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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN

PUSKESMAS : KELURAHAN............................................ PELAPORAN


KECAMATAN : KEBAYORAN LAMA PERMINTAAN
KAB/KOTA : JAKARTA SELATAN
PROPINSI : DKI JAKARTA

KODE
NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
OBAT
1 2 3 4 5 6 7
A.B.U. I (khusus ular dari luar
1 vial -
Papua) inj (i.m./i.v.)
A.B.U.II (khusus ular dari Papua)
2 vial -
inj (i.m./i.v.)
3 Air untuk vial amp 25 mL ampul -
4 Albendazol tab 400 mg tablet -
5 Albendazol susp 200 mg/5 mL botol -
6 Alopurinol tab 100 mg tablet 200 500 700
7 Alopurinol tab 300 mg tablet -
8 Amilorid tab 5 mg tablet -
9 Aminofilin tab 150 mg tablet -
10 Aminofilin tab 200 mg tablet -
11 Aminofilin inj 24 mg/mL vial -
12 Amitriptilin tab sal 25 mg tablet salut -
13 5mg Amlodipin tab sal 25 mg tablet -
14 Amlodipin tab 10 mg tablet 90 600 690
15 Amoksisilin tab 500 mg tablet 3,400 1,600 5,000
16 Amoksisilin sir forte 250 mg/5 mL botol -
17 Ampisilin serb inj 1000 mg/vial vial -
18 Ampisilin serb inj 250 mg/vial vial -
Anestetik lokal gigi kombinasi :
19 lidokain HCl 2% + epinefrin 1 : vial -
80.000
Antasida,inj 2kombinasi
mL : aluminium
tablet
20 hidroksida 200 mg + magnesium 4,000 1,500 5,500
kunyah
hidroksida 200 mg :aluminium
Antasida, kombinasi
21 hidroksida 200 mg + magnesium botol -
hidroksida 200 mg
Antifungi salep, kombinasi : asam
22 tube -
benzoat 6% + asam salisilat 3%
Antihemoroid, kombinasi: bismut
subgalat 150 mg + heksaklorofen
23 supp 30 30
2,5 mg + lidokain 10 mg + seng
oksida 120 mg,
Antimalaria sup ad :2 g
kombinasi
24 sulfadoksin 500 mg + pirimetamin kapsul -
25 mg
Antiparkinson kombinasi :
25 benserazid 25 mg + levodopa 100 kapsul -
mg
26 Artemether inj 80 mg/mL vial -
Artesunat serb inj 60 mg/mL
27 vial -
(i.v./i.m.)
kertas
warna
28 Articulating paper -
penanda
oklusi
Asam asetilsalisilat (asetosal) tab
29 tablet 400 400
80 mg askorbat (vitamin C) tab 50
Asam
30 tablet 600 440 1,040
mg
Asam askorbat (vitamin C) tab 250
31 tablet -
mg
32 Asam folat tab 0,4 mg tablet -
33 Asam folat tab 1 mg tablet -
34 Asam folat tab 5 mg tablet -
35 Asam mefenamat kaps 250 kapsul -
36 Asam mefenamat kaps 500 kapsul 600 600
37 Asam salisilat 5% salep -
38 Asam salisilat 0,1% larutan -
39 Asiklovir tab 200 mg tablet -
40 Asiklovir tab 400 mg tablet 200 200
41 Atapulgit tablet -
42 Atenolol tab 50 mg tablet -
43 Atropin tab 0,5 mg tablet -
Atropin inj 0,25 mg/mL
44 vial -
(i.v./i.m./s.k.)
Bahan tumpatan sementara lar,
45 botol -
serb
46 Bedak salisil serb 2% serbuk -
Benzatin penisilin inj 1,2 juta
47 vial -
UI/mL
Benzatin(i.m.)
penisilin inj 2,4 juta
48 vial -
UI/mL (i.m.)
49 Betametason krim 0,5 mg/g krim -
50 Betametason tts mata 1 mg/mL botol -
51 Bisakodil sup 10 mg tab salut -
52 Bisakodil sup 5 mg supp -
53 Bisakodil tab salut 5 mg supp -
54 Coal tar lar 5 % botol -
55 Copper T set/buah -
56 Dapson tab scored 100 mg tab scored -
Deksametason inj 5 mg/mL
57 vial 16 16
(i.v./i.m.)
58 Deksametason tab 0,5 mg tablet 1,000 1,000 2,000
59 Diazepam inj 5 mg/mL (i.v./i.m.) vial
60 Diazepam lar rektal 10 mg/2,5 mL lar rektal -
61 Diazepam lar rektal 5 mg/2,5 mL lar rektal -
62 Diazepam tab 2 mg tablet -
63 Diazepam tab 5 mg tablet -
64 Dietilkarbamazin tab 100 mg tablet -
Difenhidramin inj 10 mg/mL
65 vial -
(i.v./i.m.)
66 Digoksin tab 0,25 mg tablet -
67 Diltiazem HCl tab 30 mg tablet -
68 Dimenhidrinat tab 50 mg tablet 300 300
69 Doksisiklin kaps 100 mg kapsul -
70 Domperidon tab 10 mg tablet 700 700
Epinefrin (adrenalin) inj 0,1%
71 ampul -
(i.v./s.k./i.m.)
72 Epinefrin (adrenalin) inj 1 mg/mL ampul -
Ergokalsiferol (vitamin D2) kaps
73 kapsul -
50.000 UI
Ergokalsiferol (vitamin D2) susp
74 botol -
10.000 UI/mL
75 Ergotamin tab 1 mg tablet -
76 500mg Eritromisin kaps 250 mg kapsul 100 500 600
77 Eritromisin sir 200 mg/5 mL botol -
78 Etambutol tab 250 mg tablet -
79 Etambutol tab 400 mg tablet -
80 Etambutol tab 500 mg tablet -
81 Etanol botol 70% botol -
82 Etil klorida semprot 100 mL botol -
83 Etonogestrel implan 68 mg implan -
84 Eugenol botol -
85 Fenitoin Na kaps 50 mg kapsul -
86 Fenitoin Na kaps 100 mg kapsul -
87 Fenitoin Na inj 100 mg/2 ampul -
88 Fenitoin Na inj 50 mg/mL ampul -
89 Fenobarbital tab 30 mg tablet -
90 Fenobarbital tab 100 mg tablet -
Fenoksimetil penisilin (penisilin V)
91 tablet -
tab 250 mg
Fenoksimetil penisilin (penisilin V)
92 tablet -
tab 500 mg
Fenoksimetil penisilin (penisilin V)
93 vial -
serb inj 3 juta UI/vial (i.m.)
94 Ferro fumarat kaps lunak 300 mg kaps. Lunak -
95 Ferro sulfat tab salut 300 mg tablet salut -
96 Ferro sulfat sir. 15 mg/5 mL botol -
Fitomenadion (vitamin K 1) tab sal
97 tab. Salut 200 200
10 mg
Fitomenadion (vitamin K 1) inj 2
98 vial -
mg/mL (i.m.)
99 Fluor tab 0,5 mg tablet -
100 Fluor kapl 1 mg kapsul -
101 Fluor sediaan topikal tube -
102 Fluoresein tts mata 2,5 mg/mL botol -
103 Formokresol botol -
104 Furosemid tab 40 mg tablet -
105 Furosemid inj 10 mg/mL (i.v./i.m.) ampul -
Galactose microparticle200- 400
106 gel -
mg micropart/mL
Garam oralit kombinasi : natrium
klorida 0,52 g + kalium klorida 0,30
107 g + trinatrium sitrat dihidrat 0,58 g+ sachet 400 400
glukosa anhidrat 2,7 g serbuk
untuk 200 ml air
Glass ionomer ART (Atraumatic
108 sachet -
Restorative Treatment)
Glass ionomer ART (Atraumatic
109 botol -
Restorative Treatment)
Glass ionomer ART (Atraumatic
110 Restorative Treatment) cocoa cocoa butter -
butter 5 g
111 Glibenklamid tab 2,5 mg tablet -
112 Glibenklamid tab 5 mg tablet 900 900
113 Glimepirid tab 1 mg tablet -
114 Glimepirid tab 2 mg tablet -
115 Glipizid tab 5 mg tablet -
Gliseril trinitrat tab sublingual 0,5
116 tablet sub. -
mg
117 Gliserin tts 10 mg/mL botol -
118 Gliserin tts 100 mg/mL botol -
Griseofulvin (micronized ) tab 125
119 tablet 700 700
mg
Griseofulvin (micronized ) tab
120 tablet score -
scored 250 mg
Gutta percha dan paper points 15
121 roll -
- 40 mm
Gutta percha dan paper points 45
122 roll -
- 80 mm
123 Haloperidol tab 0,5 mg tablet -
124 Haloperidol tab 1,5 mg tablet -
125 Haloperidol tab 2 mg tablet -
126 Haloperidol tab 5 mg tablet -
127 Haloperidol tts 2 mg/mL botol -
128 Haloperidol inj 5 mg/mL (i.m.) vial -
Hepatitis B imunoglobulin (human)
129 vial -
inj 0,5 mL
130 Hidrogen peroksida botol 3% botol -
Hidrogen peroksida lar. konsentrat
131 botol -
3%
132 Hidroklorotiazid tab 25 mg tablet 200 300 500
133 Hidrokortison serb inj 100 mg/vial vial 72 72
134 Hidrokortison krim 2,5% krim -
135 # Hyorex Hiosina butilbromida tab 10 mg tablet -
Human tetanus imunoglobulin inj
136 vial -
250 UI(i.m)
Human tetanus imunoglobulin inj
137 vial -
500 UI (i.m.)
138 Ibuprofen tab 200 mg tablet 2,500 2,500
139 Ibuprofen tab 400 mg tablet -
140 Ibuprofen sir 100 mg/5 mL botol -
141 Ibuprofen sir 200 mg/5 mL botol -
Ipratropium bromida ih padat 20
142 botol -
mg
Ipratropium bromida nebulizer
143 botol -
0,025%
144 Isoniazid tab 100 mg tablet -
145 Isoniazid tab 300 mg tablet -
146 Isosorbid dinitrat tab 5 mg tablet 400 400
147 Kalamin botol -
148 Kalsium glukonat inj 100 mg/mL ampul -
149 Kalsium hidroksida pasta -
150 Kalsium karbonat tab 500 mg tablet -
151 Kalsium laktat (kalk) tab 500 mg tablet 1,200 1,000 2,200
152 Kaptopril tab 12,5 mg tablet 500 500
153 Kaptopril tab 25 mg tablet 1,500 1,500
154 Karbamazepin tab 200 mg tablet -
155 Karbamazepin sir 100 mg/5 mL botol -
156 Karbo adsorben tab 0,5 g tablet -
157 FenolgliseKarbogliserin tts telinga 10 % botol 48 48
158 Ketamin inj 50 mg/mL ampul -
159 Ketamin inj 100 mg/mL (i.v.) ampul -
160 Ketokonazol tab 200 mg tablet 100 100
Klofazimin, micronizedkaps 100
161 kapsul -
mg
162 Kloramfenikol kaps 250 mg kapsil 1,000 1,000
163 Kloramfenikol susp 125 mg/5 mL botol -
164 Kloramfenikol salep kulit 2% pot -
165 Kloramfenikol tts mata 0,5% botol -
166 Kloramfenikol tts mata 1% botol -
167 Kloramfenikol salep mata 1% pot -
168 Klorfeniramin maleat tab 4 mg tablet 2,500 2,500
169 Klorfenol kamfer mentol (CHKM) botol -
170 Klorheksidin lar 15% botol -
171 Klorheksidin lar 0,2% botol -
172 Klorpromazin tab sal 25 mg tablet salut -
173 Klorpromazin tab sal 100 mg tablet salut -
174 Klorpromazin inj 5 mg/mL (i.m.) vial -
Klorpromazin inj 25 mg/mL vial
175 vial -
(i.m.)
176 Klortalidon tab 50 mg tablet -
177 Kodein tab 10 mg tablet -
178 Kodein tab 20 mg tablet -
Kombinasi untuk anak : Paduan
dalam bentuk dosis tetap
179 Paket -
(KDT/FDC) Rifampisin kaplet 75
mg + isoniazid tablet 50 mg
kombinasi (kombipak) : artesunat
180 tab 50 mg + amodiakuin tab 200 Tablet -
mg
kombinasi : tablet salut ferro sulfat
181 Tablet salut -
200 mg + asam folat 0,25 mg

Kombinasi : artemeter 20 mg +
182 Tablet -
lumefantrin 120 mg
kombinasi untuk anak : (Paduan
dalam bentuk Kombipak)
183 Rifampisin kaplet 75 mg + Paket -
isoniazid tablet 100 mg +
pirazinamid tablet 200 mg
kombinasi untuk anak : (Paduan
dalam bentuk kombipak)
Rifampicin kaplet75 mg + isoniazid
184 anak Paket -
tablet
100 mg

Kombinasi untuk anak : Paduan


dalam bentuk dosis tetap
185 sisipan (KDT/FDC) Rifampisin kaplet 75 Paket -
mg + isoniazid tablet 50 mg +
pirazinamid tablet 150 mg
Kombinasi untuk dewasa : Paduan
dalam bentuk kombipak Rifampisin
186 Paket -
kaplet 450 mg + isoniazid tablet
300 mg
kombinasi untuk dewasa: (Paduan
dalam bentuk Kombipak)
Rifampisin kaplet 450 mg +
187 I isoniazid tablet 300 mg + Paket -
pirazinamid tablet 500 mg +
etambutol tablet 250 mg dan 500
mg

kombinasi untuk dewasa: Paduan


dalam bentuk dosis tetap
(KDT/FDC) Rifampisin kaplet 150
188 II Paket -
mg + isoniazid tablet 75 mg +
pirazinamid tablet 400 mg +
etambutol tablet 275 mg
kombinasi untuk dewasa: Paduan
dalam bentuk dosis tetap
189 Paket -
(KDT/FDC) Rifampisin kaplet 150
mg + isoniazid tablet 150 mg
Kombinasi: kaolin 550 mg + pektin
190 tablet -
20 mg
kombinasi: ipratropium Br 0,5 mg
191 botol -
+ salbutamol 2,5 mg
192 Komposit resin set -
Kontrasepsi oral kombinasi tablet :
193 levonorgestrel 150 mcg + tablet -
etinilestradiol 30 mcg
Kotrimoksazol 240 mg :
194 sulfametoksazol 200 mg + botol 50 50
trimetoprim 40 mg
Kotrimoksazol (dewasa) 480 mg :
195 sulfametoksazol 400 mg + tablet 1,500 1,500
trimetoprim 80
Kotrimoksazol forte kombinasi 960
196 mg: sulfametoksazol 800 mg + tablet -
trimetoprim 160 mg
197 Kuinin tab 200 mg tablet -
198 Kuinin tab 222 mg tablet -
199 Kuinin tab 250 mg tablet -
200 Kuinin inj 25% (i.v.) vial -
Levonorgestrel implan 2 rods, 75
201 implan -
mg (3-4 tahun)
202 Lidokain inj 1 % (infltr) ampul -
203 Lidokain inj 2% (infiltr/p.v.) ampul -
204 Xylocain Lidokain gel 2% gel -
205 Lidokain semprot 10% botol -
206 Lidokain pasta 5% (HCl) tube -
207 Lidokain semprot 15% (HCl) botol -
208 Loratadin tab 10 mg tablet -
209 Lugol botol -
210 Magnesium sulfat serb, ktg 30 g sachet -
211 Magnesium sulfat inj 20% ampul -
212 Magnesium sulfat inj 40% ampul -
213 Mebendazol tab 100 mg tablet -
214 Mebendazol tab 500 mg tablet -
215 Mebendazol sir 50 mg/mL botol -
Medroksi progesteron asetat inj
216 vial -
depo 150 mg
Metenamin mandelat (heksamin
217 tablet salut -
mandelat) tab salut enterik 500 mg
218 Metformin tab 500 mg tablet 600 600
219 Metformin tab 850 mg tablet -
220 Metilergometrin tab salut 0,125 mg tablet -
221 Metilergometrin inj 0,2 mg/Ml ampul -
222 Metoklopramid tab 5 mg tablet -
223 Metoklopramid tab 10 mg tablet -
224 Metronidazol tab 250 mg tablet -
225 Metronidazol tab 500 mg tablet -
226 Metronidazol sir 125 mg/5 mL botol -
227 Metronidazol lar inf 5 mg/mL botol -
228 Metronidazol ovula 500 mg supp -
229 Mikonazol serb 2% vial -
230 Mikonazol krim 2% krim -
231 Natrium bikarbonat tab 500 mg tablet -
232 Natrium diklofenak tab 25 mg tablet -
233 Natrium diklofenak tab 50 mg tab 50 mg 150 300 450
Natrium hipoklorit botol konsentrat
234 botol -
5%
235 Natrium tiosulfat inj 25% (i.v.) vial -
236 Nifedipin kaps 10 mg kapsul 100 100
237 Nikotinamid tab 5 mg tablet -
238 Nikotinamid tab 20 mg tabet -
239 Nikotinamid tab 100 mg tablet -
240 # Nistatin tab salut 500.000 UI tablet salut -
241 # Nistatin susp 100.000 UI/mL botol -
242 # Nistatin tab vaginal 100.000 UI/tab supp 100 100
243 Nitrofurantoin tab 50 mg tablet -
244 Norepinefrin inj 1 mg/mL ampul -
245 Oksigen ih, gas dlm tabung botl -
246 Oksimetazolin tts hidung 0,025% botol -
247 Oksimetazolin tts hidung 0,05% botol -
248 Oksitosin inj 10 UI/mL ampul -
249 Olopatadin tts mata 0,1% botol -
250 Omeprazol kaps 20 mg kapsul 210 210
251 Omeprazol inj 40 mg/10 mL ampul -
252 Paraformaldehid tab 1 g tablet -
253 Parasetamol tab 500 mg tablet 1,000 10,000 11,000
254 Parasetamol sir 120 mg/5 mL botol -
255 Parasetamol tts 60 mg/0,6 mL botol -
256 Pasta devitalisasi (non arsen) tube -
257 Pasta pengisi saluran akar tube -
258 Perak nitrat lar 20% botol -
259 Burnazin Perak sulfadiazin krim 1% pot -
260 Scabisid Permetrin krim 5 % pot -
Pirantel pamoat tab scored 125
261 tablet score -
mg
Pirantel pamoat tab scored 250
262 tablet score -
mg
263 Pirantel pamoat tab 500 mg tablet -
Pirantel pamoat susp 125 mg/5
264 botol -
mL
265 Pirazinamid tab 500 mg tablet -
266 Piridoksin (vitamin B6) tab 10 mg tablet 1,000 300 1,300
267 Piridoksin (vitamin B6) tab 25 mg tablet -
Piridoksin (vitamin B6) inj 100
268 ampul -
mg/mL
269 Povidon iodin lar 100 mg/mL botol -
270 Prazikuantel tab scored 300 mg tablet score -
271 Prazikuantel tab scored 600 mg tablet score -
272 Prednison 5 mg tablet -
273 Primakuin 15 mg tablet -
274 Probenesid 500 mg tablet -
Prokain benzilpenisilin inj 1 juta
275 vial -
UI/vial (i.m.)
Prokain benzilpenisilin serb inj 3
276 vial -
juta UI/vial (i.m.)
277 Propiltiourasil 100 mg tablet -
278 propranolol 10 mg tablet -
279 Ranitidin 150 mg tablet 500 500 1,000
Retinol (vitamin A) kaps lunak
280 kapsul lunak -
100.000 UI
Retinol (vitamin A) kaps lunak
281 kaps lunak -
200.000 UI
282 Rifampisin 300 mg kapsul -
283 Salbutamol 2 mg tablet 100 200 300
284 Salbutamol 4 mg tablet -
285 Salbutamol lar ih 0,5 % botol -
286 Salbutamol botol ih 0,1% botol -
Salep 2-4, kombinasi : asam
287 tube -
salisilat 2% + belerang endap 4%
Serum antidifteri (A.D.S) i.m
288 vial -
10.000 UI/vial
Serum antidifteri (A.D.S) i.m
289 vial -
20.000 UI/vial
290 Serum antirabies inj 200 UI/mL vial -
291 Serum antirabies inj100 UI/mL vial -
Serum antitetanus (A.T.S) inj 1500
292 ampul -
UI/amp (i.m.)
Serum antitetanus (A.T.S) inj
293 vial -
10.000 UI/vial (i.m /i.v.)
Serum antitetanus (A.T.S) inj
294 vial -
20.000 UI/vial (i.m /i.v.)
295 Setirizin 5 mg/5 mL botol -
Sianokobalamin (vitamin B12) 50
296 # tablet 2,500 2,500
mcg
Sianokobalamin (vitamin B12) 500
297 ampul -
mcg/mL
298 Simvastatin 10 mg tablet salut 600 600
299 Simvastatin 20 mg tabet salut -
300 Siprofloksasin 500 mg tablet scored 600 600
301 Spironolakton 25 mg tablet -
302 Streptomisin 1000 mg/vial vial -
303 Surgical ginggival pack pasta -
304 Tetanus toxoid vial -
305 Tetrakain 0,5% botol -
306 Tetrasiklin 250 mg kapsul -
307 Tetrasiklin 500 mg kapsul -
308 Tiamin (vitamin B1) 50 mg tablet 4,000 4,000
309 Triheksifenidil 2 mg tablet -
Tuberkulin protein purified
310 ampul -
derivative 1:10 (i.k.)
311 Vaksin BCG vial -
312 Vaksin campak vial -
Vaksin jerap difteri tetanus
313 vial -
pertusis (DTP)
314 Vaksin jerap difteri tetanus (DT) vial -
Vaksin jerap tetanus (tetanus
315 vial -
adsorbed toxoid
Vaksin kombinasi DPT + hepatitis
316 vial -
B
317 Vaksin polio botol -
318 Vaksin rabies, untuk manusia vial -
319 Valproat 250 mg tablet salut -
320 Valproat 500 mg tablet salut -
321 Valproat 250 mg/5 mL botol -
322 Vitamin B kompleks tablet 2,700 700 3,400
323 Zinc 10 mg/mL botol -
324 Zinc 20 mg tablet disp 300 500 800
325 Zinc 20 mg/5 mL botol -
326 Zinc 10 mg sachet -

Mengetahui,
Kepala Puskesmas
Kelurahan ................................

NIP.
DAN LEMBAR PERMINTAAN OBAT (LPLPO)

: BULAN AGUSTUS 2017 DOKUMEN NOMOR TGL


DINKES
IF KAB/KOTA
PUSKESMAS

PEMBERIAN
STOK AKHIR PERMINTAAN
APBD I APBD II DAK PROGRAM LAIN-LAIN JUMLAH
8 9 10 11 12 13 14 15 16=11+12+13+14
- - -
- -
- -
- -
- -
100 600 500
- -
- -
- -
- -
- -
- -
- -
540 150 1,200
2,600 2,400 4,100
- -
- -
- -
- -

1,000 4,500 - 2,000

- -

- -

10 20 5

- -

- -
- -
- -

- -

- 400 - 400
- 960 2,000 - 4,400

- -
- 1,000 1,000 - 3,500
- -
- -
- 700 1,300 - 3,050
- -
- -
- -
200 500
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- 16 - 16
2,000 5,000
- -
- -
- -
- -
- -
- -
- -
- -
- -
- 300 - 300
- 200
200 500 300
- -
- -
- -

- -
- -
- 600 - 600
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

- -
- -
- -
- -
- 200 - 200

- -
- -
- -
- -
- -
- -
- -
- -
- -

- 400 - 400

- -

- -

- -

- -
200 700 - 200
- -
- -
- -
- -
- -
- -
- 700 - 700

- -

- -

- -
- -
- -
- -
- -
- -
- -
- -
- 3
- -
100 400 - 150
72 180
-
- -
- -

- -
100 2,400 - 2,150
- -
- -
- -
- -

- -
- -
- -
- 400 - 400
- -
- -
- -
- -
1,500 700 3,050
200 300 1,000
1,500 2,000
- -
- -
- -
24 24 48
- -
- -
100 250
- -
300 700 50
- -
- -
- -
- -
- -
2,500 6,250
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

- -

- -
- -

- -

- -

- -

- -

- -

- -

- -

- -

- -

- -
- -

- -

50 100

300 1,200 500

- -

- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

- -
400 200 1,000
- -
- -
- -
- -
- -
- -
- 500
- -
- -
- -
- -
- 200
- -
- -
450 1,000
- -
- -
- 100 - 100
- -
- -
- -
- 100
- -
- 100 - 100
- -
- -
- -
- -
- -
- -
- -
60 150 100
- -
- -
4,500 6,500 4,750
- -
- -
- -
- -
- -
- 5
- 10
- -

- -
- -
- -
- -
800 500 1,500
- -
- -
- -
- -
- -
- 500
- -
- -
- -

- -
- -
- -
1,000 2,500
- -

- -
- -
300 750
- -
- -
- -
- -

- -

- -
- -
- -
- -

- -

- -
- -
1,200 1,300 2,000
- -
60 540 - 390
- -
100 500 - 250
- -
- -
- -
- -
- -
- -
- -
- 4,000 - 4,000
- -
- -
- -
- -
- -
- -
- -

- -
- -
- -
- -
- -
- -
1,700 1,700 2,550
- -
400 400 600
- -
- -

Jakarta, ......................... 2017


Yang Membuat,
Koordinator Instalasi Farmasi

No. SIKTTK : ...........................................................


TIDAK MAMPU
KETERANGAN
DILAPORKAN
LAPORAN PEMAKAIAN DAN LEMBAR PERMIN

PUSKESMAS : PKM KELURAHAN ..........................................


KECAMATAN : KEBAYORAN LAMA
KAB/KOTA : JAKARTA SELATAN
PROPINSI : DKI JAKARTA

KODE
NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN
OBAT

1 2 3 4 5 6
1 Acyclovir Injeksi Vial
Alumunium Hidroksida, Magnesium Hidroksida ,
2 Botol
Simethicone
3 Ambroksol Drop 7.5 Mg/ml Botol
4 # Ambroksol Syr 15mg/5ml 60 Ml Botol
5 Ambroksol Syr 30mg/5ml 60 Ml Botol
6 # Ambroksol Tablet 30 Mg Tablet 3,000
7 Amiodaron inj 150 mg/3 ml Ampul
8 Amoksisilin 125 mg + Kalium Klavulanat 31,25 mg sirup Botol
9 Amoksisilin 250 mg + Kalium Klavulanat 62,5 mg sirup Botol
10 Amoksisilin 500 mg + Kalium klavulanat 125 mg Tablet
11 Ampisilin 1 gram + Sulbaktam 500 mg injeksi Vial
12 Ampisilin 500 mg + Sulbaktam 250 mg Vial
Amylase, protease, lipase, desoxycholic acid,
13 dimethylpolysiloxane, vit B1, vit B2, vit B6, vit B12, Tablet
niacinamide, Ca pantothenate tablet
14 # Antalgin Tablet 500 Mg Tablet 1,300
Antibakteri, kombinasi : basitrasin 500 UI/g+ Polimiskin
15 # Tube
B 10.000 UI/g
16 Antidulafungin 100 mg injeksi Ampul
17 Aripiprazol 10 mg tablet Tablet
As.Folat, ß-Carotene, Vit.B1, B2, B6, Ca.Pantothenate,
18 Ca carbonate, vitamin D3, vitamin K1, biotin, besi Tablet
glukonat, IPC, DHA, ARA
19 Asam Risedronic tablet 35 mg Tablet
20 # Asam traneksamat tab 500 mg Tablet
21 Asefillin Piperazine injeksi 500 mg/5 ml Ampul
22 # Asiklovir Krim 5 % Tube 100
23 Astasantin kapsul Kapsul
24 Atorvastatin 10 Mg Tab Tablet
25 Atorvastatin 20mg tab Tablet
26 Azitromisin 500mg inj Vial
27 Besi II Sulfat , Folic acid, Magnesium, Vit A, Copper, vit B botol

Beta karoten 6000 IU, Extract billberry 80 mg, Vitamin C


28 Biovision 100 mg, Vitamin E 25 mg, Lutein 3 mg, Lycopene 2 mg, Tablet
Zn 10 mg
29 Betametason valerat 0,1 % + neomisin sulfat 0,5 % Tube
30 Betamethasone valerate 0.1% + gentamicin sulfate 0.1% Tube
31 Bisoprolol 1.25 mg tablet
32 # Borak Glyserol 5 % larutan Botol 48 24
33 Bromheksin HCl 4 mg/2ml injeksi Ampul
34 Bromheksin HCl Elixir 4 Mg/5 Ml 60 Ml Botol
35 # Bromheksin HCl Sol 2mg/ml 50 Ml Botol
36 # Bromheksin HCl Tablet 8 Mg Tablet
Cacl anhidrat 0.075 gram, kalium iodida, 0.075 gram,
37 Botol
natrium tiosulfat 0.005 gram, fenilmerkuri nitrat 0.3 mg
38 Carbazochrome Na Sulfonate Injeksi Ampul
39 celecoxib 100 mg Tablet
40 celecoxib 200 mg Tablet
41 Cetirizine Drop Botol
42 Chlorhexidine Botol
43 Citicoline 500 Mg/ 4Ml, Injeksi Ampul
44 Clidinium Br 2.5 Mg, Chlordiazepoxide 5 Mg. Tablet
45 Curcuma Root Sirup Botol
46 Curcumaminoid, B1, B2, B6, B12, B caroten Tablet
Deksametason 0,1%, Neomisin sulfat 3,5 mg, Polimiksin-
47 # InMatrol Botol
B-Sulfat 6000 UI tetes mata
48 Deksketoprofen injeksi 50 mg Ampul
49 Deksketoprofen tablet 25 mg Tablet
50 Dekspanthenol krim 5 % Tube
51 # Apolar Desonide Krim 0,05 % Tube
Dexamethasone/Deksametason 0,1 %, Neomisin sulfat
52 Strip
3,5 mg/mL, Polimiksin B sulfat 6000 iu/mL.
53 Dextromethorphan, maleate, phenylephrine sirup Botol
54 Diazepam 2 mg + Metampiron 500 mg Tablet
Dibasic Ca phosphate 200 mg, Ca lactate 100 mg, vit B6
55 Tablet
20 mg, vit C 25 mg, vit D3 100 IU tablet
56 Dibekacin Vial 100 mg/2 ml Ampul
57 Dibekacin vial 50 mg/ 2 ml Ampul
58 Diosmin 450 mg + hesperidin 50 mg tablet Tablet
Drop per ml : Isothipendyl HCl 1 mg, acetaminophen 120
59 Botol
mg, phenylephrine HCl 1 mg
60 # Efedrin HCl tablet 25 mg Tablet
Bioplacent
61 Ekstrak plasenta 10 %, neomisin sulfat 0.5 % Gel Tube
on
ekstrak plasenta 15 mg, Vitamin B12 20 mcg, dan
62 Tablet
tribasic calcium phosphate 12 mcg.
63 Elemen Besi + Asam Folat oral drop 15 mg/ml Botol
64 Entecavir 0.5 mg Tablet
65 Eperisone Tablet Tablet
66 Erdosteine sirup 175 mg/5 ml Botol
67 Estazolam Tablet 2 Mg Tablet
68 Ethamsilat injeksi 250 mg Ampul
69 Etoricoxib tab 60 mg Tablet
70 Flavoxate hidroklorida 200 mg Tablet
71 Florometolon 1 mg + Neomisin sulfat 3.5 mg/ml Botol
fludrocortisone, lidocaine, neomysin, polymiksin B tetes
72 Ottopain Botol
telinga
73 Flunarizin tablet 10 mg Tablet
74 Flunarizin tablet 5 mg Tablet
75 Fluorometolon tts mata 0,1% Botol
76 Fosfomisin Vial 2 G Vial
77 Fradiomisin Sulfat 2,5 mg, Gramisidin-S HCl 1 mg tablet Tablet
78 Fructus schizandrae extract siccum 7,5mg Kapsul
79 Gatifloxacin tetes mata Botol
80 Gentamisin tts mata 0,3% Botol
81 # Otogenta Gentamycin Salep Kulit Tube 24
82 # Gentian Violet Larutan 1 % Botol
83 Guafenisin Gliseril guaiakolat 100 mg Tablet 1,200
84 Glucosamin Hcl 500 Mg + Kondroitin Sulfat 400 Mg Kaplet
85 Glucosamin Tablet 250 Mg Tablet
86 Glucosamin tablet 500 mg Tablet
Glucosamine sulphate 500 mg, chondroitin sulfate 400
87 mg, vit C 50 mg, manganese 0.5 mg, Mg 10 mg, Tablet
selenium 10 mcg, Zn 5 mg, MSM 350 mg tablet
88 Glukosa 40% Vial
89 Granisetron injeksi 3 mg Ampul
Hidrokortison 0.5 % + Kloramfenikol 0.2 % salep mata
90 Tube
3,5 g
91 Hiosina butilbromida tab 10 mg Tablet
92 Hyoscine-N-butylbromide 10 mg, Paracetamol 500 mg Tablet
93 # Hyoscine-N-butylbromide 20 mg/ml injeksi Ampul
94 Ibuprofen Supp 125mg Suppos
95 # Ichtyol salep ( salep hitam ) pot 30
96 ilberry extract,gliserin,gelatin,minyak sayur Botol
97 Imipenem Cilastatin Vial 1 G Vial
Ion Natrium & Kalium dengan Benzalkonium Cl tetes
98 Botol
mata
99 Isoksuprin Hcl Ampul
100 Isoksuprine Tablet 20 Mg Tablet
101 Itraconazole Kapsul 100 Mg Kapsul
102 # Kalium Diklofenak 25 mg tablet Tablet
103 # Kalium Diklofenak 50 Mg Tablet Tablet
104 # Kalium Permanganat ( PK ) pot
105 # Diaform Kaolin + pektin tablet Tablet
Kaplet mengandung:Acetaminofen 500 mg, Gliseril
106 guaiacolat 50 mg, Fenilpropanolamin HCl 15 mg, Kaplet
Dekstrometorfan HBr 15 mg, Chlorfeniramine maleat
107 Karbazochrom 50 Mg/10 Ml Inj Ampul
108 # Cenfresh Karboksimetilselulosa 5 mg tetes mata mini dose 0,6 Ml strip
109 Ketoacid essensial Tablet
110 Ketoprofen Tablet 100 Mg Tablet
111 Ketorolac injeksi 10 mg/ml Ampul
112 Ketorolac tablet 10 mg Tablet
113 Ketotifen sirup 0,2 mg/ml Botol
114 Ketotifen tablet 1 mg Tablet
115 Klobetasol 10 G Krim Tube
116 Klobetasol Propionat salep tube
117 Reco Kloramfenikol tts mata 1% Botol 25 25
118 Amacort Kloramfenikol 2% + Hydrokortison 2,5% krim Tube
119 Kloramfenikol Basa + Prednisolone krim Tube
120 Reco Kloramfenikol tetes telinga 3 % Botol 25 25
121 Kloramfenikol tts mata 0,5% Botol
122 Kodein 30 mg + feniltoloksamin 10 mg Botol
Tablet
Setiap tablet tambah darah SEKURANGNYA
tambah
mengandung Zat besi setara dengan 60 mg besi
123 darah Tablet 1,100 1,000
elemental (dalam bentuk sediaan Ferro) Asam folat
WHO
0,400 mg
sachet
124 Prenase Kombinasi Fe, Asam folat, Vitamin B Kapsul
125 Kombinasi Metampiron 500 mg + Vit B tablet Tablet
126 Laktulosa Kombinasi Suspensi Parafin+Gliserin+Fenolftalein Botol
127 Kortison Acetat Inj 5 ml Vial
128 Lactobacillus serbuk Sachet
129 Larutan mengandung Lipid (Emulsi lemak 20%) Botol
Lecithin 100 mg + Serratiopeptidase 5 mg + pancreatin
130 Kapsul
25 mg kapsul
131 Nikomisin Lincomycin 500 MG Kapsul 450
132 Linezolid infus 600 mg Botol
133 Loratadine 5 mg, pseudoephedrine sulfate 120 mg Tablet
134 L-Ornithine-L-Aspartate injeksi 500 mg/ml Ampul
135 Mekobalamin 500 Mcg Kapsul
136 Mekobalamin 250 Mcg Kapsul
137 Mekobalamin Injeksi Ampul
138 Meloksikam Tablet 15 Mg Tablet
139 Meloksikam Tablet 7,5 Mg Tablet
140 Menadion ( Vit K 3) Amp 10 mg/ml Ampul
Metampiron 500 mg + Thiamin HCl50 mg + Pridoksin
141 HCl 10 mg + Sianokobalamin HCl 10 mcg + Tablet
Trimetilsantin 50 mg tablet (Neuralgin)
142 Methisoprinol 250 mg/5 ml sirup 60 ml Botol
143 Methisoprinol Tablet 500 Mg Tablet
Methyl salicylate 102 mg, menthol 54.4 mg, eugenol 13.6
144 # Molakrim Tube
mg salep
145 Metronidazole 500 mg + nystatin 100.000 iu ovula Ovula
146 Metronidazole Inj Botol
Micobacterium Tuberculosisi 0,4 mcg + disodium fosfat
147 7,6 mg+Potasium fosfat 1,45 mg +sodium klorida 4,8 mg Vial
(PPD RT23)
148 Milrinone injeksi Vial
149 # Cystol Misoprostol Tablet 200 Mcg Tablet
150 Moksifloksasin tts mata 0,5% Botol
151 Multivitamin + Lysine Drop botol
152 Novakids# Multivitamin + Lysine Sirup Anak Botol
153 Multivitamin + Lysine Sirup Anak Botol
154 Mupirosin Krim Tube
155 Na Hyaluronat 0.1% tetes mata Botol
Na lauril sulfoasetat 45 mg, Na sitrat 450 mg, asam
156 Tube
sorbat 5 mg, PEG-400 625 mg, sorbitol 4.465 mg
157 NaCL 0,9% 100 ml Botol
158 NaCL 0,9% 1000 ml botol
159 Naftidrofuryl Oxalate tablet 100 mg Tablet
160 Natium diklofenak tetes mata 1 mg Botol
161 Natrium diklofenak gel 1% Tube
162 Natrium dokusate tetes telinga 5 mg Botol
Neomisin 3,5 mg + Polimiksin 16.250 IU + Fenilefrin 1,2
163 Botol
mg + asam borat 1,769 mg/ ml tetes mata
Neomisin sulfat 3,5 mg + polimiksin B sulfat 10000 iu +
164 Botol
deksametason sodium fospat 1 mg tetes mata

neomycin sulfate setara dengan neomycin base 3.5 mg


165 polymixin b sulfate 10000 iu dan dexamethason sodium Botol
phosphate 1 mg
166 Nifuroksazide sirup 250 mg/5 ml Botol
167 Nistatin 100.000 IU 12 ml drop Botol
168 Nitrogliserin injeksi 10 mg Ampul
169 Norephineprine injeksi Ampul
170 Noretisteron tab 5 mg Tablet
Obat Batuk Pilek Sirup Anak (Mengandung
171 Botol
Pseudoefedrin, Tanpa Parasetamol)
172 Babycough Obat Batuk Pilek Sirup Anak (Mengandung Parasetamol) Botol
173 # OBH sirup 100 ml Botol
174 Ofloksasin 2 Mg/ml Infus 100 Ml bag
175 Ofloksasin 3 mg tetes mata mini dose 0.6 ml strip
176 Ofloxacin 3mg/ml tetes telinga Botol
177 # Oksitetrasiklin Salep Kulit 3 % Tube
178 Ossein hydroxyapatite compound tablet 800 mg Tablet
179 Otilonium Br Tablet
180 Oxytetrasiklin salep Kulit Tube
181 # Oxytetrasiklin salep mata Tube 25
182 Pantoprazole Injeksi 40 Mg Vial
183 Pantoprazole kapsul 20 mg Kapsul
184 # Papaverin 40 mg tablet Tablet 400
Paracetamol 500mg, Phenylpropanolamine HCl 12,5mg,
185 Tablet
chlorpheniramine maleate 2mg
186 Parasetamol 500 mg + n-asetilsitein 200 mg tablet Tablet
187 # Parasetamol Rectal Tube 125 mg Tube 5
188 # Parasetamol Rectal Tube 250 mg Tube
189 Parasetamol supp 125 mg Suppos
190 Parasetamol supp 160 mg Suppos
191 Parasetamol supp 240 mg Suppos
192 Parasetamol supp 250mg Suppos
193 Parekoksib injeksi 40 mg/2 ml Ampul
194 Piperacillin 4 g, tazobactam 500 mg injeksi Vial
195 PIRASETAM 12gr 60ml infus Vial
196 PIRASETAM 1gr injeksi Ampul
197 Pirasetam Amp 3 G Ampul
198 Pirasetam tablet 1200 mg Tablet
199 Pirenoxin Sodium 0.05 mg/ml tts mata Botol
200 Piroksikam 15 mg gel Tube
201 # Piroksikam Tablet 10 Mg Tablet 700 500
202 # Piroksikam Tablet 20 Mg Tablet
Polimiksin B sulfat 10.000 UI, Neomisin sulfat 5 mg,
203 Ampul
Fludokortison asetat 1 mg, Lidokain HCl 40 mg
204 Polivinilpirolidon 20 mg tetes mata Botol
Polymixin b-sulfat 1.000.000 IU, Neomisin sulfat 0.5 mg,
205 # Ottopain Fludokortison asetat 100 mg, Lidokain HCl 4 g, PEG, Botol
Gliserin Tetes telinga
206 Povidon Iodine Gargle 1% Botol
207 Pregabalin kapsul 150 mg Kapsul
208 Pregabalin kapsul 75 mg Kapsul
209 Preparat optalmik tetes mata Botol
210 Pseudoefedrin 7,5 mg Drop Botol
Pseudoefedrin HCL 15 mg + Terfenadine HCl 20 mg/ml
211 Botol
sirup
212 Pseudoefedrin HCl 30 mg + Terfenadin 40 mg Tablet
213 Pseudoefedrin Hcl 60 mg + Loratadin 5 mg Tablet
Pseudoephedrine Hcl 15 mg + klorfeniramin maleat 1 mg
214 Botol
sirup
Pseudoephedrine HCl 30 mg + Brompheniramine maleat
215 Botol
2 mg/5 ml sirup
216 Pseudoephedrine Hcl 30 mg, Triprolidine 2,5 mg tab Tablet
Pure lecithin (PPC 95%) 300 mg, vit B1 6 mg, vit B2 6
217 mg, vit B6 6 mg, vit B12 6 mcg, vit E 10 mg, nicotinamide Kapsul
30 mg kapsul
218 Ranitidin sirup 75 mg/5 ml Botol
219 Rebamipide 100 Mg Tablet Tablet
Recombinan hepatitis B inj 10 mcg/0.5 mL (syringe) 0.5
220 Ampul
mL
221 Rocuronium Bromide Vial
222 Ropivacain hidroklorida injeksi 2 mg/ml Vial
223 Salbutamol sulfat injeksi 0,5 mg/ml Vial
224 # Sefiksim kapsul/kaplet 200 mg Kapsul
225 Sefoperazone + Sulbactam Vial 1 G Vial
226 Sefotiam dihidroklorida 1 gram injeksi Vial
227 Setirizine tetes 10 mg/ml Botol
228 Sianokobalamin (vitamin B12) tab 50 mcg Tablet
229 interflox# Siprofloksasin 3 mg/ml tetes mata Botol
230 Sitikolin Amp 1000 mg/8 ml Ampul
231 Sitikolin Amp 125mg/ml 2ml Ampul
232 Sitikolin Tablet 1000 Mg Tablet
233 Sitikolin Tablet 500 Mg Tablet
234 Sodium Klorida Semprot Hidung Botol
Monoammonium glycyrrhizinate (sebagai glycyrrhizin) 4
mg
235 Ampul
Aminoacetic acid 40 mg
L-cystein hydrochloride 2 mg Injeksi
236 Sulpirida tablet 200 mg Tablet
237 Sulpirida tablet 50 mg Tablet
Tablet Flu Batuk Bromheksin, Difenhidramin,
238 Tablet
Parasetamol

Tetes Mata CaCl2 anhidrat 0.075 gr, Kalium iodida 0.075


239 Botol
gr, Na Tiosulfat 0.005 gr, Fenilmerkuri nitrat 0.3 mg

240 # Cenfresh Tetes Mata HPMC 5 mg, Dextran 70 1 mg, Gliserin 2 mg Strip
241 Thiamphenicol sirup 125/5ml Botol
242 # Tiamfenikol kapsul 500 mg Kapsul
Thrombhop
243 Tiap 100 gram mengandung Heparin sodum 20.000 IU Tube
ob
244 Tigesiklin injeksi 50 mg/5ml Vial
245 Tizanidine tablet 2 mg Tablet
246 Tobramisin 3 mg + Deksametason 1 mg mini dose/ml Strip
247 Tobramisin 3 mg + dexamethason 1 mg/ml tetes mata Botol
248 Tramadol 37,5 mg + Parasetamol 325 mg Tablet
249 # Tramadol Kapsul 50 Mg Kapsul
250 Tramadol supp 100 mg Suppos
251 Trimetazidine hidroklorida tablet 35 mg Tablet
Tripolidin HCl 2mg,Pseudoefedrin HCl 30 mg,
252 Tablet
Parasetamol 500 mg tablet
253 Vekuronium bromida Vial 10 Mg Vial
254 Vekuronium bromida Vial 4 Mg Vial
255 Vit A palmitate, karbomer gel 10 gram Tube
256 Vit B1 100 mg, B6 200 mg, B12 200 mcg injeksi Ampul
Vit B1 100 Mg, Vit B6 50 Mg, Vit B12 100 Mcg, Vit E 30
257 Tablet
Iu.
258 Vit B1 100 mg,vit B6 100 mg, vit B12 5000 mcg Ampul
259 Vit B1 100mg + Vit B6 100mg + Vit B12 5000ug tablet Tablet
#
260 Vit B1 100mg + Vit B6 200mg + Vit B12 200ug tablet Tablet
Idaneuron
261 # Pritavit Vit B1, B2, B6, B12, Vit C 500Mg, Ca Pantotenate tablet Tablet 200
Vitamin A 4000 IU, C 50 mg, D 400 IU, E 10 mg, B1 3mg,
B2 3 mg, B6 2 mg, B12 2 mcg, B3 20 mg, Ca pantotenat
262 5 mg, Asam folat 1 mg, Biotin 0.1 mg, Fe fumarat 20 mg, Tablet
Ca 100 mg, Cu 0.5 mg, Mn 0.5 mg, Mg 1 mg, Zn 0.25 mg
tablet
263 Vitamin B1 100 Mg Tab (Thiamin/Aneurin Hcl) Tablet
264 Vitamin C injeksi 200 mg/ ml Ampul
265 Vitamin C injeksi 500 mg/5 mL Ampul
266 YAL JELLY SOLUTION Botol
267 .......

1 Amoksisilin kapsul 250 mg Tablet


2 Amoksisilin sir 125 mg/5ml Botol
3 Ampisilin kaplet 500mg Tablet
4 Aqua pro injeksi steril, bebas pirogen Vial
5 # Urinter Asam Pipemidat tab 400 mg Tablet
6 Asam Traneksamat Injeksi 10mg/ml AMP
7 Asetilsistein TAB
8 Azitromisin tab 500mg Tablet
9 Betahistin Mesilat tab 6 mg Tablet 120
10 Betametason Krim 0,1% Tube
# Pulmicort
11 Budesonid susp for ihalation 0,5mg/ml FLAC
Respules
12 Cairan Ringer Laktat steril 500ml Kolf 1
13 Diazepam inj 10 mg/mL (i.v./i.m.) vial
14 Domperidon syrup 5mg/5ml Botol
# Berotec
15 Fenoterol Hbr 0,1% for Inhalation larutan 50 ml BTL
Inh
16 Flukonazol kapsul 150 mg TAB
17 Gemfibrozil kapsul 300 mg TAB
18 Gentamisin Injeksi 40 mg/2 ml Vial
19 Hidrokortison Krim 2,5% Botol 72
20 Kanamisin Sulfat Injeksi 1000 mg Vial
21 Karbo Gliserol tetes telinga 10% Botol
22 # Ketokonazol Krim 2% Tube
23 Ketoprofen Suppos Supp
24 Klindamisin kapsul 300 mg capsule 300
25 Klobazam tablet 10 mg (Frissium) Tablet
26 # Klozapin tab 25 mg Tablet
27 # Novadiar Kombinasi Kaolin Pektin sir. Botol
Kombinasi tablet Influenza dengan Parasetamol (Kaplet
28 # Nodrof mengandung: Acetaminofen 500 mg, Fenilpropanolamin tablet 200
HCl 15 mg)
29 Larutan Glukosa 10% 500ml BTL
30 Larutan Glukosa 5% steril 500ml Botol 3
31 Larutan NaCl 0,9% Steril 500ml Botol 6
32 Loperamide Tablet
33 # Dopamet Metildopa tablet 250 mg tablet
34 Metilprednisolon tab 16 mg TAB
35 Metilprednisolon tab 4 mg Tablet
36 Metoklopramid Injeksi Ampul
37 # Levertran Minyak Ikan Salep 10 % POT
38 # Aptyl Polikresulen botol
39 Ranitidin Injeksi 25 mg/2 ml Ampul
40 Rifampisin Kapsul 450 mg Kapsul
41 Risperidon Tablet 2 mg TAB
42 Sakarin pemanis tablet tablet
43 Salbutamol 200 mcg for rotacaps tablet
44 # Ventolin Salbutamol sulfat nebules 2,5mg/ml BTL
45 Sefadroksil Kaps 500 mg Kapsul 100
46 Sefotaksim serbuk injeksi 1000 mg Vial
47 Seftriakson serbuk injeksi 1000 mg Vial
48 Setirizine kapsul 10 mg Kapsul
49 Simetidin tablet 200 mg Tablet
50 Trifluoperazin tab 5 mg (Stelazin) Tablet
51 Vitamin A tab 6000 IU Tablet
52 Whitefield Salep POT

Mengetahui,
Kepala Puskesmas Kelurahan ................................

NIP.
AIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PELAPORAN : BULAN AGUSTUS 2017 DOKUMEN NOMOR TGL


PERMINTAAN DINKES
IF KAB/KOTA
PUSKESMAS

PEMBERIAN
PERSEDIAAN PEMAKAIAN STOK AKHIR
PERMINTAAN
APBD I APBD II DAK PROGRAMLAIN-LAIN
7 8 9 10 11 12 13 14 15
- - -
- - -
- - -
- - -
- - -
3,000 2,000 1,000 5,000
- - -
- - -
- - -
- - -
- - -
- - -

- - -

1,300 500 800 500


- - -
- - -
- - -

- - 500

- - -
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- - -
100 50 50 100
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- - -

- - -
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72 24 48 48
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- - -
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- - -
- - -
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- - -
- - -
- - 10

- - -
- - -
- - -
- - 300
- - -
- - -
- - -
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- - -
- - -
- - -
- - 300
- - -
- - -
- - -
- - -
- - -
- - -
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24 24 100
- - 50
1,200 1,200 3,000
- - -
- - -
- - -

- - -
- - -
- - -
- - -
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- - -
- - -
- - -
30 - 30 - 30
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- - -
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- - -
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- - - 1,000
- - -

- - -

- - -
- - 3
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- - -
- - -
- - -
- - -
- - -
- - -
50 25 25 50
- - -
- - -
50 25 25 50
- - -
- - -

2,100 1,700 400 3,850

- - -
- - -

- - -
- - -
- - -
- - -
450 60 390 -
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- - -
- - 120
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- - -
- - -
- - 100
- - -
- - -
- - 100
25 25 100
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400 200 200 300
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5 5 13
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- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
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1,200 400 800 1,000
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- - -

- - -
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- - -
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- - 3
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- - -
- - -
200 100 100 150

- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - 120
- - -
- - -
- - -
- - -
- - -
- - -
120 120 500
- - -
- - -
1 - 1 4
- - -
- - -
- - -
- - -
- - -
- - -
72 72 200
- - -
- - -
- - 200
- - -
300 - 300 - 300
- - -
- - -
- - -

200 100 100 150

- - -
3 - 3 - 3
6 1 5 - 3
- - -
- - -
- - -
- - -
- - -
- - 50
- - 5
- - -
- - -
- - -
- - -
- - -
- - -
100 100 250
- - -
- - -
- - -
- - -
- - -
- - -
- - 100
- - -

Jakarta, ......................... 2017


Yang Membuat,
Penanggung Jawab Farmasi

No. SIKTTK : ...........................................................


TIDAK MAMPU
KETERANGAN
DILAPORKAN
JUMLAH
16=11+12+13+14
0
LAPORAN PEMAKAIAN ALAT KESEHATAN HABIS PAKAI
PUSKESMAS : PKM KELURAHAN .............................. PELAPORAN : BULAN AGUSTUS 2017
KECAMATAN : KEBAYORAN LAMA PERMINTAAN : -
KAB/KOTA : JAKARTA SELATAN
PROPINSI : DKI JAKARTA

KODE HARGA
NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
OBAT SATUAN

1 2 3 4 5 6 7
ALAT KESEHATAN HABIS PAKAI

1 ABBOCATH 18 PCS 8,700 -


2 ABBOCATH 20 PCS 8,700 -
3 ABBOCATH 22 PCS 8,700 -
4 ABBOCATH 24 PCS 8,700 -
5 ABBOCATH 26 (NEOFLON) PCS 17,000 -
6 ADHESIVE TAPE FOR STERILISATION ROLL 64,648 -
7 ALAT SUNTIK DISP 0,5 ML PCS 957 -
8 ALAT SUNTIK DISP 20 ML PCS 3,080 -
9 ALAT SUNTIK DISP 3 ML PC 1,138 200 200
10 ALAT SUNTIK DISPOSIBLE 10 CC FLS 6,500 -
11 ALAT SUNTIK SEKALI PAKAI 1 ML SET 1,614 113 113
12 ALAT SUNTIK SEKALI PAKAI 2,5 ML SET 1,265 -
13 ALAT SUNTIK SEKALI PAKAI 5 ML SET 1,600 200 200
14 BISTURI PCS 2,070 -
15 CAT GUT 100 M Roll 925,000 -
16 CAT GUT CHROME NO. 3/0 HR 26 MM SACH 32,800 -
17 CAT GUT CHROME NO. 3/0 HR 30 MM PCS 34,170 -
18 CAT GUT PLAIN NO. 3/0 HR 26 MM SACH 34,300 -
20 CATETER NELATON pcs 4,100 -
21 FOLLEY CATHETER PCS 19,000 -
22 INFUSION SET ANAK SET 10,406 - -
23 INFUSION SET DEWASA SET 7,321 2 2
24 INHALER ROTACAPS PCS 5,000 -
25 JARUM AKUPUNTUR 20X15 BOX -
26 JARUM AKUPUNTUR 25X25 BOX -
27 JARUM AKUPUNTUR 25X30 BOX -
28 JARUM AKUPUNTUR 25X40 BOX -
29 JARUM AKUPUNTUR 25X50 BOX -
30 JARUM AKUPUNTUR 30X40 BOX -
JARUM JAHIT (BEDAH) KULIT NO.9 S/D
31 BH 27,000 -
14
JARUM JAHIT (BEDAH) OTOT NO.9 S/D
32 -
14
33 JARUM TINDIK BOX 42,900 -
KANTONG PLASTIK KLIP ETIKET 13 x 8,7
34 LB -
CM
KANTONG PLASTIK KLIP ETIKET 15 x 10
35 PACK 13,636 -
CM
PAK 100
36 KANTONG PLASTIK BINTANG 10,000 -
LMBR
37 KANTONG PLASTIK KLIP LB 136 -
KANTONG PLASTIK KLIP ETIKET 7 x 10
38 PACK 6,000 -
CM
KAPAS PEMBALUT/ABSORBEN 250
39 ROL 24,000 1 5 6
GRAM
40 KASA 5 x 75 CM ROL 10,000 -
41 KASA GULUNG ± 40 YARD x 80 CM ROL 130,000 2 2
42 KASA KOMPRES 40/40 STERIL ROL 4,600 -
43 KASA PEMBALUT 2M X 80 CM ROL 9,400 -
44 KASA PEMBALUT 4M X 15 CM ROL 3,800 10 10
45 KASA PEMBALUT 4M X 3 CM ROL 3,066 -
46 KASA STERIL 16 x 16 CM PACK 7,900 -
47 KERTAS ECG ROL 90,000 -
48 KERTAS PH PAK 70,000 -
49 KERTAS POWDER PACK 13,636 -
50 KERTAS PUYER PAK 44,400 -
51 LANCET PCS -
52 MASKER EARLOP (KARET) LBR 609 10 10
53 MASKER EARLOP 3 PLY PCS 609 10 10
54 MASKER N95 PCS 19,500 -
55 MASKER NEBULIZER ANAK PCS -
56 MASKER NEBULIZER DEWASA PCS -
57 MASKER OKSIGEN ANAK PCS 19,800 -
58 MASKER OKSIGEN DEWASA PCS 19,800 -
59 MASKER TIE ON (TALI) PCS 609 -
60 MASKER WITH VISOR PCS -
61 MICROPORE 0,5 INCHI PCS 10,953 -
62 MICROPORE 1 INCHI PCS 18,086 2 2
63 MICROPORE 2 INCHI PCS 32,934 -
64 NEEDLE 18 PCS 560 -
65 NEEDLE 24 PCS 560 -
66 NEEDLE 27 PCS 560 -
67 OKSIGEN NASAL CANUL DWS PCS 28,000 -
68 OKSIGEN NASAL CANULA PED PCS -
69 PENENG BAYI (Biru n Pink) PCS 1,078 -
70 PENJEPIT TALI PUSAT PCS 2,750 -
71 PLESTER 4X1.25 -
72 PLESTER ANTI AIR UK. 10 CM X 5 M -
73 POT PLASTIK 50 GRAM POT 550 -
74 POUCHES STERICLIN FLAT 15 CM/200M ROLL 1,266,000 -
75 POUCHES STERICLIN FLAT 20 CM/200M ROLL 1,538,000 -
76 POUCHES STERICLIN FLAT 5 CM/200M ROLL 755,000 -
POUCHES STERICLIN GUSSETS 20X5
77 ROLL 1,271,000 -
CM/200M
78 ROTAHELER VENTOLIN BTL 6,550 -
79 SARUNG TANGAN L PCS 462 300 300
80 SARUNG TANGAN M PCS 462 400 300 700
81 SARUNG TANGAN NITRIL UK. M BOX 62,700 -
82 SARUNG TANGAN NITRIL UK. S BOX 62,700 -
83 SARUNG TANGAN OBGYN PCS 13,500 -
84 SARUNG TANGAN S PCS 462 300 300 600
85 SARUNG TANGAN STERIL NO. 6,5 PCS 6,325 -
86 SARUNG TANGAN STERIL NO. 7 PCS 10,720 -
87 SARUNG TANGAN XS PCS 462 300 300
88 SENDOK OBAT PLASTIK 5 ML buah 250 -
89 URINE BAG PCS 8,070 -
VAGINA SPECULUM DISPOSSIBLE (UK.
90 PCS 12,000 -
L)
VAGINA SPECULUM DISPOSSIBLE (UK.
91 PCS 12,000 -
M)
VAGINA SPECULUM DISPOSSIBLE (UK.
92 PCS 12,000 -
S)
93 WING NEEDLE 21 PCS 5,643 -

94 WING NEEDLE 23 PCS 5,643 -

95 WING NEEDLE 25 PCS 5,643 -

96 WING NEEDLE 27 PCS 14,600 -

-
NILAI PERSEDIAAN ALKES HABIS
-
PAKAI
-
-
BAHAN MEDIS HABIS PAKAI -
-
1 ALKOHOL / ETANOL 70% 100 ML BTL 3,000 3 3
2 ALKOHOL / ETANOL 70% BOTOL 1 LITER BTL 12,250 -
3 ALKOHOL SWAB PCS 100 -
4 AQUADEST STERIL BTL 42,900 -
CAIRAN ALKACIDE (HIGH LEVEL
5 BTL 2,702,700 -
DISINFECTAN, 1L)
CAIRAN ALKAZYME (PAK @25 SACHET
6 PAK 801,000 -
25 MG)
ETAKRIDIN (RIVANOL) LARUTAN 0.1 %
7 BTL 2,550 -
300ML
8 FRAMISETIN SULFAT KASA STERIL 1 % LEMBAR 14,658 5 5
9 HANDRUB BTL 500 ML BOTOL 60,800 -
10 HANDRUB ISI ULANG GALON 532,546 -
11 HYDROGEN PEROKSIDA (H2O2) BTL 20,700 -
12 JELLY USG / AQUAGEL SACHET 2,566 -
13 LISOL BTL 30,000 1 1
14 POVIDON IODIN 60 ML BOTOL 5,453 -
15 SALISIL SPIRITUS 10 % BTL 5,600 -
16 YODIUM POVIDON LARUTAN 10% 1 LT BTL 31,174 -
17 YODIUM POVIDON LARUTAN 10% 30 ML BTL 6,800 -

18 YODIUM POVIDON LARUTAN 10% 300 ML BTL 14,203 2 1 3

NILAI PERSEDIAAN BAHAN MEDIS HABIS PAKAI

Mengetahui,
Kepala Puskesmas
Kelurahan ................................

NIP.
S PAKAI

TIDAK MAMPU
PEMAKAIAN STOK AKHIR PERMINTAAN KETERANGAN
DILAPORKAN

8 9 10

- 8
- 8
- 8
- 8
- -
- -
- -
- -
- 200 (200)
- 8
- 113 (113)
- -
- 200 (200)
- 10
- -
- -
- -
- 10 (SILK)
- -
- -
- 2
1 1 2
- -
- -
- -
- -
- -
- -
- -
- 10
- -
- -

- 50
- 50

- -
- -

- 100

- 6 (6)

- -
2 5
- -
- -
- 10 (10)
- -
- -
- -
- -
- -
- 10 BERLOGO
- -
10 20
10 20
- -
- -
- -
- -
- -
- -
- -
- -
2 5
- -
- 4
- 4
- 4
-
- -
- -
- -
- -
- -
- 100
- -
- -
- -

- -
- -
- 300 (300)
200 500 300
- -
- -
- -
300 300 500
- -
- -
- 300 (300)
- 100
- -
- -
- -
- -

- 8

- 8

- 8

- 8

- -

- -

- -

- -
- -
- -
- -
3 8
(3) 3 (11)
- -
- -

- -

- -

- -
5 13
- -
- -
- -
- -
- 1 (1)
- -
- -
- -
- -

- 3 (3)

Jakarta, ......................... 2017


Yang Membuat,
Penanggung Jawab Farmasi

No. SIKTTK : ...........................................................