F.F.

49
RSUP Dr Mohammad Hoesin
Instalasi Farmasi
Pemeriksaan Perbekalan Farmasi Emergensi

Ruang Rawat : Tanggal :

Tanggal : Pukul :
No Segel (buka)
No Segel (tutup)

LACI 1 Obat- Obatan

Jumlah
No Item Perbekalan Farmasi Jumlah Awal Keterangan
(Diisi checklist)
1 Aminofilin 240mg/10 ml 1 amp
2 Atropine Sulfas 0,25mg/mL 10 amp
3 Diazepam 10mg/2ml 2 amp
4 Dobutamine 250mg/5ml 1 vial
5 Dopamin 200 mg/5ml 1 vial
6 Methylprednisolon 125 mg 1 vial
7 Norephinephrine bitartrat 4 mg/4ml 1 amp
8 Natrium Klorida 0,9% 25 ml 3 amp
9 Epinephrin 1 mg/ml 10 amp
10 Amiodarone HCl 150mg/3ml 3 amp
11 Dextrose 40% 25 ml 2 amp
12 Digoxin 0,5mg/2ml 1 amp
13 Midazolam 15 mg/3ml 1 amp
14 Lidocain 40 mg/2 ml 5 amp
LACI 2 Sirkulasi
Jumlah
No Item Perbekalan Farmasi Jumlah Awal Keterangan
(Diisi checklist)
1 Alkohol Swab 10 pcs
2 Disposible Syringe 3 ml 2 pcs
3 Disposible Syringe 5 ml 2 pcs
4 Disposible Syringe 10 ml 2 pcs
5 Ringer Laktat 1 kolf
6 Natrium Klorida 0,9 % 100 ml 1 kolf
7 Intravena Catheter No 18 2 pcs
8 Intravena Catheter No 20 2 pcs
9 Intravena Catheter No 22 2 pcs
10 Transparan Dressing 10 pcs
11 Infus set makro 2 pcs
12 Infus set mikro 2 pcs
13 Transfusi set 1 pcs
Ka.Ruangan
Jumlah
No Item Perbekalan Farmasi Jumlah Awal Keterangan
(Diisi checklist)
1 Gudel no 8 1 pcs
2 Gudel no 9 1 pcs
3 Mandrin 1 pcs
4 Lidocain gel 1 tube
5 Endotracheal Tube no 7 2 pcs
6 Endotracheal Tube no 7,5 2 pcs
7 Endotracheal Tube no 8 2 pcs
8 Endotracheal Tube no 8,5 2 pcs
9 Face mask dewasa No 4 1 pcs
10 Face mask dewasa No 5 1 pcs
11 Suction Catheter No 12 2 pcs
12 Suction Catheter No 14 2 pcs
Ka.Ruangan Petugas Farmasi

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