 KALIUM PERMANGANAT SERBUK Pot
229 KETOKONAZOL KRIM 2% Tube
230 Kloramfenikol salep mata 1 % Tube
231 Kloramfenikol teter telinnga 3 % Botol
232 MICONAZOLE CREAM 2% Tube
233 OKSITETRASIKLIN SK 3% Tube
234 OKSITETRASIKLIN SM 1% Tube
235 Povidon Iodida larutan 10% 30 ml Botol
236 Povidon Iodida larutan 10% 300 ml Botol
237 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang endap 4% Botol
238 SALEP LUKA BAKAR (bioplacenton) Pot
239 Bedak salisil serbuk 2% Tube
240 Scabicid / Scabimite Cream Tube
241 SULFASETAMID NATRIUM TM 15 % Kotak
OBAT GIGI
242 DEVITALISASI PASTA ( NON ARSEN ) Pot

243 ETIL KLORIDA SPRAY Botol
244 EUGENOL CAIRAN Botol
245 GLASS IONOMER CEMENT ART Botol
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
246 KALSIUM HIDROKSIDA PASTA Pot
247 KLORFENOL KAMFER MENTHOL (CHKM) Botol
248 MUMMIFYING PASTA Pot
249 POLIKRESULEN (ALBOTYL) Botol
250 SEMEN SENG FOSFAT SERBUK + CAIRAN Pot
251 SPONGOSTAN Kotak
252 TEMPORARY STOPPING FLETCER SERBUK+CAIRAN (caviton) Pot
253 TRIKRESOL FORMALIN (TKF) Botol
BAHAN LABORATORIUM
254 CARIK CELUP / URIN TES 3 GPH Stik

255 CARIK CELUP / URIN TES 11 GPH Stik
256 Antiseptik dan Disinfektan - alkohol 70% 100 ml Botol
257 Antiseptik dan Disinfektan - alkohol 70% 1 liter Botol
258 GLISERIN Botol
259 HB TEST KIT Set
260 KIT GOL DARAH Set
261 LART AS ACETAT Botol
262 LART ASAM KLORIDA 0,1 N Botol
263 LAR ASAM KLORIDA 0,1% Botol
264 LART BARIUM CHLORIDA 10 % Botol
265 LART BENEDICT Botol
266 LART E D T A 10 % Botol
267 LART ETANOL ASAM Botol
268 LART KOH 10 % Botol
269 LART NACL 0,9 % Botol
270 LART NATRIUM CITRAT 0,38 % Botol
271 LART ASAM CITRAT 3,8% Botol
272 LART REES ECKER Botol
273 LART SCHLESINGER Botol
274 LART TURK Botol
275 OIL EMERSI Botol
276 PP TEST Stik
277 RDT TEST MALARIA Stik
278 STIK GULA DARAH Stik
1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
279 STIK ASAM URAT Stik
280 STIK KOLESTEROL Stik
281 STIK HBSAG Stik
282 STIK HBSAG Stik
283 WIDAL TEST Set
REAGEN
284 REAGEN ABX MINIDIL LMG PAKET

285 REAGEN ABC MINILYSE LMG PAKET
286 REAGEN ABX MINICLEAN PAKET
287 REAGEN ABX MINOTROL PAKET
TAMBAHAN
288 HALOPERIDOL INJ 5 Mg/Ml Ampul

289 Cover Glass 24x24 MM BUAH
290 DASABION KAPSUL
291 KETOROLAC INJ AMPUL
292 ONDANCETRON INJ AMPUL
293 METAMIZOLE INJ AMPUL
294 BISOPROLOL 5 MG TABLET
295 OXYFLOW ANAK BUAH
BAYAR TIDAK BAYAR JUMLAH

1263 3582 60 4905

1 2 3 4 5=3+4 6 7=5-6 8 9=8-7 10 11 12 13 14 15
NIP :19610512 198203 1 009 NIP. 19680916200112 2 003 NIP. 19680702 199003 1 006 NIP. 19780402 199803 2 001
KETERANGAN :
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Lplpo Tahun 2019

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Lplpo Tahun 2019

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

NAMA PUSKESMAS : Puskesmas Dasan Tapen NO DOC :

STOK PENERIM PERSEDIA PEMAKAI SISA PEMBERIAN

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet 0 0 0 0 0 - 100

158 AMBROXOL SYR 15 mg/ml Botol 100 0 100 49 51 78 100

172 Aminofilin injeksi 24 mg/ml Ampul 28 0 28 1 27 2 0

211 Glukosa larutan infus 10 % steril Botol 0 0 0 0 0 - 5

243 DEVITALISASI PASTA ( NON ARSEN ) Pot 0 0 0 0 0 - 1

285 REAGEN ABX MINIDIL LMG PAKET 0 0 0 0 0 - 0

289 HALOPERIDOL INJ 5 Mg/Ml Ampul 0 0 0 0 0 - 0

STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet - 100 100 - 100 - -

157 AMBROXOL SYR 15 mg/ml Botol 51 50 101 79 22 126 50

171 Aminofilin injeksi 24 mg/ml Ampul 27 - 27 - 27 - -

210 Glukosa larutan infus 10 % steril Botol - 20 20 - 20 - -

242 DEVITALISASI PASTA ( NON ARSEN ) Pot - - - - - - 1

284 REAGEN ABX MINIDIL LMG PAKET - - - - - - -

288 HALOPERIDOL INJ 5 Mg/Ml Ampul - - - - - - -

Mengetahui Yang Menyerahkan Yang Menerima/ Melapor Yang Menerima

STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet 100 - 100 - 100 - -

157 AMBROXOL SYR 15 mg/ml Botol 22 50 72 72 - 115 100

171 Aminofilin injeksi 24 mg/ml Ampul 27 - 27 - 27 - -

210 Glukosa larutan infus 10 % steril Botol 20 - 20 7 13 11 -

242 DEVITALISASI PASTA ( NON ARSEN ) Pot - 1 1 1 - 2 1

284 REAGEN ABX MINIDIL LMG PAKET - - - - - - -

288 HALOPERIDOL INJ 5 Mg/Ml Ampul - - - - - - -

Mengetahui Yang Menyerahkan Yang Menerima/ Melapor Yang Menerima

STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet 100 - 100 - 100 - -

157 AMBROXOL SYR 15 mg/ml Botol - 100 100 81 19 130 100

171 Aminofilin injeksi 24 mg/ml Ampul 27 - 27 - 27 - -

210 Glukosa larutan infus 10 % steril Botol 13 - 13 - 13 - -

242 DEVITALISASI PASTA ( NON ARSEN ) Pot - 1 1 1 - 2 1

254 CARIK CELUP / URIN TES 3 GPH Stik - - - - - - 200

284 REAGEN ABX MINIDIL LMG PAKET - - - - - - -

288 HALOPERIDOL INJ 5 Mg/Ml Ampul - - - - - - -

Mengetahui Yang Menyerahkan Yang Menerima/ Melapor Yang Menerima

STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet 100 - 100 - 100 - -

171 Aminofilin injeksi 24 mg/ml Ampul 27 - 27 - 27 - -

210 Glukosa larutan infus 10 % steril Botol 13 - 13 2 11 3 -

242 DEVITALISASI PASTA ( NON ARSEN ) Pot - - - - - - 1

254 CARIK CELUP / URIN TES 3 GPH Stik - - - - - - 200

284 REAGEN ABX MINIDIL LMG PAKET - - - - - - -

Mengetahui Yang Menyerahkan Yang Menerima/ Melapor Yang Menerima

STOK PENERIM PERSEDIA PEMAKAI SISA PERMINT PEMBERIAN

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

TABLET DAN SERBUK ORAL

47 Asam Asetilsalisilat (asetosal) tablet 100 mg Tablet

157 AMBROXOL SYR 15 mg/ml Botol

171 Aminofilin injeksi 24 mg/ml Ampul

199 Antihemoroid, kombinasi: bismut subgalat 150 mg heksaklorofen 2 SUPP

210 Glukosa larutan infus 10 % steril Botol

242 DEVITALISASI PASTA ( NON ARSEN ) Pot

254 CARIK CELUP / URIN TES 3 GPH Stik

284 REAGEN ABX MINIDIL LMG PAKET

288 HALOPERIDOL INJ 5 Mg/Ml Ampul