Format LPLPO 2015 PKM MARIUK BLN Januari 2015

Halaman 1
LAPORAN PEMAKAIAN OBAT TAHUN 2012

DAN STOK OPTIMUM TAHUN 2013
PUSKESMAS : .........................................................
KECAMATAN : .........................................................
KAB/KOTA : .........................................................
PROPINSI : .........................................................
STOK AWAL PENERIMAA

N TAHUN PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT.
No. NAMA OBAT SATUAN JAN'12 TAHUN 2012 TAHUN 2012 DES'12 TAHUN 2013
2012
1 2 3 4 5 6 7 8 9
1 Acetaminophen Drop / Parasetamol Drop Fls
2 Activated Charcoal (Karbon aktiv) Tablet
3 Air Raksa Dental Use Botol
4 Alat Suntik Sekali Pakai 1ml Set
5 Alat Suntik Sekali Pakai 2,5 ml Set
6 Alat Suntik Sekali Pakai 5 ml Set
7 Albendazol 400 mg Tablet
8 Alopurinol tablet 100 mg Tablet
9 Ambroxol Syrup 15 mg/ml Botol
10 Ambroxol Tablet 5 mg Tablet
11 Amilodipin 5 mg Tablet
12 Aminofilin Inj 24 mg/ml-10 ml Ampul
13 Aminofilin Tablet 200 mg Tablet
14 Amitriptilina HCl tablet salut 25 mg Tablet
15 Amoksilin Kapsul 250 mg Tablet
16 Amoksilin sirup kering 125 mg/ml Botol
17 Amoksisilin 500 mg Tablet
18 Amoksisilin Serbuk Injeksi 1000 mg Vial
19 Ampisillin Kaplet 500 mg Tablet
20 Ampisillin Syrup Botol
21 Antalgin Injeksi 250 mg/ml-2 ml Ampul
22 Antalgin(Metampiron) Tablet 500 mg Tablet
Halaman 2
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
23 Antasida DOEN Tablet
24 Antasida Suspensi Sirup Botol
25 Anti Hemmorooid DOEN Supp
26 Antibakteri DOEN Tube
27 Antifungi DOEN kombinasi Pot
28 Antimigren DOEN Tablet
29 Antiparkinson DOEN Tablet
30 Aqua Pro Injeksi steril bebas pirogen- 20 ml Vial
31 Aquadest steril -500 ml Botol
32 Asam Askorbat (VIT C) Tablet 50 mg Tablet
33 Asam Askorbat(VIT C) Tablet 250 mg Tablet
34 Asam Folat Tablet
35 Asam Mefenamat Kaplet 500 mg Tablet
36 Asiklovir 200 mg (herpes genitalis) Tablet
37 Asiklovir 400 mg Tablet
38 Asiklovir Krim Tube
39 Atorvastatin 20 mg Tablet
40 Atropin Injeksi Vial
41 Atropin Sulfat Tetes Mata 0,5 % Botol
42 Besi Sirup 150 ml Botol
43 Betametason Krim 0.1 % Tube
44 Bromhexin Tablet Tablet
45 Calcium Laktat Tablet 500 mg Tablet
46 Captopril 12,5 mg tab Tablet
47 Captopril 25 mg tab Tablet
48 Catgut/Benang Bedah No. 2/0 - 3/0 dgn ja Sachet
49 Caviton Box
50 Cefadroxil 500 mg Tablet
51 Cefadroxil Sirup Kering Botol
52 Ciprofloksasin Tablet 500 mg Tablet
53 Clindamicin 150 mg Tablet
54 Clindamicin 300 mg Tablet
55 Cloramfenicol Salep Kulit Tube
Halaman 3
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
56 Cloramfenicol Syrup Botol
57 Cloramfenikol kapsul 250 mg Tablet
58 Cloramfenikol salep mata 1 % Tube
59 Cloramfenikol tetes Mata 1 % Fles
60 Cloramfenikol tetes telinga 3 % Fles
61 Clorfeniramin maleat (CTM) tablet 4 mg Tablet
62 Cotrimoksazol Sus p : Sulf 200 + Trim 40 m Botol
63 Cotrimoksazol Tablet Dws : Sulf 400 + Trim Tablet
64 Cotrimoksazol Tablet Ped : Sulf 100 + Trim Tablet
65 Cyanokobalamin (Vit B12 ) inj 500 mcg/ml- Ampul
66 Dapson tablet 100 mg Tablet
67 Deksametason inj 5 mg/ml-1 ml Ampul
68 Deksametason Tablet 0,5 mg Tablet
69 Dekstran 70-Larutan Infus 6 % Steril-500 ml Botol
70 Dekstrometorfan tablet 15 mg Tablet
71 Dektrometorfan sirup 10 mg/5 ml-60 ml Botol
72 Devitalisasi Pasta (Non arsen) Botol
73 Diaform Tablet / Obat Diare Tablet
74 Diazepam inj 5 mg/ml-2 ml Ampul
75 Diazepam tablet 2 mg Tablet
76 Diazepam tablet 5 mg Tablet
77 Dietilkarbamazin sitrat tablet 100 mg Tablet
78 Difenhidramin inj 10 mg/ml Ampul
79 Digoksin tablet 0,25 mg Tablet
80 Dimenhidrinat Tablet Tablet
81 Doksisiklin Hcl Kapsul 100 mg Tablet
82 Domperidon Tablet 10 mg Tablet
83 Efedrin HCl tablet 25 mg Tablet
84 Ekstrak Belladon tablet 10 mg Tablet
85 Epinefrina HCl/Bitartrat(Adrenalin) inj 0,1 Ampul
86 Eritromisin kapsul 250 mg Tablet
87 Eritromisin kapsul 500 mg Tablet
88 Eritromisin Sirup Botol
Halaman 4
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
89 Etakridin (Rivanol) Larutan 0,1 %-300 ml Botol
90 Etambutol Hcl tablet 500 mg Tablet
91 Etanol 70 %- 1000 ml Botol
92 Etil Klorida semprot-100 ml Botol
93 Eugenol Cairan Botol
94 Famotidin 20 mg Tablet
95 Fenilbutason Tablet 20 mg Tablet
96 Fenitoin Natrium kapsul 30 mg Tablet
97 Fenobarbital inj 50 mg/ml-2ml Ampul
98 Fenobarbital tablet 100 mg Tablet
99 Fenobarbital tablet 30 mg Tablet
100 Fenoksimetil Penisilin tablet 250 mg Tablet
101 Fenoksimetil Penisilin tablet 500 mg Tablet
102 Fenol Gliserol Tetes telinga 10 % Fles
103 Fitomenadion(Vit K1) inj 10 mg/ml-1ml Ampul
104 Fitomenadion(Vit K1) tablet salut gula 10 Tablet
105 Fluor Tablet 0,5 mg Tablet
106 Folley Catether No. 14, 16, 18, 20, 22, 24 Botol
107 Forinokresol ( Pengganti TKF ) 10 ml Botol

108 Furosemid tablet 40 mg Tablet
109 Gameksan emulsi 1%-100 ml Botol
110 Garam Oralit 200 ml air Kantong
111 Gentamisin injeksi 80 mg/ml Ampul
112 Gentamisin sulfat tetes mata 0,3% Tube
113 Gentian violet larutan 1 %-10 ml Botol
114 Glass Ionomer Cement Set
115 Glibenklamid tablet 5 mg Tablet
116 Glimepiride Tablet
117 Gliseril Gyayakolat tablet 100 mg Tablet
118 Gliserin-100 ml Botol
119 Glucosamin 500 mg Tablet
120 Glukosa Laruran infus 5% steril-500 ml Labu
121 Glukosa larutan infus 10 % steril- 500 ml Labu
Halaman 5
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
122 Griseofulvin tablet 125 mg micronized Tablet
123 Gutta Percha Points Stick
124 Haloperidol tablet 0,5 mg Tablet
125 Haloperidol tablet 1,5 mg Tablet
126 Haloperidol tablet 5 mg Tablet
127 Hidroklortiazid (HCT) tablet 25 mg Tablet
128 Hidrokortison krim 2,5 % Tube
129 Ibuprofen Syrup Fls
130 Ibuprofen tablet 200 mg Tablet
131 Ibuprofen tablet 400 mg Tablet
132 Infusion set anak Set
133 Infusion set dewasa Set
134 Insulin reguler inj 40 IU/ml-10 ml (human) Vial
135 Iodiol kapsul lunak Kapsul
136 Isoniazid tablet 100 mg Tablet
137 Isoniazid tablet 300 mg Tablet
138 Isorbid dinitrat talet sublingual 5 mg Tablet
139 IV Catether / Abocat No. 20 Buah
143 Jarum jahit (Kulit) No. 12, 13 Buah
144 Jarum jahit (Otot) No. 9, 11 Buah
145 Kalium Diklofenak tablet 25 mg Tablet
146 Kalium Diklofenak tablet 50 mg Tablet
147 Kalsium hidroksida pasta Kotak
148 Kapas berlemak 500 garam Bungkus
149 Kapas pembalut/absorben 250 mg Bungkus
150 Karbamazepin tablet 200 mg Tablet
151 Kasa kompres 40/40 steril Rol
152 Kasa pembalut 2 m x 80 cm Rol
153 Kasa pembalut hidrofil 100 x 80 yard Rol
154 Kasa pembalut hidrofil 4 m x 15 cm Rol
Halaman 6
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
155 Kasa pembalut hidrofil 4 m x 3 cm Rol
156 Keterolac Injeksi 10 mg Ampul
157 Ketokonazol Krim 2% Tube
158 Ketokonazol Tablet 200 mg Tablet
159 Klorokuin tablet 150 mg Tablet
160 Klorpropmazin HCl inj 5 mg/ml-2 ml Ampul
161 Klorpropmazin HCl tablet salut 100 mg Tablet
162 Klorpropmazin HCl tablet salut 25 mg Tablet
163 Kodein fosfat tablet 10 mg Tablet
164 Larutan Amonium Oxalat Botol
165 Larutan Asam Klorida 0,1 N-100 ml Botol
166 Larutan Asam Sulfosalisilat 20 %- 100 ml Botol
167 Larutan Benedict-100 ml Botol
168 Larutan Eosin 2%-100 ml Botol
169 Larutan Etanol asam -100 ml Botol
170 Larutan Gabbet-100 ml Botol
171 Larutan Giemsa stain-100 ml Botol
172 Larutan Karbol Fuchsin -100 ml Botol
173 Larutan Kinyoun-100 ml Botol
174 Larutan Metilen Biru-100 ml Botol
175 Larutan Turk-100 ml Botol
176 Lidocain HCl 20 mg, Adrenaline 0,0125 mg Ampul
177 Lidokain inj Komp : Lidokain %+ Efinep 1:8 Ampul

178 Lisol, mengandung kresol tersabun 50% -1 Botol
179 Loperamid Tablet 2 mg Tablet
180 Loratadin Tablet 2 mg Tablet
181 Magnesium sulfat inj(IV) 20 %-25 ml Vial
182 Magnesium sulfat inj(IV) 40 %-25 ml Vial
183 Masker Pcs
184 Meloksikam suppositoria Supp
185 Meloxicam Supp Supp
186 Membendazol sirup 100 mg/5 ml Botol
187 Membendazol tablet 100 mg Tablet
Halaman 7
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
188 Metanol-100 ml Botol
189 Metilergomatrin maleat inj 0,200 mg - ml Ampul
190 Metilergomatrin maleat(Metilergometrin) Tablet
191 Metilprednisolon 4 mg Tablet
192 Metilprednisolon 8 mg Tablet
193 Metoklopramida HCl 10 mg/2 ml Injeksi Ampul
194 Metoklorpropamide Tablet Tablet
195 Metronidazol tablet 250 mg Tablet
196 Metronidazol tablet 500 mg Tablet
197 Miconazol Cream Tube
198 Monoklorkamfer mentol cairan Botol
199 Multivitamin + Fe Tablet Tablet
200 Multivitamin Syrup Fls
201 Multivitamin Tablet Tablet
202 Mummying Pasta Botol
203 Natrium Bikarbonat tablet 500 mg Tablet
204 Natrium Klorida Lar.infus 0,9 % steril Labu
205 Needle G No. 23 Box
206 Nipedipin 10 mg Tablet
207 Nistatin tablet salut gula 500.000 IU/g Tablet
208 Nistatin tablet vaginal 100.000 IU/g Supp
209 Obat anti anemia tablet, terdiri dari : Fer Kapsul
210 Obat antituberkulosis kategori 1 Paket
213 Obat antituberkulosis Kategori Anak Paket
214 Obat antituberkulosis sisipan dewasa Botol
215 Obat Batuk Flu Syrup Fls
216 Obat Batuk Flu Tablet Tablet
217 Obat batuk Hitam (OBH) Cairan -100 ml Botol
218 Obat Spasmolitik Tablet
219 Ofloxacin 200 mg Tablet
220 Oksigen gas dalam tabung M3
Halaman 8
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
221 Oksitetrasiklin HCl 1 % Salep mata Tube
222 Oksitetrasiklin HCl inj i.m 50 mg/ml-10 ml Vial
223 Oksitetrasiklin HCl Salep 3 % Tube
224 Oksitoksin in 10 IU/ml- 1 ml Ampul
225 Omeprazol Kapsul 20 mg Kapsul
226 Paraformaldehid tablet 1 gram Tablet
227 Parasetamol sirup 120 mg / 5ml Botol
228 Parasetamol tablet 500 mg Tablet
229 Parasetamol tablet 100 mg Tablet
230 Perfenazin HCl tablet 4 mg Tablet
231 Pirantel tablet 125 Tablet
232 Pirazinamida Tablet 500 mg Tablet
233 Piridoksin HCl (Vit B6) tablet 10 mg Tablet
234 Piroksikam 10 mg Tablet
235 Piroksikam 20 mg Tablet
236 Plester 5 yard x 2 inch Rol
237 Policresulen 360 mg (36%) Botol
238 Povidon Iodiada 10 %-1000 ml Botol
241 Prednison tablet 5 mg Tablet
242 Prokain Benzil Penilsilin 3 juta IU/vial inj Vial
243 Propanolol HCl tablet 40 mg Tablet
244 Propiltiourasil tablet 100 mg Tablet
245 Rabies Immunoglobulin ( Human) 150 IU/ m Vial
246 Ranitidin 150 mg Tablet

247 Reserpin tablet 0,10 mg Tablet
248 Reserpin tablet 0,25 mg Tablet
249 Retinol (VIT A) Kapsul 100.000 IU Kapsul
250 Retinol (VIT A) Kapsul 200.000 IU Kapsul
251 Rifampisin kaplet 300 mg Tablet
252 Rifampisin kapsul 450 mg Tablet
253 Rifampisin kapsul 600 mg Tablet
Halaman 9
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
254 Ringer Laktat Larutan Infus Steril Labu
255 Salbutamol tablet 2 mg Tablet
256 Salbutamol tablet 4 mg Tablet
257 Salep 2-4 kombinasi : as.asal 2 % + Bel. 4 % Pot
258 Salisil Bedak 2 % - 50 gram Kotak
259 Salisil Spiritus 10 % - 25 ml Botol
260 Sarung Tangan Set
261 Sefotaksim injeksi 1 gram Vial
262 Semen seng fosfat serbuk cairan Botol
263 Serum Anti Difteri ( ADS ) Vial
264 Serum anti rabies Vial
265 Serum anti tetanus inj 1.500 IU/amp (ATS) Vial
266 Serum anti tetanus inj 20.000 IU/vial (ATS) Vial
267 Serum antibisa ular Polivalen inj 5 ml (SABU Vial
268 Serum antibisa ular Polivalen inj 50 ml (SAB Vial

269 Silk (Benang Bedah Sutera) No. 3/0 + Jarum Pcs
270 Silver amalgam serbuk 65-75 % Botol
271 Simetidin Tablet 200 mg Tablet
272 Simvastatin Kotak
273 Spons Gelatin Cubicles 1 x 1 1 cm Set
274 Streptomisin inj 1.000 mg/vial Ampul
275 Sulfa Conus Krucut(Preparat) Tablet
276 Sulfadimidin tablet 500 mg Tablet
277 Sulfasetamid Natrium Tetes mata 15 % Botol
278 Syntetic filling Material Set
279 Tablet Tambah darah kombinasi : Besi II Sul Tablet
280 Temporary Stopping Fletcher(Fletcher) Set

281 Tetes Mata, terdiri dari : K-ionida 5 mg, K- Btl 5 ml
282 Tetrakain tetes mata 0,5 % Botol
283 Tetrasiklin Kapsul 250 mg Tablet
284 Tetrasiklin Kapsul 500 mg Tablet
285 Thiamphenicol 500 mg Tablet
286 Tiamin HCL (Vit B1) inj 100 mg/ml-1ml Ampul
Halaman 10
STOK AWAL PENERIMAA

2012
1 2 3 4 5 6 7 8 9
287 Tiamin HCL (Vit B1) tablet 50 mg Tablet
288 Tramadol Kapsul 50 mg Kapsul
289 Triheksifenidil Hidroklorida 2 mg Tablet Tablet
290 Urine Bag Pcs
291 Valetamat bromida 8 mg/ml Injeksi Ampul
292 Vitamin B Kompleks tablet Tablet
293 Wing Needle No. 21 G Pcs
297 Zinc Tablet 20 mg Tablet
298
299
300
301
302
303
304
305
306
307
308
309
310
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Mengetahui/Menyetujui : Pengelola Obat

Kepala UPTD Puskesmas …………………….. Puskesmas ……………………………
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Halaman 21
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OB

PUSKESMAS
PUSKESMAS : MARIUK
KECAMATAN : TAMBAKDAHAN
KAB/KOTA : SUBANG PELAPORAN BULAN/PERIODE : JULI2014

PROVINSI : JAWA BARAT PERMINTAAN BULAN/PERIODE : AGUSTUS2014
SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
SEDIAAN TABLET/KAPLET/KAPSUL
1 Activated Charcoal (Karbon Aktif) Tablet - -
2 Albendazol 400 mg Tablet - -
3 Alopurinol tablet 100 mg Tablet - 300 300 200 100
4 Ambroksol Tablet 5 mg Tablet - - - - -
5 Aminofilin Tablet 200 mg Tablet - - - - -
6 Amlodipin 10 mg Tablet - - - - -
7 Amlodipin 5 mg Tablet - -
8 Amoksisilin + Asam Klavulanat 625 mg Tablet - -
9 Amoksisilin 500 mg Tablet 500 500 1,000 600 400
10 Amoksisilin Kapsul 250 mg Tablet - 960 960 120 840
11 Ampisillin Kaplet 500 mg Tablet - - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet 500 1,000 1,500 900 600
13 Antasida DOEN Tablet 11,000 - 11,000 1,000 10,000
14 Antimigren DOEN Tablet - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 1,000 2,000 1,000 1,000
16 Asam Askorbat(VIT C) Tablet 250 mg Tablet - -
17 Asam Folat Tablet - -
18 Asam Mefenamat 250 mg Tablet - - - -
19 Asam Mefenamat 500 mg Tablet 500 700 1,200 1,100 100
20 Asiklovir 200 mg (herpes genitalis) Tablet - - -
21 Asiklovir 400 mg Tablet - - - - -
22 Deksametason Tablet 0,5 mg Tablet 200 500 700 400 300
Halaman 22

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
23 Dietilkarbamazin sitrat tablet 100 mg Tablet - -
24 Digoksin tablet 0,25 mg Tablet - - - - -
25 Dimenhidrinat Tablet Tablet - -
26 Doksisiklin Hcl Kapsul 100 mg Tablet - -
27 Domperidon Tablet 10 mg Tablet - -
28 Ekstrak Belladon tablet 10 mg Tablet 200 - 200 - 200
29 Eritromisin kapsul 250 mg Tablet - - -
30 Eritromisin kapsul 500 mg Tablet 800 - 800 - 800
31 Etambutol Hcl tablet 500 mg Tablet 1,000 - 1,000 200 800
32 Famotidin 20 mg Tablet - -
33 Fenilbutason Tablet 20 mg Tablet - -
34 Fenitoin Natrium kapsul 30 mg Tablet - -
35 Fenoksimetil Penisilin tablet 250 mg Tablet - -
36 Fenoksimetil Penisilin tablet 500 mg Tablet - -
37 Fitomenadion(Vit K1) tablet salut gula 10 mg Tablet - -
38 Furosemid tablet 40 mg Tablet - 200 200 100 100
39 Glibenklamid tablet 5 mg Tablet - - - - -
40 Gliseril Gyayakolat tablet 100 mg Tablet 3,000 - 3,000 1,000 2,000
41 Glucosamin 500 mg Tablet - - - - -
42 Griseofulvin tablet 125 mg micronized Tablet - - - -
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - 3,000 3,000 1,000 2,000
44 Ibuprofen tablet 200 mg Tablet - - - -
45 Ibuprofen tablet 400 mg Tablet 200 300 500 200 300
46 Isoniazid tablet 100 mg Tablet 1,000 - 1,000 - 1,000
47 Isoniazid tablet 300 mg Tablet - -
48 Isosorbid dinitrat talet sublingual 5 mg Tablet - -
49 Kalium Diklofenak tablet 25 mg Tablet - -
50 Kalium Diklofenak tablet 50 mg Tablet - -
51 Kalsium Laktat Tablet 500 mg Tablet - -
52 Kaptopril 12,5 mg Tablet 500 300 800 300 500
53 Kaptopril 25 mg Tablet - - - - -
54 Kaptopril 50 mg Tablet - -
55 Ketokonazol Tablet 200 mg Tablet - 200 200 100 100
56 Klindamisin 150 mg Tablet 250 - 250 - 250
57 Klindamisin 300 mg Tablet 500 - 500 400 100
Halaman 23

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
58 Kloramfenikol kapsul 250 mg Tablet - 1,000 1,000 200 800
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 3,000 - 3,000 1,000 2,000
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 400 100 500 100 400
61 Kotrimoksazol Tablet Ped : Sulf 100 + Trim 20 mg Tablet - -
62 Lansoprazol 30 mg Tablet - -
63 Loperamid Tablet 2 mg Tablet - -
64 Loratadin Tablet 2 mg Tablet 300 - 300 - 300
65 Meloksikam 15 mg Tablet - - - - -
66 Meloksikam 7,5 mg Tablet - - - - -
67 Membendazol tablet 100 mg Tablet - -
68 Metformin 500 mg Tablet 100 - 100 100 -
69 Metformin 850 mg Tablet - -
70 Metilprednisolon 4 mg Tablet 100 - 100 100 -
71 Metilprednisolon 8 mg Tablet 200 - 200 200 -
72 Metoklorpropamide Tablet Tablet - -
73 Metronidazol tablet 250 mg Tablet - -
74 Metronidazol tablet 500 mg Tablet - 500 500 200 300
75 Multivitamin + Fe Tablet Tablet - - - - -
76 Multivitamin Tablet Tablet - - - - -
77 Natrium Bikarbonat tablet 500 mg Tablet - -
78 Natrium Diklofenak 25 mg Tablet - -
79 Natrium Diklofenak 50 mg Tablet - -
80 Nipedipin 10 mg Tablet 100 500 600 400 200
81 Nistatin tablet salut gula 500.000 IU/g Tablet - -
82 Obat Batuk Flu Tablet Tablet - - - - -
83 Obat Diare Tablet - -
84 Obat Spasmolitik Tablet - -
85 Omeprazol Kapsul 20 mg Kapsul - - - - -
86 Parasetamol tablet 500 mg Tablet 1,000 2,000 3,000 2,000 1,000
87 Parasetamol tablet 100 mg Tablet - - - - -
88 Pirantel tablet 125 Tablet - -
89 Pirazinamida Tablet 500 mg Tablet 400 - 400 - 400
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 2,000 3,000 2,000 1,000
91 Piroksikam 10 mg Tablet - - - - -
92 Piroksikam 20 mg Tablet - - - - -
Halaman 24

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
93 Prednison tablet 5 mg Tablet 8,000 - 8,000 1,000 7,000
94 Propanolol HCl tablet 40 mg Tablet - -
95 Propiltiourasil tablet 100 mg Tablet - -
96 Ranitidin 150 mg Tablet - 500 500 300 200
97 Reserpin tablet 0,10 mg Tablet - -
98 Reserpin tablet 0,25 mg Tablet - -
99 Retinol (VIT A) Kapsul 100.000 IU Kapsul - -
100 Retinol (VIT A) Kapsul 200.000 IU Kapsul - -
101 Rifampisin kaplet 300 mg Tablet - -
102 Rifampisin kapsul 450 mg Tablet - - - - -
103 Rifampisin kapsul 600 mg Tablet - -
104 Salbutamol tablet 2 mg Tablet 400 - 400 100 300
105 Salbutamol tablet 4 mg Tablet - - - - -
106 Sefadroksil 500 mg Tablet - - - - -
107 Sefiksim 100 mg Tablet - - - - -
108 Setirizin Tablet - -
109 Simetidin Tablet 200 mg Tablet - - - - -
110 Simvastatin Tablet - - - - -
111 Siprofloksasin Tablet 500 mg Tablet - - - - -
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet - 3,000 3,000 3,000 -
113 Tetrasiklin Kapsul 250 mg Tablet - -
114 Tetrasiklin Kapsul 500 mg Tablet - -
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet - 3,000 3,000 1,000 2,000
116 Tiamphenikol 500 mg Tablet - - - - -
117 Vitamin B Kompleks tablet Tablet - 1,000 1,000 1,000 -
118 Zink Tablet 20 mg Tablet - -
Halaman 25

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
PSIKOTROPIK, PREKURSOR, OBAT JIWA

119 Amitriptilin 25 mg Tablet - -
120 Dekstrometorfan 15 mg Tablet - - - - -
121 Diazepam 2 mg Tablet - 200 200 200 -
122 Diazepam 5 mg Tablet - -
123 Diazepam Inj Ampul - 10 10 10 -
124 Efedrin 0,25 mg Tablet - - - - -
125 Fenobarbital 30 mg Tablet - 200 200 200 -
126 Fenobarbital Inj Ampul - -
127 Haloperidol 0,5 mg Tablet - -
128 Haloperidol 1 mg Tablet - -
129 Haloperidol 5 mg Tablet - -
130 Metilergometrin 0,125 mg Tablet 200 100 300 - 300
131 Metilergometrin Inj Ampul - -
132 Karbamazepin 200 mg Tablet - -
133 Klorpromazin 25 mg Tablet - -
134 Klorpromazin 100 mg Tablet - -
135 Triheksifenidil Hidroklorida 2 mg Tablet - -
SEDIAAN SIRUP/SUSPENSI
136 Ambroksol Sirup Botol 40 - 40 20 20
137 Amoksisilin Sirup Kering 125mg/ml Botol 100 50 150 150 -
138 Ampisilin Sirup Botol - -
139 Antasida Suspensi Botol - 260 260 60 200
140 Dekstrometorfan sirup 10 mg/5 ml Botol - - - - -
141 Domperidon Sirup Botol - -
142 Eritromisin Sirup Sachet - -
143 Ibuprofen Sirup Botol - 20 20 20 -
144 Kloramfenikol Suspensi Botol - 50 50 20 30
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - - - - -
146 Multivitamin Drop Botol - - - - -
147 Multivitamin Sirup Botol - - - - -
Halaman 26

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
148 Obat Batuk Flu Sirup Botol - 50 50 50 -
149 Obat Batuk Hitam (OBH) Botol 30 50 80 50 30
150 Parasetamol Drop Botol - - - - -
151 Parasetamol Sirup 120 mg/5 ml Botol - 100 100 50 50
152 Sefadroksil Sirup Botol - 100 100 100 -
153 Setirizin Sirup Botol - -
OBAT LUAR (INJEKSI-LARUTAN)

154 Aminofilin Inj 24 mg/ml Ampul - -
155 Amoksisilin Serbuk Injeksi 1000 mg Ampul - -
156 Ampisilin Injeksi Ampul - -
157 Antalgin Inj 250 mg/ml Ampul - -
158 Aqua Pro Injeksi Vial - -
159 Aquades Steril-500 ml Botol - -
160 Atropin Injeksi Ampul - -
161 Atropin Sulfat Tetes Mata 0,5% Fls - -
162 Deksametason Inj 5 mg/ml Ampul - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - 20 20 - 20
164 Difenhidramin Inj 10 mg/ml Ampul - -
165 Efinefrin HCl/Bitartrat (Adrenalin) Inj 0,1% Ampul - -
166 Etakridin (Rivanol) 0,1% Botol - - - - -
167 Etanol 70%-1000 ml Botol - 3 3 3 -
168 Fitomenadion (Vit K1) Inj 10 mg/ml Ampul - -
169 Furosemid Inj 1 mg/ml Ampul - -
170 Garam Oralit 200 ml Sachet - -
171 Gentamisin Inj 80 mg/ml Ampul - -
172 Gentian Violet Larutan 1% Botol - -
173 Glukosa Larutan Infus 10% Steril-500 ml Labu - -
Halaman 27

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 5 5 - 5
175 Ketorolak Inj Ampul - -
176 Lidokain Inj Ampul - - - - -
177 Lidokain Inj Komp : Lidokain % + Efinefrin 1:80000 Ampul - - - - -
178 Lisol, mengandung kresol tersabun 50% Botol - -
179 Magnesium Sulfat Inj (IV) 20% Ampul - -
180 Magnesium Sulfat Inj (IV) 40% Ampul - -
181 Metoklopramida HCl 10 mg/2 ml Inj Ampul - -
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - -
183 Oksitetrasiklin HCl Inj i.m 50 mg/ml Ampul - -
184 Oksitoksin Inj 10 IU/ml Ampul - - - - -
185 Povidon Iodida 10%-1000 ml Botol - - - - -
186 Povidon Iodida 10%-30 ml Botol - 10 10 - 10
187 Povidon Iodida 10%-300 ml Botol - -
188 Ranitidin Inj Ampul - -
189 Ringer Laktat Larutan Infus Steril Labu - 100 100 100 -
190 Sefotaksim Injeksi 1 gram Ampul - -
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - 20 20 20 -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - -
193 Valetamat Bromida 8 mg/ml Inj (Epidosin) Ampul - -
OBAT LUAR (KRIM/SALEP-TETES MATA-TETES TELINGA-SALEP MATA-SALEP KULIT)

194 Anti Bakteri DOEN Tube - -
195 Anti Fungi Pot - -
196 Anti Hemoroid DOEN Supp - -
197 Asiklovir Krim Tube - 48 48 24 24
198 Betametason Krim 0,1% Tube - 48 48 24 24
199 Fenol Gliserol Tetes Telinga 10% Botol - -
200 Gentamisin Salep Kulit 0,1% Tube - 48 48 24 24
Halaman 28

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
201 Gentamisin Sulfat Tetes Mata 0,3% Botol - 48 48 24 24
202 Hidrokortison Krim 2,5% Tube - - - - -
203 Ketokonazol Krim 2% Tube - 25 25 25 -
204 Kloramfenikol Salep Kulit Tube - -
205 Kloramfenikol Salep Mata 1% Tube - 24 24 14 10
206 Kloramfenikol Tetes Mata 1% Botol - - - - -
207 Kloramfenikol Tetes Telinga 3% Tube - - - - -
208 Meloksikam Suppositoria Supp - -
209 Mikonazol Krim Tube - 24 24 - 24
210 Nistatin Tablet Vaginal 100.000 IU/g Supp - -
211 Oksitetrasiklin HCl 1% Salep Mata Tube - -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - -
213 Salep 2-4 Kombinasi : As. Sal 2% + Bel. 4% Pot - -
214 Salisil Bedak 2% Box - - - - -
215 Sulfasetamida Natrium Tetes Mata 15% Botol - -
216 Tetrakain 0,5% Tetes Mata Botol - -
PERBEKALAN KESEHATAN
217 Alat Suntik Sekali Pakai 1 ml Pcs - 100 100 50 50
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - 100 100 50 50
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - -
222 Folley Catheter No. 14 Pcs - -
225 Infuset Anak Pcs - -
226 Infuset Dewasa Pcs - -
227 IV Catether/Abocat No. 18 Pcs - -
Halaman 29

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
231 Jarum Hecting Kulit 1/2 GT 9 Lusin - -
234 Jarum Hecting Otot GT 9 Lusin - -
235 Jarum Hecting Otot GT 10 Lusin - -
236 Kapas Berlemak 500 gram Rol - -
237 Kapas Pembalut/Absorben 250 mg Rol - - - - -
238 Kasa Steril 16x16 Rol - -
239 Kasa Kompres 40x40 Rol - -
240 Kasa Pembalut 2x80 Rol - -
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - -
243 Masker Pcs - 100 100 100 -
244 Needle G No. 23 Pcs - -
245 Plester 5 yard x 2 inch Rol - -
246 Sarung Tangan Pcs - 200 200 200 -
247 Sarung Tangan Steril Pasang - 200 200 200 -
248 Silk (Benang Bedah Sutera) Pcs - -
249 Urine Bag Pcs - - - - -
250 Umbilikal Klem Pcs - -
251 Wing Needle No. 27 Pcs - -
OBAT GIGI
252 Air Raksa Dental use Botol - -
253 Alloy Botol - -
254 Caviton Box - -
255 Devitalisasi Pasta (Arsen) Botol - -
256 Etil Klorida Semprot Botol - 1 1 1 -
257 Eugenol Cairan Botol - -
Halaman 30

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
258 Flour Tablet - -
259 Glass Ionomer Set - -
260 Iodoform Paste Tablet - -
261 Kalsium Hidroksida Pasta (Calcidor) Set - -
262 Monoklorkamfer Mentol Cairan (CHKM) Botol - -
263 Semen Seng Fosfat (Serbuk + Cairan) Set - -
264 Spongostan Buah - -
265 Temporary Stopping Fletcher Set - -
266 Tri Kresol Formalin (TKF) Botol - -
SERUM
267 Serum Anti Difteri ( ADS ) Ampul - -
268 Serum anti rabies Ampul - -
269 Serum anti tetanus inj 1.500 IU/amp (ATS) Ampul - -
270 Serum anti tetanus inj 20.000 IU/vial (ATS) Vial - -
271 Serum antibisa ular Polivalen inj 5 ml (SABU) I Vial - -
272 Serum antibisa ular Polivalen inj 50 ml (SABU) II Vial - -
REAGEN
273 Larutan Amonium Oxalat Botol - -
274 Larutan Asam Klorida 0,1 N-100 ml Botol - -
275 Larutan Asam Sulfosalisilat 20 %- 100 ml Botol - -
276 Larutan Benedict-100 ml Botol - -
277 Larutan Eosin 2%-100 ml Botol - -
278 Larutan Etanol asam -100 ml Botol - -
279 Larutan Gabbet-100 ml Botol - -
280 Larutan Giemsa stain-100 ml Botol - -
281 Larutan Karbol Fuchsin -100 ml Botol - -
282 Larutan Kinyoun-100 ml Botol - -
283 Larutan Metilen Biru-100 ml Botol - -
284 Larutan Turk-100 ml Botol - -
Halaman 31

No. NAMA OBAT N N N
1 2 3 4 5 6 7 8
BADAN PENYELENGGARA JAMINAN SOSIAL

BAYAR / UMUM
(BPJS)
JUMLAH KUNJUNGAN RESEP

RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP
312 92
JUMLAH TOTAL
Mengetahui/Menyetujui : Yang Menyerahkan : Yang Meminta

Kepala Dinas Kesehatan Kabupaten Subang Kepala UPTD Farmasi Kepala Puskesm
……………………………………………………. ……………………………………………………. Sri Rohayati, SE,

NIP. NIP. NIP. 19660811 198703 2
Halaman 32
TAAN OBAT (LPLPO)
DOKUMEN NOMOR TANGGAL
DINKES KAB
UPTD FARMASI
PUSKESMAS
Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

Lembar Merah : Puskesmas
Lembar Kuning : Arsip
PEMBERIAN
STOK OPT. PERMINTAA JUMLAH
N
BS/APBN APBD I APBD II DAK BPJS
9 10 11 12 13 14 15 16
-
-
233 300
- 500
- -
- 800
- 800
-
700 2,500
140 -
- 500
1,050 500
1,167 -
-
1,167 1,000
-
-
-
1,283 1,000
-
- 500
467 500
Halaman 33
PEMBERIAN
N
9 10 11 12 13 14 15 16
-
- -
-
-
-
- -
- -
- -
233 -
-
-
-
-
-
-
117 200
- 800
1,167 -
- 800
- -
1,167 1,000
- 800
233 500
- -
-
-
-
-
-
350 -
- 500
-
117 100
- -
467 -
Halaman 34
PEMBERIAN
N
9 10 11 12 13 14 15 16
233 -
1,167 -
117 200
-
-
-
- -
- 800
- 800
-
117 500
-
117 500
233 500
-
-
233 500
- 3,000
- 1,000
-
-
-
467 500
-
- 1,000
-
-
- 500
2,333 2,000
- 500
-
- -
2,333 2,000
- 800
- 800
Halaman 35
PEMBERIAN
N
9 10 11 12 13 14 15 16
1,167 -
-
-
350 500
-
-
-
-
-
- 300
-
117 200
- 500
- 1,000
- 1,000
-
- 800
- 800
- 800
3,500 3,000
-
-
1,167 -
- 1,000
1,167 2,000
-
Halaman 36
PEMBERIAN
N
9 10 11 12 13 14 15 16
-
- 1,000
233 200
-
12 10
- 800
233 200
-
-
-
-
- -
-
-
-
-
-
23 20
175 100
-
70 -
- 100
-
-
23 -
23 50
- -
- 50
- 50
Halaman 37
PEMBERIAN
N
9 10 11 12 13 14 15 16
58 55
58 50
- 50
58 -
117 -
-
-
-
-
-
-
-
-
-
-
- -
-
-
- -
4 3
-
-
-
-
-
-
Halaman 38
PEMBERIAN
N
9 10 11 12 13 14 15 16
- 10
-
- 60
- 90
-
-
-
-
-
-
- 100
- -
- -
-
-
117 100
-
23 20
-
-
-
-
-
28 48
28 -
-
28 -
Halaman 39
PEMBERIAN
N
9 10 11 12 13 14 15 16
28 25
- -
29 30
-
16 24
- 48
- 48
-
- -
-
-
-
-
- 20
-
-
58 -
58 -
58 -
58 -
-
-
-
-
-
-
-
-
Halaman 40
PEMBERIAN
N
9 10 11 12 13 14 15 16
-
-
-
-
-
-
-
-
-
-
-
-
-
-
117 200
-
-
233 200
233 200
-
- -
-
-
-
-
-
-
1 5
-
Halaman 41
PEMBERIAN
N
9 10 11 12 13 14 15 16
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Halaman 42
PEMBERIAN
N
9 10 11 12 13 14 15 16
JAMINAN KESEHATAN DAERAH JUMLAH TOTAL

(JAMKESDA)
404
Subang, 15 AGUSTUS 2014
Meminta : Yang Menerima :

a Puskesmas Petugas Puskesmas
ayati, SE, MM Rizki Iman Nurahman

1 198703 2 005 NIP.19911125 201101 1 001
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLP
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : DESEMBER 2014
PERMINTAAN BULAN / PERIODE : JANUARI 2015

PROVINSI : JAWA BARAT
No. NAMA OBAT SATUAN STOK PENERIMA PERSEDIAA PEMAKAIA STOK STOK
AWAL AN N N AKHIR OPT.
1 2 3 4 5 6 7 8 9
1 Activated Charcoal (Karbon Aktif) Tablet - - -
2 Albendazol 400 mg Tablet - - -
3 Alopurinol tablet 100 mg Tablet - 400 400 400 - 467
4 Ambroksol Tablet 5 mg Tablet - - - - - -
5 Aminofilin Tablet 200 mg Tablet - 500 500 - 500 -
6 Amlodipin 10 mg Tablet - - - - - -
8 Amoksisilin + Asam Klavulanat 625 mg Tablet - - - - - -
9 Amoksisilin 500 mg Tablet 600 3,000 3,600 2,100 1,500 2,450
10 Amoksisilin Kapsul 250 mg Tablet - - - - - -
11 Ampisillin Kaplet 500 mg Tablet - - - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet 1,100 500 1,600 1,400 200 1,633
13 Antasida DOEN Tablet 5,000 - 5,000 1,000 4,000 1,167
14 Antimigren DOEN Tablet 200 300 500 - 500 -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 1,000 2,000 1,000 1,000 1,167
16 Asam Askorbat(VIT C) Tablet 250 mg Tablet - - -
17 Asam Folat Tablet - - -
18 Asam Mefenamat 250 mg Tablet - - - - -
19 Asam Mefenamat 500 mg Tablet 400 1,000 1,400 900 500 1,050
20 Asiklovir 200 mg (herpes genitalis) Tablet - - - -
21 Asiklovir 400 mg Tablet 300 - 300 100 200 117
22 Deksametason Tablet 0,5 mg Tablet 400 - 400 400 - 467
23 Dietilkarbamazin sitrat tablet 100 mg Tablet - - -
24 Digoksin tablet 0,25 mg Tablet - - - - - -
25 Dimenhidrinat Tablet Tablet - - -
26 Doksisiklin Hcl Kapsul 100 mg Tablet - - -
27 Domperidon Tablet 10 mg Tablet 1,000 - 1,000 300 700 350
28 Ekstrak Belladon tablet 10 mg Tablet - - - - - -
29 Eritromisin kapsul 250 mg Tablet - - - -
30 Eritromisin kapsul 500 mg Tablet 100 - 100 - 100 -
31 Etambutol Hcl tablet 500 mg Tablet 600 - 600 200 400 233
32 Famotidin 20 mg Tablet - - -
33 Fenilbutason Tablet 20 mg Tablet - - -
34 Fenitoin Natrium kapsul 30 mg Tablet - - -
35 Fenoksimetil Penisilin tablet 250 mg Tablet - - -
37 Fitomenadion(Vit K1) tablet salut gula 10 mg Tablet - - -
38 Furosemid tablet 40 mg Tablet 200 200 400 300 100 350
39 Glibenklamid tablet 5 mg Tablet 100 500 600 400 200 467
40 Gliseril Gyayakolat tablet 100 mg Tablet 2,000 - 2,000 - 2,000 -
41 Glucosamin 500 mg Tablet - - - - - -
42 Griseofulvin tablet 125 mg micronized Tablet 100 100 100 - 117
43 Hidroklortiazid (HCT) tablet 25 mg Tablet 3,000 - 3,000 3,000 - 3,500
44 Ibuprofen tablet 200 mg Tablet 200 - 200 200 - 233
45 Ibuprofen tablet 400 mg Tablet 200 1,000 1,200 1,200 - 1,400
46 Isoniazid tablet 100 mg Tablet 1,000 - 1,000 - 1,000 -
47 Isoniazid tablet 300 mg Tablet - - -
48 Isosorbid dinitrat talet sublingual 5 mg Tablet - - -
49 Kalium Diklofenak tablet 25 mg Tablet - - -
51 Kalsium Laktat Tablet 500 mg Tablet 1,000 - 1,000 - 1,000 -
52 Kaptopril 12,5 mg Tablet 100 800 900 500 400 583
53 Kaptopril 25 mg Tablet 100 800 900 900 - 1,050
54 Kaptopril 50 mg Tablet - - -
55 Ketokonazol Tablet 200 mg Tablet 150 200 350 150 200 175
56 Klindamisin 150 mg Tablet 150 - 150 100 50 117
57 Klindamisin 300 mg Tablet - - - - - -
58 Kloramfenikol kapsul 250 mg Tablet 600 - 600 600 - 700
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 1,000 - 1,167
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet - 400 400 100 300 117
61 Kotrimoksazol Tablet Ped : Sulf 100 + Trim 20 mg Tablet - - -
62 Lansoprazol 30 mg Tablet - - -
63 Loperamid Tablet 2 mg Tablet 100 - 100 100 - 117
64 Loratadin Tablet 2 mg Tablet 200 100 300 - 300 -
65 Meloksikam 15 mg Tablet - - - - - -
66 Meloksikam 7,5 mg Tablet - - - - - -
67 Membendazol tablet 100 mg Tablet - - -
68 Metformin 500 mg Tablet - - - - - -
69 Metformin 850 mg Tablet - - -
70 Metilprednisolon 4 mg Tablet - - - - - -
72 Metoklorpropamide Tablet Tablet - - -
73 Metronidazol tablet 250 mg Tablet 300 300 - 300 -
74 Metronidazol tablet 500 mg Tablet 200 500 700 400 300 467
75 Multivitamin + Fe Tablet Tablet - - - - - -
76 Multivitamin Tablet Tablet - - - - - -
77 Natrium Bikarbonat tablet 500 mg Tablet - - -
78 Natrium Diklofenak 25 mg Tablet - - -
79 Natrium Diklofenak 50 mg Tablet - - - - - -
80 Nipedipin 10 mg Tablet 100 200 300 100 200 117
81 Nistatin tablet salut gula 500.000 IU/g Tablet - 100 100 - 100 -
82 Obat Batuk Flu Tablet Tablet - - - - - -
83 Obat Diare Tablet - - - - - -
84 Obat Spasmolitik Tablet - - - - - -
85 Omeprazol Kapsul 20 mg Kapsul - 150 150 150 - 175
86 Parasetamol tablet 500 mg Tablet - 3,000 3,000 3,000 - 3,500
87 Parasetamol tablet 100 mg Tablet - - - - - -
88 Pirantel tablet 125 Tablet - - -
89 Pirazinamida Tablet 500 mg Tablet 400 - 400 400 - 467
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet - 1,000 1,000 - 1,000 -
91 Piroksikam 10 mg Tablet - - - - - -
93 Prednison tablet 5 mg Tablet 3,000 - 3,000 1,000 2,000 1,167
94 Propanolol HCl tablet 40 mg Tablet - - -
95 Propiltiourasil tablet 100 mg Tablet - - -
96 Ranitidin 150 mg Tablet 100 500 600 400 200 467
97 Reserpin tablet 0,10 mg Tablet - - -
99 Retinol (VIT A) Kapsul 100.000 IU Kapsul - - -
101 Rifampisin kaplet 300 mg Tablet - - -
102 Rifampisin kapsul 450 mg Tablet - - - - - -
103 Rifampisin kapsul 600 mg Tablet - - -
104 Salbutamol tablet 2 mg Tablet 100 - 100 - 100 -
105 Salbutamol tablet 4 mg Tablet - - - - - -
106 Sefadroksil 500 mg Tablet - - - - - -
107 Sefiksim 100 mg Tablet - - - - - -
108 Setirizin Tablet - - - - - -
109 Simetidin Tablet 200 mg Tablet - - - - - -
110 Simvastatin Tablet - 200 200 200 - 233
111 Siprofloksasin Tablet 500 mg Tablet - 500 500 500 - 583
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 3,000 - 3,000 - 3,000 -
113 Tetrasiklin Kapsul 250 mg Tablet - - -
114 Tetrasiklin Kapsul 500 mg Tablet 400 - 400 100 300 117
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet 1,000 - 1,000 1,000 - 1,167
116 Tiamphenikol 500 mg Tablet - - - - - -
117 Vitamin B Kompleks tablet Tablet - 3,000 3,000 2,000 1,000 2,333
118 Zink Tablet 20 mg Tablet - - -

119 Amitriptilin 25 mg Tablet - - -
120 Dekstrometorfan 15 mg Tablet - - - - - -
121 Diazepam 2 mg Tablet - - - - - -
122 Diazepam 5 mg Tablet - - -
123 Diazepam Inj Ampul - 10 10 10 - 12
124 Efedrin 0,25 mg Tablet - - - - - -
125 Fenobarbital 30 mg Tablet 200 - 200 100 100 117
126 Fenobarbital Inj Ampul - - -
127 Haloperidol 0,5 mg Tablet - - -
128 Haloperidol 1 mg Tablet - - -
130 Metilergometrin 0,125 mg Tablet 300 - 300 100 200 117
131 Metilergometrin Inj Ampul - - -
132 Karbamazepin 200 mg Tablet - - -
133 Klorpromazin 25 mg Tablet - - -
135 Triheksifenidil Hidroklorida 2 mg Tablet - - -
136 Ambroksol Sirup Botol - 50 50 10 40 12
137 Amoksisilin Sirup Kering 125mg/ml Botol 40 100 140 80 60 93
138 Ampisilin Sirup Botol - - -
139 Antasida Suspensi Botol - 100 100 100 - 117
140 Dekstrometorfan sirup 10 mg/5 ml Botol - - - - - -
141 Domperidon Sirup Botol - - -
142 Eritromisin Sirup Sachet - - -
143 Ibuprofen Sirup Botol - 40 40 - 40 -
144 Kloramfenikol Suspensi Botol 50 - 50 - 50 -
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - - - - - -
146 Multivitamin Drop Botol - - - - - -
147 Multivitamin Sirup Botol - - - - - -
148 Obat Batuk Flu Sirup Botol - - - - - -
149 Obat Batuk Hitam (OBH) Botol 50 - 50 - 50 -
150 Parasetamol Drop Botol - - - - - -
151 Parasetamol Sirup 120 mg/5 ml Botol 40 100 140 110 30 128
152 Sefadroksil Sirup Botol - - - - - -
153 Setirizin Sirup Botol - - -

154 Aminofilin Inj 24 mg/ml Ampul - - -
155 Amoksisilin Serbuk Injeksi 1000 mg Ampul - - -
156 Ampisilin Injeksi Ampul - - -
157 Antalgin Inj 250 mg/ml Ampul - - -
158 Aqua Pro Injeksi Vial - - -
159 Aquades Steril-500 ml Botol - - -
160 Atropin Injeksi Ampul - - -
161 Atropin Sulfat Tetes Mata 0,5% Fls - - -
162 Deksametason Inj 5 mg/ml Ampul - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol 10 - 10 10 - 12
164 Difenhidramin Inj 10 mg/ml Ampul - - -
165 Efinefrin HCl/Bitartrat (Adrenalin) Inj 0,1% Ampul - - -
166 Etakridin (Rivanol) 0,1% Botol - - - - - -
167 Etanol 70%-200 ml Botol - 10 10 10 - 12
168 Fitomenadion (Vit K1) Inj 10 mg/ml Ampul - - -
169 Furosemid Inj 1 mg/ml Ampul - - -
170 Garam Oralit 200 ml Sachet - - -
171 Gentamisin Inj 80 mg/ml Ampul - - -
172 Gentian Violet Larutan 1% Botol - - -
173 Glukosa Larutan Infus 10% Steril-500 ml Labu - - -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 5 5 5 - 6
175 Ketorolak Inj Ampul - - -
176 Lidokain Inj Ampul - 20 20 20 - 23
177 Lidokain Inj Komp : Lidokain % + Efinefrin 1:80000 Ampul - - - - - -
178 Lisol, mengandung kresol tersabun 50% Botol - - -
179 Magnesium Sulfat Inj (IV) 20% Ampul - - -
181 Metoklopramida HCl 10 mg/2 ml Inj Ampul - - -
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - - -
183 Oksitetrasiklin HCl Inj i.m 50 mg/ml Ampul - - -
184 Oksitoksin Inj 10 IU/ml Ampul - 5 5 5 - 6
185 Povidon Iodida 10%-1000 ml Botol - - - - - -
187 Povidon Iodida 10%-300 ml Botol - - -
188 Ranitidin Inj Ampul - - -
189 Ringer Laktat Larutan Infus Steril Labu 80 80 80 - 93
190 Sefotaksim Injeksi 1 gram Ampul - - -
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - - - - - -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - -
193 Valetamat Bromida 8 mg/ml Inj (Epidosin) Ampul - - -

194 Anti Bakteri DOEN Tube - - -
195 Anti Fungi Pot - - -
196 Anti Hemoroid DOEN Supp - - -
197 Asiklovir Krim Tube 28 - 28 10 18 12
198 Betametason Krim 0,1% Tube 25 - 25 - 25 -
199 Fenol Gliserol Tetes Telinga 10% Botol - - -
200 Gentamisin Salep Kulit 0,1% Tube 20 - 20 - 20 -
201 Gentamisin Sulfat Tetes Mata 0,3% Botol - - - - - -
202 Hidrokortison Krim 2,5% Tube - - - - - -
203 Ketokonazol Krim 2% Tube 5 - 5 5 - 6
204 Kloramfenikol Salep Kulit Tube - - -
205 Kloramfenikol Salep Mata 1% Tube 24 24 48 24 24 28
206 Kloramfenikol Tetes Mata 1% Botol - - - - - -
207 Kloramfenikol Tetes Telinga 3% Tube - - - - - -
208 Meloksikam Suppositoria Supp - - -
209 Mikonazol Krim Tube 24 - 24 - 24 -
210 Nistatin Tablet Vaginal 100.000 IU/g Supp - - -
211 Oksitetrasiklin HCl 1% Salep Mata Tube - - -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - -
213 Salep 2-4 Kombinasi : As. Sal 2% + Bel. 4% Pot - - -
214 Salisil Bedak 2% Box 10 15 25 15 10 18
215 Sulfasetamida Natrium Tetes Mata 15% Botol - - -
216 Tetrakain 0,5% Tetes Mata Botol - - -
217 Alat Suntik Sekali Pakai 1 ml Pcs 100 - 100 - 100 -
218 Alat Suntik Sekali Pakai 2,5 ml Pcs 100 200 300 300 - 350
219 Alat Suntik Sekali Pakai 5 ml Pcs 100 - 100 100 - 117
220 Alat Suntik Sekali Pakai 10 ml Pcs 100 - 100 100 - 117
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - - - - - -
222 Folley Catheter No. 14 Pcs - - -
225 Infuset Anak Pcs - - -
226 Infuset Dewasa Pcs - 50 50 50 - 58
227 IV Catether/Abocat No. 18 Pcs - 15 15 15 - 18
231 Jarum Hecting Kulit 1/2 GT 9 Lusin - - -
234 Jarum Hecting Otot GT 9 Lusin - - -
236 Kapas Berlemak 500 gram Rol - - -
237 Kapas Pembalut/Absorben 250 mg Rol - - - - - -
238 Kasa Steril 16x16 Rol - - -
239 Kasa Kompres 40x40 Rol - - -
240 Kasa Pembalut 2x80 Rol 10 - 10 10 - 12
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - 10 10 10 - 12
243 Masker Pcs - 100 100 100 - 117
244 Needle G No. 23 Pcs - - -
245 Plester 5 yard x 2 inch Rol 1 3 4 4 - 5
246 Sarung Tangan Pcs - 100 100 100 - 117
247 Sarung Tangan Steril Pasang - - - - - -
248 Silk (Benang Bedah Sutera) Pcs - - -
249 Urine Bag Pcs - - - - - -
250 Umbilikal Klem Pcs - - -
251 Wing Needle No. 27 Pcs - - -
OBAT GIGI
252 Air Raksa Dental use Botol - - -
253 Alloy Botol - - -
254 Caviton Box - - -
255 Devitalisasi Pasta (Arsen) Botol - - -
256 Etil Klorida Semprot Botol - 2 2 2 - 2
257 Eugenol Cairan Botol - - -
258 Flour Tablet - - -
259 Glass Ionomer Set - 1 1 - 1 -
260 Iodoform Paste Tablet - - -
261 Kalsium Hidroksida Pasta (Calcidor) Set - - -
262 Monoklorkamfer Mentol Cairan (CHKM) Botol - - -
263 Semen Seng Fosfat (Serbuk + Cairan) Set - - -
264 Spongostan Buah - - -
265 Temporary Stopping Fletcher Set - - -
266 Tri Kresol Formalin (TKF) Botol - - -
SERUM
267 Serum Anti Difteri ( ADS ) Ampul - - -
268 Serum anti rabies Ampul - - -
269 Serum anti tetanus inj 1.500 IU/amp (ATS) Ampul - - -
270 Serum anti tetanus inj 20.000 IU/vial (ATS) Vial - - -
271 Serum antibisa ular Polivalen inj 5 ml (SABU) I Vial - - -
272 Serum antibisa ular Polivalen inj 50 ml (SABU) II Vial - - -
REAGEN
273 Larutan Amonium Oxalat Botol - - -
274 Larutan Asam Klorida 0,1 N-100 ml Botol - - -
275 Larutan Asam Sulfosalisilat 20 %- 100 ml Botol - - -
276 Larutan Benedict-100 ml Botol - - -
277 Larutan Eosin 2%-100 ml Botol - - -
278 Larutan Etanol asam -100 ml Botol - - -
279 Larutan Gabbet-100 ml Botol - - -
280 Larutan Giemsa stain-100 ml Botol - - -
281 Larutan Karbol Fuchsin -100 ml Botol - - -
282 Larutan Kinyoun-100 ml Botol - - -
283 Larutan Metilen Biru-100 ml Botol - - -
284 Larutan Turk-100 ml Botol - - -
305
306
307
308
309
310
311
312
BAYAR / UMUM
BADAN PENYELENGGARA JAMINAN JAMINAN KES
SOSIAL (BPJS) (JAM

RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN
220 0 673 0 98
JUMLAH TOTAL
Mengetahui/Menyetujui : Yang Menyerahkan : Yang Meminta :

Kepala Dinas Kesehatan Kabupaten Subang Kepala UPTD Farmasi Kepala Puskesmas
……………………………………………………. ……………………………………………………. Sri Rohayati, SE, MM

NIP. NIP. NIP. 19660811 198703 2 00
AT (LPLPO)

DINKES KAB
UPTD FARMASI
PUSKESMAS

PEMBERIAN
PERMINT JUMLAH
AAN BS/APBN APBD I APBD II DAK BPJS
10 11 12 13 14 15 16
500
500
-
-
500
-
2,000
500
-
500
-
-
1,000
1,000
-
500
500
-
-
-
-
-
-
300
500
-
800
-
2,000
500
1,000
-
-
800
1,000
100
-
-
500
1,000
-
500
-
800
800
800
-
800
800
200
500
-
1,000
500
500
-
1,000
500
500
400
4,000
-
500
-
800
800
-
700
1,000
-
500
1,000
500
500
800
500
600
-
-
2,000
500
3,000
-
200
10
-
-
-
-
-
100
-
-
-
-
-
-
50
50
100
-
50
100
-
20
10
60
-
50
-
20
100
10
-
-
-
-
-
10
24
48
48
-
20
-
-
100
-
10
50
20
20
20
20
10
10
100
5
100
-
-
-
-
-
MINAN KESEHATAN DAERAH JUMLAH TOTAL
(JAMKESDA)
WAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP
98 0 991 0
Subang, 11 JANUARI 2014
ta : Yang Menerima :
mas Petugas Puskesmas
, MM Rizki Iman Nurahman

8703 2 005 NIP.19911125 201101 1 001
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : JANUARI 2015
PERMINTAAN BULAN / PERIODE : FEBRUARI 2015

STOK PENERIMA PERSEDIAA PEMAKAIA

No. NAMA OBAT SATUAN AWAL AN N N
1 2 3 4 5 6 7
1 Activated Charcoal (Karbon Aktif) Tablet -
2 Albendazol 400 mg Tablet -
3 Alopurinol tablet 100 mg Tablet - 500 500 500
4 Ambroksol Tablet 5 mg Tablet - - - -
5 Aminofilin Tablet 200 mg Tablet - 500 500 500
6 Amlodipin 10 mg Tablet - - - -
8 Amoksisilin + Asam Klavulanat 625 mg Tablet - - - -
9 Amoksisilin 500 mg Tablet 1,500 2,000 3,500 3,500
10 Amoksisilin Kapsul 250 mg Tablet - - - -
11 Ampisillin Kaplet 500 mg Tablet - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet 200 500 700 600
13 Antasida DOEN Tablet 4,000 - 4,000 2,000
14 Antimigren DOEN Tablet 200 300 500 500
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 1,000 2,000 1,000
16 Asam Askorbat(VIT C) Tablet 250 mg Tablet -
17 Asam Folat Tablet -
18 Asam Mefenamat 250 mg Tablet - - -
19 Asam Mefenamat 500 mg Tablet 500 1,000 1,500 1,000
20 Asiklovir 200 mg (herpes genitalis) Tablet - -
21 Asiklovir 400 mg Tablet 200 - 200 200
22 Deksametason Tablet 0,5 mg Tablet 500 - 500 400
23 Dietilkarbamazin sitrat tablet 100 mg Tablet -
24 Digoksin tablet 0,25 mg Tablet - - - -
25 Dimenhidrinat Tablet Tablet -
26 Doksisiklin Hcl Kapsul 100 mg Tablet -
27 Domperidon Tablet 10 mg Tablet 700 - 700 500
28 Ekstrak Belladon tablet 10 mg Tablet - - - -
29 Eritromisin kapsul 250 mg Tablet - -
30 Eritromisin kapsul 500 mg Tablet 100 - 100 -
31 Etambutol Hcl tablet 500 mg Tablet 400 - 400 200
32 Famotidin 20 mg Tablet -
33 Fenilbutason Tablet 20 mg Tablet -
34 Fenitoin Natrium kapsul 30 mg Tablet -
35 Fenoksimetil Penisilin tablet 250 mg Tablet -
37 Fitomenadion(Vit K1) tablet salut gula 10 mg Tablet -
38 Furosemid tablet 40 mg Tablet 100 300 400 400
39 Glibenklamid tablet 5 mg Tablet 200 500 700 700
40 Gliseril Gyayakolat tablet 100 mg Tablet 2,000 - 2,000 1,000
41 Glucosamin 500 mg Tablet - - - -
42 Griseofulvin tablet 125 mg micronized Tablet 100 100 100
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - 2,000 2,000 -
45 Ibuprofen tablet 400 mg Tablet - 1,000 1,000 1,000
46 Isoniazid tablet 100 mg Tablet 1,000 - 1,000 1,000
47 Isoniazid tablet 300 mg Tablet -
48 Isosorbid dinitrat talet sublingual 5 mg Tablet -
49 Kalium Diklofenak tablet 25 mg Tablet -
51 Kalsium Laktat Tablet 500 mg Tablet 1,000 - 1,000 1,000
52 Kaptopril 12,5 mg Tablet 400 800 1,200 1,000
53 Kaptopril 25 mg Tablet - 1,000 1,000 900
54 Kaptopril 50 mg Tablet -
55 Ketokonazol Tablet 200 mg Tablet 200 100 300 150
56 Klindamisin 150 mg Tablet 150 - 150 100
57 Klindamisin 300 mg Tablet - - - -
58 Kloramfenikol kapsul 250 mg Tablet 600 - 600 600
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 200
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet - 400 400 100
61 Kotrimoksazol Tablet Ped : Sulf 100 + Trim 20 mg Tablet -
62 Lansoprazol 30 mg Tablet -
63 Loperamid Tablet 2 mg Tablet 100 - 100 100
64 Loratadin Tablet 2 mg Tablet 200 100 300 300
65 Meloksikam 15 mg Tablet - - - -
66 Meloksikam 7,5 mg Tablet - - - -
67 Membendazol tablet 100 mg Tablet -
68 Metformin 500 mg Tablet - - - -
69 Metformin 850 mg Tablet -
70 Metilprednisolon 4 mg Tablet - - - -
72 Metoklorpropamide Tablet Tablet -
73 Metronidazol tablet 250 mg Tablet 300 300 300
74 Metronidazol tablet 500 mg Tablet 300 500 800 700
75 Multivitamin + Fe Tablet Tablet - - - -
76 Multivitamin Tablet Tablet - - - -
77 Natrium Bikarbonat tablet 500 mg Tablet -
78 Natrium Diklofenak 25 mg Tablet -
79 Natrium Diklofenak 50 mg Tablet - - - -
80 Nipedipin 10 mg Tablet 200 500 700 700
81 Nistatin tablet salut gula 500.000 IU/g Tablet - 100 100 100
82 Obat Batuk Flu Tablet Tablet - - - -
83 Obat Diare Tablet - - - -
84 Obat Spasmolitik Tablet - - - -
85 Omeprazol Kapsul 20 mg Kapsul 400 - 400 400
86 Parasetamol tablet 500 mg Tablet - 4,000 4,000 3,000
87 Parasetamol tablet 100 mg Tablet - - - -
88 Pirantel tablet 125 Tablet -
89 Pirazinamida Tablet 500 mg Tablet 400 - 400 400
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet - 1,000 1,000 -
91 Piroksikam 10 mg Tablet - - - -
93 Prednison tablet 5 mg Tablet 3,000 - 3,000 1,000
94 Propanolol HCl tablet 40 mg Tablet -
95 Propiltiourasil tablet 100 mg Tablet -
96 Ranitidin 150 mg Tablet 200 700 900 900
97 Reserpin tablet 0,10 mg Tablet -
99 Retinol (VIT A) Kapsul 100.000 IU Kapsul -
101 Rifampisin kaplet 300 mg Tablet -
102 Rifampisin kapsul 450 mg Tablet - - - -
103 Rifampisin kapsul 600 mg Tablet -
104 Salbutamol tablet 2 mg Tablet 100 - 100 100
105 Salbutamol tablet 4 mg Tablet - - - -
106 Sefadroksil 500 mg Tablet - - - -
107 Sefiksim 100 mg Tablet - - - -
108 Setirizin Tablet - - - -
109 Simetidin Tablet 200 mg Tablet - - - -
110 Simvastatin Tablet - 500 500 500
111 Siprofloksasin Tablet 500 mg Tablet - 600 600 500
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 3,000 - 3,000 -
113 Tetrasiklin Kapsul 250 mg Tablet -
114 Tetrasiklin Kapsul 500 mg Tablet 400 - 400 100
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet 1,000 - 1,000 1,000
116 Tiamphenikol 500 mg Tablet - - - -
117 Vitamin B Kompleks tablet Tablet - 3,000 3,000 2,000
118 Zink Tablet 20 mg Tablet -

119 Amitriptilin 25 mg Tablet -
120 Dekstrometorfan 15 mg Tablet - - - -
121 Diazepam 2 mg Tablet - - - -
122 Diazepam 5 mg Tablet -
123 Diazepam Inj Ampul - 10 10 10
124 Efedrin 0,25 mg Tablet - - - -
125 Fenobarbital 30 mg Tablet 100 - 100 100
126 Fenobarbital Inj Ampul -
127 Haloperidol 0,5 mg Tablet -
128 Haloperidol 1 mg Tablet -
130 Metilergometrin 0,125 mg Tablet 200 - 200 100
131 Metilergometrin Inj Ampul -
132 Karbamazepin 200 mg Tablet -
133 Klorpromazin 25 mg Tablet -
135 Triheksifenidil Hidroklorida 2 mg Tablet -
136 Ambroksol Sirup Botol 30 - 30 10
137 Amoksisilin Sirup Kering 125mg/ml Botol 60 - 60 60
138 Ampisilin Sirup Botol -
139 Antasida Suspensi Botol - 100 100 100
140 Dekstrometorfan sirup 10 mg/5 ml Botol - - - -
141 Domperidon Sirup Botol -
142 Eritromisin Sirup Sachet -
143 Ibuprofen Sirup Botol - 40 40 40
144 Kloramfenikol Suspensi Botol 50 - 50 50
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - - - -
146 Multivitamin Drop Botol - - - -
147 Multivitamin Sirup Botol - - - -
148 Obat Batuk Flu Sirup Botol - - - -
149 Obat Batuk Hitam (OBH) Botol 50 - 50 -
150 Parasetamol Drop Botol - - - -
151 Parasetamol Sirup 120 mg/5 ml Botol 30 100 130 130
152 Sefadroksil Sirup Botol - - - -
153 Setirizin Sirup Botol -

154 Aminofilin Inj 24 mg/ml Ampul -
155 Amoksisilin Serbuk Injeksi 1000 mg Ampul -
156 Ampisilin Injeksi Ampul -
157 Antalgin Inj 250 mg/ml Ampul -
158 Aqua Pro Injeksi Vial -
159 Aquades Steril-500 ml Botol -
160 Atropin Injeksi Ampul -
161 Atropin Sulfat Tetes Mata 0,5% Fls -
162 Deksametason Inj 5 mg/ml Ampul -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - 12 12 10
164 Difenhidramin Inj 10 mg/ml Ampul -
165 Efinefrin HCl/Bitartrat (Adrenalin) Inj 0,1% Ampul -
166 Etakridin (Rivanol) 0,1% Botol - - - -
167 Etanol 70%-200 ml Botol - 10 10 10
168 Fitomenadion (Vit K1) Inj 10 mg/ml Ampul -
169 Furosemid Inj 1 mg/ml Ampul -
170 Garam Oralit 200 ml Sachet -
171 Gentamisin Inj 80 mg/ml Ampul -
172 Gentian Violet Larutan 1% Botol -
173 Glukosa Larutan Infus 10% Steril-500 ml Labu -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 10 10 10
175 Ketorolak Inj Ampul -
176 Lidokain Inj Ampul - 60 60 60
177 Lidokain Inj Komp : Lidokain % + Efinefrin 1:80000 Ampul - - - -
178 Lisol, mengandung kresol tersabun 50% Botol -
179 Magnesium Sulfat Inj (IV) 20% Ampul -
181 Metoklopramida HCl 10 mg/2 ml Inj Ampul -
182 Natrium Klorida Lar. Infus 0.9% Steril Labu -
183 Oksitetrasiklin HCl Inj i.m 50 mg/ml Ampul -
184 Oksitoksin Inj 10 IU/ml Ampul - 50 50 50
185 Povidon Iodida 10%-1000 ml Botol - - - -
186 Povidon Iodida 10%-30 ml Botol - 20 20 20
187 Povidon Iodida 10%-300 ml Botol -
188 Ranitidin Inj Ampul -
189 Ringer Laktat Larutan Infus Steril Labu 80 80 80
190 Sefotaksim Injeksi 1 gram Ampul -
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - - - -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul -
193 Valetamat Bromida 8 mg/ml Inj (Epidosin) Ampul -
194 Anti Bakteri DOEN Tube -
195 Anti Fungi Pot -
196 Anti Hemoroid DOEN Supp -
197 Asiklovir Krim Tube 18 - 18 18
198 Betametason Krim 0,1% Tube 25 - 25 25
199 Fenol Gliserol Tetes Telinga 10% Botol -
200 Gentamisin Salep Kulit 0,1% Tube 20 - 20 20
201 Gentamisin Sulfat Tetes Mata 0,3% Botol - - - -
202 Hidrokortison Krim 2,5% Tube - - - -
203 Ketokonazol Krim 2% Tube - 10 10 5
204 Kloramfenikol Salep Kulit Tube -
205 Kloramfenikol Salep Mata 1% Tube 24 24 48 48
206 Kloramfenikol Tetes Mata 1% Botol - - - -
207 Kloramfenikol Tetes Telinga 3% Tube - - - -
208 Meloksikam Suppositoria Supp -
209 Mikonazol Krim Tube 24 - 24 24
210 Nistatin Tablet Vaginal 100.000 IU/g Supp -
211 Oksitetrasiklin HCl 1% Salep Mata Tube -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube -
213 Salep 2-4 Kombinasi : As. Sal 2% + Bel. 4% Pot -
214 Salisil Bedak 2% Box 10 20 30 30
215 Sulfasetamida Natrium Tetes Mata 15% Botol -
216 Tetrakain 0,5% Tetes Mata Botol -
217 Alat Suntik Sekali Pakai 1 ml Pcs 100 - 100 100
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - -
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - - - -
222 Folley Catheter No. 14 Pcs -
225 Infuset Anak Pcs -
226 Infuset Dewasa Pcs - 50 50 50
227 IV Catether/Abocat No. 18 Pcs - 15 15 15
231 Jarum Hecting Kulit 1/2 GT 9 Lusin -
234 Jarum Hecting Otot GT 9 Lusin -
236 Kapas Berlemak 500 gram Rol -
237 Kapas Pembalut/Absorben 250 mg Rol - - - -
238 Kasa Steril 16x16 Rol -
239 Kasa Kompres 40x40 Rol -
240 Kasa Pembalut 2x80 Rol 10 - 10 10
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - 10 10 10
243 Masker Pcs - 100 100 100
244 Needle G No. 23 Pcs -
245 Plester 5 yard x 2 inch Rol - 5 5 5
246 Sarung Tangan Pcs - 100 100 100
247 Sarung Tangan Steril Pasang - - - -
248 Silk (Benang Bedah Sutera) Pcs - - - -
249 Urine Bag Pcs - - - -
250 Umbilikal Klem Pcs -
251 Wing Needle No. 27 Pcs -
OBAT GIGI
252 Air Raksa Dental use Botol -
253 Alloy Botol -
254 Caviton Box -
255 Devitalisasi Pasta (Arsen) Botol -
256 Etil Klorida Semprot Botol - 3 3 3
257 Eugenol Cairan Botol -
258 Flour Tablet -
259 Glass Ionomer Set - 1 1 -
260 Iodoform Paste Tablet -
261 Kalsium Hidroksida Pasta (Calcidor) Set -
262 Monoklorkamfer Mentol Cairan (CHKM) Botol -
263 Semen Seng Fosfat (Serbuk + Cairan) Set -
264 Spongostan Buah -
265 Temporary Stopping Fletcher Set -
266 Tri Kresol Formalin (TKF) Botol -
SERUM
267 Serum Anti Difteri ( ADS ) Ampul -
268 Serum anti rabies Ampul -
269 Serum anti tetanus inj 1.500 IU/amp (ATS) Ampul -
270 Serum anti tetanus inj 20.000 IU/vial (ATS) Vial -
271 Serum antibisa ular Polivalen inj 5 ml (SABU) I Vial -
272 Serum antibisa ular Polivalen inj 50 ml (SABU) II Vial -
REAGEN
273 Larutan Amonium Oxalat Botol -
274 Larutan Asam Klorida 0,1 N-100 ml Botol -
275 Larutan Asam Sulfosalisilat 20 %- 100 ml Botol -
276 Larutan Benedict-100 ml Botol -
277 Larutan Eosin 2%-100 ml Botol -
278 Larutan Etanol asam -100 ml Botol -
279 Larutan Gabbet-100 ml Botol -
280 Larutan Giemsa stain-100 ml Botol -
281 Larutan Karbol Fuchsin -100 ml Botol -
282 Larutan Kinyoun-100 ml Botol -
283 Larutan Metilen Biru-100 ml Botol -
284 Larutan Turk-100 ml Botol -
305
306
307
308
309
310
311
312
BADAN PENYELENGGARA JAMINAN

BAYAR / UMUM
SOSIAL (BPJS)

251 0 630 0
251 0 630 0
JUMLAH TOTAL


NIP. NIP. NIP. 19660811 19870
AR PERMINTAAN OBAT (LPLPO)
MAS

DINKES KAB
UPTD FARMASI
PUSKESMAS
ANUARI 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

EBRUARI 2015 Lembar Kuning : Arsip
PEMBERIAN
STOK STOK PERMINT JUMLAH
AKHIR OPT. AAN BS/APBN APBD I APBD II DAK BPJS
8 9 10 11 12 13 14 15 16
- -
- -
- 583 600
- - 500
- 583 -
- - -
- - 500
- - -
- 4,083 4,000
- - 500
- - -
100 700 500
2,000 2,333 2,000
- 583 -
1,000 1,167 1,000
- -
- -
- -
500 1,167 500
- -
- 233 300
100 467 500
- -
- - 500
- -
- - -
200 583 500
- - -
- - -
100 - -
200 233 -
- -
- -
- -
- -
- -
- -
- 467 400
- 817 700
1,000 1,167 -
- - 800
- 117 -
2,000 - -
- - 500
- 1,167 1,100
- 1,167 -
- -
- -
- -
- -
- 1,167 2,000
200 1,167 800
100 1,050 800
- -
150 175 -
50 117 -
- - -
- 700 500
800 233 -
300 117 -
- -
- -
- 117 500
- 350 200
- - 800
- - 800
- -
- - 800
- - -
- - 800
- - 800
- -
- 350 200
100 817 800
- - -
- - 1,000
- -
- -
- - 500
- 817 800
- 117 -
- - 1,000
- - 500
- - 500
- 467 500
1,000 3,500 3,000
- - -
- -
- 467 500
1,000 - -
- - 800
- - 800
2,000 1,167 -
- -
- -
- 1,050 700
- -
- -
- -
- -
- -
- - 1,000
- -
- 117 200
- - 500
- - 1,000
- - 500
- - 500
- - 800
- 583 600
100 583 600
3,000 - -
- -
300 117 -
- 1,167 2,000
- - 500
1,000 2,333 3,000
- -
- -
- - -
- - 200
- -
- 12 10
- - -
- 117 -
- -
- -
- -
- -
100 117 -
- -
- -
- -
- -
- -
20 12 -
- 70 100
- -
- 117 100
- - -
- - -
- - -
- 47 50
- 58 100
- - -
- - 50
- - 50
- - 100
50 - -
- - 50
- 152 150
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
2 12 12
- -
- -
- - -
- 12 20
- -
- -
- -
- -
- -
- -
- 12 10
- -
- 70 60
- - -
- -
- -
- -
- -
- -
- -
- 58 50
- - -
- 23 20
- -
- -
- 93 100
- -
- - 10
- -
- -
- -
- -
- -
- 21 24
- 29 24
- -
- 23 24
- - -
- - -
5 6 10
- -
- 56 48
- - 48
- - 48
- -
- 28 24
- -
- -
- -
- -
- 35 20
- -
- -
- 117 -
- - 100
- 117 100
- 117 -
- - 10
- -
- -
- -
- -
- 58 50
- 18 20
- 18 20
- 18 20
- 18 20
- -
- -
- -
- -
- -
- -
- -
- -
- -
- 12 10
- - 10
- 12 10
- 117 100
- -
- 6 5
- 117 100
- - -
- - 10
- - -
- - -
- - -
- -
- -
- -
- -
- 4 3
- -
- -
1 - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
NGGARA JAMINAN JAMINAN KESEHATAN DAERAH

(BPJS) JUMLAH TOTAL
(JAMKESDA)
RAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP
0 98 0 979 0
0 98 0 979 0
Subang, 11 FEBRUARI 2015
Yang Meminta : Yang Menerima :

Kepala Puskesmas Petugas Puskesmas
Sri Rohayati, SE, MM Rizki Iman Nurahman

NIP. 19660811 198703 2 005 NIP.19911125 201101 1 001
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLP
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : FEBRUARI 2015
PERMINTAAN BULAN / PERIODE : MARET 2015

STOK PENERIMA PERSEDIAA PEMAKAIA STOK STOK

No. NAMA OBAT SATUAN AWAL AN N N AKHIR OPT.
1 2 3 4 5 6 7 8 9
5 Aminofilin Tablet 200 mg Tablet - 500 500 500 - 583
9 Amoksisilin 500 mg Tablet - 3,000 3,000 2,000 1,000 2,333
10 Amoksisilin Kapsul 250 mg Tablet - 500 500 100 400 117
12 Antalgin(Metampiron) Tablet 500 mg Tablet 200 500 700 600 100 700
13 Antasida DOEN Tablet 2,000 2,000 4,000 2,000 2,000 2,333
14 Antimigren DOEN Tablet - - - - - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 - 1,000 1,000 - 1,167
19 Asam Mefenamat 500 mg Tablet 500 500 1,000 500 500 583
21 Asiklovir 400 mg Tablet - 300 300 200 100 233
22 Deksametason Tablet 0,5 mg Tablet 500 - 500 400 100 467
27 Domperidon Tablet 10 mg Tablet 200 500 700 200 500 233
30 Eritromisin kapsul 500 mg Tablet 100 - 100 - 100 -
31 Etambutol Hcl tablet 500 mg Tablet 400 - 400 200 200 233
38 Furosemid tablet 40 mg Tablet - 400 400 400 - 467
39 Glibenklamid tablet 5 mg Tablet - 500 500 200 300 233
40 Gliseril Gyayakolat tablet 100 mg Tablet 1,000 - 1,000 1,000 - 1,167
42 Griseofulvin tablet 125 mg micronized Tablet - - - - - -
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - 2,000 2,000 - 2,000 -
44 Ibuprofen tablet 200 mg Tablet - - - - - -
45 Ibuprofen tablet 400 mg Tablet - 1,000 1,000 1,000 - 1,167
46 Isoniazid tablet 100 mg Tablet - - - - - -
51 Kalsium Laktat Tablet 500 mg Tablet 1,000 - 1,000 - 1,000 -
52 Kaptopril 12,5 mg Tablet 200 800 1,000 700 300 817
53 Kaptopril 25 mg Tablet 100 800 900 500 400 583
55 Ketokonazol Tablet 200 mg Tablet - - - - - -
56 Klindamisin 150 mg Tablet 50 - 50 - 50 -
58 Kloramfenikol kapsul 250 mg Tablet - - - - - -
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 - 1,000 -
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 300 - 300 - 300 -
63 Loperamid Tablet 2 mg Tablet 100 - 100 100 - 117
64 Loratadin Tablet 2 mg Tablet - - - - - -
73 Metronidazol tablet 250 mg Tablet - 200 200 - 200 -
74 Metronidazol tablet 500 mg Tablet 100 800 900 700 200 817
80 Nipedipin 10 mg Tablet - 500 500 500 - 583
81 Nistatin tablet salut gula 500.000 IU/g Tablet - - - - - -
85 Omeprazol Kapsul 20 mg Kapsul - 210 210 60 150 70
86 Parasetamol tablet 500 mg Tablet 1,000 3,000 4,000 4,000 - 4,667
87 Parasetamol tablet 100 mg Tablet - - - - - -
89 Pirazinamida Tablet 500 mg Tablet - - - - - -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet - 1,000 1,000 - 1,000 -
93 Prednison tablet 5 mg Tablet 2,000 - 2,000 - 2,000 -
96 Ranitidin 150 mg Tablet - 700 700 600 100 700
106 Sefadroksil 500 mg Tablet - - - - - -
110 Simvastatin Tablet - 100 100 100 - 117
111 Siprofloksasin Tablet 500 mg Tablet 100 600 700 400 300 467
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 2,000 - 2,000 - 2,000 -
113 Tetrasiklin Kapsul 250 mg Tablet 2,000 2,000 - 2,000 -
114 Tetrasiklin Kapsul 500 mg Tablet 400 - 400 100 300 117
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet - 2,000 2,000 2,000 - 2,333
117 Vitamin B Kompleks tablet Tablet - 500 500 500 - 583
118 Zink Tablet 20 mg Tablet - 3,000 3,000 - 3,000 -

121 Diazepam 2 mg Tablet - 100 100 - 100 -
123 Diazepam Inj Ampul - - - - - -
125 Fenobarbital 30 mg Tablet 100 - 100 100 - 117
130 Metilergometrin 0,125 mg Tablet 200 - 200 100 100 117
131 Metilergometrin Inj Ampul - - -
136 Ambroksol Sirup Botol 20 - 20 - 20 -
137 Amoksisilin Sirup Kering 125mg/ml Botol - 70 70 70 - 82
142 Eritromisin Sirup Sachet - - -
143 Ibuprofen Sirup Botol - - - - - -
144 Kloramfenikol Suspensi Botol - - - - - -
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - - - - - -
149 Obat Batuk Hitam (OBH) Botol 50 - 50 50 - 58
151 Parasetamol Sirup 120 mg/5 ml Botol - 100 100 100 - 117
152 Sefadroksil Sirup Botol - - - - - -

157 Antalgin Inj 250 mg/ml Ampul - - - - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - 2 2 2 - 2
167 Etanol 70%-200 ml Botol - 15 15 10 5 12
170 Garam Oralit 200 ml Sachet - - -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 10 10 - 10 -
176 Lidokain Inj Ampul - 30 30 20 10 23
178 Lisol, mengandung kresol tersabun 50% Botol - - -
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - - - - - -
184 Oksitoksin Inj 10 IU/ml Ampul - - - - - -
187 Povidon Iodida 10%-300 ml Botol - - -
189 Ringer Laktat Larutan Infus Steril Labu 80 80 60 20 70
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - 10 10 - 10 -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - - - - -
197 Asiklovir Krim Tube - - - - - -
198 Betametason Krim 0,1% Tube - - - - - -
200 Gentamisin Salep Kulit 0,1% Tube - 20 20 20 - 23
202 Hidrokortison Krim 2,5% Tube - - - - - -
203 Ketokonazol Krim 2% Tube 5 - 5 5 - 6
205 Kloramfenikol Salep Mata 1% Tube - - - - - -
206 Kloramfenikol Tetes Mata 1% Botol - - - - - -
207 Kloramfenikol Tetes Telinga 3% Tube - - - - - -
209 Mikonazol Krim Tube - 24 24 - 24 -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - -
214 Salisil Bedak 2% Box - 20 20 10 10 12
217 Alat Suntik Sekali Pakai 1 ml Pcs - - - - - -
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - 100 100 - 100 -
219 Alat Suntik Sekali Pakai 5 ml Pcs - 100 100 - 100 -
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - - - - - -
226 Infuset Dewasa Pcs - - - - - -
238 Kasa Steril 16x16 Rol - - - - - -
240 Kasa Pembalut 2x80 Rol - - - - - -
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - - - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - 10 10 10 - 12
243 Masker Pcs - 100 100 100 - 117
245 Plester 5 yard x 2 inch Rol - 5 5 5 - 6
246 Sarung Tangan Pcs - 100 100 100 - 117
248 Silk (Benang Bedah Sutera) Pcs - - - - - -
249 Urine Bag Pcs - - - - - -
OBAT GIGI
259 Glass Ionomer Set - - - - - -
SERUM
REAGEN
305
306
307
308
309
310
311
312
BAYAR / UMUM
BADAN PENYELENGGARA JAMINAN JAMINAN KE
SOSIAL (BPJS) (JA

RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALA
298 0 640 0 98
298 0 640 0 98
JUMLAH TOTAL


NIP. NIP. NIP. 19660811 198703 2 00
BAT (LPLPO)

DINKES KAB
UPTD FARMASI
PUSKESMAS

PEMBERIAN
PERMINT JUMLAH
10 11 12 13 14 15 16
600
500
-
-
500
-
2,000
-
-
600
-
-
1,000
500
200
500
500
-
-
-
-
-
-
500
-
1,000
800
-
-
500
1,000
1,000
-
800
800
800
-
-
500
-
-
500
200
800
800
800
-
800
800
-
-
-
1,000
-
-
-
600
-
1,000
500
-
90
4,000
-
500
-
800
800
-
-
-
600
1,000
500
500
1,000
500
-
800
600
200
-
-
-
2,000
500
600
-
-
-
-
-
200
-
100
100
-
-
-
-
100
-
50
50
100
50
-
150
10
-
10
10
-
10
50
-
20
70
-
-
48
48
40
-
48
10
48
48
48
10
-
-
-
-
10
50
20
20
20
20
10
20
10
10
10
100
5
100
-
10
-
-
-
-
MINAN KESEHATAN DAERAH JUMLAH TOTAL
(JAMKESDA)
AWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP
98 0 1036 0
98 0 1036 0
Subang, 17 MARET 2015
nta : Yang Menerima :

smas Petugas Puskesmas
E, MM Rizki Iman Nurahman

98703 2 005 NIP.19911125 201101 1 001
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : MARET 2015
PERMINTAAN BULAN / PERIODE : APRIL 2015


1 2 3 4 5 6 7
10 Amoksisilin Kapsul 250 mg Tablet 400 - 400 -
12 Antalgin(Metampiron) Tablet 500 mg Tablet 100 600 700 700
13 Antasida DOEN Tablet 2,000 - 2,000 2,000
14 Antimigren DOEN Tablet - - - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet - 1,000 1,000 -
19 Asam Mefenamat 500 mg Tablet 500 500 1,000 500
21 Asiklovir 400 mg Tablet 100 200 300 100
22 Deksametason Tablet 0,5 mg Tablet 100 500 600 400
24 Digoksin tablet 0,25 mg Tablet - 500 500 -
38 Furosemid tablet 40 mg Tablet - 500 500 200
39 Glibenklamid tablet 5 mg Tablet 300 - 300 200
40 Gliseril Gyayakolat tablet 100 mg Tablet - 1,000 1,000 500
43 Hidroklortiazid (HCT) tablet 25 mg Tablet 2,000 - 2,000 -
45 Ibuprofen tablet 400 mg Tablet - 300 300 300
46 Isoniazid tablet 100 mg Tablet - - - -
51 Kalsium Laktat Tablet 500 mg Tablet 1,000 - 1,000 -
52 Kaptopril 12,5 mg Tablet 300 800 1,100 800
53 Kaptopril 25 mg Tablet 400 800 1,200 700
55 Ketokonazol Tablet 200 mg Tablet - - - -
56 Klindamisin 150 mg Tablet 50 - 50 -
58 Kloramfenikol kapsul 250 mg Tablet - - - -
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 -
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 300 - 300 -
63 Loperamid Tablet 2 mg Tablet 100 - 100 100
64 Loratadin Tablet 2 mg Tablet - - - -
73 Metronidazol tablet 250 mg Tablet 200 - 200 200
80 Nipedipin 10 mg Tablet - - - -
81 Nistatin tablet salut gula 500.000 IU/g Tablet - - - -
85 Omeprazol Kapsul 20 mg Kapsul 150 90 240 120
89 Pirazinamida Tablet 500 mg Tablet - - - -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 - 1,000 -
93 Prednison tablet 5 mg Tablet 2,000 - 2,000 -
110 Simvastatin Tablet - 200 200 200
111 Siprofloksasin Tablet 500 mg Tablet 300 200 500 500
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 2,000 - 2,000 -
113 Tetrasiklin Kapsul 250 mg Tablet 2,000 - 2,000 -
114 Tetrasiklin Kapsul 500 mg Tablet 300 - 300 -
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet - 2,000 2,000 2,000
117 Vitamin B Kompleks tablet Tablet - - - -
118 Zink Tablet 20 mg Tablet 3,000 - 3,000 -

121 Diazepam 2 mg Tablet - 100 100 100
123 Diazepam Inj Ampul - - - -
125 Fenobarbital 30 mg Tablet - 200 200 -
137 Amoksisilin Sirup Kering 125mg/ml Botol - 100 100 100
143 Ibuprofen Sirup Botol - - - -
144 Kloramfenikol Suspensi Botol - - - -
149 Obat Batuk Hitam (OBH) Botol - 50 50 50
151 Parasetamol Sirup 120 mg/5 ml Botol - 150 150 150

157 Antalgin Inj 250 mg/ml Ampul - - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - - - -
167 Etanol 70%-200 ml Botol 5 10 15 15
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 10 10 -
176 Lidokain Inj Ampul 10 10 20 20
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 10 10 -
184 Oksitoksin Inj 10 IU/ml Ampul - - - -
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - 10 10 -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - - -
197 Asiklovir Krim Tube - - - -
198 Betametason Krim 0,1% Tube - - - -
200 Gentamisin Salep Kulit 0,1% Tube - - - -
202 Hidrokortison Krim 2,5% Tube - 48 48 14
203 Ketokonazol Krim 2% Tube - - - -
205 Kloramfenikol Salep Mata 1% Tube - - - -
209 Mikonazol Krim Tube - 24 24 -
214 Salisil Bedak 2% Box 10 10 20 20
217 Alat Suntik Sekali Pakai 1 ml Pcs - - - -
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - 100 100 100
219 Alat Suntik Sekali Pakai 5 ml Pcs - 100 100 100
226 Infuset Dewasa Pcs - 50 50 50
238 Kasa Steril 16x16 Rol - - - -
240 Kasa Pembalut 2x80 Rol - - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - 10 10 10
243 Masker Pcs - 100 100 100
246 Sarung Tangan Pcs - 100 100 100
OBAT GIGI
253 Alloy Botol -
254 Caviton Box -
258 Flour Tablet -
259 Glass Ionomer Set - - - -
SERUM
REAGEN
305
306
307
308
309
310
311
312

BAYAR / UMUM
SOSIAL (BPJS)

433 0 167 0
433 0 167 0
JUMLAH TOTAL


NIP. NIP. NIP. 19660811 19870
MAS

DINKES KAB
UPTD FARMASI
PUSKESMAS
MARET 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

APRIL 2015 Lembar Kuning : Arsip
PEMBERIAN
8 9 10 11 12 13 14 15 16
- -
- -
- 583 600
- - 500
- 583 -
- - -
- - 500
- - -
- 3,500 3,500
400 - -
- - -
- 817 800
- 2,333 2,000
- - -
1,000 - -
- -
- -
- -
500 583 600
- -
200 117 200
200 467 500
- -
500 - -
- -
- - -
400 117 -
- - -
- - -
100 - -
200 233 -
- -
- -
- -
- -
- -
- -
300 233 500
100 233 300
500 583 500
- - 800
- - -
2,000 - -
- - 500
- 350 1,000
- - -
- - -
- - -
- - -
- - -
1,000 - -
300 933 800
500 817 800
- -
- - 800
50 - -
- - -
- - 500
1,000 - -
300 - -
- -
- -
- 117 500
- - 200
- - 800
- - 800
- - -
- - -
- - 800
- - 800
- - 800
- - -
- 233 500
- 233 300
- - -
- - 1,000
- - -
- - -
- - -
- - 600
- - -
- - 1,000
- - 500
- - -
120 140 240
- 4,667 4,000
- - -
- -
- - 500
1,000 - -
- - 800
- - 800
2,000 - -
- - -
- - -
200 583 500
- -
- -
- -
- -
- -
- - 1,000
- -
- - 500
- - 500
- - 1,000
- - 500
- - -
- - 800
- 233 600
- 583 600
2,000 - -
2,000 - -
300 - -
- 2,333 2,000
- - 500
- - 800
3,000 - -
- -
- - -
- 117 200
- -
- - -
- - -
200 - 200
- -
- -
- -
- -
100 117 -
- -
- -
- -
- -
- -
- 23 50
- 117 100
- -
- 117 100
- - -
- - -
- - -
- - 100
- - 100
- - -
- - 50
- - 50
- - 100
- 58 50
- - -
- 175 200
- -
- -
- -
- -
- -
- - -
- -
- -
- -
- -
- -
- - -
- -
- -
- - -
- 18 20
- -
- -
- -
- -
- -
- -
10 - -
- -
- 23 50
- - -
- -
- -
- -
- -
10 - -
- -
- - 50
- - -
- - 20
- -
- -
- 82 100
- -
10 - -
- - -
- -
- -
- -
- -
- - 48
- - 48
- -
- - -
- - -
34 16 -
- - -
- - -
- - 48
- - 48
- - 48
- -
24 - -
- -
- -
- -
- -
- 23 10
- -
- - 15
- - -
- 117 200
- 117 -
- - -
- - 10
- -
- -
- -
- -
- 58 50
- 23 20
- 23 20
- 23 20
- 23 20
- -
- -
- -
- -
- -
- -
- - -
- - 20
- -
- - 10
- - 10
- 12 10
- 117 100
- -
- 6 5
- 117 100
- - -
- - 10
- - -
- - -
- - -
- -
- -
- -
- -
- 4 4
- -
- -
- - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

(BPJS) JUMLAH TOTAL
(JAMKESDA)
0 98 0 698 0
0 98 0 698 0
Subang, 12 APRIL 2015


NIP. 19660811 198703 2 005 NIP.19911125 201101 1 001
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : APRIL 2015
PERMINTAAN BULAN / PERIODE : MEI 2015


1 2 3 4 5 6 7
9 Amoksisilin 500 mg Tablet - 3,000 3,000 2,000
12 Antalgin(Metampiron) Tablet 500 mg Tablet - 800 800 800
13 Antasida DOEN Tablet - 2,000 2,000 2,000
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet - 1,000 1,000 1,000
19 Asam Mefenamat 500 mg Tablet - 600 600 500
21 Asiklovir 400 mg Tablet - 200 200 100
22 Deksametason Tablet 0,5 mg Tablet - 500 500 400
38 Furosemid tablet 40 mg Tablet - 500 500 300
39 Glibenklamid tablet 5 mg Tablet 100 300 400 400
40 Gliseril Gyayakolat tablet 100 mg Tablet 500 - 500 500
53 Kaptopril 25 mg Tablet 500 800 1,300 1,000
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 -
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 300 - 300 300
63 Loperamid Tablet 2 mg Tablet - - - -
73 Metronidazol tablet 250 mg Tablet - 500 500 300
74 Metronidazol tablet 500 mg Tablet - 300 300 200
80 Nipedipin 10 mg Tablet - 100 100 100
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 - 1,000 -
110 Simvastatin Tablet - - - -
111 Siprofloksasin Tablet 500 mg Tablet - 600 600 500
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 2,000 - 2,000 1,000
117 Vitamin B Kompleks tablet Tablet - - - -
118 Zink Tablet 20 mg Tablet 3,000 - 3,000 1,000

121 Diazepam 2 mg Tablet - 200 200 -
125 Fenobarbital 30 mg Tablet - 200 200 -
149 Obat Batuk Hitam (OBH) Botol - - - -

167 Etanol 70%-200 ml Botol - 20 20 15
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - 10 10 10
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 10 10 10
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - 10 10 10
197 Asiklovir Krim Tube - - - -
202 Hidrokortison Krim 2,5% Tube 34 - 34 20
209 Mikonazol Krim Tube - 24 24 24
214 Salisil Bedak 2% Box - 10 10 10
226 Infuset Dewasa Pcs - - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - - - -
243 Masker Pcs - - - -
246 Sarung Tangan Pcs - - - -
OBAT GIGI
253 Alloy Botol -
254 Caviton Box -
258 Flour Tablet -
SERUM
REAGEN
305
306
307
308
309
310
311
312

BAYAR / UMUM
SOSIAL (BPJS)

433 0 167 0
433 0 167 0
JUMLAH TOTAL


NIP. NIP. NIP. 19660811 19870
MAS

DINKES KAB
UPTD FARMASI
PUSKESMAS
APRIL 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

MEI 2015 Lembar Kuning : Arsip
PEMBERIAN
8 9 10 11 12 13 14 15 16
- -
- -
100 583 500
- - 500
- 583 -
- - -
- - 500
- - -
1,000 2,333 1,000
400 - -
- - -
- 933 900
- 2,333 2,500
- - -
- 1,167 2,000
- -
- -
- -
100 583 500
- -
100 117 200
100 467 400
- -
- - -
- -
- - -
400 117 -
- - -
- - -
100 - -
200 233 -
- -
- -
- -
- -
- -
- -
200 350 300
- 467 400
- 583 1,000
- - 800
- - -
2,000 - -
- - 500
- 350 1,000
- - -
- - -
- - -
- - -
- - -
- 1,167 1,000
200 1,050 800
300 1,167 800
- -
- - 800
50 - -
- - -
- - 500
1,000 - -
- 350 300
- -
- -
- - -
- - 500
- - 800
- - 800
- - -
- - -
- - 800
- - 800
- - 800
- - -
200 350 -
100 233 300
- - -
- - 1,000
- - -
- - -
- - -
- 117 600
- - -
- - 1,000
- - 500
- - -
150 140 240
1,000 3,500 1,000
- - 500
- -
- - 500
1,000 - -
- - 800
- - 800
1,000 1,167 -
- - -
- - -
100 700 500
- -
- -
- -
- -
- -
- - 1,000
- -
- - 500
- - 500
- - 1,000
- - 500
- - -
- - 800
- - 600
100 583 600
1,000 1,167 -
2,000 - -
300 - -
- 1,167 2,000
- - 500
- - 800
2,000 1,167 -
- -
- - -
200 - -
- -
- - -
- - -
200 - -
- -
- -
- -
- -
- 117 500
- -
- -
- -
- -
- -
- 23 50
- 117 100
- -
- 117 100
- - -
- - -
- - -
- - 100
- - 100
- - -
- - 50
- - 50
- - 100
- - 100
- - -
100 93 100
- -
- -
- -
- -
- -
- - -
- -
- -
- -
- -
- -
- - -
- -
- -
- - -
5 18 20
- -
- -
- -
- -
- -
- -
- 12 5
- -
30 23 10
- - -
- -
- -
- -
- -
- 12 5
- -
- - 50
- - -
- - 20
- -
- -
- 117 100
- -
- 12 -
- - -
- -
- -
- -
- -
- - 48
- - 48
- -
- - -
- - -
14 23 24
- - 48
- - -
- - 48
- - 48
- - 48
- -
- 28 24
- -
- -
- -
- -
- 12 10
- -
- - 15
- - -
- - 300
- - 200
- - -
- - 10
- -
- -
- -
- -
- - 50
- 23 20
- 23 20
- 23 20
- 23 20
- -
- -
- -
- -
- -
- -
- - -
- - 20
- -
- - 10
- - 10
- - 10
- - 100
- -
- 6 6
- - 100
- - -
- - 10
- - -
- - -
- - -
- -
- -
- -
- -
- 4 3
- -
- -
- - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

(BPJS) JUMLAH TOTAL
(JAMKESDA)
0 98 0 698 0
0 98 0 698 0
Subang, 12 MEI 2015


NIP. 19660811 198703 2 005 NIP.19911125 201101 1 001
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : MEI 2015
PERMINTAAN BULAN / PERIODE : JUNI 2015


1 2 3 4 5 6 7
3 Alopurinol tablet 100 mg Tablet 100 - 100 100
5 Aminofilin Tablet 200 mg Tablet - - - -
10 Amoksisilin Kapsul 250 mg Tablet 400 - 400 200
12 Antalgin(Metampiron) Tablet 500 mg Tablet - 900 900 800
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet - - - -
21 Asiklovir 400 mg Tablet 100 200 300 300
22 Deksametason Tablet 0,5 mg Tablet 100 400 500 200
30 Eritromisin kapsul 500 mg Tablet 100 - 100 100
31 Etambutol Hcl tablet 500 mg Tablet - 200 200 200
39 Glibenklamid tablet 5 mg Tablet - 400 400 100
40 Gliseril Gyayakolat tablet 100 mg Tablet - 1,000 1,000 1,000
43 Hidroklortiazid (HCT) tablet 25 mg Tablet 2,000 - 2,000 1,000
53 Kaptopril 25 mg Tablet 300 800 1,100 600
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet 1,000 - 1,000 1,000
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet - 300 300 100
86 Parasetamol tablet 500 mg Tablet 1,000 1,000 2,000 2,000
87 Parasetamol tablet 100 mg Tablet - 500 500 -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 - 1,000 1,000
96 Ranitidin 150 mg Tablet 100 - 100 100
106 Sefadroksil 500 mg Tablet - 1,000 1,000 900
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet 1,000 - 1,000 1,000
117 Vitamin B Kompleks tablet Tablet - 800 800 800

121 Diazepam 2 mg Tablet - 200 200 100
125 Fenobarbital 30 mg Tablet - 200 200 100
130 Metilergometrin 0,125 mg Tablet - 200 200 200
131 Metilergometrin Inj Ampul - - - -
136 Ambroksol Sirup Botol - - - -
139 Antasida Suspensi Botol - - - -
142 Eritromisin Sirup Sachet - - - -
149 Obat Batuk Hitam (OBH) Botol - - - -

167 Etanol 70%-200 ml Botol 5 20 25 20
176 Lidokain Inj Ampul 30 10 40 40
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 10 10 10
197 Asiklovir Krim Tube - 25 25 25
202 Hidrokortison Krim 2,5% Tube 14 - 14 -
209 Mikonazol Krim Tube - - - -
OBAT GIGI
253 Alloy Botol -
254 Caviton Box -
258 Flour Tablet -
SERUM
REAGEN
305
306
307
308
309
310
311
312

BAYAR / UMUM
SOSIAL (BPJS)

217 0 512 0
217 0 512 0
JUMLAH TOTAL

Kepala Dinas Kesehatan Kabupaten Subang Kepala UPTD Farmasi Kepala Puskesma
……………………………………………………. ……………………………………………………. Sri Rohayati, SE, M

NIP. NIP. NIP. 19660811198
R PERMINTAAN OBAT (LPLPO)
MAS

DINKES KAB
UPTD FARMASI
PUSKESMAS
MEI 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

UNI 2015 Lembar Kuning : Arsip
PEMBERIAN
8 9 10 11 12 13 14 15 16
- -
- -
- 117 500
- - 500
- - -
- - -
- - 500
- - -
- 2,333 2,000
200 233 -
- - -
100 933 1,000
- 2,333 3,000
- - -
- - 2,000
- -
- -
- -
- 583 800
- -
- 350 500
300 233 -
- -
- - -
- -
- - -
300 117 -
- - -
- - -
- 117 500
- 233 -
- -
- -
- -
- -
- -
- -
200 350 200
300 117 -
- 1,167 2,000
- - 800
- - -
1,000 1,167 -
- - -
- 583 1,000
- - -
- - -
- - -
- - -
- - -
- 1,167 -
500 583 200
500 700 200
- -
- - 800
50 - -
- - -
- - 500
- 1,167 2,000
200 117 300
- -
- -
- - -
- - 500
- - 800
- - 800
- - -
- - -
- - 800
- - 800
- - 800
- - -
100 117 -
300 117 -
- - -
- - 1,000
- - -
- - -
- - -
- 117 600
- - -
- - 1,000
- - 500
- - -
- 455 420
- 2,333 2,000
500 - 500
- -
- - -
- 1,167 2,000
- - 800
- - 800
- 1,167 2,000
- - -
- - -
- 117 500
- -
- -
- -
- -
- -
- - 1,000
- -
- - 500
- - 500
100 1,050 1,000
- - 500
- - -
- - 800
- - 600
200 583 400
- 1,167 3,000
2,000 - -
300 - -
- 1,167 2,000
- - 500
- 933 1,000
2,000 - -
- -
- - -
100 117 -
- -
- - -
- - -
100 117 -
- -
- -
- -
- -
- 233 500
- - 100
- -
- -
- -
- -
- - 50
- 117 100
- -
- - 100
- - -
- - -
- - 100
- - 100
- - 100
- - 100
- - 50
- - 50
- - 100
- - 100
- - -
20 93 50
- - 100
- -
- -
- -
- -
- - -
- -
- -
- -
- -
- -
- - -
- -
- -
- - -
5 23 20
- -
- -
- -
- -
- -
- -
5 - -
- -
- 47 50
- - -
- - 2
- -
- -
- -
- 12 5
- -
- - 50
- - -
- - 20
- - 3
- -
- 117 100
- -
- - -
- - -
- -
- -
- -
- -
- 29 25
- - 48
- -
- - -
- - -
14 - 24
- - 48
- - -
- - 48
- - 48
- - 48
- -
- - 24
- -
- -
- -
- -
- 12 10
- -
- - 15
- - -
- - 300
- - 100
- - -
- - 10
- -
- -
- -
- -
- - 50
- 23 20
- 23 20
- 23 20
- 23 20
- -
- -
- -
- - -
- -
- -
- - -
- - 20
- -
- - 10
- - 10
- - 10
- - 100
- - 10
1 6 6
- - 100
- - -
- - 10
- - -
- - -
- - -
- -
- -
- -
- -
- 2 3
- -
- -
- - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

(BPJS) JUMLAH TOTAL
(JAMKESDA)
0 98 0 827 0
0 98 0 827 0
Subang, JUNI 2015


NIP. 19660811198702005 NIP.199111252011011001
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : JUNI 2015
PERMINTAAN BULAN / PERIODE : JULI 2015


1 2 3 4 5 6 7
3 Alopurinol tablet 100 mg Tablet - - - -
5 Aminofilin Tablet 200 mg Tablet - - - -
9 Amoksisilin 500 mg Tablet - 2,000 2,000 1,800
12 Antalgin(Metampiron) Tablet 500 mg Tablet 100 1,000 1,100 500
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet - 1,000 1,000 1,000
21 Asiklovir 400 mg Tablet - 500 500 400
22 Deksametason Tablet 0,5 mg Tablet 300 - 300 300
27 Domperidon Tablet 10 mg Tablet 300 - 300 -
31 Etambutol Hcl tablet 500 mg Tablet - - - -
39 Glibenklamid tablet 5 mg Tablet 300 - 300 200
40 Gliseril Gyayakolat tablet 100 mg Tablet - 1,000 1,000 1,000
45 Ibuprofen tablet 400 mg Tablet - 1,000 1,000 800
51 Kalsium Laktat Tablet 500 mg Tablet - - - -
52 Kaptopril 12,5 mg Tablet 500 200 700 500
53 Kaptopril 25 mg Tablet 500 200 700 600
55 Ketokonazol Tablet 200 mg Tablet - 200 200 200
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet - 1,000 1,000 1,000
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 200 300 500 300
85 Omeprazol Kapsul 20 mg Kapsul - 150 150 150
87 Parasetamol tablet 100 mg Tablet - 500 500 500
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet - 2,000 2,000 1,000
92 Piroksikam 20 mg Tablet - 100 100 100
93 Prednison tablet 5 mg Tablet - 1,000 1,000 1,000
96 Ranitidin 150 mg Tablet - 500 500 500
105 Salbutamol tablet 4 mg Tablet - 100 100 100
106 Sefadroksil 500 mg Tablet 100 500 600 600
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet - 3,000 3,000 -
117 Vitamin B Kompleks tablet Tablet - 1,000 1,000 1,000

121 Diazepam 2 mg Tablet 100 - 100 100
125 Fenobarbital 30 mg Tablet 100 - 100 100
130 Metilergometrin 0,125 mg Tablet 300 300 600 200
131 Metilergometrin Inj Ampul - 10 10 10
136 Ambroksol Sirup Botol - - - -
137 Amoksisilin Sirup Kering 125mg/ml Botol - - - -
142 Eritromisin Sirup Sachet - - - -
143 Ibuprofen Sirup Botol - 50 50 50
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - 50 50 50
149 Obat Batuk Hitam (OBH) Botol - 5 5 5
152 Sefadroksil Sirup Botol - 10 10 10

167 Etanol 70%-200 ml Botol 5 20 25 10
170 Garam Oralit 200 ml Sachet - - - -
178 Lisol, mengandung kresol tersabun 50% Botol 2 2
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 5 5 -
184 Oksitoksin Inj 10 IU/ml Ampul - 10 10 10
197 Asiklovir Krim Tube - 25 25 25
198 Betametason Krim 0,1% Tube - 25 25 -
202 Hidrokortison Krim 2,5% Tube 14 24 38 38
206 Kloramfenikol Tetes Mata 1% Botol - 10 10 10
207 Kloramfenikol Tetes Telinga 3% Tube - 10 10 10
209 Mikonazol Krim Tube - 24 24 -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - - -
OBAT GIGI
253 Alloy Botol -
254 Caviton Box -
258 Flour Tablet -
SERUM
REAGEN
305
306
307
308
309
310
311
312

BAYAR / UMUM
SOSIAL (BPJS)

220 0 553 0
220 0 553 0
JUMLAH TOTAL

Kepala Dinas Kesehatan Kabupaten Subang Kepala UPTD Farmasi Kepala Puskesma
……………………………………………………. ……………………………………………………. Sri Rohayati, SE, M

NIP. NIP. NIP. 19660811198
R PERMINTAAN OBAT (LPLPO)
MAS

DINKES KAB
UPTD FARMASI
PUSKESMAS
UNI 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

ULI 2015 Lembar Kuning : Arsip
PEMBERIAN
8 9 10 11 12 13 14 15 16
- -
- -
- - 500
- - 500
- - -
- - -
- - 500
- - -
200 2,100 2,000
200 - -
- - -
600 583 200
500 2,917 2,500
- - -
- 1,167 1,000
- -
- -
- -
- 583 800
- -
100 467 500
- 350 800
- -
- - -
- -
- - -
300 - -
- - -
- - -
- - -
- - -
- -
- -
- -
- -
- -
- -
100 350 300
100 233 500
- 1,167 2,000
- - 800
- - -
1,000 - -
- - -
200 933 1,000
- - -
- - -
- - -
- - -
- - -
- - -
200 583 500
100 700 500
- -
- 233 500
50 - -
- - -
- - 500
- 1,167 2,000
200 350 300
- -
- -
- - -
- - 500
- - 800
- - 800
- - -
- - -
- - 800
- - 800
- - 800
- - -
100 117 -
300 117 -
- - -
- - 1,000
- - -
- - -
- - -
- 233 500
- - -
- - 1,000
- - 500
- - -
- 175 420
- 2,333 2,000
- 583 500
- -
- - -
1,000 1,167 1,000
- - -
- 117 500
- 1,167 1,000
- - -
- - -
- 583 600
- -
- -
- -
- -
- -
- - 1,000
- -
- - 500
- 117 300
- 700 1,000
- - 500
- - -
- - 800
- - 600
100 583 500
3,000 - -
2,000 - -
300 - -
- 2,333 2,000
- - 500
- 1,167 1,000
2,000 - -
- -
- - -
- 117 100
- -
- - 10
- - -
- 117 -
- -
- -
- -
- -
400 233 -
- 12 20
- -
- -
- -
- -
- - 50
- - 150
- -
- 58 100
- - -
- - -
- - 100
- 58 50
- - 100
- 58 50
- - 50
- - 50
- - 100
- 6 50
- - -
- 58 100
- 12 50
- -
- -
- -
- -
- - -
- -
- -
- -
- -
- -
- - -
- -
- -
- - -
15 12 10
- -
- -
- - 600
- -
- -
- -
5 - -
- -
10 47 50
- - -
2 - -
- -
- -
- -
5 - -
- -
- 12 20
- - -
- - 20
- - 4
- -
- 117 100
- -
- - -
- - -
- -
- -
- -
- -
- 29 50
25 - -
- -
- - -
- - -
- 44 48
- - 48
- - -
- - 48
- 12 20
- 12 20
- -
24 - -
- -
- -
- - 24
- -
- 12 20
- -
- - 15
- - -
- - 300
- - 100
- - -
- - 10
- -
- -
- -
- -
- - 50
- 23 20
- 23 20
- 23 20
- 23 20
- -
- -
- -
- - -
- -
- -
- - -
- - 20
- -
- - 10
- - 10
- - 10
- - 100
- - 10
1 6 6
- - 100
- - -
- - 10
- - -
- - -
- - -
- -
- -
- -
- -
- 2 3
- -
- -
- - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

(BPJS) JUMLAH TOTAL
(JAMKESDA)
0 98 0 871 0
0 98 0 871 0
Subang, JUNI 2015


NIP. 19660811198702005 NIP.199111252011011001
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS

DINKES KAB
UPTD FARMASI
PUSKESMAS : MARIUK PUSKESMAS
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : JUNI 2015 Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi
PERMINTAAN BULAN / PERIODE : JULI 2015 Lembar Kuning : Arsip
PEMBERIAN
STOK PENERIMA PERSEDIA PEMAKAI STOK STOK PERMINT
No. NAMA OBAT SATUAN AWAL AN AN AN AKHIR OPT. AAN BS/APBN APBD I APBD II DAK BPJS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
3 Alopurinol tablet 100 mg Tablet - 500 500 500 - 583 500
4 Ambroksol Tablet 5 mg Tablet - - - - - - 500
5 Aminofilin Tablet 200 mg Tablet - - - - - - -
6 Amlodipin 10 mg Tablet - - - - - - -
7 Amlodipin 5 mg Tablet - 120 120 120 - 140 240
8 Amoksisilin + Asam Klavulanat 625 mg Tablet - - - - - - -
9 Amoksisilin 500 mg Tablet 200 2,000 2,200 1,500 700 1,750 1,500
10 Amoksisilin Kapsul 250 mg Tablet 200 - 200 - 200 - -
11 Ampisillin Kaplet 500 mg Tablet - - - - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet 600 200 800 500 300 583 300
13 Antasida DOEN Tablet 500 2,000 2,500 1,000 1,500 1,167 1,000
14 Antimigren DOEN Tablet - - - - - - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 1,000 300 700 350 -
19 Asam Mefenamat 500 mg Tablet - - - - - - 500
21 Asiklovir 400 mg Tablet 100 500 600 200 400 233 200
22 Deksametason Tablet 0,5 mg Tablet - 800 800 300 500 350 200
24 Digoksin tablet 0,25 mg Tablet - - - - - - -
25 Dimenhidrinat Tablet Tablet - - - -
26 Doksisiklin Hcl Kapsul 100 mg Tablet - - - -
27 Domperidon Tablet 10 mg Tablet 300 - 300 - 300 - -
28 Ekstrak Belladon tablet 10 mg Tablet - - - - - - 500
29 Eritromisin kapsul 250 mg Tablet - - - - -
30 Eritromisin kapsul 500 mg Tablet - - - - - - -
31 Etambutol Hcl tablet 500 mg Tablet - - - - - - -
38 Furosemid tablet 40 mg Tablet 100 300 400 200 200 233 100
39 Glibenklamid tablet 5 mg Tablet 100 500 600 200 400 233 200
40 Gliseril Gyayakolat tablet 100 mg Tablet - 2,000 2,000 1,000 1,000 1,167 1,000
41 Glucosamin 500 mg Tablet - - - - - - 800
42 Griseofulvin tablet 125 mg micronized Tablet - - - - - - 500
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - - - - - - -
44 Ibuprofen tablet 200 mg Tablet - - - - - - -
45 Ibuprofen tablet 400 mg Tablet 200 1,000 1,200 800 400 933 800
46 Isoniazid tablet 100 mg Tablet - - - - - - -
48 Isosorbid dinitrat talet sublingual 5 mg Tablet - - - -
49 Kalium Diklofenak tablet 25 mg Tablet - - - -
51 Kalsium Laktat Tablet 500 mg Tablet - - - - - - 1,000
52 Kaptopril 12,5 mg Tablet 200 300 500 500 - 583 600
53 Kaptopril 25 mg Tablet 100 500 600 600 - 700 600
55 Ketokonazol Tablet 200 mg Tablet - 200 200 200 - 233 500
56 Klindamisin 150 mg Tablet - - - - - - -
58 Kloramfenikol kapsul 250 mg Tablet - - - - - - -
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet - - - - - - 2,000
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 mg Tablet 200 300 500 100 400 117 200
62 Lansoprazol 30 mg Tablet - - - 500
63 Loperamid Tablet 2 mg Tablet - - - - - - -
64 Loratadin Tablet 2 mg Tablet - - - - - - 500
65 Meloksikam 15 mg Tablet - - - - - - -
66 Meloksikam 7,5 mg Tablet - - - - - - -
67 Membendazol tablet 100 mg Tablet - - - -
68 Metformin 500 mg Tablet - - - - - - -
69 Metformin 850 mg Tablet - - - 800
70 Metilprednisolon 4 mg Tablet - - - - - - 800
72 Metoklorpropamide Tablet Tablet - - - -
73 Metronidazol tablet 250 mg Tablet 100 - 100 - 100 - -
75 Multivitamin + Fe Tablet Tablet - - - - - - -
76 Multivitamin Tablet Tablet - - - - - - -
77 Natrium Bikarbonat tablet 500 mg Tablet - - - -
79 Natrium Diklofenak 50 mg Tablet - - - - - - -
80 Nipedipin 10 mg Tablet - 100 100 100 - 117 500
81 Nistatin tablet salut gula 500.000 IU/g Tablet - - - - - - -
82 Obat Batuk Flu Tablet Tablet - - - - - - 1,000
83 Obat Diare Tablet - - - - - - 500
84 Obat Spasmolitik Tablet - - - - - - -
85 Omeprazol Kapsul 20 mg Kapsul - 300 300 150 150 175 420
86 Parasetamol tablet 500 mg Tablet - 2,000 2,000 1,000 1,000 1,167 1,500
87 Parasetamol tablet 100 mg Tablet - 500 500 500 - 583 500
89 Pirazinamida Tablet 500 mg Tablet - - - - - - -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 2,000 3,000 2,000 1,000 2,333 -
91 Piroksikam 10 mg Tablet - - - - - - -
92 Piroksikam 20 mg Tablet - 100 100 100 - 117 500
93 Prednison tablet 5 mg Tablet - 1,000 1,000 1,000 - 1,167 1,000
94 Propanolol HCl tablet 40 mg Tablet - - - -
95 Propiltiourasil tablet 100 mg Tablet - - - -
96 Ranitidin 150 mg Tablet - 500 500 500 - 583 600
102 Rifampisin kapsul 450 mg Tablet - - - - - - -
104 Salbutamol tablet 2 mg Tablet - - - - - - 500
105 Salbutamol tablet 4 mg Tablet - 100 100 100 - 117 300
106 Sefadroksil 500 mg Tablet - 1,000 1,000 700 300 817 800
107 Sefiksim 100 mg Tablet - - - - - - 500
108 Setirizin Tablet - - - - - - -
109 Simetidin Tablet 200 mg Tablet - - - - - - 800
110 Simvastatin Tablet - - - - - - 600
111 Siprofloksasin Tablet 500 mg Tablet 100 500 600 600 - 700 700
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet - 3,000 3,000 - 3,000 - -
113 Tetrasiklin Kapsul 250 mg Tablet 2,000 - 2,000 - 2,000 - -
114 Tetrasiklin Kapsul 500 mg Tablet 300 - 300 - 300 - -
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet - 2,000 2,000 1,000 1,000 1,167 -
116 Tiamphenikol 500 mg Tablet - - - - - - 500
117 Vitamin B Kompleks tablet Tablet - 1,000 1,000 1,000 - 1,167 1,000
118 Zink Tablet 20 mg Tablet 2,000 - 2,000 - 2,000 - -
120 Dekstrometorfan 15 mg Tablet - - - - - - -
121 Diazepam 2 mg Tablet - 100 100 100 - 117 -
123 Diazepam Inj Ampul - - - - - - -
124 Efedrin 0,25 mg Tablet - - - - - - -
125 Fenobarbital 30 mg Tablet - - - - - - -
130 Metilergometrin 0,125 mg Tablet 200 - 200 200 - 233 -
131 Metilergometrin Inj Ampul - 10 10 10 - 12 20
136 Ambroksol Sirup Botol - - - - - - 50
137 Amoksisilin Sirup Kering 125mg/ml Botol - 60 60 60 - 70 100
139 Antasida Suspensi Botol - 50 50 50 - 58 100
140 Dekstrometorfan sirup 10 mg/5 ml Botol - - - - - - -
141 Domperidon Sirup Botol - - - -
142 Eritromisin Sirup Sachet - 50 50 - 50 - -
143 Ibuprofen Sirup Botol - 30 30 10 20 12 10
144 Kloramfenikol Suspensi Botol - - - - - - 100
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg/5 ml Botol - 50 50 20 30 23 10
146 Multivitamin Drop Botol - - - - - - 50
147 Multivitamin Sirup Botol - - - - - - 50
148 Obat Batuk Flu Sirup Botol - - - - - - 100
149 Obat Batuk Hitam (OBH) Botol - 5 5 5 - 6 10
150 Parasetamol Drop Botol - - - - - - -
151 Parasetamol Sirup 120 mg/5 ml Botol - 100 100 50 50 58 50
152 Sefadroksil Sirup Botol - 10 10 10 - 12 50

157 Antalgin Inj 250 mg/ml Ampul - - - - - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - - - - - - -
165 Efinefrin HCl/Bitartrat (Adrenalin) Inj 0,1% Ampul - - - 10
166 Etakridin (Rivanol) 0,1% Botol - - - - - - 3
167 Etanol 70%-200 ml Botol 15 10 25 20 5 23 10
170 Garam Oralit 200 ml Sachet - 600 600 - 600 - -
173 Glukosa Larutan Infus 10% Steril-500 ml Labu - - - -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - - - - - - 20
176 Lidokain Inj Ampul 10 50 60 20 40 23 10
177 Lidokain Inj Komp : Lidokain % + Efinefrin 1:80000 Ampul - - - - - - -
178 Lisol, mengandung kresol tersabun 50% Botol 2 2 2 - -
180 Magnesium Sulfat Inj (IV) 40% Ampul - - - - - - 20
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 5 5 - 5 - -
184 Oksitoksin Inj 10 IU/ml Ampul - 10 10 10 - 12 20
185 Povidon Iodida 10%-1000 ml Botol - - - - - - -
186 Povidon Iodida 10%-30 ml Botol - 5 5 5 - 6 10
187 Povidon Iodida 10%-300 ml Botol 4 4 4 - 5 5
189 Ringer Laktat Larutan Infus Steril Labu 80 80 80 - 93 100
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - - - - - - -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - - - - - -
Asering Larutan infus steril Labu 20 20 20 - 23 20
197 Asiklovir Krim Tube - 25 25 25 - 29 50
198 Betametason Krim 0,1% Tube - 25 25 - 25 - -
200 Gentamisin Salep Kulit 0,1% Tube - - - - - - -
201 Gentamisin Sulfat Tetes Mata 0,3% Botol - - - - - - -
202 Hidrokortison Krim 2,5% Tube 14 24 38 38 - 44 48
203 Ketokonazol Krim 2% Tube - - - - - - 48
204 Kloramfenikol Salep Kulit Tube - - - -
205 Kloramfenikol Salep Mata 1% Tube - 24 24 24 - 28 48
206 Kloramfenikol Tetes Mata 1% Botol - 5 5 5 - 6 10
207 Kloramfenikol Tetes Telinga 3% Tube - 3 3 3 - 4 10
209 Mikonazol Krim Tube - 24 24 - 24 - -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - - - - - 24
214 Salisil Bedak 2% Box - 20 20 10 10 12 -
216 Tetrakain 0,5% Tetes Mata Botol - - - 15
217 Alat Suntik Sekali Pakai 1 ml Pcs - - - - - - -
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - - 100
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - 10 10 5 5 6 -
226 Infuset Dewasa Pcs - 50 50 50 - 58 50
227 IV Catether/Abocat No. 18 Pcs - 20 20 20 - 23 20
228 IV Catether/Abocat No. 20 Pcs - - - - - - 20
234 Jarum Hecting Otot GT 9 Lusin - - - -
237 Kapas Pembalut/Absorben 250 mg Rol - - - - - - -
238 Kasa Steril 16x16 Rol - - - - - - 20
240 Kasa Pembalut 2x80 Rol - - - - - - 10
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - - - - - 10
242 Kasa Pembalut Hidrofil 4 x 15 Rol - - - - - - 10
243 Masker Pcs - 100 100 100 - 117 100
244 Needle G No. 23 Pcs - - - 10
245 Plester 5 yard x 2 inch Rol - 6 6 5 1 6 6
246 Sarung Tangan Pcs - - - - - - 100
247 Sarung Tangan Steril Pasang - - - - - - -
248 Silk (Benang Bedah Sutera) Pcs - - - - - - 10
249 Urine Bag Pcs - - - - - - -
250 Umbilikal Klem Pcs - - - -
251 Wing Needle No. 27 Pcs - - - -
OBAT GIGI
256 Etil Klorida Semprot Botol - 1 1 1 - 1 3
259 Glass Ionomer Set - - - - - - -
SERUM
REAGEN
305
306
307
308
309
310
311
312
BADAN PENYELENGGARA JAMINAN JAMINAN KESEHATAN DAERAH
BAYAR / UMUM
SOSIAL (BPJS) JUMLAH TOTAL
(JAMKESDA)

RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP
122 0 608 0 0 0 730 0

JUMLAH TOTAL
Subang, JULI
Mengetahui/Menyetujui : Yang Menyerahkan : Yang Meminta : Yang Menerima :

Kepala Dinas Kesehatan Kabupaten Subang Kepala UPTD Farmasi Kepala Puskesmas Petugas Puskesmas
……………………………………………………. ……………………………………………………. Sri Rohayati, SE, MM Rizki Iman Nurahman

NIP. NIP. NIP. 19660811198702005 NIP.199111252011011001
GGAL
JUMLAH
16
T INAP
2015
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPL
PUSKESMAS
PUSKESMAS : MARIUK
KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : OKTOBER 2015
PERMINTAAN BULAN / PERIODE : NOVEMBER 2015

STOK PENERIMA PERSEDIA PEMAKAI STOK STOK

No. NAMA OBAT SATUAN AWAL AN AN AN AKHIR OPT.
1 2 3 4 5 6 7 8 9
5 Aminofilin Tablet 200 mg Tablet - - - - - -
7 Amlodipin 5 mg Tablet - 120 120 120 - 140
9 Amoksisilin 500 mg Tablet - - - - - -
10 Amoksisilin Kapsul 250 mg Tablet - - - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet - - - - - -
13 Antasida DOEN Tablet - - - - - -
14 Antimigren DOEN Tablet - - - - - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 1,000 300 700 350
19 Asam Mefenamat 500 mg Tablet - - - - - -
21 Asiklovir 400 mg Tablet - - - - - -
22 Deksametason Tablet 0,5 mg Tablet - 500 500 300 200 350
27 Domperidon Tablet 10 mg Tablet 300 - 300 - 300 -
30 Eritromisin kapsul 500 mg Tablet - - - - - -
31 Etambutol Hcl tablet 500 mg Tablet - - - - - -
38 Furosemid tablet 40 mg Tablet 100 300 400 200 200 233
39 Glibenklamid tablet 5 mg Tablet - - - - - -
40 Gliseril Gyayakolat tablet 100 mg Tablet - 2,000 2,000 1,000 1,000 1,167
42 Griseofulvin tablet 125 mg micronized Tablet - - - - - -
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - - - - - -
44 Ibuprofen tablet 200 mg Tablet - - - - - -
45 Ibuprofen tablet 400 mg Tablet 200 1,000 1,200 800 400 933
46 Isoniazid tablet 100 mg Tablet - - - - - -
51 Kalsium Laktat Tablet 500 mg Tablet - - - - - -
52 Kaptopril 12,5 mg Tablet 200 300 500 500 - 583
53 Kaptopril 25 mg Tablet 100 500 600 600 - 700
55 Ketokonazol Tablet 200 mg Tablet - 200 200 200 - 233
58 Kloramfenikol kapsul 250 mg Tablet - - - - - -
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet - - - - - -
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 Tablet 200 300 500 100 400 117
61 Kotrimoksazol Tablet Ped : Sulf 100 + Trim 20 Tablet - - -
63 Loperamid Tablet 2 mg Tablet - - - - - -
64 Loratadin Tablet 2 mg Tablet - - - - - -
73 Metronidazol tablet 250 mg Tablet 100 - 100 - 100 -
74 Metronidazol tablet 500 mg Tablet 300 - 300 - 300 -
80 Nipedipin 10 mg Tablet - 100 100 100 - 117
81 Nistatin tablet salut gula 500.000 IU/g Tablet - - - - - -
85 Omeprazol Kapsul 20 mg Kapsul - 300 300 150 150 175
86 Parasetamol tablet 500 mg Tablet - 2,000 2,000 1,000 1,000 1,167
87 Parasetamol tablet 100 mg Tablet - 500 500 500 - 583
89 Pirazinamida Tablet 500 mg Tablet - - - - - -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 2,000 3,000 2,000 1,000 2,333
92 Piroksikam 20 mg Tablet - 100 100 100 - 117
93 Prednison tablet 5 mg Tablet - 1,000 1,000 - 1,000 -
96 Ranitidin 150 mg Tablet - 500 500 500 - 583
105 Salbutamol tablet 4 mg Tablet - 100 100 100 - 117
106 Sefadroksil 500 mg Tablet - 1,000 1,000 1,000 - 1,167
110 Simvastatin Tablet - - - - - -
111 Siprofloksasin Tablet 500 mg Tablet 100 500 600 600 - 700
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet - 3,000 3,000 - 3,000 -
113 Tetrasiklin Kapsul 250 mg Tablet 2,000 - 2,000 - 2,000 -
114 Tetrasiklin Kapsul 500 mg Tablet 300 - 300 - 300 -
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet - 2,000 2,000 1,000 1,000 1,167
117 Vitamin B Kompleks tablet Tablet - 1,000 1,000 1,000 - 1,167
118 Zink Tablet 20 mg Tablet 2,000 - 2,000 2,000 - 2,333

121 Diazepam 2 mg Tablet - 100 100 100 - 117
123 Diazepam Inj Ampul - - - - - -
125 Fenobarbital 30 mg Tablet - - - - - -
130 Metilergometrin 0,125 mg Tablet 200 - 200 200 - 233
131 Metilergometrin Inj Ampul - 10 10 10 - 12
136 Ambroksol Sirup Botol - - - - - -
137 Amoksisilin Sirup Kering 125mg/ml Botol - 60 60 60 - 70
142 Eritromisin Sirup Sachet - - - - - -
143 Ibuprofen Sirup Botol - - - - - -
144 Kloramfenikol Suspensi Botol - - - - - -
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg Botol - - - - - -
149 Obat Batuk Hitam (OBH) Botol - 5 5 5 - 6
151 Parasetamol Sirup 120 mg/5 ml Botol - 100 100 50 50 58
152 Sefadroksil Sirup Botol - 10 10 10 - 12

157 Antalgin Inj 250 mg/ml Ampul - - - - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - - - - - -
167 Etanol 70%-200 ml Botol 15 10 25 20 5 23
170 Garam Oralit 200 ml Sachet - - - - - -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - - - - - -
176 Lidokain Inj Ampul 10 50 60 20 40 23
178 Lisol, mengandung kresol tersabun 50% Botol 2 2 2 -
180 Magnesium Sulfat Inj (IV) 40% Ampul - - - - - -
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 5 5 - 5 -
184 Oksitoksin Inj 10 IU/ml Ampul - 10 10 10 - 12
186 Povidon Iodida 10%-30 ml Botol - 5 5 5 - 6
187 Povidon Iodida 10%-300 ml Botol 4 4 4 - 5
189 Ringer Laktat Larutan Infus Steril Labu 80 80 80 - 93
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - - - - - -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - - - - -
Asering Larutan infus steril Labu - - - - -
197 Asiklovir Krim Tube - 25 25 25 - 29
198 Betametason Krim 0,1% Tube - 25 25 - 25 -
200 Gentamisin Salep Kulit 0,1% Tube - - - - - -
202 Hidrokortison Krim 2,5% Tube 14 24 38 38 - 44
203 Ketokonazol Krim 2% Tube - - - - - -
205 Kloramfenikol Salep Mata 1% Tube - 24 24 24 - 28
206 Kloramfenikol Tetes Mata 1% Botol - 5 5 5 - 6
207 Kloramfenikol Tetes Telinga 3% Tube - 3 3 3 - 4
209 Mikonazol Krim Tube - 24 24 - 24 -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - - - - -
214 Salisil Bedak 2% Box - 20 20 10 10 12
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs - 10 10 5 5 6
226 Infuset Dewasa Pcs - 50 50 50 - 58
228 IV Catether/Abocat No. 20 Pcs - - - - - -
238 Kasa Steril 16x16 Rol - - - - - -
240 Kasa Pembalut 2x80 Rol - - - - - -
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - - - - -
242 Kasa Pembalut Hidrofil 4 x 15 Rol - - - - - -
243 Masker Pcs - 100 100 100 - 117
245 Plester 5 yard x 2 inch Rol - 6 6 5 1 6
246 Sarung Tangan Pcs - - - - - -
248 Silk (Benang Bedah Sutera) Pcs - - - - - -
249 Urine Bag Pcs - - - - - -
OBAT GIGI
259 Glass Ionomer Set - - - - - -
SERUM
REAGEN
305
306
307
308
309
310
311
312
BADAN PENYELENGGARA JAMINAN JAMINAN KESEHA

BAYAR / UMUM
SOSIAL (BPJS) (JAMKES

RAWAT JALANRAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN
121 0 608 0 0
121 0 608 0 0
JUMLAH TOTAL

Kepala Dinas Kesehatan Kabupaten Kepala UPTD Farmasi Kepala Puskesmas

NIP. NIP. NIP. 19660811198702005
NTAAN OBAT (LPLPO)

DINKES KAB
UPTD FARMASI
PUSKESMAS

PEMBERIAN
PERMINT JUMLAH
10 11 12 13 14 15 16
500
500
-
-
240
-
2,000
200
-
500
1,000
-
-
1,000
-
500
-
-
-
-
500
-
-
-
100
-
1,000
800
500
-
-
800
-
-
-
-
-
500
600
600
500
-
-
-
1,000
200
500
-
500
-
-
-
-
800
800
800
-
-
-
-
-
-
-
-
500
-
1,000
500
-
420
1,500
500
-
-
-
500
-
-
-
-
500
300
1,000
500
-
800
600
700
-
-
-
-
500
1,000
1,000
-
100
10
-
-
-
20
50
100
100
-
-
-
-
100
-
50
50
100
10
-
50
50
-
-
3
10
-
10
10
-
-
20
20
-
10
5
100
-
-
-
50
-
-
-
48
48
-
48
10
10
24
15
-
100
100
-
-
50
20
20
20
20
-
20
10
10
10
100
10
6
100
100
10
-
-
-
-
JAMINAN KESEHATAN DAERAH JUMLAH TOTAL
(JAMKESDA)
0 0 729 0
0 0 729 0
Subang, NOVEMBER 2015
Meminta : Yang Menerima :

Puskesmas Petugas Puskesmas
yati, SE, MM Rizki Iman Nurahman

60811198702005 NIP.199111252011011001
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS
DOKUME
DINKES KAB
UPTD FARMASI
PUSKESMAS : MARIUK PUSKESMAS
PELAPORAN BULAN / PERIODE : NOVEMBER Lembar Putih
KAB/KOTA : SUBANG 2015
Lembar Merah
PROVINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : DESEMBER 2015 Lembar Kuning
STOK PENERIM PERSEDIAA PEMAKAI STOK STOK PERMINT

No. NAMA OBAT SATUAN AWAL AAN N AN AKHIR OPT. AAN
1 2 3 4 5 6 7 8 9 10
3 Alopurinol tablet 100 mg Tablet - 500 500 500 - 583 500
4 Ambroksol Tablet 5 mg Tablet - - - - - - 500
5 Aminofilin Tablet 200 mg Tablet - - - - - - -
6 Amlodipin 10 mg Tablet - - - - - - -
7 Amlodipin 5 mg Tablet - 240 240 120 120 140 -
8 Amoksisilin + Asam Klavulanat 625 mg Tablet - - - - - - -
9 Amoksisilin 500 mg Tablet - - - - - - 2,000
10 Amoksisilin Kapsul 250 mg Tablet - - - - - - 200
11 Ampisillin Kaplet 500 mg Tablet - - - - - - -
12 Antalgin(Metampiron) Tablet 500 mg Tablet - 500 500 500 - 583 1,000
13 Antasida DOEN Tablet - 1,000 1,000 1,000 - 1,167 1,000
14 Antimigren DOEN Tablet - - - - - - -
15 Asam Askorbat (VIT C) Tablet 50 mg Tablet 1,000 - 1,000 500 500 583 -
19 Asam Mefenamat 500 mg Tablet - - - - - - 1,000
21 Asiklovir 400 mg Tablet - - - - - - -
22 Deksametason Tablet 0,5 mg Tablet 200 - 200 200 - 233 500
24 Digoksin tablet 0,25 mg Tablet - - - - - - -
25 Dimenhidrinat Tablet Tablet - - - -
26 Doksisiklin Hcl Kapsul 100 mg Tablet - - - -
27 Domperidon Tablet 10 mg Tablet 300 - 300 - 300 - -
28 Ekstrak Belladon tablet 10 mg Tablet - - - - - - 500
29 Eritromisin kapsul 250 mg Tablet - - - - -
30 Eritromisin kapsul 500 mg Tablet - - - - - - -
31 Etambutol Hcl tablet 500 mg Tablet - - - - - - -
38 Furosemid tablet 40 mg Tablet 200 100 300 100 200 117 -
39 Glibenklamid tablet 5 mg Tablet - - - - - - -
40 Gliseril Gyayakolat tablet 100 mg Tablet 1,000 1,000 2,000 2,000 - 2,333 1,000
41 Glucosamin 500 mg Tablet - - - - - - 800
42 Griseofulvin tablet 125 mg micronized Tablet - - - - - - -
43 Hidroklortiazid (HCT) tablet 25 mg Tablet - - - - - - -
44 Ibuprofen tablet 200 mg Tablet - - - - - - -
45 Ibuprofen tablet 400 mg Tablet - 400 400 400 - 467 1,000
46 Isoniazid tablet 100 mg Tablet - - - - - - -
48 Isosorbid dinitrat talet sublingual 5 mg Tablet - - - -
51 Kalsium Laktat Tablet 500 mg Tablet - - - - - - 500
52 Kaptopril 12,5 mg Tablet - 600 600 500 100 583 600
53 Kaptopril 25 mg Tablet - 600 600 600 - 700 600
55 Ketokonazol Tablet 200 mg Tablet - 200 200 200 - 233 500
58 Kloramfenikol kapsul 250 mg Tablet - - - - - - -
59 Klorfeniramin Maleat (CTM) tablet 4 mg Tablet - 1,000 1,000 400 600 467 -
60 Kotrimoksazol Tablet Dws : Sulf 400 + Trim 80 Tablet 200 300 500 100 400 117 200
61 Kotrimoksazol Tablet Ped : Sulf 100 + Trim 20 Tablet - - -
62 Lansoprazol 30 mg Tablet - - - 500
63 Loperamid Tablet 2 mg Tablet - - - - - - -
64 Loratadin Tablet 2 mg Tablet - - - - - - 500
65 Meloksikam 15 mg Tablet - - - - - - -
66 Meloksikam 7,5 mg Tablet - - - - - - -
67 Membendazol tablet 100 mg Tablet - - - -
68 Metformin 500 mg Tablet - - - - - - -
69 Metformin 850 mg Tablet - - - 800
72 Metoklorpropamide Tablet Tablet - - - -
74 Metronidazol tablet 500 mg Tablet 300 - 300 300 - 350 500
75 Multivitamin + Fe Tablet Tablet - - - - - - -
76 Multivitamin Tablet Tablet - - - - - - -
77 Natrium Bikarbonat tablet 500 mg Tablet - - - -
79 Natrium Diklofenak 50 mg Tablet - - - - - - -
80 Nipedipin 10 mg Tablet - 100 100 100 - 117 500
81 Nistatin tablet salut gula 500.000 IU/g Tablet - - - - - - -
82 Obat Batuk Flu Tablet Tablet - - - - - - 1,000
83 Obat Diare Tablet - - - - - - 500
84 Obat Spasmolitik Tablet - - - - - - -
85 Omeprazol Kapsul 20 mg Kapsul - 420 420 150 270 175 -
86 Parasetamol tablet 500 mg Tablet 1,000 1,500 2,500 2,500 - 2,917 2,000
87 Parasetamol tablet 100 mg Tablet - 500 500 300 200 350 -
89 Pirazinamida Tablet 500 mg Tablet - - - - - - -
90 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 1,000 - 1,000 - 1,000 - -
91 Piroksikam 10 mg Tablet - - - - - - -
92 Piroksikam 20 mg Tablet - 100 100 100 - 117 500
93 Prednison tablet 5 mg Tablet 1,000 - 1,000 - 1,000 - -
94 Propanolol HCl tablet 40 mg Tablet - - - -
95 Propiltiourasil tablet 100 mg Tablet - - - -
96 Ranitidin 150 mg Tablet - 500 500 500 - 583 500
102 Rifampisin kapsul 450 mg Tablet - - - - - - -
104 Salbutamol tablet 2 mg Tablet - - - - - - -
105 Salbutamol tablet 4 mg Tablet - 100 100 - 100 - -
106 Sefadroksil 500 mg Tablet - 1,000 1,000 800 200 933 1,000
107 Sefiksim 100 mg Tablet - - - - - - 500
108 Setirizin Tablet - - - - - - -
109 Simetidin Tablet 200 mg Tablet - - - - - - 800
110 Simvastatin Tablet - - - - - - 600
111 Siprofloksasin Tablet 500 mg Tablet - 200 200 200 - 233 500
112 Tablet Tambah darah kombinasi : Besi II Sulfat Tablet - 3,000 3,000 3,000 - -
113 Tetrasiklin Kapsul 250 mg Tablet 2,000 - 2,000 - 2,000 - -
114 Tetrasiklin Kapsul 500 mg Tablet 300 - 300 - 300 - -
115 Tiamin HCL (Vit B1) tablet 50 mg Tablet 2,000 - 2,000 1,000 1,000 1,167 -
116 Tiamphenikol 500 mg Tablet - - - - - - 500
117 Vitamin B Kompleks tablet Tablet - 1,000 1,000 1,000 - 1,167 1,000
118 Zink Tablet 20 mg Tablet 2,000 - 2,000 2,000 - 2,333 1,000

120 Dekstrometorfan 15 mg Tablet - - - - - - -
121 Diazepam 2 mg Tablet - - - - - - -
122 Diazepam 5 mg Tablet - - - 200
123 Diazepam Inj Ampul - 10 10 10 - 12 10
124 Efedrin 0,25 mg Tablet - - - - - - -
125 Fenobarbital 30 mg Tablet - - - - - - -
130 Metilergometrin 0,125 mg Tablet 200 - 200 200 - 233 -
131 Metilergometrin Inj Ampul - 10 10 10 - 12 20
136 Ambroksol Sirup Botol - - - - - - 50
137 Amoksisilin Sirup Kering 125mg/ml Botol - 60 60 60 - 70 100
139 Antasida Suspensi Botol - 50 50 50 - 58 100
140 Dekstrometorfan sirup 10 mg/5 ml Botol - - - - - - -
141 Domperidon Sirup Botol - - - -
142 Eritromisin Sirup Sachet - - - - - - -
143 Ibuprofen Sirup Botol - - - - - - -
144 Kloramfenikol Suspensi Botol - - - - - - -
145 Kotrimoksazol Suspensi : Sulf 200 + Trim 40 mg Botol - - - - - - -
146 Multivitamin Drop Botol - - - - - - 50
147 Multivitamin Sirup Botol - - - - - - 50
148 Obat Batuk Flu Sirup Botol - - - - - - -
149 Obat Batuk Hitam (OBH) Botol - 5 5 5 - 6 10
150 Parasetamol Drop Botol - - - - - - -
151 Parasetamol Sirup 120 mg/5 ml Botol - 100 100 50 50 58 50
152 Sefadroksil Sirup Botol - 10 10 10 - 12 60

157 Antalgin Inj 250 mg/ml Ampul - - - - - - -
163 Dekstran 70-Larutan Infus 6% Steril-500 ml Botol - - - - - - -
165 Efinefrin HCl/Bitartrat (Adrenalin) Inj 0,1% Ampul - - - -
166 Etakridin (Rivanol) 0,1% Botol - - - - - - -
167 Etanol 70%-200 ml Botol 15 10 25 20 5 23 10
170 Garam Oralit 200 ml Sachet - - - - - - -
173 Glukosa Larutan Infus 10% Steril-500 ml Labu - - - -
174 Glukosa Larutan Infus 5% Steril-500 ml Labu - - - - - - 20
176 Lidokain Inj Ampul 10 50 60 20 40 23 10
177 Lidokain Inj Komp : Lidokain % + Efinefrin 1:80 Ampul - - - - - - -
178 Lisol, mengandung kresol tersabun 50% Botol 2 2 2 - -
180 Magnesium Sulfat Inj (IV) 40% Ampul - - - - - - 20
182 Natrium Klorida Lar. Infus 0.9% Steril Labu - 5 5 5 - 6 20
184 Oksitoksin Inj 10 IU/ml Ampul - 10 10 10 - 12 10
185 Povidon Iodida 10%-1000 ml Botol - - - - - - -
186 Povidon Iodida 10%-30 ml Botol - 5 5 5 - 6 10
187 Povidon Iodida 10%-300 ml Botol 4 4 4 - 5 5
189 Ringer Laktat Larutan Infus Steril Labu 100 100 100 - 117 60
191 Sianokonalamin (Vit B12) Inj 500 mcg/ml Ampul - - - - - - -
192 Thiamin HCl (Vit B1) Inj 100 mg/ml Ampul - - - - - - -
Labu - - - - -

197 Asiklovir Krim Tube - 25 25 25 - 29 24
198 Betametason Krim 0,1% Tube - 25 25 - 25 - -
200 Gentamisin Salep Kulit 0,1% Tube - - - - - - -
201 Gentamisin Sulfat Tetes Mata 0,3% Botol - - - - - - -
202 Hidrokortison Krim 2,5% Tube 14 24 38 38 - 44 -
203 Ketokonazol Krim 2% Tube - - - - - - -
204 Kloramfenikol Salep Kulit Tube - - - -
205 Kloramfenikol Salep Mata 1% Tube - 24 24 24 - 28 24
206 Kloramfenikol Tetes Mata 1% Botol - 5 5 5 - 6 10
207 Kloramfenikol Tetes Telinga 3% Tube - 3 3 3 - 4 10
208 Meloksikam Suppositoria Supp - - - -
209 Mikonazol Krim Tube - 24 24 - 24 - -
212 Oksitetrasiklin HCl Salep Kulit 3% Tube - - - - - - 24
214 Salisil Bedak 2% Box - 20 20 10 10 12 -
216 Tetrakain 0,5% Tetes Mata Botol - - - 15
218 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - - 100
219 Alat Suntik Sekali Pakai 5 ml Pcs - - - - - - 100
220 Alat Suntik Sekali Pakai 10 ml Pcs - - - - - - 100
221 Catgut/Benang Bedah No. 2/0-3/0 Pcs 5 - 5 5 - 6 -
226 Infuset Dewasa Pcs - 50 50 50 - 58 50
227 IV Catether/Abocat No. 18 Pcs - 20 20 20 - 23 20
234 Jarum Hecting Otot GT 9 Lusin - - - -
237 Kapas Pembalut/Absorben 250 mg Rol - - - - - - -
238 Kasa Steril 16x16 Rol - - - - - - 20
240 Kasa Pembalut 2x80 Rol - - - - - - 10
241 Kasa Pembalut Hidrofil 36 x 40 yard Rol - - - - - - 10
242 Kasa Pembalut Hidrofil 4 x 15 Rol - - - - - - 10
243 Masker Pcs - 100 100 100 - 117 100
244 Needle G No. 23 Pcs - - - 10
245 Plester 5 yard x 2 inch Rol - 6 6 5 1 6 6
246 Sarung Tangan Pcs - - - - - - 100
247 Sarung Tangan Steril Pasang - - - - - - 100
248 Silk (Benang Bedah Sutera) Pcs - - - - - - 10
249 Urine Bag Pcs - - - - - - -
250 Umbilikal Klem Pcs - - - -
251 Wing Needle No. 27 Pcs - - - -
OBAT GIGI
256 Etil Klorida Semprot Botol - 1 1 1 - 1 3
259 Glass Ionomer Set - - - - - - -
SERUM
REAGEN
305
306
307
308
309
310
311
312
BADAN PENYELENGGARA JAMINAN JAMINAN KESEHATAN

BAYAR / UMUM
SOSIAL (BPJS) (JAMKESDA)

RAWAT JALANRAWAT INAP RAWAT JALAN RAWAT INAP RAWAT JALAN
121 0 608 0 0
JUMLAH TOTAL

Kepala Dinas Kesehatan Kabupaten Kepala UPTD Farmasi Kepala Puskesmas
…………………………………… ……………………………………………………. Sri Rohayati, SE, MM

NIP. NIP. NIP. 19660811198702005
BAT (LPLPO)

DINKES KAB
UPTD FARMASI
PUSKESMAS
embar Putih : Dinkes Kab. Subang/UPTD Farmasi

embar Merah : Puskesmas
embar Kuning : Arsip
PEMBERIAN
JUMLAH
11 12 13 14 15 16
N KESEHATAN DAERAH JUMLAH TOTAL
(JAMKESDA)
RAWAT INAP RAWAT JALAN RAWAT INAP
0 729 0
Subang, DESEMBER 2015
Yang Menerima :
Petugas Puskesmas
Rizki Iman Nurahman

NIP.199111252011011001

Format LPLPO 2015 PKM MARIUK BLN Januari 2015

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Halaman 1

LAPORAN PEMAKAIAN OBAT TAHUN 2012

STOK AWAL PENERIMAA

STOK AWAL PENERIMAA

STOK AWAL PENERIMAA

STOK AWAL PENERIMAA

107 Forinokresol ( Pengganti TKF ) 10 ml Botol

STOK AWAL PENERIMAA

STOK AWAL PENERIMAA

177 Lidokain inj Komp : Lidokain %+ Efinep 1:8 Ampul

STOK AWAL PENERIMAA

STOK AWAL PENERIMAA

246 Ranitidin 150 mg Tablet

STOK AWAL PENERIMAA

268 Serum antibisa ular Polivalen inj 50 ml (SAB Vial

280 Temporary Stopping Fletcher(Fletcher) Set

STOK AWAL PENERIMAA

Subang, ……………………………. 20 ...

Mengetahui/Menyetujui : Pengelola Obat

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OB

KAB/KOTA : SUBANG PELAPORAN BULAN/PERIODE : JULI2014

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

PSIKOTROPIK, PREKURSOR, OBAT JIWA

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

OBAT LUAR (INJEKSI-LARUTAN)

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

OBAT LUAR (KRIM/SALEP-TETES MATA-TETES TELINGA-SALEP MATA-SALEP KULIT)

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

SATUAN STOK AWAL PENERIMAA PERSEDIAA PEMAKAIA STOK AKHIR

BADAN PENYELENGGARA JAMINAN SOSIAL

JUMLAH KUNJUNGAN RESEP

Mengetahui/Menyetujui : Yang Menyerahkan : Yang Meminta

……………………………………………………. ……………………………………………………. Sri Rohayati, SE,

TAAN OBAT (LPLPO)

DOKUMEN NOMOR TANGGAL

Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

JAMINAN KESEHATAN DAERAH JUMLAH TOTAL

RAWAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP

Subang, 15 AGUSTUS 2014

Meminta : Yang Menerima :

ayati, SE, MM Rizki Iman Nurahman

KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : DESEMBER 2014

PERMINTAAN BULAN / PERIODE : JANUARI 2015

PSIKOTROPIK, PREKURSOR, OBAT JIWA

OBAT LUAR (INJEKSI-LARUTAN)

OBAT LUAR (KRIM/SALEP-TETES MATA-TETES TELINGA-SALEP MATA-SALEP KULIT)

JUMLAH KUNJUNGAN RESEP

Mengetahui/Menyetujui : Yang Menyerahkan : Yang Meminta :

……………………………………………………. ……………………………………………………. Sri Rohayati, SE, MM

DOKUMEN NOMOR TANGGAL

Lembar Putih : Dinkes Kab. Subang/UPTD Farmasi

WAT JALAN RAWAT INAP RAWAT JALAN RAWAT INAP

Subang, 11 JANUARI 2014

, MM Rizki Iman Nurahman

KAB/KOTA : SUBANG PELAPORAN BULAN / PERIODE : JANUARI 2015

PERMINTAAN BULAN / PERIODE : FEBRUARI 2015

STOK PENERIMA PERSEDIAA PEMAKAIA