LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LPLPO)

SUB UNIT PELAYANAN : POLINDES ROWOTENGAH

PUSKESMAS : ROWOTENGAH BULAN : November
KECAMATAN : SUMBERBARU TAHUN : 2017
KABUPATEN : JEMBER MASUK TGL. : November 2017
PROPINSI : JAWA TIMUR

No. No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1 102 Acyclovir krim tube
2 103 Acyclovir tablet - 200 mg tablet
3 104 Acyclovir tablet - 400 mg tablet
4 106 Alat Suntik 10 ml set
5 107 Alat suntik sekali pakai 1 ml set
6 108 Alat suntik sekali pakai 2,5 ml set
7 109 Alat suntik sekali pakai 5 ml set
8 110 Albendazol tablet 400 mg tablet
9 112 Alkohol 70% 100 ml botol
10 115 Alopurinol tablet tablet
11 116 Alpara tablet
12 117 Ambroxol sirup 60 ml botol
13 118 Ambroxol tablet 30 mg tablet
14 120 Aminofilina tablet 200 mg tablet
15 122 Amlodipin 10 mg tablet
16 124 Amoksilin kaplet - 500 mg kaplet
17 125 Amoksilin kapsul - 250 mg kapsul
18 126 Amoksilin Sirup Kering botol
19 129 Antalgin tablet 500mg tablet
20 130 Antasi DOEN II Suspensi,Kombi botol
21 131 Antasida Doen tablet tablet
22 132 Anti Hemmoroid Suppositoria supp
23 133 Antibakteri DOEN (Basitrasin + Polimiksin) tube

Antifungi DOEN (As Benzoat 3%+As

24 134 pot
Salisilat 6%)
25 137 Aqua pro injeksi steril - 20 ml ampul
26 141 Asam Askorbat (vit C) tablet 50 mg tablet
27 143 Asam Mefenamat kaplet 500 mg kaplet
 No. No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
28 146 Aseptic Gel + Disp 500 ml botol
29 147 Asetosal tablet 100 mg tablet
30 149 Asetosal tablet 80 mg tablet
31 150 Atapulgit 630 mg tablet
37 208 Betametason krim tube
38 209 Betametason N crem tube
39 213 Bisoprolol tablet 5 mg tablet
40 301 Calcium Gluconas infus botol
41 302 Captopril tablet 25 mg tablet
42 304 Catgut Chrom 2/0 + jarum sachet
43 305 Catgut Chrom 3/0 + jarum sachet
44 306 Catgut Plain 2/0 + jarum sachet
45 307 Catgut Plain 3/0 + jarum sachet
46 312 Celemek buah
47 315 Chlorhexidine gluconat 0,2% / ASEPTAN botol
Chlorhexidine gluconat 4% 500 cc +
48 316 botol
dispenser / ONE SCROB
49 318 Clorin / One Clean botol

50 402 Daryan Tulle :Flamisetin Sulfat 10 x 10 cm lembar

51 404 Deksametason Injeksi 5mg/ml ampul

52 405 Deksametason tablet 0,5 mg tablet
53 406 Demacolin tablet tablet
54 417 Difenhidramina HCL injeksi 10 mg ampul
55 419 Doksisiklin kapsul 100 mg kapsul
56 504 Epinefrina HCL/Bitart injeksi 0.1% - l ml ampul
57 610 Fenoksimetil Penisilina tablet 500 mg tablet
58 611 Fenol Gliserol tetes telinga botol
59 612 Fitomenadion injeksi 10mg/ml ampul
60 613 Fitomenadion injeksi 2 mg/ml ampul
61 614 Fitomenadion tablet 10 mg tablet
62 701 Garam Oralit untuk 200 ml air kantong
63 705 Gentamycin salep kulit tube
64 706 Gentamycin salep mata tube
65 707 Gentamycin tetes mata botol
66 708 Gentian violet larutan 1% botol
67 713 Gliseril Guayakolat tablet 100 mg tablet
68 714 Gliserin 1 liter botol
 No. No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
69 725 Gynaecology gloves/ OBGYN set
70 810 Hidrokortison Krim 2,5% tube
71 901 Ibuprofen suspensi 100 mg/ 5ml botol
72 902 Ibuprofen tablet 200 mg tablet
73 903 Ibuprofen tablet 400 mg tablet
74 907 Infusion set dewasa set
75 908 Iodiol kapsul lunak kapsul
76 1104 Kalsium Laktat tablet 500mg. tablet
77 1105 Kapas pembalut abs 250 gram rol
78 1108 Kasa Hidrofil 16x16 box
79 1110 Kasa pembalut 2 m x 80 cm bungkus
80 1111 Kasa Pembalut 4x10 cm rol
81 1113 Kasa pembalut hidrofil 4mx15cm rol
82 1120 Kloramfenikol Salep Mata 1% tube
83 1122 Kloramfenikol tetes mata 0,5% - 5 ml botol
84 1123 Kloramfenikol tetes telinga 3% botol
85 1124 Klorfeniramina Maleat tablet 4mg tablet
86 1129 Kotrimoksazol sirup botol
87 1130 Kotrimoksazol tablet Adult tablet
88 1131 Kotrimoksazol tablet Pediatrik tablet
89 1216 Lidocain 2% injeksi ampul
90 1217 Lidokaina Comp. Injeksi 2% ampul
91 1222 Lytacur 60 ml botol
92 1301 Magnesium Sulfat injeksi 20% ampul
93 1302 Magnesium Sulfat injeksi 40% ampul
94 1303 Maltodextrin tablet / TABURIA tablet
95 1306 Masker Surgical ear loop'50 biji
96 1307 Masker Surgical Plus 3 Ply Plus Earloop biji
97 1308 Masker Surgical tie on'50 biji
98 1311 Medicut No. 18 biji
99 1312 Medicut No. 20 biji
100 1320 Metformin H Cl tablet 500 mg tablet

101 1324 Metilergometrina injeksi 0,2 mg/ml -1 ml ampul

102 1325 Metilergometrina Maleat tablet tablet

103 1326 Metoclopramide 5 mg tablet
104 1330 Metronidazol tablet 250 mg tablet
105 1331 Metronidazol tablet 500 mg tablet
106 1333 Miconazol 2% salep kulit tube
107 1334 Mineral mix sachet
 No. No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17

108 1401 Na ClO 5.,25 % dan CaOCl212 / BYCLIN botol

109 1408 Nelato Catether No. 12 set
110 1416 Nifedipin 200 mg tablet tablet
111 1510 OBH Tropica Exta Mentol 60 ml botol
112 1511 OBH Tropica Plus Anak Jeruk 60 ml botol
113 1512 OBH Tropica Plus Mentol 60 ml botol
114 1520 Oksitosina injeksi 10 IU/ml-1ml ampul
115 1603 Paracetamol Drop botol
116 1604 Parasetamol sirup 120 mg/5ml botol
117 1605 Parasetamol tablet 100 mg tablet
118 1606 Parasetamol tablet 500 mg tablet
119 1616 Pirantel Pamoat tablet 125 mg tablet
120 1617 Pirantel Susp 125mg / 5 ml botol
121 1618 Piridoksina HCL tablet 10mg tablet
122 1620 Planotest Strip strip
123 1623 Plester Kain Roll 1,25cm x 4,5m rol
124 1624 Plester Kain Roll 2,5cm x 4,5m rol
125 1625 PM-ASI Biskuit bungkus
126 1626 PMT Untuk BUMIL bungkus

127 1628 Polikresulen ( Metakresolsulfonat ) - 10 ml botol

128 1630 Prednison tablet 5 mg tablet

129 1634 Procurma Plus Syrup botol
130 1718 Retinol kap. lunak 100.000 IU kapsul
131 1719 Retinol kap. lunak 200.000 IU kapsul
132 1725 Ringer Laktat Larutan infus - 500 ml botol
Salep 2-4 DOEN (As.Salisilat 2%
133 1808 pot
+Belerang Endap 4%)
134 1809 Salisil Bedak 2% - 50 gram kotak
135 1810 Sarung Tangan Obgyn ( STERIL ) set
136 1811 Scabicid salep kulit tube
137 1820 Sianokobalamina (Vit B12) injeksi ampul
138 1826 Solvita sirup - 60 ml botol
139 1841 Sulfasetamida tetes mata 15% botol
 No. No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
140 1842 Surgical glove no. 6 set
141 1843 Surgical Glove No. 7 set
142 1844 Surgical Glove No. 7,5 set
143 1845 Surgical Glove No. 8 set
Tablet Tambah Darah (Besi II Sulfat)
144 1901 tablet
tab.300mg
145 1908 TES KEHAMILAN box
146 1911 Tetrasiklina HCl kapsul 500 mg kapsul
147 1915 Tiamina (Vit B1) tablet 100 mg tablet
148 1916 Tiamina (Vit B1) tablet 50 mg tablet
149 2002 Umbilical Cord biji
150 2003 Underpad biji
151 2201 Vitamin B Kompleks tablet tablet
152 2501 Yodium Povidon 10% - 30 ml botol
153 2502 Yodium Povidon 10% - 300 ml botol
154 2602 ZINC tablet 20 mg tablet
155 2603 Zircum KID sirup botol

LAIN-
UMUM BPJS JUMLAH
LAIN
KUNJUNGAN RESEP

Jember,
Kepala Puskesmas Yang menerima Yang melaporkan
Pengelola Obat Puskesmas

dr.Dina Nurul Agustina Hamilatul Imaniyah

NIP.198208222014122001
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)

SUB UNIT PELAYANAN : UGD

PUSKESMAS : ROWOTENGAH BULAN :
KECAMATAN : SUMBERBARU TAHUN : 2016
KABUPATEN : JEMBER MASUK TGL. :
PROPINSI : JAWA TIMUR

No. No. SATUA STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT PEMBERIAN
NAMA OBAT KET.
URUT KODE N AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1 106 Alat Suntik 10 ml set
2 107 Alat suntik sekali pakai 1 ml set
3 108 Alat suntik sekali pakai 2,5 ml set
4 109 Alat suntik sekali pakai 5 ml set
5 113 Alkohol 95 % botol
6 114 Alkohol Swab dos
7 115 Alopurinol tablet tablet
8 116 Alpara tablet
9 117 Ambroxol sirup 60 ml botol
10 118 Ambroxol tablet 30 mg tablet
11 121 Amitriptilina HCL tablet 25 mg tablet
12 122 Amlodipin 10 mg tablet
13 124 Amoksilin kaplet - 500 mg kaplet
14 125 Amoksilin kapsul - 250 mg kapsul
15 126 Amoksilin Sirup Kering botol
16 129 Antalgin tablet 500mg tablet
17 130 Antasi DOEN II Suspensi,Kombi botol
18 131 Antasida Doen tablet tablet
19 137 Aqua pro injeksi steril - 20 ml ampul
20 139 Aquadest steril - 500 ml botol
21 140 Aquagel Sterile Jely 82 gr tube
22 141 Asam Askorbat (vit C) tablet 50 mg tablet
23 143 Asam Mefenamat kaplet 500 mg kaplet
24 146 Aseptic Gel + Disp 500 ml botol
25 147 Asetosal tablet 100 mg tablet
26 149 Asetosal tablet 80 mg tablet
27 150 Atapulgit 630 mg tablet
28 151 Atropina Sulfat injeksi ampul
29 213 Bisoprolol tablet 5 mg tablet
30 214 Bist Mess No.24 set
31 215 Blood Lancet set
32 302 Captopril tablet 25 mg tablet
33 304 Catgut Chrom 2/0 + jarum sachet
34 305 Catgut Chrom 3/0 + jarum sachet
35 306 Catgut Plain 2/0 + jarum sachet
36 307 Catgut Plain 3/0 + jarum sachet
37 308 Cefadroxil kapsul 500 mg kapsul
38 312 Celemek buah
Chlorhexidine gluconat 0,2% /
39 315 botol
ASEPTAN
Chlorhexidine gluconat 4% 500 cc +
40 316 botol
dispenser / ONE SCROB
41 317 Cimetidin tablet 200 mg tablet
42 318 Clorin / One Clean botol
43 326 Cyprofloxacin kapsul 500 mg kapsul
Daryan Tulle :Flamisetin Sulfat 10 x
44 402 lembar
10 cm
45 403 Decullin tablet 30mg tablet
46 404 Deksametason Injeksi 5mg/ml ampul
47 405 Deksametason tablet 0,5 mg tablet
48 406 Demacolin tablet tablet
49 410 Dextral sirup botol
50 413 Diazepam Injeksi 5mg/ml-2ml ampul
51 417 Difenhidramina HCL injeksi 10 mg ampul
52 418 Digoksina tablet 0,25 mg tablet
53 419 Doksisiklin kapsul 100 mg kapsul
54 420 Domperidon tablet 10 mg tablet
55 421 Duk 140 x 180 cm pcs
56 422 Duk 50 x 60 cm pcs
57 423 Duk 90 x 125 cm pcs
58 424 Duk Lubang Bulat 50x60 cm pcs
59 425 Duk Lubang Bulat 60x90 cm pcs
60 426 Duk Lubang Bulat 90x125 cm pcs
Epinefrina HCL/Bitart injeksi 0.1% - l
61 504 ampul
ml
62 505 Erithromicin kaplet 500 mg kaplet
63 509 Etanol 70% - 1000 ml botol
64 513 Etil Klorida semprot botol
65 602 Feeding tube No. 10 set
66 603 Feeding tube No. 16 set
67 604 Feeding tube No. 5 set
68 605 Feeding tube No. 8 set
69 618 Folley Catheter No. 14 set
70 619 Folley Catheter No. 16 set
71 620 Folley Catheter No. 18 set
72 621 Formaten 25 mg tablet
73 622 Furosemida tablet 40 mg tablet
74 701 Garam Oralit untuk 200 ml air kantong
75 711 Glibenklamida tablet 5 mg tablet
76 713 Gliseril Guayakolat tablet 100 mg tablet
77 714 Gliserin 1 liter botol
78 716 Gluco DR strip
79 717 Gluco M strip isi 25 strip
80 719 Gludepatic tablet
81 808 Hidrogen Peroksida / H2O2 botol
82 901 Ibuprofen suspensi 100 mg/ 5ml botol
83 902 Ibuprofen tablet 200 mg tablet
84 903 Ibuprofen tablet 400 mg tablet
85 906 Infusion set anak set
86 907 Infusion set dewasa set
87 910 Isosorbid Dinitrat tablet 5 mg tablet
88 1001 Jarum Jahit Bedah No. 12 biji
89 1002 Jarum Jahit Bedah No. 13 biji
90 1003 Jarum Jahit Bedah No. 14 biji
91 1104 Kalsium Laktat tablet 500mg. tablet
92 1105 Kapas pembalut abs 250 gram rol
93 1108 Kasa Hidrofil 16x16 box
94 1109 Kasa kompres steril 40cm/40cm bungkus
95 1110 Kasa pembalut 2 m x 80 cm bungkus
96 1111 Kasa Pembalut 4x10 cm rol
97 1113 Kasa pembalut hidrofil 4mx15cm rol
98 1119 Kloramfenikol kapsul 250 mg kapsul
99 1121 Kloramfenikol sirup - 125 mg/ml -60ml botol
100 1124 Klorfeniramina Maleat tablet 4mg tablet
101 1129 Kotrimoksazol sirup botol
102 1130 Kotrimoksazol tablet Adult tablet
103 1131 Kotrimoksazol tablet Pediatrik tablet
104 1132 Kuinina Sulfat tablet tablet
105 1201 Lanzoprazol kapsul 30 mg kapsul
106 1215 Levofloksasin tablet 500 mg tablet
107 1216 Lidocain 2% injeksi ampul
108 1217 Lidokaina Comp. Injeksi 2% ampul
109 1218 Lisol - 1000 ml botol
110 1219 Loperamide tablet - 2mg tablet
111 1303 Maltodextrin tablet / TABURIA tablet
112 1304 Masker disposable biji
113 1305 Masker Oksigen Dewasa biji
114 1306 Masker Surgical ear loop'50 biji
115 1307 Masker Surgical Plus 3 Ply Plus Earlo biji
116 1308 Masker Surgical tie on'50 biji
117 1315 Meloksikam tablet 15 mg tablet
118 1316 Meloksikam tablet 7,5 mg tablet
119 1317 Metamizole / Norages injeksi 500mg ampul
120 1318 Metaneuron tablet tablet
121 1319 Metanol - 100 ml botol
122 1320 Metformin H Cl tablet 500 mg tablet
123 1321 Metformin HCL tablet 850mg tablet
124 1326 Metoclopramide 5 mg tablet
125 1327 Metoklopramid 10 mg tablet
126 1328 Metoklopramid Syrup 60 ml botol
127 1330 Metronidazol tablet 250 mg tablet
128 1331 Metronidazol tablet 500 mg tablet
129 1332 Meylon injeksi ampul
130 1334 Mineral mix sachet
Na ClO 5.,25 % dan CaOCl212 /
131 1401 botol
BYCLIN
132 1402 Na F Kristal botol
133 1406 Natrium Diklofenak 50 mg tablet
134 1407 Natrium Klorida larutan infus 0.9% botol
135 1408 Nelato Catether No. 12 set
136 1409 Nelato Catether No. 14 set
137 1410 Nelato Catether No. 16 set
138 1411 Nelato Catether No. 18 set
139 1412 Neo Kaominal sirup botol
140 1415 Neurosanbe 5000 tablet tablet
141 1416 Nifedipin 200 mg tablet tablet
142 1420 Nodiar tablet
143 1504 Obat Batuk Hitam cairan 100ml botol
144 1510 OBH Tropica Exta Mentol 60 ml botol
145 1511 OBH Tropica Plus Anak Jeruk 60 ml botol
146 1512 OBH Tropica Plus Mentol 60 ml botol
147 1521 Omeprazol kapsul kapsul
148 1522 Ondansetron tab 4 mg tablet
149 1602 Papaverine tablet 40 mg tablet
150 1603 Paracetamol Drop botol
151 1604 Parasetamol sirup 120 mg/5ml botol
152 1605 Parasetamol tablet 100 mg tablet
153 1606 Parasetamol tablet 500 mg tablet
154 1614 Piracetam 800 mg tablet tablet
155 1616 Pirantel Pamoat tablet 125 mg tablet
156 1618 Piridoksina HCL tablet 10mg tablet
157 1619 Piroxicam 20 mg kapsul
158 1621 Plester 5 yard x 2 inch rol
159 1622 Plester Flexible non woven 5 x 5 rol
160 1623 Plester Kain Roll 1,25cm x 4,5m rol
161 1624 Plester Kain Roll 2,5cm x 4,5m rol
Polikresulen ( Metakresolsulfonat ) -
162 1628 botol
10 ml
163 1634 Procurma Plus Syrup botol
164 1636 Propanolol HCL tablet 10 mg tablet
165 1637 Propanolol HCL tablet 40 mg tablet
166 1716 Renadinac 25 mg kaplet
167 1718 Retinol kap. lunak 100.000 IU kapsul
168 1719 Retinol kap. lunak 200.000 IU kapsul
169 1727 Rovital Tablet tablet
170 1801 Safe Glove Exam L set
171 1802 Safe Glove Exam M set
172 1803 Safe Glove Exam S set
173 1805 Sakaneuron tablet tablet
174 1806 Salbutamol 2 mg tablet
175 1807 Salbutamol 4 mg tablet
176 1820 Sianokobalamina (Vit B12) injeksi ampul
177 1822 Silk no 2/0, 24x13x60 cm sachet
178 1823 Silk no 3/0, 24x13x60 cm sachet
179 1825 Simvastatin tablet 10 mg tablet
180 1826 Solvita sirup - 60 ml botol
181 1827 Solvitral kaplet kaplet
182 1842 Surgical glove no. 6 set
183 1843 Surgical Glove No. 7 set
184 1844 Surgical Glove No. 7,5 set
185 1845 Surgical Glove No. 8 set
186 1911 Tetrasiklina HCl kapsul 500 mg kapsul
187 1912 Thiampenicol Sirup botol
188 1913 Thiamphenicol 500 mg kapsul
189 1915 Tiamina (Vit B1) tablet 100 mg tablet
190 1916 Tiamina (Vit B1) tablet 50 mg tablet
191 1921 Tramadol kapsul 50 mg tablet
192 1922 Transfusion set set
Trikresol Formalin (Forinokresol)
193 1926 botol
cairan - 10 ml
194 2004 Urine bag set
195 2102 Ventolin / Salbutamol Inhaler 0,5 % botol
Ventolin Nebules /Salbutamol Cairan
196 2103 ampul
2,5 mg
197 2201 Vitamin B Kompleks tablet tablet
198 2303 Wing Needle bayi no.25 biji
199 2402 Xylomidon inj vial
200 2501 Yodium Povidon 10% - 30 ml botol
201 2502 Yodium Povidon 10% - 300 ml botol
202 2602 ZINC tablet 20 mg tablet
203 2604 Zoralin tablet

LAIN-
UMUM BPJS JUMLAH
LAIN
KUNJUNGAN RESEP

Yang menerima Rowotengah, - - 2016

Kepala Puskesmas Rowotengah Pengelola Obat Puskesmas Yang melaporkan

dr.Dina Nurul Agustina Hamilatul Imaniyah ..................................

NIP.198208222014122001 NIP:198002112006042020
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)

SUB UNIT PELAYANAN : VK/KIA

PUSKESMAS : ROWOTENGAH BULAN :
KECAMATAN : SUMBERBARU TAHUN :
KABUPATEN : JEMBER MASUK TGL. :
PROPINSI : JAWA TIMUR

No. No. PEMBERIAN

STOK PENERIM PERSEDI PEMAKAI SISA STOK PERMINT
URU KOD NAMA OBAT SATUAN KET.
AWAL AAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
T E
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1 101 Acon Stik for Plano Test kotak
6 106 Alat Suntik 10 ml set
7 107 Alat suntik sekali pakai 1 ml set
8 108 Alat suntik sekali pakai 2,5 ml set
9 109 Alat suntik sekali pakai 5 ml set
13 113 Alkohol 95 % botol
14 114 Alkohol Swab dos
37 137 Aqua pro injeksi steril - 20 ml ampul
46 146 Aseptic Gel + Disp 500 ml botol
73 214 Bist Mess No.24 set
74 215 Blood Lancet set
80 301 Calcium Gluconas infus botol
83 304 Catgut Chrom 2/0 + jarum sachet
84 305 Catgut Chrom 3/0 + jarum sachet
85 306 Catgut Plain 2/0 + jarum sachet
86 307 Catgut Plain 3/0 + jarum sachet
91 312 Celemek buah
Chlorhexidine gluconat 0,2% /
94 315 botol
ASEPTAN
Chlorhexidine gluconat 4% 500
95 316 botol
cc + dispenser / ONE SCROB
109 404 Deksametason Injeksi 5mg/ml ampul
112 407 Depo Progestin Injeksi 3 bln vial
122 417 Difenhidramina HCL injeksi 10 m ampul
126 421 Duk 140 x 180 cm pcs
127 422 Duk 50 x 60 cm pcs
128 423 Duk 90 x 125 cm pcs
129 424 Duk Lubang Bulat 50x60 cm pcs
130 425 Duk Lubang Bulat 60x90 cm pcs
131 426 Duk Lubang Bulat 90x125 cm pcs
Epinefrina HCL/Bitart injeksi
135 504 ampul
0.1% - l ml
157 612
Fitomenadion injeksi 10mg/ml ampul
158 613
Fitomenadion injeksi 2 mg/ml ampul
163 618
Folley Catheter No. 14 set
164 619
Folley Catheter No. 16 set
165 620
Folley Catheter No. 18 set
182 714
Gliserin 1 liter botol
191 723
Glukosa lar. infus 5% steril botol
193 725
Gynaecology gloves/ OBGYN set
211 907
Infusion set dewasa set
216 1001
Jarum Jahit Bedah No. 12 biji
217 1002
Jarum Jahit Bedah No. 13 biji
218 1003
Jarum Jahit Bedah No. 14 biji
224 1105
Kapas pembalut abs 250 gram rol
227 1108
Kasa Hidrofil 16x16 box
228 1109
Kasa kompres steril 40cm/40cm bungkus
229 1110
Kasa pembalut 2 m x 80 cm bungkus
230 1111
Kasa Pembalut 4x10 cm rol
232 1113
Kasa pembalut hidrofil 4mx15cm rol
267 1216
Lidocain 2% injeksi ampul
268 1217
Lidokaina Comp. Injeksi 2% ampul
274 1301
Magnesium Sulfat injeksi 20% ampul
275 1302
Magnesium Sulfat injeksi 40% ampul
277 1304
Masker disposable biji
278 1305
Masker Oksigen Dewasa biji
284 1311
Medicut No. 18 biji
285 1312
Medicut No. 20 biji
286 1313
Medicut No. 22 biji
Metilergometrina injeksi 0,2
297 1324 ampul
mg/ml -1 ml
Na ClO 5.,25 % dan
311 1401 botol
CaOCl212 / BYCLIN
318 1408 Nelato Catether No. 12 set
319 1409 Nelato Catether No. 14 set
320 1410 Nelato Catether No. 16 set
321 1411 Nelato Catether No. 18 set
349 1515 Oksigen Gas dalam tabung - 1m tabung
350 1516 Oksigen Gas dalam tabung - 6m tabung
354 1520 Oksitosina injeksi 10 IU/ml-1ml ampul
370 1613 Pil Kontrasepsi (Microdiol) strip
377 1620 Planotest Strip strip
378 1621 Plester 5 yard x 2 inch rol
379 1622 Plester Flexible non woven 5 x 5 rol
380 1623 Plester Kain Roll 1,25cm x 4,5m rol
381 1624 Plester Kain Roll 2,5cm x 4,5m rol
420 1725 Ringer Laktat Larutan infus - 500 botol
423 1801 Safe Glove Exam L set
424 1802 Safe Glove Exam M set
425 1803 Safe Glove Exam S set
432 1810 Sarung Tangan Obgyn ( STERIL set
436 1814 Sepatu Tertutup pcs
442 1820 Sianokobalamina (Vit B12) injeks ampul
444 1822 Silk no 2/0, 24x13x60 cm sachet
445 1823 Silk no 3/0, 24x13x60 cm sachet
464 1842 Surgical glove no. 6 set
465 1843 Surgical Glove No. 7 set
466 1844 Surgical Glove No. 7,5 set
467 1845 Surgical Glove No. 8 set
476 1908 TES KEHAMILAN box
490 1922 Transfusion set set
496 2002 Umbilical Cord biji
497 2003 Underpad biji
498 2004 Urine bag set
506 2301 Washlap 15x20 pcs
508 2303 Wing Needle bayi no.25 biji
511 2501 Yodium Povidon 10% - 30 ml botol
512 2502 Yodium Povidon 10% - 300 ml botol

LAIN-
UMUM BPJS JUMLAH
LAIN
KUNJUNGAN RESEP

Jember, 05 Februari 2016

Mengetahui/menyetujui Yang menyerahkan Yang melaporkan/meminta Yang menerima

Kepala Gudang Farmasi Sie Penyimpanan & Penyaluran Kepala Puskesmas Pengelola Obat Puskesmas
Kabupaten Jember GFK Jember ……………………………………

dr.Dina Nurul Agustina Hamilatul Imaniyah

NIP. NIP. NIP.198208222014122001 NIP:198002112006042020
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)

SUB UNIT PELAYANAN : ZAAL

PUSKESMAS : ROWOTENGAH BULAN :
KECAMATAN : SUMBERBARU TAHUN :
KABUPATEN : JEMBER MASUK TGL. :
PROPINSI : JAWA TIMUR

No. No. PEMBERIAN

STOK PENERI PERSEDI PEMAKAI SISA STOK PERMINT
URU KOD NAMA OBAT SATUAN KET.
AWAL MAAN AAN AN STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
T E
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1 106 Alat Suntik 10 ml set
2 107 Alat suntik sekali pakai 1 ml set
3 108 Alat suntik sekali pakai 2,5 ml set 30 30 30 0
4 109 Alat suntik sekali pakai 5 ml set 90 90 30 60
5 113 Alkohol 95 % botol
6 114 Alkohol Swab dos -
7 139 Aquadest steril - 500 ml botol
8 146 Aseptic Gel + Disp 500 ml botol
9 151 Atropina Sulfat injeksi ampul 20 20 20
10 204 Benzatin Bensil Pen.inj 1,2 juta vial
11 205 Benzatin Bensil Pen.inj 2,4 juta vial
12 212 Bioneuro injeksi ampul
13 214 Bist Mess No.24 set
14 215 Blood Lancet set 90 90 20 70
15 216 Blood Lancet ( GEA ) set
16 220 Buscopan injeksi ampul
17 310 Cefotaxim injeksi vial 40 40 20 20
18 311 Ceftriaxone 1.Og inj Kering vial
19 312 Celemek buah
Chlorhexidine gluconat 0,2% /
20 315 botol
ASEPTAN
 Chlorhexidine gluconat 4%
21 316 500 cc + dispenser / ONE botol 1 1 1
22 318 SCROB
Clorin / One Clean botol
23 404 Deksametason Injeksi 5mg/ml ampul 40 40 20 20
24 411 Dextran infus - 500 ml botol
25 413 Diazepam Injeksi 5mg/ml-2ml ampul 10 10 5 15
26 417 Difenhidramina HCL injeksi 10 ampul 80 80 30 50
27 501 EDTA botol
Epinefrina HCL/Bitart injeksi
28 504 ampul 10 10 10
0.1% - l ml
29 509 Etanol 70% - 1000 ml botol
30 513 Etil Klorida semprot botol
31 602 Feeding tube No. 10 set
32 603 Feeding tube No. 16 set
33 604 Feeding tube No. 5 set
34 605 Feeding tube No. 8 set
35 607 Fenobarbital Injeksi 50mg/ml-2m ampul 10 10 10
36 612 Fitomenadion injeksi 10mg/ml ampul
37 613 Fitomenadion injeksi 2 mg/ml ampul
38 618 Folley Catheter No. 14 set
39 619 Folley Catheter No. 16 set
40 620 Folley Catheter No. 18 set 3 3 1 2
41 623 Furosemide 10mg/ml injeksi ampul
42 704 Gentamycin injeksi 80 mg/2 ml vial 20 20 10 10
43 714 Gliserin 1 liter botol
44 716 Gluco DR strip
45 717 Gluco M strip isi 25 strip
46 718 Glucocard box
47 720 Glukosa infus 0,225% - 500 ml botol
48 721 Glukosa lar. infus 10% steril botol
49 722 Glukosa lar. infus 40% steril ampul 10 10 10
50 723 Glukosa lar. infus 5% steril botol - 20 20 10 10
51 906 Infusion set anak set 15 15 10 5
52 907 Infusion set dewasa set 20 20 20 0
53 1101 KA-EN 3B infus - 500 ml botol
54 1105 Kapas pembalut abs 250 gram rol
55 1107 Kasa 2 x 8 m rol
56 1108 Kasa Hidrofil 16x16 box
57 1109 Kasa kompres steril 40cm/40cm bungkus 1 1 1
58 1110 Kasa pembalut 2 m x 80 cm bungkus 1 1 1
59 1111 Kasa Pembalut 4x10 cm rol
60 1112 Kasa pembalut hidrofil 4mx 3cm rol
61 1113 Kasa pembalut hidrofil 4mx15c rol
62 1118 Kloramfenikol injeksi 1 gram vial
63 1125 Klorpromazina HCL inj 25 mg/m ampul 8 8 8
64 1216 Lidocain 2% injeksi ampul
65 1217 Lidokaina Comp. Injeksi 2% ampul
66 1218 Lisol - 1000 ml botol
67 1304 Masker disposable biji
68 1305 Masker Oksigen Dewasa biji 5 5 5
69 1306 Masker Surgical ear loop'50 biji
70 1307 Masker Surgical Plus 3 Ply Plus biji
71 1308 Masker Surgical tie on'50 biji
72 1311 Medicut No. 18 biji -
73 1312 Medicut No. 20 biji -
74 1313 Medicut No. 22 biji 5 5 5 0
75 1314 Medicut No. 24 biji 10 10 10 0
76 1317 Metamizole / Norages injeksi 5 ampul
77 1407 Natrium Klorida larutan infus 0 botol 60 60 40 20
78 1413 Neurobat injeksi ampul
79 1515 Oksigen Gas dalam tabung - 1 tabung 4 4 4
80 1516 Oksigen Gas dalam tabung - 6 tabung 2 2 2
81 1517 Oksitetrasiklina HCl injeksi 50 vial
82 1523 Ondansetron tab 4 mg/2 ml Inj - ampul
83 1601 Papaverine injeksi 40 mg/ml ampul
84 1610 Petidina HCL injeksi 50 mg/ml- ampul
85 1615 Piracetam inj 1 gram/5ml ampul
86 1621 Plester 5 yard x 2 inch rol
87 1622 Plester Flexible non woven 5 x rol -
88 1623 Plester Kain Roll 1,25cm x 4,5m rol
89 1624 Plester Kain Roll 2,5cm x 4,5m rol 1 1 1 0
90 1635 Prokaina Pen. G injeksi 3 juta I vial
91 1702 Ranitidin 50 mg / 2 ml Inj ampul
92 1723 Ringer Asetat infus - 500ml botol 20 20 10 10
Ringer Laktat + Glucose 5%
93 1724 botol
infus-500ml
94 1725 Ringer Laktat Larutan infus - 50 botol 20 140 160 140 20
95 1801 Safe Glove Exam L set -
96 1802 Safe Glove Exam M set
97 1803 Safe Glove Exam S set
98 1815 Serum Anti Bisa Ular injeksi (AB vial 1 1 1
99 1816 Serum Anti Dipteri injeksi 20.00 vial
100 1817 Serum Anti Tetanus injeksi 1.50 ampul 1 1 1
101 1818 Serum Anti Tetanus injeksi 20.0 vial
102 1820 Sianokobalamina (Vit B12) injeks ampul 20 20 10 10
103 1821 Sikzonoate injeksi 25 mg /ml ampul
104 1834 Stesolid Rectal 10 mg/2,5 ml tube -
105 1835 Stesolid Rectal 5 mg/2,5 ml tube 1 1 1
106 1838 Streptomisina Sulfat injeksi 1gr vial
107 1842 Surgical glove no. 6 set
108 1843 Surgical Glove No. 7 set
109 1844 Surgical Glove No. 7,5 set
110 1845 Surgical Glove No. 8 set
111 1917 Tiamina HCL injeksi 100mg/ml ampul 25 25 25
112 1920 Tramadol injiksi 50 mg/ml ampul
113 1922 Transfusion set set
114 2001 Ulsikur/ Ulcumet injeksi 200mg ampul
115 2004 Urine bag set 3 3 1 2
116 2102 Ventolin / Salbutamol Inhaler 0, botol 25 25 10 15
117 2302 Wida D5 1/2 NS botol 40 40 10 30
118 2303 Wing Needle bayi no.25 biji
119 2402 Xylomidon inj vial
120 2501 Yodium Povidon 10% - 30 ml botol
121 2502 Yodium Povidon 10% - 300 ml botol
aminophilin 5 5 5
aqua pro inj -
asam tranexamat 25 25 5 20
semilas hospital -

LAIN-
UMUM BPJS JUMLAH
LAIN
KUNJUNGAN RESEP

Rowotengah,
Mengetahui Yang menerima Yang melaporkan
Kepala Puskesmas Pengelola Obat Puskesmas

dr.Dina Nurul Agustina Hamilatul Imaniyah

NIP.198208222014122001 NIP:198002112006042020
 LAPORAN PEMAKAIAN DAN LEMBAR PERM
(LPLPO)

KODE PUSKESMAS : 030

PUSKESMAS : ROWOTENGAH
KECAMATAN : SUMBERBARU
KABUPATEN : JEMBER
PROPINSI : JAWA TIMUR

No. No. STOK PENERIM PERSEDI PEMAKAI

NAMA OBAT SATUAN
URUT KODE AWAL AAN AAN AN
1 2 3 4 5 6 7 ( 5+6 ) 8
1 101 Acon Stik for Plano Test kotak 238 - 238 15
2 102 Acyclovir krim tube 17 - 17 4
3 103 Acyclovir tablet - 200 mg tablet 100 - 100 -
4 104 Acyclovir tablet - 400 mg tablet 219 - 219 28
5 105 Air raksa dental use botol 1 - 1 -
6 106 Alat Suntik 10 ml set 55 - 55 5
7 107 Alat suntik sekali pakai 1 ml set 269 - 269 60
8 108 Alat suntik sekali pakai 2,5 ml set 1,227 - 1,227 501
9 109 Alat suntik sekali pakai 5 ml set 445 - 445 95
10 110 Albendazol tablet 400 mg tablet 953 - 953 41
11 111 Albumin kit - - - -
12 112 Alkohol 70% 100 ml botol - - - -
13 113 Alkohol 95 % botol 3 - 3 -
14 114 Alkohol Swab dos 156 - 156 108
15 115 Alopurinol tablet tablet 1,267 - 1,267 626
16 116 Alpara tablet 903 - 903 187
17 117 Ambroxol sirup 60 ml botol - - - -
18 118 Ambroxol tablet 30 mg tablet 290 - 290 290
19 119 Aminofilina injeksi 24mg/ml-10m ampul 19 - 19 -
20 120 Aminofilina tablet 200 mg tablet 805 - 805 234
21 121 Amitriptilina HCL tablet 25 mg tablet 190 - 190 -
22 122 Amlodipin 10 mg tablet - - - -
23 123 Amoksilin Forte Sirup Kering botol - - - -
24 124 Amoksilin kaplet - 500 mg kaplet 5,599 - 5,599 2,906
25 125 Amoksilin kapsul - 250 mg kapsul 1,665 - 1,665 610
26 126 Amoksilin Sirup Kering botol 164 - 164 92
27 127 Ampisilina injeksi 1 gram vial - - - -
28 128 Antalgin injeksi 24 mg/ml-10ml ampul - - - -
29 129 Antalgin tablet 500mg tablet 3,237 - 3,237 2,404
30 130 Antasi DOEN II Suspensi,Kombi botol 72 - 72 6
31 131 Antasida Doen tablet tablet 3,165 - 3,165 2,595
32 132 Anti Hemmoroid Suppositoria supp 10 - 10 -
Antibakteri DOEN (Basitrasin +
33 133 tube
Polimiksin) 49 - 49 14
Antifungi DOEN (As Benzoat
34 134 pot
3%+As Salisilat 6%) 20 - 20 -
Antimigren DOEN (Ergotamina
35 135 tablet
Trt + Kofeina) - - - -
36 136 Antrain injeksi 2ml /5 ampul 30 - 30 20
37 137 Aqua pro injeksi steril - 20 ml ampul 41 - 41 6
38 138 Aquadest steril - 1000 ml botol - - - -
39 139 Aquadest steril - 500 ml botol - - - -
40 140 Aquagel Sterile Jely 82 gr tube - - - -
41 141 Asam Askorbat (vit C) tablet 50 tablet 9,543 - 9,543 4,095
42 142 Asam Askorbat (vit C) tablet 25 tablet - - - -
43 143 Asam Mefenamat kaplet 500 mg kaplet 1,024 - 1,024 764
44 144 Asam tranexamat injeksi 100mg ampul - - - -
45 145 AsamTraneksamat HCL tablet 5 tablet 56 - 56 10
46 146 Aseptic Gel + Disp 500 ml botol 5 - 5 -
47 147 Asetosal tablet 100 mg tablet - - - -
48 148 Asetosal tablet 500 mg tablet - - - -
49 149 Asetosal tablet 80 mg tablet 200 - 200 -
50 150 Atapulgit 630 mg tablet 25 - 25 25
51 151 Atropina Sulfat injeksi ampul 20 - 20 -
52 152 Atropina Sulfat tablet 0,5 mg tablet - - - -
53 153 Autodisposable Syringe 0,05 ml set 200 - 200 -
Autodisposable Syringe 0,5 ml
54 154 set
(Soloshot) 500 - 500 200
55 155 Autodisposable Syringe 10 ml set - - - -
Autodisposable Syringe 2 ml
56 156 set
(Soloshot) - - - -
Autodisposable Syringe 5 ml
57 157 set
(Soloshot) 665 - 665 32
58 158 Azitromicin 250 mg tab tablet - - - -
59 159 Azitromicin 500 mg tab tablet - - - -
60 201 Bahan tumpatan sementara/Cavi botol 2 - 2 1
61 202 Balsem pot - - - -
62 203 Becefort tablet tablet - - - -
63 204 Benzatin Bensil Pen.inj 1,2 juta vial - - - -
64 205 Benzatin Bensil Pen.inj 2,4 juta vial - - - -
65 206 Besi sirup botol - - - -
66 207 Betahistin Mesilat 6 mg tablet - - - -
67 208 Betametason krim tube 32 - 32 7
68 209 Betametason N crem tube 47 - 47 11
69 210 Bidicef 500 mg kapsul - - - -
70 211 Bidicef DS Syrup botol - - - -
71 212 Bioneuro injeksi ampul - - - -
72 213 Bisoprolol tablet 5 mg tablet 357 - 357 -
73 214 Bist Mess No.24 set 100 - 100 -
74 215 Blood Lancet set 70 - 70 -
75 216 Blood Lancet ( GEA ) set - - - -
76 217 Bonding Liq botol - - - -
77 218 Buffer Wright kit - - - -
78 219 Bunofa 400 kaplet - - - -
79 220 Buscopan injeksi ampul - - - -
80 301 Calcium Gluconas infus botol 23 - 23 -
81 302 Captopril tablet 25 mg tablet 1,245 - 1,245 1,127
82 303 Carpiaton 100 mg tablet 51 - 51 -
83 304 Catgut Chrom 2/0 + jarum sachet 44 - 44 9
84 305 Catgut Chrom 3/0 + jarum sachet 69 - 69 16
85 306 Catgut Plain 2/0 + jarum sachet 29 - 29 5
86 307 Catgut Plain 3/0 + jarum sachet 3 - 3 1
87 308 Cefadroxil kapsul 500 mg kapsul 170 - 170 108
88 309 Cefixime 100mg tablet - - - -
89 310 Cefotaxim injeksi vial - - - -
90 311 Ceftriaxone 1.Og inj Kering vial - - - -
91 312 Celemek buah 9 - 9 -
92 313 Cendo Lyteer botol - - - -
93 314 Cetirizine Kapsul 10mg kapsul - - - -
Chlorhexidine gluconat 0,2% /
94 315 botol
ASEPTAN 4 - 4 -

Chlorhexidine gluconat 4% 500

95 316 botol
cc + dispenser / ONE SCROB
5 - 5 -
96 317 Cimetidin tablet 200 mg tablet 68 - 68 -
97 318 Clorin / One Clean botol - - - -
98 319 Colfin Syrup botol - - - -
99 320 Composit Light Curing A2 syringe - - - -
100 321 Composit Light Curing A3 syringe - - - -
101 322 Composit Light Curing A3,5 syringe - - - -
102 323 Corsafen 500 mg kapsul 20 - 20 -
103 324 Cover Glass pcs - - - -
104 325 Cresopen (obat gigi) botol - - - -
105 326 Cyprofloxacin kapsul 500 mg kapsul 508 - 508 120
106 401 Darah Kontrol set - - - -
Daryan Tulle :Flamisetin Sulfat
107 402 lembar
10 x 10 cm 90 - 90 -
108 403 Decullin tablet 30mg tablet 200 - 200 23
109 404 Deksametason Injeksi 5mg/ml ampul 274 - 274 37
110 405 Deksametason tablet 0,5 mg tablet 5,027 - 5,027 1,777
111 406 Demacolin tablet tablet 929 - 929 552
112 407 Depo Progestin Injeksi 3 bln vial - - - -
Dermazin salep kulit 1% -
113 408 tube
25gram /BioplaN - - - -
114 409 Devitalisasi pasta botol - - - -
115 410 Dextral sirup botol 60 - 60 -
116 411 Dextran infus - 500 ml botol - - - -
117 412 Dextrofen Sirup botol - - - -
118 413 Diazepam Injeksi 5mg/ml-2ml ampul 20 - 20 2
119 414 Diazepam tablet 2 mg tablet 100 - 100 97
120 415 Diazepam tablet 5 mg tablet 175 - 175 175
121 416 Diethylcarbamazine tablet - - - -
122 417 Difenhidramina HCL injeksi 10 ampul 428 - 428 151
123 418 Digoksina tablet 0,25 mg tablet 294 - 294 -
124 419 Doksisiklin kapsul 100 mg kapsul 300 - 300 -
125 420 Domperidon tablet 10 mg tablet 285 - 285 285
126 421 Duk 140 x 180 cm pcs - - - -
127 422 Duk 50 x 60 cm pcs - - - -
128 423 Duk 90 x 125 cm pcs - - - -
129 424 Duk Lubang Bulat 50x60 cm pcs - - - -
130 425 Duk Lubang Bulat 60x90 cm pcs - - - -
131 426 Duk Lubang Bulat 90x125 cm pcs - - - -
132 501 EDTA botol - - - -
133 502 Efedrina HCL 25 mg tablet - - - -
134 503 Envios - FB botol - - - -
 Epinefrina HCL/Bitart injeksi
135 504 ampul
0.1% - l ml 79 - 79 -
136 505 Erithromicin kaplet 500 mg kaplet 300 - 300 -
137 506 Erithromicin kapsul 250 mg kapsul 200 - 200 -
138 507 Erithromicin sirup - 60 ml botol - - - -
139 508 Etakridina larutan 0,1%-300 ml botol - - - -
140 509 Etanol 70% - 1000 ml botol 3 - 3 -
141 510 Etching+bonding Liquit SDI set - - - -
142 511 Ethambutol 250 mg tablet - - - -
143 512 Ethambutol 500 mg tablet - - - -
144 513 Etil Klorida semprot botol 2 - 2 1
145 514 Eugenol Cairan - 10 ml botol 1 - 1 -
146 601 Farmoten 12,5 mg tablet - - - -
147 602 Feeding tube No. 10 set - - - -
148 603 Feeding tube No. 16 set - - - -
149 604 Feeding tube No. 5 set - - - -
150 605 Feeding tube No. 8 set - - - -
151 606 Fenitoina Natrium kapsul 100 m kapsul 460 - 460 380
152 607 Fenobarbital Injeksi 50mg/ml-2m ampul 15 - 15 -
153 608 Fenobarbital tablet 30 mg tablet - - - -
154 609 Fenoksimetil Penisilina tablet 2 tablet - - - -
155 610 Fenoksimetil Penisilina tablet 5 tablet 48 - 48 -
156 611 Fenol Gliserol tetes telinga botol 54 - 54 54
157 612 Fitomenadion injeksi 10mg/ml ampul - - - -
158 613 Fitomenadion injeksi 2 mg/ml ampul 130 - 130 5
159 614 Fitomenadion tablet 10 mg tablet 616 - 616 12
160 615 Flagil / Metronidazol Ovuo 500m Tablet 10 - 10 -
161 616 Fluconazole 150 mg tablet - - - -
162 617 Fluoride Sediaan Topical/Clinpro botol 60 - 60 2
163 618 Folley Catheter No. 14 set 1 - 1 1
164 619 Folley Catheter No. 16 set 2 - 2 -
165 620 Folley Catheter No. 18 set 5 - 5 3
166 621 Formaten 25 mg tablet - - - -
167 622 Furosemida tablet 40 mg tablet 541 - 541 341
168 623 Furosemide 10mg/ml injeksi ampul 20 - 20 -
169 701 Garam Oralit untuk 200 ml air kantong 1,379 - 1,379 435
170 702 Gastrusid Blister tablet - - - -
171 703 Gastrusid sirup - 60ml botol - - - -
172 704 Gentamycin injeksi 80 mg/2 ml vial 40 - 40 -
173 705 Gentamycin salep kulit tube - - - -
174 706 Gentamycin salep mata tube 2 - 2 2
175 707 Gentamycin tetes mata botol - - - -
176 708 Gentian violet larutan 1% botol - - - -
177 709 Giemsa + Buffer Giemds botol - - - -
178 710 Glass Ionomer Cement set 1 - 1 1
179 711 Glibenklamida tablet 5 mg tablet 526 - 526 84
180 712 Glimepiride 2 mg tablet - - - -
181 713 Gliseril Guayakolat tablet 100 tablet 4,473 - 4,473 2,317
182 714 Gliserin 1 liter botol - - - -
183 715 Gliserin 100 ml botol - - - -
184 716 Gluco DR strip - - - -
185 717 Gluco M strip isi 25 strip - - - -
186 718 Glucocard box - - - -
187 719 Gludepatic tablet 218 - 218 -
188 720 Glukosa infus 0,225% - 500 ml botol 20 - 20 -
189 721 Glukosa lar. infus 10% steril botol 25 - 25 -
190 722 Glukosa lar. infus 40% steril ampul 10 - 10 -
191 723 Glukosa lar. infus 5% steril botol 48 - 48 41
192 724 Griseofulvin tablet 125mg tablet 500 - 500 10
193 725 Gynaecology gloves/ OBGYN set 42 - 42 -
194 801 H Cl 0,1 N botol 2 - 2 -
195 802 Haloperidol tablet 0.5 mg tablet - - - -
196 803 Haloperidol tablet 1.5 mg tablet - - - -
197 804 Haloperidol tablet 2 mg tablet - - - -
198 805 Halopuridol tablet 5 mg tablet 39 - 39 10
199 806 Hemocue ( Tube ) tube - - - -
200 807 Hemoglobin (500 ml/btl) botol - - - -
201 808 Hidrogen Peroksida / H2O2 botol - - - -
202 809 Hidroklortiazida tab 25 mg tablet - - - -
203 810 Hidrokortison Krim 2,5% tube 68 - 68 13
204 811 Holimol Kaplet kaplet 107 - 107 -
205 901 Ibuprofen suspensi 100 mg/ 5ml botol - - - -
206 902 Ibuprofen tablet 200 mg tablet 96 - 96 -
207 903 Ibuprofen tablet 400 mg tablet 1,130 - 1,130 940
208 904 Imipramine 25 mg tablet - - - -
209 905 Implant KB / Levenogestrel 75 vial - - - -
210 906 Infusion set anak set 37 - 37 7
211 907 Infusion set dewasa set 108 50 158 79
212 908 Iodiol kapsul lunak kapsul - - - -
213 909 Isoniazid 100 mg kaplet 200 - 200 -
214 910 Isosorbid Dinitrat tablet 5 mg tablet 200 - 200 30
215 911 IUD set - - - -
216 1001 Jarum Jahit Bedah No. 12 biji 40 - 40 -
217 1002 Jarum Jahit Bedah No. 13 biji 42 - 42 -
218 1003 Jarum Jahit Bedah No. 14 biji 44 - 44 -
219 1004 Jas Operasi Water Rep pcs - - - -
220 1101 KA-EN 3B infus - 500 ml botol - - - -
221 1102 Kalium Permanganat serbuk botol - - - -
222 1103 Kalsium Hidroksida pasta tube 1 - 1 1
223 1104 Kalsium Laktat tablet 500mg. tablet 11,336 - 11,336 2,481
224 1105 Kapas pembalut abs 250 gram rol 14 - 14 1
225 1106 Karbamazepin tablet 200 mg tablet 100 - 100 -
226 1107 Kasa 2 x 8 m rol 51 - 51 5
227 1108 Kasa Hidrofil 16x16 box 11 - 11 5
228 1109 Kasa kompres steril 40cm/40cm bungkus - - - -
229 1110 Kasa pembalut 2 m x 80 cm bungkus - - - -
230 1111 Kasa Pembalut 4x10 cm rol 72 - 72 1
231 1112 Kasa pembalut hidrofil 4mx 3cm rol - - - -
232 1113 Kasa pembalut hidrofil 4mx15cm rol 70 - 70 17
233 1114 Kertas PH kotak - - - -
234 1115 Ketokonazol tablet tablet 276 - 276 2
235 1116 Klindamycin kapsul 150 mg kapsul - - - -
236 1117 Klindamycin kapsul 300 mg kapsul - - - -
237 1118 Kloramfenikol injeksi 1 gram vial - - - -
238 1119 Kloramfenikol kapsul 250 mg kapsul 594 - 594 260
239 1120 Kloramfenikol Salep Mata 1% tube 23 - 23 7
 Kloramfenikol sirup - 125 mg/ml
240 1121 botol
-60ml 3 - 3 -
241 1122 Kloramfenikol tetes mata 0,5% - botol 25 - 25 14
242 1123 Kloramfenikol tetes telinga 3% botol 25 - 25 -
243 1124 Klorfeniramina Maleat tablet 4m tablet - - - -
244 1125 Klorpromazina HCL inj 25 mg/ml ampul - - - -
245 1126 Klorpromazina HCL tab salut 10 tablet 202 - 202 46
246 1127 Klorpromazina HCL tab salut 25 tablet 100 - 100 -
247 1128 Kodeina tablet. 10mg tablet - - - -
248 1129 Kotrimoksazol sirup botol 129 - 129 53
249 1130 Kotrimoksazol tablet Adult tablet 1,006 - 1,006 462
250 1131 Kotrimoksazol tablet Pediatrik tablet - - - -
251 1132 Kuinina Sulfat tablet tablet - - - -
252 1201 Lanzoprazol kapsul 30 mg kapsul - - - -
253 1202 Larutan Benedict - 100 ml botol - - - -
254 1203 Larutan Drapkin kit - - - -
255 1204 Larutan Eosin 2 % - 100 ml botol - - - -
256 1205 Larutan Etanol Asam - 100 ml botol - - - -
257 1206 Larutan Gabbet - 100 ml botol - - - -
258 1207 Larutan Giemsa Stain - 100 ml botol - - - -
259 1208 Larutan Hayem botol - - - -
260 1209 Larutan Karbol Fuksin - 100 ml botol - - - -
261 1210 Larutan Kinyoun - 100 ml botol - - - -
262 1211 Larutan Metilen Biru - 100 ml botol - - - -
263 1212 Larutan Turk - 100 ml botol - - - -
264 1213 Larutan Wright / Pewarna Wright kit - - - -
265 1214 Laxadin sirup 60 ml botol 11 - 11 3
266 1215 Levofloksasin tablet 500 mg tablet 450 - 450 -
267 1216 Lidocain 2% injeksi ampul 112 - 112 8
268 1217 Lidokaina Comp. Injeksi 2% ampul 110 - 110 10
269 1218 Lisol - 1000 ml botol 2 - 2 1
270 1219 Loperamide tablet - 2mg tablet 648 - 648 98
271 1220 Loratadin tablet 300 - 300 16
272 1221 Lysofit sirup botol - - - -
273 1222 Lytacur 60 ml botol 44 - 44 12
274 1301 Magnesium Sulfat injeksi 20% ampul 16 - 16 -
275 1302 Magnesium Sulfat injeksi 40% ampul 23 - 23 -
276 1303 Maltodextrin tablet / TABURIA tablet 12,060 - 12,060 4,950
277 1304 Masker disposable biji 200 - 200 -
278 1305 Masker Oksigen Dewasa biji 6 - 6 -
279 1306 Masker Surgical ear loop'50 biji - - - -
280 1307 Masker Surgical Plus 3 Ply Plus biji 245 - 245 23
281 1308 Masker Surgical tie on'50 biji 305 - 305 65
282 1309 Mebendazol sirup 100 mg/ 5 ml botol - - - -
283 1310 Mebendazol tablet 100 mg tablet - - - -
284 1311 Medicut No. 18 biji 25 - 25 20
285 1312 Medicut No. 20 biji 45 - 45 41
286 1313 Medicut No. 22 biji 80 - 80 25
287 1314 Medicut No. 24 biji 60 - 60 15
288 1315 Meloksikam tablet 15 mg tablet - - - -
289 1316 Meloksikam tablet 7,5 mg tablet - - - -
290 1317 Metamizole / Norages injeksi 5 ampul - - - -
291 1318 Metaneuron tablet tablet 12 - 12 -
292 1319 Metanol - 100 ml botol - - - -
293 1320 Metformin H Cl tablet 500 mg tablet 1,078 - 1,078 238
294 1321 Metformin HCL tablet 850mg tablet - - - -
295 1322 Methylpredhisolon 16mg tablet 150 - 150 30
296 1323 Metidrol tablet 6 - 6 -
Metilergometrina injeksi 0,2
297 1324 ampul
mg/ml -1 ml 44 - 44 9
298 1325 Metilergometrina Maleat tablet tablet 200 - 200 -
299 1326 Metoclopramide 5 mg tablet - - - -
300 1327 Metoklopramid 10 mg tablet - - - -
301 1328 Metoklopramid Syrup 60 ml botol 38 - 38 5
302 1329 Metronidazol 500mg infus vial - - - -
303 1330 Metronidazol tablet 250 mg tablet 717 - 717 50
304 1331 Metronidazol tablet 500 mg tablet 1,036 - 1,036 347
305 1332 Meylon injeksi ampul - - - -
306 1333 Miconazol 2% salep kulit tube 24 - 24 -
307 1334 Mineral mix sachet 145 - 145 -
308 1335 Minyak Kayu Putih botol - - - -
309 1336 Monoklorkamfer Mentol cairan botol 1 - 1 1
310 1337 Mummifying pasta botol 1 - 1 1
Na ClO 5.,25 % dan CaOCl212
311 1401 botol
/ BYCLIN - - - -
312 1402 Na F Kristal botol - - - -
313 1403 Nasaflam 100 mg tablet - - - -
314 1404 Nasaflam 50 mg tablet - - - -
315 1405 Natrium Bikarbonat tablet 500 m tablet - - - -
316 1406 Natrium Diklofenak 50 mg tablet 62 - 62 62
317 1407 Natrium Klorida larutan infus 0. botol 16 60 76 56
318 1408 Nelato Catether No. 12 set 7 - 7 2
319 1409 Nelato Catether No. 14 set 2 - 2 -
320 1410 Nelato Catether No. 16 set - - - -
321 1411 Nelato Catether No. 18 set - - - -
322 1412 Neo Kaominal sirup botol 10 - 10 1
323 1413 Neurobat injeksi ampul 30 - 30 15
324 1414 Neurofit E tablet tablet - - - -
325 1415 Neurosanbe 5000 tablet tablet 24 - 24 -
326 1416 Nifedipin 200 mg tablet tablet 300 - 300 200
327 1417 Nistatin 100.000 IU suspensi botol 9 - 9 1
328 1418 Nistatin 100.000 IU/g tablet vagi tablet 10 - 10 -
329 1419 Nistatin 500.000 IU/g tablet oral tablet - - - -
330 1420 Nodiar tablet - - - -
331 1421 Novagesic 500mg kaplet kaplet - - - -
332 1422 Novamag kaplet kaplet - - - -
333 1423 Novastan 500mg kaplet kaplet - - - -
334 1424 Novatrim 480mg kaplet kaplet - - - -
335 1501 Obat Antituberkulosis kat - Anak paket 1 - 1 -
336 1502 Obat Antituberkulosis kat - I paket 5 - 5 -
337 1503 Obat Antituberkulosis kat -II paket - 2 2 2
338 1504 Obat Batuk Hitam cairan 100ml botol - - - -
339 1505 OBAT KUSTA M B anak strip 4 - 4 3
340 1506 OBAT KUSTA M B dewasa strip 18 - 18 10
341 1507 OBAT KUSTA P B anak strip - - - -
342 1508 OBAT KUSTA P B dewasa strip 5 - 5 2
343 1509 Obat Malaria tablet tablet - - - -
344 1510 OBH Tropica Exta Mentol 60 ml botol - - - -
345 1511 OBH Tropica Plus Anak Jeruk 60 botol 2 - 2 -
346 1512 OBH Tropica Plus Mentol 60 ml botol 43 - 43 16
347 1513 Obyek Glass pcs - - - -
348 1514 Oil Imersion boto - - - -
349 1515 Oksigen Gas dalam tabung - 1m tabung - 5 5 4
350 1516 Oksigen Gas dalam tabung - 6m tabung 1 6 7 5
351 1517 Oksitetrasiklina HCl injeksi 50 m vial - - - -
352 1518 Oksitetrasiklina HCL salep kulit tube - - - -
353 1519 Oksitetrasiklina HCL salep mata tube - - - -
354 1520 Oksitosina injeksi 10 IU/ml-1ml ampul 144 - 144 22
355 1521 Omeprazol kapsul kapsul 391 - 391 296
356 1522 Ondansetron tab 4 mg tablet 300 - 300 83
357 1523 Ondansetron tab 4 mg/2 ml Inj - ampul - - - -
358 1601 Papaverine injeksi 40 mg/ml ampul - - - -
359 1602 Papaverine tablet 40 mg tablet - - - -
360 1603 Paracetamol Drop botol 10 - 10 -
361 1604 Parasetamol sirup 120 mg/5ml botol 76 - 76 57
362 1605 Parasetamol tablet 100 mg tablet - - - -
363 1606 Parasetamol tablet 500 mg tablet 8,537 - 8,537 3,447
364 1607 Perfenazin tablet 16 mg tablet - - - -
365 1608 Perfenazin tablet 4 mg tablet - - - -
366 1609 Permetrin Krim 5% / Scabimite tube - - - -
367 1610 Petidina HCL injeksi 50 mg/ml-2 ampul - - - -
368 1611 Pewarna Gram / 1 set bot - - - -
369 1612 Pewarna Ziehl-Neesen / 1 set botol - - - -
370 1613 Pil Kontrasepsi (Microdiol) strip - - - -
371 1614 Piracetam 800 mg tablet tablet - - - -
372 1615 Piracetam inj 1 gram/5ml ampul - - - -
373 1616 Pirantel Pamoat tablet 125 mg tablet 414 - 414 14
374 1617 Pirantel Susp 125mg / 5 ml botol 30 - 30 -
375 1618 Piridoksina HCL tablet 10mg tablet - - - -
376 1619 Piroxicam 20 mg kapsul - - - -
377 1620 Planotest Strip strip 13 - 13 -
378 1621 Plester 5 yard x 2 inch rol - - - -
379 1622 Plester Flexible non woven 5 x 5 rol 3 - 3 2
380 1623 Plester Kain Roll 1,25cm x 4,5m rol 5 - 5 1
381 1624 Plester Kain Roll 2,5cm x 4,5m rol 4 - 4 3
382 1625 PM-ASI Biskuit bungkus - - - -
383 1626 PMT Untuk BUMIL bungkus - - - -
384 1627 PMT-AS biskuit bungkus - - - -
Polikresulen
385 1628 botol
( Metakresolsulfonat ) - 10 ml 8 - 8 -
386 1629 Pot Urine pcs - - - -
387 1630 Prednison tablet 5 mg tablet 2,534 - 2,534 134
388 1631 Prenase Caps kaplet - - - -
389 1632 Prenatin Plus tablet - - - -
390 1633 Primakina tablet 15 mg tablet - - - -
391 1634 Procurma Plus Syrup botol - - - -
392 1635 Prokaina Pen. G injeksi 3 juta IU vial - - - -
393 1636 Propanolol HCL tablet 10 mg tablet 340 - 340 6
394 1637 Propanolol HCL tablet 40 mg tablet - - - -
395 1638 Propiltiourasil tablet 100 mg tablet 300 - 300 -
396 1701 Ranitidin 150 mg tablet 159 - 159 16
397 1702 Ranitidin 50 mg / 2 ml Inj ampul - - - -
398 1703 RDT Malaria card - - - -
399 1704 Reagen BUN ( Enzymatic ) set - - - -
400 1705 Reagen Cholesterol ( CHOD-PAP kit - - - -
401 1706 Reagen Creatinin ( Picrate ) set - - - -
402 1707 Reagen Glukosa ( GOD-PAP ) kit - - - -
403 1708 Reagen Golongan Darangan Da set 2 - 2 -
Reagen Hematologi
(Analyzer)
404 1709 Isotonac 18 liter set
Hemoline 1,5 liter
Cleanac 5 liter - - - -
405 1710 Reagen Hematology Sysmex kit - - - -
406 1711 Reagen Hematology Urit kit - - - -
407 1712 Reagen SGOT ( 5X20 ST ) kit - - - -
408 1713 Reagen SGOT ( IFCC ) kit - - - -
409 1714 Reagen Widal Set ( O, H, AO,B set - - - -
410 1715 Rees Ecker kit - - - -
411 1716 Renadinac 25 mg kaplet - - - -
412 1717 Reserpina tablet 0,25 mg tablet - - - -
413 1718 Retinol kap. lunak 100.000 IU kapsul 102 300 402 26
414 1719 Retinol kap. lunak 200.000 IU kapsul 923 4,050 4,973 126
415 1720 Rifampisin Kapsul 300 mg kapsul - - - -
416 1721 Rifampisin Kapsul 450 mg kapsul - - - -
417 1722 Rifampisin Tablet 600 mg tablet - - - -
418 1723 Ringer Asetat infus - 500ml botol 3 20 23 5
Ringer Laktat + Glucose 5%
419 1724 botol
infus-500ml 20 - 20 -
420 1725 Ringer Laktat Larutan infus - 50 botol 152 200 352 231
421 1726 Risperidone 2 mg tablet - - - -
422 1727 Rovital Tablet tablet 490 - 490 116
423 1801 Safe Glove Exam L set - - - -
424 1802 Safe Glove Exam M set 100 - 100 50
425 1803 Safe Glove Exam S set - - - -
426 1804 Safety box set 18 - 18 18
427 1805 Sakaneuron tablet tablet - - - -
428 1806 Salbutamol 2 mg tablet 200 - 200 105
429 1807 Salbutamol 4 mg tablet 52 - 52 52
Salep 2-4 DOEN (As.Salisilat
430 1808 pot
2%+Belerang Endap 4%) 37 - 37 9
431 1809 Salisil Bedak 2% - 50 gram kotak 28 - 28 2
432 1810 Sarung Tangan Obgyn ( STERIL set - - - -
433 1811 Scabicid salep kulit tube 12 - 12 -
434 1812 Semen Seng Fosfat set 1 - 1 1
435 1813 Semillas Non Woven 5x500cm rol - - - -
436 1814 Sepatu Tertutup pcs - - - -
437 1815 Serum Anti Bisa Ular injeksi (ABU vial - - - -
438 1816 Serum Anti Dipteri injeksi 20.000 vial - - - -
439 1817 Serum Anti Tetanus injeksi 1.500 ampul - - - -
440 1818 Serum Anti Tetanus injeksi 20.00 vial - - - -
441 1819 Serum Kontrol kit - - - -
442 1820 Sianokobalamina (Vit B12) injeks ampul 314 - 314 108
443 1821 Sikzonoate injeksi 25 mg /ml ampul - - - -
444 1822 Silk no 2/0, 24x13x60 cm sachet 93 - 93 5
445 1823 Silk no 3/0, 24x13x60 cm sachet - - - -
446 1824 Silver Amalgam serbuk 65-75% botol 1 - 1 -
447 1825 Simvastatin tablet 10 mg tablet 2 - 2 2
448 1826 Solvita sirup - 60 ml botol - - - -
449 1827 Solvitral kaplet kaplet - - - -
450 1828 Sotatic tablet - - - -
451 1829 Spasmal tablet tablet - - - -
452 1830 Spironolactone 25 mg tablet - - - -
453 1831 Spons Gelatin cubicles 1x1x1cm biji - - - -
454 1832 Sprei Karet Premium 90x200x15 pcs - - - -
455 1833 Spuit KB vial - - - -
456 1834 Stesolid Rectal 10 mg/2,5 ml tube 4 - 4 1
457 1835 Stesolid Rectal 5 mg/2,5 ml tube 5 - 5 -
458 1836 Stick Urine 10 PM stick 1 - 1 -
459 1837 Stolax /Bisakodil Supp 10mg tablet - - - -
460 1838 Streptomisina Sulfat injeksi 1gr vial - - - -
461 1839 Strip Urine 11 PM tube - - - -
462 1840 Strip Urine 3 PM tube - - - -
463 1841 Sulfasetamida tetes mata 15% botol - - - -
464 1842 Surgical glove no. 6 set 70 - 70 5
465 1843 Surgical Glove No. 7 set 6 - 6 1
466 1844 Surgical Glove No. 7,5 set 90 - 90 25
467 1845 Surgical Glove No. 8 set 67 - 67 10
Tablet Tambah Darah (Besi II
468 1901 tablet
Sulfat) tab.300mg 6,804 - 6,804 3,721
469 1902 Tabung K3 EDTA box - - - -
471 1903 Temporary Stopping Fletcher set - - - -
472 1904 Teosal tablet tablet - - - -
473 1905 Tes HIV I (Oncoprobe ) set - - - -
474 1906 Tes HIV II ( Intech Triline ) ) set - - - -
475 1907 Tes HIV III (Vikia ) set - - - -
476 1908 TES KEHAMILAN box - - - -
477 1909 Tetrakain / Pantocain 0,5 % Tts botol - - - -
478 1910 Tetrasiklina HCl kapsul 250 mg kapsul - - - -
479 1911 Tetrasiklina HCl kapsul 500 mg kapsul 744 - 744 217
480 1912 Thiampenicol Sirup botol - - - -
481 1913 Thiamphenicol 500 mg kapsul 305 - 305 105
482 1914 Three way Stop Cock pcs - - - -
483 1915 Tiamina (Vit B1) tablet 100 mg tablet - - - -
484 1916 Tiamina (Vit B1) tablet 50 mg tablet - - - -
485 1917 Tiamina HCL injeksi 100mg/ml ampul - - - -
486 1918 Topi Tali pcs - - - -
487 1919 Topical Anastesi Gel/Prime Gel 1 - 1 1
488 1920 Tramadol injiksi 50 mg/ml ampul - - - -
489 1921 Tramadol kapsul 50 mg tablet 52 - 52 -
490 1922 Transfusion set set 3 - 3 -
491 1923 Trifluoperazin 5 mg / Stesoli tab tablet - - - -
492 1924 Trigliserida ( 3X50 ST ) kit - - - -
493 1925 Triheksilfenidil Hcl tablet - 2 mg tablet 75 - 75 20
 Trikresol Formalin
494 1926 botol
(Forinokresol) cairan - 10 ml 1 - 1 1
495 2001 Ulsikur/ Ulcumet injeksi 200mg ampul - - - -
496 2002 Umbilical Cord biji 55 - 55 5
497 2003 Underpad biji 69 - 69 30
498 2004 Urine bag set 6 - 6 4
499 2005 Uriscan Gen 11 / 10 Parameter botol - - - -
500 2006 Uriscan Glucose 1 kit - - - -
501 2007 Uriscan GP2 for Reduksi + Albu kit - - - -
502 2101 Vaselin Alba botol 2 - 2 2
503 2102 Ventolin / Salbutamol Inhaler 0, botol - - - -
Ventolin Nebules /Salbutamol
504 2103 ampul
Cairan 2,5 mg - - - -
505 2201 Vitamin B Kompleks tablet tablet 5,834 - 5,834 4,580
506 2301 Washlap 15x20 pcs - - - -
507 2302 Wida D5 1/2 NS botol 40 - 40 10
508 2303 Wing Needle bayi no.25 biji 10 - 10 -
509 2401 Xylol botol - - - -
510 2402 Xylomidon inj vial - - - -
511 2501 Yodium Povidon 10% - 30 ml botol 13 - 13 3
512 2502 Yodium Povidon 10% - 300 ml botol 4 - 4 1
513 2503 Y-Rins Cuci Mata botol - - - -
514 2601 Zentral sirup botol - - - -
515 2602 ZINC tablet 20 mg tablet 1,268 - 1,268 534
516 2603 Zircum KID sirup botol 2 - 2 2
517 2604 Zoralin tablet - - - -
- - - -
PROGRAM IMUNISASI - - - -
518 2701 Pelarut BCG ampul 26 10 36 17
519 2702 Pelarut Campak ampul 42 10 52 28
520 2703 Pipet Polio set 45 30 75 51
521 2704 Vaksin BCG ampul 26 10 36 17
522 2705 Vaksin CAMPAK vial 42 10 52 28
523 2706 Vaksin DPT Hb - Hib / PENTABI vial 46 - 46 46
524 2707 Vaksin DPT HB COMB0 vial - - - -
525 2708 Vaksin DT vial 32 - 32 -
526 2709 Vaksin HB Unijeck vial 41 20 61 39
527 2710 Vaksin POLIO botol 45 30 75 51
528 2711 Vaksin Td vial 44 - 44 -
529 2712 Vaksin TT vial 38 10 48 28
530 2713 Vaksin Meningitis vial - - - -
531 2714 Spuit Meningitis set - - - -
532 2715 Alkohol Swab Meningitis set - - - -
533 2716 Needle Meningitis set - - - -
- - - -
PROGRAM IMS - - - -
534 2801 Alcohol Swab - - - -
535 2802 Cotton Applicators Sterile - - - -
536 2803 Cover Glass - - - -
537 2804 Hand Gloves - - - -
538 2805 Immersion Oil - - - -
539 2806 Kertas PH 3,8 - 4,2 - - - -
540 2807 KOH 10% - - - -
541 2808 Methylated Spirit - - - -
542 2809 Methylen Blue 0.3% - - - -
543 2810 Nacl 0.9% - - - -
544 2811 Object Glass - - - -
545 2812 Reagen Sifilis RPR/kit (10ml untk 500 test) - - - -
546 2813 Reagen Sifilis TPHA - - - -
547 2814 Vaculab/Tabung darah plastic tutup merah - - - -
548 2815 Xylol - - - -
549 2816 Yellow dan Blue Tip - - - -
- - - -
LABKEDA - -
Kimia Klinik - -
550 2901 Albumin kit - -
551 2902 Alkali Phosphatase kit - -
552 2903 Billirubin kit - -
553 2904 Cholesterol Liq kit - -
554 2905 Control Serum Abnormal kit - -
555 2906 Control Serum Normal kit - -
556 2907 Creatinin kit - -
557 2908 Gamma GT kit - -
558 2909 Glucose Ox Liq kit - -
559 2910 HDL Chol Direct kit - -
560 2911 LDL Chol Direct kit - -
561 2912 SGOT kit - -
562 2913 SGPT kit - -
563 2914 Total Protein kit - -
564 2915 Trigliserida kit - -
565 2916 Ureum kit - -
566 2917 Uric Acid Liquid kit - -
Immuno Serologi - -
567 3001 Widal - -
3002 Salmonella Thypi O Antigen A vial - -
3003 Salmonella Thypi O Antigen B vial - -
3004 Salmonella Thypi O Antigen C vial - -
3005 Salmonella Thypi O Antigen D vial - -
3006 Salmonella Thypi H Antigen A vial - -
3007 Salmonella Thypi H Antigen B vial - -
3008 Salmonella Thypi H Antigen C vial - -
3009 Salmonella Thypi H Antigen D vial - -
568 3010 Control Positive Polyvalent vial - -
569 3011 Control Negatif Polyvalent box - -
570 3012 HBsAg Strip Tes box - -
571 3013 HBsAb Strip Tes box - -
572 3014 Determine HIV box - -
573 3015 Rapid Syphilis box - -
574 3016 ICT Malaria box - -
575 3017 Golongan Darah - -
3018 Anti A vial - -
3019 Anti B vial - -
3020 Anti AB vial - -
3021 Anti D vial - -
576 3022 Urine Analisa - -
577 3023 Stick Urine 10 parameter tube - -
578 3024 Narkoba - -
579 3025 Amphetamine box - -
580 3026 Methaphetamine box - -
581 3027 Opiate box - -
582 3028 Marijuana box - -
583 3029 Cocaine box - -
584 3030 Drug Abuse Multi Panel 6 Param box - -
585 3031 Pregnancy Strip Test box - -
Pengecatan - -
586 3101 Brilliant Cresyl Blue 1 % botol - -
587 3102 Giemsa botol - -
588 3103 Larutan Drabkin botol - -
589 3104 Larutan Eosin 2 % botol - -
590 3105 Larutan Turk botol - -
591 3106 Oil Imersion botol - -
592 3107 Pewarna Gram set - -
593 3108 Pewarna Rapid/ sediaan apus da set - -
594 3109 Pewarna Ziehl Nellsen set - -
595 3110 Xylol botol - -
UNIT LABKESLING - -
596 3201 Brillian Green L. Broth - -
597 3202 Cell Clean 50 ml - -
598 3203 Cell Pack (Diluent) 20 Liter - -
599 3204 Chloride Test test - -
600 3205 Chromate Test test - -
601 3206 Control Eight Check @ 1,5 ml - -
602 3207 Control High Hematology @ 1,5 ml - -
603 3208 Control Low Hematology @ 1,5 ml - -
604 3209 Control Normal Hematology @ 1,5 ml - -
605 3210 Copper Test test - -
606 3211 Iron test test - -
607 3212 Kesadahan Test test - -
608 3213 Lactosa Broth botol - -
609 3214 Mangan Test test - -
610 3215 Na. Thio Sulfat 10 % botol - -
611 3216 Nitrite Test test - -
612 3217 Pepton Alkali botol - -
613 3218 Stroma 500 ml - -

LAIN-
UMUM BPJS JUMLAH
LAIN
KUNJUNGAN RESEP
1733 1029 2762

Mengetahui/menyetujui Yang menyerahkan

Kepala Gudang Farmasi Sie Penyimpanan & Penyaluran
Kabupaten Jember GFK Jember
NIP. NIP.
DAN LEMBAR PERMINTAAN OBAT
LPLPO)

BULAN : FEBRUARI
TAHUN : 2016
MASUK TGL. : 05

SISA STOK PERMINT PEMBERIAN

KET.
STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
223
13
100
191
1
50
209
726
350
912
-
-
3
48
641
716
-
-
19
571
190
-
-
2,693
1,055
72
-
-
833
66
570
10

35

20

-
10
 35
-
-
-
5,448
-
260
-
46
5
-
-
200
-
20
-
200

300
-

633
-
-
1
-
-
-
-
-
-
25
36
-
-
-
357
100
70
-
-
-
-
-
23
118
51
35
53
24
2
 62
-
-
-
9
-
-

5
68
-
-
-
-
-
20
-
-
388
-

90
177
237
3,250
377
-

-
-
60
-
-
18
3
-
-
277
294
300
-
-
-
-
-
-
-
-
-
-
 79
300
200
-
-
3
-
-
-
1
1
-
-
-
-
-
80
15
-
-
48
-
-
125
604
10
-
58
-
2
2
-
200
20
944
-
-
40
-
-
-
-
-
-
442
-
2,156
-
-
-
-
-
 218
20
25
10
7
490
42
2
-
-
-
29
-
-
-
-
55
107
-
96
190
-
-
30
79
-
200
170
-
40
42
44
-
-
-
-
8,855
13
100
46
6
-
-
71
-
53
-
274
-
-
-
334
16
 3
11
25
-
-
156
100
-
76
544
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
8
450
104
100
1
550
284
-
32
16
23
7,110
200
6
-
222
240
-
-
5
4
55
45
-
-
-
12
 -
840
-
120
6

35
200
-
-
33
-
667
689
-
24
145
-
-
-

-
-
-
-
-
-
20
5
2
-
-
9
15
-
24
100
8
10
-
-
-
-
-
-
1
5
-
-
1
8
-
3
 -
-
2
27
-
-
1
2
-
-
-
122
95
217
-
-
-
10
19
-
5,090
-
-
-
-
-
-
-
-
-
400
30
-
-
13
-
1
4
1
-
-
-

8
-
2,400
-
-
-
-
-
334
-
 300
143
-
-
-
-
-
-
2

-
-
-
-
-
-
-
-
-
376
4,847
-
-
-
18

20
121
-
374
-
50
-
-
-
95
-

28
26
-
12
-
-
-
-
-
-
-
-
 206
-
88
-
1
-
-
-
-
-
-
-
-
-
3
5
1
-
-
-
-
-
65
5
65
57

3,083
-
-
-
-
-
-
-
-
-
527
-
200
-
-
-
-
-
-
-
52
3
-
-
55
 -
-
50
39
2
-
-
-
-
-

-
1,254
-
30
10
-
-
10
3
-
-
734
-
-
-
-
19
24
24
19
24
-
-
32
22
24
44
20
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
 Jember, 05 Februari 2016

Yang melaporkan/meminta Yang menerima

Kepala Puskesmas Pengelola Obat Puskesmas
……………………………………
dr.Dina Nurul Agustina Hamilatul Imaniyah
NIP.198208222014122001 NIP:198002112006042020
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)

SUB UNIT PELAYANAN : ZAAL

PUSKESMAS : ROWOTENGAH BULAN :
KECAMATAN : SUMBERBARU TAHUN :
KABUPATEN : JEMBER MASUK TGL. :
PROPINSI : JAWA TIMUR

No. STOK PENERIM PERSEDI PEMAKAI SISA STOK PEMBERIAN

No. URUT NAMA OBAT SATUAN KET.
KODE AWAL AAN AAN AN STOK OPT. DAU BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 12 13 14 15 16 17
1 CEFTRIAXONE 1gr vial 105 105 30 75
2 CETADOP 200 mg ampul 5 5 5
3 CITICOLINE 500mg ampul 65 65 5 60
4 COLSANCETINE 1gr vial 50 50 20 30
5 HYOSCINE N-B ampul 120 120 10 110
6 IKANEURON 5000 ampul 80 80 10 70
7 METOCLOPRAMIDE 5 mg botol 100 100 10 90
8 ONDANSENTRON 4mg ampul 60 60 20 40
9 PIRCETAM 1gr ampul 40 40 40
10 LIDOCAIN 2ml vial 90 90 10 80
11 RANITIDIN ampul 110 100 210 120 90
12 MEDICUT NO 20 biji 90 50 140 10 130
13 STOMACH TUBE NO 16 set 5 5 5
14 STOMACH TUBE NO 12 set 5 5 5
15 JET NEBUL MASK ANAK set 20 20 5 15
16 JET NEBUL MASK DEWASA set 20 20 10 10
17 PLESTER ROLL NON WOVEN roll 1 1 1 0
18 ASEPTIC GEL botol 3 3 1 2
19 SABUN ANTI BAKTERI botol 3 3 1 2
MEDICUT NO 22 biji 50 50 10 40
MEDICUT NO 24 biji 50 50 10 40
MEDICUT NO 26 biji 50 50 10 40
PLESTER 5 X 5 M roll 5 5 1 4
INFUS SET DEWASA set 50 50 20 30
JELLY J biji 1 1 1 0
KAPAS 250 roll 1 1 1 0
SAFE GLOVE biji 200 200 100 100
UNDER PAD biji 20 20 2 18
KASSA 40 YARD X 8 CM roll 1 1 1 0
BLOOD LUNCET biji 200 200 100 100
SPUIT 3CC biji 200 200 50 150
SURGIKAL MASK FARLOOP + 3PLY biji 100 10 90
 LAIN-
KUNJUNGAN RESEP UMUM BPJS
LAIN
JUMLAH

Mengetahui Yang menerima Rowotengah,

Kepala Puskesmas Pengelola Obat Puskesmas Yang melaporkan

dr.Dina Nurul Agustina Hamilatul Imaniyah

NIP.198208222014122001 NIP:198002112006042020 Yudha dwi kristanto
 LAPORAN PEMAKAIAN DAN LEMBAR PER
(LPLPO)

SUB UNIT PELAYANAN : ZAAL

PUSKESMAS : ROWOTENGAH
KECAMATAN : SUMBERBARU
KABUPATEN : JEMBER
PROPINSI : JAWA TIMUR

No. STOK PENERIM PERSEDI PEMAKAI

No. URUT NAMA OBAT SATUAN
KODE AWAL AAN AAN AN
1 2 3 4 5 6 7 ( 5+6 ) 8
1 CHATGUT CHROM Biji - 1 1
2 CHATGUT BRAUN Biji - 1 1
3 KASSA HIDROFIL 40X80CM Biji 1 1 1
4 SAFE GLOVE M Biji 200 200 45
5 SURGIGAL GLOVE NO 7 Biji 50 50 27
6 UNDHERPAD Biji 100 100 24
7 KASSA HIDROFIL 4MX10CM BIji 100 100 20
8 SABUN ANTI BAKTERI Biji 2 2 1
9 ASEPTIK GEL Biji 2 2 1
10 MY JELLY Biji 2 2 1
11 URINE BAG Biji 5 5 2

LAIN-
KUNJUNGAN RESEP UMUM BPJS
LAIN
JUMLAH

Mengetahui Yang menerima

Kepala Puskesmas Pengelola Obat Puskesmas

dr.Dina Nurul Agustina Hamilatul Imaniyah

NIP.198208222014122001 NIP:198002112006042020
DAN LEMBAR PERMINTAAN OBAT
LPLPO)

BULAN :
TAHUN :
MASUK TGL. :

SISA STOK PERMINT PEMBERIAN

KET.
STOK OPT. AAN DAU BPJS PROG LAIN-2 TOTAL
9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1
1
o
155
23
76
80
1
1
1
3

Yang menerima Rowotengah,

engelola Obat Puskesmas Yang melaporkan

Hamilatul Imaniyah Yudha dwi kristanto

NIP:198002112006042020