LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

( TABUNG OKSIGEN )

KODE PUSKESMA: 435 102 128

PUSKESMAS : MASALEMBU
KECAMATAN : MASALEMBU
KABUPATEN : SUMENEP Bulan : : Desember
PROPINSI : JAWA TIMUR Tahun : 2022

STOK PENERI PERSE PENGE SISA PERMIN PEMBE

NO NAMA OBAT KEMASAN KETERANGAN
AWAL MAAN DIAAN LUARAN STOK TAAN RIAN
1 T. OKSIGEN BESAR TBG 17 0 17 17 0 17
2
3
4
5
6
7

Mengetahui Petugas Farmasi Puskesmas Masalembu

Plt Kepala Puskesmas Masalembu
Kabupaten Sumenep

Hollilah, A. Md., Kep Eka Septiana Wulandari, S.Farm., Apt.

Nip. 19690715 199102 1 003 Nip. 19900920 202012 2 003
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS :
PUSKESMAS :
KECAMATAN :
KABUPATEN : SUMENEP Bulan : DESEMBER
PROPINSI : JAWA TIMUR Tahun : 2013

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
1 Albendazol tab 400mg Kotak 5x6tab 100 100 200 100 100
2 Allopurinol 100mg ktk 10x10 tab 0 0
3 Ambroksol 30mg tab ktk 10x10 tab 0 0
4 Ambroxol syr 15mg/ml botol 60ml 0 0
5 Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0
6 Aminofilin tab 200mg btl 100tab 0 0
7 Amitriptilin tab 25mg 10x10tab 0 0
8 Amoksisilin 500mg kap 10x10kap 0 0
9 Amoksisilin kapsul 250mg ktk 100 kaps 0 0
10 Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0
11 Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0
12 Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0
13 Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0
14 Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0
15 +As.salisilat3%) 24pot 30g 0 0
16 Antihemorrhoid DOEN Komb. ktk 10 supp 0 0
17 Aqua pro injeksi steril ktk 10vial 20ml 0 0
18 Asam Askorbat 50 mg btl 1000 tablet 0 0
19 Asam Askorbat/Vit.C 250mg 10x10tab 0 0
20 Asam Mefenamat 500mg 100kaps 0 0
21 Asiklovir 400mg 100tab 0 0
22 Asiklovir krim 5% Dus 25 tube@5 g 0 0
23 Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0
24 Betahistin mesilat tab 6mg ktk / 3x10tab 0 0
25 Betametason krim 0,1% ktk,25 tube@5 g 0 0
26 Bromheksin tab. ktk 10 x 10 tab 0 0
27 Codein 10 mg btl 250 tab 0 0
28 CTM tab 4 mg btl 100 tab 0 0
29 Deksametason 0,5mg strip 10x10 tab 0 0
30 Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0
31 Dekstrometorphan 15mg 100tab 0 0
32 Dekstrometorphan sir.10mg/5ml btl 60ml 0 0
33 Diazepam inj 5mg/ml 30ampul 2ml 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
34 Diazepam tab 2mg btl 100tab 0 0
35 Diazepam tab 5mg 10x10tab 0 0
36 Difenhidramin inj im 10mg/ml ktk 30 ampx 1ml 0 0
37 Digoksin 0,25mg 10x10 tab 0 0
38 Efedrin Hcl 25mg btl 250 tab 0 0
39 Efedrin Tab. 25 mg btl 250 tablet 0 0
40 Epinefrin/adrenalin inj 0,1% ktk 30 ampx 1ml 0 0
41 Eritromisin 500 mg 10x10 tab 0 0
42 Eritromisin sir.200mg/5ml btl60ml 0 0
43 Etakridin lar.0,1% btl 300ml 0 0
44 Etanol 70 % btl 1000 ml 0 0
45 Famotidin tab 20mg 5x10tab 0 0
46 Fenobarbital inj im/iv 50mg/ml 30amp 1ml 0 0
47 Fenobarbital tab 100mg btl 250 tab 0 0
48 Fenobarbital tab 30mg 10x10tab 0 0
49 Fenol Gliserol tts telinga 10% 24btl 5ml 0 0
50 Fitomenadion/Vit K inj 10mg/ml ktk 30 ampx 1ml 0 0
51 Fitomenadion/Vit K tab 10mg btl 100tab 0 0
52 Furosemid 40mg 20x10tab 0 0
53 Furosemid inj ktk 25 ampul 0 0
54 Garam Oralit I 100 sachet 0 0
55 Gemfibrozil kap 300mg 10x12kaps 0 0
56 Gentamisin salep kulit 0,1% 10tube 5g 0 0
57 Gentamisin Sulfat tts mata 0,3% ktk 10btl@5ml 0 0
58 Gentamycin Injeksi 40 mg/ml ktk 5vial @ 2 ml 0 0
59 Gentian Violet 1 % botol 10ml 0 0
60 Glibenklamid tab 5 mg dus,10 blister@10tab 0 0
61 Gliseril guaiakolat 100 mg btl 1000 tablet 0 0
62 Glukosa lar.infus 10% steril btl 500ml 0 0
63 Glukosa lar.infus 40% steril ampul@25ml 0 0
64 Glukosa lar.infus 5% steril btl 500ml 0 0
65 Griseofulvin 125mg 10x10tab 0 0
66 Haloperidol 5 mg ktk 10 x 10 tab 0 0
67 Haloperidol tab 0,5mg 10x10tab 0 0
68 Haloperidol tab 1,5mg 10x10tab 0 0
69 Hidroklortiazid (HCT) tab 0 0
70 Hidrokortison krim 2,5% dus,24 tube @ 5 g 0 0
71 Ibuprofen 200mg btl 100 tab 0 0
72 Ibuprofen 200mg btl 100tab 0 0
73 Ibuprofen 400mg ktk 10 strip x 10's 0 0
74 Ibuprofen suspensi 100mg/5ml botol 60ml 0 0
75 Isosorbid dinitrat tab sublingual 5mg dus,10strip@10 tab 0 0
76 Kalium diklofenak 50mg ktk 5x10 tab 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
77 Kalsium Laktat 500 mg btl 1000 tablet 0 0
78 Kaptopril 12,5 mg ktk 10 strip x 10's 0 0
79 Kaptopril 25mg dus,10strip@10 tab 0 0
80 Karbamazepin 200mg dus,10 blister@10tab 0 0
81 Ketokonazol tab 200mg ktk 5x10 tab 0 0
82 Klindamisin 300mg Dus,5 blister@10kaps 0 0
83 Kloramfenikol 250mg ktk 10 strip x 10's 0 0
84 Kloramfenikol salep mata 1% 5g 0 0
85 Kloramfenikol susp 125mg/5ml botol 60ml 0 0
86 Kloramfenikol Tetes Mata 0,5 % btl 5 ml 0 0
87 Kloramfenikol tts telinga 3% btl 5ml 0 0
Kotrimoksazol DOEN II
88 Pediatrik(sulfa100mg+trimet20mg) 10x10tab 0 0
89 Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml 0 0
90 Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml 0 0
91 Lisol botol 1000 ml 0 0
92 Mebendazol sir. 100mg/5ml btl 30ml 0 0
93 Mebendazol tab 100mg 3x10tab 0 0
94 Metampiron inj 250mg 30amp 2ml 0 0
95 Metampiron tab 500mg 10x10tab 0 0
96 Metformin Hcl tab 500mg ktk 10x10 tab 0 0
97 Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul 0 0
98 Metronidasol 250mg tab ktk 10x10 tab 0 0
99 Metronidasol 500mg tab ktk 10x10 tab 0 0
100 Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml 0 0
101 Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet 0 0
102 Natrium klorida lar.infus 0,9% btl 500ml 0 0
103 Nifedipin 10mg 10x10tab 0 0
104 Nistatin 500.000 IU/g ktk 10 strip x 10's 0 0
105 Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's 0 0
106 OAT FDC kategori 2 paket 0 0
107 OAT FDC kategori Anak paket 0 0
108 OAT FDC kategori I paket 0 0
109 OBH cairan btl 100ml 0 0
110 Oksitetra salep kulit 3% dus,25 tube@5g 0 0
111 Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial 0 0
112 Oksitetrasiklin salep mata 1% 25tube 3,5g 0 0
113 Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc 0 0
114 Omeprazol kap 20mg ktk 3x10 kap 0 0
115 Parasetamol 100mg btl 100tab 0 0
116 Parasetamol sir.120mg/5ml btl 60ml 0 0
117 Parasetamol tab 500mg 10x10tab 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
118 Pirantel sir.125mg/5ml btl 60ml 0 0
119 Pirantel tab tab 0 0
120 Piroksikam 20mg 10x10 tab 0 0
121 Povidon Iodida lar.10% btl 300ml 0 0
122 Povidon Iodida lar.10% btl 30ml 0 0
123 Prednison 5mg 10x10tab 0 0
124 Propanolol 10mg tab 10x10tab 0 0
125 Propanolol tab 40mg btl 100tab 0 0
126 Propiltiourasil tab 100mg btl 100tab 0 0
127 Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0
128 Ranitidin tab 150mg ktk 10x10 tab 0 0
129 Reserpin tab 0,25mg 10x10tab 0 0
130 RL infus btl 500ml 0 0
131 Salbutamol 2mg 10x10 tab 0 0
132 Salbutamol 4mg 10x10tab 0 0
133 Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0
134 salisil Bedak 2% ktk 50 g 0 0
135 Sefadroksil 500mg ktk 10x10 tab 0 0
136 Sefadroksil sir kering125mg/5ml ktk 60ml 0 0
137 Sefotaksim inj 1g 10vial 1g 0 0
138 Seftriakson inj 1 g ktk 2vial 1 g 0 0
139 Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0
140 Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0
141 Simetidin 200mg tab 10x10tab 0 0
142 Simvastatin tab 10mg ktk 3x10 kap 0 0
143 Siprofloksasin tab 500mg ktk 100tab 0 0
144 Sulfasetamid tts mata 15% btl 5ml 0 0
145 Tetrasiklin 250mg ktk 10 strip x 10's 0 0
146 Tetrasiklin 500mg ktk 10 strip x 10's 0 0
147 Tiamfenikol kap 500mg 10x10kap 0 0
148 Tiamin tab. 50 mg btl 1000 tablet 0 0
149 Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0
150 Triheksifenidil ktk 10 strip x 10's 0 0
151 Vitamin B Complek tablet botol 1000 tab 0 0
152 Zinc tab 20mg dus,10strip@10 tab 0 0
0 0
0 0
OBAT GIGI 0 0
153 Etil Klorida Spray vial/can/100 ml 0 0
154 Glass Ionomer Cement ART set/btl 0 0
155 Kalsium Hidroksida Pasta ktk 2 tube 0 0
156 Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0
157 Mummifying Pasta btl/ktk 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
158 Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0
159 Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0
0 0
PERBEKALAN KESEHATAN 0 0
160 alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0
161 alat suntik sekali pakai 5 ml 100 set/ktk 0 0
162 catgut benang bedah no 2/0 dg jarum bedah pcs 0 0
163 infusion set dewasa set/kantong 0 0
164 kapas pembalut/adsorben 250gr bungkus 0 0
165 kasa 16 x 16 cm rol 0 0
166 plester 5 yards x 2 inch kotak 6 roll 0 0
167 sarung tangan no 7,5 50 pasang/ktk 0 0
0 0
APBD 0 0
168 catgut benang bedah no 3/0 dg jarum bedah pcs 0 0
169 folley catheter 16 pcs 0 0
170 folley catheter 18 pcs 0 0
171 infusion set anak set/kantong 0 0
172 IV catheter 18 G 50buah/ktk 0 0
173 IV catheter 22 G 50buah/ktk 0 0
174 IV catheter 24G 50buah/ktk 0 0
175 kasa hidrofil 36mx80 cm roll 0 0
176 kasa hidrofil 4mx10 cm rol/50 0 0
177 kasa hidrofil 4mx5 cm rol/100 0 0
178 masker 20pcs/ktk 0 0
179 sarung tangan no 7 50 pasang/ktk 0 0
180 Serum Anti Bisa Ular ABU I vial 5 ml 0 0
181 Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0
182 Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0
183 silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0

Sumenep, 2013
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip.
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD

catatan kolom
- stock awal (hanya bulan DES 2013 saja), penerimaan, stock ahir, permintaan di isi secara manual
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESM

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : JANUARY KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
1 Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
2 Allopurinol 100mg ktk 10x10 tab 0 0 0 2
3 Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
4 Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
5 Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
6 Aminofilin tab 200mg btl 100tab 0 0 0 6
7 Amitriptilin tab 25mg 10x10tab 0 0 0 7
8 Amoksisilin 500mg kap 10x10kap 0 0 0 8
9 Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
10 Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
11 Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
12 Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
13 Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
14 Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
15 +As.salisilat3%) 24pot 30g 0 0 0 15
16 Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
17 Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
18 Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
19 Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
20 Asam Mefenamat 500mg 100kaps 0 0 0 20
21 Asiklovir 400mg 100tab 0 0 0 21
22 Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
23 Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
24 Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
25 Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
26 Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
27 Codein 10 mg btl 250 tab 0 0 0 27
28 CTM tab 4 mg btl 100 tab 0 0 0 28
29 Deksametason 0,5mg strip 10x10 tab 0 0 0 29
30 Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
31 Dekstrometorphan 15mg 100tab 0 0 0 31
32 Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
33 Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
34 Diazepam tab 2mg btl 100tab 0 0 0 34
35 Diazepam tab 5mg 10x10tab 0 0 0 35
36 Difenhidramin inj im 10mg/ml ktk 30 ampx 1ml 0 0 0 36
37 Digoksin 0,25mg 10x10 tab 0 0 0 37
38 Efedrin Hcl 25mg btl 250 tab 0 0 0 38
39 Efedrin Tab. 25 mg btl 250 tablet 0 0 0 39
40 Epinefrin/adrenalin inj 0,1% ktk 30 ampx 1ml 0 0 0 40
41 Eritromisin 500 mg 10x10 tab 0 0 0 41
42 Eritromisin sir.200mg/5ml btl60ml 0 0 0 42
43 Etakridin lar.0,1% btl 300ml 0 0 0 43
44 Etanol 70 % btl 1000 ml 0 0 0 44
45 Famotidin tab 20mg 5x10tab 0 0 0 45
46 Fenobarbital inj im/iv 50mg/ml 30amp 1ml 0 0 0 46
47 Fenobarbital tab 100mg btl 250 tab 0 0 0 47
48 Fenobarbital tab 30mg 10x10tab 0 0 0 48
49 Fenol Gliserol tts telinga 10% 24btl 5ml 0 0 0 49
50 Fitomenadion/Vit K inj 10mg/ml ktk 30 ampx 1ml 0 0 0 50
51 Fitomenadion/Vit K tab 10mg btl 100tab 0 0 0 51
52 Furosemid 40mg 20x10tab 0 0 0 52
53 Furosemid inj ktk 25 ampul 0 0 0 53
54 Garam Oralit I 100 sachet 0 0 0 54
55 Gemfibrozil kap 300mg 10x12kaps 0 0 0 55
56 Gentamisin salep kulit 0,1% 10tube 5g 0 0 0 56
57 Gentamisin Sulfat tts mata 0,3% ktk 10btl@5ml 0 0 0 57
58 Gentamycin Injeksi 40 mg/ml ktk 5vial @ 2 ml 0 0 0 58
59 Gentian Violet 1 % botol 10ml 0 0 0 59
60 Glibenklamid tab 5 mg dus,10 blister@10tab 0 0 0 60
61 Gliseril guaiakolat 100 mg btl 1000 tablet 0 0 0 61
62 Glukosa lar.infus 10% steril btl 500ml 0 0 0 62
63 Glukosa lar.infus 40% steril ampul@25ml 0 0 0 63
64 Glukosa lar.infus 5% steril btl 500ml 0 0 0 64
65 Griseofulvin 125mg 10x10tab 0 0 0 65
66 Haloperidol 5 mg ktk 10 x 10 tab 0 0 0 66
67 Haloperidol tab 0,5mg 10x10tab 0 0 0 67
68 Haloperidol tab 1,5mg 10x10tab 0 0 0 68
69 Hidroklortiazid (HCT) tab 0 0 0 69
70 Hidrokortison krim 2,5% dus,24 tube @ 5 g 0 0 0 70
71 Ibuprofen 200mg btl 100 tab 0 0 0 71
72 Ibuprofen 200mg btl 100tab 0 0 0 72
73 Ibuprofen 400mg ktk 10 strip x 10's 0 0 0 73
74 Ibuprofen suspensi 100mg/5ml botol 60ml 0 0 0 74
75 Isosorbid dinitrat tab sublingual 5mg dus,10strip@10 tab 0 0 0 75
76 Kalium diklofenak 50mg ktk 5x10 tab 0 0 0 76
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
77 Kalsium Laktat 500 mg btl 1000 tablet 0 0 0 77
78 Kaptopril 12,5 mg ktk 10 strip x 10's 0 0 0 78
79 Kaptopril 25mg dus,10strip@10 tab 0 0 0 79
80 Karbamazepin 200mg dus,10 blister@10tab 0 0 0 80
81 Ketokonazol tab 200mg ktk 5x10 tab 0 0 0 81
82 Klindamisin 300mg Dus,5 blister@10kaps 0 0 0 82
83 Kloramfenikol 250mg ktk 10 strip x 10's 0 0 0 83
84 Kloramfenikol salep mata 1% 5g 0 0 0 84
85 Kloramfenikol susp 125mg/5ml botol 60ml 0 0 0 85
86 Kloramfenikol Tetes Mata 0,5 % btl 5 ml 0 0 0 86
87 Kloramfenikol tts telinga 3% btl 5ml 0 0 0 87
Kotrimoksazol DOEN II
88 Pediatrik(sulfa100mg+trimet20mg) 10x10tab 0 0 0 88
89 Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml 0 0 0 89
90 Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml 0 0 0 90
91 Lisol botol 1000 ml 0 0 0 91
92 Mebendazol sir. 100mg/5ml btl 30ml 0 0 0 92
93 Mebendazol tab 100mg 3x10tab 0 0 0 93
94 Metampiron inj 250mg 30amp 2ml 0 0 0 94
95 Metampiron tab 500mg 10x10tab 0 0 0 95
96 Metformin Hcl tab 500mg ktk 10x10 tab 0 0 0 96
97 Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul 0 0 0 97
98 Metronidasol 250mg tab ktk 10x10 tab 0 0 0 98
99 Metronidasol 500mg tab ktk 10x10 tab 0 0 0 99
100 Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml 0 0 0 100
101 Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet 0 0 0 101
102 Natrium klorida lar.infus 0,9% btl 500ml 0 0 0 102
103 Nifedipin 10mg 10x10tab 0 0 0 103
104 Nistatin 500.000 IU/g ktk 10 strip x 10's 0 0 0 104
105 Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's 0 0 0 105
106 OAT FDC kategori 2 paket 0 0 0 106
107 OAT FDC kategori Anak paket 0 0 0 107
108 OAT FDC kategori I paket 0 0 0 108
109 OBH cairan btl 100ml 0 0 0 109
110 Oksitetra salep kulit 3% dus,25 tube@5g 0 0 0 110
111 Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial 0 0 0 111
112 Oksitetrasiklin salep mata 1% 25tube 3,5g 0 0 0 112
113 Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc 0 0 0 113
114 Omeprazol kap 20mg ktk 3x10 kap 0 0 0 114
115 Parasetamol 100mg btl 100tab 0 0 0 115
116 Parasetamol sir.120mg/5ml btl 60ml 0 0 0 116
117 Parasetamol tab 500mg 10x10tab 0 0 0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
118 Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
119 Pirantel tab tab 0 0 0 119
120 Piroksikam 20mg 10x10 tab 0 0 0 120
121 Povidon Iodida lar.10% btl 300ml 0 0 0 121
122 Povidon Iodida lar.10% btl 30ml 0 0 0 122
123 Prednison 5mg 10x10tab 0 0 0 123
124 Propanolol 10mg tab 10x10tab 0 0 0 124
125 Propanolol tab 40mg btl 100tab 0 0 0 125
126 Propiltiourasil tab 100mg btl 100tab 0 0 0 126
127 Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
128 Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
129 Reserpin tab 0,25mg 10x10tab 0 0 0 129
130 RL infus btl 500ml 0 0 0 130
131 Salbutamol 2mg 10x10 tab 0 0 0 131
132 Salbutamol 4mg 10x10tab 0 0 0 132
133 Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
134 salisil Bedak 2% ktk 50 g 0 0 0 134
135 Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
136 Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
137 Sefotaksim inj 1g 10vial 1g 0 0 0 137
138 Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
139 Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
140 Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
141 Simetidin 200mg tab 10x10tab 0 0 0 141
142 Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
143 Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
144 Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
145 Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
146 Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
147 Tiamfenikol kap 500mg 10x10kap 0 0 0 147
148 Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
149 Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
150 Triheksifenidil ktk 10 strip x 10's 0 0 0 150
151 Vitamin B Complek tablet botol 1000 tab 0 0 0 151
152 Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
153 Etil Klorida Spray vial/can/100 ml 0 0 0 153
154 Glass Ionomer Cement ART set/btl 0 0 0 154
155 Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
156 Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
157 Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
158 Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
159 Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
160 alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
161 alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
162 catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
163 infusion set dewasa set/kantong 0 0 0 163
164 kapas pembalut/adsorben 250gr bungkus 0 0 0 164
165 kasa 16 x 16 cm rol 0 0 0 165
166 plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
167 sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
168 catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
169 folley catheter 16 pcs 0 0 0 169
170 folley catheter 18 pcs 0 0 0 170
171 infusion set anak set/kantong 0 0 0 171
172 IV catheter 18 G 50buah/ktk 0 0 0 172
173 IV catheter 22 G 50buah/ktk 0 0 0 173
174 IV catheter 24G 50buah/ktk 0 0 0 174
175 kasa hidrofil 36mx80 cm roll 0 0 0 175
176 kasa hidrofil 4mx10 cm rol/50 0 0 0 176
177 kasa hidrofil 4mx5 cm rol/100 0 0 0 177
178 masker 20pcs/ktk 0 0 0 178
179 sarung tangan no 7 50 pasang/ktk 0 0 0 179
180 Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
181 Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
182 Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
183 silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.AN

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. N
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NO NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD

catatan kolom
- penerimaan, stock akhir, permintaan di isi secara manual
(BULAN JANUARY S/D DESEMBER 2014)
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : FEBRUARY KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : MARET KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : APRIL KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : MEI KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : JUNI KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : JULI KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : AGUSTUS KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : SEPTEMBER KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : OKTOBER KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS : KODE PUSKESMAS

PUSKESMAS : PUSKESMAS
KECAMATAN : KECAMATAN
KABUPATEN : SUMENEP Bulan : NOPEMBER KABUPATEN
PROPINSI : JAWA TIMUR Tahun : 2014 PROPINSI

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100 1
Allopurinol 100mg ktk 10x10 tab 0 0 0 2
Ambroksol 30mg tab ktk 10x10 tab 0 0 0 3
Ambroxol syr 15mg/ml botol 60ml 0 0 0 4
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0 5
Aminofilin tab 200mg btl 100tab 0 0 0 6
Amitriptilin tab 25mg 10x10tab 0 0 0 7
Amoksisilin 500mg kap 10x10kap 0 0 0 8
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0 9
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0 10
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0 11
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0 12
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0 13
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0 14
+As.salisilat3%) 24pot 30g 0 0 0 15
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0 16
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0 17
Asam Askorbat 50 mg btl 1000 tablet 0 0 0 18
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0 19
Asam Mefenamat 500mg 100kaps 0 0 0 20
Asiklovir 400mg 100tab 0 0 0 21
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0 22
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0 23
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0 24
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0 25
Bromheksin tab. ktk 10 x 10 tab 0 0 0 26
Codein 10 mg btl 250 tab 0 0 0 27
CTM tab 4 mg btl 100 tab 0 0 0 28
Deksametason 0,5mg strip 10x10 tab 0 0 0 29
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0 30
Dekstrometorphan 15mg 100tab 0 0 0 31
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0 32
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0 33

NAMA OBAT
Diazepam tab 2mg
Diazepam tab 5mg
Difenhidramin inj im 10mg/ml
Digoksin 0,25mg
Efedrin Hcl 25mg
Efedrin Tab. 25 mg
Epinefrin/adrenalin inj 0,1%
Eritromisin 500 mg
Eritromisin sir.200mg/5ml
Etakridin lar.0,1%
Etanol 70 %
Famotidin tab 20mg
Fenobarbital inj im/iv 50mg/ml
Fenobarbital tab 100mg
Fenobarbital tab 30mg
Fenol Gliserol tts telinga 10%
Fitomenadion/Vit K inj 10mg/ml
Fitomenadion/Vit K tab 10mg
Furosemid 40mg
Furosemid inj
Garam Oralit I
Gemfibrozil kap 300mg
Gentamisin salep kulit 0,1%
Gentamisin Sulfat tts mata 0,3%
Gentamycin Injeksi 40 mg/ml
Gentian Violet 1 %
Glibenklamid tab 5 mg
Gliseril guaiakolat 100 mg
Glukosa lar.infus 10% steril
Glukosa lar.infus 40% steril
Glukosa lar.infus 5% steril
Griseofulvin 125mg
Haloperidol 5 mg
Haloperidol tab 0,5mg
Haloperidol tab 1,5mg
Hidroklortiazid (HCT)
Hidrokortison krim 2,5%
Ibuprofen 200mg
Ibuprofen 200mg
Ibuprofen 400mg
Ibuprofen suspensi 100mg/5ml
Isosorbid dinitrat tab sublingual 5mg
Kalium diklofenak 50mg
STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
btl 100tab 0 0 0 34
10x10tab 0 0 0 35
ktk 30 ampx 1ml 0 0 0 36
10x10 tab 0 0 0 37
btl 250 tab 0 0 0 38
btl 250 tablet 0 0 0 39
ktk 30 ampx 1ml 0 0 0 40
10x10 tab 0 0 0 41
btl60ml 0 0 0 42
btl 300ml 0 0 0 43
btl 1000 ml 0 0 0 44
5x10tab 0 0 0 45
30amp 1ml 0 0 0 46
btl 250 tab 0 0 0 47
10x10tab 0 0 0 48
24btl 5ml 0 0 0 49
ktk 30 ampx 1ml 0 0 0 50
btl 100tab 0 0 0 51
20x10tab 0 0 0 52
ktk 25 ampul 0 0 0 53
100 sachet 0 0 0 54
10x12kaps 0 0 0 55
10tube 5g 0 0 0 56
ktk 10btl@5ml 0 0 0 57
ktk 5vial @ 2 ml 0 0 0 58
botol 10ml 0 0 0 59
dus,10 blister@10tab 0 0 0 60
btl 1000 tablet 0 0 0 61
btl 500ml 0 0 0 62
ampul@25ml 0 0 0 63
btl 500ml 0 0 0 64
10x10tab 0 0 0 65
ktk 10 x 10 tab 0 0 0 66
10x10tab 0 0 0 67
10x10tab 0 0 0 68
tab 0 0 0 69
dus,24 tube @ 5 g 0 0 0 70
btl 100 tab 0 0 0 71
btl 100tab 0 0 0 72
ktk 10 strip x 10's 0 0 0 73
botol 60ml 0 0 0 74
dus,10strip@10 tab 0 0 0 75
ktk 5x10 tab 0 0 0 76
 STOK
NAMA OBAT KEMASAN
AWAL
Kalsium Laktat 500 mg btl 1000 tablet
Kaptopril 12,5 mg ktk 10 strip x 10's
Kaptopril 25mg dus,10strip@10 tab
Karbamazepin 200mg dus,10 blister@10tab
Ketokonazol tab 200mg ktk 5x10 tab
Klindamisin 300mg Dus,5 blister@10kaps
Kloramfenikol 250mg ktk 10 strip x 10's
Kloramfenikol salep mata 1% 5g
Kloramfenikol susp 125mg/5ml botol 60ml
Kloramfenikol Tetes Mata 0,5 % btl 5 ml
Kloramfenikol tts telinga 3% btl 5ml
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml
Lisol botol 1000 ml
Mebendazol sir. 100mg/5ml btl 30ml
Mebendazol tab 100mg 3x10tab
Metampiron inj 250mg 30amp 2ml
Metampiron tab 500mg 10x10tab
Metformin Hcl tab 500mg ktk 10x10 tab
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul
Metronidasol 250mg tab ktk 10x10 tab
Metronidasol 500mg tab ktk 10x10 tab
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet
Natrium klorida lar.infus 0,9% btl 500ml
Nifedipin 10mg 10x10tab
Nistatin 500.000 IU/g ktk 10 strip x 10's
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's
OAT FDC kategori 2 paket
OAT FDC kategori Anak paket
OAT FDC kategori I paket
OBH cairan btl 100ml
Oksitetra salep kulit 3% dus,25 tube@5g
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial
Oksitetrasiklin salep mata 1% 25tube 3,5g
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc
Omeprazol kap 20mg ktk 3x10 kap
Parasetamol 100mg btl 100tab
Parasetamol sir.120mg/5ml btl 60ml
Parasetamol tab 500mg 10x10tab
PENERI PERSE PENGE
MAAN DIAAN LUARAN
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
SISA PERMIN PEMBERIAN
KETR NO
STOK TAAN DAK APBD
0 77
0 78
0 79
0 80
0 81
0 82
0 83
0 84
0 85
0 86
0 87
0 88
0 89
0 90
0 91
0 92
0 93
0 94
0 95
0 96
0 97
0 98
0 99
0 100
0 101
0 102
0 103
0 104
0 105
0 106
0 107
0 108
0 109
0 110
0 111
0 112
0 113
0 114
0 115
0 116
0 117
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0 118
Pirantel tab tab 0 0 0 119
Piroksikam 20mg 10x10 tab 0 0 0 120
Povidon Iodida lar.10% btl 300ml 0 0 0 121
Povidon Iodida lar.10% btl 30ml 0 0 0 122
Prednison 5mg 10x10tab 0 0 0 123
Propanolol 10mg tab 10x10tab 0 0 0 124
Propanolol tab 40mg btl 100tab 0 0 0 125
Propiltiourasil tab 100mg btl 100tab 0 0 0 126
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0 127
Ranitidin tab 150mg ktk 10x10 tab 0 0 0 128
Reserpin tab 0,25mg 10x10tab 0 0 0 129
RL infus btl 500ml 0 0 0 130
Salbutamol 2mg 10x10 tab 0 0 0 131
Salbutamol 4mg 10x10tab 0 0 0 132
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0 133
salisil Bedak 2% ktk 50 g 0 0 0 134
Sefadroksil 500mg ktk 10x10 tab 0 0 0 135
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0 136
Sefotaksim inj 1g 10vial 1g 0 0 0 137
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0 138
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0 139
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0 140
Simetidin 200mg tab 10x10tab 0 0 0 141
Simvastatin tab 10mg ktk 3x10 kap 0 0 0 142
Siprofloksasin tab 500mg ktk 100tab 0 0 0 143
Sulfasetamid tts mata 15% btl 5ml 0 0 0 144
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0 145
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0 146
Tiamfenikol kap 500mg 10x10kap 0 0 0 147
Tiamin tab. 50 mg btl 1000 tablet 0 0 0 148
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0 149
Triheksifenidil ktk 10 strip x 10's 0 0 0 150
Vitamin B Complek tablet botol 1000 tab 0 0 0 151
Zinc tab 20mg dus,10strip@10 tab 0 0 0 152
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0 153
Glass Ionomer Cement ART set/btl 0 0 0 154
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0 155
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0 156
Mummifying Pasta btl/ktk 0 0 0 157
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR NO
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0 158
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0 159
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0 160
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0 161
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0 162
infusion set dewasa set/kantong 0 0 0 163
kapas pembalut/adsorben 250gr bungkus 0 0 0 164
kasa 16 x 16 cm rol 0 0 0 165
plester 5 yards x 2 inch kotak 6 roll 0 0 0 166
sarung tangan no 7,5 50 pasang/ktk 0 0 0 167
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0 168
folley catheter 16 pcs 0 0 0 169
folley catheter 18 pcs 0 0 0 170
infusion set anak set/kantong 0 0 0 171
IV catheter 18 G 50buah/ktk 0 0 0 172
IV catheter 22 G 50buah/ktk 0 0 0 173
IV catheter 24G 50buah/ktk 0 0 0 174
kasa hidrofil 36mx80 cm roll 0 0 0 175
kasa hidrofil 4mx10 cm rol/50 0 0 0 176
kasa hidrofil 4mx5 cm rol/100 0 0 0 177
masker 20pcs/ktk 0 0 0 178
sarung tangan no 7 50 pasang/ktk 0 0 0 179
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0 180
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0 181
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0 182
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0 183

Sumenep, 2014
Mengetahui Yang Menyerahkan Yang Menerima
Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas Kep
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................ K

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM dr.H.ANUG

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PKD TAHUN ANGGARAN 2013

KODE PUSKESMAS :
PUSKESMAS :
KECAMATAN :
KABUPATEN : SUMENEP Bulan : DESEMBER
PROPINSI : JAWA TIMUR Tahun : 2014

STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN

NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Albendazol tab 400mg Kotak 5x6tab 100 100 100
Allopurinol 100mg ktk 10x10 tab 0 0 0
Ambroksol 30mg tab ktk 10x10 tab 0 0 0
Ambroxol syr 15mg/ml botol 60ml 0 0 0
Aminofilin inj 24mg/ml ktk 30 ampx 10ml 0 0 0
Aminofilin tab 200mg btl 100tab 0 0 0
Amitriptilin tab 25mg 10x10tab 0 0 0
Amoksisilin 500mg kap 10x10kap 0 0 0
Amoksisilin kapsul 250mg ktk 100 kaps 0 0 0
Amoksisilin sirup kering 125mg/5ml botol 60ml 0 0 0
Amoksisilin+As.Klavulanat 625mg tab 5x6tab 0 0 0
Ampisilin serbuk inj im iv 1000mg/vial ktk 10 vial 0 0 0
Antasida DOEN
Antifungi DOEN I(AlOH200mg,MgOH200mg) 10x10tab 0 0 0
Antibakteri DOEN salep Basitrasin 500IU/g
(As.benzoat6% Dus 25 tube@5 g 0 0 0
+As.salisilat3%) 24pot 30g 0 0 0
Antihemorrhoid DOEN Komb. ktk 10 supp 0 0 0
Aqua pro injeksi steril ktk 10vial 20ml 0 0 0
Asam Askorbat 50 mg btl 1000 tablet 0 0 0
Asam Askorbat/Vit.C 250mg 10x10tab 0 0 0
Asam Mefenamat 500mg 100kaps 0 0 0
Asiklovir 400mg 100tab 0 0 0
Asiklovir krim 5% Dus 25 tube@5 g 0 0 0
Atropin inj i.m i.v s.k 0,25mg/ml dus 30 ampul@1ml 0 0 0
Betahistin mesilat tab 6mg ktk / 3x10tab 0 0 0
Betametason krim 0,1% ktk,25 tube@5 g 0 0 0
Bromheksin tab. ktk 10 x 10 tab 0 0 0
Codein 10 mg btl 250 tab 0 0 0
CTM tab 4 mg btl 100 tab 0 0 0
Deksametason 0,5mg strip 10x10 tab 0 0 0
Deksametason inj.i.v 5mg/ml ktk 100amp 1 ml 0 0 0
Dekstrometorphan 15mg 100tab 0 0 0
Dekstrometorphan sir.10mg/5ml btl 60ml 0 0 0
Diazepam inj 5mg/ml 30ampul 2ml 0 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Diazepam tab 2mg btl 100tab 0 0 0
Diazepam tab 5mg 10x10tab 0 0 0
Difenhidramin inj im 10mg/ml ktk 30 ampx 1ml 0 0 0
Digoksin 0,25mg 10x10 tab 0 0 0
Efedrin Hcl 25mg btl 250 tab 0 0 0
Efedrin Tab. 25 mg btl 250 tablet 0 0 0
Epinefrin/adrenalin inj 0,1% ktk 30 ampx 1ml 0 0 0
Eritromisin 500 mg 10x10 tab 0 0 0
Eritromisin sir.200mg/5ml btl60ml 0 0 0
Etakridin lar.0,1% btl 300ml 0 0 0
Etanol 70 % btl 1000 ml 0 0 0
Famotidin tab 20mg 5x10tab 0 0 0
Fenobarbital inj im/iv 50mg/ml 30amp 1ml 0 0 0
Fenobarbital tab 100mg btl 250 tab 0 0 0
Fenobarbital tab 30mg 10x10tab 0 0 0
Fenol Gliserol tts telinga 10% 24btl 5ml 0 0 0
Fitomenadion/Vit K inj 10mg/ml ktk 30 ampx 1ml 0 0 0
Fitomenadion/Vit K tab 10mg btl 100tab 0 0 0
Furosemid 40mg 20x10tab 0 0 0
Furosemid inj ktk 25 ampul 0 0 0
Garam Oralit I 100 sachet 0 0 0
Gemfibrozil kap 300mg 10x12kaps 0 0 0
Gentamisin salep kulit 0,1% 10tube 5g 0 0 0
Gentamisin Sulfat tts mata 0,3% ktk 10btl@5ml 0 0 0
Gentamycin Injeksi 40 mg/ml ktk 5vial @ 2 ml 0 0 0
Gentian Violet 1 % botol 10ml 0 0 0
Glibenklamid tab 5 mg dus,10 blister@10tab 0 0 0
Gliseril guaiakolat 100 mg btl 1000 tablet 0 0 0
Glukosa lar.infus 10% steril btl 500ml 0 0 0
Glukosa lar.infus 40% steril ampul@25ml 0 0 0
Glukosa lar.infus 5% steril btl 500ml 0 0 0
Griseofulvin 125mg 10x10tab 0 0 0
Haloperidol 5 mg ktk 10 x 10 tab 0 0 0
Haloperidol tab 0,5mg 10x10tab 0 0 0
Haloperidol tab 1,5mg 10x10tab 0 0 0
Hidroklortiazid (HCT) tab 0 0 0
Hidrokortison krim 2,5% dus,24 tube @ 5 g 0 0 0
Ibuprofen 200mg btl 100 tab 0 0 0
Ibuprofen 200mg btl 100tab 0 0 0
Ibuprofen 400mg ktk 10 strip x 10's 0 0 0
Ibuprofen suspensi 100mg/5ml botol 60ml 0 0 0
Isosorbid dinitrat tab sublingual 5mg dus,10strip@10 tab 0 0 0
Kalium diklofenak 50mg ktk 5x10 tab 0 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Kalsium Laktat 500 mg btl 1000 tablet 0 0 0
Kaptopril 12,5 mg ktk 10 strip x 10's 0 0 0
Kaptopril 25mg dus,10strip@10 tab 0 0 0
Karbamazepin 200mg dus,10 blister@10tab 0 0 0
Ketokonazol tab 200mg ktk 5x10 tab 0 0 0
Klindamisin 300mg Dus,5 blister@10kaps 0 0 0
Kloramfenikol 250mg ktk 10 strip x 10's 0 0 0
Kloramfenikol salep mata 1% 5g 0 0 0
Kloramfenikol susp 125mg/5ml botol 60ml 0 0 0
Kloramfenikol Tetes Mata 0,5 % btl 5 ml 0 0 0
Kloramfenikol tts telinga 3% btl 5ml 0 0 0
Kotrimoksazol DOEN II
Pediatrik(sulfa100mg+trimet20mg) 10x10tab 0 0 0
Kotrimoksazol susp sulfametoksaszol 200mg botol 60ml 0 0 0
Lidokain inj 2% + epinefrin 2ml dus,30 ampul@2ml 0 0 0
Lisol botol 1000 ml 0 0 0
Mebendazol sir. 100mg/5ml btl 30ml 0 0 0
Mebendazol tab 100mg 3x10tab 0 0 0
Metampiron inj 250mg 30amp 2ml 0 0 0
Metampiron tab 500mg 10x10tab 0 0 0
Metformin Hcl tab 500mg ktk 10x10 tab 0 0 0
Metilergometrin Injeksi 0,200 mg/1 ml kotak 10 ampul 0 0 0
Metronidasol 250mg tab ktk 10x10 tab 0 0 0
Metronidasol 500mg tab ktk 10x10 tab 0 0 0
Metronidazol infus 500mg/100ml ktk 1vial/btl 100ml 0 0 0
Mineral mix KCl,MgCl,Znasetat,CuSO4 dus,40 sachet 0 0 0
Natrium klorida lar.infus 0,9% btl 500ml 0 0 0
Nifedipin 10mg 10x10tab 0 0 0
Nistatin 500.000 IU/g ktk 10 strip x 10's 0 0 0
Nistatin Vag tab 100.000 IU/g ktk 10 strip x 10's 0 0 0
OAT FDC kategori 2 paket 0 0 0
OAT FDC kategori Anak paket 0 0 0
OAT FDC kategori I paket 0 0 0
OBH cairan btl 100ml 0 0 0
Oksitetra salep kulit 3% dus,25 tube@5g 0 0 0
Oksitetrasiklin Inj. i.m 50 mg/ml-10 ml ktk 10 vial 0 0 0
Oksitetrasiklin salep mata 1% 25tube 3,5g 0 0 0
Oksitosin inj 10IU/ml-1ml dus/100 amp/1cc 0 0 0
Omeprazol kap 20mg ktk 3x10 kap 0 0 0
Parasetamol 100mg btl 100tab 0 0 0
Parasetamol sir.120mg/5ml btl 60ml 0 0 0
Parasetamol tab 500mg 10x10tab 0 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Pirantel sir.125mg/5ml btl 60ml 0 0 0
Pirantel tab tab 0 0 0
Piroksikam 20mg 10x10 tab 0 0 0
Povidon Iodida lar.10% btl 300ml 0 0 0
Povidon Iodida lar.10% btl 30ml 0 0 0
Prednison 5mg 10x10tab 0 0 0
Propanolol 10mg tab 10x10tab 0 0 0
Propanolol tab 40mg btl 100tab 0 0 0
Propiltiourasil tab 100mg btl 100tab 0 0 0
Ranitidin inj 25mg/2ml ktk 25ampx2ml 0 0 0
Ranitidin tab 150mg ktk 10x10 tab 0 0 0
Reserpin tab 0,25mg 10x10tab 0 0 0
RL infus btl 500ml 0 0 0
Salbutamol 2mg 10x10 tab 0 0 0
Salbutamol 4mg 10x10tab 0 0 0
Salep 2-4(As.salisilat2%+ sulfur endap4%) pot 30g 0 0 0
salisil Bedak 2% ktk 50 g 0 0 0
Sefadroksil 500mg ktk 10x10 tab 0 0 0
Sefadroksil sir kering125mg/5ml ktk 60ml 0 0 0
Sefotaksim inj 1g 10vial 1g 0 0 0
Seftriakson inj 1 g ktk 2vial 1 g 0 0 0
Siankobalamin inj 500mcg dus,100 ampul@1ml 0 0 0
Sianokobalamin/Vit.B12 tab 50mcg 10x10tab 0 0 0
Simetidin 200mg tab 10x10tab 0 0 0
Simvastatin tab 10mg ktk 3x10 kap 0 0 0
Siprofloksasin tab 500mg ktk 100tab 0 0 0
Sulfasetamid tts mata 15% btl 5ml 0 0 0
Tetrasiklin 250mg ktk 10 strip x 10's 0 0 0
Tetrasiklin 500mg ktk 10 strip x 10's 0 0 0
Tiamfenikol kap 500mg 10x10kap 0 0 0
Tiamin tab. 50 mg btl 1000 tablet 0 0 0
Tiamin/Vit B1 inj 100mg/ml ktk 30amp x 1ml 0 0 0
Triheksifenidil ktk 10 strip x 10's 0 0 0
Vitamin B Complek tablet botol 1000 tab 0 0 0
Zinc tab 20mg dus,10strip@10 tab 0 0 0
0 0 0
0 0 0
OBAT GIGI 0 0 0
Etil Klorida Spray vial/can/100 ml 0 0 0
Glass Ionomer Cement ART set/btl 0 0 0
Kalsium Hidroksida Pasta ktk 2 tube 0 0 0
Klorfenol Kamfer Mentol (CHKM) btl 10 ml 0 0 0
Mummifying Pasta btl/ktk 0 0 0
 STOK PENERI PERSE PENGE SISA PERMIN PEMBERIAN
NAMA OBAT KEMASAN KETR
AWAL MAAN DIAAN LUARAN STOK TAAN DAK APBD
Semen Seng Fosfat Serbuk dan Cairan set @ 30 gram/btl 0 0 0
Temporary Stopping Fletcher (Serbuk&cairan) set @ 100 gram/btl 0 0 0
0 0 0
PERBEKALAN KESEHATAN 0 0 0
alat suntik sekali pakai 2,5 ml 100 set/ktk 0 0 0
alat suntik sekali pakai 5 ml 100 set/ktk 0 0 0
catgut benang bedah no 2/0 dg jarum bedah pcs 0 0 0
infusion set dewasa set/kantong 0 0 0
kapas pembalut/adsorben 250gr bungkus 0 0 0
kasa 16 x 16 cm rol 0 0 0
plester 5 yards x 2 inch kotak 6 roll 0 0 0
sarung tangan no 7,5 50 pasang/ktk 0 0 0
0 0 0
APBD 0 0 0
catgut benang bedah no 3/0 dg jarum bedah pcs 0 0 0
folley catheter 16 pcs 0 0 0
folley catheter 18 pcs 0 0 0
infusion set anak set/kantong 0 0 0
IV catheter 18 G 50buah/ktk 0 0 0
IV catheter 22 G 50buah/ktk 0 0 0
IV catheter 24G 50buah/ktk 0 0 0
kasa hidrofil 36mx80 cm roll 0 0 0
kasa hidrofil 4mx10 cm rol/50 0 0 0
kasa hidrofil 4mx5 cm rol/100 0 0 0
masker 20pcs/ktk 0 0 0
sarung tangan no 7 50 pasang/ktk 0 0 0
Serum Anti Bisa Ular ABU I vial 5 ml 0 0 0
Serum Anti Difteri (ADS) Inj. 20.000 IU vial 10 ml 0 0 0
Serum Anti Tetanus (ATS) 1.500 IU/amp amp @ 1 ml 0 0 0
silk no 3/0 dg jarum bedah 12x3x75/ktk 0 0 0

Sumenep, 2014
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Kepala Dinas Kesehatan Kepala UPT Gudang Farmasi Kepala UPT Puskesmas Petugas Gudang Puskesmas
Kabupaten Sumenep Kabupaten Sumenep Kecamatan................................ Kecamatan................................

dr.H.ANUGRAH RIZKA RAHADI,M.Kes SITI MARYAM

Nip.19630212 198910 1 001 Nip. 196319081985032007 Nip. Nip.