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RENCANA KEBUTUHAN BARANG UNIT (RKBU) NON MEDIS - TAHUN 2017

UNIT : IRNA TULIP TAMBAHAN


RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

INVENTARIS JANGKA PENDEK INVENTARIS JANGKA PENDEK


1 Bantal Dakron bh 4 4 55,000 220,000
2 Baskom Stainlist Besar bh 4 4 125,000 500,000
3 Jemuran Stainlist bh 4 4 75,000 300,000
4 Kotak obat bh 4 4 45,000 180,000
5 Seprei + sarung bantal 12 12 115,000 1,380,000
6 Selimut bedcover motif 12 12 180,000 2,160,000
7 Stik laken 12 12 60,000 720,000
8 Perlak 4 4 70,000 280,000
9 Sarung bantal oscar 4 4 70,000 280,000
INVENTARIS JANGKA PANJANG INVENTARIS JANGKA PANJANG
1 Kursi susun bh 16 16 200,000 3,200,000
2 Bed pasien set 16 16 14,000,000 224,000,000
3 Lemari kecil unt 4 4 700,000 2,800,000
4 Gorden bh 4 4 2,000,000 8,000,000
5 Sandart infus 4 4 500,000 2,000,000
6 Foot step 4 4 600,000 2,400,000
7 TV LED 4 4 2,800,000 11,200,000
8 Termometer 4 4 15,000 60,000
TOTAL 259,680,000

AR
RENCANA KEBUTUHAN BARANG UNIT (RKBU) NON MEDIS - TAHUN 2017
UNIT : EDELWEIS
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

INVENTARIS JANGKA PENDEK INVENTARIS JANGKA PENDEK


1 Bantal Dakron bh 3 3 55,000 165,000
2 Baskom Stainlist Besar bh 8 8 125,000 1,000,000
3 Kotak obat bh 5 5 45,000 225,000
4 Seprei + sarung bantal 25 25 115,000 2,875,000
5 Selimut bedcover motif 25 25 180,000 4,500,000
6 Stik laken 25 25 60,000 1,500,000
7 Perlak 5 5 70,000 350,000
8 Sarung bantal oscar 5 5 70,000 350,000
INVENTARIS JANGKA PANJANG INVENTARIS JANGKA PANJANG
1 Bed pasien dewasa set 3 3 14,000,000 42,000,000
2 Bed pasien anak bh 1 ada
3 Box bayi bh 1 1 25,000,000 25,000,000
4 Patient monitor unt 5 5 18,000,000 90,000,000
5 Syringe pump bh 5 5 20,000,000 100,000,000
6 Infuse pimp 5 5 25,000,000 125,000,000
7 Sandart infus 5 5 500,000 2,500,000
8 Termometer 4 4 15,000 60,000
9 Tensimeter anak 1 1 1,000,000 1,000,000
10 Oximetri anak 1 1 5,000,000 5,000,000

11 Stetoscop anak 1 1 500,000 500,000


CPAP 1 1 150000000 150,000,000
WSD 1 1 30,000,000 30,000,000

TOTAL 582,025,000

AR
RENCANA KEBUTUHAN BARANG UNIT (RKBU) NON MEDIS - TAHUN 2017
UNIT : IRNA NEW
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

KERUMAHTANGGAAN HABIS PAKAI KERUMAHTANGGAAN HABIS PAKAI


1 Air Mineral Galon bh 10 10 10 10 10 10 10 10 10 10 10 10 120 13,000 1,560,000
2 Baterai A2 Alkaline bh 2 2 2 4 2 2 2 4 2 2 2 4 30 4,000 120,000
3 Baterai A3 Alkaline bh 2 2 2 2 2 2 2 2 2 2 2 2 24 4,500 108,000
4 Bayfresh btl 1 1 1 1 1 1 1 1 1 1 1 1 12 18,000 216,000
5 Baygon btl 1 1 1 1 1 1 1 1 1 1 1 1 12 39,000 468,000
6 Bayklin Besar btl 1 1 1 1 1 1 1 1 1 1 1 1 12 11,500 138,000
7 Gayung bh 0 -
8 Handsoap Refil bh 10 10 10 10 10 10 10 10 10 10 10 10 120 9,000 1,080,000
9 Kresek Hitam Super Pak 3 3 3 3 3 3 3 3 3 3 3 3 36 17,500 630,000
10 Kresek Hitam Jumbo Pak 3 4 3 4 3 4 3 4 3 4 3 4 42 24,500 1,029,000
11 Kresek Kuning Jumbo Pak 6 6 6 6 6 6 6 6 6 6 6 6 72 24,500 1,764,000
12 Plastik 1/2 kg Tipis Pak 4 4 4 4 4 4 4 4 4 4 4 4 48 3,500 168,000
13 Plastik Klip 8 x 5 Pak 3 3 3 3 3 3 3 3 3 3 3 3 36 2,500 90,000
14 Sabut Besi bh 1 1 2 2,500 5,000
15 Sabut Busa bh 1 1 2 2,500 5,000
16 Sarung Tangan Karet psg 1 1 1 1 1 1 6 15,000 90,000
17 Sedotan Pak 2 2 2 2 2 2 2 2 2 2 2 2 24 1,500 36,000
18 Skiren Plastik bh 0 6,500 -
19 Soklin 360 gr bh 1 2 1 2 1 2 1 2 1 2 1 2 18 5,500 99,000
20 SOS bh 1 1 1 1 1 1 6 10,000 60,000
21 Sunlight Cair Refil bh 3 3 3 3 3 3 3 3 3 3 3 3 36 8,000 288,000
22 Sunlight Cream Refil bh 1 1 1 1 1 1 1 1 1 1 1 1 12 6,000 72,000
23 Tissu Gulung bh 10 10 10 10 10 10 60 1,250 75,000
24 Tissue Hand Hygiene bh 28 28 28 28 28 28 28 28 28 28 28 28 336 7,500 2,520,000
25 Waslap bh 150 150 150 150 150 150 150 150 150 150 150 150 1800 3,000 5,400,000
26 Safety Box bh 11 11 11 11 11 11 11 11 11 11 11 11 132 25,500 3,366,000
27 0 -
28 0 -
29 0 -
30 0 -
ALAT TULIS DAN PERLENGKAPAN KANTOR ALAT TULIS DAN PERLENGKAPAN KANTOR -
1 Bolpoin Hitam bh 37 37 37 37 37 37 37 37 37 37 37 37 444 1,500 666,000
2 Buku Expedisi bh 2 2 2 2 2 2 2 2 2 2 2 2 24 6,500 156,000
3 Buku F5 200 bh 0 -
4 Buku Folio 100 bh 1 1 1 1 1 1 6 12,000 72,000
5 Buku Folio 200 bh 1 1 1 1 1 1 1 1 1 1 1 1 12 22,500 270,000
6 Buku Tulis Kecil bh 2 2 2 2 2 2 2 2 2 2 2 2 24 5,500 132,000
7 Clipboard bh 0 -
8 Gunting Besar bh 1 1 2 15,000 30,000
9 Gunting Tanggung bh 1 1 2 7,000 14,000
10 Isi Stapler Kecil Pak 5 5 5 5 5 5 5 5 5 5 5 5 60 2,500 150,000
11 Isolasi Double Tipe bh 0 -
12 Klip Kecil Pak 1 1 1 1 1 1 6 2,500 15,000
13 Label 107 Pak 0 -
14 Label 109 Pak 12 12 12 12 12 12 12 12 12 12 12 12 144 2,500 360,000
15 Label 125 Pak 5 5 5 5 5 5 5 5 5 5 5 5 60 2,500 150,000
16 Lakban Bening bh 1 1 10,000 10,000
17 Lakban Coklat bh 1 1 10,000 10,000
18 Map Dokumen Isi 60 bh 2 2 29,500 59,000
19 Map Transparan bh 25 25 25 25 100 1,300 130,000
20 Pensil Blue Red bh 1 1 1 3 2,500 7,500
21 Spidol Boardmarker bh 3 3 3 3 3 3 3 3 3 3 3 3 36 6,400 230,400
22 Spidol Permanen (Snowman) bh 1 1 1 1 1 1 1 1 1 1 1 1 12 6,000 72,000
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

23 Stapler Kecil bh 1 1 1 1 4 15,000 60,000


24 Tip-ex Kertas bh 0 7,500 -
25 0 -
26 0 -
27 0 -
28 0 -
PERCETAKAN PERCETAKAN -
1 Amplop RSI Pak 2 3 2 3 2 3 2 3 2 3 2 3 30 1,500 45,000
2 Assesmen Pra Bedah bk 1 1 2 12,500 25,000
3 Assesmen Pra Sedasi / Pra Anasth Rim 1 1 2 12,500 25,000
4 Blanko Laboratorium bk 4 4 4 4 4 4 4 4 4 4 4 4 48 8,000 384,000
5 Blanko Radiologi bk 1 1 1 1 1 1 6 8,000 48,000
6 Blanko Rincian Biaya Tindakan (Japel) bk 0 -
7 Blanko Rujukan Rumah Sakit bk 0 -
8 Blanko Surveylans PPI bk 0 -
9 Bukti Pengambilan Hasil Laboratorium bk 0 -
10 Bukti Visite / Tindakan bk 0 -
11 Catatan Edukasi Terintegrasi bk 1 1 1 3 10,000 30,000
12 Ceklist KPI Pekarya lbr 12 12 12 12 12 12 12 12 12 12 12 12 144 120 17,280
13 Ceklist KPI Perawat lbr 150 150 150 150 150 150 150 150 150 150 150 150 1800 120 216,000
14 Clinical Pathway CVA Dengue Shock Syndrom lbr 1 1 2 250 500
15 Clinical Pathway CVA Gastroenteritis Acute lbr 1 1 250 250
16 Clinical Pathway CVA Hemmorage lbr 1 1 250 250
17 Clinical Pathway CVA Infark lbr 1 1 2 250 500
18 Clinical Pathway Demam Berdarah Dengue (D lbr 1 1 1 1 4 250 1,000
19 Clinical Pathway Typhoid Fever lbr 1 1 1 3 250 750
20 Form. Lap.Insiden Keselamatan P lbr 30 30 30 30 30 30 30 30 30 30 30 30 360 70 25,200
21 Form.Evaluasi Standart Asuhan Kelbr 0 100 -
22 Form Pengukrn Indikator Klinik Mutu Pelyn Keperwtn Kepuasan bk 0 -
23 Format Pengukuran Indikator Klinik Mutu Palayanan Keperawatan lbr 0 -
24 Format Pengukuran Indikator Klinik mutu Pelayanan Keperawatan lbr 0 -
25 Format Pengukuran Indikator Klinik Mutu Pelayanan Keperawata lbr 0 -
26 Format Pengukuran Indikator Klinik Mutu Pelayanan Keperawata lbr 0 -
27 Format Pengukuran Indikator Klinik Mutu Pelayanan Keperawatan lbr 0 -
28 Format Pengukuran Indikator Klinik mutu Pelayanan Keperawata lbr 0 -
29 Format Pengukuran Indikator Klinik Mutu Pelayanan Keperawat lbr 0 -
30 Format Pengukuruan Indikator Klinik Mutu Pelayanan Keperawat lbr 0 -
31 Formulir Catatan Penerimaan Pes bk 1 1 2 6,000 12,000
32 Hasil GDA lbr 50 50 100 700 70,000
33 Instrumen Dekubitus lbr 0 -
34 Instrumen Penilaian Nyeri Anak (Flacc Pa bk 1 1 9,000 9,000
35 Instrumen Penilaian Nyeri Dewasa bk 1 1 1 3 9,000 27,000
36 Instrumen Penilaian Nyeri Tidak Sadar bk 1 1 2 9,000 18,000
37 Leaflet Cuci Tangan lbr 0 -
38 Lembar Informasi & Persetujuan Tindakan Med bk 1 1 1 3 6,500 19,500
39 Lembar Informasi & Persetujuan Tindakan Pem bk 1 1 1 3 6,500 19,500
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

40 Penilaian Infeksi Saluran Kemih (ISK) I lbr 15 15 15 15 15 15 15 15 15 15 15 15 180 120 21,600


41 Penilaian Instrumen C lbr 30 30 30 30 30 30 30 30 30 30 30 30 360 120 43,200
42 Penilaian Pasien Resiko Jatuh Dewasa (18 s/d bk 1 1 1 1 4 9,000 36,000
43 Penilaian Pasien Resiko Jatuh Geriatri (Orang bk 1 1 1 1 4 9,000 36,000
44 Penilaian Tingkat Kecemasan Pasien bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 108,000
45 Persepsi Pasien Thdp Mutu Askep Rawat Inap bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 108,000
46 Resep BPJS bk 10 10 10 10 10 10 10 10 10 10 10 10 120 11,000 1,320,000
47 Resep Umum bk 7 7 7 7 7 7 7 7 7 7 7 7 84 9,000 756,000
48 Rincian AHP Rawat Inap bk 0 -
49 Rincian Kaber bk 0 -
50 Rincian Rawat Inap Sementara bk 0 -
51 RM No.11 / Lembar EKG bk 1 1 2 9,000 18,000
52 RM No.4A / Catatan Terintegrasi bk 3 4 3 4 3 4 3 4 3 4 3 4 42 9,000 378,000
53 RM No.4B / Catatan Perawat bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 108,000
54 RM No.5A / Observasi Fisik bk 1 1 1 1 1 1 6 9,000 54,000
55 RM No.6A / Pemberian Cairan bk 3 3 3 3 3 3 18 9,000 162,000
56 RM No.6B / Pemakaian Obat bk 3 3 3 3 3 3 18 9,000 162,000
57 RM No.7B / Asuhan Keperawatan bk 6 6 6 6 6 6 6 6 6 6 6 6 72 9,000 648,000
58 RM No.8C / Transfer Pasien bk 1 1 1 1 4 9,000 36,000
59 RM No.9 / Konsul Dr. Ahli bk 1 1 2 9,000 18,000
60 Sensus PMKP Angka Asesmen Gizi Yang Dilaku lbr 0 -
61 Sensus PMKP Angka Kejadian Reaksi Transfusi lbr 6 6 12 70 840
62 Sensus PMKP Angka Kelengkapan Formullir Ca lbr 0 -
63 Sensus PMKP Angka Kelengkapan Identifikasi lbr 0 -
64 Sensus PMKP Angka Kelengkapan Pengisian Re lbr 0 -
65 Sensus PMKP Angka Ketepatan Waktu Pemberia lbr 0 -
66 Sensus PMKP Angka Pelaporan Hasil Kritis lbr 0 -
67 Sensus PMKP Angka Pencegahan & Pengendalianlbr 0 -
68 Sensus PMKP Visite dr.Anasthesi Sebelum Pasie lbr 6 6 12 70 840
69 Skrining Bartle Index lbr 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 108,000
70 Skrining Gizi Pasien Dewasa Rim 1 1 1 3 60,000 180,000
71 Skrining ILO lbr 10 10 10 10 10 10 10 10 10 10 10 10 120 7,500 900,000
72 Skrining Phlebitis bk 1 1 1 1 1 1 1 1 1 1 1 1 12 7,500 90,000
73 Surat Keterangan Dirawat bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 108,000
74 Surat Keterangan Sakit bk 1 1 1 1 1 1 6 9,000 54,000
75 Surat Pernyataan BPJS (Farmasi) bk 1 1 1 1 1 1 6 12,000 72,000
76 Surat Pernyataan Pulang Atas Permintaan bk 1 1 2 6,000 12,000
77 Lembar bantuan visite dokter bk 3 3 3 3 3 3 3 3 3 3 3 3 36 9,000 324,000
78 0 -
79 0 -
80 0 -
INVENTARIS JANGKA PENDEK INVENTARIS JANGKA PENDEK 6,856,210
1 Ember kamar mandi + gayung bh 26 26 150,000 3,900,000
2 Bantal Dakron bh 25 25 55,000 1,375,000
3 Baskom Stainlist Besar bh 25 25 125,000 3,125,000
4 Gantungan Baju Pak 25 25 25,000 625,000
5 Jam Dinding bh 26 26 130,000 3,380,000
6 Jemuran Stainlist bh 25 25 75,000 1,875,000
7 Keset Kamar Mandi bh 26 26 40,000 1,040,000
8 Keset Karet bh 26 26 60,000 1,560,000
9 Rak Sepatu bh 25 25 30,000 750,000
10 Kotak obat bh 25 25 45,000 1,125,000
11 Ember besar linen kotor bh 2 2 200,000 400,000
12 Tempat Sampah Injak bh 27 27 115,000 3,105,000
13 Lampu Dinding bh 25 25 150,000 3,750,000
14 Dispenser handrub bh 25 25 -
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

15 Seprei + sarung bantal 75 75 115,000 8,625,000


16 Selimut bedcover motif 75 75 180,000 13,500,000
17 Stik laken 75 75 60,000 4,500,000
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

18 Baju pasien 75 75 100,000 7,500,000


19 Perlak 25 25 50,000 1,250,000
20 Sarung bantal oscar 25 25 70,000 1,750,000
INVENTARIS JANGKA PANJANG INVENTARIS JANGKA PANJANG -
1 Air Conditioning unt 26 26 6,000,000 156,000,000
2 Kursi Tunggu Pasien unt 25 25 200,000 5,000,000
3 Bed set cabinet(bed pasien,bed sid set 25 25 20,000,000 500,000,000
4 Meja kursi tamu unt 25 25 3,000,000 75,000,000
5 Sofa bed 25 25 2,500,000 62,500,000
6 Sandart infus 25 25 500,000 12,500,000
7 Foot step 25 25 600,000 15,000,000
8 Meja kerja perawat 1 1 2,000,000 2,000,000
9 Kursi kerja perawat 6 6 200,000 1,200,000
10 Meja kerja karu 1 1 1,000,000 1,000,000
11 Kursi kerja karu 1 1 200,000 200,000
12 Almari dokumen 1 1 4,000,000 4,000,000
13 Almari obat 1 1 4,000,000 4,000,000
14 Meja UDD 1 1 1,000,000 1,000,000
15 Kursi kerja UDD 1 1 200,000 200,000
16 Loker kerja 1 1 3,500,000 3,500,000
17 Trolly stenlist 4 4 1,250,000 5,000,000
18 Waterheater 25 25 3,000,000 75,000,000
19 Tas emergency 1 1 6,000,000 6,000,000
TOTAL 999,091,210

Mengetahui,
Kepala Ruang / Unit / Instalasi

(........................................................)

TTD & Nama Terang

AR
RENCANA KEBUTUHAN BARANG UNIT (RKBU) MEDIS - TAHUN 2017
UNIT : IRNA NEW
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags

Sep
Jan

Des
Jul
TTL

ALAT HABIS PAKAI RUANGAN ALAT HABIS PAKAI RUANGAN


1 Accu Performa Test GDA (k) box 4 4 4 4 4 4 4 4 4 4 4 4 48 264,385
2 Accu Safe T/ jarum GDA box 1 1 1 1 1 1 1 1 1 1 1 1 12 184,800
Alkohol 70% @ 1 ltr btl 1 1 1 1 1 1 6 25,000
3 Aseptan ltr 0
4 Aseptan (+botol ) btl 0
5 ECG Paper Kecil glg 1 1 1 1 4 45,000
1 Handscrub btl 0
2 Handscun non steril sensi S box 51 51 51 51 51 51 51 51 51 51 51 51 612 37,327
3 Hipafix 10 cm glg 6 6 6 6 6 6 6 6 6 6 6 6 72 104,906
4 Hipafix 15 cm glg 0
5 Kapas Alkohol Swap Box 40 40 40 40 40 40 40 40 40 40 40 40 480 11,000
6 Kassa Hydrofil braja BIRU glg 0
7 Kassa Hydrofil bunda emas glg 0
8 Leukoplast Besar glg 1 1 2 36,634
9 Masker Karet plus box 28 28 28 28 28 28 28 28 28 28 28 28 336 22,000
10 MY Jelly tub 1 1 1 1 1 1 6 23,375
11 Plesterin /0k plast Box 2 2 2 2 2 2 2 2 2 2 2 2 24 170,000
12 Softanol gln 1 1 1 1 1 1 6 743,700
INVENTARIS INVENTARIS
1 Acutran / glukotest 1 1
2 Suction 1 1 Rp 5,000,000
3 Pispot 10 10 Rp 600,000
4 Bengkok stenlis 4 4 Rp 50,000
5 Brankard safety 1 1 Rp 10,000,000
6 Trolly emegency 1 1 Rp 7,000,000
7 ECG/ EKG 1 1 Rp 25,000,000
8 Ice cape 2 2 Rp 25,000
9 Stemper martil 1 1 Rp 300,000
10 Gunting verban 1 1 Rp 50,000
11 Hammer reflek 1 1 Rp 100,000
12 Resusitator anak 1 1 Rp 3,500,000
13 Resusitator dewasa 1 1 Rp 3,500,000
14 Kasur angin 1 1 Rp 700,000
16 Stetoscope 4 4 Rp 400,000
17 Tensimeter 2 2 Rp 1,000,000
18 Thermometer axilla 10 10 Rp 12,000
19 Tongue spatel 2 2 Rp 35,000
20 Tourniquet 2 2 Rp 35,000
21 Urinal 10 10 Rp 10,000
22 WWZ 4 4 Rp 30,000
23 Syringe pump 1 1 Rp 24,000,000
24 Rawat luka set 3 3 Rp 250,000
25 Cateter set 3 3 Rp 250,000
27 Kursi roda 2 2 Rp 3,500,000
28 Manometer 02 10 10 Rp 900,000
29 Nebulizer 1 1 Rp 800,000
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags

Sep
Jan

Des
Jul
TTL

30 Oximetri 1 1 Rp 800,000
Err:522

Mengetahui,
Kepala Ruang / Unit / Instalasi

(........................................................)

TTD & Nama Terang


12,690,480
2,217,600
150,000
-
-
180,000
-
22,844,124
7,553,232
-
5,280,000
-
-
73,268
7,392,000
140,250
4,080,000
4,462,200

Rp 5,000,000
Rp 6,000,000
Rp 200,000
Rp 10,000,000
Rp 7,000,000
Rp 25,000,000
Rp 50,000
Rp 300,000
Rp 50,000
Rp 100,000
Rp 3,500,000
Rp 3,500,000
Rp 700,000
Rp 1,600,000
Rp 2,000,000
Rp 120,000
Rp 70,000
Rp 70,000
Rp 100,000
Rp 120,000
Rp 24,000,000
Rp 750,000
Rp 750,000
Rp 7,000,000
Rp 9,000,000
Rp 800,000
Rp 800,000
Rp 175,643,154
RENCANA KEBUTUHAN BARANG UNIT (RKBU) NON MEDIS - TAHUN 2017
UNIT : IRNA VIP
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags

Sep
Jan

Des
Jul
TTL

KERUMAHTANGGAAN HABIS PAKAI KERUMAHTANGGAAN HABIS PAKAI


1 Air Mineral Galon bh 16 16 16 16 16 16 16 16 16 16 16 16 192 13,000 208,000
2 Baterai A2 ABC bh 0 -
3 Baterai A2 Alkaline bh 2 2 2 2 2 2 12 4,000 8,000
4 Baterai A3 Alkaline bh 2 2 2 2 2 2 12 4,500 9,000
5 Baterai Besar bh 4 4 4 4 4 4 24 5,000 20,000
6 Kresek Hitam Super Pak 6 6 6 6 6 6 6 6 6 6 6 6 72 17,500 105,000
7 Kresek Hitam Jumbo Pak 1 1 1 1 1 1 1 1 1 1 1 1 12 24,500 24,500
8 Kresek Kuning Jumbo Pak 4 4 4 4 4 4 4 4 4 4 4 4 48 24,500 98,000
9 Plastik 1/2 kg Tipis Pak 4 4 4 4 4 4 4 4 4 4 4 4 48 3,500 14,000
10 Plastik Klip 8 x 5 Pak 9 9 9 9 9 9 9 9 9 9 9 9 108 2,500 22,500
11 Sabut Besi bh 1 1 1 1 1 1 1 1 1 1 1 1 12 2,000 2,000
12 Sabut Busa bh 1 2 1 2 1 2 1 2 1 2 1 2 18 2,500 2,500
13 Safety box lbr 4 4 4 4 4 4 4 4 4 4 4 4 48 25,500 102,000
14 Sedotan Pak 2 2 2 2 2 2 2 2 2 2 2 2 24 1,500 3,000
15 Skiren Plastik bh 0 -
16 Sunlight Cair Refil bh 7 7 7 7 7 7 7 7 7 7 7 7 84 8,000 56,000
17 Sunlight Cream Refil bh 0 -
18 Tas Suvenir (Biru & Pink) bh 0 -
19 0 -
ALAT TULIS DAN PERLENGKAPAN KANTOR ALAT TULIS DAN PERLENGKAPAN KANTOR
1 Bolpoin Hitam bh 13 13 13 13 13 13 13 13 13 13 13 13 156 1,500 19,500
2 Buku Expedisi bh 3 3 3 3 3 3 3 3 3 3 3 3 36 6,500 19,500
3 Buku Folio 200 bh 2 2 2 2 2 2 2 2 2 2 2 2 24 22,500 45,000
4 Buku Tulis Kecil bh 2 2 2 2 2 2 12 2,500 5,000
5 Gunting Besar bh 1 1 2 13,000 13,000
6 Isi Stapler Kecil Pak 2 2 2 2 2 2 2 2 2 2 2 2 24 2,500 5,000
7 Isolasi Double Tipe bh 1 1 2 5,000 5,000
8 Kertas Karbon bh 1 1 1 1 1 1 1 1 1 1 1 1 12 500 500
9 Label 107 Pak 0 -
10 Label 109 Pak 7 7 7 7 7 7 7 7 7 7 7 7 84 2,500 17,500
11 Map Dokumen Isi 60 bh 2 2 4 29,500 59,000
12 Map transparan lbr 2 2 4 1,300 2,600
13 Pensil Blue Red bh 2 2 3,000 -
14 Sis Box bh 2 2 15,000 -
15 Spidol Boardmarker bh 2 2 2 6 6,400 12,800
16 Spidol permanen bh 2 2 4 6,000 12,000
17 Tip-ex Kertas bh 1 1 1 1 1 1 1 1 1 1 1 1 12 7,500 7,500
18 Tip-ex Cair bh 0 -
PERCETAKAN PERCETAKAN
1 Amplop RSI Pak 2 2 2 2 2 2 2 2 2 2 2 2 24 10,000 20,000
2 Blanko Alih Rawat bk 1 1 1 1 1 1 6 6,500 6,500
3 Blanko Cuti Pegawai bk 1 1 12,000 12,000
4 Blanko Laboratorium bk 2 2 2 2 2 2 2 2 2 2 2 2 24 3,750 7,500
5 Blanko PMI bk 1 1 2 -
6 Blanko Radiologi bk 1 1 1 1 1 1 6 8,000 8,000
7 Blanko Rincian Biaya Tindakan (Jap bk 0 -
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

8 Blanko Rujukan Rumah Sakit bk 1 1 2 5,000 -


9 Blanko Surveylans PPI bk 0 -
10 Catatan Edukasi Terintegrasi bk 1 1 1 1 1 1 6 9,500 9,500
11 Ceklist KPI Pekarya lbr 18 18 18 18 18 18 18 18 18 18 18 18 216 120 2,160
12 Ceklist KPI Perawat lbr 132 132 132 132 132 132 132 132 132 132 132 132 1584 120 15,840
13 Clinical Pathway CVA Dengue Shock Syndr lbr 1 1 250 250
14 Clinical Pathway CVA Gastroenteritis Acute lbr 1 1 250 250
15 Clinical Pathway CVA Hemmorage lbr 1 1 250 250
16 Clinical Pathway CVA Infark lbr 1 1 250 250
17 Clinical Pathway Demam Berdarah lbr 1 1 1 3 250 250
18 Clinical Pathway Typhoid Fever lbr 1 1 2 250 250
19 Form. Lap.Insiden Keselamatan Pasien lbr 30 30 30 30 30 30 30 30 30 30 30 30 360 70 2,100
20 Form.Evaluasi Standart Asuhan Keperawatan (Inst. A) lbr 4 4 4 4 4 4 4 4 4 4 4 4 48 100 400
21 Format Pengukuran Indikator Klinik Mutu Palayanan Kepera lbr 0 -
22 Format Pengukuran Indikator Klinik mutu Pelayanan Kepera lbr 0 -
23 Format Pengukuran Indikator Klinik Mutu Pelayanan Keper lbr 0 -
24 Format Pengukuran Indikator Klinik Mutu Pelayanan Kepe lbr 0 -
25 Format Pengukuran Indikator Klinik Mutu Pelayanan Keper lbr 0 -
26 Format Pengukuran Indikator Klinik mutu Pelayanan Keper lbr 0 -
27 Format Pengukuran Indikator Klinik Mutu Pelayanan Kepe lbr 0 -
28 Format Pengukuruan Indikator Klinik Mutu Pelayanan Kepe lbr 0 -
29 Instrumen Dekubitus bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 9,000
30 Instrumen Penilaian Nyeri Anak (Flacc Pain Scale) bk 1 1 2 9,000 -
31 Instrumen Penilaian Nyeri Dewasa bk 1 1 1 1 1 1 6 9,000 9,000
32 Instrumen Penilaian Nyeri Tidak Sadar bk 1 1 9,000 -
33 Lembar Informasi & Persetujuan Tindakan Medik bk 1 1 2 6,500 6,500
34 Lembar Informasi & Persetujuan Tindakan Pembiusan bk 1 1 2 6,500 6,500
35 Penilaian Infeksi Saluran Kemih (ISK) I bk 1 1 2 120 120
36 Penilaian Instrumen C lbr 21 21 21 21 21 21 21 21 21 21 21 21 252 120 2,520
37 Penilaian Pasien Resiko Jatuh Anak (<18 Th) lbr 1 1 9,000 9,000
38 Penilaian Pasien Resiko Jatuh Dewasa (18 s/d <60 Th) bk 1 1 9,000 9,000
39 Penilaian Tingkat Kecemasan Pasien bk 1 1 1 1 1 1 6 9,000 9,000
40 Persepsi Pasien Thdp Mutu Askep Rawat Inap bk 1 1 1 1 1 1 6 9,000 9,000
41 Resep BPJS bk 6 6 6 6 6 6 6 6 6 6 6 6 72 11,000 66,000
42 Resep Umum bk 8 8 8 8 8 8 8 8 8 8 8 8 96 9,000 72,000
43 Rincian AHP Rawat Inap bk 0 -
44 Rincian Rawat Inap Sementara bk 0 -
45 RM No.3C / Persetujuan Tindakan bk 1 1 2 9,000 9,000
46 RM No.4A / Catatan Terintegrasi bk 2 3 2 3 2 3 2 3 2 3 2 3 30 9,000 18,000
47 RM No.4B / Catatan Perawat bk 2 2 2 2 2 2 2 2 2 2 2 2 24 9,000 18,000
48 RM No.6A / Pemberian Cairan bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 9,000
49 RM No.6B / Pemakaian Obat bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 9,000
50 RM No.7B / Asuhan Keperawatan bk 4 4 4 4 4 4 4 4 4 4 4 4 48 9,000 36,000
51 RM No.8C / Transfer Pasien bk 1 1 1 3 9,000 9,000
52 RM No.9 / Konsul Dr. Ahli bk 1 1 2 9,000 9,000
53 RMK 4 / Catatan Perkembangan bk 1 1 1 3 9,000 9,000
54 Rujuk Parsial Radiologi & Laborat bk 1 1 2 6,000 6,000
55 Sensus PMKP Angka Asesmen Gizi Yang Dilakukan Pada Pa lbr 0 -
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

56 Sensus PMKP Angka Kejadian Reaksi Transfusi lbr 6 6 12 70 420


57 Sensus PMKP Angka Kelengkapan Formullir Catatan Pesan lbr 0 -
58 Sensus PMKP Angka Kelengkapan Identifikasi Pasien lbr 0 -
59 Sensus PMKP Angka Pelaporan Hasil Kritis lbr 0 -
60 Sensus PMKP Visite dr.Anasthesi Sebelum Pasien Dilakukan lbr 6 6 12 70 420
61 Skrining Bartle Index bk 1 1 1 1 1 1 1 1 1 1 1 1 12 9,000 9,000
62 Skrining Gizi Pasien Dewasa bk 1 1 1 1 1 1 6 9,000 9,000
63 Skrining Phlebitis bk 1 1 1 1 1 1 6 7,500 7,500
64 Surat Keterangan Dirawat bk 1 1 1 1 1 1 1 1 1 1 1 1 12 12,000 12,000
65 Surat Keterangan Sakit bk 1 1 1 1 1 1 6 7,000 7,000
66 Surat Pernyataan Pulang Atas Permi bk 1 1 2 6,000 6,000
67 0 -
INVENTARIS JANGKA PENDEK INVENTARIS JANGKA PENDEK
1 Ember kamar mandi + gayung bh 48 75,000 3,600,000
2 Bantal Dakron bh 15 55,000 825,000
3 Guling bh 15 50,000 750,000
4 Baskom Stainlist Besar bh 15 65,000 975,000
5 Gantungan Baju Pak 15 20,000 300,000
6 Jam Dinding bh 16 160,000 2,560,000
7 Jemuran Stainlist bh 15 60,000 900,000
8 Keset Kamar Mandi bh 16 30,000 480,000
9 Keset Karet bh 16 100,000 1,600,000
10 Rak Sepatu bh 15 45,000 675,000
11 Kotak obat bh 15 40,000 600,000
12 Ember besar linen kotor bh 2 200,000 400,000
Tempat sampah injak besar bh 3 150,000 450,000
13 Tempat Sampah Injak tanggung bh 16 100,000 1,600,000
Tempat Sampah Injak kecil bh 16 50,000 800,000
14 Lampu Dinding bh 15 60,000 900,000
15 Dispenser handrub bh 16 -
16 Seprei + sarung bantal+guling 45 160,000 7,200,000
17 Selimut bedcover motif 45 215,000 9,675,000
18 Stik laken 45 65,000 2,925,000
19 Baju pasien 45 100,000 4,500,000
20 Perlak 15 75,000 1,125,000
21 Sarung bantal oscar 20 75,000 1,500,000
INVENTARIS JANGKA PANJANG INVENTARIS JANGKA PANJANG
1 Air Conditioning unt 16 6,000,000 96,000,000
2 Kursi Tunggu Pasien + busa set 15 2,500,000 37,500,000
3 Bed set cabinet(bed pasien,bed side, set 15 35,000,000 525,000,000
4 Sofa tamu unt 15 5,000,000 75,000,000
5 Sofa bed 15 6,000,000 90,000,000
6 Sandart infus 15 750,000 11,250,000
7 Foot step 15 750,000 11,250,000
8 Meja kerja perawat 1 16,000,000 16,000,000
9 Kursi kerja perawat 5 200,000 1,000,000
10 Meja kerja karu 1 1,000,000 1,000,000
11 Kursi kerja karu 2 700,000 1,400,000
Meja makan set 15 3,500,000 52,500,000
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

12 Almari dokumen 1 3,000,000 3,000,000


13 Rak obat UDD 1 3,000,000 3,000,000
14 Meja UDD 1 1,000,000 1,000,000
15 Kursi kerja UDD 2 200,000 400,000
16 Loker kerja 1 2,500,000 2,500,000
17 Trolly stenlist 4 1,500,000 6,000,000
18 Waterheater daalderop listrik 15 5,000,000 75,000,000
19 Tas emergensy 1 1,500,000 1,500,000
20 Kursi susun bh 16 200,000 3,200,000
21 LED TV bh 16 2,800,000 44,800,000
Lemari es 1 pintu bh 16 2,500,000 40,000,000
Kaca cermin 16 300,000 4,800,000
Dispenser tissue 16 150,000 2,400,000
Gorden set 16 2,000,000 32,000,000
TOTAL 1,183,214,880

AR
RENCANA KEBUTUHAN BARANG UNIT (RKBU) MEDIS - TAHUN 2017
UNIT : IRNA VIP
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags

Sep
Jan

Des
Jul
TTL

ALAT HABIS PAKAI RUANGAN ALAT HABIS PAKAI RUANGAN


1 Accu Performa Test GDA (k) box 2 2 2 2 2 2 2 2 2 2 2 2 24 264,385 528,770
2 Accu Safe T/ jarum GDA box 1 1 1 3 184,800 184,800
3 Betadine 60 ml btl 1 1 1 3 30,800 30,800
4 ECG Paper 3 chanel glg 1 1 2 45,000 45,000
5 Handscun non steril sensi S box 32 32 32 32 32 32 32 32 32 32 32 32 384 37,327 1,194,464
6 Hipafix 10 cm glg 2 3 2 3 2 3 2 3 2 3 2 3 30 104,906 209,812
7 Hipafix 15 cm glg 0 -
8 Kapas Alkohol Swap box 16 16 16 16 16 16 16 16 16 16 16 16 192 11,000 176,000
9 Kassa Hydrofil braja BIRU glg 0 -
10 Kassa Hydrofil bunda emas glg 0 -
11 Leukoplast Besar glg 1 1 2 36,634 36,634
12 Masker Karet plus box 22 22 22 22 22 22 22 22 22 22 22 22 264 22,000 484,000
13 MY Jelly tub 1 1 1 1 4 23,375 23,375
14 Plesterin /0k plast box 3 3 3 3 3 3 3 3 3 3 3 3 36 19,800 59,400
15 Softanol gln 2 2 2 2 2 2 2 2 2 2 2 2 24 743,700 1,487,400
16 Micropore 1 1 1 3 33,048 33,048
17 0 -
18 0 -
INVENTARIS INVENTARIS
1 Acutran / glukotest 1 800000 800,000
2 Suction 1 5000000 5,000,000
3 Pispot 15 750000 11,250,000
4 Bengkok stenlis 5 35000 175,000
5 Brankard safety 1 12000000 12,000,000
6 Trolly emegency 1 7000000 7,000,000
7 ECG/ EKG 1 30000000 30,000,000
8 Ice cup 4 35000 140,000
9 Stemper martil 1 50000 50,000
10 Gunting verban 1 50000 50,000
11 Hammer reflek 1 50000 50,000
12 Resusitator anak 1 5000000 5,000,000
13 Resusitator dewasa 1 4000000 4,000,000
14 Kasur angin 1 750000 750,000
15 Stetoscope 4 500000 2,000,000
16 Tensimeter 4 1000000 4,000,000
18 Tongue spatel 2 50000 100,000
19 Tourniquet 2 50000 100,000
20 Urinal 15 10000 150,000
21 WWZ 4 35000 140,000
22 Syringe pump 1 40000000 40,000,000
23 Rawat luka set 3 500000 1,500,000
24 Cateter set 3 500000 1,500,000
25 -
26 Kursi roda 2 2,500,000 5,000,000
Manometer 02 15 1,000,000 15,000,000
RENCANA PENGAJUAN BULANAN TAHUN 2017
NO NAMA BARANG Stn

Mar

Nop
Apr

Mei

Okt
Feb

Jun

Ags
Jan

Sep

Des
Jul
TTL

Nebulizer 1 800,000 800,000


Oximetri 1 900,000 900,000
TOTAL 130,248,503

(........................................................)

TTD & Nama Terang