Nama : Tanggal Lahir :

No RM :
PAKET SC (dr.Daniel Sp.Og)

No Nama Barang Terima Pakai Kembali Keterangan

1 T-DIO no 1 2 Sachet T- silk 1 ( 1 sachet)
2 T-Plain no 2/0 (90 Cm) 1 Sachet
3 T-Vio no 1, Safil no 1 2 Sachet
4 T-mono 4/0 1 Sachet
5 Spongostan 2 Buah
6 T- Chromic 1 / T- Chromic @ 1Sachet
1 Hepar
7 Atramat PGC 1 (150cm) 1 sachet
8 Chromic Roll no .........m
9 Plain Roll no .........m
10 Silk Roll no .........m
11 Surgical Mess no 10/15/20 @1 Sachet
12 Handscoon Gammex no 6,5 6 Sachet
13 Handscoon Gammex no 7 10 Sachet
14 Handscoon Gammex no 7,5 6 Sachet
15 Handscoon Gammex no 8 8 Sachet
16 Underpad 3 Buah
17 Catheter no 16 1 Buah
18 Urobag 1 Buah
19 Nasal Canul Dws 1 Buah
20 Noprostol 0,2 mg 4 Biji
21 Aquabidest 1000 cc 1 Flash
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m

26 Oksigen .........ltr
27 Aquabidest 25 ml 1 Flacon
28 Atropine Sulfate 0,25 mg 2 Amp
29 Epinephrine 50 mg 1 Amp
30 Lidocaine HCI 40 mg 3 Amp
31 Miloz 5 mg 1 Amp
32 Propofol 200 mg 1 Vial
33 Rocuronium 5 mg 1 Amp
34 Fentanyl 100 mcg 2 Amp
35 Pethidin HCI 100 mg 1 Amp
36 Morphine 10 mg 1 Amp
37 Metoclopramide 1 Amp
38 Ketorolac 30 mg 1 Amp
39 Antrain 500 mg 1 Amp
40 Neostigmine 0,5 mg 2 Amp
41 Aminophylline 240 mg 1 Amp
42 Ondansetron 4 mg 1 Amp
43 Ranitidine 50 mg 1 Amp
44 Dexamethasone 5 mg 2 Amp
45 Iphadryl 10 mg 1 Amp
46 Asam Traneksamat 500 mg 2 Amp
47 Phytomenadione 10 mg 1 Amp
48 Ca Gluconas 10% 1 Amp
49 Ropivel 150 mg /Regivel 1 Amp
50 Farsix 20 mg 2 Amp
51 Oxytocin 10 iu 10 Amp
52 Metvell 0,2 mg 2 Amp
53 Epedrine 1 amp
54 Granisetron 1 amp
55 WIDAHES 130 1 Flash
56 Ringer Laktat 500 cc 4 Flash
57 NaCl 0,9% 500 cc 3 Flash
58 Elektroda EKG0 3 Biji
59 Spinocan no 26/27 @1 Buah
60 Spuit no 3 cc/5 cc/10 cc @4 Buah
61 Dexketoprofen inj 1 Amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET SC (dr.Novi Sp.Og)

No Nama Barang Terima Pakai Kembali Keterangan

1 T-Mono no 1 2 Sachet
2 T-Plain no 2/0 (90Cm) 2 Sachet
3 T-Vio no 1, Safil no 1 2 Sachet
4 T-mono 4/0 1 Sachet
5 Spongostan 2 Buah
6 T- Chromic 1 / T- Chromic 1Sachet / 3
1 Hepar Sachet
7 T-DIO no. 1 2 Sachet
8 T- silk 1 1 sachet
9 Plain Roll no .........m
10 Silk Roll no .........m
11 Surgical Mess no 10/15/20 @1 Sachet
12 Handscoon Gammex no 6,5 6 Sachet
13 Handscoon Gammex no 7 10 Sachet
14 Handscoon Gammex no 7,5 6 Sachet
15 Handscoon Gammex no 8 8 Sachet
16 Underpad 3 Buah
17 Catheter no 16 1 Buah
18 Urobag 1 Buah
19 Nasal Canul Dws 1 Buah
20 Noprostol 0,2 mg 4 Biji
21 Aquabidest 1000 cc 1 Flash
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m
26 SANMOL/FIORAMOL INF 1 Flash
Obat Anestesi
1 Oksigen .........ltr
2 Aquabidest 25 ml 1 Flacon
3 Atropine Sulfate 0,25 mg 2 Amp
4 Epinephrine 50 mg 1 Amp
5 Lidocaine HCI 40 mg 3 Amp
6 Miloz 5 mg 1 Amp
7 Propofol 200 mg 1 Vial
8 Rocuronium 5 mg 1 Amp
9 Fentanyl 100 mcg 2 Amp
10 Pethidin HCI 100 mg 1 Amp
11 Morphine 10 mg 1 Amp
12 Metoclopramide 1 Amp
13 Ketorolac 30 mg 1 Amp
14 Antrain 500 mg 1 Amp
15 Neostigmine 0,5 mg 2 Amp
16 Aminophylline 240 mg 1 Amp
17 Ondansetron 4 mg 1 Amp
18 Ranitidine 50 mg 1 Amp
19 Dexamethasone 5 mg 2 Amp
20 Iphadryl 10 mg 1 Amp
21 Asam Traneksamat 500 mg 2 Amp
22 Phytomenadione 10 mg 1 Amp
23 Ca Gluconas 10% 1 Amp
24 Ropivel 150 mg /Regivel 1 Amp
25 Farsix 20 mg 2 Amp
26 Oxytocin 10 iu 10 Amp
27 Metvell 0,2 mg 2 Amp
28 Epedrine 1 amp
29 Granisetron 1 amp
30 WIDAHES 130 1 Flash
31 Ringer Laktat 500 cc 4 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 Elektroda EKG0 3 Biji
34 Spinocan no 26/27 @1 Buah
35 Spuit no 3 cc/5 cc/10 cc @4 Buah
36 Dexketoprofen inj 1 Amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :

PAKET SC (dr.Zaki Sp.Og)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2 2Sachet
2 T-Plain no 2/0 1Sachet
3 T-Vio no 1, Safil no 1 3Sachet
4 T-Mono no 4/0 1 Sachet
5 T-Chromic 2/0 round 1 Sachet
6 T- Chromic 1 1 Buah
7 Chromic Roll no .........m
8 Plain Roll no .........m
9 Silk Roll no .........m
10 Surgical Mess no 10/20 @1 Sachet
11 Handscoon Gammex no 6,5 4 Sachet
12 Handscoon Gammex no 7 8 Sachet
13 Handscoon Gammex no 7,5 10 Sachet
14 Handscoon Gammex no 8 8 Sachet
15 Underpad 3 Buah
16 Catheter no 16 1 Buah
17 Urobag 1 Buah
18 Nasal Canul Dws 1 Buah
19 Noprostol 0,2 mg 4 Biji
20 Povidone Iodine 10% .........cc
21 Alkohol 70% .........cc
22 Kasa Steril .........m
23 Hypavix .........m
Obat Anestesi
1 Oksigen .........ltr
2 Aquabidest 25 ml 1 Flacon
3 Atropine Sulfate 0,25 mg 2 Amp
4 Epinephrine 50 mg 1 Amp
5 Lidocaine HCI 40 mg 3 Amp
6 Miloz 5 mg 1 Amp
7 Propofol 200 mg 1 Vial
8 Epedrine 1 Amp
9 Fentanyl 100 mcg 2 Amp
10 Rocuronium 5 mg 2 Amp
11 Morphine 10 mg 1 Amp
12 Pethidin HCI 100 mg 1 Amp
13 Ketorolac 30 mg 1 Amp
14 Antrain 500 mg 1 Amp
15 Neostigmine 0,5 mg 2 Amp
16 Aminophylline 240 mg 1 Amp
17 Ondansetron 4 mg 1 Amp
18 Ranitidine 50 mg 1 Amp
19 Dexamethasone 5 mg 2 Amp
20 Iphadryl 10 mg 1 Amp
21 Asam Traneksamat 500 mg 2 Amp
22 Phytomenadione 10 mg 1 Amp
23 Metoclopramide 1 Amp
24 Ropivel 150 mg /Regivel 1 Amp
25 Farsix 20 mg 2 Amp
26 Oxytocin 10 iu 10 Amp
27 Metvell 0,2 mg 2 Amp
28 Epedrine 1 Amp
29 Ca Gluconas 10% 1 Amp
30 Granisetron 1 Amp
31 Ringer Laktat 500 cc 4 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 WIDAHES 130 1 Flash
34 Elektroda EKG 3 Biji
35 Spinocan no 26/27 @1 Buah
36 Spuit no 3 cc/5 cc/10 cc @4 Buah
37 Dexketoprofen inj 1 Amp

Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....

Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY KABER (dr.Daniel Sp.Og)

No Nama Barang Terima Pakai Kembali Keterangan

1 T-Chromic no 2 3 Sachet
2 T-Chromic no 2/0 3 Sachet
3 T-Mono no 1 3 Sachet
4 T-Plain no 2/0 2 Sachet
5 T-Vio no 1, Safil no 1 1 Sachet
6 T-Mono no 4/0 1 Sachet
7 T-Chromic no 1 HEPAR 3 Sachet
8 Plain Roll no .........m
9 Silk Roll no .........m
10 Surgical Mess no 10/15/20 @1 Sachet
11 Handscoon Gammex no 6,5 6 Sachet
12 Handscoon Gammex no 7 10 Sachet
13 Handscoon Gammex no 7,5 6 Sachet
14 Handscoon Gammex no 8 10 Sachet
15 Underpad 2 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 NGT no 16 1 Buah
19 Spongostan 2 Buah
20 Rectal Tube no 28 1 Buah
21 Nasal Canul Dws 1 Buah
22 Aquabidest 1000 cc 2 flash
23 Povidone Iodine 10% .........cc
24 Alkohol 70% .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen .........ltr
2 Aquabidest 25 ml 1 Flacon
3 Atropine Sulfate 0,25 mg 2 Amp
4 Epinephrine 50 mg 1 Amp
5 Lidocaine HCI 40 mg 3 Amp
6 Miloz 5 mg 1 Amp
7 Propofol 200 mg 1 Vial
8 Epedrine 1 Amp
9 Fentanyl 100 mcg 2 Amp
10 Tramus 25 mg 2 Amp
11 Morphine 10 mg 1 Amp
12 Pethidin HCI 50mg 1 Amp
13 Ketorolac 30 mg 1 Amp
14 Antrain 500 mg 1 Amp
15 Neostigmine 0,5 mg 2 Amp
16 Aminophylline 240 mg 1 Amp
17 Ondansetron 4 mg 1 Amp
18 Ranitidine 50 mg 1 Amp
19 Dexamethasone 5 mg 2 Amp
20 Iphadryl 10 mg 1 Amp
21 Asam Traneksamat 500 mg 2 Amp
22 Phytomenadione 10 mg 1 Amp
23 Rocuronium 5 mg 1 Vial
24 Ropivel 150 mg /Regivel 1 Amp
25 Farsix 20 mg 2 Amp
26 Udopa 200 mg 1 Amp
27 Ca Gluconas 10% 1 Amp
28 Granisetron 1 Amp
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 2 Flash
31 WIDAHES 130 1 Flash
32 Elektroda EKG 3 Biji
33 Spinocan no 26/27 @1 Buah
34 Spuit no 3 cc/5 cc/10 cc @4 Buah
35 Dexketoprofen inj 1 Amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY KABER (dr.Novi Sp.Og)

No Nama Barang Terima Pakai Kembali Keterangan

1 T-Chromic no 2 3 Sachet
2 T-Chromic no 2/0 3 Sachet
3 T-Mono no 1 3 Sachet
4 T-Plain no 2/0 2 Sachet
5 T-Vio no 1, Safil no 1 1 Sachet
6 T-Mono no 4/0 1 Sachet
7 T-Chromic no 1 HEPAR 3 Sachet
8 Plain Roll no .........m
9 Silk Roll no .........m
10 Surgical Mess no 10/15/20 @1 Sachet
11 Handscoon Gammex no 6,5 6 Sachet
12 Handscoon Gammex no 7 10 Sachet
13 Handscoon Gammex no 7,5 6 Sachet
14 Handscoon Gammex no 8 10 Sachet
15 Underpad 2 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 NGT no 16 1 Buah
19 Spongostan 2 Buah
20 Rectal Tube no 28 1 Buah
21 Nasal Canul Dws 1 Buah
22 Aquabidest 1000 cc 2 flash
23 Povidone Iodine 10% .........cc
24 Alkohol 70% .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen .........ltr
2 Aquabidest 25 ml 1 Flacon
3 Atropine Sulfate 0,25 mg 2 Amp
4 Epinephrine 50 mg 1 Amp
5 Lidocaine HCI 40 mg 3 Amp
6 Miloz 5 mg 1 Amp
7 Propofol 200 mg 1 Vial
8 Epedrine 1 Amp
9 Fentanyl 100 mcg 2 Amp
10 Tramus 25 mg 2 Amp
11 Morphine 10 mg 1 Amp
12 Pethidin HCI 50mg 1 Amp
13 Ketorolac 30 mg 1 Amp
14 Antrain 500 mg 1 Amp
15 Neostigmine 0,5 mg 2 Amp
16 Aminophylline 240 mg 1 Amp
17 Ondansetron 4 mg 1 Amp
18 Ranitidine 50 mg 1 Amp
19 Dexamethasone 5 mg 2 Amp
20 Iphadryl 10 mg 1 Amp
21 Asam Traneksamat 500 mg 2 Amp
22 Phytomenadione 10 mg 1 Amp
23 Rocuronium 5 mg 1 Vial
24 Ropivel 150 mg /Regivel 1 Amp
25 Farsix 20 mg 2 Amp
26 Udopa 200 mg 1 Amp
27 Ca Gluconas 10% 1 Amp
28 Granisetron 1 Amp
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 2 Flash
31 WIDAHES 130 1 Flash
32 Elektroda EKG 3 Biji
33 Spinocan no 26/27 @1 Buah
34 Spuit no 3 cc/5 cc/10 cc @4 Buah
35 Dexketoprofen inj 1 Amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY KABER (dr.Zaki Sp.Og)

No Nama Barang Terima Pakai Kembali Keterangan

1 T-Chromic no 2 2 Sachet
2 T-Chromic no 2/0 1 Sachet
3 T-Vio no 2 2 Sachet
4 T-Plain no 2/0 1Sachet
5 T-Vio no 1, Safil no 1 3 Sachet
6 T-Mono no 4/0 1 Sachet
7 Chromic Roll no .........m
8 Plain Roll no .........m
9 Silk Roll no .........m
10 Surgical Mess no 10/20 @1 Sachet
11 Handscoon Gammex no 6,5 4 Sachet
12 Handscoon Gammex no 7 10 Sachet
13 Handscoon Gammex no 7,5 10 Sachet
14 Handscoon Gammex no 8 8 Sachet
15 Underpad 2 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 NGT no 16 1 Buah
19 Spongostan 2 Buah
20 Rectal Tube no 28 1 Buah
21 Nasal Canul Dws 1 Buah
22 NaCl 0,9% 1000 cc 2 Flash
23 Povidone Iodine 10% .........cc
24 Alkohol 70% .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Aquabidest 25 ml 1 Flacon
3 Atropine Sulfate 0,25 mg 2 Amp
4 Epinephrine 50 mg 1 Amp
5 Lidocaine HCI 40 mg 3 Amp
6 Miloz 5 mg 1 Amp
7 Propofol 200 mg 1 Vial
8 Epedrine 1 Amp
9 Fentanyl 100 mcg 2 Amp
10 Tramus 25 mg 2 Amp
11 Morphine 10 mg 1 Amp
12 Pethidin HCI 50mg 1 Amp
13 Ketorolac 30 mg/ Dekxketop @1 Amp
14 Antrain 500 mg 1 Amp
15 Neostigmine 0,5 mg 2 Amp
16 Aminophylline 240 mg 1 Amp
17 Ondansetron 4 mg 1 Amp
18 Ranitidine 50 mg 1 Amp
19 Dexamethasone 5 mg 2 Amp
20 Iphadryl 10 mg 1 Amp
21 Asam Traneksamat 500 mg 2 Amp
22 Phytomenadione 10 mg 1 Amp
23 Epedrine 1 Amp
24 Ropivel 150 mg /Regivel 1 Amp
25 Farsix 20 mg 2 Amp
26 Ca Gluconas 10% 1 Amp
27 Metoclopramide 1 Amp
28 Granisetron 1 Amp
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Elektroda EKG 3 Biji
33 Spinocan no 26/27 @1 Buah
34 Spuit no 3 cc/5 cc/10 cc @4 Buah
35 Deksketoprofen 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET PAKET STT (dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1Sachet
2 T-Plain no 2/0 1Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon no 2/0,3/0,4/0,5/0 @1 Sachet
5 T-Vio no 1, Safil no 1 1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/11/15 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 8 Sachet
12 Handscoon Gammex no 7,5 8 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Handscoon Gammex no 8,5 4 Sachet
15 Underpad 1 Buah
16 Blood Set 1 Buah
17 Urobag 1 Buah
18 Nasal Canul Dws 1 Buah
19 Povidone Iodine 10% .........cc
20 Alkohol 70% .........cc
21 Perhidrol H2O2 .........cc
22 Kasa Steril .........m
23 Hipavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 25 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Rocuronium 1 Amp
29 Granisetron 1 Amp
30 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 3 Flash
33 NaCl 0,9% 500 cc 2 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 ETT no 6,5/ 7/ 7,5 @1 Buah
36 Mayo Kuning/ Hijau @1 Buah
37 Suction Catheter no 12 1 Buah
38 3 way Extention 1 Buah
39 Dexketoprofen inj 1 Amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET STT (dr.Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon 2/0,3/0,4/0,5/0 @1 Sachet
5 Chromic Roll no .........m
6 Plain Roll no .........m
7 Silk Roll no .........m
8 Surgical Mess no 10/11/15 @1 Sachet
9 Handscoon Gammex no 6,5 4 Sachet
10 Handscoon Gammex no 7 10 Sachet
11 Handscoon Gammex no 7,5 10 Sachet
12 Handscoon Gammex no 8 4 Sachet
13 Underpad 1 Buah
14 Blood Set 1 Buah
15 Urobag 1 Buah
16 NGT no 8,10&12 @1 Buah
17 Lomatuell H 1 Buah
18 Nasal Canul Dws 1 Buah
19 Aquabidest 1000 cc 1 Flash
20 Povidone Iodine 10% .........cc
21 Alkohol 70% .........cc
22 Perhidrol H2O2 .........cc
23 Kasa Steril .........m
24 Hipavix .........m
25 ETT NKK (6.5/7/7.5) @1 PCS
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg/Dexketop @1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Rocuronium 1 Amp
29 Granisetron 1 Amp
30 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 3 Flash
33 NaCl 0,9% 500 cc 2 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 ETT no 6,5/ 7/ 7,5 @1 Buah
36 Mayo Kuning/ Hijau @1 Buah
37 Suction Catheter no 12 1 Buah
38 3 Way Extention 1 Buah
39 Deksketoprofen 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET STT (dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 2 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon 2/0,3/0,4/0,5/0 @1 Sachet
5 T-Vio no. 1, Safil no 1 1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/11/15 @1 Sachet
10 Handscoon Gammex no 6,5 6 Sachet
11 Handscoon Gammex no 7 12 Sachet
12 Handscoon Gammex no 7,5 6 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Underpad 1 Buah
15 Blood Set 1 Buah
16 Urobag 1 Buah
17 NGT no 8,10&12 @1 Buah
18 Lomatuell H 1 Buah
19 Nasal Canul Dws 1 Buah
20 Povidone Iodine 10% .........cc
21 Alkohol 70% .........cc
22 Perhidrol H2O2 .........cc
23 Kasa Steril .........m
24 Hipavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg @1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Rocuronium 1 Amp
29 Granisetron 1 Amp
30 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 3 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 ETT no 6,5/ 7/ 7,5 @1 Buah
36 Mayo Kuning/ Hijau @1 Buah
37 Suction Catheter no 12 1 Buah
38 3 Way Extention 1 Buah
39 Deksketoprofen 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET DEBRIDEMENT(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Silk Roll no .........m
2 Surgical Mess no 10/11/15 @1 Sachet
3 Handscoon Gammex no 6,5 4 Sachet
4 Handscoon Gammex no 7 8 Sachet
5 Handscoon Gammex no 7,5 8 Sachet
6 Handscoon Gammex no 8 4 Sachet
7 Handscoon Gammex no 8,5 4 Sachet
8 Underpad 1 Buah
9 Blood Set 1 Buah
10 Urobag 1 Buah
11 Lomatuell H 2 Buah
12 Suprasorb A 2 Buah
13 Tensocrepe no 4/6 inc @1 Buah
14 Nasal Canul Dws 1 Buah
15 Povidone Iodine 10% .........cc
16 Alkohol 70 % .........cc
17 Perhidrol H2O2 .........cc
18 Kasa Steril .........m
19 Hypavix .........m
20
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron / Dexketoprofen @1 Amp
29 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 2 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 WIDAHES 130 1 Flash
35 Spuit no 3 cc/5 cc/10 cc @3 Buah
36 ETT 6,5/7/7,5 @1 Buah
37 Mayo Kuning/ Hijau @1 Buah
38 Suction Catheter No 12 1 Buah
39 3 Way Extension @1 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET DEBRIDEMENT(dr.Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1 Sachet
2 T-Mono no 4/0 1 Sachet
3 Dermalon 2/0,3/0&4/0 @1 Sachet
4 Silk Roll no .........m
5 Surgical Mess no 10/11/15 @1 Sachet
6 Handscoon Gammex no 6,5 4 Sachet
7 Handscoon Gammex no 7 8 Sachet
8 Handscoon Gammex no 7,5 8 Sachet
9 Handscoon Gammex no 8 4 Sachet
10 NGT no 8,10&12 @1 Buah
11 Underpad 1 Buah
12 Blood Set 1 Buah
13 Urobag 1 Buah
14 Lomatuell H 2 Buah
15 Suprasorb A 2 Buah
16 Tensocrape no 4/6 inc @1 Buah
17 Nasal Canul Dws 1 Buah
18 Aquabidest 1000 cc 1 Flash
19 Povidon Iodine 10% .........cc
20 Alkohol 70 % .........cc
21 Perhidrol H2O2 .........cc
22 Kasa Steril .........m
23 Hypavix .........m
24
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron/ Deksketoprofen 1 Amp/ 1
29 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 2 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 WIDAHES 130 1 Flash
35 Spuit no 3 cc/5 cc/10 cc @3 Buah
36 ETT 6,5/7/7,5 @1 Buah
37 Mayo Kuning/ Hijau @1 Buah
38 Suction Catheter No 12 1 Buah
39 3 Way Extension @1 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET DEBRIDEMENT(dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1 Sachet
2 Dermalon 2/0,3/0&4/0 @1 Sachet
3 Silk Roll no .........m
4 Surgical Mess no 10/11/15 @1 Sachet
5 Handscoon Gammex no 6,5 6 Sachet
6 Handscoon Gammex no 7 12 Sachet
7 Handscoon Gammex no 7,5 8 Sachet
8 Handscoon Gammex no 8 4 Sachet
9 NGT no 8,10&12 @1 Buah
10 Underpad 1 Buah
11 Blood Set 1 Buah
12 Urobag 1 Buah
13 Lomatuell H 2 Buah
14 Suprasorb A 2 Buah
15 Tensocrape no 4/6 inc @1 Buah
16 Nasal Canul Dws 1 Buah
17 Povidone Iodine 10% .........cc
18 Alkohol 70 % .........cc
19 Perhidrol H2O2 .........cc
20 Kasa Steril .........m
21 Hypavix .........m
22
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 26/27 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 WIDAHES 130 1 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 Deksketoprofen 1 Amp
36 ETT 6,5/7/7,5 @1 Buah
37 Mayo Kuning/ Hijau @1 Buah
38 Suction Catheter No 12 1 Buah
39 3 Way Extension @1 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET HERNIA(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1, Safil no 1 1 Sachet
2 Silkam no 2/0 2Sachet
3 T-Plain no 2/0 1 Sachet
4 T-Mono no 4/0 1 Sachet
5 Dermalon 2/0,3/0,4/0,5/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/15/20 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 10 Sachet
12 Handscoon Gammex no 7,5 6 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Handscoon Gammex no 8,5 4 Sachet
15 Underpad 1 Buah
16 Blood Set 1 Buah
17 Catheter no 16 1 Buah
18 Urobag 1 Buah
19 PROLENE Mesh 1 Buah
20 Nasal Canul Dws 1 Buah
21 Povidone Iodine 10% .........cc
22 Alkohol 70% .........cc
23 Kasa Steril .........m
24 Hypavix .........m
25
26
Obat Anestesi
1 Oksigen .........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 26/27 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 2 Flash
33 Spuit no 3 cc/5 cc/10 cc @3 Buah
34 Dexketoprofen inj
35
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET HERNIA (dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1, Safil no 1 1 Sachet
2 T-Vio no 2/0 2 Sachet
3 Dermalon no 2/0 2 Sachet
4 Chromic Roll no .........m
5 Plain Roll no .........m
6 Silk Roll no .........m
7 Surgical Mess no 10/20 @1 Sachet
8 Handscoon Gammex no 6,5 6 Sachet
9 Handscoon Gammex no 7 12 Sachet
10 Handscoon Gammex no 7,5 6 Sachet
11 Handscoon Gammex no 8 4 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 1 Buah
16 Lomatuell H 1 Buah
17 PROLENE Mesh 1 Buah
18 Nasal Canul Dws 1 Buah
19 Povidone Iodine 10% .........cc
20 Alkohol 70% .........cc
21 Kasa Steril .........m
22 Hypavix .........m
23
24
25
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 26/27 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 Spuit no 3 cc/5 cc/10 cc @3 Buah
34 Dexketoprofen inj
35
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET APENDIK(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Silkam no 2/0 1Sachet
2 Silkam no 3/0 2Sachet
3 T-Vio no 1, Safil no 1 1 Sachet
4 T-Vio no 2/0 1 Sachet
5 T-Plain no 2/0 1 Sachet
6 T-Mono no 4/0 1 Sachet
7 Dermalon 2/0,3/0,4/0,5/0 @1 Sachet
8 Chromic Roll no .........m
9 Plain Roll no .........m
10 Silk Roll no .........m
11 Surgical Mess no 10/15 @1 Sachet
12 Handscoon Gammex no 6,5 4 Sachet
13 Handscoon Gammex no 7 10 Sachet
14 Handscoon Gammex no 7,5 10 Sachet
15 Handscoon Gammex no 8 4 Sachet
16 Handscoon Gammex no 8,5 4 Sachet
17 Underpad 1 Buah
18 Blood Set 1 Buah
19 Catheter no 16 1 Buah
20 Urobag 2 Buah
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m
26
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 26/27 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 Spuit no 3 cc/5 cc/10 cc @3 Buah
34 Dexketoprofen inj
35
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET APPENDIK (dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Silkam no 2/0 2 Sachet
2 Silkam no 3/0 2Sachet
3 T-Vio no 1, Safil no 1 1 Sachet
4 T-Vio no 2/0 2 Sachet
5 Dermalon no 2/0,3/0 1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/15 @1 Sachet
10 Handscoon Gammex no 6,5 6 Sachet
11 Handscoon Gammex no 7 12 Sachet
12 Handscoon Gammex no 7,5 8 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 NGT no 10&12 @1 Buah
15 Underpad 1 Buah
16 Blood Set 1 Buah
17 Catheter no 16 1 Buah
18 Urobag 2 Buah
19 Lomatuell H 1 Buah
20 Nasal Canul Dws 1 Buah
21 Povidone Iodine 10% .........cc
22 Alkohol 70% .........cc
23 Kasa Steril .........m
24 Hypavix .........m
25
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 26/27 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 Spuit no 3 cc/5 cc/10 cc @3 Buah
34 Dexketoprofen inj 1 amp
35 Sanbehest 1 Flash
36 ETT NO 6,5/7/7,5 @1 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET CA MAMMAE (dr. Arif, Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @2Sachet
2 Dermalon no 2/0&3/0 @2Sachet
3 T-Plain no 2/0 2 sachet
4 Chromic Roll no .........m
5 Plain Roll no .........m
6 Silk Roll no .........m
7 Surgical Mess no 10/20 @1 Sachet
8 Handscoon Gammex no 6,5 4 Sachet
9 Handscoon Gammex no 7 10 Sachet
10 Handscoon Gammex no 7,5 10 Sachet
11 Handscoon Gammex no 8 4 Sachet
12 Handscoon Gammex no 8,5 4 Sachet
13 Underpad 1 Buah
14 Blood Set 1 Buah
15 Catheter no 16 1 Buah
16 Urobag 2 Buah
17 Polivax no 14 1 Buah
18 Nasal Canul Dws 1 Buah
19 Povidone Iodine 10% .........cc
20 Alkohol 70% .........cc
21 Perhidrol H2O2 .........cc
22 Kasa Steril .........m
23 Hypavix .........m
24
25
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Rocuronium 5 mg 1 Vial
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Metoclopramide 1 Amp
25 Granisetron 1 Amp
26 3 Way Extention 1 Buah
27 Mayo Hijau 1 Buah
28 Elektroda EKG 3 Biji
29 Ringer Laktat 500 cc 4Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Suction Catheter no 12 1 Buah
35 Dexketoprofen inj
36 Regivel
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET CA MAMMAE (dr.Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @2Sachet
2 Silkam no 2/0&3/0 @2Sachet
3 Dermalon no 2/0&3/0 @2 Sachet
4 Chromic Roll no .........m
5 Plain Roll no .........m
6 Silk Roll no .........m
7 Surgical Mess no 10/20 @1 Sachet
8 Handscoon Gammex no 6,5 4 Sachet
9 Handscoon Gammex no 7 8 Sachet
10 Handscoon Gammex no 7,5 10 Sachet
11 Handscoon Gammex no 8 4 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 1 Buah
16 Polivax no 14 1 Buah
17 NGT no 12&14 @1 Buah
18 Lomatuell H 2 Buah
19 Aquabidest 1000 cc 1 Buah
20 Tensocrepe 4 inc 1 Buah
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Perhidrol H2O2 .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Rocuronium 5 mg 1 Vial
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Pethidin HCI 100 mg 1 Amp
14 Ketorolac 30 mg 1 Amp
15 Antrain 500 mg 1 Amp
16 Neostigmine 0,5 mg 2 Amp
17 Aminophylline 240 mg 1 Amp
18 Ondansetron 4 mg 1 Amp
19 Ranitidine 50 mg 1 Amp
20 Dexamethasone 5 mg 2 Amp
21 Iphadryl 10 mg 1 Amp
22 Asam Traneksamat 500 mg 2 Amp
23 Metoclopramide 1 Amp
24 Granisetron 1 Amp
25 3 Way Extention 1 Amp
26 Mayo Hijau 1 Buah
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4Flash
29 NaCl 0,9% 500 cc 3 Flash
30 WIDAHES 130 1 Flash
31 Spuit no 3 cc/5 cc/10 cc @3 Buah
32 ETT no 6,5/ 7/ 7,5 @1 Buah
33 Suction Catheter no 12 1 Buah
34 Dexketoprofen inj 1 amp
35 Regivel 1 amp
Petugas OK Petugas Anestesi Petugas ApotikJember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET CA MAMMAE (dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @2Sachet
2 Silkam no 2/0&3/0 @2Sachet
3 Dermalon no 2/0&3/0 @2 Sachet
4 Chromic Roll no .........m
5 Plain Roll no .........m
6 Silk Roll no .........m
7 Surgical Mess no 10/20 @1 Sachet
8 Handscoon Gammex no 6,5 6 Sachet
9 Handscoon Gammex no 7 12 Sachet
10 Handscoon Gammex no 7,5 8 Sachet
11 Handscoon Gammex no 8 4 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 2 Buah
16 Polivax no 14 1 Buah
17 NGT no 12&14 @1 Buah
18 Lomatuell H 2 Buah
19 Aquabidest 1000 cc 1 Buah
20 Tensocrepe 4 inc 1 Buah
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Perhidrol H2O2 .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Rocuronium 5 mg 1 Vial
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Pethidin HCI 100 mg 1 Amp
14 Ketorolac 30 mg 1 Amp
15 Antrain 500 mg 1 Amp
16 Neostigmine 0,5 mg 2 Amp
17 Aminophylline 240 mg 1 Amp
18 Ondansetron 4 mg 1 Amp
19 Ranitidine 50 mg 1 Amp
20 Dexamethasone 5 mg 2 Amp
21 Iphadryl 10 mg 1 Amp
22 Asam Traneksamat 500 mg 2 Amp
23 Metoclopramide 1 Amp
24 Granisetron 1 Amp
25 Suction Catheter no 12 1 Buah
26 Mayo Hijau 1 Buah
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4Flash
29 NaCl 0,9% 500 cc 3 Flash
30 WIDAHES 130 1 Flash
31 Spuit no 3 cc/5 cc/10 cc @3 Buah
32 ETT no 6,5/ 7/ 7,5 @1 Buah
33 3 Way Extention 1 Buah
34 Dexketoprofen inj
35 Regivel
Petugas OK Petugas Anestesi Petugas ApotikJember, ...........20....
Nama : Tanggal Lahir :
No RM :

PAKET STRUMA (dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Mono no 3/0 2Sachet
2 T-Mono no 4/0 1 Sachet
3 T-Plain no 2/0 1 Sachet
4 T-Vio no 2/0 1 Sachet
5 Dermalon no 3/0&4/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/15 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 8 Sachet
12 Handscoon Gammex no 7,5 8 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Handscoon Gammex no 8,5 4 Sachet
15 Underpad 1 Buah
16 Blood Set 1 Buah
17 NGT no 16 @1 Buah
18 Catheter no 16 1 Buah
19 Urobag 2 Buah
20 Polivax no 12 1 Buah
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Rocuronium5 mg 1 Vial
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Metoclopramide 1 Amp
25 Granisetron 1 Amp
26 3 Way/ Extention 1/1Buah
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4 Flash
29 NaCl 0,9 % 500 cc 3 Flash
30 WIDAHES 130 1 Flash
31 Spuit no 3 cc/5 cc/10 cc @3 Buah
32 ETT non king 6,5/ 7/ 7,5 @1 Buah
33 Mayo Kuning/ Hijau @1 Buah
34 Suction Catheter 12 1 Buah
35 Dexketoprofen inj 1 Amp
36 Rocuronium 1 Vial
37 Regivel
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET STRUMA (dr. Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Mono no 3/0&4/0 @1 Sachet
2 T-Vio no 2/0 1 Sachet
3 Silkam no 2/0&3/0 @1 Sachet
4 T-Plain no 2/0 1 Sachet
5 Dermalon no 3/0&4/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/15 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 8 Sachet
12 Handscoon Gammex no 7,5 10 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Underpad 1 Buah
15 Blood Set 1 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 Polivax no 12 1 Buah
19 NGT no 12&16 @1 Buah
20 Lomatuell H 1 Buah
21 Aquabidest 1000 cc 1 Flash
22 Nasal Canul Dws 1 Buah
23 Povidone Iodine 10% .........cc
24 Alkohol 70% .........cc
25 Kasa Steril .........m
26 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Pethidin HCI 100 mg 1 Amp
14 Ketorolac 30 mg/ Dexketop @1 Amp
15 Antrain 500 mg 1 Amp
16 Neostigmine 0,5 mg 2 Amp
17 Aminophylline 240 mg 1 Amp
18 Ondansetron 4 mg 1 Amp
19 Ranitidine 50 mg 1 Amp
20 Dexamethasone 5 mg 2 Amp
21 Iphadryl 10 mg 1 Amp
22 Asam Traneksamat 500 mg 2 Amp
23 Farsix 20 mg 2 Amp
24 Phytomenadione 10 mg 1 Amp
25 Granisetron 1 Amp
26 Elektroda EKG 3 Biji
27 Ringer Laktat 500 cc 4 Flash
28 NaCl 0,9% 500 cc 3 Flash
29 WIDAHES 130 1 Flash
30 Spuit no 3 cc/5 cc/10 cc @3 Buah
31 ETT non king 6,5/ 7/ 7,5 @1 Buah
32 Mayo Kuning/ Hijau @1 Buah
33 Suction Catheter 12 1 Buah
34 3 Way/ Extention 1/1 Buah
35 Deksketoprofen 1 amp
36 Rocuronium/Regivel 1 Vial
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET STRUMA (dr. Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Mono no 3/0&4/0 @1 Sachet
2 Silkam no 2/0&3/0 @1 Sachet
3 T-Vio no 2/0 1 Sachet
4 T-Plain no 2/0 1 Sachet
5 Dermalon no 3/0&4/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/15 @1 Sachet
10 Handscoon Gammex no 6,5 6 Sachet
11 Handscoon Gammex no 7 12 Sachet
12 Handscoon Gammex no 7,5 8 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Underpad 1 Buah
15 Blood Set 1 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 Polivax no 12 1 Buah
19 NGT no 12&16 @1 Buah
20 Lomatuell H 1 Buah
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron 1 Amp
27 Deksketoprofen 1 amp
28 Elektroda EKG 3 Biji
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT non king 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter 12 1 Buah
36 3 Way/ Extention 1/1 Buah
37 Rocuronium/Regivel 1 Vial
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Silkam no 2/0&3/0 @3Sachet
2 T-Vio no 1&2/0, Safil no 1 @1Sachet
3 T-Plain no 2/0 1 Sachet
4 T-Mono no 4/0 1 Sachet
5 Dermalon no 2/0&3/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no10/11/15/20 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 10 Sachet
12 Handscoon Gammex no 7,5 10 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Handscoon Gammex no 8,5 4 Sachet
15 Underpad 2 Buah
16 Blood Set 1 Buah
17 Catheter no 16 1 Buah
18 Urobag 2 Buah
19 Rectal Tube no 28 1 Buah
20 NGT no 12,14,16 @1 Buah
21 Spongostan 2 Buah
22 NaCl 0,9% 1000 cc 3 Flash
23 Nasal Canul Dws 1 Buah
24 Povidone Iodine 10% .........cc
25 Alkohol 70% .........cc
26 Kasa Steril .........m
27 Hypavix .........m
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg / Rocuronium 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Levica/Regivel 1 Amp
26 Granisetron 1 Amp
27 Deksketoprofen 1 amp
28 Elektroda EKG 3 Biji
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Spinocan 26/27 @1 buah
36 Suction Catheter no 12 1 Buah

Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....

Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY (dr. Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Silkam no 2/0&3/0 @3Sachet
2 T-Vio no 1&2/0,. Safil no 1 @1 Sachet
3 T-Plain no 2/0 1 Sachet
4 T-Mono no 4/0 1Sachet
5 Dermalon no 2/0&3/0 @1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no10/11/15/20 @1 Sachet
10 Handscoon Gammex no 6,5 4 Sachet
11 Handscoon Gammex no 7 10 Sachet
12 Handscoon Gammex no 7,5 10 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Lomatuell H 1 Buah
15 Underpad 2 Buah
16 Blood Set 1 Buah
17 Catheter no 16 1 Buah
18 Urobag 2 Buah
19 Rectal Tube no 28 1 Buah
20 NGT no 14&16 @1 Buah
21 Spongostan 3 Buah
22 Aquabidest 1000cc 3 Flash
23 Nasal Canul Dws 1 Buah
24 Povidone Iodine 10% .........cc
25 Alkohol 70% .........cc
26 Kasa Steril .........m
27 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron/Regivel 1 Amp
27 Deksketoprofen 1 amp
28 Elektroda EKG 3 Biji
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter no 12 1 Buah
Petugas OK Petugas Anestesi Petugas ApotikJember, ...........20.........
Nama : Tanggal Lahir :
No RM :
PAKET LAPARATOMY (dr. Cyhntia Sp. B)

No Nama Barang Terima Pakai Kembali Keterangan

1 Silkam no 2/0&3/0 @3Sachet
2 T-Vio no 1&2/0, Safil no 1 @1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon no 2/0&3/0 @1 Sachet
5 Chromic Roll no .........m
6 Plain Roll no .........m
7 Silk Roll no .........m
8 Surgical Mess no10/11/15/20 @1 Sachet
9 Handscoon Gammex no 6,5 4 Sachet
10 Handscoon Gammex no 7 12 Sachet
11 Handscoon Gammex no 7,5 8 Sachet
12 Handscoon Gammex no 8 4 Sachet
13 Lomatuell H 1 Buah
14 Underpad 2 Buah
15 Blood Set 1 Buah
16 Catheter no 16 1 Buah
17 Urobag 2 Buah
18 Rectal Tube no 28 1 Buah
19 NGT no 14&16 @1 Buah
20 Spongostan 3 Buah
21 NaCl 0,9% 1000cc 3 Flash
22 Nasal Canul Dws 1 Buah
23 Povidone Iodine 10% .........cc
24 Alkohol 70% .........cc
25 Kasa Steril .........m
26 Hypavix .........m
27 Spinocan 26/27 @1 buah
.
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Rocuronium 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron 1 Amp
27 Deksketoprofen 1 Amp
28 Elektroda EKG 3 Biji
29 Ringer Laktat 500 cc 4 Flash
30 NaCl 0,9% 500 cc 3 Flash
31 WIDAHES 130 1 Flash
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter no 12 1 Buah
36 Levica/ Ropivell/ Regivell @1 Amp
Petugas OK Petugas Anestesi Petugas ApotikJember, ...........20.........
Nama : Tanggal Lahir :
No RM :
PAKET BPH(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @1 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon no 2/0&3/0 @1 Sachet
5 Chromic Roll no .........m
6 Plain Roll no .........m
7 Silk Roll no .........m
8 Surgical Mess no 10/20 @1 Sachet
9 Handscoon Gammex no 6,5 4 Sachet
10 Handscoon Gammex no 7 10 Sachet
11 Handscoon Gammex no 7,5 8 Sachet
12 Handscoon Gammex no 8 4 Sachet
13 Handscoon Gammex no 8,5 4 Sachet
14 Underpad 1 Buah
15 Blood Set 2 Buah
16 Catheter 3 Way no 24 Rusch 1 Buah
17 Urobag 2000 ml 1 Buah
18 Polivax no 14 1 Buah
19 NGT no 16 1 Buah
20 NaCl 0,9% 1000 cc 5 Flash
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Deksketoprofen 1 amp
30 Spinocan no 25/26 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 4 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 WIDAHES 130 1 Flash
35 Spuit no 3 cc/5 cc/10 cc @3 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET BPH (dr.Prima Sp.B, onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @1 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon no 2/0&3/0 @1 Sachet
5 Chromic Roll no .........m
6 Plain Roll no .........m
7 Silk Roll no .........m
8 Surgical Mess no 10/20 @1 Sachet
9 Handscoon Gammex no 6,5 4 Sachet
10 Handscoon Gammex no 7 8 Sachet
11 Handscoon Gammex no 7,5 10 Sachet
12 Handscoon Gammex no 8 4 Sachet
13 Lomatuell H 1 Buah
14 Underpad 1 Buah
15 Blood Set 2 Buah
16 Catheter 3 Way no 24 Rusch 1 Buah
17 Urobag 2000 ml 1 Buah
18 Polivax no 14 1 Buah
19 NGT no 16 1 Buah
20 NaCl 0,9% 1000 cc 5 Flash
21 Nasal Canul Dws 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Kasa Steril .........m
25 Hypavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Granisetron 1 Amp
29 Deksketoprofen 1 amp
30 Spinocan no 25/26 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 4 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 WIDAHES 130 1 Flash
35 Spuit no 3 cc/5 cc/10 cc @3 Buah
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET BPH (dr.Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1&2/0, Safil no 1 @1 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon no 2/0&3/0 @1 Sachet
5 Chromic Roll no .........m
6 Plain Roll no .........m
7 Silk Roll no .........m
8 Surgical Mess no 10/20 @1 Sachet
9 Handscoon Gammex no 6,5 6 Sachet
10 Handscoon Gammex no 7 12 Sachet
11 Handscoon Gammex no 7,5 8 Sachet
12 Handscoon Gammex no 8 4 Sachet
13 Lomatuell H 1 Buah
14 Underpad 1 Buah
15 Blood Set 2 Buah
16 Catheter 3 Way no 24 Rusch 1 Buah
17 Urobag 2000 ml 1 Buah
18 Polivax no 14 1 Buah
19 NGT no 16 1 Buah
20 NaCl 0,9% 1000 cc 3 Flash
21 Povidone Iodine 10% .........cc
22 Alkohol 70% .........cc
23 Kasa Steril .........m
24 Hypavix .........m
25
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg/Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 25/26 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 4 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 WIDAHES 130 1 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 Deksketoprofen 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET HEMOROID / PERIANAL FISTEL(dr.Arif Sp.B)

No Nama Barang Terima Pakai Kembali Keterangan

1 Chromic 2 3 Sachet .........m
2 Silk Roll no .........m
3 Surgical Mess no10/11/15/20 @1 Sachet
4 Handscoon Gammex no 6,5 4 Sachet
5 Handscoon Gammex no 7 8 Sachet
6 Handscoon Gammex no 7,5 8 Sachet
7 Handscoon Gammex no 8 4 Sachet
8 Handscoon Gammex no 8,5 4 Sachet
9 Underpad 1 Buah
10 Catheter no 16 1 Buah
11 Urobag 1 Buah
12 Rectal Tube no 28 1 Buah
13 Gentian Violet 1% 1 Buah
14 Surflo no 16&20 @1 Buah
15 Povidone Iodine 10% .........cc
16 Alkohol 70% .........cc
17 Perhidrol H2O2 .........cc
18 Kasa Steril .........m
19 Hypavix .........m
20
21
22
23
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg/Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 25/26 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 3 Flash
32 NaCl 0,9% 500 cc 2 Flash
33 WIDAHES 130 1 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 Deksketoprofen 1 amp
36
37
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET HEMOROID / PERIANAL FISTEL (dr. Prima Sp.B, Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1 Sachet
2 Dermalon no 2/0&3/0 @1 Sachet
3 Chromic Roll no .........m
4 Silk Roll no .........m
5 Surgical Mess no10/11/15/20 @1 Sachet
6 Handscoon Gammex no 6,5 4 Sachet
7 Handscoon Gammex no 7 8 Sachet
8 Handscoon Gammex no 7,5 10 Sachet
9 Handscoon Gammex no 8 4 Sachet
10 Lomatuell H 1 Sachet
11 Underpad 1 Buah
12 Catheter no 16 1 Buah
13 Urobag 1 Buah
14 Gentian Violet 1% 1 Buah
15 Surflo no 16&20 @1 Buah
16 Aquabidest 1000 cc 1 Flash
17 Povidone Iodine 10% .........cc
18 Alkohol 70% .........cc
19 Perhidrol H2O2 .........cc
20 Kasa Steril .........m
21 Hypavix .........m
22
23
24
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg/Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 25/26 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 4 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 WIDAHES 130 1 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 Deksketoprofen 1 amp
36
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET HEMOROID / PERIANAL FISTEL (dr. Chyntia Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 1 Sachet
2 Dermalon no 2/0&3/0 @1 Sachet
3 Chromic Roll no .........m
4 Silk Roll no .........m
5 Surgical Mess no10/11/15/20 @1 Sachet
6 Handscoon Gammex no 6,5 6 Sachet
7 Handscoon Gammex no 7 12 Sachet
8 Handscoon Gammex no 7,5 8 Sachet
9 Handscoon Gammex no 8 4 Sachet
10 Lomatuell H 1 Sachet
11 Underpad 1 Buah
12 Catheter no 16 1 Buah
13 Urobag 1 Buah
14 Gentian Violet 1% 1 Buah
15 Surflo no 16&20 @1 Buah
16 Povidone Iodine 10% .........cc
17 Alkohol 70% .........cc
18 Perhidrol H2O2 .........cc
19 Kasa Steril .........m
20 Hypavix .........m
21
22
23
24
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg/Regivel 1 Amp
28 Granisetron 1 Amp
29 Spinocan no 25/26 @1 Buah
30 Elektroda EKG 3 Biji
31 Ringer Laktat 500 cc 2 Flash
32 NaCl 0,9% 500 cc 3 Flash
33 WIDAHES 130 1 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 Deksketoprofen
36
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET SIRKUMSISI(dr.Arif Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Plain no 3/0&4/0 @1 Sachet
2 Surgical Mess no 10/15 @1 Sachet
3 Handscoon Gammex no 6,5 4Sachet
4 Handscoon Gammex no 7 8Sachet
5 Handscoon Gammex no 7,5 8Sachet
6 Handscoon Gammex no 8 4Sachet
7 Handscoon Gammex no 8,5 4Sachet
8 Underpad 1Buah
9 Blood Set 1 Buah
10 Lomatuell H 1 Buah
11 Povidone Iodine 10% .........cc
12 Alkohol 70% .........cc
13 Kasa Steril .........m
14 Hypavix .........m
15
16
17
18
19
20
21
22
23
24
25
26
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Granisetron/Regivel 1 Amp
25 Elektroda EKG 3 Biji
26 Ringer Laktat 500 cc 2 Flash
27 NaCl 0,9% 500 cc 2 Flash
28 Spuit no 3 cc/5 cc/10 cc @3 Buah
29 ETT no 4,5/5/5,5 @1 Buah
30 Mayo Biru/ Hitam @1 Buah
31 Suction Catheter no 10 1 Buah
32 Deksketoprofen 1 amp
33
34
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET SIRKUMSISI (dr.Prima Sp.B,Onk)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Plain no 3/0&4/0 @1 Sachet
2 Surgical Mess no 10/15 @1 Sachet
3 Handscoon Gammex no 6,5 4Sachet
4 Handscoon Gammex no 7 8Sachet
5 Handscoon Gammex no 7,5 10Sachet
6 Handscoon Gammex no 8 4Sachet
7 Underpad 1Buah
8 Blood Set 1 Buah
9 Lomatuell H 1 Buah
10 Povidone Iodine 10% .........cc
11 Alkohol 70% .........cc
12 Kasa Steril .........m
13 Hypavix .........m
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Granisetron/Regivel 1 Amp
25 Elektroda EKG 3 Biji
26 Ringer Laktat 500 cc 2 Flash
27 NaCl 0,9% 500 cc 2 Flash
28 Spuit no 3 cc/5 cc/10 cc @3 Buah
29 ETT no 4,5/5/5,5 @1 Buah
30 Mayo Biru/ Hitam @1 Buah
31 Suction Catheter no 10 1 Buah
32 Deksketoprofen 1 amp
33
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET SIRKUMSISI (dr.Chyntia Sp. B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Plain no 3/0&4/0 @1 Sachet
2 Surgical Mess no 10/15 @1 Sachet
3 Handscoon Gammex no 6,5 4Sachet
4 Handscoon Gammex no 7 10Sachet
5 Handscoon Gammex no 7,5 8Sachet
6 Handscoon Gammex no 8 4Sachet
7 Underpad 1Buah
8 Blood Set 1 Buah
9 Lomatuell H 1 Buah
10 Povidone Iodine 10% .........cc
11 Alkohol 70% .........cc
12 Kasa Steril .........m
13 Hypavix .........m
14
15
16
17
18
19
20
21
22
23
24
25
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Granisetronl 1 Amp
25 Elektroda EKG 3 Biji
26 Ringer Laktat 500 cc 2 Flash
27 NaCl 0,9% 500 cc 2 Flash
28 Spuit no 3 cc/5 cc/10 cc @3 Buah
29 ETT no 4,5/5/5,5 @1 Buah
30 Mayo Biru/ Hitam @1 Buah
31 Suction Catheter no 10 1 Buah
32 Deksketoprofen 1 amp
33 Regivel
34
35
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET DEBRIDEMENT ORTHO (dr. Ainul Sp.B)

N NaSCma Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1,2/0, Safil no 1 @2Sachet
4 Dermalon no 2/0,3/0,4/0,5/0 @1Sachet
5 Plain Roll no .........m
7 Surgical Mess no10/11/15/20 @1 Sachet
8 Handscoon Gammex no 6,5 4 Sachet
9 Handscoon Gammex no 7 8 Sachet
10 Handscoon Gammex no 7,5 4 Sachet
11 Handscoon Gammex no 8 8 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 2 Buah
16 NGT no 12,14&16 @1 Buah
17 Lomatuell H 2 Buah
18 Gypsona 4/6 2/2 Buah
19 Tensocrepe 4/6 1/1 Buah
20 Softband 4/6 1/1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Perhidrol H2O2 .........cc
25 Kasa Steril .........m
26 Hypavix .........m
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron 1 Amp
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4 Flash
29 NaCl 0,9% 500 cc 3 Flash
NaCl 0,9%1000 cc 5 Flash
30 WIDAHES 130 1 Flash
31 Spinocan 26/27 1/1 buah
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter no 12 1 Buah
36 Deksketoprofen 1 amp
37 Ropivel / levica/Regivel 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET MINOR ORTHO (dr. Ainul Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0 @1 Sachet
2 T-Plain no 2/0 1 Sachet
4 Dermalon no 2/0,3/0,4/0,5/0 @1 Sachet
5 Plain Roll no .........m
7 Surgical Mess no10/11/15/20 @1 Sachet
8 Handscoon Gammex no 6,5 4 Sachet
9 Handscoon Gammex no 7 8 Sachet
10 Handscoon Gammex no 7,5 4 Sachet
11 Handscoon Gammex no 8 8 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 2 Buah
16 NGT no 12,14&16 @1 Buah
17 Lomatuell H 2 Buah
18 Gypsona 4/6 2/2 Buah
19 Tensocrepe 4/6 1/1 Buah
20 Softband 4/6 1/1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Perhidrol H2O2 .........cc
25 Kasa Steril .........m
26 Hypavix .........m
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 ASTTmp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron 1 Amp
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4 Flash
29 NaCl 0,9% 500 cc 3 Flash
30 WIDAHES 130 1 Flash
31 Spinocan 26/27 1/1 buah
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter no 12 1 Buah
36 Deksketoprofen 1 amp
37 Ropivel / levica/Regivel 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET MAYOR ORTHO (dr. Ainul Sp.B)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 1,2&2/0, Safil no 1 @1 Sachet
2 T-Plain no 2/0 1 Sachet
4 Dermalon no 2/0&3/0 @2 Sachet
5 Plain Roll no .........m
7 Surgical Mess no10/11/15/20 @1 Sachet
8 Handscoon Gammex no 6,5 4 Sachet
9 Handscoon Gammex no 7 8 Sachet
10 Handscoon Gammex no 7,5 4 Sachet
11 Handscoon Gammex no 8 8 Sachet
12 Underpad 1 Buah
13 Blood Set 1 Buah
14 Catheter no 16 1 Buah
15 Urobag 2 Buah
16 NGT no 12,14&16 @1 Buah
17 Lomatuell H 2 Buah
18 Gypsona 4/6 2/2 Buah
19 Tensocrepe 4/6 1/1 Buah
20 Softband 4/6 1/1 Buah
21 Polivax no 14 1 Buah
22 Povidone Iodine 10% .........cc
23 Alkohol 70% .........cc
24 Perhidrol H2O2 .........cc
25 Kasa Steril .........m
26 Hypavix .........m
Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg 1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Granisetron 1 Amp
27 Elektroda EKG 3 Biji
28 Ringer Laktat 500 cc 4 Flash
29 NaCl 0,9% 500 cc 3 Flash
30 WIDAHES 130 1 Flash
31 Spinocan 26/27 1/1 buah
32 Spuit no 3 cc/5 cc/10 cc @3 Buah
33 ETT no 6,5/ 7/ 7,5 @1 Buah
34 Mayo Kuning/ Hijau @1 Buah
35 Suction Catheter no 12 1 Buah
36 Deksketoprofen 1 amp
37 Ropivel / levica/Regivel 1 amp
38 Rocuronium 1 vial
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET MATAKONVENSIONAL / PHACO / PTERIGIUM (dr. Bagas Sp.M)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 Nylon no 10/0 1 Sachet
2 Vicryl no 8/0 1 Sachet
3 Handscoon Gammex no 6,5 4Sachet
4 Handscoon Gammex no 7 4Sachet
5 Handscoon Gammex no 7,5 4Sachet
6 Ceratome 1 Buah
7 Cerezen 1 Buah
8 Slip Knife 1 Buah
9 Underpad 1 Buah
10 Eye Draper 1 Buah
11 Couter Auron 1 Buah
12 Blood Set 1 Buah
13 Kapas mata ........ biji
14 Cotton bud ........ biji
15 Povidone Iodine 10% ..........cc
16 Alkohol ..........cc
17 Kasa Steril ...........m
18 Hypavix ..........m
19
20
21
22
23
24
25
26
27
28
29
30
31
Obat Mata
1 Mydriatil 1% 1 Buah .......tts
2 Efrisel 10% 1 Buah .......tts
3 Pantocain 0,5 % 1 Buah .......tts
4 Xylocaine 2% 1 Buah .......tts
5 Genta 1% 1 Buah .......tts
6 Anbacim 1 gr 1 Vial .......cc
7 Lidocaine HCI 40 mg 1 Amp
8 Pehacain 1 Amp
9 Gentamicin 80 mg 1 Amp
10 Dexamethasone 5 mg 1 Amp
11 Catachol 1 Buah
12 Mede-Blu 1 Buah
13 Rohto Visc 1 Buah
14 Rohto Hyron 1 Buah
15 Lensa PMMA (IOL) 1 Buah No.....
16 Lensa Foldable (IOL) 1 Buah No.....
17 Xitrol Zalf 1 Buah
18 Ringer Laktat 500 cc 1 Flash
19 Spuit no 1 cc 3 Buah
20 Spuit no 3 cc 3 Buah
21 Spuit no 5 cc 3 Buah
22 Spuit no 10 cc 1 Buah
23
24
25
26
27
28
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....
Nama : Tanggal Lahir :
No RM :
PAKET TONSILEKTOMY (dr.HENGKY Sp.THT)

N Nama Barang Terima Pakai Kembali Keterangan

o
1 T-Vio no 2/0/ T-Vio no 4/0 @2 Sachet
2 T-Plain no 2/0 1 Sachet
3 T-Mono no 4/0 1 Sachet
4 Dermalon 2/0,3/0,4/0,5/0 @1 Sachet
5 T-Vio no. 1, Safil no 1 1 Sachet
6 Chromic Roll no .........m
7 Plain Roll no .........m
8 Silk Roll no .........m
9 Surgical Mess no 10/11/15 @1 Sachet
10 Handscoon Gammex no 6,5 6 Sachet
11 Handscoon Gammex no 7 12 Sachet
12 Handscoon Gammex no 7,5 6 Sachet
13 Handscoon Gammex no 8 4 Sachet
14 Underpad 1 Buah
15 Blood Set 1 Buah
16 Urobag 1 Buah
17 NGT no 8,10&12 @1 Buah
18 Lomatuell H 1 Buah
19 Nasal Canul Dws 1 Buah
20 Povidone Iodine 10% .........cc
21 Alkohol 70% .........cc
22 Perhidrol H2O2 .........cc
23 Kasa Steril .........m
24 Hipavix .........m

Obat Anestesi
1 Oksigen ........ltr
2 Isoflurane USP 100% ........ml
3 Aquabidest 25 ml 1 Flacon
4 Atropine Sulfate 0,25 mg 2 Amp
5 Ephedrine HCI 50 mg 1 Amp
6 Epinephrine 50 mg 1 Amp
7 Lidocaine HCI 40 mg 2 Amp
8 Ketamine HCI 50 mg 1 Amp
9 Miloz 5 mg 1 Amp
10 Propofol 200 mg 1 Vial
11 Fentanyl 100 mcg 2 Amp
12 Tramus 25 mg 2 Amp
13 Morphine 10 mg 1 Amp
14 Pethidin HCI 100 mg 1 Amp
15 Ketorolac 30 mg @1 Amp
16 Antrain 500 mg 1 Amp
17 Neostigmine 0,5 mg 2 Amp
18 Aminophylline 240 mg 1 Amp
19 Ondansetron 4 mg 1 Amp
20 Ranitidine 50 mg 1 Amp
21 Dexamethasone 5 mg 2 Amp
22 Iphadryl 10 mg 1 Amp
23 Asam Traneksamat 500 mg 2 Amp
24 Farsix 20 mg 2 Amp
25 Phytomenadione 10 mg 1 Amp
26 Levica 50 mg 1 Amp
27 Ropivel 150 mg /Regivel 1 Amp
28 Rocuronium 1 Amp
29 Granisetron 1 Amp
30 Spinocan no 26/27 @1 Buah
31 Elektroda EKG 3 Biji
32 Ringer Laktat 500 cc 3 Flash
33 NaCl 0,9% 500 cc 3 Flash
34 Spuit no 3 cc/5 cc/10 cc @3 Buah
35 ETT no 6,5/ 7/ 7,5 @1 Buah
36 Mayo Kuning/ Hijau @1 Buah
37 Suction Catheter no 12 1 Buah
38 3 Way Extention 1 Buah
39 Deksketoprofen 1 amp
Petugas OK Petugas Anestesi Petugas Apotik Jember, ...........20....

ACC BENANG

No Jenis Operasi Nama Benang Harga

Benang T-Mono no 1 142,313
Benang T-Vio no 1 102.712,5
1 SC Benang T-Mono no 4/0 117,563
Benang Dermalon no 2/0 83,125
Benang Ecosorb no 2 104,500

Benang T-Mono no 1 142,313

Benang T-Vio no 1 102.712,5
2 STT Benang T-Mono no 4/0 117,563
Benang Dermalon no 2/0 83,125
Benang Dermalon no 3/0 80,000

Benang T-Vio no 1 102.712,5

3 Debridemen Benang Safil no 2/0 97.452,5
Benang Dermalon no 3/0 80,000

Benang Monosyn no 3/0 156.062,5

4 Struma Benang T-Mono no 4/0 117,563
Benang Dermalon no 3/0 80,000

Benang T-Vio no 1 102.712,5

5 BPH Benang Dermalon no 2/0 83,125
Benang Dermalon no 3/0 80,000

Benang T-Mono no 1 142,313

Benang T-Vio no 1 102.712,5
6 Hernia
Benang T-Mono no 4/0 117,563
Benang Dermalon no 3/0 80,000

Benang Silkam no 2/0 80,850

Benang T-Vio no 1 102.712,5
7 Appendik Benang Safil no 2/0 97.452,5
Benang T-Mono no 4/0 117,563
Benang Dermalon no 3/0 80,000

Benang T-Vio no 1 102.712,5

8 Ca Mammae Benang T-Mono no 4/0 117,563
Benang Dermalon no 3/0 80,000

Benang T-Mono no 1 142,313

9 Laparatomy Benang T-Vio no 1 102.712,5
Benang Dermalon no 3/0 80,000

Benang Plain no 3/0 ?

10 Sirkumsisi
Benang Plain no 4/0 ?

Benang Dermalon no 10/0 201,630

11 Mata
Benang Vycril no 8/0 ?