FORM CHECKLIST TROLI EMERGENSI

RUMAH SAKIT SURYA ASIH PRINGSEWU

SUPERVISI PETUGAS FARMASI DI AMBULANCE
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
ISDN 5 mg Tab 10
Clopidogrel 25 mg Tab 10
Cartylo 80 mg Tab 10
INJEKSI
Ephynephrine 50 mg/mL Amp 7
Aminophillin inj Amp 1
Dexamethasone inj Amp 1
Lidocain 20 mg/mL Amp 1
Ca Gluconas 100 mg/mL Amp 2
Diphenhidramin 150 mg/mL Amp 1
Fargoxin 0,25 mg/mL Amp 2
Dopamin 40 mg/mL Amp 2
Dobutamin 40 mg/mL Amp 2
Ephedrine 50 mg/mL Amp 2
Furosemide 10 mg/mL Amp 2
Norepinephrine 1 mg/mL Amp 2
Atrofin Sulfat 0,25 mg/mL Amp 1
Nicardipine 1 mg/mL Amp 2
CAIRAN DAN BMHP
Aquabidest 25 ml fls 1
Kassa Steril pcs 1
Abocath no.18 pcs 1
Abocath no.20 pcs 1
Abocath no.22 pcs 1
Abocath no 24 pcs 1
Handscoon steril No.6,5 pcs 1
Handscoon steril No. 7 pcs 1
Handscoon steril No. 7,5 pcs 1
Handscoon steril No.8 pcs 1
Needle No. 23 pcs 1
betadine solution 30 mL pcs 1
Spuit 1 cc pcs 1
Spuit 3 cc pcs 1
Spuit 5 cc pcs 1
Spuit 10 cc pcs 1

Minggu
NAMA OBAT DAN BMHP Jumlah Keterangan
1 3
Canul Dewasa pcs 1
Canul Anak pcs 1
Canul Bayi pcs 1
D5% 500 mL pcs 1
NaCl 0,9% 500 mL fls 1
Ringer Laktat fls 1
D10% fls 1
Novelhes fls 1
Infuset Macro pcs 1
Infuset Micro pcs 1
Alkohol 70% pcs 1
Micropore 1 inci pcs 1
Leukoplast Besar pcs 1
PD fix 5 x 10 pcs 1
Masker NRM anak pcs 1
Masker NRM dewasa pcs 1

PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI PERINA
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
AMINOPHYLIN INJ Amp 2
DEXAMETASON INJ Amp 2
ATROPIN SULFAT INJ Amp 2
EPHYNEPRIN INJ Amp 7
PHENOBARBITAL INJ Amp 1
PHENYTOIN INJ Amp 1
DOPAMIN INJ Amp 2
DOBUTAMIN INJ Amp 2
NOREPHYNEPHRINE INJ Amp 2
NACL 100 ML Fls 2
NACL 500 ML Fls 1
D40% Fls 1
MGSO4 40% Fls 1
RL Fls 2
D5% 500 ML Fls 1
D10% 500 ML Fls 1
D10% 1/5 NS Fls 1
KAEN 1B Fls 1
AQUADEST 25 ML Fls 3
NOVELHEST Pcs 1
AB. 26 Pcs 2
SPUIT 1 CC Pcs 2
SPUIT 3 CC Pcs 2
SPUIT 5 CC Pcs 2
SPUIT 10 CC Pcs 2
MIKRO SET Pcs 1
HS. STERIL NO 6.5 Pcs 1
HS. STERIL NO 7.5 Pcs 1
BETADINE SOLUTION 30 ML Fls 1
CANUL BAYI Pcs 1
NGT NO, 3,5 Pcs 1
NGT NO. 5 Pcs 1
NGT NO. 8 Pcs 1
KASA STERIL Pcs 1
ELEKTRODA Pcs 6
 PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI PERINA
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
AMINOPHYLIN INJ Amp 2
DEXAMETASON INJ Amp 2
ATROPIN SULFAT INJ Amp 2
EPHYNEPRIN INJ Amp 2
PHENOBARBITAL INJ Amp 1
PHENYTOIN INJ Amp 1
VALISANBE INJ Amp 1
STESOLID SUPP 5 MG Supp 1
STESOLID SUPP 10 MG Supp 1
DOPAMIN INJ Amp 2
DOBUTAMIN INJ Amp 2
NOREPHYNEPHRINE INJ Amp 2
FARGOXIN INJ Amp 1
NACL 0,9% 100 ML Fls 2
NACL 0,9% 500 ML Fls 1
RL Fls 2
TRIDEX PLAIN Fls 2
D5% 100 ML Fls 1
D10% 500 ML Fls 1
D5 ¼ NS Fls 1
D5 1/5 NS Fls 1
D5 1/2 NS Fls 1
AQUADEST 25 ML Fls 3
AB. 24 Pcs 2
AB. 26 Pcs 2
SPUIT 1 CC Pcs 2
SPUIT 3 CC Pcs 2
SPUIT 5 CC Pcs 2
SPUIT 10 CC Pcs 2
MAKRO SET Pcs 1
MIKRO SET Pcs 1
HS. STERIL NO 6.5 Pcs 1
HS. STERIL NO 7 Pcs 1
HS. STERIL NO 7.5 Pcs 1
CANUL BAYI Pcs 1
CANUL ANAK Pcs 1
NGT NO, 3,5 Pcs 1
NGT NO. 5 Pcs 1
NGT NO. 8 Pcs 1
KASA STERIL Pcs 1
AMBU BAG Pcs 1
DILI Pcs 1
BETADIN 30 ML Pcs 1
SUNGKUP ANAK Pcs 1
NOVELHEST Pcs 1
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST KIT EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI SAKURA
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
AMINOPHYLIN INJ Amp 2
DEXAMETASON INJ Amp 2
ATROPIN SULFAT INJ Amp 5
EPHYNEPRIN INJ Amp 7
PHENYTOIN INJ Amp 1
DOBUTAMIN INJ Amp 2
NACL 0,9% 100 ML Fls 2
D5% 100 ML Fls 1
D5 ¼ NS Fls 1
D40% Fls 2
AB. 24 Pcs 1
AB. 26 Pcs 1
SPUIT 1 CC Pcs 2
SPUIT 3 CC Pcs 2
SPUIT 5 CC Pcs 2
CANUL BAYI Pcs 1
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI KEBIDANAN VK
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
NIFEIDIPINE tab 10
MISOPROSTOL tab 5
AMINOPHYLIN amp 3
DEXAMETASON amp 6
CA GLUCONAS amp 3
LIDOCAIN amp 3
ASAM TRANEXAMAT amp 3
ATROPIN SULFAT amp 2
DOPAMIN amp 3
DOBUTAMIN amp 3
EPHYNEPHRINE amp 7
NOREPHYNEPHRINE amp 2
OXYTOCIN amp 7
METHYL ERGOMETRIN amp 3
RL fls 2
NACL 0,9% 500 ML fls 1
NACL 0,9% 100 ML fls 2
D5% 500 ML fls 2
D40% 25 ML fls 2
D10% 500 ML fls 1
MGSO4 40% 25 ML fls 2
AQUADES 25 ML fls 2
NACL 0,9 25 ML fls 2
TRANFUSION SET pcs 1
MAKRO SET pcs 1
MIKRO SET pcs 1
KASA STERIL pcs 1
AB 18 pcs 1
AB 20 pcs 1
AB 22 pcs 1
AB 24 pcs 1
DRESING pcs 1
SWAB pcs 10
CATHETER NO 14 pcs 1
CATHETER NO 14 pcs 1
URINE BAG pcs 1
CANUL DEWASA pcs 1
SUNGKUP NRM DEWASA pcs 1
SUNGKUP RM DEWASA pcs 1
SUCTION CATHETER NO 8 pcs 1
SUCTION CATHETER NO 12 pcs 1
NGT NO 16 pcs 1
NGT NO 14 pcs 1
HS STERIL NO 6,5 pcs 1
HS STERIL NO 7 pcs 1
HS STERIL NO 7,5 pcs 1
HS PANJANG pcs 1
SPUIT 1 CC pcs 3
SPUIT 3 CC pcs 3
SPUIT 5 CC pcs 3
SPUIT 10 CC pcs 3
NALD 23 pcs 3
NALD 27 pcs 3
BETADINE SOLUTION 30 ML pcs 1
CANUL BAYI pcs 1
SUNGKUP BAYI pcs 1

PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Mengetahui

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI INTERNA
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT & BMHP Sediaan Jumlah Hasil Supervisi
ISDN 5 mg Tab 10
Captopril 25 mg Tab 10
Cartylo 80 mg Tab 10
Clopidogrel 75 mg Tab 10
fargoksin inj Amp 2
Dopamin inj Amp 2
Dobutamin inj Amp 2
norephiephrine inj Amp 2
Epinephrine inj Amp 7
Ephedrine Amp 2
Atrofin Sulfat inj Amp 1
Ca Gluconas inj Amp 1
Phenitoin inj Amp 1
D40% 25 mL Fls 1
MGSO4 40% 25 mL Fls 1
NaCl 0,9% 100 mL Fls 2
D5% Fls 1
NaCl 0,9% 500 mL Fls 2
RL Fls 7
D10% Fls 1
Novelhest Fls 1
Aquabidest 25 ml Fls 1
Ab 18 Pcs 1
Ab 20 Pcs 1
Ab 22 Pcs 1
Catheter 14 Pcs 1
Catheter 16 Pcs 1
Nald 23 Pcs 1
Nald 27 Pcs 1
Tranfusion set Pcs 1
Makro set Pcs 1
Mikro set Pcs 1
Spuit 1 cc Pcs 1
Spuit 3 cc Pcs 1
Spuit 5 cc Pcs 1
Spuit 10 cc Pcs 1
HD Steril 6,5 Pcs 1
HD Steril 7 Pcs 1
HD Steril 7,5 Pcs 1
Canul Dewasa Pcs 1
NRM Dewasa Pcs 1
RM Dewasa Pcs 1
Nebu Dewasa Pcs 1
Urin bag Pcs 1
Betadine solution 30 mL Pcs 1
Kasa Steril Pcs 1
Elektroda Pcs 6
NGT 14 Pcs 1
NGT 16 Pcs 1
Guedel Hitam Pcs 1
Guedel Kuning Pcs 1
Guedel Putih
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Mengetahui

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI KEBIDANAN
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT DAN BMHP Sediaan Jumlah Hasil Supervisi
NIFEIDIPINE tab 10
MISOPROSTOL tab 5
AMINOPHYLIN INJ amp 3
FARGOXIN INJ amp 2
NOREPHYNEPRINE INJ amp 2
EPHYNEPRINE INJ amp 7
DEXAMETASON INJ amp 6
CA GLUCONAS INJ amp 3
LIDOCAIN INJ amp 3
ASAM TRANEXAMAT INJ amp 3
OXYTOCIN INJ amp 7
METHYL ERGOMETRIN INJ amp 3
ATROPIN SULFAT INJ amp 2
DOPAMIN INJ amp 3
DOBUTAMIN INJ amp 3
D40% 25 ML Fls 1
MGSO4 40% 25 ML Fls 1
RL 500 ML fls 2
NACL 0,9% 500 ML fls 1
D5% 500 ML fls 2
AQUADES 25 ML fls 2
NACL 0,9 25 ML fls 2
D10% 500 ML fls 1
SANBE HEST fls 1
TRANFUSION SET pcs 1
MAKRO SET pcs 1
MIKRO SET pcs 1
AB 18 pcs 1
AB 20 pcs 1
AB 24 pcs 1
AB 22 pcs 1
DRESING pcs 1
SWAB pcs 10
FOLLEY CATHETER NO 14 pcs 1
URINE BAG pcs 1
CANUL DEWASA pcs 1
SUNGKUP NRM DEWASA pcs 1
SUNGKUP RM DEWASA pcs 1
SUCTION CATHETER NO 8 pcs 1
SUCTION CATHETER NO 12 pcs 1
NGT NO 16 pcs 1
NGT NO 5 pcs 1
HS STERIL NO 6,5 pcs 1
HS STERIL NO 7 pcs 1
HS PANJANG pcs 1
SPUIT 1 CC pcs 3
SPUIT 3 CC pcs 3
SPUIT 5 CC pcs 3
SPUIT 10 CC pcs 3
NALD 23 pcs 3
NALD 27 pcs 3
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI UGD
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT &BMHP Sediaan Jumlah Hasil Supervisi
ISDN Tab 10
Captopril 25 mg Tab 10
Aspirin 80 mg Tab 10
Clopidogrel 75 mg Tab 10
Amiodaron 50 mg/ml Amp 2
Atropin Sulfas 0,25 Amp 5
Ca Gkuconas 100 mg/ml Amp 2
Dipenhidramin 150 mg/ 15 ml Amp 1
Fargoksin 0,25 mg/ml Amp 2
Dopamin 40 mg/ml Amp 2
Dobutamin 40 mg/ml Amp 2
Ephedrine 50 mg/ml Amp 2
Ephinephrine 50 mg/ml Amp 7
Furosemide 10 mg/ml Amp 2
Lidocain 20 mg/ml Amp 2
Norepinephrine 1 mg/ml Amp 2
Nicardipin 1 mg/ml Amp 2
D40% 25 ML Fls 2
Novelhest Fls 1
NaCl 0,9% 100 Fls 2
NaCl 0,9% 500 Fls 2
RL Fls 7
Ambu bag Pcs 1
Ab. 18 Pcs 1
Ab. 20 Pcs 1
Folly Catheter No.14 Pcs 1
Folly Catheter No. 16 Pcs 1
Folly Catheter No. 20 Pcs 1
ETT No. 4 Pcs 1
ETT No. 7,5 Pcs 1
Nald 23 Pcs 2
Nald 27 Pcs 2
Tranfusion set Pcs 1
Spuit 10CC Pcs 2
Spuit 5CC Pcs 2
Spuit 3CC Pcs 2
Spuit 1CC Pcs 2
infuset makro Pcs 1
infuset mikro Pcs 1
HD. Steril No. 8 Pcs 1
HD. Steril No. 7,5 Pcs 1
HD. Steril No. 7 Pcs 1
HD. Steril No.6,5 Pcs 1
Canul Dewasa Pcs 1
Canul Anak Pcs 1
Canul bayi Pcs 1
Urin Bag Pcs 1
Kasa Steril Pcs 1
Elektroda Pcs 6
NGT 3,5 Pcs 1
NGT 5 Pcs 1
NGT 8 Pcs 1
Gudel Pink Pcs 1
Gudel Hijau Pcs 1
Gudel Merah Pcs 1
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Kepala Ruangan

(...................................)
 FORM CHECKLIST TROLI EMERGENSI
RUMAH SAKIT SURYA ASIH PRINGSEWU
SUPERVISI PETUGAS FARMASI DI OK
MINGGU
BULAN :
1 3
TANGGAL : Keterangan
NO SERI KUNCI :
NAMA OBAT &BMHP Sediaan Jumlah Hasil Supervisi
ISDN 10
Aspirin 80 mg Tab 10
Clopidogrel Tab 10
Amiodaron 50 mg/ml Amp 2
Atropin Sulfas 0,25 Amp 5
Ca Glukonas 100 mg/ml Amp 2
Difenhidramin 150 mg/ 15 ml Amp 1
Fargoksin 0,25 mg/ml Amp 2
Dopamin 40 mg/ml Amp 2
Dobutamin 40 mg/ml Amp 2
Ephedrine 50 mg/ml Amp 2
Ephinephrine 50 mg/ml Amp 7
Furosemide 10 mg/ml Amp 2
Lidocain 20 mg/ml Amp 2
Norepinephrine 1 mg/ml Amp 2
Nicardipin 1 mg/ml Amp 2
Traneksamat acid Amp 4
D40% 25 ML Fls 2
MgSO4 25 Fls 2
Novelhest Fls 1
NaCl 0,9% 100 mL Fls 2
NaCl 0,9% 500 Ml Fls 2
RL Fls 7
Aquabides Fls 1
Alkohol 70% Fls 1
PCT infus Fls 1
Ambu bag Pcs 1
Ab 14 Pcs 2
Ab. 18 Pcs 2
Ab. 20 Pcs 2
Folly Catheter No.14 Pcs 1
Folly Catheter No. 16 Pcs 1
Folly Catheter No. 20 Pcs 1
ETT No. 4 Pcs 1
ETT No. 7,5 Pcs 1
Nald 23 Pcs 2
Nald 27 Pcs 2
Tranfusion set Pcs 1
Spuit 10CC Pcs 2
Spuit 5CC Pcs 2
Spuit 3CC Pcs 2
Spuit 1CC Pcs 2
infuset makro Pcs 1
infuset mikro Pcs 1
HD. Steril No. 8 Pcs 1
HD. Steril No. 7,5 Pcs 1
HD. Steril No. 7 Pcs 1
HD. Steril No.6,5 Pcs 1
Canul Dewasa Pcs 1
Canul Anak Pcs 1
Canul bayi Pcs 1
Urin Bag Pcs 1
Kasa Steril Pcs 1
Elektroda Pcs 6
NGT 3,5 Pcs 1
NGT 5 Pcs 1
NGT 8 Pcs 1
NGT 16 Pcs 1
NGT 18 Pcs 1
Gudel Pink Pcs 1
Gudel Hijau Pcs 1
Swab alkohol Pcs 10
Suction Catheter 10 Pcs 1
Gel Spoon Pcs 1
Gudel Merah Pcs 1
PARAF SUPERVISOR

PARAF KOORDINATOR RUANGAN

√ = Sesuai
- = Tidak Sesuai

Kepala Instalasi Supervisor

apt. Isnaini Adinda Pratiwi, S.Farm. (..............................)

Mengetahui
(...................................)