BLANGKO USU

PUSKESM

NO NAMA OBAT SATUAN

OBAT FORNAS

1 Air untuk injeksi amp 25 ml ampul/vial/botol 25 mL

2 Albendazol susp 200 mg/5 ml Botol
3 Albendazol tab 400 mg tablet/kapsul/kaplet
4 Alopurinol tab 100 mg Tab
5 Alopurinol tab 300 mg tablet/kapsul/kaplet
6 Aminofilin Tab 200 mg tablet/kapsul/kaplet
7 Amitriptilin tab sal 25 mg tablet/kapsul/kaplet
8 Amlodipin tab 10 mg tablet/kapsul/kaplet
9 Amlodipin tab 5 mg tablet/kapsul/kaplet
10 Amoksisilin tab 500 mg tablet/kapsul/kaplet
11 Anestetik lokal gigi kombinasi : lidokain hcl ampul/vial
2% + epinefrin 1 : 80.000 inj 2 ml
12 Antasida, kombinasi : aluminium hidroksida tablet/kapsul/kaplet
200 mg + magnesium hidroksida 200 mg
13 Antifungi salep, kombinasi : asam benzoat 6% pot 30 g
+ asam salisilat 3%
14 Antihemoroid, kombinasi: bismut subgalat 150 Suppositoria
mg + heksaklorofen 2,5 mg + lidokain lidokain
10 mg+ seng oksida 120 mg + sup ad 2 g

15 Asam asetilsalisilat (asetosal) tab 80 mg tablet/kapsul/kaplet

16 Asam askorbat (vitamin C) tab 50 mg tablet/kapsul/kaplet
17 Asam folat tab 1 mg tablet/kapsul/kaplet
18 Asam mefenamat kaps 500 mg tablet/kapsul/kaplet/kaptab
19 Asiklovir tab 200 mg tablet/kapsul/kaplet
20 Asiklovir tab 400 mg tablet/kapsul/kaplet
21 Atapulgit 600 mg tablet/kapsul/kaplet
22 Atropin inj 0,25 mg/ml (i.m./i.v./s.k) Ampul
23 Bedak salisil serb 2% Dus/Sachet/Plastik
24 Benzatin benzilpenisilin inj 2,4 juta UI/ml Vial
(i.m.)
25 Betahistin tab 6 mg tablet/kapsul/kaplet
26 Betametason krim 0,1% tube 5 gram
27 Bisakodil sup 10 mg Suppositoria
28 Bisakodil sup 5 mg Suppositoria
29 Bisakodil tab sal 5 mg tablet/kapsul/kaplet
30 Bisoprolol tab 2,5 mg tablet/kapsul/kaplet
31 Budesonid cairan ih 0,25mg/ml Botol @ 4 ml
32 Deksametason inj 5 mg/ml (i.v./i.m.) ampul/vial
33 Diazepam enema 10 mg/2,5 ml tube @ 2,5 mL
34 Diazepam enema 5 mg/2,5 ml tube @ 2,5 mL
35 Diazepam inj 5 mg/ml (i.v./i.m.) ampul/vial
36 Diazepam tab 2 mg tablet/kapsul/kaplet
37 Diazepam tab 5 mg tablet/kapsul/kaplet
38 Difenhidramin inj 10 mg/ml (i.v./i.m.) ampul/vial
39 Dimenhidrinat tab 50 mg tablet/kapsul/kaplet
40 Doksisiklin kaps 100 mg tablet/kapsul/kaplet
41 Domperidon tab 10 mg tablet/kapsul/kaplet
42 Epinefrin (adrenalin) inj 1 mg/ml Ampul
43 Eritromisin tab 500 mg tablet/kapsul/kaplet
44 Etanol 70% cairan 70% Botol
45 Etil klorida semprot 100 ml Botol
46 Eugenol Botol
47 Fenobarbital inj 50 mg/ml Ampul
48 Fenobarbital tab 30 mg tablet/kapsul/kaplet
49 Fitomenadion (vitamin K 1) inj 2 mg/ml (i.m.) ampul/vial
50 Fitomenadion (vitamin K 1) tab sal 10 mg Tab sal
51 Framisetin Sulfat Tulle 1% Patch
52 Furosemid tab 40 mg tablet/kapsul/kaplet
53 Garam oralit kombinasi : natrium klorida 0,52 sachet
g + kalium klorida 0,30 g + trinatrium sitrat
0,58 g + glukosa anhidrat 2,7 g
54 Gentamisin tts mata 0,3% Botol
55 Glibenklamid tab 5 mg tablet/kapsul/kaplet
56 Glimepirid tab 1 mg tablet/kapsul/kaplet
57 Glimepirid tab 2 mg tablet/kapsul/kaplet
58 Glimepirid tab 3 mg tablet/kapsul/kaplet
59 Glimepirid tab 4 mg tablet/kapsul/kaplet
60 Glukosa Larutan Infus 5% steril 500 ml Botol
61 Griseofulvin (micronized) tab 125 mg tablet/kapsul/kaplet
62 Haloperidol tab 5 mg tablet/kapsul/kaplet
63 Hidroklorotiazid tab 25 mg tablet/kapsul/kaplet
64 Hidrokortison krim 1% tube @ 5 g
65 Hidrokortison krim 2,5% tube @ 5 g
66 Hiosina butilbromida tab 10 mg tablet/kapsul/kaplet
67 Ibuprofen tab 200 mg tablet/kapsul/kaplet
68 Ibuprofen tab 400 mg tablet/kapsul/kaplet
69 Isoniazid tab 100 mg Tablet/kapsul/kaplet
70 Isoniazid tab 300 mg Tablet/kapsul/kaplet
71 Isosorbid dinitrat tab 5 mg tablet/kapsul/kaplet
72 Kalsium glukonat inj 100 mg/ml ampul/vial
 73 Kalsium laktat (kalk) tab 500 mg tablet/kapsul/kaplet
74 Kaptopril tab 12,5 mg tablet/kaplet
75 Kaptopril tab 25 mg tablet/kaplet
76 Karbogliserin tts telinga 10 % Botol
77 Ketokonazol krim 2% Tube 10 g
78 Ketokonazol tab 200 mg tablet/kapsul/kaplet
79 Klindamisin kaps 150 mg Tablet/kapsul/kaplet
80 Klindamisin kaps 300 mg tablet/kapsul/kaplet
81 Kloramfenikol kaps 250 mg tablet/kapsul/kaplet
82 Kloramfenikol salep mata 1% tube @ 5 gram
83 Kloramfenikol tetes telinga 3% Botol
84 Kloramfenikol tts mata 0,5% botol
85 Klorfeniramin tab 4 mg tablet/kapsul/kaplet
86 Klorpromazin tab sal 100 mg tablet salut selaput/kaplet salut selaput
87 Kodein tab 10 mg tablet/kapsul/kaplet
88 Kodein tab 20 mg tablet/kapsul/kaplet
89 Kombinasi : ergotamin 1 mg+ kafein 50 mg tablet/kapsul/kaplet
90 Kombinasi ekstrak Herba seledri (Apii Kapsul
graveolentis herba) dan ekstrak Daun kumis
kucing (Orthosiphonis staminei folium)
91 Kombinasi: Ipratropium bromida 0,5 mg + Ampul/vial
Salbutamol 2,5 mg, cairan ih
92 Kombinasi: kaolin 550 mg + pektin 20 mg Tab
93 Kotrimoksazol (dewasa) kombinasi : tab/kaptab
sulfametoksazol 400 mg+ trimetoprim 80 mg
94 Kotrimoksazol (dewasa) kombinasi : tab/kaptab
sulfametoksazol 800 mg+ trimetoprim 160 mg
95 Lidokain inj 2% (infiltr/p.v.) ampul/vial
96 Magnesium sulfat inj 20% ampul/vial @25 ml
97 Magnesium sulfat inj 40% ampul/vial @25 ml
98 Metformin tab 500 mg tablet/kapsul/kaplet
99 Metilergometrin inj 0,2 mg/ml ampul/vial
100 Metilergometrin tab salut 0,125 mg tablet/kaplet salut selaput
101 Metoklopramid tab 10 mg tablet/kapsul/kaplet
102 Metronidazol tab 500 mg tablet/kapsul/kaplet
103 Mikonazol krim 2% tube
104 Mometason furoat krim 0,1% tube 10 gram
105 N-asetil sistein kaps 200 mg tablet/kapsul/kaplet
106 NaCl 0,9% Larutan Botol @500 ml
107 Natrium diklofenak tab 50 mg tablet salut enterik/kaplet salut enterik
108 Nistatin susp 100.000 UI/ml botol/vial
109 Nistatin tab salut 500.000 UI tablet salut gula/kaplet salut gula
110 Nistatin tab vaginal 100.000 UI tablet/kaplet
111 Oksitetrasiklin 1% Salep Mata tube
112 Oksitosin inj 10 UI/ml ampul/vial
113 Omeprazol kaps 20 mg tablet/kapsul/kaplet
114 Parasetamol tab 500 mg tablet/kapsul/kaplet
115 Permetrin krim 5 % Tube 15 g
116 Pirantel pamoat tab scored 125 mg tablet/kapsul/kaplet
117 Piridoksin (vitamin B6) tab 10 mg tab/kap/kapl
118 Piridoksin (vitamin B6) tab 25 mg tablet/kapsul/kaplet
122 Povidon iodin lar obat kumur 1% Botol
123 Prednison tab 5 mg tablet/kapsul/kaplet
124 Propranolol tab 10 mg tablet/kapsul/kaplet
125 Ranitidin tab 150 mg tablet/kapsul/kaplet
126 Ringer Laktat Larutan Botol 500 ml
127 Risperidon tab sal 2 mg tablet/kapsul/kaplet
128 Salbutamol cairan ih 1 mg/mL ampul/vial/botol
129 Salbutamol tab 2 mg tablet/kapsul/kaplet
130 Salep 2-4, kombinasi : asam salisilat 2 %+ pot 15 gram
belerang endap 4 %
131 Sefadroksil kaps/tab 500 mg tablet/kapsul/kaplet
132 Serum antitetanus (A.T.S) inj 1500 UI/amp Ampul
133 (i.m.)
Setirizin tab 10 mg tablet/kapsul/kaplet
134 Sianokobalamin (vitamin B12) tab 50 mcg tablet/kapsul/kaplet
135 Simvastatin tab sal 10 mg tablet/kaplet/tablet salut selaput
136 Simvastatin tab sal 20 mg tablet/kaplet/tablet salut selaput
137 Siprofloksasin tab scored 500 mg tablet/kaplet/tablet salut selaput
138 Spironolakton tab 25 mg tablet/kapsul/kaplet
139 Tiamin (vitamin B1) tab 50 mg tablet/kapsul/kaplet
140 Vitamin B kompleks tablet
141 Zinc tab disp 20 mg tablet dispersible

SEDIAAN SIRUP

1 Albendazol susp 200 mg/5 ml Botol

2 Amoksisilin sir forte 250 mg/5 ml botol 60 ml
3 Amoksisilin sir kering 125 mg/5 ml Botol
4 Antasida, kombinasi : aluminium hidroksida botol 60 ml
200 mg + magnesium hidroksida 200 mg
5 Domperidon susp 5 mg/5 ml botol @60 ml
6 Eritromisin sir 200 mg/5 ml Botol @ 60 ml
7 Haloperidol tts 2 mg/ml botol
8 Ibuprofen sir 100 mg/5 ml botol @ 60 ml
9 Ibuprofen sir 200 mg/5 ml botol @ 60 ml
10 Kloramfenikol susp 125 mg/5 ml botol 60 ml
11 Kotrimoksazol kombinasi tiap 5 ml suspensi : botol 60 mL
sulfametoksazol 200 mg + trimetoprim 40 mg
12 Metronidazol susp 125 mg/5 ml Botol @ 60 ml
13 Parasetamol sir 120 mg/5 ml botol @ 60 mL
14 Parasetamol tts 60 mg/0,6 ml botol @ 15 mL
15 Pirantel pamoat susp 125 mg/5 ml Botol
 16 Sefadroksil sir kering 125 mg/5 ml botol @ 60 mL
17 Setirizin sir 5 mg/5 ml. botol @ 60 mL
18 Zinc sir 20 mg/5 ml botol

OBAT GIGI

1 Bahan tumpatan sementara lar, serb Pcs

2 Formokresol Botol
3 Kalsium hidroksida bubuk, pasta Tube
4 Klorfenol kamfer mentol (CHKM) Botol
5 Komposit Resin + eching+ bonding Set
6 Pasta devitalisasi (non arsen) Tube
7 Glas ionomer Pcs
8 Semen powder Pcs

OBAT NON FORNAS

1 Acyclovir salep tube

2 Ambroxol 30 mg tablet
3 Anti biotik + Kortikosteroid TM botol
4 Cefotaksim inj 1 g vial
5 Ceftriakson inj 1 g vial
6 Dexametason 0,5 mg tablet
7 Gentamisin salep kulit (5 gr) tube
8 Guaifenesin 100 mg tablet
9 Ichtyol 15 gr pot
10 Ipratropium Br 0,5 mg+ Salbutamol 2,5 mg botol
11 Kalium diklofenak 50 mg tablet
12 Kloramfenikol salep kulit 2% tube
13 AB + Placenta ekstrac ( pengganti levertrant ) tube
14 Lincomycin 500 mg tablet
15 Meloksikam 15 mg tablet
16 Metampiron/ Metamizol/ Antalgin 500 mg tablet
17 Multivitamin tablet
18 Multivitamin sirup botol
19 Obat Batuk tablet tablet
20 Obat Flu tablet tablet
21 Obat Flu sirup botol
22 OBH 60 ml botol
23 Ondansentron inj 4 mg / 2 ml ampul
24 Piroksikam 10 mg tablet
25 Simetidin tablet
26 Vitamin Neurotropik tablet
JUMLAH TOTAL :

Mengetahui :
Kepala Puskesmas …………………

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Nama Kapus
BLANGKO USULAN OBAT TAHUN 2024
PUSKESMAS ………………….

SISA STOK USULAN PEMAKAIAN PREDIKSI JUMLAH RENCANA

PER 31 PENGADAAN RATA-RATA SISA KEBUTUHA KEBUTUHA
DESEMBER TAHUN 2023 PER BULAN STOK 31 N TAHUN N TAHUN
2023 SELAMA 2023 DESEMBE 2024 2024
R 2023
(a) (b) (c) (d) = (a)+(b)-(e) = (c) x 18 (f) = (e) - (d)

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0

0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0
0 0 0

0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RENCANA HARGA TOTAL
PENGADAAN SATUAN
TAHUN 2024

(g) (j)

2,955 -
5,100 -
490 -
258 -
466 -
270 -
210 -
472 -
291 -
583 -
1,848 -

337 -

5,900 -

3,250 -

216 -
67 -
56 -
279 -
550 -
650 -
304 -
3,778 -
5,550 -
31,419 -

555 -
2,000 -
12,000 -
10,000 -
 184 -
400 -
14,236 -
1,097 -
19,872 -
13,669 -
1,545 -
127 -
216 -
2,220 -
151 -
387 -
230 -
3,885 -
850 -
45,000 -
187,550 -
25,000 -
1,500 -
182 -
4,440 -
1,055 -
-
263 -
610 -

8,547 -
172 -
110 -
200 -
330 -
395 -
7,753 -
330 -
218 -
148 -
3,800 -
4,300 -
695 -
210 -
401 -
160 -
254 -
300 -
7,100 -
 165 -
85 -
120 -
6,500 -
2,349 -
400 -
708 -
1,211 -
708 -
7,475 -
8,000 -
9,300 -
49 -
888 -
600 -
1,360 -
6,260 -
2,146 -

5,000 -

250 -
240 -

575 -

1,210 -
4,973 -
5,661 -
201 -
3,030 -
388.5 -
117 -
211 -
3,917 -
7,215 -
373 -
7,673 -
192 -
15,629 -
850 -
600 -
5,934 -
3,297 -
390 -
 189 -
6,325 -
471 -
85 -
333 -
31,320 -
105 -
100 - turun tayang
172 -
8,498 -
210 -
4,800 -
86 -
4,500 -

960 -
152,625 -
188 -
70 -
230 -
385 -
360 -
250 -
97 -
121 -
214 -
-

5,100
6,069 -
5,544 -
6,458 -

7,659 -
12,100 -
33,000 -
6,660 -
7,150 -
7,200 -
8,880 -

3,765 -
4,721 -
6,125 -
13,350 -
 8,000 -
6,650 -
4,440 -
0

86,500 -
92,150 -
242,000 -
86,600 -
1,241,000 -
275,300 -
319,700
225,350
-

-
-
2,764 -
186 -
8,325 -
6,220 -
5,880 -
106 -
5,000 -
220 -
10,329 -
5,000 -
331 -
7,865 -
22,500 -
1,200 -
479 -
246 -
2,747 -
12,654 -
632 -
832.5 -
9,100 -
8,600 -
1,254 -
131 -
- turun tayang
443 -
-
 -

Penanggung Jawab Farmasi

Puskesmas ……………..

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Nama Penanggung jawab farmasi