So 3 Bulan Desember 2020 LB

LAPORAN PEMAKAIAN DAN LEMB
PUSKESMAS : CIKEUSIK/ LEUWIBALANG

KECAMATAN : CIKEUSIK
KAB / KOTA : PANDEGLANG PELAPORAN BULAN / PERIODE
PROVINSI : BANTEN PERMINTAAN BULAN / PERIODE
Jumlah
N0 NAMA OBAT SATUAN Stok Awal Penerimaan
Persediaan
1 2 3 4 5 6
A NAMA OBAT ( 4+5 )
1 Alprazolam Tablet - - -
2 Albendazol Tablet 400 mg Tablet - - -
3 Allopurinol tablet 100 mg Tablet 30 - 30
4 Ambroxol sirup Botol - 3 3
5 Ambroxol tablet 30 mg Tablet - - -
6 Aminofilin Tablet 200 mg Tablet - - -
7 Aminofilina injeksi 24 mg/ml - 10 ml Ampul - - -
8 Amlodipin 10 mg Tablet - - -
9 Amlodipin Besilate 5 mg Tablet - - -
10 Amoksisilin Forte sirup kering 250mg Botol - - -
11 Amoksisilin Injeksi 1 gr Vial - - -
12 Amoksisilin Tablet 500 mg Tablet 250 200 450
13 Amoksisillin kapsul 250 mg Kapsul - - -
14 Amoksisillin Sirup Kering 125 mg/5 ml Botol - 3 3
15 Ampisilin Injeksi 1 gr Vial - - -
16 Analog insulin Long Acting Pen - - -
17 Analog insulin Mix Acting Pen - - -
18 Antalgin (Metampiron) tablet 500 mg Tablet - - -
19 Antalgin (Metampiron) tablet 500 mg Tablet - - -
20 Antasida DOEN suspensi Botol 10 - 10
21 ANTASIDA DOEN Tablet Tablet 100 200 300
22 Anti Bakteri DOEN ( Bacitrasin ) Tube - - -
23 anti hemoroid doen kombinasi supp - - -
24 Antifungi DOEN Tube - - -
25 Antimigren DOEN Kombinasi : Tablet - - -
26 Antiparkinson DOEN tablet KombinasiTablet - - -
27 Antiparkinson Tablet ( Levopar ) Tablet - - -
28 Aqua Pro Injeksi Vial - - -
29 Artermeter injeksi Ampul - - -
30 Artesunate injeksi 60 mg/ml vial - - -
31 Asam Ascorbat ( Vit. C ) 50 MG Tablet - - -
32 Asam Folat Botol - - -
33 Asam Fusidat Cream Tube - - -
34 Asam Klorida 0,1 N Botol - - -
35 Asam Mefenamat 500 mg Tablet 50 - 50
36 Asam Traneksamat Inj 5% Ampul - - -
37 Asering Botol - - -
38 Asetosal tablet 500 mg Tablet - - -
39 Asetyl Cysteine Capsul - - -
40 Asiklovir Cream 5% Tube - - -
41 Asiklovir tablet 200 mg Tablet - - -
42 Asiklovir tablet 400 mg Tablet - - -
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Ampul - - -
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Vial - - -
45 Atropin Sulfat tablet 0,5 mg Tablet - - -
46 Berotec Metered Aerosol 100 mg Bok - - -
47 Betadine Salep Antiseptik 5 mg Tube - - -
48 Betametason krim 0,1 % Tube 2 2 4
49 Bisakodil Suppositoria supp - - -
50 Bisoprolol 2,5 mg Tablet - - -
51 Bisoprolol 5 mg Tablet - - -
52 Cairan Infus KN-3B Botol - - -
53 Cairan Infus Wida KDN 1 Botol - - -
54 Cairan Pembersih ( Protektor ) Botol - - -
55 Captopril Tablet 12,5 mg Tablet 30 50 80
56 Captopril Tablet 25 mg Tablet - - -
57 Cefadroxil Capsul 500 mg Capsul - - -
58 Cefixime Capsul 100 mg Capsul - - -
59 Cefixime Sirup Botol - - -
60 Cefotaksime 1 gr Injeksi Vial - - -
61 Cetirizine Capsul 50 mg Capsul 50 100 150
62 Cetirizine sirup 5 mg/5 ml Botol - - -
63 Ciprofloxcacin 500 mg tablet Tablet 30 - 30
64 Combivent UDV 2,5 mg+0,5mg/2,5 mlAmpul - - -
65 D-Artepp tablet Tablet - - -
66 deksametason tab Tablet 100 100 200
67 Dekstran 70 - larutan infus 6% steril Botol - - -
68 Dekstrometorfan sirup Botol - - -
69 Dekstrometorfan tablet 15 mg Tablet - - -
70 Diazepam Rektal 0,5 mg / 2 ml supp - - -
71 Diazepam tablet 2 mg Tablet - - -
72 Diazepam tablet 5 mg Tablet - - -
73 Difenhidramin HCL injeksi 10 mg/ml - Ampul - - -
74 Digoksin tablet 0,25 mg Tablet - - -
75 Diltiazem Tablet - - -
76 Doksisiklin Kapsul 100 mg Capsul - - -
77 Domperidon 10mg Tablet Tablet 100 100 200
78 Domperidon Suspensi 5 mg/ 5 ml Botol 2 - 2
79 Doxicyclin 500mg capsul - - -
80 Efedrin HCLTablet 25 mg Tablet - - -
81 Epinefrina HCL/Bitartrat Injeksi Ampul - - -
82 Eritromicyn kapsul 250 mg capsul - - -
83 Erytromicin kapsul 500 mg Kapsul - - -
84 Erytromicin sirup 125 mg Botol - - -
85 Etakridin ( Rivanol ) larutan 0,1% Botol - - -
86 Etambutol 500 mg Tablet - - -
87 Etanol 70 % Botol - - -
88 Etil Klorida Semprot Botol - - -
89 Fenitoin Natrium kapsul 30 mg Kapsul - - -
90 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul - - -
91 Fenobarbital tablet 30 mg Tablet - - -
92 Fenoksimetil Penisilina tablet 250 mg Tablet - - -
93 Fenol Gliserol tetes telinga 10 % Botol - - -
94 Fitomenadion (Vit.K1) Injeksi 10 mg/mlAmpul - - -
95 Fitomenadion (Vit.K1) tab salut gula 1 Tablet 50 - 50
96 Flufenazine Deconat Inj 25 mg/ml Ampul - - -
97 Furosemida tablet 40 mg Tablet - - -
98 Furosemide Injeksi Ampul - - -
99 Garam Oralit Sachet - 20 20
100 Gemfibrozil 300 mg Tablet - - -
101 Gentamicin Injeksi Ampul - - -
102 Gentamicin Salep Kulit Tube - - -
103 Gentamicin Salep mata Tube - - -
104 Gentamicin Tetes Mata Botol - - -
105 Gentian Violet 1 % Botol - - -
106 Glibenclamid tablet 5 mg Tablet - - -
107 Glicerin Guaiacolat ( GG ) 100 mg Tablet - - -
108 Glikazid 80 mg Tablet Tablet - - -
109 Glimepiride 2 mg Tablet - - -
110 Glukosa larutan infus 10% steril Botol - - -
111 Glukosa larutan infus 5 % steril Botol - - -
112 Griseofulvin tablet 500 mg, Tablet - - -
113 Guaiafenesin 100 mg Tablet - - -
114 Hidroklortiniazid ( HCT )Tab.25 mg Tablet - - -
115 Hidrokortison krim 2,5% Tube - 5 5
116 Ibuprofen Suspensi Tablet - - -
117 Ibuprofen tablet 200 mg Tablet - - -
118 Ibuprofen tablet 400 mg Tablet - - -
119 Imunomodulator sirup( STIMUNO) Botol - - -
120 Isosorbid Dinitrat tablet sublingual 5 mTablet - - -
121 Kalsium Glukonas Injeksi Ampul - - -
122 Kalsium Laktat (Kalk) tablet 500 mg Tablet 100 100 200
123 Kapas Berlemak 500 mg Bungkus - - -
124 Ketokonazol Kream Tube 2 10 12
125 Ketokonazol Tablet 200 mg Tablet 50 50 100
126 Ketorolac inj Ampul - - -
127 Kifadene tablet 20 mg Tablet - - -
128 Kloramfenikol salep mata 1 % capsul - 2 2
129 Kloramfenikol suspensi Botol - - -
130 Kloramfenikol tetes telinga 3% Tube - - -
131 Kloramphenicol 250 mg Capsul - - -
132 Kloramphenicol 500 mg capsul - - -
133 Kloramphenicol Tetes Mata Botol 3 - 3
134 Klorfeniramin Maleat (CTM) tablet 4 mTablet 250 100 350
135 Klorokuin tablet 150 mg Tablet - - -
136 Klorpromazin HCL tablet salut 25 mg Tablet - - -
137 Kombinasi (Pirimetamin 25 mg + SolfaTablet - - -
138 Kotrimoksazol Dewasa Tablet 480 mgTablet 250 - 250
139 Kotrimoksazol Sirup / Suspensi Botol 15 - 15
140 Kuinin Dihidroklorida injeksi 25% - 2 mAmpul - - -
141 Kuinin Dihidroklorida injeksi 25% - 2 mBotol - - -
142 Lactobacilus serbuk Sachet - - -
143 Lidocain 2%+efinefrin injeksi Ampul - - -
144 Lidocain injeksi 2 ml Ampul - - -
145 Lisinopril 10 mg tablet Tablet - - -
146 Lisinopril 5 mg tablet Tablet - - -
147 Loperamid 4 mg tablet Tablet - - -
148 Lytacur Sirup Botol - - -
149 Magnesium Sulfat Inj. 25 ml 20% Ampul - - -
150 Metamizol 500 mg Tablet - - -
151 Metformin 500 mg Tablet Tablet 50 - 50
152 Methilprednisolon tablet 8 mg Tablet - - -
153 Metilergometrin Maleat injeksi 1 ml Ampul 3 - 3
154 Metilergometrin Maleat Tablet Tablet - - -
155 Metoklopramid Suspensi Botol - - -
156 Metoklopramid tablet Tablet - - -
157 Metronidazol 500 mg Tablet - - -
158 Metronidazol infus / injeksi Botol - - -
159 Metronidazol Ovula supp - - -
160 Metronidazol suspensi Botol - - -
161 Mikonazol kream Tube 5 - 5
162 Multivitamin Anak Sirup Botol - - -
163 Multivitamin Dewasa Antioksidan ( Be Tablet - - -
164 Natrium Diklofenak 25 mg Tablet Tablet - - -
165 Natrium Diklofenak 50 mg Tablet Tablet 100 50 150
166 Natrium Klorida Cairan Infus ( NaCL ) Botol - - -
167 Nifedipine Tablet 10 mg Tablet - - -
168 Nistatin tablet vaginal 100.000 IU/g Tube 10 - 10
169 Obat anti Diare suspensi Botol - - -
170 Obat Anti Diare Tablet (Akita / Molagit Tablet 50 - 50
171 Obat Batuk Flu ( Molexflu ) Tablet - - -
172 Obat Batuk Hitam (OBH) Botol - - -
173 Obat Batuk Sirup Herbal ( Herbacop ) Botol - - -
174 Ofloxsacin Tetes Telinga Tube - - -
175 Oksitetrasiklin HCL salep mata 1% Botol - - -
176 Oksitosin injeksi 10 IU/ml - 1 ml Ampul 5 - 5
177 Omeprazol injeksi Ampul - - -
178 Omeprazol Kapsul 20 mg capsul - - -
179 Ondancentron injeksi 4 mg Ampul - - -
180 Ondancentron Tablet4 mg Tablet - - -
181 Paracetamol Drop 15 ml Botol 2 - 2
182 Paracetamol Sirup 120 mg/5 ml Botol 20 10 30
183 Parafin Dresing ( Bioplacenton Tull ) pcs - - -
184 Parasetamol tablet 100 mg Tablet - - -
185 Parasetamol tablet 500 mg Tablet 150 100 250
186 Permetrin Krim 5 % Tube - - -
187 Pirantel Sirup Botol - - -
188 Pirantel tablet 125 mg Tablet - - -
189 Pirazinamid Botol - - -
190 Piridoksin HCL (VIT B6) tablet 10mg Botol 50 - 50
191 Piroksikam tablet 20 mg Tablet - - -
192 Polikresulen Tube - - -
193 Povidon lodida 10% 300 ml - - -
194 Povidon lodida 10% 60 ml Tablet - - -
195 Prazikuantel tablet 600 mg Botol - - -
196 Prednison Tablet 5 mg Tablet 100 100 200
197 Primakuin 15 mg Tablet - - -
198 Probenesid 500 mg tablet Tablet - - -
199 Prokain Benzil Penisilin 3 juta IU/vial i Ampul - - -
200 Propanolol HCL tablet 10 mg Tablet - - -
201 Ranitidin injeksi Ampul - - -
202 Ranitidin tablet Tablet 50 100 150
203 Resperidone 2 mg tablet Tablet - - -
204 Ringer Laktat cairan infus (Otsuka) - - -
205 Ringer Laktat cairan infus (Widatra) Botol - - -
206 Rivanol 300 ml Botol - - -
207 Salbutamol Tablet 2 mg Tablet 30 - 30
208 Salbutamol tablet 4mg Tablet 50 - 50
209 Salep 2-4 Tube 3 - 3
210 Salep kombinasi cream ( Berloson ) Tube - - -
211 Salicil bedak Kotak - - -
212 Serum Anti Bisa Ular Polivalen Inj 50 Vial - - -
213 Serum Anti Tetanus inj 1500 IU ( TetaVial - - -
214 Sianokobalamin Injeksi Ampul - - -
215 Simvastatin 10 mg tablet Tablet - - -
216 Simvastatin 20 mg tablet Tablet - - -
217 Sukralfat Suspensi Botol - - -
218 Sukralfat tablet 500 mg Tablet - - -
219 Suspensi Seng Insulin inj.40 IU/ml - 1 Tube - - -
220 Temporary Stopping Fletcher serbuk &Tablet - - -
221 Tetrakain HCL tetes mata 0,5% Tube - - -
222 Tetrasiklin 250 mg capsul capsul - - -
223 Tetrasiklin 500 mg capsul capsul - - -
224 Tiamin Tablet 50 mg ( B1 ) Tablet 100 - 100
225 Ventolin Nebulizer Ampul - - -
226 Vitamin B komplek Tablet 100 100 200
227 Zink sirup Botol 2 - 2
228 Zink tablet 20 mg Tablet 200 - 200
229 Deksametason inj Ampul - - -
230 Diazepam inj 5 mg/ml Ampul - - -
231 Griseofulvin 125 mcg Tablet - - -
232 Kloramfenikol SK Tube - - -
233 Nystatin tab 500.000 IU Tablet - - -
234 magnesium Sulfat Inj. 25 ml 40% ampul 10 - 10
- - -
- - -
OBAT PROGRAM - - -
1 Albendazol Tablet 400 mg Tablet - - -
2 Isoniazid Tablet 100 mg Tablet - - -
3 Obat Antituberkulosis kategori 1 Paket - - -
4 Obat Antituberkulosis Kategori 2 Paket - - -
5 Obat Antituberkulosis Kategori Anak Paket - - -
6 Pot Dahak Non Steril Biji - - -
7 Pot Dahak Steril Biji - - -
8 Reagen Ziehl Neelsen Kit - - -
9 MDT MB Anak Tablet Tablet - - -
10 MDT MB Dewasa Tablet Tablet - - -
11 MDT PB Dewasa Tablet Tablet - - -
12 MDT PB Anak Tablet Tablet - - -
13 Retinol (Vitamin A) kapsul 200.000 IU capsul - - -
14 Retinol (Vitamin A) kapsul 100.000 IU capsul - - -
15 Tablet Penambah Darah ( FE ) Tablet - - -
16 Amitriptilin tablet 25 mg Tablet - - -
17 Carbamazepin 200 mg tablet Tablet - - -
18 Clobazam 10 mg Tablet Tablet - - -
19 Clozapine 25 mg Tablet Tablet - - -
20 Fenitoin Natrium kapsul 30 mg capsul - - -
21 Haloperidol 1,5 mg Tablet Tablet - - -
22 Haloperidol 2 mg tablet Tablet - - -
23 Haloperidol 5 mg Tablet Tablet - - -
24 Haloperidol Injeksi Ampul - - -
25 Klorpromazin HCL tablet salut 100 mgTablet - - -
26 Klorpromazine Tablet 25 mg Tablet - - -
27 Triheksilfenidil Hcl 2 mg tablet Tablet - - -
28 Depakote 250 mg Botol - - -
29 Flufenazine (sikzonoat inj) Ampul - - -
30 Risperidon 2 mg Tablet - - -
31 DHP tab - - -
32 Primaquin tab - - -
B NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - - -
- - -
1 Alat suntik 1 ml Pcs 15 10 25
2 Alat suntik 10 ml Pcs - - -
3 Alat suntik 2,5 ml Pcs - - -
4 Alat suntik 20 ml Pcs - - -
5 Alat suntik 3 cc (Remedi) - - -
6 Alat suntik 3 ml Pcs - 5 5
7 Alat suntik 5 ml pcs 5 - 5
8 Alkazide 1 L High Level Desinfectant Botol - - -
9 Alkazyme Sachet 25 mg Pack - - -
10 Alkohol 70 % 1 L Botol - - -
11 Alkohol swab Sachet - 1 1
12 Anti Septik Hand Rub Botol - - -
13 Anti Septik Surgikal Hand Scrub Botol - - -
14 Cat Gut no 2/0 Sachet 6 - 6
15 Cat Gut no 3/0 Sachet - - -
16 Cat Gut No 3/0 (24 mm) Sachet - - -
17 Cat Gut No 3/0 (26 mm) Sachet - - -
18 Cathetter Jelly Biji - - -
19 Demetech Silk 3/0 Set - - -
20 E Care I.V Dresing Pcs 10 - 10
21 E-Care Surgical Mask Tie On Lembar - - -
22 Folly No 14 Catether pcs - - -
23 Folly No 16 Catether pcs - - -
24 I.V Cathetter No. 20 Set 2 5 7
25 I.V Cathetter No. 22 Set - - -
26 I.V Cathetter No. 24 Set 2 - 2
27 I.V Cathetter No. 26 Set 3 - 3
28 Infuset Anak Set 17 - 17
29 Infuset Dewasa Set - - -
30 Jarum Insulin Tablet 3 - 3
31 Kapas Berlemak 250 gr Bungkus - - -
32 Kapas Berlemak 500 gr Bungkus - - -
33 Kasa 4 m x 10 cm Rol - - -
34 Kasa Hidrofil 36 x 80 cm Rol - - -
35 Kasa Pembalut 2 x 80 cm Pack - - -
36 Kasa Steril 16 x 16 cm Kotak - 5 5
37 Lisol 1 L Botol - - -
38 Masker karet Ear Loop Lembar 10 - 10
39 Masker tali Tube - - -
40 Nasal Canula Oksigen Set - - -
41 Plester 1" Rol - - -
42 Plester Kertas 2,5 cm Rol - - -
43 Plester Non Woven 5cm x 5 cm Rol - - -
44 Policlean Botol - - -
45 Polifik Kotak - - -
46 Saraya Alsof A 500 ml Botol - - -
47 Saraya Alsof Pure 500 ml Botol - - -
48 Sarung Tangan Gynecolog No 7 Pasang - - -
49 Sarung tangan M (Non Steril) Pasang - - -
50 Sarung tangan no 6,5 Pasang - - -
51 Sarung tangan no 6,5 Steril Gloves Pasang - - -
52 Sarung tangan no 7,0 Steril Pasang - - -
53 Selang Section ( Surgikal Conection TPcs - - -
54 Underpad Lembar - - -
55 Urine Bag Biji - - -
56 safety blackblood BOX - - -
57 safety box BOX - - -
58 Tabung BD Vacutener pcs - - -
59 masker n95 box - - -
60 t silk black 3/0 26 mm pcs - - -
NAMA OBAT VAKSIN - - -
- - -
1 Vaksin Anti Rabies ( VAR ) Vial - - -
2 Vaksin BCG Vial - - -
3 Vaksin DT Vial - - -
4 Vaksin HB 0 Pcs - - -
5 Vaksin HBIG Vial - - -
6 Vaksin Measless Rubella (MR) Vial - - -
7 Vaksin Pentabio ( DPT - HB - Hib ) Vial - - -
8 Vaksin Polio B OPV Vial - - -
9 Vaksin Polio IPV Vial - - -
10 Vaksin TD Vial - - -
11 Vaksin Tuberculin Vial - - -
12 ADS 0,05 ml Unit - - -
13 ADS 0,5 ml Unit - - -
14 ADS 5 ml Unit - - -
15 Safety Box Unit - - -
- - -
- - -
NAMA OBAT REAGEN - - -
- - -
1 Albumin (Reagen) Kotak - - -
2 anti A Monoclonal ( GolDar 10 ml) Vial - - -
3 Anti A-B Monoclonal ( GolDar 10 ml) Vial - - -
4 Anti B Monoclonal ( GolDar 10ml) Vial - - -
5 Anti D Monoclonal ( GolGar 10ml) Vial - - -
6 Benecheck Plus Cholesterol Test Strip - - -
7 Benecheck Plus Glukosa Test Strip - - -
8 Benecheck Plus Uric Test Strip - - -
9 Bilirubin T/D (Reagen) Kotak - - -
10 Brilian Green Bile Broth Kotak - - -
11 Cellclean (CL-50) (Reagen) Kotak - - -
12 Cellpack (PK-30L) (Reagen) Kotak - - -
13 Chikungunya IgM (Reagen) Kotak - - -
14 Cholesterol (Reagen) Kotak - - -
15 Cholesterol Stik (Reagen) Kotak - - -
16 CK-MB (Reagen) Kotak - - -
17 Creatinin Reagen Kit - - -
18 Dengue IgM / IgM ( Reagen ) Kotak - - -
19 Eight Check ( LNH ) Serial - - -
20 Febrile Antingen H Parathpy Vial - - -
21 Febrile Antingen H-A Parathpy Vial - - -
22 Febrile Antingen H-B Parathpy Vial - - -
23 Febrile Antingen H-C Parathpy Vial - - -
24 Febrile Antingen O Parathpy Vial - - -
25 Febrile Antingen O-A Parathpy Vial - - -
26 Febrile Antingen O-B Parathpy Vial - - -
27 Febrile Antingen O-C Parathpy Vial - - -
28 Glukosa Reagen Kotak - - -
29 GOT ( ALAT ) Kotak - - -
30 GPT ( ALAT ) Kotak - - -
31 HBSAG Reagen Box - - -
32 HCG Strip Vial - - -
33 HDL Cholesterol ( Precipitan ) Kotak - - -
34 Hematologi Calibrator (Nscs 1000 ) Botol - - -
35 Hemoglobin Reagen Kotak - - -
36 Lactose Broth 500 mg Botol - - -
37 LDL Cholesterol Kotak - - -
38 Leptospira IgM (Reagen) Kotak - - -
39 Micropippets MT-1-up to 200 ui Pcs - - -
40 MIcropippets MT-up to 1 ml Pcs - - -
41 NS1 Antigen Test (Reagen) Kotak - - -
42 Pipet Ukur 10 ml biji - - -
43 Poch Pack D (II) Reagen Kotak - - -
44 Poch Pack L (II) Reagen Kotak - - -
45 Stik Uric Acid Kotak - - -
46 Strip Narkoba 3 Parameter Kotak - - -
49 Total Protein Kotak - - -
50 Trigleserida Kotak - - -
51 Urea Kotak - - -
52 Uric Acid Kotak - - -
- - -
NAMA OBAT REAGEN PROGRAM HIV - - -
1 Rapid 1 HIV (SD Bioline ) Tes - - -
2 Rapid 2 HIV (Fokus ) Tes - - -
3 Rapid 3 HIV (Biomeriux Vikia ) Tes - - -
4 SD Biosensore Standart Q Syphlis Tes - - -
5 RPR Syphlis ( Fokus ) Tes - - -
6 Reagen CD4 Control Tes - - -
7 Reagen CD4 Mobile Tes - - -
8 RPR Syphlis Komponen Kit - - -
9 Anuscopy Buah - - -
10 Kertas PH Indikator Buah - - -
11 Rotator Buah - - -
12 Tip. Uk.60 Bks - - -
13 Tip. Uk.61 Bks - - -
14 Pronto / Holder Buah - - -
15 rapid HBSAG tes - - -
NAMA OBAT GIGI - - -
- - -
1 Anastesi Citojek Box - - -
2 Articulating Paper (Kertas warna penaKotak - - -
3 Bahan Tumpatan sementara Botol - - -
4 Bonding Syringe - - -
5 Cairan Desinfectan ( Perendaman InstBotol - - -
6 Cairan untuk desinfectan pembersih Botol - - -
7 Carpule Citojek Kotak - - -
8 Chlorfeson Kamfer menthol ( CHKM )Botol - - -
9 Composite Nanohibrid A1 Tube - - -
12 Composite Nanohibrid A3,5 Tube - - -
13 Devitalisasi Pasta/pulpa Pot - - -
14 Disclosing Solution Botol - - -
15 Etcing Gel Pcs - - -
16 Etil Klorida Semprot Botol - - -
17 Eugenol Cairan Botol - - -
18 Formokesol Botol - - -
19 Gas Powred Jet Injector Botol - - -
20 Glass Ionomer Cement ART Pot - - -
21 Jarum citojek uk 16 mm Box - - -
22 Kalsium Hidroksida pasta Botol - - -
23 Klorhekdidin Larutan 2 % Botol - - -
24 Mummifiying Fasta Botol - - -
25 Natrium Hipoklorit airan konsentrat 5%Botol - - -
26 Paper Points 15-40 mm Box - - -
27 Pasta Devitalisasi ( Non Arsen ) Tube - - -
28 Pasta Pengisi Saluran Akar Syringe - - -
29 Semen seng Fosfat serbuk Set - - -
30 Spon Gelatin Cubicis 1x1x1 cm (SpongostaBotol - - -
31 Temporary Filling Fasta Set - - -
32 Tooth Stain Remover ( TSR ) Botol - - -
33 Wipes Desinfektan Botol - - -
34 caviton pak - - -
35 endometason pak - - -
36 fuji 9 gic pak - - -
PROGRAM KB - - -
1 iud COP T each - - -
2 susuk kB II set - - -
3 suntik kb 3 bulan vial - - -
4 pil KB kombinasi cycle - - -
5 kondom pcs - - -
6 disposable pcs - - -
7 lidocain ampul - - -
8 dermafix pcs - - -
9 povidone botol - - -
10 amoksisilin Strip - - -
11 asam mefenamat strip - - -
12 Safety Box BH - - -
13 Kasa Steril 16 x 16 cm pak - - -
14 masker pcs - - -
- - -
OBAT JKN - - -
1 acylovir cream tube - - -
2 alkohol 70% botol - - -
3 cefadroksil tab box - - -
4 cetirizin syr box - - -
5 etil klorida spray box - - -
6 flagsol tab box - - -
7 lexigo tab box - - -
8 mecobalamin kap box - - -
9 mersibion inj box - - -
10 Metronidazol tab 500 MG Tablet - - -
11 Metronidazol tab 500 MG box - - -
12 obh syr botol - - -
13 paraflu syr botol - - -
14 parasetamol inf botol - - -
15 piroksikam 20 mg tab box - - -
16 propyretic suppo box - - -
17 reco tube - - -
18 selkom c tab box - - -
19 sianokobalamin tab box - - -
20 trifadium tab box - - -
21 vit k1 inj box - - -
B BMHP JKN Set - - -
1 CARPUL CITOJET pcs - - -
2 CAVITON pcs - - -
3 CHEROPHEN pcs - - -
4 DEVITALISASI pcs - - -
5 LANSET pcs - - -
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) pcs - - -
7 SARUNG TANGAN NON STERIL M pcs - - -
8 GLASS IONOMER pcs - - -
9 SUNGKUP DEWASA pcs - - -
10 SUNGKUP ANAK pcs - - -
11 BISTURI pcs - - -
12 PIPET OBAT pcs - - -
13 PLESTER pcs - - -
14 SENDOK OBAT 5 ML pcs - - -
15 SARUNG TANGAN STERIL pcs - - -
16 STAIN REMOVEL pcs - - -
17 VASELIN pcs - - -
18 CHKM pcs - - -
19 Jely pcs - - -
20 disp 10 cc pcs - - -
21 f cath 18 pcs - - -
22 handscoon non steril uk L pcs - - -
23 handscoon non steril uk M pcs - - -
24 handscoon steril 6,5 pcs - - -
25 handscoon steril 7,5 pcs - - -
26 Kertas puyer pcs - - -
27 Needle no 23 pcs - - -
28 Needle no 24 pcs - - -
29 Plastik klip besar pcs - - -
30 Plastik klip kecil pcs - - -
31 plastik klip sedang pcs - - -
32 Plester 5 yard x2 inci pcs - - -
33 Sarung tangan No M pcs - - -
34 Sarung tangan No S pcs - - -
35 Selang Oksigen Anak-anak pcs - - -
36 Selang Oksigen Dewasa pcs - - -
37 Larutan Gentian Violet pcs - - -
38 mukus ekstraktor pcs - - -
39 nasal kanul bayi pcs - - -
40 nesco asam urat pcs - - -
41 nesco gds pcs - - -
42 nesco kolesterol pcs - - -
43 pipet obat 1 ml pcs - - -
44 plester pcs - - -
45 pot urin pcs - - -
46 reagen goldar A pcs - - -
47 kertas goldar pcs - - -
48 Rebreathing mask O2 anak pcs - - -
49 Rebreathing mask O2 bayi pcs - - -
50 Rebreathing mask O2 dewasa pcs - - -
51 sendok obat pcs - - -
52 SOFRATULLE pcs - - -
53 stain removel pasta pcs - - -
54 suction no 8 pcs - - -
55 sungkup bayi pcs - - -
56 t silk pcs - - -
57 tes kehamilan pcs - - -
58 umbilical klem pcs - - -
59 vaselin pcs - - -
60 yellow tip pcs - - -
YANG MENYERAHKAN
PETUGAS OBAT PUSKESMAS
RENY WIGIAWATI, A.Pt

NIP.198601142019 02 2 003
AIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN
PUSKESMAS
DOKUMEN
JAN DINKES KAB/KOTA
FEB GFK KAB/KOTA
PUSKESMAS
JANUARI
Jumlah
Stok
Permintaa PEMBERIAN
HARGA Optimum
Pemakaian Stok Akhir n
APBD II JKN PROG
7 8 9 10 11 12 13
(6-7)
- - 0
- - 407
30 - 99
- 3 3300
- - 0
- - 91
- - 3345
- - 93
- - 70
- - 3400
- - 5368
200 250 233
- - 0
3 - 5500
- - 10300
- - 0
- - 0
- - 305
- - 305
5 5 1995
140 160 58
- - 3035
- - 3167
- - 0
- - 173
- - 0
- - 0
- - 2860
- - 1000
- - 0
- - 105
- - 52
- - 5506
- - 0
50 - 103
- - 1748
- - 9646
- - 0
- - 382
- - 8800
- - 236
- - 380
- - 1595
- - 0
- - 0
- - 80000
- - 7039
4 - 1340
- - 5800
- - 597
- - 263
- - 10696
- - 11435
- - 22000
30 50 66
- - 72
- - 516
- - 590
- - 7490
- - 4200
80 70 90
- - 2849
30 - 265
- - 4550
- - 0
130 70 77
- - 0
- - 0
- - 0
- - 12573
- - 0
- - 109
- - 1176
- - 105
- - 0
- - 264
100 100 91
2 - 2700
- - 0
- - 0
- - 1408
- - 583
- - 0
- - 0
- - 2992
- - 0
- - 0
- - 137500
- - 0
- - 1740
- - 171
- - 0
- - 2590
- - 3550
- 50 0
- - 57500
- - 82
- - 0
- 20 274
- - 380
- - 1010
- - 2800
- - 4232
- - 4232
- - 0
- - 119
- - 0
- - 235
- - 207
- - 0
- - 5700
- - 906
- - 132
- - 155
- 5 2475
- - 0
- - 105
- - 0
- - 23540
- - 89
- - 4800
100 100 63
- - 0
3 9 2518
50 50 270
- - 1045
- - 0
- 2 1881
- - 5015
- - 0
- - 310
- - 1090
- 3 0
210 140 23
- - 0
- - 0
- - 0
80 170 125
3 12 2052
- - 0
- - 0
- - 14707
- - 1152
- - 1140
- - 448
- - 375
- - 85
- - 0
- - 3328
- - 473
- 50 102
- - 0
3 - 2550
- - 210
- - 2345
- - 0
- - 0
- - 0
- - 4100
- - 3799
5 - 3414
- - 9900
- - 1440
- - 0
80 70 123
- - 6410
- - 0
- 10 598
- - 0
50 - 145
- - 64900
- - 0
- - 12100
- - 0
- - 12700
2 3 0
- - 9898
- - 130
- - 1070
- - 385
- 2 6647
12 18 1107
- - 0
- - 0
150 100 132
- - 11825
- - 9700
- - 291
- - 0
50 - 131
- - 0
- - 0
- - 17996
- - 6550
- - 0
100 100 73
- - 224
- - 0
- - 0
- - 60
- - 1155
70 80 105
- - 273
- - 7150
- - 7630
- - 2992
30 - 63
50 - 70
3 - 2621
- - 11000
- - 1025
- - 512204
- - 130999
- - 1035
- - 110
- - 205
- - 6789
- - 368
- - 0
- - 0
- - 0
- - 163
- - 0
30 70 91
- - 0
120 80 118
2 - 3171
50 150 524
- - 1097
- - 9800
- - 210
- - 3008
- - 843
- 10 11100
- -
- -
- -
- - 431
- - 125
- - 389342
- - 1384983
- - 248120
- - 0
- - 5890
- - 233411
- - 2706
- - 39880
- - 12569
- - 13300
- - 519
- - 505
- - 354
- - 167
- - 230
- - 739
- - 1121
- - 0
- - 59
- - 90
- - 60
- - 5000
- - 157
- - 0
- - 91
- - 990000
- - 59800
- - 287
- - 2000
- - 253
- -
- -
- 25 777
- - 1067
- - 649
- - 2650
- - 816
2 3 924
- 5 856
- - 2702700
- - 801000
- - 25000
- 1 29000
- - 26500
- - 0
2 4 40200
- - 38536
- - 84601
- - 68433
- - 41600
- - 3825
2 8 6850
- - 520
- - 16610
- - 12036
2 5 23100
- - 23100
- 2 23100
- 3 13464
17 - 8400
- - 23056
- 3 2083
- - 20600
- - 0
- - 1440
- - 127600
- - 9400
3 2 7370
- - 40997
6 4 15700
- - 520
- - 0
- - 8167
- - 7624
- - 23760
- - 74494
- - 7370
- - 0
- - 0
- - 40733
- - 968
- - 13178
- - 7931
- - 0
- - 30003
- - 7900
- - 7038
- - 204167
- - 22433
- - 1690
- - 130240
- - 19700
- -
- -
- -
- -
- -
- -
- -
- -
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- -
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MENGETAHUI YANG MEMINTA :

KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING
HJ,IYOT SA'DIAH,S.ST
NIP.19710804 199103 2 002 NIP.-
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
PUSKESMAS
NOMOR TANGGAL
PELAPORAN BULAN / PERIODE FEB
PERMINTAAN BULAN / PERIODE MAR
FEBRUARI
EMBERIAN JUMLAH Jumlah

Stok Awal Penerimaan Persediaa Pemakaian Stok Akhir HARGA
BUFFER n
LAIN LAIN
STOK
14 15 16 4 5 6 7 8
( 4+5 ) (6-7)
- - - - - 0
- - - - - 407
- - - - - 99
3 - 3 3 - 3300
- - - - - 0
- - - - - 91
- - - - - 3345
- - - - - 93
- - - - - 70
- - - - - 3400
- - - - - 5368
250 - 250 100 150 233
- - - - - 0
- - - - - 5500
- - - - - 10300
- - - - - 0
- - - - - 0
- - - - - 305
- - - - - 305
5 - 5 5 - 1995
160 - 160 90 70 58
- - - - - 3035
- - - - - 3167
- - - - - 0
- - - - - 173
- - - - - 0
- - - - - 0
- - - - - 2860
- - - - - 1000
- - - - - 0
- - - - - 105
- - - - - 52
- - - - - 5506
- - - - - 0
- - - - - 103
- - - - - 1748
- - - - - 9646
- - - - - 0
- - - - - 382
- - - - - 8800
- - - - - 236
- - - - - 380
- - - - - 1595
- - - - - 0
- - - - - 0
- - - - - 80000
- - - - - 7039
- - - - - 1340
- - - - - 5800
- - - - - 597
- - - - - 263
- - - - - 10696
- - - - - 11435
- - - - - 22000
50 - 50 50 - 66
- - - - - 72
- - - - - 516
- - - - - 590
- - - - - 7490
- - - - - 4200
70 - 70 40 30 90
- - - - - 2849
- - - - - 265
- - - - - 4550
- - - - - 0
70 - 70 70 - 77
- - - - - 0
- - - - - 0
- - - - - 0
- - - - - 12573
- - - - - 0
- - - - - 109
- - - - - 1176
- - - - - 105
- - - - - 0
- - - - - 264
100 - 100 60 40 91
- - - - - 2700
- - - - - 0
- - - - - 0
- - - - - 1408
- - - - - 583
- - - - - 0
- - - - - 0
- - - - - 2992
- - - - - 0
- - - - - 0
- - - - - 137500
- - - - - 0
- - - - - 1740
- - - - - 171
- - - - - 0
- - - - - 2590
- - - - - 3550
50 - 50 30 20 0
- - - - - 57500
- - - - - 82
- - - - - 0
20 - 20 20 - 274
- - - - - 380
- - - - - 1010
- - - - - 2800
- - - - - 4232
- - - - - 4232
- - - - - 0
- - - - - 119
- - - - - 0
- - - - - 235
- - - - - 207
- - - - - 0
- - - - - 5700
- - - - - 906
- - - - - 132
- - - - - 155
5 - 5 3 2 2475
- - - - - 0
- - - - - 105
- - - - - 0
- - - - - 23540
- - - - - 89
- - - - - 4800
100 - 100 50 50 63
- - - - - 0
9 - 9 7 2 2518
50 - 50 50 - 270
- - - - - 1045
- - - - - 0
2 - 2 2 - 1881
- - - - - 5015
- - - - - 0
- - - - - 310
- - - - - 1090
3 - 3 3 - 0
140 - 140 60 80 23
- - - - - 0
- - - - - 0
- - - - - 0
170 - 170 50 120 125
12 - 12 7 5 2052
- - - - - 0
- - - - - 0
- - - - - 14707
- - - - - 1152
- - - - - 1140
- - - - - 448
- - - - - 375
- - - - - 85
- - - - - 0
- - - - - 3328
- - - - - 473
50 - 50 20 30 102
- - - - - 0
- - - - - 2550
- - - - - 210
- - - - - 2345
- - - - - 0
- - - - - 0
- - - - - 0
- - - - - 4100
- - - - - 3799
- - - - - 3414
- - - - - 9900
- - - - - 1440
- - - - - 0
70 - 70 70 - 123
- - - - - 6410
- - - - - 0
10 - 10 10 - 598
- - - - - 0
- - - - - 145
- - - - - 64900
- - - - - 0
- - - - - 12100
- - - - - 0
- - - - - 12700
3 - 3 2 1 0
- - - - - 9898
- - - - - 130
- - - - - 1070
- - - - - 385
2 - 2 2 - 6647
18 - 18 10 8 1107
- - - - - 0
- - - - - 0
100 - 100 60 40 132
- - - - - 11825
- - - - - 9700
- - - - - 291
- - - - - 0
- - - - - 131
- - - - - 0
- - - - - 0
- - - - - 17996
- - - - - 6550
- - - - - 0
100 - 100 100 - 73
- - - - - 224
- - - - - 0
- - - - - 0
- - - - - 60
- - - - - 1155
80 - 80 50 30 105
- - - - - 273
- - - - - 7150
- - - - - 7630
- - - - - 2992
- - - - - 63
- - - - - 70
- - - - - 2621
- - - - - 11000
- - - - - 1025
- - - - - 512204
- - - - - 130999
- - - - - 1035
- - - - - 110
- - - - - 205
- - - - - 6789
- - - - - 368
- - - - - 0
- - - - - 0
- - - - - 0
- - - - - 163
- - - - - 0
70 - 70 40 30 91
- - - - - 0
80 - 80 60 20 118
- - - - - 3171
150 - 150 100 50 524
- - - - - 1097
- - - - - 9800
- - - - - 210
- - - - - 3008
- - - - - 843
10 - 10 10 - 11100
- - - - -
- - - - -
- - - - -
- - - - - 431
- - - - - 125
- - - - - 389342
- - - - - 1384983
- - - - - 248120
- - - - - 0
- - - - - 5890
- - - - - 233411
- - - - - 2706
- - - - - 39880
- - - - - 12569
- - - - - 13300
- - - - - 519
- - - - - 505
- - - - - 354
- - - - - 167
- - - - - 230
- - - - - 739
- - - - - 1121
- - - - - 0
- - - - - 59
- - - - - 90
- - - - - 60
- - - - - 5000
- - - - - 157
- - - - - 0
- - - - - 91
- - - - - 990000
- - - - - 59800
- - - - - 287
- - - - - 2000
- - - - - 253
- - - - -
- - - - -
25 - 25 8 17 777
- - - - - 1067
- - - - - 649
- - - - - 2650
- - - - - 816
3 - 3 3 - 924
5 - 5 5 - 856
- - - - - 2702700
- - - - - 801000
- - - - - 25000
1 - 1 1 - 29000
- - - - - 26500
- - - - - 0
4 - 4 2 2 40200
- - - - - 38536
- - - - - 84601
- - - - - 68433
- - - - - 41600
- - - - - 3825
8 - 8 8 - 6850
- - - - - 520
- - - - - 16610
- - - - - 12036
5 - 5 5 - 23100
- - - - - 23100
2 - 2 - 2 23100
3 - 3 - 3 13464
- - - - - 8400
- - - - - 23056
3 - 3 3 - 2083
- - - - - 20600
- - - - - 0
- - - - - 1440
- - - - - 127600
- - - - - 9400
2 - 2 2 - 7370
- - - - - 40997
4 - 4 4 - 15700
- - - - - 520
- - - - - 0
- - - - - 8167
- - - - - 7624
- - - - - 23760
- - - - - 74494
- - - - - 7370
- - - - - 0
- - - - - 0
- - - - - 40733
- - - - - 968
- - - - - 13178
- - - - - 7931
- - - - - 0
- - - - - 30003
- - - - - 7900
- - - - - 7038
- - - - - 204167
- - - - - 22433
- - - - - 1690
- - - - - 130240
- - - - - 19700
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
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- - - - -
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- - - - -
- - - - -
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NG MEMINTA : YANG MENYERAHKAN MENGETAHUI

STU/POSKEDES/PUSLING PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS
RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

NIP.198601142019 02 2 003 NIP.19710804 199103 2 00
R PERMINTAAN OBAT ( LPLPO ) RUTIN LAPORAN PEM
DOKUMEN NOMOR TANGGAL

DINKES KAB/KOTA PELAPORAN BULAN / PE
GFK KAB/KOTA PERMINTAAN BULAN / P
PUSKESMAS
Jumlah
Stok
Permintaa PEMBERIAN JUMLAH
Optimum
n Stok Awal
BUFFER
APBD II JKN PROG LAIN LAIN
STOK
9 10 11 12 13 14 15 16 4
-
-
-
-
-
-
-
-
-
-
-
150
-
-
-
-
-
-
-
-
70
-
-
-
-
-
-
-
-
-
-
-
-
-
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-
-
-
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-
-
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-
-
30
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
40
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
20
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2
-
-
-
-
-
-
50
-
2
-
-
-
-
-
-
-
-
-
80
-
-
-
120
5
-
-
-
-
-
-
-
-
-
-
-
30
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
1
-
-
-
-
-
8
-
-
40
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
30
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
30
-
20
-
50
-
-
-
-
-
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-
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-
-
-
-
-
-
17
-
-
-
-
-
-
-
-
-
-
-
-
2
-
-
-
-
-
-
-
-
-
-
-
2
3
-
-
-
-
-
-
-
-
-
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MENGETAHUI YANG MEMINTA : YANG MENYE

KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING PETUGAS OBAT
HJ,IYOT SA'DIAH,S.ST RENY WIGIAW

IP.19710804 199103 2 002 NIP.- NIP.1986011420
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN
PUSKESMAS
DOKUMEN
PELAPORAN BULAN / PERIODE MAR DINKES KAB/KOTA
PERMINTAAN BULAN / PERIODE APR GFK KAB/KOTA
PUSKESMAS
MARET
Jumlah
Stok
Jumlah Permintaa PEMBERIAN
HARGA Optimum
Penerimaan Persediaa Pemakaian Stok Akhir n
n
APBD II JKN
5 6 7 8 9 10 11 12
( 4+5 ) (6-7)
- - - - 0
- - - - 407
- - - - 99
5 5 3 2 3300
- - - - 0
- - - - 91
- - - - 3345
- - - - 93
- - - - 70
- - - - 3400
- - - - 5368
- 150 80 70 233
- - - - 0
- - - - 5500
- - - - 10300
- - - - 0
- - - - 0
- - - - 305
- - - - 305
- - - - 1995
- 70 70 - 58
- - - - 3035
- - - - 3167
- - - - 0
- - - - 173
- - - - 0
- - - - 0
- - - - 2860
- - - - 1000
- - - - 0
- - - - 105
- - - - 52
- - - - 5506
- - - - 0
- - - - 103
- - - - 1748
- - - - 9646
- - - - 0
60 60 40 20 382
- - - - 8800
- - - - 236
- - - - 380
- - - - 1595
- - - - 0
- - - - 0
- - - - 80000
- - - - 7039
3 3 3 - 1340
- - - - 5800
- - - - 597
- - - - 263
- - - - 10696
- - - - 11435
- - - - 22000
100 100 50 50 66
- - - - 72
- - - - 516
- - - - 590
- - - - 7490
- - - - 4200
- 30 30 - 90
- - - - 2849
- - - - 265
- - - - 4550
- - - - 0
100 100 70 30 77
- - - - 0
- - - - 0
- - - - 0
- - - - 12573
- - - - 0
- - - - 109
- - - - 1176
- - - - 105
- - - - 0
- - - - 264
- 40 40 - 91
- - - - 2700
- - - - 0
- - - - 0
- - - - 1408
- - - - 583
- - - - 0
- - - - 0
- - - - 2992
- - - - 0
- - - - 0
- - - - 137500
- - - - 0
- - - - 1740
- - - - 171
- - - - 0
- - - - 2590
- - - - 3550
100 120 50 70 0
- - - - 57500
- - - - 82
- - - - 0
- - - - 274
- - - - 380
- - - - 1010
- - - - 2800
- - - - 4232
- - - - 4232
- - - - 0
- - - - 119
- - - - 0
- - - - 235
- - - - 207
- - - - 0
- - - - 5700
- - - - 906
- - - - 132
- - - - 155
- 2 2 - 2475
- - - - 0
- - - - 105
- - - - 0
- - - - 23540
- - - - 89
- - - - 4800
100 150 70 80 63
- - - - 0
- 2 2 - 2518
50 50 50 - 270
- - - - 1045
- - - - 0
5 5 4 1 1881
- - - - 5015
- - - - 0
- - - - 310
- - - - 1090
- - - - 0
- 80 50 30 23
- - - - 0
- - - - 0
- - - - 0
- 120 60 60 125
- 5 5 - 2052
- - - - 0
- - - - 0
- - - - 14707
- - - - 1152
- - - - 1140
- - - - 448
- - - - 375
- - - - 85
- - - - 0
- - - - 3328
- - - - 473
- 30 30 - 102
- - - - 0
10 10 4 6 2550
- - - - 210
- - - - 2345
- - - - 0
- - - - 0
- - - - 0
- - - - 4100
- - - - 3799
- - - - 3414
- - - - 9900
- - - - 1440
- - - - 0
50 50 50 - 123
- - - - 6410
- - - - 0
- - - - 598
- - - - 0
- - - - 145
- - - - 64900
- - - - 0
- - - - 12100
- - - - 0
- - - - 12700
10 11 2 9 0
- - - - 9898
- - - - 130
- - - - 1070
- - - - 385
- - - - 6647
5 13 10 3 1107
- - - - 0
- - - - 0
100 140 90 50 132
- - - - 11825
- - - - 9700
- - - - 291
- - - - 0
- - - - 131
- - - - 0
- - - - 0
- - - - 17996
- - - - 6550
- - - - 0
- - - - 73
- - - - 224
- - - - 0
- - - - 0
- - - - 60
- - - - 1155
100 130 90 40 105
- - - - 273
- - - - 7150
3 3 3 - 7630
- - - - 2992
100 100 50 50 63
- - - - 70
- - - - 2621
- - - - 11000
- - - - 1025
- - - - 512204
- - - - 130999
- - - - 1035
- - - - 110
- - - - 205
- - - - 6789
- - - - 368
- - - - 0
- - - - 0
- - - - 0
- - - - 163
- - - - 0
- 30 30 - 91
- - - - 0
- 20 20 - 118
- - - - 3171
- 50 50 - 524
- - - - 1097
- - - - 9800
- - - - 210
- - - - 3008
- - - - 843
- - - - 11100
- - - -
- - - -
- - - -
- - - - 431
- - - - 125
- - - - 389342
- - - - 1384983
- - - - 248120
- - - - 0
- - - - 5890
- - - - 233411
- - - - 2706
- - - - 39880
- - - - 12569
- - - - 13300
- - - - 519
- - - - 505
- - - - 354
- - - - 167
- - - - 230
- - - - 739
- - - - 1121
- - - - 0
- - - - 59
- - - - 90
- - - - 60
- - - - 5000
- - - - 157
- - - - 0
- - - - 91
- - - - 990000
- - - - 59800
- - - - 287
- - - - 2000
- - - - 253
- - - -
- - - -
- 17 7 10 777
- - - - 1067
- - - - 649
- - - - 2650
- - - - 816
10 10 7 3 924
- - - - 856
- - - - 2702700
- - - - 801000
- - - - 25000
- - - - 29000
- - - - 26500
- - - - 0
- 2 2 - 40200
- - - - 38536
- - - - 84601
- - - - 68433
- - - - 41600
- - - - 3825
- - - - 6850
- - - - 520
- - - - 16610
- - - - 12036
5 5 - 5 23100
5 5 3 2 23100
- 2 - 2 23100
- 3 - 3 13464
5 5 - 5 8400
5 5 3 2 23056
- - - - 2083
- - - - 20600
- - - - 0
- - - - 1440
- - - - 127600
- - - - 9400
3 3 3 - 7370
- - - - 40997
- - - - 15700
- - - - 520
- - - - 0
- - - - 8167
- - - - 7624
- - - - 23760
- - - - 74494
- - - - 7370
- - - - 0
- - - - 0
- - - - 40733
- - - - 968
- - - - 13178
- - - - 7931
- - - - 0
- - - - 30003
- - - - 7900
- - - - 7038
- - - - 204167
- - - - 22433
- - - - 1690
- - - - 130240
- - - - 19700
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
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YANG MENYERAHKAN MENGETAHUI YAN

PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS PETUGAS PUST

NIP.198601142019 02 2 003 NIP.19710804 199103 2 002
PO ) RUTIN
NOMOR TANGGAL
PEMBERIAN JUMLAH
BUFFER
PROG LAIN LAIN
STOK
13 14 15 16
YANG MEMINTA :
PETUGAS PUSTU/POSKEDES/PUSLING
NIP.-
LAPORAN PEMAKAIAN DAN LEMB

KECAMATAN : CIKEUSIK
KAB / KOTA : PANDEGLANG PELAPORAN BULAN / PERIODE
PROVINSI : BANTEN PERMINTAAN BULAN / PERIODE
Jumlah
N0 NAMA OBAT SATUAN Stok Awal Penerimaan
Persediaan
1 2 3 4 5 6
A NAMA OBAT ( 4+5 )
1 Alprazolam Tablet - -
2 Albendazol Tablet 400 mg Tablet - -
3 Allopurinol tablet 100 mg Tablet - 100 100
4 Ambroxol sirup Botol 2 2
5 Ambroxol tablet 30 mg Tablet - -
6 Aminofilin Tablet 200 mg Tablet - -
7 Aminofilina injeksi 24 mg/ml - 10 ml Ampul - -
8 Amlodipin 10 mg Tablet - -
9 Amlodipin Besilate 5 mg Tablet - 300 300
10 Amoksisilin Forte sirup kering 250mg Botol - -
11 Amoksisilin Injeksi 1 gr Vial - -
12 Amoksisilin Tablet 500 mg Tablet 70 100 170
13 Amoksisillin kapsul 250 mg Kapsul - -
14 Amoksisillin Sirup Kering 125 mg/5 ml Botol - -
15 Ampisilin Injeksi 1 gr Vial - -
16 Analog insulin Long Acting Pen - -
17 Analog insulin Mix Acting Pen - -
18 Antalgin (Metampiron) tablet 500 mg Tablet - -
19 Antalgin (Metampiron) tablet 500 mg Tablet - -
20 Antasida DOEN suspensi Botol - -
21 ANTASIDA DOEN Tablet Tablet - 100 100
22 Anti Bakteri DOEN ( Bacitrasin ) Tube - -
23 anti hemoroid doen kombinasi supp - -
24 Antifungi DOEN Tube - -
25 Antimigren DOEN Kombinasi : Tablet - -
26 Antiparkinson DOEN tablet KombinasiTablet - -
27 Antiparkinson Tablet ( Levopar ) Tablet - -
28 Aqua Pro Injeksi Vial - 6 6
29 Artermeter injeksi Ampul - -
30 Artesunate injeksi 60 mg/ml vial - -
31 Asam Ascorbat ( Vit. C ) 50 MG Tablet - 100 100
32 Asam Folat Botol - -
33 Asam Fusidat Cream Tube - -
34 Asam Klorida 0,1 N Botol - -
35 Asam Mefenamat 500 mg Tablet - 50 50
36 Asam Traneksamat Inj 5% Ampul - -
37 Asering Botol - 20 20
38 Asetosal tablet 500 mg Tablet - -
39 Asetyl Cysteine Capsul 20 60 80
40 Asiklovir Cream 5% Tube - -
41 Asiklovir tablet 200 mg Tablet - -
42 Asiklovir tablet 400 mg Tablet - -
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Ampul - -
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Vial - -
45 Atropin Sulfat tablet 0,5 mg Tablet - -
46 Berotec Metered Aerosol 100 mg Bok - -
47 Betadine Salep Antiseptik 5 mg Tube - -
48 Betametason krim 0,1 % Tube - 3 3
49 Bisakodil Suppositoria supp - -
50 Bisoprolol 2,5 mg Tablet - -
51 Bisoprolol 5 mg Tablet - -
52 Cairan Infus KN-3B Botol - -
53 Cairan Infus Wida KDN 1 Botol - -
54 Cairan Pembersih ( Protektor ) Botol - -
55 Captopril Tablet 12,5 mg Tablet 50 100 150
56 Captopril Tablet 25 mg Tablet - -
57 Cefadroxil Capsul 500 mg Capsul - -
58 Cefixime Capsul 100 mg Capsul - -
59 Cefixime Sirup Botol - -
60 Cefotaksime 1 gr Injeksi Vial - -
61 Cetirizine Capsul 50 mg Capsul - 100 100
62 Cetirizine sirup 5 mg/5 ml Botol - -
63 Ciprofloxcacin 500 mg tablet Tablet - -
64 Combivent UDV 2,5 mg+0,5mg/2,5 mlAmpul - -
65 D-Artepp tablet Tablet - -
66 deksametason tab Tablet 30 100 130
67 Dekstran 70 - larutan infus 6% steril Botol - -
68 Dekstrometorfan sirup Botol - -
69 Dekstrometorfan tablet 15 mg Tablet - -
70 Diazepam Rektal 0,5 mg / 2 ml supp - -
71 Diazepam tablet 2 mg Tablet - -
72 Diazepam tablet 5 mg Tablet - -
73 Difenhidramin HCL injeksi 10 mg/ml - Ampul - -
74 Digoksin tablet 0,25 mg Tablet - -
75 Diltiazem Tablet - -
76 Doksisiklin Kapsul 100 mg Capsul - -
77 Domperidon 10mg Tablet Tablet - 100 100
78 Domperidon Suspensi 5 mg/ 5 ml Botol - 10 10
79 Doxicyclin 500mg capsul - -
80 Efedrin HCLTablet 25 mg Tablet - -
81 Epinefrina HCL/Bitartrat Injeksi Ampul - -
82 Eritromicyn kapsul 250 mg capsul - -
83 Erytromicin kapsul 500 mg Kapsul - -
84 Erytromicin sirup 125 mg Botol - -
85 Etakridin ( Rivanol ) larutan 0,1% Botol - 3 3
86 Etambutol 500 mg Tablet - -
87 Etanol 70 % Botol - -
88 Etil Klorida Semprot Botol - -
89 Fenitoin Natrium kapsul 30 mg Kapsul - -
90 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul - -
91 Fenobarbital tablet 30 mg Tablet - -
92 Fenoksimetil Penisilina tablet 250 mg Tablet - -
93 Fenol Gliserol tetes telinga 10 % Botol - -
94 Fitomenadion (Vit.K1) Injeksi 10 mg/mlAmpul - -
95 Fitomenadion (Vit.K1) tab salut gula 1 Tablet 70 70
96 Flufenazine Deconat Inj 25 mg/ml Ampul - -
97 Furosemida tablet 40 mg Tablet - 200 200
98 Furosemide Injeksi Ampul - -
99 Garam Oralit Sachet - -
100 Gemfibrozil 300 mg Tablet - -
101 Gentamicin Injeksi Ampul - -
102 Gentamicin Salep Kulit Tube - -
103 Gentamicin Salep mata Tube - -
104 Gentamicin Tetes Mata Botol - -
105 Gentian Violet 1 % Botol - -
106 Glibenclamid tablet 5 mg Tablet - -
107 Glicerin Guaiacolat ( GG ) 100 mg Tablet - -
108 Glikazid 80 mg Tablet Tablet - -
109 Glimepiride 2 mg Tablet - 100 100
110 Glukosa larutan infus 10% steril Botol - -
111 Glukosa larutan infus 5 % steril Botol - -
112 Griseofulvin tablet 500 mg, Tablet - -
113 Guaiafenesin 100 mg Tablet - -
114 Hidroklortiniazid ( HCT )Tab.25 mg Tablet - -
115 Hidrokortison krim 2,5% Tube - -
116 Ibuprofen Suspensi Tablet - -
117 Ibuprofen tablet 200 mg Tablet - -
118 Ibuprofen tablet 400 mg Tablet - -
119 Imunomodulator sirup( STIMUNO) Botol - -
120 Isosorbid Dinitrat tablet sublingual 5 mTablet - -
121 Kalsium Glukonas Injeksi Ampul - -
122 Kalsium Laktat (Kalk) tablet 500 mg Tablet 80 100 180
123 Kapas Berlemak 500 mg Bungkus - -
124 Ketokonazol Kream Tube - 3 3
125 Ketokonazol Tablet 200 mg Tablet - 50 50
126 Ketorolac inj Ampul - -
127 Kifadene tablet 20 mg Tablet - -
128 Kloramfenikol salep mata 1 % capsul 1 3 4
129 Kloramfenikol suspensi Botol - -
130 Kloramfenikol tetes telinga 3% Tube - -
131 Kloramphenicol 250 mg Capsul - -
132 Kloramphenicol 500 mg capsul - -
133 Kloramphenicol Tetes Mata Botol - -
134 Klorfeniramin Maleat (CTM) tablet 4 mTablet 30 100 130
135 Klorokuin tablet 150 mg Tablet - -
136 Klorpromazin HCL tablet salut 25 mg Tablet - -
137 Kombinasi (Pirimetamin 25 mg + SolfaTablet - -
138 Kotrimoksazol Dewasa Tablet 480 mgTablet 60 60
139 Kotrimoksazol Sirup / Suspensi Botol - 10 10
140 Kuinin Dihidroklorida injeksi 25% - 2 mAmpul - -
141 Kuinin Dihidroklorida injeksi 25% - 2 mBotol - -
142 Lactobacilus serbuk Sachet - -
143 Lidocain 2%+efinefrin injeksi Ampul - 10 10
144 Lidocain injeksi 2 ml Ampul - -
145 Lisinopril 10 mg tablet Tablet - -
146 Lisinopril 5 mg tablet Tablet - -
147 Loperamid 4 mg tablet Tablet - -
148 Lytacur Sirup Botol - -
149 Magnesium Sulfat Inj. 25 ml 20% Ampul - -
150 Metamizol 500 mg Tablet - -
151 Metformin 500 mg Tablet Tablet - -
152 Methilprednisolon tablet 8 mg Tablet - -
153 Metilergometrin Maleat injeksi 1 ml Ampul 6 6
154 Metilergometrin Maleat Tablet Tablet - -
155 Metoklopramid Suspensi Botol - -
156 Metoklopramid tablet Tablet - -
157 Metronidazol 500 mg Tablet - -
158 Metronidazol infus / injeksi Botol - -
159 Metronidazol Ovula supp - -
160 Metronidazol suspensi Botol - -
161 Mikonazol kream Tube - -
162 Multivitamin Anak Sirup Botol - -
163 Multivitamin Dewasa Antioksidan ( Be Tablet - -
164 Natrium Diklofenak 25 mg Tablet Tablet - -
165 Natrium Diklofenak 50 mg Tablet Tablet - 100 100
166 Natrium Klorida Cairan Infus ( NaCL ) Botol - 5 5
167 Nifedipine Tablet 10 mg Tablet - -
168 Nistatin tablet vaginal 100.000 IU/g Tube - -
169 Obat anti Diare suspensi Botol - -
170 Obat Anti Diare Tablet (Akita / Molagit Tablet - -
171 Obat Batuk Flu ( Molexflu ) Tablet - -
172 Obat Batuk Hitam (OBH) Botol - -
173 Obat Batuk Sirup Herbal ( Herbacop ) Botol - 10 10
174 Ofloxsacin Tetes Telinga Tube - -
175 Oksitetrasiklin HCL salep mata 1% Botol - -
176 Oksitosin injeksi 10 IU/ml - 1 ml Ampul 9 10 19
177 Omeprazol injeksi Ampul - -
178 Omeprazol Kapsul 20 mg capsul - -
179 Ondancentron injeksi 4 mg Ampul - -
180 Ondancentron Tablet4 mg Tablet - -
181 Paracetamol Drop 15 ml Botol - -
182 Paracetamol Sirup 120 mg/5 ml Botol 3 10 13
183 Parafin Dresing ( Bioplacenton Tull ) pcs - -
184 Parasetamol tablet 100 mg Tablet - -
185 Parasetamol tablet 500 mg Tablet 50 100 150
186 Permetrin Krim 5 % Tube - -
187 Pirantel Sirup Botol - -
188 Pirantel tablet 125 mg Tablet - -
189 Pirazinamid Botol - -
190 Piridoksin HCL (VIT B6) tablet 10mg Botol - -
191 Piroksikam tablet 20 mg Tablet - -
192 Polikresulen Tube - -
193 Povidon lodida 10% 300 ml - -
194 Povidon lodida 10% 60 ml Tablet - -
195 Prazikuantel tablet 600 mg Botol - -
196 Prednison Tablet 5 mg Tablet - -
197 Primakuin 15 mg Tablet - -
198 Probenesid 500 mg tablet Tablet - -
199 Prokain Benzil Penisilin 3 juta IU/vial i Ampul - -
200 Propanolol HCL tablet 10 mg Tablet - -
201 Ranitidin injeksi Ampul - -
202 Ranitidin tablet Tablet 40 100 140
203 Resperidone 2 mg tablet Tablet - -
204 Ringer Laktat cairan infus (Otsuka) - -
205 Ringer Laktat cairan infus (Widatra) Botol - -
206 Rivanol 300 ml Botol - -
207 Salbutamol Tablet 2 mg Tablet 50 100 150
208 Salbutamol tablet 4mg Tablet - 100 100
209 Salep 2-4 Tube - -
210 Salep kombinasi cream ( Berloson ) Tube - -
211 Salicil bedak Kotak - -
212 Serum Anti Bisa Ular Polivalen Inj 50 Vial - -
213 Serum Anti Tetanus inj 1500 IU ( TetaVial - -
214 Sianokobalamin Injeksi Ampul - -
215 Simvastatin 10 mg tablet Tablet - 90 90
216 Simvastatin 20 mg tablet Tablet - -
217 Sukralfat Suspensi Botol - -
218 Sukralfat tablet 500 mg Tablet - -
219 Suspensi Seng Insulin inj.40 IU/ml - 1 Tube - -
220 Temporary Stopping Fletcher serbuk &Tablet - -
221 Tetrakain HCL tetes mata 0,5% Tube - -
222 Tetrasiklin 250 mg capsul capsul - -
223 Tetrasiklin 500 mg capsul capsul - -
224 Tiamin Tablet 50 mg ( B1 ) Tablet - -
225 Ventolin Nebulizer Ampul - -
226 Vitamin B komplek Tablet - 100 100
227 Zink sirup Botol - -
228 Zink tablet 20 mg Tablet - -
229 Deksametason inj Ampul - -
230 Diazepam inj 5 mg/ml Ampul - -
231 Griseofulvin 125 mcg Tablet - -
232 Kloramfenikol SK Tube - -
233 Nystatin tab 500.000 IU Tablet - -
234 magnesium Sulfat Inj. 25 ml 40% ampul - -
- -
- -
B NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - -
1 Alat suntik 1 ml Pcs 10 10
2 Alat suntik 10 ml Pcs - -
3 Alat suntik 2,5 ml Pcs - -
4 Alat suntik 20 ml Pcs - -
5 Alat suntik 3 cc (Remedi) - -
6 Alat suntik 3 ml Pcs 3 10 13
7 Alat suntik 5 ml pcs - -
8 Alkazide 1 L High Level Desinfectant Botol - -
9 Alkazyme Sachet 25 mg Pack - -
10 Alkohol 70 % 1 L Botol - -
11 Alkohol swab Sachet - -
12 Anti Septik Hand Rub Botol - -
13 Anti Septik Surgikal Hand Scrub Botol - -
14 Cat Gut no 2/0 Sachet - -
15 Cat Gut no 3/0 Sachet - -
16 Cat Gut No 3/0 (24 mm) Sachet - -
17 Cat Gut No 3/0 (26 mm) Sachet - -
18 Cathetter Jelly Biji - -
19 Demetech Silk 3/0 Set - -
20 E Care I.V Dresing Pcs - -
21 E-Care Surgical Mask Tie On Lembar - -
22 Folly No 14 Catether pcs - -
23 Folly No 16 Catether pcs - -
24 I.V Cathetter No. 20 Set 5 5
28 Infuset Anak Set 5 5
29 Infuset Dewasa Set 2 5 7
30 Jarum Insulin Tablet - -
31 Kapas Berlemak 250 gr Bungkus - -
32 Kapas Berlemak 500 gr Bungkus - -
33 Kasa 4 m x 10 cm Rol - -
34 Kasa Hidrofil 36 x 80 cm Rol - -
35 Kasa Pembalut 2 x 80 cm Pack - -
36 Kasa Steril 16 x 16 cm Kotak - -
37 Lisol 1 L Botol - -
38 Masker karet Ear Loop Lembar - -
39 Masker tali Tube - -
40 Nasal Canula Oksigen Set - -
41 Plester 1" Rol - - -
42 Plester Kertas 2,5 cm Rol - -
43 Plester Non Woven 5cm x 5 cm Rol - 2 2
44 Policlean Botol - -
45 Polifik Kotak - -
46 Saraya Alsof A 500 ml Botol - -
47 Saraya Alsof Pure 500 ml Botol - -
48 Sarung Tangan Gynecolog No 7 Pasang - -
49 Sarung tangan M (Non Steril) Pasang - -
50 Sarung tangan no 6,5 Pasang - -
51 Sarung tangan no 6,5 Steril Gloves Pasang - -
52 Sarung tangan no 7,0 Steril Pasang - -
53 Selang Section ( Surgikal Conection TPcs - -
54 Underpad Lembar - -
55 Urine Bag Biji - -
56 safety blackblood BOX - -
57 safety box BOX - -
58 Tabung BD Vacutener pcs - -
59 masker n95 box - -
60 t silk black 3/0 26 mm pcs - -
YANG MENYERAHKAN
PETUGAS OBAT PUSKESMAS
RENY WIGIAWATI, A.Pt

NIP.198601142019 02 2 003
AIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN
PUSKESMAS
DOKUMEN
APR DINKES KAB/KOTA
MEI GFK KAB/KOTA
PUSKESMAS
APRIL
Jumlah
Stok
Permintaa PEMBERIAN
HARGA Optimum
Pemakaian Stok Akhir n
APBD II JKN PROG
7 8 9 10 11 12 13
(6-7)
- -
- -
40 60
2 -
- -
- -
- -
- -
50 250
- -
- -
70 100
- -
- -
- -
- -
- -
- -
- -
- -
100 -
- -
- -
- -
- -
- -
- -
2 4
- -
- -
60 40
- -
- -
- -
50 -
- -
2 18
- -
30 50
- -
- -
- -
- -
- -
- -
- -
- -
3 -
- -
- -
- -
- -
- -
- -
60 90
- -
- -
- -
- -
- -
60 40
- -
- -
- -
- -
55 75
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
60 40
6 4
- -
- -
- -
- -
- -
- -
1 2
- -
- -
- -
- -
- -
- -
- -
- -
- -
30 40
- -
50 150
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
10 90
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
60 120
- -
3 -
40 10
- -
- -
4 -
- -
- -
- -
- -
- -
50 80
- -
- -
- -
60 -
5 5
- -
- -
- -
2 8
- -
- -
- -
- -
- -
- -
- -
- -
- -
3 3
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
70 30
5 -
- -
- -
- -
- -
- -
- -
2 8
- -
- -
5 14
2 - 2
- -
- -
- -
- -
10 3
- -
- -
100 50
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
80 60
- -
- -
- -
- -
40 110
70 30
- -
- -
- -
- -
- -
- -
50 40
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
90 10
-
-
-
-
-
-
-
-
-
-
-
2 8
- -
- -
- -
- -
13 -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
4 1
2 -
- 2
- 3
- 5
6 1
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
-
- -
1 1
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
MENGETAHUI YANG MEMINTA :
KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING
HJ,IYOT SA'DIAH,S.ST
NIP.19710804 199103 2 002 NIP.-
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
PUSKESMAS
NOMOR TANGGAL
PELAPORAN BULAN / PERIODE MEI
PERMINTAAN BULAN / PERIODE JUN
ME
EMBERIAN JUMLAH
Jumlah HARGA
Stok Awal Penerimaan Pemakaian Stok Akhir
Persediaan
BUFFER
LAIN LAIN
STOK
14 15 16 4 5 6 7 8
( 4+5 ) (6-7)
- - - -
- - - -
60 60 60 -
- - - -
- - - -
- - - -
- - - -
- - - -
250 250 60 190
- - - -
- - - -
100 100 200 90 110
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 100 100 100 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
4 4 2 2
- - - -
- - - -
40 100 140 70 70
- - - -
- - - -
- - - -
- - - -
- - - -
18 18 4 14
- - - -
50 180 230 80 150
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 5 5 5 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
90 90 40 50
- - - -
- - - -
- - - -
- - - -
- - - -
40 100 140 80 60
- - - -
- - - -
- - - -
- - - -
75 100 175 105 70
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
40 100 140 90 50
4 10 14 7 7
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
2 2 1 1
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
40 100 140 60 80
- - - -
150 150 60 90
- - - -
- - - -
- - - -
- 5 5 - 5
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
90 90 30 60
- - - -
- - - -
- - - -
- - - -
- - - -
- 3 3 3 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
120 120 70 50
- - - -
- 5 5 5 -
10 100 110 60 50
- - - -
- - - -
- - - -
- 10 10 7 3
- - - -
- - - -
- - - -
- - - -
80 100 180 50 130
- - - -
- - - -
- - - -
- - - -
5 5 5 -
- - - -
- - - -
- - - -
8 10 18 5 13
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
3 3 3 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
30 100 130 110 20
- 5 5 2 3
- - - -
- - - -
- - - -
- - - -
- 1 1 1 -
- - - -
8 10 18 7 11
- - - -
- 10 10 4 6
14 14 4 10
- 2 10 8 2 6
- - - -
- - - -
- - - -
- - - -
3 10 13 8 5
- - - -
- - - -
50 100 150 100 50
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 100 100 100 -
- - - -
- - - -
- - - -
- - - -
- - - -
60 100 160 100 60
- - - -
- - - -
- 5 5 3 2
- - - -
110 110 60 50
30 30 30 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
40 40 40 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
10 200 210 100 110
- - - -
- - - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
8 8 4 4
- - - -
- - - -
- - - -
- - - -
- 10 10 10 -
- 10 10 2 8
- - - -
- - - -
- - - -
- 1 1 1 -
- - - -
- - - -
- 3 3 2 1
- - - -
- - - -
- - - -
- 5 5 2 3
- - - -
- - - -
- - - -
- - - -
- - - -
1 1 1 -
- - - -
2 2 2 -
3 3 1 2
5 5 - 5
1 5 6 4 2
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 5 5 5 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
1 1 2 1 1
- 1 1 1 -
- - - -
- - - -
- - - -
- 2 2 2 -
- 50 50 5 45
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
NG MEMINTA : YANG MENYERAHKAN MENGETAHUI
STU/POSKEDES/PUSLING PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS

NIP.198601142019 02 2 003 NIP.19710804 199103 2 0
R PERMINTAAN OBAT ( LPLPO ) RUTIN LAPORAN PEM

DINKES KAB/KOTA PELAPORAN BULAN / PE
GFK KAB/KOTA PERMINTAAN BULAN / P
PUSKESMAS
MEI
Jumlah
Stok
Optimum
n Stok Awal
BUFFER
STOK
9 10 11 12 13 14 15 16 4
-
-
-
-
-
-
-
-
190
-
-
110
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2
-
-
70
-
-
-
-
-
14
-
150
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
50
-
-
-
-
-
60
-
-
-
-
70
-
-
-
-
-
-
-
-
-
-
50
7
-
-
-
-
-
-
1
-
-
-
-
-
-
-
-
-
80
-
90
-
-
-
5
-
-
-
-
-
-
-
60
-
-
-
-
-
-
-
-
-
-
-
-
50
-
-
50
-
-
-
3
-
-
-
-
130
-
-
-
-
-
-
-
-
13
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
20
3
-
-
-
-
-
-
11
-
6
10
6
-
-
-
-
5
-
-
50
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
60
-
-
2
-
50
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
110
-
-
-
-
-
-
-
-
-
-
-
4
-
-
-
-
-
8
-
-
-
-
-
-
1
-
-
-
3
-
-
-
-
-
-
-
-
2
5
2
-
-
-
-
-
-
-
-
-
-
-
-
-
1
-
-
-
-
-
45
-
-
-
-
-
-
-
-
-
-
-
MENGETAHUI YANG MEMINTA : YANG MEN
KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING PETUGAS OBA
HJ,IYOT SA'DIAH,S.ST RENY WIGIA

IP.19710804 199103 2 002 NIP.- NIP.1986011420
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN
PUSKESMAS
DOKUMEN
PELAPORAN BULAN / PERIODE JUN DINKES KAB/KOTA
PERMINTAAN BULAN / PERIODE JUL GFK KAB/KOTA
PUSKESMAS
JUNI
Jumlah
Stok
Permintaa PEMBERIA
Jumlah HARGA Optimum
Penerimaan Pemakaian Stok Akhir n
Persediaan
APBD II
5 6 7 8 9 10 11
( 4+5 ) (6-7)
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 190 70 120
- - - -
- - - -
- 110 100 10
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
100 100 80 20
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 2 1 1
- - - -
- - - -
100 170 70 100
- - - -
- - - -
- - - -
- - - -
- - - -
- 14 9 5
- - - -
- 150 90 60
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
5 5 5 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 50 40 10
- - - -
- - - -
- - - -
- - - -
- - - -
100 160 100 60
- - - -
- - - -
- - - -
- - - -
100 170 100 70
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
100 150 100 50
5 12 8 4
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 1 1 -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- 80 70 10
- - - -
- 90 50 40
- - - -
- - - -
- - - -
- 5 - 5
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
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100 150 100 50
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50 100 60 40
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10 13 9 4
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5 5 3 2
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100 120 120 -
2 5 5 -
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- 11 11 -
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- 6 6 -
10 20 2 18
- 6 4 2
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10 10 5 5
10 15 9 6
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- 50 50 -
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100 160 100 60
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100 100 40 60
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10 18 7 11
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5 7 5 2
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YANG MENYERAHKAN MENGETAHUI
PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS

NIP.198601142019 02 2 003 NIP.19710804 199103 2 002
LPLPO ) RUTIN
NOMOR TANGGAL
DINKES KAB/KOTA
GFK KAB/KOTA
PUSKESMAS
PEMBERIAN JUMLAH
BUFFER
JKN PROG LAIN LAIN
STOK
12 13 14 15 16
YANG MEMINTA :
PETUGAS PUSTU/POSKEDES/PUSLING
NIP.-
LAPORAN PERSEDIAAN PUSKESMAS CIKEUSIK
Nama Puskesmas : PKM CIKEUSIK/ LEUWIBALANG

Bulan : MARET
Saldo Awal 2020 Penerimaan T.A 2020 Pengeluaran TA. 2020 Saldo Akhir
No Uraian Harga per Unit Harga per Unit Harga per Unit Harga per Unit
Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp)
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5=3x4 6 7 8=6x7 9 10 11=9x10 12=3+6-9 13 14=12x13
1 Alprazolam - - - - - - - -
2 Albendazol Tablet 400 mg - 407 - 407 - 407 - 407
3 Allopurinol tablet 100 mg - 99 - 99 - 99 - 99
4 Ambroxol sirup - 3,300 5 3,300 3 3,300 2 3,300
5 Ambroxol tablet 30 mg - - - - - - - -
6 Aminofilin Tablet 200 mg - 91 - 91 - 91 - 91
7 Aminofilina injeksi 24 mg/ml - 10 ml - 3,345 - 3,345 - 3,345 - 3,345
8 Amlodipin 10 mg - 93 - 93 - 93 - 93
9 Amlodipin Besilate 5 mg - 70 - 70 - 70 - 70
10 Amoksisilin Forte sirup kering 250mg - 3,400 - 3,400 - 3,400 - 3,400
11 Amoksisilin Injeksi 1 gr - 5,368 - 5,368 - 5,368 - 5,368
12 Amoksisilin Tablet 500 mg 150 249 - 249 80 249 70 249
13 Amoksisillin kapsul 250 mg - - - - - - - -
14 Amoksisillin Sirup Kering 125 mg/5 ml - 5,500 - 5,500 - 5,500 - 5,500
15 Ampisilin Injeksi 1 gr - 10,300 - 10,300 - 10,300 - 10,300
16 Analog insulin Long Acting - - - - - - - -
17 Analog insulin Mix Acting - - - - - - - -
18 Antalgin (Metampiron) tablet 500 mg - 305 - 305 - 305 - 305
20 Antasida DOEN suspensi - 1,995 - 1,995 - 1,995 - 1,995
21 ANTASIDA DOEN Tablet 70 58 - 58 70 58 - 58
22 Anti Bakteri DOEN ( Bacitrasin ) - 3,035 - 3,035 - 3,035 - 3,035
23 anti hemoroid doen kombinasi - 3,167 - 3,167 - 3,167 - 3,167
24 Antifungi DOEN - - - - - - - -
25 Antimigren DOEN Kombinasi : - 173 - 173 - 173 - 173
26 Antiparkinson DOEN tablet Kombinasi : - - - - - - - -
27 Antiparkinson Tablet ( Levopar ) - - - - - - - -
28 Aqua Pro Injeksi - 2,860 - 2,860 - 2,860 - 2,860
29 Artermeter injeksi - 1,000 - 1,000 - 1,000 - 1,000
30 Artesunate injeksi 60 mg/ml - - - - - - - -
31 Asam Ascorbat ( Vit. C ) 50 MG - 105 - 105 - 105 - 105
32 Asam Folat - 52 - 52 - 52 - 52
33 Asam Fusidat Cream - 5,506 - 5,506 - 5,506 - 5,506
34 Asam Klorida 0,1 N - - - - - - - -
35 Asam Mefenamat 500 mg - 103 - 103 - 103 - 103
36 Asam Traneksamat Inj 5% - 1,748 - 1,748 - 1,748 - 1,748
37 Asering - 9,646 - 9,646 - 9,646 - 9,646
38 Asetosal tablet 500 mg - - - - - - - -
39 Asetyl Cysteine - 382 60 382 40 382 20 382
40 Asiklovir Cream 5% - 8,800 - 8,800 - 8,800 - 8,800
41 Asiklovir tablet 200 mg - 236 - 236 - 236 - 236
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - 1,595 - 1,595 - 1,595 - 1,595
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - - - - - - - -
45 Atropin Sulfat tablet 0,5 mg - - - - - - - -
46 Berotec Metered Aerosol 100 mg - 80,000 - 80,000 - 80,000 - 80,000
47 Betadine Salep Antiseptik 5 mg - 7,039 - 7,039 - 7,039 - 7,039
48 Betametason krim 0,1 % - 1,340 3 1,340 3 1,340 - 1,340
49 Bisakodil Suppositoria - 5,800 - 5,800 - 5,800 - 5,800
50 Bisoprolol 2,5 mg - 650 - 650 - 650 - 650
51 Bisoprolol 5 mg - 263 - 263 - 263 - 263
52 Cairan Infus KN-3B - 10,696 - 10,696 - 10,696 - 10,696
53 Cairan Infus Wida KDN 1 - 1,007 - 1,007 - 1,007 - 1,007
54 Cairan Pembersih ( Protektor ) - 22,000 - 22,000 - 22,000 - 22,000
55 Captopril Tablet 12,5 mg - 66 100 66 50 66 50 66
56 Captopril Tablet 25 mg - 72 - 72 - 72 - 72
57 Cefadroxil Capsul 500 mg - 516 - 516 - 516 - 516
58 Cefixime Capsul 100 mg - 590 - 590 - 590 - 590
59 Cefixime Sirup - 7,490 - 7,490 - 7,490 - 7,490
60 Cefotaksime 1 gr Injeksi - 4,200 - 4,200 - 4,200 - 4,200
61 Cetirizine Capsul 50 mg 30 90 - 90 30 90 - 90
62 Cetirizine sirup 5 mg/5 ml - 2,849 - 2,849 - 2,849 - 2,849
63 Ciprofloxcacin 500 mg tablet - 265 - 265 - 265 - 265
64 Combivent UDV 2,5 mg+0,5mg/2,5 ml - 4,550 - 4,550 - 4,550 - 4,550
65 D-Artepp tablet - - - - - - - -
66 deksametason tab - 77 100 77 70 77 30 77
67 Dekstran 70 - larutan infus 6% steril - - - - - - - -
68 Dekstrometorfan sirup - - - - - - - -
69 Dekstrometorfan tablet 15 mg - - - - - - - -
70 Diazepam Rektal 0,5 mg / 2 ml - 12,573 - 12,573 - 12,573 - 12,573
71 Diazepam tablet 2 mg - - - - - - - -
72 Diazepam tablet 5 mg - 109 - 109 - 109 - 109
73 Difenhidramin HCL injeksi 10 mg/ml - 1ml - 1,176 - 1,176 - 1,176 - 1,176
74 Digoksin tablet 0,25 mg - 105 - 105 - 105 - 105
75 Diltiazem - - - - - - - -
76 Doksisiklin Kapsul 100 mg - 264 - 264 - 264 - 264
77 Domperidon 10mg Tablet 40 91 - 91 40 91 - 91
78 Domperidon Suspensi 5 mg/ 5 ml - 2,700 - 2,700 - 2,700 - 2,700
79 Doxicyclin 500mg - - - - - - - -
80 Efedrin HCLTablet 25 mg - - - - - - - -
81 Epinefrina HCL/Bitartrat Injeksi - 1,408 - 1,408 - 1,408 - 1,408
82 Eritromicyn kapsul 250 mg - 583 - 583 - 583 - 583
83 Erytromicin kapsul 500 mg - - - - - - - -
84 Erytromicin sirup 125 mg - - - - - - - -
85 Etakridin ( Rivanol ) larutan 0,1% - 2,992 - 2,992 - 2,992 - 2,992
86 Etambutol 500 mg - - - - - - - -
87 Etanol 70 % - - - - - - - -
88 Etil Klorida Semprot - 137,500 - 137,500 - 137,500 - 137,500
89 Fenitoin Natrium kapsul 30 mg - - - - - - - -
90 Fenobarbital injeksi 50 mg/ml - 2 ml - 1,740 - 1,740 - 1,740 - 1,740
91 Fenobarbital tablet 30 mg - 171 - 171 - 171 - 171
92 Fenoksimetil Penisilina tablet 250 mg - - - - - - - -
93 Fenol Gliserol tetes telinga 10 % - 2,764 - 2,764 - 2,764 - 2,764
94 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 m - 3,550 - 3,550 - 3,550 - 3,550
95 Fitomenadion (Vit.K1) tab salut gula 10 mg 20 710 100 710 50 710 70 710
96 Flufenazine Deconat Inj 25 mg/ml - 57,500 - 57,500 - 57,500 - 57,500
97 Furosemida tablet 40 mg - 82 - 82 - 82 - 82
98 Furosemide Injeksi - - - - - - - -
99 Garam Oralit - 260 - 260 - 260 - 260
100 Gemfibrozil 300 mg - 380 - 380 - 380 - 380
101 Gentamicin Injeksi - 1,010 - 1,010 - 1,010 - 1,010
102 Gentamicin Salep Kulit - 2,800 - 2,800 - 2,800 - 2,800
103 Gentamicin Salep mata - 4,232 - 4,232 - 4,232 - 4,232
104 Gentamicin Tetes Mata - 4,232 - 4,232 - 4,232 - 4,232
105 Gentian Violet 1 % - - - - - - - -
106 Glibenclamid tablet 5 mg - 119 - 119 - 119 - 119
107 Glicerin Guaiacolat ( GG ) 100 mg - - - - - - - -
108 Glikazid 80 mg Tablet - 235 - 235 - 235 - 235
109 Glimepiride 2 mg - 207 - 207 - 207 - 207
110 Glukosa larutan infus 10% steril - - - - - - - -
111 Glukosa larutan infus 5 % steril - 6,900 - 6,900 - 6,900 - 6,900
112 Griseofulvin tablet 500 mg, - 906 - 906 - 906 - 906
113 Guaiafenesin 100 mg - 132 - 132 - 132 - 132
114 Hidroklortiniazid ( HCT )Tab.25 mg - 155 - 155 - 155 - 155
115 Hidrokortison krim 2,5% 2 2,475 - 2,475 2 2,475 - 2,475
116 Ibuprofen Suspensi - - - - - - - -
117 Ibuprofen tablet 200 mg - 105 - 105 - 105 - 105
118 Ibuprofen tablet 400 mg - - - - - - - -
119 Imunomodulator sirup( STIMUNO) - 23,540 - 23,540 - 23,540 - 23,540
120 Isosorbid Dinitrat tablet sublingual 5 mg - 89 - 89 - 89 - 89
121 Kalsium Glukonas Injeksi - 4,800 - 4,800 - 4,800 - 4,800
122 Kalsium Laktat (Kalk) tablet 500 mg 50 63 100 63 70 63 80 63
123 Kapas Berlemak 500 mg - - - - - - - -
124 Ketokonazol Kream 2 2,518 - 2,518 2 2,518 - 2,518
125 Ketokonazol Tablet 200 mg - 270 50 270 50 270 - 270
126 Ketorolac inj - 1,045 - 1,045 - 1,045 - 1,045
127 Kifadene tablet 20 mg - - - - - - - -
128 Kloramfenikol salep mata 1 % - 1,881 5 1,881 4 1,881 1 1,881
129 Kloramfenikol suspensi - 5,015 - 5,015 - 5,015 - 5,015
130 Kloramfenikol tetes telinga 3% - - - - - - - -
131 Kloramphenicol 250 mg - 310 - 310 - 310 - 310
132 Kloramphenicol 500 mg - 1,090 - 1,090 - 1,090 - 1,090
133 Kloramphenicol Tetes Mata - - - - - - - -
134 Klorfeniramin Maleat (CTM) tablet 4 mg 80 23 - 23 50 23 30 23
135 Klorokuin tablet 150 mg - - - - - - - -
136 Klorpromazin HCL tablet salut 25 mg - - - - - - - -
137 Kombinasi (Pirimetamin 25 mg + Solfadoxi - - - - - - - -
138 Kotrimoksazol Dewasa Tablet 480 mg 120 125 - 125 60 125 60 125
139 Kotrimoksazol Sirup / Suspensi 5 2,052 - 2,052 5 2,052 - 2,052
140 Kuinin Dihidroklorida injeksi 25% - 2 ml - - - - - - - -
142 Lactobacilus serbuk - 14,707 - 14,707 - 14,707 - 14,707
143 Lidocain 2%+efinefrin injeksi - 1,152 - 1,152 - 1,152 - 1,152
144 Lidocain injeksi 2 ml - 1,140 - 1,140 - 1,140 - 1,140
145 Lisinopril 10 mg tablet - 448 - 448 - 448 - 448
147 Loperamid 4 mg tablet - 85 - 85 - 85 - 85
148 Lytacur Sirup - - - - - - - -
149 Magnesium Sulfat Inj. 25 ml 20% - 3,328 - 3,328 - 3,328 - 3,328
150 Metamizol 500 mg - 473 - 473 - 473 - 473
151 Metformin 500 mg Tablet 30 102 - 102 30 102 - 102
152 Methilprednisolon tablet 8 mg - - - - - - - -
153 Metilergometrin Maleat injeksi 1 ml - 2,550 10 2,550 4 2,550 6 2,550
154 Metilergometrin Maleat Tablet - 210 - 210 - 210 - 210
155 Metoklopramid Suspensi - 2,345 - 2,345 - 2,345 - 2,345
156 Metoklopramid tablet - - - - - - - -
157 Metronidazol 500 mg - - - - - - - -
158 Metronidazol infus / injeksi - - - - - - - -
159 Metronidazol Ovula - 4,100 - 4,100 - 4,100 - 4,100
160 Metronidazol suspensi - 3,799 - 3,799 - 3,799 - 3,799
161 Mikonazol kream - 3,414 - 3,414 - 3,414 - 3,414
162 Multivitamin Anak Sirup - 9,900 - 9,900 - 9,900 - 9,900
163 Multivitamin Dewasa Antioksidan ( Becom - 1,440 - 1,440 - 1,440 - 1,440
164 Natrium Diklofenak 25 mg Tablet - - - - - - - -
165 Natrium Diklofenak 50 mg Tablet - 123 50 123 50 123 - 123
166 Natrium Klorida Cairan Infus ( NaCL ) - 6,410 - 6,410 - 6,410 - 6,410
167 Nifedipine Tablet 10 mg - - - - - - - -
168 Nistatin tablet vaginal 100.000 IU/g - 598 - 598 - 598 - 598
169 Obat anti Diare suspensi - - - - - - - -
170 Obat Anti Diare Tablet (Akita / Molagit ) - 145 - 145 - 145 - 145
171 Obat Batuk Flu ( Molexflu ) - 64,900 - 64,900 - 64,900 - 64,900
172 Obat Batuk Hitam (OBH) - - - - - - - -
173 Obat Batuk Sirup Herbal ( Herbacop ) - 12,100 - 12,100 - 12,100 - 12,100
174 Ofloxsacin Tetes Telinga - - - - - - - -
175 Oksitetrasiklin HCL salep mata 1% - 12,700 - 12,700 - 12,700 - 12,700
176 Oksitosin injeksi 10 IU/ml - 1 ml 1 - 10 - 2 - 9 -
177 Omeprazol injeksi - 9,898 - 9,898 - 9,898 - 9,898
178 Omeprazol Kapsul 20 mg - 130 - 130 - 130 - 130
179 Ondancentron injeksi 4 mg - 1,070 - 1,070 - 1,070 - 1,070
180 Ondancentron Tablet4 mg - 385 - 385 - 385 - 385
181 Paracetamol Drop 15 ml - 6,649 - 6,649 - 6,649 - 6,649
182 Paracetamol Sirup 120 mg/5 ml 8 1,107 5 1,107 10 1,107 3 1,107
183 Parafin Dresing ( Bioplacenton Tull ) - - - - - - - -
184 Parasetamol tablet 100 mg - - - - - - - -
185 Parasetamol tablet 500 mg 40 132 100 132 90 132 50 132
186 Permetrin Krim 5 % - 11,825 - 11,825 - 11,825 - 11,825
187 Pirantel Sirup - 9,700 - 9,700 - 9,700 - 9,700
188 Pirantel tablet 125 mg - 291 - 291 - 291 - 291
189 Pirazinamid - - - - - - - -
190 Piridoksin HCL (VIT B6) tablet 10mg - 131 - 131 - 131 - 131
191 Piroksikam tablet 20 mg - - - - - - - -
192 Polikresulen - - - - - - - -
193 Povidon lodida 10% 300 ml - 17,996 - 17,996 - 17,996 - 17,996
195 Prazikuantel tablet 600 mg - - - - - - - -
196 Prednison Tablet 5 mg - 73 - 73 - 73 - 73
197 Primakuin 15 mg - 224 - 224 - 224 - 224
198 Probenesid 500 mg tablet - - - - - - - -
199 Prokain Benzil Penisilin 3 juta IU/vial injeks - - - - - - - -
200 Propanolol HCL tablet 10 mg - 60 - 60 - 60 - 60
201 Ranitidin injeksi - 1,155 - 1,155 - 1,155 - 1,155
202 Ranitidin tablet 30 105 100 105 90 105 40 105
203 Resperidone 2 mg tablet - 273 - 273 - 273 - 273
204 Ringer Laktat cairan infus (Otsuka) - 7,150 - 7,150 - 7,150 - 7,150
205 Ringer Laktat cairan infus (Widatra) - 7,630 3 7,630 3 7,630 - 7,630
206 Rivanol 300 ml - 2,992 - 2,992 - 2,992 - 2,992
207 Salbutamol Tablet 2 mg - 63 100 63 50 63 50 63
208 Salbutamol tablet 4mg - 70 - 70 - 70 - 70
209 Salep 2-4 - 2,621 - 2,621 - 2,621 - 2,621
210 Salep kombinasi cream ( Berloson ) - 11,000 - 11,000 - 11,000 - 11,000
211 Salicil bedak - 1,025 - 1,025 - 1,025 - 1,025
212 Serum Anti Bisa Ular Polivalen Inj 50 ml - 512,204 - 512,204 - 512,204 - 512,204
213 Serum Anti Tetanus inj 1500 IU ( Tetagam - 130,999 - 130,999 - 130,999 - 130,999
214 Sianokobalamin Injeksi - 1,035 - 1,035 - 1,035 - 1,035
215 Simvastatin 10 mg tablet - 110 - 110 - 110 - 110
217 Sukralfat Suspensi - 6,789 - 6,789 - 6,789 - 6,789
218 Sukralfat tablet 500 mg - 368 - 368 - 368 - 368
219 Suspensi Seng Insulin inj.40 IU/ml - 10 ml - - - - - - - -
220 Temporary Stopping Fletcher serbuk & cai - - - - - - - -
221 Tetrakain HCL tetes mata 0,5% - - - - - - - -
222 Tetrasiklin 250 mg capsul - 163 - 163 - 163 - 163
223 Tetrasiklin 500 mg capsul - - - - - - - -
224 Tiamin Tablet 50 mg ( B1 ) 30 91 - 91 30 91 - 91
225 Ventolin Nebulizer - - - - - - - -
226 Vitamin B komplek 20 118 - 118 20 118 - 118
227 Zink sirup - 3,171 - 3,171 - 3,171 - 3,171
228 Zink tablet 20 mg 50 524 - 524 50 524 - 524
229 Deksametason inj - 1,097 - 1,097 - 1,097 - 1,097
230 Diazepam inj 5 mg/ml - 9,800 - 9,800 - 9,800 - 9,800
231 Griseofulvin 125 mcg - 210 - 210 - 210 - 210
232 Kloramfenikol SK - 3,008 - 3,008 - 3,008 - 3,008
233 Nystatin tab 500.000 IU - 843 - 843 - 843 - 843
234 magnesium Sulfat Inj. 25 ml 40% - 11,100 - 11,100 - 11,100 - 11,100
- - - -
- - - -
OBAT PROGRAM - - - -
2 Isoniazid Tablet 100 mg - 125 - 125 - 125 - 125
3 Obat Antituberkulosis kategori 1 - 389,342 - 389,342 - 389,342 - 389,342
4 Obat Antituberkulosis Kategori 2 - 1,384,983 - 1,384,983 - 1,384,983 - 1,384,983
5 Obat Antituberkulosis Kategori Anak - 248,120 - 248,120 - 248,120 - 248,120
6 Pot Dahak Non Steril - - - - - - - -
7 Pot Dahak Steril - 5,890 - 5,890 - 5,890 - 5,890
8 Reagen Ziehl Neelsen - 233,411 - 233,411 - 233,411 - 233,411
9 MDT MB Anak Tablet - 2,706 - 2,706 - 2,706 - 2,706
10 MDT MB Dewasa Tablet - 39,880 - 39,880 - 39,880 - 39,880
11 MDT PB Dewasa Tablet - 12,569 - 12,569 - 12,569 - 12,569
12 MDT PB Anak Tablet - 13,300 - 13,300 - 13,300 - 13,300
13 Retinol (Vitamin A) kapsul 200.000 IU - 519 - 519 - 519 - 519
14 Retinol (Vitamin A) kapsul 100.000 IU - 505 - 505 - 505 - 505
15 Tablet Penambah Darah ( FE ) - 354 - 354 - 354 - 354
16 Amitriptilin tablet 25 mg - 167 - 167 - 167 - 167
17 Carbamazepin 200 mg tablet - 245 - 245 - 245 - 245
18 Clobazam 10 mg Tablet - 739 - 739 - 739 - 739
19 Clozapine 25 mg Tablet - 1,121 - 1,121 - 1,121 - 1,121
21 Haloperidol 1,5 mg Tablet - 59 - 59 - 59 - 59
22 Haloperidol 2 mg tablet - 90 - 90 - 90 - 90
23 Haloperidol 5 mg Tablet - 60 - 60 - 60 - 60
24 Haloperidol Injeksi - 5,000 - 5,000 - 5,000 - 5,000
25 Klorpromazin HCL tablet salut 100 mg (cpz - 157 - 157 - 157 - 157
26 Klorpromazine Tablet 25 mg - - - - - - - -
27 Triheksilfenidil Hcl 2 mg tablet - 91 - 91 - 91 - 91
28 Depakote 250 mg - 990,000 - 990,000 - 990,000 - 990,000
29 Flufenazine (sikzonoat inj) - 59,800 - 59,800 - 59,800 - 59,800
30 Risperidon 2 mg - 287 - 287 - 287 - 287
31 DHP - 2,000 - 2,000 - 2,000 - 2,000
32 Primaquin - 253 - 253 - 253 - 253
B NAMA BAHAN MEDIS HABIS PAKAI (BMH - - - -
- - - -
1 Alat suntik 1 ml 17 777 - 777 7 777 10 777
2 Alat suntik 10 ml - 1,067 - 1,067 - 1,067 - 1,067
3 Alat suntik 2,5 ml - 649 - 649 - 649 - 649
4 Alat suntik 20 ml - 2,650 - 2,650 - 2,650 - 2,650
5 Alat suntik 3 cc (Remedi) - 816 - 816 - 816 - 816
6 Alat suntik 3 ml - 924 10 924 7 924 3 924
7 Alat suntik 5 ml - 856 - 856 - 856 - 856
8 Alkazide 1 L High Level Desinfectant - 2,702,700 - 2,702,700 - 2,702,700 - 2,702,700
9 Alkazyme Sachet 25 mg - 801,000 - 801,000 - 801,000 - 801,000
10 Alkohol 70 % 1 L - 25,000 - 25,000 - 25,000 - 25,000
11 Alkohol swab - 29,000 - 29,000 - 29,000 - 29,000
12 Anti Septik Hand Rub - 26,500 - 26,500 - 26,500 - 26,500
13 Anti Septik Surgikal Hand Scrub - - - - - - - -
14 Cat Gut no 2/0 2 40,200 - 40,200 2 40,200 - 40,200
15 Cat Gut no 3/0 - 38,536 - 38,536 - 38,536 - 38,536
16 Cat Gut No 3/0 (24 mm) - 84,601 - 84,601 - 84,601 - 84,601
17 Cat Gut No 3/0 (26 mm) - 68,433 - 68,433 - 68,433 - 68,433
18 Cathetter Jelly - 41,600 - 41,600 - 41,600 - 41,600
19 Demetech Silk 3/0 - 3,825 - 3,825 - 3,825 - 3,825
20 E Care I.V Dresing - 6,850 - 6,850 - 6,850 - 6,850
21 E-Care Surgical Mask Tie On - 549 - 549 - 549 - 549
22 Folly No 14 Catether - 16,610 - 16,610 - 16,610 - 16,610
24 I.V Cathetter No. 20 - 23,100 5 23,100 - 23,100 5 23,100
25 I.V Cathetter No. 22 - 23,100 5 23,100 3 23,100 2 23,100
26 I.V Cathetter No. 24 2 23,100 - 23,100 - 23,100 2 23,100
27 I.V Cathetter No. 26 3 13,464 - 13,464 - 13,464 3 13,464
28 Infuset Anak - 8,400 5 8,400 - 8,400 5 8,400
29 Infuset Dewasa - 23,056 5 23,056 3 23,056 2 23,056
30 Jarum Insulin - 2,083 - 2,083 - 2,083 - 2,083
31 Kapas Berlemak 250 gr - 20,600 - 20,600 - 20,600 - 20,600
32 Kapas Berlemak 500 gr - - - - - - - -
33 Kasa 4 m x 10 cm - 1,440 - 1,440 - 1,440 - 1,440
34 Kasa Hidrofil 36 x 80 cm - 127,600 - 127,600 - 127,600 - 127,600
35 Kasa Pembalut 2 x 80 cm - 9,400 - 9,400 - 9,400 - 9,400
36 Kasa Steril 16 x 16 cm - 7,370 3 7,370 3 7,370 - 7,370
37 Lisol 1 L - 40,997 - 40,997 - 40,997 - 40,997
38 Masker karet Ear Loop - 15,700 - 15,700 - 15,700 - 15,700
39 Masker tali - 500 - 500 - 500 - 500
40 Nasal Canula Oksigen - - - - - - - -
41 Plester 1" - 8,167 - 8,167 - 8,167 - 8,167
42 Plester Kertas 2,5 cm - 7,624 - 7,624 - 7,624 - 7,624
43 Plester Non Woven 5cm x 5 cm - 23,760 - 23,760 - 23,760 - 23,760
44 Policlean - 74,494 - 74,494 - 74,494 - 74,494
45 Polifik - 7,370 - 7,370 - 7,370 - 7,370
46 Saraya Alsof A 500 ml - - - - - - - -
47 Saraya Alsof Pure 500 ml - - - - - - - -
48 Sarung Tangan Gynecolog No 7 - 40,733 - 40,733 - 40,733 - 40,733
49 Sarung tangan M (Non Steril) - 968 - 968 - 968 - 968
50 Sarung tangan no 6,5 - 13,178 - 13,178 - 13,178 - 13,178
51 Sarung tangan no 6,5 Steril Gloves - 7,931 - 7,931 - 7,931 - 7,931
52 Sarung tangan no 7,0 Steril - - - - - - - -
53 Selang Section ( Surgikal Conection Tube - 30,003 - 30,003 - 30,003 - 30,003
54 Underpad - 7,900 - 7,900 - 7,900 - 7,900
55 Urine Bag - 7,038 - 7,038 - 7,038 - 7,038
56 safety blackblood - 204,167 - 204,167 - 204,167 - 204,167
57 safety box - 22,433 - 22,433 - 22,433 - 22,433
58 Tabung BD Vacutener - 1,690 - 1,690 - 1,690 - 1,690
59 masker n95 - 130,240 - 130,240 - 130,240 - 130,240
60 t silk black 3/0 26 mm - 19,700 - 19,700 - 19,700 - 19,700
NAMA OBAT VAKSIN - - - -
- - - -
1 Vaksin Anti Rabies ( VAR ) - 78,500 - 78,500 - 78,500 - 78,500
2 Vaksin BCG - 56,360 - 56,360 - 56,360 - 56,360
3 Vaksin DT - 16,412 - 16,412 - 16,412 - 16,412
4 Vaksin HB 0 - 21,810 - 21,810 - 21,810 - 21,810
5 Vaksin HBIG - 1,325,000 - 1,325,000 - 1,325,000 - 1,325,000
6 Vaksin Measless Rubella (MR) - 141,648 - 141,648 - 141,648 - 141,648
7 Vaksin Pentabio ( DPT - HB - Hib ) - 71,810 - 71,810 - 71,810 - 71,810
8 Vaksin Polio B OPV - 18,140 - 18,140 - 18,140 - 18,140
9 Vaksin Polio IPV - 144,540 - 144,540 - 144,540 - 144,540
10 Vaksin TD - 15,450 - 15,450 - 15,450 - 15,450
11 Vaksin Tuberculin - 625,900 - 625,900 - 625,900 - 625,900
12 ADS 0,05 ml - 1,550 - 1,550 - 1,550 - 1,550
13 ADS 0,5 ml - 1,185 - 1,185 - 1,185 - 1,185
14 ADS 5 ml - 1,583 - 1,583 - 1,583 - 1,583
15 Safety Box - 22,433 - 22,433 - 22,433 - 22,433
- - - -
- - - -
NAMA OBAT REAGEN - - - -
- - - -
1 Albumin (Reagen) - - - -
2 anti A Monoclonal ( GolDar 10 ml) - - - -
3 Anti A-B Monoclonal ( GolDar 10 ml) - - - -
4 Anti B Monoclonal ( GolDar 10ml) - - - -
5 Anti D Monoclonal ( GolGar 10ml) - - - -
6 Benecheck Plus Cholesterol Test - - - -
7 Benecheck Plus Glukosa Test - - - -
8 Benecheck Plus Uric Test - - - -
9 Bilirubin T/D (Reagen) - - - -
10 Brilian Green Bile Broth - - - -
11 Cellclean (CL-50) (Reagen) - - - -
12 Cellpack (PK-30L) (Reagen) - - - -
13 Chikungunya IgM (Reagen) - - - -
14 Cholesterol (Reagen) - - - -
15 Cholesterol Stik (Reagen) - - - -
16 CK-MB (Reagen) - - - -
17 Creatinin Reagen - - - -
18 Dengue IgM / IgM ( Reagen ) - - - -
19 Eight Check ( LNH ) - - - -
20 Febrile Antingen H Parathpy - - - -
21 Febrile Antingen H-A Parathpy - - - -
22 Febrile Antingen H-B Parathpy - - - -
23 Febrile Antingen H-C Parathpy - - - -
24 Febrile Antingen O Parathpy - - - -
25 Febrile Antingen O-A Parathpy - - - -
26 Febrile Antingen O-B Parathpy - - - -
27 Febrile Antingen O-C Parathpy - - - -
28 Glukosa Reagen - - - -
29 GOT ( ALAT ) - - - -
30 GPT ( ALAT ) - - - -
31 HBSAG Reagen - - - -
32 HCG Strip - - - -
33 HDL Cholesterol ( Precipitan ) - - - -
34 Hematologi Calibrator (Nscs 1000 ) - - - -
35 Hemoglobin Reagen - - - -
36 Lactose Broth 500 mg - - - -
37 LDL Cholesterol - - - -
38 Leptospira IgM (Reagen) - - - -
39 Micropippets MT-1-up to 200 ui - - - -
40 MIcropippets MT-up to 1 ml - - - -
41 NS1 Antigen Test (Reagen) - - - -
42 Pipet Ukur 10 ml - - - -
43 Poch Pack D (II) Reagen - - - -
44 Poch Pack L (II) Reagen - - - -
45 Stik Uric Acid - - - -
46 Strip Narkoba 3 Parameter - - - -
49 Total Protein - - - -
50 Trigleserida - - - -
51 Urea - - - -
52 Uric Acid - - - -
- - - -
NAMA OBAT REAGEN PROGRAM HIV - - - -
1 Rapid 1 HIV (SD Bioline ) - 11,975 - 11,975 - 11,975 - 11,975
2 Rapid 2 HIV (Fokus ) - 13,435 - 13,435 - 13,435 - 13,435
3 Rapid 3 HIV (Biomeriux Vikia ) - 487,000 - 487,000 - 487,000 - 487,000
4 SD Biosensore Standart Q Syphlis - 20,400 - 20,400 - 20,400 - 20,400
5 RPR Syphlis ( Fokus ) - 4,120 - 4,120 - 4,120 - 4,120
6 Reagen CD4 Control - 66,000 - 66,000 - 66,000 - 66,000
7 Reagen CD4 Mobile - 158,400 - 158,400 - 158,400 - 158,400
8 RPR Syphlis Komponen - 4,120 - 4,120 - 4,120 - 4,120
9 Anuscopy - 324,951 - 324,951 - 324,951 - 324,951
10 Kertas PH Indikator - 235,000 - 235,000 - 235,000 - 235,000
11 Rotator - 3,885,000 - 3,885,000 - 3,885,000 - 3,885,000
12 Tip. Uk.60 - 179,200 - 179,200 - 179,200 - 179,200
13 Tip. Uk.61 - 230,600 - 230,600 - 230,600 - 230,600
14 Pronto / Holder - 35,000 - 35,000 - 35,000 - 35,000
15 rapid HBSAG - 9,850 - 9,850 - 9,850 - 9,850
NAMA OBAT GIGI - - - -
- - - -
1 Anastesi Citojek - - - - - - - -
2 Articulating Paper (Kertas warna penanda - - - - - - - -
3 Bahan Tumpatan sementara - - - -
4 Bonding - 963,600 - 963,600 - 963,600 - 963,600
5 Cairan Desinfectan ( Perendaman Instrume - - - - - - - -
6 Cairan untuk desinfectan pembersih perm - - - -
7 Carpule Citojek - 28,600 - 28,600 - 28,600 - 28,600
8 Chlorfeson Kamfer menthol ( CHKM ) Cai - - - - - - - -
9 Composite Nanohibrid A1 - 251,900 - 251,900 - 251,900 - 251,900
12 Composite Nanohibrid A3,5 - 251,900 - 251,900 - 251,900 - 251,900
13 Devitalisasi Pasta/pulpa - 260,000 - 260,000 - 260,000 - 260,000
14 Disclosing Solution - - - - - - - -
15 Etcing Gel - 646,800 - 646,800 - 646,800 - 646,800
16 Etil Klorida Semprot - - - - - - - -
17 Eugenol Cairan - - - - - - - -
18 Formokesol - - - - - - - -
19 Gas Powred Jet Injector - - - - - - - -
20 Glass Ionomer Cement ART - - - - - - - -
21 Jarum citojek uk 16 mm - - - - - - - -
22 Kalsium Hidroksida pasta - - - - - - - -
23 Klorhekdidin Larutan 2 % - - - - - - - -
24 Mummifiying Fasta - - - - - - - -
25 Natrium Hipoklorit airan konsentrat 5% - - - - - - - -
26 Paper Points 15-40 mm - - - - - - - -
27 Pasta Devitalisasi ( Non Arsen ) - - - - - - - -
28 Pasta Pengisi Saluran Akar - - - - - - - -
29 Semen seng Fosfat serbuk - - - - - - - -
30 Spon Gelatin Cubicis 1x1x1 cm (Spongostan) - - - - - - - -
31 Temporary Filling Fasta - - - - - - - -
32 Tooth Stain Remover ( TSR ) - - - - - - - -
33 Wipes Desinfektan - - - -
34 caviton - 165,000 - 165,000 - 165,000 - 165,000
35 endometason - 396,000 - 396,000 - 396,000 - 396,000
36 fuji 9 gic - 836,000 - 836,000 - 836,000 - 836,000
PROGRAM KB - - - -
1 iud COP T - 12,500 - 12,500 - 12,500 - 12,500
2 susuk kB II - 175,181 - 175,181 - 175,181 - 175,181
3 suntik kb 3 bulan - 6,090 - 6,090 - 6,090 - 6,090
4 pil KB kombinasi - 1,518 - 1,518 - 1,518 - 1,518
5 kondom - 4,100 - 4,100 - 4,100 - 4,100
6 disposable - 1,215 - 1,215 - 1,215 - 1,215
7 lidocain - - - - - - - -
8 dermafix - - - - - - - -
9 povidone - - - - - - - -
10 amoksisilin - - - - - - - -
11 asam mefenamat - - - - - - - -
12 Safety Box - - - - - - - -
13 Kasa Steril 16 x 16 cm - - - - - - - -
14 masker - - - - - - - -
- - - -
OBAT JKN - - - -
1 acylovir cream - 3,619 - 3,619 - 3,619 - 3,619
2 alkohol 70% - 50,000 - 50,000 - 50,000 - 50,000
3 cefadroksil tab - 110,000 - 110,000 - 110,000 - 110,000
4 cetirizin syr - 3,636 - 3,636 - 3,636 - 3,636
5 etil klorida spray - 352,000 - 352,000 - 352,000 - 352,000
6 flagsol tab - 26,400 - 26,400 - 26,400 - 26,400
7 lexigo tab - 22,000 - 22,000 - 22,000 - 22,000
8 mecobalamin kap - 88,000 - 88,000 - 88,000 - 88,000
9 mersibion inj - 54,670 - 54,670 - 54,670 - 54,670
10 Metronidazol tab 500 MG - 204 - 204 - 204 - 204
11 Metronidazol tab 500 MG - 26,400 - 26,400 - 26,400 - 26,400
12 obh syr - 4,950 - 4,950 - 4,950 - 4,950
13 paraflu syr - 6,000 - 6,000 - 6,000 - 6,000
14 parasetamol inf - 67,100 - 67,100 - 67,100 - 67,100
15 piroksikam 20 mg tab - 18,480 - 18,480 - 18,480 - 18,480
16 propyretic suppo - 105,600 - 105,600 - 105,600 - 105,600
17 reco - 11,330 - 11,330 - 11,330 - 11,330
18 selkom c tab - 65,000 - 65,000 - 65,000 - 65,000
19 sianokobalamin tab - 4,000 - 4,000 - 4,000 - 4,000
20 trifadium tab - 20,434 - 20,434 - 20,434 - 20,434
21 vit k1 inj - 825,000 - 825,000 - 825,000 - 825,000
B BMHP JKN - - - -
1 CARPUL CITOJET - 112,000 - 112,000 - 112,000 - 112,000
2 CAVITON - 186,490 - 186,490 - 186,490 - 186,490
3 CHEROPHEN - 484,250 - 484,250 - 484,250 - 484,250
4 DEVITALISASI - 87,455 - 87,455 - 87,455 - 87,455
5 LANSET - 36,700 - 36,700 - 36,700 - 36,700
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) - 322,000 - 322,000 - 322,000 - 322,000
7 SARUNG TANGAN NON STERIL M - 286,364 - 286,364 - 286,364 - 286,364
8 GLASS IONOMER - 438,182 - 438,182 - 438,182 - 438,182
9 SUNGKUP DEWASA - 1,064,000 - 1,064,000 - 1,064,000 - 1,064,000
10 SUNGKUP ANAK - 58,409 - 58,409 - 58,409 - 58,409
11 BISTURI - 438,750 - 438,750 - 438,750 - 438,750
12 PIPET OBAT - 58,409 - 58,409 - 58,409 - 58,409
13 PLESTER - 318,182 - 318,182 - 318,182 - 318,182
14 SENDOK OBAT 5 ML - 452,045 - 452,045 - 452,045 - 452,045
15 SARUNG TANGAN STERIL - 193,636 - 193,636 - 193,636 - 193,636
16 STAIN REMOVEL - 216,364 - 216,364 - 216,364 - 216,364
17 VASELIN - 25,200 - 25,200 - 25,200 - 25,200
18 CHKM - 96,200 - 96,200 - 96,200 - 96,200
19 Jely - 22,000 - 22,000 - 22,000 - 22,000
20 disp 10 cc - 150,525 - 150,525 - 150,525 - 150,525
21 f cath 18 - 11,200 - 11,200 - 11,200 - 11,200
22 handscoon non steril uk L - 48,200 - 48,200 - 48,200 - 48,200
23 handscoon non steril uk M - 48,200 - 48,200 - 48,200 - 48,200
24 handscoon steril 6,5 - 262,000 - 262,000 - 262,000 - 262,000
25 handscoon steril 7,5 - 262,000 - 262,000 - 262,000 - 262,000
26 Kertas puyer - 14,365 - 14,365 - 14,365 - 14,365
27 Needle no 23 - 995 - 995 - 995 - 995
28 Needle no 24 - 995 - 995 - 995 - 995
29 Plastik klip besar - 122,100 - 122,100 - 122,100 - 122,100
30 Plastik klip kecil - 99,450 - 99,450 - 99,450 - 99,450
31 plastik klip sedang - 99,450 - 99,450 - 99,450 - 99,450
32 Plester 5 yard x2 inci - 23,625 - 23,625 - 23,625 - 23,625
33 Sarung tangan No M - 88,000 - 88,000 - 88,000 - 88,000
34 Sarung tangan No S - 88,000 - 88,000 - 88,000 - 88,000
35 Selang Oksigen Anak-anak - 11,000 - 11,000 - 11,000 - 11,000
36 Selang Oksigen Dewasa - 11,000 - 11,000 - 11,000 - 11,000
37 Larutan Gentian Violet - 256,300 - 256,300 - 256,300 - 256,300
38 mukus ekstraktor - 9,800 - 9,800 - 9,800 - 9,800
39 nasal kanul bayi - 8,870 - 8,870 - 8,870 - 8,870
40 nesco asam urat - 99,450 - 99,450 - 99,450 - 99,450
41 nesco gds - 121,550 - 121,550 - 121,550 - 121,550
42 nesco kolesterol - 206,550 - 206,550 - 206,550 - 206,550
43 pipet obat 1 ml - 350,000 - 350,000 - 350,000 - 350,000
44 plester - 306,300 - 306,300 - 306,300 - 306,300
45 pot urin - 1,500 - 1,500 - 1,500 - 1,500
46 reagen goldar A - 355,750 - 355,750 - 355,750 - 355,750
47 kertas goldar - 38,675 - 38,675 - 38,675 - 38,675
48 Rebreathing mask O2 anak - 35,100 - 35,100 - 35,100 - 35,100
49 Rebreathing mask O2 bayi - 35,100 - 35,100 - 35,100 - 35,100
50 Rebreathing mask O2 dewasa - 35,100 - 35,100 - 35,100 - 35,100
51 sendok obat - 53,200 - 53,200 - 53,200 - 53,200
52 SOFRATULLE - 175,000 - 175,000 - 175,000 - 175,000
53 stain removel pasta - 238,000 - 238,000 - 238,000 - 238,000
54 suction no 8 - 4,000 - 4,000 - 4,000 - 4,000
55 sungkup bayi - 25,725 - 25,725 - 25,725 - 25,725
56 t silk - 165,750 - 165,750 - 165,750 - 165,750
57 tes kehamilan - 88,400 - 88,400 - 88,400 - 88,400
58 umbilical klem - 88,275 - 88,275 - 88,275 - 88,275
59 vaselin - 9,240 - 9,240 - 9,240 - 9,240
60 yellow tip - 193,375 - 193,375 - 193,375 - 193,375
Nama Puskesmas : PKM CIKEUSIK/ LEUWIBALANG

Bulan : JUNI
No Uraian Harga per Unit Harga per Unit Harga per Unit Harga per Unit
Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp)
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5=3x4 6 7 8=6x7 9 10 11=9x10 12=3+6-9 13 14=12x13
1 Alprazolam - - - - - - - -
3 Allopurinol tablet 100 mg - 105 - 105 - 105 - 105
4 Ambroxol sirup - 3,300 - 3,300 - 3,300 - 3,300
5 Ambroxol tablet 30 mg - - - - - - - -
6 Aminofilin Tablet 200 mg - 91 - 91 - 91 - 91
7 Aminofilina injeksi 24 mg/ml - 10 ml - 3,345 - 3,345 - 3,345 - 3,345
8 Amlodipin 10 mg - 93 - 93 - 93 - 93
9 Amlodipin Besilate 5 mg 190 70 - 70 70 70 120 70
10 Amoksisilin Forte sirup kering 250mg - 3,400 - 3,400 - 3,400 - 3,400
11 Amoksisilin Injeksi 1 gr - 5,368 - 5,368 - 5,368 - 5,368
12 Amoksisilin Tablet 500 mg 110 249 - 249 100 249 10 249
13 Amoksisillin kapsul 250 mg - - - - - - - -
14 Amoksisillin Sirup Kering 125 mg/5 ml - 5,500 - 5,500 - 5,500 - 5,500
15 Ampisilin Injeksi 1 gr - 10,300 - 10,300 - 10,300 - 10,300
16 Analog insulin Long Acting - - - - - - - -
17 Analog insulin Mix Acting - - - - - - - -
20 Antasida DOEN suspensi - 2,129 - 2,129 - 2,129 - 2,129
21 ANTASIDA DOEN Tablet - 58 100 58 80 58 20 58
22 Anti Bakteri DOEN ( Bacitrasin ) - 3,035 - 3,035 - 3,035 - 3,035
23 anti hemoroid doen kombinasi - 3,167 - 3,167 - 3,167 - 3,167
24 Antifungi DOEN - - - - - - - -
25 Antimigren DOEN Kombinasi : - 173 - 173 - 173 - 173
26 Antiparkinson DOEN tablet Kombinasi : - - - - - - - -
27 Antiparkinson Tablet ( Levopar ) - - - - - - - -
28 Aqua Pro Injeksi 2 2,860 - 2,860 1 2,860 1 2,860
29 Artermeter injeksi - 1,000 - 1,000 - 1,000 - 1,000
30 Artesunate injeksi 60 mg/ml - - - - - - - -
31 Asam Ascorbat ( Vit. C ) 50 MG 70 105 100 105 70 105 100 105
32 Asam Folat - 52 - 52 - 52 - 52
33 Asam Fusidat Cream - 5,506 - 5,506 - 5,506 - 5,506
34 Asam Klorida 0,1 N - - - - - - - -
35 Asam Mefenamat 500 mg - 103 - 103 - 103 - 103
36 Asam Traneksamat Inj 5% - 1,748 - 1,748 - 1,748 - 1,748
37 Asering 14 9,646 - 9,646 9 9,646 5 9,646
38 Asetosal tablet 500 mg - - - - - - - -
39 Asetyl Cysteine 150 382 - 382 90 382 60 382
40 Asiklovir Cream 5% - 8,800 - 8,800 - 8,800 - 8,800
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - 1,595 - 1,595 - 1,595 - 1,595
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - - - - - - - -
45 Atropin Sulfat tablet 0,5 mg - - - - - - - -
46 Berotec Metered Aerosol 100 mg - 80,000 - 80,000 - 80,000 - 80,000
47 Betadine Salep Antiseptik 5 mg - 7,039 - 7,039 - 7,039 - 7,039
48 Betametason krim 0,1 % - 1,340 5 1,340 5 1,340 - 1,340
49 Bisakodil Suppositoria - 5,800 - 5,800 - 5,800 - 5,800
50 Bisoprolol 2,5 mg - 650 - 650 - 650 - 650
51 Bisoprolol 5 mg - 263 - 263 - 263 - 263
52 Cairan Infus KN-3B - 10,696 - 10,696 - 10,696 - 10,696
53 Cairan Infus Wida KDN 1 - 1,007 - 1,007 - 1,007 - 1,007
54 Cairan Pembersih ( Protektor ) - 22,000 - 22,000 - 22,000 - 22,000
55 Captopril Tablet 12,5 mg 50 66 - 66 40 66 10 66
56 Captopril Tablet 25 mg - 72 - 72 - 72 - 72
57 Cefadroxil Capsul 500 mg - 516 - 516 - 516 - 516
58 Cefixime Capsul 100 mg - 590 - 590 - 590 - 590
59 Cefixime Sirup - 7,490 - 7,490 - 7,490 - 7,490
60 Cefotaksime 1 gr Injeksi - 4,200 - 4,200 - 4,200 - 4,200
61 Cetirizine Capsul 50 mg 60 90 100 90 100 90 60 90
62 Cetirizine sirup 5 mg/5 ml - 2,849 - 2,849 - 2,849 - 2,849
63 Ciprofloxcacin 500 mg tablet - 265 - 265 - 265 - 265
64 Combivent UDV 2,5 mg+0,5mg/2,5 ml - 4,550 - 4,550 - 4,550 - 4,550
65 D-Artepp tablet - - - - - - - -
66 deksametason tab 70 77 100 77 100 77 70 77
67 Dekstran 70 - larutan infus 6% steril - - - - - - - -
68 Dekstrometorfan sirup - - - - - - - -
69 Dekstrometorfan tablet 15 mg - - - - - - - -
70 Diazepam Rektal 0,5 mg / 2 ml - 12,573 - 12,573 - 12,573 - 12,573
71 Diazepam tablet 2 mg - - - - - - - -
72 Diazepam tablet 5 mg - 109 - 109 - 109 - 109
73 Difenhidramin HCL injeksi 10 mg/ml - 1ml - 1,176 - 1,176 - 1,176 - 1,176
74 Digoksin tablet 0,25 mg - 105 - 105 - 105 - 105
75 Diltiazem - - - - - - - -
76 Doksisiklin Kapsul 100 mg - 264 - 264 - 264 - 264
77 Domperidon 10mg Tablet 50 91 100 91 100 91 50 91
78 Domperidon Suspensi 5 mg/ 5 ml 7 2,700 5 2,700 8 2,700 4 2,700
79 Doxicyclin 500mg - - - - - - - -
80 Efedrin HCLTablet 25 mg - - - - - - - -
81 Epinefrina HCL/Bitartrat Injeksi - 1,408 - 1,408 - 1,408 - 1,408
82 Eritromicyn kapsul 250 mg - 583 - 583 - 583 - 583
83 Erytromicin kapsul 500 mg - - - - - - - -
84 Erytromicin sirup 125 mg - - - - - - - -
85 Etakridin ( Rivanol ) larutan 0,1% 1 2,992 - 2,992 1 2,992 - 2,992
86 Etambutol 500 mg - - - - - - - -
87 Etanol 70 % - - - - - - - -
88 Etil Klorida Semprot - 137,500 - 137,500 - 137,500 - 137,500
90 Fenobarbital injeksi 50 mg/ml - 2 ml - 1,740 - 1,740 - 1,740 - 1,740
91 Fenobarbital tablet 30 mg - 171 - 171 - 171 - 171
92 Fenoksimetil Penisilina tablet 250 mg - - - - - - - -
93 Fenol Gliserol tetes telinga 10 % - 2,764 - 2,764 - 2,764 - 2,764
94 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 - 3,550 - 3,550 - 3,550 - 3,550
95 Fitomenadion (Vit.K1) tab salut gula 10 m 80 710 - 710 70 710 10 710
96 Flufenazine Deconat Inj 25 mg/ml - 57,500 - 57,500 - 57,500 - 57,500
97 Furosemida tablet 40 mg 90 82 - 82 50 82 40 82
98 Furosemide Injeksi - - - - - - - -
99 Garam Oralit - 260 - 260 - 260 - 260
100 Gemfibrozil 300 mg - 380 - 380 - 380 - 380
101 Gentamicin Injeksi 5 1,010 - 1,010 - 1,010 5 1,010
102 Gentamicin Salep Kulit - 2,800 - 2,800 - 2,800 - 2,800
103 Gentamicin Salep mata - 4,232 - 4,232 - 4,232 - 4,232
104 Gentamicin Tetes Mata - 4,232 - 4,232 - 4,232 - 4,232
105 Gentian Violet 1 % - - - - - - - -
106 Glibenclamid tablet 5 mg - 119 - 119 - 119 - 119
107 Glicerin Guaiacolat ( GG ) 100 mg - - - - - - - -
108 Glikazid 80 mg Tablet - 235 - 235 - 235 - 235
109 Glimepiride 2 mg 60 207 - 207 30 207 30 207
110 Glukosa larutan infus 10% steril - - - - - - - -
111 Glukosa larutan infus 5 % steril - 6,900 - 6,900 - 6,900 - 6,900
112 Griseofulvin tablet 500 mg, - 906 - 906 - 906 - 906
113 Guaiafenesin 100 mg - 132 - 132 - 132 - 132
114 Hidroklortiniazid ( HCT )Tab.25 mg - 155 - 155 - 155 - 155
115 Hidrokortison krim 2,5% - 2,475 3 2,475 3 2,475 - 2,475
116 Ibuprofen Suspensi - - - - - - - -
117 Ibuprofen tablet 200 mg - 105 - 105 - 105 - 105
118 Ibuprofen tablet 400 mg - - - - - - - -
119 Imunomodulator sirup( STIMUNO) - 23,540 - 23,540 - 23,540 - 23,540
120 Isosorbid Dinitrat tablet sublingual 5 mg - 89 - 89 - 89 - 89
121 Kalsium Glukonas Injeksi - 4,800 - 4,800 - 4,800 - 4,800
122 Kalsium Laktat (Kalk) tablet 500 mg 50 63 100 63 100 63 50 63
123 Kapas Berlemak 500 mg - - - - - - - -
124 Ketokonazol Kream - 2,518 5 2,518 5 2,518 - 2,518
125 Ketokonazol Tablet 200 mg 50 270 50 270 60 270 40 270
126 Ketorolac inj - 1,045 - 1,045 - 1,045 - 1,045
127 Kifadene tablet 20 mg - - - - - - - -
128 Kloramfenikol salep mata 1 % - 1,881 - 1,881 - 1,881 - 1,881
129 Kloramfenikol suspensi 3 5,015 10 5,015 9 5,015 4 5,015
130 Kloramfenikol tetes telinga 3% - - - - - - - -
131 Kloramphenicol 250 mg - 310 - 310 - 310 - 310
132 Kloramphenicol 500 mg - 1,090 - 1,090 - 1,090 - 1,090
133 Kloramphenicol Tetes Mata - - - - - - - -
134 Klorfeniramin Maleat (CTM) tablet 4 mg 130 23 - 23 50 23 80 23
135 Klorokuin tablet 150 mg - - - - - - - -
136 Klorpromazin HCL tablet salut 25 mg - - - - - - - -
137 Kombinasi (Pirimetamin 25 mg + Solfadox - - - - - - - -
138 Kotrimoksazol Dewasa Tablet 480 mg - 133 - 133 - 133 - 133
139 Kotrimoksazol Sirup / Suspensi - 2,190 - 2,190 - 2,190 - 2,190
142 Lactobacilus serbuk - 14,707 - 14,707 - 14,707 - 14,707
143 Lidocain 2%+efinefrin injeksi 13 1,152 - 1,152 3 1,152 10 1,152
144 Lidocain injeksi 2 ml - 1,140 - 1,140 - 1,140 - 1,140
147 Loperamid 4 mg tablet - 85 - 85 - 85 - 85
148 Lytacur Sirup - - - - - - - -
149 Magnesium Sulfat Inj. 25 ml 20% - 3,328 - 3,328 - 3,328 - 3,328
150 Metamizol 500 mg - 473 - 473 - 473 - 473
151 Metformin 500 mg Tablet - 102 - 102 - 102 - 102
152 Methilprednisolon tablet 8 mg - - - - - - - -
153 Metilergometrin Maleat injeksi 1 ml - 2,550 30 2,550 2 2,550 28 2,550
154 Metilergometrin Maleat Tablet - 210 - 210 - 210 - 210
155 Metoklopramid Suspensi - 2,345 - 2,345 - 2,345 - 2,345
156 Metoklopramid tablet - - - - - - - -
157 Metronidazol 500 mg - - - - - - - -
158 Metronidazol infus / injeksi - - - - - - - -
159 Metronidazol Ovula - 4,100 - 4,100 - 4,100 - 4,100
160 Metronidazol suspensi - 3,799 - 3,799 - 3,799 - 3,799
161 Mikonazol kream - 3,414 - 3,414 - 3,414 - 3,414
162 Multivitamin Anak Sirup - 9,900 5 9,900 3 9,900 2 9,900
163 Multivitamin Dewasa Antioksidan ( Becom - 1,440 - 1,440 - 1,440 - 1,440
164 Natrium Diklofenak 25 mg Tablet - - - - - - - -
165 Natrium Diklofenak 50 mg Tablet 20 123 100 123 120 123 - 123
166 Natrium Klorida Cairan Infus ( NaCL ) 3 6,410 2 6,410 5 6,410 - 6,410
167 Nifedipine Tablet 10 mg - - - - - - - -
168 Nistatin tablet vaginal 100.000 IU/g - 598 - 598 - 598 - 598
169 Obat anti Diare suspensi - - - - - - - -
170 Obat Anti Diare Tablet (Akita / Molagit ) - 145 - 145 - 145 - 145
171 Obat Batuk Flu ( Molexflu ) - 64,900 - 64,900 - 64,900 - 64,900
172 Obat Batuk Hitam (OBH) - - - - - - - -
173 Obat Batuk Sirup Herbal ( Herbacop ) 11 12,100 - 12,100 11 12,100 - 12,100
174 Ofloxsacin Tetes Telinga - - - - - - - -
175 Oksitetrasiklin HCL salep mata 1% 6 12,700 - 12,700 6 12,700 - 12,700
176 Oksitosin injeksi 10 IU/ml - 1 ml 10 - 10 - 2 - 18 -
177 Omeprazol injeksi 6 9,898 - 9,898 4 9,898 2 9,898
178 Omeprazol Kapsul 20 mg - 130 - 130 - 130 - 130
179 Ondancentron injeksi 4 mg - 1,070 - 1,070 - 1,070 - 1,070
180 Ondancentron Tablet4 mg - 385 - 385 - 385 - 385
181 Paracetamol Drop 15 ml - 6,649 10 6,649 5 6,649 5 6,649
182 Paracetamol Sirup 120 mg/5 ml 5 1,181 10 1,181 9 1,181 6 1,181
183 Parafin Dresing ( Bioplacenton Tull ) - - - - - - - -
184 Parasetamol tablet 100 mg - - - - - - - -
185 Parasetamol tablet 500 mg 50 132 - 132 50 132 - 132
186 Permetrin Krim 5 % - 11,825 - 11,825 - 11,825 - 11,825
187 Pirantel Sirup - 9,700 - 9,700 - 9,700 - 9,700
188 Pirantel tablet 125 mg - 291 - 291 - 291 - 291
189 Pirazinamid - - - - - - - -
190 Piridoksin HCL (VIT B6) tablet 10mg - 131 - 131 - 131 - 131
191 Piroksikam tablet 20 mg - - - - - - - -
192 Polikresulen - - - - - - - -
195 Prazikuantel tablet 600 mg - - - - - - - -
196 Prednison Tablet 5 mg - 73 100 73 100 73 - 73
197 Primakuin 15 mg - 224 - 224 - 224 - 224
198 Probenesid 500 mg tablet - - - - - - - -
199 Prokain Benzil Penisilin 3 juta IU/vial injek - - - - - - - -
200 Propanolol HCL tablet 10 mg - 60 - 60 - 60 - 60
201 Ranitidin injeksi - 1,155 - 1,155 - 1,155 - 1,155
202 Ranitidin tablet 60 105 100 105 100 105 60 105
203 Resperidone 2 mg tablet - 273 - 273 - 273 - 273
204 Ringer Laktat cairan infus (Otsuka) - 7,150 - 7,150 - 7,150 - 7,150
205 Ringer Laktat cairan infus (Widatra) 2 7,630 2 7,630 4 7,630 - 7,630
206 Rivanol 300 ml - 2,992 - 2,992 - 2,992 - 2,992
207 Salbutamol Tablet 2 mg 50 63 - 63 50 63 - 63
208 Salbutamol tablet 4mg - 70 100 70 40 70 60 70
209 Salep 2-4 - 2,621 - 2,621 - 2,621 - 2,621
210 Salep kombinasi cream ( Berloson ) - 11,000 - 11,000 - 11,000 - 11,000
211 Salicil bedak - 1,025 - 1,025 - 1,025 - 1,025
212 Serum Anti Bisa Ular Polivalen Inj 50 ml - 512,204 - 512,204 - 512,204 - 512,204
213 Serum Anti Tetanus inj 1500 IU ( Tetagam - 130,999 - 130,999 - 130,999 - 130,999
214 Sianokobalamin Injeksi - 1,035 - 1,035 - 1,035 - 1,035
215 Simvastatin 10 mg tablet - 110 30 110 30 110 - 110
217 Sukralfat Suspensi - 6,789 - 6,789 - 6,789 - 6,789
218 Sukralfat tablet 500 mg - 368 - 368 - 368 - 368
219 Suspensi Seng Insulin inj.40 IU/ml - 10 ml - - - - - - - -
220 Temporary Stopping Fletcher serbuk & cai - - - - - - - -
221 Tetrakain HCL tetes mata 0,5% - - - - - - - -
222 Tetrasiklin 250 mg capsul - 163 - 163 - 163 - 163
223 Tetrasiklin 500 mg capsul - - - - - - - -
224 Tiamin Tablet 50 mg ( B1 ) - 91 - 91 - 91 - 91
225 Ventolin Nebulizer - - - - - - - -
226 Vitamin B komplek 110 118 100 118 100 118 110 118
227 Zink sirup - 3,171 - 3,171 - 3,171 - 3,171
228 Zink tablet 20 mg - 524 - 524 - 524 - 524
229 Deksametason inj - 1,097 - 1,097 - 1,097 - 1,097
230 Diazepam inj 5 mg/ml - 9,800 - 9,800 - 9,800 - 9,800
231 Griseofulvin 125 mcg - 210 - 210 - 210 - 210
232 Kloramfenikol SK - 3,008 - 3,008 - 3,008 - 3,008
233 Nystatin tab 500.000 IU - 843 - 843 - 843 - 843
234 magnesium Sulfat Inj. 25 ml 40% - 11,100 - 11,100 - 11,100 - 11,100
- - - -
- - - -
OBAT PROGRAM - - -
1 Albendazol Tablet 400 mg - 431 431 - 431 - 431
2 Isoniazid Tablet 100 mg - 125 125 - 125 - 125
3 Obat Antituberkulosis kategori 1 - 415,467 415,467 - 415,467 - 415,467
4 Obat Antituberkulosis Kategori 2 - 1,384,983 1,384,983 - 1,384,983 - 1,384,983
5 Obat Antituberkulosis Kategori Anak - 248,120 248,120 - 248,120 - 248,120
6 Pot Dahak Non Steril - - - - - - -
7 Pot Dahak Steril - 5,890 5,890 - 5,890 - 5,890
8 Reagen Ziehl Neelsen - 233,411 233,411 - 233,411 - 233,411
9 MDT MB Anak Tablet - 2,706 2,706 - 2,706 - 2,706
10 MDT MB Dewasa Tablet - 39,880 39,880 - 39,880 - 39,880
11 MDT PB Dewasa Tablet - 12,569 12,569 - 12,569 - 12,569
12 MDT PB Anak Tablet - 13,300 13,300 - 13,300 - 13,300
13 Retinol (Vitamin A) kapsul 200.000 IU - 519 519 - 519 - 519
14 Retinol (Vitamin A) kapsul 100.000 IU - 505 505 - 505 - 505
15 Tablet Penambah Darah ( FE ) - 354 354 - 354 - 354
16 Amitriptilin tablet 25 mg - 167 167 - 167 - 167
17 Carbamazepin 200 mg tablet - 245 245 - 245 - 245
18 Clobazam 10 mg Tablet - 739 739 - 739 - 739
19 Clozapine 25 mg Tablet - 1,121 1,121 - 1,121 - 1,121
20 Fenitoin Natrium kapsul 30 mg - - - - - - -
21 Haloperidol 1,5 mg Tablet - 59 59 - 59 - 59
22 Haloperidol 2 mg tablet - 90 90 - 90 - 90
23 Haloperidol 5 mg Tablet - 60 60 - 60 - 60
24 Haloperidol Injeksi - 5,000 5,000 - 5,000 - 5,000
25 Klorpromazin HCL tablet salut 100 mg (cp - 157 157 - 157 - 157
26 Klorpromazine Tablet 25 mg - - - - - - -
27 Triheksilfenidil Hcl 2 mg tablet - 91 91 - 91 - 91
28 Depakote 250 mg - 990,000 990,000 - 990,000 - 990,000
29 Flufenazine (sikzonoat inj) - 63,813 63,813 - 63,813 - 63,813
30 Risperidon 2 mg - 287 287 - 287 - 287
31 DHP - 2,000 2,000 - 2,000 - 2,000
32 Primaquin - 253 253 - 253 - 253
33 HALDOL INJ - 5,000 - 5,000 - 5,000 - 5,000
34 tes malaria 4 - - - 4 - - -
B NAMA BAHAN MEDIS HABIS PAKAI (BMH - - - -
1 Alat suntik 1 ml - 777 - 777 - 777 - 777
2 Alat suntik 10 ml - 1,067 - 1,067 - 1,067 - 1,067
3 Alat suntik 2,5 ml - 649 - 649 - 649 - 649
4 Alat suntik 20 ml - 2,650 10 2,650 6 2,650 4 2,650
5 Alat suntik 3 cc (Remedi) 8 816 10 816 7 816 11 816
6 Alat suntik 3 ml - 924 - 924 - 924 - 924
7 Alat suntik 5 ml - 856 - 856 - 856 - 856
8 Alkazide 1 L High Level Desinfectant - 2,702,700 - 2,702,700 - 2,702,700 - 2,702,700
9 Alkazyme Sachet 25 mg - 801,000 1 801,000 1 801,000 - 801,000
10 Alkohol 70 % 1 L - 25,000 - 25,000 - 25,000 - 25,000
11 Alkohol swab - 29,000 - 29,000 - 29,000 - 29,000
12 Anti Septik Hand Rub 1 26,500 - 26,500 1 26,500 - 26,500
13 Anti Septik Surgikal Hand Scrub - - - - - - - -
14 Cat Gut no 2/0 - 40,200 - 40,200 - 40,200 - 40,200
15 Cat Gut no 3/0 - 38,536 - 38,536 - 38,536 - 38,536
16 Cat Gut No 3/0 (24 mm) 3 84,601 - 84,601 2 84,601 1 84,601
17 Cat Gut No 3/0 (26 mm) - 68,433 - 68,433 - 68,433 - 68,433
18 Cathetter Jelly - 41,600 - 41,600 - 41,600 - 41,600
19 Demetech Silk 3/0 - 3,825 - 3,825 - 3,825 - 3,825
20 E Care I.V Dresing - 6,850 - 6,850 - 6,850 - 6,850
21 E-Care Surgical Mask Tie On - 549 - 549 - 549 - 549
24 I.V Cathetter No. 20 - 6,600 - 6,600 - 6,600 - 6,600
25 I.V Cathetter No. 22 2 6,600 - 6,600 2 6,600 - 6,600
26 I.V Cathetter No. 24 5 7,293 - 7,293 2 7,293 3 7,293
27 I.V Cathetter No. 26 2 13,464 5 13,464 5 13,464 2 13,464
28 Infuset Anak - 8,400 - 8,400 - 8,400 - 8,400
29 Infuset Dewasa - 23,056 - 23,056 - 23,056 - 23,056
30 Jarum Insulin - 2,083 - 2,083 - 2,083 - 2,083
31 Kapas Berlemak 250 gr - 20,600 - 20,600 - 20,600 - 20,600
32 Kapas Berlemak 500 gr - - - - - - - -
33 Kasa 4 m x 10 cm - 1,440 - 1,440 - 1,440 - 1,440
34 Kasa Hidrofil 36 x 80 cm - 127,600 5 127,600 5 127,600 - 127,600
35 Kasa Pembalut 2 x 80 cm - 9,400 - 9,400 - 9,400 - 9,400
36 Kasa Steril 16 x 16 cm - 7,370 - 7,370 - 7,370 - 7,370
37 Lisol 1 L - 40,997 - 40,997 - 40,997 - 40,997
38 Masker karet Ear Loop - 15,700 - 15,700 - 15,700 - 15,700
39 Masker tali - 500 - 500 - 500 - 500
40 Nasal Canula Oksigen - - - - - - - -
41 Plester 1" 1 8,167 - 8,167 1 8,167 - 8,167
42 Plester Kertas 2,5 cm - 7,624 - 7,624 - 7,624 - 7,624
43 Plester Non Woven 5cm x 5 cm - 23,760 - 23,760 - 23,760 - 23,760
44 Policlean - 78,200 - 78,200 - 78,200 - 78,200
45 Polifik - 7,370 - 7,370 - 7,370 - 7,370
46 Saraya Alsof A 500 ml - - - - - - - -
47 Saraya Alsof Pure 500 ml 45 - - - 11 - 34 -
48 Sarung Tangan Gynecolog No 7 - 40,733 - 40,733 - 40,733 - 40,733
49 Sarung tangan M (Non Steril) - 968 - 968 - 968 - 968
50 Sarung tangan no 6,5 - 13,178 - 13,178 - 13,178 - 13,178
51 Sarung tangan no 6,5 Steril Gloves - 7,931 - 7,931 - 7,931 - 7,931
52 Sarung tangan no 7,0 Steril - - - - - - - -
53 Selang Section ( Surgikal Conection Tube - 30,003 - 30,003 - 30,003 - 30,003
54 Underpad - 7,900 - 7,900 - 7,900 - 7,900
55 Urine Bag - 7,038 - 7,038 - 7,038 - 7,038
56 safety blackblood - 204,167 - 204,167 - 204,167 - 204,167
57 safety box - 22,433 - 22,433 - 22,433 - 22,433
58 Tabung BD Vacutener - 1,690 - 1,690 - 1,690 - 1,690
59 masker n95 130,240 130,240 130,240 130,240
60 t silk black 3/0 26 mm 19,700 19,700 19,700 19,700
NAMA OBAT VAKSIN
1 Vaksin Anti Rabies ( VAR ) 78,500 78,500 78,500 78,500

2 Vaksin BCG 56,360 56,360 56,360 56,360
3 Vaksin DT 16,412 16,412 16,412 16,412
4 Vaksin HB 0 21,810 21,810 21,810 21,810
5 Vaksin HBIG 1,325,000 1,325,000 1,325,000 1,325,000
6 Vaksin Measless Rubella (MR) 141,648 141,648 141,648 141,648
7 Vaksin Pentabio ( DPT - HB - Hib ) 71,810 71,810 71,810 71,810
8 Vaksin Polio B OPV 18,140 18,140 18,140 18,140
9 Vaksin Polio IPV 144,540 144,540 144,540 144,540
10 Vaksin TD 15,450 15,450 15,450 15,450
11 Vaksin Tuberculin 625,900 625,900 625,900 625,900
12 ADS 0,05 ml 1,550 1,550 1,550 1,550
13 ADS 0,5 ml 1,185 1,185 1,185 1,185
14 ADS 5 ml 1,583 1,583 1,583 1,583
15 Safety Box 22,433 22,433 22,433 22,433
- - - -
- - - -
NAMA OBAT REAGEN - - - -
- - - -
1 Albumin (Reagen) - - - -
2 anti A Monoclonal ( GolDar 10 ml) - - - -
3 Anti A-B Monoclonal ( GolDar 10 ml) - - - -
4 Anti B Monoclonal ( GolDar 10ml) - - - -
5 Anti D Monoclonal ( GolGar 10ml) - - - -
6 Benecheck Plus Cholesterol Test - - - -
7 Benecheck Plus Glukosa Test - - - -
8 Benecheck Plus Uric Test - - - -
9 Bilirubin T/D (Reagen) - - - -
10 Brilian Green Bile Broth - - - -
11 Cellclean (CL-50) (Reagen) - - - -
12 Cellpack (PK-30L) (Reagen) - - - -
13 Chikungunya IgM (Reagen) - - - -
14 Cholesterol (Reagen) - - - -
15 Cholesterol Stik (Reagen) - - - -
16 CK-MB (Reagen) - - - -
17 Creatinin Reagen - - - -
18 Dengue IgM / IgM ( Reagen ) - - - -
19 Eight Check ( LNH ) - - - -
20 Febrile Antingen H Parathpy - - - -
21 Febrile Antingen H-A Parathpy - - - -
22 Febrile Antingen H-B Parathpy - - - -
23 Febrile Antingen H-C Parathpy - - - -
24 Febrile Antingen O Parathpy - - - -
25 Febrile Antingen O-A Parathpy - - - -
26 Febrile Antingen O-B Parathpy - - - -
27 Febrile Antingen O-C Parathpy - - - -
28 Glukosa Reagen - - - -
29 GOT ( ALAT ) - - - -
30 GPT ( ALAT ) - - - -
31 HBSAG Reagen - - - -
32 HCG Strip - - - -
33 HDL Cholesterol ( Precipitan ) - - - -
34 Hematologi Calibrator (Nscs 1000 ) - - - -
35 Hemoglobin Reagen - - - -
36 Lactose Broth 500 mg - - - -
37 LDL Cholesterol - - - -
38 Leptospira IgM (Reagen) - - - -
39 Micropippets MT-1-up to 200 ui - - - -
40 MIcropippets MT-up to 1 ml - - - -
41 NS1 Antigen Test (Reagen) - - - -
42 Pipet Ukur 10 ml - - - -
43 Poch Pack D (II) Reagen - - - -
44 Poch Pack L (II) Reagen - - - -
45 Stik Uric Acid - - - -
49 Total Protein - - - -
50 Trigleserida - - - -
51 Urea - - - -
52 Uric Acid - - - -
- - - -
NAMA OBAT REAGEN PROGRAM HIV - - - -
1 Rapid 1 HIV (SD Bioline ) 11,975 11,975 11,975 11,975
2 Rapid 2 HIV (Fokus ) 13,435 13,435 13,435 13,435
3 Rapid 3 HIV (Biomeriux Vikia ) 487,000 487,000 487,000 487,000
4 SD Biosensore Standart Q Syphlis 20,400 20,400 20,400 20,400
5 RPR Syphlis ( Fokus ) 4,120 4,120 4,120 4,120
6 Reagen CD4 Control 66,000 66,000 66,000 66,000
7 Reagen CD4 Mobile 158,400 158,400 158,400 158,400
8 RPR Syphlis Komponen 4,120 4,120 4,120 4,120
9 Anuscopy 324,951 324,951 324,951 324,951
10 Kertas PH Indikator 235,000 235,000 235,000 235,000
11 Rotator 3,885,000 3,885,000 3,885,000 3,885,000
12 Tip. Uk.60 179,200 179,200 179,200 179,200
13 Tip. Uk.61 230,600 230,600 230,600 230,600
14 Pronto / Holder 35,000 35,000 35,000 35,000
15 rapid HBSAG 7,940 7,940 7,940 7,940
NAMA OBAT GIGI - - - -
- - - -
1 Anastesi Citojek - - - -
2 Articulating Paper (Kertas warna penanda oklusi) - - - -
3 Bahan Tumpatan sementara - - - -
4 Bonding 963,600 963,600 963,600 963,600
5 Cairan Desinfectan ( Perendaman Instrumen Gigi ) - - - -
6 Cairan untuk desinfectan pembersih permukaan - - - -
7 Carpule Citojek 28,600 28,600 28,600 28,600
8 Chlorfeson Kamfer menthol ( CHKM ) Cairan - - - -
9 Composite Nanohibrid A1 251,900 251,900 251,900 251,900
12 Composite Nanohibrid A3,5 251,900 251,900 251,900 251,900
13 Devitalisasi Pasta/pulpa 260,000 260,000 260,000 260,000
14 Disclosing Solution - - - -
15 Etcing Gel 646,800 646,800 646,800 646,800
16 Etil Klorida Semprot - - - -
17 Eugenol Cairan - - - -
18 Formokesol - - - -
19 Gas Powred Jet Injector - - - -
20 Glass Ionomer Cement ART - - - -
21 Jarum citojek uk 16 mm - - - -
22 Kalsium Hidroksida pasta - - - -
23 Klorhekdidin Larutan 2 % - - - -
24 Mummifiying Fasta - - - -
25 Natrium Hipoklorit airan konsentrat 5% - - - -
26 Paper Points 15-40 mm - - - -
27 Pasta Devitalisasi ( Non Arsen ) - - - -
28 Pasta Pengisi Saluran Akar - - - -
29 Semen seng Fosfat serbuk - - - -
30 Spon Gelatin Cubicis 1x1x1 cm (Spongostan) - - - -
31 Temporary Filling Fasta - - - -
32 Tooth Stain Remover ( TSR ) - - - -
33 Wipes Desinfektan - - - -
34 caviton 165,000 165,000 165,000 165,000
35 endometason 396,000 396,000 396,000 396,000
36 fuji 9 gic 836,000 836,000 836,000 836,000
PROGRAM KB - - - -
1 iud COP T 12,500 12,500 12,500 12,500
2 susuk kB II 175,181 175,181 175,181 175,181
3 suntik kb 3 bulan 6,090 6,090 6,090 6,090
4 pil KB kombinasi 1,518 1,518 1,518 1,518
5 kondom 4,100 4,100 4,100 4,100
6 disposable 1,215 1,215 1,215 1,215
7 lidocain 860 860 860 860
8 dermafix 4,339 4,339 4,339 4,339
9 povidone - - - -
10 amoksisilin 3,300 3,300 3,300 3,300
11 asam mefenamat 2,140 2,140 2,140 2,140
12 Safety Box - - - -
13 Kasa Steril 16 x 16 cm - - - -
14 masker 20,570 20,570 20,570 20,570
15 hadnscoon 5,971 5,971 5,971 5,971
OBAT JKN
1 acylovir cream 3,169 3,169 3,169 3,169
2 alkohol 70% 50,000 50,000 50,000 50,000
3 cefadroksil tab 110,000 110,000 110,000 110,000
4 cetirizin syr 3,636 3,636 3,636 3,636
5 etil klorida spray 352,000 352,000 352,000 352,000
6 flagsol tab 26,400 26,400 26,400 26,400
7 lexigo tab 22,000 22,000 22,000 22,000
8 mecobalamin kap 88,000 88,000 88,000 88,000
9 mersibion inj 54,670 54,670 54,670 54,670
10 Metronidazol tab 500 MG 204 204 204 204
11 Metronidazol tab 500 MG 26,400 26,400 26,400 26,400
12 obh syr 4,950 4,950 4,950 4,950
13 paraflu syr 6,000 6,000 6,000 6,000
14 parasetamol inf 33,350 33,350 33,350 33,350
15 piroksikam 20 mg tab 18,480 18,480 18,480 18,480
16 propyretic suppo 105,600 105,600 105,600 105,600
17 reco 11,330 11,330 11,330 11,330
18 selkom c tab 65,000 65,000 65,000 65,000
19 sianokobalamin tab 4,000 4,000 4,000 4,000
20 trifadium tab 20,434 20,434 20,434 20,434
21 vit k1 inj 825,000 825,000 825,000 825,000
23 Ketorolac inj 20,010 20,010 20,010 20,010
24 mp 4 mg 44,000 44,000 44,000 44,000
25 parasetamol tab 16,939 16,939 16,939 16,939
26 aminofilin inj 107,998 107,998 107,998 107,998
27 ciprofloksasin tab 27,632 27,632 27,632 27,632
28 ambroksol syr 6,300 6,300 6,300 6,300
29 asam mefenamat 32,746 32,746 32,746 32,746
- - - -
- - - -
- - - -
- - - -
- - - -
B BMHP JKN
1 CARPUL CITOJET 112,000 112,000 112,000 112,000
2 CAVITON 186,490 186,490 186,490 186,490
3 CHEROPHEN 484,250 484,250 484,250 484,250
4 DEVITALISASI 87,455 87,455 87,455 87,455
5 LANSET 36,700 36,700 36,700 36,700
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) 322,000 322,000 322,000 322,000
7 SARUNG TANGAN NON STERIL M 286,364 286,364 286,364 286,364
8 GLASS IONOMER 438,182 438,182 438,182 438,182
9 SUNGKUP DEWASA 1,064,000 1,064,000 1,064,000 1,064,000
10 SUNGKUP ANAK 58,409 58,409 58,409 58,409
11 BISTURI 438,750 438,750 438,750 438,750
12 PIPET OBAT 58,409 58,409 58,409 58,409
13 PLESTER 318,182 318,182 318,182 318,182
14 SENDOK OBAT 5 ML 452,045 452,045 452,045 452,045
15 SARUNG TANGAN STERIL 193,636 193,636 193,636 193,636
16 STAIN REMOVEL 216,364 216,364 216,364 216,364
17 VASELIN 25,200 25,200 25,200 25,200
18 CHKM 96,200 96,200 96,200 96,200
19 Jely 22,000 22,000 22,000 22,000
20 disp 10 cc 150,525 150,525 150,525 150,525
21 f cath 18 11,200 11,200 11,200 11,200
22 handscoon non steril uk L 48,200 48,200 48,200 48,200
23 handscoon non steril uk M 48,200 48,200 48,200 48,200
24 handscoon steril 6,5 262,000 262,000 262,000 262,000
25 handscoon steril 7,5 262,000 262,000 262,000 262,000
26 Kertas puyer 14,365 14,365 14,365 14,365
27 Needle no 23 995 995 995 995
28 Needle no 24 995 995 995 995
29 Plastik klip besar 122,100 122,100 122,100 122,100
30 Plastik klip kecil 99,450 99,450 99,450 99,450
31 plastik klip sedang 99,450 99,450 99,450 99,450
32 Plester 5 yard x2 inci 23,625 23,625 23,625 23,625
33 Sarung tangan No M 88,000 88,000 88,000 88,000
34 Sarung tangan No S 88,000 88,000 88,000 88,000
35 Selang Oksigen Anak-anak 7,163 7,163 7,163 7,163
36 Selang Oksigen Dewasa 7,136 7,136 7,136 7,136
37 Larutan Gentian Violet 256,300 256,300 256,300 256,300
38 mukus ekstraktor 9,800 9,800 9,800 9,800
39 nasal kanul bayi 8,450 8,450 8,450 8,450
40 nesco asam urat 99,450 99,450 99,450 99,450
41 nesco gds 121,550 121,550 121,550 121,550
42 nesco kolesterol 206,550 206,550 206,550 206,550
43 pipet obat 1 ml 350,000 350,000 350,000 350,000
44 plester 306,300 306,300 306,300 306,300
45 pot urin 1,500 1,500 1,500 1,500
46 reagen goldar A 355,750 355,750 355,750 355,750
47 kertas goldar 38,675 38,675 38,675 38,675
48 Rebreathing mask O2 anak 35,100 35,100 35,100 35,100
49 Rebreathing mask O2 bayi 35,100 35,100 35,100 35,100
50 Rebreathing mask O2 dewasa 35,100 35,100 35,100 35,100
51 sendok obat 53,200 53,200 53,200 53,200
52 SOFRATULLE 175,000 175,000 175,000 175,000
53 stain removel pasta 238,000 238,000 238,000 238,000
54 suction no 8 4,000 4,000 4,000 4,000
55 sungkup bayi 25,725 25,725 25,725 25,725
56 t silk 165,750 165,750 165,750 165,750
57 tes kehamilan 88,400 88,400 88,400 88,400
58 umbilical klem 88,275 88,275 88,275 88,275
59 vaselin 9,240 9,240 9,240 9,240
60 yellow tip 193,375 193,375 193,375 193,375
61 rapid test dengue nst 1,375,000 1,375,000 1,375,000 1,375,000
62 suntik 20 cc 150,525 150,525 150,525 150,525
63 rapid test dengue 1gg 1,440,000 1,440,000 1,440,000 1,440,000
64 catgut plain 120,000 120,000 120,000 120,000
65 antiseptik 5 L 925,000 925,000 925,000 925,000
66 nesco hb 206,550 206,550 206,550 206,550
67 UNDERPAD 45,140 45,140 45,140 45,140
68 rivanol 8,500 8,500 8,500 8,500
69 povidone 105,000 105,000 105,000 105,000
70 alkohol 75,250 75,250 75,250 75,250
71 suction no 8 8,000 8,000 8,000 8,000
72 nesco gds 99,450 99,450 99,450 99,450
74 nesco asam urat 121,550 121,550 121,550 121,550
75 hcg test 88,400 88,400 88,400 88,400
76 lancet 20,909 20,909 20,909 20,909
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN LAPORAN PEMAKAIAN DAN L
PUSKESMAS

KECAMATAN : CIKEUSIK DOKUMEN NOMOR TANGGAL
KAB / KOTA : PANDEGLANG PELAPORAN BULAN / PERIODE JULI DINKES KAB/KOTA PELAPORAN BULAN / PERIODE
PROVINSI : BANTEN PERMINTAAN BULAN / PERIODE AGUSTUS GFK KAB/KOTA PERMINTAAN BULAN / PERIODE
PUSKESMAS
JULI
Jumlah
Stok
N0 NAMA OBAT SATUAN Jumlah HARGA Optimum
Stok Awal Penerimaan Pemakaian Stok Akhir n Stok AwalPenerimaan
Persediaan
BUFFER
STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 4 5
A NAMA OBAT ( 4+5 ) (6-7)
1 Alprazolam Tablet - - 0 - 0 -
2 Albendazol Tablet 400 mg Tablet - - 0 - 0 -
3 Allopurinol tablet 100 mg Tablet - - 0 - 100 - 100
4 Ambroxol sirup Botol - - 0 - 5 -
5 Ambroxol tablet 30 mg Tablet - - 0 - 0 -
6 Aminofilin Tablet 200 mg Tablet - - 0 - 0 -
7 Aminofilina injeksi 24 mg/ml - 10 ml Ampul - - 0 - 0 -
8 Amlodipin 10 mg Tablet - 50 50 0 50 50 50 50
9 Amlodipin Besilate 5 mg Tablet 120 120 70 50 50 50
10 Amoksisilin Forte sirup kering 250mg Botol - - 0 - 10 -
11 Amoksisilin Injeksi 1 gr Vial - - 0 - 0 -
12 Amoksisilin Tablet 500 mg Tablet 10 100 110 60 50 100 50 100
13 Amoksisillin kapsul 250 mg Kapsul - - 0 - 0 -
14 Amoksisillin Sirup Kering 125 mg/5 ml Botol - - 0 - 10 -
15 Ampisilin Injeksi 1 gr Vial - - 0 - 0 -
16 Analog insulin Long Acting Pen - - 0 - 0 -
17 Analog insulin Mix Acting Pen - - 0 - 0 -
18 Antalgin (Metampiron) tablet 500 mg Tablet - - 0 - 0 -
19 Antalgin (Metampiron) tablet 500 mg Tablet - - 0 - 0 -
20 Antasida DOEN suspensi Botol - 10 10 5 5 10 5 5
21 ANTASIDA DOEN Tablet Tablet 20 200 220 100 120 100 120 100
22 Anti Bakteri DOEN ( Bacitrasin ) Tube - - 0 - 0 -
23 anti hemoroid doen kombinasi supp - - 0 - 0 -
24 Antifungi DOEN Tube - - 0 - 0 -
25 Antimigren DOEN Kombinasi : Tablet - - 0 - 0 -
26 Antiparkinson DOEN tablet Kombinasi : Tablet - - 0 - 0 -
27 Antiparkinson Tablet ( Levopar ) Tablet - - 0 - 0 -
28 Aqua Pro Injeksi Vial 1 1 1 - 3 - 6
29 Artermeter injeksi Ampul - - 0 - 0 -
30 Artesunate injeksi 60 mg/ml vial - - 0 - 0 -
31 Asam Ascorbat ( Vit. C ) 50 MG Tablet 100 100 200 100 100 50 100 100
32 Asam Folat Botol - - 0 - 0 -
33 Asam Fusidat Cream Tube - - 0 - 0 -
34 Asam Klorida 0,1 N Botol - - 0 - 0 -
35 Asam Mefenamat 500 mg Tablet - 50 50 50 - 100 -
36 Asam Traneksamat Inj 5% Ampul - - - 5 -
37 Asering Botol 5 5 5 - 5 -
38 Asetosal tablet 500 mg Tablet - - - 0 -
39 Asetyl Cysteine Capsul 60 60 60 - 50 - 60
40 Asiklovir Cream 5% Tube - - 0 - 5 -
41 Asiklovir tablet 200 mg Tablet - - 0 - 50 -
42 Asiklovir tablet 400 mg Tablet - - 0 - 50 -
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Ampul - - 0 - 0 -
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Vial - - 0 - 0 -
45 Atropin Sulfat tablet 0,5 mg Tablet - - 0 - 0 -
46 Berotec Metered Aerosol 100 mg Bok - - 0 - 0 -
47 Betadine Salep Antiseptik 5 mg Tube - - 0 - 5 - 5
48 Betametason krim 0,1 % Tube - 5 5 5 - 5 - 5
49 Bisakodil Suppositoria supp - - 0 - 0 -
50 Bisoprolol 2,5 mg Tablet - - 0 - 0 -
51 Bisoprolol 5 mg Tablet - - 0 - 0 -
52 Cairan Infus KN-3B Botol - - 0 - 5 -
53 Cairan Infus Wida KDN 1 Botol - 3 3 0 3 5 3 5
54 Cairan Pembersih ( Protektor ) Botol - - 0 - 0 -
55 Captopril Tablet 12,5 mg Tablet 10 50 60 10 50 100 50 100
56 Captopril Tablet 25 mg Tablet - - 0 - 100 -
57 Cefadroxil Capsul 500 mg Capsul - - 0 - 100 -
58 Cefixime Capsul 100 mg Capsul - - 0 - 100 -
59 Cefixime Sirup Botol - - 0 - 5 -
60 Cefotaksime 1 gr Injeksi Vial - - 0 - 0 -
61 Cetirizine Capsul 50 mg Capsul 60 100 160 60 100 100 100 50
62 Cetirizine sirup 5 mg/5 ml Botol - - 0 - 5 -
63 Ciprofloxcacin 500 mg tablet Tablet - - 0 - 100 -
64 Combivent UDV 2,5 mg+0,5mg/2,5 ml Ampul - - 0 - 0 -
65 D-Artepp tablet Tablet - - 0 - 0 -
66 deksametason tab 0,5 mg Tablet 70 100 170 70 100 100 100
67 Dekstran 70 - larutan infus 6% steril Botol - - 0 - 0 -
68 Dekstrometorfan sirup Botol - - 0 - 0 -
69 Dekstrometorfan tablet 15 mg Tablet - - 0 - 0 -
70 Diazepam Rektal 0,5 mg / 2 ml supp - - 0 - 0 -
71 Diazepam tablet 2 mg Tablet - - 0 - 0 -
72 Diazepam tablet 5 mg Tablet - - 0 - 0 -
73 Difenhidramin HCL injeksi 10 mg/ml - 1mlAmpul - - 0 - 0 -
74 Digoksin tablet 0,25 mg Tablet - - 0 - 50 -
75 Diltiazem Tablet - - 0 - 0 -
76 Doksisiklin Kapsul 100 mg Capsul - - 0 - 0 -
77 Domperidon 10mg Tablet Tablet 50 100 150 50 100 100 100 100
78 Domperidon Suspensi 5 mg/ 5 ml Botol 4 10 14 7 7 5 7 5
79 Doxicyclin 500mg capsul - - 0 - 0 -
80 Efedrin HCLTablet 25 mg Tablet - - 0 - 0 -
81 Epinefrina HCL/Bitartrat Injeksi Ampul - - 0 - 0 -
82 Eritromicyn kapsul 250 mg capsul - - 0 - 0 -
83 Erytromicin kapsul 500 mg Kapsul - - 0 - 100 -
84 Erytromicin sirup 125 mg Botol - - 0 - 0 -
85 Etakridin ( Rivanol ) larutan 0,1% Botol - - 0 - 2 -
86 Etambutol 500 mg Tablet - - 0 - 0 -
87 Etanol 70 % Botol - - 0 - 2 -
88 Etil Klorida Semprot Botol - - 0 - 0 -
89 Fenitoin Natrium kapsul 30 mg Kapsul - - 0 - 0 -
90 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul - - 0 - 0 -
91 Fenobarbital tablet 30 mg Tablet - - 0 - 0 -
92 Fenoksimetil Penisilina tablet 250 mg Tablet - - 0 - 0 -
93 Fenol Gliserol tetes telinga 10 % Botol - - 0 - 0 -
94 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 Ampul - - 0 - 0 -
95 Fitomenadion (Vit.K1) tab salut gula 10 mTablet 10 10 10 - 0 -
96 Flufenazine Deconat Inj 25 mg/ml Ampul - - 0 - 0 -
97 Furosemida tablet 40 mg Tablet 40 200 240 50 190 0 190
98 Furosemide Injeksi Ampul - - 0 - 0 -
99 Garam Oralit Sachet - - 0 - 20 -
100 Gemfibrozil 300 mg Tablet - - 0 - 0 -
101 Gentamicin Injeksi Ampul 5 20 25 5 20 0 20
102 Gentamicin Salep Kulit Tube - - 0 - 0 -
103 Gentamicin Salep mata Tube - - 0 - 0 -
104 Gentamicin Tetes Mata Botol - - 0 - 0 -
105 Gentian Violet 1 % Botol - - 0 - 0 -
106 Glibenclamid tablet 5 mg Tablet - - 0 - 50 -
107 Glicerin Guaiacolat ( GG ) 100 mg Tablet - - 0 - 50 -
108 Glikazid 80 mg Tablet Tablet - - 0 - 0 -
109 Glimepiride 2 mg Tablet 30 30 30 - 0 -
110 Glukosa larutan infus 10% steril Botol - - 0 - 5 -
111 Glukosa larutan infus 5 % steril Botol - - 0 - 5 -
112 Griseofulvin tablet 500 mg, Tablet - - 0 - 100 -
113 Guaiafenesin 100 mg Tablet - - 0 - 0 -
114 Hidroklortiniazid ( HCT )Tab.25 mg Tablet - - 0 - 0 -
115 Hidrokortison krim 2,5% Tube - 3 3 3 - 5 -
116 Ibuprofen Suspensi Tablet - - 0 - 0 -
117 Ibuprofen tablet 200 mg Tablet - - 0 - 0 -
118 Ibuprofen tablet 400 mg Tablet - - 0 - 100 -
119 Imunomodulator sirup( STIMUNO) Botol - - 0 - 5 -
120 Isosorbid Dinitrat tablet sublingual 5 mg Tablet - - 0 - 50 -
121 Kalsium Glukonas Injeksi Ampul - - 0 - 0 -
122 Kalsium Laktat (Kalk) tablet 500 mg Tablet 50 200 250 100 150 100 150 100
123 Kapas Berlemak 500 mg Bungkus - - 0 - 0 -
124 Ketokonazol Kream Tube - 5 5 2 3 5 3 3
125 Ketokonazol Tablet 200 mg Tablet 40 100 140 70 70 100 70 100
126 Ketorolac inj Ampul - - 0 - 10 -
127 Kifadene tablet 20 mg Tablet - - 0 - 0 -
128 Kloramfenikol salep mata 1 % capsul - - 0 - 0 -
129 Kloramfenikol suspensi Botol 4 10 14 4 10 0 10
130 Kloramfenikol tetes telinga 3% Tube - - 0 - 5 -
131 Kloramphenicol 250 mg Capsul - - 0 - 0 -
132 Kloramphenicol 500 mg capsul - - 0 - 0 -
133 Kloramphenicol Tetes Mata Botol - - 0 - 0 -
134 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 80 100 180 100 80 100 80
135 Klorokuin tablet 150 mg Tablet - - 0 - 0 -
136 Klorpromazin HCL tablet salut 25 mg Tablet - - 0 - 0 -
137 Kombinasi (Pirimetamin 25 mg + SolfadoxTablet - - 0 - 0 -
138 Kotrimoksazol Dewasa Tablet 480 mg Tablet - 50 50 50 - 100 - 100
139 Kotrimoksazol Sirup / Suspensi Botol - - 0 - 0 -
140 Kuinin Dihidroklorida injeksi 25% - 2 ml Ampul - - 0 - 0 -
141 Kuinin Dihidroklorida injeksi 25% - 2 ml Botol - - 0 - 0 -
142 Lactobacilus serbuk Sachet - - 0 - 0 -
143 Lidocain 2%+efinefrin injeksi Ampul 10 5 15 10 5 10 5
144 Lidocain injeksi 2 ml Ampul - - 0 - 0 -
145 Lisinopril 10 mg tablet Tablet - - 0 - 0 -
146 Lisinopril 5 mg tablet Tablet - - 0 - 0 -
147 Loperamid 4 mg tablet Tablet - - 0 - 0 -
148 Lytacur Sirup Botol - - 0 - 5 -
149 Magnesium Sulfat Inj. 25 ml 20% Ampul - - 0 - 0 -
150 Metamizol 500 mg Tablet - - 0 - 0 -
151 Metformin 500 mg Tablet Tablet - 100 100 50 50 50 50 100
152 Methilprednisolon tablet 8 mg Tablet - - 0 - 50 -
153 Metilergometrin Maleat injeksi 1 ml Ampul 28 50 78 28 50 0 50
154 Metilergometrin Maleat Tablet Tablet - - 0 - 0 -
155 Metoklopramid Suspensi Botol - - 0 - 0 -
156 Metoklopramid tablet Tablet - - 0 - 0 -
157 Metronidazol 500 mg Tablet - - 0 - 0 -
158 Metronidazol infus / injeksi Botol - - 0 - 0 -
159 Metronidazol Ovula supp - - 0 - 0 -
160 Metronidazol suspensi Botol - - 0 - 0 -
161 Mikonazol kream Tube - - 0 - 0 -
162 Multivitamin Anak Sirup Botol 2 5 7 4 3 5 3 2
163 Multivitamin Dewasa Antioksidan ( BecomTablet - - 0 - 0 -
164 Natrium Diklofenak 25 mg Tablet Tablet - - 0 - 0 -
165 Natrium Diklofenak 50 mg Tablet Tablet - 100 100 50 50 100 50 100
166 Natrium Klorida Cairan Infus ( NaCL ) Botol - - 0 - 5 - 2
167 Nifedipine Tablet 10 mg Tablet - - 0 - 100 -
168 Nistatin tablet vaginal 100.000 IU/g Tube - - 0 - 0 -
169 Obat anti Diare suspensi Botol - - 0 - 0 -
170 Obat Anti Diare Tablet (Akita / Molagit ) Tablet - 100 100 50 50 100 50 100
171 Obat Batuk Flu ( Molexflu ) Tablet - - 0 - 0 -
172 Obat Batuk Hitam (OBH) Botol - - 0 - 0 -
173 Obat Batuk Sirup Herbal ( Herbacop ) Botol - 10 10 5 5 5 5
174 Ofloxsacin Tetes Telinga Tube - - 0 - 0 -
175 Oksitetrasiklin HCL salep mata 1% Botol - 25 25 5 20 0 20
176 Oksitosin injeksi 10 IU/ml - 1 ml Ampul 18 10 28 18 10 0 10
177 Omeprazol injeksi Ampul 2 2 2 - 5 -
178 Omeprazol Kapsul 20 mg capsul - - 0 - 50 -
179 Ondancentron injeksi 4 mg Ampul - - 0 - 5 -
180 Ondancentron Tablet4 mg Tablet - - 0 - 0 -
181 Paracetamol Drop 15 ml Botol 5 5 5 - 0 - 5
182 Paracetamol Sirup 120 mg/5 ml Botol 6 10 16 6 10 10 10 2
183 Parafin Dresing ( Bioplacenton Tull ) pcs - - 0 - 0 -
184 Parasetamol tablet 100 mg Tablet - - 0 - 0 -
185 Parasetamol tablet 500 mg Tablet - - 0 - 100 -
186 Permetrin Krim 5 % Tube - - 0 - 0 -
187 Pirantel Sirup Botol - - 0 - 0 -
188 Pirantel tablet 125 mg Tablet - - 0 - 0 -
189 Pirazinamid Botol - - 0 - 0 -
190 Piridoksin HCL (VIT B6) tablet 10mg Botol - 100 100 30 70 0 70
191 Piroksikam tablet 20 mg Tablet - - 0 - 0 -
192 Polikresulen Tube - - 0 - 0 -
193 Povidon lodida 10% 300 ml - - 0 - 0 -
194 Povidon lodida 10% 60 ml Tablet - - 0 - 0 -
195 Prazikuantel tablet 600 mg Botol - - 0 - 0 -
196 Prednison Tablet 5 mg Tablet - 100 100 50 50 100 50 100
197 Primakuin 15 mg Tablet - - 0 - 0 -
198 Probenesid 500 mg tablet Tablet - - 0 - 0 -
199 Prokain Benzil Penisilin 3 juta IU/vial injekAmpul - - 0 - 0 -
200 Propanolol HCL tablet 10 mg Tablet - - 0 - 0 -
201 Ranitidin injeksi Ampul - 5 5 5 - 5 -
202 Ranitidin tablet Tablet 60 100 160 60 100 100 100
203 Resperidone 2 mg tablet Tablet - - 0 - 0 -
204 Ringer Laktat cairan infus (Otsuka) - - 0 - 0 -
205 Ringer Laktat cairan infus (Widatra) Botol - 5 5 3 2 5 2 5
206 Rivanol 300 ml Botol - - 0 - 2 -
207 Salbutamol Tablet 2 mg Tablet - 50 50 50 - 100 -
208 Salbutamol tablet 4mg Tablet 60 100 160 60 100 100 100
209 Salep 2-4 Tube - - 0 - 0 -
210 Salep kombinasi cream ( Berloson ) Tube - - 0 - 0 -
211 Salicil bedak Kotak - - 0 - 0 -
212 Serum Anti Bisa Ular Polivalen Inj 50 ml Vial - - 0 - 0 -
213 Serum Anti Tetanus inj 1500 IU ( TetagamVial - - 0 - 0 -
214 Sianokobalamin Injeksi Ampul - - 0 - 0 -
215 Simvastatin 10 mg tablet Tablet - 60 60 30 30 50 30 60
216 Simvastatin 20 mg tablet Tablet - - 0 - 50 -
217 Sukralfat Suspensi Botol - - 0 - 10 -
218 Sukralfat tablet 500 mg Tablet - - 0 - 0 -
219 Suspensi Seng Insulin inj.40 IU/ml - 10 ml Tube - - 0 - 0 -
220 Temporary Stopping Fletcher serbuk & caTablet - - 0 - 0 -
221 Tetrakain HCL tetes mata 0,5% Tube - - 0 - 0 -
222 Tetrasiklin 250 mg capsul capsul - - 0 - 0 -
223 Tetrasiklin 500 mg capsul capsul - - 0 - 100 -
224 Tiamin Tablet 50 mg ( B1 ) Tablet - - 0 - 0 -
225 Ventolin Nebulizer Ampul - - 0 - 0 -
226 Vitamin B komplek Tablet 110 100 210 110 100 100 100 100
227 Zink sirup Botol - - 0 - -
228 Zink tablet 20 mg Tablet - - 0 - -
229 Deksametason inj Ampul - - 0 - -
230 Diazepam inj 5 mg/ml Ampul - - 0 - -
231 Griseofulvin 125 mcg Tablet - - 0 - -
232 Kloramfenikol SK Tube - - 0 - -
233 Nystatin tab 500.000 IU Tablet - - 0 - -
234 magnesium Sulfat Inj. 25 ml 40% ampul - - 0 - -
- - - -
- - - -
B NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - - - - -

1 Alat suntik 1 ml Pcs - - - 0 -
3 Alat suntik 2,5 ml Pcs - - - 0 -
5 Alat suntik 3 cc (Remedi) - - - 0 -
6 Alat suntik 3 ml Pcs 4 10 14 7 7 10 7 10
7 Alat suntik 5 ml pcs 11 11 0 11 10 11 10
8 Alkazide 1 L High Level Desinfectant Botol - - 0 - 0 -
9 Alkazyme Sachet 25 mg Pack - - 0 - 0 -
10 Alkohol 70 % 1 L Botol - - 0 - 1 -
11 Alkohol swab Sachet - 1 1 1 - 1 -
12 Anti Septik Hand Rub Botol - - 0 - 0 -
13 Anti Septik Surgikal Hand Scrub Botol - - 0 - 0 -
14 Cat Gut no 2/0 Sachet - - 0 - 3 -
15 Cat Gut no 3/0 Sachet - - 0 - 3 -
16 Cat Gut No 3/0 (24 mm) Sachet - - 0 - 0 -
17 Cat Gut No 3/0 (26 mm) Sachet - - 0 - 0 -
18 Cathetter Jelly Biji 1 5 6 3 3 0 3
19 Demetech Silk 3/0 Set - - 0 - 0 -
20 E Care I.V Dresing Pcs - - 0 - 0 -
21 E-Care Surgical Mask Tie On Lembar - - 0 - 0 -
22 Folly No 14 Catether pcs - - 0 - 0 -
23 Folly No 16 Catether pcs - - 0 - 0 -
24 I.V Cathetter No. 20 Set - 5 5 2 3 5 3 5
25 I.V Cathetter No. 22 Set - 5 5 5 - 5 -
26 I.V Cathetter No. 24 Set - 5 5 0 5 0 5
27 I.V Cathetter No. 26 Set - - 0 - 0 -
28 Infuset Anak Set 3 3 0 3 5 3 5
29 Infuset Dewasa Set 2 5 7 5 2 5 2 5
30 Jarum Insulin Tablet - - 0 - 0 -
31 Kapas Berlemak 250 gr Bungkus - - 0 - 0 -
32 Kapas Berlemak 500 gr Bungkus - - 0 - 0 -
33 Kasa 4 m x 10 cm Rol - - 0 - 5 -
34 Kasa Hidrofil 36 x 80 cm Rol - - 0 - 0 -
35 Kasa Pembalut 2 x 80 cm Pack - - 0 - 5 -
36 Kasa Steril 16 x 16 cm Kotak - - 0 - 10 -
37 Lisol 1 L Botol - - 0 - 0 -
38 Masker karet Ear Loop Lembar - - 0 - 10 -
39 Masker tali Tube - - 0 - 0 -
40 Nasal Canula Oksigen Set - - 0 - 0 -
41 Plester 1" Rol - - 0 - 2 -
42 Plester Kertas 2,5 cm Rol - - 0 - 3 -
43 Plester Non Woven 5cm x 5 cm Rol - - 0 - 0 - 1
44 Policlean Botol - - 0 - 0 -
45 Polifik Kotak - - 0 - 0 -
46 Saraya Alsof A 500 ml Botol - - 0 - 0 -
47 Saraya Alsof Pure 500 ml Botol - - 0 - 0 -
48 Sarung Tangan Gynecolog No 7 Pasang - - 0 - 5 -
49 Sarung tangan M (Non Steril) Pasang 34 34 0 34 10 34 50
50 Sarung tangan no 6,5 Pasang - - 0 - 5 -
51 Sarung tangan no 6,5 Steril Gloves Pasang - - 0 - 5 -
52 Sarung tangan no 7,0 Steril Pasang - - 0 - 5 -
53 Selang Section ( Surgikal Conection Tube Pcs - - 0 - 0 -
54 Underpad Lembar - 1 1 1 - 5 - 2
55 Urine Bag Biji - - 0 - 3 -
56 safety blackblood BOX - - 0 - 0 -
57 safety box BOX - - 0 - 0 -
58 Tabung BD Vacutener pcs - - 0 - 0 -
59 masker n95 box - - 0 - 0 -
60 t silk black 3/0 26 mm pcs - - - 0 - 0 -
-
OBAT JKN - - - - -
1 acylovir cream tube - - 0 - 0 -
2 alkohol 70% botol - 1 1 1 - 1 -
3 cefadroksil tab box - - 0 - 1 -
4 cetirizin syr box - - 0 - 0 -
5 etil klorida spray btl - - 0 - 0 -
6 flagsol tab box - - 0 - 0 -
7 lexigo tab box - - 0 - 0 -
8 mecobalamin kap box - - 0 - 0 -
9 mersibion inj box - - 0 - 5 -
10 Metronidazol tab 500 MG Tablet - - 0 - 100 -
11 Metronidazol tab 500 MG box - - 0 - 0 -
12 obh syr botol - - 0 - 0 -
13 paraflu syr botol - - 0 - 0 -
14 parasetamol inf botol - - 0 - 0 -
15 piroksikam 20 mg tab box - - 0 - 0 -
16 propyretic suppo box - 1 1 0 1 0 1
17 reco tube - - 0 - 0 -
18 selkom c tab box - 2 2 1 1 2 1
19 sianokobalamin tab box - - 0 - 0 -
20 trifadium tab box - - 0 - 0 -
21 vit k1 inj box - - 0 - 1 -
23 Ketorolac inj box - 1 1 1 - 1 -
24 mp 4 mg box - 1 1 0 1 0 1
25 parasetamol tab box - 7 7 2 5 0 5
26 aminofilin inj box - - 0 - 0 -
27 ciprofloksasin tab box - - 0 - 0 -
28 ambroksol syr btl - - 0 - 0 -
29 asam mefenamat box - 3 3 1 2 1 2
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
B BMHP JKN Set - - - - -
1 CARPUL CITOJET pcs - - - -
2 CAVITON pcs - - - -
3 CHEROPHEN pcs - - - -
4 DEVITALISASI pcs - - - -
5 LANSET pcs - - - -
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) pcs - - - -
7 SARUNG TANGAN NON STERIL M pcs - - - -
8 GLASS IONOMER pcs - - - -
9 SUNGKUP DEWASA pcs - - - -
10 SUNGKUP ANAK pcs - - - -
11 BISTURI pcs - - - -
12 PIPET OBAT pcs - - - -
13 PLESTER pcs - - - -
14 SENDOK OBAT 5 ML pcs - - - -
15 SARUNG TANGAN STERIL pcs - - - -
16 STAIN REMOVEL pcs - - - -
17 VASELIN pcs - - - -
18 CHKM pcs - - - -
19 Jely pcs - - - -
20 disp 10 cc pcs - - - -
21 f cath 18 pcs - - - -
22 handscoon non steril uk L pcs - - - -
23 handscoon non steril uk M pcs - - - -
24 handscoon steril 6,5 pcs - - - -
25 handscoon steril 7,5 pcs - - - -
26 Kertas puyer pcs - - - -
27 Needle no 23 pcs - - - -
28 Needle no 24 pcs - - - -
29 Plastik klip besar pcs - - - -
30 Plastik klip kecil pcs - - - -
31 plastik klip sedang pcs - - - -
32 Plester 5 yard x2 inci pcs - - - -
33 Sarung tangan No M pcs - - - -
34 Sarung tangan No S pcs - - - -
35 Selang Oksigen Anak-anak pcs - - - -
36 Selang Oksigen Dewasa pcs - - - -
37 Larutan Gentian Violet pcs - - - -
38 mukus ekstraktor pcs - - - -
39 nasal kanul bayi pcs - - - -
40 nesco asam urat pcs - - - -
41 nesco gds pcs - - - -
42 nesco kolesterol pcs - - - -
43 pipet obat 1 ml pcs - - - -
44 plester pcs - - - -
45 pot urin pcs - - - -
46 reagen goldar A pcs - - - -
47 kertas goldar pcs - - - -
48 Rebreathing mask O2 anak pcs - - - -
49 Rebreathing mask O2 bayi pcs - - - -
50 Rebreathing mask O2 dewasa pcs - - - -
51 sendok obat pcs - - - -
52 SOFRATULLE pcs - - - -
53 stain removel pasta pcs - - - -
54 suction no 8 pcs - - - -
55 sungkup bayi pcs - - - -
56 t silk pcs - - - -
57 tes kehamilan pcs - - - -
58 umbilical klem pcs - - - -
59 vaselin pcs - - - -
60 yellow tip pcs - - - -
61 rapid test dengue nst box - - - -
62 suntik 20 cc box - - - -
63 rapid test dengue 1gg box - - - -
64 catgut plain box - - - -
65 antiseptik 5 L kompan - - - -
66 nesco hb box - - - -
67 UNDERPAD pack - - - -
68 rivanol botol - - - -
69 povidone botol - - - -
70 alkohol botol - - - -
71 suction no 8 pcs - - - -
72 nesco gds box - - - -
74 nesco asam urat box - - - -
75 hcg test box - - - -
76 lancet box - - - -
YANG MENYERAHKAN MENGETAHUI YANG MEMINTA : YANG MENYERAHKAN
PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING PETUGAS OBAT PUSKESMAS
RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST RENY WIGIAWATI, A.Pt

NIP.198601142019 02 2 003 NIP.19710804 199103 2 002 NIP.- NIP.198601142019 02 2 003
APORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO ) RUTIN
PUSKESMAS

LAPORAN BULAN / PERIODE AGUSTUS DINKES KAB/KOTA
RMINTAAN BULAN / PERIODE SEPTEMBER GFK KAB/KOTA
PUSKESMAS
AGUSTUS
Jumlah
Stok
Jumlah Stok HARGA Optimum
Pemakaian n
Persediaan Akhir
BUFFER
STOK
6 7 8 9 10 11 12 13 14 15 16
( 4+5 ) (6-7)
- - 0
- - 0
100 50 50 100
- - 0
- - 0
- - 0
- - 0
100 50 50 100
50 50 - 100
- - 0
- - 0
150 100 50 100
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
10 10 - 10
220 150 70 100
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
6 3 3 5
- - 0
- - 0
200 100 100 100
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
60 60 - 100
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
5 3 2 0
5 2 3 10
- - 0
- - 0
- - 0
- - 0
8 3 5 10
- - 0
150 50 100 100
- - 0
- - 0
- - 0
- - 0
- - 0
150 50 100 100
- -
- - 0
- - 0
- - 0
100 50 50 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
200 100 100 0
12 7 5 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
190 90 100 100
- - 0
- - 0
- - 0
20 10 10 10
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- - 0
- -
- -
250 150 100 100
- -
6 3 3 5
170 70 100 100
- -
- -
- -
10 10 - 10
- -
- -
- -
- -
80 80 - 100
- -
- -
- -
100 50 50 100
- -
- -
- -
- -
5 3 2 5
- -
- -
- -
- -
- -
- -
- -
150 50 100 100
- -
50 10 40 100
- -
- -
- -
- -
- -
- -
- -
- -
5 3 2 5
- -
- -
150 100 50 100
2 2 - 5
- -
- -
- -
150 50 100 100
- -
- -
5 5 - 5
- -
20 20 - 10
10 10 - 10
- -
- -
- -
- -
5 3 2 10
12 7 5 10
- -
- -
- -
- -
- -
- -
- -
70 70 - 100
- -
- -
- -
- -
- -
150 50 100 100
- -
- -
- -
- -
- -
100 100 - 100
- -
- -
7 4 3 5
- -
- -
100 100 - 100
- -
- -
- -
- -
- -
- -
90 30 60 100
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
200 100 100 100
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
17 8 9 10
21 5 16 10
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
3 3 - 10
- -
- -
- -
- -
- -
8 4 4 10
- -
5 5 - 10
- -
8 2 6 10
7 3 4 10
- -
- -
- -
- -
- -
- -
- -
- -
- -
- 0 - 10
- -
- -
- -
1 1 - 5
- -
- -
- -
- -
- -
84 34 50 5
- -
- -
- -
- -
2 2 - 5
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
1 1 - 5
- -
1 1 - 5
- -
- -
- -
- -
1 1 - 5
5 5 - 5
- -
- -
- -
2 2 - 5
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
YANG MENYERAHKAN MENGETAHUI YANG MEMINTA :
PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING

NIP.198601142019 02 2 003 NIP.19710804 199103 2 002 NIP.-
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO )
PUSKESMAS
PUSKESMAS : CIKEUSIK/ LB
KECAMATAN : CIKEUSIK DOKUMEN NOMOR TANGGAL
KAB / KOTA : PANDEGLANG PELAPORAN BULAN / PERIODE DESEMBER DINKES KAB/KOTA
PROVINSI : BANTEN PERMINTAAN BULAN / PERIODE JANUARI GFK KAB/KOTA
PUSKESMAS
DESEMBER
Jumlah
Stok
Jumlah Permintaa PEMBERIAN JUMLAH
Optimum
N0 NAMA OBAT SATUAN Stok Awal Penerimaan Persediaa Pemakaian Stok Akhir n
n BUFFER
STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Alprazolam Tablet - 0 - 0 -
2 Albendazol Tablet 400 mg Tablet - 0 - 0 -
3 Allopurinol tablet 100 mg Tablet - 100 100 50 50
4 Ambroxol sirup Botol - 0 - 0 -
5 Ambroxol tablet 30 mg Tablet - 0 - 0 -
6 Aminofilin Tablet 200 mg Tablet - 0 - 0 -
7 Aminofilina injeksi 24 mg/ml - 10 ml Ampul - 0 - 0 -
8 Amlodipin 10 mg Tablet - 0 - 0 -
9 Amlodipin Besilate 5 mg Tablet - 0 - 0 -
10 Amoksisilin Forte sirup kering 250mg Botol - 0 - 0 -
11 Amoksisilin Injeksi 1 gr Vial - 0 - 0 -
12 Amoksisilin Tablet 500 mg Tablet 100 100 200 100 100
13 Amoksisillin kapsul 250 mg Kapsul - 0 - 0 -
14 Amoksisillin Sirup Kering 125 mg/5 ml Botol - 0 - 0 -
15 Ampisilin Injeksi 1 gr Vial - 0 - 0 -
16 Analog insulin Long Acting Pen - 0 - 0 -
17 Analog insulin Mix Acting Pen - 0 - 0 -
18 Antalgin (Metampiron) tablet 500 mg Tablet - 0 - 0 -
19 Antalgin (Metampiron) tablet 500 mg Tablet - 0 - 0 -
20 Antasida DOEN suspensi Botol - 0 - 0 -
21 ANTASIDA DOEN Tablet Tablet 50 100 150 100 50
22 Anti Bakteri DOEN ( Bacitrasin ) Tube - 0 - 0 -
23 anti hemoroid doen kombinasi supp - 0 - 0 -
24 Antifungi DOEN Tube - 0 - 0 -
25 Antimigren DOEN Kombinasi : Tablet - 0 - 0 -
26 Antiparkinson DOEN tablet Kombinasi : Tablet - 0 - 0 -
27 Antiparkinson Tablet ( Levopar ) Tablet - 0 - 0 -
28 Aqua Pro Injeksi Vial - 0 - 0 -
29 Artermeter injeksi Ampul - 0 - 0 -
30 Artesunate injeksi 60 mg/ml vial - 0 - 0 -
31 Asam Ascorbat ( Vit. C ) 50 MG Tablet - 0 - 0 -
32 Asam Folat Botol - 0 - 0 -
33 Asam Fusidat Cream Tube - 0 - 0 -
34 Asam Klorida 0,1 N Botol - 0 - 0 -
35 Asam Mefenamat 500 mg Tablet - 0 - 0 -
36 Asam Traneksamat Inj 5% Ampul - 0 - 0 -
37 Asering Botol - 0 - 0 -
38 Asetosal tablet 500 mg Tablet - 0 - 0 -
39 Asetyl Cysteine Capsul - 60 60 60 -
40 Asiklovir Cream 5% Tube - 0 - 0 -
41 Asiklovir tablet 200 mg Tablet - 0 - 0 -
42 Asiklovir tablet 400 mg Tablet - 0 - 0 -
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Ampul - 0 - 0 -
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml Vial - 0 - 0 -
45 Atropin Sulfat tablet 0,5 mg Tablet - 0 - 0 -
46 Berotec Metered Aerosol 100 mg Bok - 0 - 0 -
47 Betadine Salep Antiseptik 5 mg Tube - 0 - 0 -
48 Betametason krim 0,1 % Tube - 0 - 0 -
49 Bisakodil Suppositoria supp - 0 - 0 -
50 Bisoprolol 2,5 mg Tablet - 0 - 0 -
51 Bisoprolol 5 mg Tablet - 0 - 0 -
52 Cairan Infus KN-3B Botol - 0 - 0 -
53 Cairan Infus Wida KDN 1 Botol - 0 - 0 -
54 Cairan Pembersih ( Protektor ) Botol - 0 - 0 -
55 Captopril Tablet 12,5 mg Tablet - 100 100 50 50
56 Captopril Tablet 25 mg Tablet - 0 - 0 -
57 Cefadroxil Capsul 500 mg Capsul - 0 - 0 -
58 Cefixime Capsul 100 mg Capsul - 0 - 0 -
59 Cefixime Sirup Botol - 0 - 0 -
60 Cefotaksime 1 gr Injeksi Vial - 0 - 0 -
61 Cetirizine Capsul 50 mg Capsul - 0 - 0 -
62 Cetirizine sirup 5 mg/5 ml Botol - 0 - 0 -
63 Ciprofloxcacin 500 mg tablet Tablet - 0 - 0 -
64 Combivent UDV 2,5 mg+0,5mg/2,5 ml Ampul - 0 - 0 -
65 D-Artepp tablet Tablet - 0 - 0 -
66 deksametason tab Tablet - 100 100 50 50
67 Dekstran 70 - larutan infus 6% steril Botol - 0 - 0 -
68 Dekstrometorfan sirup Botol - 0 - 0 -
69 Dekstrometorfan tablet 15 mg Tablet - 0 - 0 -
70 Diazepam Rektal 0,5 mg / 2 ml supp - 0 - 0 -
71 Diazepam tablet 2 mg Tablet - 0 - 0 -
72 Diazepam tablet 5 mg Tablet - 0 - 0 -
73 Difenhidramin HCL injeksi 10 mg/ml - 1ml Ampul - 0 - 0 -
74 Digoksin tablet 0,25 mg Tablet - 0 - 0 -
75 Diltiazem Tablet - 0 - 0 -
76 Doksisiklin Kapsul 100 mg Capsul - 0 - 0 -
77 Domperidon 10mg Tablet Tablet - 0 - 0 -
78 Domperidon Suspensi 5 mg/ 5 ml Botol - 0 - 0 -
79 Doxicyclin 500mg capsul - 0 - 0 -
80 Efedrin HCLTablet 25 mg Tablet - 0 - 0 -
81 Epinefrina HCL/Bitartrat Injeksi Ampul - 0 - 0 -
82 Eritromicyn kapsul 250 mg capsul - 0 - 0 -
83 Erytromicin kapsul 500 mg Kapsul - 0 - 0 -
84 Erytromicin sirup 125 mg Botol - 0 - 0 -
85 Etakridin ( Rivanol ) larutan 0,1% Botol - 0 - 0 -
86 Etambutol 500 mg Tablet - 0 - 0 -
87 Etanol 70 % Botol - 0 - 0 -
88 Etil Klorida Semprot Botol - 0 - 0 -
89 Fenitoin Natrium kapsul 30 mg Kapsul - 0 - 0 -
90 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul - 0 - 0 -
91 Fenobarbital tablet 30 mg Tablet - 0 - 0 -
92 Fenoksimetil Penisilina tablet 250 mg Tablet - 0 - 0 -
93 Fenol Gliserol tetes telinga 10 % Botol - 0 - 0 -
94 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 mlAmpul - 0 - 0 -
95 Fitomenadion (Vit.K1) tab salut gula 10 mg Tablet - 0 - 0 -
96 Flufenazine Deconat Inj 25 mg/ml Ampul - 0 - 0 -
97 Furosemida tablet 40 mg Tablet - 0 - 0 -
98 Furosemide Injeksi Ampul - 0 - 0 -
99 Garam Oralit Sachet - 0 - 0 -
100 Gemfibrozil 300 mg Tablet - 0 - 0 -
101 Gentamicin Injeksi Ampul - 0 - 0 -
102 Gentamicin Salep Kulit Tube - 0 - 0 -
103 Gentamicin Salep mata Tube - 0 - 0 -
104 Gentamicin Tetes Mata Botol - 0 - 0 -
105 Gentian Violet 1 % Botol - 0 - 0 -
106 Glibenclamid tablet 5 mg Tablet - 0 - 0 -
107 Glicerin Guaiacolat ( GG ) 100 mg Tablet - 0 - 0 -
108 Glikazid 80 mg Tablet Tablet - 0 - 0 -
109 Glimepiride 2 mg Tablet - 0 - 0 -
110 Glukosa larutan infus 10% steril Botol - 0 - 0 -
111 Glukosa larutan infus 5 % steril Botol - 0 - 0 -
112 Griseofulvin tablet 500 mg, Tablet - 0 - 0 -
113 Guaiafenesin 100 mg Tablet - 0 - 0 -
114 Hidroklortiniazid ( HCT )Tab.25 mg Tablet - 0 - 0 -
115 Hidrokortison krim 2,5% Tube - 0 - 0 -
116 Ibuprofen Suspensi Tablet - 0 - 0 -
117 Ibuprofen tablet 200 mg Tablet - 0 - 0 -
118 Ibuprofen tablet 400 mg Tablet - 0 - 0 -
119 Imunomodulator sirup( STIMUNO) Botol - 0 - 0 -
120 Isosorbid Dinitrat tablet sublingual 5 mg Tablet - 0 - 0 -
121 Kalsium Glukonas Injeksi Ampul - 0 - 0 -
122 Kalsium Laktat (Kalk) tablet 500 mg Tablet - 0 - 0 -
123 Kapas Berlemak 500 mg Bungkus - 0 - 0 -
124 Ketokonazol Kream Tube - 0 - 0 -
125 Ketokonazol Tablet 200 mg Tablet - 0 - 0 -
126 Ketorolac inj Ampul - 0 - 0 -
127 Kifadene tablet 20 mg Tablet - 0 - 0 -
128 Kloramfenikol salep mata 1 % capsul - 0 - 0 -
129 Kloramfenikol suspensi Botol - 0 - 0 -
130 Kloramfenikol tetes telinga 3% Tube - 0 - 0 -
131 Kloramphenicol 250 mg Capsul - 0 - 0 -
132 Kloramphenicol 500 mg capsul - 0 - 0 -
133 Kloramphenicol Tetes Mata Botol - 0 - 0 -
134 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet - 0 - 0 -
135 Klorokuin tablet 150 mg Tablet - 0 - 0 -
136 Klorpromazin HCL tablet salut 25 mg Tablet - 0 - 0 -
137 Kombinasi (Pirimetamin 25 mg + SolfadoxinTablet - 0 - 0 -
138 Kotrimoksazol Dewasa Tablet 480 mg Tablet - 0 - 0 -
139 Kotrimoksazol Sirup / Suspensi Botol - 0 - 0 -
140 Kuinin Dihidroklorida injeksi 25% - 2 ml Ampul - 0 - 0 -
141 Kuinin Dihidroklorida injeksi 25% - 2 ml Botol - 0 - 0 -
142 Lactobacilus serbuk Sachet - 0 - 0 -
143 Lidocain 2%+efinefrin injeksi Ampul - 0 - 0 -
144 Lidocain injeksi 2 ml Ampul - 0 - 0 -
145 Lisinopril 10 mg tablet Tablet - 0 - 0 -
146 Lisinopril 5 mg tablet Tablet - 0 - 0 -
147 Loperamid 4 mg tablet Tablet - 0 - 0 -
148 Lytacur Sirup Botol - 0 - 0 -
149 Magnesium Sulfat Inj. 25 ml 20% Ampul - 0 - 0 -
150 Metamizol 500 mg Tablet - 0 - 0 -
151 Metformin 500 mg Tablet Tablet - 0 - 0 -
152 Methilprednisolon tablet 8 mg Tablet - 0 - 0 -
153 Metilergometrin Maleat injeksi 1 ml Ampul - 0 - 0 -
154 Metilergometrin Maleat Tablet Tablet 20 0 20 20 -
155 Metoklopramid Suspensi Botol - 0 - 0 -
156 Metoklopramid tablet Tablet - 0 - 0 -
157 Metronidazol 500 mg Tablet - 0 - 0 -
158 Metronidazol infus / injeksi Botol - 0 - 0 -
159 Metronidazol Ovula supp - 0 - 0 -
160 Metronidazol suspensi Botol - 0 - 0 -
161 Mikonazol kream Tube - 0 - 0 -
162 Multivitamin Anak Sirup Botol 2 0 2 2 -
163 Multivitamin Dewasa Antioksidan ( Becom cTablet - 0 - 0 -
164 Natrium Diklofenak 25 mg Tablet Tablet - 0 - 0 -
165 Natrium Diklofenak 50 mg Tablet Tablet 50 100 150 100 50
166 Natrium Klorida Cairan Infus ( NaCL ) Botol - 0 - 0 -
167 Nifedipine Tablet 10 mg Tablet - 0 - 0 -
168 Nistatin tablet vaginal 100.000 IU/g Tube - 0 - 0 -
169 Obat anti Diare suspensi Botol - 0 - 0 -
170 Obat Anti Diare Tablet (Akita / Molagit ) Tablet 50 0 50 50 -
171 Obat Batuk Flu ( Molexflu ) Tablet 1 0 1 1 -
172 Obat Batuk Hitam (OBH) Botol - 0 - 0 -
173 Obat Batuk Sirup Herbal ( Herbacop ) Botol - 0 - 0 -
174 Ofloxsacin Tetes Telinga Tube - 0 - 0 -
175 Oksitetrasiklin HCL salep mata 1% Botol - 0 - 0 -
176 Oksitosin injeksi 10 IU/ml - 1 ml Ampul 7 0 7 7 -
177 Omeprazol injeksi Ampul - 0 - 0 -
178 Omeprazol Kapsul 20 mg capsul - 0 - 0 -
179 Ondancentron injeksi 4 mg Ampul - 0 - 0 -
180 Ondancentron Tablet4 mg Tablet - 30 30 30 -
181 Paracetamol Drop 15 ml Botol - 0 - 0 -
182 Paracetamol Sirup 120 mg/5 ml Botol - 0 - 0 -
183 Parafin Dresing ( Bioplacenton Tull ) pcs - 0 - 0 -
184 Parasetamol tablet 100 mg Tablet - 0 - 0 -
185 Parasetamol tablet 500 mg Tablet - 0 - 0 -
186 Permetrin Krim 5 % Tube - 0 - 0 -
187 Pirantel Sirup Botol - 0 - 0 -
188 Pirantel tablet 125 mg Tablet - 0 - 0 -
189 Pirazinamid Botol - 0 - 0 -
190 Piridoksin HCL (VIT B6) tablet 10mg Botol - 0 - 0 -
191 Piroksikam tablet 20 mg Tablet - 0 - 0 -
192 Polikresulen Tube - 0 - 0 -
193 Povidon lodida 10% 300 ml - 0 - 0 -
194 Povidon lodida 10% 60 ml Tablet - 0 - 0 -
195 Prazikuantel tablet 600 mg Botol - 0 - 0 -
196 Prednison Tablet 5 mg Tablet - 0 - 0 -
197 Primakuin 15 mg Tablet - 0 - 0 -
198 Probenesid 500 mg tablet Tablet - 0 - 0 -
199 Prokain Benzil Penisilin 3 juta IU/vial injeksiAmpul - 0 - 0 -
200 Propanolol HCL tablet 10 mg Tablet - 0 - 0 -
201 Ranitidin injeksi Ampul - 0 - 0 -
202 Ranitidin tablet Tablet - 0 - 0 -
203 Resperidone 2 mg tablet Tablet - 0 - 0 -
204 Ringer Laktat cairan infus (Otsuka) - 0 - 0 -
205 Ringer Laktat cairan infus (Widatra) Botol - 0 - 0 -
206 Rivanol 300 ml Botol - 0 - 0 -
207 Salbutamol Tablet 2 mg Tablet 50 100 150 50 100
208 Salbutamol tablet 4mg Tablet - 0 - 0 -
209 Salep 2-4 Tube - 0 - 0 -
210 Salep kombinasi cream ( Berloson ) Tube - 0 - 0 -
211 Salicil bedak Kotak - 0 - 0 -
212 Serum Anti Bisa Ular Polivalen Inj 50 ml Vial - 0 - 0 -
213 Serum Anti Tetanus inj 1500 IU ( Tetagam )Vial - 0 - 0 -
214 Sianokobalamin Injeksi Ampul - 0 - 0 -
215 Simvastatin 10 mg tablet Tablet - 30 30 30 -
216 Simvastatin 20 mg tablet Tablet - 0 - 0 -
217 Sukralfat Suspensi Botol - 0 - 0 -
218 Sukralfat tablet 500 mg Tablet - 0 - 0 -
219 Suspensi Seng Insulin inj.40 IU/ml - 10 ml Tube - 0 - 0 -
220 Temporary Stopping Fletcher serbuk & cair Tablet - 0 - 0 -
221 Tetrakain HCL tetes mata 0,5% Tube - 0 - 0 -
222 Tetrasiklin 250 mg capsul capsul - 0 - 0 -
223 Tetrasiklin 500 mg capsul capsul - 0 - 0 -
224 Tiamin Tablet 50 mg ( B1 ) Tablet - 0 - 0 -
225 Ventolin Nebulizer Ampul - 0 - 0 -
226 Vitamin B komplek Tablet 100 100 200 100 100
227 Zink sirup Botol - 0 - 0 -
228 Zink tablet 20 mg Tablet - 0 - 0 -
229 Deksametason inj Ampul 5 0 5 5 -
230 Diazepam inj 5 mg/ml Ampul - 0 - 0 -
231 Griseofulvin 125 mcg Tablet - 0 - 0 -
232 Kloramfenikol SK Tube - 0 - 0 -
233 Nystatin tab 500.000 IU Tablet - 0 - 0 -
234 magnesium Sulfat Inj. 25 ml 40% ampul - 0 - 0 -
- - -
- - -
- - -
- - -
- - -
- - -
NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - - -
1 Alat suntik 1 ml Pcs - 0 - 0 -
3 Alat suntik 2,5 ml Pcs - 0 - 0 -
5 Alat suntik 3 cc (Remedi) - 0 - 0 -
7 Alat suntik 5 ml pcs - 0 - 0 -
8 Alkazide 1 L High Level Desinfectant Botol - 0 - 0 -
9 Alkazyme Sachet 25 mg Pack - 0 - 0 -
10 Alkohol 70 % 1 L Botol - 0 - 0 -
11 Alkohol swab Sachet - 0 - 0 -
12 Anti Septik Hand Rub Botol - 0 - 0 -
13 Anti Septik Surgikal Hand Scrub Botol - 0 - 0 -
14 Cat Gut no 2/0 Sachet - 0 - 0 -
15 Cat Gut no 3/0 Sachet - 0 - 0 -
16 Cat Gut No 2/0 (24 mm) Sachet - 0 - 0 -
17 Cat Gut No 3/0 (26 mm) Sachet - 0 - 0 -
18 Cathetter Jelly Biji - 0 - 0 -
19 Demetech Silk 3/0 Set - 0 - 0 -
20 E Care I.V Dresing Pcs - 0 - 0 -
21 E-Care Surgical Mask Tie On Lembar - 0 - 0 -
22 Folly No 14 Catether pcs - 0 - 0 -
23 Folly No 16 Catether pcs - 0 - 0 -
24 I.V Cathetter No. 20 Set - 0 - 0 -
28 Infuset Anak Set - 0 - 0 -
29 Infuset Dewasa Set - 0 - 0 -
30 Jarum Insulin Tablet - 0 - 0 -
31 Kapas Berlemak 250 gr Bungkus - 0 - 0 -
32 Kapas Berlemak 500 gr Bungkus - 0 - 0 -
33 Kasa 4 m x 10 cm Rol - 0 - 0 -
34 Kasa Hidrofil 36 x 80 cm Rol - 0 - 0 -
35 Kasa Pembalut 2 x 80 cm Pack - 0 - 0 -
36 Kasa Steril 16 x 16 cm Kotak - 0 - 0 -
37 Lisol 1 L Botol - 0 - 0 -
38 Masker karet Ear Loop Lembar - 0 - 0 -
39 Masker tali Tube - 0 - 0 -
40 Nasal Canula Oksigen Set - 0 - 0 -
41 Plester 1" Rol - 0 - 0 -
42 Plester Kertas 2,5 cm Rol - 0 - 0 -
43 Plester Non Woven 5cm x 5 cm Rol - 0 - 0 -
44 Policlean Botol - 0 - 0 -
45 Polifik Kotak - 0 - 0 -
46 Saraya Alsof A 500 ml Botol - 0 - 0 -
47 Saraya Alsof Pure 500 ml Botol - 0 - 0 -
48 Sarung Tangan Gynecolog No 7 Pasang - 0 - 0 -
49 Sarung tangan M (Non Steril) Pasang - 0 - 0 -
50 Sarung tangan no 6,5 Pasang - 0 - 0 -
51 Sarung tangan no 6,5 Steril Gloves Pasang - 0 - 0 -
52 Sarung tangan no 7,0 Steril Pasang - 0 - 0 -
53 Selang Section ( Surgikal Conection Tube wPcs - 0 - 0 -
54 Underpad Lembar 1 0 1 1 -
55 Urine Bag Biji - 0 - 0 -
56 safety blackblood BOX - 0 - 0 -
57 safety box BOX - 0 - 0 -
58 Tabung BD Vacutener pcs - 0 - 0 -
59 masker n95 box - 0 - 0 -
60 t silk black 3/0 26 mm pcs - 0 - 0 -
61 ALAT SUNTIK 1 ML BOX - 0 - 0 -
62 alat suntik 3 ml box - 0 - 0 -
- - -
OBAT JKN - - -
1 acylovir cream tube - 0 - 0 -
2 alkohol 70% botol - 0 - 0 -
3 cefadroksil tab box - 0 - 0 -
4 cetirizin syr box - 0 - 0 -
5 etil klorida spray btl - 0 - 0 -
6 flagsol tab box - 0 - 0 -
7 lexigo tab box - 0 - 0 -
8 mecobalamin kap box - 0 - 0 -
9 mersibion inj box - 0 - 0 -
10 Metronidazol tab 500 MG Tablet - 0 - 0 -
11 Metronidazol tab 500 MG box - 0 - 0 -
12 obh syr botol - 0 - 0 -
13 paraflu syr botol - 0 - 0 -
14 parasetamol inf botol - 0 - 0 -
15 piroksikam 20 mg tab box - 0 - 0 -
16 propyretic suppo box - 0 - 0 -
17 reco tube - 0 - 0 -
18 selkom c tab box - 0 - 0 -
19 sianokobalamin tab box - 0 - 0 -
20 trifadium tab box - 0 - 0 -
21 vit k1 inj box - 0 - 0 -
22 Ketorolac inj box - 0 - 0 -
23 mp 4 mg box - 0 - 0 -
24 parasetamol tab box - 0 - 0 -
25 aminofilin inj box - 0 - 0 -
26 ciprofloksasin tab box - 0 - 0 -
27 ambroksol syr btl - 0 - 0 -
28 asam mefenamat box - 0 - 0 -
29 Acyclovir 200 mg box - 0 - 0 -
30 Acyclovir 400 mg box - 0 - 0 -
31 Ciprofloxacin 500 mg box - 0 - 0 -
32 GLUKOSA 5% BOTOL - 0 - 0 -
33 glukosa 10% BOTOL - 0 - 0 -
34 SIANOKOBALAMIN INJ 500 mg box - 0 - 0 -
35 asam folat 400 mcg box - 0 - 0 -
36 AMBROKSOL SYR BOTOL - 0 - 0 -
37 asam tranexamat inj box - 0 - 0 -
38 Bedak Salicyl 2% box - 0 - 0 -
39 Cefadroxil 500 mg box 1 0 1 1 -
40 Cetirizine syr BOTOL - 0 - 0 -
41 d40 BOTOL - 0 - 0 -
42 Guanistrep syr BOTOL - 0 - 0 -
43 IBUPROFEN 400 mg box - 0 - 0 -
44 kloramfenikol tetes mata TUBE - 0 - 0 -
45 Mecobalamin 500 Mg Tab box - 0 - 0 -
46 metronidazol syr BOTOL - 0 - 0 -
47 Metronidazole 500 mg box 1 0 1 1 -
48 Ondansetron inj 4 mg BOX - 0 - 0 -
49 Paraflu Sirup BOTOL - 0 - 0 -
50 parasetamol syr BOTOL - 0 - 0 -
51 ranitidin tab 50 mg box 1 0 1 1 -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
BMHP JKN Set - - -
1 CARPUL CITOJET pcs - 0 - 0 -
2 CAVITON pcs - 0 - 0 -
3 CHEROPHEN pcs - 0 - 0 -
4 DEVITALISASI pcs - 0 - 0 -
5 LANSET pcs - 0 - 0 -
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) pcs - 0 - 0 -
7 SARUNG TANGAN NON STERIL M pcs - 0 - 0 -
8 GLASS IONOMER pcs - 0 - 0 -
9 SUNGKUP DEWASA pcs - 0 - 0 -
10 SUNGKUP ANAK pcs - 0 - 0 -
11 BISTURI pcs - 0 - 0 -
12 PIPET OBAT pcs - 0 - 0 -
13 PLESTER pcs - 0 - 0 -
14 SENDOK OBAT 5 ML pcs - 0 - 0 -
15 SARUNG TANGAN STERIL pcs - 0 - 0 -
16 STAIN REMOVEL pcs - 0 - 0 -
17 VASELIN pcs - 0 - 0 -
18 CHKM pcs - 0 - 0 -
19 Jely pcs - 0 - 0 -
20 disp 10 cc pcs - 0 - 0 -
21 f cath 18 pcs - 0 - 0 -
22 handscoon non steril uk L pcs - 0 - 0 -
23 handscoon non steril uk M pcs - 0 - 0 -
24 handscoon steril 6,5 pcs - 0 - 0 -
25 handscoon steril 7,5 pcs - 0 - 0 -
26 Kertas puyer pcs - 0 - 0 -
27 Needle no 23 pcs - 0 - 0 -
28 Needle no 24 pcs - 0 - 0 -
29 Plastik klip besar pcs - 0 - 0 -
30 Plastik klip kecil pcs - 0 - 0 -
31 plastik klip sedang pcs - 0 - 0 -
32 Plester 5 yard x2 inci pcs - 0 - 0 -
33 Sarung tangan No M pcs - 0 - 0 -
34 Sarung tangan No S pcs - 0 - 0 -
35 Selang Oksigen Anak-anak pcs - 0 - 0 -
36 Selang Oksigen Dewasa pcs - 0 - 0 -
37 Larutan Gentian Violet pcs - 0 - 0 -
38 mukus ekstraktor pcs - 0 - 0 -
39 nasal kanul bayi pcs - 0 - 0 -
40 nesco asam urat pcs - 0 - 0 -
41 nesco gds pcs - 0 - 0 -
42 nesco kolesterol pcs - 0 - 0 -
43 pipet obat 1 ml pcs - 0 - 0 -
44 plester pcs - 0 - 0 -
45 pot urin pcs - 0 - 0 -
46 reagen goldar A pcs - 0 - 0 -
47 kertas goldar pcs - 0 - 0 -
48 Rebreathing mask O2 anak pcs - 0 - 0 -
49 Rebreathing mask O2 bayi pcs - 0 - 0 -
50 Rebreathing mask O2 dewasa pcs - 0 - 0 -
51 sendok obat pcs - 0 - 0 -
52 SOFRATULLE pcs - 0 - 0 -
53 stain removel pasta pcs - 0 - 0 -
54 suction no 8 pcs - 0 - 0 -
55 sungkup bayi pcs - 0 - 0 -
56 t silk pcs - 0 - 0 -
57 tes kehamilan pcs - 0 - 0 -
58 umbilical klem pcs - 0 - 0 -
59 vaselin pcs - 0 - 0 -
60 yellow tip pcs - 0 - 0 -
61 rapid test dengue nst box - 0 - 0 -
62 suntik 20 cc box - 0 - 0 -
63 rapid test dengue 1gg box - 0 - 0 -
64 catgut plain box - 0 - 0 -
65 antiseptik 5 L kompan - 0 - 0 -
66 nesco hb box - 0 - 0 -
67 UNDERPAD pack - 0 - 0 -
68 rivanol botol - 0 - 0 -
69 povidone botol - 0 - 0 -
70 alkohol botol 1 0 1 1 -
71 suction no 8 pcs - 0 - 0 -
72 nesco gds box - 0 - 0 -
73 nesco asam urat box - 0 - 0 -
74 hcg test box - 0 - 0 -
75 lancet box - 0 - 0 -
76 IV CATHETER no 26 Pcs - 0 - 0 -
77 MASKER EARLOOP Box - 0 - 0 -
78 OIL IMMERSI Botol - 0 - 0 -
79 OKSIGEN MASKER STANDAR BAYI pcs - 0 - 0 -
80 OKSIGEN MASKER STANDAR ANAK pcs - 0 - 0 -
81 OKSIGEN MASKER STANDAR DEWASA pcs - 0 - 0 -
82 OXYGEN NASAL CANNULA NEONATUS Pcs - 0 - 0 -
83 PLASTIK KLIP SEDANG 13x8,7 CM Pack - 0 - 0 -
84 PROTEIN URIN VERIFY botol - 0 - 0 -
85 REAGEN GOLDAR Botol - 0 - 0 -
86 SENDOK OBAT 5ML Pack - 0 - 0 -
87 STRIP CHOLESTEROL Botol - 0 - 0 -
88 STRIP GULA DARAH Botol - 0 - 0 -
89 STRIP HB Botol - 0 - 0 -
90 SUNGKUP ANAK NEBU pcs - 0 - 0 -
91 SUNGKUP BAYI NEBU pcs - 0 - 0 -
92 SUNGKUP DEWASA NEBU pcs - 0 - 0 -
93 UMBILICAL KLEM Box - 0 - 0 -
- - -
YANG MENYERAHKAN YANG MENYERAHKAN MENGETAHUI YANG MEMINTA :

PETUGAS OBAT PUSKESMAS PETUGAS OBAT PUSKESMAS KEPALA PUSKESMAS PETUGAS PUSTU/POSKEDES/PUSLING
RENY WIGIAWATI, A.Pt RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

NIP.198601142019 02 2 003 NIP.19710804 199103 2 002 NIP.-
Nama Puskesmas : PKM CIKEUSIK/RANCASENENG

Bulan : DESEMBER
No Uraian Harga per Unit Harga per Unit Harga per Unit
Jumlah satuan Jumlah (Rp) Jumlah satuan Jumlah (Rp) Jumlah satuan Harga per Unit (Rp) Jumlah (Rp) Jumlah satuan Jumlah (Rp)
(Rp) (Rp) (Rp)
1 Alprazolam - - - - - - - - - - - -
2 Albendazol Tablet 400 mg - 407 - - 407 - - 407 - - 407 -
3 Allopurinol tablet 100 mg - 105 - 100 105 10,500 50 105 5,250 50 105 5,250
4 Ambroxol sirup - 3,300 - - 3,300 - - 3,300 - - 3,300 -
5 Ambroxol tablet 30 mg - - - - - - - - - - - -
6 Aminofilin Tablet 200 mg - 91 - - 91 - - 91 - - 91 -
7 Aminofilina injeksi 24 mg/ml - 10 ml - 3,345 - - 3,345 - - 3,345 - - 3,345 -
8 Amlodipin 10 mg - 93 - - 93 - - 93 - - 93 -
9 Amlodipin Besilate 5 mg - 70 - - 70 - - 70 - - 70 -
10 Amoksisilin Forte sirup kering 250mg - 3,050 - - 3,050 - - 3,050 - - 3,050 -
11 Amoksisilin Injeksi 1 gr - 5,368 - - 5,368 - - 5,368 - - 5,368 -
12 Amoksisilin Tablet 500 mg 100 249 24,900 100 249 24,900 100 249 24,900 100 249 24,900
13 Amoksisillin kapsul 250 mg - - - - - - - - - - - -
14 Amoksisillin Sirup Kering 125 mg/5 ml - 5,500 - - 5,500 - - 5,500 - - 5,500 -
15 Ampisilin Injeksi 1 gr - 10,300 - - 10,300 - - 10,300 - - 10,300 -
16 Analog insulin Long Acting - - - - - - - - - - - -
17 Analog insulin Mix Acting - - - - - - - - - - - -
18 Antalgin (Metampiron) tablet 500 mg - 305 - - 305 - - 305 - - 305 -
19 Antalgin (Metampiron) tablet 500 mg - 305 - - 305 - - 305 - - 305 -
20 Antasida DOEN suspensi - 2,129 - - 2,129 - - 2,129 - - 2,129 -
21 ANTASIDA DOEN Tablet 50 58 2,900 100 58 5,800 100 58 5,800 50 58 2,900
22 Anti Bakteri DOEN ( Bacitrasin ) - 3,035 - - 3,035 - - 3,035 - - 3,035 -
23 anti hemoroid doen kombinasi - 3,167 - - 3,167 - - 3,167 - - 3,167 -
24 Antifungi DOEN - - - - - - - - - - - -
25 Antimigren DOEN Kombinasi : - 173 - - 173 - - 173 - - 173 -
26 Antiparkinson DOEN tablet Kombinasi : - - - - - - - - - - - -
27 Antiparkinson Tablet ( Levopar ) - - - - - - - - - - - -
28 Aqua Pro Injeksi - - - - - - - - - - - -
29 Artermeter injeksi - 1,000 - - 1,000 - - 1,000 - - 1,000 -
30 Artesunate injeksi 60 mg/ml - - - - - - - - - - - -
31 Asam Ascorbat ( Vit. C ) 50 MG - 105 - - 105 - - 105 - - 105 -
32 Asam Folat - 55 - - 55 - - 55 - - 55 -
33 Asam Fusidat Cream - 5,506 - - 5,506 - - 5,506 - - 5,506 -
34 Asam Klorida 0,1 N - - - - - - - - - - - -
35 Asam Mefenamat 500 mg - 103 - - 103 - - 103 - - 103 -
36 Asam Traneksamat Inj 5% - 1,748 - - 1,748 - - 1,748 - - 1,748 -
37 Asering - 9,646 - - 9,646 - - 9,646 - - 9,646 -
38 Asetosal tablet 500 mg - - - - - - - - - - - -
39 Asetyl Cysteine - 382 - 60 382 22,920 60 382 22,920 - 382 -
40 Asiklovir Cream 5% - 8,800 - - 8,800 - - 8,800 - - 8,800 -
41 Asiklovir tablet 200 mg - 236 - - 236 - - 236 - - 236 -
42 Asiklovir tablet 400 mg - 380 - - 380 - - 380 - - 380 -
43 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - 1,639 - - 1,639 - - 1,639 - - 1,639 -
44 Atropin Sulfat injeksi 0,25 mg/ml-1 ml - - - - - - - - - - - -
45 Atropin Sulfat tablet 0,5 mg - - - - - - - - - - - -
46 Berotec Metered Aerosol 100 mg - 80,000 - - 80,000 - - 80,000 - - 80,000 -
47 Betadine Salep Antiseptik 5 mg - 7,083 - - 7,083 - - 7,083 - - 7,083 -
48 Betametason krim 0,1 % - 1,340 - - 1,340 - - 1,340 - - 1,340 -
49 Bisakodil Suppositoria - 5,800 - - 5,800 - - 5,800 - - 5,800 -
50 Bisoprolol 2,5 mg - 650 - - 650 - - 650 - - 650 -
51 Bisoprolol 5 mg - 263 - - 263 - - 263 - - 263 -
52 Cairan Infus KN-3B - 10,696 - - 10,696 - - 10,696 - - 10,696 -
53 Cairan Infus Wida KDN 1 - 1,007 - - 1,007 - - 1,007 - - 1,007 -
54 Cairan Pembersih ( Protektor ) - 22,000 - - 22,000 - - 22,000 - - 22,000 -
55 Captopril Tablet 12,5 mg - 66 - 100 66 6,600 50 66 3,300 50 66 3,300
56 Captopril Tablet 25 mg - 72 - - 72 - - 72 - - 72 -
57 Cefadroxil Capsul 500 mg - 516 - - 516 - - 516 - - 516 -
58 Cefixime Capsul 100 mg - 590 - - 590 - - 590 - - 590 -
59 Cefixime Sirup - 7,490 - - 7,490 - - 7,490 - - 7,490 -
60 Cefotaksime 1 gr Injeksi - 4,200 - - 4,200 - - 4,200 - - 4,200 -
61 Cetirizine Capsul 50 mg - 90 - - 90 - - 90 - - 90 -
62 Cetirizine sirup 5 mg/5 ml - 2,849 - - 2,849 - - 2,849 - - 2,849 -
63 Ciprofloxcacin 500 mg tablet - 265 - - 265 - - 265 - - 265 -
64 Combivent UDV 2,5 mg+0,5mg/2,5 ml - 4,550 - - 4,550 - - 4,550 - - 4,550 -
65 D-Artepp tablet - - - - - - - - - - - -
66 deksametason tab - 77 - 100 77 7,700 50 77 3,850 50 77 3,850
67 Dekstran 70 - larutan infus 6% steril - - - - - - - - - - - -
68 Dekstrometorfan sirup - - - - - - - - - - - -
69 Dekstrometorfan tablet 15 mg - - - - - - - - - - - -
70 Diazepam Rektal 0,5 mg / 2 ml - 12,573 - - 12,573 - - 12,573 - - 12,573 -
71 Diazepam tablet 2 mg - - - - - - - - - - - -
72 Diazepam tablet 5 mg - 109 - - 109 - - 109 - - 109 -
73 Difenhidramin HCL injeksi 10 mg/ml - 1ml - 1,176 - - 1,176 - - 1,176 - - 1,176 -
74 Digoksin tablet 0,25 mg - 105 - - 105 - - 105 - - 105 -
75 Diltiazem - - - - - - - - - - - -
76 Doksisiklin Kapsul 100 mg - 264 - - 264 - - 264 - - 264 -
77 Domperidon 10mg Tablet - 91 - - 91 - - 91 - - 91 -
78 Domperidon Suspensi 5 mg/ 5 ml - 2,700 - - 2,700 - - 2,700 - - 2,700 -
79 Doxicyclin 500mg - - - - - - - - - - - -
80 Efedrin HCLTablet 25 mg - - - - - - - - - - - -
81 Epinefrina HCL/Bitartrat Injeksi - 1,408 - - 1,408 - - 1,408 - - 1,408 -
82 Eritromicyn kapsul 250 mg - 583 - - 583 - - 583 - - 583 -
83 Erytromicin kapsul 500 mg - - - - - - - - - - - -
84 Erytromicin sirup 125 mg - - - - - - - - - - - -
85 Etakridin ( Rivanol ) larutan 0,1% - 2,992 - - 2,992 - - 2,992 - - 2,992 -
86 Etambutol 500 mg - - - - - - - - - - - -
87 Etanol 70 % - - - - - - - - - - - -
88 Etil Klorida Semprot - 137,500 - - 137,500 - - 137,500 - - 137,500 -
89 Fenitoin Natrium kapsul 30 mg - - - - - - - - - - - -
90 Fenobarbital injeksi 50 mg/ml - 2 ml - 1,740 - - 1,740 - - 1,740 - - 1,740 -
91 Fenobarbital tablet 30 mg - 171 - - 171 - - 171 - - 171 -
92 Fenoksimetil Penisilina tablet 250 mg - - - - - - - - - - - -
93 Fenol Gliserol tetes telinga 10 % - 2,764 - - 2,764 - - 2,764 - - 2,764 -
94 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 ml - 3,550 - - 3,550 - - 3,550 - - 3,550 -
95 Fitomenadion (Vit.K1) tab salut gula 10 mg - 710 - - 710 - - 710 - - 710 -
96 Flufenazine Deconat Inj 25 mg/ml - 57,500 - - 57,500 - - 57,500 - - 57,500 -
97 Furosemida tablet 40 mg - 82 - - 82 - - 82 - - 82 -
98 Furosemide Injeksi - - - - - - - - - - - -
99 Garam Oralit - 260 - - 260 - - 260 - - 260 -
100 Gemfibrozil 300 mg - 380 - - 380 - - 380 - - 380 -
101 Gentamicin Injeksi - 1,010 - - 1,010 - - 1,010 - - 1,010 -
102 Gentamicin Salep Kulit - 2,800 - - 2,800 - - 2,800 - - 2,800 -
103 Gentamicin Salep mata - 4,232 - - 4,232 - - 4,232 - - 4,232 -
104 Gentamicin Tetes Mata - 4,232 - - 4,232 - - 4,232 - - 4,232 -
105 Gentian Violet 1 % - - - - - - - - - - - -
106 Glibenclamid tablet 5 mg - 119 - - 119 - - 119 - - 119 -
107 Glicerin Guaiacolat ( GG ) 100 mg - - - - - - - - - - - -
108 Glikazid 80 mg Tablet - 235 - - 235 - - 235 - - 235 -
109 Glimepiride 2 mg - 207 - - 207 - - 207 - - 207 -
110 Glukosa larutan infus 10% steril - - - - - - - - - - - -
111 Glukosa larutan infus 5 % steril - 6,900 - - 6,900 - - 6,900 - - 6,900 -
112 Griseofulvin tablet 500 mg, - 906 - - 906 - - 906 - - 906 -
113 Guaiafenesin 100 mg - 132 - - 132 - - 132 - - 132 -
114 Hidroklortiniazid ( HCT )Tab.25 mg - 155 - - 155 - - 155 - - 155 -
115 Hidrokortison krim 2,5% - 2,475 - - 2,475 - - 2,475 - - 2,475 -
116 Ibuprofen Suspensi - - - - - - - - - - - -
117 Ibuprofen tablet 200 mg - 105 - - 105 - - 105 - - 105 -
118 Ibuprofen tablet 400 mg - - - - - - - - - - - -
119 Imunomodulator sirup( STIMUNO) - 23,540 - - 23,540 - - 23,540 - - 23,540 -
120 Isosorbid Dinitrat tablet sublingual 5 mg - 89 - - 89 - - 89 - - 89 -
121 Kalsium Glukonas Injeksi - 4,800 - - 4,800 - - 4,800 - - 4,800 -
122 Kalsium Laktat (Kalk) tablet 500 mg - 63 - - 63 - - 63 - - 63 -
123 Kapas Berlemak 500 mg - - - - - - - - - - - -
124 Ketokonazol Kream - 2,518 - - 2,518 - - 2,518 - - 2,518 -
125 Ketokonazol Tablet 200 mg - 270 - - 270 - - 270 - - 270 -
126 Ketorolac inj - 1,045 - - 1,045 - - 1,045 - - 1,045 -
127 Kifadene tablet 20 mg - - - - - - - - - - - -
128 Kloramfenikol salep mata 1 % - 1,881 - - 1,881 - - 1,881 - - 1,881 -
129 Kloramfenikol suspensi - 5,015 - - 5,015 - - 5,015 - - 5,015 -
130 Kloramfenikol tetes telinga 3% - - - - - - - - - - - -
131 Kloramphenicol 250 mg - 310 - - 310 - - 310 - - 310 -
132 Kloramphenicol 500 mg - 1,163 - - 1,163 - - 1,163 - - 1,163 -
133 Kloramphenicol Tetes Mata - - - - - - - - - - - -
134 Klorfeniramin Maleat (CTM) tablet 4 mg - 60 - - 60 - - 60 - - 60 -
135 Klorokuin tablet 150 mg - - - - - - - - - - - -
136 Klorpromazin HCL tablet salut 25 mg - - - - - - - - - - - -
137 Kombinasi (Pirimetamin 25 mg + Solfadoxin - - - - - - - - - - - -
138 Kotrimoksazol Dewasa Tablet 480 mg - 133 - - 133 - - 133 - - 133 -
139 Kotrimoksazol Sirup / Suspensi - 2,190 - - 2,190 - - 2,190 - - 2,190 -
140 Kuinin Dihidroklorida injeksi 25% - 2 ml - - - - - - - - - - - -
141 Kuinin Dihidroklorida injeksi 25% - 2 ml - - - - - - - - - - - -
142 Lactobacilus serbuk - 14,707 - - 14,707 - - 14,707 - - 14,707 -
143 Lidocain 2%+efinefrin injeksi - 1,229 - - 1,229 - - 1,229 - - 1,229 -
144 Lidocain injeksi 2 ml - 1,140 - - 1,140 - - 1,140 - - 1,140 -
145 Lisinopril 10 mg tablet - 448 - - 448 - - 448 - - 448 -
146 Lisinopril 5 mg tablet - 375 - - 375 - - 375 - - 375 -
147 Loperamid 4 mg tablet - 85 - - 85 - - 85 - - 85 -
148 Lytacur Sirup - - - - - - - - - - - -
149 Magnesium Sulfat Inj. 25 ml 20% - 3,328 - - 3,328 - - 3,328 - - 3,328 -
150 Metamizol 500 mg - 473 - - 473 - - 473 - - 473 -
151 Metformin 500 mg Tablet - 102 - - 102 - - 102 - - 102 -
152 Methilprednisolon tablet 8 mg - - - - - - - - - - - -
153 Metilergometrin Maleat injeksi 1 ml - 2,550 - - 2,550 - - 2,550 - - 2,550 -
154 Metilergometrin Maleat Tablet 20 224 4,480 - 224 - 20 224 4,480 - 224 -
155 Metoklopramid Suspensi - 2,345 - - 2,345 - - 2,345 - - 2,345 -
156 Metoklopramid tablet - - - - - - - - - - - -
157 Metronidazol 500 mg - - - - - - - - - - - -
158 Metronidazol infus / injeksi - - - - - - - - - - - -
159 Metronidazol Ovula - 4,100 - - 4,100 - - 4,100 - - 4,100 -
160 Metronidazol suspensi - 3,799 - - 3,799 - - 3,799 - - 3,799 -
161 Mikonazol kream - 3,414 - - 3,414 - - 3,414 - - 3,414 -
162 Multivitamin Anak Sirup 2 9,900 19,800 - 9,900 - 2 9,900 19,800 - 9,900 -
163 Multivitamin Dewasa Antioksidan ( Becom c ) - 1,440 - - 1,440 - - 1,440 - - 1,440 -
164 Natrium Diklofenak 25 mg Tablet - - - - - - - - - - - -
165 Natrium Diklofenak 50 mg Tablet 50 123 6,150 100 123 12,300 100 123 12,300 50 123 6,150
166 Natrium Klorida Cairan Infus ( NaCL ) - 6,840 - - 6,840 - - 6,840 - - 6,840 -
167 Nifedipine Tablet 10 mg - - - - - - - - - - - -
168 Nistatin tablet vaginal 100.000 IU/g - 598 - - 598 - - 598 - - 598 -
169 Obat anti Diare suspensi - - - - - - - - - - - -
170 Obat Anti Diare Tablet (Akita / Molagit ) 50 145 7,250 - 145 - 50 145 7,250 - 145 -
171 Obat Batuk Flu ( Molexflu ) 1 64,900 64,900 - 64,900 - 1 64,900 64,900 - 64,900 -
172 Obat Batuk Hitam (OBH) - - - - - - - - - - - -
173 Obat Batuk Sirup Herbal ( Herbacop ) - 12,100 - - 12,100 - - 12,100 - - 12,100 -
174 Ofloxsacin Tetes Telinga - - - - - - - - - - - -
175 Oksitetrasiklin HCL salep mata 1% - 12,700 - - 12,700 - - 12,700 - - 12,700 -
176 Oksitosin injeksi 10 IU/ml - 1 ml 7 - - - - - 7 - - - - -
177 Omeprazol injeksi - 9,898 - - 9,898 - - 9,898 - - 9,898 -
178 Omeprazol Kapsul 20 mg - 130 - - 130 - - 130 - - 130 -
179 Ondancentron injeksi 4 mg - 1,070 - - 1,070 - - 1,070 - - 1,070 -
180 Ondancentron Tablet4 mg - 385 - 30 385 11,550 30 385 11,550 - 385 -
181 Paracetamol Drop 15 ml - 6,649 - - 6,649 - - 6,649 - - 6,649 -
182 Paracetamol Sirup 120 mg/5 ml - 1,181 - - 1,181 - - 1,181 - - 1,181 -
183 Parafin Dresing ( Bioplacenton Tull ) - - - - - - - - - - - -
184 Parasetamol tablet 100 mg - - - - - - - - - - - -
185 Parasetamol tablet 500 mg - 132 - - 132 - - 132 - - 132 -
186 Permetrin Krim 5 % - 11,825 - - 11,825 - - 11,825 - - 11,825 -
187 Pirantel Sirup - 9,700 - - 9,700 - - 9,700 - - 9,700 -
188 Pirantel tablet 125 mg - 291 - - 291 - - 291 - - 291 -
189 Pirazinamid - - - - - - - - - - - -
190 Piridoksin HCL (VIT B6) tablet 10mg - 131 - - 131 - - 131 - - 131 -
191 Piroksikam tablet 20 mg - - - - - - - - - - - -
192 Polikresulen - - - - - - - - - - - -
193 Povidon lodida 10% 300 ml - 17,996 - - 17,996 - - 17,996 - - 17,996 -
194 Povidon lodida 10% 60 ml - 6,550 - - 6,550 - - 6,550 - - 6,550 -
195 Prazikuantel tablet 600 mg - - - - - - - - - - - -
196 Prednison Tablet 5 mg - 73 - - 73 - - 73 - - 73 -
197 Primakuin 15 mg - 224 - - 224 - - 224 - - 224 -
198 Probenesid 500 mg tablet - - - - - - - - - - - -
199 Prokain Benzil Penisilin 3 juta IU/vial injeksi - - - - - - - - - - - -
200 Propanolol HCL tablet 10 mg - 60 - - 60 - - 60 - - 60 -
201 Ranitidin injeksi - 1,188 - - 1,188 - - 1,188 - - 1,188 -
202 Ranitidin tablet - 105 - - 105 - - 105 - - 105 -
203 Resperidone 2 mg tablet - 273 - - 273 - - 273 - - 273 -
204 Ringer Laktat cairan infus (Otsuka) - 7,150 - - 7,150 - - 7,150 - - 7,150 -
205 Ringer Laktat cairan infus (Widatra) - 7,630 - - 7,630 - - 7,630 - - 7,630 -
206 Rivanol 300 ml - 2,992 - - 2,992 - - 2,992 - - 2,992 -
207 Salbutamol Tablet 2 mg 50 67 3,350 100 67 6,700 50 67 3,350 100 67 6,700
208 Salbutamol tablet 4mg - 70 - - 70 - - 70 - - 70 -
209 Salep 2-4 - 2,797 - - 2,797 - - 2,797 - - 2,797 -
210 Salep kombinasi cream ( Berloson ) - 11,000 - - 11,000 - - 11,000 - - 11,000 -
211 Salicil bedak - 1,025 - - 1,025 - - 1,025 - - 1,025 -
212 Serum Anti Bisa Ular Polivalen Inj 50 ml - 512,204 - - 512,204 - - 512,204 - - 512,204 -
213 Serum Anti Tetanus inj 1500 IU ( Tetagam ) - 130,999 - - 130,999 - - 130,999 - - 130,999 -
214 Sianokobalamin Injeksi - 1,035 - - 1,035 - - 1,035 - - 1,035 -
215 Simvastatin 10 mg tablet - 110 - 30 110 3,300 30 110 3,300 - 110 -
216 Simvastatin 20 mg tablet - 205 - - 205 - - 205 - - 205 -
217 Sukralfat Suspensi - 6,789 - - 6,789 - - 6,789 - - 6,789 -
218 Sukralfat tablet 500 mg - 368 - - 368 - - 368 - - 368 -
219 Suspensi Seng Insulin inj.40 IU/ml - 10 ml - - - - - - - - - - - -
220 Temporary Stopping Fletcher serbuk & cairan - - - - - - - - - - - -
221 Tetrakain HCL tetes mata 0,5% - - - - - - - - - - - -
222 Tetrasiklin 250 mg capsul - 163 - - 163 - - 163 - - 163 -
223 Tetrasiklin 500 mg capsul - - - - - - - - - - - -
224 Tiamin Tablet 50 mg ( B1 ) - 91 - - 91 - - 91 - - 91 -
225 Ventolin Nebulizer - - - - - - - - - - - -
226 Vitamin B komplek 100 118 11,800 100 118 11,800 100 118 11,800 100 118 11,800
227 Zink sirup - 3,171 - - 3,171 - - 3,171 - - 3,171 -
228 Zink tablet 20 mg - 524 - - 524 - - 524 - - 524 -
229 Deksametason inj 5 1,097 5,485 - 1,097 - 5 1,097 5,485 - 1,097 -
230 Diazepam inj 5 mg/ml - 9,800 - - 9,800 - - 9,800 - - 9,800 -
231 Griseofulvin 125 mcg - 210 - - 210 - - 210 - - 210 -
232 Kloramfenikol SK - 3,242 - - 3,242 - - 3,242 - - 3,242 -
233 Nystatin tab 500.000 IU - 843 - - 843 - - 843 - - 843 -
234 magnesium Sulfat Inj. 25 ml 40% - 11,100 - - 11,100 - - 11,100 - - 11,100 -
235 natrium bicarbonat - - - - - - - - -
-
-
-
-
-
NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - - - - -
1 Alat suntik 1 ml - 777 - 777 - - 777 - 777 -
2 Alat suntik 10 ml - 1,067 - 1,067 - - 1,067 - 1,067 -
3 Alat suntik 2,5 ml - 649 - 649 - - 649 - 649 -
4 Alat suntik 20 ml - 2,650 - 2,650 - - 2,650 - 2,650 -
5 Alat suntik 3 cc (Remedi) - 816 - 816 - - 816 - 816 -
6 Alat suntik 3 ml - 924 - 924 - - 924 - 924 -
7 Alat suntik 5 ml - 856 - 856 - - 856 - 856 -
8 Alkazide 1 L High Level Desinfectant - 2,702,700 - 2,702,700 - - 2,702,700 - 2,702,700 -
9 Alkazyme Sachet 25 mg - 801,000 - 801,000 - - 801,000 - 801,000 -
10 Alkohol 70 % 1 L - 25,000 - 25,000 - - 25,000 - 25,000 -
11 Alkohol swab - 29,000 - 29,000 - - 29,000 - 29,000 -
12 Anti Septik Hand Rub - 26,500 - 26,500 - - 26,500 - 26,500 -
13 Anti Septik Surgikal Hand Scrub - - - - - - - - - -
14 Cat Gut no 2/0 - 40,200 - 40,200 - - 40,200 - 40,200 -
15 Cat Gut no 3/0 - 38,536 - 38,536 - - 38,536 - 38,536 -
16 Cat Gut No 2/0 (24 mm) - 61,800 - 61,800 - - 61,800 - 61,800 -
17 Cat Gut No 3/0 (26 mm) - 58,700 - 58,700 - - 58,700 - 58,700 -
18 Cathetter Jelly - 41,600 - 41,600 - - 41,600 - 41,600 -
19 Demetech Silk 3/0 - 3,825 - 3,825 - - 3,825 - 3,825 -
20 E Care I.V Dresing - 6,850 - 6,850 - - 6,850 - 6,850 -
21 E-Care Surgical Mask Tie On - 520 - 520 - - 520 - 520 -
22 Folly No 14 Catether - 16,610 - 16,610 - - 16,610 - 16,610 -
23 Folly No 16 Catether - 12,036 - 12,036 - - 12,036 - 12,036 -
24 I.V Cathetter No. 20 - 6,600 - 6,600 - - 6,600 - 6,600 -
25 I.V Cathetter No. 22 - 6,600 - 6,600 - - 6,600 - 6,600 -
26 I.V Cathetter No. 24 - 7,293 - 7,293 - - 7,293 - 7,293 -
27 I.V Cathetter No. 26 - 13,464 - 13,464 - - 13,464 - 13,464 -
28 Infuset Anak - 8,400 - 8,400 - - 8,400 - 8,400 -
29 Infuset Dewasa - 23,056 - 23,056 - - 23,056 - 23,056 -
30 Jarum Insulin - 2,083 - 2,083 - - 2,083 - 2,083 -
31 Kapas Berlemak 250 gr - 20,600 - 20,600 - - 20,600 - 20,600 -
32 Kapas Berlemak 500 gr - - - - - - - - - -
33 Kasa 4 m x 10 cm - 1,440 - 1,440 - - 1,440 - 1,440 -
34 Kasa Hidrofil 36 x 80 cm - 127,600 - 127,600 - - 127,600 - 127,600 -
35 Kasa Pembalut 2 x 80 cm - 9,400 - 9,400 - - 9,400 - 9,400 -
36 Kasa Steril 16 x 16 cm - 3,500 - 3,500 - - 3,500 - 3,500 -
37 Lisol 1 L - 40,997 - 40,997 - - 40,997 - 40,997 -
38 Masker karet Ear Loop - 15,700 - 15,700 - - 15,700 - 15,700 -
39 Masker tali - 500 - 500 - - 500 - 500 -
40 Nasal Canula Oksigen - - - - - - - - - -
41 Plester 1" - 8,167 - 8,167 - - 8,167 - 8,167 -
42 Plester Kertas 2,5 cm - 7,624 - 7,624 - - 7,624 - 7,624 -
43 Plester Non Woven 5cm x 5 cm - 23,760 - 23,760 - - 23,760 - 23,760 -
44 Policlean - 78,200 - 78,200 - - 78,200 - 78,200 -
45 Polifik - 7,370 - 7,370 - - 7,370 - 7,370 -
46 Saraya Alsof A 500 ml - - - - - - - - - -
47 Saraya Alsof Pure 500 ml - - - - - - - - - -
48 Sarung Tangan Gynecolog No 7 - 40,733 - 40,733 - - 40,733 - 40,733 -
49 Sarung tangan M (Non Steril) - 968 - 968 - - 968 - 968 -
50 Sarung tangan no 6,5 - 13,178 - 13,178 - - 13,178 - 13,178 -
51 Sarung tangan no 6,5 Steril Gloves - 7,931 - 7,931 - - 7,931 - 7,931 -
52 Sarung tangan no 7,0 Steril - 13,178 - 13,178 - - 13,178 - 13,178 -
53 Selang Section ( Surgikal Conection Tube with yan - 30,003 - 30,003 - - 30,003 - 30,003 -
54 Underpad 1 7,900 7,900 7,900 - 1 7,900 7,900 7,900 -
55 Urine Bag - - - - - - - - - -
56 safety blackblood - 204,167 - 204,167 - - 204,167 - 204,167 -
57 safety box - 22,433 - 22,433 - - 22,433 - 22,433 -
58 Tabung BD Vacutener - 1,690 - 1,690 - - 1,690 - 1,690 -
59 masker n95 - 130,240 - 130,240 - - 130,240 - 130,240 -
60 t silk black 3/0 26 mm - 19,700 - 19,700 - - 19,700 - 19,700 -
61 ALAT SUNTIK 1 ML - 64,694 - 64,694 - - 64,694 - 64,694 -
62 alat suntik 3 ml - 65,251 - 65,251 - - 65,251 - 65,251 -
63 iv catheter 18 - - - - - - - - -
-
OBAT JKN - - - - -
1 acylovir cream - 3,169 - 3,169 - - 3,169 - 3,169 -
2 alkohol 70% - 50,000 - 50,000 - - 50,000 - 50,000 -
3 cefadroksil tab - 110,000 - 110,000 - - 110,000 - 110,000 -
4 cetirizin syr - 3,636 - 3,636 - - 3,636 - 3,636 -
5 etil klorida spray - 352,000 - 352,000 - - 352,000 - 352,000 -
6 flagsol tab - 26,400 - 26,400 - - 26,400 - 26,400 -
7 lexigo tab - 22,000 - 22,000 - - 22,000 - 22,000 -
8 mecobalamin kap - 88,000 - 88,000 - - 88,000 - 88,000 -
9 mersibion inj - 54,670 - 54,670 - - 54,670 - 54,670 -
10 Metronidazol tab 500 MG - 204 - 204 - - 204 - 204 -
11 Metronidazol tab 500 MG - 26,400 - 26,400 - - 26,400 - 26,400 -
12 obh syr - 4,950 - 4,950 - - 4,950 - 4,950 -
13 paraflu syr - 6,000 - 6,000 - - 6,000 - 6,000 -
14 parasetamol inf - 33,350 - 33,350 - - 33,350 - 33,350 -
15 piroksikam 20 mg tab - 18,480 - 18,480 - - 18,480 - 18,480 -
16 propyretic suppo - 105,600 - 105,600 - - 105,600 - 105,600 -
17 reco - 11,330 - 11,330 - - 11,330 - 11,330 -
18 selkom c tab - 65,000 - 65,000 - - 65,000 - 65,000 -
19 sianokobalamin tab - 4,000 - 4,000 - - 4,000 - 4,000 -
20 trifadium tab - 20,434 - 20,434 - - 20,434 - 20,434 -
21 vit k1 inj - 825,000 - 825,000 - - 825,000 - 825,000 -
22 Ketorolac inj - 20,010 - 20,010 - - 20,010 - 20,010 -
23 mp 4 mg - 44,000 - 44,000 - - 44,000 - 44,000 -
24 parasetamol tab - 16,939 - 16,939 - - 16,939 - 16,939 -
25 aminofilin inj - 107,998 - 107,998 - - 107,998 - 107,998 -
26 ciprofloksasin tab - 27,632 - 27,632 - - 27,632 - 27,632 -
27 ambroksol syr - 6,300 - 6,300 - - 6,300 - 6,300 -
28 asam mefenamat - 32,746 - 32,746 - - 32,746 - 32,746 -
29 Acyclovir 200 mg - 26,675 - 26,675 - - 26,675 - 26,675 -
30 Acyclovir 400 mg - 37,829 - 37,829 - - 37,829 - 37,829 -
31 Ciprofloxacin 500 mg - 27,632 - 27,632 - - 27,632 - 27,632 -
32 GLUKOSA 5% - 7,363 - 7,363 - - 7,363 - 7,363 -
33 glukosa 10% - 8,003 - 8,003 - - 8,003 - 8,003 -
34 SIANOKOBALAMIN INJ 500 mg - 110,400 - 110,400 - - 110,400 - 110,400 -
35 asam folat 400 mcg - 24,000 - 24,000 - - 24,000 - 24,000 -
36 AMBROKSOL SYR - 5,500 - 5,500 - - 5,500 - 5,500 -
37 asam tranexamat inj - 110,000 - 110,000 - - 110,000 - 110,000 -
38 Bedak Salicyl 2% - 6,000 - 6,000 - - 6,000 - 6,000 -
39 Cefadroxil 500 mg 1 110,000 110,000 110,000 - 1 110,000 110,000 110,000 -
40 Cetirizine syr - 6,875 - 6,875 - - 6,875 - 6,875 -
41 d40 - 24,000 - 24,000 - - 24,000 - 24,000 -
42 Guanistrep syr - 6,325 - 6,325 - - 6,325 - 6,325 -
43 IBUPROFEN 400 mg - 52,800 - 52,800 - - 52,800 - 52,800 -
44 kloramfenikol tetes mata - 11,330 - 11,330 - - 11,330 - 11,330 -
45 Mecobalamin 500 Mg Tab - 77,000 - 77,000 - - 77,000 - 77,000 -
46 metronidazol syr - 7,480 - 7,480 - - 7,480 - 7,480 -
47 Metronidazole 500 mg 1 26,400 26,400 26,400 - 1 26,400 26,400 26,400 -
48 Ondansetron inj 4 mg - 55,000 - 55,000 - - 55,000 - 55,000 -
49 Paraflu Sirup - 6,000 - 6,000 - - 6,000 - 6,000 -
50 parasetamol syr - 5,500 - 5,500 - - 5,500 - 5,500 -
51 ranitidin tab 50 mg 1 22,000 22,000 22,000 - 1 22,000 22,000 22,000 -
52 asam fusidat krim - 12,320 - 12,320 - 12,320 - 12,320 -
53 amlodipin 10 mg - 15,400 - 15,400 - 15,400 - 15,400 -
54 amlodipin 5 mg - 8,250 - 8,250 - 8,250 - 8,250 -
55 asam traneksamat tab 500 mg - 102,300 - 102,300 - 102,300 - 102,300 -
56 cetirizin tab - 31,350 - 31,350 - 31,350 - 31,350 -
57 d40 % - 24,000 - 24,000 - 24,000 - 24,000 -
58 dulcolax anak suppo - 146,396 - 146,396 - 146,396 - 146,396 -
59 gom - 95,040 - 95,040 - 95,040 - 95,040 -
60 HERBAKOF SYR - 12,100 - 12,100 - 12,100 - 12,100 -
61 kloramfenikol tetes mata - 11,330 - 11,330 - 11,330 - 11,330 -
62 Lexigo - 27,500 - 27,500 - 27,500 - 27,500 -
63 METRONIDAZOL SYR - 6,600 - 6,600 - 6,600 - 6,600 -
64 mgso 4 40% - 13,200 - 13,200 - 13,200 - 13,200 -
65 mikrolax suppositoria - 20,625 - 20,625 - 20,625 - 20,625 -
66 natrium bicarbonat tab - 15,000 - 15,000 - 15,000 - 15,000 -
67 nifedipin tab - 17,050 - 17,050 - 17,050 - 17,050 -
68 nisagon krim - 7,097 - 7,097 - 7,097 - 7,097 -
69 oksitosin inj - 324,500 - 324,500 - 324,500 - 324,500 -
70 piroksikam 20 mg tab - 18,480 - 18,480 - 18,480 - 18,480 -
71 SELKOM C - 143,000 - 143,000 - 143,000 - 143,000 -
72 serum abu - 974,050 - 974,050 - 974,050 - 974,050 -
73 SUKRALFAT SYR - 27,500 - 27,500 - 27,500 - 27,500 -
74 ventolin nebu - 220,000 - 220,000 - 220,000 - 220,000 -
75 nacl - 6,840 - 6,840 - 6,840 - 6,840 -
76 ringer laktat - 7,630 - 7,630 - 7,630 - 7,630 -
- - - - -
- - - - -
- - - - -
- - - - -
-
-
- - - - -
BMHP JKN - - - - -
1 CARPUL CITOJET - 112,000 - 112,000 - - 112,000 - 112,000 -
2 CAVITON - 186,490 - 186,490 - - 186,490 - 186,490 -
3 CHEROPHEN - 484,250 - 484,250 - - 484,250 - 484,250 -
4 DEVITALISASI - 87,455 - 87,455 - - 87,455 - 87,455 -
5 LANSET - 36,700 - 36,700 - - 36,700 - 36,700 -
6 DISPOSABLE DENTAL NEEDLES (SCHEJET) - 322,000 - 322,000 - - 322,000 - 322,000 -
7 SARUNG TANGAN NON STERIL M - 286,364 - 286,364 - - 286,364 - 286,364 -
8 GLASS IONOMER - 438,182 - 438,182 - - 438,182 - 438,182 -
9 SUNGKUP DEWASA - 1,064,000 - 1,064,000 - - 1,064,000 - 1,064,000 -
10 SUNGKUP ANAK - 58,409 - 58,409 - - 58,409 - 58,409 -
11 BISTURI - 438,750 - 438,750 - - 438,750 - 438,750 -
12 PIPET OBAT - 58,409 - 58,409 - - 58,409 - 58,409 -
13 PLESTER - 318,182 - 318,182 - - 318,182 - 318,182 -
14 SENDOK OBAT 5 ML - 452,045 - 452,045 - - 452,045 - 452,045 -
15 SARUNG TANGAN STERIL - 193,636 - 193,636 - - 193,636 - 193,636 -
16 STAIN REMOVEL - 216,364 - 216,364 - - 216,364 - 216,364 -
17 VASELIN - 25,200 - 25,200 - - 25,200 - 25,200 -
18 CHKM - 96,200 - 96,200 - - 96,200 - 96,200 -
19 Jely - 22,000 - 22,000 - - 22,000 - 22,000 -
20 disp 10 cc - 150,525 - 150,525 - - 150,525 - 150,525 -
21 f cath 18 - 11,200 - 11,200 - - 11,200 - 11,200 -
22 handscoon non steril uk L - 48,200 - 48,200 - - 48,200 - 48,200 -
23 handscoon non steril uk M - 48,200 - 48,200 - - 48,200 - 48,200 -
24 handscoon steril 6,5 - 262,000 - 262,000 - - 262,000 - 262,000 -
25 handscoon steril 7,5 - 262,000 - 262,000 - - 262,000 - 262,000 -
26 Kertas puyer - 14,365 - 14,365 - - 14,365 - 14,365 -
27 Needle no 23 - 995 - 995 - - 995 - 995 -
28 Needle no 24 - 995 - 995 - - 995 - 995 -
29 Plastik klip besar - 122,100 - 122,100 - - 122,100 - 122,100 -
30 Plastik klip kecil - 99,450 - 99,450 - - 99,450 - 99,450 -
31 plastik klip sedang - 99,450 - 99,450 - - 99,450 - 99,450 -
32 Plester 5 yard x2 inci - 23,625 - 23,625 - - 23,625 - 23,625 -
33 Sarung tangan No M - 88,000 - 88,000 - - 88,000 - 88,000 -
34 Sarung tangan No S - 88,000 - 88,000 - - 88,000 - 88,000 -
35 Selang Oksigen Anak-anak - 7,163 - 7,163 - - 7,163 - 7,163 -
36 Selang Oksigen Dewasa - 7,136 - 7,136 - - 7,136 - 7,136 -
37 Larutan Gentian Violet - 256,300 - 256,300 - - 256,300 - 256,300 -
38 mukus ekstraktor - 9,800 - 9,800 - - 9,800 - 9,800 -
39 nasal kanul bayi - 8,450 - 8,450 - - 8,450 - 8,450 -
40 nesco asam urat - 99,450 - 99,450 - - 99,450 - 99,450 -
41 nesco gds - 121,550 - 121,550 - - 121,550 - 121,550 -
42 nesco kolesterol - 206,550 - 206,550 - - 206,550 - 206,550 -
43 pipet obat 1 ml - 350,000 - 350,000 - - 350,000 - 350,000 -
44 plester - 306,300 - 306,300 - - 306,300 - 306,300 -
45 pot urin - 1,500 - 1,500 - - 1,500 - 1,500 -
46 reagen goldar A - 355,750 - 355,750 - - 355,750 - 355,750 -
47 kertas goldar - 38,675 - 38,675 - - 38,675 - 38,675 -
48 Rebreathing mask O2 anak - 35,100 - 35,100 - - 35,100 - 35,100 -
49 Rebreathing mask O2 bayi - 35,100 - 35,100 - - 35,100 - 35,100 -
50 Rebreathing mask O2 dewasa - 35,100 - 35,100 - - 35,100 - 35,100 -
51 sendok obat - 53,200 - 53,200 - - 53,200 - 53,200 -
52 SOFRATULLE - 175,000 - 175,000 - - 175,000 - 175,000 -
53 stain removel pasta - 238,000 - 238,000 - - 238,000 - 238,000 -
54 suction no 8 - 4,000 - 4,000 - - 4,000 - 4,000 -
55 sungkup bayi - 25,725 - 25,725 - - 25,725 - 25,725 -
56 t silk - 165,750 - 165,750 - - 165,750 - 165,750 -
57 tes kehamilan - 88,400 - 88,400 - - 88,400 - 88,400 -
58 umbilical klem - 88,275 - 88,275 - - 88,275 - 88,275 -
59 vaselin - 9,240 - 9,240 - - 9,240 - 9,240 -
60 yellow tip - 193,375 - 193,375 - - 193,375 - 193,375 -
61 rapid test dengue nst - 1,375,000 - 1,375,000 - - 1,375,000 - 1,375,000 -
62 suntik 20 cc - 150,525 - 150,525 - - 150,525 - 150,525 -
63 rapid test dengue 1gg - 1,440,000 - 1,440,000 - - 1,440,000 - 1,440,000 -
64 catgut plain - 120,000 - 120,000 - - 120,000 - 120,000 -
65 antiseptik 5 L - 925,000 - 925,000 - - 925,000 - 925,000 -
66 nesco hb - 206,550 - 206,550 - - 206,550 - 206,550 -
67 UNDERPAD - 45,140 - 45,140 - - 45,140 - 45,140 -
68 rivanol - 8,500 - 8,500 - - 8,500 - 8,500 -
69 povidone - 105,000 - 105,000 - - 105,000 - 105,000 -
70 alkohol 1 75,250 75,250 75,250 - 1 75,250 75,250 75,250 -
71 suction no 8 - 8,000 - 8,000 - - 8,000 - 8,000 -
72 nesco gds - 99,450 - 99,450 - - 99,450 - 99,450 -
73 nesco asam urat - 121,550 - 121,550 - - 121,550 - 121,550 -
74 hcg test - 88,400 - 88,400 - - 88,400 - 88,400 -
75 lancet - 20,909 - 20,909 - - 20,909 - 20,909 -
76 IV CATHETER no 26 - 26,400 - 26,400 - - 26,400 - 26,400 -
77 MASKER EARLOOP - 115,900 - 115,900 - - 115,900 - 115,900 -
78 OIL IMMERSI - 695,310 - 695,310 - - 695,310 - 695,310
79 OKSIGEN MASKER STANDAR BAYI - 19,400 - 19,400 - - 19,400 - 19,400 -
80 OKSIGEN MASKER STANDAR ANAK - 19,400 - 19,400 - - 19,400 - 19,400 -
81 OKSIGEN MASKER STANDAR DEWASA - 19,400 - 19,400 - - 19,400 - 19,400 -
82 OXYGEN NASAL CANNULA NEONATUS - 8,450 - 8,450 - - 8,450 - 8,450 -
83 PLASTIK KLIP SEDANG 13x8,7 CM - 95,000 - 95,000 - - 95,000 - 95,000 -
84 PROTEIN URIN VERIFY - 249,250 - 249,250 - - 249,250 - 249,250 -
85 REAGEN GOLDAR - 396,700 - 396,700 - - 396,700 - 396,700 -
86 SENDOK OBAT 5ML - 53,200 - 53,200 - - 53,200 - 53,200 -
87 STRIP CHOLESTEROL - 206,550 - 206,550 - - 206,550 - 206,550 -
88 STRIP GULA DARAH - 99,450 - 99,450 - - 99,450 - 99,450 -
89 STRIP HB - 206,550 - 206,550 - - 206,550 - 206,550 -
90 SUNGKUP ANAK NEBU - 36,125 - 36,125 - - 36,125 - 36,125 -
91 SUNGKUP BAYI NEBU - 36,125 - 36,125 - - 36,125 - 36,125 -
92 SUNGKUP DEWASA NEBU - 36,125 - 36,125 - - 36,125 - 36,125 -
93 UMBILICAL KLEM - 88,275 - 88,275 - - 88,275 - 88,275 -
94 ALKOHOL SWAB - 24,850 - 24,850 - 24,850 - 24,850 -
95 CATGUT CHROME SIZE : 2/0 WITH NEEDLE STERILE - 91,000 - 91,000 - 91,000 - 91,000 -
96 EXAMINATION GLOVE uk. M - 203,900 - 203,900 - 203,900 - 203,900 -
97 FOLLEY CATHETER NO 16 - 16,400 - 16,400 - 16,400 - 16,400 -
98 FOLLEY CATHETER NO 18 - 16,400 - 16,400 - 16,400 - 16,400 -
99 GLOVE STERILE GYNECOLOG NO. 6.5 - 28,500 - 28,500 - 28,500 - 28,500 -
100 INFUSION SET DEWASA - 6,150 - 6,150 - 6,150 - 6,150 -
101 IV CATHETER NO. 18 - 214,100 - 214,100 - 214,100 - 214,100 -
102 IV CATHETER NO. 20 - 214,100 - 214,100 - 214,100 - 214,100 -
103 IV CATHETER NO. 22 - 214,100 - 214,100 - 214,100 - 214,100 -
104 IV CATHETER NO. 24 - 214,100 - 214,100 - 214,100 - 214,100 -
105 KASA 40X80 - 108,400 - 108,400 - 108,400 - 108,400 -
106 MASKER MEDIS HEADLOOP - 75,250 - 75,250 - 75,250 - 75,250 -
107 PERBAN ELASTIS 10M - 22,500 - 22,500 - 22,500 - 22,500 -
108 PLESTER INCL DISPENSER 1 INCH - 306,300 - 306,300 - 306,300 - 306,300 -
109 POVIDION IODINE 15ML - 3,680 - 3,680 - 3,680 - 3,680 -
110 STRIP CHOLESTEROL - 206,550 - 206,550 - 206,550 - 206,550 -
111 STRIP GULA DARAH - 99,450 - 99,450 - 99,450 - 99,450 -
112 SYRINGE 1ML - 150,525 - 150,525 - 150,525 - 150,525 -
113 SYRINGE 3ML - 150,525 - 150,525 - 150,525 - 150,525 -
114 UMBILICAL KLEM - 88,275 - 88,275 - 88,275 - 88,275 -
115 URINE BAG - 8,150 - 8,150 - 8,150 - 8,150 -
TOTAL 392,565 124,070 451,785 64,850
Kepala Puskesmas Cikeusik Pengurus Barang Tim Pemeriksa,

Kabupaten Pandeglang Puskesmas Cikeusik
1 Iing, SKM
NIP. 19630407 198603 1 014
Hj. Iyot Sadiah, S. ST ELAH NURHAYATI. Amd. Keb
NIP 19710804 199103 2 002 NIP. 198301082017042001
2 Reny Wigyawati. Apt
NIP. 19860114201902 2 003
3 Jujum Jumiati, Amd. Keb

NIP. 19780401 200604 2 020
Lampiran
Berita Acara Pemeriksaan Persediaan
Lokasi Persediaan : UPT PUSKESMAS CIKEUSIK
PERHITUNGAN PERSEDIAAN
PER 31 MARET 2020
Perhitungan Persedia
Harga Satuan
No Uraian Satuan
(Rp)
Administrasi Reviu Fisik Selisih
1 2 3 4 5 6 7 = (5-6)
BMHP+OBAT+HIBAH
BAHAN HABIS PAKAI
LEUWIBALANG (BOP) 0
Alat suntik 1 ml Pcs 777 10 10
I.V Cathetter No. 20 Set 23,100 5 5
Infuset Anak Set 8,400 5 5
Infuset Dewasa Set 23,056 2 2
0
OBAT
GUDANG OBAT
GUDANG OBAT (BOP)
LEUWIBALANG (BOP) 0
Ambroxol sirup Botol 3,300 2
Amoksisilin Tablet 500 mg Tablet 233 70
Asetyl Cysteine Capsul 382 20
Captopril Tablet 12,5 mg Tablet 66 50
deksametason tab Tablet 77 30
Fitomenadion (Vit.K1) tab salut gula 10 Tablet 710 70
Kalsium Laktat (Kalk) tablet 500 mg Tablet 63 80
Kloramfenikol salep mata 1 % capsul 1,881 1
Klorfeniramin Maleat (CTM) tablet 4 m Tablet 23 30
Kotrimoksazol Dewasa Tablet 480 mg Tablet 125 60
Metilergometrin Maleat injeksi 1 ml Ampul 2,550 6
Oksitosin injeksi 10 IU/ml - 1 ml Ampul 1,199 9
Paracetamol Sirup 120 mg/5 ml Botol 1,107 3
Parasetamol tablet 500 mg Tablet 132 50
Ranitidin tablet Tablet 105 40
Salbutamol Tablet 2 mg Tablet 63 50
0
Kepala Puskesmas Cikeusik Pengurus Barang

NIP 19710804 199103 2 002
NIP. 198301082017042001
Lampiran
Berita Acara Pemeriksaan Persedia
Lokasi Persediaan : UPT PUSKESM
Perhitungan Persediaan :
Penjelasan
No
Mutasi Selisih
Nilai
Jumlah Fisik
(+) (-) Persediaan
8 9 10 (6-8+9) 11 (4 x 10) 12 1
#REF!
0 346,946
10 7,770
3 2,772
5 115,500
2 46,200
2 46,200
3 40,392
5 42,000
2 46,112
0 346,946
-
-
-
0 144,333
2 6,600
70 16,310
20 7,640
50 3,300
30 2,310
70 49,700
80 5,040
1 1,881
30 690
60 7,500
6 15,300
9 10,791
3 3,321
50 6,600
40 4,200
50 3,150
0 144,333
Tim Pemeriksa,
engurus Barang
skesmas Cikeusik
1 Iing, SKM
NIP. 19630407 198603 1 014

NIP. 19860114201902 2 003

NIP. 19780401 200604 2 020
PER 30 juni 2020
Uraian Satuan Harga Satuan (Rp)
Mutasi
Administrasi Reviu Fisik Selisih
(+)
2 3 4 5 6 7 = (5-6) 8
BMHP+OBAT+HIBAH
BAHAN HABIS PAKAI
LEUWIBALANG (BOP)
Alat suntik 5 ml pcs 856 11 11
Cathetter Jelly Biji 41,600 1 1
Infuset Anak Set 8,400 3 3
Infuset Dewasa Set 23,056 2 2
Sarung tangan M (Non St
Pasang 968 34 34
OBAT
GUDANG OBAT
GUDANG OBAT (BOP)
LEUWIBALANG (BOP)
Amlodipin Besilate 5 mgTablet 70 120 120
Amoksisilin Tablet 500 Tablet 249 10 10
ANTASIDA DOEN Table Tablet 58 20 20
Aqua Pro Injeksi Vial 2,860 1 1
Asam Ascorbat ( Vit. C Tablet 105 100 100
Asering Botol 9,646 5 5
Asetyl Cysteine Capsul 382 60 60
Captopril Tablet 12,5 m Tablet 66 10 10
Cetirizine Capsul 50 mgCapsul 90 60 60
deksametason tab Tablet 77 70 70
Domperidon 10mg TableTablet 91 50 50
Domperidon Suspensi 5Botol 2,700 4 4
Fitomenadion (Vit.K1) taTablet 710 10 10
Furosemida tablet 40 m Tablet 82 40 40
Gentamicin Injeksi Ampul 1,010 5 5
Glimepiride 2 mg Tablet 207 30 30
Kalsium Laktat (Kalk) ta Tablet 63 50 50
Ketokonazol Tablet 200 Tablet 270 40 40
Kloramfenikol suspensi Botol 5,015 4 4
Klorfeniramin Maleat (C Tablet 23 80 80
Lidocain 2%+efinefrin injAmpul 1,152 20 20
Metilergometrin Maleat iAmpul 2,550 28 28
Multivitamin Anak Sirup Botol 9,900 2 2
Oksitosin injeksi 10 IU/mAmpul - 18 18
Omeprazol injeksi Ampul 9,898 2 2
Paracetamol Drop 15 mlBotol 6,649 5 5
Paracetamol Sirup 120 Botol 1,181 6 6
Ranitidin tablet Tablet 105 60 60
Salbutamol tablet 4mg Tablet 70 60 60
Vitamin B komplek Tablet 118 110 110


NIP 19710804 199103 2 002 NIP. 198301082017042001
Lampiran
Lokasi Persediaan : UPT PUSKESMAS
Penjelasan
No
Mutasi Selisih
Jumlah Fisik Nilai Persediaan
(-)
9 10 (6-8+9) 11 (4 x 10) 12 1
#REF!
158,936
4 3,696 1
11 9,416 2
1 41,600 3
3 25,200 4
2 46,112 5
34 32,912 6
0 158,936 7
- 1
- 2
- 3
378,697 4
120 8,400 5
10 2,490 6
20 1,160 7
1 2,860 8
100 10,500 9
5 48,230 10
60 22,920 11
10 660 12
60 5,400 13
70 5,390 14
50 4,550 15
4 10,800 16
10 7,100 17
40 3,280 18
5 5,050 19
30 6,210 20
50 3,150 21
40 10,800 22
4 20,060 23
80 1,840 24
20 23,040 25
28 71,400 26
2 19,800 27
18 -
2 19,796
5 33,245
6 7,086 1
60 6,300 2
60 4,200 3
110 12,980
0 378,697
Kepala Puskesmas Cikeusik
Tim Pemeriksa, Kabupaten Pandeglang
1 Iing, SKM
NIP. 19630407 198603 1 014 Hj. Iyot Sadiah, S. ST
NIP 19710804 199103 2 002

NIP. 19860114201902 2 003

NIP. 19780401 200604 2 020
PER 30 September 2020
Harga Satuan
Uraian Satuan
(Rp) Mutasi
Administrasi Reviu Fisik Selisih Jumlah Fisik
(+) (-)
2 3 4 5 6 7 = (5-6) 8 9 10 (6-8+9)
BMHP+OBAT+HIBAH
BAHAN HABIS PAKAI
LEUWIBALANG (BOP) - - -
Alat suntik Pcs 924 4 4 - - - 4
Alat suntik pcs 856 6 6 - - - 6
E Care I.V Pcs 6,850 5 5 - - - 5
I.V Cathett Set 6,600 2 2 - - - 2
Infuset AnaSet 8,400 3 3 - - - 3
Infuset De Set 23,056 1 1 - - - 1
Sarung tangPasang 968 30 30 - - - 30
- - - - 0
LEUWIBALANG (BOP) - - -
Amoksisilin Tablet 249 100 100 - - - 100
ANTASIDA DTablet 58 100 100 - - - 100
Asam Ascorba
Tablet 105 100 100 - - - 100
BetametasonTube 1,340 2 2 - - - 2
Cairan Infus Botol 1,007 2 2 - - - 2
Captopril Ta Tablet 66 100 100 - - - 100
Cetirizine C Capsul 90 100 100 - - - 100
DomperidonTablet 91 50 50 - - - 50
Furosemida Tablet 82 50 50 - - - 50
Gentamicin IAmpul 1,010 5 5 - - - 5
Kalsium LaktTablet 63 250 250 - - - 250
KetokonazolTube 2,518 2 2 - - - 2
KetokonazolTablet 270 50 50 - - - 50
KotrimoksazTablet 133 100 100 - - - 100
Metformin 5Tablet 102 50 50 - - - 50
Metilergomet
Ampul 2,550 57 57 - - - 57
Natrium DiklTablet 123 50 50 - - - 50
Obat Anti DiaTablet 145 50 50 - - - 50
Obat Batuk FlTablet 64,900 1 1 - - - 1
Obat Batuk SBotol 12,100 2 2 - - - 2
ParacetamolBotol 6,649 10 10 - - - 10
ParacetamolBotol 1,181 2 2 - - - 2
Piridoksin H Botol 131 50 50 - - - 50
Prednison TaTablet 73 50 50 - - - 50
Ringer LaktatBotol 7,630 2 2 - - - 2
Simvastatin Tablet 110 40 40 - - - 40
Vitamin B k Tablet 118 150 150 - - - 150
- - - - 0
- - - - 0
JKN - - - - 0
mp 4 mg box 44,000 2 2 - - - 2
parasetamolbox 16,939 1 1 - - - 1
ciprofloksasibox 27,632 1 1 - - - 1
- - - - 0


NIP 19710804 199103 2 002 NIP. 198301082017042001
2
3
Lampiran
PERHIT
PER
Penjelasan Harga Satuan

No Uraian Satuan
Selisih (Rp)
Nilai Persediaan
11 (4 x 10) 12 1 2 3 4
758,291 BMHP+OBAT+HIBAH
BAHAN HABIS PAKAI
133,578 LEUWIBALANG (BOP)
3,696 KOSONG
5,136
34,250 LEUWIBALANG (JKN)
13,200 KOSONG
25,200 LEUWIBALANG (BOP)
23,056 1 Allopurinol tabTablet 105
29,040 2 Amoksisilin TaTablet 249
133,578 3 ANTASIDA DO
Tablet 58
624,713 4 Captopril TableTablet 66
24,900 5 deksametason tTablet 77
5,800 6 Natrium DiklofTablet 123
10,500 7 Salbutamol TabTablet 67
2,680 8 Vitamin B komTablet 118
2,014
6,600
9,000 LEUWIBALANG (JKN)
4,550 KOSONG
4,100
5,050 Kepala Puskesmas Cikeusik
15,750 Kabupaten Pandeglang
5,036
13,500
13,300
5,100 Hj. Iyot Sadiah, S. ST
NIP 19710804 199103 2 002
145,350
6,150
7,250
64,900
24,200
66,490
2,362
6,550
3,650
15,260
4,400
17,700
492,142
-
132,571
88,000
16,939
27,632
132,571
Tim Pemeriksa,
Iing, SKM
NIP. 19630407 198603 1 014
Reny Wigyawati. Apt

NIP. 19860114201902 2 003
Jujum Jumiati, Amd. Keb

NIP. 19780401 200604 2 020
PER 30 Desember 2020
Penjelasan
Mutasi Selisih
Nilai
Administrasi Reviu Fisik Selisih Jumlah Fisik
(+) (-) Persediaan
5 6 7 = (5-6) 8 9 10 (6-8+9) 11 (4 x 10) 12

64,850
- - -
- - -
64,850
50 50 50 5,250
100 100 100 24,900

50 50 50 2,900
50 50 50 3,300
50 50 50 3,850
50 50 50 6,150
100 100 100 6,700
100 100 100 11,800
64,850
- 0 -
Tim Pemeriksa,
Pengurus Barang
Puskesmas Cikeusik
1 Iing, SKM
NIP. 19630407 198603 1 014
ELAH NURHAYATI. Amd. Keb
NIP. 198301082017042001

NIP. 19860114201902 2 003

NIP. 19780401 200604 2 020

So 3 Bulan Desember 2020 LB

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LAPORAN PEMAKAIAN DAN LEMB

PUSKESMAS : CIKEUSIK/ LEUWIBALANG

RENY WIGIAWATI, A.Pt

MENGETAHUI YANG MEMINTA :

EMBERIAN JUMLAH Jumlah

NG MEMINTA : YANG MENYERAHKAN MENGETAHUI

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

DOKUMEN NOMOR TANGGAL

MENGETAHUI YANG MEMINTA : YANG MENYE

HJ,IYOT SA'DIAH,S.ST RENY WIGIAW

YANG MENYERAHKAN MENGETAHUI YAN

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

PUSKESMAS : CIKEUSIK/ LEUWIBALANG

RENY WIGIAWATI, A.Pt

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

DOKUMEN NOMOR TANGGAL

HJ,IYOT SA'DIAH,S.ST RENY WIGIA

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

Nama Puskesmas : PKM CIKEUSIK/ LEUWIBALANG

Nama Puskesmas : PKM CIKEUSIK/ LEUWIBALANG

1 Vaksin Anti Rabies ( VAR ) 78,500 78,500 78,500 78,500

PUSKESMAS : CIKEUSIK/ LEUWIBALANG

B NAMA BAHAN MEDIS HABIS PAKAI (BMHP ) - - - - -

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST RENY WIGIAWATI, A.Pt

DOKUMEN NOMOR TANGGAL

RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

YANG MENYERAHKAN YANG MENYERAHKAN MENGETAHUI YANG MEMINTA :

RENY WIGIAWATI, A.Pt RENY WIGIAWATI, A.Pt HJ,IYOT SA'DIAH,S.ST

Nama Puskesmas : PKM CIKEUSIK/RANCASENENG

Kepala Puskesmas Cikeusik Pengurus Barang Tim Pemeriksa,

3 Jujum Jumiati, Amd. Keb

Kepala Puskesmas Cikeusik Pengurus Barang

Kabupaten Pandeglang Puskesmas Cikeusik

Hj. Iyot Sadiah, S. ST ELAH NURHAYATI. Amd. Keb

2 Reny Wigyawati. Apt

3 Jujum Jumiati, Amd. Keb

Kepala Puskesmas Cikeusik Pengurus Barang

Hj. Iyot Sadiah, S. ST ELAH NURHAYATI. Amd. Keb

2 Reny Wigyawati. Apt

3 Jujum Jumiati, Amd. Keb

Kepala Puskesmas Cikeusik Pengurus Barang

Hj. Iyot Sadiah, S. ST ELAH NURHAYATI. Amd. Keb

Penjelasan Harga Satuan

Reny Wigyawati. Apt

Jujum Jumiati, Amd. Keb

5 6 7 = (5-6) 8 9 10 (6-8+9) 11 (4 x 10) 12

100 100 100 24,900

100 100 100 6,700

100 100 100 11,800

2 Reny Wigyawati. Apt

3 Jujum Jumiati, Amd. Keb

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