LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN REAGEN ( LPLPR )

PUSKESMAS CIPONDOH

PUSKESMAS : CIPONDOH
KECAMATAN : Cipondoh
PROVINSI : BANTEN PELAPORAN BULAN : April 2020
KOTA : KOTA TANGERANG PERMINTAAN BULAN : Mei 2020

NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
GLUKOSA TEST STRIP
100 strip/box (2 PT. Roche
1 Accucheck Performa Strip BOX Tube@50 strip) Indonesia - - -
PT. Roche
2 Accucheck Softclix Uno Lancet BOX 200 Pcs/box Indonesia - - -
PT. Jayamas-
3 Alkohol Swab PCS 1 Onemed - 10 10
4 Alkohol swab Kotak Kotak PT.Axion - - -
REAGENT KIMIA KLINIK
5 Amonium Oxalat (Trombosit AO) Botol 100 ml/ btl Indoreagen - - -
6 Aquabidest Steril Botol 500 ml/btl Ikapharmindo 1 1 2
7 Asam Sulfosalisilat Botol Botol/100ml Indoreagen - - -
5 X 80 ml + 1 X
8 Asam Urat FS TBHBA DSI KIT 100 ml DSI - - -
25 Test Strip /
9 Asam Urat NESCO Test Strip Botol NESCO - - -
PT. Rajawali
10 Asam Urat Rajawali Botol 4 x 100 ml Nusindo - - -
11 Chemistry Control Level 1-Normal Botol 20 Botol x 5 ml Biorad - 1 1
5X25 ml + 1X3 ml
12 Cholesterol FS DSI Botol std DSI - - -
10 Test Strip /
13 Cholesterol NESCO Test Strip Botol NESCO - - -
PT. Rajawali
14 Cholesterol Rajawali Botol 4 x 100 ml Nusindo - - -

15 Cholesterol Test Strip Humasens Test Strip 20 Test Strip / Box PT. HUMAN - - -

1
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
4X20 ml + 1X20
16 Creatinin FS DSI KIT ml +1X3 ml DSI - - -
PT. Rajawali
17 Creatinin Rajawali KIT 2 x 100 ml Nusindo - 1 1
18 Disposible Waastergren PAK Pak @ 10 pcs Assistant - - -
19 Eosin 2 % Botol Botol 100 ml Indoreagen - - -
20 Extran Netral Botol Botol 500 ml Indoreagen - - -
21 Flasback Neddle 22G PCS 50 Pcs/Box PT. BD - - -
22 Giemsa Botol Botol 100 ml Indoreagen - - -

23 Glucose Test Strip Humasens Test Strip 50 Test Strip / Box PT. HUMAN - - -
5X25 ml + 1X3 ml
24 Glukose GOD FS DSI Botol std DSI - - -
PT. Rajawali
25 Glukose Rajawali Botol 4 x 100 ml Nusindo - - -
26 Gol.Darah A,B,AB dan Rhesus (Atlass) SET 4 x 10 ml Atlass - - -

27 Gol.Darah A,B,AB dan Rhesus (Rafa Topaz) KIT 5 x 10 ml PT. Rafa Topaz - - -
28 HCl 0.1 N (Indoreagen) Botol 100 ml/btl Indoreagen - - -
PT. Jayamas-
29 HCl 0.1 N (Jayamas) Botol 100 ml/btl Onemed - - -
30 HDL Cholesterol ( Precipitant ) DSI Botol Botol 250 ml DSI - - -
PT. Rajawali
31 HDL Cholesterol ( Precipitant ) Rajawali Botol 4 x 80 ml Nusindo - 4 4
32 Hemoglobin Drabkin Botol Botol 500 ml Indoreagen - - -
33 Iodine Test 1% Botol Botol 100 ml Pabrikan - - -
34 Kapiler Hematokrit Tube 100 pcs/tube - 1 1
LDL CHOLESTEROL 2G DIRECT COMBO +
35 CONTROL LDL KIT - BOULE - - -
36 Methanol Teknis p.a 100 ml Botol Botol 100 ml Indoreagen - - -
37 Methanol Teknis p.a 100 ml Botol Botol 100 ml Pabrikan - - -
PT. Jayamas
38 Mikrocentrifuge set ( SAMPLE CUP ) 2 mL PAK 500 Pcs/Pack Medica - - -
39 Na. Sitrat 3.13% Botol 100 ml/btl Indoreagen - - -
40 Neddle Holder PCS 20 Pcs/Box PT. BD - - -

2
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
41 Pewarnaan Gram (Indoreagen) KIT 3 x 100 ml Indoreagen - - -
42 Pewarnaan Gram (ST-Reagensia) KIT 3 x 100 ml ST-Reagensia - - -
PT. Jayamas-
43 Plesterin Bulat BOX Box @ 200 pcs Onemed 1 2 3
PT. Jayamas
44 Pot Feces (Spesimen Container) PCS Pcs Medica - - -
PT. Jayamas
45 Pot Urine (Spesimen Container) PCS Pcs Medica 100 100 200
5 X 20 ml + 1 X 25
46 SGOT FS DSI KIT ml DSI - - -
PT. Rajawali
47 SGOT RAJAWALI KIT 20 x 5 ml Nusindo - - -
5 X 20 ml + 1 X 25
48 SGPT FS DSI KIT ml DSI - - -
PT. Rajawali
49 SGPT RAJAWALI KIT 20 x 5 ml Nusindo - - -
PT. Jayamas
50 Tabung Centrifuge Plastik 15 ml PCS PCS Medica - - -
51 Tabung EDTA-K2/K3 (0.5 ml) PCS 50 Pcs/Box PT. BD - - -
52 Tabung EDTA-K2/K3 (2 ml) PCS 100 Pcs/Pack PT. BD - - -
53 Tabung EDTA-K3 (0.5 ml) PCS 100 Pcs/Pack Sunphoria - - -

Tabung Plain / SST With Gel 3-3,5 ml PT. Hospi Medik

54 Vacusera PCS 100 pcs / Pack Indonesia - 200 200
55 Tabung Plain/ SST with gel 3-3,5 ml PCS 100 Pcs/ Pack PT. BD - - -

PT. Fokus
Diagnostic
56 Test Kehamilan (Fokus) Test Strip 25 Test Strip/Box Indonesia - - -
PT. Jayamas-
57 Test Kehamilan (Jayamas-One Med) Test Strip 50 Test Strip / Box Onemed - - -

58 Test Kehamilan (Oncoprobe) Test Strip 50 Test Strip / Box Oncoprobe - - -

59 Thypoid Tes (Widal)- 8 Parameter KIT 8 x 5 ml/ Pkt AIM - - -
60 Thypoid Tes (Widal)- 8 Parameter SET 8 x 5 ml/ Pkt PT. Rafa Topaz - - -

3
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
PT. Jayamas
61 Tip Biru PAK 500 Pcs/PAK Medica - 1 1
PT. Jayamas
62 Tip Kuning PAK 1000 Pcs/Pak Medica - - -
PT. Jayamas
63 Tip Putih PAK 1000 Pcs/Pak Medica - - -
PT. Rajawali
64 Trigliserid Rajawali Botol 4 x 100 ml Nusindo - - -
5X25 ml + 1X3 ml
65 Trigliserida FS DSI Botol std DSI - - -
66 Trulab N (Kontrol Normal) Botol 6 x 5 ml DSI - - -
67 Turk Botol 100 ml/btl Indoreagen - - -
4X20 ml + 1X20
68 Urea FS DSI KIT ml +1X3 ml DSI - - -
PT. Rajawali
69 Urea Rajawali KIT 2 x 100 ml Nusindo - - -

70 Uric Acid Test Strip Humasens Test Strip 25 Test Strip / Box PT. HUMAN - - -
71 Urine Test Strip 10 Parameter Botol 100 Strip/ Btl Cybow - - -
72 Urine Test Strip 10 Parameter Botol 100 Strip/Btl Oncoprobe - - -
73 Urine Test Strip 3 Parameter Botol 100 Strip/ Btl Lokal - - -
74 Wax Hematokrit PCS Pcs - - -
75 Wing Needle No. 21 ( BD ) PCS 50 pcs / Box PT. BD - 10 10
PT. Anugrah
76 Wing Needle No. 21 (BD) PCS Kotak/50 Pcs Argon Medica - - -
RAPID TES HIV AIDS DAN HEPATITIS

PT. Fokus
Diagnostic
77 HBsAg Strip Test Strip 25 Strip / Box Indonesia 25 200 225

78 HBsAg Strip Strip 100 Strip / Kotak SD - Bioline - - -

79 HBsAg Strip Strip 100 Strip / Kotak SD - Bioline - - -

80 HBsAg WB Strip Strip 100 Strip / Kotak SD - Bioline - - -

4
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
81 Kertas Lakmus Buku Buku PT. LITMUS - - -
82 KOH 10% Botol Botol 100 ml Indoreagen - - -
83 Pedophilin Tincture Botol Botol Pabrikan - - -
PT. Indec
84 Rapid Tes HIV 1 ( Virocheck ) Card/Device 25 Card Test / Box Diagnostics 25 - 25
40 Card-Device /
85 Rapid Tes HIV 1 (Answer) Card/Device Box Answer - - -
86 Rapid Tes HIV 1 (SD-BIOLINE) Card/Device Box SD - Bioline - 100 100

PT. Fokus
Diagnostic
87 Rapid Tes HIV 2 (FOKUS) Card/Device Card-Device / Box Indonesia - 100 100
100 Card-Device /
88 Rapid Tes HIV 2 (INTEC) Card/Device Box INTEC - - -
25 Card-Device /
89 Rapid Tes HIV 3 Card/Device Box Biocare - - -
25 Card-Device /
90 Rapid Tes HIV 3 (Biomerieux) Card/Device Box Biomeriux - Vikia - 100 100

PT. Fokus
Diagnostic
91 Rapid Tes Syphilis Test 25 Test / Box Indonesia 25 - 25
92 Rapid Tes Syphilis Test Box SD - Biosensor 200 - 200
PT. Sali Polapa
93 Rapid Tes Syphilis Test 20 Test/Kit Bersama - - -

94 Reagen CD4 Mobile Test Box PT. Alere Health - - -

95 Reaggen CD4 Control Test Box PT. Alere Health - - -

PT. Sali Polapa
96 RPR Test KIT 100 Test / Kit Bersama - - -

PT. Fokus
Diagnostic
97 RPR TEST (FOKUS) KIT 100 Test / Kit Indonesia - 1 1
BAHAN KIMIA DBD
50 Sachet@10
98 Abate Sachet gr / Box BASF - - -

5
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
Bacillus Thuringiensi Var.Isra Serotype H- PT.Mahakam
99 14/BACTIVEC Botol Botol 30 ml Beta Farma 90 - 90
Sumitomo
100 d,d-Trans - Sifenotrin (GOKILATH) Botol Botol 1 Liter Chemical - 9 9
REAGENT TB PARU
101 Box Slide PCS Box Lokal - - -
102 Catrige (Gene Xpert) MTB/Rif Paket 50 Pcs/Box PT. CEPHEID - - -
PT. Jayamas-
103 Deck Glass/Cover Glass Kotak 100 Pcs/Kotak Onemed - - -
104 Eter Alkohol Botol 100 ml Botol 100 ml/Btl Indoreagen - 1 1
105 Immersion Oil Botol 100 ml/btl Indoreagen - - -
106 Object Glass/ Slide Kotak Kotak - 2 2
107 Pot Dahak PCS Pcs - - -
108 Pot Dahak Steril PCS Pcs 300 - 300
109 Spiritus Botol 1 Liter Botol 1 Ltr/ btl Lokal - 1 1
110 Tissue Lensa Kotak Kotak Kimtech - 2 2
111 Xylol/ Xylene 100 ml/ Btl Botol 100 ml/ btl - - -
PT. ST.
112 Xylol/ Xylene 500 ml/ Btl Botol 500 ml/ Btl REAGENSIA - - -
113 Ziehl Nielsen KIT Set Indoreagen 3 - 3
REAGENT HEMATOLOGI ANALYZER
125 Boule Cleaning Kit KIT KIT Medonic - - -
126 Boule M Series Dual Pack (D+L) KIT KIT BOULE - - -
127 Boule M Series Lyse KIT KIT Medonic - - -
PT. Rajawali
128 CD 18 Plus Control (F Pack) Botol 12 x 2,5 ml Nusindo - - -
129 Cell Clean Botol 1 x 50 ml Sysmex - - -
130 Cell-DYN Control Seri 1 Box 4 Seri PT. ABBOTT - - -
131 Cellpack Botol 20 L - - -
132 Cleaner Botol 960 ml PT. ABBOTT - - -
Control Diff Low, Normal dan High 16
133 Parameter SET SET Medonic - - -
134 Control Diff Normal 16 parameter KIT KIT Medonic - - -
135 Control Normal Botol KIT - - -

6
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8
PT. Rajawali
136 Control Normal For Fotometer Rajawali Botol 12 X 5 ml Nusindo - - -
PT. Rajawali
137 Diluent Botol Botol 10 Liter Nusindo - - -
138 Eight Check (L,N,H)/ Control 3 x 1,5 ml Botol Botol 3 x 1,5 ml Sysmex - - -
139 Lyse Botol Botol 960 ml PT. ABBOTT - - -
140 Miniclean Botol Botol 1 Liter ABX - - -
141 Minidil LMG Botol Botol 10 Liter ABX - - -
142 Minilyse Botol Botol 1 Liter ABX - - -
143 Minitrol 16 twinpack Botol Botol 1 X 2,5 ml - - -
144 Plastic Micropipettes For MPA Tube 100 Pcs/Tube BOULE - - -
145 Poch-pack D (II) Botol 1x5L Sysmex - - -
146 Poch-Pack L (II) Botol 1 x 500 ml Sysmex - - -
147 Stromatolyzer Botol 500 ml/btl Sysmex - - -
REAGENT TAMBAHAN
148 Backer Glass PCS uk 50 ml Pyrex - - -
149 Batang Pengaduk PCS Pcs Lokal - - -
150 Blood Lancet BOX 200 Pcs/Box General Care - - -
151 Botol Semprot PCS Pcs Lokal - - -
152 Corong Kaca Diameter 10cm PCS Pcs Lokal - - -
153 Gelas Ukur 100ml PCS Uk 100 ml Pyrex - - -
154 Karet Penghisap PCS - Lokal - - -

155 Kartu Golongan Darah PAK Pak @100 lembar PT. Rafa Topaz - 1 1
156 Lampu Spirtus/Bunsen PCS Pcs Lokal - - -
157 Needle 23 G PCS 1 - - -
158 Ose Bulat PCS Pcs Lokal - - -
159 Penjepit Tabung PCS Pcs Lokal - - -
160 Pipet Skala 10 ml PCS Pcs Pyrex - - -
161 Plat Widal PCS Pcs PT. Rafa Topaz - - -
162 Rak Pewarnaan Akrilik PCS Box Lokal - - -
163 Rak Tabung Kaca PCS Pcs Lokal - - -

164 Rapid Tes HIV 3 Triline Card Test 40 Card Test / Box PT. Intec - - -
165 RDT COVID-19 Test 20 Test/Box SD - Biosensor - - -

7
NO NAMA PERBEKALAN FARMASI SATUAN KEMASAN PABRIK STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7 8

166 Reagen CD4 Control Test 1 PT. Alere Health - - -

167 Sikat Tabung PCS Pcs Lokal - - -
168 Swab Nasofaring (Covid-19) PCS 1 PT. J.able - - -
169 Swab Oropharynx (Covid-19) PCS 1 - - -
170 Tabung Reaksi 4ml PCS - Pyrex - - -
171 Tabung Reaksi 7ml PCS Pcs Pyrex - - -
172 Touriniquet PCS Pcs Lokal - - -
173 Viral Transport Medium (VTM) PCS 1 - - -

JUMLAH KUNJUNGAN PASIEN LABORATORIUM

Mengetahui / Menyetujui Yang Menyerahkan ,

Kepala Dinas Kesehatan Kepala Instalasi Farmasi

DR. HJ. LIZA PUSPADEWI, M. KES RATNA SUMIRAT, S.SI, M.FARM, APT
NIP. 196107131989112001 NIP. 197805101997022001

8
GEN ( LPLPR )

DOKUMEN NOMOR TANGGAL

DINKES KOTA
GUDANG KOTA
PUSKESMAS

PEMAKAIAN STOK AKHIR PERMINTAAN PEMBERIAN KETERANGAN

9 10 11 12 13

- 0 - -

- 0 - -

5 5 - -
- 0 - -

- 0 - -
1 1 1 -
- 0 - -

- 0 - -

- 0 - -

- 0 - -
- 1 - -

- 0 - -

- 0 - -

- 0 - -

- 0 - -

9
PEMAKAIAN STOK AKHIR PERMINTAAN
9 10 11
- 0
1 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 4
- 0
- 0
1 0
- 0
- 0
- 0
- 0
- 0
- 0
PEMBERIAN KETERANGAN
12 13
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
10
PEMAKAIAN STOK AKHIR PERMINTAAN PEMBERIAN KETERANGAN
9 10 11 12 13
- 0 - -
- 0 - -

- 3 - -

- 0 - -

100 100 - -

- 0 - -

- 0 - -

- 0 - -

- 0 - -

- 0 - -
- 0 - -
- 0 - -
- 0 - -

- 200 - -
- 0 - -

- 0 - -

- 0 - -

- 0 - -
- 0 - -
- 0 - -

11
PEMAKAIAN STOK AKHIR PERMINTAAN
9 10 11
1 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 10
- 0
100 125
- 0
- 0
- 0
PEMBERIAN KETERANGAN
12 13
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
12
PEMAKAIAN STOK AKHIR PERMINTAAN PEMBERIAN KETERANGAN
9 10 11 12 13
- 0 - -
- 0 - -
- 0 - -

- 25 - -

- 0 - -
50 50 - -

50 50 - -

- 0 - -

- 0 - -

50 50 - -

10 15 - -
100 100 - -

- 0 - -

- 0 - -

- 0 - -

- 0 - -

1 0 - -

- 0 - -

13
PEMAKAIAN STOK AKHIR PERMINTAAN
9 10 11
7 83
8 1 (1)
- 0
- 0
- 0
1 0
- 0
2 0
- 0
100 200
1 0
2 0
- 0
- 0
- 3
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
PEMBERIAN KETERANGAN
12 13
- -
-
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
14
PEMAKAIAN STOK AKHIR PERMINTAAN
9 10 11
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 1
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
PEMBERIAN KETERANGAN
12 13
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
15
 PEMAKAIAN STOK AKHIR PERMINTAAN
9 10 11
- 0
- 0
- 0
- 0
- 0
- 0
- 0
- 0
UMUM BPJS
Yang Meminta ,
Kepala Puskesmas
NIP.
PEMBERIAN KETERANGAN
12 13
- -
- -
- -
- -
- -
- -
- -
- -
Yang Membuat ,
Pengelola Bahan Kimia
NIP.
16