PT.

PUTRA TUNGGAL MANDIRITAMA

INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : AGUSTUSN 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN STOCK MASUK

1 ACITRAL 1-Mar-23 2 BOTOL 0

2 ACYCLOVIR 1-Jan-23 1 SALEP 0
3 ANTIMO 1-Oct-25 700 TABLET 0
4 AQUADEST 4-Feb-23 2 BTL 0
5 BALSEM 1-Oct-23 1 BTL 0
6 BURNAZIN 1-Mar-23 1 SALEP 0
7 CYTYOL 1-Jul-24 1 SALEP 0
8 DEXTROX 5 % 1-Apr-23 2 BOTOL 0
9 ELLAMCYCETIN 1-Oct-23 1 SALEP 0
10 FLAMAR 1-Feb-23 2 SALEP 0
11 FORUMEN 30-Sep-22 4 0
12 GENTAMICIN 1-Dec-23 1 SALEP 0
13 KENALOG 1-Jan-22 2 SALEP 0
14 LIDOCAIN 1-Jan-23 4 AMPUL 0
15 NACL INFUS 1-Apr-25 1 BOTOL 0
16 NEBACETIN 1-Nov-23 3 0
17 NORIT 1-Sep-24 2 BOTOL 0
18 SAGESTAN 20-Sep-22 1 SALEP 0
19 SERENITY 1-Jul-22 200 0
20 SUPRATUL 1-Apr-24 2 BOX 0
21 SUTURE 1-Sep-24 10 TABLET 0
22 TUDERM 1-Nov-23 1 SALEP 0
23 VENARON 1-Oct-24 24 TABLET 0
24 VENTOLIN INHALER 1-Mar-22 2 0
25 VIT B COM 1-Jun-22 3 BOTOL 0

Inspected By: Acknowledged By:

Name : Name
Position : Position
Sign : Sign
A TUNGGAL MANDIRITAMA
PECTION CHECK LIST
LIST OF MEDICINE

STOCK KELUAR STOCK AKHIR CONDITION

(V/X)
2 0 v
0 1 v
10 690 v
0 2 v
0 1 v
0 1 v
0 1 v
0 2 v
0 1 v
0 2 v
0 4 v
0 1 v
0 2 v
0 4 v
0 1 v
0 3 v
0 2 v
0 1 v
0 200 v
0 2 v
0 10 v
0 1 v
0 24 v
0 2 v
0 3 v

Acknowledged By:
:
:
:
 PT. PUTRA TUNGGAL MANDIRITAMA
INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : SEPTEMBER 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN STOCK MASUK

1 ACITRAL 1-Mar-23 0 BOTOL 0

2 ACYCLOVIR 1-Jan-23 1 SALEP 0
3 ANTIMO 1-Oct-25 690 TABLET 0
4 AQUADEST 4-Feb-23 2 BTL 0
5 BALSEM 1-Oct-23 1 BTL 0
6 BURNAZIN 1-Mar-23 1 SALEP 0
7 CYTYOL 1-Jul-24 1 SALEP 0
8 DEXTROX 5 % 1-Apr-23 2 BOTOL 0
9 ELLAMCYCETIN 1-Oct-23 1 SALEP 0
10 FLAMAR 1-Feb-23 2 SALEP 0
11 FORUMEN 30-Sep-22 4 0
12 GENTAMICIN 1-Dec-23 1 SALEP 0
13 KENALOG 1-Jan-22 2 SALEP 0
14 LIDOCAIN 1-Jan-23 4 AMPUL 0
15 NACL INFUS 1-Apr-25 1 BOTOL 0
16 NEBACETIN 1-Nov-23 3 0
17 NORIT 1-Sep-24 2 BOTOL 0
18 SAGESTAN 20-Sep-22 1 SALEP 0
19 SERENITY 1-Jul-22 200 0
20 SUPRATUL 1-Apr-24 2 BOX 0
21 SUTURE 1-Sep-24 10 TABLET 0
22 TUDERM 1-Nov-23 1 SALEP 0
23 VENARON 1-Oct-24 24 TABLET 0
24 VENTOLIN INHALER 1-Mar-22 2 0
25 VIT B COM 1-Jun-22 3 BOTOL 0

Inspected By: Acknowledged By:

Name : Name
Position : Position
Sign : Sign
A TUNGGAL MANDIRITAMA
PECTION CHECK LIST
LIST OF MEDICINE

STOCK KELUAR STOCK AKHIR CONDITION

(V/X)
0 0 v
0 1 v
50 640 v
0 2 v
1 0 v
0 1 v
0 1 v
0 2 v
0 1 v
0 2 v
0 4 v
1 0 v
1 1 v
0 4 v
0 1 v
0 3 v
1 1 v
0 1 v
0 200 v
0 2 v
0 10 v
0 1 v
0 24 v
0 2 v
0 3 v

Acknowledged By:
:
:
:
 PT. PUTRA TUNGGAL MANDIRITAMA
INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : OKTOBER 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN STOCK MASUK

1 ACITRAL 1-Mar-23 0 BOTOL 0

2 ACYCLOVIR 1-Jan-23 1 SALEP 0
3 ANTIMO 1-Oct-25 640 TABLET 0
4 AQUADEST 4-Feb-23 2 BTL 0
5 BALSEM 1-Oct-23 0 BTL 0
6 BURNAZIN 1-Mar-23 1 SALEP 0
7 CYTYOL 1-Jul-24 1 SALEP 0
8 DEXTROX 5 % 1-Apr-23 2 BOTOL 0
9 ELLAMCYCETIN 1-Oct-23 1 SALEP 0
10 FLAMAR 1-Feb-23 2 SALEP 0
11 FORUMEN 30-Sep-22 4 SALEP 0
12 GENTAMICIN 1-Dec-23 0 SALEP 0
13 KENALOG 1-Jan-22 1 SALEP 0
14 LIDOCAIN 1-Jan-23 4 AMPUL 0
15 NACL INFUS 1-Apr-25 1 BOTOL 0
16 NEBACETIN 1-Nov-23 3 0
17 NORIT 1-Sep-24 1 BOTOL 0
18 SAGESTAN 20-Sep-22 1 SALEP 0
19 SERENITY 1-Jul-22 200 0
20 SUPRATUL 1-Apr-24 2 BOX 0
21 SUTURE 1-Sep-24 10 TABLET 0
22 TUDERM 1-Nov-23 1 SALEP 0
23 VENARON 1-Oct-24 24 TABLET 0
24 VENTOLIN INHALER 1-Mar-22 2 0
25 VIT B COM 1-Jun-22 3 BOTOL 0

Inspected By: Acknowledged By:

Name : Name
Position : Position
Sign : Sign
A TUNGGAL MANDIRITAMA
PECTION CHECK LIST
LIST OF MEDICINE

STOCK KELUAR STOCK AKHIR CONDITION

(V/X)
0 0 v
0 1 v
150 490 v
0 2 v
0 0 v
0 1 v
0 1 v
0 2 v
1 0 v
1 1 v
0 4 v
0 0 v
0 1 v
0 4 v
0 1 v
0 3 v
0 1 v
0 1 v
0 200 v
0 2 v
0 10 v
0 1 v
0 24 v
0 2 v
0 3 v

Acknowledged By:
:
:
:
 PT. PUTRA TUNGGAL MANDIRITAMA
INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : AGUSTUS 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN

1 ALPARA 1-Jun-24 10 TABLET

2 AMLODIPINE 10MG 1-Nov-24 10 TABLET
3 BISOPROLOL 1-May-22 10 TABLET
4 BODREX 1-Mar-23 70 TABLET
5 BUSCOPAN 1-Dec-22 10 TABLET
6 CIMETIDINE 1-Jan-24 20 TABLET
7 DEMACOLIN 13-Dec-24 32 TABLET
8 DEXTRAL 1-Mar-23 15 TABLET
9 DOMPERIDONE 1-May-25 17 TABLET
10 FARMALAT/NIFEDIPINE 10MG 1-Apr-23 19 TABLET
11 FLAMUR 1-Feb-22 20 TABLET
12 FUROSEMID 1-Jun-23 20 TABLET
13 GLIMEPIRIDE 1-Jan-23 20 TABLET
14 GRAFIX 1-Dec-24 14 TABLET
15 HISTIGO 1-May-22 10 TABLET
16 HYDROCHLOROTHIAZIDE 1-Jul-23 20 TABLET
17 HYPOFIL/GEMFIBROZIL 1-May-22 20 TABLET
18 INTERHISTIN 1-Sep-23 16 TABLET
19 KETONAZOLE 20MG 1-Nov-21 5 TABLET
20 LORATADINE 1-Sep-24 24 TABLET
21 MALTIRON PLUS 1-Oct-22 8 TABLET
22 MEFIX 1-Nov-21 16 TABLET
23 MELOXICAM 1-Feb-22 8 TABLET
24 METFORMIN 1-May-25 20 TABLET
25 METHILPREDINISOLONE 1-Apr-22 10 TABLET
26 NEURALGIN 1-Jun-22 12 TABLET
27 NIFEDIPINE 10MG 1-Nov-23 10 TABLET
28 PARACETAMOL 1-Nov-23 6 TABLET
 29 PIROXICAM 1-Jan-24 6 TABLET
30 PRIMPERAN 1-Feb-22 10 TABLET
31 PRO LIVER 1-Sep-22 18 TABLET
32 PROCELES 1-May-22 10 TABLET
33 PROHISTIN/ LORATADINE 1-Dec-23 30 TABLET
34 SANMOL 1-Feb-23 56 TABLET
35 TROLIP 1-Oct-21 20 TABLET
36 VOLTADEX 1-Dec-21 20 TABLET

Inspected By: Ackn

Name : Name
Position : Position
Sign : Sign
RA TUNGGAL MANDIRITAMA
NSPECTION CHECK LIST
LIST OF MEDICINE

CONDITION
STOCK MASUK STOCK KELUAR STOCK AKHIR (V/X)
0 10 v
0 10 v
0 10 v
0 70 v
0 10 v
0 20 v
0 32 v
0 15 v
0 17 v
0 19 v
0 20 v
0 20 v
0 20 v
0 14 v
0 10 v
0 20 v
0 20 v
0 16 v
0 5 v
5 19 v
0 8 v
0 16 v
0 8 v
0 20 v
0 10 v
0 12 v
0 10 v
0 6 v
 0 6 v
0 10 v
5 13 v
0 10 v
0 30 v
30 26 v
0 20 v
0 20 v

Acknowledged By:
:
:
:
 PT. PUTRA TUNGGAL MANDIRITAMA
INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : SEPT 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN

1 ALPARA 1-Jun-24 10 TABLET

2 AMLODIPINE 10MG 1-Nov-24 10 TABLET
3 BISOPROLOL 1-May-22 10 TABLET
4 BODREX 1-Mar-23 70 TABLET
5 BUSCOPAN 1-Dec-22 10 TABLET
6 CIMETIDINE 1-Jan-24 20 TABLET
7 DEMACOLIN 13-Dec-24 32 TABLET
8 DEXTRAL 1-Mar-23 15 TABLET
9 DOMPERIDONE 1-May-25 17 TABLET
10 FARMALAT/NIFEDIPINE 10MG 1-Apr-23 19 TABLET
11 FLAMUR 1-Feb-22 20 TABLET
12 FUROSEMID 1-Jun-23 20 TABLET
13 GLIMEPIRIDE 1-Jan-23 20 TABLET
14 GRAFIX 1-Dec-24 14 TABLET
15 HISTIGO 1-May-22 10 TABLET
16 HYDROCHLOROTHIAZIDE 1-Jul-23 20 TABLET
17 HYPOFIL/GEMFIBROZIL 1-May-22 20 TABLET
18 INTERHISTIN 1-Sep-23 16 TABLET
19 KETONAZOLE 20MG 1-Nov-21 5 TABLET
20 LORATADINE 1-Sep-24 19 TABLET
21 MALTIRON PLUS 1-Oct-22 8 TABLET
22 MEFIX 1-Nov-21 16 TABLET
23 MELOXICAM 1-Feb-22 8 TABLET
24 METFORMIN 1-May-25 20 TABLET
25 METHILPREDINISOLONE 1-Apr-22 10 TABLET
26 NEURALGIN 1-Jun-22 12 TABLET
27 NIFEDIPINE 10MG 1-Nov-23 10 TABLET
28 PARACETAMOL 1-Nov-23 6 TABLET
29 PIROXICAM 1-Jan-24 6 TABLET
30 PRIMPERAN 1-Feb-22 10 TABLET
31 PRO LIVER 1-Sep-22 13 TABLET
32 PROCELES 1-May-22 10 TABLET
 33 PROHISTIN/ LORATADINE 1-Dec-23 30 TABLET
34 SANMOL 1-Feb-23 26 TABLET
35 TROLIP 1-Oct-21 20 TABLET
36 VOLTADEX 1-Dec-21 20 TABLET

Inspected By: Ackn

Name : Name
Position : Position
Sign : Sign
RA TUNGGAL MANDIRITAMA
NSPECTION CHECK LIST
LIST OF MEDICINE

CONDITION
STOCK MASUK STOCK KELUAR STOCK AKHIR
(V/X)
0 0 10 v
0 5 5 v
0 0 10 v
0 0 70 v
0 0 10 v
0 0 20 v
0 10 22 v
0 5 10 v
0 0 17 v
0 0 19 v
0 0 20 v
0 0 20 v
0 0 20 v
0 0 14 v
0 6 4 v
0 0 20 v
0 0 20 v
0 0 16 v
0 2 3 v
0 5 14 v
0 0 8 v
0 0 16 v
0 4 4 v
0 0 20 v
0 0 10 v
0 5 7 v
0 0 10 v
0 3 3 v
0 0 6 v
0 0 10 v
0 5 8 v
0 0 10 v
0 0 30 v
40 15 51 v
0 0 20 v
0 0 20 v

Acknowledged By:
:
:
:
 PT. PUTRA TUNGGAL MANDIRITAMA
INSPECTION CHECK LIST
LIST OF MEDICINE

PROJECT SITE : WELCONE

DATE INSPECTION : OCTO 2021
LOCATION : BARGE SADEWA
UNIT :
CURRENT ACTIVITY :
CLIENT : PT PTM
NO NAMA TANGGAL EXP STOCK AWAL SATUAN

1 ALPARA 1-Jun-24 10 TABLET

2 AMLODIPINE 10MG 1-Nov-24 5 TABLET
3 BISOPROLOL 1-May-22 10 TABLET
4 BODREX 1-Mar-23 70 TABLET
5 BUSCOPAN 1-Dec-22 10 TABLET
6 CIMETIDINE 1-Jan-24 20 TABLET
7 DEMACOLIN 13-Dec-24 22 TABLET
8 DEXTRAL 1-Mar-23 10 TABLET
9 DOMPERIDONE 1-May-25 17 TABLET
10 FARMALAT/NIFEDIPINE 10MG 1-Apr-23 19 TABLET
11 FLAMUR 1-Feb-22 20 TABLET
12 FUROSEMID 1-Jun-23 20 TABLET
13 GLIMEPIRIDE 1-Jan-23 20 TABLET
14 GRAFIX 1-Dec-24 14 TABLET
15 HISTIGO 1-May-22 4 TABLET
16 HYDROCHLOROTHIAZIDE 1-Jul-23 20 TABLET
17 HYPOFIL/GEMFIBROZIL 1-May-22 20 TABLET
18 INTERHISTIN 1-Sep-23 16 TABLET
19 KETONAZOLE 20MG 1-Nov-21 3 TABLET
20 LORATADINE 1-Sep-24 14 TABLET
21 MALTIRON PLUS 1-Oct-22 8 TABLET
22 MEFIX 1-Nov-21 16 TABLET
23 MELOXICAM 1-Feb-22 4 TABLET
24 METFORMIN 1-May-25 20 TABLET
25 METHILPREDINISOLONE 1-Apr-22 10 TABLET
26 NEURALGIN 1-Jun-22 7 TABLET
27 NIFEDIPINE 10MG 1-Nov-23 10 TABLET
28 PARACETAMOL 1-Nov-23 3 TABLET
29 PIROXICAM 1-Jan-24 6 TABLET
30 PRIMPERAN 1-Feb-22 10 TABLET
31 PRO LIVER 1-Sep-22 8 TABLET
32 PROCELES 1-May-22 10 TABLET
 33 PROHISTIN/ LORATADINE 1-Dec-23 30 TABLET
34 SANMOL 1-Feb-23 51 TABLET
35 TROLIP 1-Oct-21 20 TABLET
36 VOLTADEX 1-Dec-21 20 TABLET

Inspected By: Ackn

Name : Name
Position : Position
Sign : Sign
RA TUNGGAL MANDIRITAMA
NSPECTION CHECK LIST
LIST OF MEDICINE

CONDITION
STOCK MASUK STOCK KELUAR STOCK AKHIR
(V/X)
0 0 10 v
0 0 5 v
0 0 10 v
0 0 70 v
0 0 10 v
0 0 20 v
0 0 22 v
0 0 10 v
0 0 17 v
0 0 19 v
0 0 20 v
0 0 20 v
0 0 20 v
0 0 14 v
0 0 4 v
0 0 20 v
0 0 20 v
0 0 16 v
0 2 1 v
0 5 9 v
0 0 8 v
0 0 16 v
0 4 0 v
0 0 20 v
0 0 10 v
0 0 7 v
0 0 10 v
0 0 3 v
0 0 6 v
0 0 10 v
0 5 3 v
0 0 10 v
0 0 30 v
0 20 31 v
0 0 20 v
0 0 20 v

Acknowledged By:
:
:
:
 QTY CONDTION
NO Description Unit QTY Remark
AKTUAL (V/X)
1 Abbocath 18 Pcs 2 2 V
2 Abbocath 20 Pcs 2 2 V
3 Abbocath 22 Pcs 2 2 V
4 Alcohol Swab Box 1 1 V 1 box
5 catgut 2-0 Pcs 5 5 V
6 Catgut 3-0 Pcs 5 5 V
7 Silk Braided 3/0 Pcs 2 2 V
8 Silk Braided 2/0 Pcs 2 2 V
9 Needle Terrumo 23 G Pcs 2 2 V
10 Otsu WL ( Sterile Water ) Bottle 2 2 V
11 Scalpel ( Surgical Blade ) Box 2 2 V
12 Snake Bite Pcs 2 2 V
13 Spoit 3 cc Pcs 5 5 V
14 Spoit 5 cc Pcs 5 5 V
15 Stick Asam Urat Btl 1 1 V
16 Stick Cholesterol Btl 1 1 V
17 Stick Glucosa Btl 1 1 V
18 Infus Set Ea 2 2 V
19 Termometer Air Raksa Ea 2 0 V
20 Duk Clothes ( Kain Duk ) Ea 2 0 V
21 Sofratul Ea 5 0 V
22 Pocket Mask Ea 2 2 V
23 spuit 1 cc Ea 5 1 V
24 Surgical Instrument Kit Pcs 2 1 V
25 Neck Collar Pcs 2 4 V
26 Laryngoscospe Pcs 2 0 V
27 Nebulizer Omron Pcs 2 0 V
28 Pulse Oximeter Pcs 2 1 V
29 Pen Light Pcs 2 0 V
30 THT Set Pcs 1 0 V
31 Tensimeter Aneroid Pcs 2 2 V manual
32 Splint Angin SET 1 0 V
33 Sthetoscope Pcs 1 1 V
34 Surgical Instrument Kit Pcs 1 1 V
35 Neck Collar Ea 1 4 V
36 Bioplacenton Tube 1 0 V
37 Ethyl Chloroide Sprai Btl 1 0 V
38 Nostren Tube 1 0 V
39 Oxicam Btl 1 0 V
40 Trombophob gel Tube 1 0 V
41 Ephineprine inj Amp 1 0 V
42 Infus Liquid D5 Btl 1 1 V
43 Infus Liquid NaCl Btl 1 1 V
44 Infus Liquid Ringer Laktat Btl 1 1 V
45 Lidocain Amp 1 4 V
46 Ethyl Chloroide Sprai Btl 1 0 V
47 Alkohol 100 ml Btl 1 0 V
48 Alkohol swab box 1 1 V
49 Bethadine 15 ml Btl 1 0 V
50 Sofra Tulle Strip 1 0 V
51 Elastis Bandage 7.5cm Roll 1 1 V
52 Elastis Bandage 15 cm Roll 1 1 V
53 Hansaplast Ea 1 1 V
54 Hypavix Roll 1 1 V
55 Fire Blanket Ea 1 1 V
56 Kain Segitiga Lmbr 1 1 V
57 Kapas 25 ml Roll 1 1 V
58 Kassa Gulung 5 cm Roll 1 1 V
59 Kassa Gulung 10 cm Roll 1 1 V
60 Kasa Sterile Box 1 1 V
61 Masker Ea 1 1 V
62 Plester Roll 1 1 V
63 Rivanol 100 ml Btl 1 1 V
64 Steril Gloves 7.5 Ea 1 1 V
65 Abbocateh No. 20 Ea 1 1 V
66 Abbocateh No. 22 Ea 1 1 V
67 Abbocateh No. 18 Ea 1 1 V
68 Ambubag/Balon Peniup Unit 1 1 V
69 Catguat Plain Ea 1 1 V
70 Silk Braided No3/0 Ea 1 1 V
71 Gunting Scisor Ea 1 1 V
72 Infus Set Ea 2 1 V
73 Neck Collar Ea 3 3 V
74 Needle heating no 9 Ea 1 1 V
75 Needle heating no 13 Ea 1 1 V
76 Mayo Ea 1 1 V
77 Pocket Mask Ea 1 1 V
78 Steril Surgical Blade Ea 1 1 V
79 Syring 3 cc Ea 1 1 V
80 Syring 5 cc Ea 1 1 V
81 Safety Pin Lusin 1 1 V
82 Wound Dressing Large Ea 1 1 V
83 Wound Dressing Medium Ea 1 1 V
84 Y-rins Btl 2 1 V
85 Spinal Board Ea 1 1 V
86 Basket Stretcher Ea 1 1 V
87 Meja +kursi Ea 1 1 V
88 Lemari obat Ea 1 1 V tiadak layak
89First Aid Kit Bag / Tas Medis Emergency Ea 1 1 V
90 Eye Wash Ea 1 1 V
91 Oxygen Ea 2 2 V Regulator 2
92 Termogan Ea 2 1 V
93 AED Ea 1 1 V Baterray 2