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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS

(LPLPO)

PUSKESMAS : BRAGOLAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI LAPORAN BULAN / PERIODE : DESEMBER 2016 INST. FARMASI
KABUPATEN : PURWOREJO PERMINTAAN BULAN / PERIODE : JANUARI 2017.. PUSKESMAS 442/ /XI/2016 5 Nop 2016

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN STOK OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK I.A.
1 Alopurinol tablet 100 mg tablet 1,272 500 1,772 602 1,170 1
2 Alprazolam tablet 0,25 mg tablet 0 0 0 2
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 3
4 Ambroxol tablet 30 mg tablet 0 0 4
5 Aminofilin injeksi 24 mg/ml ampul 30 30 0 30 5
6 Aminofilin tablet 200 mg tablet 674 674 674 0 300 6
7 Amitriptilin tablet 25 mg tablet 370 370 61 309 7
8 Amlodipin tablet 10 mg tablet 1,500 1,500 180 1,320 8
9 Amlodipin tablet 5 mg tablet 649 649 599 50 500 9
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0 10
11 Amoksisilin kaplet 500 mg tablet 7,273 10,000 17,273 6,883 10,390 10,000 11
12 Amoksisilin kapsul 250 mg kapsul 0 0 12
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 199 240 439 146 293 120 13
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 0 0 14
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 25 25 0 25 15
16 Antalgin (Metampiron) tablet 500 mg tablet 0 0 16
17 Antasida DOEN I tablet kunyah kombinasi tablet 7,400 15,000 22,400 2,480 19,920 17
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 169 300 469 142 327 100 18
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 0 0 19
20 polimiksin 10.000 kombinasi
Antifungi DOEN IU/g : Asam Benzoat 6% + Asam pot 0 0 20
21 Salisilat 3 % DOEN kombinasi (Generik)
Antihemoroid supp 21 30 51 37 14 30 21
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet tablet 0 0 22
23 Aqua pro injeksi steril, bebas pirogen vial 390 240 630 184 446 23
24 Asam asetil salisilat 80 mg tablet 0 0 24
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 720 720 160 560 25
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 5,307 5,307 1,217 4,090 26
27 Asam folat tablet 1 mg tablet 0 0 1,000 27
28 Asam mefenamat kaplet 250 mg Tablet 4,100 7,000 11,100 4,010 7,090 7,000 28
29 Asam mefenamat kaplet 500 mg tablet 0 0 5,000 29
30 Asam traneksamat injeksi 100 mg/ml ampul 100 100 100 0 300 30
31 Asiklovir krim 5 % tube 5 gram 92 50 142 30 112 31
32 Asiklovir tablet 200 mg tablet 0 0 32
33 Asiklovir tablet 400 mg tablet 301 300 601 81 520 33
34 Atapulgit tablet 600 mg tablet 400 1,800 2,200 430 1,770 1,000 34
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 90 90 0 90 35
36 Betahistin mesilat tablet 6 mg tablet 0 0 36
37 Betametason cream 0,1 % tube 49 50 99 49 50 100 37
38 Betametason tetes mata 1 mg/ml botol 0 0 38
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 10 30 40 3 37 39
40 Bromheksin tablet 8 mg tablet 0 0 40
41 Cetirizine kapsul 10 mg kapsul 1,690 2,000 3,690 1,375 2,315 1,500 41
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 160 160 22 138 42
43 Deksametason injeksi i.v. 5 mg/ml ampul 0 500 500 200 300 500 43
44 Deksametason tablet 0,5 mg tablet 9,180 5,000 14,180 5,460 8,720 8,000 44
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 45
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 46
47 Diazepam injeksi 5 mg/ml ampul 0 0 5 47
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 0 0 48
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 4 4 4 0 5 49
50 Diazepam tablet 2 mg tablet 835 500 1,335 711 624 1,000 50
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 437 437 437 0 1,000 51
52 Digoksin tablet 0,25 mg tablet 100 100 0 100 52
53 Diltiazem HCl Tablet 30 mg tablet 0 0 53
54 Dimenhidrinat tablet 50 mg tablet 0 0 300 54
55 Doksisiklin kapsul 100 mg kapsul 0 0 55
56 Domperidon suspensi 5 mg/5 ml botol-60ml 89 50 139 17 122 56
57 Domperidon tablet 10 mg tablet 2,570 2,570 590 1,980 57
58 Efedrin HCl tablet 25 mg tablet 0 0 58
59 Ekstraks beladona tablet 10 mg tablet 0 0 500 59
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 105 105 5 100 60
61 Eritromisin kapsul 250 mg kapsul 0 0 61
62 Eritromisin kapsul 500 mg kapsul 300 300 40 260 62
63 Eritromisin sirup 200 mg/5 ml botol 0 0 63
64 Fenilbutason 200 mg tablet tablet 0 0 64
65 Fenitoin Natrium Kapsul 100 mg kapsul 185 185 0 185 65
66 Fenobarbital injeksi ampul 0 0 66
67 Fenobarbital tablet 30 mg tablet 300 300 0 300 67
68 Fenolgliserol tetes telinga 10 % botol 0 0 50 68
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 26 26 2 24 69
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 260 200 460 110 350 200 70
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 20 20 0 20 71
72 Furosemida tablet 40 mg tablet 50 300 350 211 139 500 72
73 Gameksan lotion 1 % botol-30 ml 0 0 73
74 Gemfibrosil kapsul 300 mg kapsul 2,032 600 2,632 1,228 1,404 1,200 74
75 Gemfibrozil kapsul 600 mg kapsul 0 0 75
76 Gentamisin salep kulit 0,1% tube 0 0 76
77 Gentamisin salep mata 0,3 % botol 0 0 77
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 0 0 78
79 Gentian violet larutan 1 % botol 0 0 79
80 Glibenklamid tablet 5 mg tablet 0 0 80
81 Gliclazid 80 mg tablet tablet 0 0 81
82 Glimepirid tablet 2 mg tablet 840 1,500 2,340 600 1,740 82
83 Gliseril Guayakolat tablet 100 mg tablet 3,640 3,640 1,720 1,920 5,000 83
84 Gliserin lar 50 % botol-100 ml 0 0 84
85 Glukosa larutan infus 10 % botol 500 ml 100 100 0 100 85
86 Glukosa larutan infus 40 % ampul 0 0 5 86
87 Glukosa larutan infus 5 % botol 500 ml 140 200 340 80 260 87
88 Griseofulvin tablet 125 mg micronized tablet 190 190 90 100 300 88
89 Haloperidol injeksi 5 mg/ml ampul 28 28 4 24 89
90 Haloperidol injeksi 50 mg/ml ampul 0 0 90
91 Haloperidol tablet 1,5 mg tablet 0 0 0 500 91
92 Haloperidol tablet 2 mg tablet 1,000 1,000 192 808 92
93 Haloperidol tablet 5 mg tablet 90 90 90 0 500 93
94 Hidroklorotiazida tablet 25 mg tablet 0 0 94
95 Hidrokortison krim 2,5% tube 64 96 160 65 95 100 95
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 1,000 96
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 97
98 Ibuprofen tablet 200 mg tablet 0 0 98
99 Ibuprofen tablet 400 mg tablet 6,180 6,180 2,470 3,710 3,000 99
100 Isoniasida tablet 100 mg tablet 0 0 100
101 Isosorbid dinitrat tablet sublingual 10 mg 1,000 1,000 260 740 101
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 102
103 Kalium diklofenak 50 mg tablet tablet 0 0 103
104 Kalsium glukonas injeksi ampul 0 0 104
105 Kalsium laktat tablet 500 mg tablet 4,160 4,160 1,860 2,300 1,000 105
106 Kaptopril tablet 12,5 mg tablet 530 530 310 220 300 106
107 Kaptopril tablet 25 mg tablet 1,775 3,000 4,775 1,581 3,194 1,000 107
108 Karbamazepin tablet 200 mg tablet 150 150 50 100 108
109 Karbogliserin tetes telinga botol 0 0 109
110 Ketokonazol krim 2 % tube 15 gram 50 75 125 39 86 50 110
111 Ketokonazol tablet 200 mg tablet 150 500 650 290 360 500 111
112 Ketorolac injeksi 10 mg ampul 1 ml 0 0 112
113 Ketorolac injeksi 30 mg ampul 1 ml 96 96 25 71 113
114 Klindamisin kapsul 300 mg kapsul 0 0 500 114
115 Klobazam tablet 10 mg tablet 160 500 660 114 546 115
116 Klonidin tablet 0,15 mg tablet 0 0 116
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 117
118 Kloramfenikol kapsul 250 mg kapsul 0 0 118
119 Kloramfenikol kapsul 500 mg kapsul 3,080 2,000 5,080 1,630 3,450 1,000 119
120 Kloramfenikol salep kulit (Bufacetin) tube 34 72 106 20 86 24 120
121 Kloramfenikol salep mata 1 % tube 5 gram 80 80 9 71 121
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 0 0 100 122
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 106 75 181 88 93 100 123
124 Kloramfenikol tetes telinga 3 % botol 5 ml 121 121 9 112 124
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 8,030 8,000 16,030 6,300 9,730 8,000 125
127 Klorpromazin tablet salut 100 mg (HCl) tablet 300 200 500 136 364 200 126
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 127
129 Kodein tablet 10 mg tablet 0 0 128
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 1,200 1,200 220 980 129
131 Kotrimoksasol suspensi botol 60 ml 188 150 338 78 260 130
132 Lamivudin tablet 150 mg tablet 0 0 131
133 Lanzoprazol kapsul 30 mg kapsul 0 0 132
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 80 500 580 340 240 300 133
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 160 200 360 100 260 100 134
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 140 200 340 80 260 100 135
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 136
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 1 1 1 0 137
139 Lidokain injeksi 2 % ampul 0 0 138
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 150 120 270 94 176 139
141 Lidokain semprot 10 % botol 0 0 0 140
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 2 10 12 3 9 141
143 Magnesium sulfat injeksi 20 % ampul 0 0 142
144 Magnesium sulfat injeksi 40 % ampul 0 0 0 143
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 144
146 Mebendazol tablet 100 mg tablet 0 0 145
147 Mekobalamin tablet 500 mg tablet 0 0 146
148 Meloksikam 7.5 mg tablet 0 0 147
149 Metformin HCl tablet 500 mg tablet 580 1,000 1,580 370 1,210 148
150 Metil Prednisolon tablet 4 mg tablet 1,280 1,280 970 310 1,500 149
151 Metil Prednisolon tablet 8 mg tablet 0 0 150
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 93 93 0 93 151
153 Metilergometrin maleat tablet 0,125 mg tablet 180 100 280 0 280 152
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 153
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 154
156 Metoklopramid tablet 10 mg tablet 0 0 155
157 Metoklopramid tablet 5 mg tablet 0 0 156
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 90 90 3 87 157
159 Metronidasol tablet 250 mg tablet 0 0 158
160 Metronidasol tablet 500 mg tablet 920 920 510 410 1,000 159
161 Metronidazol infus 500 mg/100 ml botol-100 ml 2 2 0 2 160
162 Mikonazol krim 2 % tube 68 48 116 54 62 48 161
163 N-asetyl sistein kaplet 200 mg tablet 4,960 4,960 1,460 3,500 3,000 162
164 Natrium Diklofenak tablet 25 mg tablet 0 0 163
165 Natrium Diklofenak tablet 50 mg tablet 4,910 5,000 9,910 2,630 7,280 164
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 180 200 380 40 340 165
167 Nifedipin tablet 10 mg tablet 380 380 380 0 1,000 166
168 Nifedipin tablet 20 mg SR tablet 1,140 1,200 2,340 250 2,090 167
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 0 0 100 168
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 169
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 170
173 Oksitetrasiklin salep mata 1% tube 0 0 171
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 63 63 0 63 172
175 Omeprazol injeksi 40 mg/10 ml vial 23 100 123 63 60 100 173
176 Omeprazol kapsul 20 mg kapsul 2,220 900 3,120 1,150 1,970 900 174
177 Ondansentron injeksi 4 mg / 2 ml ampul 28 80 108 108 0 300 175
178 Papaverin injeksi ampul 0 0 176
179 Papaverin tablet 40 mg tablet 0 0 177
180 Parasetamol drops botol 15 ml 0 0 178
181 Parasetamol sirup 120 mg/5 ml botol 399 400 799 268 531 179
182 Parasetamol tablet 500 mg tablet 3,985 15,000 18,985 9,225 9,760 15,000 180
183 Permetrin (Scabimite) tube 0 0 181
184 Petidin injeksi (Narkotika) ampul 0 0 182
185 Piracetam 800 mg tablet tablet 0 0 183
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 184
187 Pirantel tablet score 125 mg tablet 120 120 0 120 185
188 Piridoksin (Vit. B6) tablet 10 mg tablet 2,877 5,000 7,877 2,957 4,920 2,000 186
189 Piroksikam kapsul 20 mg tablet 2,610 2,000 4,610 1,840 2,770 2,000 187
190 Piroksikam tablet 10 mg tablet 0 0 188
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 30 30 0 30 189
192 Prednison tablet 5 mg tablet 820 820 20 800 190
193 Probenesid tablet 500 mg tablet 0 0 191
194 Propanolol tablet 10 mg tablet 0 0 192
195 Propiltiourasil tablet 100 mg tablet 0 0 193
196 Ranitidin injeksi 25 mg/2 ml ampul 430 430 430 0 1,000 194
197 Ranitidin tablet 150 mg tablet 2,390 3,000 5,390 1,740 3,650 3,000 195
198 Rifampisin kaplet salut 450 mg kaplet 0 0 196
199 Rifampisin kapsul 300 mg kapsul 0 0 197
200 Ringer laktat larutan infus botol 500 ml 180 180 100 80 500 198
201 Risperidon tablet tablet 180 200 380 45 335 199
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 200
203 Salbutamol tablet 2 mg tablet 0 0 201
204 Salbutamol tablet 4 mg tablet 2,340 2,340 2,200 140 5,000 202
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap pot 44 44 8 36 203
206 4%
Salisil bedak 2% kotak-50 gram 111 111 40 71 100 204
208 Sefadroksil kapsul 250 mg kaplet 0 0 205
209 Sefadroksil kapsul 500 mg kaplet 2,240 2,240 320 1,920 206
210 Sefadroksil sirup kering 125 mg/5 ml botol 40 60 100 26 74 100 207
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 208
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 589 800 1,389 699 690 1,000 209
213 Sefotaksim serbuk injeksi 500 mg/vial vial 0 0 210
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 211
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 1 5 6 5 1 5 212
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAGAM) dos 20 20 40 10 30 10 213
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 0 0 214
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 215
219 Simetidin tablet 200 mg tablet 0 0 216
220 Simvastatin tablet 10 mg tablet 619 500 1,119 309 810 500 217
221 Simvastatin tablet 30 mg tablet 0 0 218
222 Siprofloksasin tablet 250 mg tablet 0 0 219
223 Siprofloksasin tablet 500 mg tablet 1,788 1,788 708 1,080 1,000 220
224 Spironolakton tablet 25 mg tablet 0 0 221
225 Sukralfat suspensi (Ulsafate) botol 0 0 222
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 223
227 Sulfasetamid Na tetes mata 15 % botol 0 0 224
228 Tetrasiklin kapsul 250 mg kapsul 0 0 225
229 Tetrasiklin kapsul 500 mg kapsul 0 0 226
230 Tiamfenikol kapsul 500 mg kapsul 0 0 227
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 228
232 Tiamin (Vitamin B1) tablet 50 mg tablet 4,530 4,530 1,680 2,850 3,000 229
233 Tramadol kapsul 50 mg tablet 0 0 230
234 Trifluoperazin 5 mg tablet tablet 0 0 231
235 Triheksifenidil tablet 2 mg tablet 480 1,000 1,480 280 1,200 232
236 Vaksin rabies untuk manusia set 0 0 233
237 Vitamin B Kompleks tablet tablet 5,800 5,800 1,460 4,340 234
0 0 235
B OBAT DAN BAHAN KEDOKTERAN GIGI 0 0 236
1 Air raksa dental use botol 0 0 237
2 Alvogyl paste dus 0 0 238
3 Amalgam Perak (Silver Alloy) botol 0 0 239
4 Articulating papper kotak 0 0 240
5 Bahan pensteril gigi : Trikresol formalin botol 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 B
7 Dentin conditioner botol 0 0 1
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 2
9 Etil klorida spray vial/100 ml 1 3 4 1 3 3
10 Eugenol cairan botol@10 ml 0 0 4
11 Fuji VII dus 0 0 5
12 Fuji IX dus 0 0 6
13 Glass inonomer cement ART set/botol 0 0 7
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 8
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 9
16 Kalsium hidroksida pasta kotak 2 tube 0 0 10
17 K-file perawatan akar gigi 0 0 11
- K-file No. 15 set 0 0 12
- K-file No. 20 set 0 0 13
- K-file No. 25 set 0 0 14
- K-file No. 30 set 0 0 15
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 16
19 Mummifying pasta botol/kotak 0 0 17
20 Pasta pengisi saliran akar botol 0 0 18
21 Seluloid strip rol 0 0 19
22 Semen Seng Fosfat serbuk dan cairan set/botol 0 0 20
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) 0 0
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram 0 0 C
25 Tooth mouse box 0 0 1
0 0 2
C OBAT TAMBAHAN / BRANDED 0 0 3
1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 4
2 Anti asma/bronkodilator nebulizer (ventolin) vial 101 60 161 41 120 40 5
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 6
4 Antidiare sirup : . botol 60 ml 0 0 7
6 Antidiare Tablet : tablet 0 0 8
7 Antidiare Tablet (Molagit) tablet 0 0 9
9 Antihemoroid DOEN (Superhoid) supp 0 0 10
10 Antihistamin kombinasi (Pritacort) tablet 0 0 11
11 Antiinfeksi kulit (luka bakar) pot 37 37 0 37 12
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 13
13 Antikretinisme tablet tablet 0 0 14
14 Antiscabies krim (Scabicid) tube 10 gram 52 52 8 44 15
15 Antispasme injeksi (Spashi) vial 0 0 16
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 17
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 18
18 Laksantia tablet 5 mg (Dulcolax) tablet 0 0 19
19 Laksantia tablet 5 mg (Laxana) tablet 66 66 16 50 20
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 3,880 5,000 8,880 3,600 5,280 5,000 21
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 31 31 31 0 22
22 Multivitamin + mineral utk ibu hamil : . kaplet 0 0 1,000 23
27 Multivitamin kaplet : VITALAMIN kaplet 65 65 65 0 24
28 Multivitamin sirup : CURBION Botol 300 300 106 194 200 25
31 Multivitamin tabur untuk balita Saset 0 0 26
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 27
33 Neurotropik 5000 injeksi ampul 208 208 80 128 100 28
34 Neurotropik kaplet : kaplet 4,449 5,000 9,449 4,669 4,780 5,000 29
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 30
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 31
40 Obat Antiflu kombinasi : SAMCODRYL SIRUP botol 60 ml 390 500 890 357 533 32
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 33
42 Obat batuk / flu sirup : .. botol 100 ml 0 0 34
47 Vasodilator perifer (Citicholin) ampul 0 0 35
0 0
D OBAT ASLI INDONESIA (OAI) 0 0 36
1 Asifit kapsul 0 0 37
2 Batugin elixir botol 0 0 38
3 Enkasari botol 0 0 39
4 Fitogen Dragge kapsul 0 0 40
5 Hepagard kapsul 0 0 41
6 Imulan kapsul kapsul 0 0 42
7 Imulan sirup botol 60 ml 0 0 43
8 Kurkumex sirup botol 60 ml 0 0 44
9 Kurkumex tablet kaplet 0 0 45
10 OB Herbal 0 0
11 Tensigard kapsul kapsul 0 0 46
12 Xanvit sirup 0 0
0 0 D
II. BAHAN MEDIS HABIS PAKAI 0 0 1
1 Alkohol swab box 7 20 27 8 19 10 2
2 Aquagel jelly 28 gram tube 0 2 2 0 2 3
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 9 9 0 9 4
4 Desinfektan - Aseptan liquid botol-500 ml 31 12 43 3 40 5
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 6 6 0 6 6
6 Etanol 70 % botol 100 ml 35 30 65 32 33 30 7
7 Etanol 70 % botol 1000 ml 0 0 8
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 0 0 9
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 17 20 37 17 20 20 10
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 6 6 1 5 11
0 0 12
III. PERBEKALAN KESEHATAN 0 0
1 Alat suntik sekali pakai 1 ml set 340 200 540 147 393 E
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 1
3 Alat suntik sekali pakai 3 ml (Terumo) set 1,275 2,000 3,275 1,346 1,929 2,000 2
4 Alat suntik sekali pakai 5 ml (Terumo) set 1,340 1,000 2,340 910 1,430 1,000 3
5 Bisturi (mata pisau) Pcs 0 0 4
6 Blood lancet 28 box-100 0 0 5
7 Blood Tranfusion set (MAS) Pcs 8 20 28 3 25 6
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm 23 23 0 23 7
9 Catgut chromic 2/0 saset/pack 0 0 8
10 Catgut chromic 2/0 100 M kotak 0 0 0 9
11 Catgut chromic 3/0 saset/pack 0 0 10
12 Catgut chromic 3/0 100 M kotak 0 0 11
13 Catgut plain 2/0 saset/pack 0 0 12
14 Catgut plain 3/0 saset/pack 0 0 13
15 Dermafix T 10 x 15 cm rol 0 0 14
16 Dermafix T 5 x 7 cm rol 3 3 3 0 10
17 Developer untuk Film Rontgen Botol 5 ltr Repl 20 ltr 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 1 1 1 0 5 II
19 Film Rontgen ukuran 24 x 30 lembar 0 0 1
20 Film Rontgen ukuran 30 x 40 lembar 0 0 2
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 3
22 Folley catheter No. 16 (Norta) Pcs 20 20 5 15 10 4
23 Folley catheter No. 18 (Norta) Pcs 17 20 37 0 37 5
24 Folley catheter No. 20 Pcs 0 0 6
25 Folley catheter No. 22 Pcs 0 0 7
26 Folley catheter No. 24 Pcs 0 0 8
27 Infus set - Bbraun Intrafix with microdriper set 0 0 9
28 Infus set (Otsu Y) pices 160 200 360 110 250 10
29 Infus set anak set/kantong 100 100 0 100 11
30 Infus set dengan micridripper (Otsu) pices 0 0 12
31 Infus set dewasa (Stardec) set/kantong 0 0 13
32 IV catheter No. 18 G buah 58 58 1 57 14
33 IV catheter No. 20 G buah 0 0 15
34 IV catheter No. 22 G buah 200 200 400 150 250 100 16
35 IV catheter No. 24 G buah 200 200 0 200 17
36 Jarum jahit kulit saset 5 5 0 5 18
37 Jarum jahit otot saset 5 5 0 5 19
38 Kapas pembalut/absorben 250 gram bungkus 5 5 10 1 9 20
39 Kasa 10 x 10 cm rol 0 0 21
40 Kasa hidrofil 80 cm x 40 yard rol 2 2 2 0 3 22
41 Kasa hidrofil steril ukuran 16 x 16 box 31 30 61 20 41 20 23
42 Kasa hidrofil ukuran 16 x 16 lembar 0 0 24
43 Kasa kompres 40/40 steril bungkus 12 12 1 11 25
44 Kasa pembalut hidrofil 4 m x 10 cm roll 100 100 200 50 150 100 26
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 80 100 180 30 150 100 27
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 75 75 0 75 28
47 Kertas EKG ( 50 x 30) rol 0 0 29
48 Masker : - Earloop pcs 700 500 1,200 300 900 500 30
49 Masker : - Earloop (Stardec) Pcs 0 0 31
50 Masker : - tie on Pcs 1,020 1,000 2,020 480 1,540 32
Masker : - tie on (Stardec) Pcs 0 0 33
51 Mata Bor gigi 0 0 34
- type inverted No. 010 buah 0 0 35
- type cylinder No. 010 buah 0 0 36
- type tuppered No. 010 buah 0 0
- type round No. 010 buah 0 0
52 Micropipet Socorex - Acura 0 0 37
- Volume 1 - 10 uL set 0 0 38
- Volume 10 - 100 uL set 0 0 39
- Volume 100 - 1000 uL set 0 0 40
53 N-95 Medical Respirator box 0 0 41
54 Nasal oxygen canula - adult sraight pieces 26 26 10 16 15 42
55 Nasal oxygen canula - child pieces 1 10 11 5 6 10 43
56 Nasal oxygen canula - infant 0 0 44
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton tule Pcs 15 20 35 7 28 45
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 0 0 46
59 Plester 5 yards x 2 inchi rol 0 0 47
60 Plester hypafix/pharmafix 5 cm x 5 m rol 3 3 3 0 10 48
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 14 20 34 28 6 30 49
62 Pot sputum buah 0 0 50
63 Sarung tangan steril nomor 6,5 : MAS pasang 60 60 0 60
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0 51
67 Sarung tangan steril nomor 7,5 : MAS pasang 24 24 0 24 52
68 Sarung tangan steril nomor 8 0 0 0 53
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 10 10 5 5 54
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 10 10 5 5 55
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0 56
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 800 2,000 2,800 1,200 1,600 100 57
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 500 2,000 2,500 200 2,300
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgical) pack/saset 10 36 46 10 36 58
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0
77 Silk 2/0 box-12 pacs 0 0 59
78 Silk 3/0 box-12 pacs 0 0 60
80 Tabung oksigen 1 m3 + regulator set 0 0 61
81 Under pad buah 10 10 20 0 20 62
82 Urine bag Pcs 32 32 12 20 20 63
83 Wing needle 23 G - 25 G buah 8 8 0 8 64
65
TAMBAHAN PERBEKALAN KESEHATAN 66
1 Alat pengukur HB 201 + analizer unit 67
2 Dek glass (cover glass) box 68
3 Microcuvet Hb 201 buah 69
4 Object glass box 70
5 Occu check (alat pemegang lancet ROCHE) kit 71
6 Softclick lanciet 200 box 72
7 Softclick lancing device kit 73
8 Tabung hematokrit botol 74
9 Kotak slide 75
10 Performa Accu check Blood glucose meter set
- Performa Accu check tes strip box
1
III REAGEN 2
1 Aquabidest steril botol 500 ml 3
2 Aquabidest steril botol 1000 ml 0 4
3 Pemeriksaan kadar gula darah 5
Glocodoctor Box-50 test 6
Accutrand 25 strip 7
Easy Touch box/25 8
Nesco gluco strip box/25
Glucostar box/25

4 Reagen Pemeriksaan Asam Urat


Nesco box-25
Easy Touch box-25 III
UA Sure box-25 0 5 5 5 0 5 1
5 Reagen Pemeriksaan Kolesterol 0 0 2
Accutrand box/25 0 0 3
Easy touch cholesterol box-10 0 0
Nesco box-10 0 0
Multicare box/25 0 0 5
6 Hb Sahli 0 0
- Assistant set 0 0
- Superior set 0 0 4
7 Reagen untuk spektrofotometr 0 0
- Reagen glukosa box-4 btl 0 0
- Reagen Trigliserida box-4 btl 0 0
- Reagen asam urat box-4 btl 0 0 5
8 Trigliserida 0 0
- Accutrend box / 25 0 0
- Multicare box / 25 5 5 5 0 5
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0 6
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0
10 Larutan Benedict Botol 100 ml 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 7
12 Larutan Eosin Botol 100 ml 0 0
13 Larutan Giemsa Stain Botol 100 ml 1 1 1 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0
15 Larutan Metanol Botol 100 ml 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 7
17 Larutan Natrium citrat Botol 100 ml 0 0 8
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0 9
19 Larutan Turk Botol 100 ml 0 0 10
20 Larutan Ziehl Neelsen set 0 0 11
21 Reagen pemeriksaan yodium botol 0 0 12
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0 13
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0 14
- RDT Combo Malaria tes 0 0 15
24 Rapid test Leptospirosis box/50 strip 0 0 16
25 Rapid test Chikungunya tes 0 0 17
26 Rapid test demam berdarah kit-25 tes 0 0 18
27 Rapid test demam thypoid kit-25 tes 0 0 19
28 Tes Kehamilan 0 0 20
PPTEST Box 40 tes 0 0 21
HCG strip (answer) strip 0 0 22
UltraOne tes kehamilan box 50 tes 0 0 23
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 0 2 24
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0 25
31 Urine Test 10 Parameter btl - 100 test 0 0 0 26
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0
34 Tes Narkoba 0 0 27
- Amfetamin kot@25 strip 0 0
- Metamfetamin kot@25 strip 0 0
- Cocain kot@25 strip 0 0 28
- Cannabidoid kot@25 strip 0 0 29
- Benzodiasepin kot@25 strip 0 0
- Babiturat kot@25 strip 0 0 30
35 Reagen Mantoux ampul 0 0 31
36 Tes Golongan darah 0 0 32
- Anti A Botol 10 ml 0 0 0 33
- Anti B Botol 10 ml 0 0
- Anti AB Botol 10 ml 0 0
37 Oil emersi botol 100 ml 0 0
38 Reagen untuk fotometer 0 0
- reagen kolesterol 4 botol @ 100 ml 0 0
- reagen glukosa 4 botol @ 100 ml 0 0 34
- reagen asam urat 4 botol @ 100 ml 0 0 35
- reagen trigliserida 4 botol @ 100 ml 0 0
0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet tablet 0 0 36
2 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin tablet 0 0
3 posphat
Artemeter320) tablet
injeksi 1 ml 80 mg ampul 6 6 0 6 IV
4 Artesunat injeksi vial 60 mg kotak/set 0 0 1
5 Kloroquin tablet 150 mg tablet 0 0 2
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 0 0 3
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0 4
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 60 60 0 60 5
9 Primaquin tablet 15 mg tablet 100 100 0 100 6
10 Doksisiklin kapsul 100 mg tablet 0 0 7
0 0 8
V OBAT PROGRAM DIARE (P2M) 0 0 9
1
Garam oralit serbuk kombinasi saset 124 100 224 194 30 200 10
2
Zink Dispersible 20 mg tablet 70 1,500 1,570 370 1,200
3
Zincpro drops 15 ml botol 18 50 68 14 54 V
4
Zink sirup Botol 46 50 96 15 81 1
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0 2
1 Dietil karbamasin sitrat tablet 0 0 3
0 0 4
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0 VI.
0 0 1
VIII OBAT PROGRAM KUSTA (P2M) 0 0
1 Prednison tablet 5 mg tablet 0 0 VII
0 0 1
IX OBAT PROGRAM FLU BURUNG 0 0
1 Oseltamivir kapsul kapsul 0 0 VIII
0 0 1
X OBAT PROGRAM GIZI (KIA) 0 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 0 0 IX
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 0 0 1
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + tablet 330 6,000 6,330 1,440 4,890 3,000
4 Asam
MineralFolat
Mix 0,25 mg) saset 0 0 X
5 Iodol kapsul kapsul 0 0 1
0 0 2
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0 3
1 Albendazol tablet 400 mg tablet 1,800 1,800 720 1,080 4
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 5
3 Pirantel pamoat tablet 125 mg
XI.
XII. OBAT ANTI TUBERKULOSIS 1
1 Obat FDC kategori 1 paket 2
2 Obat FDC kategori 2 paket 3
3 Obat FDC Sisipan paket
4 OAT Anak paket
5 OAT Kombipak 1 paket

XIII. PROGRAM P2
1 Zidovudin + lamivudin (300 mg/150 mg tablet
2 Efavirenz 600 mg tablet
3 Tenofovir (TDF) 300 mg tablet
4 Nevirapin 200 mg tablet
5 Lamivudin 3 TC 150 mg tablet

XIV. PROGRAM KUSTA


1 Obat MDT Kusta PB Dewasa blister
2 Obat MDT Kusta MB Anak blister
3 Obat MDT Kusta MB Dewasa blister

JUMLAH KUNJUNNGAN RESEP UMUM JKN LAIN-2 JUMLAH


BAYAR
1054 1897 435 3206

Purworejo, 5 Nopember 2016


Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bragolan Petugas Puskesmas Bragolan
Kabupaten Purworejo
dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. ( Nursinah ) ( dr. Hanuke Ari Racmawati B,M.M )
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19730829 200604 2 003 NIP. 19760526 200212 2 006
g.obat

JML GDNG R Obat UGD


OBAT ESENSIAL/GENERIK
Alopurinol tablet 100 mg 1170 850 180 140
Alprazolam tablet 0,25 mg 0
Ambroksol sirup 15 mg/ml 0
Ambroxol tablet 30 mg 0
Aminofilin injeksi 24 mg/ml 41 30 11
Aminofilin tablet 200 mg 0 0
Amitriptilin tablet 25 mg 309 300 9
Amlodipin tablet 10 mg 1320 1170 60 90
Amlodipin tablet 5 mg 50 0 50
Amoksisilin 500 mg + klavulanat 125 mg tablet 0
Amoksisilin kaplet 500 mg 10390 10000 230 160
Amoksisilin kapsul 250 mg 0
Amoksisilin sirup kering 125 mg/5 ml 293 267 16 10
Amoksisilin sirup kering 125 mg/5 ml 0
Amoksisilin sirup kering forte 250 mg/5 ml 0
Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml 30 20 10
Antalgin (Metampiron) tablet 500 mg 0
Antasida DOEN I tablet kunyah kombinasi 19920 19600 210 110
Antasida DOEN II Suspensi, kombinasi 327 310 7 10
Antibakteri DOEN salep komb : Basitrasin 500 IU/g + polim 0
Antifungi DOEN kombinasi : Asam Benzoat 6% + Asam Salis 0
Antihemoroid DOEN kombinasi (Generik) 14 14
Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet 0
Aqua pro injeksi steril, bebas pirogen 446 426 20
Asam Asetil Salisilat tablet 100 mg (Asetosal) 560 400 120 40
Asam asetil salisilat 80 mg 0
Asam Askorbat (Vitamin C) tablet 50 mg 4090 3740 200 150
Asam folat tablet 1 mg 0
Asam mefenamat kaplet 500 mg 0
Asam mefenamat kaplet 250 mg 7090 6570 230 290
Asam traneksamat injeksi 100 mg/ml 0 0
Asiklovir krim 5 % 112 94 9 9
Asiklovir tablet 200 mg 0
Asiklovir tablet 400 mg 520 350 20 150
Atapulgit tablet 600 mg 0
Atapulgit tablet 600 mg (New Antides) 1770 1600 50 120
Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml 90 90
Betahistin mesilat tablet 6 mg 0
Betametason cream 0,1 % 50 50
Betametason tetes mata 1 mg/ml 0
Bisakodil suppositoria 5 mg (Dulcolax) 37 37
Bromheksin tablet 8 mg 0
Cetirizine kapsul 10 mg 2315 2000 125 190
Cetirizine sirup 5 mg/5 ml 138 110 17 11
Deksametason injeksi i.v. 5 mg/ml 300 300
Deksametason tablet 0,5 mg 8720 8050 570 100
Dekstrometorfan sirup 10 mg/5 ml (HBr) 0
Dekstrometorfan tablet 15 mg (HBr) 0
Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) 0
Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) 0
Diazepam injeksi 5 mg/ml 0
Diazepam tablet 2 mg 624 600 24
Difenhidramin injeksi i.m. 10 mg/ml (HCl) 0 0
Digoksin tablet 0,25 mg 100 100 0
Diltiazem HCl Tablet 30 mg 0
Dimenhidrinat tablet 50 mg 0
Doksisiklin kapsul 100 mg 0
Domperidon suspensi 5 mg/5 ml 122 100 13 9
Domperidon tablet 10 mg 1980 1500 390 90
Efedrin HCl tablet 25 mg 0
Ekstraks beladona tablet 10 mg 0
Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) 100 100
Eritromisin kapsul 250 mg 0
Eritromisin kapsul 250 mg 0
Eritromisin kapsul 500 mg 260 200 60
Eritromisin sirup 200 mg/5 ml 0
Fenilbutason 200 mg tablet 0
Fenitoin Natrium Kapsul 100 mg 100 100
Fenitoin Natrium Kapsul 100 mg 0
Fenobarbital tablet 30 mg 300 300
Fenobarbital injeksi 0
Fenolgliserol tetes telinga 10 % 0
Fitomenadion (Vit. K) injeksi 10 mg/ml 24 24
Fitomenadion (Vit. K) tablet salut gula 10 mg 350 200 40 110
Furosemida injeksi 1.v/i.m 10 mg/ml 20 20
Furosemida tablet 40 mg 139 50 19 70
Furosemida tablet 40 mg 0
Gameksan lotion 1 % 0
Gemfibrosil kapsul 300 mg 1404 1188 84 132
Gemfibrosil kapsul 300 mg 0
Gemfibrozil kapsul 600 mg 0
Gentamisin salep kulit 0,1% 0
Gentamisin salep mata 0,3 % 0
Gentamisin sulfat tetes mata 0,3% 0
Gentian violet larutan 1 % 0
Glibenklamid tablet 5 mg 0
Gliclazid 80 mg tablet 0
Glimepirid tablet 2 mg 1740 1600 50 90
Gliseril Guayakolat tablet 100 mg 1920 1000 120 800
Gliserin lar 50 % 0
Glukosa larutan infus 10 % 100 100
Glukosa larutan infus 40 % 0
Glukosa larutan infus 5 % 260 260
Griseofulvin tablet 125 mg micronized 100 0 100
Haloperidol injeksi 5 mg/ml 24 24
Haloperidol injeksi 50 mg/ml 0
Haloperidol tablet 1,5 mg 0
Haloperidol tablet 2 mg 808 800 8
Haloperidol tablet 5 mg 0
Hidroklorotiazida tablet 25 mg 0
Hidrokortison krim 2,5% 95 78 17
Hyoscine-N-Butilbromide tablet 10 mg (Spashi) 0
Ibuprofen sirup 100 mg/5 ml 0
Ibuprofen tablet 200 mg 0
Ibuprofen tablet 400 mg 3710 3250 300 160
Isoniasida tablet 100 mg 0
Isosorbid dinitrat tablet sublingual 5 mg 0
Isosorbid dinitrat tablet sublingual 10 mg 740 500 140 100
Kalium diklofenak 50 mg tablet 0
Kalsium glukonas injeksi i.v. 10 % (100 mg/ml) 0
Kalsium laktat tablet 500 mg 2300 2050 160 90
Kalsium laktat tablet 500 mg 0
Kaptopril tablet 12,5 mg 220 100 120
Kaptopril tablet 25 mg 3194 3000 34 160
Karbamazepin tablet 200 mg 100 100
Ketokonazol krim 2 % 86 69 16 1
Ketokonazol tablet 200 mg 360 350 10
Ketorolac injeksi 10 mg 0
Ketorolac injeksi 30 mg 71 67 4
Klindamisin kapsul 300 mg 0
Klobazam tablet 10 mg 546 500 46
Klonidin tablet 0,15 mg 0
Kloramfenikol injeksi 1000 mg/ml 0
Kloramfenikol kapsul 500 mg 3450 3200 70 180
Kloramfenikol kapsul 250 mg (Licoklor) 0
Kloramfenikol salep mata 1 % 71 70 1
Kloramfenikol salep kulit (Bufacetin) 86 76 10
Kloramfenikol suspensi 125 mg/5 ml 0
Kloramfenikol tetes mata 0,5 % 93 77 15 1
Kloramfenikol tetes telinga 3 % 112 101 11
Klorfeniramin maleat (CTM) tablet 4 mg (Box-100 tabl) 9730 9200 350 180
Klorfeniramin maleat (CTM) tablet 4 mg (Box-288 tabl) 0
Klorpromazin tablet salut 100 mg (HCl) 364 300 64
Klorpromazin tablet salut 100 mg (HCl) 0
Klorpromazin tablet salut 25 mg (HCl) 0
Kodein tablet 10 mg 0
Kotrimoksasol DOEN I (dewasa) komb. 980 520 230 230
Kotrimoksasol suspensi 260 248 7 5
Lamivudin tablet 150 mg 0
Lanzoprazol kapsul 30 mg 0
Larutan mengandung elektrolit : (Asering) 240 240
Larutan mengandung elektrolit : (KAEN 3A) 260 260
Larutan mengandung elektrolit : (KAEN 3B) 260 260
Levotiroksin tablet 100 mg (Euthyrox) 0
Lidokain injeksi 2 % 0
Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml 176 130 30 16
Lidokain semprot 10 % 0
Magnesium sulfat injeksi 20 % 0
Magnesium sulfat injeksi 40 % 0
Mebendazol sirup 100 mg/5 ml 0
Mebendazol tablet 100 mg 0
Mekobalamin tablet 500 mg 0
Meloksikam 7.5 mg 0
Metformin HCl tablet 500 mg 1210 1100 20 90
Metil Prednisolon tablet 4 mg 310 300 10
Metil Prednisolon tablet 8 mg 0
Metilergometrin Maleat injeksi 0,200 mg - 1 ml 93 93
Metilergometrin maleat tablet 0,125 mg 280 210 70
Metoklopramid injeksi 5 mg/ml 0
Metoklopramid sirup 5 mg/5 ml 0
Metoklopramid tablet 10 mg 0
Metoklopramid tablet 5 mg 0
Metronidasol sirup 125 mg/5 ml (Novagyl) 87 65 10 12
Metronidasol tablet 250 mg 0
Metronidasol tablet 500 mg 410 200 100 110
Metronidazol infus 500 mg/100 ml 2 2
Mikonazol krim 2 % 62 53 9
N -asetyl sistein 200 mg 3500 3240 170 90
Natrium Diklofenak tablet 25 mg 0
Natrium Diklofenak tablet 50 mg 7280 6900 190 190
Natrium Diklofenak tablet 50 mg 0
Natrium Klorida Larutan Infus 0,9% steril 340 340
Nifedipin tablet 10 mg 0 0
Nifedipin tablet 20 mg SR 2090 1800 270 20
Nistatin vaginal tablet 100.000 IU/g 0
Obat Batuk Hitam (OBH) cairan 0
Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml 0
Oksitetrasiklin salep kulit 3% 0
Oksitetrasiklin salep mata 1% 0
Oksitosin injeksi 10 IU/ml - 1 ml 63 63
Omeprazol injeksi 40 mg/10 ml 60 60
Omeprazol kapsul 20 mg 1970 1830 50 90
Ondansentron injeksi 4 mg / 2 ml 0 0
Papaverin injeksi 0
Papaverin tablet 40 mg 0
Parasetamol drops 0
Parasetamol sirup 120 mg/5 ml 531 500 26 5
Parasetamol tablet 500 mg 9760 9700 60
Petidin injeksi (Narkotika) 0
Piracetam 800 mg tablet 0
Piracetam injeksi 1 gram/5 ml 0
Pirantel tablet score 125 mg 278 80 198
Piridoksin (Vit. B6) tablet 10 mg 4920 4350 430 140
Piroksikam kapsul 20 mg 2770 2080 300 390
Piroksikam tablet 10 mg 0
Polikresolsulfonat cairan 50 mg/ml (Aptil) 42 30 12
Prednison tablet 5 mg 800 710 10 80
Propanolol tablet 10 mg 0
Propiltiourasil tablet 100 mg 0
Ranitidin injeksi 25 mg/2 ml 0 0
Ranitidin tablet 150 mg 3650 3130 100 420
Rifampisin kaplet salut 450 mg 0
Rifampisin kapsul 300 mg 0
Ringer laktat larutan infus 80 80
Risperidon tablet 335 300 35
Salbutamol cairan inhales 0,1 % 0
Salbutamol tablet 2 mg 0
Salbutamol tablet 4 mg 140 0 50 90
Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap 36 29 7
Salisil bedak 2% 71 66 5
Sefadroksil 500 mg kapsul 1920 1700 70 150
Sefadroksil kapsul 250 mg 0
Sefadroksil kapsul 500 mg 0
Sefadroksil sirup kering 125 mg/5 ml 74 55 9 10
Sefadroksil sirup kering 250 mg/5 ml 0
Sefotaksim serbuk injeksi 1000 mg/vial 690 690
Sefotaksim serbuk injeksi 500 mg/vial 0
Seftriakson serbuk injeksi 1 gr/vial 0
Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) 1 1
Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) 30 30
Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml 0
Simetidin tablet 200 mg 0
Simvastatin tablet 10 mg 810 600 40 170
Simvastatin tablet 30 mg 0
Siprofloksasin tablet 250 mg 0
Siprofloksasin tablet 500 mg 1080 660 230 190
Siprofloksasin tablet 500 mg 0
Spironolakton tablet 25 mg 0
Sukralfat tablet 500 mg (Ulsidex) 0
Sukralfat suspensi (Ulsafate) 0
Sulfasetamid Na tetes mata 15 % 0
Tetrasiklin kapsul 250 mg 0
Tetrasiklin kapsul 500 mg 0
Tiamfenikol kapsul 500 mg 0
Tiamin (Vitamin B1) injeksi 100 mg/ml 0
Tiamin (Vitamin B1) tablet 50 mg 2850 2450 190 210
Tramadol kapsul 50 mg 0
Trifluoperazin 5 mg tablet 0
Triheksifenidil tablet 2 mg 1200 1200
Vaksin rabies untuk manusia 0
Vitamin B Kompleks tablet 4340 3950 190 200
0
OBAT DAN BAHAN KEDOKTERAN GIGI 0
Air raksa dental use 0
Alvogyl paste 0
Amalgam Perak (Silver Alloy) 0
Articulating papper 0
Bahan pensteril gigi : Trikresol formalin 0
Bahan tambalan sementara gigi siap pakai (Cavit) 0
Devitalisasi pasta (Non Arsen) 0
Etil klorida spray 3 3
Eugenol cairan 0
Fuji VII 0
Glass inonomer cement ART 0
Gutta percha dan papper point : 15 - 40 0
Gutta percha dan papper point : 45 - 60 0
Kalsium hidroksida pasta 0
Klorfenol Kamfer Menthol (CHKM) 0
Mummifying pasta 0
Pasta pengisi saliran akar 0
Semen Seng Fosfat serbuk dan cairan 0
Spon gelatin cubicles 1x1x1 0
Temporary stoping fletcher serbuk+cairan 0
0
OBAT TAMBAHAN / BRANDED 0
Anti asma/bronkodilator inhalasi (ventolin) 0
Anti asma/bronkodilator nebulizer (ventolin) 120 115 5
Antibiotik injeksi serbuk (seftriakson 1 g) 0
Antidiare sirup : Kaotin 0
Antidiare sirup : Neo Kaominal 0
Antidiare Tablet (Enterodin) 0
Antidiare Tablet (Molagit) 0
Antidiare Tablet (Omegdiar) 0
Antihemoroid DOEN (Superhoid) 0
Antihistamin kombinasi (Pritacort) 0
Antiinfeksi kulit (luka bakar) 39 31 8
Antiinflamasi gel (Provenid) 0
Antikretinisme tablet 0
Antiscabies krim (Scabicid) 44 27 7 10
Antispasme injeksi (Spashi) 0
Antispasme/analgetik tablet (Scopamin Plus) 0
Antispasme/analgetik tablet (SCOPMA) 0
Laksantia tablet 5 mg (Dulcolax) 0
Laksantia tablet 5 mg (Laxana) 50 50
Multivitamin + mineral + biotin tablet (Caviplex) 5280 4800 190 290
Multivitamin + mineral sirup (Recovit) 0 0
Multivitamin + mineral utk ibu hamil (Vitabion) 0
Multivitamin + minyak ikan (untuk ibu menyusui) Nulacta 0
Multivitamin geriatri (Osteos) 0
Multivitamin kaplet (Hemafort) 0
Multivitamin kaplet (Pritavit) 0
Multivitamin kaplet (VITALAMIN) 0
Multivitamin kaplet salut gula 0
Multivitamin sirup (CURBION) 194 167 13 14
Multivitamin sirup + DHA (Caviplex + DHA) 0
Multivitamin tabur untuk balita 0
Nasal dekongestan tablet ( Alerfed) 0
Neurotropik 5000 injeksi 128 120 8
Neurotropik kaplet (MOLANEURON) 0
Neurotropik kaplet (Nutrifar)
Neurotropik kaplet (Nutralix) 4780 4400 180 200
Nutrisi/Vitamin injeksi (Alinamin F) 0
Nutrisi/vitamin tablet (Aspar K) 0
Obat antifibrinolitik kapsul (NEXITRA) 0
Obat Antiflu kombinasi (Tremenza) 0
Obat Antiulkus peptikum tablet (Nucral) 0
Obat batuk / flu sirup : Coredryl 0
Obat batuk / flu sirup : Erphaflu 0
Obat batuk / flu sirup : Erphakaf 0
Obat batuk / flu sirup : Fortusin 0
Obat batuk / flu sirup : Iafed 0
Obat batuk / flu sirup : Samcodryl sy 533 519 3 11
Vasodilator perifer (Citicholin) 0
0
OBAT ASLI INDONESIA (OAI) 0
Asifit kapsul 0
Batugin elixir 0
Enkasari 0
Fitogen Dragge 0
Hepagard 0
Imulan kapsul 0
Imulan sirup 0
Kurkumex sirup 0
Kurkumex tablet 0
OB Herbal 0
Tensigard kapsul 0
Xanvit sirup 0
0
BAHAN MEDIS HABIS PAKAI 0
Alkohol swab 19 19
KY Jelly 28 gram / Aquagel jelly 2 2
Desinfektan - Aseptin liquid 40 40
Desinfektan - Antiseptic surgical hand scrub (E-Care) 9 9
Etakridin (Rivanol) larutan 0,1 % 6 6
Etanol 70 % 33 33
Etanol 70 % 0
Gelang pasien dewasa (4 warna) 2 2
Gelang pasien anak (4 warna) 0
Lisol, mengandung kresol tersabun 50% 9 9
Povidon iodida larutan 10 % 30 ml 0
Povidon iodida larutan 60 ml 20 20
Povidon iodida larutan 10 % 300 ml 5 5
Swab desinfektan (P2L) 0
0
0
PERBEKALAN KESEHATAN 0
Alat suntik sekali pakai 1 ml 393 393
Alat suntik sekali pakai 2,5 ml (Stera) 0
Alat suntik sekali pakai 3 ml 1929 1929
Alat suntik sekali pakai 5 ml 1430 1430
Bbraun Intrafix with microdriper 0
Bisturi (mata pisau) 0 0
Blood lancet 28 0
Blood Tranfusion set 25 25
Catgut / benang bedah No. 2/0 - 3/0 23 23
Catgut chromic 2/0 100 M 0
Catgut chromic 3/0 100 M 0
Catgut chromic 2/0 0
Catgut chromic 3/0 0
Catgut plain 2/0 0
Catgut plain 3/0 0
Surgical advantime 3/0, 3/8 xC, 19 mm, 70 cm (Peters surg 0
Dermafix T 10 x 15 cm 0
Dermafix T 5 x 7 cm 2 2
Developer untuk Film Rontgen 0
Film Rontgen ukuran 24 x 30 0
Film Rontgen ukuran 30 x 40 0
Fixer untuk Film Rontgen 0
Folley catheter No. 16 (Norta) 15 15
Folley catheter No. 18 (Norta) 37 37
Folley catheter No. 20 (serenity) 0
Folley catheter No. 22 (serenity) 0
Folley catheter No. 24 (serenity) 0
Infus set (Otsu Y) 250 250
Infus set dengan micridripper (Otsu) 0
Infus set anak 100 100
Infus set dewasa 0
IV catheter No. 18 G 57 57
IV catheter No. 20 G 0
IV catheter No. 22 G 250 250
IV catheter No. 24 G 200 200
Jarum jahit kombinasi 0
Jarum jahit otot 5 5
Jarum jahit kulit 5 5
Kapas pembalut/absorben 250 gram 9 9
Kasa 10 x 10 cm 0
Kasa hidrofil 80 cm x 40 yard 0
Kasa hidrofil steril ukuran 16 x 16 41 41
Kasa hidrofil ukuran 16 x 16 0
Kasa kompres 40/40 steril 11 11
Kasa pembalut hidrofil 4 m x 10 cm 150 150
Kasa pembalut hidrofil 4 m x 15 cm elastic 150 150
Kasa pembalut hidrofil 4 m x 3 cm elastic 75 75
Kertas EKG ( 50 x 30) 0
Masker, Earloop 900 900
Masker, tie on 1540 1540
Mata Bor gigi 0
Micropipet Socorex - Acua 0
- Volume 1 - 10 uL 0
- Volume 10 - 100 uL 0
- Volume 100 - 1000 uL 0
Nasal oxygen canula adult sraight 16 16
Nasal oxygen canula - child 6 6
Penutup luka dengan antibiotika 10 x 10 cm (Cuticell) 28 28
Penutup luka dengan antibiotika 10 x 10 cm (Bioplacenton 0
Plester 2.5 cm x 4.5 m (Leucoplast) 0
Plester 5 yards x 2 inchi 0
Plester 5 cm x 5 m (Pharmafix) 0
Plester 5 cm x 5 m (Fixomull) 0
Plester kain 1,25 cm x 4,5 m (Leukoplast) 6 6
Pembalut elastis 7,5 cm x 4,5 M (Uniflex) 0
Pot sputum 0
Sarung tangan steril nomor 6,5 (MAS) 60 60
Sarung tangan steril nomor 7 0
Sarung tangan steril nomor 7,5 (MAS) 24 24
Sarung tangan steril nomor 8 0
Sarung tangan ukuran M sekali pakai 1600 1600
Sarung tangan ukuran S sekali pakai 2300 2300
Silk (benang bedah sutera no 2/0 dg jarum (Peters surgical 0
Silk (benang bedah sutera no 3/0 dg jarum 3 3
Silk 3/0 jarum 3/8 26 M (demetech) 0
Silk 2/0 jarum 3/8 30 M (demetech) 0
Silk 3/0 jarum 1/2 17 M (demetech) 0
Silk 2/0 jarum 1/2 30 M (demetech) 0
Tabung oksigen 1 m3 + regulator 0
Urine bag 20 20
Under pad 20 20
Wing needle 23 G - 25 G 8 8
0
TAMBAHAN PERBEKALAN KESEHATAN 0
Alat pengukur HB 201 + analizer 0
Dek glass (cover glass) 0
Microcuvet Hb 201 0
Object glass 0
Occu check (alat pemegang lancet ROCHE) 0
Softclick lanciet 200 0
Softclick lancing device 0
Tabung hematokrit 0
Kertas pH indikator 0
0
0
0
0
REAGEN 0
Aquabidest steril 0
Aquabidest steril 0
Pemeriksaan kadar gula darah 0
Glocodoctor 0
Accutrand 0
Easy Touch 0
Nesco gluco strip 0
Glucostar 0
Reagen Pemeriksaan Asam Urat 0
Nesco 0
Easy Touch 0
UA Sure 0
Reagen Pemeriksaan Kolesterol 0
Accutrand 0
Easy touch cholesterol 0
Nesco 0
Multicare 0
Hb Sahli 0
- Assistant 0
- Superior 0
Reagen untuk spektrofotometr 0
- Reagen kolesterol 0
- Reagen glukosa 0
- Reagen Trigliserida 0
- Reagen asam urat 0
Larutan amonium oksalat 1 % 0
Larutan Asam Klorida 0,1 N 0
Larutan Benedict 0
Larutan EDTA 10 % 0
Larutan Eosin 0
Larutan Giemsa Stain 0
Larutan Karbol Fuksin 0
Larutan Metanol 0
Larutan Metilen Blue 0
Larutan Natrium citrat 0
Larutan Perhidrol (H2O2) 0
Larutan Turk 0
Larutan Ziehl Neelsen 0
Reagen pemeriksaan yodium 0
Reagen dan alat pengujian lab makanan 0
Rapid Diagnostic Test Malaria 0
Rapid test Leptospirosis 0
Rapid test Chikungunya 0
Rapid test demam berdarah 0
Tes Kehamilan 0
PPTEST 0
HCG strip (answer) 0
UltraOne tes kehamilan 0
Trigliserida 0
- Accutrend) 0
- Multicare 0
Tes HBsAG S/P strip (Answer) 0
Tes HIV I & II Antibody Card (IR-100c) 0
Rapid HIV 1 (SD) 0
Urine Test 10 Parameter 0
Widal Test Tg H (SS-01) 0
Widal Test Tg O (SS-90) 0
Tes Narkoba 0
- Metamfetamin 0
- Cocain 0
- Cannabidoid 0
- Benzodiasepin 0
- Babiturat 0
Reagen Mantoux 0
Tes Golongan darah 0
- Anti A 0
- Anti B 0
- Anti AB 0
Oil emersi 0
0
OBAT PROGRAM MALARIA (P2M) 0
ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tab 0
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin p 0
Artemeter injeksi 1 ml 80 mg 6 6
Artesunat injeksi vial 60 mg 0
Kloroquin tablet 150 mg 0
Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg 0
Kuinin Dihidroklorida injeksi 25% - 2 ml 0
Kuinin tablet 222 mg (H2SO4.7H2O) 60 60
Primaquin tablet 15 mg 100 100
Doksisiklin kapsul 100 mg 0
0
OBAT PROGRAM DIARE (P2M) 0
Garam oralit serbuk kombinasi 30 30
Zink Dispersible 20 mg 1200 1200
Zincpro drops 15 ml 54 54
Zink sirup 20 mg/5 ml (Zirkum Kids) 81 81
0
OBAT PROGRAM FILARIA (KAKI GAJAH) 0
Dietil karbamasin sitrat 0
0
OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0
Benzatin Benzil Penisilin injeksi 2,4 juta IU 0
0
OBAT PROGRAM KUSTA (P2M) 0
Prednison tablet 5 mg 0
0
OBAT PROGRAM FLU BURUNG 0
Oseltamivir kapsul 0
0
OBAT PROGRAM GIZI (KIA) 0
Retinol (Vitamin A) 100.000 IU kapsul lunak 0
Retinol (Vitamin A) 200.000 IU kapsul lunak 0
Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + A 4890 4590 270 30
Mineral Mix 0
Iodol kapsul 0
0
OBAT PROGRAM KECACINGAN (P2M) 0
Albendazol tablet 400 mg 0
Albendazol suspensi 200 mg/5 ml 0
Pirantel pamoat tablet 125 mg 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
LAMPIRAN
BULAN DESEMBER 2016
I.A OBAT ESENSIAL / GENERIK Satuan Jumlah Penerimaan
1 Alopurinol tabet 100 mg tablet 500
2 Amlodipin 10 mg tablet 1500
3 Amoksisillin sy 125 mg botol 240
4 Amoksisillin 500 mg tablet 10000
5 Antasida DOEN tablet tablet 15000
6 Antasida DOEN sy botol 300
7 Aqua proinjeksi vial 240
8 Antihaemoroid supp supp 30
9 Asam Mefenamat 250 mg tablet 7000
10 Asiklovir krim tube 50
11 Asiklovir tablet 400 mg tablet 300
12 Betametason krim tube 50
13 Bisakodril suppositoria / Dulcolac supp 30
14 Cetirizin kapsul 10 mg kapsul 2000
15 Dexametason injeksi ampul 500
16 Dexametason tablet 0,5 mg tablet 5000
17 Diasepam tablet 2 mg tablet 500
18 Domperidon suspensi botol 50
19 Eritromisin kapsul 500 mg kapsul 300
20 Vit K tablet 10 mg tablet 200
21 Furosemide tablet 300
22 Gemfibroksil kapsul 300 mg tablet 600
23 Glimeperide 2 mg tablet 1500
24 Glukosa 5 % botol 200
25 Haloperidol 2 mg tablet 1000
26 Hidrokortison krim tube 96
27 Kaptrofil 25 mg tablet 3000
28 Ketokonasol krim tube 75
29 Ketokonasol tablet 200 mg tablet 500
30 Klobazam tablet 500
31 Kloramphenikol tablet 500 mg tablet 2000
32 Kloramphenikol salep kulit /Bufactin tube 72
33 Kloramphenikol tetes mata botol 75
34 CTM tablet 8000
35 Klorpromazim tablet 200
36 Kotrimoksasol suspensi botol 150
37 Larutan Asering botol 500
38 Larutan KAEN 3A botol 200
39 Larutan KAEN 3B botol 200
40 Lidocain comp. injeksi ampul 120
41 Metformin Hcl 500 mg tablet 1000
42 Metilergometrin maleat tab.0,125 mg tablet 100
43 Mikonazol krim tube 48
44 Na Diklofenak tablet 5000
45 NaCl 0,9 % botol 200
46 Nifedipin 20 mg / Adalat ortos tablet 1200
47 Omeprazol kapsul kapsul 900
48 ondansentron injeksi 4 mg/10 mg ampul 80
49 Parasetamol sirup 120 mg/5 ml botol 400
50 Parasetamol 500 mg tablet 15000
51 Vit B6 tablet 5000
52 Piroksicam tablet 20 mg tablet 2000
53 Ranitidine tablet 150 mg tablet 3000
54 Resperidon tablet tablet 200
55 Sefadroksil sirup botol 60
56 Sefotaksim injeksi 1000mg/vial ampul 800
57 ABU 1 vial 5
58 ATS tetagam vial 20
59 Sinvastatin tablet 10 mg tablet 500
60 Triheksifenidil tablet 20 mg tablet 1000
61 Ventolin neb vial 60
62 Caviplek kaplet 5000
63 Multivitamin sirup curbion botol 300
64 neurotropik tablet ( Nutralix ) tablet 5000
65 Obat antiflu kombinasi ( samcodryil ) botol 500

III PERBEKALAN KESEHATAN


1 Alat suntik sekai pakai 1 ml Pcs 200
2 Alat suntik sekai pakai 3ml Pcs 2000
3 Alat suntik sekai pakai 5 ml Pcs 1000
4 Blood tranfusi set (MAS) Pcs 20
5 Folley Catheter 16 (Norta) Pcs 20
6 Folley Catheter 18 (Norta) pcs 20
7 Infus Set dewasa ( Otsu Y ) set/kantong 200
8 IV Catt no. 22 G buah 200
9 Kapas pembalut bungkus 5
10 Kasa hidrofil steril 16 x 16 box 30
11 Kasa 4 m x10 cm rol 100
12 Kasa 4 m x15 cm rol 100
13 masker tie-on Pcs 1000
14 masker earlop Pcs 500
15 under pad Pcs 10
16 canul oksigen anak Pcs 10
17 penutup luka Cuticell Pcs 20
18 Plester kain (leukoplast ) Pcs 20
19 Plester hypafix rol 3
20 Sarung tangan sekali pakai M (MAS) pasang 2000
21 Sarung tangan sekali pakai S (MAS) pasang 2000
22 Silk Pcs 36
23 gelang pasien dewasa box 2
24 gelang pasien dewasa box 6
25 Etanol 100 ml botol 30
26 Aseptan Liquid botol 12
27 Alkohol swab botol 20
28 Aquagel jelly 28 gr tube 2
29 Povidon iodida 10% 60 ml botol 20
IV REAGEN DAN OBAT MALARIA, GIZI dan GIGI
1 Reagen asam urat UA sure box 5
2 Reagent trigliserida box 5
3 larutan Giemsa stain botol 1
4 Garam Oralit saset 100
5 Zink Disposible 20 mg tablet 1500
6 Zinkpro drop botol 50
7 Zink sirup botol 50
8 FE tablet 6000

Purwodadi, 22 Nopember 2016


Panitia Pemeriksa

1. drg. Risnantoko 1.

2. Sutarmo 2.

3. Pratinah 3.

4. Kosidah 4.
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

PUSKESMAS BUBUTAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI LAPORAN BULAN / PERIODE : JANUARI 2017 INST. FARMASI
KABUPATEN : PURWOREJO PERMINTAAN BULAN / PERIODE : FEBRUARI 2017 PUSKESMAS

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN STOK OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 mg tablet 1,445 100 1,545 898 647 1,000
2 Alprazolam tablet 0,25 mg tablet 162 0 162 0 162 0
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 0 0
4 Ambroxol tablet 30 mg tablet 0 0 0 1,000
5 Aminofilin injeksi 24 mg/ml ampul 15 15 3 12 0
6 Aminofilin tablet 200 mg tablet 1,000 0 1,000 351 649 1,000
7 Amitriptilin tablet 25 mg tablet 100 100 0 100
8 Amlodipin tablet 10 mg tablet 0 0 0 0 500
9 Amlodipin tablet 5 mg tablet 485 485 141 344 500
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0 0 0
11 Amoksisilin kaplet 500 mg tablet 10,153 4,000 14,153 7,053 7,100 4,000
12 Amoksisilin kapsul 250 mg kapsul 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 126 120 226 103 123 100
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 0 0 0
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 158 158 1 157
16 Antalgin (Metampiron) tablet 500 mg tablet 920 920 0 920 0
17 Antasida DOEN I tablet kunyah kombinasi tablet 4,943 3,000 7,943 2,385 5,558 3,000
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 105 0 105 30 75 0
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 0 0 0
20 polimiksin 10.000 kombinasi
Antifungi DOEN IU/g : Asam Benzoat 6% + Asam pot 0 0 0 50
21 Salisilat 3 % DOEN kombinasi (Generik)
Antihemoroid supp 16 20 36 3 33 0
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet tablet 0 0 0 0 0 500
23 Aqua pro injeksi steril, bebas pirogen vial 31 0 31 10 21 30
24 Asam asetil salisilat 80 mg tablet 0 0 0 0 0
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 685 0 685 0 685 100
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 3,425 0 3,425 1,016 2,409 1,000
27 Asam folat tablet 1 mg tablet 0 0 0 0 1,000
28 Asam mefenamat kaplet 250 mg Tablet 3,369 2,000 5,369 1,501 3,868 1,000
29 Asam mefenamat kaplet 500 mg tablet 0 0 0 3,000
30 Asam traneksamat injeksi 100 mg/ml ampul 15 15 0 15 0
31 Asiklovir krim 5 % tube 5 gram 67 67 16 51 60
32 Asiklovir tablet 200 mg tablet 0 0 0 0
33 Asiklovir tablet 400 mg tablet 585 585 105 480 0
34 Atapulgit tablet 600 mg tablet 900 0 900 629 271 1,000
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 30 0 30 0 30 0
36 Betahistin mesilat tablet 6 mg tablet 0 0 0 0 0
37 Betametason cream 0,1 % tube 93 0 93 28 65 0
38 Betametason tetes mata 1 mg/ml botol 0 0 0 0 0 0
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 22 0 22 3 19 0
40 Bromheksin tablet 8 mg tablet 0 0 0 0 0 0
41 Cetirizine kapsul 10 mg kapsul 1,242 0 1,242 118 1,124 0
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 0 0 0 0 0
43 Deksametason injeksi i.v. 5 mg/ml ampul 85 0 85 0 85 0
44 Deksametason tablet 0,5 mg tablet 3,552 4,000 7,552 3,893 3,659 4,000
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 0 0 0
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 0 0 0
47 Diazepam injeksi 5 mg/ml ampul 0 0 0 0 0
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 0 0 0 0 0 0
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 0 0 0 0 10
50 Diazepam tablet 2 mg tablet 736 0 736 44 692 0
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 30 30 0 30 0
52 Digoksin tablet 0,25 mg tablet 400 0 400 50 350 0
53 Diltiazem HCl Tablet 30 mg tablet 0 0 0 0 0 0
54 Dimenhidrinat tablet 50 mg tablet 711 0 711 181 530 0
55 Doksisiklin kapsul 100 mg kapsul 584 0 584 26 558 0
56 Domperidon suspensi 5 mg/5 ml botol-60ml 44 0 44 2 42 0
57 Domperidon tablet 10 mg tablet 1,200 0 1,200 32 1,160 0
58 Efedrin HCl tablet 25 mg tablet 0 0 0 0 0 0
59 Ekstraks beladona tablet 10 mg tablet 0 0 0 0 0 100
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 0 100 0 100 0
61 Eritromisin kapsul 250 mg kapsul 0 0 0 0 0
62 Eritromisin kapsul 500 mg kapsul 500 0 500 0 500 0
63 Eritromisin sirup 200 mg/5 ml botol 0 0 0 0 0
64 Fenilbutason 200 mg tablet tablet 0 0 0 0 0
65 Fenitoin Natrium Kapsul 100 mg kapsul 0 0 0 0 0
66 Fenobarbital injeksi ampul 0 0 0 0 0
67 Fenobarbital tablet 30 mg tablet 0 0 0 0 0
68 Fenolgliserol tetes telinga 10 % botol 0 0 0 0 24
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 29 29 0 0 0
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 708 0 708 60 648 0
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 0 0 0 0 0
72 Furosemida tablet 40 mg tablet 748 0 748 186 562 200
73 Gameksan lotion 1 % botol-30 ml 0 0 0 0 0
74 Gemfibrosil kapsul 300 mg kapsul 696 0 696 115 581 0
75 Gemfibrozil kapsul 600 mg kapsul 0 0 0 0 0
76 Gentamisin salep kulit 0,1% tube 0 0 0 0 0
77 Gentamisin salep mata 0,3 % botol 42 0 42 0 42 0
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 0 0 0 0 0
79 Gentian violet larutan 1 % botol 0 0 0 0 0
80 Glibenklamid tablet 5 mg tablet 0 0 0 0 0
81 Gliclazid 80 mg tablet tablet 0 0 0 0 0
82 Glimepirid tablet 2 mg tablet 1,319 1,319 480 839 500
83 Gliseril Guayakolat tablet 100 mg tablet 0 0 0 0 500
84 Gliserin lar 50 % botol-100 ml 0 0 0 0 0
85 Glukosa larutan infus 10 % botol 500 ml 0 0 0 0 0
86 Glukosa larutan infus 40 % ampul 0 0 0 0 0
87 Glukosa larutan infus 5 % botol 500 ml 142 142 6 136 0
88 Griseofulvin tablet 125 mg micronized tablet 442 0 442 0 442 0
89 Haloperidol injeksi 5 mg/ml ampul 0 0 0 0 0
90 Haloperidol injeksi 50 mg/ml ampul 0 0 0 0 0
91 Haloperidol tablet 1,5 mg tablet 0 0 0 0 0
92 Haloperidol tablet 2 mg tablet 100 100 200 0 200 0
93 Haloperidol tablet 5 mg tablet 200 0 200 40 160 100
94 Hidroklorotiazida tablet 25 mg tablet 0 0 0 0 0
95 Hidrokortison krim 2,5% tube 45 24 69 15 54 24
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 0 0 0 100
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 0 0 0 0
98 Ibuprofen tablet 200 mg tablet 0 0 0 0 0 0
99 Ibuprofen tablet 400 mg tablet 3,564 3,000 6,564 2,011 4,563 3,000
100 Isoniasida tablet 100 mg tablet 0 0 0 0 0
101 Isosorbid dinitrat tablet sublingual 10 mg 0 0 0 0 0
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 0 0 100
103 Kalium diklofenak 50 mg tablet tablet 0 0 0 0 0
104 Kalsium glukonas injeksi ampul 0 0 0 0 0
105 Kalsium laktat tablet 500 mg tablet 2,613 0 2,613 1,631 1,000 3,000
106 Kaptopril tablet 12,5 mg tablet 1,253 0 1,253 150 1,103 0
107 Kaptopril tablet 25 mg tablet 842 2,000 2,842 6 2,836 0
108 Karbamazepin tablet 200 mg tablet 0 0 0 0 0
109 Karbogliserin tetes telinga botol 0 0 0 0 0
110 Ketokonazol krim 2 % tube 15 gram 33 25 58 40 18 44
111 Ketokonazol tablet 200 mg tablet 441 0 441 441 0 1,000
112 Ketorolac injeksi 10 mg ampul 1 ml 44 0 44 2 42 0
113 Ketorolac injeksi 30 mg ampul 1 ml 0 0 0 0 0 0
114 Klindamisin kapsul 300 mg kapsul 0 0 0 0 0 0
115 Klobazam tablet 10 mg tablet 0 0 0 0 0 0
116 Klonidin tablet 0,15 mg tablet 0 0 0 0 0 0
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 0 0 0 0
118 Kloramfenikol kapsul 250 mg kapsul 0 0 0 0 0 0
119 Kloramfenikol kapsul 500 mg kapsul 1,705 0 1,705 230 1,475 0
120 Kloramfenikol salep kulit (Bufacetin) tube 64 0 64 0 64 0
121 Kloramfenikol salep mata 1 % tube 5 gram 36 24 60 19 41 24
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 39 0 39 9 30 50
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 10 50 60 39 21 50
124 Kloramfenikol tetes telinga 3 % botol 5 ml 30 0 30 15 15 48
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 6,257 5,000 11,257 6,023 5,234 5,000
127 Klorpromazin tablet salut 100 mg (HCl) tablet 309 0 309 50 259 0
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0 0 0
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 1,200 0 1,200 126 1,074 0
131 Kotrimoksasol suspensi botol 60 ml 106 0 106 6 100 0
132 Lamivudin tablet 150 mg tablet 0 0 0 0 0 0
133 Lanzoprazol kapsul 30 mg kapsul 0 0 0 0 0
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 40 0 40 0 40 40
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 40 0 40 9 31 0
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 0 0 0 0 0 0
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 0 0 0 0
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 0 0 0 0 0
139 Lidokain injeksi 2 % ampul 0 0 0 0 0 0
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 40 0 40 0 40 0
141 Lidokain semprot 10 % botol 0 0 0 0 0 2
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 0 0 0 0 0 0
143 Magnesium sulfat injeksi 20 % ampul 0 0 0 0 0 0
144 Magnesium sulfat injeksi 40 % ampul 0 0 0 0 0 0
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 0 0 0 0
146 Mebendazol tablet 100 mg tablet 0 0 0 0 0 0
147 Mekobalamin tablet 500 mg tablet 0 0 0 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0 0 0
149 Metformin HCl tablet 500 mg tablet 1,103 1,103 20 1,083 0
150 Metil Prednisolon tablet 4 mg tablet 563 0 563 0 563 0
151 Metil Prednisolon tablet 8 mg tablet 0 0 0 0 0
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 0 0 0 0 0
153 Metilergometrin maleat tablet 0,125 mg tablet 723 0 723 310 413 500
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 0 0 20
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 0 0 0 0
156 Metoklopramid tablet 10 mg tablet 700 0 700 0 700 0
157 Metoklopramid tablet 5 mg tablet 0 0 0 0 0
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 0 0 0 0 0
159 Metronidasol tablet 250 mg tablet 0 0 0 0 0
160 Metronidasol tablet 500 mg tablet 415 0 415 48 367 1,000
161 Metronidazol infus 500 mg/100 ml botol-100 ml 9 0 9 0 9 0
162 Mikonazol krim 2 % tube 69 0 69 11 58 0
163 N-asetyl sistein kaplet 200 mg tablet 334 0 334 334 0 2,000
164 Natrium Diklofenak tablet 25 mg tablet 0 0 0 0 0
165 Natrium Diklofenak tablet 50 mg tablet 31 3,000 3,031 1,153 1,878 2,000
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 33 0 33 0 33 0
167 Nifedipin tablet 10 mg tablet 632 0 632 187 445 500
168 Nifedipin tablet 20 mg SR tablet 0 0 0 0 0 0
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 0 0 0 0
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 0 0
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 0 0
173 Oksitetrasiklin salep mata 1% tube 0 0 0 0
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 63 63 63 0 10
175 Omeprazol injeksi 40 mg/10 ml vial 60 100 160 160 0 30
176 Omeprazol kapsul 20 mg kapsul 1,063 0 1,063 54 1,019 0
177 Ondansentron injeksi 4 mg / 2 ml ampul 0 0 0 0 0
178 Papaverin injeksi ampul 0 0 0 0
179 Papaverin tablet 40 mg tablet 0 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0 0
181 Parasetamol sirup 120 mg/5 ml botol 56 150 206 112 94 100
182 Parasetamol tablet 500 mg tablet 13,300 0 13,300 4,800 8,500 1,000
183 Permetrin (Scabimite) tube 10 10 0 10 0
184 Petidin injeksi (Narkotika) ampul 0 0 0 0
185 Piracetam 800 mg tablet tablet 0 0 0 0 2,000
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 0 0 10
187 Pirantel tablet score 125 mg tablet 120 120 120 0
188 Piridoksin (Vit. B6) tablet 10 mg tablet 4,920 2,000 6,920 6,920 0 2,000
189 Piroksikam kapsul 20 mg tablet 2,770 2,000 4,770 4,770 0 3,000
190 Piroksikam tablet 10 mg tablet 0 0 0
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 30 30 30 0
192 Prednison tablet 5 mg tablet 800 800 800 0
193 Probenesid tablet 500 mg tablet 0 0 0
194 Propanolol tablet 10 mg tablet 0 0 0
195 Propiltiourasil tablet 100 mg tablet 0 0 0
196 Ranitidin injeksi 25 mg/2 ml ampul 0 0 0 0 200
197 Ranitidin tablet 150 mg tablet 3,650 3,650 3,650 0 5,000
198 Rifampisin kaplet salut 450 mg kaplet 0 0 0
199 Rifampisin kapsul 300 mg kapsul 0 0 0
200 Ringer laktat larutan infus botol 500 ml 80 500 580 580 0 300
201 Risperidon tablet tablet 335 335 335 0 300
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 0
203 Salbutamol tablet 2 mg tablet 0 0 0
204 Salbutamol tablet 4 mg tablet 140 5,000 5,140 5,140 0 3,000
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap pot 36 36 36 0 48
206 4%
Salisil bedak 2% kotak-50 gram 71 100 171 171 0 100
208 Sefadroksil kapsul 250 mg kaplet 0 0 0
209 Sefadroksil kapsul 500 mg kaplet 1,920 1,920 1,920 0
210 Sefadroksil sirup kering 125 mg/5 ml botol 74 60 134 134 0 60
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 0
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 690 800 1,490 1,490 0 800
213 Sefotaksim serbuk injeksi 500 mg/vial vial 0 0 0
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 0
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 1 5 6 6 0
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAGAM) dos 30 30 30 0
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 10 10 0 20
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 0 500
219 Simetidin tablet 200 mg tablet 0 0 0 1,000
220 Simvastatin tablet 10 mg tablet 810 500 1,310 1,310 0 500
221 Simvastatin tablet 30 mg tablet 0 0 0
222 Siprofloksasin tablet 250 mg tablet 0 0 0
223 Siprofloksasin tablet 500 mg tablet 1,080 1,000 2,080 2,080 0 1,000
224 Spironolakton tablet 25 mg tablet 0 0 0
225 Sukralfat suspensi (Ulsafate) botol 0 0 0
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 0
227 Sulfasetamid Na tetes mata 15 % botol 0 0 0
228 Tetrasiklin kapsul 250 mg kapsul 0 0 0
229 Tetrasiklin kapsul 500 mg kapsul 0 0 0
230 Tiamfenikol kapsul 500 mg kapsul 0 0 0 3,000
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 0
232 Tiamin (Vitamin B1) tablet 50 mg tablet 2,850 3,000 5,850 5,850 0 5,000
233 Tramadol kapsul 50 mg tablet 0 0 0
234 Trifluoperazin 5 mg tablet tablet 0 0 0
235 Triheksifenidil tablet 2 mg tablet 1,200 1,200 1,200 0
236 Vaksin rabies untuk manusia set 0 0 0
237 Vitamin B Kompleks tablet tablet 4,340 4,340 4,340 0 5,000
0 0 0
B OBAT DAN BAHAN KEDOKTERAN GIGI 0 0 0
1 Air raksa dental use botol 0 0 0
2 Alvogyl paste dus 0 0 0
3 Amalgam Perak (Silver Alloy) botol 0 0 0
4 Articulating papper kotak 0 0 0
5 Bahan pensteril gigi : Trikresol formalin botol 0 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 0
7 Dentin conditioner botol 0 0 0
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 0
9 Etil klorida spray vial/100 ml 3 3 3 0
10 Eugenol cairan botol@10 ml 0 0 0
11 Fuji VII dus 1 1 1 0 2
12 Fuji IX dus 1 1 1 0 2
13 Glass inonomer cement ART set/botol 0 0 0 2
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 0
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 0
16 Kalsium hidroksida pasta kotak 2 tube 0 0 0
17 K-file perawatan akar gigi 0 0 0
- K-file No. 15 set 0 0 0
- K-file No. 20 set 0 0 0
- K-file No. 25 set 0 0 0
- K-file No. 30 set 0 0 0
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 0
19 Mummifying pasta botol/kotak 0 0 0
20 Pasta pengisi saliran akar botol 0 0 0
21 Seluloid strip rol 0 0 0
22 Semen Seng Fosfat serbuk dan cairan set/botol 2 2 2 0
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) 2 2 2 0
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram 0 0 0
25 Tooth mouse box 0 0 0
0 0 0
C OBAT TAMBAHAN / BRANDED 0 0 0
1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 0
2 Anti asma/bronkodilator nebulizer (ventolin) vial 120 20 140 140 0 100
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 0
4 Antidiare sirup : . botol 60 ml 0 0 0 100
6 Antidiare Tablet : tablet 0 0 0
7 Antidiare Tablet (Molagit) tablet 0 0 0
9 Antihemoroid DOEN (Superhoid) supp 0 0 0
10 Antihistamin kombinasi (Pritacort) tablet 0 0 0
11 Antiinfeksi kulit (luka bakar) pot 37 37 37 0 24
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 0
13 Antikretinisme tablet tablet 0 0 0
14 Antiscabies krim (Scabicid) tube 10 gram 44 44 44 0
15 Antispasme injeksi (Spashi) vial 0 0 0 50
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 0 1,000
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 0 2,000
18 Laksantia tablet 5 mg (Dulcolax) tablet 0 0 0
19 Laksantia tablet 5 mg (Laxana) tablet 50 50 50 0
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 5,280 5,000 10,280 10,280 0 5,000
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 0 0 0 0
22 Multivitamin + mineral utk ibu hamil : . kaplet 0 0 0 1,000
27 Multivitamin kaplet : VITALAMIN kaplet 0 0 0 0 1,000
28 Multivitamin sirup : CURBION Botol 194 200 394 394 0 200
31 Multivitamin tabur untuk balita Saset 0 0 0
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 0
33 Neurotropik 5000 injeksi ampul 128 100 228 228 0 100
34 Neurotropik kaplet : kaplet 4,780 5,000 9,780 9,780 0 10,000
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 0 10
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 0 1,000
40 Obat Antiflu kombinasi : SAMCODRYL SIRUP botol 60 ml 533 533 533 0 500
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 0
42 Obat batuk / flu sirup : .. botol 100 ml 0 0 0
47 Vasodilator perifer (Citicholin) ampul 0 0 0 50
0 0 0
D OBAT ASLI INDONESIA (OAI) 0 0 0
1 Asifit kapsul 0 0 0
2 Batugin elixir botol 0 0 0
3 Enkasari botol 0 0 0
4 Fitogen Dragge kapsul 0 0 0
5 Hepagard kapsul 0 0 0
6 Imulan kapsul kapsul 0 0 0
7 Imulan sirup botol 60 ml 0 0 0
8 Kurkumex sirup botol 60 ml 0 0 0
9 Kurkumex tablet kaplet 0 0 0
10 OB Herbal 0 0 0
11 Tensigard kapsul kapsul 0 0 0
12 Xanvit sirup 0 0 0
0 0 0
II. BAHAN MEDIS HABIS PAKAI 0 0 0
1 Alkohol swab box 19 10 29 29 0 10
2 Aquagel jelly 28 gram tube 2 2 2 0
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 9 9 9 0
4 Desinfektan - Aseptan liquid botol-500 ml 40 40 40 0
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 6 6 6 0
6 Etanol 70 % botol 100 ml 33 30 63 63 0 20
7 Etanol 70 % botol 1000 ml 0 0 0
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 0 0 0
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 20 20 40 40 0 20
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 5 5 5 0
0 0 0
III. PERBEKALAN KESEHATAN 0 0 0
1 Alat suntik sekali pakai 1 ml set 393 393 393 0
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 0
3 Alat suntik sekali pakai 3 ml (Terumo) set 1,929 2,000 3,929 3,929 0 2,000
4 Alat suntik sekali pakai 5 ml (Terumo) set 1,430 1,000 2,430 2,430 0 2,000
5 Bisturi (mata pisau) Pcs 0 0 0
6 Blood lancet 28 box-100 0 0 0
7 Blood Tranfusion set (MAS) Pcs 25 25 25 0
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm 23 23 23 0
9 Catgut chromic 2/0 saset/pack 0 0 0
10 Catgut chromic 2/0 100 M kotak 0 0 0
11 Catgut chromic 3/0 saset/pack 0 0 0
12 Catgut chromic 3/0 100 M kotak 0 0 0
13 Catgut plain 2/0 saset/pack 0 0 0
14 Catgut plain 3/0 saset/pack 0 0 0
15 Dermafix T 10 x 15 cm rol 0 0 0
16 Dermafix T 5 x 7 cm rol 0 0 0 0
17 Developer untuk Film Rontgen Botol 5 ltr Repl 20 ltr 0 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 0 5 5 5 0 10
19 Film Rontgen ukuran 24 x 30 lembar 0 0 0
20 Film Rontgen ukuran 30 x 40 lembar 0 0 0
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 0
22 Folley catheter No. 16 (Norta) Pcs 15 10 25 25 0 10
23 Folley catheter No. 18 (Norta) Pcs 37 37 37 0
24 Folley catheter No. 20 Pcs 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0
27 Infus set - Bbraun Intrafix with microdriper set 0 0 0
28 Infus set (Otsu Y) pices 250 250 250 0 200
29 Infus set anak set/kantong 100 100 100 0 50
30 Infus set dengan micridripper (Otsu) pices 0 0 0
31 Infus set dewasa (Stardec) set/kantong 0 0 0
32 IV catheter No. 18 G buah 57 57 57 0
33 IV catheter No. 20 G buah 0 0 0
34 IV catheter No. 22 G buah 250 100 350 350 0 200
35 IV catheter No. 24 G buah 200 200 200 0 50
36 Jarum jahit kulit saset 5 5 5 0
37 Jarum jahit otot saset 5 5 5 0
38 Kapas pembalut/absorben 250 gram bungkus 9 9 9 0 5
39 Kasa 10 x 10 cm rol 0 0 0
40 Kasa hidrofil 80 cm x 40 yard rol 0 3 3 3 0 2
41 Kasa hidrofil steril ukuran 16 x 16 box 41 20 61 61 0 50
42 Kasa hidrofil ukuran 16 x 16 lembar 0 0 0
43 Kasa kompres 40/40 steril bungkus 11 11 11 0
44 Kasa pembalut hidrofil 4 m x 10 cm roll 150 100 250 250 0 50
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 150 100 250 250 0 50
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 75 75 75 0
47 Kertas EKG ( 50 x 30) rol 0 0 0
48 Masker : - Earloop pcs 900 500 1,400 1,400 0 500
49 Masker : - Earloop (Stardec) Pcs 0 0 0
50 Masker : - tie on Pcs 1,540 1,540 1,540 0 1,000
Masker : - tie on (Stardec) Pcs 0 0 0
51 Mata Bor gigi 0 0 0
- type inverted No. 010 buah 0 0 0
- type cylinder No. 010 buah 0 0 0
- type tuppered No. 010 buah 0 0 0
- type round No. 010 buah 0 0 0
52 Micropipet Socorex - Acura 0 0 0
- Volume 1 - 10 uL set 0 0 0
- Volume 10 - 100 uL set 0 0 0
- Volume 100 - 1000 uL set 0 0 0
53 N-95 Medical Respirator box 0 0 0
54 Nasal oxygen canula - adult sraight pieces 16 15 31 31 0 15
55 Nasal oxygen canula - child pieces 6 10 16 16 0
56 Nasal oxygen canula - infant 0 0 0
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton tule Pcs 28 28 28 0 10
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 0 0 0 10
59 Plester 5 yards x 2 inchi rol 0 0 0 10
60 Plester hypafix/pharmafix 5 cm x 5 m rol 0 2 2 2 0 20
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 6 30 36 36 0 50
62 Pot sputum buah 0 0 0
63 Sarung tangan steril nomor 6,5 : MAS pasang 60 60 60 0
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0 0
67 Sarung tangan steril nomor 7,5 : MAS pasang 24 24 24 0
68 Sarung tangan steril nomor 8 0 0 0
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 5 5 5 0 10
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 5 5 5 0 10
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0 0
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 1,600 1,000 2,600 2,600 0 2,000
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 2,300 2,300 2,300 0
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgical) pack/saset 36 36 36 0 2
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0 0 2
77 Silk 2/0 box-12 pacs 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0
80 Tabung oksigen 1 m3 + regulator set 0 0 0
81 Under pad buah 20 20 20 0 20
82 Urine bag Pcs 20 20 40 40 0
83 Wing needle 23 G - 25 G buah 8 8 8 0
Safety bok biji 30 30 30 0
TAMBAHAN PERBEKALAN KESEHATAN
1 Alat pengukur HB 201 + analizer unit 0 0 0
2 Dek glass (cover glass) box 0 0 0
3 Microcuvet Hb 201 buah 0 0 0
4 Object glass box 0 0 0
5 Occu check (alat pemegang lancet ROCHE) kit 0 0 0
6 Softclick lanciet 200 box 0 0 0
7 Softclick lancing device kit 0 0 0
8 Tabung hematokrit botol 0 0 0
9 Kotak slide 0 0 0
10 Performa Accu check Blood glucose meter set 0 0 0
- Performa Accu check tes strip box 0 0 0
0 0 0
III REAGEN 0 0 0
1 Aquabidest steril botol 500 ml 0 0 0
2 Aquabidest steril botol 1000 ml 0 0 0
3 Pemeriksaan kadar gula darah 0 0 0
Glocodoctor Box-50 test 0 0 0
Accutrand 25 strip 0 0 0
Easy Touch box/25 0 0 0
Nesco gluco strip box/25 0 0 0
Glucostar box/25 0 0 0 5
4 Reagen Pemeriksaan Asam Urat 0 0 0
Nesco box-25 0 0 0
Easy Touch box-25 0 0 0
UA Sure box-25 0 5 5 5 0 5
5 Reagen Pemeriksaan Kolesterol 0 0 0
Accutrand box/25 0 0 0
Easy touch cholesterol box-10 0 0 0
Nesco box-10 0 0 0
Multicare box/25 0 0 0 5
6 Hb Sahli 0 0 0
- Assistant set 0 0 0
- Superior set 0 0 0
7 Reagen untuk spektrofotometr 0 0 0
- Reagen glukosa box-4 btl 0 0 0
- Reagen Trigliserida box-4 btl 0 0 0
- Reagen asam urat box-4 btl 0 0 0
8 Trigliserida 0 0 0
- Accutrend box / 25 0 0 0
- Multicare box / 25 0 5 5 5 0 5
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0 0
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0 0
10 Larutan Benedict Botol 100 ml 0 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 0
12 Larutan Eosin Botol 100 ml 0 0 0
13 Larutan Giemsa Stain Botol 100 ml 0 1 1 1 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0 0
15 Larutan Metanol Botol 100 ml 0 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 0
17 Larutan Natrium citrat Botol 100 ml 0 0 0
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0 0
19 Larutan Turk Botol 100 ml 0 0 0 1
20 Larutan Ziehl Neelsen set 0 0 0
21 Reagen pemeriksaan yodium botol 0 0 0
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0 0
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0 0
- RDT Combo Malaria tes 0 0 0
24 Rapid test Leptospirosis box/50 strip 0 0 0
25 Rapid test Chikungunya tes 0 0 0
26 Rapid test demam berdarah kit-25 tes 0 0 0
27 Rapid test demam thypoid kit-25 tes 0 0 0
28 Tes Kehamilan 0 0 0
PPTEST Box 40 tes 0 0 0
HCG strip (answer) strip 0 0 0
UltraOne tes kehamilan box 50 tes 0 0 0
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 0 0 2
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0 0
31 Urine Test 10 Parameter btl - 100 test 0 0 0
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0 0 1
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0 0 1
34 Tes Narkoba 0 0 0
- Amfetamin kot@25 strip 0 0 0
- Metamfetamin kot@25 strip 0 0 0
- Cocain kot@25 strip 0 0 0
- Cannabidoid kot@25 strip 0 0 0
- Benzodiasepin kot@25 strip 0 0 0
- Babiturat kot@25 strip 0 0 0
35 Reagen Mantoux ampul 0 0 0
36 Tes Golongan darah 0 0 0
- Anti A Botol 10 ml 0 0 0
- Anti B Botol 10 ml 0 0 0
- Anti AB Botol 10 ml 0 0 0
37 Oil emersi botol 100 ml 0 0 0
38 Reagen untuk fotometer 0 0 0
- reagen kolesterol 4 botol @ 100 ml 0 0 0 1
- reagen glukosa 4 botol @ 100 ml 0 0 0 1
- reagen asam urat 4 botol @ 100 ml 0 0 0
- reagen trigliserida 4 botol @ 100 ml 0 0 0 1
0 0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet tablet 0 0 0
2 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin tablet 0 0 0
3 posphat
Artemeter320) tablet
injeksi 1 ml 80 mg ampul 6 6 6 0
4 Artesunat injeksi vial 60 mg kotak/set 0 0 0
5 Kloroquin tablet 150 mg tablet 0 0 0
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 0 0 0
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0 0
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 60 60 60 0
9 Primaquin tablet 15 mg tablet 100 100 100 0
10 Doksisiklin kapsul 100 mg tablet 0 0 0
0 0 0
V OBAT PROGRAM DIARE (P2M) 0 0 0
1 Garam oralit serbuk kombinasi saset 30 200 230 230 0 200
2 Zink Dispersible 20 mg tablet 1,200 1,200 1,200 0
3 Zincpro drops 15 ml botol 54 54 54 0
4 Zink sirup Botol 81 81 81 0 50
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0 0
1 Dietil karbamasin sitrat tablet 0 0 0
0 0 0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0 0
0 0 0
VIII OBAT PROGRAM KUSTA (P2M) 0 0 0
1 Prednison tablet 5 mg tablet 0 0 0
0 0 0
IX OBAT PROGRAM FLU BURUNG 0 0 0
1 Oseltamivir kapsul kapsul 0 0 0
0 0 0
X OBAT PROGRAM GIZI (KIA) 0 0 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 100 100 100 0
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 1,100 1,100 1,100 0
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + tablet 4,890 3,000 7,890 7,890 0 6,000
Asam Folat 0,25 mg)
4 Mineral Mix saset 0 0 0
5 Iodol kapsul kapsul 0 0 0
0 0 0
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0 0
1 Albendazol tablet 400 mg tablet 1,080 1,080 1,080 0
2 Albendazol suspensi 200 mg/5 ml botol 10 ml
3 Pirantel pamoat tablet 125 mg

XII. OBAT ANTI TUBERKULOSIS


1 Obat FDC kategori 1 paket
2 Obat FDC kategori 2 paket
3 Obat FDC Sisipan paket
4 OAT Anak paket
5 OAT Kombipak 1 paket

XIII. PROGRAM P2
1 Zidovudin + lamivudin (300 mg/150 mg tablet
2 Efavirenz 600 mg tablet
3 Tenofovir (TDF) 300 mg tablet
4 Nevirapin 200 mg tablet
5 Lamivudin 3 TC 150 mg tablet

XIV. PROGRAM KUSTA


1 Obat MDT Kusta PB Dewasa blister
2 Obat MDT Kusta MB Anak blister
3 Obat MDT Kusta MB Dewasa blister

JUMLAH KUNJUNNGAN RESEP UMUM JKN LAIN-2 JUMLAH


BAYAR
1680 2240 503 4423

Purworejo, 5 Nopember 2016


Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bragolan Petugas Puskesmas Bragolan
Kabupaten Purworejo
dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. ( Nursinah ) ( dr. Hanuke Ari Racmawati B,M.M )
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19730829 200604 2 003 NIP. 19760526 200212 2 006
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/

NO. NAMA OBAT SATUAN JUMLAH


BARANG
1 2 3 4
1 Allopurinol tablet 100 mg tablet 1000
2 Aminofillin tablet 200 mg tablet 1000
3 Amoksisillin kaplet 500 mg tablet 4000
4 Amoksisillin siruo kering 125mg/5ml botol 60 ml 120
5 Antasida DOEN Itablet kunyah kombinasi tablet 3000
6 Aqua pro injeksi steril, bebas pirogen vial 30
7 Asam Askorbat (Vitamin C) tablet 50 mg tablet 1000
8 Asam Mefenamat 250 mg tablet 1000
9 Attapulgit tablet 600 mg tablet 1000
10 Dexametason tablet 0,5 mg tablet 4000
11 Diazepam lar rectal 10 mg/2,5 ml (stesolid) rect tube 10
12 Furosemid tablet 40 mg tablet 200
13 Glimeperid tablet 2 mg tablet 200
14 Hidrokortison krim 2,5 % tube 24
15 Ibuprofen tablet 400 mg tablet 3000
16 Isosorbid dinitrat tab sublingual 10 mg tablet 100
17 Ketokenazol krim 2 % tube 15 mg 50
18 Kloramfenikol salep mata 1% tube 5 mg 24
19 Klorfeniramin meleat (CTM) tab 4 mg tablet 5000
20 Lar mengandung elektrolit : (Asering) botol 500 ml 40
21 Metilergometrin maleat inj 0,200 mg-1ml ampul 10
22 Metilergometrin maleat tablet 0,125 mg tablet 500
23 Metronidasol tablet 500 mg tablet 1000
24 N-asetyl sistein kaplet 200 mg tablet 2640
25 Natrium diklofenak tablet 50 mg tablet 2000
26 Nifedipin tablet 10 mg tablet 500
27 Nifedipin tablet 20 mg tablet 600
28 Oksitosin injeksi 10 IU/ml-1ml ampul 10
29 Parasetamol sirup 120 mg/5 ml botol 100
30 Parasetamol tablet 500 mg tablet 1000
31 Piroksikam kapsul 20 mg tablet 500
32 Prednison tablet 5 mg tablet 1000
33 Ringer laktat larutan infus botol 500 ml 160
34 Sefadroksil kapsul 500 mg kaplet 1000
35 Sefotaksim serbuk injeksi 1000 mg/vial vial

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
PURWOREJO

KETERANGAN
SUMBER
5

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


9830323 201406 2 005
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

PUSKESMAS : BRAGOLAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI LAPORAN BULAN / PERIODE : FEBRUARI 2017 INST. FARMASI
KABUPATEN : PURWOREJO PERMINTAAN BULAN / PERIODE : MARET 2017 PUSKESMAS 442/ /XI/2016 2017

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN STOK OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK I.A.
1 Alopurinol tablet 100 mg tablet 310 2,000 2,310 235 2,075 1
2 Alprazolam tablet 0,25 mg tablet 2
3 Ambroksol sirup 15 mg/ml botol 60 ml 3
4 Ambroxol tablet 30 mg tablet 4
5 Aminofilin injeksi 24 mg/ml ampul 30 30 0 30 5
6 Aminofilin tablet 200 mg tablet 200 300 500 110 390 300 6
7 Amitriptilin tablet 25 mg tablet 250 250 5 245 7
8 Amlodipin tablet 10 mg tablet 770 770 475 295 2,000 8
9 Amlodipin tablet 5 mg tablet 1,000 9
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 10
11 Amoksisilin kaplet 500 mg tablet 13,200 5,000 18,200 6,150 12,050 5,000 11
12 Amoksisilin kapsul 250 mg kapsul 0 0 0 0 12
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 198 240 438 175 263 240 13
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 14
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 25 25 0 25 15
16 Antalgin (Metampiron) tablet 500 mg tablet 16
17 Antasida DOEN I tablet kunyah kombinasi tablet 16,310 16,310 4,000 12310 17
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 298 100 398 132 266 100 18
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 19
20 polimiksin 10.000 kombinasi
Antifungi DOEN IU/g : Asam Benzoat 6% + Asam pot 20
21 Salisilat 3 % DOEN kombinasi (Generik)
Antihemoroid supp 35 35 18 17 30 21
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet tablet 22
23 Aqua pro injeksi steril, bebas pirogen vial 264 120 384 132 252 120 23
24 Asam asetil salisilat 80 mg tablet 24
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 358 500 858 148 710 25
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 1,775 3,000 4,775 2,315 2,460 5,000 26
27 Asam folat tablet 1 mg tablet 27
28 Asam mefenamat kaplet 250 mg Tablet 10,290 10,290 3,504 6,786 3,000 28
29 Asam mefenamat kaplet 500 mg tablet 29
30 Asam traneksamat injeksi 100 mg/ml ampul 100 30
31 Asiklovir krim 5 % tube 5 gram 89 89 31 58 50 31
32 Asiklovir tablet 200 mg tablet 32
33 Asiklovir tablet 400 mg tablet 380 300 680 145 535 33
34 Atapulgit tablet 600 mg tablet 1,980 1,000 2,980 590 2390 34
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 90 90 90 0 30 35
36 Betahistin mesilat tablet 6 mg tablet 1,000 36
37 Betametason cream 0,1 % tube 128 128 58 70 50 37
38 Betametason tetes mata 1 mg/ml botol 38
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 27 12 39 1 38 39
40 Bromheksin tablet 8 mg tablet 40
41 Cetirizine kapsul 10 mg kapsul 1,550 3,000 4,550 1,830 2,720 2,000 41
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 93 100 193 56 137 50 42
43 Deksametason injeksi i.v. 5 mg/ml ampul 183 500 683 383 300 1,000 43
44 Deksametason tablet 0,5 mg tablet 10,160 8,000 18,160 7,270 10,890 4,000 44
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 45
46 Dekstrometorfan tablet 15 mg (HBr) tablet 46
47 Diazepam injeksi 5 mg/ml ampul 47
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 5 5 1 4 48
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 49
50 Diazepam tablet 2 mg tablet 980 500 1,480 750 730 1,000 50
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 2,000 51
52 Digoksin tablet 0,25 mg tablet 99 99 20 79 100 52
53 Diltiazem HCl Tablet 30 mg tablet 53
54 Dimenhidrinat tablet 50 mg tablet 200 54
55 Doksisiklin kapsul 100 mg kapsul 55
56 Domperidon suspensi 5 mg/5 ml botol-60ml 107 107 14 93 56
57 Domperidon tablet 10 mg tablet 1,528 1,528 585 943 1,000 57
58 Efedrin HCl tablet 25 mg tablet 58
59 Ekstraks beladona tablet 10 mg tablet 59
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 100 0 100 60
61 Eritromisin kapsul 250 mg kapsul 61
62 Eritromisin kapsul 500 mg kapsul 200 500 700 180 520 500 62
63 Eritromisin sirup 200 mg/5 ml botol 0 120 120 10 110 63
64 Fenilbutason 200 mg tablet tablet 64
65 Fenitoin Natrium Kapsul 100 mg kapsul 185 185 0 185 65
66 Fenobarbital injeksi ampul 66
67 Fenobarbital tablet 30 mg tablet 300 300 0 300 67
68 Fenolgliserol tetes telinga 10 % botol 50 68
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 21 21 1 20 69
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 130 1,000 1,130 595 535 1,000 70
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 20 20 0 20 71
72 Furosemida tablet 40 mg tablet 507 507 95 412 72
73 Gameksan lotion 1 % botol-30 ml 73
74 Gemfibrosil kapsul 300 mg kapsul 1,236 1,800 3,036 1,251 1785 1,800 74
75 Gemfibrozil kapsul 600 mg kapsul 75
76 Gentamisin salep kulit 0,1% tube 76
77 Gentamisin salep mata 0,3 % botol 77
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 0 96 96 71 25 96 78
79 Gentian violet larutan 1 % botol 79
80 Glibenklamid tablet 5 mg tablet 80
81 Gliclazid 80 mg tablet tablet 81
82 Glimepirid tablet 2 mg tablet 957 1,000 1,957 467 1490 82
83 Gliseril Guayakolat tablet 100 mg tablet 140 140 140 0 5,000 83
84 Gliserin lar 50 % botol-100 ml 84
85 Glukosa larutan infus 10 % botol 500 ml 100 100 0 100 85
86 Glukosa larutan infus 40 % ampul 86
87 Glukosa larutan infus 5 % botol 500 ml 220 220 40 180 87
88 Griseofulvin tablet 125 mg micronized tablet 370 370 100 270 200 88
89 Haloperidol injeksi 5 mg/ml ampul 19 19 0 19 89
90 Haloperidol injeksi 50 mg/ml ampul 90
91 Haloperidol tablet 1,5 mg tablet 300 91
92 Haloperidol tablet 2 mg tablet 680 680 170 510 92
93 Haloperidol tablet 5 mg tablet 200 93
94 Hidroklorotiazida tablet 25 mg tablet 94
95 Hidrokortison krim 2,5% tube 132 72 204 33 171 95
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 2,000 96
97 Ibuprofen sirup 100 mg/5 ml botol 97
98 Ibuprofen tablet 200 mg tablet 98
99 Ibuprofen tablet 400 mg tablet 3,880 5,000 8,880 2,340 6540 2,000 99
100 Isoniasida tablet 100 mg tablet 0 100 100 100 0 100
101 Isosorbid dinitrat tablet sublingual 10 mg 420 500 920 80 840 101
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 102
103 Kalium diklofenak 50 mg tablet tablet 103
104 Kalsium glukonas injeksi ampul 104
105 Kalsium laktat tablet 500 mg tablet 810 810 810 0 3,000 105
106 Kaptopril tablet 12,5 mg tablet 520 520 0 520 106
107 Kaptopril tablet 25 mg tablet 3,260 1,000 4,260 1,112 3148 107
108 Karbamazepin tablet 200 mg tablet 100 100 30 70 100 108
109 Karbogliserin tetes telinga botol 109
110 Ketokonazol krim 2 % tube 15 gram 124 124 16 108 110
111 Ketokonazol tablet 200 mg tablet 240 240 200 40 300 111
112 Ketorolac injeksi 10 mg ampul 1 ml 112
113 Ketorolac injeksi 30 mg ampul 1 ml 64 64 28 36 24 113
114 Klindamisin kapsul 300 mg kapsul 114
115 Klobazam tablet 10 mg tablet 350 500 850 50 800 115
116 Klonidin tablet 0,15 mg tablet 116
117 Kloramfenikol injeksi 1000 mg/ml vial 117
118 Kloramfenikol kapsul 250 mg kapsul 118
119 Kloramfenikol kapsul 500 mg kapsul 2,118 3,000 5,118 1,798 3320 119
120 Kloramfenikol salep kulit (Bufacetin) tube 87 24 111 18 93 120
121 Kloramfenikol salep mata 1 % tube 5 gram 40 48 88 37 51 48 121
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 100 122
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 68 68 68 0 100 123
124 Kloramfenikol tetes telinga 3 % botol 5 ml 98 98 16 82 124
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 13,060 13,060 5,490 7570 10,000 125
127 Klorpromazin tablet salut 100 mg (HCl) tablet 490 490 164 326 126
128 Klorpromazin tablet salut 25 mg (HCl) tablet 127
129 Kodein tablet 10 mg tablet 128
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 770 500 1,270 1,070 200 500 ed 129
131 Kotrimoksasol suspensi botol 60 ml 167 150 317 87 230 130
132 Lamivudin tablet 150 mg tablet 131
133 Lanzoprazol kapsul 30 mg kapsul 132
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 320 320 140 180 100 133
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 200 100 300 100 200 100 134
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 220 100 320 100 220 100 135
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 136
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 2 2 1 1 137
139 Lidokain injeksi 2 % ampul 138
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 105 105 82 23 90 139
141 Lidokain semprot 10 % botol 140
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 6 10 16 2 14 141
143 Magnesium sulfat injeksi 20 % ampul 142
144 Magnesium sulfat injeksi 40 % ampul 143
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 144
146 Mebendazol tablet 100 mg tablet 145
147 Mekobalamin tablet 500 mg tablet 146
148 Meloksikam 7.5 mg tablet 147
149 Metformin HCl tablet 500 mg tablet 898 1,000 1,898 508 1390 148
150 Metil Prednisolon tablet 4 mg tablet 1,244 1,500 2,744 324 2420 149
151 Metil Prednisolon tablet 8 mg tablet 150
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 91 91 1 90 151
153 Metilergometrin maleat tablet 0,125 mg tablet 210 210 10 200 152
154 Metoklopramid injeksi 5 mg/ml ampul 153
155 Metoklopramid sirup 5 mg/5 ml botol 154
156 Metoklopramid tablet 10 mg tablet 155
157 Metoklopramid tablet 5 mg tablet 156
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 83 83 3 80 157
159 Metronidasol tablet 250 mg tablet 158
160 Metronidasol tablet 500 mg tablet 1,030 1,000 2,030 400 1630 159
161 Metronidazol infus 500 mg/100 ml botol-100 ml 2 2 0 2 160
162 Mikonazol krim 2 % tube 63 96 159 37 122 161
163 N-asetyl sistein kaplet 200 mg tablet 5,190 3,000 8,190 2,970 5220 2,000 162
164 Natrium Diklofenak tablet 25 mg tablet 163
165 Natrium Diklofenak tablet 50 mg tablet 5,580 5,580 3,430 2150 6,000 164
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 260 260 60 200 165
167 Nifedipin tablet 10 mg tablet 0 200 200 0 200 1,000 166
168 Nifedipin tablet 20 mg SR tablet 2,270 600 2,870 544 2326 167
169 Nistatin vaginal tablet 100.000 IU/g tablet
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 100 168
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 169
172 Oksitetrasiklin salep kulit 3% tube 5 gram 170
173 Oksitetrasiklin salep mata 1% tube 171
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 58 58 2 56 172
175 Omeprazol injeksi 40 mg/10 ml vial 4 4 4 0 200 173
176 Omeprazol kapsul 20 mg kapsul 2,358 2,358 813 1545 1,000 174
177 Ondansentron injeksi 4 mg / 2 ml ampul 175
178 Papaverin injeksi ampul 176
179 Papaverin tablet 40 mg tablet 177
180 Parasetamol drops botol 15 ml 178
181 Parasetamol sirup 120 mg/5 ml botol 251 300 551 333 218 300 179
182 Parasetamol tablet 500 mg tablet 13,657 15,000 28,657 7,167 21490 180
183 Permetrin (Scabimite) tube 181
184 Petidin injeksi (Narkotika) ampul 182
185 Piracetam 800 mg tablet tablet 183
186 Piracetam injeksi 1 gram/5 ml ampul 184
187 Pirantel tablet score 125 mg tablet 120 120 0 120 185
188 Piridoksin (Vit. B6) tablet 10 mg tablet 4,260 2,000 6,260 2,810 3450 2,000 186
189 Piroksikam kapsul 20 mg tablet 2,780 3,000 5,780 2,010 3770 2,000 187
190 Piroksikam tablet 10 mg tablet 188
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 30 30 0 30 189
192 Prednison tablet 5 mg tablet 670 670 0 670 190
193 Probenesid tablet 500 mg tablet 191
194 Propanolol tablet 10 mg tablet 192
195 Propiltiourasil tablet 100 mg tablet 193
196 Ranitidin injeksi 25 mg/2 ml ampul 500 194
197 Ranitidin tablet 150 mg tablet 1,297 1,297 1,297 0 5,000 195
198 Rifampisin kaplet salut 450 mg kaplet 196
199 Rifampisin kapsul 300 mg kapsul 197
200 Ringer laktat larutan infus botol 500 ml 340 300 640 240 400 200 198
201 Risperidon tablet tablet 235 235 185 50 200 199
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 200
203 Salbutamol tablet 2 mg tablet 201
204 Salbutamol tablet 4 mg tablet 3,916 3,000 6,916 1,446 5470 202
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap pot 26 26 5 21 203
206 4%
Salisil bedak 2% kotak-50 gram 121 100 221 55 166 204
208 Sefadroksil kapsul 250 mg kaplet 205
209 Sefadroksil kapsul 500 mg kaplet 1,520 1,520 706 814 1,000 206
210 Sefadroksil sirup kering 125 mg/5 ml botol 105 60 165 30 135 207
211 Sefadroksil sirup kering 250 mg/5 ml botol 208
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 884 800 1,684 554 1130 500 209
213 Sefotaksim serbuk injeksi 500 mg/vial vial 210
214 Seftriakson serbuk injeksi 1 gr/vial vial 211
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 6 6 1 5 212
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAGAM) dos 8 8 8 0 213
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 20 30 7 23 214
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 215
219 Simetidin tablet 200 mg tablet 1,000 216
220 Simvastatin tablet 10 mg tablet 958 958 388 570 1,000 217
221 Simvastatin tablet 30 mg tablet 218
222 Siprofloksasin tablet 250 mg tablet 219
223 Siprofloksasin tablet 500 mg tablet 1,300 1,000 2,300 940 1360 1,000 220
224 Spironolakton tablet 25 mg tablet 221
225 Sukralfat suspensi (Ulsafate) botol 222
226 Sukralfat tablet 500 mg (Ulsidex) tablet 223
227 Sulfasetamid Na tetes mata 15 % botol 224
228 Tetrasiklin kapsul 250 mg kapsul 225
229 Tetrasiklin kapsul 500 mg kapsul 226
230 Tiamfenikol kapsul 500 mg kapsul 1,000 227
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 228
232 Tiamin (Vitamin B1) tablet 50 mg tablet 3,796 3,000 6,796 2,846 3950 3,000 229
233 Tramadol kapsul 50 mg tablet 230
234 Trifluoperazin 5 mg tablet tablet 231
235 Triheksifenidil tablet 2 mg tablet 950 950 320 630 1,000 232
236 Vaksin rabies untuk manusia set 233
237 Vitamin B Kompleks tablet tablet 2,338 5,000 7,338 2,798 4540 2,000 234
235
B OBAT DAN BAHAN KEDOKTERAN GIGI 236
1 Air raksa dental use botol 237
2 Alvogyl paste dus 238
3 Amalgam Perak (Silver Alloy) botol 239
4 Articulating papper kotak 240
5 Bahan pensteril gigi : Trikresol formalin botol
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram B
7 Dentin conditioner botol 1
8 Devitalisasi pasta (Non Arsen) botol/kotak 2
9 Etil klorida spray vial/100 ml 3 3 1 2 2 3
10 Eugenol cairan botol@10 ml 4
11 Fuji VII dus 0 2 2 2 0 2 5
12 Fuji IX dus 2 6
13 Glass inonomer cement ART set/botol 2 7
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 8
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 9
16 Kalsium hidroksida pasta kotak 2 tube 10
17 K-file perawatan akar gigi 11
- K-file No. 15 set 12
- K-file No. 20 set 13
- K-file No. 25 set 14
- K-file No. 30 set 15
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 16
19 Mummifying pasta botol/kotak 17
20 Pasta pengisi saliran akar botol 18
21 Seluloid strip rol 19
22 Semen Seng Fosfat serbuk dan cairan set/botol 20
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm)
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram C
25 Tooth mouse box 1
2
C OBAT TAMBAHAN / BRANDED 3
1 Anti asma/bronkodilator inhalasi (ventolin) vial 4
2 Anti asma/bronkodilator nebulizer (ventolin) vial 76 76 61 15 100 5
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 6
4 Antidiare sirup : . botol 60 ml 100 7
6 Antidiare Tablet : tablet 8
7 Antidiare Tablet (Molagit) tablet 9
9 Antihemoroid DOEN (Superhoid) supp 10
10 Antihistamin kombinasi (Pritacort) tablet 11
11 Antiinfeksi kulit (luka bakar) pot 27 27 11 16 24 12
12 Antiinflamasi gel (Provenid) tube 30 gr 13
13 Antikretinisme tablet tablet 14
14 Antiscabies krim (Scabicid) tube 10 gram 37 37 3 34 15
15 Antispasme injeksi (Spashi) vial 20 16
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 500 17
17 Antispasme/analgetik tablet (SCOPMA) tablet 1,000 18
18 Laksantia tablet 5 mg (Dulcolax) tablet 19
19 Laksantia tablet 5 mg (Laxana) tablet 40 40 10 30 20
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 7,275 5,000 12,275 2,170 10105 21
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 100 22
22 Multivitamin + mineral utk ibu hamil : . kaplet 23
27 Multivitamin kaplet : VITALAMIN kaplet 1,000 24
28 Multivitamin sirup : CURBION Botol 264 200 464 145 319 25
31 Multivitamin tabur untuk balita Saset 26
32 Nasal dekongestan tablet ( Alerfed) tablet 27
33 Neurotropik 5000 injeksi ampul 173 80 253 73 180 50 28
34 Neurotropik kaplet : kaplet 3,566 5,000 8,566 4,556 4010 8,000 29
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 30
38 Nutrisi/vitamin tablet (Aspar K) tablet 500 31
40 Obat Antiflu kombinasi : SAMCODRYL SIRUP botol 60 ml 133 133 133 0 300 32
41 Obat Antiulkus peptikum tablet (Nucral) tablet 33
42 Obat batuk / flu sirup : .. botol 100 ml 200 34
47 Vasodilator perifer (Citicholin) ampul 100 35

D OBAT ASLI INDONESIA (OAI) 36


1 Asifit kapsul 37
2 Batugin elixir botol 38
3 Enkasari botol 39
4 Fitogen Dragge kapsul 40
5 Hepagard kapsul 41
6 Imulan kapsul kapsul 42
7 Imulan sirup botol 60 ml 43
8 Kurkumex sirup botol 60 ml 44
9 Kurkumex tablet kaplet 45
10 OB Herbal
11 Tensigard kapsul kapsul 46
12 Xanvit sirup
D
II. BAHAN MEDIS HABIS PAKAI 1
1 Alkohol swab box 21 10 31 5 26 2
2 Aquagel jelly 28 gram tube 2 2 1 1 3
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 8 8 6 2 10 4
4 Desinfektan - Aseptan liquid botol-500 ml 29 29 10 19 5
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 5 5 2 3 3 6
6 Etanol 70 % botol 100 ml 36 36 10 26 7
7 Etanol 70 % botol 1000 ml 0 5 5 1 4 8
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 9
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 25 20 45 10 35 10
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 4 4 0 4 11
12
III. PERBEKALAN KESEHATAN
1 Alat suntik sekali pakai 1 ml set 363 363 169 194 300 E
2 Alat suntik sekali pakai 2,5 ml (Stera) set 1
3 Alat suntik sekali pakai 3 ml (Terumo) set 1,917 1,800 3,717 1,369 2348 2
4 Alat suntik sekali pakai 5 ml (Terumo) set 1,330 1,200 2,530 624 1906 3
5 Bisturi (mata pisau) Pcs 4
6 Blood lancet 28 box-100 5
7 Blood Tranfusion set (MAS) Pcs 25 25 5 20 6
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm 20 20 6 14 7
9 Catgut chromic 2/0 saset/pack 8
10 Catgut chromic 2/0 100 M kotak 9
11 Catgut chromic 3/0 saset/pack 10
12 Catgut chromic 3/0 100 M kotak 11
13 Catgut plain 2/0 saset/pack 12
14 Catgut plain 3/0 saset/pack 13
15 Dermafix T 10 x 15 cm rol 10 14
16 Dermafix T 5 x 7 cm rol 10
17 Developer untuk Film Rontgen Botol 5 ltr Repl 20 ltr
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 4 2 6 3 3 10 II
19 Film Rontgen ukuran 24 x 30 lembar 1
20 Film Rontgen ukuran 30 x 40 lembar 2
21 Fixer untuk Film Rontgen Galon 20 liter 3
22 Folley catheter No. 16 (Norta) Pcs 17 10 27 6 21 4
23 Folley catheter No. 18 (Norta) Pcs 30 30 2 28 5
24 Folley catheter No. 20 Pcs 6
25 Folley catheter No. 22 Pcs 7
26 Folley catheter No. 24 Pcs 8
27 Infus set - Bbraun Intrafix with microdriper set 9
28 Infus set (Otsu Y) pices 130 200 330 210 120 200 10
29 Infus set anak set/kantong 80 50 130 30 100 11
30 Infus set dengan micridripper (Otsu) pices 12
31 Infus set dewasa (Stardec) set/kantong 13
32 IV catheter No. 18 G buah 57 57 0 57 14
33 IV catheter No. 20 G buah 15
34 IV catheter No. 22 G buah 200 200 400 150 250 100 16
35 IV catheter No. 24 G buah 150 50 200 50 150 100 17
36 Jarum jahit kulit saset 5 5 1 4 18
37 Jarum jahit otot saset 5 5 1 4 19
38 Kapas pembalut/absorben 250 gram bungkus 7 5 12 1 11 20
39 Kasa 10 x 10 cm rol 21
40 Kasa hidrofil 80 cm x 40 yard rol 1 2 3 2 1 2 22
41 Kasa hidrofil steril ukuran 16 x 16 box 28 50 78 26 52 20 23
42 Kasa hidrofil ukuran 16 x 16 lembar 24
43 Kasa kompres 40/40 steril bungkus 11 11 4 7 25
44 Kasa pembalut hidrofil 4 m x 10 cm roll 200 50 250 0 250 26
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 190 50 240 50 190 27
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 75 75 0 75 28
47 Kertas EKG ( 50 x 30) rol 29
48 Masker : - Earloop pcs 950 500 1,450 850 600 500 30
49 Masker : - Earloop (Stardec) Pcs 31
50 Masker : - tie on Pcs 700 1,000 1,700 560 1140 32
Masker : - tie on (Stardec) Pcs 33
51 Mata Bor gigi 34
- type inverted No. 010 buah 5 35
- type cylinder No. 010 buah 36
- type tuppered No. 010 buah 5
- type round No. 010 buah 5
52 Micropipet Socorex - Acura 37
- Volume 1 - 10 uL set 38
- Volume 10 - 100 uL set 39
- Volume 100 - 1000 uL set 40
53 N-95 Medical Respirator box 41
54 Nasal oxygen canula - adult sraight pieces 25 15 40 8 32 42
55 Nasal oxygen canula - child pieces 16 16 2 14 43
56 Nasal oxygen canula - infant 44
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton tule Pcs 11 10 21 0 21 45
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 50 46
59 Plester 5 yards x 2 inchi rol 10 47
60 Plester hypafix/pharmafix 5 cm x 5 m rol 30 48
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 11 10 21 21 0 50 49
62 Pot sputum buah 50
63 Sarung tangan steril nomor 6,5 : MAS pasang 60 60 10 50
64 Sarung tangan steril nomor 6,5 : Vasco pasang
65 Sarung tangan steril nomor 7 : MAS pasang
66 Sarung tangan steril nomor 7 : Vasco pasang 51
67 Sarung tangan steril nomor 7,5 : MAS pasang 21 21 0 21 52
68 Sarung tangan steril nomor 8 53
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 5 10 15 5 10 54
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 2 10 12 2 10 55
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 56
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 1,300 2,000 3,300 1,300 2000 57
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 1,830 1,830 250 1580
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgical) pack/saset 21 12 33 8 25 58
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 12 12 5 7
77 Silk 2/0 box-12 pacs 59
78 Silk 3/0 box-12 pacs 60
80 Tabung oksigen 1 m3 + regulator set 61
81 Under pad buah 10 20 30 3 27 62
82 Urine bag Pcs 39 39 9 30 63
83 Wing needle 23 G - 25 G buah 8 8 0 8 64
Safety bok biji 30 30 0 30 65
TAMBAHAN PERBEKALAN KESEHATAN 66
1 Alat pengukur HB 201 + analizer unit 67
2 Dek glass (cover glass) box 68
3 Microcuvet Hb 201 buah 69
4 Object glass box 70
5 Occu check (alat pemegang lancet ROCHE) kit 71
6 Softclick lanciet 200 box 72
7 Softclick lancing device kit 73
8 Tabung hematokrit botol 3 74
9 Kotak slide 75
10 Performa Accu check Blood glucose meter set
- Performa Accu check tes strip box
1
III REAGEN 2
1 Aquabidest steril botol 500 ml 3
2 Aquabidest steril botol 1000 ml 4
3 Pemeriksaan kadar gula darah 5
Glocodoctor Box-50 test 6
Accutrand 25 strip 5 7
Easy Touch box/25 8
Nesco gluco strip box/25
Glucostar box/25
4 Reagen Pemeriksaan Asam Urat
Nesco box-25
Easy Touch box-25 III
UA Sure box-25 0 5 5 0 5 5 1
5 Reagen Pemeriksaan Kolesterol 2
Accutrand box/25 3
Easy touch cholesterol box-10
Nesco box-10
Multicare box/25 5
6 Hb Sahli
- Assistant set
- Superior set 4
7 Reagen untuk spektrofotometr
- Reagen glukosa box-4 btl
- Reagen Trigliserida box-4 btl
- Reagen asam urat box-4 btl 5
8 Trigliserida
- Accutrend box / 25
- Multicare box / 25 0 5 5 0 5 5
7 Larutan amonium oksalat 1 % Botol 100 ml
8 Larutan Asam asetat 6 % Botol 100 ml 6
9 Larutan Asam Klorida 0,1 N Botol 100 ml 2
10 Larutan Benedict Botol 100 ml
11 Larutan EDTA 10 % Botol 100 ml 7
12 Larutan Eosin Botol 100 ml
13 Larutan Giemsa Stain Botol 100 ml 2
14 Larutan Karbol Fuksin Botol 100 ml
15 Larutan Metanol Botol 100 ml
16 Larutan Metilen Blue Botol 100 ml 7
17 Larutan Natrium citrat Botol 100 ml 8
18 Larutan Perhidrol (H2O2) Botol 100 ml 9
19 Larutan Turk Botol 100 ml 10
20 Larutan Ziehl Neelsen set 11
21 Reagen pemeriksaan yodium botol 12
22 Reagen dan alat pengujian lab makanan 100 tes / unit 13
23 Rapid Diagnostic Test Malaria kit-25 tes 14
- RDT Combo Malaria tes 15
24 Rapid test Leptospirosis box/50 strip 16
25 Rapid test Chikungunya tes 17
26 Rapid test demam berdarah kit-25 tes 18
27 Rapid test demam thypoid kit-25 tes 19
28 Tes Kehamilan 20
PPTEST Box 40 tes 21
HCG strip (answer) strip 22
UltraOne tes kehamilan box 50 tes 23
29 Tes HBsAG S/P strip (Answer) box-40 strip 2 24
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 25
31 Urine Test 10 Parameter btl - 100 test 26
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip
32 Widal Test Tg H (SS-01) Botol 5 ml 1
33 Widal Test Tg O (SS-90) Botol 5 ml 1
34 Tes Narkoba 27
- Amfetamin kot@25 strip 1
- Metamfetamin kot@25 strip 1
- Cocain kot@25 strip 1 28
- Cannabidoid kot@25 strip 1 29
- Benzodiasepin kot@25 strip 1
- Babiturat kot@25 strip 1 30
35 Reagen Mantoux ampul 31
36 Tes Golongan darah 32
- Anti A Botol 10 ml 33
- Anti B Botol 10 ml
- Anti AB Botol 10 ml
37 Oil emersi botol 100 ml
38 Reagen untuk fotometer
- reagen kolesterol 4 botol @ 100 ml
- reagen glukosa 4 botol @ 100 ml 34
- reagen asam urat 4 botol @ 100 ml 35
- reagen trigliserida 4 botol @ 100 ml

IV OBAT PROGRAM MALARIA (P2M)


1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet tablet 36
2 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin tablet
3 posphat
Artemeter320) tablet
injeksi 1 ml 80 mg ampul IV
4 Artesunat injeksi vial 60 mg kotak/set 1
5 Kloroquin tablet 150 mg tablet 2
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 3
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 4
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 60 60 60 0 5
9 Primaquin tablet 15 mg tablet 0 100 100 0 100 6
10 Doksisiklin kapsul 100 mg tablet 7
8
V OBAT PROGRAM DIARE (P2M) 9
1 Garam oralit serbuk kombinasi saset 164 200 364 254 110 200 10
2 Zink Dispersible 20 mg tablet 1,200 1,200 490 710 500
3 Zincpro drops 15 ml botol 54 54 0 54 V
4 Zink sirup Botol 54 54 50 4 50 1
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 2
1 Dietil karbamasin sitrat tablet 3
4
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M)
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial VI.
1
VIII OBAT PROGRAM KUSTA (P2M)
1 Prednison tablet 5 mg tablet VII
1
IX OBAT PROGRAM FLU BURUNG
1 Oseltamivir kapsul kapsul VIII
1
X OBAT PROGRAM GIZI (KIA)
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul IX
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 1
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + tablet 3,300 6,000 9,300 2,940 6360
Asam Folat 0,25 mg)
4 Mineral Mix saset X
5 Iodol kapsul kapsul 1
2
XI. OBAT PROGRAM KECACINGAN (P2M) 3
1 Albendazol tablet 400 mg tablet 960 960 90 870 4
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 5
3 Pirantel pamoat tablet 125 mg
XI.
XII. OBAT ANTI TUBERKULOSIS 1
1 Obat FDC kategori 1 paket 2
2 Obat FDC kategori 2 paket 3
3 Obat FDC Sisipan paket
4 OAT Anak paket
5 OAT Kombipak 1 paket

XIII. PROGRAM P2
1 Zidovudin + lamivudin (300 mg/150 mg tablet
2 Efavirenz 600 mg tablet
3 Tenofovir (TDF) 300 mg tablet
4 Nevirapin 200 mg tablet
5 Lamivudin 3 TC 150 mg tablet

XIV. PROGRAM KUSTA


1 Obat MDT Kusta PB Dewasa blister
2 Obat MDT Kusta MB Anak blister
3 Obat MDT Kusta MB Dewasa blister

JUMLAH KUNJUNNGAN RESEP UMUM JKN LAIN-2 JUMLAH


BAYAR
1098 1862 385 4203

Purworejo, 5 Maret 2017


Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bragolan Petugas Puskesmas Bragolan
Kabupaten Purworejo
dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. ( Nursinah ) ( dr. Hanuke Ari Racmawati B,M.M )
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19730829 200604 2 003 NIP. 19760526 200212 2 006
JML GDNG R Obat UGD

2075 1850 195 30


0
0
0
30 30
390 370 20
245 200 45
295 90 95 110
0 0
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12050 10600 790 660
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263 235 9 19
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27 20 7
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12310 11900 330 80
266 239 10 17
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252 252
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710 400 100 210
2460 2300 70 90
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6786 6370 66 350
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58 51 2 5
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535 300 95 140
2390 1820 350 220
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70 44 15 11
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38 38
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2720 2200 300 220
137 130 2 5
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10890 10550 70 270
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93 70 12 11
943 600 170 173
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520 300 80 140
110 100 10
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185 100 85
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300 300
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535 500 35
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412 270 33 109
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1785 1500 216 69
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1490 1200 180 110
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180 180
270 250 20
19 12 7
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510 500 10
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171 141 23 7
0
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6540 5900 540 100
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420 550 96 100

0
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3148 2850 220 78
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108 94 14
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36 36
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800 700 100
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3320 2700 190 430
93 72 21
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82 56 17 9
7570 6700 770 100
326 300 26
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230 219 6 5
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180 180
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2420 2200 140 80
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80 65 8 7
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1630 1380 70 180
2 2
122 102 20
5220 4820 240 160
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2150 1500 460 190
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2326 2040 100 186
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21490 20600 570 320
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3770 3480 140 150
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700 610 10 80
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166 150 7 9

1250 800 250 200


149 135 1 13
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75 75
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1580 1580
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DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/

NO. NAMA OBAT SATUAN JUMLAH KETERANGAN


BARANG SUMBER
1 2 3 4 5
1 Allopurinol tablet 100 mg tablet 1000
2 Aminofillin tablet 200 mg tablet 1000
3 Amoksisillin kaplet 500 mg tablet 4000
4 Amoksisillin siruo kering 125mg/5ml botol 60 ml 120
5 Antasida DOEN Itablet kunyah kombinasi tablet 3000
6 Aqua pro injeksi steril, bebas pirogen vial 30
7 Asam Askorbat (Vitamin C) tablet 50 mg tablet 1000
8 Asam Mefenamat 250 mg tablet 1000
9 Attapulgit tablet 600 mg tablet 1000
10 Dexametason tablet 0,5 mg tablet 4000
11 Diazepam lar rectal 10 mg/2,5 ml (stesolid) rect tube 10
12 Furosemid tablet 40 mg tablet 200
13 Glimeperid tablet 2 mg tablet 200
14 Hidrokortison krim 2,5 % tube 24
15 Ibuprofen tablet 400 mg tablet 3000
16 Isosorbid dinitrat tab sublingual 10 mg tablet 100
17 Ketokenazol krim 2 % tube 15 mg 50
18 Kloramfenikol salep mata 1% tube 5 mg 24
19 Klorfeniramin meleat (CTM) tab 4 mg tablet 5000
20 Lar mengandung elektrolit : (Asering) botol 500 ml 40
21 Metilergometrin maleat inj 0,200 mg-1ml ampul 10
22 Metilergometrin maleat tablet 0,125 mg tablet 500
23 Metronidasol tablet 500 mg tablet 1000
24 N-asetyl sistein kaplet 200 mg tablet 2640
25 Natrium diklofenak tablet 50 mg tablet 2000
26 Nifedipin tablet 10 mg tablet 500
27 Nifedipin tablet 20 mg tablet 600
28 Oksitosin injeksi 10 IU/ml-1ml ampul 10
29 Parasetamol sirup 120 mg/5 ml botol 100
30 Parasetamol tablet 500 mg tablet 1000
31 Piroksikam kapsul 20 mg tablet 500
32 Prednison tablet 5 mg tablet 1000
33 Ringer laktat larutan infus botol 500 ml 160
34 Sefadroksil kapsul 500 mg kaplet 1000
35 Sefotaksim serbuk injeksi 1000 mg/vial vial
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

PUSKESMAS : BUBUTAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI : MARET 2017 INST. FARMASI 442/ /2017
KABUPATEN : PURWOREJO : APRIL 2017 PUSKESMAS

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 mg tablet 747 1,000 1,747 847 900 1,000
2 Alprazolam tablet 0,25 mg tablet 162 0 162 6 156 0
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 0 0 0 0
4 Ambroxol tablet 30 mg tablet 0 0 0 0 0 3,000
5 Aminofilin injeksi 24 mg/ml ampul 7 30 37 5 32 10
6 Aminofilin tablet 200 mg tablet 1,249 0 1,249 500 749 1,500
7 Amitriptilin tablet 25 mg tablet 100 0 100 0 100 0
8 Amlodipin tablet 10 mg tablet 0 0 0 0 0 1,000
9 Amlodipin tablet 5 mg tablet 344 0 344 284 60 1,500
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0 0 0 0
11 Amoksisilin kaplet 500 mg tablet 7,000 4,000 11,000 4,100 6,900 4,000
12 Amoksisilin kapsul 250 mg kapsul 0 0 0 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 193 60 253 81 172 0
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 95 0 95 0 95 0
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 118 0 118 18 100 0
16 Antalgin (Metampiron) tablet 500 mg tablet 920 0 920 0 920 0
17 Antasida DOEN I tablet kunyah kombinasi tablet 6,858 500 7,358 2,908 4,450 3,000
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 57 0 57 20 37 50
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 0 0 0 0 0 0
20 polimiksin 10.000 kombinasi
Antifungi DOEN IU/g : Asam Benzoat 6% + Asam pot 0 0 0 0 0 0
21 Salisilat 3 % DOEN kombinasi (Generik)
Antihemoroid supp 29 0 29 9 20 0
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet tablet 0 0 0 0 0 0
23 Aqua pro injeksi steril, bebas pirogen vial 30 60 90 33 57 0
24 Asam asetil salisilat 80 mg tablet 600 100 700 0 700 0
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 0 0 0 0 0 0
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 2,609 0 2,609 609 2,000 0
27 Asam folat tablet 1 mg tablet 0 0 0 0 0 0
28 Asam mefenamat kaplet 250 mg Tablet 3,668 500 4,168 1,200 2,968 3,000
29 Asam mefenamat kaplet 500 mg tablet 0 0 0 0 0 1,000
30 Asam traneksamat injeksi 100 mg/ml ampul 15 10 25 10 15 0
31 Asiklovir krim 5 % tube 5 gram 20 0 20 10 10 50
32 Asiklovir tablet 200 mg tablet 0 0 0 0 0 0
33 Asiklovir tablet 400 mg tablet 180 1,000 1,180 50 1,130 0
34 Atapulgit tablet 600 mg tablet 921 0 921 100 821 0
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 30 0 30 0 30 0
36 Betahistin mesilat tablet 6 mg tablet - 1,500 1,500 660 840 0
37 Betametason cream 0,1 % tube 40 25 65 25 40 25
38 Betametason tetes mata 1 mg/ml botol 0 0 0 0 0 0
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 19 0 19 0 19 0
40 Bromheksin tablet 8 mg tablet 0 0 0 0 0 0
41 Cetirizine kapsul 10 mg kapsul 824 500 1,324 224 1,100 0
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 0 0 0 0 0 0
43 Deksametason injeksi i.v. 5 mg/ml ampul 66 0 66 30 36 100
44 Deksametason tablet 0,5 mg tablet 3,059 4,000 7,059 4,759 2,300 5,000
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 0 0 0 50
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 0 0 0 1,000
47 Diazepam injeksi 5 mg/ml ampul 0 0 0 0 0 10
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
50 Diazepam tablet 2 mg tablet 692 0 692 15 677 0
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 30 0 30 0 30 0
52 Digoksin tablet 0,25 mg tablet 200 200 400 100 300 0
53 Diltiazem HCl Tablet 30 mg tablet 0 0 0 0 0 0
54 Dimenhidrinat tablet 50 mg tablet 200 0 200 100 100 500
55 Doksisiklin kapsul 100 mg kapsul 0 0 0 0 0 500
56 Domperidon suspensi 5 mg/5 ml botol-60ml 34 0 34 4 30 50
57 Domperidon tablet 10 mg tablet 700 0 700 200 500 1,000
58 Efedrin HCl tablet 25 mg tablet 0 0 0 0 0 0
59 Ekstraks beladona tablet 10 mg tablet 0 0 0 0 0 0
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 0 100 0 100 0
61 Eritromisin kapsul 250 mg kapsul 0 0 0 0 0 0
62 Eritromisin kapsul 500 mg kapsul 500 500 0 500 0
63 Eritromisin sirup 200 mg/5 ml botol 0 0 0 0 0 0
64 Fenilbutason 200 mg tablet tablet 0 0 0 0 0 0
65 Fenitoin Natrium Kapsul 100 mg kapsul 0 0 0 0 0 0
66 Fenobarbital injeksi ampul 0 0 0 0 0 0
67 Fenobarbital tablet 30 mg tablet 0 0 0 0 0 0
68 Fenolgliserol tetes telinga 10 % botol 0 0 0 0 0 30
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 29 0 29 5 24 0
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 648 0 648 0 648 0
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 0 0 0 0 0 10
72 Furosemida tablet 40 mg tablet 562 200 762 200 562 0
73 Gameksan lotion 1 % botol-30 ml 0 0 0 0 0 0
74 Gemfibrosil kapsul 300 mg kapsul 500 0 500 140 360 0
75 Gemfibrozil kapsul 600 mg kapsul 0 0 0 0 0 0
76 Gentamisin salep kulit 0,1% tube 42 0 42 0 42 0
77 Gentamisin salep mata 0,3 % botol 0 0 0 0 0 0
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 0 0 0 0 0
79 Gentian violet larutan 1 % botol 0 0 0 0 0 0
80 Glibenklamid tablet 5 mg tablet 0 0 0 0 0 500
81 Gliclazid 80 mg tablet tablet 0 0 0 0 0
82 Glimepirid tablet 2 mg tablet 500 0 500 200 300 1,000
83 Gliseril Guayakolat tablet 100 mg tablet 0 0 0 0 0 3,000
84 Gliserin lar 50 % botol-100 ml 0 0 0 0 0 0
85 Glukosa larutan infus 10 % botol 500 ml 0 0 0 0 0 0
86 Glukosa larutan infus 40 % ampul 0 0 0 0 0 0
87 Glukosa larutan infus 5 % botol 500 ml 106 40 146 18 128 0
88 Griseofulvin tablet 125 mg micronized tablet 200 500 700 100 600 500
89 Haloperidol injeksi 5 mg/ml ampul 0 0 0 0 0 0
90 Haloperidol injeksi 50 mg/ml ampul 0 0 0 0 0 0
91 Haloperidol tablet 1,5 mg tablet 0 0 0 0 0 0
92 Haloperidol tablet 2 mg tablet 200 0 200 0 200 0
93 Haloperidol tablet 5 mg tablet 100 0 100 60 40 100
94 Hidroklorotiazida tablet 25 mg tablet 0 0 0 0 0 0
95 Hidrokortison krim 2,5% tube 24 0 24 24
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 0 0 0 100
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 0 0 0 0
98 Ibuprofen tablet 200 mg tablet 0 0 0 0 0 0
99 Ibuprofen tablet 400 mg tablet 5,000 1,000 6,000 2,400 3,600 3,000
100 Isoniasida tablet 100 mg tablet 0 0 0 0 0 0
101 Isosorbid dinitrat tablet sublingual 10 mg 100 0 100 10 90 0
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 0 0 0 0
103 Kalium diklofenak 50 mg tablet tablet 0 0 0 0 0 0
104 Kalsium glukonas injeksi ampul 0 0 0 0 0 0
105 Kalsium laktat tablet 500 mg tablet 400 2,000 2,400 800 1,600 3,000
106 Kaptopril tablet 12,5 mg tablet 903 0 903 400 503 500
107 Kaptopril tablet 25 mg tablet 2,536 0 2,536 436 2,100 0
108 Karbamazepin tablet 200 mg tablet 0 0 0 0 0 0
109 Karbogliserin tetes telinga botol 0 0 0 0 0 0
110 Ketokonazol krim 2 % tube 15 gram 68 0 68 68 0
111 Ketokonazol tablet 200 mg tablet 0 0 0 0 0 1,000
112 Ketorolac injeksi 10 mg ampul 1 ml 24 0 24 18 6 0
113 Ketorolac injeksi 30 mg ampul 1 ml 0 0 0 0 0 0
114 Klindamisin kapsul 300 mg kapsul 0 0 0 0 0
115 Klobazam tablet 10 mg tablet 0 0 0 0 0 0
116 Klonidin tablet 0,15 mg tablet 0 0 0 0 0 100
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 0 0 0 0
118 Kloramfenikol kapsul 250 mg kapsul 0 0 0 0 0 0
119 Kloramfenikol kapsul 500 mg kapsul 1,175 0 1,175 175 1,000 0
120 Kloramfenikol salep kulit (Bufacetin) tube 48 0 48 48 0
121 Kloramfenikol salep mata 1 % tube 5 gram 48 0 48 24 24 0
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 30 0 30 30 0 100
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 21 0 21 21 0 50
124 Kloramfenikol tetes telinga 3 % botol 5 ml 15 0 15 0 15 0
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 6,434 5,000 11,434 4,000 7,434 3,000
127 Klorpromazin tablet salut 100 mg (HCl) tablet 159 0 159 59 100 100
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 0 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0 0 0 500
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 1,074 0 1,074 100 974 0
131 Kotrimoksasol suspensi botol 60 ml 90 0 90 18 72 0
132 Lamivudin tablet 150 mg tablet 0 0 0 0 0 0
133 Lanzoprazol kapsul 30 mg kapsul 0 0 0 0 0 0
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 0 40 40 4 36 60
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 21 20 41 7 34 0
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 0 0 0 0 0 0
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 0 0 0 0
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 1 1 0 1 0
139 Lidokain injeksi 2 % ampul 0 0 0 0 0 0
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 40 0 40 12 28 100
141 Lidokain semprot 10 % botol 0 0 0 0 0 0
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 0 0 0 0 0 0
143 Magnesium sulfat injeksi 20 % ampul 0 0 0 0 0 0
144 Magnesium sulfat injeksi 40 % ampul 0 0 0 0 0 0
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 0 0 0 0
146 Mebendazol tablet 100 mg tablet 0 0 0 0 0 0
147 Mekobalamin tablet 500 mg tablet 0 0 0 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0 0 0 500
149 Metformin HCl tablet 500 mg tablet 983 0 983 183 800 0
150 Metil Prednisolon tablet 4 mg tablet 563 0 563 203 360 0
151 Metil Prednisolon tablet 8 mg tablet 0 0 0 0 0 0
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 10 0 10 0 10 0
153 Metilergometrin maleat tablet 0,125 mg tablet 913 0 913 0 913 0
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 0 0 0 10
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 0 0 0 0
156 Metoklopramid tablet 10 mg tablet 700 0 700 0 700 0
157 Metoklopramid tablet 5 mg tablet 0 0 0 0 0 0
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 0 0 0 0 0 0
159 Metronidasol tablet 250 mg tablet 0 0 0 0 0 0
160 Metronidasol tablet 500 mg tablet 867 0 867 500 367 2,000
161 Metronidazol infus 500 mg/100 ml botol-100 ml 9 0 9 0 9 0
162 Mikonazol krim 2 % tube 38 0 38 28 10 48
163 N-asetyl sistein kaplet 200 mg tablet 1,320 2,640 3,960 1,260 2,700 0
164 Natrium Diklofenak tablet 25 mg tablet 0 0 0 0 0 0
165 Natrium Diklofenak tablet 50 mg tablet 2,978 0 2,978 678 2,300 0
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 30 20 50 7 43 0
167 Nifedipin tablet 10 mg tablet 745 0 745 145 600 0
168 Nifedipin tablet 20 mg SR tablet 600 0 600 0 600 0
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0 0 0 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 0 0 0 0 0 100
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 0 0 0 0
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 0 0 0 40
173 Oksitetrasiklin salep mata 1% tube 0 0 0 0 0 0
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 0 10 10 0 10 0
175 Omeprazol injeksi 40 mg/10 ml vial 0 0 0 0 0 10
176 Omeprazol kapsul 20 mg kapsul 1,019 0 1,019 99 920 0
177 Ondansentron injeksi 4 mg / 2 ml ampul 0 70 70 10 60 50
178 Papaverin injeksi ampul 0 0 0 0 0 0
179 Papaverin tablet 40 mg tablet 0 0 0 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0 0 0 0
181 Parasetamol sirup 120 mg/5 ml botol 154 0 154 94 60 50
182 Parasetamol tablet 500 mg tablet 5,500 3,000 8,500 4,200 4,300 5,000
183 Permetrin (Scabimite) tube 10 0 10 1 9 0
184 Petidin injeksi (Narkotika) ampul 0 0 0 0 0 0
185 Piracetam 800 mg tablet tablet 0 0 0 0 0 0
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 0 0 0 20
187 Pirantel tablet score 125 mg tablet 0 0 0 0 0 0
188 Piridoksin (Vit. B6) tablet 10 mg tablet 2,083 1,000 3,083 633 2,450 2,000
189 Piroksikam kapsul 20 mg tablet 1,022 0 1,022 22 1,000 0
190 Piroksikam tablet 10 mg tablet 0 0 0 0 0 0
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 0 0 0 0 0 0
192 Prednison tablet 5 mg tablet 2,149 0 2,149 1,200 949 2,000
193 Probenesid tablet 500 mg tablet 0 0 0 0 0 0
194 Propanolol tablet 10 mg tablet 180 0 180 180 0
195 Propiltiourasil tablet 100 mg tablet 200 0 200 0 200 0
196 Ranitidin injeksi 25 mg/2 ml ampul 50 100 150 100 50 200
197 Ranitidin tablet 150 mg tablet 773 0 773 100 673 0
198 Rifampisin kaplet salut 450 mg kaplet 0 0 0 0 0 0
199 Rifampisin kapsul 300 mg kapsul 0 0 0 0 0 0
200 Ringer laktat larutan infus botol 500 ml 60 160 220 120 100 160
201 Risperidon tablet tablet 0 0 0 0 0 0
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 0 0 0 0
203 Salbutamol tablet 2 mg tablet 0 0 0 0 0 0
204 Salbutamol tablet 4 mg tablet 500 0 500 100 400 0
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap pot 24 0 24 24 0
206 4%
Salisil bedak 2% kotak-50 gram 11 20 31 15 16 20
208 Sefadroksil kapsul 250 mg kaplet 0 0 0 0 0
209 Sefadroksil kapsul 500 mg kaplet 1,200 0 1,200 500 700 1,000
210 Sefadroksil sirup kering 125 mg/5 ml botol 0 0 0 0 0 0
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 0 0 0 0
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 150 0 150 50 100 50
213 Sefotaksim serbuk injeksi 500 mg/vial vial 0 50 50 30 20 50
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 0 0 0 50
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 0 0 0 0 0 5
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAGAM) dos 6 0 6 0 6 0
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 0 10 0 10 0
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 0 0 0 0
219 Simetidin tablet 200 mg tablet 146 0 146 146 0 1,000
220 Simvastatin tablet 10 mg tablet 362 0 362 0 362 0
221 Simvastatin tablet 30 mg tablet 0 0 0 0 0 0
222 Siprofloksasin tablet 250 mg tablet 0 0 0 0 0
223 Siprofloksasin tablet 500 mg tablet 1,214 0 1,214 114 1,100 0
224 Spironolakton tablet 25 mg tablet 0 0 0 0 0 0
225 Sukralfat suspensi (Ulsafate) botol 0 0 0 0 0 0
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 0 0 0 0
227 Sulfasetamid Na tetes mata 15 % botol 0 0 0 0 0 0
228 Tetrasiklin kapsul 250 mg kapsul 0 0 0 0 0 0
229 Tetrasiklin kapsul 500 mg kapsul 0 0 0 0 0 0
230 Tiamfenikol kapsul 500 mg kapsul 0 0 0 0 0 0
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 0 0 0 0
232 Tiamin (Vitamin B1) tablet 50 mg tablet 3,800 0 3,800 600 3,200 0
233 Tramadol kapsul 50 mg tablet 0 0 0 0 0 0
234 Trifluoperazin 5 mg tablet tablet 0 0 0 0 0 0
235 Triheksifenidil tablet 2 mg tablet 0 0 0 0 0 0
236 Vaksin rabies untuk manusia set 0 0 0 0 0 0
237 Vitamin B Kompleks tablet tablet 1,479 0 1,479 629 850 3,000

B OBAT DAN BAHAN KEDOKTERAN GIGI


1 Air raksa dental use botol 0 0 0 0 0 0
2 Alvogyl paste dus 0 0 0 0 0 0
3 Amalgam Perak (Silver Alloy) botol 0 0 0 0 0 0
4 Articulating papper kotak 0 0 0 0 0 0
5 Bahan pensteril gigi : Trikresol formalin botol 0 0 0 0 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 0 0 0 2
7 Dentin conditioner botol 0 0 0 0 0 0
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 0 0 0 0
9 Etil klorida spray vial/100 ml 4 0 4 2 2 0
10 Eugenol cairan botol@10 ml 0 0 0 0 0 0
11 Fuji VII dus 0 0 0 0 0 0
12 Fuji IX dus 0 0 0 0 0 0
13 Glass inonomer cement ART set/botol 0 0 0 0 0 2
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 0 0 0 0
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 0 0 0 0
16 Kalsium hidroksida pasta kotak 2 tube 0 0 0 0 0 0
17 K-file perawatan akar gigi 0 0 0 0 0 0
- K-file No. 15 set 0 0 0 0 0 0
- K-file No. 20 set 0 0 0 0 0 0
- K-file No. 25 set 0 0 0 0 0 0
- K-file No. 30 set 0 0 0 0 0 0
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 0 0 0 0
19 Mummifying pasta botol/kotak 0 0 0 0 0 0
20 Pasta pengisi saliran akar botol 0 0 0 0 0 0
21 Seluloid strip rol 0 0 0 0 0 0
22 Semen Seng Fosfat serbuk dan cairan set/botol 0 0 0 0 0 0
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) - 0 0 0 0 0
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram0 0 0 0 0 0
25 Tooth mouse box 0 0 0 0 0 0

C OBAT TAMBAHAN / BRANDED


1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 0 0 0 0
2 Anti asma/bronkodilator nebulizer (ventolin) vial 10 0 10 3 7 10
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 0 0 0 1,000
4 Antidiare sirup : . botol 60 ml 0 0 0 0 0 50
6 Antidiare Tablet : tablet 0 0 0 0 0 0
7 Antidiare Tablet (Molagit) tablet 0 0 0 0 0 0
9 Antihemoroid DOEN (Superhoid) supp 0 0 0 0 0
10 Antihistamin kombinasi (Pritacort) tablet 100 0 100 100 0 500
11 Antiinfeksi kulit (luka bakar) pot 0 0 0 0 0 0
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 0 0 0 0
13 Antikretinisme tablet tablet 0 0 0 0 0 0
14 Antiscabies krim (Scabicid) tube 10 gram 0 0 0 0 0 0
15 Antispasme injeksi (Spashi) vial 0 0 0 0 0 0
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 0 0 0 0
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 0 0 0 0
18 Laksantia tablet 5 mg (Dulcolax) tablet 18 0 18 0 18 0
19 Laksantia tablet 5 mg (Laxana) tablet 0 0 0 0 0
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 1,249 2,000 3,249 800 2,449 0
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 0 0 0 0 0 60
22 Multivitamin + mineral utk ibu hamil : . kaplet 0 0 0 0 0 0
27 Multivitamin kaplet : VITALAMIN kaplet 1,774 0 1,774 200 1,574 0
28 Multivitamin sirup : CURBION Botol 83 50 133 0 133 60
31 Multivitamin tabur untuk balita Saset 0 0 0 0 0 0
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 0 0 0
33 Neurotropik 5000 injeksi ampul 30 0 30 30 0
34 Neurotropik kaplet : kaplet 4,077 0 4,077 2,100 1,977 3,000
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 0 0 0 0
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 0 0 0 0
40 Obat Antiflu kombinasi : botol 60 ml 0 0 0 0 0 100
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 0 0 0 0
42 Obat batuk / flu sirup : .. botol 100 ml 184 0 184 184 0 200
47 Vasodilator perifer (Citicholin) ampul 0 0 0 0 10

D OBAT ASLI INDONESIA (OAI)


1 Asifit kapsul 0 0 0 0
2 Batugin elixir botol 0 0 0 0
3 Enkasari botol 0 0 0 0
4 Fitogen Dragge kapsul 0 0 0 0
5 Hepagard kapsul 0 0 0 0
6 Imulan kapsul kapsul 0 0 0 0
7 Imulan sirup botol 60 ml 0 0 0 0
8 Kurkumex sirup botol 60 ml 0 0 0 0
9 Kurkumex tablet kaplet 0 0 0 0
10 OB Herbal 0 0 0 0
11 Tensigard kapsul kapsul 0 0 0 0
12 Xanvit sirup 0 0 0 0

II. BAHAN MEDIS HABIS PAKAI


1 Alkohol swab box 16 0 16 1 15 0
2 Aquagel jelly 28 gram tube 0 0 0 0 0 0
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 3 0 3 0 3 0
4 Desinfektan - Aseptan liquid botol-500 ml 0 0 0 0 0 0
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 0 0 0 0 0 0
6 Etanol 70 % botol 100 ml 48 0 48 2 46 0
7 Etanol 70 % botol 1000 ml 4 0 4 1 3 0
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 23 0 23 3 20 0
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 8 0 8 3 5 0
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 0 0 0 0 0 0

III. PERBEKALAN KESEHATAN


1 Alat suntik sekali pakai 1 ml set 100 100 200 100 100 0
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 0 0 0 0
3 Alat suntik sekali pakai 3 ml (Terumo) set 200 200 400 100 300 0
4 Alat suntik sekali pakai 5 ml (Terumo) set 300 0 300 0 300 0
5 Bisturi (mata pisau) Pcs 100 0 100 5 95 0
6 Blood lancet 28 box-100 0 0 0 0 0 0
7 Blood Tranfusion set (MAS) Pcs 0 5 5 2 3 0
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm0 0 0 0 0 0
9 Catgut chromic 2/0 saset/pack 0 0 0 0 0 0
10 Catgut chromic 2/0 100 M kotak 0 0 0 0 0 0
11 Catgut chromic 3/0 saset/pack 0 1 1 0 1 0
12 Catgut chromic 3/0 100 M kotak 0 0 0 0 0 0
13 Catgut plain 2/0 saset/pack 1 0 1 0 1 0
14 Catgut plain 3/0 saset/pack 1 0 1 0 1 0
15 Dermafix T 10 x 15 cm rol 5 0 5 0 5 0
16 Dermafix T 5 x 7 cm rol 0 0 0 0 0 5
17 Developer untuk Film Rontgen Botol 5 ltr Repl 20 ltr
0 0 0 0 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 0 0 0 0 0 0
19 Film Rontgen ukuran 24 x 30 lembar 0 0 0 0 0 0
20 Film Rontgen ukuran 30 x 40 lembar 0 0 0 0 0 0
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 0 0 0
22 Folley catheter No. 16 (Norta) Pcs 0 5 5 0 5 0
23 Folley catheter No. 18 (Norta) Pcs 6 5 11 4 7 0
24 Folley catheter No. 20 Pcs 0 0 0 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0 0 0 0
27 Infus set - Bbraun Intrafix with microdriper set 0 0 0 0 0 00
28 Infus set (Otsu Y) pices 50 50 100 36 64 50
29 Infus set anak set/kantong 8 50 58 16 42 0
30 Infus set dengan micridripper (Otsu) pices 0 0 0 0 0 0
31 Infus set dewasa (Stardec) set/kantong 0 0 0 0 0 0
32 IV catheter No. 18 G buah 0 50 50 2 48 0
33 IV catheter No. 20 G buah 50 0 50 3 47 0
34 IV catheter No. 22 G buah 110 50 160 37 123 0
35 IV catheter No. 24 G buah 206 0 206 56 150 0
36 Jarum jahit kulit saset 24 0 24 0 24 0
37 Jarum jahit otot saset 0 0 0 0 0 0
38 Kapas pembalut/absorben 250 gram bungkus 5 0 5 0 5 0
39 Kasa 10 x 10 cm rol 3 0 3 0 3 0
40 Kasa hidrofil 80 cm x 40 yard rol 45 0 45 0 45 0
41 Kasa hidrofil steril ukuran 16 x 16 box 52 0 52 0 52 0
42 Kasa hidrofil ukuran 16 x 16 lembar 20 0 20 0 20 0
43 Kasa kompres 40/40 steril bungkus 0 0 0 0 0 0
44 Kasa pembalut hidrofil 4 m x 10 cm roll 0 0 0 0 0 0
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 0 0 0 0 0 0
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 0 0 0 0 0 0
47 Kertas EKG ( 50 x 30) rol 0 0 0 0 0
48 Masker : - Earloop pcs 100 0 100 0 100 0
49 Masker : - Earloop (Stardec) Pcs 0 0 0 0 0 0
50 Masker : - tie on Pcs 250 0 250 250 0
Masker : - tie on (Stardec) Pcs 0 0 0 0 0 0
51 Mata Bor gigi 0 0 0 0 0
- type inverted No. 010 buah 0 0 0 0 0 0
- type cylinder No. 010 buah 0 0 0 0 0 0
- type tuppered No. 010 buah 0 0 0 0 0 0
- type round No. 010 buah 0 0 0 0 0 0
52 Micropipet Socorex - Acura 0 0 0 0 0 0
- Volume 1 - 10 uL set 0 0 0 0 0 0
- Volume 10 - 100 uL set 0 0 0 0 0 0
- Volume 100 - 1000 uL set 0 0 0 0 0 0
53 N-95 Medical Respirator box 0 0 0 0 0 0
54 Nasal oxygen canula - adult sraight pieces 5 0 5 0 5 0
55 Nasal oxygen canula - child pieces 2 0 2 0 2 0
56 Nasal oxygen canula - infant 0 0 0 0 0 0
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton tule Pcs 29 0 29 29 0
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 26 10 36 1 35 0
59 Plester 5 yards x 2 inchi rol 0 0 0 0 0 0
60 Plester hypafix/pharmafix 5 cm x 5 m rol 0 0 0 0 2
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 0 0 0 0 0 0
62 Pot sputum buah 0 0 0 0 0 0
63 Sarung tangan steril nomor 6,5 : MAS pasang 0 0 0 0 0
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0 0 0 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0 0 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0 0 0 0
67 Sarung tangan steril nomor 7,5 : MAS pasang 0 0 0 0 0
68 Sarung tangan steril nomor 8 0 0 0 0 0
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 0 0 0 0 0
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 0 0 0 0 0
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0 0 0 0
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 900 0 900 300 600 0
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 0 0 0 0 0 0
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgical) pack/saset 0 0 0 0 0 0
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0 0 0 0 0
77 Silk 2/0 box-12 pacs 0 0 0 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0 0 0 0
80 Tabung oksigen 1 m3 + regulator set 0 0 0 0 0 0
81 Under pad buah 19 10 29 0 29 0
82 Urine bag Pcs 5 0 5 0 5 0
83 Wing needle 23 G - 25 G buah 0 0 0 0 0 0
Safety bok biji 0 0 0 0 0 5
TAMBAHAN PERBEKALAN KESEHATAN 0 0
1 Alat pengukur HB 201 + analizer unit 0 0 0 0 0 0
2 Dek glass (cover glass) box 0 0 0 0 0 0
3 Microcuvet Hb 201 buah 0 0 0 0 0 0
4 Object glass box 0 0 0 0 0 0
5 Occu check (alat pemegang lancet ROCHE) kit 0 0 0 0 0 0
6 Softclick lanciet 200 box 0 0 0 0
7 Softclick lancing device kit 0 0 0 0
8 Tabung hematokrit botol 0 0 0 0 0 3
9 Kotak slide 0 0 0 0 0 0
10 Performa Accu check Blood glucose meter set 0 0 0 0 0 0
- Performa Accu check tes strip box 0 0 0 0 0 0
0 0
III REAGEN 0 0 0
1 Aquabidest steril botol 500 ml 2 0 2 2 0
2 Aquabidest steril botol 1000 ml 0 0 0
3 Pemeriksaan kadar gula darah 0 0 0
Glocodoctor Box-50 test 0 0 0 0
Accutrand 25 strip 0 0 0 0 6
Easy Touch box/25 0 0 0 0
Nesco gluco strip box/25 0 0 0 0
Glucostar box/25 0 0 0 0
4 Reagen Pemeriksaan Asam Urat 0 0 0 0
Nesco box-25 0 0 0 0
Easy Touch box-25 0 0 0 0
UA Sure box-25 0 0 0 0
5 Reagen Pemeriksaan Kolesterol 0 0 0 0
Accutrand box/25 0 0 0 1
Easy touch cholesterol box-10 0 0 0 0
Nesco box-10 0 0 0 0
Multicare box/25 0 0 0 0
6 Hb Sahli 0 0 0 0
- Assistant set 0 0 0 0
- Superior set 0 0 0 0
7 Reagen untuk spektrofotometr 0 0 0
- Reagen glukosa box-4 btl 0 0 0 1
- Reagen Trigliserida box-4 btl 0 0 0 0
- Reagen asam urat box-4 btl 0 0 0
8 Trigliserida 0 0
- Accutrend box / 25 0 0 0 1
- Multicare box / 25 0 0 0 0
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0 0 0
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0 0 0
10 Larutan Benedict Botol 100 ml 0 0 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 0 0
12 Larutan Eosin Botol 100 ml 0 0 0 0
13 Larutan Giemsa Stain Botol 100 ml 0 0 0 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0 0 0
15 Larutan Metanol Botol 100 ml 0 0 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 0 0
17 Larutan Natrium citrat Botol 100 ml 0 0 0 0
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0 0 0
19 Larutan Turk Botol 100 ml 0 0 0 0
20 Larutan Ziehl Neelsen set 0 0 0 0
21 Reagen pemeriksaan yodium botol 0 0 0 0
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0 0 0
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0 0 0
- RDT Combo Malaria tes 0 0 0 0
24 Rapid test Leptospirosis box/50 strip 0 0 0 0
25 Rapid test Chikungunya tes 0 0 0 0
26 Rapid test demam berdarah kit-25 tes 0 0 0 0
27 Rapid test demam thypoid kit-25 tes 0 0 0 0
28 Tes Kehamilan 0 0 0 0
PPTEST Box 40 tes 0 0 0 0
HCG strip (answer) strip 0 0 0 0
UltraOne tes kehamilan box 50 tes 0 0 0 0
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 0 0 1
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0 0 0
31 Urine Test 10 Parameter btl - 100 test 0 0 0 0
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0 0 1
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0 0 1
34 Tes Narkoba 0 0 0 0
- Amfetamin kot@25 strip 0 0 0 0
- Metamfetamin kot@25 strip 0 0 0 0
- Cocain kot@25 strip 0 0 0 0
- Cannabidoid kot@25 strip 0 0 0 0
- Benzodiasepin kot@25 strip 0 0 0 0
- Babiturat kot@25 strip 0 0 0 0
35 Reagen Mantoux ampul 0 0 0 0
36 Tes Golongan darah 0 0 0
- Anti A Botol 10 ml 0 0 0 1
- Anti B Botol 10 ml 0 0 0 1
- Anti AB Botol 10 ml 0 0 0 1
37 Oil emersi botol 100 ml 0 0 0 0
38 Reagen untuk fotometer 0 0 0
- reagen kolesterol 4 botol @ 100 ml 0 0 0 0
- reagen glukosa 4 botol @ 100 ml 0 0 0 0
- reagen asam urat 4 botol @ 100 ml 0 0 0 0
- reagen trigliserida 4 botol @ 100 ml 0 0 0 0
0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet tablet 0 0 0 0
2 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin tablet 36 36 36 0
3 posphat
Artemeter320) tablet
injeksi 1 ml 80 mg ampul 0 0 0 0
4 Artesunat injeksi vial 60 mg kotak/set 0 0 0 0
5 Kloroquin tablet 150 mg tablet 0 0 0 0
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 0 0 0 0
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0 0 0
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 0 0 0 0
9 Primaquin tablet 15 mg tablet 200 0 200 0 200 0
10 Doksisiklin kapsul 100 mg tablet 0 0 0 0
0 0
V OBAT PROGRAM DIARE (P2M) 0 0
1 Garam oralit serbuk kombinasi saset 110 110 20 90 0
2 Zink Dispersible 20 mg tablet 0 0 0
3 Zincpro drops 15 ml botol 0 0 0 0
4 Zink sirup Botol 0 0 0 0
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0 0
1 Dietil karbamasin sitrat tablet 0 0 0 0
0 0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0 0 0
0 0
VIII OBAT PROGRAM KUSTA (P2M) 0 0
1 Prednison tablet 5 mg tablet 0 0 0 0
0 0
IX OBAT PROGRAM FLU BURUNG 0 0
1 Oseltamivir kapsul kapsul 0 0 0 0
0 0
X OBAT PROGRAM GIZI (KIA) 0 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 0 0 0 0
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 0 0 0 0
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + tablet 0 0 0 0
Asam Folat 0,25 mg)
4 Mineral Mix saset 0 0 0 0
5 Iodol kapsul kapsul 0 0 0 0
0 0
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0
1 Albendazol tablet 400 mg tablet 0 0 0 0
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 0 0 0 0
3 Pirantel pamoat tablet 125 mg 0 0 0
0 0
XII. OBAT ANTI TUBERKULOSIS 0 0
1 Obat FDC kategori 1 paket 0 0 0 0
2 Obat FDC kategori 2 paket 0 0 0 0
3 Obat FDC Sisipan paket 0 0 0 0
4 OAT Anak paket 0 0 0 0
5 OAT Kombipak 1 paket 0 0 0 0
0 0
XIII. PROGRAM P2 0 0
1 Zidovudin + lamivudin (300 mg/150 mg tablet 0 0 0 0
2 Efavirenz 600 mg tablet 0 0 0 0
3 Tenofovir (TDF) 300 mg tablet 0 0 0 0
4 Nevirapin 200 mg tablet 0 0 0 0
5 Lamivudin 3 TC 150 mg tablet 0 0 0 0
0 0
XIV. PROGRAM KUSTA 0 0
1 Obat MDT Kusta PB Dewasa blister 0 0 0 0
2 Obat MDT Kusta MB Anak blister 0 0 0 0
3 Obat MDT Kusta MB Dewasa blister 0 0 0 0
0 0

JUMLAH KUNJUNNGAN RESEP UMUM JKN LAIN-2 JUMLAH


BAYAR
990 516 0 1506

Purworejo, ......................
Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bubutan Petugas Puskesmas Bubutan
Kabupaten Purworejo
dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. dr. Riyo Suhardono .......................................
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19710418 201312 1 005 NIP.
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/ 24-03-2017

NO. NAMA OBAT SATUAN JUMLAH KETERANGAN


BARANG SUMBER
1 2 3 4 5
1 Allopurinol tablet 100 mg tablet 1000
2 Aminofilin injeksi 24 mg/ml ampul 30
3 Amoksisillin kaplet 500 mg tablet 4000
4 Amoksisillin sirup kering 125mg/5ml botol 60 ml 60
5 Amoksisillin sirup kering forte 250 mg/ 5 ml botol 60 ml 100
6 Antasida DOEN I tablet kunyah kombinasi tablet 500
7 Aqua pro injeksi steril, bebas pirogen vial 60
8 Asam asetil salisilat 80 mg tablet 100
9 Attapulgit tablet 600 mg tablet 1000
10 Asam mefenamat kaplet 250 mg tablet 500
11 Asam Traneksamat injeksi 100 mg/ml ampul 10
12 Asiklovir tablet 400 mg tablet 1000
13 Betahistin mesilat tablet 6 mg tablet 900
14 Betametason cream 0,1 % tube 25
15 Cetirizine kapsul 10 mg kapsul 500
16 Deksametason tablet 0,5 mg tablet 4000
17 Digoksin tablet 0,25 mg tablet 200
18 Glukosa larutan infus 5 % botol -500 ml 40
19 Griseofulvin tablet 125 mg micronized tablet 500
20 Ibuprofen tablet 400 mg tablet 1000
21 Kalsium laktat tablet 500 mg tablet 2000
22 Klorfeniramin maleat (CTM) tablet 4 mg tablet 3000
23 Larutan mengandung elektrolit : (Asering) botol -500 ml 40
24 Larutan mengandung elektrolit : (KAEN 3 A) botol -500 ml 20
25 Lidokain HCI 20 mg/g jely (Xylocain jely) kotak/set 1
26 N-asetyl sistein kaplet 200 mg tablet 2640
27 Natrium Klorida Larutan Infus 0,9% steril botol -500 ml 20
28 Ondansentron injeksi 4 mg / 2 ml ampul 20
29 Parasetamol tablet 500 mg tablet 3000
30 Piridoksin (Vit. B6) tablet 10 mg tablet 1000
31 Ranitidin injeksi 25 mg/2ml ampul 100
32 Ringer Laktat larutan infus botol -500 ml 160
33 Salisil bedak 2 % kotak -50 gram 20
34 Sefotaksim serbuk injeksi 500 mg/vial vial 50
35 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 2000
36 Multivitamin sirup : CURBION Botol 50
37 alat suntik sekali pakai 1 ml set 100
38 alat suntik sekali pakai 3 ml (Terumo) set 200
39 Blood Tranfusion set (MAS) pcs 5
40 Catgut chromic 3/0 saset/pack 1
41 Folley catheter No. 16 ( Norta ) Pcs 5
42 Folley catheter No. 18 ( Norta ) pcs 5
43 Infus set ( Otsu Y ) pices 50
44 Infus set anak set/kantong 50
45 IV catheter No. 18 G buah 50
46 IV catheter No. 22 G buah 50
47 Tabung hematokrit botol 3
48 Tes HIV I & II Antibody Card ( IR - 100C) btl-25 tes 1 box
49 Arteraquin ( dihydro artemisin 40 mg tablet + diperaquin ) tablet 36

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
LAPORAN PEMAKAIAN DAN LEMBAR
(LPLPO

PUSKESMAS : BUBUTAN
KECAMATAN : PURWODADI
KABUPATEN : PURWOREJO

SATUAN STOK PENERI- PERSE-


No. NAMA OBAT KEMASAN AWAL MAAN DIAAN

1 2 3 4 5 6
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 mg tablet 900 1,000 1,900
2 Alprazolam tablet 0,25 mg tablet 162 0 162
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 0
4 Ambroxol tablet 30 mg tablet 0 0 0
5 Aminofilin injeksi 24 mg/ml ampul 32 30 62
6 Aminofilin tablet 200 mg tablet 749 1,500 2,249
7 Amitriptilin tablet 25 mg tablet 100 0 100
8 Amlodipin tablet 10 mg tablet 0 900 900
9 Amlodipin tablet 5 mg tablet 60 600 660
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0
11 Amoksisilin kaplet 500 mg tablet 6,900 4,000 10,900
12 Amoksisilin kapsul 250 mg kapsul 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 172 0 172
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 95 50 145
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 118 0 118
16 Antalgin (Metampiron) tablet 500 mg tablet 920 0 920
17 Antasida DOEN I tablet kunyah kombinasi tablet 4,450 3,000 7,450
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 37 50 87
19 Antibakteri DOEN salep komb : Basitrasin 500 tube 0 0 0
20 IU/g + polimiksin 10.000 IU/g
Antifungi DOEN kombinasi : Asam Benzoat 6% + pot 0 0 0
21 Asam Salisilat 3 %
Antihemoroid DOEN kombinasi (Generik) supp 20 0 20
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet 0 0 0
23 Aqua pro injeksi steril, bebas pirogen vial 57 0 57
24 Asam asetil salisilat 80 mg tablet 700 0 700
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 0 0 0
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 2,000 0 2,000
27 Asam folat tablet 1 mg tablet 0 0 0
28 Asam mefenamat kaplet 250 mg Tablet 2,968 3,000 5,968
29 Asam mefenamat kaplet 500 mg tablet 0 0 0
30 Asam traneksamat injeksi 100 mg/ml ampul 15 0 15
31 Asiklovir krim 5 % tube 5 gram 10 0 10
32 Asiklovir tablet 200 mg tablet 0 0 0
33 Asiklovir tablet 400 mg tablet 1,130 0 1,130
34 Atapulgit tablet 600 mg tablet 821 0 821
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 30 0 30
36 Betahistin mesilat tablet 6 mg tablet 840 0 840
37 Betametason cream 0,1 % tube 40 25 65
38 Betametason tetes mata 1 mg/ml botol 0 0 0
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 19 0 19
40 Bromheksin tablet 8 mg tablet 0 0 0
41 Cetirizine kapsul 10 mg kapsul 1,100 0 1,100
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 0 0 0
43 Deksametason injeksi i.v. 5 mg/ml ampul 36 100 136
44 Deksametason tablet 0,5 mg tablet 2,300 5,000 7,300
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 0
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 0
47 Diazepam injeksi 5 mg/ml ampul 0 0 0
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 10 0 10
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 10 0 10
50 Diazepam tablet 2 mg tablet 677 0 677
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 30 0 30
52 Digoksin tablet 0,25 mg tablet 300 0 300
53 Diltiazem HCl Tablet 30 mg tablet 0 0 0
54 Dimenhidrinat tablet 50 mg tablet 200 0 200
55 Doksisiklin kapsul 100 mg kapsul 0 0 0
56 Domperidon suspensi 5 mg/5 ml botol-60ml 34 0 34
57 Domperidon tablet 10 mg tablet 700 0 700
58 Efedrin HCl tablet 25 mg tablet 0 0 0
59 Ekstraks beladona tablet 10 mg tablet 0 0 0
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 0 100
61 Eritromisin kapsul 250 mg kapsul 0 0 0
62 Eritromisin kapsul 500 mg kapsul 500 500
63 Eritromisin sirup 200 mg/5 ml botol 0 0 0
64 Fenilbutason 200 mg tablet tablet 0 0 0
65 Fenitoin Natrium Kapsul 100 mg kapsul 0 0 0
66 Fenobarbital injeksi ampul 0 0 0
67 Fenobarbital tablet 30 mg tablet 0 0 0
68 Fenolgliserol tetes telinga 10 % botol 0 0 0
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 29 0 29
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 648 0 648
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 0 0 0
72 Furosemida tablet 40 mg tablet 562 200 762
73 Gameksan lotion 1 % botol-30 ml 0 0 0
74 Gemfibrosil kapsul 300 mg kapsul 500 0 500
75 Gemfibrozil kapsul 600 mg kapsul 0 0 0
76 Gentamisin salep kulit 0,1% tube 42 0 42
77 Gentamisin salep mata 0,3 % botol 0 0 0
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 0 0 0
79 Gentian violet larutan 1 % botol 0 0 0
80 Glibenklamid tablet 5 mg tablet 0 0 0
81 Gliclazid 80 mg tablet tablet 0 0
82 Glimepirid tablet 2 mg tablet 500 0 500
83 Gliseril Guayakolat tablet 100 mg tablet 0 0 0
84 Gliserin lar 50 % botol-100 ml 0 0 0
85 Glukosa larutan infus 10 % botol 500 ml 0 0 0
86 Glukosa larutan infus 40 % ampul 0 0 0
87 Glukosa larutan infus 5 % botol 500 ml 106 40 146
88 Griseofulvin tablet 125 mg micronized tablet 200 500 700
89 Haloperidol injeksi 5 mg/ml ampul 0 0 0
90 Haloperidol injeksi 50 mg/ml ampul 0 0 0
91 Haloperidol tablet 1,5 mg tablet 0 0 0
92 Haloperidol tablet 2 mg tablet 200 0 200
93 Haloperidol tablet 5 mg tablet 100 0 100
94 Hidroklorotiazida tablet 25 mg tablet 0 0 0
95 Hidrokortison krim 2,5% tube 24 0 24
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 0
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 0
98 Ibuprofen tablet 200 mg tablet 0 0 0
99 Ibuprofen tablet 400 mg tablet 5,000 1,000 6,000
100 Isoniasida tablet 100 mg tablet 0 0 0
101 Isosorbid dinitrat tablet sublingual 10 mg 100 0 100
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 0
103 Kalium diklofenak 50 mg tablet tablet 0 0 0
104 Kalsium glukonas injeksi ampul 0 0 0
105 Kalsium laktat tablet 500 mg tablet 400 2,000 2,400
106 Kaptopril tablet 12,5 mg tablet 903 0 903
107 Kaptopril tablet 25 mg tablet 2,536 0 2,536
108 Karbamazepin tablet 200 mg tablet 0 0 0
109 Karbogliserin tetes telinga botol 0 0 0
110 Ketokonazol krim 2 % tube 15 gram 68 0 68
111 Ketokonazol tablet 200 mg tablet 0 0 0
112 Ketorolac injeksi 10 mg ampul 1 ml 24 0 24
113 Ketorolac injeksi 30 mg ampul 1 ml 0 0 0
114 Klindamisin kapsul 300 mg kapsul 0 0 0
115 Klobazam tablet 10 mg tablet 0 0 0
116 Klonidin tablet 0,15 mg tablet 0 0 0
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 0
118 Kloramfenikol kapsul 250 mg kapsul 0 0 0
119 Kloramfenikol kapsul 500 mg kapsul 1,175 0 1,175
120 Kloramfenikol salep kulit (Bufacetin) tube 48 0 48
121 Kloramfenikol salep mata 1 % tube 5 gram 48 0 48
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 30 0 30
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 21 0 21
124 Kloramfenikol tetes telinga 3 % botol 5 ml 15 0 15
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 6,434 5,000 11,434
127 Klorpromazin tablet salut 100 mg (HCl) tablet 159 0 159
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 1,074 0 1,074
131 Kotrimoksasol suspensi botol 60 ml 90 0 90
132 Lamivudin tablet 150 mg tablet 0 0 0
133 Lanzoprazol kapsul 30 mg kapsul 0 0 0
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 0 40 40
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 21 20 41
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 0 0 0
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 0
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 1 1
139 Lidokain injeksi 2 % ampul 0 0 0
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ampul 40 0 40
141 Lidokain semprot 10 % botol 0 0 0
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 0 0 0
143 Magnesium sulfat injeksi 20 % ampul 0 0 0
144 Magnesium sulfat injeksi 40 % ampul 0 0 0
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 0
146 Mebendazol tablet 100 mg tablet 0 0 0
147 Mekobalamin tablet 500 mg tablet 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0
149 Metformin HCl tablet 500 mg tablet 983 0 983
150 Metil Prednisolon tablet 4 mg tablet 563 0 563
151 Metil Prednisolon tablet 8 mg tablet 0 0 0
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 10 0 10
153 Metilergometrin maleat tablet 0,125 mg tablet 913 0 913
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 0
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 0
156 Metoklopramid tablet 10 mg tablet 700 0 700
157 Metoklopramid tablet 5 mg tablet 0 0 0
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 0 0 0
159 Metronidasol tablet 250 mg tablet 0 0 0
160 Metronidasol tablet 500 mg tablet 867 0 867
161 Metronidazol infus 500 mg/100 ml botol-100 ml 9 0 9
162 Mikonazol krim 2 % tube 38 0 38
163 N-asetyl sistein kaplet 200 mg tablet 1,320 2,640 3,960
164 Natrium Diklofenak tablet 25 mg tablet 0 0 0
165 Natrium Diklofenak tablet 50 mg tablet 2,978 0 2,978
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 30 20 50
167 Nifedipin tablet 10 mg tablet 745 0 745
168 Nifedipin tablet 20 mg SR tablet 600 0 600
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 0 0 0
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 0
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 0
173 Oksitetrasiklin salep mata 1% tube 0 0 0
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 0 10 10
175 Omeprazol injeksi 40 mg/10 ml vial 0 0 0
176 Omeprazol kapsul 20 mg kapsul 1,019 0 1,019
177 Ondansentron injeksi 4 mg / 2 ml ampul 0 70 70
178 Papaverin injeksi ampul 0 0 0
179 Papaverin tablet 40 mg tablet 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0
181 Parasetamol sirup 120 mg/5 ml botol 154 0 154
182 Parasetamol tablet 500 mg tablet 5,500 3,000 8,500
183 Permetrin (Scabimite) tube 10 0 10
184 Petidin injeksi (Narkotika) ampul 0 0 0
185 Piracetam 800 mg tablet tablet 0 0 0
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 0
187 Pirantel tablet score 125 mg tablet 0 0 0
188 Piridoksin (Vit. B6) tablet 10 mg tablet 2,083 1,000 3,083
189 Piroksikam kapsul 20 mg tablet 1,022 0 1,022
190 Piroksikam tablet 10 mg tablet 0 0 0
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 0 0 0
192 Prednison tablet 5 mg tablet 2,149 0 2,149
193 Probenesid tablet 500 mg tablet 0 0 0
194 Propanolol tablet 10 mg tablet 180 0 180
195 Propiltiourasil tablet 100 mg tablet 200 0 200
196 Ranitidin injeksi 25 mg/2 ml ampul 50 100 150
197 Ranitidin tablet 150 mg tablet 773 0 773
198 Rifampisin kaplet salut 450 mg kaplet 0 0 0
199 Rifampisin kapsul 300 mg kapsul 0 0 0
200 Ringer laktat larutan infus botol 500 ml 60 160 220
201 Risperidon tablet tablet 0 0 0
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 0
203 Salbutamol tablet 2 mg tablet 0 0 0
204 Salbutamol tablet 4 mg tablet 500 0 500
205 Salep 2-4, Kombinasi Asam Salisilat 2% + pot 24 0 24
206 Belerang endap
Salisil bedak 2% 4% kotak-50 gram 11 20 31
208 Sefadroksil kapsul 250 mg kaplet 0 0 0
209 Sefadroksil kapsul 500 mg kaplet 1,200 0 1,200
210 Sefadroksil sirup kering 125 mg/5 ml botol 0 0 0
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 0
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 150 0 150
213 Sefotaksim serbuk injeksi 500 mg/vial vial 0 50 50
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 0
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I vial 5 ml 0 0 0
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU ( dos 6 0 6
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 0 10
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 0
219 Simetidin tablet 200 mg tablet 146 0 146
220 Simvastatin tablet 10 mg tablet 362 0 362
221 Simvastatin tablet 30 mg tablet 0 0 0
222 Siprofloksasin tablet 250 mg tablet 0 0 0
223 Siprofloksasin tablet 500 mg tablet 1,214 0 1,214
224 Spironolakton tablet 25 mg tablet 0 0 0
225 Sukralfat suspensi (Ulsafate) botol 0 0 0
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 0
227 Sulfasetamid Na tetes mata 15 % botol 0 0 0
228 Tetrasiklin kapsul 250 mg kapsul 0 0 0
229 Tetrasiklin kapsul 500 mg kapsul 0 0 0
230 Tiamfenikol kapsul 500 mg kapsul 0 0 0
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 0
232 Tiamin (Vitamin B1) tablet 50 mg tablet 3,800 0 3,800
233 Tramadol kapsul 50 mg tablet 0 0 0
234 Trifluoperazin 5 mg tablet tablet 0 0 0
235 Triheksifenidil tablet 2 mg tablet 0 0 0
236 Vaksin rabies untuk manusia set 0 0 0
237 Vitamin B Kompleks tablet tablet 1,479 0 1,479

B OBAT DAN BAHAN KEDOKTERAN GIGI


1 Air raksa dental use botol 0 0 0
2 Alvogyl paste dus 0 0 0
3 Amalgam Perak (Silver Alloy) botol 0 0 0
4 Articulating papper kotak 0 0 0
5 Bahan pensteril gigi : Trikresol formalin botol 0 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 0
7 Dentin conditioner botol 0 0 0
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 0
9 Etil klorida spray vial/100 ml 4 0 4
10 Eugenol cairan botol@10 ml 0 0 0
11 Fuji VII dus 0 0 0
12 Fuji IX dus 0 0 0
13 Glass inonomer cement ART set/botol 0 0 0
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 0
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 0
16 Kalsium hidroksida pasta kotak 2 tube 0 0 0
17 K-file perawatan akar gigi 0 0 0
- K-file No. 15 set 0 0 0
- K-file No. 20 set 0 0 0
- K-file No. 25 set 0 0 0
- K-file No. 30 set 0 0 0
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 0
19 Mummifying pasta botol/kotak 0 0 0
20 Pasta pengisi saliran akar botol 0 0 0
21 Seluloid strip rol 0 0 0
22 Semen Seng Fosfat serbuk dan cairan set/botol 0 0 0
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) - 0 0
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram 0 0 0
25 Tooth mouse box 0 0 0

C OBAT TAMBAHAN / BRANDED


1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 0
2 Anti asma/bronkodilator nebulizer (ventolin) vial 10 0 10
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 0
4 Antidiare sirup : . botol 60 ml 0 0 0
6 Antidiare Tablet : tablet 0 0 0
7 Antidiare Tablet (Molagit) tablet 0 0 0
9 Antihemoroid DOEN (Superhoid) supp 0 0
10 Antihistamin kombinasi (Pritacort) tablet 100 0 100
11 Antiinfeksi kulit (luka bakar) pot 0 0 0
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 0
13 Antikretinisme tablet tablet 0 0 0
14 Antiscabies krim (Scabicid) tube 10 gram 0 0 0
15 Antispasme injeksi (Spashi) vial 0 0 0
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 0
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 0
18 Laksantia tablet 5 mg (Dulcolax) tablet 18 0 18
19 Laksantia tablet 5 mg (Laxana) tablet 0 0
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 1,249 2,000 3,249
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 0 0 0
22 Multivitamin + mineral utk ibu hamil : kaplet 0 0 0
27 Multivitamin kaplet : VITALAMIN kaplet 1,774 0 1,774
28 Multivitamin sirup : CURBION Botol 83 50 133
31 Multivitamin tabur untuk balita Saset 0 0 0
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 0
33 Neurotropik 5000 injeksi ampul 30 0 30
34 Neurotropik kaplet : kaplet 4,077 0 4,077
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 0
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 0
40 Obat Antiflu kombinasi : botol 60 ml 0 0 0
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 0
42 Obat batuk / flu sirup : .. botol 100 ml 184 0 184
47 Vasodilator perifer (Citicholin) ampul 0 0

D OBAT ASLI INDONESIA (OAI)


1 Asifit kapsul 0 0
2 Batugin elixir botol 0 0
3 Enkasari botol 0 0
4 Fitogen Dragge kapsul 0 0
5 Hepagard kapsul 0 0
6 Imulan kapsul kapsul 0 0
7 Imulan sirup botol 60 ml 0 0
8 Kurkumex sirup botol 60 ml 0 0
9 Kurkumex tablet kaplet 0 0
10 OB Herbal 0 0
11 Tensigard kapsul kapsul 0 0
12 Xanvit sirup 0 0

II. BAHAN MEDIS HABIS PAKAI


1 Alkohol swab box 16 0 16
2 Aquagel jelly 28 gram tube 0 0 0
3 Desinfektan - Antiseptic surgical hand scrub (E-Ca botol-500 ml 3 0 3
4 Desinfektan - Aseptan liquid botol-500 ml 0 0 0
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 0 0 0
6 Etanol 70 % botol 100 ml 48 0 48
7 Etanol 70 % botol 1000 ml 4 0 4
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 23 0 23
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 8 0 8
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 0 0 0

III. PERBEKALAN KESEHATAN


1 Alat suntik sekali pakai 1 ml set 100 100 200
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 0
3 Alat suntik sekali pakai 3 ml (Terumo) set 200 200 400
4 Alat suntik sekali pakai 5 ml (Terumo) set 300 0 300
5 Bisturi (mata pisau) Pcs 100 0 100
6 Blood lancet 28 box-100 0 0 0
7 Blood Tranfusion set (MAS) Pcs 0 5 5
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm 0 0 0
9 Catgut chromic 2/0 saset/pack 0 0 0
10 Catgut chromic 2/0 100 M kotak 0 0 0
11 Catgut chromic 3/0 saset/pack 0 1 1
12 Catgut chromic 3/0 100 M kotak 0 0 0
13 Catgut plain 2/0 saset/pack 1 0 1
14 Catgut plain 3/0 saset/pack 1 0 1
15 Dermafix T 10 x 15 cm rol 5 0 5
16 Dermafix T 5 x 7 cm rol 0 0 0
17 Developer untuk Film Rontgen Botol 5 ltr Repl 20 ltr0 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 0 0 0
19 Film Rontgen ukuran 24 x 30 lembar 0 0 0
20 Film Rontgen ukuran 30 x 40 lembar 0 0 0
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 0
22 Folley catheter No. 16 (Norta) Pcs 0 5 5
23 Folley catheter No. 18 (Norta) Pcs 6 5 11
24 Folley catheter No. 20 Pcs 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0
27 Infus set - Bbraun Intrafix with microdriper set 0 0 0
28 Infus set (Otsu Y) pices 50 50 100
29 Infus set anak set/kantong 8 50 58
30 Infus set dengan micridripper (Otsu) pices 0 0 0
31 Infus set dewasa (Stardec) set/kantong 0 0 0
32 IV catheter No. 18 G buah 0 50 50
33 IV catheter No. 20 G buah 50 0 50
34 IV catheter No. 22 G buah 110 50 160
35 IV catheter No. 24 G buah 206 0 206
36 Jarum jahit kulit saset 24 0 24
37 Jarum jahit otot saset 0 0 0
38 Kapas pembalut/absorben 250 gram bungkus 5 0 5
39 Kasa 10 x 10 cm rol 3 0 3
40 Kasa hidrofil 80 cm x 40 yard rol 45 0 45
41 Kasa hidrofil steril ukuran 16 x 16 box 52 0 52
42 Kasa hidrofil ukuran 16 x 16 lembar 20 0 20
43 Kasa kompres 40/40 steril bungkus 0 0 0
44 Kasa pembalut hidrofil 4 m x 10 cm roll 0 0 0
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 0 0 0
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 0 0 0
47 Kertas EKG ( 50 x 30) rol 0 0
48 Masker : - Earloop pcs 100 0 100
49 Masker : - Earloop (Stardec) Pcs 0 0 0
50 Masker : - tie on Pcs 250 0 250
Masker : - tie on (Stardec) Pcs 0 0 0
51 Mata Bor gigi 0 0
- type inverted No. 010 buah 0 0 0
- type cylinder No. 010 buah 0 0 0
- type tuppered No. 010 buah 0 0 0
- type round No. 010 buah 0 0 0
52 Micropipet Socorex - Acura 0 0 0
- Volume 1 - 10 uL set 0 0 0
- Volume 10 - 100 uL set 0 0 0
- Volume 100 - 1000 uL set 0 0 0
53 N-95 Medical Respirator box 0 0 0
54 Nasal oxygen canula - adult sraight pieces 5 0 5
55 Nasal oxygen canula - child pieces 2 0 2
56 Nasal oxygen canula - infant 0 0 0
57 Penutup luka dengan antibiotika (Cuticell)/Bioplac Pcs 29 0 29
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 26 10 36
59 Plester 5 yards x 2 inchi rol 0 0 0
60 Plester hypafix/pharmafix 5 cm x 5 m rol 0 0 0
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 0 0 0
62 Pot sputum buah 0 0 0
63 Sarung tangan steril nomor 6,5 : MAS pasang 0 0
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0
67 Sarung tangan steril nomor 7,5 : MAS pasang 0 0
68 Sarung tangan steril nomor 8 0 0
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 0 0
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 0 0
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 900 0 900
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 0 0 0
74 Silk (benang bedah sutera no 2/0 dg jarum (peter pack/saset 0 0 0
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0 0
77 Silk 2/0 box-12 pacs 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0
80 Tabung oksigen 1 m3 + regulator set 0 0 0
81 Under pad buah 19 10 29
82 Urine bag Pcs 5 0 5
83 Wing needle 23 G - 25 G buah 0 0 0
Safety bok biji 0 0 0
TAMBAHAN PERBEKALAN KESEHATAN 0
1 Alat pengukur HB 201 + analizer unit 0 0 0
2 Dek glass (cover glass) box 0 0 0
3 Microcuvet Hb 201 buah 0 0 0
4 Object glass box 0 0 0
5 Occu check (alat pemegang lancet ROCHE) kit 0 0 0
6 Softclick lanciet 200 box 0 0
7 Softclick lancing device kit 0 0
8 Tabung hematokrit botol 0 0 0
9 Kotak slide 0 0 0
10 Performa Accu check Blood glucose meter set 0 0 0
- Performa Accu check tes strip box 0 0 0
0
III REAGEN 0
1 Aquabidest steril botol 500 ml 2 0 2
2 Aquabidest steril botol 1000 ml 0 0
3 Pemeriksaan kadar gula darah 0 0
Glocodoctor Box-50 test 0 0
Accutrand 25 strip 0 0 0
Easy Touch box/25 0 0
Nesco gluco strip box/25 0 0
Glucostar box/25 0 0
4 Reagen Pemeriksaan Asam Urat 0 0
Nesco box-25 0 0
Easy Touch box-25 0 0
UA Sure box-25 0 0
5 Reagen Pemeriksaan Kolesterol 0 0
Accutrand box/25 0 0
Easy touch cholesterol box-10 0 0
Nesco box-10 0 0
Multicare box/25 0 0
6 Hb Sahli 0 0
- Assistant set 0 0
- Superior set 0 0
7 Reagen untuk spektrofotometr 0
- Reagen glukosa box-4 btl 0 0
- Reagen Trigliserida box-4 btl 0 0
- Reagen asam urat box-4 btl 0 0
8 Trigliserida 0
- Accutrend box / 25 0 0
- Multicare box / 25 0 0
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0
10 Larutan Benedict Botol 100 ml 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0
12 Larutan Eosin Botol 100 ml 0 0
13 Larutan Giemsa Stain Botol 100 ml 0 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0
15 Larutan Metanol Botol 100 ml 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0
17 Larutan Natrium citrat Botol 100 ml 0 0
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0
19 Larutan Turk Botol 100 ml 0 0
20 Larutan Ziehl Neelsen set 0 0
21 Reagen pemeriksaan yodium botol 0 0
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0
- RDT Combo Malaria tes 0 0
24 Rapid test Leptospirosis box/50 strip 0 0
25 Rapid test Chikungunya tes 0 0
26 Rapid test demam berdarah kit-25 tes 0 0
27 Rapid test demam thypoid kit-25 tes 0 0
28 Tes Kehamilan 0 0
PPTEST Box 40 tes 0 0
HCG strip (answer) strip 0 0
UltraOne tes kehamilan box 50 tes 0 0
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 0
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0
31 Urine Test 10 Parameter btl - 100 test 0 0
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0
34 Tes Narkoba 0 0
- Amfetamin kot@25 strip 0 0
- Metamfetamin kot@25 strip 0 0
- Cocain kot@25 strip 0 0
- Cannabidoid kot@25 strip 0 0
- Benzodiasepin kot@25 strip 0 0
- Babiturat kot@25 strip 0 0
35 Reagen Mantoux ampul 0 0
36 Tes Golongan darah 0
- Anti A Botol 10 ml 0 0
- Anti B Botol 10 ml 0 0
- Anti AB Botol 10 ml 0 0
37 Oil emersi botol 100 ml 0 0
38 Reagen untuk fotometer 0
- reagen kolesterol 4 botol @ 100 ml 0 0
- reagen glukosa 4 botol @ 100 ml 0 0
- reagen asam urat 4 botol @ 100 ml 0 0
- reagen trigliserida 4 botol @ 100 ml 0 0
0
IV OBAT PROGRAM MALARIA (P2M) 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin tablet 0 0
2 Anhydrat
Arteraquintablet 200 mg)
(dihydro artemisin 40 mg tablet + tablet 36 36
3 diperaquin posphat
Artemeter injeksi 320)
1 ml 80 tablet
mg ampul 0 0
4 Artesunat injeksi vial 60 mg kotak/set 0 0
5 Kloroquin tablet 150 mg tablet 0 0
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 tablet 0 0
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 0 0
9 Primaquin tablet 15 mg tablet 200 0 200
10 Doksisiklin kapsul 100 mg tablet 0 0
0
V OBAT PROGRAM DIARE (P2M) 0
1 Garam oralit serbuk kombinasi saset 110 110
2 Zink Dispersible 20 mg tablet 0
3 Zincpro drops 15 ml botol 0 0
4 Zink sirup Botol 0 0
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0
1 Dietil karbamasin sitrat tablet 0 0
0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0
0
VIII OBAT PROGRAM KUSTA (P2M) 0
1 Prednison tablet 5 mg tablet 0 0
0
IX OBAT PROGRAM FLU BURUNG 0
1 Oseltamivir kapsul kapsul 0 0
0
X OBAT PROGRAM GIZI (KIA) 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 0 0
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 0 0
3 Tablet tambah darah kombinasi : Besi II Sulfat tablet 0 0
4 200 mg Mix
Mineral + Asam Folat 0,25 mg) saset 0 0
5 Iodol kapsul kapsul 0 0
0
XI. OBAT PROGRAM KECACINGAN (P2M) 0
1 Albendazol tablet 400 mg tablet 0 0
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 0 0
3 Pirantel pamoat tablet 125 mg 0
0
XII. OBAT ANTI TUBERKULOSIS 0
1 Obat FDC kategori 1 paket 0 0
2 Obat FDC kategori 2 paket 0 0
3 Obat FDC Sisipan paket 0 0
4 OAT Anak paket 0 0
5 OAT Kombipak 1 paket 0 0
0
XIII. PROGRAM P2 0
1 Zidovudin + lamivudin (300 mg/150 mg tablet 0 0
2 Efavirenz 600 mg tablet 0 0
3 Tenofovir (TDF) 300 mg tablet 0 0
4 Nevirapin 200 mg tablet 0 0
5 Lamivudin 3 TC 150 mg tablet 0 0
0
XIV. PROGRAM KUSTA 0
1 Obat MDT Kusta PB Dewasa blister 0 0
2 Obat MDT Kusta MB Anak blister 0 0
3 Obat MDT Kusta MB Dewasa blister 0 0
0

JUMLAH KUNJUNNGAN RESEP UMUM JKN


BAYAR
990 516

Mengetahui
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi
Kabupaten Purworejo

dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt.


NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002
AKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

DOKUMEN NOMOR
: APRIL 2017 INST. FARMASI 442/ /2017
: MEI 2017 PUSKESMAS

PEMA- SISA STOK PERMIN- PEMBERIAN


KAIAN OPTIMUM TAAN APBD DAK JKN PRO- APBD
KAB GRAM PROV
7 8 9 10 11 12 13 14 15

400 1,500 1,000


6 156 0
0 0 0
0 0 1,000
0 62 0
400 1,849 0
0 100 0
30 870 1,000
60 600 1,000
0 0 0
3,800 7,100 4,000
0 0 0
55 117 0
5 140 0
0 118 0
0 920 0
3,000 4,450 3,000
23 64 50
0 0 0
0 0 0
0 20 0
0 0 0
12 45 0
0 700 0
0 0 0
500 1,500 0
0 0 0
2,068 3,900 3,000
0 0 1,000
0 15 0
10 0 50
0 0 0
100 1,030 0
300 521 500
0 30 0
450 390 1,000
25 40 25
0 0 0
0 19 0
0 0 0
300 800 0
0 0 0
10 126 0
3,500 3,800 5,000
0 0 50
0 0 1,000
0 0 10
0 10 0
0 10 0
221 456 0
0 30 0
0 300 0
0 0 0
100 100 500
0 0 500
4 30 50
200 500 1,000
0 0 0
0 0 0
0 100 0
0 0 0
0 500 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 30
5 24 0
0 648 0
0 0 10
200 562 0
0 0 0
140 360 0
0 0 0
0 42 0
0 0 0
0 0
0 0 0
0 0 500
0 0 0
200 300 1,000
0 0 3,000
0 0 0
0 0 0
0 0 0
18 128 0
100 600 500
0 0 0
0 0 0
0 0 0
0 200 0
60 40 100
0 0 0
24
0 0 100
0 0 0
0 0 0
2,400 3,600 3,000
0 0 0
10 90 0
0 0 0
0 0 0
0 0 0
800 1,600 3,000
400 503 500
436 2,100 0
0 0 0
0 0 0
68 0
0 0 1,000
18 6 0
0 0 0
0 0
0 0 0
0 0 100
0 0 0
0 0 0
175 1,000 0
48 0
24 24 0
30 0 100
21 0 50
0 15 0
4,000 7,434 3,000
59 100 100
0 0 0
0 0 500
100 974 0
18 72 0
0 0 0
0 0 0
4 36 60
7 34 0
0 0 0
0 0 0
0 1 0
0 0 0
12 28 100
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 500
183 800 0
203 360 0
0 0 0
0 10 0
0 913 0
0 0 10
0 0 0
0 700 0
0 0 0
0 0 0
0 0 0
500 367 2,000
0 9 0
28 10 48
1,260 2,700 0
0 0 0
678 2,300 0
7 43 0
145 600 0
0 600 0
0 0 0
0 0 50
0 0 0
0 0 40
0 0 0
0 10 0
0 0 10
99 920 0
10 60 50
0 0 0
0 0 0
0 0 0
94 60 50
4,200 4,300 5,000
1 9 0
0 0 0
0 0 0
0 0 20
0 0 0
633 2,450 2,000
22 1,000 0
0 0 0
0 0 0
1,200 949 2,000
0 0 0
180 0
0 200 0
100 50 200
100 673 0
0 0 0
0 0 0
120 100 160
0 0 0
0 0 0
0 0 0
100 400 0
24 0
15 16 20
0 0
500 700 1,000
0 0 0
0 0 0
50 100 50
30 20 50
0 0 50
0 0 5
0 6 0
0 10 0
0 0 0
146 0 1,000
0 362 0
0 0 0
0 0
114 1,100 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
600 3,200 0
0 0 0
0 0 0
0 0 0
0 0 0
629 850 3,000

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 2
0 0 0
0 0 0
2 2 0
0 0 0
0 0 0
0 0 0
0 0 2
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0
3 7 10
0 0 1,000
0 0 50
0 0 0
0 0 0
0 0 0
100 0 500
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 18 0
0 0 0
800 2,449 0
0 0 60
0 0 0
200 1,574 0
0 133 60
0 0 0
0 0
30 0
1,500 2,577 3,000
0 0 0
0 0 0
0 0 100
0 0 0
184 0 200
0 0 10

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

1 15 0
0 0 0
0 3 0
0 0 0
0 0 0
2 46 0
1 3 0
3 20 0
3 5 0
0 0 0

100 100 0
0 0 0
100 300 0
0 300 0
5 95 0
0 0 0
2 3 0
0 0 0
0 0 0
0 0 0
0 1 0
0 0 0
0 1 0
0 1 0
0 5 0
0 0 5
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 5 0
4 7 0
0 0 0
0 0 0
0 0 0
0 0 00
36 64 50
16 42 0
0 0 0
0 0 0
2 48 0
3 47 0
37 123 0
56 150 0
0 24 0
0 0 0
0 5 0
0 3 0
0 45 0
0 52 0
0 20 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 100 0
0 0 0
250 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 5 0
0 2 0
0 0 0
29 0
1 35 0
0 0 0
0 2
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
300 600 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 29 0
0 5 0
0 0 0
0 0 5
0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0
0 0 3
0 0 0
0 0 0
0 0 0
0
0 0
2 0
0
0
0 0
0 6
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0
0
0 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 1
0 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 1
0 1
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
36 0
0 0
0 0
0 0
0 0
0 0
0 0
0 200 0
0 0
0
0
20 90 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0

JKN LAIN-2 JUMLAH

516 0 1506

Purworejo, ......................
Yang meminta Yang menerima
UPT Instalasi Farmasi Kepala Puskesmas Bubutan Petugas Puskesmas Bubutan

nang Wijayanto, Apt. dr. Riyo Suhardono .......................................


80601 199312 1 002 NIP. 19710418 201312 1 005 NIP.
TANGGAL

N KET
LAIN-2 JUMLAH

16 17 18
Purworejo, ......................
Yang menerima
Petugas Puskesmas Bubutan

.......................................
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

PUSKESMAS : BUBUTAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI : JUNI 2017 INST. FARMASI 442/ /2017
KABUPATEN : PURWOREJO : JULI 2017 PUSKESMAS

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 mg tablet 2,200 0 2,200 200 2,000 0
2 Alprazolam tablet 0,25 mg tablet 156 0 156 0 156 0
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 0 0 0 0
4 Ambroxol tablet 30 mg tablet 2,000 0 2,000 0 2,000 0
5 Aminofilin injeksi 24 mg/ml ampul 62 0 62 0 62 0
6 Aminofilin tablet 200 mg tablet 1,649 300 1,949 200 1,749 0
7 Amitriptilin tablet 25 mg tablet 100 0 100 0 100 0
8 Amlodipin tablet 10 mg tablet 990 0 990 750 240 0
9 Amlodipin tablet 5 mg tablet 570 900 1,470 120 1,350 0
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0 0 0 0
11 Amoksisilin kaplet 500 mg tablet 7,300 4,000 11,300 2,700 8,600 4,000
12 Amoksisilin kapsul 250 mg kapsul 0 0 0 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 56 120 176 40 136 0
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 120 50 170 20 150 0
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 100 0 100 18 82 0
16 Antalgin (Metampiron) tablet 500 mg tablet 800 0 800 100 700 0
17 Antasida DOEN I tablet kunyah kombinasi tablet 4,950 2,000 6,950 1,500 5,450 0
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 76 0 76 5 71 0
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 0 0 0 0 0 0
20 polimiksin 10.000kombinasi
Antifungi DOEN IU/g : Asam Benzoat 6% + Asam pot 0 0 0 0 0 0
21 Salisilat 3 % DOEN kombinasi (Generik)
Antihemoroid supp 19 0 19 1 18 0
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg tablet tablet 0 0 0 0 0 0
23 Aqua pro injeksi steril, bebas pirogen vial 27 0 27 0 27 0
24 Asam asetil salisilat 80 mg tablet 700 0 700 0 700 0
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 0 0 0 0 0 0
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 1,200 0 1,200 300 900 0
27 Asam folat tablet 1 mg tablet 0 2,000 2,000 2,000 0 2,000
28 Asam mefenamat kaplet 250 mg Tablet 4,500 3,000 7,500 1,900 5,600 0
29 Asam mefenamat kaplet 500 mg tablet 800 600 1,400 100 1,300 0
30 Asam traneksamat injeksi 100 mg/ml ampul 15 0 15 0 15 0
31 Asiklovir krim 5 % tube 5 gram 0 0 0 0 0 50
32 Asiklovir tablet 200 mg tablet 0 0 0 0 0 0
33 Asiklovir tablet 400 mg tablet 1,030 0 1,030 30 1,000 0
34 Atapulgit tablet 600 mg tablet 100 500 600 400 200 1,000
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 30 0 30 0 30 0
36 Betahistin mesilat tablet 6 mg tablet 540 480 1,020 2,400 540 480
37 Betametason cream 0,1 % tube 40 0 40 15 25 25
38 Betametason tetes mata 1 mg/ml botol 0 0 0 0 0 0
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 19 0 19 0 19 0
40 Bromheksin tablet 8 mg tablet 0 0 0 0 0 0
41 Cetirizine kapsul 10 mg kapsul 400 500 900 400 500 1,000
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 0 0 0 0 0 0
43 Deksametason injeksi i.v. 5 mg/ml ampul 116 0 116 0 116 0
44 Deksametason tablet 0,5 mg tablet 3,100 5,000 8,100 4,100 4,000 5,000
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 0 0 0 0
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 0 0 0 0
47 Diazepam injeksi 5 mg/ml ampul 0 0 0 0 0 0
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
50 Diazepam tablet 2 mg tablet 100 500 600 290 310 200
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 30 0 30 0 30 0
52 Digoksin tablet 0,25 mg tablet 200 0 200 0 200 0
53 Diltiazem HCl Tablet 30 mg tablet 0 0 0 0 0 0
54 Dimenhidrinat tablet 50 mg tablet 100 500 600 100 500 0
55 Doksisiklin kapsul 100 mg kapsul 600 100 700 0 700 0
56 Domperidon suspensi 5 mg/5 ml botol-60ml 77 60 137 0 137 0
57 Domperidon tablet 10 mg tablet 1,400 500 1,900 200 1,700 0
58 Efedrin HCl tablet 25 mg tablet 0 0 0 0 0 0
59 Ekstraks beladona tablet 10 mg tablet 0 0 0 0 0 0
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 0 100 0 100 0
61 Eritromisin kapsul 250 mg kapsul 0 0 0 0 0 0
62 Eritromisin kapsul 500 mg kapsul 500 500 0 500 0
63 Eritromisin sirup 200 mg/5 ml botol 0 0 0 0 0 0
64 Fenilbutason 200 mg tablet tablet 0 0 0 0 0 0
65 Fenitoin Natrium Kapsul 100 mg kapsul 0 0 0 0 0 0
66 Fenobarbital injeksi ampul 0 0 0 0 0 0
67 Fenobarbital tablet 30 mg tablet 0 0 0 0 0 0
68 Fenolgliserol tetes telinga 10 % botol 0 48 48 0 48 24
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 24 0 24 0 24 0
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 448 100 548 0 548 0
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 0 0 0 0 0 0
72 Furosemida tablet 40 mg tablet 300 500 800 100 700 0
73 Gameksan lotion 1 % botol-30 ml 0 0 0 0 0 0
74 Gemfibrosil kapsul 300 mg kapsul 360 0 360 0 360 0
75 Gemfibrozil kapsul 600 mg kapsul 0 0 0 0 0 0
76 Gentamisin salep kulit 0,1% tube 41 0 41 0 41 0
77 Gentamisin salep mata 0,3 % botol 0 0 0 0 0 0
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 48 24 72 24 48 0
79 Gentian violet larutan 1 % botol 0 0 0 0 0 0
80 Glibenklamid tablet 5 mg tablet 0 0 0 0 0 500
81 Gliclazid 80 mg tablet tablet 0 0 0 0 0
82 Glimepirid tablet 2 mg tablet 0 0 0 0 0 1,000
83 Gliseril Guayakolat tablet 100 mg tablet 0 3,000 3,000 0 3,000 1,000
84 Gliserin lar 50 % botol-100 ml 0 0 0 0 0 0
85 Glukosa larutan infus 10 % botol 500 ml 0 0 0 0 0 0
86 Glukosa larutan infus 40 % ampul 0 0 0 0 0 0
87 Glukosa larutan infus 5 % botol 500 ml 68 0 68 0 68 0
88 Griseofulvin tablet 125 mg micronized tablet 900 0 900 300 600 500
89 Haloperidol injeksi 5 mg/ml ampul 0 0 0 0 0 0
90 Haloperidol injeksi 50 mg/ml ampul 0 0 0 0 0 0
91 Haloperidol tablet 1,5 mg tablet 0 0 0 0 0 0
92 Haloperidol tablet 2 mg tablet 200 0 200 0 200 0
93 Haloperidol tablet 5 mg tablet 40 0 40 0 40 0
94 Hidroklorotiazida tablet 25 mg tablet 0 0 0 0 0 0
95 Hidrokortison krim 2,5% tube 48 0 48 24 24 0
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 0 0 0 0
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 0 0 0 0
98 Ibuprofen tablet 200 mg tablet 0 0 0 0 0 0
99 Ibuprofen tablet 400 mg tablet 5,400 3,000 8,400 1,100 7,300 0
100 Isoniasida tablet 100 mg tablet 0 0 0 0 0 0
101 Isosorbid dinitrat tablet sublingual 10 mg 500 100 600 0 600 0
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 0 0 0 0
103 Kalium diklofenak 50 mg tablet tablet 0 0 0 0 0 0
104 Kalsium glukonas injeksi ampul 0 0 0 0 0 0
105 Kalsium laktat tablet 500 mg tablet 3,700 3,000 6,700 900 5,800 1,000
106 Kaptopril tablet 12,5 mg tablet 1,300 500 1,800 100 1,700 0
107 Kaptopril tablet 25 mg tablet 1,300 0 1,300 500 800 0
108 Karbamazepin tablet 200 mg tablet 0 0 0 0 0 0
109 Karbogliserin tetes telinga botol 0 0 0 0 0 0
110 Ketokonazol krim 2 % tube 15 gram 18 25 43 18 25 25
111 Ketokonazol tablet 200 mg tablet 0 0 0 0 0 1,000
112 Ketorolac injeksi 10 mg ampul 1 ml 6 0 6 0 6 0
113 Ketorolac injeksi 30 mg ampul 1 ml 0 0 0 0 0 0
114 Klindamisin kapsul 300 mg kapsul 0 0 0 0 0
115 Klobazam tablet 10 mg tablet 0 0 0 0 0 0
116 Klonidin tablet 0,15 mg tablet 0 0 0 0 0 0
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 0 0 0 0
118 Kloramfenikol kapsul 250 mg kapsul 0 0 0 0 0 0
119 Kloramfenikol kapsul 500 mg kapsul 800 0 800 0 800 0
120 Kloramfenikol salep kulit (Bufacetin) tube 48 0 48 24 24 0
121 Kloramfenikol salep mata 1 % tube 5 gram 24 0 24 0 24 0
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 0 0 0 0 0 0
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 0 0 0 0 0 50
124 Kloramfenikol tetes telinga 3 % botol 5 ml 0 0 0 0 0 0
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 4,000 3,000 7,000 4,400 2,600 3,000
127 Klorpromazin tablet salut 100 mg (HCl) tablet 100 0 100 0 100 0
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 0 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0 0 0 0
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 500 0 500 0 500 0
131 Kotrimoksasol suspensi botol 60 ml 43 0 43 10 33 0
132 Lamivudin tablet 150 mg tablet 0 0 0 0 0 0
133 Lanzoprazol kapsul 30 mg kapsul 0 0 0 0 0 0
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 30 0 30 0 30 60
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 34 0 34 0 34 0
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 0 0 0 0 0 0
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 0 0 0 0
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 0 0 0 0 0
139 Lidokain injeksi 2 % ampul 0 0 0 0 0 0
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 18 0 18 0 18 0
141 Lidokain semprot 10 % botol 0 0 0 0 0 0
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 0 0 0 0 0 0
143 Magnesium sulfat injeksi 20 % ampul 0 0 0 0 0 0
144 Magnesium sulfat injeksi 40 % ampul 0 0 0 0 0 0
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 0 0 0 0
146 Mebendazol tablet 100 mg tablet 0 0 0 0 0 0
147 Mekobalamin tablet 500 mg tablet 0 0 0 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0 0 0 0
149 Metformin HCl tablet 500 mg tablet 500 0 500 0 500 0
150 Metil Prednisolon tablet 4 mg tablet 360 0 360 0 360 0
151 Metil Prednisolon tablet 8 mg tablet 0 0 0 0 0 0
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 10 20 30 0 30 0
153 Metilergometrin maleat tablet 0,125 mg tablet 913 0 913 0 913 0
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 0 0 0 10
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 0 0 0 0
156 Metoklopramid tablet 10 mg tablet 700 0 700 0 700 0
157 Metoklopramid tablet 5 mg tablet 0 0 0 0 0 0
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 0 0 0 0 0 0
159 Metronidasol tablet 250 mg tablet 0 0 0 0 0 0
160 Metronidasol tablet 500 mg tablet 2,167 0 2,167 200 1,967 0
161 Metronidazol infus 500 mg/100 ml botol-100 ml 9 0 9 0 9 0
162 Mikonazol krim 2 % tube 0 0 0 0 0 48
163 N-asetyl sistein kaplet 200 mg tablet 1,420 1,320 2,740 0 2,740 0
164 Natrium Diklofenak tablet 25 mg tablet 0 0 0 0 0 0
165 Natrium Diklofenak tablet 50 mg tablet 1,650 0 1,650 900 750 3,000
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 37 0 37 13 24 20
167 Nifedipin tablet 10 mg tablet 300 0 300 145 155 0
168 Nifedipin tablet 20 mg SR tablet 600 0 600 0 600 0
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0 0 0 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 0 96 96 0 96 0
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 0 0 0 0
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 0 0 0 40
173 Oksitetrasiklin salep mata 1% tube 0 0 0 0 0 0
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 10 20 30 0 30 0
175 Omeprazol injeksi 40 mg/10 ml vial 0 0 0 0 0 0
176 Omeprazol kapsul 20 mg kapsul 650 0 650 120 530 0
177 Ondansentron injeksi 4 mg / 2 ml ampul 50 50 100 15 85 0
178 Papaverin injeksi ampul 0 0 0 0 0 0
179 Papaverin tablet 40 mg tablet 0 0 0 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0 0 0 0
181 Parasetamol sirup 120 mg/5 ml botol 16 50 66 30 36 50
182 Parasetamol tablet 500 mg tablet 4,500 5,000 9,500 3,000 6,500 5,000
183 Permetrin (Scabimite) tube 8 0 8 0 8 0
184 Petidin injeksi (Narkotika) ampul 0 0 0 0 0 0
185 Piracetam 800 mg tablet tablet 0 0 0 0 0 0
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 0 0 0 0
187 Pirantel tablet score 125 mg tablet 0 0 0 0 0 0
188 Piridoksin (Vit. B6) tablet 10 mg tablet 5,300 0 5,300 200 5,100 0
189 Piroksikam kapsul 20 mg tablet 700 0 700 200 500 500
190 Piroksikam tablet 10 mg tablet 0 0 0 0 0 0
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 0 0 0 0 0 0
192 Prednison tablet 5 mg tablet 2,000 0 2,000 500 1,500 0
193 Probenesid tablet 500 mg tablet 0 0 0 0 0 0
194 Propanolol tablet 10 mg tablet 180 0 180 180 0
195 Propiltiourasil tablet 100 mg tablet 200 0 200 0 200 0
196 Ranitidin injeksi 25 mg/2 ml ampul 0 0 0 0 0 150
197 Ranitidin tablet 150 mg tablet 1,300 0 1,300 200 1,100 0
198 Rifampisin kaplet salut 450 mg kaplet 0 0 0 0 0 0
199 Rifampisin kapsul 300 mg kapsul 0 0 0 0 0 0
200 Ringer laktat larutan infus botol 500 ml 60 100 160 60 100 100
201 Risperidon tablet tablet 0 0 0 0 0 0
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 0 0 0 0
203 Salbutamol tablet 2 mg tablet 0 0 0 0 0 0
204 Salbutamol tablet 4 mg tablet 400 0 400 0 400 0
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang endap pot 24 0 24 24 0
206 4%
Salisil bedak 2% kotak-50 gram 46 10 56 12 44 0
208 Sefadroksil kapsul 250 mg kaplet 0 0 0 0 0
209 Sefadroksil kapsul 500 mg kaplet 1,300 1,000 2,300 200 2,100 0
210 Sefadroksil sirup kering 125 mg/5 ml botol 0 0 0 0 0 0
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 0 0 0 0
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 85 50 135 20 115 50
213 Sefotaksim serbuk injeksi 500 mg/vial vial 55 0 55 0 55 0
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 0 0 0 0
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 5 0 5 0 5 0
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAGAM) dos 6 0 6 0 6 0
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 0 10 0 10 0
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 0 0 0 0
219 Simetidin tablet 200 mg tablet 0 0 0 0 0 0
220 Simvastatin tablet 10 mg tablet 362 0 362 0 362 0
221 Simvastatin tablet 30 mg tablet 0 0 0 0 0 0
222 Siprofloksasin tablet 250 mg tablet 0 0 0 0 0
223 Siprofloksasin tablet 500 mg tablet 486 0 486 186 300 1,000
224 Spironolakton tablet 25 mg tablet 0 0 0 0 0 0
225 Sukralfat suspensi (Ulsafate) botol 0 0 0 0 0 0
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 0 0 0 0
227 Sulfasetamid Na tetes mata 15 % botol 0 0 0 0 0 0
228 Tetrasiklin kapsul 250 mg kapsul 0 0 0 0 0 0
229 Tetrasiklin kapsul 500 mg kapsul 0 0 0 0 0 0
230 Tiamfenikol kapsul 500 mg kapsul 0 0 0 0 0 0
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 0 0 0 0
232 Tiamin (Vitamin B1) tablet 50 mg tablet 2,000 0 2,000 300 1,700 0
233 Tramadol kapsul 50 mg tablet 0 0 0 0 0 0
234 Trifluoperazin 5 mg tablet tablet 0 0 0 0 0 0
235 Triheksifenidil tablet 2 mg tablet 0 0 0 0 0 0
236 Vaksin rabies untuk manusia set 0 0 0 0 0 0
237 Vitamin B Kompleks tablet tablet 4,650 3,000 7,650 650 7,000 0

B OBAT DAN BAHAN KEDOKTERAN GIGI


1 Air raksa dental use botol 0 0 0 0 0 0
2 Alvogyl paste dus 0 0 0 0 0 0
3 Amalgam Perak (Silver Alloy) botol 0 0 0 0 0 0
4 Articulating papper kotak 0 0 0 0 0 0
5 Bahan pensteril gigi : Trikresol formalin botol 0 0 0 0 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 0 0 0 0
7 Dentin conditioner botol 0 0 0 0 0 0
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 0 0 0 0
9 Etil klorida spray vial/100 ml 2 0 2 1 1 2
10 Eugenol cairan botol@10 ml 0 0 0 0 0 0
11 Fuji VII dus 0 0 0 0 0 0
12 Fuji IX dus 0 0 0 0 0 0
13 Glass inonomer cement ART set/botol 0 0 0 0 0 0
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 0 0 0 0
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 0 0 0 0
16 Kalsium hidroksida pasta kotak 2 tube 0 0 0 0 0 0
17 K-file perawatan akar gigi 0 0 0 0 0 0
- K-file No. 15 set 0 0 0 0 0 0
- K-file No. 20 set 0 0 0 0 0 0
- K-file No. 25 set 0 0 0 0 0 0
- K-file No. 30 set 0 0 0 0 0 0
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 0 0 0 0
19 Mummifying pasta botol/kotak 0 0 0 0 0 0
20 Pasta pengisi saliran akar botol 0 0 0 0 0 0
21 Seluloid strip rol 0 0 0 0 0 0
22 Semen Seng Fosfat serbuk dan cairan set/botol 0 0 0 0 0 0
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) - 0 0 0 0 0
24 Temporary stoping fletcher serbuk+cairan botol @ 100 gram
0 0 0 0 0 0
25 Tooth mouse box 0 0 0 0 0 0

C OBAT TAMBAHAN / BRANDED


1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 0 0 0 0
2 Anti asma/bronkodilator nebulizer (ventolin) vial 19 20 39 5 34 0
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 0 0 0 0
4 Antidiare sirup : . botol 60 ml 0 0 0 0 0 50
6 Antidiare Tablet : tablet 0 0 0 0 0 0
7 Antidiare Tablet (Molagit) tablet 0 0 0 0 0 0
9 Antihemoroid DOEN (Superhoid) supp 0 0 0 0 0
10 Antihistamin kombinasi (Pritacort) tablet 100 0 100 100 0 0
11 Antiinfeksi kulit (luka bakar) pot 0 0 0 0 0 0
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 0 0 0 0
13 Antikretinisme tablet tablet 0 0 0 0 0 0
14 Antiscabies krim (Scabicid) tube 10 gram 0 0 0 0 0 0
15 Antispasme injeksi (Spashi) vial 0 0 0 0 0 0
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 0 0 0 0
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 0 0 0 0
18 Laksantia tablet 5 mg (Dulcolax) tablet 18 0 18 1 17 0
19 Laksantia tablet 5 mg (Laxana) tablet 0 0 0 0 0
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 700 3,000 3,700 400 3,300 3,000
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 0 0 0 0 0 60
22 Multivitamin + mineral utk ibu hamil : . kaplet 0 0 0 0 0 0
27 Multivitamin kaplet : VITALAMIN kaplet 1,200 0 1,200 300 900 0
28 Multivitamin sirup : CURBION Botol 90 60 150 55 95 60
31 Multivitamin tabur untuk balita Saset 0 0 0 0 0 0
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 0 0 0
33 Neurotropik 5000 injeksi ampul 30 0 30 30 0
34 Neurotropik kaplet : kaplet 0 500 500 500 0 3,000
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 0 0 0 0
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 0 0 0 0
40 Obat Antiflu kombinasi : botol 60 ml 0 0 0 0 0 0
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 0 0 0 0
42 Obat batuk / flu sirup : .. botol 100 ml 0 180 180 0 180 0
47 Vasodilator perifer (Citicholin) ampul 0 0 0 0 0
D OBAT ASLI INDONESIA (OAI)
1 Asifit kapsul 0 0 0 0
2 Batugin elixir botol 0 0 0 0
3 Enkasari botol 0 0 0 0
4 Fitogen Dragge kapsul 0 0 0 0
5 Hepagard kapsul 0 0 0 0
6 Imulan kapsul kapsul 0 0 0 0
7 Imulan sirup botol 60 ml 0 0 0 0
8 Kurkumex sirup botol 60 ml 0 0 0 0
9 Kurkumex tablet kaplet 0 0 0 0
10 OB Herbal 0 0 0 0
11 Tensigard kapsul kapsul 0 0 0 0
12 Xanvit sirup 0 0 0 0

II. BAHAN MEDIS HABIS PAKAI


1 Alkohol swab box 14 0 14 1 13 0
2 Aquagel jelly 28 gram tube 0 0 0 0 0 0
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 3 0 3 0 3 0
4 Desinfektan - Aseptan liquid botol-500 ml 0 0 0 0 0 0
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 0 0 0 0 0 0
6 Etanol 70 % botol 100 ml 41 0 41 0 41 0
7 Etanol 70 % botol 1000 ml 2 1 3 1 2 0
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 14 0 14 0 14 0
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 32 20 52 3 49 0
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 0 0 0 0 0 0

III. PERBEKALAN KESEHATAN


1 Alat suntik sekali pakai 1 ml set 0 100 100 0 100 100
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 0 0 0 0
3 Alat suntik sekali pakai 3 ml (Terumo) set 100 200 300 100 200 0
4 Alat suntik sekali pakai 5 ml (Terumo) set 200 200 400 100 300 0
5 Bisturi (mata pisau) Pcs 88 0 88 5 83 0
6 Blood lancet 28 box-100 0 0 0 0 0 0
7 Blood Tranfusion set (MAS) Pcs 3 10 13 0 13 0
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm0 0 0 0 0 0
9 Catgut chromic 2/0 saset/pack 0 0 0 0 0 0
10 Catgut chromic 2/0 100 M kotak 0 0 0 0 0 0
11 Catgut chromic 3/0 saset/pack 2 0 2 0 2 0
12 Catgut chromic 3/0 100 M kotak 0 0 0 0 0 0
13 Catgut plain 2/0 saset/pack 1 0 1 0 1 0
14 Catgut plain 3/0 saset/pack 1 0 1 0 1 0
15 Dermafix T 10 x 15 cm rol 4 0 4 0 4 0
16 Dermafix T 5 x 7 cm rol 0 0 0 0 0 0
17 Developer untuk Film Rontgen Botol 5 ltr Repl 200ltr 0 0 0 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 0 1 1 1 0 0
19 Film Rontgen ukuran 24 x 30 lembar 0 0 0 0 0 0
20 Film Rontgen ukuran 30 x 40 lembar 0 0 0 0 0 0
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 0 0 0
22 Folley catheter No. 16 (Norta) Pcs 10 5 15 0 15 0
23 Folley catheter No. 18 (Norta) Pcs 8 5 13 4 9 0
24 Folley catheter No. 20 Pcs 0 0 0 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0 0 0 0
27 Infus set - Bbraun Intrafix with microdriper set 0 0 0 0 0 00
28 Infus set (Otsu Y) pices 0 0 0 30 0 0
29 Infus set anak set/kantong 24 0 24 0 24 0
30 Infus set dengan micridripper (Otsu) pices 0 0 0 0 0 0
31 Infus set dewasa (Stardec) set/kantong 80 0 80 26 54 0
32 IV catheter No. 18 G buah 28 0 28 1 27 0
33 IV catheter No. 20 G buah 27 0 27 0 27 0
34 IV catheter No. 22 G buah 50 0 50 11 39 100
35 IV catheter No. 24 G buah 150 0 150 5 145 0
36 Jarum jahit kulit saset 12 0 12 0 12 0
37 Jarum jahit otot saset 0 0 0 0 0 0
38 Kapas pembalut/absorben 250 gram bungkus 4 0 4 0 4 0
39 Kasa 10 x 10 cm rol 3 0 3 0 3 0
40 Kasa hidrofil 80 cm x 40 yard rol 45 0 45 0 45 0
41 Kasa hidrofil steril ukuran 16 x 16 box 52 0 52 0 52 0
42 Kasa hidrofil ukuran 16 x 16 lembar 15 0 15 0 15 0
43 Kasa kompres 40/40 steril bungkus 0 0 0 0 0 0
44 Kasa pembalut hidrofil 4 m x 10 cm roll 0 0 0 0 0 0
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 0 0 0 0 0 0
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 0 0 0 0 0 0
47 Kertas EKG ( 50 x 30) rol 0 0 0 0 0
48 Masker : - Earloop pcs 100 0 100 0 100 0
49 Masker : - Earloop (Stardec) Pcs 0 0 0 0 0 0
50 Masker : - tie on Pcs 50 0 50 0 50 0
Masker : - tie on (Stardec) Pcs 0 200 200 0 200 0
51 Mata Bor gigi 0 0 0 0 0
- type inverted No. 010 buah 0 0 0 0 0 0
- type cylinder No. 010 buah 0 0 0 0 0 0
- type tuppered No. 010 buah 0 0 0 0 0 0
- type round No. 010 buah 0 0 0 0 0 0
52 Micropipet Socorex - Acura 0 0 0 0 0 0
- Volume 1 - 10 uL set 0 0 0 0 0 0
- Volume 10 - 100 uL set 0 0 0 0 0 0
- Volume 100 - 1000 uL set 0 0 0 0 0 0
53 N-95 Medical Respirator box 0 0 0 0 0 0
54 Nasal oxygen canula - adult sraight pieces 5 0 5 0 5 0
55 Nasal oxygen canula - child pieces 2 0 2 0 2 0
56 Nasal oxygen canula - infant 0 0 0 0 0 0
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton tul Pcs 27 0 27 27 0
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 45 10 55 10 45 0
59 Plester 5 yards x 2 inchi rol 0 0 0 0 0 0
60 Plester hypafix/pharmafix 5 cm x 5 m rol 0 5 5 5 0
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 0 0 0 0 0 0
62 Pot sputum buah 0 0 0 0 0 0
63 Sarung tangan steril nomor 6,5 : MAS pasang 0 0 0 0 0
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0 0 0 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0 0 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0 0 0 0
67 Sarung tangan steril nomor 7,5 : MAS pasang 0 0 0 0 0
68 Sarung tangan steril nomor 8 0 0 0 0 0
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 0 0 0 0 0
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 0 0 0 0 0
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0 0 0 0
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 200 0 200 0 200 100
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 0 0 0 0 0 0
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgical) pack/saset 0 0 0 0 0 0
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0 0 0 0 0
77 Silk 2/0 box-12 pacs 0 0 0 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0 0 0 0
80 Tabung oksigen 1 m3 + regulator set 0 0 0 0 0 0
81 Under pad buah 10 0 10 10 0 10
82 Urine bag Pcs 5 0 5 0 5 0
83 Wing needle 23 G - 25 G buah 0 0 0 0 0 0
Safety bok biji 0 5 5 0 5 0
TAMBAHAN PERBEKALAN KESEHATAN
1 Alat pengukur HB 201 + analizer unit 0 0 0 0 0 0
2 Dek glass (cover glass) box 0 0 0 0 0 0
3 Microcuvet Hb 201 buah 0 0 0 0 0 0
4 Object glass box 0 0 0 0 0 0
5 Occu check (alat pemegang lancet ROCHE) kit 0 0 0 0 0 0
6 Softclick lanciet 200 box 0 0 0 0
7 Softclick lancing device kit 0 0 0 0
8 Tabung hematokrit botol 0 0 0 0 0 0
9 Kotak slide 0 0 0 0 0 0
10 Performa Accu check Blood glucose meter set 0 0 0 0 0 0
- Performa Accu check tes strip box 0 0 0 0 0 0
0 0
III REAGEN 0 0 0
1 Aquabidest steril botol 500 ml 2 0 2 2 0
2 Aquabidest steril botol 1000 ml 0 0 0
3 Pemeriksaan kadar gula darah 0 0 0
Glocodoctor Box-50 test 0 0 0 0
Accutrand 25 strip 0 0 0 0 5
Easy Touch box/25 0 0 0 0
Nesco gluco strip box/25 0 0 0 0
Glucostar box/25 0 0 0 0
4 Reagen Pemeriksaan Asam Urat 0 0 0 0
Nesco box-25 0 0 0 0
Easy Touch box-25 0 0 0 0
UA Sure box-25 0 0 0 0
5 Reagen Pemeriksaan Kolesterol 0 0 0 0
Accutrand box/25 0 0 0 1
Easy touch cholesterol box-10 0 0 0 0
Nesco box-10 0 0 0 0
Multicare box/25 0 0 0 0
6 Hb Sahli 0 0 0 0
- Assistant set 0 0 0 0
- Superior set 0 0 0 0
7 Reagen untuk spektrofotometr 0 0 0
- Reagen glukosa box-4 btl 0 0 0 1
- Reagen Trigliserida box-4 btl 0 0 0 0
- Reagen asam urat box-4 btl 0 0 0
8 Trigliserida 0 0
- Accutrend box / 25 0 0 0 1
- Multicare box / 25 0 0 0 0
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0 0 0
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0 0 0
10 Larutan Benedict Botol 100 ml 0 0 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 0 0
12 Larutan Eosin Botol 100 ml 0 0 0 0
13 Larutan Giemsa Stain Botol 100 ml 0 0 0 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0 0 0
15 Larutan Metanol Botol 100 ml 0 0 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 0 0
17 Larutan Natrium citrat Botol 100 ml 0 0 0 0
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0 0 0
19 Larutan Turk Botol 100 ml 0 0 0 0
20 Larutan Ziehl Neelsen set 0 0 0 0
21 Reagen pemeriksaan yodium botol 0 0 0 0
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0 0 0
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0 0 0
- RDT Combo Malaria tes 0 0 0 0
24 Rapid test Leptospirosis box/50 strip 0 0 0 0
25 Rapid test Chikungunya tes 0 0 0 0
26 Rapid test demam berdarah kit-25 tes 0 0 0 0
27 Rapid test demam thypoid kit-25 tes 0 0 0 0
28 Tes Kehamilan 0 0 0 0
PPTEST Box 40 tes 0 0 0 0
HCG strip (answer) strip 0 0 0 0
UltraOne tes kehamilan box 50 tes 0 0 0 0
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 1 1 1 0 1
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0 0 0
31 Urine Test 10 Parameter btl - 100 test 0 0 0 0
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0 0 0 0 1
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0 0 0 0 1
34 Tes Narkoba 0 0 0 0
- Amfetamin kot@25 strip 0 0 0 0
- Metamfetamin kot@25 strip 0 0 0 0
- Cocain kot@25 strip 0 0 0 0
- Cannabidoid kot@25 strip 0 0 0 0
- Benzodiasepin kot@25 strip 0 0 0 0
- Babiturat kot@25 strip 0 0 0 0
35 Reagen Mantoux ampul 0 0 0 0
36 Tes Golongan darah 0 0 0
- Anti A Botol 10 ml 0 1 1 1 0 0
- Anti B Botol 10 ml 0 1 1 1 0 0
- Anti AB Botol 10 ml 0 1 1 1 0 0
37 Oil emersi botol 100 ml 0 0 0 0
38 Reagen untuk fotometer 0 0 0
- reagen kolesterol 4 botol @ 100 ml 0 0 0 0
- reagen glukosa 4 botol @ 100 ml 0 0 0 0
- reagen asam urat 4 botol @ 100 ml 0 0 0 0
- reagen trigliserida 4 botol @ 100 ml 0 0 0 0
0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet 0 0 0 0
2 tablet 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + diperaquin tablet 36 36 36 0
3 posphat
Artemeter320) tablet
injeksi 1 ml 80 mg ampul 0 0 0 0
4 Artesunat injeksi vial 60 mg kotak/set 0 0 0 0
5 Kloroquin tablet 150 mg tablet 0 0 0 0
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 0 0 0 0
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0 0 0
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 0 0 0 0
9 Primaquin tablet 15 mg tablet 200 0 200 0 200 0
10 Doksisiklin kapsul 100 mg tablet 0 0 0 0
0 0
V OBAT PROGRAM DIARE (P2M) 0 0
1 Garam oralit serbuk kombinasi saset 90 90 20 70 100
2 Zink Dispersible 20 mg tablet 0 0 0
3 Zincpro drops 15 ml botol 0 0 0 0
4 Zink sirup Botol 0 0 0 0
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0 0
1 Dietil karbamasin sitrat tablet 0 0 0 0
0 0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0 0 0
0 0
VIII OBAT PROGRAM KUSTA (P2M) 0 0
1 Prednison tablet 5 mg tablet 0 0 0 0
0 0
IX OBAT PROGRAM FLU BURUNG 0 0
1 Oseltamivir kapsul kapsul 0 0 0 0
0 0
X OBAT PROGRAM GIZI (KIA) 0 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 0 0 0 0
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 0 0 0 0
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg + tablet 0 0 0 0
4 Asam
MineralFolat
Mix 0,25 mg) saset 0 0 0 0
5 Iodol kapsul kapsul 0 0 0 0
0 0
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0
1 Albendazol tablet 400 mg tablet 0 0 0 0
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 0 0 0 0
3 Pirantel pamoat tablet 125 mg 0 0 0
0 0
XII. OBAT ANTI TUBERKULOSIS 0 0
1 Obat FDC kategori 1 paket 0 0 0 0
2 Obat FDC kategori 2 paket 0 0 0 0
3 Obat FDC Sisipan paket 0 0 0 0
4 OAT Anak paket 0 0 0 0
5 OAT Kombipak 1 paket 0 0 0 0
0 0
XIII. PROGRAM P2 0 0
1 Zidovudin + lamivudin (300 mg/150 mg tablet 0 0 0 0
2 Efavirenz 600 mg tablet 0 0 0 0
3 Tenofovir (TDF) 300 mg tablet 0 0 0 0
4 Nevirapin 200 mg tablet 0 0 0 0
5 Lamivudin 3 TC 150 mg tablet 0 0 0 0
0 0
XIV. PROGRAM KUSTA 0 0
1 Obat MDT Kusta PB Dewasa blister 0 0 0 0
2 Obat MDT Kusta MB Anak blister 0 0 0 0
3 Obat MDT Kusta MB Dewasa blister 0 0 0 0
0 0

JUMLAH KUNJUNNGAN RESEP UMUM PBI NPBI JUMLAH


BAYAR
JUMLAH KUNJUNNGAN RESEP

763 315 101 1179

Purworejo, ......................
Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bubutan Petugas Puskesmas Bubutan
Kabupaten Purworejo

dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. dr. Riyo Suhardono .......................................
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19710418 201312 1 005 NIP.
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN
(LPLPO)

PUSKESMAS : BUBUTAN
KECAMATAN : PURWODADI : JUNI 2017
KABUPATEN : PURWOREJO : JULI 2017

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK


No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN OPTIMUM

1 2 3 4 5 6 7 8 9
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 tablet 2,200 0 2,200 200 2,000
2 Alprazolam tablet 0,2 tablet 156 0 156 0 156
3 Ambroksol sirup 15 mbotol 60 ml 0 0 0 0 0
4 Ambroxol tablet 30 m tablet 2,000 0 2,000 0 2,000
5 Aminofilin injeksi 24 ampul 62 0 62 0 62
6 Aminofilin tablet 200 tablet 1,649 300 1,949 200 1,749
7 Amitriptilin tablet 25 tablet 100 0 100 0 100
8 Amlodipin tablet 10 m tablet 990 0 990 750 240
9 Amlodipin tablet 5 mg tablet 570 900 1,470 120 1,350
10 Amoksisilin 500 mg +tablet/kaplet 0 0 0 0 0
11 Amoksisilin kaplet 50 tablet 7,300 4,000 11,300 2,700 8,600
12 Amoksisilin kapsul 25 kapsul 0 0 0 0 0
13 Amoksisilin sirup keri Botol 60 ml 56 120 176 40 136
14 Amoksisilin sirup keri Botol 60 ml 120 50 170 20 150
15 Ampisilin serbuk injeks vial 100 0 100 18 82
16 Antalgin (Metampiron) tablet 800 0 800 100 700
17 Antasida DOEN I tabl tablet 4,950 2,000 6,950 1,500 5,450
18 Antasida DOEN II Susbotol-60ml 76 0 76 5 71
19 Antibakteri DOEN tube 0 0 0 0 0
20 salep
Antifungi komb DOEN : pot 0 0 0 0 0
21 kombinasi : Asam
Antihemoroid DOEN ko supp 19 0 19 1 18
22 Antimigrain : ergotami tablet 0 0 0 0 0
23 Aqua pro injeksi steril vial 27 0 27 0 27
24 Asam asetil salisilat tablet 700 0 700 0 700
25 Asam Asetil Salisilat tablet 0 0 0 0 0
26 Asam Askorbat (Vitami tablet 1,200 0 1,200 300 900
27 Asam folat tablet 1 mg tablet 0 2,000 2,000 2,000 0
28 Asam mefenamat kapl Tablet 4,500 3,000 7,500 1,900 5,600
29 Asam mefenamat kapl tablet 800 600 1,400 100 1,300
30 Asam traneksamat inj ampul 15 0 15 0 15
31 Asiklovir krim 5 % tube 5 gram 0 0 0 0 0
32 Asiklovir tablet 200 m tablet 0 0 0 0 0
33 Asiklovir tablet 400 m tablet 1,030 0 1,030 30 1,000
34 Atapulgit tablet 600 m tablet 100 500 600 400 200
35 Atropin injeksi i.m./i.v ampul 30 0 30 0 30
36 Betahistin mesilat tab tablet 540 480 1,020 2,400 540
37 Betametason cream 0 tube 40 0 40 15 25
38 Betametason tetes ma botol 0 0 0 0 0
39 Bisakodil suppositoria supp 19 0 19 0 19
40 Bromheksin tablet 8 tablet 0 0 0 0 0
41 Cetirizine kapsul 10 m kapsul 400 500 900 400 500
42 Cetirizine sirup 5 mg/ botol 60 ml 0 0 0 0 0
43 Deksametason injeksi ampul 116 0 116 0 116
44 Deksametason tablet tablet 3,100 5,000 8,100 4,100 4,000
45 Dekstrometorfan sirupbotol 60 ml 0 0 0 0 0
46 Dekstrometorfan table tablet 0 0 0 0 0
47 Diazepam injeksi 5 mg ampul 0 0 0 0 0
48 Diazepam larutan rectarect tube 10 0 10 0 10
49 Diazepam larutan rectarect tube 10 0 10 0 10
50 Diazepam tablet 2 mg tablet 100 500 600 290 310
51 Difenhidramin injeksi ampul 30 0 30 0 30
52 Digoksin tablet 0,25 tablet 200 0 200 0 200
53 Diltiazem HCl Tablet tablet 0 0 0 0 0
54 Dimenhidrinat tablet tablet 100 500 600 100 500
55 Doksisiklin kapsul 10 kapsul 600 100 700 0 700
56 Domperidon suspensi botol-60ml 77 60 137 0 137
57 Domperidon tablet 10 tablet 1,400 500 1,900 200 1,700
58 Efedrin HCl tablet 25 tablet 0 0 0 0 0
59 Ekstraks beladona tab tablet 0 0 0 0 0
60 Epinefrin (Adrenalin) ampul 100 0 100 0 100
61 Eritromisin kapsul 25 kapsul 0 0 0 0 0
62 Eritromisin kapsul 50 kapsul 500 500 0 500
63 Eritromisin sirup 200 botol 0 0 0 0 0
64 Fenilbutason 200 mg t tablet 0 0 0 0 0
65 Fenitoin Natrium Kaps kapsul 0 0 0 0 0
66 Fenobarbital injeksi ampul 0 0 0 0 0
67 Fenobarbital tablet 3 tablet 0 0 0 0 0
68 Fenolgliserol tetes te botol 0 48 48 0 48
69 Fitomenadion (Vit. K) ampul 24 0 24 0 24
70 Fitomenadion (Vit. K) tablet 448 100 548 0 548
71 Furosemida injeksi 1. ampul 0 0 0 0 0
72 Furosemida tablet 40 tablet 300 500 800 100 700
73 Gameksan lotion 1 % botol-30 ml 0 0 0 0 0
74 Gemfibrosil kapsul 30 kapsul 360 0 360 0 360
75 Gemfibrozil kapsul 60 kapsul 0 0 0 0 0
76 Gentamisin salep kuli tube 41 0 41 0 41
77 Gentamisin salep mat botol 0 0 0 0 0
78 Gentamisin sulfat tet botol 5 ml 48 24 72 24 48
79 Gentian violet larutan botol 0 0 0 0 0
80 Glibenklamid tablet 5 tablet 0 0 0 0 0
81 Gliclazid 80 mg tablet tablet 0 0 0 0
82 Glimepirid tablet 2 mg tablet 0 0 0 0 0
83 Gliseril Guayakolat ta tablet 0 3,000 3,000 0 3,000
84 Gliserin lar 50 % botol-100 ml 0 0 0 0 0
85 Glukosa larutan infusbotol 500 ml 0 0 0 0 0
86 Glukosa larutan infus ampul 0 0 0 0 0
87 Glukosa larutan infusbotol 500 ml 68 0 68 0 68
88 Griseofulvin tablet 12 tablet 900 0 900 300 600
89 Haloperidol injeksi 5 ampul 0 0 0 0 0
90 Haloperidol injeksi 50 ampul 0 0 0 0 0
91 Haloperidol tablet 1,5 tablet 0 0 0 0 0
92 Haloperidol tablet 2 m tablet 200 0 200 0 200
93 Haloperidol tablet 5 m tablet 40 0 40 0 40
94 Hidroklorotiazida tabl tablet 0 0 0 0 0
95 Hidrokortison krim 2, tube 48 0 48 24 24
96 Hyoscine-N-Butilbromi tablet 0 0 0 0 0
97 Ibuprofen sirup 100 m botol 0 0 0 0 0
98 Ibuprofen tablet 200 tablet 0 0 0 0 0
99 Ibuprofen tablet 400 tablet 5,400 3,000 8,400 1,100 7,300
100 Isoniasida tablet 100 tablet 0 0 0 0 0
101 Isosorbid dinitrat tablet sublingu 500 100 600 0 600
102 Isosorbid dinitrat tabl tablet 0 0 0 0 0
103 Kalium diklofenak 50 tablet 0 0 0 0 0
104 Kalsium glukonas injek ampul 0 0 0 0 0
105 Kalsium laktat tablet tablet 3,700 3,000 6,700 900 5,800
106 Kaptopril tablet 12,5 tablet 1,300 500 1,800 100 1,700
107 Kaptopril tablet 25 mg tablet 1,300 0 1,300 500 800
108 Karbamazepin tablet tablet 0 0 0 0 0
109 Karbogliserin tetes tel botol 0 0 0 0 0
110 Ketokonazol krim 2 %tube 15 gram 18 25 43 18 25
111 Ketokonazol tablet 20 tablet 0 0 0 0 0
112 Ketorolac injeksi 10 mampul 1 ml 6 0 6 0 6
113 Ketorolac injeksi 30 mampul 1 ml 0 0 0 0 0
114 Klindamisin kapsul 30 kapsul 0 0 0 0 0
115 Klobazam tablet 10 m tablet 0 0 0 0 0
116 Klonidin tablet 0,15 m tablet 0 0 0 0 0
117 Kloramfenikol injeksi vial 0 0 0 0 0
118 Kloramfenikol kapsul kapsul 0 0 0 0 0
119 Kloramfenikol kapsul kapsul 800 0 800 0 800
120 Kloramfenikol salep kul tube 48 0 48 24 24
121 Kloramfenikol salep mtube 5 gram 24 0 24 0 24
122 Kloramfenikol suspensbotol 60 ml 0 0 0 0 0
123 Kloramfenikol tetes m botol 5 ml 0 0 0 0 0
124 Kloramfenikol tetes te botol 5 ml 0 0 0 0 0
125 Klorfeniramin maleat tablet 4,000 3,000 7,000 4,400 2,600
127 Klorpromazin tablet sa tablet 100 0 100 0 100
128 Klorpromazin tablet sa tablet 0 0 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0 0 0
130 Kotrimoksasol DOEN I tablet 500 0 500 0 500
131 Kotrimoksasol suspenbotol 60 ml 43 0 43 10 33
132 Lamivudin tablet 150 tablet 0 0 0 0 0
133 Lanzoprazol kapsul 3 kapsul 0 0 0 0 0
134 Larutan mengandungbotol ele 500 ml 30 0 30 0 30
135 Larutan mengandungbotol el 500 ml 34 0 34 0 34
136 Larutan mengandungbotol el 500 ml 0 0 0 0 0
137 Levotiroksin tablet 10 tablet 0 0 0 0 0
138 Lidokain HCl 20 mg/g j kotak/set 0 0 0 0 0
139 Lidokain injeksi 2 % ampul 0 0 0 0 0
140 Lidokain injeksi 2 % (H ampul 18 0 18 0 18
141 Lidokain semprot 10 botol 0 0 0 0 0
142 Lisol, mengandung krbotol 1000 ml0 0 0 0 0
143 Magnesium sulfat inje ampul 0 0 0 0 0
144 Magnesium sulfat inje ampul 0 0 0 0 0
145 Mebendazol sirup 100botol 30 ml 0 0 0 0 0
146 Mebendazol tablet 10 tablet 0 0 0 0 0
147 Mekobalamin tablet 5 tablet 0 0 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0 0 0
149 Metformin HCl tablet tablet 500 0 500 0 500
150 Metil Prednisolon tabl tablet 360 0 360 0 360
151 Metil Prednisolon tabl tablet 0 0 0 0 0
152 Metilergometrin Maleat ampul 10 20 30 0 30
153 Metilergometrin malea tablet 913 0 913 0 913
154 Metoklopramid injeksi ampul 0 0 0 0 0
155 Metoklopramid sirup 5 botol 0 0 0 0 0
156 Metoklopramid tablet tablet 700 0 700 0 700
157 Metoklopramid tablet tablet 0 0 0 0 0
158 Metronidasol sirup 12 botol 60 ml 0 0 0 0 0
159 Metronidasol tablet 2 tablet 0 0 0 0 0
160 Metronidasol tablet 5 tablet 2,167 0 2,167 200 1,967
161 Metronidazol infus 50botol-100 ml 9 0 9 0 9
162 Mikonazol krim 2 % tube 0 0 0 0 0
163 N-asetyl sistein kaple tablet 1,420 1,320 2,740 0 2,740
164 Natrium Diklofenak ta tablet 0 0 0 0 0
165 Natrium Diklofenak ta tablet 1,650 0 1,650 900 750
166 Natrium Klorida Laruta botol-500 ml 37 0 37 13 24
167 Nifedipin tablet 10 mg tablet 300 0 300 145 155
168 Nifedipin tablet 20 m tablet 600 0 600 0 600
169 Nistatin vaginal tablet tablet 0 0 0 0 0
170 Obat Batuk Hitam (OBbotol-100 ml 0 96 96 0 96
171 Oksitetrasiklin injeksi vial 0 0 0 0 0
172 Oksitetrasiklin salep ktube 5 gram 0 0 0 0 0
173 Oksitetrasiklin salep tube 0 0 0 0 0
174 Oksitosin injeksi 10 IU ampul 10 20 30 0 30
175 Omeprazol injeksi 40 vial 0 0 0 0 0
176 Omeprazol kapsul 20 kapsul 650 0 650 120 530
177 Ondansentron injeksi ampul 50 50 100 15 85
178 Papaverin injeksi ampul 0 0 0 0 0
179 Papaverin tablet 40 m tablet 0 0 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0 0 0
181 Parasetamol sirup 12 botol 16 50 66 30 36
182 Parasetamol tablet 5 tablet 4,500 5,000 9,500 3,000 6,500
183 Permetrin (Scabimite) tube 8 0 8 0 8
184 Petidin injeksi (Narkot ampul 0 0 0 0 0
185 Piracetam 800 mg tabl tablet 0 0 0 0 0
186 Piracetam injeksi 1 gr ampul 0 0 0 0 0
187 Pirantel tablet score tablet 0 0 0 0 0
188 Piridoksin (Vit. B6) ta tablet 5,300 0 5,300 200 5,100
189 Piroksikam kapsul 20 tablet 700 0 700 200 500
190 Piroksikam tablet 10 tablet 0 0 0 0 0
191 Polikresolsulfonat cairbotol 10 ml 0 0 0 0 0
192 Prednison tablet 5 mg tablet 2,000 0 2,000 500 1,500
193 Probenesid tablet 500 tablet 0 0 0 0 0
194 Propanolol tablet 10 tablet 180 0 180 180
195 Propiltiourasil tablet tablet 200 0 200 0 200
196 Ranitidin injeksi 25 m ampul 0 0 0 0 0
197 Ranitidin tablet 150 m tablet 1,300 0 1,300 200 1,100
198 Rifampisin kaplet sal kaplet 0 0 0 0 0
199 Rifampisin kapsul 30 kapsul 0 0 0 0 0
200 Ringer laktat larutan ibotol 500 ml 60 100 160 60 100
201 Risperidon tablet tablet 0 0 0 0 0
202 Salbutamol cairan inhbotol 2,5 ml 0 0 0 0 0
203 Salbutamol tablet 2 m tablet 0 0 0 0 0
204 Salbutamol tablet 4 m tablet 400 0 400 0 400
205 Salep 2-4, Kombinasi pot 24 0 24 24
206 Asam Salisilat
Salisil bedak 2% 2% +
kotak-50 gram 46 10 56 12 44
208 Sefadroksil kapsul 25 kaplet 0 0 0 0
209 Sefadroksil kapsul 50 kaplet 1,300 1,000 2,300 200 2,100
210 Sefadroksil sirup keri botol 0 0 0 0 0
211 Sefadroksil sirup keri botol 0 0 0 0 0
212 Sefotaksim serbuk inje vial 85 50 135 20 115
213 Sefotaksim serbuk inje vial 55 0 55 0 55
214 Seftriakson serbuk inje vial 0 0 0 0 0
215 Serum Anti Bisa Ular P vial 5 ml 5 0 5 0 5
216 Serum Anti Tetanus i dos 6 0 6 0 6
217 Serum Anti Tetanus In vial 1.500 10 0 10 0 10
218 Sianokobalamin (Vitam ampul 0 0 0 0 0
219 Simetidin tablet 200 tablet 0 0 0 0 0
220 Simvastatin tablet 10 tablet 362 0 362 0 362
221 Simvastatin tablet 30 tablet 0 0 0 0 0
222 Siprofloksasin tablet tablet 0 0 0 0
223 Siprofloksasin tablet tablet 486 0 486 186 300
224 Spironolakton tablet tablet 0 0 0 0 0
225 Sukralfat suspensi (Ul botol 0 0 0 0 0
226 Sukralfat tablet 500 m tablet 0 0 0 0 0
227 Sulfasetamid Na tete botol 0 0 0 0 0
228 Tetrasiklin kapsul 250 kapsul 0 0 0 0 0
229 Tetrasiklin kapsul 500 kapsul 0 0 0 0 0
230 Tiamfenikol kapsul 50 kapsul 0 0 0 0 0
231 Tiamin (Vitamin B1) in ampul 0 0 0 0 0
232 Tiamin (Vitamin B1) ta tablet 2,000 0 2,000 300 1,700
233 Tramadol kapsul 50 m tablet 0 0 0 0 0
234 Trifluoperazin 5 mg tab tablet 0 0 0 0 0
235 Triheksifenidil tablet tablet 0 0 0 0 0
236 Vaksin rabies untuk m set 0 0 0 0 0
237 Vitamin B Kompleks ta tablet 4,650 3,000 7,650 650 7,000

B OBAT DAN BAHAN KEDOKTERAN GIGI


1 Air raksa dental use botol 0 0 0 0 0
2 Alvogyl paste dus 0 0 0 0 0
3 Amalgam Perak (Silver botol 0 0 0 0 0
4 Articulating papper kotak 0 0 0 0 0
5 Bahan pensteril gigi : botol 0 0 0 0 0
6 Bahan tambalan sementbotol 28 gram0 0 0 0 0
7 Dentin conditioner botol 0 0 0 0 0
8 Devitalisasi pasta (No botol/kotak 0 0 0 0 0
9 Etil klorida spray vial/100 ml 2 0 2 1 1
10 Eugenol cairan botol@10 ml 0 0 0 0 0
11 Fuji VII dus 0 0 0 0 0
12 Fuji IX dus 0 0 0 0 0
13 Glass inonomer ceme set/botol 0 0 0 0 0
14 Gutta percha dan pappekotak/pasang0 0 0 0 0
15 Gutta percha dan pappekotak/pasang0 0 0 0 0
16 Kalsium hidroksida pakotak 2 tube 0 0 0 0 0
17 K-file perawatan akar gigi 0 0 0 0 0
- K-file No. 15 set 0 0 0 0 0
- K-file No. 20 set 0 0 0 0 0
- K-file No. 25 set 0 0 0 0 0
- K-file No. 30 set 0 0 0 0 0
18 Klorfenol Kamfer Menbotol 10 ml 0 0 0 0 0
19 Mummifying pasta botol/kotak 0 0 0 0 0
20 Pasta pengisi saliran botol 0 0 0 0 0
21 Seluloid strip rol 0 0 0 0 0
22 Semen Seng Fosfat se set/botol 0 0 0 0 0
23 Spon gelatin cubicles
box-10 (1x1x1 cm) - 0 0 0 0
24 Temporary stopingbotol
fle @ 100 gram 0 0 0 0 0
25 Tooth mouse box 0 0 0 0 0

C OBAT TAMBAHAN / BRANDED


1 Anti asma/bronkodilator vial 0 0 0 0 0
2 Anti asma/bronkodilato vial 19 20 39 5 34
3 Antibiotik injeksi serb vial 0 0 0 0 0
4 Antidiare sirup botol 60 ml 0 0 0 0 0
6 Antidiare Tablet tablet 0 0 0 0 0
7 Antidiare Tablet (Molag tablet 0 0 0 0 0
9 Antihemoroid DOEN ( supp 0 0 0 0
10 Antihistamin kombinasi tablet 100 0 100 100 0
11 Antiinfeksi kulit (luka pot 0 0 0 0 0
12 Antiinflamasi gel (Pro tube 30 gr 0 0 0 0 0
13 Antikretinisme tablet tablet 0 0 0 0 0
14 Antiscabies krim (Scab tube 10 gram0 0 0 0 0
15 Antispasme injeksi (S vial 0 0 0 0 0
16 Antispasme/analgetik tablet 0 0 0 0 0
17 Antispasme/analgetik tablet 0 0 0 0 0
18 Laksantia tablet 5 mg tablet 18 0 18 1 17
19 Laksantia tablet 5 mg tablet 0 0 0 0
20 Multivitamin + mineral kaplet 700 3,000 3,700 400 3,300
21 Multivitamin + mineralbotol 100 ml 0 0 0 0 0
22 Multivitamin + miner kaplet 0 0 0 0 0
27 Multivitamin kaplet kaplet 1,200 0 1,200 300 900
28 Multivitamin sirup : Botol 90 60 150 55 95
31 Multivitamin tabur untu Saset 0 0 0 0 0
32 Nasal dekongestan tabl tablet 0 0 0 0
33 Neurotropik 5000 injek ampul 30 0 30 30
34 Neurotropik kaple kaplet 0 500 500 500 0
37 Nutrisi/Vitamin injeksi ampul 0 0 0 0 0
38 Nutrisi/vitamin tablet tablet 0 0 0 0 0
40 Obat Antiflu kombinasibotol 60 ml 0 0 0 0 0
41 Obat Antiulkus peptiku tablet 0 0 0 0 0
42 Obat batuk / flu si botol 100 ml 0 180 180 0 180
47 Vasodilator perifer (Cit ampul 0 0 0 0

D OBAT ASLI INDONESIA (OAI)


1 Asifit kapsul 0 0 0
2 Batugin elixir botol 0 0 0
3 Enkasari botol 0 0 0
4 Fitogen Dragge kapsul 0 0 0
5 Hepagard kapsul 0 0 0
6 Imulan kapsul kapsul 0 0 0
7 Imulan sirup botol 60 ml 0 0 0
8 Kurkumex sirup botol 60 ml 0 0 0
9 Kurkumex tablet kaplet 0 0 0
10 OB Herbal 0 0 0
11 Tensigard kapsul kapsul 0 0 0
12 Xanvit sirup 0 0 0

II. BAHAN MEDIS HABIS PAKAI


1 Alkohol swab box 14 0 14 1 13
2 Aquagel jelly 28 gram tube 0 0 0 0 0
3 Desinfektan - Antiseptbotol-500 ml 3 0 3 0 3
4 Desinfektan - Aseptanbotol-500 ml 0 0 0 0 0
5 Etakridin (Rivanol) la botol 300 ml 0 0 0 0 0
6 Etanol 70 % botol 100 ml 41 0 41 0 41
7 Etanol 70 % botol 1000 ml 2 1 3 1 2
8 Povidon iodida laruta botol 30 ml 14 0 14 0 14
9 Povidon iodida laruta botol 60 ml 32 20 52 3 49
10 Povidon iodida laruta botol 300 ml 0 0 0 0 0

III. PERBEKALAN KESEHATAN


1 Alat suntik sekali paka set 0 100 100 0 100
2 Alat suntik sekali paka set 0 0 0 0 0
3 Alat suntik sekali pak set 100 200 300 100 200
4 Alat suntik sekali pak set 200 200 400 100 300
5 Bisturi (mata pisau) Pcs 88 0 88 5 83
6 Blood lancet 28 box-100 0 0 0 0 0
7 Blood Tranfusion set Pcs 3 10 13 0 13
8 Catgut / benang bedah 0
Kotak@24x75 cm 0 0 0 0
9 Catgut chromic 2/0 saset/pack 0 0 0 0 0
10 Catgut chromic 2/0 1 kotak 0 0 0 0 0
11 Catgut chromic 3/0 saset/pack 2 0 2 0 2
12 Catgut chromic 3/0 1 kotak 0 0 0 0 0
13 Catgut plain 2/0 saset/pack 1 0 1 0 1
14 Catgut plain 3/0 saset/pack 1 0 1 0 1
15 Dermafix T 10 x 15 c rol 4 0 4 0 4
16 Dermafix T 5 x 7 cm rol 0 0 0 0 0
17 Botol 5 ltr Repl 200 ltr
Developer untuk Film 0 0 0 0
18 kotak-100 pcs0
Film IV dressing 6 x 7 1 1 1 0
19 Film Rontgen ukuran 2 lembar 0 0 0 0 0
20 Film Rontgen ukuran 3 lembar 0 0 0 0 0
21 Fixer untuk Film RontGalon 20 liter0 0 0 0
22 Folley catheter No. 16 Pcs 10 5 15 0 15
23 Folley catheter No. 18 Pcs 8 5 13 4 9
24 Folley catheter No. 20 Pcs 0 0 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0 0 0
27 Infus set - Bbraun Intr set 0 0 0 0 0
28 Infus set (Otsu Y) pices 0 0 0 30 0
29 Infus set anak set/kantong 24 0 24 0 24
30 Infus set dengan micri pices 0 0 0 0 0
31 Infus set dewasa (Staset/kantong 80 0 80 26 54
32 IV catheter No. 18 G buah 28 0 28 1 27
33 IV catheter No. 20 G buah 27 0 27 0 27
34 IV catheter No. 22 G buah 50 0 50 11 39
35 IV catheter No. 24 G buah 150 0 150 5 145
36 Jarum jahit kulit saset 12 0 12 0 12
37 Jarum jahit otot saset 0 0 0 0 0
38 Kapas pembalut/abso bungkus 4 0 4 0 4
39 Kasa 10 x 10 cm rol 3 0 3 0 3
40 Kasa hidrofil 80 cm x rol 45 0 45 0 45
41 Kasa hidrofil steril uk box 52 0 52 0 52
42 Kasa hidrofil ukuran 1 lembar 15 0 15 0 15
43 Kasa kompres 40/40 stbungkus 0 0 0 0 0
44 Kasa pembalut hidrofi roll 0 0 0 0 0
45 Kasa pembalut hidrofil rol 0 0 0 0 0
46 Kasa pembalut hidrofil rol 0 0 0 0 0
47 Kertas EKG ( 50 x 30) rol 0 0 0 0
48 Masker : - Earloop pcs 100 0 100 0 100
49 Masker : - Earloop (St Pcs 0 0 0 0 0
50 Masker : - tie on Pcs 50 0 50 0 50
Masker : - tie on (Star Pcs 0 200 200 0 200
51 Mata Bor gigi 0 0 0 0
- type inverted No. 01 buah 0 0 0 0 0
- type cylinder No. 01 buah 0 0 0 0 0
- type tuppered No. 0 buah 0 0 0 0 0
- type round No. 010 buah 0 0 0 0 0
52 Micropipet Socorex - Acura 0 0 0 0 0
- Volume 1 - 10 uL set 0 0 0 0 0
- Volume 10 - 100 uL set 0 0 0 0 0
- Volume 100 - 1000 u set 0 0 0 0 0
53 N-95 Medical Respirat box 0 0 0 0 0
54 Nasal oxygen canula - pieces 5 0 5 0 5
55 Nasal oxygen canula - pieces 2 0 2 0 2
56 Nasal oxygen canula - infant 0 0 0 0 0
57 Penutup luka dengan an Pcs 27 0 27 27
58 Plester 2.5 cm x 4.5 m rol 45 10 55 10 45
59 Plester 5 yards x 2 inc rol 0 0 0 0 0
60 Plester hypafix/pharm rol 0 5 5 5
61 Plester kain 1,25 cm x Rol 0 0 0 0 0
62 Pot sputum buah 0 0 0 0 0
63 Sarung tangan steril pasang 0 0 0 0
64 Sarung tangan steril n pasang 0 0 0 0 0
65 Sarung tangan steril pasang 0 0 0 0
66 Sarung tangan steril n pasang 0 0 0 0
67 Sarung tangan steril pasang 0 0 0 0
68 Sarung tangan steril nomor 8 0 0 0 0
69 Sarung tangan steril pasang 0 0 0 0
70 Sarung tangan steril pasang 0 0 0 0
71 Sarung tangan steril pasang 0 0 0 0
72 Sarung tangan ukuran Pcs 200 0 200 0 200
73 Sarung tangan ukuran Pcs 0 0 0 0 0
74 Silk (benang bedah sutpack/saset 0 0 0 0 0
75 Silk (benang bedah supack/saset 0 0 0 0 0
77 Silk 2/0 box-12 pacs 0 0 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0 0 0
80 Tabung oksigen 1 m3 + set 0 0 0 0 0
81 Under pad buah 10 0 10 10 0
82 Urine bag Pcs 5 0 5 0 5
83 Wing needle 23 G - 2 buah 0 0 0 0 0
Safety bok biji 0 5 5 0 5
TAMBAHAN PERBEKALAN KESEHATAN
1 Alat pengukur HB 201 unit 0 0 0 0 0
2 Dek glass (cover glass box 0 0 0 0 0
3 Microcuvet Hb 201 buah 0 0 0 0 0
4 Object glass box 0 0 0 0 0
5 Occu check (alat pe kit 0 0 0 0 0
6 Softclick lanciet 200 box 0 0 0
7 Softclick lancing devic kit 0 0 0
8 Tabung hematokrit botol 0 0 0 0 0
9 Kotak slide 0 0 0 0 0
10 Performa Accu check set 0 0 0 0 0
- Performa Accu check box 0 0 0 0 0
0 0
III REAGEN 0 0
1 Aquabidest steril botol 500 ml 2 0 2 2
2 Aquabidest steril botol 1000 ml0 0 0
3 Pemeriksaan kadar gula darah 0 0 0
Glocodoctor Box-50 test 0 0 0
Accutrand 25 strip 0 0 0 0
Easy Touch box/25 0 0 0
Nesco gluco strip box/25 0 0 0
Glucostar box/25 0 0 0
4 Reagen Pemeriksaan Asam Urat 0 0 0
Nesco box-25 0 0 0
Easy Touch box-25 0 0 0
UA Sure box-25 0 0 0
5 Reagen Pemeriksaan Kolesterol 0 0 0
Accutrand box/25 0 0 0
Easy touch choleste box-10 0 0 0
Nesco box-10 0 0 0
Multicare box/25 0 0 0
6 Hb Sahli 0 0 0
- Assistant set 0 0 0
- Superior set 0 0 0
7 Reagen untuk spektrofotometr 0 0
- Reagen glukosa box-4 btl 0 0 0
- Reagen Trigliserida box-4 btl 0 0 0
- Reagen asam urat box-4 btl 0 0 0
8 Trigliserida 0 0
- Accutrend box / 25 0 0 0
- Multicare box / 25 0 0 0
7 Larutan amonium oksa Botol 100 ml 0 0 0
8 Larutan Asam asetat Botol 100 ml 0 0 0
9 Larutan Asam KloridaBotol 100 ml 0 0 0
10 Larutan Benedict Botol 100 ml 0 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 0
12 Larutan Eosin Botol 100 ml 0 0 0
13 Larutan Giemsa StainBotol 100 ml 0 0 0
14 Larutan Karbol FuksinBotol 100 ml 0 0 0
15 Larutan Metanol Botol 100 ml 0 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 0
17 Larutan Natrium citratBotol 100 ml 0 0 0
18 Larutan Perhidrol (H2Botol 100 ml 0 0 0
19 Larutan Turk Botol 100 ml 0 0 0
20 Larutan Ziehl Neelsen set 0 0 0
21 Reagen pemeriksaan botol 0 0 0
22 Reagen dan alat peng 100 tes / unit 0 0 0
23 Rapid Diagnostic Test kit-25 tes 0 0 0
- RDT Combo Malaria tes 0 0 0
24 Rapid test Leptospirosbox/50 strip 0 0 0
25 Rapid test Chikungun tes 0 0 0
26 Rapid test demam ber kit-25 tes 0 0 0
27 Rapid test demam thy kit-25 tes 0 0 0
28 Tes Kehamilan 0 0 0
PPTEST Box 40 tes 0 0 0
HCG strip (answer) strip 0 0 0
UltraOne tes kehamilabox 50 tes 0 0 0
29 Tes HBsAG S/P strip box-40 strip 0 1 1 1 0
30 Tes HIV I & II Antibod btl-25 tes 0 0 0
31 Urine Test 10 Parametbtl - 100 test 0 0 0
Urin test strip @ 150tube-150
st strip0 0 0
32 Widal Test Tg H (SS-0 Botol 5 ml 0 0 0 0 0
33 Widal Test Tg O (SS-9 Botol 5 ml 0 0 0 0 0
34 Tes Narkoba 0 0 0
- Amfetamin kot@25 strip 0 0 0
- Metamfetamin kot@25 strip 0 0 0
- Cocain kot@25 strip 0 0 0
- Cannabidoid kot@25 strip 0 0 0
- Benzodiasepin kot@25 strip 0 0 0
- Babiturat kot@25 strip 0 0 0
35 Reagen Mantoux ampul 0 0 0
36 Tes Golongan darah 0 0
- Anti A Botol 10 ml 0 1 1 1 0
- Anti B Botol 10 ml 0 1 1 1 0
- Anti AB Botol 10 ml 0 1 1 1 0
37 Oil emersi botol 100 ml 0 0 0
38 Reagen untuk fotometer 0 0
- reagen kolesterol 4 botol @ 100 ml0 0 0
- reagen glukosa 4 botol @ 100 ml0 0 0
- reagen asam urat 4 botol @ 100 ml0 0 0
- reagen trigliserida 4 botol @ 100 ml0 0 0
0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0
1 ACT (Artesunate tablet 0 0 0
2 tablet 50 mg
Arteraquin (dihydro + tablet 36 36 36
3 artemisin 40 1mg
Artemeter injeksi ml ampul 0 0 0
4 Artesunat injeksi vial kotak/set 0 0 0
5 Kloroquin tablet 150 tablet 0 0 0
6 Kombinasi Pirimetami tablet 0 0 0
7 Kuinin Dihidroklorida i ampul 0 0 0
8 Kuinin tablet 222 mg tablet 0 0 0
9 Primaquin tablet 15 m tablet 200 0 200 0 200
10 Doksisiklin kapsul 10 tablet 0 0 0
0 0
V OBAT PROGRAM DIARE (P2M) 0 0
1 Garam oralit serbuk k saset 90 90 20 70
2 Zink Dispersible 20 m tablet 0 0
3 Zincpro drops 15 ml botol 0 0 0
4 Zink sirup Botol 0 0 0
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0
1 Dietil karbamasin sitra tablet 0 0 0
0 0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0
1 Benzatin Benzil Penisil vial 0 0 0
0 0
VIII OBAT PROGRAM KUSTA (P2M) 0 0
1 Prednison tablet 5 mg tablet 0 0 0
0 0
IX OBAT PROGRAM FLU BURUNG 0 0
1 Oseltamivir kapsul kapsul 0 0 0
0 0
X OBAT PROGRAM GIZI (KIA) 0 0
1 Retinol (Vitamin A) 10 kapsul 0 0 0
2 Retinol (Vitamin A) 20 kapsul 0 0 0
3 Tablet tambah darah tablet 0 0 0
4 kombinasi
Mineral Mix : Besi II saset 0 0 0
5 Iodol kapsul kapsul 0 0 0
0 0
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0
1 Albendazol tablet 400 tablet 0 0 0
2 Albendazol suspensi botol 10 ml 0 0 0
3 Pirantel pamoat tablet 125 mg 0 0
0 0
XII. OBAT ANTI TUBERKULOSIS 0 0
1 Obat FDC kategori 1 paket 0 0 0
2 Obat FDC kategori 2 paket 0 0 0
3 Obat FDC Sisipan paket 0 0 0
4 OAT Anak paket 0 0 0
5 OAT Kombipak 1 paket 0 0 0
0 0
XIII. PROGRAM P2 0 0
1 Zidovudin + lamivudi tablet 0 0 0
2 Efavirenz 600 mg tablet 0 0 0
3 Tenofovir (TDF) 300 tablet 0 0 0
4 Nevirapin 200 mg tablet 0 0 0
5 Lamivudin 3 TC 150 tablet 0 0 0
0 0
XIV. PROGRAM KUSTA 0 0
1 Obat MDT Kusta PB blister 0 0 0
2 Obat MDT Kusta MB blister 0 0 0
3 Obat MDT Kusta MB blister 0 0 0
0 0

JUMLAH KUNJUNNGAN RESEP UMUM PBI NPBI


BAYAR
JUMLAH KUNJUNNGAN RESEP

763 315 101

Mengetahui
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi
Kabupaten Purworejo

dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt.


NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002
MBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

DOKUMEN NOMOR TANGGAL


INST. FARMASI 442/ /2017
PUSKESMAS

PERMIN- PEMBERIAN KET


TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
10 11 12 13 14 15 16 17 18

0
0
0
0
0
0
0
0
0
0
4,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2,000
0
0
0
50
0
0
1,000
0
480
25
0
0
0
1,000
0
0
5,000
0
0
0
0
0
200
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
24
0
0
0
0
0
0
0
0
0
0
0
500
0
1,000
1,000
0
0
0
0
500
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1,000
0
0
0
0
25
1,000
0
0

0
0
0
0
0
0
0
0
50
0
3,000
0
0
0
0
0
0
0
60
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
10
0
0
0
0
0
0
0
48
0
0
3,000
20
0
0
0
0
0
40
0
0
0
0
0
0
0
0
50
5,000
0
0
0
0
0
0
500
0
0
0
0
0
0
150
0
0
0
100
0
0
0
0
0
0
0
0
0
0
50
0
0
0
0
0
0
0
0
0
0
1,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
50
0
0
0
0
0
0
0
0
0
0
0
0
0
3,000
60
0
0
60
0
0
0
3,000
0
0
0
0
0
0

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

0
0
0
0
0
0
0
0
0
0

100
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
00
0
0
0
0
0
0
100
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100
0
0
0
0
0
0
10
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0

0
5
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0

1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

100
0
0
0
0
0

0
0
0
0
0

0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0

NPBI JUMLAH
101 1179

Purworejo, ......................
Yang meminta Yang menerima
Kepala Puskesmas Bubutan Petugas Puskesmas Bubutan

dr. Riyo Suhardono .......................................


NIP. 19710418 201312 1 005 NIP.
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/ 29-05-2017

NO. NAMA OBAT SATUAN JUMLAH KETERANGAN


BARANG SUMBER
1 2 3 4 5
1 Allopurinol tablet 100 mg tablet 1000
2 Amlodipin tablet 10 mg tablet 300
3 Amlodipin tablet 5 mg tablet 300
4 Amoksisillin kaplet 500 mg tablet 4000
6 Antasida DOEN I tablet kunyah kombinasi tablet 3000
7 Antasida DOEN II Suspensi, kombinasi botol 60 ml 50
8 Asam mefenamat kaplet 250 mg tablet 3000
10 Betahistin mesilat tablet 6 mg tablet 480
11 Betametasone cream 0,1% tube 25
12 Dexametason tablet 0,5 mg tablet 5000
13 Doksisiklin kapsul 100 mg kapsul 100
14 Domperidone suspensi 5 mg/5 ml botol 60 ml 50
15 Domperidone tablet 10 mg tablet 1000
16 Gentamisin sulfat tetes mata 0,3 % botol 5 ml 24
17 Hidrokortison krim 2,5% tube 48
18 Ibuprofen tablet 400 mg tablet 3000
19 Isosorbid dinitrat tab sublingual 10 mg tablet 500
20 Kalsium laktat tablet 500 mg tablet 2500
21 Kaptopril tablet 12,5 mg tablet 500
22 Kloramfenikol salep kulit (Bufacetin) tube 24
23 Kloramfenikol salep mata 1 % tube 5 gram 24
24 Klorfeniramin maleat (CTM) tablet 4 mg tablet 3000
25 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 20
26 Metronidasol tablet 500 mg tablet 1500
27 N-asetyl sistein kaplet 200 mg tablet 2640
28 Natrium Diklofenak tablet 50 mg tablet 1000
29 Oksitosin inj 10 IU/ml-1ml ampul 20
30 Ondansetron inj 4mg/2 ml ampul 30
32 Parasetamol tablet 500 mg tablet 4000
33 Piridoksin (Vit. B6) tablet 10 mg tablet 2000
34 Ranitidin tablet 150 mg tablet 1000
35 Ringer laktat larutan infus botol 500 ml 160
36 Sefotaksim serbuk injeksi 500 mg/vial vial 70
37 Vitamin B Komplek tablet tablet 3000
38 Etil klorida spray vial/100ml 4
39 Anti asma/bronkodilator nebulizer (ventolin) box 6
40 Blood Tranfusion set (MAS) box 40 strip 1
41 Multivitamin sirup : CURBION botol 60
42 Infus set ( Stardec ) set 50
43 Safety bok biji 5
44 Tabung hematokrit botol 3
45 Tes HBsAG S/P strip (Answer) box 1
46 tes gol darah anti A botol 1
47 tes gol darah anti B botol 1
48 tes gol darah anti AB botol 1
49 oksigen mask adult 10
50 nebulizer adult 10
51 Pembalut siku 10
52 Spalk 10

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
(LPLPO)

PUSKESMAS : BUBUTAN DOKUMEN NOMOR TANGGAL


KECAMATAN : PURWODADI : JULI 2017 INST. FARMASI 442/ /2017
KABUPATEN : PURWOREJO : AGUSTUS 2017 PUSKESMAS

SATUAN STOK PENERI- PERSE- PEMA- SISA STOK PERMIN- PEMBERIAN KET
No. NAMA OBAT KEMASAN AWAL MAAN DIAAN KAIAN OPTIMUM TAAN APBD DAK JKN PRO- APBD LAIN-2 JUMLAH
KAB GRAM PROV
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
I.A. OBAT ESENSIAL/GENERIK
1 Alopurinol tablet 100 mg tablet 2,000 0 2,000 800 1,200 0
2 Alprazolam tablet 0,25 mg tablet 156 0 156 0 156 100 ed
3 Ambroksol sirup 15 mg/ml botol 60 ml 0 0 0 0 0 0
4 Ambroxol tablet 30 mg tablet 2,000 0 2,000 200 1,800 0
5 Aminofilin injeksi 24 mg/ml ampul 62 0 62 0 62 0
6 Aminofilin tablet 200 mg tablet 1,749 300 2,049 200 1,849 0
7 Amitriptilin tablet 25 mg tablet 100 0 100 0 100 0
8 Amlodipin tablet 10 mg tablet 240 0 240 120 120 0
9 Amlodipin tablet 5 mg tablet 1,350 900 2,250 300 1,950 0
10 Amoksisilin 500 mg + klavulanat 125 mg tablet tablet/kaplet 0 0 0 0 0 0
11 Amoksisilin kaplet 500 mg tablet 8,600 4,000 12,600 3,800 8,800 4,000
12 Amoksisilin kapsul 250 mg kapsul 0 0 0 0 0 0
13 Amoksisilin sirup kering 125 mg/5 ml Botol 60 ml 136 120 256 54 202 0
14 Amoksisilin sirup kering forte 250 mg/5 ml Botol 60 ml 150 50 200 18 182 0
15 Ampisilin serbuk injeksi I.M./I.V. 1000 mg/ml vial 82 0 82 0 82 0
16 Antalgin (Metampiron) tablet 500 mg tablet 700 0 700 100 600 0
17 Antasida DOEN I tablet kunyah kombinasi tablet 5,450 2,000 7,450 2,600 4,850 0
18 Antasida DOEN II Suspensi, kombinasi botol-60ml 71 0 71 46 25 50
19 Antibakteri DOEN salep komb : Basitrasin 500 IU/g + tube 0 0 0 0 0 0
polimiksin DOEN
20 Antifungi 10.000 IU/g
kombinasi : Asam Benzoat 6% + pot 0 0 0 0 0 0
Asam Salisilat 3 %
21 Antihemoroid DOEN kombinasi (Generik) supp 18 0 18 1 17 0
22 Antimigrain : ergotamin tartrat 1 mg + kofein 60 mg table tablet 0 0 0 0 0 0
23 Aqua pro injeksi steril, bebas pirogen vial 27 0 27 6 21 0
24 Asam asetil salisilat 80 mg tablet 700 0 700 100 600 0
25 Asam Asetil Salisilat tablet 100 mg (Asetosal) tablet 0 0 0 0 0 0
26 Asam Askorbat (Vitamin C) tablet 50 mg tablet 900 0 900 300 600 0
27 Asam folat tablet 1 mg tablet 0 2,000 2,000 2,000 0 0
28 Asam mefenamat kaplet 250 mg Tablet 5,600 0 5,600 2,200 3,400 0
29 Asam mefenamat kaplet 500 mg tablet 1,300 0 1,300 200 1,100 0
30 Asam traneksamat injeksi 100 mg/ml ampul 15 0 15 0 15 0
31 Asiklovir krim 5 % tube 5 gram 0 0 0 0 0 50
32 Asiklovir tablet 200 mg tablet 0 0 0 0 0 0
33 Asiklovir tablet 400 mg tablet 1,000 0 1,000 50 950 0
34 Atapulgit tablet 600 mg tablet 200 1,000 1,200 600 600 1,000
35 Atropin injeksi i.m./i.v./s.c. 0,25 mg/ml ampul 30 0 30 0 30 0
36 Betahistin mesilat tablet 6 mg tablet 540 0 540 2,400 540 480
37 Betametason cream 0,1 % tube 25 0 25 25 0 25
38 Betametason tetes mata 1 mg/ml botol 0 0 0 0 0 0
39 Bisakodil suppositoria 5 mg (Dulcolax) supp 19 0 19 0 19 0
40 Bromheksin tablet 8 mg tablet 0 0 0 0 0 0
41 Cetirizine kapsul 10 mg kapsul 500 1,000 1,500 100 1,400 0
42 Cetirizine sirup 5 mg/5 ml botol 60 ml 0 0 0 0 0 0
43 Deksametason injeksi i.v. 5 mg/ml ampul 116 0 116 0 116 0
44 Deksametason tablet 0,5 mg tablet 4,000 5,000 9,000 3,400 5,600 5,000
45 Dekstrometorfan sirup 10 mg/5 ml (HBr) botol 60 ml 0 0 0 0 0 0
46 Dekstrometorfan tablet 15 mg (HBr) tablet 0 0 0 0 0 0
47 Diazepam injeksi 5 mg/ml ampul 0 0 0 0 0 0
48 Diazepam larutan rectal 10 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
49 Diazepam larutan rectal 5 mg / 2,5 ml (Stesolid) rect tube 10 0 10 0 10 0
50 Diazepam tablet 2 mg tablet 310 500 810 290 520 200
51 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul 30 0 30 0 30 0
52 Digoksin tablet 0,25 mg tablet 200 0 200 0 200 0
53 Diltiazem HCl Tablet 30 mg tablet 0 0 0 0 0 0
54 Dimenhidrinat tablet 50 mg tablet 500 500 1,000 100 900 0
55 Doksisiklin kapsul 100 mg kapsul 700 100 800 0 800 0
56 Domperidon suspensi 5 mg/5 ml botol-60ml 137 60 197 0 197 0
57 Domperidon tablet 10 mg tablet 1,700 0 1,700 600 1,100 1,000
58 Efedrin HCl tablet 25 mg tablet 0 0 0 0 0 0
59 Ekstraks beladona tablet 10 mg tablet 0 0 0 0 0 0
60 Epinefrin (Adrenalin) injeksi 0,1 % sebagai HCl) ampul 100 0 100 0 100 0
61 Eritromisin kapsul 250 mg kapsul 0 0 0 0 0 0
62 Eritromisin kapsul 500 mg kapsul 500 500 0 500 0
63 Eritromisin sirup 200 mg/5 ml botol 0 0 0 0 0 0
64 Fenilbutason 200 mg tablet tablet 0 0 0 0 0 0
65 Fenitoin Natrium Kapsul 100 mg kapsul 0 0 0 0 0 0
66 Fenobarbital injeksi ampul 0 0 0 0 0 0
67 Fenobarbital tablet 30 mg tablet 0 0 0 0 0 0
68 Fenolgliserol tetes telinga 10 % botol 48 24 72 24 48 0
69 Fitomenadion (Vit. K) injeksi 10 mg/ml ampul 24 0 24 0 24 0
70 Fitomenadion (Vit. K) tablet salut gula 10 mg tablet 548 100 648 0 648 0
71 Furosemida injeksi 1.v/i.m 10 mg/ml ampul 0 0 0 0 0 0
72 Furosemida tablet 40 mg tablet 700 0 700 100 600 0
73 Gameksan lotion 1 % botol-30 ml 0 0 0 0 0 0
74 Gemfibrosil kapsul 300 mg kapsul 360 0 360 120 240 0
75 Gemfibrozil kapsul 600 mg kapsul 0 0 0 0 0 0
76 Gentamisin salep kulit 0,1% tube 41 0 41 0 41 0
77 Gentamisin salep mata 0,3 % botol 0 0 0 0 0 0
78 Gentamisin sulfat tetes mata 0,3% botol 5 ml 48 0 48 24 24 0
79 Gentian violet larutan 1 % botol 0 0 0 0 0 0
80 Glibenklamid tablet 5 mg tablet 0 0 0 0 0 500
81 Gliclazid 80 mg tablet tablet 0 0 0 0 0
82 Glimepirid tablet 2 mg tablet 0 0 0 0 0 2,000
83 Gliseril Guayakolat tablet 100 mg tablet 3,000 1,000 4,000 1,700 2,300 1,000
84 Gliserin lar 50 % botol-100 ml 0 0 0 0 0 0
85 Glukosa larutan infus 10 % botol 500 ml 0 0 0 0 0 0
86 Glukosa larutan infus 40 % ampul 0 0 0 0 0 0
87 Glukosa larutan infus 5 % botol 500 ml 68 0 68 0 68 0
88 Griseofulvin tablet 125 mg micronized tablet 600 0 600 500 100 500
89 Haloperidol injeksi 5 mg/ml ampul 0 0 0 0 0 0
90 Haloperidol injeksi 50 mg/ml ampul 0 0 0 0 0 0
91 Haloperidol tablet 1,5 mg tablet 0 0 0 0 0 0
92 Haloperidol tablet 2 mg tablet 200 0 200 100 100 0
93 Haloperidol tablet 5 mg tablet 40 0 40 40 0 0
94 Hidroklorotiazida tablet 25 mg tablet 0 0 0 0 0 0
95 Hidrokortison krim 2,5% tube 24 0 24 24 0 24
96 Hyoscine-N-Butilbromide tablet 10 mg (Spashi) tablet 0 0 0 0 0 0
97 Ibuprofen sirup 100 mg/5 ml botol 0 0 0 0 0 0
98 Ibuprofen tablet 200 mg tablet 0 0 0 0 0 0
99 Ibuprofen tablet 400 mg tablet 7,300 0 7,300 1,300 6,000 0
100 Isoniasida tablet 100 mg tablet 0 0 0 0 0 0
101 Isosorbid dinitrat tablet sublingual 10 mg 500 0 500 0 500 0
102 Isosorbid dinitrat tablet sublingual 5 mg tablet 0 0 0 0 0 0
103 Kalium diklofenak 50 mg tablet tablet 0 0 0 0 0 0
104 Kalsium glukonas injeksi ampul 0 0 0 0 0 0
105 Kalsium laktat tablet 500 mg tablet 5,800 1,000 6,800 1,300 5,500 1,000
106 Kaptopril tablet 12,5 mg tablet 1,700 0 1,700 100 1,600 0
107 Kaptopril tablet 25 mg tablet 800 0 800 300 500 0
108 Karbamazepin tablet 200 mg tablet 0 0 0 0 0 0
109 Karbogliserin tetes telinga botol 0 0 0 0 0 0
110 Ketokonazol krim 2 % tube 15 gram 25 25 50 0 50 0
111 Ketokonazol tablet 200 mg tablet 0 0 0 0 0 1,000
112 Ketorolac injeksi 10 mg ampul 1 ml 6 0 6 0 6 0
113 Ketorolac injeksi 30 mg ampul 1 ml 0 0 0 0 0 12
114 Klindamisin kapsul 300 mg kapsul 0 0 0 0 0
115 Klobazam tablet 10 mg tablet 0 0 0 0 0 0
116 Klonidin tablet 0,15 mg tablet 0 0 0 0 0 0
117 Kloramfenikol injeksi 1000 mg/ml vial 0 0 0 0 0 0
118 Kloramfenikol kapsul 250 mg kapsul 0 0 0 0 0 0
119 Kloramfenikol kapsul 500 mg kapsul 800 0 800 100 700 0
120 Kloramfenikol salep kulit (Bufacetin) tube 24 0 24 24 0 0
121 Kloramfenikol salep mata 1 % tube 5 gram 24 0 24 0 24 0
122 Kloramfenikol suspensi 125 mg/5 ml botol 60 ml 0 0 0 0 0 0
123 Kloramfenikol tetes mata 0,5 % botol 5 ml 0 0 0 0 0 50
124 Kloramfenikol tetes telinga 3 % botol 5 ml 0 0 0 0 0 0
125 Klorfeniramin maleat (CTM) tablet 4 mg tablet 2,600 5,000 7,600 4,500 3,100 3,000
127 Klorpromazin tablet salut 100 mg (HCl) tablet 100 0 100 0 100 0
128 Klorpromazin tablet salut 25 mg (HCl) tablet 0 0 0 0 0 0
129 Kodein tablet 10 mg tablet 0 0 0 0 0 0
130 Kotrimoksasol DOEN I (dewasa) komb. tablet 500 0 500 0 500 0
131 Kotrimoksasol suspensi botol 60 ml 33 0 33 20 13 50
132 Lamivudin tablet 150 mg tablet 0 0 0 0 0 0
133 Lanzoprazol kapsul 30 mg kapsul 0 0 0 0 0 0
134 Larutan mengandung elektrolit : (Asering) botol 500 ml 30 0 30 0 30 60
135 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 34 0 34 0 34 0
136 Larutan mengandung elektrolit : (KAEN 3B) botol 500 ml 0 0 0 0 0 0
137 Levotiroksin tablet 100 mg (Euthyrox) tablet 0 0 0 0 0 0
138 Lidokain HCl 20 mg/g jely (Xylocain jely) kotak/set 0 0 0 0 0 0
139 Lidokain injeksi 2 % ampul 0 0 0 0 0 0
140 Lidokain injeksi 2 % (HCl) + epinefrin 1 : 80.000-2 ml ampul 18 0 18 0 18 0
141 Lidokain semprot 10 % botol 0 0 0 0 0 0
142 Lisol, mengandung kresol tersabun 50% botol 1000 ml 0 0 0 0 0 0
143 Magnesium sulfat injeksi 20 % ampul 0 0 0 0 0 0
144 Magnesium sulfat injeksi 40 % ampul 0 0 0 0 0 0
145 Mebendazol sirup 100 mg/5 ml botol 30 ml 0 0 0 0 0 0
146 Mebendazol tablet 100 mg tablet 0 0 0 0 0 0
147 Mekobalamin tablet 500 mg tablet 0 0 0 0 0 0
148 Meloksikam 7.5 mg tablet 0 0 0 0 0 0
149 Metformin HCl tablet 500 mg tablet 500 0 500 0 500 0
150 Metil Prednisolon tablet 4 mg tablet 360 0 360 160 200 500
151 Metil Prednisolon tablet 8 mg tablet 0 0 0 0 0 0
152 Metilergometrin Maleat injeksi 0,200 mg - 1 ml ampul 30 0 30 20 10 0
153 Metilergometrin maleat tablet 0,125 mg tablet 913 0 913 113 800 0
154 Metoklopramid injeksi 5 mg/ml ampul 0 0 0 0 0 10
155 Metoklopramid sirup 5 mg/5 ml botol 0 0 0 0 0 0
156 Metoklopramid tablet 10 mg tablet 700 0 700 0 700 0
157 Metoklopramid tablet 5 mg tablet 0 0 0 0 0 0
158 Metronidasol sirup 125 mg/5 ml (Novagyl) botol 60 ml 0 0 0 0 0 0
159 Metronidasol tablet 250 mg tablet 0 0 0 0 0 0
160 Metronidasol tablet 500 mg tablet 1,967 0 1,967 567 1,400 0
161 Metronidazol infus 500 mg/100 ml botol-100 ml 9 0 9 0 9 0
162 Mikonazol krim 2 % tube 0 0 0 0 0 48
163 N-asetyl sistein kaplet 200 mg tablet 2,740 0 2,740 1,380 1,360 0
164 Natrium Diklofenak tablet 25 mg tablet 0 0 0 0 0 0
165 Natrium Diklofenak tablet 50 mg tablet 750 2,800 3,550 1,000 2,550 3,000
166 Natrium Klorida Larutan Infus 0,9% steril botol-500 ml 24 20 44 22 22 20
167 Nifedipin tablet 10 mg tablet 155 0 155 155 0 0
168 Nifedipin tablet 20 mg SR tablet 600 0 600 120 480 0
169 Nistatin vaginal tablet 100.000 IU/g tablet 0 0 0 0 0 0
170 Obat Batuk Hitam (OBH) cairan botol-100 ml 96 0 96 19 77 0
171 Oksitetrasiklin injeksi i.m. 50 mg/ml-10 ml vial 0 0 0 0 0 0
172 Oksitetrasiklin salep kulit 3% tube 5 gram 0 0 0 0 0 40
173 Oksitetrasiklin salep mata 1% tube 0 0 0 0 0 0
174 Oksitosin injeksi 10 IU/ml - 1 ml ampul 30 0 30 0 30 0
175 Omeprazol injeksi 40 mg/10 ml vial 0 0 0 0 0 0
176 Omeprazol kapsul 20 mg kapsul 530 0 530 30 500 0
177 Ondansentron injeksi 4 mg / 2 ml ampul 85 0 85 5 80 0
178 Papaverin injeksi ampul 0 0 0 0 0 0
179 Papaverin tablet 40 mg tablet 0 0 0 0 0 0
180 Parasetamol drops botol 15 ml 0 0 0 0 0 0
181 Parasetamol sirup 120 mg/5 ml botol 36 50 86 56 30 100
182 Parasetamol tablet 500 mg tablet 6,500 5,000 11,500 4,500 7,000 5,000
183 Permetrin (Scabimite) tube 8 0 8 0 8 0
184 Petidin injeksi (Narkotika) ampul 0 0 0 0 0 0
185 Piracetam 800 mg tablet tablet 0 0 0 0 0 0
186 Piracetam injeksi 1 gram/5 ml ampul 0 0 0 0 0 0
187 Pirantel tablet score 125 mg tablet 0 0 0 0 0 0
188 Piridoksin (Vit. B6) tablet 10 mg tablet 5,100 0 5,100 700 4,400 0
189 Piroksikam kapsul 20 mg tablet 500 0 500 100 400 500
190 Piroksikam tablet 10 mg tablet 0 0 0 0 0 0
191 Polikresolsulfonat cairan 50 mg/ml (Aptil) botol 10 ml 0 0 0 0 0 0
192 Prednison tablet 5 mg tablet 1,500 0 1,500 500 1,000 0
193 Probenesid tablet 500 mg tablet 0 0 0 0 0 0
194 Propanolol tablet 10 mg tablet 180 0 180 180 0
195 Propiltiourasil tablet 100 mg tablet 200 0 200 0 200 0
196 Ranitidin injeksi 25 mg/2 ml ampul 0 0 0 0 0 100
197 Ranitidin tablet 150 mg tablet 1,100 0 1,100 500 600 500
198 Rifampisin kaplet salut 450 mg kaplet 0 0 0 0 0 0
199 Rifampisin kapsul 300 mg kapsul 0 0 0 0 0 0
200 Ringer laktat larutan infus botol 500 ml 100 100 200 120 80 100
201 Risperidon tablet tablet 0 0 0 0 0 0
202 Salbutamol cairan inhales 0,1 % nebules botol 2,5 ml 0 0 0 0 0 0
203 Salbutamol tablet 2 mg tablet 0 0 0 0 0 0
204 Salbutamol tablet 4 mg tablet 400 0 400 0 400 0
205 Salep 2-4, Kombinasi Asam Salisilat 2% + Belerang pot 24 0 24 24 0
206 endap 4% 2%
Salisil bedak kotak-50 gram 44 0 44 2 42 0
208 Sefadroksil kapsul 250 mg kaplet 0 0 0 0 0
209 Sefadroksil kapsul 500 mg kaplet 2,100 0 2,100 100 2,000 0
210 Sefadroksil sirup kering 125 mg/5 ml botol 0 0 0 0 0 0
211 Sefadroksil sirup kering 250 mg/5 ml botol 0 0 0 0 0 0
212 Sefotaksim serbuk injeksi 1000 mg/vial vial 115 50 165 10 155 0
213 Sefotaksim serbuk injeksi 500 mg/vial vial 55 0 55 0 55 0
214 Seftriakson serbuk injeksi 1 gr/vial vial 0 0 0 0 0 0
215 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) vial 5 ml 5 0 5 0 5 0
216 Serum Anti Tetanus imunoglobulin i.m. 250 IU (TETAG dos 6 0 6 0 6 0
217 Serum Anti Tetanus Injeksi 1500 IU/Ampul (ATS) vial 1.500 10 0 10 6 4 10
218 Sianokobalamin (Vitamin B12) injeksi 500 mcg/ml ampul 0 0 0 0 0 0
219 Simetidin tablet 200 mg tablet 0 0 0 0 0 0
220 Simvastatin tablet 10 mg tablet 362 0 362 12 350 0
221 Simvastatin tablet 30 mg tablet 0 0 0 0 0 0
222 Siprofloksasin tablet 250 mg tablet 0 0 0 0 0
223 Siprofloksasin tablet 500 mg tablet 300 1,000 1,300 600 700 1,000
224 Spironolakton tablet 25 mg tablet 0 0 0 0 0 0
225 Sukralfat suspensi (Ulsafate) botol 0 0 0 0 0 0
226 Sukralfat tablet 500 mg (Ulsidex) tablet 0 0 0 0 0 0
227 Sulfasetamid Na tetes mata 15 % botol 0 0 0 0 0 0
228 Tetrasiklin kapsul 250 mg kapsul 0 0 0 0 0 0
229 Tetrasiklin kapsul 500 mg kapsul 0 0 0 0 0 0
230 Tiamfenikol kapsul 500 mg kapsul 0 0 0 0 0 0
231 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul 0 0 0 0 0 0
232 Tiamin (Vitamin B1) tablet 50 mg tablet 1,700 0 1,700 600 1,100 1,000
233 Tramadol kapsul 50 mg tablet 0 0 0 0 0 0
234 Trifluoperazin 5 mg tablet tablet 0 0 0 0 0 0
235 Triheksifenidil tablet 2 mg tablet 0 0 0 0 0 0
236 Vaksin rabies untuk manusia set 0 0 0 0 0 0
237 Vitamin B Kompleks tablet tablet 4,000 0 4,000 500 3,500 1,000

B OBAT DAN BAHAN KEDOKTERAN GIGI


1 Air raksa dental use botol 0 0 0 0 0 0
2 Alvogyl paste dus 0 0 0 0 0 0
3 Amalgam Perak (Silver Alloy) botol 0 0 0 0 0 0
4 Articulating papper kotak 0 0 0 0 0 0
5 Bahan pensteril gigi : Trikresol formalin botol 0 0 0 0 0 0
6 Bahan tambalan sementara gigi siap pakai (Cavit) botol 28 gram 0 0 0 0 0 0
7 Dentin conditioner botol 0 0 0 0 0 0
8 Devitalisasi pasta (Non Arsen) botol/kotak 0 0 0 0 0 0
9 Etil klorida spray vial/100 ml 1 2 3 1 2 2
10 Eugenol cairan botol@10 ml 0 0 0 0 0 0
11 Fuji VII dus 0 0 0 0 0 0
12 Fuji IX dus 0 0 0 0 0 0
13 Glass inonomer cement ART set/botol 0 0 0 0 0 0
14 Gutta percha dan papper point : 15 - 40 kotak/pasang 0 0 0 0 0 0
15 Gutta percha dan papper point : 45 - 60 kotak/pasang 0 0 0 0 0 0
16 Kalsium hidroksida pasta kotak 2 tube 0 0 0 0 0 0
17 K-file perawatan akar gigi 0 0 0 0 0 0
- K-file No. 15 set 0 0 0 0 0 0
- K-file No. 20 set 0 0 0 0 0 0
- K-file No. 25 set 0 0 0 0 0 0
- K-file No. 30 set 0 0 0 0 0 0
18 Klorfenol Kamfer Menthol (CHKM) botol 10 ml 0 0 0 0 0 0
19 Mummifying pasta botol/kotak 0 0 0 0 0 0
20 Pasta pengisi saliran akar botol 0 0 0 0 0 0
21 Seluloid strip rol 0 0 0 0 0 0
22 Semen Seng Fosfat serbuk dan cairan set/botol 0 0 0 0 0 0
23 Spon gelatin cubicles 1x1x1 box-10 (1x1x1 cm) - 0 0 0 0 0
24 Temporary stoping fletcher serbuk+cairan 0
botol @ 100 gram 0 0 0 0 0
25 Tooth mouse box 0 0 0 0 0 0

C OBAT TAMBAHAN / BRANDED


1 Anti asma/bronkodilator inhalasi (ventolin) vial 0 0 0 0 0 0
2 Anti asma/bronkodilator nebulizer (ventolin) vial 34 0 34 9 25 0
3 Antibiotik injeksi serbuk (seftriakson 1 g) vial 0 0 0 0 0 0
4 Antidiare sirup : . botol 60 ml 0 0 0 0 0 50
6 Antidiare Tablet : tablet 0 0 0 0 0 0
7 Antidiare Tablet (Molagit) tablet 0 0 0 0 0 0
9 Antihemoroid DOEN (Superhoid) supp 0 0 0 0 0
10 Antihistamin kombinasi (Pritacort) tablet 0 0 0 0 0 0
11 Antiinfeksi kulit (luka bakar) pot 0 0 0 0 0 0
12 Antiinflamasi gel (Provenid) tube 30 gr 0 0 0 0 0 0
13 Antikretinisme tablet tablet 0 0 0 0 0 0
14 Antiscabies krim (Scabicid) tube 10 gram 0 0 0 0 0 0
15 Antispasme injeksi (Spashi) vial 0 0 0 0 0 0
16 Antispasme/analgetik tablet (Scopamin Plus) tablet 0 0 0 0 0 0
17 Antispasme/analgetik tablet (SCOPMA) tablet 0 0 0 0 0 0
18 Laksantia tablet 5 mg (Dulcolax) tablet 17 0 17 2 15 0
19 Laksantia tablet 5 mg (Laxana) tablet 0 0 0 0 0
20 Multivitamin + mineral + biotin tablet (Caviplex) kaplet 3,300 3,000 6,300 1,400 4,900 2,000
21 Multivitamin + mineral sirup (Recovit) botol 100 ml 0 0 0 0 0 0
22 Multivitamin + mineral utk ibu hamil : . kaplet 0 0 0 0 0 0
27 Multivitamin kaplet : VITALAMIN kaplet 900 0 900 200 700 0
28 Multivitamin sirup : CURBION Botol 95 60 155 20 135 0
31 Multivitamin tabur untuk balita Saset 0 0 0 0 0 0
32 Nasal dekongestan tablet ( Alerfed) tablet 0 0 0 0 0
33 Neurotropik 5000 injeksi ampul 30 0 30 10 20 0
34 Neurotropik kaplet : kaplet 0 0 0 0 0 3,000
37 Nutrisi/Vitamin injeksi (Alinamin F) ampul 0 0 0 0 0 0
38 Nutrisi/vitamin tablet (Aspar K) tablet 0 0 0 0 0 0
40 Obat Antiflu kombinasi : botol 60 ml 0 0 0 0 0 0
41 Obat Antiulkus peptikum tablet (Nucral) tablet 0 0 0 0 0 0
42 Obat batuk / flu sirup : wicold syr botol 100 ml 180 0 180 0 180 0
47 Vasodilator perifer (Citicholin) ampul 0 0 0 0 0

D OBAT ASLI INDONESIA (OAI)


1 Asifit kapsul 0 0 0 0
2 Batugin elixir botol 0 0 0 0
3 Enkasari botol 0 0 0 0
4 Fitogen Dragge kapsul 0 0 0 0
5 Hepagard kapsul 0 0 0 0
6 Imulan kapsul kapsul 0 0 0 0
7 Imulan sirup botol 60 ml 0 0 0 0
8 Kurkumex sirup botol 60 ml 0 0 0 0
9 Kurkumex tablet kaplet 0 0 0 0
10 OB Herbal 0 0 0 0
11 Tensigard kapsul kapsul 0 0 0 0
12 Xanvit sirup 0 0 0 0

II. BAHAN MEDIS HABIS PAKAI


1 Alkohol swab box 13 0 13 1 12 0
2 Aquagel jelly 28 gram tube 0 0 0 0 0 0
3 Desinfektan - Antiseptic surgical hand scrub (E-Care) botol-500 ml 3 0 3 0 3 10
4 Desinfektan - Aseptan liquid botol-500 ml 0 0 0 0 0 0
5 Etakridin (Rivanol) larutan 0,1 % botol 300 ml 0 0 0 0 0 0
6 Etanol 70 % botol 100 ml 41 0 41 1 40 0
7 Etanol 70 % botol 1000 ml 2 0 2 0 2 0
8 Povidon iodida larutan 10 % 30 ml botol 30 ml 14 0 14 2 12 0
9 Povidon iodida larutan 10 % 60 ml botol 60 ml 49 0 49 1 48 0
10 Povidon iodida larutan 10 % 300 ml botol 300 ml 0 0 0 0 0 0

III. PERBEKALAN KESEHATAN


1 Alat suntik sekali pakai 1 ml set 100 0 100 0 100 100
2 Alat suntik sekali pakai 2,5 ml (Stera) set 0 0 0 0 0 0
3 Alat suntik sekali pakai 3 ml (Terumo) set 200 0 200 100 100 200
4 Alat suntik sekali pakai 5 ml (Terumo) set 300 0 300 100 200 0
5 Bisturi (mata pisau) Pcs 83 0 83 5 78 0
6 Blood lancet 28 box-100 0 0 0 0 0 0
7 Blood Tranfusion set (MAS) Pcs 13 0 13 3 10 0
8 Catgut / benang bedah No. 2/0 - 3/0 Kotak@24x75 cm0 0 0 0 0 0
9 Catgut chromic 2/0 saset/pack 0 0 0 0 0 0
10 Catgut chromic 2/0 100 M kotak 0 0 0 0 0 0
11 Catgut chromic 3/0 saset/pack 2 0 2 1 1 0
12 Catgut chromic 3/0 100 M kotak 0 0 0 0 0 0
13 Catgut plain 2/0 saset/pack 1 0 1 1 0 0
14 Catgut plain 3/0 saset/pack 1 0 1 0 1 0
15 Dermafix T 10 x 15 cm rol - 0 0 2 0 0
16 Dermafix T 5 x 7 cm rol 0 0 0 0 0 0
17 Developer untuk Film Rontgen Botol 5 ltr Repl 200ltr 0 0 0 0 0
18 Film IV dressing 6 x 7,5 cm (E-Care) kotak-100 pcs 0 0 0 1 0 1
19 Film Rontgen ukuran 24 x 30 lembar 0 0 0 0 0 0
20 Film Rontgen ukuran 30 x 40 lembar 0 0 0 0 0 0
21 Fixer untuk Film Rontgen Galon 20 liter 0 0 0 0 0
22 Folley catheter No. 16 (Norta) Pcs 15 0 15 4 11 0
23 Folley catheter No. 18 (Norta) Pcs 9 0 9 4 5 0
24 Folley catheter No. 20 Pcs 0 0 0 0 0 0
25 Folley catheter No. 22 Pcs 0 0 0 0 0 0
26 Folley catheter No. 24 Pcs 0 0 0 0 0 0
27 Infus set - Bbraun Intrafix with microdriper set 0 0 0 0 0 00
28 Infus set (Otsu Y) pices 0 0 0 0 0 0
29 Infus set anak set/kantong 24 0 24 15 9 50
30 Infus set dengan micridripper (Otsu) pices 0 0 0 0 0 0
31 Infus set dewasa (Stardec) set/kantong 54 0 54 35 19 50
32 IV catheter No. 18 G buah 27 0 27 0 27 0
33 IV catheter No. 20 G buah 27 0 27 0 27 0
34 IV catheter No. 22 G buah 39 100 139 25 114 0
35 IV catheter No. 24 G buah 145 0 145 35 110 50
36 Jarum jahit kulit saset 12 0 12 1 11 0
37 Jarum jahit otot saset 0 0 0 0 0 0
38 Kapas pembalut/absorben 250 gram bungkus 4 0 4 4 0 2
39 Kasa 10 x 10 cm rol 3 0 3 0 3 0
40 Kasa hidrofil 80 cm x 40 yard rol 3 0 3 2 1 1
41 Kasa hidrofil steril ukuran 16 x 16 box 52 0 52 15 37 0
42 Kasa hidrofil ukuran 16 x 16 lembar 15 0 15 0 15 0
43 Kasa kompres 40/40 steril bungkus 0 0 0 0 0 0
44 Kasa pembalut hidrofil 4 m x 10 cm roll 0 0 0 0 0 0
45 Kasa pembalut hidrofil 4 m x 15 cm elastic rol 0 0 0 0 0 0
46 Kasa pembalut hidrofil 4 m x 3 cm elastic rol 0 0 0 0 0 0
47 Kertas EKG ( 50 x 30) rol 0 0 0 0 0
48 Masker : - Earloop pcs 100 0 100 0 100 0
49 Masker : - Earloop (Stardec) Pcs 0 0 0 0 0 0
50 Masker : - tie on Pcs 50 0 50 50 0 0
Masker : - tie on (Stardec) Pcs 0 200 200 0 200 300
51 Mata Bor gigi 0 0 0 0 0
- type inverted No. 010 buah 0 0 0 0 0 0
- type cylinder No. 010 buah 0 0 0 0 0 0
- type tuppered No. 010 buah 0 0 0 0 0 0
- type round No. 010 buah 0 0 0 0 0 0
52 Micropipet Socorex - Acura 0 0 0 0 0 0
- Volume 1 - 10 uL set 0 0 0 0 0 0
- Volume 10 - 100 uL set 0 0 0 0 0 0
- Volume 100 - 1000 uL set 0 0 0 0 0 0
53 N-95 Medical Respirator box 0 0 0 0 0 0
54 Nasal oxygen canula - adult sraight pieces 5 0 5 0 5 0
55 Nasal oxygen canula - child pieces 2 0 2 0 2 0
56 Nasal oxygen canula - infant 0 0 0 0 0 0
57 Penutup luka dengan antibiotika (Cuticell)/Bioplacenton Pcs 27 0 27 8 19 0
58 Plester 2.5 cm x 4.5 m (Leucoplast) rol 35 0 35 10 25 0
59 Plester 5 yards x 2 inchi rol 0 0 0 0 0 0
60 Plester hypafix/pharmafix 5 cm x 5 m rol 0 5 5 3 2 5
61 Plester kain 1,25 cm x 4,5 m (Leukoplast) Rol 0 0 0 0 0 0
62 Pot sputum buah 0 0 0 0 0 0
63 Sarung tangan steril nomor 6,5 : MAS pasang 0 0 0 0 0
64 Sarung tangan steril nomor 6,5 : Vasco pasang 0 0 0 0 0 0
65 Sarung tangan steril nomor 7 : MAS pasang 0 0 0 0 0
66 Sarung tangan steril nomor 7 : Vasco pasang 0 0 0 0 0
67 Sarung tangan steril nomor 7,5 : MAS pasang 0 0 0 0 50
68 Sarung tangan steril nomor 8 0 0 0 0 0
69 Sarung tangan steril obsgyn nomor 6,5 (Remedi) pasang 0 0 0 0 0
70 Sarung tangan steril obsgyn nomor 7 (Remedi) pasang 0 0 0 0 0
71 Sarung tangan steril obsgyn nomor 7,5 (Remedi) pasang 0 0 0 0 0
72 Sarung tangan ukuran M sekali pakai (MAS) Pcs 200 0 200 100 100 1,000
73 Sarung tangan ukuran S sekali pakai (MAS) Pcs 0 0 0 0 0 0
74 Silk (benang bedah sutera no 2/0 dg jarum (peter Surgic pack/saset 0 0 0 0 0 0
75 Silk (benang bedah sutera no 3/0 dg jarum pack/saset 0 0 0 0 0 0
77 Silk 2/0 box-12 pacs 0 0 0 0 0 0
78 Silk 3/0 box-12 pacs 0 0 0 0 0 0
80 Tabung oksigen 1 m3 + regulator set 0 0 0 0 0 0
81 Under pad buah 0 10 10 10 0 50
82 Urine bag Pcs 5 0 5 0 5 5
83 Wing needle 23 G - 25 G buah 0 0 0 0 0 0
Safety bok biji 0 0 0 0 0 0
TAMBAHAN PERBEKALAN KESEHATAN
1 Alat pengukur HB 201 + analizer unit 0 0 0 0 0 0
2 Dek glass (cover glass) box 0 0 0 0 0 0
3 Microcuvet Hb 201 buah 0 0 0 0 0 0
4 Object glass box 0 0 0 0 0 0
5 Occu check (alat pemegang lancet ROCHE) kit 0 0 0 0 0 0
6 Softclick lanciet 200 box 0 0 0 0
7 Softclick lancing device kit 0 0 0 0
8 Tabung hematokrit botol 0 0 0 0 0 0
9 Kotak slide 0 0 0 0 0 0
10 Performa Accu check Blood glucose meter set 0 0 0 0 0 0
- Performa Accu check tes strip box 0 0 0 0 0 0
0 0
III REAGEN 0 0 0
1 Aquabidest steril botol 500 ml 2 0 2 2 0
2 Aquabidest steril botol 1000 ml 0 0 0
3 Pemeriksaan kadar gula darah 0 0 0
Glocodoctor Box-50 test 0 0 0 0
Accutrand 25 strip 0 0 0 0 5
Easy Touch box/25 0 0 0 0
Nesco gluco strip box/25 0 0 0 0
Glucostar box/25 0 0 0 0
4 Reagen Pemeriksaan Asam Urat 0 0 0 0
Nesco box-25 0 0 0 0
Easy Touch box-25 0 0 0 0
UA Sure box-25 0 0 0 0
5 Reagen Pemeriksaan Kolesterol 0 0 0 0
Accutrand box/25 0 0 0 1
Easy touch cholesterol box-10 0 0 0 0
Nesco box-10 0 0 0 0
Multicare box/25 0 0 0 0
6 Hb Sahli 0 0 0 0
- Assistant set 0 0 0 0
- Superior set 0 0 0 0
7 Reagen untuk spektrofotometr 0 0 0
- Reagen glukosa box-4 btl 0 0 0 1
- Reagen Trigliserida box-4 btl 0 0 0 0
- Reagen asam urat box-4 btl 0 0 0
8 Trigliserida 0 0
- Accutrend box / 25 0 0 0 1
- Multicare box / 25 0 0 0 0
7 Larutan amonium oksalat 1 % Botol 100 ml 0 0 0 0
8 Larutan Asam asetat 6 % Botol 100 ml 0 0 0 0
9 Larutan Asam Klorida 0,1 N Botol 100 ml 0 0 0 0
10 Larutan Benedict Botol 100 ml 0 0 0 0
11 Larutan EDTA 10 % Botol 100 ml 0 0 0 0
12 Larutan Eosin Botol 100 ml 0 0 0 0
13 Larutan Giemsa Stain Botol 100 ml 0 0 0 0
14 Larutan Karbol Fuksin Botol 100 ml 0 0 0 0
15 Larutan Metanol Botol 100 ml 0 0 0 0
16 Larutan Metilen Blue Botol 100 ml 0 0 0 0
17 Larutan Natrium citrat Botol 100 ml 0 0 0 0
18 Larutan Perhidrol (H2O2) Botol 100 ml 0 0 0 0
19 Larutan Turk Botol 100 ml 0 0 0 0
20 Larutan Ziehl Neelsen set 0 0 0 0
21 Reagen pemeriksaan yodium botol 0 0 0 0
22 Reagen dan alat pengujian lab makanan 100 tes / unit 0 0 0 0
23 Rapid Diagnostic Test Malaria kit-25 tes 0 0 0 0
- RDT Combo Malaria tes 0 0 0 0
24 Rapid test Leptospirosis box/50 strip 0 0 0 0
25 Rapid test Chikungunya tes 0 0 0 0
26 Rapid test demam berdarah kit-25 tes 0 0 0 0
27 Rapid test demam thypoid kit-25 tes 0 0 0 0
28 Tes Kehamilan 0 0 0 0
PPTEST Box 40 tes 0 0 0 80
HCG strip (answer) strip 0 0 0 0
UltraOne tes kehamilan box 50 tes 0 0 0 0
29 Tes HBsAG S/P strip (Answer) box-40 strip 0 1 1 1 0 1
30 Tes HIV I & II Antibody Card (IR-100c) btl-25 tes 0 0 0 1
31 Urine Test 10 Parameter btl - 100 test 0 0 0 0
Urin test strip @ 150 strip (Elektrinika Labstrip) tube-150 strip 0 0 0 0
32 Widal Test Tg H (SS-01) Botol 5 ml 0 0 0 0 0 1
33 Widal Test Tg O (SS-90) Botol 5 ml 0 0 0 0 0 1
34 Tes Narkoba 0 0 0 0
- Amfetamin kot@25 strip 0 0 0 0
- Metamfetamin kot@25 strip 0 0 0 0
- Cocain kot@25 strip 0 0 0 0
- Cannabidoid kot@25 strip 0 0 0 0
- Benzodiasepin kot@25 strip 0 0 0 0
- Babiturat kot@25 strip 0 0 0 0
35 Reagen Mantoux ampul 0 0 0 0
36 Tes Golongan darah 0 0 0
- Anti A Botol 10 ml 0 0 0 0 0 0
- Anti B Botol 10 ml 0 0 0 0 0 0
- Anti AB Botol 10 ml 0 0 0 0 0 0
37 Oil emersi botol 100 ml 0 0 0 0
38 Reagen untuk fotometer 0 0 0
- reagen kolesterol 4 botol @ 100 ml 0 0 0 0
- reagen glukosa 4 botol @ 100 ml 0 0 0 0
- reagen asam urat 4 botol @ 100 ml 0 0 0 0
- reagen trigliserida 4 botol @ 100 ml 0 0 0 0
0 0
IV OBAT PROGRAM MALARIA (P2M) 0 0
1 ACT (Artesunate tablet 50 mg + Amodiaquin Anhydrat tablet 0 0 0 0
2 tablet 200 mg)
Arteraquin (dihydro artemisin 40 mg tablet + tablet 36 36 36 0
diperaquin posphat
3 Artemeter injeksi 320)
1 ml 80 tablet
mg ampul 0 0 0 0
4 Artesunat injeksi vial 60 mg kotak/set 0 0 0 0
5 Kloroquin tablet 150 mg tablet 0 0 0 0
6 Kombinasi Pirimetamin 25 mg + Sulfadoksin 500 mg tablet 0 0 0 0
7 Kuinin Dihidroklorida injeksi 25% - 2 ml ampul 0 0 0 0
8 Kuinin tablet 222 mg (H2SO4.7H2O) tablet 0 0 0 0
9 Primaquin tablet 15 mg tablet 200 0 200 0 200 0
10 Doksisiklin kapsul 100 mg tablet 0 0 0 0
0 0
V OBAT PROGRAM DIARE (P2M) 0 0
1 Garam oralit serbuk kombinasi saset 70 100 170 170 0 0
2 Zink Dispersible 20 mg tablet 300 500 800 300 500 500
3 Zincpro drops 15 ml botol 0 0 0 0
4 Zink sirup Botol 0 24 24 24 0
VI. OBAT PROGRAM FILARIA (KAKI GAJAH) 0 0 0
1 Dietil karbamasin sitrat tablet 0 0 0 0
0 0
VII OBAT PROGRAM KELAMIN /SIFILIS (P2M) 0 0
1 Benzatin Benzil Penisilin injeksi 2,4 juta IU vial 0 0 0 0
0 0
VIII OBAT PROGRAM KUSTA (P2M) 0 0
1 Prednison tablet 5 mg tablet 0 0 0 0
0 0
IX OBAT PROGRAM FLU BURUNG 0 0
1 Oseltamivir kapsul kapsul 0 0 0 0
0 0
X OBAT PROGRAM GIZI (KIA) 0 0
1 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul 0 0 0 0
2 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul 0 0 0 0
3 Tablet tambah darah kombinasi : Besi II Sulfat 200 mg tablet 0 0 0 0
4+ Asam Mix
Mineral Folat 0,25 mg) saset 0 0 0 0
5 Iodol kapsul kapsul 0 0 0 0
0 0
XI. OBAT PROGRAM KECACINGAN (P2M) 0 0
1 Albendazol tablet 400 mg tablet 0 0 0 0
2 Albendazol suspensi 200 mg/5 ml botol 10 ml 0 0 0 0
3 Pirantel pamoat tablet 125 mg 0 0 0
0 0
XII. OBAT ANTI TUBERKULOSIS 0 0
1 Obat FDC kategori 1 paket 0 0 0 0
2 Obat FDC kategori 2 paket 0 0 0 0
3 Obat FDC Sisipan paket 0 0 0 0
4 OAT Anak paket 0 0 0 0
5 OAT Kombipak 1 paket 0 0 0 0
0 0
XIII. PROGRAM P2 0 0
1 Zidovudin + lamivudin (300 mg/150 mg tablet 0 0 0 0
2 Efavirenz 600 mg tablet 0 0 0 0
3 Tenofovir (TDF) 300 mg tablet 0 0 0 0
4 Nevirapin 200 mg tablet 0 0 0 0
5 Lamivudin 3 TC 150 mg tablet 0 0 0 0
0 0

XIV. PROGRAM KUSTA 0 0


1 Obat MDT Kusta PB Dewasa blister 0 0 0 0
2 Obat MDT Kusta MB Anak blister 0 0 0 0
3 Obat MDT Kusta MB Dewasa blister 0 0 0 0
0 0

JUMLAH KUNJUNNGAN RESEP UMUM PBI NPBI JUMLAH


BAYAR
1225 389 237 1851

Purworejo, ......................
Mengetahui Yang meminta Yang menerima
Kepala Dinas Kesehatan Kepala UPT Instalasi Farmasi Kepala Puskesmas Bubutan Petugas Puskesmas Bubutan
Kabupaten Purworejo

dr. KUSWANTORO, M.Kes. Drs. Nanang Wijayanto, Apt. dr. Riyo Suhardono .......................................
NIP. 19621204 198803 1 011 NIP. 19680601 199312 1 002 NIP. 19710418 201312 1 005 NIP.
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/ 29-05-2017

NO. NAMA OBAT SATUAN JUMLAH KETERANGAN


BARANG SUMBER
1 2 3 4 5
1 Allopurinol tablet 100 mg tablet 1000
2 Amlodipin tablet 10 mg tablet 300
3 Amlodipin tablet 5 mg tablet 300
4 Amoksisillin kaplet 500 mg tablet 4000
6 Antasida DOEN I tablet kunyah kombinasi tablet 3000
7 Antasida DOEN II Suspensi, kombinasi botol 60 ml 50
8 Asam mefenamat kaplet 250 mg tablet 3000
10 Betahistin mesilat tablet 6 mg tablet 480
11 Betametasone cream 0,1% tube 25
12 Dexametason tablet 0,5 mg tablet 5000
13 Doksisiklin kapsul 100 mg kapsul 100
14 Domperidone suspensi 5 mg/5 ml botol 60 ml 50
15 Domperidone tablet 10 mg tablet 1000
16 Gentamisin sulfat tetes mata 0,3 % botol 5 ml 24
17 Hidrokortison krim 2,5% tube 48
18 Ibuprofen tablet 400 mg tablet 3000
19 Isosorbid dinitrat tab sublingual 10 mg tablet 500
20 Kalsium laktat tablet 500 mg tablet 2500
21 Kaptopril tablet 12,5 mg tablet 500
22 Kloramfenikol salep kulit (Bufacetin) tube 24
23 Kloramfenikol salep mata 1 % tube 5 gram 24
24 Klorfeniramin maleat (CTM) tablet 4 mg tablet 3000
25 Larutan mengandung elektrolit : (KAEN 3A) botol 500 ml 20
26 Metronidasol tablet 500 mg tablet 1500
27 N-asetyl sistein kaplet 200 mg tablet 2640
28 Natrium Diklofenak tablet 50 mg tablet 1000
29 Oksitosin inj 10 IU/ml-1ml ampul 20
30 Ondansetron inj 4mg/2 ml ampul 30
32 Parasetamol tablet 500 mg tablet 4000
33 Piridoksin (Vit. B6) tablet 10 mg tablet 2000
34 Ranitidin tablet 150 mg tablet 1000
35 Ringer laktat larutan infus botol 500 ml 160
36 Sefotaksim serbuk injeksi 500 mg/vial vial 70
37 Vitamin B Komplek tablet tablet 3000
38 Etil klorida spray vial/100ml 4
39 Anti asma/bronkodilator nebulizer (ventolin) box 6
40 Blood Tranfusion set (MAS) box 40 strip 1
41 Multivitamin sirup : CURBION botol 60
42 Infus set ( Stardec ) set 50
43 Safety bok biji 5
44 Tabung hematokrit botol 3
45 Tes HBsAG S/P strip (Answer) box 1
46 tes gol darah anti A botol 1
47 tes gol darah anti B botol 1
48 tes gol darah anti AB botol 1
49 oksigen mask adult 10
50 nebulizer adult 10
51 Pembalut siku 10
52 Spalk 10

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 442 / / 2017/ 24-03-2017

NO. NAMA OBAT SATUAN JUMLAH


BARANG
1 2 3 4
1 Allopurinol tablet 100 mg tablet 1000
2 Aminofilin injeksi 24 mg/ml ampul 30
3 Aminofillin tablet 200 mg tablet 1500
4 Amlodipin tablet 10 mg tablet 900
5 Amlodipin 5 mg tablet 600
6 Amoksisillin kaplet 500 mg tablet 4000
7 Amoksisillin sirup kering forte 250 mg/ 5 ml botol 60 ml 50
8 Antasida DOEN I tablet kunyah kombinasi tablet 3000
9 Antasida DOEN II Suspensi, kombinasi botol 60 ml 50
10 Asam mefenamat kaplet 250 mg tablet 3000
11 Asam mefenamat kaplet 500 mg tablet 1000
12 Betametason cream 0,1 mg tube 25
13 Dexametason injeksi i.v 5 mg/ml ampul 100
14 Dexametason tablet 0,5 mg tablet 5000
15 Doksisiklin kapsul 100 mg kapsul 500
16 Domperidone tablet tablet 10 mg tablet 1000
17 Gentamisin sulfat tetes mata 0,3 % botol 5 ml 48
18 Griseofulvin tablet 125 mg micronized tablet 500
19 Ibuprofen tablet 400 mg tablet 3000
20 Kalsium laktat tablet 500 mg tablet 2000
21 Kaptopril tablet 12,5 mg tablet 500
22 Klorfeniramin maleat (CTM) tablet 4 mg tablet 3000
23 Klorpromazin tablet salut 100 mg (HCL) tablet 100
24 Larutan mengandung elektrolit : (Asering) botol -500 ml 60
25 Metronidasol tablet 500 mg tablet 1000
26 Ondansentron injeksi 4 mg / 2 ml ampul 20
27 Parasetamol sirup 120 mg/5ml botol 100
28 Parasetamol tablet 500 mg tablet 5000
29 Piridoksin (Vit. B6) tablet 10 mg tablet 2000
30 Prednison tablet 5 mg tablet 2000
31 Salisil bedak 2 % kotak -50 gram 20
32 Sefadroksil kapsul 500 mg kaplet 1000
33 Sefotaksim serbuk injeksi 500 mg/vial vial 50
34 Serum Anti Bisa Ular Polivalen injeksi 5ml (ABU I) vial 5ml 5
35 Vitamin B Komplek tablet tablet 2000
36 Bahan tambalan sementara gigi siap pakai (cavit) botol 28 gram 1
37 Anti asma/bronkodilator nebulizer (ventolin) vial 20
38 Blood Tranfusion set (MAS) pcs 5
39 Multivitamin sirup : CURBION botol 60
40 Povidon iodida larutan 10% 60 ml botol 60 ml 30
41 Infus set ( Stardec ) set/kantong 50
42 Safety bok biji 5
43 Tabung hematokrit botol 3
44 Performa Accu check tes strip box 6
45 Tes HBsAG S/P strip (Answer) box 40 strip 1

UPT Puskesmas Bubutan


Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
N KABUPATEN PURWOREJO

KETERANGAN
SUMBER
5
UPT Puskesmas Bubutan
Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005
DAFTAR PENERIMAAN OBAT DROPING DINAS KESEHATAN KABUPATEN PURWOREJO

PUSKESMAS : UPT PUSKESMAS BUBUTAN


NOMOR : 445 / 154 / 07/ 27-07-2017

NO. NAMA OBAT SATUAN JUMLAH KETERANGAN


BARANG SUMBER
1 2 3 4 5
1 Amoksisillin kaplet 500 mg tablet 4000
2 Asam folat tablet 1 mg tablet 2000
3 Atapulgit tablet 600 mg tablet 1000
4 Cetirizine kapsul 10 mg kapsul 1000
5 Deksametason tablet 0,5 mg tablet 5000
6 Diazepam tablet 2 mg tablet 200
7 Fenogliserol tetes telinga 10 % botol 24
8 Gliseril Guayakolat tablet 100 mg tablet 1000
9 Griseofulvin tablet 25 mg micronized tablet 500
10 Gentamisin sulfat tetes mata 0,3 % botol 5 ml 24
11 Kalsium laktat tablet 500 mg tablet 1000
12 Ketokenazol krim 2 % tube 15 mg 25
13 Klorfeniramin meleat (CTM ) tablet tablet 5000
14 Natrium Diklofenak tablet 50 mg tablet 2800
15 Natrium klorida larutan infus 0,9 % steril botol 500 ml 20
16 Parasetamol syrup 120 mg/5ml botol 50
17 Parasetamol tablet 500 mg tablet 5000
18 Ringer laktat larutan infus botol 500 ml 100
19 Sefotaksim serbuk injeksi 1000 mg/vial vial 50
20 Siprofloksasin tablet 500 mg tablet 1000
21 Etil klorida spray vial/100ml 2
22 Multivitamin + mineral + biotin tablet (caviplek) kaplet 3000
23 Multivitamin syrup : analgens botol 60
24 Alat suntik sekali pakai 1 ml set 100
25 IV catheter no. 22 G buah 100
26 Sarung tangan ukuran M sekali pakai (MAS) pcs 100
27 Under pad pcs 10
28 Reagen pemeriksaan yodium botol 52
29 tes HBsAG S/P strip (answer) box 40 strip 1
30 Garam oralit serbuk kombinasi saset 100
31 Zink dispersible 20 mg tablet 500
32 Zink syrup botol 24
33 Retinol (vitamin A) 100.000 IU kapsul lunak kapsul 200
34 Retinol (vitamin A) 200.000 IU kapsul lunak kapsul 1600
UPT Puskesmas Bubutan
Pengelola Obat

Ika Rusmawati, AMK


NIP. 19830323 201406 2 005