LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LP LPO)
KODE PUSKESMAS :
POSKESRI : BATU PAYUANG BULAN : Januari
KECAMATAN : LAREH SAGO HALABAN TAHUN : 2022
KABUPATEN : LIMA PULUH KOTA
PROPINSI : SUMATERA BARAT
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA PERMIN PEMBER KET
AWAL MAAN DIAAN KAIAN STOK TAAN IAAN
1 2 3 4 5 6 7 8 9 10 12
1 Acetosal Tab 100 mg Tablet 0 0 0 0 0
2 Acetyl Sisten Tablet 100 0 100 100 0
9 Ambroxol tab Set 0 0 0 0 0
10 Ambroxol syr Tablet 0 0 0 0 0
12 Aminophylin tab Tablet 30 0 30 30 0
14 Amlodipin tab 5 mg Tablet 0 0 0 0 0
15 Amlodipin tab 10 mg Ampul 0 0 0 0 0
16 Amoxicilin dry sir Tablet 0 0 0 0 0
17 Amoxicilin kap 500 mg Tablet 0 0 0 0 0
18 Antasida DOEN sirup Tablet 0 0 0 0 0
19 Antasida DOEN tab Tablet 80 0 80 60 20
24 As Ascorbic Tab 50 mg (Vit C) Tablet 100 0 100 100 0
25 Asam Folat Tab 1 mg Tablet 0 0 0 0 0
26 Asam Mefenamat 500 mg Kaplet 0 0 0 0 0
33 Betametason slp Tube 0 0 0 0 0
38 Combivent 2.5 ml Pot 0 0 0 0 0
39 Dexametason inj Ampul 0 0 0 0 0
40 Dexametason tab 0,5 mg Tablet 70 0 70 50 20
41 Diazepam tab 2 mg Tablet 0 0 0 0 0
42 Diazepam inj 10 ml Ampul 0 0 0 0 0
52 Efedrin tab 25 mg Tablet 0 0 0 0 0
65 Fitomenadion inj Ampul 1 0 1 1 0
66 Fitomenadion tab 10 mg Tablet 90 0 90 10 80
68 Furosemid tab 40 mg Tablet 20 0 20 20 0
69 Furosemid Injeksi Ampul 0 0 0 0 0
70 G Guayakolat tab 100 mg Tablet 0 0 0 0 0
72 Garam Oralit 200 ml Sace 72 0 72 18 54
73 Gentian Violet lrt Botol 0 0 0 0 0
79 Glukosa 5 % infus Botol 0 0 0 0 0
80 Glukosa 10 % infus Botol 0 0 0 0 0
83 H C T tab 25 mg Tablet 20 0 20 20 0
88 Hidrokortison slp 2,5 % Tube 0 0 0 0 0
89 Ichtyol Salep Pot 0 0 0 0 0
92 Ibuprofen 200 mg Tablet 20 0 20 20 0
93 Ibuprofen 400 mg Tablet 160 0 160 50 110
94 Ibuprofen Suspensi Botol 0 0 0 0 0
98 Kal Permanganat Kristal Pot 2 0 2 1 1
100 Kals Lactas Tab 500 mg Tablet 50 0 50 50 0
101 Kaptopril tab 25 mg Tablet 0 0 0 0 0
102 Kaptopril tab 12,5 mg Tablet 0 0 0 0 0
106 Kloramfenicol kap 250 mg Kapsul 10 0 10 10 0
107 Kloramfenicol SK/Bufaudin Tube 1 0 1 1 0
108 Kloramfenicol SM 1 % Tube 2 0 2 1 1
109 Kloramfenicol TM 0,5 % Botol 1 0 1 1 0
110 Kloramfenicol TT 3 % Botol 0 0 0 0 0
112 Klorfeniramin Mal Tab 4 mg Tablet 180 0 180 100 80
115 Kotri Tab 480 mg Tablet 50 0 50 30 20
116 KotrI Suspensi Botol 3 0 3 1 2
117 Levetran Zalf Pot 0 0 0 0 0
118 Lidocain inj Ampul 0 0 0 0 0
120 Megotrin Inj 0,2 mg / 1 ml Ampul 1 0 1 1 0
121 Megotrin Tab 0,125 mg Tablet 20 70 90 0 90
129 Na Bicarbonas tab 500 mg Tablet 0 0 0 0 0
130 NaCl 0,9 Infus Botol 0 0 0 0 0
135 Norit Tab Tablet 0 0 0 0 0
136 OBH Sirup Botol 0 0 0 0 0
137 Oksitetra SK 3 % Tube 3 0 3 1 2
138 Oksitetra SM 1 % Tube 2 0 2 0 2
139 Oksitosin Inj Ampul 2 0 2 2 0
143 Parasetamol tab 500 mg Tablet 100 0 100 100 0
144 Parasetamol Sirup Botol 4 0 4 2 2
145 Pirantel Pamoat Tab 125 mg Tablet 0 0 0 0 0
146 Piridoxin (B6) tab 10 mg Tablet 140 0 140 80 60
147 Piroksikam 20 mg Tablet 0 0 0 0 0
148 Prednison tab 5 mg Tablet 70 0 70 50 20
153 Ranitidin Tab Tablet 0 0 0 0 0
157 Ringer Lactat Infus Botol 0 0 0 0 0
159 Salbutamol Tab 2 mg Tablet 0 0 0 0 0
160 Salbutamol Tab 4 mg Tablet 0 0 0 0 0
STOK PENERI PERSE PEMA SISA PERMIN PEMBE
NO NAMA OBAT Satuan MAAN
KET
AWAL DIAAN KAIAN STOK TAAN RIAAN
1 2 3 4 5 6 7 8 9 10 15
161 Salep 2-4 Komb Pot/30g 0 0 0 0 0
162 Salisil Bedak 2 % Bks/50g 1 0 1 1 0
165 Sianokobalamin Tab Tablet 0 0 0 0 0
166 Simetidin tab 200 mg Tablet 0 0 0 0 0
171 Sulfa Setamid TM 5 % Botol 0 0 0 0 0
172 Tablet + DARAH Tablet 200 0 200 100 100
174 Tetra kap 250 mg Kapsul 0 0 0 0 0
175 Tetra kap 500 mg Kapsul 0 0 0 0 0
176 Tiamin (B1) Tab 50 mg Tablet 70 0 70 50 20
182 Vitamin B komplekx tab Tablet 50 0 50 50 0
183 Zinc Tab Tablet 20 0 20 20 0
ALAT LABOR
3 Alat suntik skl pakai 3 ml set 2 0 2 2 0
14 Cat Gut chromic 24 mm pcs 0 0 0 0 0
16 Cat Gut plain 24 mm pcs 0 0 0
17 Cat Gut plain 26 mm pcs 0 0 0
18 Cat Gut 2/0 plain pcs 0 0 0
19 Cat Gut 2/0 chromic pcs 0 0 0
28 Etakridin Btl 0 0 0 0 0
29 Etanol 70 % Btl 0 0 0 0 0
40 H2O2 larutan Btl 0 0 0
41 Infusion set anak set 0 0 0
42 Infusion set dws set 0 0 0 0 0
43 IV Cateter 18 pcs 0 0 0 0 0
44 IV Cateter 20 pcs 0 0 0
45 IV Cateter 22 pcs 0 0 0
46 IV Cateter 24 pcs 0 0 0
47 Kapas 250 gr roll 0 0 0
48 Kassa 4x3 xm roll 0 0 0
49 Kassa 4m x 15cm roll 2 0 2 1 1
50 Kassa Pembalut 2m x 80cm roll 1 0 1 1 0
51 Kassa Steril 40/40 roll 0 0 0
95 Plester 5x5 roll 0 0 0 0
96 Plester 5x4,5 roll 0 0
97 Pipet Tes Buah 0 0
101 Pov Yodida 60 ml btl 0 0 0 0 0
102 Pov Yodida 10 % 300 ml btl 0 0 0
121 Silk (Benang bedah + JJ) 26 mm pcs 0 0 0 0 0
122 Silk (Benang bedah + JJ) 24 mm pcs

UMUM TOTAL
KUNJUNGAN RESEP PBI JUMLAH JUMLAH
BAYAR TDK BYR NPBI R/
8 0 5 53 66 66 192

Pakan Raba 31 Januari 2022

Petugas IFK Puskesmas Yang Melapor / Meminta

Meri Elfiati, Amd.Farm Mustika Ayu

NIP : 19690615 199403 2 009 NIP : 19770621 2006042018

Diketahui
Kepala Puskesmas

Ns. Dediyas S,Keb

NIP : 19740816 199503 1 002
1
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LP LPO)
KODE PUSKESMAS :
POSKESRI BULAN
KECAMATAN : LAREH SAGO HALABAN TAHUN
KABUPATEN : LIMA PULUH KOTA
PROPINSI : SUMATERA BARAT
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA PERMIN PEMBER KET
AWAL MAAN DIAAN KAIAN STOK TAAN IAAN
1 2 3 4 5 6 7 8 9 10 12
1 Acetosal Tab 100 mg Tablet
2 Acetyl Sisten Tablet
9 Ambroxol tab Set
10 Ambroxol syr Tablet
12 Aminophylin tab Tablet
14 Amlodipin tab 5 mg Tablet
15 Amlodipin tab 10 mg Ampul
16 Amoxicilin dry sir Tablet
17 Amoxicilin kap 500 mg Tablet
18 Antasida DOEN sirup Tablet
19 Antasida DOEN tab Tablet
24 As Ascorbic Tab 50 mg (Vit C) Tablet
25 Asam Folat Tab 1 mg Tablet
26 Asam Mefenamat 500 mg Kaplet
33 Betametason slp Tube
38 Combivent 2.5 ml Pot
39 Dexametason inj Ampul
40 Dexametason tab 0,5 mg Tablet
41 Diazepam tab 2 mg Tablet
42 Diazepam inj 10 ml Ampul
52 Efedrin tab 25 mg Tablet
65 Fitomenadion inj Ampul
66 Fitomenadion tab 10 mg Tablet
68 Furosemid tab 40 mg Tablet
69 Furosemid Injeksi Ampul
70 G Guayakolat tab 100 mg Tablet
72 Garam Oralit 200 ml Sace
73 Gentian Violet lrt Botol
79 Glukosa 5 % infus Botol
80 Glukosa 10 % infus Botol
83 H C T tab 25 mg Tablet
88 Hidrokortison slp 2,5 % Tube
89 Ichtyol Salep Pot
92 Ibuprofen 200 mg Tablet
93 Ibuprofen 400 mg Tablet
94 Ibuprofen Suspensi Botol
98 Kal Permanganat Kristal Pot
100 Kals Lactas Tab 500 mg Tablet
101 Kaptopril tab 25 mg Tablet
102 Kaptopril tab 12,5 mg Tablet
106 Kloramfenicol kap 250 mg Kapsul
107 Kloramfenicol SK/Bufaudin Tube
108 Kloramfenicol SM 1 % Tube
109 Kloramfenicol TM 0,5 % Botol
110 Kloramfenicol TT 3 % Botol
112 Klorfeniramin Mal Tab 4 mg Tablet
115 Kotri Tab 480 mg Tablet
116 KotrI Suspensi Botol
117 Levetran Zalf Pot
118 Lidocain inj Ampul
120 Megotrin Inj 0,2 mg / 1 ml Ampul
121 Megotrin Tab 0,125 mg Tablet
129 Na Bicarbonas tab 500 mg Tablet
130 NaCl 0,9 Infus Botol
135 Norit Tab Tablet
136 OBH Sirup Botol
137 Oksitetra SK 3 % Tube
138 Oksitetra SM 1 % Tube
139 Oksitosin Inj Ampul
143 Parasetamol tab 500 mg Tablet
144 Parasetamol Sirup Botol
145 Pirantel Pamoat Tab 125 mg Tablet
146 Piridoxin (B6) tab 10 mg Tablet
147 Piroksikam 20 mg Tablet
148 Prednison tab 5 mg Tablet
153 Ranitidin Tab Tablet
157 Ringer Lactat Infus Botol
159 Salbutamol Tab 2 mg Tablet
160 Salbutamol Tab 4 mg Tablet
STOK PENERI PERSE PEMA SISA PERMIN PEMBE
NO NAMA OBAT Satuan MAAN
KET
AWAL DIAAN KAIAN STOK TAAN RIAAN
1 2 3 4 5 6 7 8 9 10 15
161 Salep 2-4 Komb Pot/30g
162 Salisil Bedak 2 % Bks/50g
165 Sianokobalamin Tab Tablet
166 Simetidin tab 200 mg Tablet
171 Sulfa Setamid TM 5 % Botol
172 Tablet + DARAH Tablet
174 Tetra kap 250 mg Kapsul
175 Tetra kap 500 mg Kapsul
176 Tiamin (B1) Tab 50 mg Tablet
182 Vitamin B komplekx tab Tablet
183 Zinc Tab Tablet
ALAT LABOR
3 Alat suntik skl pakai 3 ml set
14 Cat Gut chromic 24 mm pcs
16 Cat Gut plain 24 mm pcs
17 Cat Gut plain 26 mm pcs
18 Cat Gut 2/0 plain pcs
19 Cat Gut 2/0 chromic pcs
28 Etakridin Btl
29 Etanol 70 % Btl
40 H2O2 larutan Btl
41 Infusion set anak set
42 Infusion set dws set
43 IV Cateter 18 pcs
44 IV Cateter 20 pcs
45 IV Cateter 22 pcs
46 IV Cateter 24 pcs
47 Kapas 250 gr roll
48 Kassa 4x3 xm roll
49 Kassa 4m x 15cm roll
50 Kassa Pembalut 2m x 80cm roll
51 Kassa Steril 40/40 roll
95 Plester 5x5 roll
96 Plester 5x4,5 roll
97 Pipet Tes Buah
101 Pov Yodida 60 ml btl
102 Pov Yodida 10 % 300 ml btl
121 Silk (Benang bedah + JJ) 26 mm pcs
122 Silk (Benang bedah + JJ) 24 mm pcs

UMUM TOTAL
KUNJUNGAN RESEP PBI JUMLAH JUMLAH
BAYAR TDK BYR NPBI R/

Pakan Raba 2022

Petugas IFK Puskesmas Yang Melapor / Meminta

Meri Elfiati, Amd.Farm

NIP : 19690615 199403 2 009 NIP :

Diketahui
Kepala Puskesmas

Ns. Dediyas S,Keb

NIP : 19740816 199503 1 002
1
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LP LPO)
POSKESRI : BATU PAYUANG
BULAN : MARET
TAHUN : 2021
TANGGAL
NO NAMA OBAT Satuan
JUMLAH
1 2 3 4 5 6 7 8 9 10 12
16 Amoxicilin dry sir Tablet 0
17 Amoxicilin kap 500 mg Tablet 0
19 Antasida DOEN tab Tablet 0
24 As Ascorbic Tab 50 mg (Vit C) Tablet 0
34 Betametason slp Suppos 0
40 Dexametason tab 0,5 mg Tablet 0
65 Fitomenadion inj Ampul 0
66 Fitomenadion tab 10 mg Tablet 0
68 Furosemid tab 40 mg Tablet 0
70 G Guayakolat tab 100 mg Tablet 0
72 Garam Oralit 200 ml Sace 0
73 Gentian Violet lrt Botol 0
83 H C T tab 25 mg Tablet 0
92 Ibuprofen 200 mg Tablet 0
98 Kal Permanganat Kristal Pot 0
100 Kals Lactas Tab 500 mg Tablet 0
106 Kloramfenicol kap 250 mg Kapsul 0
107 Kloramfenicol SK Tube 0
108 Kloramfenicol SM 1 % Tube 0
110 Kloramfenicol TT 3 % Botol 0
112 Klorfeniramin Mal Tab 4 mg Tablet 0
115 Kotri Tab 480 mg Tablet 0
116 KotrI Suspensi Botol 0
118 Lidocain 2 % Jelly Ampul 0
120 Megotrin Inj 0,2 mg / 1 ml Ampul 0
121 Megotrin Tab 0,125 mg Tablet 0
129 Na Bicarbonas tab 500 mg Tablet 0
130 NaCl 0,9 Infus Botol 0
136 OBH Sirup Botol 0
137 Oksitetra SK 3 % Tube 0
138 Oksitetra SM 1 % Tube 0
139 Oksitosin Inj Ampul 0
143 Parasetamol tab 500 mg Tablet 0
144 Parasetamol Sirup Botol 0
146 Piridoxin (B6) tab 10 mg Tablet 0
148 Prednison tab 5 mg Tablet 0
157 Ringer Lactat Infus Botol 0
161 Salep 2-4 Komb Pot/30g 0
162 Salisil Bedak 2 % Bks/50g 0
171 Sulfa Setamid TM 5 % Botol 0
172 Tablet + DARAH Tablet 0
175 Tetra kap 500 mg Kapsul 0
176 Tiamin (B1) Tab 50 mg Tablet 0
182 Vitamin B komplekx tab Tablet 0
183 Zinc Tab Tablet 0
3 Alat suntik skl pakai 0.3 ml set 0
14 Cat Gut chromic 24 mm pcs 0
15 Cat Gut chromic 26 mm pcs 0
28 Etakridin Btl 0
29 Etanol 70 % Btl 0
42 Infusion set dws set 0
43 IV Cateter 18 pcs 0
47 Kapas 250 gr roll 0
49 Kassa 4m x 15cm roll 0
50 Kassa Pembalut 2m x 80cm roll 0
95 Plester 5x5 roll 0
101 Pov Yodida 60 ml btl 0
121 Silk (Benang bedah + JJ) 26 mm pcs 0
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
(LP LPO)
KODE PUSKESMAS :
PUSKESMAS : PAKAN RABAA
KECAMATAN : LAREH SAGO HALABAN
KABUPATEN : LIMA PULUH KOTA
PROPINSI : SUMATERA BARAT
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
I. OBAT / ALKES PKD
1 Acetosal Tab 500 mg Tablet #REF! #REF! #REF!
2 Acetosal Tab 100 mg Tablet #REF! 500 #REF! #REF!
3 Acyclovir Tab 200 mg Tablet #REF! #REF! #REF!
4 Acyclovir Tab 400 mg Tablet #REF! #REF! #REF!
5 Acyclovir Krim Tube #REF! #REF! #REF!
6 Air Raksa dental use Botol #REF! #REF! #REF!
7 Alat suntik skl pakai 1 ml Set #REF! #REF! #REF!
8 Alat suntik skl pakai 5 ml Set #REF! #REF! #REF!
9 Alat suntik skl pakai 2,5 ml Set #REF! #REF! 126 #REF!
10 Alprazolam tab 0,5 mg Tablet #REF! #REF! 170 #REF!
11 Allopurinol tab 100 mg Tablet #REF! #REF! #REF!
12 Allopurinol tab 300 mg Tablet #REF! #REF! 30 #REF!
13 Ambroxol tab Tablet #REF! #REF! #REF!
14 Ambroxol syr Tablet #REF! #REF! #REF!
15 Aminophylin inj Ampul #REF! #REF! #REF!
16 Aminophylin tab Tablet #REF! #REF! 945 #REF!
17 Amitriptilin tab Tablet #REF! #REF! 315 #REF!
18 Amlodipin tab 5 mg Tablet #REF! 300 #REF! 130 #REF!
19 Amlodipin tab 10 mg Tablet #REF! #REF! 113 #REF!
20 Amoxicilin dry sir Botol #REF! #REF! 13 #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
21 Amoxicilin kap 500 mg Kaplet #REF! #REF! 2486 #REF!
22 Antasida DOEN sirup Botol #REF! #REF! 25 #REF!
23 Antasida DOEN tab Tablet #REF! #REF! 1737 #REF!
24 Anti Bakteri Salf Pot #REF! #REF! #REF!
25 Anti Fungi Doen (WF) slp Pot/30g #REF! #REF! 6 #REF!
26 Anti Haemorhoid Suppos Suppos #REF! #REF! #REF!
27 Anti Migren D komb Tablet #REF! #REF! 10 #REF!
28 As Ascorbic Tab 25 mg (Vit C) Tablet #REF! #REF! #REF!
29 As Ascorbic Tab 50 mg (Vit C) Tablet #REF! 1000 #REF! 2870 #REF!
30 Asam Folat Tab 1 mg Tablet #REF! 1000 #REF! 60 #REF!
31 Asam Folat Tab 5 mg Tablet #REF! #REF! #REF!
32 Asam Mefenamat 500 mg Kaplet #REF! #REF! 225 #REF!
33 Asam Traneksamat Injeksi Ampul #REF! #REF! #REF!
34 Asam Traneksamat Tablet Tablet #REF! #REF! 60 #REF!
35 Attapulgit Tab Tablet #REF! #REF! 80 #REF!
36 Atropin Sulfat Tab Tablet #REF! #REF! #REF!
37 Atropin Sulfat Injeksi Ampul #REF! #REF! 1 #REF!
38 Betahistin Tab Tablet #REF! #REF! #REF!
39 Betametason slp Tube #REF! #REF! 42 #REF!
40 Bisakodil Suppos Suppos #REF! #REF! #REF!
41 Carbamazepin 200 mg Tablet #REF! #REF! #REF!
42 Cat Gut + Jarum bedah Set #REF! 4 #REF! #REF!
43 Cetrizin Tab Tablet #REF! #REF! 308 #REF!
44 Cetrizin Sirup Botol #REF! #REF! #REF!
45 Devitalisasi Pata (obat gigi) Pot #REF! #REF! #REF!
46 Dexametason inj Ampul #REF! #REF! 5 #REF!
47 Dexametason tab 0,5 mg Tablet #REF! #REF! 2439 #REF!
48 Diazepam tab 2 mg Tablet #REF! #REF! 610 #REF!
49 Diazepam inj Ampul #REF! #REF! 2 #REF!
50 Diazepam Rectal 2 mg Buah #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
51 Diazepam Rectal 5 mg Buah #REF! #REF! 10 #REF!
52 Diazepam Rectal 10 mg Buah #REF! #REF! #REF!
53 Difenhidramin inj Ampul #REF! #REF! 15 #REF!
54 Digoxin tab 0,25 mg Tablet #REF! #REF! 140 #REF!
55 Diltiazem Tab Tablet #REF! #REF! #REF!
56 Dimenhidrinat Tab Tablet #REF! #REF! #REF!
57 Domperidon Tab Tablet #REF! #REF! 60 #REF!
58 Domperidon Suspensi Botol #REF! #REF! #REF!
59 Doksisiklin Tablet Tablet #REF! #REF! #REF!
60 Efedrin tab 25 mg Tablet #REF! #REF! #REF!
61 Epinefrin inj Ampul #REF! #REF! 2 #REF!
62 Erytromisin Kap 250 mg Kaplet #REF! #REF! #REF!
63 Erytromisin Kap 500 mg Kaplet #REF! #REF! 90 #REF!
64 Erytromisin Sirup Botol #REF! #REF! #REF!
65 Etakridin lrt 0,1 Botol #REF! #REF! 2 #REF!
66 Etambutol 500 mg Tablet #REF! #REF! #REF!
67 Etanol 70 % Botol #REF! #REF! 5 #REF!
68 Etilklorida semprot Botol #REF! #REF! 2 #REF!
69 Eugenol Cairan Botol #REF! #REF! #REF!
70 Ergotamin Coffein 1 mg Tablet #REF! #REF! #REF!
71 Extrac Belad 100 mg Tablet #REF! #REF! #REF!
72 Fenitoin Na Kap 100 mg Kapsul #REF! #REF! 468 #REF!
73 Fenobarbital tab 30 mg Tablet #REF! #REF! 100 #REF!
74 Fenobarbital injeksi Ampul #REF! #REF! 13 #REF!
75 Fenol Glyserol Lrt TT Botol #REF! #REF! 3 #REF!
76 Fitomenadion inj Ampul #REF! #REF! 26 #REF!
77 Fitomenadion tab 10 mg Tablet #REF! #REF! 812 #REF!
78 Furosemid tab 40 mg Tablet #REF! #REF! 287 #REF!
79 Furosemid Injeksi Ampul #REF! #REF! #REF!
80 G Guayakolat tab 100 mg Tablet #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
81 Garam Inggris (Mg SO4) Sace #REF! #REF! #REF!
82 Garam Oralit 200 ml Sace #REF! 300 #REF! 560 #REF!
83 Gentian Violet lrt Botol #REF! #REF! #REF!
84 Gentamicyn injeksi Ampul #REF! #REF! #REF!
85 Glass lonomer (ART) Botol #REF! #REF! #REF!
86 Glibenklamid tab 5 mg Tablet #REF! #REF! 135 #REF!
87 Glimepiride Tab 1 mg Tablet #REF! #REF! #REF!
88 Glimepiride Tab 2 mg Tablet #REF! #REF! #REF!
89 Glukosa 5 % infus Botol #REF! #REF! 2 #REF!
90 Glukosa 10 % infus Botol #REF! #REF! 1 #REF!
91 Griseofulvin tab 125 mg Tablet #REF! #REF! 70 #REF!
92 Griseofulvin tab 500 mg Tablet #REF! #REF! #REF!
93 H C T tab 25 mg Tablet #REF! #REF! 166 #REF!
94 Halloperidol tab 1,5 mg Tablet #REF! #REF! 675 #REF!
95 Halloperidol tab 5 mg Tablet #REF! #REF! 140 #REF!
96 Halloperidol Injeksi Ampul #REF! #REF! #REF!
97 H2O2 Larutan 50 % Botol #REF! #REF! #REF!
98 Hidrokortison slp 2,5 % Tube #REF! #REF! 25 #REF!
99 Ichtyol Salep Pot #REF! #REF! #REF!
100 INH Tab 100 mg Tablet #REF! #REF! 20 #REF!
101 INH Tab 300 mg Tablet #REF! #REF! #REF!
102 Ibuprofen 200 mg Tablet #REF! #REF! 620 #REF!
103 Ibuprofen 400 mg Tablet #REF! #REF! 594 #REF!
104 Ibuprofen Suspensi Botol #REF! #REF! #REF!
105 Infusion set anak Set #REF! #REF! #REF!
106 Infusion set dws Set #REF! #REF! 4 #REF!
107 Isosorbid DNT tab mg Tablet #REF! #REF! 60 #REF!
108 IV catheter no 18 Buah #REF! #REF! 2 #REF!
109 IV catheter no 20 Buah #REF! #REF! #REF!
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
110 IV catheter no 22 Buah #REF! #REF! #REF!
111 IV catheter no 24 Buah #REF! #REF! #REF!
112 KODEIN Tab 10 mg Tablet #REF! #REF! #REF!
113 KODEIN Tab 20 mg Tablet #REF! #REF! #REF!
114 Kal Permanganat Kristal Pot #REF! #REF! #REF!
115 Kals Hidroksida Pata Set #REF! #REF! #REF!
116 Kals Lactas Tab 500 mg Tablet #REF! #REF! 1180 #REF!
117 Kapas Berlemak Rol #REF! #REF! #REF!
118 Kapas Pembalut 250 gr Bks #REF! #REF! 2 #REF!
119 Kapas Pembalut 1000 gr Bks #REF! #REF! #REF!
120 Kaptopril tab 25 mg Tablet #REF! #REF! 50 #REF!
121 Kaptopril tab 12,5 mg Tablet #REF! #REF! 614 #REF!
122 Kassa 4x3 xm Tablet #REF! #REF! #REF!
123 Kassa 4m x 15cm Rol #REF! #REF! 25 #REF!
124 Kassa Pembalut 2m x 80cm Rol #REF! #REF! 5 #REF!
125 Kassa Steril 40/40 Rol #REF! #REF! #REF!
126 Ketokonazol Tab Tablet #REF! #REF! 40 #REF!
127 Ketokonazol Krim Tube #REF! #REF! 5 #REF!
128 Kloramfenicol kap 250 mg Kapsul #REF! #REF! 60 #REF!
129 Kloramfenicol SK Tube #REF! #REF! 2 #REF!
130 Kloramfenicol SM 1 % Tube #REF! #REF! 5 #REF!
131 Kloramfenicol TM 0,5 % Botol #REF! #REF! 3 #REF!
132 Kloramfenicol TT 3 % Botol #REF! #REF! #REF!
133 Kloramfenicol Suspensi Botol #REF! #REF! #REF!
134 Klorfeniramin Mal Tab 4 mg Tablet #REF! 500 #REF! 2254 #REF!
135 Klorpromazin Inj 25 mg/ml Ampul #REF! #REF! 4 #REF!
136 Klorpronazin Tab 100 mg Tablet #REF! #REF! 690 #REF!
137 Kotri Tab 480 mg Tablet #REF! 2000 #REF! 1180 #REF!
138 Kotri Suspensi Botol #REF! #REF! 25 #REF!
139 Levetran Zalf Pot #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
140 Lidocain Comp Inj Ampul #REF! #REF! #REF!
141 Lidocain 2 % Jelly Ampul #REF! #REF! #REF!
142 Lisol ~ Kresol 50 % Botol #REF! #REF! 1 #REF!
143 Loratadine Tablet Tablet #REF! #REF! 70 #REF!
144 Mag Slang Set #REF! #REF! #REF!
145 Megotrin Inj 0,2 mg / 1 ml Ampul #REF! #REF! 10 #REF!
146 Megotrin Tab 0,125 mg Tablet #REF! 300 #REF! 20 #REF!
147 Metformin Tab Tablet #REF! #REF! 399 #REF!
148 Metoklopramid Tab Tablet #REF! #REF! #REF!
149 Metronidazol 250 mg Tablet #REF! #REF! #REF!
150 Metronidazol 500 mg Tablet #REF! #REF! 395 #REF!
151 Mikonazol Krim Tube #REF! #REF! 13 #REF!
152 Monoklorkamfer (Chkm) Botol #REF! #REF! #REF!
153 Na Bicarbonas tab 500 mg Tablet #REF! #REF! 558 #REF!
154 NaCl 0,9 Infus Botol #REF! #REF! 4 #REF!
155 Na Diklofenak Tab 25 mg Tablet #REF! #REF! #REF!
156 Na Diklofenak Tab 50 mg Tablet #REF! #REF! 195 #REF!
157 Nifedipin Tablet #REF! #REF! 175 #REF!
158 Nistatin Tab Tablet #REF! #REF! 10 #REF!
159 Norit Tab Tablet #REF! #REF! 205 #REF!
160 OBH Sirup Botol #REF! #REF! #REF!
161 OCO Botol #REF! #REF! #REF!
162 Oksitetra SK 3 % Tube #REF! #REF! 19 #REF!
163 Oksitetra SM 1 % Tube #REF! #REF! 5 #REF!
164 Oksitosin Inj Ampul #REF! #REF! 17 #REF!
165 Omeprazol Kap Kaplet #REF! #REF! #REF!
166 PTU tab 100 mg Tablet #REF! #REF! 140 #REF!
167 Papaverin tab 40 mg Tablet #REF! #REF! 60 #REF!
168 Paraformaldehid tab 1 gram Tablet #REF! #REF! #REF!
169 Parasetamol tab 500 mg Tablet #REF! 2000 7775 4830 2945

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
170 Parasetamol Sirup Botol #REF! #REF! 47 #REF!
171 Parasetamol Drop Botol #REF! #REF! #REF!
172 Pembalut Gips Rol #REF! #REF! #REF!
173 Pengikat Tali Pusat Buah #REF! #REF! #REF!
174 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! 40 #REF!
175 Piridoxin (B6) tab 10 mg Tablet #REF! #REF! 1920 #REF!
176 Piroksikam 20 mg Tablet #REF! #REF! 755 #REF!
177 Plester Rol #REF! #REF! 1 #REF!
178 Plester 5x5 Rol #REF! #REF! #REF!
179 Pov Yodida 60 ml Botol #REF! #REF! 8 #REF!
180 Pov Yodida 10 % 300 ml Botol #REF! #REF! #REF!
181 PP2TU Botol #REF! #REF! #REF!
182 Prednison tab 5 mg Tablet #REF! 2000 #REF! 2390 #REF!
183 Primaquin Tab Tablet #REF! #REF! #REF!
184 Propranolol tab 10 mg Tablet #REF! #REF! #REF!
185 Propranolol tab 40 mg Tablet #REF! #REF! 60 #REF!
186 Pyrazinamid tab 500 mg Tablet #REF! #REF! #REF!
187 Ranitidin Tab Tablet #REF! #REF! 687 #REF!
188 Rifampisin 300 mg Kapsul #REF! #REF! #REF!
189 Rifampisin 450 mg Kapsul #REF! #REF! 18 #REF!
190 Rifampisin 500 mg Kapsul #REF! #REF! #REF!
191 Ringer Lactat Infus Botol #REF! #REF! 12 #REF!
192 Salbutamol Tab 2 mg Tablet #REF! #REF! 75 #REF!
193 Salbutamol Tab 4 mg Tablet #REF! #REF! #REF!
194 Salep 2-4 Komb Pot/30g #REF! #REF! 15 #REF!
195 Salisil Bedak 2 % Bks/50g #REF! #REF! 9 #REF!
196 Serum ABU inj Vial #REF! #REF! #REF!
197 Serum Anti Tetanus inj 1500 IU Ampul #REF! #REF! #REF!
198 Semen Seng Phospat Set #REF! #REF! #REF!
199 Sianokobalamin Tab Tablet #REF! #REF! 215 #REF!
200 Silk (Benang bedah + JJ) Sachet #REF! #REF! 3 #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
201 Simetidin tab 200 mg Tablet #REF! #REF! #REF!
202 Simvastatin Tab Tablet #REF! #REF! 100 #REF!
203 Siprofloxasin kap 500 mg Kapsul #REF! #REF! 340 #REF!
204 Spironolacton Tab 25 mg Tablet #REF! #REF! 48 #REF!
205 Spon Gelatin Kotak #REF! #REF! #REF!
206 Sulfa Setamid TM 5 % Botol #REF! #REF! #REF!
207 Tablet + DARAH Tablet #REF! #REF! 25 #REF!
208 Temporary Flacher 2btl/set #REF! #REF! #REF!
209 Tetra kap 250 mg Kapsul #REF! #REF! 760 #REF!
210 Tetra kap 500 mg Kapsul #REF! #REF! 415 #REF!
211 Tetrakain TM 0,5 % Botol #REF! #REF! #REF!
212 Tiamin (B1) Tab 50 mg Tablet #REF! 1000 #REF! 925 #REF!
213 Trihexi Fenidil tab 2 mg Tablet #REF! 700 #REF! 370 #REF!
214 Vaksin Rabies Vero Set 4 ktk #REF! #REF! #REF!
215 Verapamil Tab 80 mg Tablet #REF! #REF! #REF!
216 Vitamin B komplekx tab Tablet #REF! #REF! 1620 #REF!
217 Wing Nedle Buah #REF! #REF! #REF!
218 Zinc Tab Tablet #REF! #REF! 60 #REF!
219 Zinc Sirup Botol #REF! #REF! 8 #REF!
II. ALAT LABOR
1 Anti Sera Gol Darah Set #REF! #REF! #REF!
2 Aquadest Set #REF! #REF! #REF!
3 Aqua Pro Injeksi Vial #REF! #REF! #REF!
4 Dengue Antigen Cassete Buah #REF! #REF! #REF!
5 Dengue IgM & IgG Cassete Buah #REF! #REF! #REF!
6 Malaria PV & PV Cassete Buah #REF! #REF! #REF!
7 Lrt Asam Asetat Btl/100 #REF! #REF! #REF!
8 Lrt Asam Sulfosalisilat 20% Btl/100 #REF! #REF! #REF!
9 Lat Asam Klorida 0,1 N Btl/100 #REF! #REF! #REF!
10 Lat BaCl Btl/100 #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
11 Lrt Benedict Btl/100 #REF! #REF! #REF!
12 Lrt Eosin 2 % Btl/100 #REF! #REF! 1 #REF!
13 Lrt Etanol Asam Btl/100 #REF! #REF! #REF!
14 Lrt Faucet Btl/100 #REF! #REF! #REF!
15 Lrt Gabbet Btl/100 #REF! #REF! #REF!
16 Lrt Giemsa Stain Btl/100 #REF! #REF! #REF!
17 Lrt Imersion Oil Btl/100 #REF! #REF! #REF!
18 Lrt Karbo Fuksin Btl/100 #REF! #REF! #REF!
19 Lrt Metanol Btl/100 #REF! #REF! #REF!
20 Lrt Metilen Blue Btl/100 #REF! #REF! #REF!
21 Lrt Sodium Citrate Buah #REF! #REF! #REF!
22 Lrt Turk Buah #REF! #REF! #REF!
23 Lrt Hayem Buah #REF! #REF! #REF!
24 Lart. Xilene Pcs #REF! #REF! #REF!
25 Lancet Darah Buah #REF! #REF! #REF!
26 Objeck Glass Buah #REF! #REF! #REF!
27 Cover Glass Helai #REF! #REF! #REF!
28 Hand Scoon Helai #REF! #REF! 25 #REF!
29 Masker Bks #REF! 250 #REF! 50 #REF!
30 Kotak Slide Buah #REF! #REF! 1 #REF!
31 Kertas Saring Buah #REF! #REF! 2 #REF!
32 Kertas Lakmus Buah #REF! #REF! #REF!
33 Tissue Lensa Buah #REF! #REF! #REF!
34 Test Kehamilan Buah #REF! #REF! 25 #REF!
35 Test Iodin Buah #REF! #REF! #REF!
36 Test Malaria Buah #REF! #REF! #REF!
37 Test DBD Buah #REF! #REF! #REF!
38 Test Protein Glucosa Buah #REF! #REF! 20 #REF!
39 Pot Sputum Buah #REF! 50 #REF! #REF!
40 Tissue Gulung Rol #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
III. OBAT GIZI
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Lipiodol Kap Iodium Kap #REF! #REF! #REF!
3 Tablet + Darah Tablet #REF! #REF! #REF!
4 Sirup + Darah Btl #REF! #REF! #REF!
5 Albendazol Tab Tablet #REF! #REF! #REF!
6 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! #REF!
7 Vitamin A 200 000 Kap #REF! #REF! 75 #REF!
8 Vitamin A 100 000 Kap #REF! #REF! 5 #REF!
IV. OBAT MALARIA
1 ACT Tablet #REF! #REF! #REF!
2 OAM Tablet #REF! #REF! #REF!
3 Artediaquin Tab Tablet #REF! #REF! #REF!
4 Doksisiklin Tab 100 mg Tablet #REF! #REF! #REF!
5 Primaquin Tab Tablet #REF! #REF! 15 #REF!
6 Tablet + Darah Tablet #REF! #REF! #REF!
V. OBAT TB PARU
1 Obat TB Kat I Pkt #REF! 9 #REF! 6 #REF!
2 Obat TB Kat II Pkt #REF! #REF! #REF!
3 Obat TB Kat III Pkt #REF! #REF! #REF!
4 Obat TB Kat Sisipan Pkt #REF! #REF! #REF!
5 Obat TB Kat Anak Pkt #REF! #REF! 1 #REF!

VI. OBAT ISPA

1 Parasetamol tab 500 mg Tablet #REF! #REF! #REF!
2 Kotri 480 Tablet #REF! #REF! #REF!
VII. OBAT DIARE
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Zinc Tab Tablet #REF! #REF! #REF!
VIII. OBAT KIA
1 MgSO4 20% Btl #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
2 MgSO4 40% Btl #REF! #REF! #REF!
3 Oksitosin Inj Ampul #REF! #REF! #REF!
4 Fetomenadion Inj Ampul #REF! #REF! #REF!
IX. VAKSIN
1 BCG #REF! #REF! 4 #REF!
2 DPT-HB-HIB #REF! #REF! 13 #REF!
3 Uni Ject #REF! #REF! 42 36
4 TT #REF! #REF! 3 #REF!
5 DT #REF! #REF! #REF!
6 POLIO #REF! #REF! 8 #REF!
7 Campak #REF! #REF! 7 19
8 pentabio
UMUM
KUNJUNGAN RESEP KS
BAYAR TDK BYR

354 5 1047

Mengetahui / Menyetujui Yang Menyerahkan

Ka. Dinas Kesehatan Ka Instalasi Farmasi
Kabupaten Lima Puluh Kota

dr. H Adel Nofiarman Anton.S.Si,Apt

NIP : 19650914 199803 1 002 NIP : 19720803 200212 1 003

CTT IFK : Tgl dikeluarkan dari Gud

Catt : LPLPO pada bulan permintaan dibuat rangkap 3 (Tiga)
a. 1 (Satu) rangkap ke Dinas Kesehatan
b. 2 (Dua) rangkap dikirim langsung ke Instalasi Farmasi Kabupaten
MBAR PERMINTAAN OBAT
O) LB.2

BULAN : JULI TAHUN : 2016

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
S PKD

48

500
1000

1000
50

3000
1000
1500
1500
50
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
5000

5000

60

5000
 2000

500

50
120
30
1000
48
1000
50

5000
2000

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
5 Exp 10

90
1000

1000
1000
100

5000

10

2
 1000
1000
5000
5
240
50
3000 Exp552
2000

5000
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

1000
120
10

5
5

300
3000
2000
1000
10

150
48
1000
1000
1000
2000

1000
10
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

1000
500
120

3000

1000
3000

100
20

500
48
1000

48
96
96

10000
5 Exp 3
2000
3000
120
10
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
300

3
3000

50
1000
 3000

48

3000

3000
3000

1500
200

120

50
500
1000
3000

10000
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
100
25

200
7000
3000
10
10

7000
 2000

10

96
30

3000
48
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
1000
2000
2000

96
9000

5000
3000

10000
1000

5000

1000
50
BOR
5
5
10
1
1
1
 1
1
2
1
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
5
5
100

5
5
2
5

5
1
1

20
PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
IZI
 3000

7000

2500
300
ARIA
240
90

ARU

PA

ARE

KIA

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

N
30

10
10
30
500
 40
TOTAL R/ OBAT
ASKES JUMLAH TOTAL R/
GENERIK

123 1529 4336

Yang Melapor / Meminta Diterima

Tgl :
Kepala Puskesmas Pengelola OBAT

Budi Margana, SKM Meri Elfiati, Amd.Farm

NIP : 19680708 199403 1 007 NIP : 19690615 199403 2 009

: Tgl dikeluarkan dari Gudang IFK

 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
(LP LPO)
KODE PUSKESMAS :
PUSKESMAS : PAKAN RABAA
KECAMATAN : LAREH SAGO HALABAN
KABUPATEN : LIMA PULUH KOTA
PROPINSI : SUMATERA BARAT
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
I. OBAT / ALKES PKD
1 Acetosal Tab 500 mg Tablet #REF! #REF! #REF!
2 Acetosal Tab 100 mg Tablet #REF! #REF! #REF!
3 Acyclovir Tab 200 mg Tablet #REF! #REF! #REF!
4 Acyclovir Tab 400 mg Tablet #REF! #REF! #REF!
5 Acyclovir Krim Tube #REF! #REF! #REF!
6 Air Raksa dental use Botol #REF! #REF! #REF!
7 Alat suntik skl pakai 1 ml Set #REF! #REF! #REF!
8 Alat suntik skl pakai 5 ml Set #REF! #REF! #REF!
9 Alat suntik skl pakai 2,5 ml Set #REF! 300 #REF! #REF!
10 Alprazolam tab 0,5 mg Tablet #REF! 500 #REF! #REF!
11 Allopurinol tab 100 mg Tablet #REF! #REF! #REF!
12 Allopurinol tab 300 mg Tablet #REF! #REF! #REF!
13 Ambroxol tab Tablet #REF! #REF! #REF!
14 Ambroxol syr Tablet #REF! #REF! #REF!
15 Aminophylin inj Ampul #REF! #REF! #REF!
16 Aminophylin tab Tablet #REF! 3000 #REF! #REF!
17 Amitriptilin tab Tablet #REF! #REF! #REF!
18 Amlodipin tab 5 mg Tablet #REF! #REF! #REF!
19 Amlodipin tab 10 mg Tablet #REF! #REF! #REF!
20 Amoxicilin dry sir Botol #REF! 60 #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
21 Amoxicilin kap 500 mg Kaplet #REF! 5000 #REF! #REF!
22 Antasida DOEN sirup Botol #REF! #REF! #REF!
23 Antasida DOEN tab Tablet #REF! 5000 #REF! #REF!
24 Anti Bakteri Salf Pot #REF! #REF! #REF!
25 Anti Fungi Doen (WF) slp Pot/30g #REF! #REF! #REF!
26 Anti Haemorhoid Suppos Suppos #REF! #REF! #REF!
27 Anti Migren D komb Tablet #REF! #REF! #REF!
28 As Ascorbic Tab 25 mg (Vit C) Tablet #REF! #REF! #REF!
29 As Ascorbic Tab 50 mg (Vit C) Tablet #REF! 5000 #REF! #REF!
30 Asam Folat Tab 1 mg Tablet #REF! #REF! #REF!
31 Asam Folat Tab 5 mg Tablet #REF! #REF! #REF!
32 Asam Mefenamat 500 mg Kaplet #REF! #REF! #REF!
33 Asam Traneksamat Injeksi Ampul #REF! #REF! #REF!
34 Asam Traneksamat Tablet Tablet #REF! #REF! #REF!
35 Attapulgit Tab Tablet #REF! #REF! #REF!
36 Atropin Sulfat Tab Tablet #REF! #REF! #REF!
37 Atropin Sulfat Injeksi Ampul #REF! #REF! #REF!
38 Betahistin Tab Tablet #REF! #REF! #REF!
39 Betametason slp Tube #REF! 50 #REF! #REF!
40 Bisakodil Suppos Suppos #REF! #REF! #REF!
41 Carbamazepin 200 mg Tablet #REF! 50 #REF! #REF!
42 Cat Gut + Jarum bedah Set #REF! #REF! #REF!
43 Cetrizin Tab Tablet #REF! #REF! #REF!
44 Cetrizin Sirup Botol #REF! #REF! #REF!
45 Devitalisasi Pata (obat gigi) Pot #REF! #REF! #REF!
46 Dexametason inj Ampul #REF! #REF! #REF!
47 Dexametason tab 0,5 mg Tablet #REF! 5000 #REF! #REF!
48 Diazepam tab 2 mg Tablet #REF! 1000 #REF! #REF!
49 Diazepam inj Ampul #REF! #REF! #REF!
50 Diazepam Rectal 2 mg Buah #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
51 Diazepam Rectal 5 mg Buah #REF! #REF! #REF!
52 Diazepam Rectal 10 mg Buah #REF! #REF! #REF!
53 Difenhidramin inj Ampul #REF! 30 #REF! #REF!
54 Digoxin tab 0,25 mg Tablet #REF! 300 #REF! #REF!
55 Diltiazem Tab Tablet #REF! #REF! #REF!
56 Dimenhidrinat Tab Tablet #REF! #REF! #REF!
57 Domperidon Tab Tablet #REF! #REF! #REF!
58 Domperidon Suspensi Botol #REF! #REF! #REF!
59 Doksisiklin Tablet Tablet #REF! #REF! #REF!
60 Efedrin tab 25 mg Tablet #REF! #REF! #REF!
61 Epinefrin inj Ampul #REF! #REF! #REF!
62 Erytromisin Kap 250 mg Kaplet #REF! #REF! #REF!
63 Erytromisin Kap 500 mg Kaplet #REF! #REF! #REF!
64 Erytromisin Sirup Botol #REF! #REF! #REF!
65 Etakridin lrt 0,1 Botol #REF! 10 #REF! #REF!
66 Etambutol 500 mg Tablet #REF! #REF! #REF!
67 Etanol 70 % Botol #REF! #REF! #REF!
68 Etilklorida semprot Botol #REF! #REF! #REF!
69 Eugenol Cairan Botol #REF! #REF! #REF!
70 Ergotamin Coffein 1 mg Tablet #REF! #REF! #REF!
71 Extrac Belad 100 mg Tablet #REF! #REF! #REF!
72 Fenitoin Na Kap 100 mg Kapsul #REF! 500 #REF! #REF!
73 Fenobarbital tab 30 mg Tablet #REF! #REF! #REF!
74 Fenobarbital injeksi Ampul #REF! 5 #REF! #REF!
75 Fenol Glyserol Lrt TT Botol #REF! 24 #REF! #REF!
76 Fitomenadion inj Ampul #REF! 30 #REF! #REF!
77 Fitomenadion tab 10 mg Tablet #REF! 2000 #REF! #REF!
78 Furosemid tab 40 mg Tablet #REF! #REF! #REF!
79 Furosemid Injeksi Ampul #REF! #REF! #REF!
80 G Guayakolat tab 100 mg Tablet 0 0

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
81 Garam Inggris (Mg SO4) Sace #REF! #REF! #REF!
82 Garam Oralit 200 ml Sace #REF! 1000 #REF! #REF!
83 Gentian Violet lrt Botol #REF! #REF! #REF!
84 Gentamicyn injeksi Ampul #REF! #REF! #REF!
85 Glass lonomer (ART) Botol #REF! #REF! #REF!
86 Glibenklamid tab 5 mg Tablet #REF! #REF! #REF!
87 Glimepiride Tab 1 mg Tablet #REF! #REF! #REF!
88 Glimepiride Tab 2 mg Tablet #REF! #REF! #REF!
89 Glukosa 5 % infus Botol #REF! 5 #REF! #REF!
90 Glukosa 10 % infus Botol #REF! 5 #REF! #REF!
91 Griseofulvin tab 125 mg Tablet #REF! #REF! #REF!
92 Griseofulvin tab 500 mg Tablet #REF! #REF! #REF!
93 H C T tab 25 mg Tablet #REF! 500 #REF! #REF!
94 Halloperidol tab 1,5 mg Tablet #REF! 2000 #REF! #REF!
95 Halloperidol tab 5 mg Tablet #REF! 300 #REF! #REF!
96 Halloperidol Injeksi Ampul #REF! #REF! #REF!
97 H2O2 Larutan 50 % Botol #REF! #REF! #REF!
98 Hidrokortison slp 2,5 % Tube #REF! 48 #REF! #REF!
99 Ichtyol Salep Pot #REF! #REF! #REF!
100 INH Tab 100 mg Tablet #REF! #REF! #REF!
101 INH Tab 300 mg Tablet #REF! #REF! #REF!
102 Ibuprofen 200 mg Tablet #REF! 1000 #REF! #REF!
103 Ibuprofen 400 mg Tablet #REF! 1000 #REF! #REF!
104 Ibuprofen Suspensi Botol #REF! #REF! #REF!
105 Infusion set anak Set #REF! #REF! #REF!
106 Infusion set dws Set #REF! #REF! #REF!
107 Isosorbid DNT tab mg Tablet #REF! #REF! #REF!
108 IV catheter no 18 Buah #REF! #REF! #REF!
109 IV catheter no 20 Buah #REF! #REF! #REF!
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
110 IV catheter no 22 Buah #REF! #REF! #REF!
111 IV catheter no 24 Buah #REF! #REF! #REF!
112 KODEIN Tab 10 mg Tablet #REF! #REF! #REF!
113 KODEIN Tab 20 mg Tablet #REF! #REF! #REF!
114 Kal Permanganat Kristal Pot #REF! #REF! #REF!
115 Kals Hidroksida Pata Set #REF! #REF! #REF!
116 Kals Lactas Tab 500 mg Tablet #REF! 1000 #REF! #REF!
117 Kapas Berlemak Rol #REF! #REF! #REF!
118 Kapas Pembalut 250 gr Bks #REF! 5 #REF! #REF!
119 Kapas Pembalut 1000 gr Bks #REF! #REF! #REF!
120 Kaptopril tab 25 mg Tablet #REF! #REF! #REF!
121 Kaptopril tab 12,5 mg Tablet #REF! 2000 #REF! #REF!
122 Kassa 4x3 xm Tablet #REF! #REF! #REF!
123 Kassa 4m x 15cm Rol #REF! 100 #REF! #REF!
124 Kassa Pembalut 2m x 80cm Rol #REF! 20 #REF! #REF!
125 Kassa Steril 40/40 Rol #REF! #REF! #REF!
126 Ketokonazol Tab Tablet #REF! 300 #REF! #REF!
127 Ketokonazol Krim Tube #REF! 25 #REF! #REF!
128 Kloramfenicol kap 250 mg Kapsul #REF! #REF! #REF!
129 Kloramfenicol SK Tube #REF! #REF! #REF!
130 Kloramfenicol SM 1 % Tube #REF! #REF! #REF!
131 Kloramfenicol TM 0,5 % Botol #REF! #REF! #REF!
132 Kloramfenicol TT 3 % Botol #REF! #REF! #REF!
133 Kloramfenicol Suspensi Botol #REF! #REF! #REF!
134 Klorfeniramin Mal Tab 4 mg Tablet #REF! #REF! #REF!
135 Klorpromazin Inj 25 mg/ml Ampul #REF! 5 #REF! #REF!
136 Klorpronazin Tab 100 mg Tablet #REF! 1000 #REF! #REF!
137 Kotri Tab 480 mg Tablet #REF! 2000 #REF! #REF!
138 Kotro Suspensi Botol #REF! 100 #REF! #REF!
139 Levetran Zalf Pot #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
140 Lidocain Comp Inj Ampul #REF! #REF! #REF!
141 Lidocain 2 % Jelly Ampul #REF! #REF! #REF!
142 Lisol ~ Kresol 50 % Botol #REF! #REF! #REF!
143 Loratadine Tablet Tablet #REF! 500 #REF! #REF!
144 Mag Slang Set #REF! #REF! #REF!
145 Megotrin Inj 0,2 mg / 1 ml Ampul #REF! 50 #REF! #REF!
146 Megotrin Tab 0,125 mg Tablet #REF! 500 #REF! #REF!
147 Metformin Tab Tablet #REF! 1000 #REF! #REF!
148 Metoklopramid Tab Tablet #REF! #REF! #REF!
149 Metronidazol 250 mg Tablet #REF! #REF! #REF!
150 Metronidazol 500 mg Tablet #REF! #REF! #REF!
151 Mikonazol Krim Tube #REF! 48 #REF! #REF!
152 Monoklorkamfer (Chkm) Botol #REF! #REF! #REF!
153 Na Bicarbonas tab 500 mg Tablet #REF! 1000 #REF! #REF!
154 NaCl 0,9 Infus Botol #REF! #REF! #REF!
155 Na Diklofenak Tab 25 mg Tablet #REF! #REF! #REF!
156 Na Diklofenak Tab 50 mg Tablet #REF! 200 #REF! #REF!
157 Nifedipin Tablet #REF! #REF! #REF!
158 Nistatin Tab Tablet #REF! #REF! #REF!
159 Norit Tab Tablet #REF! #REF! #REF!
160 OBH Sirup Botol #REF! #REF! #REF!
161 OCO Botol #REF! #REF! #REF!
162 Oksitetra SK 3 % Tube #REF! #REF! #REF!
163 Oksitetra SM 1 % Tube #REF! #REF! #REF!
164 Oksitosin Inj Ampul #REF! 50 #REF! #REF!
165 Omeprazol Kap Kaplet #REF! #REF! #REF!
166 PTU tab 100 mg Tablet #REF! 500 #REF! #REF!
167 Papaverin tab 40 mg Tablet #REF! #REF! #REF!
168 Paraformaldehid tab 1 gram Tablet #REF! #REF! #REF!
169 Parasetamol tab 500 mg Tablet 2945 10000 -7055

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
170 Parasetamol Sirup Botol #REF! 84 #REF! #REF!
171 Parasetamol Drop Botol #REF! #REF! #REF!
172 Pembalut Gips Rol #REF! #REF! #REF!
173 Pengikat Tali Pusat Buah #REF! #REF! #REF!
174 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! #REF!
175 Piridoxin (B6) tab 10 mg Tablet #REF! 3000 #REF! #REF!
176 Piroksikam 20 mg Tablet #REF! #REF! #REF!
177 Plester Rol #REF! 5 #REF! #REF!
178 Plester 5x5 Rol #REF! #REF! #REF!
179 Pov Yodida 60 ml Botol #REF! #REF! #REF!
180 Pov Yodida 10 % 300 ml Botol #REF! #REF! #REF!
181 PP2TU Botol #REF! #REF! #REF!
182 Prednison tab 5 mg Tablet #REF! 5000 #REF! #REF!
183 Primaquin Tab Tablet #REF! #REF! #REF!
184 Propranolol tab 10 mg Tablet #REF! #REF! #REF!
185 Propranolol tab 40 mg Tablet #REF! #REF! #REF!
186 Pyrazinamid tab 500 mg Tablet #REF! #REF! #REF!
187 Ranitidin Tab Tablet #REF! 1000 #REF! #REF!
188 Rifampisin 300 mg Kapsul #REF! #REF! #REF!
189 Rifampisin 450 mg Kapsul #REF! #REF! #REF!
190 Rifampisin 500 mg Kapsul #REF! #REF! #REF!
191 Ringer Lactat Infus Botol #REF! 10 #REF! #REF!
192 Salbutamol Tab 2 mg Tablet #REF! #REF! #REF!
193 Salbutamol Tab 4 mg Tablet #REF! #REF! #REF!
194 Salep 2-4 Komb Pot/30g #REF! 24 #REF! #REF!
195 Salisil Bedak 2 % Bks/50g #REF! #REF! #REF!
196 Serum ABU inj Vial #REF! #REF! #REF!
197 Serum Anti Tetanus inj 1500 IU Ampul #REF! #REF! #REF!
198 Semen Seng Phospat Set #REF! #REF! #REF!
199 Sianokobalamin Tab Tablet #REF! #REF! #REF!
200 Silk (Benang bedah + JJ) Sachet #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
201 Simetidin tab 200 mg Tablet #REF! #REF! #REF!
202 Simvastatin Tab Tablet #REF! #REF! #REF!
203 Siprofloxasin kap 500 mg Kapsul #REF! #REF! #REF!
204 Spironolacton Tab 25 mg Tablet #REF! #REF! #REF!
205 Spon Gelatin Kotak #REF! #REF! #REF!
206 Sulfa Setamid TM 5 % Botol #REF! #REF! #REF!
207 Tablet + DARAH Tablet #REF! #REF! #REF!
208 Temporary Flacher 2btl/set #REF! #REF! #REF!
209 Tetra kap 250 mg Kapsul #REF! 2000 #REF! #REF!
210 Tetra kap 500 mg Kapsul #REF! 1000 #REF! #REF!
211 Tetrakain TM 0,5 % Botol #REF! #REF! #REF!
212 Tiamin (B1) Tab 50 mg Tablet #REF! #REF! #REF!
213 Trihexi Fenidil tab 2 mg Tablet #REF! #REF! #REF!
214 Vaksin Rabies Vero Set 4 ktk #REF! #REF! #REF!
215 Verapamil Tab 80 mg Tablet #REF! #REF! #REF!
216 Vitamin B komplekx tab Tablet #REF! 2000 #REF! #REF!
217 Wing Nedle Buah #REF! #REF! #REF!
218 Zinc Tab Tablet #REF! #REF! #REF!
219 Zinc Sirup Botol #REF! #REF! #REF!
II. ALAT LABOR
1 Anti Sera Gol Darah Set #REF! #REF! #REF!
2 Aquadest Set #REF! 1 #REF! #REF!
3 Aqua Pro Injeksi Vial #REF! 6 #REF! #REF!
4 Dengue Antigen Cassete Buah #REF! #REF! #REF!
5 Dengue IgM & IgG Cassete Buah #REF! #REF! #REF!
6 Malaria PV & PV Cassete Buah #REF! #REF! #REF!
7 Lrt Asam Asetat Btl/100 #REF! #REF! #REF!
8 Lrt Asam Sulfosalisilat 20% Btl/100 #REF! #REF! #REF!
9 Lat Asam Klorida 0,1 N Btl/100 #REF! #REF! #REF!
10 Lat BaCl Btl/100 #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
11 Lrt Benedict Btl/100 #REF! #REF! #REF!
12 Lrt Eosin 2 % Btl/100 #REF! #REF! #REF!
13 Lrt Etanol Asam Btl/100 #REF! #REF! #REF!
14 Lrt Faucet Btl/100 #REF! #REF! #REF!
15 Lrt Gabbet Btl/100 #REF! #REF! #REF!
16 Lrt Giemsa Stain Btl/100 #REF! #REF! #REF!
17 Lrt Imersion Oil Btl/100 #REF! #REF! #REF!
18 Lrt Karbo Fuksin Btl/100 #REF! #REF! #REF!
19 Lrt Metanol Btl/100 #REF! #REF! #REF!
20 Lrt Metilen Blue Btl/100 #REF! #REF! #REF!
21 Lrt Sodium Citrate Buah #REF! #REF! #REF!
22 Lrt Turk Buah #REF! #REF! #REF!
23 Lrt Hayem Buah #REF! #REF! #REF!
24 Lart. Xilene Pcs #REF! #REF! #REF!
25 Lancet Darah Buah #REF! 100 #REF! #REF!
26 Objeck Glass Buah #REF! 360 #REF! #REF!
27 Cover Glass Helai #REF! 100 #REF! #REF!
28 Hand Scoon Helai #REF! 100 #REF! #REF!
29 Masker Bks #REF! #REF! #REF!
30 Kotak Slide Buah #REF! #REF! #REF!
31 Kertas Saring Buah #REF! #REF! #REF!
32 Kertas Lakmus Buah #REF! #REF! #REF!
33 Tissue Lensa Buah #REF! #REF! #REF!
34 Test Kehamilan Buah #REF! #REF! #REF!
35 Test Iodin Buah #REF! #REF! #REF!
36 Test Malaria Buah #REF! #REF! #REF!
37 Test DBD Buah #REF! #REF! #REF!
38 Test Protein Glucosa Buah #REF! #REF! #REF!
39 Pot Sputum Buah #REF! #REF! #REF!
40 Tissue Gulung Rol #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
III. OBAT GIZI
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Lipiodol Kap Iodium Kap #REF! #REF! #REF!
3 Tablet + Darah Tablet #REF! #REF! #REF!
4 Sirup + Darah Btl #REF! #REF! #REF!
5 Albendazol Tab Tablet #REF! #REF! #REF!
6 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! #REF!
7 Vitamin A 200 000 Kap #REF! 2400 #REF! #REF!
8 Vitamin A 100 000 Kap #REF! 450 #REF! #REF!
IV. OBAT MALARIA
1 ACT Tablet #REF! #REF! #REF!
2 OAM Tablet #REF! #REF! #REF!
3 Artediaquin Tab Tablet #REF! #REF! #REF!
4 Doksisiklin Tab 100 mg Tablet #REF! #REF! #REF!
5 Primaquin Tab Tablet #REF! #REF! #REF!
6 Tablet + Darah Tablet #REF! #REF! #REF!
V. OBAT TB PARU
1 Obat TB Kat I Pkt #REF! #REF! #REF!
2 Obat TB Kat II Pkt #REF! #REF! #REF!
3 Obat TB Kat III Pkt #REF! #REF! #REF!
4 Obat TB Kat Sisipan Pkt #REF! #REF! #REF!
5 Obat TB Kat Anak Pkt #REF! 2 #REF! #REF!

VI. OBAT ISPA

1 Parasetamol tab 500 mg Tablet #REF! #REF! #REF!
2 Kotri 480 Tablet #REF! #REF! #REF!
VII. OBAT DIARE
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Zinc Tab Tablet #REF! #REF! #REF!
VIII. OBAT KIA
1 MgSO4 20% Btl #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
2 MgSO4 40% Btl #REF! #REF! #REF!
3 Oksitosin Inj Ampul #REF! #REF! #REF!
4 Fetomenadion Inj Ampul #REF! #REF! #REF!
IX. VAKSIN
1 BCG #REF! 30 #REF! 30 #REF!
2 DPT-HB-HIB #REF! #REF! #REF!
3 Uni Ject 36 50 86 86
4 TT #REF! #REF! #REF!
5 DT #REF! #REF! #REF!
6 POLIO #REF! 30 #REF! 30 #REF!
7 Campak 19 500 519 300 219
8 Pentabio 40 40 38 2

UMUM
KUNJUNGAN RESEP KS
BAYAR TDK BYR

343 4 1131

Mengetahui / Menyetujui Yang Menyerahkan

Ka. Dinas Kesehatan Ka Instalasi Farmasi
Kabupaten Lima Puluh Kota

dr. H Adel Nofiarman Anton.S.Si,Apt

NIP : 19650914 199803 1 002 NIP : 19720803 200212 1 003

CTT IFK : Tgl dikeluarkan dari Gud

Catt : LPLPO pada bulan permintaan dibuat rangkap 3 (Tiga)
a. 1 (Satu) rangkap ke Dinas Kesehatan
b. 2 (Dua) rangkap dikirim langsung ke Instalasi Farmasi Kabupaten
MBAR PERMINTAAN OBAT
O) LB.2

BULAN : AGUSTUS TAHUN : 2016

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
ES PKD

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

BOR
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
IZI
LARIA

PARU

SPA

ARE

KIA

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

N
 TOTAL R/ OBAT
ASKES JUMLAH TOTAL R/
GENERIK

111 1589 4543

Yang Melapor / Meminta Diterima

Tgl :
Kepala Puskesmas Pengelola OBAT

Budi Margana, SKM Meri Elfiati, Amd.Farm

NIP : 19680708 199403 1 007 NIP : 19690615 199403 2 009

: Tgl dikeluarkan dari Gudang IFK

 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
(LP LPO)
KODE PUSKESMAS :
PUSKESMAS : PAKAN RABAA
KECAMATAN : LAREH SAGO HALABAN
KABUPATEN : LIMA PULUH KOTA
PROPINSI : SUMATERA BARAT
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
I. OBAT / ALKES PKD
1 Acetosal Tab 500 mg Tablet #REF! #REF! #REF!
2 Acetosal Tab 100 mg Tablet #REF! #REF! #REF!
3 Acyclovir Tab 200 mg Tablet #REF! #REF! #REF!
4 Acyclovir Tab 400 mg Tablet #REF! #REF! #REF!
5 Acyclovir Krim Tube #REF! #REF! #REF!
6 Air Raksa dental use Botol #REF! #REF! #REF!
7 Alat suntik skl pakai 1 ml Set #REF! #REF! #REF!
8 Alat suntik skl pakai 5 ml Set #REF! #REF! #REF!
9 Alat suntik skl pakai 2,5 ml Set #REF! #REF! #REF!
10 Alprazolam tab 0,5 mg Tablet #REF! #REF! #REF!
11 Allopurinol tab 100 mg Tablet #REF! #REF! #REF!
12 Allopurinol tab 300 mg Tablet #REF! #REF! #REF!
13 Ambroxol tab Tablet #REF! #REF! #REF!
14 Ambroxol syr Tablet #REF! #REF! #REF!
15 Aminophylin inj Ampul #REF! #REF! #REF!
16 Aminophylin tab Tablet #REF! #REF! #REF!
17 Amitriptilin tab Tablet #REF! #REF! #REF!
18 Amlodipin tab 5 mg Tablet #REF! #REF! #REF!
19 Amlodipin tab 10 mg Tablet #REF! #REF! #REF!
20 Amoxicilin dry sir Botol 0 0

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
21 Amoxicilin kap 500 mg Kaplet #REF! #REF! #REF!
22 Antasida DOEN sirup Botol #REF! #REF! #REF!
23 Antasida DOEN tab Tablet #REF! #REF! #REF!
24 Anti Bakteri Salf Pot #REF! #REF! #REF!
25 Anti Fungi Doen (WF) slp Pot/30g #REF! #REF! #REF!
26 Anti Haemorhoid Suppos Suppos #REF! #REF! #REF!
27 Anti Migren D komb Tablet #REF! #REF! #REF!
28 As Ascorbic Tab 25 mg (Vit C) Tablet #REF! #REF! #REF!
29 As Ascorbic Tab 50 mg (Vit C) Tablet #REF! #REF! #REF!
30 Asam Folat Tab 1 mg Tablet #REF! #REF! #REF!
31 Asam Folat Tab 5 mg Tablet #REF! #REF! #REF!
32 Asam Mefenamat 500 mg Kaplet #REF! #REF! #REF!
33 Asam Traneksamat Injeksi Ampul #REF! #REF! #REF!
34 Asam Traneksamat Tablet Tablet #REF! #REF! #REF!
35 Attapulgit Tab Tablet #REF! #REF! #REF!
36 Atropin Sulfat Tab Tablet #REF! #REF! #REF!
37 Atropin Sulfat Injeksi Ampul #REF! #REF! #REF!
38 Betahistin Tab Tablet #REF! #REF! #REF!
39 Betametason slp Tube #REF! #REF! #REF!
40 Bisakodil Suppos Suppos #REF! #REF! #REF!
41 Carbamazepin 200 mg Tablet #REF! #REF! #REF!
42 Cat Gut + Jarum bedah Set #REF! #REF! #REF!
43 Cetrizin Tab Tablet #REF! #REF! #REF!
44 Cetrizin Sirup Botol #REF! #REF! #REF!
45 Devitalisasi Pata (obat gigi) Pot #REF! #REF! #REF!
46 Dexametason inj Ampul #REF! #REF! #REF!
47 Dexametason tab 0,5 mg Tablet #REF! #REF! #REF!
48 Diazepam tab 2 mg Tablet #REF! #REF! #REF!
49 Diazepam inj Ampul #REF! #REF! #REF!
50 Diazepam Rectal 2 mg Buah #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
51 Diazepam Rectal 5 mg Buah #REF! #REF! #REF!
52 Diazepam Rectal 10 mg Buah #REF! #REF! #REF!
53 Difenhidramin inj Ampul #REF! #REF! #REF!
54 Digoxin tab 0,25 mg Tablet #REF! #REF! #REF!
55 Diltiazem Tab Tablet #REF! #REF! #REF!
56 Dimenhidrinat Tab Tablet #REF! #REF! #REF!
57 Domperidon Tab Tablet #REF! #REF! #REF!
58 Domperidon Suspensi Botol #REF! #REF! #REF!
59 Doksisiklin Tablet Tablet #REF! #REF! #REF!
60 Efedrin tab 25 mg Tablet #REF! #REF! #REF!
61 Epinefrin inj Ampul #REF! #REF! #REF!
62 Erytromisin Kap 250 mg Kaplet #REF! #REF! #REF!
63 Erytromisin Kap 500 mg Kaplet #REF! #REF! #REF!
64 Erytromisin Sirup Botol #REF! #REF! #REF!
65 Etakridin lrt 0,1 Botol #REF! #REF! #REF!
66 Etambutol 500 mg Tablet #REF! #REF! #REF!
67 Etanol 70 % Botol #REF! #REF! #REF!
68 Etilklorida semprot Botol #REF! #REF! #REF!
69 Eugenol Cairan Botol #REF! #REF! #REF!
70 Ergotamin Coffein 1 mg Tablet #REF! #REF! #REF!
71 Extrac Belad 100 mg Tablet #REF! #REF! #REF!
72 Fenitoin Na Kap 100 mg Kapsul #REF! #REF! #REF!
73 Fenobarbital tab 30 mg Tablet #REF! #REF! #REF!
74 Fenobarbital injeksi Ampul #REF! #REF! #REF!
75 Fenol Glyserol Lrt TT Botol #REF! #REF! #REF!
76 Fitomenadion inj Ampul #REF! #REF! #REF!
77 Fitomenadion tab 10 mg Tablet #REF! #REF! #REF!
78 Furosemid tab 40 mg Tablet #REF! #REF! #REF!
79 Furosemid Injeksi Ampul #REF! #REF! #REF!
80 G Guayakolat tab 100 mg Tablet 0 0

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
81 Garam Inggris (Mg SO4) Sace #REF! #REF! #REF!
82 Garam Oralit 200 ml Sace #REF! #REF! #REF!
83 Gentian Violet lrt Botol #REF! #REF! #REF!
84 Gentamicyn injeksi Ampul #REF! #REF! #REF!
85 Glass lonomer (ART) Botol #REF! #REF! #REF!
86 Glibenklamid tab 5 mg Tablet #REF! #REF! #REF!
87 Glimepiride Tab 1 mg Tablet #REF! #REF! #REF!
88 Glimepiride Tab 2 mg Tablet #REF! #REF! #REF!
89 Glukosa 5 % infus Botol #REF! #REF! #REF!
90 Glukosa 10 % infus Botol #REF! #REF! #REF!
91 Griseofulvin tab 125 mg Tablet #REF! #REF! #REF!
92 Griseofulvin tab 500 mg Tablet #REF! #REF! #REF!
93 H C T tab 25 mg Tablet #REF! #REF! #REF!
94 Halloperidol tab 1,5 mg Tablet #REF! #REF! #REF!
95 Halloperidol tab 5 mg Tablet #REF! #REF! #REF!
96 Halloperidol Injeksi Ampul #REF! #REF! #REF!
97 H2O2 Larutan 50 % Botol #REF! #REF! #REF!
98 Hidrokortison slp 2,5 % Tube #REF! #REF! #REF!
99 Ichtyol Salep Pot #REF! #REF! #REF!
100 INH Tab 100 mg Tablet #REF! #REF! #REF!
101 INH Tab 300 mg Tablet #REF! #REF! #REF!
102 Ibuprofen 200 mg Tablet #REF! #REF! #REF!
103 Ibuprofen 400 mg Tablet #REF! #REF! #REF!
104 Ibuprofen Suspensi Botol #REF! #REF! #REF!
105 Infusion set anak Set #REF! #REF! #REF!
106 Infusion set dws Set #REF! #REF! #REF!
107 Isosorbid DNT tab mg Tablet #REF! #REF! #REF!
108 IV catheter no 18 Buah #REF! #REF! #REF!
109 IV catheter no 20 Buah #REF! #REF! #REF!
NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA
AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
110 IV catheter no 22 Buah #REF! #REF! #REF!
111 IV catheter no 24 Buah #REF! #REF! #REF!
112 KODEIN Tab 10 mg Tablet #REF! #REF! #REF!
113 KODEIN Tab 20 mg Tablet #REF! #REF! #REF!
114 Kal Permanganat Kristal Pot #REF! #REF! #REF!
115 Kals Hidroksida Pata Set #REF! #REF! #REF!
116 Kals Lactas Tab 500 mg Tablet #REF! #REF! #REF!
117 Kapas Berlemak Rol #REF! #REF! #REF!
118 Kapas Pembalut 250 gr Bks #REF! #REF! #REF!
119 Kapas Pembalut 1000 gr Bks #REF! #REF! #REF!
120 Kaptopril tab 25 mg Tablet #REF! #REF! #REF!
121 Kaptopril tab 12,5 mg Tablet #REF! #REF! #REF!
122 Kassa 4x3 xm Tablet #REF! #REF! #REF!
123 Kassa 4m x 15cm Rol #REF! #REF! #REF!
124 Kassa Pembalut 2m x 80cm Rol #REF! #REF! #REF!
125 Kassa Steril 40/40 Rol #REF! #REF! #REF!
126 Ketokonazol Tab Tablet #REF! #REF! #REF!
127 Ketokonazol Krim Tube #REF! #REF! #REF!
128 Kloramfenicol kap 250 mg Kapsul #REF! #REF! #REF!
129 Kloramfenicol SK Tube #REF! #REF! #REF!
130 Kloramfenicol SM 1 % Tube #REF! #REF! #REF!
131 Kloramfenicol TM 0,5 % Botol #REF! #REF! #REF!
132 Kloramfenicol TT 3 % Botol #REF! #REF! #REF!
133 Kloramfenicol Suspensi Botol #REF! #REF! #REF!
134 Klorfeniramin Mal Tab 4 mg Tablet #REF! #REF! #REF!
135 Klorpromazin Inj 25 mg/ml Ampul #REF! #REF! #REF!
136 Klorpronazin Tab 100 mg Tablet #REF! #REF! #REF!
137 Kotri Tab 480 mg Tablet #REF! #REF! #REF!
138 Kotro Suspensi Botol #REF! #REF! #REF!
139 Levetran Zalf Pot #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
140 Lidocain Comp Inj Ampul #REF! #REF! #REF!
141 Lidocain 2 % Jelly Ampul #REF! #REF! #REF!
142 Lisol ~ Kresol 50 % Botol #REF! #REF! #REF!
143 Loratadine Tablet Tablet #REF! #REF! #REF!
144 Mag Slang Set #REF! #REF! #REF!
145 Megotrin Inj 0,2 mg / 1 ml Ampul #REF! #REF! #REF!
146 Megotrin Tab 0,125 mg Tablet #REF! #REF! #REF!
147 Metformin Tab Tablet #REF! #REF! #REF!
148 Metoklopramid Tab Tablet #REF! #REF! #REF!
149 Metronidazol 250 mg Tablet #REF! #REF! #REF!
150 Metronidazol 500 mg Tablet #REF! #REF! #REF!
151 Mikonazol Krim Tube #REF! #REF! #REF!
152 Monoklorkamfer (Chkm) Botol #REF! #REF! #REF!
153 Na Bicarbonas tab 500 mg Tablet #REF! #REF! #REF!
154 NaCl 0,9 Infus Botol #REF! #REF! #REF!
155 Na Diklofenak Tab 25 mg Tablet #REF! #REF! #REF!
156 Na Diklofenak Tab 50 mg Tablet #REF! #REF! #REF!
157 Nifedipin Tablet #REF! #REF! #REF!
158 Nistatin Tab Tablet #REF! #REF! #REF!
159 Norit Tab Tablet #REF! #REF! #REF!
160 OBH Sirup Botol #REF! #REF! #REF!
161 OCO Botol #REF! #REF! #REF!
162 Oksitetra SK 3 % Tube #REF! #REF! #REF!
163 Oksitetra SM 1 % Tube #REF! #REF! #REF!
164 Oksitosin Inj Ampul #REF! #REF! #REF!
165 Omeprazol Kap Kaplet #REF! #REF! #REF!
166 PTU tab 100 mg Tablet #REF! #REF! #REF!
167 Papaverin tab 40 mg Tablet #REF! #REF! #REF!
168 Paraformaldehid tab 1 gram Tablet #REF! #REF! #REF!
169 Parasetamol tab 500 mg Tablet 0 0

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
170 Parasetamol Sirup Botol #REF! #REF! #REF!
171 Parasetamol Drop Botol #REF! #REF! #REF!
172 Pembalut Gips Rol #REF! #REF! #REF!
173 Pengikat Tali Pusat Buah #REF! #REF! #REF!
174 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! #REF!
175 Piridoxin (B6) tab 10 mg Tablet #REF! #REF! #REF!
176 Piroksikam 20 mg Tablet #REF! #REF! #REF!
177 Plester Rol #REF! #REF! #REF!
178 Plester 5x5 Rol #REF! #REF! #REF!
179 Pov Yodida 60 ml Botol #REF! #REF! #REF!
180 Pov Yodida 10 % 300 ml Botol #REF! #REF! #REF!
181 PP2TU Botol #REF! #REF! #REF!
182 Prednison tab 5 mg Tablet #REF! #REF! #REF!
183 Primaquin Tab Tablet #REF! #REF! #REF!
184 Propranolol tab 10 mg Tablet #REF! #REF! #REF!
185 Propranolol tab 40 mg Tablet #REF! #REF! #REF!
186 Pyrazinamid tab 500 mg Tablet #REF! #REF! #REF!
187 Ranitidin Tab Tablet #REF! #REF! #REF!
188 Rifampisin 300 mg Kapsul #REF! #REF! #REF!
189 Rifampisin 450 mg Kapsul #REF! #REF! #REF!
190 Rifampisin 500 mg Kapsul #REF! #REF! #REF!
191 Ringer Lactat Infus Botol #REF! #REF! #REF!
192 Salbutamol Tab 2 mg Tablet #REF! #REF! #REF!
193 Salbutamol Tab 4 mg Tablet #REF! #REF! #REF!
194 Salep 2-4 Komb Pot/30g #REF! #REF! #REF!
195 Salisil Bedak 2 % Bks/50g #REF! #REF! #REF!
196 Serum ABU inj Vial #REF! #REF! #REF!
197 Serum Anti Tetanus inj 1500 IU Ampul #REF! #REF! #REF!
198 Semen Seng Phospat Set #REF! #REF! #REF!
199 Sianokobalamin Tab Tablet #REF! #REF! #REF!
200 Silk (Benang bedah + JJ) Sachet #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
201 Simetidin tab 200 mg Tablet #REF! #REF! #REF!
202 Simvastatin Tab Tablet #REF! #REF! #REF!
203 Siprofloxasin kap 500 mg Kapsul #REF! #REF! #REF!
204 Spironolacton Tab 25 mg Tablet #REF! #REF! #REF!
205 Spon Gelatin Kotak #REF! #REF! #REF!
206 Sulfa Setamid TM 5 % Botol #REF! #REF! #REF!
207 Tablet + DARAH Tablet #REF! #REF! #REF!
208 Temporary Flacher 2btl/set #REF! #REF! #REF!
209 Tetra kap 250 mg Kapsul #REF! #REF! #REF!
210 Tetra kap 500 mg Kapsul #REF! #REF! #REF!
211 Tetrakain TM 0,5 % Botol #REF! #REF! #REF!
212 Tiamin (B1) Tab 50 mg Tablet #REF! #REF! #REF!
213 Trihexi Fenidil tab 2 mg Tablet #REF! #REF! #REF!
214 Vaksin Rabies Vero Set 4 ktk #REF! #REF! #REF!
215 Verapamil Tab 80 mg Tablet #REF! #REF! #REF!
216 Vitamin B komplekx tab Tablet #REF! #REF! #REF!
217 Wing Nedle Buah #REF! #REF! #REF!
218 Zinc Tab Tablet #REF! #REF! #REF!
219 Zinc Sirup Botol #REF! #REF! #REF!
II. ALAT LABOR
1 Anti Sera Gol Darah Set #REF! #REF! #REF!
2 Aquadest Set #REF! #REF! #REF!
3 Aqua Pro Injeksi Vial #REF! #REF! #REF!
4 Dengue Antigen Cassete Buah #REF! #REF! #REF!
5 Dengue IgM & IgG Cassete Buah #REF! #REF! #REF!
6 Malaria PV & PV Cassete Buah #REF! #REF! #REF!
7 Lrt Asam Asetat Btl/100 #REF! #REF! #REF!
8 Lrt Asam Sulfosalisilat 20% Btl/100 #REF! #REF! #REF!
9 Lat Asam Klorida 0,1 N Btl/100 #REF! #REF! #REF!
10 Lat BaCl Btl/100 #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
11 Lrt Benedict Btl/100 #REF! #REF! #REF!
12 Lrt Eosin 2 % Btl/100 #REF! #REF! #REF!
13 Lrt Etanol Asam Btl/100 #REF! #REF! #REF!
14 Lrt Faucet Btl/100 #REF! #REF! #REF!
15 Lrt Gabbet Btl/100 #REF! #REF! #REF!
16 Lrt Giemsa Stain Btl/100 #REF! #REF! #REF!
17 Lrt Imersion Oil Btl/100 #REF! #REF! #REF!
18 Lrt Karbo Fuksin Btl/100 #REF! #REF! #REF!
19 Lrt Metanol Btl/100 #REF! #REF! #REF!
20 Lrt Metilen Blue Btl/100 #REF! #REF! #REF!
21 Lrt Sodium Citrate Buah #REF! #REF! #REF!
22 Lrt Turk Buah #REF! #REF! #REF!
23 Lrt Hayem Buah #REF! #REF! #REF!
24 Lart. Xilene Pcs #REF! #REF! #REF!
25 Lancet Darah Buah #REF! #REF! #REF!
26 Objeck Glass Buah #REF! #REF! #REF!
27 Cover Glass Helai #REF! #REF! #REF!
28 Hand Scoon Helai #REF! #REF! #REF!
29 Masker Bks #REF! #REF! #REF!
30 Kotak Slide Buah #REF! #REF! #REF!
31 Kertas Saring Buah #REF! #REF! #REF!
32 Kertas Lakmus Buah #REF! #REF! #REF!
33 Tissue Lensa Buah #REF! #REF! #REF!
34 Test Kehamilan Buah #REF! #REF! #REF!
35 Test Iodin Buah #REF! #REF! #REF!
36 Test Malaria Buah #REF! #REF! #REF!
37 Test DBD Buah #REF! #REF! #REF!
38 Test Protein Glucosa Buah #REF! #REF! #REF!
39 Pot Sputum Buah #REF! #REF! #REF!
40 Tissue Gulung Rol #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
III. OBAT GIZI
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Lipiodol Kap Iodium Kap #REF! #REF! #REF!
3 Tablet + Darah Tablet #REF! #REF! #REF!
4 Sirup + Darah Btl #REF! #REF! #REF!
5 Albendazol Tab Tablet #REF! #REF! #REF!
6 Pirantel Pamoat Tab 125 mg Tablet #REF! #REF! #REF!
7 Vitamin A 200 000 Kap #REF! #REF! #REF!
8 Vitamin A 100 000 Kap #REF! #REF! #REF!
IV. OBAT MALARIA
1 ACT Tablet #REF! #REF! #REF!
2 OAM Tablet #REF! #REF! #REF!
3 Artediaquin Tab Tablet #REF! #REF! #REF!
4 Doksisiklin Tab 100 mg Tablet #REF! #REF! #REF!
5 Primaquin Tab Tablet #REF! #REF! #REF!
6 Tablet + Darah Tablet #REF! #REF! #REF!
V. OBAT TB PARU
1 Obat TB Kat I Pkt #REF! #REF! #REF!
2 Obat TB Kat II Pkt #REF! #REF! #REF!
3 Obat TB Kat III Pkt #REF! #REF! #REF!
4 Obat TB Kat Sisipan Pkt #REF! #REF! #REF!
5 Obat TB Kat Anak Pkt #REF! #REF! #REF!

VI. OBAT ISPA

1 Parasetamol tab 500 mg Tablet #REF! #REF! #REF!
2 Kotri 480 Tablet #REF! #REF! #REF!
VII. OBAT DIARE
1 Oralit 200 mg Bks #REF! #REF! #REF!
2 Zinc Tab Tablet #REF! #REF! #REF!
VIII. OBAT KIA
1 MgSO4 20% Btl #REF! #REF! #REF!

NO NAMA OBAT Satuan STOK PENERI PERSE PEMA SISA

AWAL MAAN DIAAN KAIAN STOK
1 2 3 4 5 6 7 8
2 MgSO4 40% Btl #REF! #REF! #REF!
3 Oksitosin Inj Ampul #REF! #REF! #REF!
4 Fetomenadion Inj Ampul #REF! #REF! #REF!
IX. VAKSIN
1 BCG #REF! #REF! #REF!
2 DPT-HB-HIB #REF! #REF! #REF!
3 Uni Ject 86 86 86
4 TT #REF! #REF! #REF!
5 DT #REF! #REF! #REF!
6 POLIO #REF! #REF! #REF!
7 Campak 219 219 219
 UMUM
KUNJUNGAN RESEP KS
BAYAR TDK BYR

397 8 1153

Mengetahui / Menyetujui Yang Menyerahkan

Ka. Dinas Kesehatan Ka Instalasi Farmasi
Kabupaten Lima Puluh Kota

dr. H Adel Nofiarman Anton.S.Si,Apt

NIP : 19650914 199803 1 002 NIP : 19720803 200212 1 003

CTT IFK : Tgl dikeluarkan dari Gud

Catt : LPLPO pada bulan permintaan dibuat rangkap 3 (Tiga)
a. 1 (Satu) rangkap ke Dinas Kesehatan
b. 2 (Dua) rangkap dikirim langsung ke Instalasi Farmasi Kabupaten
MBAR PERMINTAAN OBAT
O) LB.2

BULAN : SEPTEMBER TAHUN : 2016

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
ES PKD

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

BOR
 PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15
IZI
LARIA

PARU

SPA

ARE

KIA

PEMBERIAAN
PERMIN KET
TAAN PKD PKG tk II Pusat L Lain JML
9 10 11 12 13 14 15

N
 TOTAL R/ OBAT
ASKES JUMLAH TOTAL R/
GENERIK

158 1716 4856

Yang Melapor / Meminta Diterima

Tgl :
Kepala Puskesmas Pengelola OBAT

Budi Margana, SKM Meri Elfiati, Amd.Farm

NIP : 19680708 199403 1 007 NIP : 19690615 199403 2 009

: Tgl dikeluarkan dari Gudang IFK