LPLPO Semester I 2019

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)
INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN :

KECAMATAN : SANGKUB BULAN PEMAKAIAN : JANUARI
KABUPATEN : BOLAANG MONGONDOW UTARA BULAN PERMINTAAN : FEBRUARI
PROPINSI : SULAWESI UTARA TAHUN : 2019
PEMBERIAAN
KODE NAMA OBAT SATUAN STOK PENERI PERSE PEMA RUSAK/ SISA STOK PERMIN
TERKECIL AWAL MAAN DIAAN KAIAN EXP STOK OPTIMUM TAAN FORNAS
DAK APBD I DAU LAIN
(TK)
1 2 3 4 5 6=4+5 7 8 9=6-7-8 10 11 12 13 14 15 16
OBAT CAIR
1 Alkohol 70% 100 ml botol 100 - 100 - 100 - - 1,2,3
2 Alkohol 70% 1000 ml botol 7 20 27 6 21 - 1,2,3
3 Albendazole Susp 200 mg/5 mL botol 50 - 50 - 50 -
4 Ambroxol sirup botol 28 - 28 10 18 60
5 Aminophylline inj ampul 120 - 120 24 96 - 1,2,3
6 Amoxicillin drops botol - - - - - 50 1,2,3
7 Amoxicillin sirup botol - - - - - 50 1,2,3
8 Analog insulin Apidra inj pen - - - - - - 1,2,3
9 Analog Long insulin (Ezelin) 100 IU pen - 20 20 - 20 - 1,2,3
10 Antalgin inj ampul - - - - - 100
11 Antasida sirup botol - - - - - - 1,2,3
12 Aqua pro inj flacon 90 - 90 18 72 - 1,2,3
13 Asering infus botol 20 - 20 20 - 60 1,2,3
14 Atropin sulfate inj ampul 30 - 30 30 - 10 1,2,3
15 Carbol fuchsin 0,3% botol 3 - 3 - 3 - -
16 Cefepime inj vial - - - - - - 2.3
17 Cefadroxil Syr 125 mg/ml botol 24 48 72 24 48 50
18 Cefixime sirup botol - - - - - 50 2.3
19 Cefotaxime inj vial 50 - 50 - 50 - - 2.3
20 Ceftriaxone inj vial - - - - - 50 2.3
21 Cetirizine sirup botol 57 200 257 53 204 - 1,2,3
22 Chloramphenicol sirup botol 50 - 50 - 50 - 1,2,3
23 Chloramphenicol tetes telinga botol - - - - - 20 1,2,3
COMBIVENT UDV Kombinasi : Ipratropium
Bromida Inhalasi 0,5 mg + salbutamol 2,5 mg vial 20 - 20 20 - 20
24
Cotrimoksazole (anak) Komb tiap 5 ml :
Sulfametoksazol 200 mg + Trimetoprim 40 mg botol 34 - 34 2 32 -
25
26 Citicholine inj ampul - - - - - 10
27 Curbion sirup multivitamin botol - - - - - 60
28 Dexamethasone inj ampul - - - - - 100 1,2,3
29 Diazepam Inj ampul - - - - - 10 1,2,3
30 Diphenhydramine inj ampul 90 - 90 90 - 120 1,2,3
31 Domperidone sirup botol 57 50 107 50 57 - 50 1,2,3
32 Epinephrine inj ampul 290 - 290 - 290 - 1,2,3
33 Erythromycin sirup botol 49 - 49 14 35 - 1,2,3
34 Eugenol cairan botol - - - - - - 1,2,3
35 Formalin cairan liter - - - - - -
36 Furosemide inj ampul - 50 50 - 50 60 1,2,3
37 Gastrucid Sirup 24 216 240 68 172 -
38 Gentamicin inj ampul 25 - 25 - 25 - 2.3
39 Gentamisin Tetes mata botol - - - - - 50 2.3
40 Gentian violet botol - - - - - 50
41 Glukosa 10% infus botol 53 - 53 53 - - 1,2,3
42 Glukosa 40% inj flacon - - - - - 20 1,2,3
43 Glukosa 5% infus botol 34 - 34 1 33 - 1,2,3
44 HCl 0,1 N 100 mL botol - 5 5 - 5
45 H2O2 3% botol 3 - 3 - 3 - 1,2,3
46 Hyoscine butylbromide inj ampul 10 - 10 10 - 20 2.3
47 Ibuprofen sirup botol 56 100 156 27 129 - 1,2,3
48 KAEN 3A infus botol 40 - 40 22 18 20 1,2,3
49 KAEN 3B infus botol 46 - 46 21 25 - 1,2,3
50 Ketamine inj vial 50 - 50 - 50 - 1,2,3
51 Ketorolac inj ampul 170 - 170 - 170 - 2.3
52 Kloramfenikol tetes mata botol - - - - - 50 1,2,3
53 Klorpromazin Injeksi 25 mg/mL ampul 30 - 30 - 30 -
54 KCL 7.46% Kalium Klorida OTSU 2 ml flacon 202 - 202 11 191 -
55 Lidocaine inj ampul 100 - 100 15 85 - 1,2,3
56 Lysol cairan botol - 20 20 - 20 -
57 Magnesium Sulfat 20% inj flacon 83 - 83 - 83 - 1,2,3
59 Metacetin sirup botol - - - - - 100
60 Methylen blue 0,3% botol 2 - 2 - 2 - -
61 Methylergometrin maleate inj ampul 200 - 200 - 200 - 1,2,3
62 Metoklopramide sirup botol 28 50 78 18 60 - 1,2,3
63 Metronidazole infus botol 26 - 26 8 18 - 1,2,3
64 Natrium klorida 0,9% infus botol 66 40 106 71 35 40 1,2,3
65 Ofloksasin (Tarivid) Tetes Telinga botol 2 - 2 2 - 20
66 OBH sirup botol - - - - - -
67 Oil emersi botol 3 - 3 - 3 - -
68 Omegdiar sirup botol 5 50 55 5 50 -
69 Omeprazole inj vial 40 - 40 - 40 - 50 1,2,3
70 Ondansetron inj ampul 30 100 130 50 80 - 2.3
71 Otopain tetes telinga botol - - - - - 20
72 Oxytocin inj ampul 400 - 400 - 400 - 1,2,3
73 Pacdin cough sirup botol 10 96 106 68 38 96
74 Paracetamol drops botol - - - - - 50 1,2,3
75 Paracetamol infus botol - 20 20 4 16 - 3
76 Paracetamol sirup botol 35 50 85 72 13 50 1,2,3
77 Phenobarbital inj ampul - - - - - - 2.3
78 Piracetam inj ampul - - - - - 30
79 Pirantel Sirup botol 40 50 90 - 90 - 1,2,3
80 Povidone 300 ml botol 14 48 62 2 - 60 15 1,2,3
81 Povidone 60 ml botol - - - - - - 1,2,3
82 Ranitidine inj ampul - 500 500 110 390 - 2.3
83 Renalyte electrolytes botol - - - - - 36 1,2,3
84 Ringer Laktat infus botol - 200 200 61 139 - 1,2,3
85 Rivanol 300 ml botol 10 24 34 5 29 - 1,2,3
86 Salbutamol sirup botol - - - - - 50 2.3
87 Sodium Bicarbonate inj flacon - - - - - - 2.3
88 Sucralfate sirup botol 16 - 16 10 6 20 2.3
89 Tetagam inj human tetanus vial 2 - 2 2 - 10 1,2,3
90 Tramadol inj ampul - - - - - - 2.3
91 Tranexamic Acid inj ampul 40 - 40 - 40 - 2.3
92 Vit amin B12 inj ampul 40 100 140 46 94 100 1,2,3
93 Vitamin B1 inj ampul - - - - - 20
94 Vitamin K inj 10 mg ampul - - - - - - 1,2,3
95 Vitamin K inj 2 mg ampul 60 120 180 60 120 - 1,2,3
96 Voluven HES 6% botol 20 - 20 - 20 - - 1,2,3
97 ZINCPRO Sulfate 10 mg/mL botol 83 58 141 12 129 - 1,2,3
98 Zinc Sirup botol 6 38 44 16 28 -
OBAT PADAT
99 Acetosal 100 mg tablet 200 - 200 - 200 - - 2.3
100 Acetylcysteine 200 mg tablet 2,800 - 2,800 - 2,800 - - 1,2,3
101 Acetysalicylic acid 80 mg tablet 800 - 800 - 800 - 1,2,3
102 ACT (artesunate + amodiaquin) tablet - - - - - -
103 Acyclovir 400 mg tablet 700 - 700 50 650 - 1,2,3
104 Albendazole 400 mg tablet 1,650 - 1,650 30 1,620 - 1,2,3
105 Allopurinol 100 mg tablet 1,100 - 1,100 300 800 - 1,2,3
106 Alprazolam 0,5 mg tablet - 200 200 200 -
107 Ambroksol 30 mg tablet - - - - - 2,000
108 Aminophillin 150 mg tablet - - - - - 1,2,3
109 Aminophillin 200 mg tablet 300 - 300 300 -
110 Amlodipine 10 mg tablet 2,610 - 2,610 870 1,740 - 1,2,3
111 Amlodipine 5 mg tablet 2,610 - 2,610 780 1,830 - 1,2,3
112 Amoxicillin 500 mg tablet 4,300 - 4,300 1,700 2,600 - 1,2,3
113 Antalgin 500 mg tablet - - - - 1,000
114 Antasida doen tablet 6,500 - 6,500 6,500 - 1,2,3
115 Anti Hemoroid supo supositoria 97 - 97 7 90 - 1,2,3
116 Asam Folat 1 mg tablet 300 - 300 300 - 1,2,3
117 Asam mefenamat 500 mg tablet 2,300 - 2,300 2,300 - 2,000 1,2,3
118 Asam traneksamat 500 mg tablet - - - - 500 2.3
119 Asiklovir 200 mg tablet - - - - - 1,2,3
120 Attapulgite tablet 900 - 900 900 - 1,2,3
121 Betahistin tab tablet 400 2,000 2,400 2,400 - 2.3
122 Bisacodyl (Dulcolax) Supp 5 mg supositoria 42 - 42 42 - - 1,2,3
123 Bisacodyl (Dulcolax) Supp 10 mg supositoria 42 - 42 1 41 -
124 Bisacodyl Tab 5 mg tablet 990 - 990 990 -
125 Bisoprolol 5 mg tablet 400 - 400 50 350 - 2.3
126 Bromhexine 8 mg tablet 600 - 600 400 200 3,000
127 Calsium lactate 500 mg tablet 300 2,000 2,300 300 2,000 - 1,2,3
128 Captopril 12,5 mg tablet - 5,200 5,200 300 4,900 - 1,2,3
129 Captopril 25 mg tablet - - - - 500 1,2,3
130 Captopril 50 mg tablet 100 - 100 100 - 500 1,2,3
131 Cefadroxil 500 mg tablet - - - - - 500 2.3
132 Cefixime 100 mg tablet - - - - 1,000 2.3
133 Cetirizine 10 mg tablet - - - - 2,000 2.3
134 Chloramphenicol 500 mg tablet 500 - 500 200 300 - 2.3
135 Chlorpheniramine 4 mg tablet - - - - - 3,000 1,2,3
136 Ciprofloxacin 500 mg tablet - - - - 500 1,2,3
137 Citicoline 500 mg tablet - - - - 500
138 Clindamycin 150 mg tablet 550 - 550 550 - 1,2,3
139 Clobazam tab 10 mg tablet - - - - 200 2.3
140 Clopidogrel tablet - 300 300 150 150 -
141 Colchicine 0,5 mg tablet 1,100 - 1,100 1,100 - 1,2,3
142 Cotrimoxazole 480 mg tablet - 2,000 2,000 100 1,900 - 1,2,3
143 Cotrimoksazole Forte Kombinasi tablet 1,500 - 1,500 1,500 -
144 Dapyrin tablet - - - - 2,000
145 Dexamethasone 0,5 mg tablet - - - - - 1,000 1,2,3
146 Diazepam 2 mg tablet - - - - - 1,2,3
147 Diazepam 5 mg tablet - - - - -
148 Diazepam stesolid 10mg supositoria 10 - 10 10 - 10 1,2,3
149 Diazepam stesolid 5mg supositoria 20 - 20 20 - 10 1,2,3
150 Diklofenac sodium 50 mg tablet 1,150 - 1,150 700 450 500 1,2,3
151 Diltiazem tab 30 mg tablet - - - - 1,2,3
152 Dimenhidrinat 50 mg tablet 900 - 900 900 -
153 Domperidone 10 mg tablet 400 2,000 2,400 100 2,300 - 1,2,3
154 Digoksin Tab 0,25 mg tablet 500 - 500 500 -
155 Doxycycline 100 mg tablet 200 - 200 200 - 1,2,3
156 Dumin rectal 125 mg supositoria 10 - 10 10 -
157 Dumin rectal 250 mg supositoria - - - - -
158 Ergotamine caffeine tablet - - - - - 1,2,3
159 Erythromycin 250 mg tablet 600 - 600 500 100 - 1,2,3
160 Erythromycin 500 mg tablet 500 500 1,000 500 500
161 Fenitoin tablet - - - - - 1,2,3
162 Fenobarbital 30 mg tablet - - - - 100 1,2,3
163 Furosemide 40 mg tablet 1,300 - 1,300 1,300 - 1,2,3
164 Glibenclamide 5 mg tablet 900 - 900 900 - 1,2,3
165 Glimepiride 2 mg tablet - - - - - 1,2,3
166 Glimepiride 4 mg tablet 600 - 600 600 -
167 Glyceryl guaiacolate 100 mg tablet 2,000 - 2,000 - 2,000 - 2,000
168 Glyceryl trinitrate 500 mcg tablet 100 - 100 100 - - 1,2,3
169 Griseofulvin 125 mg tablet 1,500 - 1,500 1,500 - 1,2,3
170 Haloperidol 0,5 mg tablet - - - - 300 2.3
171 Hydrochlorothiazide 25 mg tablet 500 - 500 500 - 1,2,3
172 Hyoscine butylbromide 10 mg tablet - - - - 1,000 1,2,3
173 Ibuprofen 400 mg tablet 1,700 1,000 2,700 1,300 1,400 1,000 1,2,3
174 Isosorbid Dinitrat 5 mg tablet 600 - 600 600 - 1,2,3
175 Isoniazid 300 mg tablet 1,000 - 1,000 200 800 -
176 Kalium aspartate tablet 100 - 100 100 - 1,000 2.3
177 Ketoconazole 200 mg tablet 1,400 - 1,400 1,400 - 1,2,3
178 Ketoprofen supo supositoria - - - - 10 2.3
179 Kloramfenikol 250 mg tablet - - - - - 1,2,3
180 Klorpromazin 100 mg tablet 400 - 400 400 - 1,2,3
181 Kuinin sulfat 222 mg tablet 1,200 - 1,200 1,200 - 1,2,3
182 Lanzoprasol 30 mg tablet - 1,000 1,000 200 800 1,000 2.3
183 Levofloxacin 500 mg tablet 400 - 400 400 - 2.3
184 Lincomycin 500 mg tablet - - - - -
185 Loperamide 2 mg tablet 1,900 - 1,900 500 1,400 - 2.3
186 Loratadine 10 mg tablet - - - - 1,000 1,2,3
187 Meloxicam tab 7,5 mg tablet 1,450 - 1,450 700 750 500
188 Metformin 500 mg tablet 1,200 1,000 2,200 200 2,000 - 1,2,3
189 Methisoprinol 500 mg tablet - - - - 1,000
190 Methyldopa 250 mg tablet 1,500 - 1,500 1,500 - 500 2.3
191 Metilergometrin maleat tab 0,125 mg tablet 1,000 - 1,000 1,000 - 1,2,3
192 Metilprednisolon tab 8 mg tablet - - - - - 1,2,3
193 Metilprednisolon tab 4 mg tablet 1,300 - 1,300 700 600 1,000
194 Metoclopramide 10 mg tablet 1,900 - 1,900 100 1,800 - 1,2,3
195 Metoclopramide 5 mg tablet - - - - - 1,2,3
196 Metronidazol 500 mg tablet 500 - 500 150 350 500 1,2,3
197 Metronidazole supo supositoria - - - - 12 2.3
198 Microlax rectal tube - - - - 12
199 Nifedipine 10 mg tablet 2,000 - 2,000 2,000 - 1,2,3
200 Norit botol - - - - - 1,2,3
201 Nystatin 500.000 IU tablet - - - - 500 1,2,3
202 Nystatin Vaginal Tablet 100.000 IU tablet 500 500 1,000 1,000 -
203 OAT kategori Sisipan - KDT kotak - - - - - 1,2,3
204 OAT Kategori II kotak - - - - -
205 Omegavit multivitamin tablet - - - - 2,000
206 Omeprazole 20 mg tablet 210 - 210 210 - 900 1,2,3
207 Ondansetron 4 mg tablet 180 - 180 180 - 2.3
208 Ondansetron 8 mg tablet 376 - 376 100 - 276 - 2.3
209 Paket stop TB kategori I kotak - - - - - 1,2,3
210 Panviton multivitamin tablet - - - - 1,000
211 Papaverin 40 mg tablet - - - - 1,000
212 Paracetamol 500 mg tablet 1,000 16,500 17,500 2,800 14,700 - 1,2,3
213 Piracetam 400 mg tablet - - - - 1,000
214 Piracetam 800 mg tablet - - - - 1,000
215 Piroxicam 20 mg tablet - - - - 1,000
216 Prednison 5 mg tablet 600 - 600 600 - 1,2,3
217 Prenase multivitamin tablet - - - - 1,000
218 Primaquine 15 mg tablet - - - - - 1,2,3
219 Probenecid 500 mg tablet 900 - 900 900 - 1,2,3
220 Propanolol 10 mg tablet 1,400 - 1,400 300 1,100 - 1,2,3
221 Propylthiouracil 100 mg tablet 1,300 - 1,300 1,300 - 1,2,3
222 Pyrantel tab 125 mg tablet 300 - 300 300 - - 1,2,3
223 Ranitidine 150 mg tablet 1,000 1,000 2,000 1,800 200 2,000 1,2,3
224 Salbutamol 2 mg tablet 300 2,000 2,300 100 2,200 - 1,2,3
225 Salbutamol 4 mg tablet 340 2,000 2,340 2,340 - 1,2,3
226 Salbutamol nebules 2,5 mg tablet - - - - -
227 Simvastatin 10 mg tablet 3,690 - 3,690 1,860 1,830 - 1,2,3
228 Spironolactone 100 mg tablet 500 - 500 500 - - 1,2,3
229 Sucralfate 500 mg tablet 400 - 400 400 - 2.3
230 Tetrasiklin 250 mg tablet 1,000 - 1,000 1,000 - 1,2,3
231 Tetrasiklin 500 mg tablet - - - - - 1,2,3
232 Thiamphenicol 500 mg tablet - - - - - -
233 Tilomix tablet - - - - 3,000
234 Triheksifenidil 2mg tablet - 500 500 500 - 1,2,3
235 Tablet Tambah Darah tablet 2,160 - 2,160 810 1,350 -
236 Valsartan tab 80 mg tablet - - - - 1,000 2.3
237 Vitalamin multivitamin tablet - - - - 2,000
238 Vitamin A 100.000 IU tablet 100 - 100 100 - - 1,2,3
239 Vitamin A 200.000 IU tablet - 450 450 450 - 300 1,2,3
240 Vitamin B complex tablet 300 10,000 10,300 300 10,000 - 1,2,3
241 Vitamin B1 50 mg tablet 1,300 - 1,300 800 500 1,000 1,2,3
242 Vitamin B6 10 mg tablet 2,000 7,000 9,000 1,600 7,400 - 1,2,3
243 Vitamin C 50 mg tablet 1,600 7,000 8,600 800 7,800 - 1,2,3
244 Vitamin K 10 mg tablet 1,800 - 1,800 550 1,250 - 1,2,3
245 Zinc 20 mg tablet 900 - 900 300 - 600 500 1,2,3
OBAT GIGI - GAS

246 Alginate 500g zak - - - - -
247 Amalgam ana2000 botol - - - - -
248 Biomedical obat semprot oral & nose Ortoviro botol - - - - -
249 Bonding stae refill botol - - - - -
250 Calcium hydroxide pasta Hydcal tube - - - - -
251 Calciumpolystyrene Kalikate sachet - - - - -
252 Caviton 30g botol - - - - -
253 Dental gipsum kg 2 - 2 2 -
254 Devitalising paste pulp botol - - - - - 1,2,3
255 Elite cement 100 semen seng fosfat set - - - - -
256 Etil Clorida spray botol - - - - 5 1,2,3
257 ETSA etching gel kit 12gm dispo - - - - -
258 Glass ionomer GC fuji IX set - - - - - 1,2,3
259 Iodoform paste Mumifing pasta botol - - - - -
260 Komposit a A2, A3, A 3,5 solareX botol - - - - -
261 L Bio sachet - - - - 50
262 Lidocain (XYLOCAINE) spray 10% botol 8 - 8 8 -
263 Oxymetazoline Nasal Spray Iliadin 0,05% botol - - - - -
264 Pulp-X botol - - - - -
265 Temporari stoping fletcher serbuk set - - - - -
OBAT SALEP/SERBUK
266 Acyclovir cream tube - - - - 50
267 Aseptic alkohol gel antiseptic pembersih tangan botol - 48 48 12 36 -
Antifungi DOEN Salep, Kombinasi : Asam
pot - 48 48 48 -
268 Benzoat 6% + Asam Salisilat 3%
AntiBakteri Salep : Basitrasin 500 IU/g + tube 49 - 49 25 24 50
269 Polimiksin 10.000 Iu/g
270 Betametason cream tube 25 100 125 25 100 - 1,2,3
271 Bioplacenton gel tube - - - - 50
272 Bricasma terbutaline can - - - - 5
273 Burnazin silver sulphadiazine tube 17 25 42 8 34 - 1,2,3
274 Caladine lotion botol - - - - 50
275 Chloramphenicol salep kulit tube - - - - 50 1,2,3
276 Chloramphenicol salep mata tube - 48 48 10 38 - 1,2,3
277 Cutimed gel tube - - - - 20
278 Desoximetasone cream tube 75 30 105 105 - 2.3
279 Diclofenac sodium gel tube - - - - 50
280 Fucilex Krim Sodium Fusidat 20% 20 mg/mL tube - 29 29 29 -
281 Gentamicin salep mata tube - - - - 25 2.3
282 Garam Oralit Serbuk Kombinasi sachet 100 - 100 100 -
283 Hydrocortisone cream tube 45 48 93 93 - 1,2,3
284 Ichtyol salep pot - - - - 50
285 Ketoconazole cream tube - 50 50 50 - 1,2,3
286 Lidocain jelly dispo - - - - 20 1,2,3
287 Miconazole cream tube 21 - 21 21 50 1,2,3
288 My Jelli tube 50 - 50 50 -
289 Nebacetin salep tube - - -
290 Salep 2-4 pot 42 - 42 3 39 - 1,2,3
291 Salisil bedak kotak 40 - 40 40 - 1,2,3
292 Dexocort Salep 0,25% tube - - - - - 2.3
293 Sabun anti bakteri 500 ml botol 5 24 29 29 10
294 Thrombophob gel tube - - - - 50
295 Ultrasound gel USG botol 10 48 58 24 34 -
OBAT LAINNYA
296 Absorbent paper points 15-40 kotak - - - - - 1,2,3
297 Absorbent paper points 45-80 kotak - - - - - 1,2,3
298 Alkohol swab pcs 200 - 200 200 - 500
299 Apron One Plastik Onemed lembar - - - - -
300 Bisturi no. 11 pcs 198 - 198 198 -
301 Bisturi no. 18 pcs 196 - 196 196 -
302 Bisturi no. 20 pcs 150 - 150 150 -
303 Bisturi no. 22 pcs 117 - 117 17 100 -
304 BeneCheck Plus Glucose Test Strip 50's strip - 50 50 50 -
305 BeneCheck Plus Total Cholesterol Test Strip 10's strip - 50 50 50 200
306 BeneCheck Plus Uric Test Strip 25's strip - 50 50 50 200
307 Blood Lancet pcs - 100 100 100 100
308 Catgut Chrom 3/0 Rol 100 meter roll 1 - 1 1 -
309 Catgut Chromic 2/0 pcs 96 - 96 96 -
310 Catgut Chromic 3/0 pcs 96 - 96 96 -
311 Catgut plain 2/0 + jarum pcs 96 - 96 96 -
312 Catgut plain 3/0 + jarum pcs 94 - 94 6 88 -
313 Celemek / Apron pcs 20 - 20 20 - -
314 Cutimed siltec 10x10cm pcs 49 - 49 29 20 -
315 Cutimed sorbact 7x9cm pcs - - - - 50
316 Duk steril disposible pcs - - - - -
317 Endotracheal Tube w/Cuffed - 3 pcs 20 - 20 20 -
323 Foley catheter 2 way no. 16 pcs - - - - 10
324 Foley catheter 2 way no. 18 pcs 7 - 7 4 3 10
325 Foley catheter 2 way no. 20 pcs 8 - 8 8 -
326 Foley catheter 2 way no. 6 pcs 100 - 100 100 -
327 Gutta percha points 15-40 pcs 1 - 1 1 - - 1,2,3
328 Gutta percha points 45-80 pcs 1 - 1 1 - 1,2,3
329 Handscoen ginekologi psg - - - - -
330 Handscoen non steril Large psg - - - - -
331 Handscoen non steril Medium psg 100 500 600 500 100 1,000
332 Handscoen Obsgyn psg 100 - 100 100 -
333 Handscoen steril no. 6,5 psg 41 100 141 56 85 -
334 Handscoen steril no. 7 psg - 100 100 6 94 -
335 Handscoen steril no. 7,5 psg - 100 100 7 93 -
336 Handscoen steril no. 8 psg 15 100 115 16 99 -
337 Hb Sahli Set - 10 10 10
338 HCG test pcs 208 - 208 93 115 -
339 Infusion set Anak pcs 40 - 40 40 -
340 Infusion set Dewasa pcs 30 400 430 81 349 50
341 IV cannula no. 18 pcs 250 200 450 450 -
342 IV cannula no. 20 pcs 50 - 50 50 - 100
343 IV cannula no. 22 pcs 98 - 98 41 57 -
344 IV cannula no. 24 pcs 200 - 200 200 -
345 IV cannula no. 26 pcs 200 - 200 200 -
346 Jarum jahit No. 10 pcs 24 - 24 24 -
347 Jarum jahit No. 11 pcs 24 - 24 12 12 -
348 Jarum jahit No. 12 pcs - - - - -
351 Jarum jahit No. 15 pcs - - - - -
352 Jarum jahit No. 9 pcs 24 12 36 36 12
353 Jarum otot besar pcs - - - - -
354 Jarum otot kecil pcs - - - - -
355 Jarum untuk insulin pen pcs 6 - 6 1 5 -
356 Kacamata Anti infeksi pcs - - - - -
357 Kapas Berlemak 500 g bungkus - - - - -
358 Kapas putih 250 g bungkus 14 - 14 1 13 -
359 Kasa hidrofil 40yard x 80cm roll 6 20 26 26 -
360 Kasa hidrofil 4m x 10cm rol - 100 100 100 -
361 Kasa hidrofil 4m x 5cm rol 100 - 100 100 -
362 Kasa sterile 16x16cm pcs 896 3,200 4,096 480 3,616 -
363 Klem tali pusat pcs 25 - 25 25 - -
364 Masker Nebulizer Set Anak Besmed pcs 25 - 25 25 -
365 Masker Nebulizer Set Dewasa Besmed pcs 25 - 25 25 -
366 Masker pcs 600 1,000 1,600 350 1,250 -
Micro brush doche Disposable micro applicators

1A6542 Fine (1,5mm) warna kuning, biru buckets - - - - -
367
368 Mucous extractor FR 10 pcs 96 - 96 12 84 -
369 NGT no.16 pcs - - - - -
370 NGT no.18 pcs - - - - -
371 NGT no.3,5 pcs - - - - -
372 NGT no.5 pcs - - - - -
373 NGT no.8 pcs - - - - -
374 Oxygen nasal cannula Anak pcs 94 - 94 4 90 -
375 Oxygen nasal cannula Dewasa pcs 78 - 78 8 70 -
376 Pembalut Gibs rol - - - - 50
377 Pen Needle Set - - - -
378 Plester coklat yard Leukoplast rol 20 10 30 1 29 -
379 Plester Infus dermafix pcs 25 - 25 25 -
380 Plester luka bakar pcs - - - - -
381 Plester putih Polifix rol 13 - 13 13 - -
382 Plester rawat luka anti air dermafix t 10x25cm pcs 40 - 40 40 -
383 Safety box pcs - - - - -
384 Silk 2/0 pcs 32 - 32 20 12 48
385 Silk 3/0 pcs 24 - 24 12 12 48
386 Sputum Pot pcs 100 - 100 10 90
387 Suction catheter FR 10 pcs 20 - 20 20 -
391 Suction catheter FR 18 pcs - - - - -
394 Surgical gown baju operasi L pcs 30 - 30 30 -
395 Surgical gown baju operasi M pcs 20 - 20 20 -
396 Surgical gown baju operasi XL pcs 10 - 10 10 -
397 Syringe 1 cc pcs 100 - 100 20 80 -
398 Syringe 3 cc pcs 14 2,000 2,014 354 1,660 500
399 Syringe 5 cc pcs 198 - 198 101 97 -
400 Syringe 10 cc pcs 104 - 104 104 -
401 Syringe 20 cc pcs 100 - 100 1 99 -
402 Syringe 50 cc pcs 19 - 19 1 18 -
403 Test Anti HCV Strip test - 100 100 100
404 Test Anti HIV 1/2 Cassette test - 50 50 50 -
405 Test HBsAg strip test 175 50 225 175 50 -
406 Test Malaria HRP2/pLDH (Pf/PAN) combo test 17 50 67 17 50 -
407 Topi Operasi pcs 100 - 100 100 -
408 Urine Bag pcs 39 - 39 39 -
409 Uritest Reagen Strips 11G Tube - 100 100 100 -
410 Venflon Pro IV Canula 18 ga 0,9 mm x 25 mm 50 50 50
411 Venflon Pro IV Canula 20 ga 1,1 mm x 32 mm 50 50 50 100
412 Venflon Pro IV Canula 22 ga 0,9 mm x 25 mm pcs - 50 50 50 -
413 softpad (Underpad) 60x90 cm One Med pcs 300 - 300 300 -
414 Buku KIA bh - - - - 50
415 Wing Needle 19 G Onemed pcs 10 - 10 10 -
418 Wing Needle 27 G Onemed pcs 10 - 10 10
419 Ziehl Neelsen Set 5 x 100 mL Set - 10 10 1 9
99,034 75,533 174,567 31,096 136,164 56,314
UMUM ASKES/ JUMLAH

BPJS
JUMLAH KUNJUNGAN RESEP TIDAK
BAYAR BAYAR 372 756
339 45
Sangkub, Februari 2019

MENGETAHUI YANG MENYERAHKAN YANG MELAPORKAN YANG MENERIMA
KEPALA DINAS KESEHATAN KEPALA INSTALASI FARMASI & KEPALA PUSKESMAS SANGKUB PETUGAS GUDANG OBAT
KAB. BOLAANG MONGONDOW UTARA PERBEKALAN KESEHATAN
JUSNAN C. MOKOGINTA, MARS ASIA, S.Si, Apt SJAMSUDIN RAHIM CINDRA DEWI J. LALU, A.MD.FARM
NIP. 19671105 200012 1 003 NIP. 19840909 201102 2 001 NIP. 1964021918802 1 002 NIP. 19900608 201502 2 001
(LPLPO)
INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN :

KECAMATAN : SANGKUB BULAN PEMAKAIAN : FEBRUARI
KABUPATEN : BOLAANG MONGONDOW UTARA BULAN PERMINTAAN : MARET
PEMBERIAAN
DAK APBD I DAU LAIN
(TK)
1 2 3 4 5 6=4+5 7 8 9=6-7-8 10 11 12 13 14 15 16
OBAT CAIR
1 Alkohol 70% 100 ml botol - - - - - 1,2,3
2 Alkohol 70% 1000 ml botol 21 - 21 6 15 - 1,2,3
3 Albendazole Susp 200 mg/5 mL botol 50 - 50 50 -
4 Ambroxol sirup botol 18 - 18 18 - 100
5 Aminophylline inj ampul 96 - 96 96 - 1,2,3
6 Amoxicillin drops botol - - - - 50 1,2,3
7 Amoxicillin sirup botol - - - - - 1,2,3
8 Analog insulin Apidra inj pen - - - - - 1,2,3
9 Analog Long insulin (Ezelin) 100 IU pen 20 - 20 1 19 - 1,2,3
10 Antalgin inj ampul - 100 100 100 -
11 Antasida sirup botol - - - - - 1,2,3
12 Aqua pro inj flacon 72 - 72 72 - 1,2,3
13 Asering infus botol - - - - 60 1,2,3
14 Atropin sulfate inj ampul - 100 100 100 - 1,2,3
15 Carbol fuchsin 0,3% botol - - - - -
16 Cefepime inj vial - - - - - 2.3
17 Cefadroxil Syr 125 mg/ml botol 48 39 87 25 62 -
18 Cefixime sirup botol - - - - 50 2.3
19 Cefotaxime inj vial - - - - - 2.3
20 Ceftriaxone inj vial - - - - 50 2.3
21 Cetirizine sirup botol 204 - 204 109 95 - 1,2,3
22 Chloramphenicol sirup botol 50 - 50 3 47 - 1,2,3
23 Chloramphenicol tetes telinga botol - - - - 20 1,2,3
Bromida Inhalasi 0,5 mg + salbutamol 2,5 mg vial - - - - 20
24
Sulfametoksazol 200 mg + Trimetoprim 40 mg botol 32 - 32 11 21 -
25
26 Citicholine inj ampul - - - - 10
27 Curbion sirup multivitamin botol - - - - -
28 Dexamethasone inj ampul - - - - 100 1,2,3
29 Diazepam Inj ampul - - - - 10 1,2,3
30 Diphenhydramine inj ampul - 120 120 40 80 - 1,2,3
31 Domperidone sirup botol - - - - 50 1,2,3
32 Epinephrine inj ampul 290 - 290 290 - 1,2,3
33 Erythromycin sirup botol 35 - 35 15 20 - 1,2,3
34 Eugenol cairan botol - - - - - 1,2,3
35 Formalin cairan liter - - - - -
36 Furosemide inj ampul 50 - 50 25 25 - 1,2,3
37 Gastrucid Sirup 172 - 172 41 131 -
38 Gentamicin inj ampul 25 25 25 - 2.3
39 Gentamisin Tetes mata botol - - - - 50 2.3
40 Gentian violet botol - - - - 50
41 Glukosa 10% infus botol - 40 40 40 - - 1,2,3
42 Glukosa 40% inj flacon - - - - 20 1,2,3
43 Glukosa 5% infus botol 33 - 33 33 - 1,2,3
44 HCl 0,1 N 100 mL botol 5 - 5 5
45 H2O2 3% botol 3 - 3 3 - 1,2,3
46 Hyoscine butylbromide inj ampul - - - - 20 2.3
47 Ibuprofen sirup botol 129 - 129 33 96 - 1,2,3
48 KAEN 3A infus botol 18 40 58 11 47 - 1,2,3
49 KAEN 3B infus botol 25 40 65 5 60 - 1,2,3
50 Ketamine inj vial 50 - 50 50 - 1,2,3
51 Ketorolac inj ampul 170 - 170 2 168 - 2.3
52 Kloramfenikol tetes mata botol - - - - 50 1,2,3
53 Klorpromazin Injeksi 25 mg/mL ampul 30 - 30 30 -
54 KCL 7.46% Kalium Klorida OTSU 2 ml flacon 191 360 551 551 -
55 Lidocaine inj ampul 85 - 85 25 60 - 1,2,3
56 Lysol cairan botol 20 - 20 2 18 -
57 Magnesium Sulfat 20% inj flacon 83 54 137 137 - 1,2,3
58 Magnesium Sulfat 40% inj flacon 72 12 84 84 - 1,2,3
59 Metacetin sirup botol - - - - 100
60 Methylen blue 0,3% botol - - - - -
61 Methylergometrin maleate inj ampul 200 - 200 200 - 1,2,3
62 Metoklopramide sirup botol 60 - 60 2 58 - 1,2,3
64 Natrium klorida 0,9% infus botol 35 40 75 55 20 40 1,2,3
65 Ofloksasin (Tarivid) Tetes Telinga botol - - - - 20
66 OBH sirup botol - - - - -
67 Oil emersi botol - - - - -
68 Omegdiar sirup botol 50 - 50 5 45 -
69 Omeprazole inj vial - - - - 50 1,2,3
70 Ondansetron inj ampul 80 - 80 30 50 - 2.3
71 Otopain tetes telinga botol - - - - 20
72 Oxytocin inj ampul 400 1,000 1,400 1,400 - 1,2,3
74 Paracetamol drops botol - - - - 50 1,2,3
75 Paracetamol infus botol 16 20 36 36 - 3
76 Paracetamol sirup botol 13 50 63 34 29 50 1,2,3
77 Phenobarbital inj ampul - - - - - 2.3
78 Piracetam inj ampul - - - - 30
79 Pirantel Sirup botol 90 - 90 90 - 1,2,3
80 Povidone 300 ml botol 60 24 84 4 80 - 1,2,3
81 Povidone 60 ml botol - - - - - 1,2,3
82 Ranitidine inj ampul 390 - 390 90 300 - 2.3
83 Renalyte electrolytes botol - - - - 36 1,2,3
84 Ringer Laktat infus botol 139 100 239 79 160 - 1,2,3
85 Rivanol 300 ml botol 29 - 29 5 24 - 1,2,3
86 Salbutamol sirup botol - - - - 50 2.3
87 Sodium Bicarbonate inj flacon - - - - - 2.3
88 Sucralfate sirup botol 6 - 6 6 - 20 2.3
89 Tetagam inj human tetanus vial - - - - 10 1,2,3
90 Tramadol inj ampul - - - - - 2.3
91 Tranexamic Acid inj ampul 40 - 40 10 30 - 2.3
92 Vit amin B12 inj ampul 94 100 194 30 164 - 1,2,3
93 Vitamin B1 inj ampul - - - - 20
94 Vitamin K inj 10 mg ampul - - - - - 1,2,3
95 Vitamin K inj 2 mg ampul 120 - 120 30 90 - 1,2,3
96 Voluven HES 6% botol - - - - - 1,2,3
97 ZINCPRO Sulfate 10 mg/mL botol 129 - 129 2 127 - 1,2,3
98 Zinc Sirup botol 28 - 28 28 -
OBAT PADAT
99 Acetosal 100 mg tablet - - - - - 2.3
100 Acetylcysteine 200 mg tablet - - - - - 1,2,3
101 Acetysalicylic acid 80 mg tablet 800 - 800 800 - 1,2,3
102 ACT (artesunate + amodiaquin) tablet - - - - -
103 Acyclovir 400 mg tablet 650 - 650 50 600 - 1,2,3
104 Albendazole 400 mg tablet 1,620 - 1,620 1,620 - 1,2,3
105 Allopurinol 100 mg tablet 800 - 800 400 400 1,000 1,2,3
106 Alprazolam 0,5 mg tablet 200 - 200 29 171 -
107 Ambroksol 30 mg tablet - - - - 2,000
108 Aminophillin 150 mg tablet - - - - - 1,2,3
109 Aminophillin 200 mg tablet 300 - 300 100 200 -
110 Amlodipine 10 mg tablet 1,740 - 1,740 810 930 600 1,2,3
111 Amlodipine 5 mg tablet 1,830 - 1,830 870 960 600 1,2,3
112 Amoxicillin 500 mg tablet 2,600 - 2,600 800 1,800 - 1,2,3
113 Antalgin 500 mg tablet - - - - 1,000
114 Antasida doen tablet 6,500 - 6,500 900 5,600 - 1,2,3
115 Anti Hemoroid supo supositoria 90 - 90 30 60 - 1,2,3
116 Asam Folat 1 mg tablet 300 - 300 100 200 - 1,2,3
117 Asam mefenamat 500 mg tablet - 9,600 9,600 1,100 8,500 - 1,2,3
118 Asam traneksamat 500 mg tablet - - - - 500 2.3
119 Asiklovir 200 mg tablet - - - - - 1,2,3
120 Attapulgite tablet 900 - 900 50 850 - 1,2,3
121 Betahistin tab tablet 2,400 - 2,400 250 2,150 - 2.3
122 Bisacodyl (Dulcolax) Supp 5 mg supositoria - - - - - 1,2,3
124 Bisacodyl Tab 5 mg tablet 990 - 990 90 900 -
125 Bisoprolol 5 mg tablet 350 - 350 350 - 2.3
126 Bromhexine 8 mg tablet 200 - 200 200 - 3,000
127 Calsium lactate 500 mg tablet 2,000 - 2,000 700 1,300 - 1,2,3
128 Captopril 12,5 mg tablet 4,900 - 4,900 800 4,100 - 1,2,3
131 Cefadroxil 500 mg tablet - - - - 1,000 2.3
132 Cefixime 100 mg tablet - - - - 1,000 2.3
133 Cetirizine 10 mg tablet - 2,000 2,000 650 1,350 - 2.3
134 Chloramphenicol 500 mg tablet 300 - 300 300 - 2.3
135 Chlorpheniramine 4 mg tablet - - - - - 1,2,3
136 Ciprofloxacin 500 mg tablet - - - - - 1,2,3
137 Citicoline 500 mg tablet - - - - 500
138 Clindamycin 150 mg tablet 550 - 550 550 - 1,2,3
139 Clobazam tab 10 mg tablet - - - - 200 2.3
140 Clopidogrel tablet 150 - 150 30 120 300
141 Colchicine 0,5 mg tablet 1,100 - 1,100 20 1,080 - 1,2,3
142 Cotrimoxazole 480 mg tablet 1,900 - 1,900 100 1,800 - 1,2,3
143 Cotrimoksazole Forte Kombinasi tablet 1,500 - 1,500 1,500 -
144 Dapyrin tablet - - - - 2,000
145 Dexamethasone 0,5 mg tablet - - - - - 1,2,3
146 Diazepam 2 mg tablet - - - - - 1,2,3
147 Diazepam 5 mg tablet - - - -
148 Diazepam stesolid 10mg supositoria - - - - 10 1,2,3
149 Diazepam stesolid 5mg supositoria - - - - 10 1,2,3
150 Diklofenac sodium 50 mg tablet 450 500 950 600 350 1,000 1,2,3
151 Diltiazem tab 30 mg tablet - 1,2,3
152 Dimenhidrinat 50 mg tablet 900 900 900 -
153 Domperidone 10 mg tablet 2,300 2,300 100 2,200 - 1,2,3
154 Digoksin Tab 0,25 mg tablet 500 500 500 -
155 Doxycycline 100 mg tablet 200 200 200 - 1,2,3
156 Dumin rectal 125 mg supositoria 10 10 10 -
157 Dumin rectal 250 mg supositoria - - - -
158 Ergotamine caffeine tablet - - - - 1,2,3
159 Erythromycin 250 mg tablet 100 100 100 - - 1,2,3
160 Erythromycin 500 mg tablet 500 500 100 400
161 Fenitoin tablet - - - - 1,2,3
162 Fenobarbital 30 mg tablet - - - 100 1,2,3
163 Furosemide 40 mg tablet 1,300 1,300 1,300 - 1,2,3
164 Glibenclamide 5 mg tablet 900 900 900 - 1,2,3
165 Glimepiride 2 mg tablet - - - - 1,2,3
166 Glimepiride 4 mg tablet 600 600 150 450 -
167 Glyceryl guaiacolate 100 mg tablet - - - 2,000
168 Glyceryl trinitrate 500 mcg tablet - - - - 1,2,3
169 Griseofulvin 125 mg tablet 1,500 1,500 1,500 - 1,2,3
170 Haloperidol 0,5 mg tablet - - - 300 2.3
171 Hydrochlorothiazide 25 mg tablet 500 500 500 - 1,2,3
172 Hyoscine butylbromide 10 mg tablet - - - 1,000 1,2,3
173 Ibuprofen 400 mg tablet 1,400 1,000 2,400 2,100 300 2,000 1,2,3
174 Isosorbid Dinitrat 5 mg tablet 600 600 600 - 1,2,3
175 Isoniazid 300 mg tablet 800 800 800 -
176 Kalium aspartate tablet - - - 1,000 2.3
177 Ketoconazole 200 mg tablet 1,400 1,400 1,400 - 1,2,3
178 Ketoprofen supo supositoria - - - 10 2.3
179 Kloramfenikol 250 mg tablet - - - - 1,2,3
180 Klorpromazin 100 mg tablet 400 400 400 - 1,2,3
181 Kuinin sulfat 222 mg tablet 1,200 1,200 1,200 - 1,2,3
182 Lanzoprasol 30 mg tablet 800 1,000 1,800 1,140 660 1,000 2.3
183 Levofloxacin 500 mg tablet 400 400 400 - 2.3
184 Lincomycin 500 mg tablet - - - -
185 Loperamide 2 mg tablet 1,400 1,400 100 1,300 - 2.3
186 Loratadine 10 mg tablet - - - 1,000 1,2,3
187 Meloxicam tab 7,5 mg tablet 750 1,000 1,750 550 1,200 -
188 Metformin 500 mg tablet 2,000 2,000 2,000 - 1,2,3
189 Methisoprinol 500 mg tablet - - - 1,000
190 Methyldopa 250 mg tablet - - - 500 2.3
191 Metilergometrin maleat tab 0,125 mg tablet 1,000 1,000 1,000 - 1,2,3
192 Metilprednisolon tab 8 mg tablet - - - - 1,2,3
193 Metilprednisolon tab 4 mg tablet 600 1,000 1,600 550 1,050 -
194 Metoclopramide 10 mg tablet 1,800 1,800 1,800 - 1,2,3
195 Metoclopramide 5 mg tablet - - - - 1,2,3
196 Metronidazol 500 mg tablet 350 350 50 300 500 1,2,3
197 Metronidazole supo supositoria - - - 12 2.3
198 Microlax rectal tube - - - 12
199 Nifedipine 10 mg tablet 2,000 2,000 2,000 - 1,2,3
200 NITROKAF Forte SR (Gliseril Trninitrat) 5 mg Capsul - 1,000 1,000 1,000
201 Norit botol - - - - 1,2,3
202 Nystatin 500.000 IU tablet - - - 500 1,2,3
203 Nystatin Vaginal Tablet 100.000 IU tablet 1,000 1,000 6 994 -
204 OAT kategori Sisipan - KDT kotak - - - - 1,2,3
205 OAT Kategori II kotak - - - -
206 Omegavit multivitamin tablet - - - 2,000
207 Omeprazole 20 mg tablet - - - 900 1,2,3
208 Ondansetron 4 mg tablet 180 180 84 96 240 2.3
209 Ondansetron 8 mg tablet 276 300 576 60 516 - 2.3
210 Paket stop TB kategori I kotak - - - - 1,2,3
211 Panviton multivitamin tablet - - - 1,000
212 Papaverin 40 mg tablet - - - 1,000
213 Paracetamol 500 mg tablet 14,700 14,700 3,200 11,500 - 1,2,3
214 Piracetam 400 mg tablet - - - 1,000
215 Piracetam 800 mg tablet - - - 1,000
216 Piroxicam 20 mg tablet - - - 1,000
217 Prednison 5 mg tablet 600 600 600 - 1,2,3
218 Prenase multivitamin tablet - - - 1,000
219 Primaquine 15 mg tablet - - - - 1,2,3
220 Probenecid 500 mg tablet 900 900 900 - 1,2,3
221 Propanolol 10 mg tablet 1,100 1,100 1,100 - 1,2,3
222 Propylthiouracil 100 mg tablet 1,300 1,300 300 1,000 - 1,2,3
223 Pyrantel tab 125 mg tablet - - - - 1,2,3
224 Ranitidine 150 mg tablet 200 2,000 2,200 1,300 900 2,000 1,2,3
225 Salbutamol 2 mg tablet 2,200 2,200 2,200 - 1,2,3
226 Salbutamol 4 mg tablet 2,340 2,340 200 2,140 - 1,2,3
227 Salbutamol nebules 2,5 mg tablet - - - -
228 Simvastatin 10 mg tablet 1,830 1,830 120 1,710 - 1,2,3
229 Spironolactone 100 mg tablet - - - - 1,2,3
230 Sucralfate 500 mg tablet 400 400 40 360 - 2.3
231 Tetrasiklin 250 mg tablet 1,000 1,000 1,000 - 1,2,3
232 Tetrasiklin 500 mg tablet - - - - 1,2,3
233 Thiamphenicol 500 mg tablet - - - -
234 Tilomix tablet - - - 3,000
235 Triheksifenidil 2mg tablet 500 500 30 470 - 1,2,3
236 Tablet Tambah Darah tablet 1,350 1,350 1,350 -
237 Valsartan tab 80 mg tablet - - - 1,000 2.3
238 Vitalamin multivitamin tablet - - - 2,000
239 Vitamin A 100.000 IU tablet - - - - 1,2,3
240 Vitamin A 200.000 IU tablet - 1,000 1,000 1,000 - 300 1,2,3
241 Vitamin B complex tablet 10,000 10,000 2,600 7,400 - 1,2,3
242 Vitamin B1 50 mg tablet 500 1,000 1,500 200 1,300 - 1,2,3
243 Vitamin B6 10 mg tablet 7,400 7,400 200 7,200 - 1,2,3
244 Vitamin C 50 mg tablet 7,800 7,800 300 7,500 - 1,2,3
245 Vitamin K 10 mg tablet 1,250 1,250 650 600 - 1,2,3
246 Zinc 20 mg tablet 600 3,000 3,600 300 3,300 - 1,2,3
OBAT GIGI - GAS

247 Alginate 500g zak - - - -
248 Amalgam ana2000 botol - - - -
249 Biomedical obat semprot oral & nose Ortoviro botol - - - -
250 Bonding stae refill botol - - - -
251 Calcium hydroxide pasta Hydcal tube - - - -
252 Calciumpolystyrene Kalikate sachet - - - -
253 Caviton 30g botol - - - -
254 Dental gipsum kg 2 2 2 -
255 Devitalising paste pulp botol - - - - 1,2,3
256 Elite cement 100 semen seng fosfat set - - - -
257 Etil Clorida spray botol - - - 5 1,2,3
258 ETSA etching gel kit 12gm dispo - - - -
259 Glass ionomer GC fuji IX set - - - - 1,2,3
260 Iodoform paste Mumifing pasta botol - - - -
261 Komposit a A2, A3, A 3,5 solareX botol - - - -
262 L Bio sachet - - - 50
263 Lidocain (XYLOCAINE) spray 10% botol 8 8 8 -
264 Oxymetazoline Nasal Spray Iliadin 0,05% botol - - - -
265 Pulp-X botol - - - -
266 Temporari stoping fletcher serbuk set - - - -
OBAT SALEP/SERBUK
267 Acyclovir cream tube - - - 50
268 Aseptic alkohol gel antiseptic pembersih tangan botol 36 36 36 -
pot 48 48 48 -
269 Benzoat 6% + Asam Salisilat 3%
AntiBakteri Salep : Basitrasin 500 IU/g + tube 24 50 74 24 50 -
270 Polimiksin 10.000 Iu/g
271 Betametason cream tube 100 100 27 73 - 1,2,3
272 Bioplacenton gel tube - - - 50
273 Bricasma terbutaline can - - - 5
274 Burnazin silver sulphadiazine tube 34 34 2 32 - 1,2,3
275 Caladine lotion botol - - - 50
276 Chloramphenicol salep kulit tube - - - 50 1,2,3
277 Chloramphenicol salep mata tube 38 38 14 24 - 1,2,3
278 Cutimed gel tube - - - 20
279 Desoximetasone cream tube 105 105 105 - 2.3
280 Diclofenac sodium gel tube - - - 50
281 Fucilex Krim Sodium Fusidat 20% 20 mg/mL tube 29 20 49 4 45 -
282 Gentamicin salep mata tube - - - 25 2.3
283 Garam Oralit Serbuk Kombinasi sachet 100 100 2 98 -
284 Hydrocortisone cream tube 93 240 333 23 310 - 1,2,3
285 Ichtyol salep pot - - - 50
286 Ketoconazole cream tube 50 50 2 48 - 1,2,3
287 Lidocain jelly dispo - - - 20 1,2,3
288 Miconazole cream tube 21 48 69 6 63 - 1,2,3
289 My Jelli tube 50 50 50 -
290 Nebacetin salep tube - -
291 Salep 2-4 pot 39 39 39 - 1,2,3
292 Salisil bedak kotak 40 40 3 37 - 1,2,3
293 Dexocort Salep 0,25% tube - - - - 2.3
294 Sabun anti bakteri 500 ml botol 29 12 41 41 -
295 Thrombophob gel tube - - - 50
296 Ultrasound gel USG botol 34 100 134 28 106 -
OBAT LAINNYA
297 Absorbent paper points 15-40 kotak - - - - 1,2,3
298 Absorbent paper points 45-80 kotak - - - - 1,2,3
299 Alkohol swab / Swab, 4 Ply pcs - 500 500 500 -
300 Apron One Plastik Onemed lembar - - - -
301 Bisturi no. 11 pcs 198 198 198 -
302 Bisturi no. 18 pcs 196 196 196 -
303 Bisturi no. 20 pcs 150 150 150 -
304 Bisturi no. 22 pcs 100 100 100 -
305 BeneCheck Plus Glucose Test Strip 50's strip 50 50 50 -
306 BeneCheck Plus Total Cholesterol Test Strip 10's strip 50 200 250 250 -
307 BeneCheck Plus Uric Test Strip 25's strip 50 200 250 250 -
308 Blood Lancet pcs 100 100 200 200 100
309 Catgut Chrom 3/0 Rol 100 meter roll 1 1 1 -
310 Catgut Chromic 2/0 pcs 96 96 96 -
311 Catgut Chromic 3/0 pcs 96 96 12 84 -
312 Catgut plain 2/0 + jarum pcs 96 96 96 -
313 Catgut plain 3/0 + jarum pcs 88 88 2 86 -
314 Celemek / Apron pcs - - - -
315 Cutimed siltec 10x10cm pcs 20 20 20 -
316 Cutimed sorbact 7x9cm pcs - - - 50
317 Duk steril disposible pcs - - - -
318 Endotracheal Tube w/Cuffed - 3 pcs 20 20 20 -
324 Foley catheter 2 way no. 16 pcs - 10 10 10 -
325 Foley catheter 2 way no. 18 pcs 3 10 13 13 -
326 Foley catheter 2 way no. 20 pcs 8 8 8 -
327 Foley catheter 2 way no. 6 pcs 100 100 100 -
328 Gutta percha points 15-40 pcs - - - - 1,2,3
329 Gutta percha points 45-80 pcs 1 1 1 - 1,2,3
330 Handscoen ginekologi psg - - - -
331 Handscoen non steril Large psg - - - -
332 Handscoen non steril Medium psg 100 1,000 1,100 300 800 -
333 Handscoen Obsgyn psg 100 100 100 -
334 Handscoen steril no. 6,5 psg 85 85 35 50 -
335 Handscoen steril no. 7 psg 94 94 28 66 -
336 Handscoen steril no. 7,5 psg 93 93 61 32 100
337 Handscoen steril no. 8 psg 99 99 10 89 -
338 Hb Sahli Set 10 10 10
339 HCG test pcs 115 115 40 75 100
340 Infusion set Anak pcs 40 40 40 -
341 Infusion set Dewasa pcs 349 400 749 49 700 -
342 IV cannula no. 18 pcs 450 450 450 -
343 IV cannula no. 20 pcs - 100 100 100 100
344 IV cannula no. 22 pcs 57 57 37 20 100
345 IV cannula no. 24 pcs 200 200 200 -
346 IV cannula no. 26 pcs 200 200 200 -
347 Jarum jahit No. 10 pcs 24 24 24 -
349 Jarum jahit No. 12 pcs - - - -
352 Jarum jahit No. 15 pcs - - - -
353 Jarum jahit No. 9 pcs 36 12 48 48 -
354 Jarum otot besar pcs - - - -
355 Jarum otot kecil pcs - - - -
356 Jarum untuk insulin pen pcs 5 5 1 4 5
357 Kacamata Anti infeksi pcs - - - -
358 Kapas Berlemak 500 g bungkus - - - -
359 Kapas putih 250 g bungkus 13 13 3 10 -
360 Kasa hidrofil 40yard x 80cm roll 26 26 1 25 -
361 Kasa hidrofil 4m x 10cm rol 100 100 100 -
362 Kasa hidrofil 4m x 5cm rol 100 100 100 -
363 Kasa sterile 16x16cm pcs 3,616 3,616 1,056 2,560 -
364 Klem tali pusat pcs - - - -
365 Masker Nebulizer Set Anak Besmed pcs 25 25 25 -
366 Masker Nebulizer Set Dewasa Besmed pcs 25 25 25 -
367 Masker pcs 1,250 1,250 450 800 -

1A6542 Fine (1,5mm) warna kuning, biru buckets - - - -
368
369 Mucous extractor FR 10 pcs 84 84 2 82 -
370 NGT no.16 pcs - - - -
371 NGT no.18 pcs - - - -
372 NGT no.3,5 pcs - - - -
373 NGT no.5 pcs - - - -
374 NGT no.8 pcs - - - -
375 Oxygen nasal cannula Anak pcs 90 90 90 -
376 Oxygen nasal cannula Dewasa pcs 70 70 70 -
377 Pembalut Gibs rol - - - 50
378 Pen Needle Set - - -
379 Plester coklat yard Leukoplast rol 29 29 1 28 -
380 Plester Infus dermafix pcs 25 25 25 -
381 Plester luka bakar pcs - - - -
382 Plester putih Polifix rol - - - -
383 Plester rawat luka anti air dermafix t 10x25cm pcs 40 40 40 -
384 Safety box pcs - - - 5
385 Silk 2/0 pcs 12 48 60 60 -
386 Silk 3/0 pcs 12 48 60 60 -
387 Sputum Pot pcs 90 90 90
388 Suction catheter FR 10 pcs 20 20 20 -
392 Suction catheter FR 18 pcs - - - -
395 Surgical gown baju operasi L pcs 30 30 30 -
396 Surgical gown baju operasi M pcs 20 20 20 -
397 Surgical gown baju operasi XL pcs 10 10 10 -
398 Syringe 1 cc pcs 80 80 80 -
399 Syringe 3 cc pcs 1,660 2,000 3,660 260 3,400 -
400 Syringe 5 cc pcs 97 97 97 -
401 Syringe 10 cc pcs 104 104 104 -
402 Syringe 20 cc pcs 99 99 99 -
403 Syringe 50 cc pcs 18 18 18 -
404 Test Anti HCV Strip test 100 100 25 75 -
405 Test Anti HIV 1/2 Cassette test 50 50 1 49 -
406 Test HBsAg strip test 50 50 25 25 50
407 Test Malaria HRP2/pLDH (Pf/PAN) combo test 50 50 50 - 50
408 Topi Operasi pcs 100 100 100 -
409 Urine Bag pcs 39 39 39 -
410 Uritest Reagen Strips 11G Tube - - - -
411 Venflon Pro IV Canula 18 ga 0,9 mm x 25 mm 50 50 50 -
412 Venflon Pro IV Canula 20 ga 1,1 mm x 32 mm 50 100 150 50 100 -
413 Venflon Pro IV Canula 22 ga 0,9 mm x 25 mm pcs 50 50 50 -
414 softpad (Underpad) 60x90 cm One Med pcs 300 310 610 370 240 -
415 Buku KIA bh - - - -
416 Wing Needle 19 G Onemed pcs 10 10 10 -
419 Wing Needle 27 G Onemed pcs 10 10 10
420 Ziehl Neelsen Set 5 x 100 mL Set 9 9 9
136,164 32,243 168,407 28,094 140,313 46,581
UMUM ASKES/ JUMLAH

BPJS
BAYAR BAYAR 292 681
382 7
Sangkub, Maret 2019

NIP. 19671105 200012 1 003 NIP. 19840909 201102 2 001 NIP. 1964021918802 1 002 NIP. 19900608 201502 2 001
(LPLPO)
INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN : 090/PKM-SKB/BMU/267/IV/2019

KECAMATAN : SANGKUB BULAN PEMAKAIAN : MARET
KABUPATEN : BOLAANG MONGONDOW UTARA BULAN PERMINTAAN : APRIL
PEMBERIAAN
DAK APBD I DAU LAIN
(TK)
1 2 3 4 5 6=4+5 7 8 9=6-7-8 10 11 12 13 14 15 16
OBAT CAIR
1 Alkohol 70% 100 ml botol - - - - - - 1,2,3
2 Alkohol 70% 1000 ml botol 15 - 15 3 12 - 1,2,3
4 Ambroxol sirup botol - - - - - 100
5 Aminophylline inj ampul 96 - 96 - 96 - 1,2,3
7 Amoxicillin sirup botol - - - - - - 1,2,3
9 Analog Long insulin (Ezelin) 100 IU pen 19 - 19 - 19 - 1,2,3
10 Antalgin inj ampul 100 - 100 - 100 -
12 Aqua pro inj flacon 72 - 72 - 72 - 1,2,3
13 Asering infus botol - - - - - 60 1,2,3
14 Atropin sulfate inj ampul 100 - 100 - 100 - 1,2,3
15 Carbol fuchsin 0,3% botol - - - - - -
17 Cefadroxil Syr 125 mg/ml botol 62 - 62 10 52 -
19 Cefotaxime inj vial - - - - - - 2.3
24 Bromida Inhalasi 0,5 mg + salbutamol 2,5 mg vial - - - - - 20

25 Sulfametoksazol 200 mg + Trimetoprim 40 mg botol 21 - 21 18 3 50

27 Curbion sirup multivitamin botol - - - - - -
29 Diazepam Inj ampul - - - - - - 1,2,3
30 Diphenhydramine inj ampul 80 - 80 - 80 - 1,2,3
31 Domperidone sirup botol - - - - - 50 1,2,3
32 Epinephrine inj ampul 290 - 290 - 290 - 1,2,3
33 Erythromycin sirup botol 20 - 20 12 8 50 1,2,3
36 Furosemide inj ampul 25 - 25 - 25 - 1,2,3
37 Gastrucid Sirup 131 - 131 26 105 -
41 Glukosa 10% infus botol - - - - - 1,2,3
43 Glukosa 5% infus botol 33 - 33 - 33 - 1,2,3
44 HCl 0,1 N 100 mL botol 5 - 5 - 5
45 H2O2 3% botol 3 - 3 - 3 - 1,2,3
46 Hyoscine butylbromide inj ampul - - - - - 20 2.3
48 KAEN 3A infus botol 47 - 47 - 47 - 1,2,3
49 KAEN 3B infus botol 60 - 60 - 60 - 1,2,3
50 Ketamine inj vial 50 - 50 50 - - 1,2,3
54 KCL 7.46% Kalium Klorida OTSU 2 ml flacon 551 - 551 551 - -
55 Lidocaine inj ampul 60 - 60 - 60 - 1,2,3
56 Lysol cairan botol 18 - 18 2 16 -
60 Methylen blue 0,3% botol - - - - - -
61 Methylergometrin maleate inj ampul 200 - 200 - 200 - 1,2,3
62 Metoklopramide sirup botol 58 - 58 - 58 - 1,2,3
63 Metronidazole infus botol 14 - 14 - 14 - 1,2,3
64 Natrium klorida 0,9% infus botol 20 100 120 20 100 - 1,2,3
65 Ofloksasin (Tarivid) Tetes Telinga botol - - - - - 20
67 Oil emersi botol - - - - - -
68 Omegdiar sirup botol 45 - 45 - 45 -
69 Omeprazole inj vial - - - - - 50 1,2,3
70 Ondansetron inj ampul 50 - 50 - 50 - 2.3
72 Oxytocin inj ampul 1,400 - 1,400 6 1,394 - 1,2,3
75 Paracetamol infus botol 36 - 36 - 36 - 3
76 Paracetamol sirup botol 29 - 29 29 - 50 1,2,3
79 Pirantel Sirup botol 90 - 90 - 90 - 1,2,3
80 Povidone 300 ml botol 80 - 80 2 78 - 1,2,3
82 Ranitidine inj ampul 300 - 300 - 300 - 2.3
84 Ringer Laktat infus botol 160 - 160 160 - 40 1,2,3
85 Rivanol 300 ml botol 24 - 24 1 23 - 1,2,3
88 Sucralfate sirup botol - - - - - 20 2.3
89 Tetagam inj human tetanus vial - - - - - 10 1,2,3
92 Vit amin B12 inj ampul 164 - 164 64 100 - 1,2,3
95 Vitamin K inj 2 mg ampul 90 - 90 - 90 - 1,2,3
96 Voluven HES 6% botol - - - - - - 1,2,3
97 ZINCPRO Sulfate 10 mg/mL botol 127 - 127 22 105 - 1,2,3
98 Zinc Sirup botol 28 - 28 7 21 -
OBAT PADAT
99 Acetosal 100 mg tablet - - - - - - 2.3
100 Acetylcysteine 200 mg tablet - - - - - - 1,2,3
103 Acyclovir 400 mg tablet 600 - 600 - 600 - 1,2,3
104 Albendazole 400 mg tablet 1,620 - 1,620 - 1,620 - 1,2,3
105 Allopurinol 100 mg tablet 400 1,000 1,400 - 1,400 - 1,2,3
108 Aminophillin 150 mg tablet - - - - - - 1,2,3
109 Aminophillin 200 mg tablet 200 - 200 - 200 -
110 Amlodipine 10 mg tablet 930 - 930 600 330 900 1,2,3
111 Amlodipine 5 mg tablet 960 900 1,860 330 1,530 - 1,2,3
112 Amoxicillin 500 mg tablet 1,800 - 1,800 1,100 700 - 1,2,3
113 Antalgin 500 mg tablet - - - - - 1,000
114 Antasida doen tablet 5,600 - 5,600 400 5,200 - 1,2,3
115 Anti Hemoroid supo supositoria 60 - 60 50 10 50 1,2,3
116 Asam Folat 1 mg tablet 200 - 200 - 200 - 1,2,3
117 Asam mefenamat 500 mg tablet 8,500 - 8,500 300 8,200 - 1,2,3
118 Asam traneksamat 500 mg tablet - - - - - 500 2.3
119 Asiklovir 200 mg tablet - - - - - - 1,2,3
120 Attapulgite tablet 850 - 850 - 850 - 1,2,3
121 Betahistin tab tablet 2,150 - 2,150 - 2,150 - 2.3
122 Bisacodyl (Dulcolax) Supp 5 mg supositoria - - - - - 20 1,2,3
124 Bisacodyl Tab 5 mg tablet 900 - 900 - 900 -
125 Bisoprolol 5 mg tablet 350 - 350 - 350 - 2.3
126 Bromhexine 8 mg tablet - - - - - 3,000
127 Calsium lactate 500 mg tablet 1,300 - 1,300 300 1,000 - 1,2,3
128 Captopril 12,5 mg tablet 4,100 - 4,100 700 3,400 - 1,2,3
129 Captopril 25 mg tablet - - - - - 500 1,2,3
131 Cefadroxil 500 mg tablet - - - - - 1,000 2.3
132 Cefixime 100 mg tablet - - - - - 1,000 2.3
133 Cetirizine 10 mg tablet 1,350 - 1,350 500 850 - 2.3
134 Chloramphenicol 500 mg tablet 300 - 300 120 180 - 2.3
135 Chlorpheniramine 4 mg tablet - - - - - - 1,2,3
136 Ciprofloxacin 500 mg tablet - - - - - - 1,2,3
137 Citicoline 500 mg tablet - - - - - 500
138 Clindamycin 150 mg tablet 550 - 550 - 550 - 1,2,3
139 Clobazam tab 10 mg tablet - - - - - 100 2.3
140 Clopidogrel tablet 120 300 420 30 390 -
141 Colchicine 0,5 mg tablet 1,080 - 1,080 - 1,080 - 1,2,3
142 Cotrimoxazole 480 mg tablet 1,800 - 1,800 - 1,800 - 1,2,3
143 Cotrimoksazole Forte Kombinasi tablet 1,500 - 1,500 - 1,500 -
144 Dapyrin tablet - - - - - 2,000
145 Dexamethasone 0,5 mg tablet - - - - - - 1,2,3
146 Diazepam 2 mg tablet - - - - - - 1,2,3
148 Diazepam stesolid 10mg supositoria - - - - - 10 1,2,3
150 Diklofenac sodium 50 mg tablet 350 1,000 1,350 300 1,050 - 1,2,3
151 Diltiazem tab 30 mg tablet - - - 1,2,3
152 Dimenhidrinat 50 mg tablet 900 - 900 - 900 -
153 Domperidone 10 mg tablet 2,200 - 2,200 500 1,700 - 1,2,3
154 Digoksin Tab 0,25 mg tablet 500 - 500 - 500 -
155 Doxycycline 100 mg tablet 200 - 200 - 200 - 1,2,3
156 Dumin rectal 125 mg supositoria 10 - 10 5 5 -
157 Dumin rectal 250 mg supositoria - - - - - -
158 Ergotamine caffeine tablet - - - - - - 1,2,3
159 Erythromycin 250 mg tablet - - - - - - 1,2,3
160 Erythromycin 500 mg tablet 400 - 400 200 200 500
161 Fenitoin tablet - - - - - - 1,2,3
162 Fenobarbital 30 mg tablet - - - - - - 1,2,3
163 Furosemide 40 mg tablet 1,300 - 1,300 - 1,300 - 1,2,3
164 Glibenclamide 5 mg tablet 900 - 900 - 900 - 1,2,3
165 Glimepiride 2 mg tablet - - - - - - 1,2,3
166 Glimepiride 4 mg tablet 450 - 450 - 450 -
167 Glyceryl guaiacolate 100 mg tablet - - - - - -
168 Glyceryl trinitrate 500 mcg tablet - - - - - - 1,2,3
169 Griseofulvin 125 mg tablet 1,500 - 1,500 - 1,500 - 1,2,3
170 Haloperidol 0,5 mg tablet - - - - - 300 2.3
171 Hydrochlorothiazide 25 mg tablet 500 - 500 - 500 - 1,2,3
172 Hyoscine butylbromide 10 mg tablet - - - - - 1,000 1,2,3
173 Ibuprofen 400 mg tablet 300 2,000 2,300 300 2,000 - 1,2,3
174 Isosorbid Dinitrat 5 mg tablet 600 - 600 - 600 - 1,2,3
175 Isoniazid 300 mg tablet 800 - 800 - 800 -
176 Kalium aspartate tablet - - - - - 1,000 2.3
177 Ketoconazole 200 mg tablet 1,400 - 1,400 - 1,400 - 1,2,3
178 Ketoprofen supo supositoria - - - - - 10 2.3
179 Kloramfenikol 250 mg tablet - - - - - - 1,2,3
180 Klorpromazin 100 mg tablet 400 - 400 - 400 - 1,2,3
181 Kuinin sulfat 222 mg tablet 1,200 - 1,200 - 1,200 - 1,2,3
182 Lanzoprasol 30 mg tablet 660 1,000 1,660 600 1,060 1,000 2.3
183 Levofloxacin 500 mg tablet 400 - 400 #VALUE! - 2.3
184 Lincomycin 500 mg tablet - - - - - -
185 Loperamide 2 mg tablet 1,300 - 1,300 300 1,000 - 2.3
186 Loratadine 10 mg tablet - - - - - 1,000 1,2,3
187 Meloxicam tab 7,5 mg tablet 1,200 - 1,200 200 1,000 -
188 Metformin 500 mg tablet 2,000 - 2,000 - 2,000 - 1,2,3
189 Methisoprinol 500 mg tablet - - - - - 1,000
190 Methyldopa 250 mg tablet - - - - - 500 2.3
191 Metilergometrin maleat tab 0,125 mg tablet 1,000 - 1,000 - 1,000 - 1,2,3
192 Metilprednisolon tab 8 mg tablet - - - - - - 1,2,3
193 Metilprednisolon tab 4 mg tablet 1,050 - 1,050 650 400 -
194 Metoclopramide 10 mg tablet 1,800 - 1,800 - 1,800 - 1,2,3
195 Metoclopramide 5 mg tablet - - - - - - 1,2,3
196 Metronidazol 500 mg tablet 300 - 300 - 300 500 1,2,3
197 Metronidazole supo supositoria - - - - - 12 2.3
198 Microlax rectal tube - - - - - 12
199 Nifedipine 10 mg tablet 2,000 - 2,000 1,000 1,000 - 1,2,3
200 NITROKAF Forte SR (Gliseril Trninitrat) 5 mg Capsul 1,000 - 1,000 1,000 -
201 Norit botol - - - - - - 1,2,3
202 Nystatin 500.000 IU tablet - - - - - 500 1,2,3
203 Nystatin Vaginal Tablet 100.000 IU tablet 994 - 994 - 994 -
204 OAT kategori Sisipan - KDT kotak - - - - - - 1,2,3
205 OAT Kategori II kotak - - - - - -
206 Omegavit multivitamin tablet - - - - - 2,000
207 Omeprazole 20 mg tablet - - - - - 900 1,2,3
208 Ondansetron 4 mg tablet 96 240 336 - 336 240 2.3
209 Ondansetron 8 mg tablet 516 - 516 - 516 - 2.3
210 Paket stop TB kategori I kotak - - - - - - 1,2,3
211 Panviton multivitamin tablet - - - - - 1,000
212 Papaverin 40 mg tablet - - - - - 1,000
213 Paracetamol 500 mg tablet 11,500 - 11,500 1,700 9,800 - 1,2,3
214 Piracetam 400 mg tablet - - - - - 1,000
216 Piroxicam 20 mg tablet - - - - - 1,000
217 Prednison 5 mg tablet 600 - 600 - 600 - 1,2,3
218 Prenase multivitamin tablet - - - - - 1,000
219 Primaquine 15 mg tablet - - - - - 1,2,3
220 Probenecid 500 mg tablet 900 - 900 100 800 - 1,2,3
221 Propanolol 10 mg tablet 1,100 - 1,100 500 600 - 1,2,3
222 Propylthiouracil 100 mg tablet 1,000 - 1,000 - 1,000 - 1,2,3
223 Pyrantel tab 125 mg tablet - - - - - - 1,2,3
224 Ranitidine 150 mg tablet 900 - 900 300 600 - 1,2,3
225 Salbutamol 2 mg tablet 2,200 - 2,200 800 1,400 - 1,2,3
226 Salbutamol 4 mg tablet 2,140 - 2,140 1,440 700 - 1,2,3
227 Salbutamol nebules 2,5 mg tablet - - - - - -
228 Simvastatin 10 mg tablet 1,710 - 1,710 - 1,710 - 1,2,3
229 Spironolactone 100 mg tablet - - - - - - 1,2,3
230 Sucralfate 500 mg tablet 360 - 360 - 360 - 2.3
231 Tetrasiklin 250 mg tablet 1,000 - 1,000 - 1,000 - 1,2,3
232 Tetrasiklin 500 mg tablet - - - - - - 1,2,3
234 Tilomix tablet - - - - - 3,000
235 Triheksifenidil 2mg tablet 470 - 470 - 470 - 1,2,3
236 Tablet Tambah Darah tablet 1,350 - 1,350 - 1,350 -
237 Valsartan tab 80 mg tablet - - - - - 1,000 2.3
238 Vitalamin multivitamin tablet - - - - - 2,000
239 Vitamin A 100.000 IU tablet - - - - - - 1,2,3
240 Vitamin A 200.000 IU tablet - 500 500 - 500 - 1,2,3
241 Vitamin B complex tablet 7,400 - 7,400 1,200 6,200 - 1,2,3
242 Vitamin B1 50 mg tablet 1,300 - 1,300 - 1,300 - 1,2,3
243 Vitamin B6 10 mg tablet 7,200 - 7,200 - 7,200 - 1,2,3
244 Vitamin C 50 mg tablet 7,500 - 7,500 100 7,400 - 1,2,3
245 Vitamin K 10 mg tablet 600 - 600 - 600 - 1,2,3
246 Zinc 20 mg tablet 3,300 - 3,300 500 2,800 - 1,2,3
OBAT GIGI - GAS

247 Alginate 500g zak - - - - - -
248 Amalgam ana2000 botol - - - - - -
249 Biomedical obat semprot oral & nose Ortoviro botol - - - - - -
250 Bonding stae refill botol - - - - - -
251 Calcium hydroxide pasta Hydcal tube - - - - - -
252 Calciumpolystyrene Kalikate sachet - - - - - -
253 Caviton 30g botol - - - - - -
254 Dental gipsum kg 2 - 2 - 2 -
255 Devitalising paste pulp botol - - - - - - 1,2,3
256 Elite cement 100 semen seng fosfat set - - - - - -
257 Etil Clorida spray botol - - - - - 5 1,2,3
258 ETSA etching gel kit 12gm dispo - - - - - -
259 Glass ionomer GC fuji IX set - - - - - - 1,2,3
260 Iodoform paste Mumifing pasta botol - - - - - -
261 Komposit a A2, A3, A 3,5 solareX botol - - - - - -
262 L Bio sachet - - - - - 50
263 Lidocain (XYLOCAINE) spray 10% botol 8 - 8 1 7 -
264 Oxymetazoline Nasal Spray Iliadin 0,05% botol - - - - - -
265 Pulp-X botol - - - - - -
266 Temporari stoping fletcher serbuk set - - - - - -
OBAT SALEP/SERBUK
267 Acyclovir cream tube - - - - - 50
268 Aseptic alkohol gel antiseptic pembersih tangan botol 36 - 36 - 36 -
269 Benzoat 6% + Asam Salisilat 3% pot 48 - 48 - 48 -
AntiBakteri Salep : Basitrasin 500 IU/g +

270 Polimiksin 10.000 Iu/g tube 50 - 50 25 25 50
271 Betametason cream tube 73 - 73 - 73 - 1,2,3

272 Bioplacenton gel tube - - - - - 10
273 Bricasma terbutaline can - - - - - 5
274 Burnazin silver sulphadiazine tube 32 - 32 5 27 - 1,2,3
275 Caladine lotion botol - - - - - 50
276 Chloramphenicol salep kulit tube - - - - - 50 1,2,3
277 Chloramphenicol salep mata tube 24 - 24 24 - 48 1,2,3
278 Cutimed gel tube - - - - - 20
279 Desoximetasone cream tube 105 - 105 - 105 - 2.3
280 Diclofenac sodium gel tube - - - - - 50
281 Fucilex Krim Sodium Fusidat 20% 20 mg/mL tube 45 - 45 6 39 -
282 Gentamicin salep mata tube - - - - - 25 2.3
283 Garam Oralit Serbuk Kombinasi sachet 98 - 98 - 98 -
284 Hydrocortisone cream tube 310 - 310 5 305 - 1,2,3
285 Ichtyol salep pot - - - - - 50
286 Ketoconazole cream tube 48 - 48 - 48 - 1,2,3
287 Lidocain jelly dispo - - - - - 20 1,2,3
288 Miconazole cream tube 63 - 63 3 60 - 1,2,3
289 My Jelli tube 50 - 50 - 50 -
290 Nebacetin salep tube - - - -
291 Salep 2-4 pot 39 - 39 39 - 50 1,2,3
292 Salisil bedak kotak 37 - 37 - 37 - 1,2,3
293 Dexocort Salep 0,25% tube - - - - - - 2.3
294 Sabun anti bakteri 500 ml botol 41 - 41 - 41 -
295 Thrombophob gel tube - - - - - 50
296 Ultrasound gel USG botol 106 - 106 - 106 -
OBAT LAINNYA
297 Absorbent paper points 15-40 kotak - - - - - - 1,2,3
299 Alkohol swab / Swab, 4 Ply pcs 500 - 500 - 500 -
300 Apron One Plastik Onemed lembar - - - - - -
301 Bisturi no. 11 pcs 198 - 198 - 198 -
302 Bisturi no. 18 pcs 196 - 196 - 196 -
303 Bisturi no. 20 pcs 150 - 150 - 150 -
304 Bisturi no. 22 pcs 100 - 100 - 100 -
305 BeneCheck Plus Glucose Test Strip 50's strip 50 - 50 50 - 100
306 BeneCheck Plus Total Cholesterol Test Strip 10's strip 250 - 250 10 240 -
307 BeneCheck Plus Uric Test Strip 25's strip 250 - 250 - 250 -
308 Blood Lancet pcs 200 500 700 - 700 100
309 Catgut Chrom 3/0 Rol 100 meter roll 1 - 1 - 1 -
310 Catgut Chromic 2/0 pcs 96 - 96 - 96 -
312 Catgut plain 2/0 + jarum pcs 96 - 96 - 96 -
314 Celemek / Apron pcs - - - - - -
315 Cutimed siltec 10x10cm pcs 20 - 20 - 20 -
316 Cutimed sorbact 7x9cm pcs - - - - - 50
317 Duk steril disposible pcs - - - - - -
318 Endotracheal Tube w/Cuffed - 3 pcs 20 - 20 - 20 -
324 Fixation N.W. 10x10 Rol - 10 10 - 10
325 Fixation N.W. 10x15 Rol - 1 1 - 1
326 Foley catheter 2 way no. 16 pcs 10 - 10 - 10 -
330 Gutta percha points 15-40 pcs - - - - - - 1,2,3
331 Gutta percha points 45-80 pcs 1 - 1 - 1 - 1,2,3
332 Handscoen ginekologi psg - - - - - -
333 Handscoen non steril Large psg - - - - - -
334 Handscoen non steril Medium psg 800 - 800 400 400 -
335 Handscoen Obsgyn psg 100 - 100 - 100 -
336 Handscoen steril no. 6,5 psg 50 - 50 10 40 -
338 Handscoen steril no. 7,5 psg 32 400 432 10 422 -
340 Hb Sahli Set 10 - 10 - 10
341 HCG test pcs 75 100 175 1 174 -
342 Infusion set Anak pcs 40 - 40 - 40 -
343 Infusion set Dewasa pcs 700 - 700 - 700 -
344 IV cannula no. 18 pcs 450 - 450 - 450 -
345 IV cannula no. 20 pcs 100 100 200 - 200 -
346 IV cannula no. 22 pcs 20 100 120 20 100 -
347 IV cannula no. 24 pcs 200 - 200 - 200 -
348 IV cannula no. 26 pcs 200 - 200 - 200 -
349 Jarum jahit No. 10 pcs 24 - 24 - 24 -
351 Jarum jahit No. 12 pcs - - - - - -
352 Jarum jahit No. 13 pcs 12 - 12 12 - -
356 Jarum otot besar pcs - - - - - -
357 Jarum otot kecil pcs - - - - - -
358 Jarum untuk insulin pen pcs 4 - 4 - 4 5
359 Kacamata Anti infeksi pcs - - - - - -
360 Kapas Berlemak 500 g bungkus - - - - - -
361 Kapas putih 250 g bungkus 10 - 10 4 6 10
362 Kasa hidrofil 40yard x 80cm roll 25 - 25 - 25 -
363 Kasa hidrofil 4m x 10cm rol 100 - 100 - 100 -
365 Kasa sterile 16x16cm pcs 2,560 - 2,560 800 1,760 -
366 Klem tali pusat pcs - - - - - -
367 Masker Nebulizer Set Anak Besmed pcs 25 - 25 - 25 -
368 Masker Nebulizer Set Dewasa Besmed pcs 25 - 25 - 25 -
369 Masker pcs 800 - 800 250 550 -

370 1A6542 Fine (1,5mm) warna kuning, biru buckets - - - - - -
371 Mucous extractor FR 10 pcs 82 - 82 - 82 -

372 NGT no.16 pcs - - - - - -
373 NGT no.18 pcs - - - - - -
374 NGT no.3,5 pcs - - - - - -
375 NGT no.5 pcs - - - - - -
376 NGT no.8 pcs - - - - - -
379 Paper Tape 1.25 x 9.14 Rol - 10 10 - 10
380 Paper Tape 2.5 x 9.14 Rol - 5 5 - 5
381 Paper Tape 5.0 x 9.14 Rol - 2 2 - 2
382 Paper Tape 7.5 x 9.14 Rol - 1 1 - 1
383 Pembalut Gibs rol - - - - - 50
384 Pen Needle Set - - - - -
385 Plester coklat yard Leukoplast rol 28 - 28 - 28 -
386 Plester Infus dermafix pcs 25 - 25 - 25 -
387 Plester luka bakar pcs - - - - - -
388 Plester putih Polifix rol - - - - - -
389 Plester rawat luka anti air dermafix t 10x25cm pcs 40 - 40 - 40 -
390 Safety box pcs - 200 200 - 200 -
391 Silk 2/0 pcs 60 - 60 - 60 -
392 Silk 3/0 pcs 60 - 60 - 60 -
393 Sputum Pot pcs 90 - 90 10 80
394 Suction catheter FR 10 pcs 20 - 20 - 20 -
398 Suction catheter FR 18 pcs - - - - - -
401 Surgical gown baju operasi L pcs 30 - 30 - 30 -
402 Surgical gown baju operasi M pcs 20 - 20 1 19 -
403 Surgical gown baju operasi XL pcs 10 - 10 - 10 -
404 Syringe 1 cc pcs 80 - 80 10 70 -
405 Syringe 3 cc pcs 3,400 - 3,400 140 3,260 -
406 Syringe 5 cc pcs 97 - 97 3 94 -
407 Syringe 10 cc pcs 104 - 104 - 104 -
408 Syringe 20 cc pcs 99 - 99 - 99 -
409 Syringe 50 cc pcs 18 - 18 1 17 -
410 Test Anti HCV Strip test 75 - 75 - 75 -
411 Test Anti HIV 1/2 Cassette test 49 - 49 26 23 -
412 Test HBsAg strip test 25 100 125 - 125 -
413 Test Malaria HRP2/pLDH (Pf/PAN) combo test - - - - - 50
414 Topi Operasi pcs 100 - 100 - 100 -
415 Urine Bag pcs 39 - 39 - 39 -
416 Uritest Reagen Strips 11G Tube - 100 100 - 100 -
417 Venflon Pro IV Canula 18 ga 0,9 mm x 25 mm 50 - 50 - 50 -
419 Venflon Pro IV Canula 22 ga 0,9 mm x 25 mm pcs 50 - 50 50 - -
420 softpad (Underpad) 60x90 cm One Med pcs 240 - 240 - 240 -
421 Buku KIA bh - - - - - -
422 Wing Needle 19 G Onemed pcs 10 - 10 - 10 -
425 Wing Needle 27 G Onemed pcs 10 - 10 - 10
426 Ziehl Neelsen Set 5 x 100 mL Set 9 - 9 - 9
140,313 9,565 149,878 19,144 #VALUE! 37,904
ASKES/
UMUM BPJS JUMLAH

BAYAR
BAYAR 248 579
319 12
Sangkub, 04 April 2019

NIP. 19671105 200012 1 003 NIP. 19840909 201102 2 001 NIP. 1964021918802 1 002 NIP. 19900608 201502 2 001
(LPLPO)
INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN : 090/PKM-SKB/BMU/ /IV/2019

KECAMATAN : SANGKUB BULAN PEMAKAIAN : APRIL
KABUPATEN : BOLAANG MONGONDOW UTARA BULAN PERMINTAAN : MEI
PEMBERIAAN
DAK APBD I DAU LAIN
(TK)
1 2 3 4 5 6=4+5 7 8 9=6-7-8 10 11 12 13 14 15 16
OBAT CAIR
1 Alkohol 70% 100 ml botol - - - - - - - 1,2,3
2 Alkohol 70% 1000 ml botol 12 - 12 2 10 - 1,2,3
4 Ambroxol sirup botol - - - - - 100
5 Aminophylline inj ampul 96 - 96 - 96 - 1,2,3
7 Amoxicillin sirup botol - - - - - - 1,2,3
9 Analog Long insulin (Ezelin) 100 IU pen 19 - 19 - 19 - 1,2,3
10 Antalgin inj ampul 100 - 100 - 100 -
12 Aqua pro inj flacon 72 - 72 - 72 - 1,2,3
13 Asering infus botol - - - - - 60 1,2,3
14 Atropin sulfate inj ampul 100 - 100 - 100 - 1,2,3
15 Carbol fuchsin 0,3% botol - - - - - -
17 Cefadroxil Syr 125 mg/ml botol 52 - 52 - 52 -
19 Cefotaxime inj vial - - - - - - 2.3
24 Bromida Inhalasi 0,5 mg + salbutamol 2,5 mg vial - - - - - 20

25 Sulfametoksazol 200 mg + Trimetoprim 40 mg botol 3 50 53 8 45 -

27 Curbion sirup multivitamin botol - - - - - -
29 Diazepam Inj ampul - - - - - - 1,2,3
30 Diphenhydramine inj ampul 80 - 80 5 75 - 1,2,3
31 Domperidone sirup botol - - - - - 50 1,2,3
32 Epinephrine inj ampul 290 100 390 - 390 - 1,2,3
33 Erythromycin sirup botol 8 50 58 - 58 - 1,2,3
36 Furosemide inj ampul 25 - 25 - 25 - 1,2,3
37 Gastrucid Sirup 105 - 105 62 43 48
41 Glukosa 10% infus botol - - - - - 1,2,3
43 Glukosa 5% infus botol 33 - 33 - 33 - 1,2,3
44 HCl 0,1 N 100 mL botol 5 - 5 - 5
45 H2O2 3% botol 3 - 3 - 3 - 1,2,3
46 Hyoscine butylbromide inj ampul - - - - - 20 2.3
48 KAEN 3A infus botol 47 - 47 10 37 - 1,2,3
49 KAEN 3B infus botol 60 - 60 5 55 - 1,2,3
50 Ketamine inj vial - - - - - - 1,2,3
54 KCL 7.46% Kalium Klorida OTSU 2 ml flacon - - - - - -
55 Lidocaine inj ampul 60 - 60 - 30 - 1,2,3
56 Lysol cairan botol 16 - 16 - 16 -
60 Methylen blue 0,3% botol - - - - - -
61 Methylergometrin maleate inj ampul 200 100 300 - 300 - 1,2,3
62 Metoklopramide sirup botol 58 - 58 - 58 - 1,2,3
64 Natrium klorida 0,9% infus botol 100 - 100 60 40 - 1,2,3
65 Ofloksasin (Tarivid) Tetes Telinga botol - - - - - 20
67 Oil emersi botol - - - - - -
68 Omegdiar sirup botol 45 - 45 - 45 -
69 Omeprazole inj vial - - - - - 50 1,2,3
70 Ondansetron inj ampul 50 - 50 - 50 - 2.3
72 Oxytocin inj ampul 1,394 100 1,494 - 1,300 194 - 1,2,3
75 Paracetamol infus botol 36 - 36 - 36 - 3
76 Paracetamol sirup botol - - - - - 50 1,2,3
79 Pirantel Sirup botol 90 - 90 - 90 - 1,2,3
80 Povidone 300 ml botol 78 - 78 - 78 - 1,2,3
82 Ranitidine inj ampul 300 - 300 - 300 - 2.3
84 Ringer Laktat infus botol - 100 100 20 80 - 1,2,3
85 Rivanol 300 ml botol 23 - 23 - 23 - 1,2,3
88 Sucralfate sirup botol - - - - - 20 2.3
89 Tetagam inj human tetanus vial - - - - - 10 1,2,3
92 Vit amin B12 inj ampul 100 - 100 - 100 - 1,2,3
95 Vitamin K inj 2 mg ampul 90 - 90 - 90 - 1,2,3
96 Voluven HES 6% botol - - - - - - 1,2,3
97 ZINCPRO Sulfate 10 mg/mL botol 105 - 105 - 105 - 1,2,3
98 Zinc Sirup botol 21 - 21 10 11 -
OBAT PADAT
99 Acetosal 100 mg tablet - - - - - - 2.3
100 Acetylcysteine 200 mg tablet - - - - - - 1,2,3
103 Acyclovir 400 mg tablet 600 - 600 - 100 500 - 1,2,3
104 Albendazole 400 mg tablet 1,620 1,650 3,270 - 1,070 2,200 - 1,2,3
105 Allopurinol 100 mg tablet 1,400 - 1,400 900 500 - 1,2,3
108 Aminophillin 150 mg tablet - - - - - - 1,2,3
109 Aminophillin 200 mg tablet 200 - 200 - 200 -
110 Amlodipine 10 mg tablet 330 - 330 330 - 900 1,2,3
111 Amlodipine 5 mg tablet 1,530 - 1,530 1,530 - 1,000 1,2,3
112 Amoxicillin 500 mg tablet 700 - 700 700 - 1,000 1,2,3
113 Antalgin 500 mg tablet - - - - - 1,000
114 Antasida doen tablet 5,200 - 5,200 1,000 4,200 - 1,2,3
115 Anti Hemoroid supo supositoria 10 50 60 10 50 - 1,2,3
116 Asam Folat 1 mg tablet 200 - 200 100 100 - 1,2,3
117 Asam mefenamat 500 mg tablet 8,200 - 8,200 8,200 - 3,000 1,2,3
118 Asam traneksamat 500 mg tablet - - - - - 500 2.3
119 Asiklovir 200 mg tablet - - - - - - 1,2,3
120 Attapulgite tablet 850 - 850 - 850 - 1,2,3
121 Betahistin tab tablet 2,150 - 2,150 250 1,900 - 2.3
122 Bisacodyl (Dulcolax) Supp 5 mg supositoria - - - - - 20 1,2,3
123 Bisacodyl (Dulcolax) Supp 10 mg supositoria 31 - 31 5 26 - 20
124 Bisacodyl Tab 5 mg tablet 900 - 900 - 900 - 500
125 Bisoprolol 5 mg tablet 350 - 350 - 350 - 2.3
126 Bromhexine 8 mg tablet - - - - - 3,000
127 Calsium lactate 500 mg tablet 1,000 - 1,000 200 800 - 1,2,3
128 Captopril 12,5 mg tablet 3,400 - 3,400 2,300 1,100 - 1,2,3
131 Cefadroxil 500 mg tablet - - - - - 1,000 2.3
132 Cefixime 100 mg tablet - - - - - 1,000 2.3
133 Cetirizine 10 mg tablet 850 - 850 850 - 1,000 2.3
134 Chloramphenicol 500 mg tablet 180 - 180 - 180 - 2.3
135 Chlorpheniramine 4 mg tablet - - - - - - 1,2,3
136 Ciprofloxacin 500 mg tablet - - - - - - 1,2,3
137 Citicoline 500 mg tablet - - - - - 500
138 Clindamycin 150 mg tablet 550 - 550 - 550 - 300 1,2,3
139 Clobazam tab 10 mg tablet - - - - - 100 2.3
140 Clopidogrel tablet 390 - 390 90 300 -
141 Colchicine 0,5 mg tablet 1,080 - 1,080 - 1,080 - 500 1,2,3
142 Cotrimoxazole 480 mg tablet 1,800 - 1,800 - 1,800 - 1,2,3
143 Cotrimoksazole Forte Kombinasi tablet 1,500 - 1,500 50 1,450 -
144 Dapyrin tablet - - - - - 2,000
145 Dexamethasone 0,5 mg tablet - - - - - - 1,2,3
146 Diazepam 2 mg tablet - - - - - - 1,2,3
150 Diklofenac sodium 50 mg tablet 1,050 - 1,050 650 400 500 1,2,3
151 Diltiazem tab 30 mg tablet - - - - 1,2,3
152 Dimenhidrinat 50 mg tablet 900 - 900 - 900 -
153 Domperidone 10 mg tablet 1,700 - 1,700 - 1,700 - 1,2,3
154 Digoksin Tab 0,25 mg tablet 500 - 500 - 500 - 500
155 Doxycycline 100 mg tablet 200 - 200 - 200 - 1,2,3
156 Dumin rectal 125 mg supositoria 5 - 5 3 2 -
157 Dumin rectal 250 mg supositoria - - - - - -
158 Ergotamine caffeine tablet - - - - - - 1,2,3
159 Erythromycin 250 mg tablet - - - - - - 1,2,3
160 Erythromycin 500 mg tablet 200 - 200 200 - 500
161 Fenitoin tablet - - - - - - 1,2,3
162 Fenobarbital 30 mg tablet - - - - - - 1,2,3
163 Furosemide 40 mg tablet 1,300 - 1,300 - 1,300 - 1,2,3
164 Glibenclamide 5 mg tablet 900 - 900 - 900 - 1,2,3
165 Glimepiride 2 mg tablet - - - - - - 1,2,3
166 Glimepiride 4 mg tablet 450 - 450 - 450 -
167 Glyceryl guaiacolate 100 mg tablet - - - - 500 -
168 Glyceryl trinitrate 500 mcg tablet - - - - - - 1,2,3
169 Griseofulvin 125 mg tablet 1,500 - 1,500 - 1,500 - 1,2,3
170 Haloperidol 0,5 mg tablet - - - - - 300 2.3
171 Hydrochlorothiazide 25 mg tablet 500 - 500 - 500 - 1,2,3
172 Hyoscine butylbromide 10 mg tablet - - - - - 1,000 1,2,3
173 Ibuprofen 400 mg tablet 2,000 - 2,000 1,500 500 2,000 1,2,3
174 Isosorbid Dinitrat 5 mg tablet 600 - 600 - 600 - 1,2,3
175 Isoniazid 300 mg tablet 800 - 800 - 800 -
176 Kalium aspartate tablet - - - - - 1,000 2.3
177 Ketoconazole 200 mg tablet 1,400 - 1,400 - 1,400 - 1,2,3
178 Ketoprofen supo supositoria - - - - - 10 2.3
179 Kloramfenikol 250 mg tablet - - - - - 1,2,3
180 Klorpromazin 100 mg tablet 400 - 400 - 400 - 300 1,2,3
181 Kuinin sulfat 222 mg tablet 1,200 - 1,200 - 1,200 - 1,2,3
182 Lanzoprasol 30 mg tablet 1,060 1,000 2,060 - 2,060 - 2.3
183 Levofloxacin 500 mg tablet 400 - 400 200 200 - 2.3
184 Lincomycin 500 mg tablet - - - - - -
185 Loperamide 2 mg tablet 1,000 - 1,000 - 1,000 - 2.3
186 Loratadine 10 mg tablet - - - - - 1,000 1,2,3
187 Meloxicam tab 7,5 mg tablet 1,000 - 1,000 1,000 - 1,000
188 Metformin 500 mg tablet 2,000 - 2,000 300 1,700 - 1,2,3
189 Methisoprinol 500 mg tablet - - - - - 1,000
190 Methyldopa 250 mg tablet - - - - - 500 2.3
191 Metilergometrin maleat tab 0,125 mg tablet 1,000 - 1,000 - 1,000 - 1,2,3
192 Metilprednisolon tab 8 mg tablet - - - - - - 1,2,3
193 Metilprednisolon tab 4 mg tablet 400 - 400 - 400 -
194 Metoclopramide 10 mg tablet 1,800 - 1,800 - 1,800 - 1,2,3
195 Metoclopramide 5 mg tablet - - - - - - 1,2,3
196 Metronidazol 500 mg tablet 300 - 300 100 200 500 1,2,3
197 Metronidazole supo supositoria - - - - - 12 2.3
198 Microlax rectal tube - - - - - 12
199 Nifedipine 10 mg tablet 1,000 - 1,000 200 800 - 1,2,3
200 NITROKAF Forte SR (Gliseril Trninitrat) 5 mg Capsul - - - - -
201 Norit botol - - - - - - 1,2,3
202 Nystatin 500.000 IU tablet - - - - - 500 1,2,3
203 Nystatin Vaginal Tablet 100.000 IU tablet 994 - 994 - 994 -
204 OAT kategori Sisipan - KDT kotak - - - - - - 1,2,3
205 OAT Kategori II kotak - - - - - -
206 Omegavit multivitamin tablet - - - - - 2,000
207 Omeprazole 20 mg tablet - - - - - 900 1,2,3
208 Ondansetron 4 mg tablet 336 480 816 - 816 240 2.3
209 Ondansetron 8 mg tablet 516 - 516 - 516 - 500 2.3
210 Paket stop TB kategori I kotak - - - - - - 1,2,3
211 Panviton multivitamin tablet - - - - - 1,000
212 Papaverin 40 mg tablet - - - - - 1,000
213 Paracetamol 500 mg tablet 9,800 - 9,800 1,200 8,600 - 1,2,3
216 Piroxicam 20 mg tablet - - - - - 1,000
217 Prednison 5 mg tablet 600 - 600 - 600 - 1,2,3
218 Prenase multivitamin tablet - - - - - 1,000
219 Primaquine 15 mg tablet - - - - - - 1,2,3
220 Probenecid 500 mg tablet 800 - 800 - 800 - 1,2,3
221 Propanolol 10 mg tablet 600 - 600 - 600 - 1,2,3
222 Propylthiouracil 100 mg tablet 1,000 - 1,000 100 900 - 1,2,3
223 Pyrantel tab 125 mg tablet - - - - - - 1,2,3
224 Ranitidine 150 mg tablet 600 - 600 - 600 - 1,2,3
225 Salbutamol 2 mg tablet 1,400 - 1,400 - 1,400 - 1,2,3
226 Salbutamol 4 mg tablet 700 - 700 - 700 - 1,2,3
227 Salbutamol nebules 2,5 mg tablet - - - - - -
228 Simvastatin 10 mg tablet 1,710 - 1,710 - 1,710 - 1,000 1,2,3
229 Spironolactone 100 mg tablet - - - - - - 1,2,3
230 Sucralfate 500 mg tablet 360 - 360 20 340 - 2.3
231 Tetrasiklin 250 mg tablet 1,000 - 1,000 - 1,000 - 500 1,2,3
232 Tetrasiklin 500 mg tablet - - - - - - 1,2,3
234 Tilomix tablet - - - - - 3,000
235 Triheksifenidil 2mg tablet 470 - 470 - 470 - 1,2,3
236 Tablet Tambah Darah tablet 1,350 - 1,350 150 1,200 -
237 Valsartan tab 80 mg tablet - - - - - 1,000 2.3
238 Vitalamin multivitamin tablet - - - - - 2,000
239 Vitamin A 100.000 IU tablet - - - - - - 1,2,3
240 Vitamin A 200.000 IU tablet 500 - 500 50 450 - 1,2,3
241 Vitamin B complex tablet 6,200 - 6,200 2,500 3,700 - 1,2,3
242 Vitamin B1 50 mg tablet 1,300 - 1,300 700 600 - 1,2,3
243 Vitamin B6 10 mg tablet 7,200 - 7,200 200 7,000 - 1,2,3
244 Vitamin C 50 mg tablet 7,400 - 7,400 1,200 6,200 - 1,2,3
245 Vitamin K 10 mg tablet 600 - 600 - 600 - 1,2,3
246 Zinc 20 mg tablet 2,800 - 2,800 100 2,700 - 1,2,3
OBAT GIGI - GAS

247 Alginate 500g zak - - - - - -
248 Amalgam ana2000 botol - - - - - -
249 Biomedical obat semprot oral & nose Ortoviro botol - - - - - -
250 Bonding stae refill botol - - - - - -
251 Calcium hydroxide pasta Hydcal tube - - - - - -
252 Calciumpolystyrene Kalikate sachet - - - - - -
253 Caviton 30g botol - - - - - -
254 Dental gipsum kg 2 - 2 - 2 -
255 Devitalising paste pulp botol - - - - - - 1,2,3
256 Elite cement 100 semen seng fosfat set - - - - - -
257 Etil Clorida spray botol - - - - - 5 1,2,3
258 ETSA etching gel kit 12gm dispo - - - - - -
259 Glass ionomer GC fuji IX set - - - - - - 1,2,3
260 Iodoform paste Mumifing pasta botol - - - - - -
261 Komposit a A2, A3, A 3,5 solareX botol - - - - - -
262 L Bio sachet - - - - - 50
263 Lidocain (XYLOCAINE) spray 10% botol 7 - 7 3 4 -
264 Oxymetazoline Nasal Spray Iliadin 0,05% botol - - - - - -
265 Pulp-X botol - - - - - -
266 Temporari stoping fletcher serbuk set - - - - - -
OBAT SALEP/SERBUK
267 Acyclovir cream tube - - - - - 50
268 Aseptic alkohol gel antiseptic pembersih tangan botol 36 - 36 - 36 -
269 Benzoat 6% + Asam Salisilat 3% pot 48 - 48 3 45 -
AntiBakteri Salep : Basitrasin 500 IU/g +

270 Polimiksin 10.000 Iu/g tube 25 25 50 25 25 25
271 Betametason cream tube 73 - 73 23 50 - 1,2,3

272 Bioplacenton gel tube - - - - - 10
273 Bricasma terbutaline can - - - - - 5
274 Burnazin silver sulphadiazine tube 27 - 27 - 27 - 1,2,3
275 Caladine lotion botol - - - - - 50
276 Chloramphenicol salep kulit tube - - - - - 50 1,2,3
277 Chloramphenicol salep mata tube - - - - - 48 1,2,3
278 Cutimed gel tube - - - - - 20
279 Desoximetasone cream tube 105 - 105 - 105 - 2.3
280 Diclofenac sodium gel tube - - - - - 50
281 Fucilex Krim Sodium Fusidat 20% 20 mg/mL tube 39 - 39 - 39 -
282 Gentamicin salep mata tube - - - - - 25 2.3
283 Garam Oralit Serbuk Kombinasi sachet 98 - 98 - 98 -
284 Hydrocortisone cream tube 305 - 305 41 264 - 1,2,3
285 Ichtyol salep pot - - - - - 50
286 Ketoconazole cream tube 48 - 48 - 48 - 1,2,3
287 Lidocain jelly dispo - - - - - 20 1,2,3
288 Miconazole cream tube 60 - 60 3 57 - 1,2,3
289 My Jelli tube 50 - 50 - 50 -
290 Nebacetin salep tube - - - -
291 Salep 2-4 pot - 48 48 - 48 - 1,2,3
292 Salisil bedak kotak 37 - 37 1 36 - 1,2,3
293 Dexocort Salep 0,25% tube - - - - - - 2.3
294 Sabun anti bakteri 500 ml botol 41 - 41 - 41 -
295 Thrombophob gel tube - - - - - 50
296 Ultrasound gel USG botol 106 - 106 3 2 101 -
OBAT LAINNYA
299 Alkohol swab / Swab, 4 Ply pcs 500 - 500 - 500 -
300 Apron One Plastik Onemed lembar - - - - - -
301 Bisturi no. 11 pcs 198 - 198 - 198 -
302 Bisturi no. 18 pcs 196 - 196 - 196 -
303 Bisturi no. 20 pcs 150 - 150 150 -
304 Bisturi no. 22 pcs 100 - 100 - 100 -
305 BeneCheck Plus Glucose Test Strip 50's strip - 200 200 - 200
306 BeneCheck Plus Total Cholesterol Test Strip 10's strip 240 - 240 90 150 -
307 BeneCheck Plus Uric Test Strip 25's strip 250 - 250 100 150 -
308 Blood Lancet pcs 700 200 900 200 700 -
309 Catgut Chrom 3/0 Rol 100 meter roll 1 - 1 - 1 -
312 Catgut plain 2/0 + jarum pcs 96 - 96 16 80 -
314 Celemek / Apron pcs - - - - - -
315 Cutimed siltec 10x10cm pcs 20 - 20 - 20 -
316 Cutimed sorbact 7x9cm pcs - - - - - 50
317 Duk steril disposible pcs - - - - - -
324 Fixation N.W. 10x10 Rol 10 - 10 1 9
325 Fixation N.W. 10x15 Rol 1 - 1 - 1
330 Gutta percha points 15-40 pcs - - - - - - 1,2,3
331 Gutta percha points 45-80 pcs 1 - 1 - 1 - 1,2,3
332 Handscoen ginekologi psg - - - - - -
333 Handscoen non steril Large psg - - - - - -
334 Handscoen non steril Medium psg 400 - 400 400 - 1,000
335 Handscoen Obsgyn psg 100 - 100 - 100 -
336 Handscoen steril no. 6,5 psg 40 - 40 40 - 500
337 Handscoen steril no. 7 psg 451 - 451 5 446 -
338 Handscoen steril no. 7,5 psg 422 - 422 22 400 -
339 Handscoen steril no. 8 psg 469 - 469 10 459 -
340 Hb Sahli Set 10 - 10 - 10
341 HCG test pcs 174 - 174 45 129 -
342 Infusion set Anak pcs 40 - 40 - 40 -
343 Infusion set Dewasa pcs 700 - 700 50 650 -
344 IV cannula no. 18 pcs 450 - 450 - 450 -
345 IV cannula no. 20 pcs 200 - 200 2 198 -
346 IV cannula no. 22 pcs 100 - 100 - 100 -
347 IV cannula no. 24 pcs 200 - 200 - 200 -
348 IV cannula no. 26 pcs 200 - 200 - 200 -
356 Jarum otot besar pcs - - - - - -
357 Jarum otot kecil pcs - - - - - -
358 Jarum untuk insulin pen pcs 4 10 14 - 14
359 Kacamata Anti infeksi pcs - - - - - -
360 Kapas Berlemak 500 g bungkus - - - - - -
361 Kapas putih 250 g bungkus 6 20 26 2 24
362 Kasa hidrofil 40yard x 80cm roll 25 - 25 1 24 -
365 Kasa sterile 16x16cm pcs 1,760 - 1,760 720 1,040 -
366 Klem tali pusat pcs - 200 200 50 150 -
367 Masker Nebulizer Set Anak Besmed pcs 25 - 25 - 25 -
368 Masker Nebulizer Set Dewasa Besmed pcs 25 - 25 - 25 -
369 Masker pcs 550 - 550 250 300 300

370 1A6542 Fine (1,5mm) warna kuning, biru buckets - - - - -
371 Mucous extractor FR 10 pcs 82 - 82 - 82 -

372 NGT no.16 pcs - - - - - -
373 NGT no.18 pcs - - - - - -
374 NGT no.3,5 pcs - - - - - -
375 NGT no.5 pcs - - - - - -
376 NGT no.8 pcs - - - - - -
379 Paper Tape 1.25 x 9.14 Rol 10 - 10 - 10
380 Paper Tape 2.5 x 9.14 Rol 5 - 5 - 5
381 Paper Tape 5.0 x 9.14 Rol 2 - 2 - 2
382 Paper Tape 7.5 x 9.14 Rol 1 - 1 - 1
383 Pembalut Gibs rol - - - - - 50
384 Pen Needle Set - - - - -
385 Plester coklat yard Leukoplast rol 28 - 28 2 26 -
386 Plester Infus dermafix pcs 25 - 25 - 25 -
387 Plester luka bakar pcs - - - - - -
388 Plester putih Polifix rol - - - - - -
389 Plester rawat luka anti air dermafix t 10x25cm pcs 40 - 40 - 40 -
390 Safety box pcs 200 - 200 - 200 -
391 Silk 2/0 pcs 60 - 60 12 48 -
392 Silk 3/0 pcs 60 - 60 24 36 -
393 Sputum Pot pcs 80 - 80 - 80
398 Suction catheter FR 18 pcs - - - - - -
401 Surgical gown baju operasi L pcs 30 - 30 - 30 -
402 Surgical gown baju operasi M pcs 19 - 19 - 19 -
403 Surgical gown baju operasi XL pcs 10 - 10 - 10 -
404 Syringe 1 cc pcs 70 - 70 - 70 -
405 Syringe 3 cc pcs 3,260 - 3,260 410 2,850 -
406 Syringe 5 cc pcs 94 - 94 94 - 200
407 Syringe 10 cc pcs 104 - 104 - 104 -
408 Syringe 20 cc pcs 99 - 99 - 99 -
409 Syringe 50 cc pcs 17 - 17 2 15 -
410 Test Anti HCV Strip test 75 - 75 25 50 -
411 Test Anti HIV 1/2 Cassette test 23 - 23 10 13 -
412 Test HBsAg strip test 125 - 125 - 125 -
413 Test Malaria HRP2/pLDH (Pf/PAN) combo test - - - - - 50
414 Topi Operasi pcs 100 - 100 - 100 -
415 Urine Bag pcs 39 - 39 - 39 -
416 Uritest Reagen Strips 11G Tube 100 - 100 - 100 -
418 Venflon Pro IV Canula 20 ga 1,1 mm x 32 mm 100 - 100 50 50 -
419 Venflon Pro IV Canula 22 ga 0,9 mm x 25 mm pcs - - - - - -
420 softpad (Underpad) 60x90 cm One Med pcs 240 - 240 40 200 -
421 Buku KIA bh - - - - - -
425 Wing Needle 27 G Onemed pcs 10 - 10 - 10
426 Ziehl Neelsen Set 5 x 100 mL Set 9 - 9 - 9
130,734 4,479 135,213 29,976 96,553 52,092
ASKES/
UMUM BPJS JUMLAH

BAYAR
BAYAR
Sangkub, 04 April 2019

JUSNAN C. MOKOGINTA, MARS ASIA, S.Si, Apt SJAMSUDIN RAHIM TUTUT H. POSANGI, S.Farm.,Apt
NIP. 19671105 200012 1 003 NIP. 19840909 201102 2 001 NIP. 1964021918802 1 002 NIP. 19920527 201903 2 008

LPLPO Semester I 2019

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LPLPO Semester I 2019

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN :

OBAT GIGI - GAS

Micro brush doche Disposable micro applicators

UMUM ASKES/ JUMLAH

Sangkub, Februari 2019

INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN :

OBAT GIGI - GAS

Micro brush doche Disposable micro applicators

UMUM ASKES/ JUMLAH

Sangkub, Maret 2019

INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN : 090/PKM-SKB/BMU/267/IV/2019

Cotrimoksazole (anak) Komb tiap 5 ml :

26 Citicholine inj ampul - - - - - 10

OBAT GIGI - GAS

AntiBakteri Salep : Basitrasin 500 IU/g +

271 Betametason cream tube 73 - 73 - 73 - 1,2,3

Micro brush doche Disposable micro applicators

371 Mucous extractor FR 10 pcs 82 - 82 - 82 -

JUMLAH KUNJUNGAN RESEP TIDAK

Sangkub, 04 April 2019

INSTANSI : PUSKESMAS SANGKUB NOMOR DOKUMEN : 090/PKM-SKB/BMU/ /IV/2019

Cotrimoksazole (anak) Komb tiap 5 ml :

26 Citicholine inj ampul - - - - - 10

OBAT GIGI - GAS

AntiBakteri Salep : Basitrasin 500 IU/g +

271 Betametason cream tube 73 - 73 23 50 - 1,2,3

Micro brush doche Disposable micro applicators

371 Mucous extractor FR 10 pcs 82 - 82 - 82 -

JUMLAH KUNJUNGAN RESEP TIDAK

Sangkub, 04 April 2019

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