59CF7000

DATA DASAR
KEPALA UPTD PUKESMAS LOHBENER

NAMA Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes
NIP NIP. 19770929 200801 2 006
Petugas Pengelola Obat

Nama dr. Yulis Susanto
NIP NIP.19820403 201412 1 001
KEPALA DINAS KESEHATAN KAB. INDRAMAYU

NAMA dr.H. Deden Bonni Koswara, MM
NIP NIP. 19740110 200212 1 008
KEPALA UPTD FARMASI KAB. INDRAMAYU

NAMA Suryatno, S.Si.,Apt
NIP NIP 19650323 198603 1 010
Hal 2
SISA STOK OBAT TIAP BULAN TAHUN 2018
Bulan
NO NAMA OBAT SATUAN Januari Februari Maret April Mei Juni Juli Agustus September Oktober Nopember Desember Jumlah
SISA STOK AKHIR
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Air Raksa Dental Use Botol - - - - - - - - - - - - -
2 Alat Suntik Sekali Pakai 1 ml Set 750 601 4,457 4,271 4,212 - - - - - - - 14,291
3 Alat Suntik Sekali Pakai 3 ml Set 1,091 699 8,056 8,004 7,765 - - - - - - - 25,615
4 Alat suntik Sekali Pakai 5 ml Set 918 912 3,870 3,835 3,823 - - - - - - - 13,358
5 Albendazol Tablet 400 mg Tablet - - - 6,480 3,437 - - - - - - - 9,917
6 Aloporinol Tablet 100 mg Tablet 4,936 4,256 4,186 3,776 3,356 - - - - - - - 20,510
7 Aminofilin Tablet 200 mg Tablet 1,200 1,080 950 820 690 - - - - - - - 4,740
8 Aminofilin Injeksi 24 mg/ml - 10 ml Ampul - - - - - - - - - - - - -
9 Amitriptilin HCL Tablet Salut 25 ml Tablet - - - - - - - - - - - - -
10 Amoksilin Kapsul 250 mg Kapsul 2,652 1,142 8,582 6,942 6,026 - - - - - - - 25,344
11 Amoksilin Kaplet 500mg Kaplet 6,740 2,820 9,490 3,060 13,760 - - - - - - - 35,870
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 586 489 642 427 720 - - - - - - - 2,864
13 Ampisilin Sirup 500 mg Kaplet - - - - - - - - - - - - -
14 Ampisilin Sirup 125 mg / 5 ml Botol - - - - - - - - - - - - -
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet - - - - - - - - - - - - -
16 Antalgin Injeksi 250 mg / ml - 2 ml Ampul - - - - - - - - - - - - -
Antasid DOEN Tablet,Kombinasi :Magnesium

Hidroksida 500 IU / g + Alumunium
17
Hidroksida 200 mg
Tablet 5,163 2,678 4,180 1,531 16,162 - - - - - - - 29,714
Anti Bakteri DOEN Salep Kombinasi

18
Basintrasin 500 IU / g + Polimiksin 1000 IU/g
Tube 49 45 41 32 25 - - - - - - - 192
19 Anti Hemoroid Doen Kombinasi Supp - - - - - - - - - - - - -
Pemakaian Obat PKM LOHBNER TAHUN 2016

Hal 3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
20 Antifungi DOEN Kombinasi : Asam Benzoat 6 Pot 185 176 175 170 168 - - - - - - - 874
% = Asam Salisilat 3 %
21 Anti Migren DOEN Kombinasi : Tablet - - - - - - - - - - - - -

Ergotamin Tartrat 1 mg + Kofein 50 mg
Antiparkinson DOEN Tablet Kombinasi :
22 Karbidopa 25 mg + Levodopa 250 mg Tablet - - - - - - - - - - - - -
23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial - - - - - - - - - - - - -

24 Aquadest Steril - 500 ml Botol - - - - - - - - - - - - -
25 Asam Askrobat ( Vit . C ) 50 mg Tablet 11,189 9,309 8,287 7,908 5,140 - - - - - - - 41,833
26 Asam Askrobat ( Vit . C ) 250 mg Tablet - - - - - - - - - - - - -
27 Asam Klorida , 0,1 N - 100 ml Botol - - - - - - - - - - - - -
28 Asam Sulfosalisilat 20 % Botol - - - - - - - - - - - - -
29 Asetosal Tablet 100 mg Tablet - - - - - - - - - - - - -
30 Asetosal Tablet 500 mg Tablet - - - - - - - - - - - - -
31 Atropin Sulfat Injeksi 0,25mg / ml - 1 ml Ampul - - - - - - - - - - - - -
32 Atropin Sulfat Tablet 0,5 mg Tablet - - - - - - - - - - - - -
33 Atropin Sulfat Tetes Mata 0,5 % - 5 ml Botol - - - - - - - - - - - - -
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Vi Vial - - - - - - - - - - - - -
35 Benzatin Benzil Penisilin Injeksi 2 ,4 Juta IU/ Vi Vial - - - - - - - - - - - - -
36 Besi Sirup 150 ml Botol - - - - - - - - - - - - -
37 Betametasol Krim , 0,1 % - 5 mg Tube 75 75 225 225 225 - - - - - - - 825
Catgut / Benang Bedah No. /0 - 3/0
38 ( Plain & Cromoic) Sachet 229 102 78 68 60 - - - - - - - 537
39 Dapson Tablet 100 mg Tablet - - - - - - - - - - - - -
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - - 200 200 200 - - - - - - - 600
41 Deksametason Tablet 0,5 mg Tablet 4,794 3,721 9,731 8,600 7,314 - - - - - - - 34,160
42 Dekstran 70 - Larutan Infus 6 % Steril - 500 ml Botol - - - - - - - - - - - - -
43 Dekstometrofan Hbr Sirup 10 mg/ 5 - 60 ml Botol - - - - - - - - - - - - -
44 Dekstrometrofan Hbr Tablet 15mg Tablet - - - - - - - - - - - - -
45 Devitalisasi Pasta (Non Asren) Botol - - - - - - - - - - - - -
46 Diazepam Injeksi 5 mg?ml - 2ml Ampul - - - - - - - - - - - - -
47 Diazepam Tablet 2 mg Tablet - - - - - - - - - - - - -
48 Diazepam Tablet 5 mg Tablet 31 21 - - - - - - - - - - 52
49 Dietikarbamazin Sitrat Tablet 100 mg Tablet - - - - - - - - - - - - -

Hal 4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - 90 90 30 - - - - - - - 210
51 Digoksin Tablet 0,25 mg Tablet 380 370 360 360 360 - - - - - - - 1,830
52 Efedrin HCL Tablet 25 mg Tablet - - - - - - - - - - - - -
53 Extrac Belladon Tablet 10 mg Tablet - - - - - - - - - - - - -
54 Epinefrina HCL / Bitartrat (Epiefrina Ampul 51 51 31 25 55 - - - - - - - 213
Adrenalina ) Injeksi 0,1 - 1ml
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - - - - - - - - - - -
56 Etambutol HCL Tablet 250 mg Tablet - - - - - - - - - - - - -
57 Etanol 70 % - 100ml Botol 22 20 15 9 45 - - - - - - - 111
58 Eter Anestetik - 140 ml Botol - - - - - - - - - - - - -
59 Etil Krorida Semprot - 100 ml Botol - - - - - - - - - - - - -
60 Eugenol Cairan - 10 ml Botol 3 3 3 3 3 - - - - - - - 15
61 Fenitoin Natrium Injeksi 50 mg / ml Ampul - - - - - - - - - - - - -
62 Fenitoin Natrium Kapsul 100 mg Kapsul - - - - - - - - - - - - -
63 Fenitoin Natrium Kapsul 30mg Kapsul - - - - - - - - - - - - -
64 Fenobarbital Injeksi 50 mg/ ml - 2 ml Ampul - - - - - - - - - - - - -
65 Fenobarbital Tablet 100 mgl Tablet - - - - - - - - - - - - -
66 Fenobarbital Tablet 30 mg Tablet - - - - - - - - - - - - -
67 Fenoksimetil Penisilin Tablet 250 mg Tablet - - - - - - - - - - - - -
68 Fenoksimetil Penisilin Tablet 500 mg Tablet - - - - - - - - - - - - -
69 Fenol Gliserol Tetes Telinga 10 % - 5 ml Botol - - - - - - - - - - - - -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 147 119 91 60 210 - - - - - - - 627
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 594 544 544 514 2,244 - - - - - - - 4,440
72 Flour Tablet 0,5 mg Tablet - - - - - - - - - - - - -
73 Furosemid Tablet 40 mg Tablet 1,374 814 814 764 500 - - - - - - - 4,266
74 Ferinokresol (Pengganti TKV) 10 ml Botol - - - - - - - - - - - - -
75 Gameksan Emulsi 1 % - ml Botol - - - - - - - - - - - - -
76 Garam Oralit 200 ml Air Sachet 400 300 150 80 80 - - - - - - - 1,010
77 Garam Oralit 1000 ml Air Sachet - - - - - - - - - - - - -
78 Gentian Violet Larutan 1 % - 10 ml Botol - - - - - - - - - - - - -
79 Glass Lonomer Cement ( GC IX ) Set - - - - - - - - - - - - -
80 Glibenklamid Tablet 5 mg Tablet - - - - - - - - - - - - -
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - - - - - - - - - - -
82 Gliserin - 10 ml Botol - - - - - - - - - - - - -

Hal 5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 100 100 120 120 120 - - - - - - - 560
84 Glukosa Larutan Infus 10 % Steril - 500 ml Botol - - - - - - - - - - - - -
85 Glukosa Larutan Infus 40 % Steril - 25 ml Ampul - - - - - - - - - - - - -
86 Griseofulvin Tablet 125 mg Mikronised Tablet 2,950 2,850 2,700 2,500 2,500 - - - - - - - 13,500
87 Gutta Percha Points Stik - - - - - - - - - - - - -
88 Haloperoidol 0,5 mg Tablet Tablet - - - - - - - - - - - - -
89 Haloperoidol 1,5 mg Tablet Tablet - - - - - - - - - - - - -
90 Haloperidol 5 mg Tablet - - - - - - - - - - - - -
91 Hidroklorotiazid ( HCT ) Tablet 25 mg Tablet - - - - - - - - - - - - -
92 Hidrokortison Krim 2,5 % Tube 141 121 279 232 216 - - - - - - - 989
93 Ibufropen Tablet 200 mg Tablet - - - - - - - - - - - - -
94 Ibufropen Tablet 400 mg Tablet 4,366 2,316 1,192 30 9,750 - - - - - - - 17,654
95 Infusion Set Anak Set 86 86 386 385 385 - - - - - - - 1,328
96 Infusion Set Dewasa Set 131 101 256 112 170 - - - - - - - 770
97 Insulin Regular Injeksi 40 IU/ml ( Human) Vial - - - - - - - - - - - - -
98 Idiol Kapsul Lunak Kapsul - - - - - - - - - - - - -
99 Ipeka 0,14 % Sirup Botol - - - - - - - - - - - - -
100 Isoniazid Tablet 300 mg Tablet - - - - - - - - - - - - -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet 500 500 500 500 500 - - - - - - - 2,500
102 Jarum Jahit ( Bedah No. 9 S/d 14 ) Pcs - - - - - - - - - - - - -
103 Kalium Permanganat Serbuk - 5 mg Botol - - - - - - - - - - - - -
104 Kalsium Hidroksida Pasta Kotak - - - - - - - - - - - - -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 6,572 3,530 5,354 3,971 7,902 - - - - - - - 27,329
106 Kapas Berlemak 500 Gram Bungkus - - - - - - - - - - - - -
107 Kapas Pembalut / Absorben 250 Gram Bungkus 4 3 7 4 1 - - - - - - - 19
108 Karbamazepin Tablet 200 mg Tablet - - - - - - - - - - - - -
109 Kasa Kompres 40 / 40 Steril Bungkus - - - - - - - - - - - - -
110 Kasa Pembalut 2 m x 80 Cm Roll 20 2 2 2 102 - - - - - - - 128
111 Kasa Kompres 18cm X 22 cm steril Roll - - - - - - - - - - - - -
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 247 230 135 85 5 - - - - - - - 702
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 55 15 15 15 200 - - - - - - - 300
114 Kasa Pembalut Hidrofil 4 m x 15 Cm Rol - - - - - - - - - - - - -
115 Ketamin 10 mg / ml Injeksi - 10 mg Vial - - - - - - - - - - - - -
116 Klofazimin,Micriize Kapsul 100 mg Kapsul - - - - - - - - - - - - -

Hal 6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
117 Kloramfenikol Kapsul 250mg Kapsul - - - - - - - - - - - - -
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - - - - - - - - - - -
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - - - - - - - - - - - - -
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 11,861 8,867 3,650 920 600 - - - - - - - 25,898
Kloroquin Fosfat Tablet 250 mg

121
( Setara Degan 100 mg Kloroquin Basa )
Tablet - - - - - - - - - - - - -
122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul - - - - - - - - - - - - -

123 Klorpromazin HCL Injeksi 5 mg/ml - 2 ml Ampul - - - - - - - - - - - - -
124 Klorpromazin HCL Tablet Salut 25 mg Tablet - - - - - - - - - - - - -
125 Klorpromazin HCL Tablet Salut 100 mg Tablet - - - - - - - - - - - - -
126 Klorpropamid Tablet 100 mg Tablet - - - - - - - - - - - - -
127 Kodein HCL Tablet 10 mg Tablet - - - - - - - - - - - - -
128 Kombinasi Pirimetamin 25 mg + Sulfadiksin 50 Tablet - - - - - - - - - - - - -
Kotrimoksazol Pediatrik Tablet,Kombinasi

129 SulfatMetoksazol 100mg + Trimetroprim 20 Tablet - - - - - - - - - - - - -
mg
Kotrimoksazol Suspensi Kombinasi :

130 Sulfametoksazol 200 mg+Trimetropin 40 Botol 280 275 270 218 180 - - - - - - - 1,223
mg/5 mg
Kotrimoksazol Tableti Kombinasi :

131 Sulfametoksazol 400 mg + Trimetropin 80 mg Tablet 5,435 5,270 4,250 3,094 15,108 - - - - - - - 33,157
132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul - - - - - - - - - - - - -

133 Kuinin (Kina) Tablet 200 mg Tablet - - - - - - - - - - - - -
134 Larutan Benedict - 100 ml Botol - - - - - - - - - - - - -
135 Larutan Eosin 2 % - 100 ml Botol - - - - - - - - - - - - -
136 Larutan Etanol Asam - 100 ml Botol - - - - - - - - - - - - -
137 Larutan Gabbet / 100 ml Botol - - - - - - - - - - - - -
138 Larutan Geimsa Stain - 100 ml Botol - - - - - - - - - - - - -
139 Larutan Karbol Fuksin - 100 ml Botol - - - - - - - - - - - - -
140 Larutan Kinyoun - 100 ml Botol - - - - - - - - - - - - -
141 Larutan Metilen Biru - 100 ml Botol - - - - - - - - - - - - -
142 Larutan Turk - 100 ml Botol - - - - - - - - - - - - -
Lidokain Komp. Injeksi, kombinasi :
143 Lidokain HCL 2% + Epineffrin 1 : 80.000 - 2 ml Ampul 443 382 329 300 472 - - - - - - - 1,926

Hal 7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
144 Lisol Mengandung Kresol Tersabun 50 % - 100 Botol - - - - - - - - - - - - -
145 Magnesium Sulfat Injeksi (IV) 20 % - 50 ml vial - - - - - - - - - - - - -
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 3 3 20 19 - - - - - - - - 45
147 Magnesium Sulfat Serbuk 30 gram Sachet - - - - - - - - - - - - -
148 Mebendazol Sirup 100 mg / 5 ml - 30 ml Botol - - - - - - - - - - - - -
149 Mebendazol 100 mg Tablet - - - - - - - - - - - - -
150 Metanol - 100 ml Botol - - - - - - - - - - - - -
151 Metilergometri Maleat (Metilergometrin) Tablet - - - - - - - - - - - - -

Tablet Salut 0,125 gram
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 Ampul 65 62 62 34 229 - - - - - - - 452

153 Metronidazol Tablet 250 mg Tablet - - - - - - - - - - - - -
154 Monoklorkamfer Mentol Cairan Botol - - - - - - - - - - - - -
155 Mummifying Pasta Botol - - - - - - - - - - - - -
156 Natrium Bikarbonat Tablet 500 mg Tablet 975 405 2,276 2,000 2,000 - - - - - - - 7,656
157 Natrium Fluoresein Tetes Mata 2 % - 5 ml Botol - - - - - - - - - - - - -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 15 9 6 4 3 - - - - - - - 37
159 Natrium Tiosulfat Injeksi 25 % - 10 ml Ampul - - - - - - - - - - - - -
160 Nistatin 100.000 IU / gram Vaginal Tablet 286 286 266 261 456 - - - - - - - 1,555
161 Nistatin 500.000 IU / gram Tablet 520 520 610 537 1,027 - - - - - - - 3,214
162 OAT Kategori 1 Dewasa Paket - - - 6 - - - - - - - - 6
163 OAT Kategori 2 Dewasa Paket - - - - - - - - - - - - -
164 OAT Kategori 3 Dewasa Paket - - - - - - - - - - - - -
165 OAT Sisipan Dewasa Paket - - - - - - - - - - - - -
166 OAT Kategori Anak Paket - - - 3 1 - - - - - - - 4
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol - - - - - - - - - - - - -
168 Oksigen Gas Dalam Tabung m3 - - - - - - - - - - - - -
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 m vial - - - - - - - - - - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 92 89 80 24 15 - - - - - - - 300
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 100 100 100 100 300 - - - - - - - 700
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 280 224 168 97 212 - - - - - - - 981
173 Paraformaldhida Tabley 1 gram Tablet - - - - - - - - - - - - -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - - - - - - - - - - - - -
175 Parasetamol Tablet 100 mg Tablet - - - - - - - - - - - - -

Hal 8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
176 Parasetamol Tablet 500 mg Tablet 7,430 5,360 16,440 9,000 1,200 - - - - - - - 39,430
177 Pembalut Gips Rol - - - - - - - - - - - - -
178 Perfenazin Tablet 4 mg Tablet - - - - - - - - - - - - -
179 Pefenazin Tablet 16 mg Tablet - - - - - - - - - - - - -
180 Petidin HCL Injeksi 50 mg / ml 2 ml Ampul - - - - - - - - - - - - -
181 Pilokarpin HCL / Nitrat Tetes Mata 2- 5 ml Botol - - - - - - - - - - - - -
182 Piperazin Sirup 20 % Botol - - - - - - - - - - - - -
183 Piperazin Tablet 500 mg Tablet - - - - - - - - - - - - -
Pirantel Pamoat Tablet 365 mg
184 (setara dgn 125 mg Basa) Tablet - - - - - - - - - - - - -
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 6,710 5,506 4,040 2,755 8,345 - - - - - - - 27,356
186 Plester 5 Yards x 2 inch Rol 15 12 9 7 14 - - - - - - - 57
Polikresulen (Kondensasi Metakresol Sulfonat

187 dan Metanal) 360 mg/ g - 10 ml Botol - - - - - - - - - - - - -
188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol - - - - - - - - - - - - -

189 Povidon Lodida 10 % - 10 ml Botol - - - - - - - - - - - - -
192 Povidon Lodida 10 % - 1000 ml Botol 1 - 8 8 8 - - - - - - - 25
193 Prazikuantel Tablet 600 ml Botol - - - - - - - - - - - - -
194 Prednison Tablet 5 mg Tablet 11,700 6,700 6,700 4,847 5,972 - - - - - - - 35,919
195 Primakuin Tablet 15 mg Tablet - - - - - - - - - - - - -
196 Prokain Benzil Penisilin 3 Juta IU / Vial Injeksi Vial - - - - - - - - - - - - -
197 Propanolol HCL Tablet 40 mg Tablet - - - - - - - - - - - - -
198 Propiltiourasil Tablet 100 mg Tablet - - - - - - - - - - - - -
199 Rabies Immune Globulin (Human) 150 IU / ml - Vial - - - - - - - - - - - - -
200 Reserpine Tablet 0,10 mg Tablet - - - - - - - - - - - - -
201 Reserpine Tablet 0,25 mg Tablet - - - - - - - - - - - - -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul - - - 250 250 - - - - - - - 500
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul - - - 1,200 1,200 - - - - - - - 2,400
204 Rifampisin Kapsul 300 mg Kapsul - - - - - - - - - - - - -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 217 110 447 396 333 - - - - - - - 1,503

Hal 9
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
208 Salbutamol Tablet 2 mg Tablet 247 136 - - - - - - - - - - 383
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 104 103 151 148 143 - - - - - - - 649
+Belerang Endap 4 % - 30 mg
210 Salisil Bedak 2 % - 50 gram Kotak 247 222 200 180 164 - - - - - - - 1,013
211 Salisil Spirtus 10 % - 25 ml Botol - - - - - - - - - - - - -
212 Semen Seng Fosfat Serbuk dan Cairan Botol 2 2 2 2 2 - - - - - - - 10
213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - - - - - - - - - - -
214 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - - - - - - - - - - -
215 Serum Anti Rabies Vial - - - - - - - - - - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 10 9 9 8 8 - - - - - - - 44
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul Vial - - - - - - - - - - - - -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml Ampul - - - - - - - - - - - - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 182 172 168 156 147 - - - - - - - 825
220 Silver Amalgam Serbuk 65 - 75 % Botol - - - - - - - - - - - - -
221 Spons Gelatin Cubicles 1 x 1 x 1 cm Buah - - - - - - - - - - - - -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Via Vial - - - - - - - - - - - - -
223 Streptomisin Sulfat Serbuk Injeksi 1500 mg/ Via Vial - - - - - - - - - - - - -
224 Sulfa Conus Kerucut (Preparat) Botol - - - - - - - - - - - - -
225 Sulfadimidin Tablet 500 mg Tablet - - - - - - - - - - - - -
226 Sulfasetmida Natrium Tetes Mata 15 % - 5 ml Botol - - - - - - - - - - - - -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Human Vial - - - - - - - - - - - - -
228 Syntetic Filing Material Set - - - - - - - - - - - - -
229 Tablet Tambah Darah Kombinasi : Tablet - - - 12,763 22,200 - - - - - - - 34,963

Besi II Sulfat 200 mg + Asam Folat 0.25 mg
230 Temporary Stooping Fletcher set - - - - - - - - - - - - -

231 Tetrasiklin HCL Tetes Mata 0,5 % - 5 ml botol - - - - - - - - - - - - -
232 Tetrasiklin HCL Kapsul 250 mg Kapsul - - - - - - - - - - - - -
233 Tetrasiklin HCL Kapsul 500 mg Kapsul 3,300 2,710 4,940 4,395 4,265 - - - - - - - 19,610
234 Tiamin HCL (Vit.B1) Injeksi 100 mg / ml -1 ml Ampul - - - - - - - - - - - - -
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 4,826 2,545 4,218 2,840 6,300 - - - - - - - 20,729
236 Tiopental Natrium Serbuk Injeksi 1000 mg / Am Ampul - - - - - - - - - - - - -
237 Triheksifenidil Hidroklorida 2 mg Tablet Tablet - - - - - - - - - - - - -
238 TriKresol Formalin (TKF) Cairan - 10 ml Botol - - - - - - - - - - - - -
239 Vaksin Rabies KeringUntuk Manusia Ampul - - - - - - - - - - - - -

Hal 10
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
240 Vaksin Rabies Vero Set - - - - - - - - - - - - -
241 Vitamin B Komplek Tablet Tablet 5,881 4,900 9,082 7,628 5,314 - - - - - - - 32,805
242 Acyclovir 200 mg Tablet 897 587 450 450 450 - - - - - - - 2,834
243 Acyclovir Krim Tube 118 93 30 30 154 - - - - - - - 425
244 Ambroxol tab 30 mg tablet - - - - - - - - - - - - -
245 Amlodipin tab 5 mg tablet 890 830 600 - - - - - - - - - 2,320
246 Amoksisilin+As klavunalat 625mg tab tablet - - - - - - - - - - - - -
247 Ampisillin serb inj 1000 mg/ml vial - - - - - - - - - - - - -
248 Antidiare Tablet - - - - - - - - - - - - -
249 Asam Mafenamat tab 500 mg Tablet 635 - 100 - - - - - - - - - 735
250 Captopril tablet 12.5 mg Tablet 2,328 1,578 850 400 7,620 - - - - - - - 12,776
251 Captopril tablet 25 mg Tablet 1,595 1,177 575 300 250 - - - - - - - 3,897
252 Ciprofloksasin tablet 500 mg tablet 450 210 1,230 1,000 700 - - - - - - - 3,590
253 Chlorampenikol TM Botol - - - - - - - - - - - - -
254 Chloramfenicol syrup 125 mg/5ml Botol - - - - - - - - - - - - -
255 Dimehydrinate 50 mg tablet tablet - - - - - - - - - - - - -
256 Domperidone tablet - - - - - - - - - - - - -
257 Domperidone syrup tablet 66 43 238 228 218 - - - - - - - 793
258 Etanol 70 % - 1000ml botol - - - - - - - - - - - -
259 Ferobion Tablet - - - - - - - - - - - - -
260 Handscoon no 7-7,5 Set - - - - - - - - - - - - -
261 IV Catheter No 18 G set 142 135 133 128 118 - - - - - - - 656
262 IV Catheter No 20 G set 100 75 38 - 155 - - - - - - - 368
265 Jeli Dopler 5000 ml botol - - - - - - - - - - - - -
266 Jeli USG 250 ml botol - - - - - - - - - - - - -
267 Loratadine tab 10 mg tablet - - - - - - - - - - - - -
268 Masker set - - - - - - - - - - - - -
269 Metronidazol tablet 500 mg tablet 3,400 3,400 3,380 3,250 3,230 - - - - - - - 16,660
270 Miconazole cream 2 % tube 162 152 149 146 146 - - - - - - - 755
271 Multivit Anak Kurang Gizi / Vical botol 120 120 120 100 100 - - - - - - - 560
272 Multivit Ibu Hamil / Hemafort kapsul 35,030 31,120 26,995 24,085 20,945 - - - - - - - 138,175
273 Nifedipin tab 10 mg tablet 1,800 1,800 1,800 1,800 3,200 - - - - - - - 10,400

Hal 11
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
274 Omeprazole tablet - - - - - - - - - - - - -
275 Ranitidin tablet 150 mg tablet 1,898 1,348 873 553 150 - - - - - - - 4,822
276 Simvastatin tab 10 mg tab 420 285 195 150 110 - - - - - - - 1,160
277 Plester 5cm x 4.5cm Roll - - - - - - - - - - - - -
278 Urine Bag set - - - - - - - - - - - - -
279 Zink Tablet 1,000 1,000 900 725 600 - - - - - - - 4,225
280 Zink Kid Botol - - - - - - - - - - - - -
281 Tes Kehamilan Set - - - - - - - - - - - - -
282 Natrium Tiroksin ( Euthyrox ) Tablet - - - - - - - - - - - - -
283 Piroksicam 10 mg Tablet - - - - - - - - - - - - -
284 Propanolol 40 mg Tablet 1,180 1,180 1,280 1,280 1,280 - - - - - - - 6,200
285 Natrium Diklofenak Tablet 1,410 960 870 670 510 - - - - - - - 4,420
286 Nefidipin kaps 10 mg Tablet - - - - - - - - - - - - -
287 Spironolakton 25 mg Tablet - - - - - - - - - - - - -
288 Mineral Mix Kotak - - - - - - - - - - - - -
289 Hemorograd ( Antihemoroid ) Kotak 924 784 774 694 134 - - - - - - - 3,310
290 Pehacaine,Lidocaine Hcl,Epineprine Ampul 46 46 26 26 26 - - - - - - - 170
291 Ampisilin serb inj i.v 1000 mg/vial Ampul - - - - - - - - - - - - -
292 Kasa 16 X 16 Roll 281 192 1,680 1,106 600 - - - - - - - 3,859
294 Molektryl Sirup Botol - - - - - - - - - - - - -
295 Yodina Tes Botol - - - - - - - - - - - - -
296 Metronidazole Suspensi 125 mg/5 ml Botol 110 102 84 84 84 - - - - - - - 464
297 Handscoon Steril no. 6.5 pcs 74 70 120 120 120 - - - - - - - 504
298 Handscoon Non Steril S pcs 1,300 1,000 1,200 800 700 - - - - - - - 5,000
299 Handscoon Non Steril M pcs 1,000 750 1,700 1,400 930 - - - - - - - 5,780
300 Handscoon Non Steril L pcs 950 875 1,200 1,025 1,000 - - - - - - - 5,050
301 Autoclik Device OneMed pcs - - - - - - - - - - - - -
302 New Antides ( Attapulgit ) tablet 1,535 1,385 1,315 1,220 1,095 - - - - - - - 6,550
303 Dextral Sirup botol - - - - - - - - - - - - -
304 Dulcolax Supp Dewasa 10 mg Supp 30 30 27 17 - - - - - - - - 104
305 Dulcolax Supp anak Supp - - - - - - - - - - - - -
306 Cefiksime Tab 100 mg tablet - - 1,315 - -
307 Alat Suntik Sekali Pakai 10 cc set 25 25 - 25 25

Hal 12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
308 Alat Suntik Sekali Pakai 20 cc set 25 25 27 25 25
309 Metformin 500 mg tab 1,875 1,865 - 1,410 1,125
310 Herbakof Sirup Botol 216 66 - - -
311 Hanscoon Steril No. 7 Pcs 200 200 25 301 300
312 Otsu Water ( Air Untuk Injeksi ) vial 18 11 25 5 -
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 281 236 1,525 353 301
314 Tropikal Anetesi Botol - - 29 - -
315 Hustab P 4 mg / 5 ml Syr Botol 198 122 320 - -
316 Seltifort Kid 60 ml Botol 109 105 8 58 49
317 Cetirizine Hcl 10 mg tab - - 404 1,034 1,000
318 Kasa 36 cm X 80 m Gulung - - - - -
319 Omeprazole kaps 20 mg Caps - - - - -
320 Ketokonazole 200 mg tab - - 85 - -
321 Acetylystein 200 mg tab - - 2,210 - -
322 Hand Rub 500 ml botol - - - - -
Indramayu,
Mengetahui : Yang Menerima :
Kepala UPTD Puskesmas Lohbener Petugas Puskesmas
Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes H. Sahrudin, S.Kep., Ners.

NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 13
REKAP PEMAKAIAN OBAT TIAP BULAN TAHUN 2018
Bulan
Rata-Rata
/ 12
PEMAKAIAN 2018
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
1 Air Raksa Dental Use Botol - - - - - - - - - - - - - -
2 Alat Suntik Sekali Pakai 1 ml Set 160 149 44 186 245 67 - - 87 63 3,995 - 4,996 416
3 Alat Suntik Sekali Pakai 3 ml Set 13 392 243 52 291 216 163 83 148 223 6,932 - 8,756 730
4 Alat suntik Sekali Pakai 5 ml Set 104 6 42 35 47 18 15 69 55 30 3,636 - 4,057 338
5 Albendazol Tablet 400 mg Tablet - - - 1,893 3,043 - - - - - 4,500 - 9,436 786
6 Aloporinol Tablet 100 mg Tablet 1,696 680 870 410 830 480 620 490 925 600 2,241 - 9,842 820
7 Aminofilin Tablet 200 mg Tablet 100 120 130 130 260 81 35 - 574 - - - 1,430 119
8 Aminofilin Injeksi 24 mg/ml - 10 ml Ampul - - - - - - - - - - - - - -
9 Amitriptilin HCL Tablet Salut 25 ml Tablet - - - - - - - - - - - - - -
10 Amoksilin Kapsul 250 mg Kapsul 3,428 1,510 1,260 1,640 2,556 2,215 825 1,800 1,150 1,740 4,296 - 22,420 1,868
11 Amoksilin Kaplet 500mg Kaplet 3,260 3,920 4,030 6,430 10,730 1,930 2,550 3,000 1,880 3,027 8,373 - 49,130 4,094
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 123 97 147 215 322 63 94 100 111 141 211 - 1,624 135
13 Ampisilin Sirup 500 mg Kaplet - - - - - - - - - - - - - -
14 Ampisilin Sirup 125 mg / 5 ml Botol - - - - - - - - - - - - - -
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet - - - - - - - - - - - - - -
16 Antalgin Injeksi 250 mg / ml - 2 ml Ampul - - - - - - - - - - - - - -

Hidroksida 500 IU / g + Alumunium
17 Tablet 2,997 2,485 3,498 2,649 4,818 1,734 2,350 1,973 2,685 3,010 4,410 - 32,609
Hidroksida 200 mg
2,717
18 Anti Bakteri DOEN Salep Kombinasi Tube 1 4 4 9 16 6 7 12 27 30 143 - 259

22
19 Anti Hemoroid Doen Kombinasi Supp - - - - - - - - - 15 25 - 40 3

Hal 14
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
20 Antifungi DOEN Kombinasi : Asam Benzoat 6 Pot 7 9 1 5 7 - - - 30 15 123 - 197

% = Asam Salisilat 3 % 16
Anti Migren DOEN Kombinasi :
21 Tablet - - - - - - - - - - - - -
Ergotamin Tartrat 1 mg + Kofein 50 mg -
22 Karbidopa 25 mg + Levodopa 250 mg Tablet - - - - - - - - - - - - -
-
23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial - - - - - - - - - - - - - -
24 Aquadest Steril - 500 ml Botol - - - - - - - - - - - - - -
25 Asam Askrobat ( Vit . C ) 50 mg Tablet 3,157 1,880 1,022 379 3,147 708 1,303 2,503 1,490 2,136 3,000 - 20,725 1,727
26 Asam Askrobat ( Vit . C ) 250 mg Tablet - - - - - - - - - - - - - -
27 Asam Klorida , 0,1 N - 100 ml Botol - - - - - - - - - - - - - -
28 Asam Sulfosalisilat 20 % Botol - - - - - - - - - - - - - -
29 Asetosal Tablet 100 mg Tablet - - - - - - - - - - - - - -
30 Asetosal Tablet 500 mg Tablet - - - - - - - - - - - - - -
31 Atropin Sulfat Injeksi 0,25mg / ml - 1 ml Ampul - - - - - - - - - - - - - -
32 Atropin Sulfat Tablet 0,5 mg Tablet - - - - - - - - - - - - - -
33 Atropin Sulfat Tetes Mata 0,5 % - 5 ml Botol - - - - - - - - - - - - - -
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Via Vial - - - - - - - - - - - - - -
35 Benzatin Benzil Penisilin Injeksi 2 ,4 Juta IU/ Via Vial - - - - - - - - - - - - - -
36 Besi Sirup 150 ml Botol - - - - - - - - - - - - - -
37 Betametasol Krim , 0,1 % - 5 mg Tube 14 - - - - - 2 - 13 9 201 - 239 20
38 Sachet 22 127 24 10 18 12 12 13 23 51 309 - 621
( Plain & Cromoic) 52
39 Dapson Tablet 100 mg Tablet - - - - - - - - - - - - - -
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - - - - - - 100 - - - 100 - 200 17
41 Deksametason Tablet 0,5 mg Tablet 1,828 1,073 990 1,131 2,417 1,449 382 701 2,420 1,890 3,472 - 17,753 1,479
42 Dekstran 70 - Larutan Infus 6 % Steril - 500 ml Botol - - - - - - - - - - - - - -
43 Dekstometrofan Hbr Sirup 10 mg/ 5 - 60 ml Botol - - - - - - - - - - - - - -
44 Dekstrometrofan Hbr Tablet 15mg Tablet - - - - - - - - - - - - - -
45 Devitalisasi Pasta (Non Asren) Botol - - - - - - - - - - - - - -
46 Diazepam Injeksi 5 mg?ml - 2ml Ampul - - - - - - - - - - - - - -
47 Diazepam Tablet 2 mg Tablet - - - - - - - - - - - - - -
48 Diazepam Tablet 5 mg Tablet 20 10 21 - - - - - - - - - 51 4
49 Dietikarbamazin Sitrat Tablet 100 mg Tablet - - - - - - - - - - - - - -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - - 60 30 - - 15 15 90 - 210 18

Hal 15
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
51 Digoksin Tablet 0,25 mg Tablet 30 10 10 - - - - - 360 - - - 410 34
52 Efedrin HCL Tablet 25 mg Tablet - - - - - - - - - - - - - -
53 Extrac Belladon Tablet 10 mg Tablet - - - - - - - - - - - - - -
Epinefrina HCL / Bitartrat (Epiefrina
54 Ampul - - 20 6 6 - 17 8 - - 30 - 87
Adrenalina ) Injeksi 0,1 - 1ml 7
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - - - - - - 2 1 7 - 10 1
56 Etambutol HCL Tablet 250 mg Tablet - - - - - - - - - - - - - -
57 Etanol 70 % - 100ml Botol 8 2 5 6 15 9 5 2 7 4 18 - 81 7
58 Eter Anestetik - 140 ml Botol - - - - - - - - - - - - - -
59 Etil Krorida Semprot - 100 ml Botol - - - - 3 - - - - - 6 - 9 1
60 Eugenol Cairan - 10 ml Botol - - - - - - - - - - 3 - 3 0
61 Fenitoin Natrium Injeksi 50 mg / ml Ampul - - - - - - - - - - - - - -
62 Fenitoin Natrium Kapsul 100 mg Kapsul - - - - - - - - - - - - - -
63 Fenitoin Natrium Kapsul 30mg Kapsul - - - - - - - - - - - - - -
64 Fenobarbital Injeksi 50 mg/ ml - 2 ml Ampul - - - - - - - - - - - - - -
65 Fenobarbital Tablet 100 mgl Tablet - - - - - - - - - - - - - -
66 Fenobarbital Tablet 30 mg Tablet - - - - - - - - - - - - - -
67 Fenoksimetil Penisilin Tablet 250 mg Tablet - - - - - - - - - - - - - -
68 Fenoksimetil Penisilin Tablet 500 mg Tablet - - - - - - - - - - - - - -
69 Fenol Gliserol Tetes Telinga 10 % - 5 ml Botol - - - - - - - - - - - - - -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 3 28 28 31 31 - - - - - 210 - 331 28
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 33 50 - 30 - 30 270 100 469 75 1,300 - 2,357 196
72 Flour Tablet 0,5 mg Tablet - - - - - - - - - - - - - -
73 Furosemid Tablet 40 mg Tablet 190 560 - 50 514 - 100 87 63 247 1,003 - 2,814 235
74 Ferinokresol (Pengganti TKV) 10 ml Botol - - - - - - - - - - - - - -
75 Gameksan Emulsi 1 % - ml Botol - - - - - - - - - - - - - -
76 Garam Oralit 200 ml Air Sachet 46 100 150 70 70 - 80 - - 40 360 - 916 76
77 Garam Oralit 1000 ml Air Sachet - - - - - - - - - - - - - -
78 Gentian Violet Larutan 1 % - 10 ml Botol - - - - - - - - - - - - - -
79 Glass Lonomer Cement ( GC IX ) Set - - 2 - - - - - - - - - 2 0
80 Glibenklamid Tablet 5 mg Tablet - - - - - - - - - 500 800 - 1,300 108
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - - - - - - - - - - - -
82 Gliserin - 10 ml Botol - - - - - - - - - - - - - -
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol - - - - - 9 1 1 1 2 106 - 120 10

Hal 16
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
84 Glukosa Larutan Infus 10 % Steril - 500 ml Botol - - - - - - - - - - - - - -
85 Glukosa Larutan Infus 40 % Steril - 25 ml Ampul - - - - - - - - - - - - - -
86 Griseofulvin Tablet 125 mg Mikronised Tablet - 100 150 200 200 - 55 40 300 90 2,015 - 3,150 263
87 Gutta Percha Points Stik - - - - - - - - - - - - - -
88 Haloperoidol 0,5 mg Tablet Tablet - - - - - - - - - - - - - -
89 Haloperoidol 1,5 mg Tablet Tablet - - - - - - - - 10 35 155 - 200 17
90 Haloperidol 5 mg Tablet - - - - - - - - - - - - - -
91 Hidroklorotiazid ( HCT ) Tablet 25 mg Tablet - - - - - - - - - - - - - -
92 Hidrokortison Krim 2,5 % Tube 51 20 34 47 63 - 8 13 17 25 153 - 431 36
93 Ibufropen Tablet 200 mg Tablet 300 - - - - - - - - 109 4,891 - 5,300 442
94 Ibufropen Tablet 400 mg Tablet 634 2,050 3,124 1,162 1,442 3,577 2,384 2,324 1,415 50 - - 18,162 1,514
95 Infusion Set Anak Set 5 - - 1 1 - - 4 - - 381 - 392 33
96 Infusion Set Dewasa Set 46 30 45 144 186 43 33 51 28 22 193 - 821 68
97 Insulin Regular Injeksi 40 IU/ml ( Human) Vial - - - - - - - - - - - - - -
98 Idiol Kapsul Lunak Kapsul - - - - - - - - - - - - - -
99 Ipeka 0,14 % Sirup Botol - - - - - - - - - - - - - -
100 Isoniazid Tablet 300 mg Tablet - - - - - - - - - - - - - -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet - - - - - - - - - - 500 - 500 42
102 Jarum Jahit ( Bedah No. 9 S/d 14 ) Pcs - - - - - - - - - - - - - -
103 Kalium Permanganat Serbuk - 5 mg Botol - - - - - - - - - - - - - -
104 Kalsium Hidroksida Pasta Kotak - - - - - - - - - - - - - -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 3,528 3,042 4,176 1,383 4,452 1,208 1,447 1,526 200 3,453 4,068 - 28,483 2,374
106 Kapas Berlemak 500 Gram Bungkus - - - - - - - - - - - - - -
107 Kapas Pembalut / Absorben 250 Gram Bungkus 1 1 - 3 6 1 - - - 1 9 - 22 2
108 Karbamazepin Tablet 200 mg Tablet - - - - - - - - - - - - - -
109 Kasa Kompres 40 / 40 Steril Bungkus - - - - - - - - - - - - - -
110 Kasa Pembalut 2 m x 80 Cm Roll 11 18 - - - 2 - - - - 100 - 131 11
111 Kasa Kompres 18cm X 22 cm steril Roll - - - - - - - - - - - - - -
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 12 17 95 50 130 5 - - - - - - 309 26
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 19 40 - - 15 100 - - 50 - 50 - 274 23
114 Kasa Pembalut Hidrofil 4 m x 15 Cm Rol - - - - - - - - - - - - - -
115 Ketamin 10 mg / ml Injeksi - 10 mg Vial - - - - - - - - - - - - - -
116 Klofazimin,Micriize Kapsul 100 mg Kapsul - - - - - - - - - - - - - -
117 Kloramfenikol Kapsul 250mg Kapsul - - - - - - - - 120 155 1,225 - 1,500 125

Hal 17
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - - - - - - - - - - - -
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - - - - - - - - - - 250 - 250 21
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 5,259 2,994 5,217 2,730 3,050 400 150 - 886 2,464 3,700 - 26,850 2,238
121 Kloroquin Fosfat Tablet 250 mg

( Setara Degan 100 mg Kloroquin Basa ) Tablet - - - - - - - - - - - - -
-
122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul - - - - - - - - - - - - - -
123 Klorpromazin HCL Injeksi 5 mg/ml - 2 ml Ampul - - - - - - - - - - - - - -
124 Klorpromazin HCL Tablet Salut 25 mg Tablet - - - - - - - - - - - - - -
125 Klorpromazin HCL Tablet Salut 100 mg Tablet - - - - - - - - - - - - - -
126 Klorpropamid Tablet 100 mg Tablet - - - - - - - - - - - - - -
127 Kodein HCL Tablet 10 mg Tablet - - - - - - - - - - - - - -
128 Kombinasi Pirimetamin 25 mg + Sulfadiksin 50 Tablet - - - - - - - - - - - - - -

129 SulfatMetoksazol 100mg + Trimetroprim 20 Tablet - - - - - - - - - - - - -
mg
-
130 Sulfametoksazol 200 mg+Trimetropin 40 Botol 50 5 26 52 90 12 24 31 46 44 173 - 553
mg/5 mg 46

131 Tablet 1,265 165 1,020 1,156 2,142 514 995 1,141 1,300 1,006 10,152 - 20,856
Sulfametoksazol 400 mg + Trimetropin 80 mg
1,738
132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul - - - - - - - - - - - - - -
133 Kuinin (Kina) Tablet 200 mg Tablet - - - - - - - - - - - - - -
134 Larutan Benedict - 100 ml Botol - - - - - - - - - - - - - -
135 Larutan Eosin 2 % - 100 ml Botol - - - - - - - - - - - - - -
136 Larutan Etanol Asam - 100 ml Botol - - - - - - - - - - - - - -
137 Larutan Gabbet / 100 ml Botol - - - - - - - - - - - - - -
138 Larutan Geimsa Stain - 100 ml Botol - - - - - - - - - - - - - -
139 Larutan Karbol Fuksin - 100 ml Botol - - - - - - - - - - - - - -
140 Larutan Kinyoun - 100 ml Botol - - - - - - - - - - - - - -
141 Larutan Metilen Biru - 100 ml Botol - - - - - - - - - - - - - -
142 Larutan Turk - 100 ml Botol - - - - - - - - - - - - - -
143 Lidokain HCL 2% + Epineffrin 1 : 80.000 - 2 ml Ampul 71 61 53 29 157 45 33 32 73 60 229 - 843
70
144 Lisol Mengandung Kresol Tersabun 50 % - 100 Botol - - - - - - - - - - - - - -

Hal 18
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
145 Magnesium Sulfat Injeksi (IV) 20 % - 50 ml vial - - - - - - - - - - - - - -
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial - - - 1 20 - - - - - - - 21 2
147 Magnesium Sulfat Serbuk 30 gram Sachet - - - - - - - - - - - - - -
148 Mebendazol Sirup 100 mg / 5 ml - 30 ml Botol - - - - - - - - - - - - - -
149 Mebendazol 100 mg Tablet - - - - - - - - - - - - - -
150 Metanol - 100 ml Botol - - - - - - - - - - - - - -
151 Metilergometri
Maleat (Metilergometrin)
Tablet Salut 0,125 gram Tablet - - - - - - - - - - - - -
-
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 3 3 - 28 33 7 22 11 7 82 100 - 296 25
153 Metronidazol Tablet 250 mg Tablet - - - - - - - - - - - - - -
154 Monoklorkamfer Mentol Cairan Botol - - - - - - - - - - - - - -
155 Mummifying Pasta Botol - - - - - - - - - - - - - -
156 Natrium Bikarbonat Tablet 500 mg Tablet 490 570 129 276 276 100 100 - 200 120 1,480 - 3,741 312
157 Natrium Fluoresein Tetes Mata 2 % - 5 ml Botol - - - - - - - - - - - - - -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 3 6 3 2 3 8 4 4 - 7 180 - 220 18
159 Natrium Tiosulfat Injeksi 25 % - 10 ml Ampul - - - - - - - - - - - - - -
160 Nistatin 100.000 IU / gram Vaginal Tablet - - 20 5 10 5 - 5 - 200 246 - 491 41
161 Nistatin 500.000 IU / gram Tablet 100 - 210 73 83 - 10 25 30 - 962 - 1,493 124
162 OAT Kategori 1 Dewasa Paket - - - - - - - - - - - - - -
165 OAT Sisipan Dewasa Paket - - - - - - - - - - - - - -
166 OAT Kategori Anak Paket - - - - - - 1 - - - - - 1 0
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol 20 - - - - - - - - - - - 20 2
168 Oksigen Gas Dalam Tabung m3 - - - - - - - - - - - - - -
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 m vial - - - - - - - - - - - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 8 3 9 56 65 1 1 3 6 15 89 - 256 21
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube - - - - - - - - 15 34 251 - 300 25
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 56 56 56 71 156 78 54 54 24 20 182 - 807 67
173 Paraformaldhida Tabley 1 gram Tablet - - - - - - - - - - - - - -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - - - - - - - 50 - - 300 - 350 29
175 Parasetamol Tablet 100 mg Tablet - - - - - - - - - - - - - -
176 Parasetamol Tablet 500 mg Tablet 6,826 2,070 11,920 7,440 15,240 900 500 - 4,550 4,530 2,920 - 56,896 4,741

Hal 19
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
177 Pembalut Gips Rol - - - - - - - - - - - - - -
178 Perfenazin Tablet 4 mg Tablet - - - - - - - - - - - - - -
179 Pefenazin Tablet 16 mg Tablet - - - - - - - - - - - - - -
180 Petidin HCL Injeksi 50 mg / ml 2 ml Ampul - - - - - - - - - - - - - -
181 Pilokarpin HCL / Nitrat Tetes Mata 2- 5 ml Botol - - - - - - - - - - - - - -
182 Piperazin Sirup 20 % Botol - - - - - - - - - - - - - -
183 Piperazin Tablet 500 mg Tablet - - - - - - - - - - - - - -
184 Pirantel Pamoat Tablet 365 mg Tablet - - - - - - - - - - - - -

(setara dgn 125 mg Basa) -
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 290 1,204 1,466 1,285 2,695 506 956 - 2,013 2,075 2,795 - 15,285 1,274
186 Plester 5 Yards x 2 inch Rol 2 3 3 2 5 4 4 3 3 4 44 - 77 6
187 Polikresulen
(Kondensasi Metakresol Sulfonat
dan Metanal) 360 mg/ g - 10 ml Botol - - - - - - - - - - - - -
-
188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol - - - - - - - - - - - - - -
189 Povidon Lodida 10 % - 10 ml Botol - - - - - - - - - - - - - -
192 Povidon Lodida 10 % - 1000 ml Botol 1 1 - - - - 1 - - - 7 - 10 1
193 Prazikuantel Tablet 600 ml Botol - - - - - - - - - - - - - -
194 Prednison Tablet 5 mg Tablet 2,970 5,000 - 1,853 3,728 1,184 1,884 1,910 794 186 1,014 - 20,523 1,710
195 Primakuin Tablet 15 mg Tablet - - - - - - - - - - - - - -
196 Prokain Benzil Penisilin 3 Juta IU / Vial Injeksi Vial - - - - - - - - - - - - - -
197 Propanolol HCL Tablet 40 mg Tablet - - - - - - - - - - - - - -
198 Propiltiourasil Tablet 100 mg Tablet - - - - - - - - - - - - - -
199 Rabies Immune Globulin (Human) 150 IU / ml - Vial - - - - - - - - - - - - - -
200 Reserpine Tablet 0,10 mg Tablet - - - - - - - - - - - - - -
201 Reserpine Tablet 0,25 mg Tablet - - - - - - - - - - - - - -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul - - - - - - - - - - 250 - 250 21
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul - - - - - - - 10 - - 1,190 - 1,200 100
204 Rifampisin Kapsul 300 mg Kapsul - - - - - - - - - - - - - -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 109 107 63 51 114 62 50 55 29 41 96 - 777 65
208 Salbutamol Tablet 2 mg Tablet 123 111 136 - - - - - 230 248 522 - 1,370 114

Hal 20
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 10 1 - 3 8 5 9 4 5 1 119 - 165

+Belerang Endap 4 % - 30 mg 14
210 Salisil Bedak 2 % - 50 gram Kotak 10 25 22 20 36 16 27 7 14 33 67 - 277 23
211 Salisil Spirtus 10 % - 25 ml Botol - - - - - - - - - - - - - -
212 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - - - - - - - 2 - 2 0
213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - - - - - - - - - - - -
214 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - - - - - - - - - - - -
215 Serum Anti Rabies Vial - - - - - - - - - - - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul - 1 - 1 1 1 2 1 1 - 13 - 21 2
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul ( Vial - - - - - - - - - - - - - -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml Ampul - - - - - - - - - - - - - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 6 10 4 12 21 15 13 5 8 26 200 - 320 27
220 Silver Amalgam Serbuk 65 - 75 % Botol - - - - - - - - - - - - - -
221 Spons Gelatin Cubicles 1 x 1 x 1 cm Buah - - - - - - - - - - - - - -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Via Vial - - - - - - - - - - - - - -
223 Streptomisin Sulfat Serbuk Injeksi 1500 mg/ Via Vial - - - - - - - - - - - - - -
224 Sulfa Conus Kerucut (Preparat) Botol - - - - - - - - - - - - - -
225 Sulfadimidin Tablet 500 mg Tablet - - - - - - - - - - - - - -
226 Sulfasetmida Natrium Tetes Mata 15 % - 5 ml Botol - - - - - - - - - - - - - -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Human Vial - - - - - - - - - - - - - -
228 Syntetic Filing Material Set - - - - - - - - - - - - - -
229 Tablet Tambah Darah Kombinasi : Tablet - - - - - - 250 44 - 2,957 54,499 - 57,750
4,813
230 Temporary Stooping Fletcher set - - 2 - - - - - - - 6 - 8 1
231 Tetrasiklin HCL Tetes Mata 0,5 % - 5 ml botol - - - - - - - - - - - - - -
232 Tetrasiklin HCL Kapsul 250 mg Kapsul - - - - - - - - - - - - - -
233 Tetrasiklin HCL Kapsul 500 mg Kapsul 2,290 590 1,270 545 675 40 90 150 230 400 3,355 - 9,635 803
234 Tiamin HCL (Vit.B1) Injeksi 100 mg / ml -1 ml Ampul - - - - - - - - - - - - - -
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 1,674 2,281 2,327 1,378 2,918 740 1,440 1,611 2,300 2,150 4,059 - 22,878 1,907
236 Tiopental Natrium Serbuk Injeksi 1000 mg / Am Ampul - - - - - - - - - - - - - -
237 Triheksifenidil Hidroklorida 2 mg Tablet Tablet - - - - - - - - - - - - - -
238 TriKresol Formalin (TKF) Cairan - 10 ml Botol - - - - - - - - - - - - - -
239 Vaksin Rabies KeringUntuk Manusia Ampul - - - - - - - - - - - - - -
240 Vaksin Rabies Vero Set - - - - - - - - - - - - - -

Hal 21
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
241 Vitamin B Komplek Tablet Tablet 1,761 981 818 1,454 3,768 1,100 1,419 1,184 2,030 44 2,537 - 17,096 1,425
242 Acyclovir 200 mg Tablet 445 310 537 - - - - - - 23 427 - 1,742 145
243 Acyclovir Krim Tube 2 25 63 - 6 - - - 1 11 132 - 240 20
244 Ambroxol tab 30 mg tablet - - - - - - - - - - - - - -
245 Amlodipin tab 5 mg tablet 10 60 230 600 600 - - - - 5 895 - 2,400 200
246 Amoksisilin+As klavunalat 625mg tab tablet - - - - - - - - - - - - - -
247 Ampisillin serb inj 1000 mg/ml vial - - - - - - - - - - - - - -
248 Antidiare Tablet - - - - - - - - - - 500 - 500 42
249 Asam Mafenamat tab 500 mg Tablet 365 635 - 100 100 - - - - - - - 1,200 100
250 Captopril tablet 12.5 mg Tablet 1,212 750 728 450 1,230 20 1,291 643 2,100 1,490 2,576 - 12,490 1,041
251 Captopril tablet 25 mg Tablet 685 418 602 275 325 150 - 100 - - 2,000 - 4,555 380
252 Ciprofloksasin tablet 500 mg tablet 590 240 180 230 530 700 - - - 520 680 - 3,670 306
253 Chlorampenikol TM Botol - - - - - - - - - - - - - -
254 Chloramfenicol syrup 125 mg/5ml Botol - - - - - - - - - - - - - -
255 Dimehydrinate 50 mg tablet tablet - - - - - - - - 180 270 550 - 1,000 83
256 Domperidone tablet 220 - - - - - - - 210 163 627 - 1,220 102
257 Domperidone syrup tablet 13 23 5 10 20 5 8 1 20 8 176 - 289 24
258 Etanol 70 % - 1000ml botol - - - - - - - - - - - - - -
259 Ferobion Tablet - - - - - - - - - - - - - -
260 Handscoon no 7-7,5 Set - - - - - - - - - - - - - -
261 IV Catheter No 18 G set - 7 2 5 15 - 1 2 3 3 109 - 147 12
262 IV Catheter No 20 G set 35 25 37 38 83 40 30 4 24 21 136 - 473 39
263 IV Catheter No 22 G set - 10 6 15 50 11 1 20 6 7 93 - 219 18
264 IV Catheter No 24 G set 6 - - 1 1 - - 4 - - 128 - 140 12
265 Jeli Dopler 5000 ml botol - - - - - - - - - - - - - -
266 Jeli USG 250 ml botol - - - - - - - - - - - - - -
267 Loratadine tab 10 mg tablet - - - - - - - - - - - - - -
268 Masker set - - - - - - - - - - 250 - 250 21
269 Metronidazol tablet 500 mg tablet 20 - 20 130 150 130 - - 720 601 1,779 - 3,550 296
270 Miconazole cream 2 % tube 11 10 3 3 3 8 1 - 21 9 107 - 176 15
271 Multivit Anak Kurang Gizi / Vical botol - - - 20 20 - - - - 7 93 - 140 12
272 Multivit Ibu Hamil / Hemafort kapsul 3,720 3,910 4,125 2,910 6,050 1,350 2,150 2,095 2,635 220 12,495 - 41,660 3,472
273 Nifedipin tab 10 mg tablet 84 - - - - - - 200 30 70 2,900 - 3,284 274
274 Omeprazole tablet - - - - - - - - 100 50 150 - 300 25

Hal 22
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
275 Ranitidin tablet 150 mg tablet 102 550 675 320 723 50 - - 510 190 1,500 - 4,620 385
276 Simvastatin tab 10 mg tab - 135 90 45 85 20 - 10 - 40 130 - 555 46
277 Plester 5cm x 4.5cm Roll - - - - - - - - - - - - - -
278 Urine Bag set - - - - - - - - - - - - - -
279 Zink Tablet - - 100 175 300 100 200 200 55 180 865 - 2,175 181
280 Zink Kid Botol - - - - - - - - - - - - - -
281 Tes Kehamilan Set - - - - - - - - - - - - - -
282 Natrium Tiroksin ( Euthyrox ) Tablet - - - - - - - - - - - - - -
283 Piroksicam 10 mg Tablet - - - - - - - - - - - - - -
284 Proponolol 10 mg Tablet - - - - - 10 100 - - 10 1,160 - 1,280 107
285 Natrium Diklofenak Tablet 550 450 90 200 360 210 150 - 1,250 1,400 1,700 - 6,360 530
286 Nefidipin kaps 10 mg Tablet - - - - - - - - - - - - - -
287 Spironolakton 25 mg Tablet - - - - - - - - - - - - - -
288 Mineral Mix Kotak - - - - - - - - - - - - - -
289 Hemorograd ( Antihemoroid ) Kotak 54 140 10 80 640 90 44 - 40 20 30 - 1,148 96
290 Pehacaine,Lidocaine Hcl,Epineprine Ampul - - 20 - - - - - 26 - - - 46 4
291 Ampisilin serb inj i.v 1000 mg/vial Ampul - - - - - - - - - - - - - -
292 Kasa 16 X 16 Roll 119 89 112 574 1,080 368 112 7 113 - - - 2,574 215
294 Molektryl Sirup Botol - - - - - - - - - - - - - -
295 Yodina Tes Botol - - - - - - - - - - - - - -
296 Metronidazole Suspensi 125 mg/5 ml Botol 19 8 18 - - - 38 - 11 5 30 - 129 11
297 Handscoon Steril no. 6.5 pcs 11 4 - - - - - 9 12 19 130 - 185 15
298 Handscoon Non Steril S pcs 300 300 100 400 500 200 200 100 100 200 900 - 3,300 275
299 Handscoon Non Steril M pcs - 250 450 300 770 450 180 50 250 600 #NAME? #NAME? #NAME? #NAME?
300 Handscoon Non Steril L pcs 250 75 175 175 200 550 75 175 100 200 700 - 2,675 223
301 Autoclik Device OneMed pcs - - - - - - #NAME? - - - 400 - #NAME? #NAME?
302 New Antides ( Attapulgit ) tablet - 150 - 95 - - - #NAME? #NAME? 967 2 - #NAME? #NAME?
303 Dextral Sirup botol 250 - 175 - 200 550 75 175 100 200 73 - 1,798 150
304 Dulcolax Supp Dewasa 10 mg Supp - - - 10 - - #NAME? - - - - - #NAME? #NAME?
305 Dulcolax Supp anak Supp - - - - - - - #NAME? #NAME? 967 - - #NAME? #NAME?
306 Cefiksime Tab 100 mg tablet - - 1,315
307 Alat Suntik Sekali Pakai 10 cc set - - (25)
308 Alat Suntik Sekali Pakai 20 cc set - - 2

Hal 23
1 2 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19
309 Metformin 500 mg tab - 10 (1,410)
310 Herbakof Sirup Botol - 150 -
311 Hanscoon Steril No. 7 Pcs - - (276)
312 Otsu Water ( Air Untuk Injeksi ) vial - 7 20
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol - 45 1,172
314 Tropikal Anetesi Botol - - 29
315 Hustab P 4 mg / 5 ml Syr Botol - 76 320
316 Seltifort Kid 60 ml Botol - 4 (50)
317 Cetirizine Hcl 10 mg tab - - (630)
318 Kasa 36 cm X 80 m Gulung - - -
319 Omeprazole kaps 20 mg Caps - - -
320 Ketokonazole 200 mg tab - - 85
321 Acetylystein 200 mg tab - - 2,210
322 Hand Rub 500 ml botol - - -
Indramayu,
Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes dr. Yulis Susanto

NIP. 19770929 200801 2 006 NIP.19820403 201412 1 001

Hal 24
PENERIMAAN OBAT TAHUN 2018
Bulan
PENERIMAAN 2018
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Air Raksa Dental Use Botol -
2 Alat Suntik Sekali Pakai 1 ml Set 3,900 3,900
3 Alat Suntik Sekali Pakai 3 ml Set 500 7,600 8,100
4 Alat suntik Sekali Pakai 5 ml Set 3,000 3,000
5 Albendazol Tablet 400 mg Tablet 8,373 1,063 9,436
6 Aloporinol Tablet 100 mg Tablet 800 2,000 2,800
7 Aminofilin Tablet 200 mg Tablet 1,000 1,000
8 Aminofilin Injeksi 24 mg/ml - 10 ml Ampul -
9 Amitriptilin HCL Tablet Salut 25 ml Tablet -
10 Amoksilin Kapsul 250 mg Kapsul 8,700 3,000 3,000 14,700
11 Amoksilin Kaplet 500mg Kaplet 10,000 10,700 15,000 2,000 5,000 42,700
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 300 400 700
13 Ampisilin Sirup 500 mg Kaplet -
14 Ampisilin Sirup 125 mg / 5 ml Botol -
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet -
16 Antalgin Injeksi 250 mg / ml - 2 ml Ampul -

Hidroksida 500 IU / g + Alumunium Hidroksida
17 200 mg Tablet 5,000 5,000 16,800 26,800

18
Tube 50 100 100 250
19 Anti Hemoroid Doen Kombinasi Supp 20 20 40
Penerimaan Obat PKM LOHBNER TAHUN 2018

Hal 25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
20 Antifungi DOEN Kombinasi : Asam Benzoat 6 Pot -
21
Tablet -
22 Karbidopa 25 mg + Levodopa 250 mg Tablet -
23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial -

24 Aquadest Steril - 500 ml Botol -
25 Asam Askrobat ( Vit . C ) 50 mg Tablet 2,000 2,000 2,000 6,000
26 Asam Askrobat ( Vit . C ) 250 mg Tablet -
27 Asam Klorida , 0,1 N - 100 ml Botol -
28 Asam Sulfosalisilat 20 % Botol -
29 Asetosal Tablet 100 mg Tablet -
30 Asetosal Tablet 500 mg Tablet -
31 Atropin Sulfat Injeksi 0,25mg / ml - 1 ml Ampul -
32 Atropin Sulfat Tablet 0,5 mg Tablet -
33 Atropin Sulfat Tetes Mata 0,5 % - 5 ml Botol -
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Via Vial -
35 Benzatin Benzil Penisilin Injeksi 2 ,4 Juta IU/ Via Vial -
36 Besi Sirup 150 ml Botol -
37 Betametasol Krim , 0,1 % - 5 mg Tube 150 150
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 240 120 360
( Plain & Cromoic)
39 Dapson Tablet 100 mg Tablet -
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul 200 200
41 Deksametason Tablet 0,5 mg Tablet 7,000 2,000 1,000 10,000
42 Dekstran 70 - Larutan Infus 6 % Steril - 500 ml Botol -
43 Dekstometrofan Hbr Sirup 10 mg/ 5 - 60 ml Botol -
44 Dekstrometrofan Hbr Tablet 15mg Tablet -
45 Devitalisasi Pasta (Non Asren) Botol -
46 Diazepam Injeksi 5 mg?ml - 2ml Ampul -
47 Diazepam Tablet 2 mg Tablet -
48 Diazepam Tablet 5 mg Tablet -
49 Dietikarbamazin Sitrat Tablet 100 mg Tablet -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 90 90 30 210

Hal 26
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
51 Digoksin Tablet 0,25 mg Tablet -
52 Efedrin HCL Tablet 25 mg Tablet -
53 Extrac Belladon Tablet 10 mg Tablet -
54
Ampul 30 30
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol 10 10
56 Etambutol HCL Tablet 250 mg Tablet -
57 Etanol 70 % - 100ml Botol 45 45
58 Eter Anestetik - 140 ml Botol -
59 Etil Krorida Semprot - 100 ml Botol 3 6 9
60 Eugenol Cairan - 10 ml Botol 3 3
61 Fenitoin Natrium Injeksi 50 mg / ml Ampul -
62 Fenitoin Natrium Kapsul 100 mg Kapsul -
63 Fenitoin Natrium Kapsul 30mg Kapsul -
64 Fenobarbital Injeksi 50 mg/ ml - 2 ml Ampul -
65 Fenobarbital Tablet 100 mgl Tablet -
66 Fenobarbital Tablet 30 mg Tablet -
67 Fenoksimetil Penisilin Tablet 250 mg Tablet -
68 Fenoksimetil Penisilin Tablet 500 mg Tablet -
69 Fenol Gliserol Tetes Telinga 10 % - 5 ml Botol -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 150 150 300
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 1,700 1,700
72 Flour Tablet 0,5 mg Tablet -
73 Furosemid Tablet 40 mg Tablet 200 1,000 1,200
74 Ferinokresol (Pengganti TKV) 10 ml Botol -
75 Gameksan Emulsi 1 % - ml Botol -
76 Garam Oralit 200 ml Air Sachet 400 400
77 Garam Oralit 1000 ml Air Sachet -
78 Gentian Violet Larutan 1 % - 10 ml Botol -
79 Glass Lonomer Cement ( GC IX ) Set 2 2
80 Glibenklamid Tablet 5 mg Tablet 1,000 300 1,300
81 Gliseril Guayakolat Tablet 100 mg Tablet -
82 Gliserin - 10 ml Botol -
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 20 20

Hal 27
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
84 Glukosa Larutan Infus 10 % Steril - 500 ml Botol -
85 Glukosa Larutan Infus 40 % Steril - 25 ml Ampul -
86 Griseofulvin Tablet 125 mg Mikronised Tablet 2,000 2,000
87 Gutta Percha Points Stik -
88 Haloperoidol 0,5 mg Tablet Tablet -
89 Haloperoidol 1,5 mg Tablet Tablet 200 200
90 Haloperidol 5 mg Tablet -
91 Hidroklorotiazid ( HCT ) Tablet 25 mg Tablet -
92 Hidrokortison Krim 2,5 % Tube 192 192
93 Ibufropen Tablet 200 mg Tablet 5,000 5,000
94 Ibufropen Tablet 400 mg Tablet 5,000 2,000 10,000 17,000
95 Infusion Set Anak Set 300 300
96 Infusion Set Dewasa Set 100 200 100 200 600
97 Insulin Regular Injeksi 40 IU/ml ( Human) Vial -
98 Idiol Kapsul Lunak Kapsul -
99 Ipeka 0,14 % Sirup Botol -
100 Isoniazid Tablet 300 mg Tablet -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet -
102 Jarum Jahit ( Bedah No. 9 S/d 14 ) Pcs -
103 Kalium Permanganat Serbuk - 5 mg Botol -
104 Kalsium Hidroksida Pasta Kotak -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 5,000 6,000 7,000 4,000 22,000
106 Kapas Berlemak 500 Gram Bungkus -
107 Kapas Pembalut / Absorben 250 Gram Bungkus 3 4 10 17
108 Karbamazepin Tablet 200 mg Tablet -
109 Kasa Kompres 40 / 40 Steril Bungkus -
110 Kasa Pembalut 2 m x 80 Cm Roll 100 100
111 Kasa Kompres 18cm X 22 cm steril Roll -
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 100 100
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 200 200
114 Kasa Pembalut Hidrofil 4 m x 15 Cm Rol -
115 Ketamin 10 mg / ml Injeksi - 10 mg Vial -
116 Klofazimin,Micriize Kapsul 100 mg Kapsul -
117 Kloramfenikol Kapsul 250mg Kapsul 1,000 500 1,500

Hal 28
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube -
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol 250 250
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 7,000 1,000 3,000 3,000 14,000
121 Kloroquin Fosfat Tablet 250 mg Tablet -

122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul -

123 Klorpromazin HCL Injeksi 5 mg/ml - 2 ml Ampul -
124 Klorpromazin HCL Tablet Salut 25 mg Tablet -
125 Klorpromazin HCL Tablet Salut 100 mg Tablet -
126 Klorpropamid Tablet 100 mg Tablet -
127 Kodein HCL Tablet 10 mg Tablet -
128 Kombinasi Pirimetamin 25 mg + Sulfadiksin 50 Tablet -

129 SulfatMetoksazol 100mg + Trimetroprim 20 Tablet -
mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 300 21 50 100 471
mg

131
Tablet 4,000 13,000 17,000
132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul -

133 Kuinin (Kina) Tablet 200 mg Tablet -
134 Larutan Benedict - 100 ml Botol -
135 Larutan Eosin 2 % - 100 ml Botol -
136 Larutan Etanol Asam - 100 ml Botol -
137 Larutan Gabbet / 100 ml Botol -
138 Larutan Geimsa Stain - 100 ml Botol -
139 Larutan Karbol Fuksin - 100 ml Botol -
140 Larutan Kinyoun - 100 ml Botol -
141 Larutan Metilen Biru - 100 ml Botol -
142 Larutan Turk - 100 ml Botol -
143 Lidokain HCL 2% + Epineffrin 1 : 80.000 - 2 ml Ampul 420 300 720

Hal 29
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
144 Lisol Mengandung Kresol Tersabun 50 % - 100 m Botol -
145 Magnesium Sulfat Injeksi (IV) 20 % - 50 ml vial -
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 17 17
147 Magnesium Sulfat Serbuk 30 gram Sachet -
148 Mebendazol Sirup 100 mg / 5 ml - 30 ml Botol -
149 Mebendazol 100 mg Tablet -
150 Metanol - 100 ml Botol -
151 Metilergometri Maleat (Metilergometrin) Tablet -

152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 200 200

153 Metronidazol Tablet 250 mg Tablet -
154 Monoklorkamfer Mentol Cairan Botol -
155 Mummifying Pasta Botol -
156 Natrium Bikarbonat Tablet 500 mg Tablet 2,000 2,000
157 Natrium Fluoresein Tetes Mata 2 % - 5 ml Botol -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 200 200
159 Natrium Tiosulfat Injeksi 25 % - 10 ml Ampul -
160 Nistatin 100.000 IU / gram Vaginal Tablet 200 200
161 Nistatin 500.000 IU / gram Tablet 500 300 500 1,300
162 OAT Kategori 1 Dewasa Paket 6 6
163 OAT Kategori 2 Dewasa Paket -
164 OAT Kategori 3 Dewasa Paket -
165 OAT Sisipan Dewasa Paket -
166 OAT Kategori Anak Paket 3 3
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol -
168 Oksigen Gas Dalam Tabung m3 -
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 m vial -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 100 100 200
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 100 200 300
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 100 200 200 500
173 Paraformaldhida Tabley 1 gram Tablet -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol 50 300 350
175 Parasetamol Tablet 100 mg Tablet -

Hal 30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
176 Parasetamol Tablet 500 mg Tablet 10,000 23,000 200 5,000 5,000 2,000 45,200
177 Pembalut Gips Rol -
178 Perfenazin Tablet 4 mg Tablet -
179 Pefenazin Tablet 16 mg Tablet -
180 Petidin HCL Injeksi 50 mg / ml 2 ml Ampul -
181 Pilokarpin HCL / Nitrat Tetes Mata 2- 5 ml Botol -
182 Piperazin Sirup 20 % Botol -
183 Piperazin Tablet 500 mg Tablet -
184 (setara dgn 125 mg Basa) Tablet -
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 7,000 7,000 14,000
186 Plester 5 Yards x 2 inch Rol 10 10 48 68

187 dan Metanal) 360 mg/ g - 10 ml Botol -
188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol -

189 Povidon Lodida 10 % - 10 ml Botol -
192 Povidon Lodida 10 % - 1000 ml Botol 2 8 10
193 Prazikuantel Tablet 600 ml Botol -
194 Prednison Tablet 5 mg Tablet 10,000 3,000 1,000 14,000
195 Primakuin Tablet 15 mg Tablet -
196 Prokain Benzil Penisilin 3 Juta IU / Vial Injeksi Vial -
197 Propanolol HCL Tablet 40 mg Tablet -
198 Propiltiourasil Tablet 100 mg Tablet -
199 Rabies Immune Globulin (Human) 150 IU / ml - Vial -
200 Reserpine Tablet 0,10 mg Tablet -
201 Reserpine Tablet 0,25 mg Tablet -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul 250 250
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul 1,200 1,200
204 Rifampisin Kapsul 300 mg Kapsul -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 300 400 700

Hal 31
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
208 Salbutamol Tablet 2 mg Tablet 500 500 1,000
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 48 48
210 Salisil Bedak 2 % - 50 gram Kotak -
211 Salisil Spirtus 10 % - 25 ml Botol -
212 Semen Seng Fosfat Serbuk dan Cairan Botol -
213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial -
214 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial -
215 Serum Anti Rabies Vial -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 10 10 20
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul ( Vial -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml - Ampul - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 120 120
220 Silver Amalgam Serbuk 65 - 75 % Botol -
221 Spons Gelatin Cubicles 1 x 1 x 1 cm Buah -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Via Vial -
223 Streptomisin Sulfat Serbuk Injeksi 1500 mg/ Via Vial -
224 Sulfa Conus Kerucut (Preparat) Botol -
225 Sulfadimidin Tablet 500 mg Tablet -
226 Sulfasetmida Natrium Tetes Mata 15 % - 5 ml Botol -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Human Vial -
228 Syntetic Filing Material Set -
229 Tablet Tambah Darah Kombinasi : Tablet 12,763 9,437 35,550 57,750
230 Temporary Stooping Fletcher set 2 6 8

231 Tetrasiklin HCL Tetes Mata 0,5 % - 5 ml botol -
232 Tetrasiklin HCL Kapsul 250 mg Kapsul -
233 Tetrasiklin HCL Kapsul 500 mg Kapsul 5,000 3,500 8,500
234 Tiamin HCL (Vit.B1) Injeksi 100 mg / ml -1 ml Ampul -
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 5,000 4,000 5,000 5,000 1,000 20,000
236 Tiopental Natrium Serbuk Injeksi 1000 mg / Am Ampul -
237 Triheksifenidil Hidroklorida 2 mg Tablet Tablet -
238 TriKresol Formalin (TKF) Cairan - 10 ml Botol -
239 Vaksin Rabies KeringUntuk Manusia Ampul -

Hal 32
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
240 Vaksin Rabies Vero Set -
241 Vitamin B Komplek Tablet Tablet 5,000 5,000 3,000 13,000
242 Acyclovir 200 mg Tablet 400 400
243 Acyclovir Krim Tube 120 120 240
244 Ambroxol tab 30 mg tablet -
245 Amlodipin tab 5 mg tablet 900 900 1,800
246 Amoksisilin+As klavunalat 625mg tab tablet -
247 Ampisillin serb inj 1000 mg/ml vial -
248 Antidiare Tablet 500 500
249 Asam Mafenamat tab 500 mg Tablet 1,000 100 1,100
250 Captopril tablet 12.5 mg Tablet 8,000 500 8,500
251 Captopril tablet 25 mg Tablet 2,000 2,000
252 Ciprofloksasin tablet 500 mg tablet 1,200 1,200 2,400
253 Chlorampenikol 0,5 % Tetes Mata Botol -
254 Chloramfenicol syrup 125 mg/5ml Botol -
255 Dimehydrinate 50 mg tablet tablet 1,000 1,000
256 Domperidone 10 mg tablet 1,000 1,000
257 Domperidone syrup tablet 200 200
258 Etanol 70 % - 1000ml botol 15
259 Ferobion Tablet -
260 Handscoon no 7-7,5 Set -
261 IV Catheter No 18 G set -
262 IV Catheter No 20 G set 100 200 100 400
263 IV Catheter No 22 G set 100 100
264 IV Catheter No 24 G set -
265 Jeli Dopler 5000 ml botol -
266 Jeli USG 250 ml botol -
267 Loratadine tab 10 mg tablet -
268 Masker set 250 250
269 Metronidazol tablet 500 mg tablet 2,000 2,000
270 Miconazole cream 2 % tube -
271 Multivit Anak Kurang Gizi / Vical botol -
272 Multivit Ibu Hamil / Hemafort kapsul -
273 Nifedipin tab 10 mg tablet 1,400 1,400

Hal 33
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
274 Omeprazole kaps 20 mg tablet 300 300
275 Ranitidin tablet 150 mg tablet 2,000 200 1,000 100 1,000 4,300
276 Simvastatin tab 10 mg tab 300 90 390
277 Plester 5cm x 4.5cm Roll -
278 Urine Bag set -
279 Zink Kid Tab dispersible 20 mg Tablet 1,000 1,000 2,000
280 Zink Kid Botol -
281 Tes kehamilan Set -
282 Natrium Tiroksin ( Euthyrox ) Tablet -
283 Piroksicam 10 mg Tablet -
284 Propanolol 40 mg Tablet 100 100
285 Natrium Diklofenak 50 mg Tablet 1,500 1,200 1,500 4,200
286 Nefidipin kaps 10 mg Tablet -
287 Spironolakton 25 mg Tablet -
288 Mineral Mix Kotak -
289 Hemorograd ( Antihemoroid ) Kotak 90 90
290 Pehacaine,Lidocaine Hcl,Epineprine Ampul -
291 Ampisilin serb inj i.v 1000 mg/vial Ampul -
292 Kasa 16 X 16 Roll 320 1,600 1,920
294 Molektryl Sirup Botol -
295 Yodina Tes Botol -
296 Metronidazole Suspensi 125 mg/5 ml Botol -
297 Handscoon Steril no. 6.5 pcs 50 50 100
298 Handscoon Non Steril S pcs 1,000 300 1,000 2,300
299 Handscoon Non Steril M pcs 1,000 1,400 1,000 300 3,700
300 Handscoon Non Steril L pcs 500 500 1,000
301 Autoclik Device OneMed pcs -
302 New Antides ( Attapulgit ) tablet -
303 Dextral Sirup botol -
304 Dulcolax Supp Dewasa 10 mg Supp -
305 Dulcolax Supp anak Supp -
306 Cefiksime Tab 100 mg tablet
307 Alat Suntik Sekali Pakai 10 cc set

Hal 34
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
308 Alat Suntik Sekali Pakai 20 cc set
309 Metformin 500 mg tab 400
310 Herbakof Sirup Botol 144 48
311 Hanscoon Steril No. 7 Pcs 150
312 Otsu Water ( Air Untuk Injeksi ) vial
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 150 200
314 Tropikal Anetesi Botol
315 Hustab P 4 mg / 5 ml Syr Botol 200
316 Seltifort Kid 60 ml Botol 120
317 Cetirizine Hcl 10 mg tab 2,250 2,250 4,500 5,000
318 Kasa 36 cm X 80 m Gulung - 10
319 Omeprazole kaps 20 mg Caps 300
320 Ketokonazole 200 mg tab 1,000
321 Acetylystein 200 mg tab 960 960 960
322 Hand Rub 500 ml botol 40
323 Sianokobalamin 50 mg Tab 100
324 Klindamicyn 150 mg Caps 2,000
Indramayu,
Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes dr. Yulis Susanto

NIP. 19770929 200801 2 006 NIP.19820403 201412 1 001

Hal 35
FORM : LPLPO
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS 2018
PUSKESMAS : LOHBENER DOKUMEN NOMOR TANGGAL

KECAMATAN : INDRAMAYU DINKES KAB.
KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : Januari 2,018 UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : Februari 2,018 PUSKESMAS 442.3/ / Pkm 8 / Pebruari / 2018
PEMBERIAN
STOK SISA STOK
NO NAMA OBAT SATUAN AWAL PENERIMA PERSEDIA PEMAKAIA AKHIR STOK OPT. PERMINTA JUMLAH
AN AN N AN APBN ASKES APBD I APBD II PROGRAM LAIN LAIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Air Raksa Dental Use Botol - - - -
2 Alat Suntik Sekali Pakai 1 ml Set 910 - 910 160 750
3 Alat Suntik Sekali Pakai 3 ml Set 604 500 1,104 13 1,091
4 Alat suntik Sekali Pakai 5 ml Set 1,022 - 1,022 104 918
5 Albendazol Tablet 400 mg Tablet - - - -
6 Aloporinol Tablet 100 mg Tablet 6,632 - 6,632 1,696 4,936
7 Aminofilin Tablet 200 mg Tablet 300 1,000 1,300 100 1,200
8 Aminofilin Injeksi 24 mg/ml - 10 ml Ampul - - - -
9 Amitriptilin HCL Tablet Salut 25 ml Tablet - - - - -
10 Amoksilin Kapsul 250 mg Kapsul 6,080 - 6,080 3,428 2,652
11 Amoksilin Kaplet 500mg Kaplet 10,000 10,000 3,260 6,740
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 709 - 709 123 586
13 Ampisilin Sirup 500 mg Kaplet - - - -
14 Ampisilin Sirup 125 mg / 5 ml Botol - - - -
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet - - - -
16 Antalgin Injeksi 250 mg / ml - 2 ml Ampul - - - -
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet 3,160 5,000 8,160 2,997 5,163
200 mg

18
Basintrasin 500 IU / g + Polimiksin 1000 IU / g
Tube 50 50 1 49
LPLPO UPT PKM LOHBENER TAHUN 2018

Hal 36
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
19 Anti Hemoroid Doen Kombinasi Supp - - - -
Antifungi DOEN Kombinasi : Asam Benzoat 6
20
Pot 192 - 192 7 185
21 Anti Migren DOEN Kombinasi : Tablet - - - -

22 Karbidopa 25 mg + Levodopa 250 mg Tablet - - - -
23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial - - - -

24 Aquadest Steril - 500 ml Botol - - - -
25 Asam Askrobat ( Vit . C ) 50 mg Tablet 14,346 - 14,346 3,157 11,189
26 Asam Askrobat ( Vit . C ) 250 mg Tablet - - - -
27 Asam Klorida , 0,1 N - 100 ml Botol - - - -
28 Asam Sulfosalisilat 20 % Botol - - - -
29 Asetosal Tablet 100 mg Tablet - - - -
30 Asetosal Tablet 500 mg Tablet - - - -
31 Atropin Sulfat Injeksi 0,25mg / ml - 1 ml Ampul - - - -
32 Atropin Sulfat Tablet 0,5 mg Tablet - - - -
33 Atropin Sulfat Tetes Mata 0,5 % - 5 ml Botol - - - -
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Via Vial - - - -
35 Benzatin Benzil Penisilin Injeksi 2 ,4 Juta IU/ Via Vial - - - -
36 Besi Sirup 150 ml Botol - - - -
37 Betametasol Krim , 0,1 % - 5 mg Tube 89 - 89 14 75
38
( Plain & Cromoic)
Sachet 251 - 251 22 229
39 Dapson Tablet 100 mg Tablet - - - -
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - - - -
41 Deksametason Tablet 0,5 mg Tablet 6,622 - 6,622 1,828 4,794
42 Dekstran 70 - Larutan Infus 6 % Steril - 500 ml Botol - - - -
43 Dekstometrofan Hbr Sirup 10 mg/ 5 - 60 ml Botol - - - -
44 Dekstrometrofan Hbr Tablet 15mg Tablet - - - -
45 Devitalisasi Pasta (Non Asren) Botol - - - -
46 Diazepam Injeksi 5 mg?ml - 2ml Ampul - - - -
47 Diazepam Tablet 2 mg Tablet - - - -
48 Diazepam Tablet 5 mg Tablet 51 - 51 20 31

Hal 37
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
49 Dietikarbamazin Sitrat Tablet 100 mg Tablet - - - -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - -
51 Digoksin Tablet 0,25 mg Tablet 410 - 410 30 380
52 Efedrin HCL Tablet 25 mg Tablet - - - -
53 Extrac Belladon Tablet 10 mg Tablet - - - -
54 Epinefrina HCL / Bitartrat (Epiefrina Ampul 51 - 51 - 51
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - -
56 Etambutol HCL Tablet 250 mg Tablet - - - -
57 Etanol 70 % - 100ml Botol 30 - 30 8 22
58 Eter Anestetik - 140 ml Botol - - - -
59 Etil Krorida Semprot - 100 ml Botol - - - -
60 Eugenol Cairan - 10 ml Botol 3 3 - 3
61 Fenitoin Natrium Injeksi 50 mg / ml Ampul - - - -
62 Fenitoin Natrium Kapsul 100 mg Kapsul - - - -
63 Fenitoin Natrium Kapsul 30mg Kapsul - - - -
64 Fenobarbital Injeksi 50 mg/ ml - 2 ml Ampul - - - -
65 Fenobarbital Tablet 100 mgl Tablet - - - -
66 Fenobarbital Tablet 30 mg Tablet - - - -
67 Fenoksimetil Penisilin Tablet 250 mg Tablet - - - -
68 Fenoksimetil Penisilin Tablet 500 mg Tablet - - - -
69 Fenol Gliserol Tetes Telinga 10 % - 5 ml Botol - - - -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 150 150 3 147
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 627 - 627 33 594
72 Flour Tablet 0,5 mg Tablet - - - -
73 Furosemid Tablet 40 mg Tablet 1,564 - 1,564 190 1,374
74 Ferinokresol (Pengganti TKV) 10 ml Botol - - - -
75 Gameksan Emulsi 1 % - ml Botol - - - -
76 Garam Oralit 200 ml Air Sachet 446 - 446 46 400
77 Garam Oralit 1000 ml Air Sachet - - - -
78 Gentian Violet Larutan 1 % - 10 ml Botol - - - -
79 Glass Lonomer Cement ( GC IX ) Set - - - -
80 Glibenklamid Tablet 5 mg Tablet - - - -
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - -

Hal 38
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
82 Gliserin - 10 ml Botol - - - -
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 100 - 100 - 100
84 Glukosa Larutan Infus 10 % Steril - 500 ml Botol - - - -
85 Glukosa Larutan Infus 40 % Steril - 25 ml Ampul - - - -
86 Griseofulvin Tablet 125 mg Mikronised Tablet 950 2,000 2,950 - 2,950
87 Gutta Percha Points Stik - - - -
88 Haloperoidol 0,5 mg Tablet Tablet - - - -
89 Haloperoidol 1,5 mg Tablet Tablet - - - -
90 Haloperidol 5 mg Tablet - - - -
91 Hidroklorotiazid ( HCT ) Tablet 25 mg Tablet - - - -
92 Hidrokortison Krim 2,5 % Tube 192 - 192 51 141
93 Ibufropen Tablet 200 mg Tablet 300 - 300 300 -
94 Ibufropen Tablet 400 mg Tablet 5,000 5,000 634 4,366
95 Infusion Set Anak Set 91 - 91 5 86
97 Insulin Regular Injeksi 40 IU/ml ( Human) Vial - - - -
98 Idiol Kapsul Lunak Kapsul - - - -
99 Ipeka 0,14 % Sirup Botol - - - -
100 Isoniazid Tablet 300 mg Tablet - - - -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet 500 - 500 - 500
102 Jarum Jahit ( Bedah No. 9 S/d 14 ) Pcs - - - -
103 Kalium Permanganat Serbuk - 5 mg Botol - - - -
104 Kalsium Hidroksida Pasta Kotak - - - -
106 Kapas Berlemak 500 Gram Bungkus - - - -
107 Kapas Pembalut / Absorben 250 Gram Bungkus 2 3 5 1 4
108 Karbamazepin Tablet 200 mg Tablet - - - -
109 Kasa Kompres 40 / 40 Steril Bungkus - - - -
110 Kasa Pembalut 2 m x 80 Cm Roll 31 - 31 11 20
111 Kasa Kompres 18cm X 22 cm steril Roll - - - -
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 159 100 259 12 247
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 74 - 74 19 55
114 Kasa Pembalut Hidrofil 4 m x 15 Cm Rol - - - -

Hal 39
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
115 Ketamin 10 mg / ml Injeksi - 10 mg Vial - - - -
116 Klofazimin,Micriize Kapsul 100 mg Kapsul - - - -
117 Kloramfenikol Kapsul 250mg Kapsul - - - -
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - -
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - - - -
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 10,120 7,000 17,120 5,259 11,861
121 Kloroquin Fosfat Tablet 250 mg Tablet - - - -

122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul - - - -

123 Klorpromazin HCL Injeksi 5 mg/ml - 2 ml Ampul - - - -
124 Klorpromazin HCL Tablet Salut 25 mg Tablet - - - -
125 Klorpromazin HCL Tablet Salut 100 mg Tablet - - - -
126 Klorpropamid Tablet 100 mg Tablet - - - -
127 Kodein HCL Tablet 10 mg Tablet - - - -
128 Kombinasi Pirimetamin 25 mg + Sulfadiksin 50 Tablet - - - -

129 SulfatMetoksazol 100mg + Trimetroprim 20 Tablet - - - -
mg

130 Sulfametoksazol 200 mg+Trimetropin 40 Botol 30 300 330 50 280
mg/5mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 2,700 4,000 6,700 1,265 5,435
132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul - - - -

133 Kuinin (Kina) Tablet 200 mg Tablet - - - -
134 Larutan Benedict - 100 ml Botol - - - -
135 Larutan Eosin 2 % - 100 ml Botol - - - -
136 Larutan Etanol Asam - 100 ml Botol - - - -
137 Larutan Gabbet / 100 ml Botol - - - -
138 Larutan Geimsa Stain - 100 ml Botol - - - -
139 Larutan Karbol Fuksin - 100 ml Botol - - - -
140 Larutan Kinyoun - 100 ml Botol - - - -
141 Larutan Metilen Biru - 100 ml Botol - - - -

Hal 40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
142 Larutan Turk - 100 ml Botol - - - -
143
Lidokain HCL 2% + Epineffrin 1 : 80.000 - 2 ml
Ampul 94 420 514 71 443
144 Lisol Mengandung Kresol Tersabun 50 % - 100 m Botol - - - -

145 Magnesium Sulfat Injeksi (IV) 20 % - 50 ml vial - - - -
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 3 - 3 - 3
147 Magnesium Sulfat Serbuk 30 gram Sachet - - - -
148 Mebendazol Sirup 100 mg / 5 ml - 30 ml Botol - - - -
149 Mebendazol 100 mg Tablet - - - -
150 Metanol - 100 ml Botol - - - -
151 Metilergometri Maleat (Metilergometrin) Tablet - - - -

152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 68 - 68 3 65

153 Metronidazol Tablet 250 mg Tablet - - - -
154 Monoklorkamfer Mentol Cairan Botol - - - -
155 Mummifying Pasta Botol - - - -
156 Natrium Bikarbonat Tablet 500 mg Tablet 1,465 - 1,465 490 975
157 Natrium Fluoresein Tetes Mata 2 % - 5 ml Botol - - - -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 18 - 18 3 15
159 Natrium Tiosulfat Injeksi 25 % - 10 ml Ampul - - - -
160 Nistatin 100.000 IU / gram Vaginal Tablet 286 - 286 - 286
161 Nistatin 500.000 IU / gram Tablet 120 500 620 100 520
162 OAT Kategori 1 Dewasa Paket - - - -
165 OAT Sisipan Dewasa Paket - - - -
166 OAT Kategori Anak Paket - - - -
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol 20 - 20 20 -
168 Oksigen Gas Dalam Tabung m3 - - - -
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 m vial - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 100 100 8 92
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 100 100 - 100
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 236 100 336 56 280

Hal 41
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
173 Paraformaldhida Tabley 1 gram Tablet - - - -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - - - -
175 Parasetamol Tablet 100 mg Tablet - - - -
176 Parasetamol Tablet 500 mg Tablet 4,256 10,000 14,256 6,826 7,430
177 Pembalut Gips Rol - - - -
178 Perfenazin Tablet 4 mg Tablet - - - -
179 Pefenazin Tablet 16 mg Tablet - - - -
180 Petidin HCL Injeksi 50 mg / ml 2 ml Ampul - - - -
181 Pilokarpin HCL / Nitrat Tetes Mata 2- 5 ml Botol - - - -
182 Piperazin Sirup 20 % Botol - - - -
183 Piperazin Tablet 500 mg Tablet - - - -
184 Pirantel Pamoat Tablet 365 mg Tablet - - - -
(setara dgn 125 mg Basa)
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 7,000 7,000 290 6,710
186 Plester 5 Yards x 2 inch Rol 7 10 17 2 15

187 dan Metanal) 360 mg/ g - 10 ml Botol - - - -
188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol - - - -

189 Povidon Lodida 10 % - 10 ml Botol - - - -
192 Povidon Lodida 10 % - 1000 ml Botol 2 2 1 1
193 Prazikuantel Tablet 600 ml Botol - - - -
194 Prednison Tablet 5 mg Tablet 4,670 10,000 14,670 2,970 11,700
195 Primakuin Tablet 15 mg Tablet - - - -
196 Prokain Benzil Penisilin 3 Juta IU / Vial Injeksi Vial - - - -
197 Propanolol HCL Tablet 40 mg Tablet - - - -
198 Propiltiourasil Tablet 100 mg Tablet - - - -
199 Rabies Immune Globulin (Human) 150 IU / ml - Vial - - - -
200 Reserpine Tablet 0,10 mg Tablet - - - -
201 Reserpine Tablet 0,25 mg Tablet - - - -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul - - - -
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul - - - -

Hal 42
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
204 Rifampisin Kapsul 300 mg Kapsul - - - -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 26 300 326 109 217
208 Salbutamol Tablet 2 mg Tablet 370 - 370 123 247
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % + Pot 114 - 114 10 104
Belerang Endap 4 % - 30 mg
210 Salisil Bedak 2 % - 50 gram Kotak 257 - 257 10 247
211 Salisil Spirtus 10 % - 25 ml Botol - - - -
212 Semen Seng Fosfat Serbuk dan Cairan Botol 2 - 2 - 2
213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - -
214 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - -
215 Serum Anti Rabies Vial - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 10 10 - 10
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul ( Vial - - - -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml - Ampul - - - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 188 - 188 6 182
220 Silver Amalgam Serbuk 65 - 75 % Botol - - - -
221 Spons Gelatin Cubicles 1 x 1 x 1 cm Buah - - - -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Via Vial - - - -
223 Streptomisin Sulfat Serbuk Injeksi 1500 mg/ Via Vial - - - -
224 Sulfa Conus Kerucut (Preparat) Botol - - - -
225 Sulfadimidin Tablet 500 mg Tablet - - - -
226 Sulfasetmida Natrium Tetes Mata 15 % - 5 ml Botol - - - -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Human Vial - - - -
228 Syntetic Filing Material Set - - - -
229 Tablet Tambah Darah Kombinasi : Tablet - - - -

230 Temporary Stooping Fletcher set - - - -

231 Tetrasiklin HCL Tetes Mata 0,5 % - 5 ml botol - - - -
232 Tetrasiklin HCL Kapsul 250 mg Kapsul - - - -
233 Tetrasiklin HCL Kapsul 500 mg Kapsul 590 5,000 5,590 2,290 3,300
234 Tiamin HCL (Vit.B1) Injeksi 100 mg / ml -1 ml Ampul - - - -

Hal 43
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 1,500 5,000 6,500 1,674 4,826
236 Tiopental Natrium Serbuk Injeksi 1000 mg / Am Ampul - - - -
237 Triheksifenidil Hidroklorida 2 mg Tablet Tablet - - - -
238 TriKresol Formalin (TKF) Cairan - 10 ml Botol - - - -
239 Vaksin Rabies KeringUntuk Manusia Ampul - - - -
240 Vaksin Rabies Vero Set - - - -
241 Vitamin B Komplek Tablet Tablet 2,642 5,000 7,642 1,761 5,881
242 Acyclovir 200 mg Tablet 1,342 - 1,342 445 897
243 Acyclovir Krim Tube 120 120 2 118
244 Ambroxol tab 30 mg tablet - - - -
245 Amlodipin tab 5 mg tablet 900 900 10 890
246 Amoksisilin+As klavunalat 625mg tab tablet - - - -
247 Ampisillin serb inj 1000 mg/ml vial - - - -
248 Antidiare Tablet - - - -
249 Asam Mafenamat tab 500 mg Tablet 1,000 1,000 365 635
250 Captopril tablet 12.5 mg Tablet 3,540 - 3,540 1,212 2,328
251 Captopril tablet 25 mg Tablet 2,280 - 2,280 685 1,595
252 Ciprofloksasin tablet 500 mg tablet 1,040 - 1,040 590 450
253 Chlorampenikol TM Botol - - - -
254 Chloramfenicol syrup 125 mg/5ml Botol - - - -
255 Dimehydrinate 50 mg tablet tablet - - - -
256 Domperidone 10 mg tablet 220 - 220 220 -
257 Domperidone syrup tablet 79 - 79 13 66
258 Etanol 70 % - 1000ml botol - - - -
259 Ferobion Tablet - - - -
260 Handscoon no 7-7,5 Set - - - -
261 IV Catheter No 18 G set 142 - 142 - 142
262 IV Catheter No 20 G set 35 100 135 35 100
263 IV Catheter No 22 G set 104 100 204 - 204
264 IV Catheter No 24 G set 139 - 139 6 133
265 Jeli Dopler 5000 ml botol - - - -
266 Jeli USG 250 ml botol - - - -
267 Loratadine tab 10 mg tablet - - - -

Hal 44
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
268 Masker set - - - -
269 Metronidazol tablet 500 mg tablet 1,420 2,000 3,420 20 3,400
270 Miconazole cream 2 % tube 173 - 173 11 162
271 Multivit Anak Kurang Gizi / Vical botol 120 - 120 - 120
272 Multivit Ibu Hamil / Hemafort kapsul 38,750 - 38,750 3,720 35,030
273 Nifedipin tab 10 mg tablet 1,884 - 1,884 84 1,800
274 Omeprazole tablet - - - -
275 Ranitidin tablet 150 mg tablet 2,000 2,000 102 1,898
276 Simvastatin tab 10 mg tab 120 300 420 - 420
277 Plester 5cm x 4.5cm Roll - - - -
278 Urine Bag set - - - -
279 Zink Kid tab dispersible 20 mg Tablet 1,000 1,000 - 1,000
280 Zink Kid Botol - - - -
281 Tes Kehamilan Set - - - -
282 Natrium Tiroksin ( Euthyrox ) Tablet - - - -
283 Piroksicam 10 mg Tablet - - - -
284 Propanolol 40 mg Tablet 1,180 - 1,180 - 1,180
285 Natrium Diklofenak Tablet 1,960 - 1,960 550 1,410
286 Nefidipin kaps 10 mg Tablet - - - -
287 Spironolakton 25 mg Tablet - - - -
288 Mineral Mix Kotak - - - -
289 Hemorograd ( Antihemoroid ) Kotak 978 - 978 54 924
290 Pehacaine,Lidocaine Hcl,Epineprine Ampul 46 - 46 - 46
291 Ampisilin serb inj i.v 1000 mg/vial Ampul - - - -
292 Kasa 16 X 16 Roll 80 320 400 119 281
294 Molektryl Sirup Botol - - - -
295 Yodina Tes Botol - - - -
296 Metronidazole Suspensi 125 mg/5 ml Botol 129 - 129 19 110
297 Handscoon Steril no. 6.5 pcs 85 - 85 11 74
298 Handscoon Non Steril S pcs 600 1,000 1,600 300 1,300
299 Handscoon Non Steril M pcs 1,000 1,000 - 1,000
300 Handscoon Non Steril L pcs 1,200 - 1,200 250 950

Hal 45
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
301 Autoclik Device OneMed pcs - - - -
302 New Antides ( Attapulgit ) tablet 1,680 - 1,680 145 1,535
303 Dextral Sirup botol 60 - 60 60 -
304 Dulcolax Supp Dewasa 10 mg Supp 30 - 30 - 30
305 Dulcolax Supp anak Supp - - - -
306 Cefiksime Tab 100 mg tablet - - - -
307 Alat Suntik Sekali Pakai 10 cc set 25 - 25 - 25
309 Metformin 500 mg tab 1,960 - 1,960 85 1,875
310 Herbakof Sirup Botol 377 - 377 161 216
311 Hanscoon Steril No. 7 Pcs 200 - 200 - 200
312 Otsu Water ( Air Untuk Injeksi ) vial 20 - 20 2 18
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 173 150 323 42 281
314 Tropikal Anetesi Botol - - - -
315 Hustab P 4 mg / 5 ml Syr Botol 200 200 2 198
316 Seltifort Kid 60 ml Botol 120 120 11 109
317 Cetirizin tab - - - -
318 Kasa 36 cm X 80 m Gulung - - - -
319 Omeprazole kaps 20 mg Caps - - - -
320 Ketokonazole 200 mg tab - - - -
321 Acetylystein 200 mg tab - - - -
322 Hand Rub 500 ml botol - - - -
UMUM BPJS /
Kasep JUMLAH
JUMLAH KUNJUNGAN RESEP Bayar Tidak bayar ASKES
# 1,583 745 2,328
Mengetahui : Yang menyerahkan : Yang Meminta : Yang Menerima :

Kepala Dinas Kesehatan Kab./kota Kepala UPTD Farmasi Kepala UPTD Puskesmas Lohbener Petugas Puskesmas
Indramayu

Hal 46
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
dr.H. Deden Bonni Koswara, MM Suryatno, S.Si.,Apt Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes dr. Yulis Susanto
Pembina Tingkat I NIP 19650323 198603 1 010 NIP. 19770929 200801 2 006 NIP.19820403 201412 1 001
NIP. 19740110 200212 1 008

Hal 47
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : FEBRUARI 2,018 UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : MARET PUSKESMAS 442.3/ / Pkm 07/ Pebruari/ 2018
PEMBERIAN
STOK SISA STOK
NO NAMA OBAT SATUAN AWAL PENERIMAA PERSEDIA PEMAKAIA AKHIR STOK OPT. PERMINTA JUMLAH
N AN N AN APBN ASKES APBD I APBD II PROGRAM LAIN LAIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Air Raksa Dental Use Botol - - - - -
2 Alat Suntik Sekali Pakai 1 ml Set 750 - 750 149 601
3 Alat Suntik Sekali Pakai 3 ml Set 1,091 - 1,091 392 699
4 Alat suntik Sekali Pakai 5 ml Set 918 - 918 6 912
5 Albendazol Tablet 400 mg Tablet - - - - -
6 Aloporinol Tablet 100 mg Tablet 4,936 - 4,936 680 4,256
7 Aminofilin Tablet 200 mg Tablet 1,200 - 1,200 120 1,080
8 Aminofilin Injeksi 24 mg/ml - 10 ml Ampul - - - - -
10 Amoksilin Kapsul 250 mg Kapsul 2,652 - 2,652 1,510 1,142 6,000
11 Amoksilin Kaplet 500mg Kaplet 6,740 - 6,740 3,920 2,820 15,000
13 Ampisilin Sirup 500 mg Kaplet - - - - -
14 Ampisilin Sirup 125 mg / 5 ml Botol - - - - -
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet - - - - -
16 Antalgin Injeksi 250 mg / ml - 2 ml Ampul - - - - -
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet 5,163 - 5,163 2,485 2,678 10,000
200 mg

18
Basintrasin 500 IU / g + Polimiksin 1000 IU / g
Tube 49 - 49 4 45
19 Anti Hemoroid Doen Kombinasi Supp - - - - -

Hal 48
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
20 Antifungi DOEN Kombinasi : Asam Benzoat 6 Pot 185 - 185 9 176
21 Anti Migren DOEN Kombinasi : Tablet - - - - -

22 Karbidopa 25 mg + Levodopa 250 mg Tablet - - - - -
23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial - - - - -

24 Aquadest Steril - 500 ml Botol - - - - -
26 Asam Askrobat ( Vit . C ) 250 mg Tablet - - - - -
27 Asam Klorida , 0,1 N - 100 ml Botol - - - - -
28 Asam Sulfosalisilat 20 % Botol - - - - -
29 Asetosal Tablet 100 mg Tablet - - - - -
31 Atropin Sulfat Injeksi 0,25mg / ml - 1 ml Ampul - - - - -
32 Atropin Sulfat Tablet 0,5 mg Tablet - - - - -
33 Atropin Sulfat Tetes Mata 0,5 % - 5 ml Botol - - - - -
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Via Vial - - - - -
36 Besi Sirup 150 ml Botol - - - - -
37 Betametasol Krim , 0,1 % - 5 mg Tube 75 - 75 - 75
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 229 - 229 127 102 120
( Plain & Cromoic)
39 Dapson Tablet 100 mg Tablet - - - - -
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - - - - -
41 Deksametason Tablet 0,5 mg Tablet 4,794 - 4,794 1,073 3,721 5,000
42 Dekstran 70 - Larutan Infus 6 % Steril - 500 ml Botol - - - - -
43 Dekstometrofan Hbr Sirup 10 mg/ 5 - 60 ml Botol - - - - -
44 Dekstrometrofan Hbr Tablet 15mg Tablet - - - - -
45 Devitalisasi Pasta (Non Asren) Botol - - - - - 2
46 Diazepam Injeksi 5 mg?ml - 2ml Ampul - - - - -
47 Diazepam Tablet 2 mg Tablet - - - - -
48 Diazepam Tablet 5 mg Tablet 31 - 31 10 21 100
49 Dietikarbamazin Sitrat Tablet 100 mg Tablet - - - - -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - - - 200
Hal 49
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
52 Efedrin HCL Tablet 25 mg Tablet - - - - -
53 Extrac Belladon Tablet 10 mg Tablet - - - - -
54
Ampul 51 - 51 - 51
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - - -
56 Etambutol HCL Tablet 250 mg Tablet - - - - -
57 Etanol 70 % - 100ml Botol 22 - 22 2 20
58 Eter Anestetik - 140 ml Botol - - - - -
59 Etil Krorida Semprot - 100 ml Botol - - - - -
60 Eugenol Cairan - 10 ml Botol 3 - 3 - 3
61 Fenitoin Natrium Injeksi 50 mg / ml Ampul - - - - -
62 Fenitoin Natrium Kapsul 100 mg Kapsul - - - - -
63 Fenitoin Natrium Kapsul 30mg Kapsul - - - - -
64 Fenobarbital Injeksi 50 mg/ ml - 2 ml Ampul - - - - -
65 Fenobarbital Tablet 100 mgl Tablet - - - - -
66 Fenobarbital Tablet 30 mg Tablet - - - - -
67 Fenoksimetil Penisilin Tablet 250 mg Tablet - - - - -
69 Fenol Gliserol Tetes Telinga 10 % - 5 ml Botol - - - - -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 147 - 147 28 119 150
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 594 - 594 50 544 1,000
72 Flour Tablet 0,5 mg Tablet - - - - -
73 Furosemid Tablet 40 mg Tablet 1,374 - 1,374 560 814
74 Ferinokresol (Pengganti TKV) 10 ml Botol - - - - -
75 Gameksan Emulsi 1 % - ml Botol - - - - -
77 Garam Oralit 1000 ml Air Sachet - - - - -
78 Gentian Violet Larutan 1 % - 10 ml Botol - - - - -
79 Glass Lonomer Cement ( GC IX ) Set - - - - -
80 Glibenklamid Tablet 5 mg Tablet - - - - -
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - - -
82 Gliserin - 10 ml Botol - - - - -
84 Glukosa Larutan Infus 10 % Steril - 500 ml Botol - - - - -
85 Glukosa Larutan Infus 40 % Steril - 25 ml Ampul - - - - -

Hal 50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
86 Griseofulvin Tablet 125 mg Mikronised Tablet 2,950 - 2,950 100 2,850
87 Gutta Percha Points Stik - - - - -
88 Haloperoidol 0,5 mg Tablet Tablet - - - - -
90 Haloperidol 5 mg Tablet - - - - -
91 Hidroklorotiazid ( HCT ) Tablet 25 mg Tablet - - - - -
93 Ibufropen Tablet 200 mg Tablet - - - - -
94 Ibufropen Tablet 400 mg Tablet 4,366 - 4,366 2,050 2,316 5,000
95 Infusion Set Anak Set 86 - 86 - 86
96 Infusion Set Dewasa Set 131 - 131 30 101 100
97 Insulin Regular Injeksi 40 IU/ml ( Human) Vial - - - - -
98 Idiol Kapsul Lunak Kapsul - - - - -
99 Ipeka 0,14 % Sirup Botol - - - - -
100 Isoniazid Tablet 300 mg Tablet - - - - -
102 Jarum Jahit ( Bedah No. 9 S/d 14 ) Pcs - - - - -
103 Kalium Permanganat Serbuk - 5 mg Botol - - - - -
104 Kalsium Hidroksida Pasta Kotak - - - - -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 6,572 - 6,572 3,042 3,530 10,000
106 Kapas Berlemak 500 Gram Bungkus - - - - -
107 Kapas Pembalut / Absorben 250 Gram Bungkus 4 - 4 1 3 5
108 Karbamazepin Tablet 200 mg Tablet - - - - -
109 Kasa Kompres 40 / 40 Steril Bungkus - - - - -
110 Kasa Pembalut 2 m x 80 Cm Roll 20 - 20 18 2 100
111 Kasa Kompres 18cm X 22 cm steril Roll - - - - - 100
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 55 - 55 40 15 100
114 Kasa Pembalut Hidrofil 4 m x 15 Cm Rol - - - - -
115 Ketamin 10 mg / ml Injeksi - 10 mg Vial - - - - -
116 Klofazimin,Micriize Kapsul 100 mg Kapsul - - - - -
117 Kloramfenikol Kapsul 250mg Kapsul - - - - - 2,000
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - - -
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - - - - - 250

Hal 51
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 11,861 - 11,861 2,994 8,867

121 ( Setara Degan 100 mg Kloroquin Basa ) Tablet - - - - -
122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul - - - - -

124 Klorpromazin HCL Tablet Salut 25 mg Tablet - - - - -
126 Klorpropamid Tablet 100 mg Tablet - - - - -
127 Kodein HCL Tablet 10 mg Tablet - - - - -
128 Kombinasi Pirimetamin 25 mg + Sulfadiksin 50 Tablet - - - - -

129 SulfatMetoksazol 100mg + Trimetroprim 20 Tablet - - - - -
mg

130 Sulfametoksazol 200 mg+Trimetropin 40 Botol 280 - 280 5 275
mg/5mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 5,435 - 5,435 165 5,270

132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul - - - - -

133 Kuinin (Kina) Tablet 200 mg Tablet - - - - -
134 Larutan Benedict - 100 ml Botol - - - - -
135 Larutan Eosin 2 % - 100 ml Botol - - - - -
136 Larutan Etanol Asam - 100 ml Botol - - - - -
137 Larutan Gabbet / 100 ml Botol - - - - -
138 Larutan Geimsa Stain - 100 ml Botol - - - - -
139 Larutan Karbol Fuksin - 100 ml Botol - - - - -
140 Larutan Kinyoun - 100 ml Botol - - - - -
141 Larutan Metilen Biru - 100 ml Botol - - - - -
142 Larutan Turk - 100 ml Botol - - - - -
143 Lidokain Komp. Injeksi, kombinasi : Ampul 443 - 443 61 382

144 Lisol Mengandung Kresol Tersabun 50 % - 100 m Botol - - - - -

145 Magnesium Sulfat Injeksi (IV) 20 % - 50 ml vial - - - - -
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 3 - 3 - 3

Hal 52
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
147 Magnesium Sulfat Serbuk 30 gram Sachet - - - - -
148 Mebendazol Sirup 100 mg / 5 ml - 30 ml Botol - - - - -
149 Mebendazol 100 mg Tablet - - - - -
150 Metanol - 100 ml Botol - - - - -
151 Metilergometri Maleat (Metilergometrin) Tablet - - - - -


153 Metronidazol Tablet 250 mg Tablet - - - - -
154 Monoklorkamfer Mentol Cairan Botol - - - - -
155 Mummifying Pasta Botol - - - - -
156 Natrium Bikarbonat Tablet 500 mg Tablet 975 - 975 570 405
157 Natrium Fluoresein Tetes Mata 2 % - 5 ml Botol - - - - -
159 Natrium Tiosulfat Injeksi 25 % - 10 ml Ampul - - - - -
161 Nistatin 500.000 IU / gram Tablet 520 - 520 - 520
162 OAT Kategori 1 Dewasa Paket - - - - -
165 OAT Sisipan Dewasa Paket - - - - -
166 OAT Kategori Anak Paket - - - - -
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol - - - - - 600
168 Oksigen Gas Dalam Tabung m3 - - - - -
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 m vial - - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 92 - 92 3 89 50
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 100 - 100 - 100
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 280 - 280 56 224 100
173 Paraformaldhida Tabley 1 gram Tablet - - - - -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - - - - - 600
175 Parasetamol Tablet 100 mg Tablet - - - - -
176 Parasetamol Tablet 500 mg Tablet 7,430 - 7,430 2,070 5,360 10,000
177 Pembalut Gips Rol - - - - -
178 Perfenazin Tablet 4 mg Tablet - - - - -
179 Pefenazin Tablet 16 mg Tablet - - - - -

Hal 53
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
180 Petidin HCL Injeksi 50 mg / ml 2 ml Ampul - - - - -
181 Pilokarpin HCL / Nitrat Tetes Mata 2- 5 ml Botol - - - - -
182 Piperazin Sirup 20 % Botol - - - - -
183 Piperazin Tablet 500 mg Tablet - - - - -
184 Pirantel Pamoat Tablet 365 mg Tablet - - - - -
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 6,710 - 6,710 1,204 5,506
186 Plester 5 Yards x 2 inch Rol 15 - 15 3 12 5
187 Polikresulen (Kondensasi Metakresol Sulfonat Botol - - - - -

dan Metanal) 360 mg/ g - 10 ml
188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol - - - - -

189 Povidon Lodida 10 % - 10 ml Botol - - - - -
191 Povidon Lodida 10 % - 300 ml Botol - - - - - 5
192 Povidon Lodida 10 % - 1000 ml Botol 1 - 1 1 - 5
193 Prazikuantel Tablet 600 ml Botol - - - - -
194 Prednison Tablet 5 mg Tablet 11,700 - 11,700 5,000 6,700
195 Primakuin Tablet 15 mg Tablet - - - - -
196 Prokain Benzil Penisilin 3 Juta IU / Vial Injeksi Vial - - - - -
197 Propanolol HCL Tablet 40 mg Tablet - - - - -
198 Propiltiourasil Tablet 100 mg Tablet - - - - -
199 Rabies Immune Globulin (Human) 150 IU / ml - Vial - - - - -
200 Reserpine Tablet 0,10 mg Tablet - - - - -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul - - - - -
204 Rifampisin Kapsul 300 mg Kapsul - - - - -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 217 - 217 107 110
208 Salbutamol Tablet 2 mg Tablet 247 - 247 111 136 1,000
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % + Pot 104 - 104 1 103
Belerang Endap 4 % - 30 mg
211 Salisil Spirtus 10 % - 25 ml Botol - - - - -

Hal 54
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU Vial - - - - -
215 Serum Anti Rabies Vial - - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 10 - 10 1 9
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul ( Vial - - - - -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml - Ampul - - - - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 182 - 182 10 172 200
220 Silver Amalgam Serbuk 65 - 75 % Botol - - - - -
221 Spons Gelatin Cubicles 1 x 1 x 1 cm Buah - - - - -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Via Vial - - - - -
224 Sulfa Conus Kerucut (Preparat) Botol - - - - -
225 Sulfadimidin Tablet 500 mg Tablet - - - - -
226 Sulfasetmida Natrium Tetes Mata 15 % - 5 ml Botol - - - - -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Human Vial - - - - -
228 Syntetic Filing Material Set - - - - -
Tablet Tambah Darah Kombinasi :

229 Besi II Sulfat 200 mg + Asam Folat 0.25 mg Tablet - - - - -
230 Temporary Stooping Fletcher set - - - - - 2

231 Tetrasiklin HCL Tetes Mata 0,5 % - 5 ml botol - - - - -
232 Tetrasiklin HCL Kapsul 250 mg Kapsul - - - - -
233 Tetrasiklin HCL Kapsul 500 mg Kapsul 3,300 - 3,300 590 2,710 5,000
234 Tiamin HCL (Vit.B1) Injeksi 100 mg / ml -1 ml Ampul - - - - -
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 4,826 - 4,826 2,281 2,545 5,000
236 Tiopental Natrium Serbuk Injeksi 1000 mg / Am Ampul - - - - -
237 Triheksifenidil Hidroklorida 2 mg Tablet Tablet - - - - -
238 TriKresol Formalin (TKF) Cairan - 10 ml Botol - - - - -
239 Vaksin Rabies KeringUntuk Manusia Ampul - - - - -
240 Vaksin Rabies Vero Set - - - - -
241 Vitamin B Komplek Tablet Tablet 5,881 - 5,881 981 4,900
242 Acyclovir 200 mg Tablet 897 - 897 310 587 1,000
243 Acyclovir Krim Tube 118 - 118 25 93
244 Ambroxol tab 30 mg tablet - - - - -

Hal 55
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet 890 - 890 60 830
246 Amoksisilin+As klavunalat 625mg tab tablet - - - - -
247 Ampisillin serb inj 1000 mg/ml vial - - - - -
248 Antidiare Tablet - - - - -
249 Asam Mafenamat tab 500 mg Tablet 635 - 635 635 - 5,000
250 Captopril tablet 12.5 mg Tablet 2,328 - 2,328 750 1,578 2,000
251 Captopril tablet 25 mg Tablet 1,595 - 1,595 418 1,177 2,000
252 Ciprofloksasin tablet 500 mg tablet 450 - 450 240 210 3,000
253 Chlorampenikol TM Botol - - - - -
254 Chloramfenicol syrup 125 mg/5ml Botol - - - - -
255 Dimehydrinate 50 mg tablet tablet - - - - - 1,000
256 Domperidone tablet - - - - -
257 Domperidone syrup tablet 66 - 66 23 43 100
258 Etanol 70 % - 1000ml botol - - - - -
259 Ferobion Tablet - - - - -
260 Handscoon no 7-7,5 Set - - - - -
262 IV Catheter No 20 G set 100 - 100 25 75 50
265 Jeli Dopler 5000 ml botol - - - - -
266 Jeli USG 250 ml botol - - - - -
267 Loratadine tab 10 mg tablet - - - - -
268 Masker set - - - - - 100
269 Metronidazol tablet 500 mg tablet 3,400 - 3,400 - 3,400 2,000
273 Nifedipin tab 10 mg tablet 1,800 - 1,800 - 1,800
274 Omeprazole tablet - - - - -
275 Ranitidin tablet 150 mg tablet 1,898 - 1,898 550 1,348 1,000
276 Simvastatin tab 10 mg tab 420 - 420 135 285 150
277 Plester 5cm x 4.5cm Roll - - - - -
278 Urine Bag set - - - - -

Hal 56
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 1,000 - 1,000 - 1,000
280 Zink Kid Botol - - - - -
281 Tes Kehamilan Set - - - - - 100
282 Natrium Tiroksin ( Euthyrox ) Tablet - - - - -
283 Piroksicam 10 mg Tablet - - - - - 1,000
284 Propanolol 40 mg Tablet 1,180 - 1,180 - 1,180
285 Natrium Diklofenak Tablet 1,410 - 1,410 450 960 2,500
286 Nefidipin kaps 10 mg Tablet - - - - -
287 Spironolakton 25 mg Tablet - - - - -
288 Mineral Mix Kotak - - - - -
290 Pehacaine,Lidocaine Hcl,Epineprine Ampul 46 - 46 - 46 150
291 Ampisilin serb inj i.v 1000 mg/vial Ampul - - - - -
292 Kasa 16 X 16 Roll 281 - 281 89 192 800
294 Molektryl Sirup Botol - - - - -
295 Yodina Tes Botol - - - - -
298 Handscoon Non Steril S pcs 1,300 - 1,300 300 1,000
299 Handscoon Non Steril M pcs 1,000 - 1,000 250 750
300 Handscoon Non Steril L pcs 950 - 950 75 875
301 Autoclik Device OneMed pcs - - - - -
303 Dextral Sirup botol - - - - -
305 Dulcolax Supp anak Supp - - - - -
306 Cefiksime Tab 100 mg tablet - - - - -
309 Metformin 500 mg tab 1,875 - 1,875 10 1,865
310 Herbakof Sirup Botol 216 - 216 150 66 600

Hal 57
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 281 - 281 45 236
314 Tropikal Anetesi Botol - - - - -
315 Hustab P 4 mg / 5 ml Syr Botol 198 - 198 76 122
316 Seltifort Kid 60 ml Botol 109 - 109 4 105
317 Cetirizine Hcl 10 mg tab - - - - -
318 Kasa 36 cm X 80 m Gulung - - - - -
320 Ketokonazole 200 mg tab - - - - -
321 Acetylystein 200 mg tab - - - - -
UMUM BPJS /
Kasep JUMLAH
# 1,929 650 2,579

Kepala Dinas Kesehatan Kab./kota Kepala UPTD Farmasi Indramayu Kepala UPTD Puskesmas Lohbener Petugas Puskesmas
Indramayu
NIP. 19740110 200212 1 008

Hal 58
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : MARET 2018 UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : APRIL PUSKESMAS 442.3/1174 /Pkm 3-Apr-18
PEMBERIAN
STOK SISA STOK
NO NAMA OBAT SATUAN AWAL PENERIMA PERSEDIA PEMAKAIA AKIR STOK OPT. PERMINTA JUMLAH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set 601 3,900 4,501 44 4,457
3 Alat Suntik Sekali Pakai 3 ml Set 699 7,600 8,299 243 8,056
4 Alat suntik Sekali Pakai 5 ml Set 912 3,000 3,912 42 3,870
6 Aloporinol Tablet 100 mg Tablet 4,256 800 5,056 870 4,186
7 Aminofilin Tablet 200 mg Tablet 1,080 - 1,080 130 950
10 Amoksilin Kapsul 250 mg Kapsul 1,142 8,700 9,842 1,260 8,582
11 Amoksilin Kaplet 500mg Kaplet 2,820 10,700 13,520 4,030 9,490
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 489 300 789 147 642
Antasid DOEN Tablet,Kombinasi:Magnesium
200 mg

18 Basintrasin 500 IU / g Tube 45 - 45 4 41
+ Polimiksin 1000 IU / g

Hal 59
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Antifungi DOEN Kombinasi :

20 Asam Benzoat 6 % = Asam Salisilat 3 % Pot 176 - 176 1 175

Antiparkinson DOEN Tablet Kombinasi

37 Betametasol Krim , 0,1 % - 5 mg Tube 75 150 225 - 225
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 102 - 102 24 78
( Plain & Cromoic)
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - 200 200 - 200
41 Deksametason Tablet 0,5 mg Tablet 3,721 7,000 10,721 990 9,731
45 Devitalisasi Pasta (Non Asren) Botol - - - - -
48 Diazepam Tablet 5 mg Tablet 21 - 21 21 -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - 90 90 - 90

Hal 60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
54
Ampul 51 - 51 20 31
57 Etanol 70 % - 100ml Botol 20 - 20 5 15
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 119 - 119 28 91
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 544 - 544 - 544
73 Furosemid Tablet 40 mg Tablet 814 - 814 - 814
79 Glass Lonomer Cement ( GC IX ) Set - 2 2 2 -
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 100 20 120 - 120

Hal 61
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
92 Hidrokortison Krim 2,5 % Tube 121 192 313 34 279
94 Ibufropen Tablet 400 mg Tablet 2,316 2,000 4,316 3,124 1,192
95 Infusion Set Anak Set 86 300 386 - 386
107 Kapas Pembalut / Absorben 250 Gram Bungkus 3 4 7 - 7
110 Kasa Pembalut 2 m x 80 Cm Roll 2 - 2 - 2
111 Kasa Kompres 18cm X 22 cm steril Roll - - - - -
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 15 - 15 - 15
117 Kloramfenikol Kapsul 250mg Kapsul - - - - -

Hal 62
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - - - - -
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 8,867 - 8,867 5,217 3,650
121 Kloroquin Fosfat Tablet 250 mg Tablet - - - - -



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 275 21 296 26 270
mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 5,270 - 5,270 1,020 4,250





Hal 63
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 3 17 20 - 20
150 Metanol - 100 ml Botol - - - - -
Metilergometri Maleat (Metilergometrin)

151
Tablet - - - - -
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 62 - 62 - 62

156 Natrium Bikarbonat Tablet 500 mg Tablet 405 2,000 2,405 129 2,276
160 Nistatin 100.000 IU / gram Vaginal Tablet 286 - 286 20 266
161 Nistatin 500.000 IU / gram Tablet 520 300 820 210 610
167 Obat Batuk Hitam (OBH) Cairan - 100 ml Botol - - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 89 - 89 9 80
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 224 - 224 56 168
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - - - - -
176 Parasetamol Tablet 500 mg Tablet 5,360 23,000 28,360 11,920 16,440

Hal 64
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
186 Plester 5 Yards x 2 inch Rol 12 - 12 3 9

187
Botol - - - - -

192 Povidon Lodida 10 % - 1000 ml Botol - 8 8 - 8
194 Prednison Tablet 5 mg Tablet 6,700 - 6,700 - 6,700
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 110 400 510 63 447
208 Salbutamol Tablet 2 mg Tablet 136 - 136 136 -
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 103 48 151 - 151

Hal 65
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 9 - 9 - 9

229
Tablet - - - - -
230 Temporary Stooping Fletcher set - 2 2 2 -

233 Tetrasiklin HCL Kapsul 500 mg Kapsul 2,710 3,500 6,210 1,270 4,940
241 Vitamin B Komplek Tablet Tablet 4,900 5,000 9,900 818 9,082
242 Acyclovir 200 mg Tablet 587 400 987 537 450

Hal 66
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet 830 - 830 230 600
249 Asam Mafenamat tab 500 mg Tablet - 100 100 - 100
250 Captopril tablet 12.5 mg Tablet 1,578 - 1,578 728 850
251 Captopril tablet 25 mg Tablet 1,177 - 1,177 602 575
252 Ciprofloksasin tablet 500 mg tablet 210 1,200 1,410 180 1,230
255 Dimehydrinate 50 mg tablet tablet - - - - -
257 Domperidone syrup tablet 43 200 243 5 238
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - - - - -
269 Metronidazol tablet 500 mg tablet 3,400 - 3,400 20 3,380
275 Ranitidin tablet 150 mg tablet 1,348 200 1,548 675 873
276 Simvastatin tab 10 mg tab 285 - 285 90 195

Hal 67
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 1,000 - 1,000 100 900
281 Tes Kehamilan Set - - - - -
282 Natrium Tiroksin ( Euthyrox ) tablet - - - - -
283 Piroksicam 10 mg tablet - - - - -
284 Propranolol 10 mg Tablet 1,180 100 1,280 - 1,280
285 Natrium Dikofenak Tablet 960 - 960 90 870
290 Pehacain,Lidocaine HCL,Epinephrine Ampul 46 - 46 20 26
292 Kasa 16 X 16 Roll 192 1,600 1,792 112 1,680
297 Handscoon Steril no. 6.5 pcs 70 50 120 - 120
298 Handscoon Non Steril S pcs 1,000 300 1,300 100 1,200
299 Handscoon Non Steril M pcs 750 1,400 2,150 450 1,700
300 Handscoon Non Steril L pcs 875 500 1,375 175 1,200
304 Dulcolax Supp Dewasa 10 mg Supp 30 - 30 3 27
306 Cefiksime Tab 100 mg tablet - - - (1,315) 1,315
307 Alat Suntik Sekali Pakai 10 cc set 25 - 25 25 -
308 Alat Suntik Sekali Pakai 20 cc set 25 - 25 (2) 27
309 Metformin 500 mg tab 1,865 - 1,865 1,865 -
310 Herbakof Sirup Botol 66 144 210 210 -
311 Hanscoon Steril No. 7 Pcs 200 150 350 325 25

Hal 68
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
312 Otsu Water ( Air Untuk Injeksi ) vial 11 - 11 (14) 25
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 236 200 436 (1,089) 1,525
314 Tropikal Anetesi Botol - - - (29) 29
315 Hustab P 4 mg / 5 ml Syr Botol 122 - 122 (198) 320
317 Cetirizine Hcl 10 mg tab - 2,250 2,250 1,846 404
318 Kasa 36 cm X 80 m Gulung - - - - -
320 Ketokonazole 200 mg tab - - - (85) 85
321 Acetylystein 200 mg tab - - - (2,210) 2,210
UMUM BPJS /
Kasep JUMLAH
-

Kepala Dinas Kesehatan Kab./kota Kepala UPTD Farmasi Kepala UPT Puskesmas Lohbener Petugas Puskesmas
Indramayu
NIP. 19740110 200212 1 008

Hal 69
FORM : LPLPO
LAPORAN PEMAKAIAN DAN LEMBARAN PEMAKAIAN OBAT (LPLPO)
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : APRIL 2,018 UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : MEI PUSKESMAS 442.3/ /Pkm 9-May-18
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set 4,457 - 4,457 186 4,271
4 Alat suntik Sekali Pakai 5 ml Set 3,870 - 3,870 35 3,835
5 Albendazol Tablet 400 mg Tablet - 8,373 8,373 1,893 6,480
7 Aminofilin Tablet 200 mg Tablet 950 - 950 130 820
11 Amoksilin Kaplet 500mg Kaplet 9,490 - 9,490 6,430 3,060 15,000
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 642 - 642 215 427 300
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet 4,180 - 4,180 2,649 1,531 10,000
200 mg

18 Basintrasin 500 IU / g Tube 41 - 41 9 32 150
LPLPO PKM LOHBENER TAHUN 2018

Hal 70
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

21
Tablet - - - - -

25 Asam Askrobat ( Vit . C ) 50 mg Tablet 8,287 - 8,287 379 7,908
38 ( Plain & Cromoic) Sachet 78 - 78 10 68
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul 200 - 200 - 200
47 Diazepam Tablet 2 mg Tablet - - - - - 1,000
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 90 - 90 - 90

Hal 71
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51 Digoksin Tablet 0,25 mg Tablet 360 - 360 - 360
54
Ampul 31 - 31 6 25
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - - - 20
57 Etanol 70 % - 100ml Botol 15 - 15 6 9 20
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 91 - 91 31 60 150
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 544 - 544 30 514 1,500
73 Furosemid Tablet 40 mg Tablet 814 - 814 50 764
76 Garam Oralit 200 ml Air Sachet 150 - 150 70 80 600
78 Gentian Violet Larutan 1 % - 10 ml Botol - - - - - 100
80 Glibenklamid Tablet 5 mg Tablet - - - - - 2,000

Hal 72
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
94 Ibufropen Tablet 400 mg Tablet 1,192 - 1,192 1,162 30 5,000
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 5,354 - 5,354 1,383 3,971 2,000
107 Kapas Pembalut / Absorben 250 Gram Bungkus 7 - 7 3 4 5
110 Kasa Pembalut 2 m x 80 Cm Roll 2 - 2 - 2 100
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 135 - 135 50 85 -
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 15 - 15 - 15 200
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - - - 100

Hal 73
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 3,650 - 3,650 2,730 920 10,000



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 270 - 270 52 218 -
mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 4,250 - 4,250 1,156 3,094 3,000

143 Lidokain Komp. Injeksi, kombinasi : Ampul 329 - 329 29 300 300


Hal 74
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 20 - 20 1 19
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - - 1,000

156 Natrium Bikarbonat Tablet 500 mg Tablet 2,276 - 2,276 276 2,000
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 6 - 6 2 4 40
161 Nistatin 500.000 IU / gram Tablet 610 - 610 73 537
162 OAT Kategori 1 Dewasa Paket - 6 6 - 6
166 OAT Kategori Anak Paket - 3 3 - 3
175 Parasetamol Tablet 100 mg Tablet - - - - - 3,000
176 Parasetamol Tablet 500 mg Tablet 16,440 - 16,440 7,440 9,000 10,000

Hal 75
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 4,040 - 4,040 1,285 2,755 2,000

187
Botol - - - - -

192 Povidon Lodida 10 % - 1000 ml Botol 8 - 8 - 8
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul - 250 250 - 250
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul - 1,200 1,200 - 1,200
208 Salbutamol Tablet 2 mg Tablet - - - - - 2,000
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 151 - 151 3 148

Hal 76
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

229
Tablet - 12,763 12,763 - 12,763
230 Temporary Stooping Fletcher set - - - - -

233 Tetrasiklin HCL Kapsul 500 mg Kapsul 4,940 - 4,940 545 4,395
241 Vitamin B Komplek Tablet Tablet 9,082 - 9,082 1,454 7,628
242 Acyclovir 200 mg Tablet 450 - 450 - 450
243 Acyclovir Krim Tube 30 - 30 - 30 50

Hal 77
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet 600 - 600 600 - 1,500
249 Asam Mafenamat tab 500 mg Tablet 100 - 100 100 - 5,000
250 Captopril tablet 12.5 mg Tablet 850 - 850 450 400 3,000
251 Captopril tablet 25 mg Tablet 575 - 575 275 300 3,000
252 Ciprofloksasin tablet 500 mg tablet 1,230 - 1,230 230 1,000 2,000
253 Chlorampenikol TM Botol - - - - - 200
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
262 IV Catheter No 20 G set 38 - 38 38 - 100
268 Masker set - - - - -
271 Multivit Anak Kurang Gizi / Vical botol 120 - 120 20 100
275 Ranitidin tablet 150 mg tablet 873 - 873 320 553 1,000

Hal 78
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 900 - 900 175 725
281 Tes Kehamilan Set - - - - - 100
284 Proponolol 10 mg Tablet 1,280 - 1,280 - 1,280
285 Natrium Diklofenak Tablet 870 - 870 200 670 2,500
290 Pehacain,Lidocaine HCL,Epinephrine Ampul 26 - 26 - 26
292 Kasa 16 X 16 Roll 1,680 - 1,680 574 1,106 3,200
296 Metronidazole Suspensi 125 mg/5 ml Botol 84 - 84 - 84
297 Handscoon Steril no. 6.5 pcs 120 - 120 - 120
298 Handscoon Non Steril S pcs 1,200 - 1,200 400 800
299 Handscoon Non Steril M pcs 1,700 - 1,700 300 1,400
300 Handscoon Non Steril L pcs 1,200 - 1,200 175 1,025
306 Cefiksime Tab 100 mg tablet 1,315 - 1,315 1,315 -
307 Alat Suntik Sekali Pakai 10 cc set - - - (25) 25
308 Alat Suntik Sekali Pakai 20 cc set 27 - 27 2 25
309 Metformin 500 mg tab - - - (1,410) 1,410
310 Herbakof Sirup Botol - - - - - 600
311 Hanscoon Steril No. 7 Pcs 25 - 25 (276) 301

Hal 79
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
312 Otsu Water ( Air Untuk Injeksi ) vial 25 - 25 20 5 10
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 1,525 - 1,525 1,172 353
314 Tropikal Anetesi Botol 29 - 29 29 -
315 Hustab P 4 mg / 5 ml Syr Botol 320 - 320 320 -
316 Seltifort Kid 60 ml Botol 8 - 8 (50) 58
317 Cetirizine Hcl 10 mg tab 404 - 404 (630) 1,034 2,250
318 Kasa 36 cm X 80 m Gulung - - - - -
320 Ketokonazole 200 mg tab 85 - 85 85 -
321 Acetylystein 200 mg tab 2,210 - 2,210 2,210 -
UMUM BPJS /
Kasep JUMLAH
- - - - -
Mengetahui : Yang menyerahkan : Yang Menerima : Yang Menerima :

Indramayu
....................................................... Suryatno, S.Si., Apt. Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes H. Sahrudin, S.Kep., Ners.
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 80
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : MEI UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : JUNI 2,018 PUSKESMAS 442.3/ / Pkm08 - Juni - 2018
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
5 Albendazol Tablet 400 mg Tablet 6,480 - 6,480 3,043 3,437
11 Amoksilin Kaplet 500mg Kaplet 9,490 15,000 24,490 10,730 13,760
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 642 400 1,042 322 720
200 mg


Hal 81
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17



38 ( Plain & Cromoic) Sachet 78 - 78 18 60
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 90 - 90 60 30

Hal 82
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
54
Ampul 31 30 61 6 55
57 Etanol 70 % - 100ml Botol 15 45 60 15 45
59 Etil Krorida Semprot - 100 ml Botol - 3 3 3 -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 91 150 241 31 210
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 544 1,700 2,244 - 2,244
73 Furosemid Tablet 40 mg Tablet 814 200 1,014 514 500

Hal 83
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
94 Ibufropen Tablet 400 mg Tablet 1,192 10,000 11,192 1,442 9,750
107 Kapas Pembalut / Absorben 250 Gram Bungkus 7 - 7 6 1
110 Kasa Pembalut 2 m x 80 Cm Roll 2 100 102 - 102
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 15 200 215 15 200

Hal 84
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 3,650 - 3,650 3,050 600



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 270 - 270 90 180
mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 4,250 13,000 17,250 2,142 15,108

143 Lidokain Komp. Injeksi, kombinasi : Ampul 329 300 629 157 472


Hal 85
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial 20 - 20 20 -
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 62 200 262 33 229

158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 6 200 206 3 203
160 Nistatin 100.000 IU / gram Vaginal Tablet 266 200 466 10 456
161 Nistatin 500.000 IU / gram Tablet 610 500 1,110 83 1,027
166 OAT Kategori Anak Paket 1 - 1 - 1
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 100 200 300 - 300
176 Parasetamol Tablet 500 mg Tablet 16,440 - 16,440 15,240 1,200

Hal 86
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 4,040 7,000 11,040 2,695 8,345

187
Botol - - - - -

194 Prednison Tablet 5 mg Tablet 6,700 3,000 9,700 3,728 5,972
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul 250 - 250 - 250
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul 1,200 - 1,200 - 1,200
208 Salbutamol Tablet 2 mg Tablet - - - - -

Hal 87
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

229
Tablet 12,763 9,437 22,200 - 22,200

243 Acyclovir Krim Tube 30 120 150 6 144

Hal 88
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet 600 - 600 600 -
249 Asam Mafenamat tab 500 mg Tablet 100 - 100 100 -
250 Captopril tablet 12.5 mg Tablet 850 8,000 8,850 1,230 7,620
251 Captopril tablet 25 mg Tablet 575 - 575 325 250
252 Ciprofloksasin tablet 500 mg tablet 1,230 - 1,230 530 700
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - - - - -
273 Nifedipin tab 10 mg tablet 1,800 1,400 3,200 - 3,200
275 Ranitidin tablet 150 mg tablet 873 - 873 723 150
276 Simvastatin tab 10 mg tab 195 - 195 85 110

Hal 89
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 900 - 900 300 600
284 Propanolol 40 mg tablet 1,280 - 1,280 - 1,280
285 Natrium Diklofenak Tablet 870 - 870 360 510
292 Kasa 16 X 16 Roll 1,680 - 1,680 1,080 600
299 Handscoon Non Steril M pcs 1,700 - 1,700 770 930
300 Handscoon Non Steril L pcs 1,200 - 1,200 200 1,000
307 Alat Suntik Sekali Pakai 10 cc set - - - (25) 25
309 Metformin 500 mg tab - - - (1,410) 1,410
310 Herbakof Sirup Botol - - - - -
311 Hanscoon Steril No. 7 Pcs 25 - 25 (276) 301

Hal 90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
313 Gentamicin Sulfat 0,5 % Tetes Mata Botol 1,525 - 1,525 1,172 353
316 Seltifort Kid 60 ml Botol 8 - 8 (50) 58
317 Cetirizine Hcl 10 mg tab 404 - 404 (630) 1,034
318 Kasa 36 cm X 80 m Gulung - - - - -
320 Ketokonazole 200 mg tab 85 - 85 85 -
321 Acetylystein 200 mg tab 2,210 - 2,210 2,210 -
UMUM BPJS /
Kasep JUMLAH
# 1,875 # 579 # 2,454

Kepala Dinas Kesehatan Kab./kota Kepala UPTD Farmasi Kepala UPTD Puskesmas Petugas Puskesmas
Indramayu Lohbener
....................................................... Suryatno, S.Si., Apt. Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes Sahrudin, S.Kep., Ners.
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 91
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : JUNI UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : JULI PUSKESMAS 442.3/ 912.1 / Pkm 05 - Juli - 2018
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
5 Albendazol Tablet 400 mg Tablet 3,437 - 3,437 - 3,437
11 Amoksilin Kaplet 500mg Kaplet 13,760 - 13,760 1,930 11,830
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet 16,162 - 16,162 1,734 14,428
200 mg


Hal 92
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

20 Asam Benzoat 6 % = Asam Salisilat 3 % Pot 168 - 168 - 168


25 Asam Askrobat ( Vit . C ) 50 mg Tablet 5,140 - 5,140 708 4,432
38 ( Plain & Cromoic) Sachet 60 - 60 12 48 120
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 30 - 30 30 - 60

Hal 93
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
54
Ampul 55 - 55 - 55
57 Etanol 70 % - 100ml Botol 45 - 45 9 36
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 210 - 210 - 210
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 2,244 - 2,244 30 2,214
73 Furosemid Tablet 40 mg Tablet 500 - 500 - 500
76 Garam Oralit 200 ml Air Sachet 80 - 80 - 80 300
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - - - 4,000
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 120 - 120 9 111

Hal 94
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
86 Griseofulvin Tablet 125 mg Mikronised Tablet 2,500 - 2,500 - 2,500
92 Hidrokortison Krim 2,5 % Tube 216 - 216 - 216
94 Ibufropen Tablet 400 mg Tablet 9,750 - 9,750 3,577 6,173
96 Infusion Set Dewasa Set 170 - 170 43 127
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 7,902 - 7,902 1,208 6,694
107 Kapas Pembalut / Absorben 250 Gram Bungkus 1 - 1 1 - 5
110 Kasa Pembalut 2 m x 80 Cm Roll 102 - 102 2 100
112 Kasa Pembalut Hidrofil 4 m x 5 Cm Rol 5 - 5 5 -

Hal 95
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 600 - 600 400 200 5,000



mg

mg





Hal 96
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial - - - - - 20
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -

161 Nistatin 500.000 IU / gram Tablet 1,027 - 1,027 - 1,027
166 OAT Kategori Anak Paket 1 - 1 - 1
176 Parasetamol Tablet 500 mg Tablet 1,200 - 1,200 900 300 20,000

Hal 97
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 8,345 - 8,345 506 7,839

187
Botol - - - - -

208 Salbutamol Tablet 2 mg Tablet - - - - - 1,000

Hal 98
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

229
Tablet 22,200 - 22,200 - 22,200

235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 6,300 - 6,300 740 5,560
243 Acyclovir Krim Tube 144 - 144 - 144

Hal 99
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet - - - - -
249 Asam Mafenamat tab 500 mg Tablet - - - - - 3,000
250 Captopril tablet 12.5 mg Tablet 7,620 - 7,620 20 7,600
251 Captopril tablet 25 mg Tablet 250 - 250 150 100 2,500
252 Ciprofloksasin tablet 500 mg tablet 700 - 700 700 - 3,000
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - - - - -
275 Ranitidin tablet 150 mg tablet 150 - 150 50 100 2,000

Hal 100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 600 - 600 100 500
284 Propanolol 40 mg tablet 1,280 - 1,280 10 1,270
285 Natrium Diklofenak 50 mg Tablet 510 - 510 210 300 1,500
292 Kasa 16 X 16 Roll 600 - 600 368 232
298 Handscoon Non Steril S pcs 700 - 700 200 500 1,000
299 Handscoon Non Steril M pcs 930 - 930 450 480 1,000
300 Handscoon Non Steril L pcs 1,000 - 1,000 550 450
309 Metformin 500 mg tab 1,410 - 1,410 475 935
311 Hanscoon Steril No. 7 Pcs 301 - 301 1 300

Hal 101
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
312 Otsu Water ( Air Untuk Injeksi ) vial 5 - 5 5 - 20
315 Hustab P 4 mg / 5 ml Syr Botol - - - - -
317 Cetirizine Hcl 10 mg tab 1,034 - 1,034 34 1,000 2,250
318 Kasa 36 cm X 80 m Gulung - - - - - 50
319 Omeprazole kaps 20 mg Caps Caps - #VALUE! #VALUE! -
320 tab
321 tab
322 botol
UMUM BPJS /
Kasep JUMLAH
# 779 555 1,334

Indramayu Lohbener
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 102
FORM : LPLPO
PUSKESMAS 2018

LAPORAN BULAN/ PERIODE : JULI UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : AGUSTUS PUSKESMAS 442.3/ 1024.1 / Pkm 21-Aug-18
KAB./KOTA : INDRAMAYU
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set 4,145 - 4,145 - 4,145
10 Amoksilin Kapsul 250 mg Kapsul 3,811 - 3,811 825 2,986 2,000
200 mg


Hal 103
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17



38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 48 - 48 12 36 120
( Plain & Cromoic)
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul 200 - 200 100 100
41 Deksametason Tablet 0,5 mg Tablet 5,865 - 5,865 382 5,483
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - - - 100

Hal 104
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
54
Ampul 55 - 55 17 38
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - - - - - -
57 Etanol 70 % - 100ml Botol 36 - 36 5 31
76 Garam Oralit 200 ml Air Sachet 80 - 80 80 - 1,000
81 Gliseril Guayakolat Tablet 100 mg Tablet - - - - - 5,000

Hal 105
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
107 Kapas Pembalut / Absorben 250 Gram Bungkus - - - - -
118 Kloramfenikol Salep Mata 1 % - 3,5 mg Tube - - - - - 120

Hal 106
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 200 - 200 150 50 10,000



mg

mg





Hal 107
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
146 Magnesium Sulfat Injeksi (IV) 40 % - 50 ml vial - - - - - 20
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -

161 Nistatin 500.000 IU / gram Tablet 1,027 - 1,027 10 1,017
166 OAT Kategori Anak Paket 1 - 1 1 -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - 50 50 - 50 840
176 Parasetamol Tablet 500 mg Tablet 300 200 500 500 - 10,000

Hal 108
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 7,839 - 7,839 956 6,883

187
Botol - - - - -

192 Povidon Lodida 10 % - 1000 ml Botol 8 - 8 1 7

Hal 109
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml - Ampul - - - - - 100

229
Tablet 22,200 - 22,200 250 21,950

235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 5,560 - 5,560 1,440 4,120

Hal 110
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
251 Captopril tablet 25 mg Tablet 100 - 100 - 100
252 Ciprofloksasin tablet 500 mg tablet - - - - - 2,000
254 Chloramfenicol syrup 125 mg/5ml Botol - - - - - 50
255 Dimehydrinate 50 mg tablet tablet - - - - - 500
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - - - - - 200
269 Metronidazol tablet 500 mg tablet 3,100 - 3,100 - 3,100
275 Ranitidin tablet 150 mg tablet 100 - 100 - 100 1,000
276 Simvastatin tab 10 mg tab 90 - 90 - 90

Hal 111
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 500 - 500 200 300 1,000
285 Natrium Diklofenak Tablet 300 - 300 150 150 250
289 Hemorograd ( Antihemoroid ) Kotak 44 - 44 44 -
292 Kasa 16 X 16 Roll 232 - 232 112 120
300 Handscoon Non Steril L pcs 450 - 450 75 375 1,000
309 Metformin 500 mg tab 1,410 - 1,410 595 815
310 Herbakof Sirup Botol - 48 48 - 48

Hal 112
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
312 Otsu Water ( Air Untuk Injeksi ) vial 5 - 5 5 - 10
317 Cetirizine Hcl 10 mg tab 1,034 - 1,034 991 43 1,000
318 Kasa 36 cm X 80 m Gulung - - -
319 Omeprazole kaps 20 mg Caps Caps - #VALUE! #VALUE! -
320
UMUM BPJS /
Kasep JUMLAH
# 2,679 682 3,361

Indramayu Lohbener
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 113
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : AGUSTUS UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : SEPTEMBER PUSKESMAS 442.3/ / Pkm 07 / Septmbr 2018
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set 4,145 - 4,145 - 4,145
7 Aminofilin Tablet 200 mg Tablet 574 - 574 - 574
17 Hidroksida 500 IU / g + Alumunium Tablet 12,078 - 12,078 1,973 10,105
Hidroksida 200 mg

18 Basintrasin 500 IU / g Tube 12 - 12 12 - 125

Hal 114
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17


21 Ergotamin Tartrat 1 mg + Kofein 50 mg Tablet - - - - -


25 Asam Askrobat ( Vit . C ) 50 mg Tablet 3,129 - 3,129 2,503 626 2,000
34 Benzatin Benzil Penisilin Injeksi 1 ,2 Juta IU/ Vi Vial - - - - -
35 Benzatin Benzil Penisilin Injeksi 2 ,4 Juta IU/ Vi Vial - - - - -
38 ( Plain & Cromoic) Sachet 36 - 36 13 23 120
41 Deksametason Tablet 0,5 mg Tablet 5,483 - 5,483 701 4,782
47 Diazepam Tablet 2 mg Tablet - - - - - 300
48 Diazepam Tablet 5 mg Tablet - - - - - 300

Hal 115
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - - -
54 Epinefrina HCL / Bitartrat (Epiefrina Ampul 38 - 38 8 30
57 Etanol 70 % - 100ml Botol 31 - 31 2 29
76 Garam Oralit 200 ml Air Sachet - - - - - 500

Hal 116
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Hal 117
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 50 - 50 - 50 10,000



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 Botol 144 - 144 31 113
mg/5 mg



144 Lisol Mengandung Kresol Tersabun 50 % - 100 Botol - - - - -

Hal 118
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
150 Metanol - 100 ml Botol - - - - -
151 Metilergometri Maleat (Metilergometrin) Tablet - - - - -

152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 Ampul 200 - 200 11 189

156 Natrium Bikarbonat Tablet 500 mg Tablet 1,800 - 1,800 - 1,800
158 Natrium Klorida Larutan Infus 0,9 + % Steril - Botol 191 - 191 4 187
161 Nistatin 500.000 IU / gram Tablet 1,017 - 1,017 25 992
169 Oksitetrasiklin HCL Injeksi I.m.50 mg/ml - 10 vial - - - - -
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol 50 - 50 50 - 500
176 Parasetamol Tablet 500 mg Tablet - - - - - 20,000

Hal 119
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 6,883 - 6,883 - 6,883
Polikresulen (Kondensasi Metakresol
187 Sulfonat Botol - - - - -
194 Prednison Tablet 5 mg Tablet 2,904 - 2,904 1,910 994
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul 1,200 - 1,200 10 1,190

Hal 120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Salep 2 - 4 Kombinasi : Asamsalisilat 2 %

209 +Belerang Endap 4 % - 30 mg Pot 129 - 129 4 125

213 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (AB Vial - - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul ( Ampul 5 - 5 1 4
217 Serum Anti Tetanus Injeksi 20.000 IU / Ampul Vial - - - - -
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml Ampul - - - - -
222 Streptomisin Sulfat Serbuk Injeksi 1000 mg/ Vi Vial - - - - -
223 Streptomisin Sulfat Serbuk Injeksi 1500 mg/ Vi Vial - - - - -
227 Suspensi Seng Insulin Injeksi 40 IU / ml (Huma Vial - - - - -

229 Besi II Sulfat 200 mg + Asam Folat 0.25 mg Tablet 21,950 - 21,950 44 21,906

236 Tiopental Natrium Serbuk Injeksi 1000 mg / A Ampul - - - - -
Hal 121
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
241 Vitamin B Komplek Tablet Tablet 2,795 - 2,795 1,184 1,611 3,000
245 Amlodipin tab 5 mg tablet - - - - - 300
250 Captopril tablet 12.5 mg Tablet 6,309 - 6,309 643 5,666
251 Captopril tablet 25 mg Tablet 100 - 100 100 - 2,000
252 Ciprofloksasin tablet 500 mg tablet - - - - -
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - - - - -
269 Metronidazol tablet 500 mg tablet 3,100 - 3,100 - 3,100
270 Miconazole cream 2 % tube 137 - 137 - 137

Hal 122
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
275 Ranitidin tablet 150 mg tablet 100 - 100 - 100 2,000
279 Zink Tablet 300 - 300 200 100 1,000
285 Natrium Diklofenak Tablet 150 - 150 - 150 2,500
289 Hemorograd ( Antihemoroid ) Kotak - - - - -
290 Pehacain,Lidocaine HCL,Epinephrine Ampul 26 - 26 - 26 300
292 Kasa 16 X 16 Roll 120 - 120 7 113
300 Handscoon Non Steril L pcs 375 - 375 175 200 300
301 Autoclik Device OneMed pcs 2 - 2 - 2
302 New Antides ( Attapulgit ) tablet 1,035 - 1,035 504 531

Hal 123
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
309 Metformin 500 mg tab 815 - 815 167 648 1000
310 Herbakof Sirup Botol 48 - 48 21 27 480
312 Otsu Water ( Air Untuk Injeksi ) vial - - - - -
316 Seltifort Kid 60 ml Botol 38 - 38 - 38
317 Cetirizine Hcl 10 mg tab 43 - 43 43 - 4500
318 Kasa 36 cm X 80 m Gulung 1 - 1 - 1
319 Omeprazole kaps 20 mg Caps - - - -
320
UMUM BPJS /
Kasep JUMLAH
# 2,533 722 3,255

Indramayu Lohbener
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 124
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
PEMBERIAN
NO NAMA OBAT SATUAN STOK PENERIMA PERSEDIA PEMAKAIA SISA STOK
AWAL AKHIR STOK OPT. PERMINTA APBN ASKES APBD I APBD II PROGRAM LAIN LAIN
JUMLAH
AN AN N AN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
1 Garam Oralit 200 ml Sacset 200
2 Eritromocin 250 mg Caps 200
3 Clindamicin 150 mg Tab 200
4 Cefadroxil 500 mg Tab 500
5 Umbilical Klem Buah 200
6 Glibenclamide 5 mg Tab 1,000
7
8
9
10
11
12
13
14
15
16

Hal 125
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

Hal 126
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51

Hal 127
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : SEPTEMBER UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : OKTOBER PUSKESMAS 1-Oct-18
SISA PEMBERIAN
STOK
NO NAMA OBAT SATUAN AWAL PENERIMA PERSEDIA PEMAKAIA STOKA STOK OPT. PERMINTA JUMLAH
AN AN N AKHIR AN APBN ASKES APBD I APBD II PROGRAM LAIN LAIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
6 Aloporinol Tablet 100 mg Tablet 1,766 - 1,766 925 841
7 Aminofilin Tablet 200 mg Tablet 574 - 574 574 -
10 Amoksilin Kapsul 250 mg Kapsul 1,186 3,000 4,186 1,150 3,036
200 mg

18 Basintrasin 500 IU / g Tube - 100 100 27 73

Hal 128
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17



25 Asam Askrobat ( Vit . C ) 50 mg Tablet 626 2,000 2,626 1,490 1,136
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 23 240 263 23 240
( Plain & Cromoic)
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - 90 90 15 75

Hal 129
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51 Digoksin Tablet 0,25 mg Tablet 360 - 360 360 -
54
Ampul 30 - 30 - 30
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol - 10 10 2 8
57 Etanol 70 % - 100ml Botol 29 - 29 7 22

Hal 130
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
89 Haloperoidol 1,5 mg Tablet Tablet - 200 200 10 190
94 Ibufropen Tablet 400 mg Tablet 1,465 - 1,465 1,415 50
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 3,721 - 3,721 200 3,521
117 Kloramfenikol Kapsul 250mg Kapsul - 1,000 1,000 120 880

Hal 131
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 50 1,000 1,050 886 164



mg

mg





Hal 132
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -

158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 187 - 187 - 187
161 Nistatin 500.000 IU / gram Tablet 992 - 992 30 962
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 10 100 110 6 104
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 300 - 300 15 285
176 Parasetamol Tablet 500 mg Tablet - 5,000 5,000 4,550 450

Hal 133
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

187
Botol - - - - -

194 Prednison Tablet 5 mg Tablet 994 - 994 794 200
208 Salbutamol Tablet 2 mg Tablet - 500 500 230 270

Hal 134
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

229
Tablet 21,906 35,550 57,456 - 57,456

241 Vitamin B Komplek Tablet Tablet 1,611 3,000 4,611 2,030 2,581

Hal 135
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
249 Asam Mafenamat tab 500 mg Tablet - - - - -
251 Captopril tablet 25 mg Tablet - - - - -
255 Dimehydrinate 50 mg tablet tablet - 1,000 1,000 180 820
256 Domperidone tablet - 1,000 1,000 210 790
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
268 Masker set - 250 250 - 250
274 Omeprazole 20 mg tablet - 300 300 100 200
275 Ranitidin tablet 150 mg tablet 100 1,000 1,100 510 590
276 Simvastatin tab 10 mg tab 80 - 80 - 80

Hal 136
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 100 1,000 1,100 55 1,045
285 Natrium Diklofenak Tablet 150 1,500 1,650 1,250 400
289 Hemorograd ( Antihemoroid ) Kotak - 90 90 40 50
290 Pehacain,Lidocaine HCL,Epinephrine Ampul 26 - 26 26 -
292 Kasa 16 X 16 Roll 113 - 113 113 -
298 Handscoon Non Steril S pcs 200 1,000 1,200 100 1,100
299 Handscoon Non Steril M pcs 250 1,000 1,250 250 1,000
300 Handscoon Non Steril L pcs 200 500 700 100 600
302 New Antides ( Attapulgit ) tablet 531 - 531 321 210
309 Metformin 500 mg tab 648 - 648 430 218
310 Herbakof Sirup Botol 27 - 27 27 -

Hal 137
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
317 Cetirizine Hcl 10 mg tab - 4,500 4,500 450 4,050
318 Kasa 36 cm X 80 m Gulung - 10 10 3 7
319 Omeprazole kaps 20 mg Caps - 300 300 100 200
320 Ketokonazole 200 mg tab - 1,000 1,000 30 970
321 Acetylystein 200 mg tab - 960 960 220 740
322 Hand Rub 500 ml botol 40 40 - 40
323 Sianokobalamin 50 mg Tab - - - - -
324 Klindamicyn 150 mg Caps -
325 -
UMUM BPJS /
Kasep JUMLAH
# # -

Indramayu
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 138
FORM : LPLPO
PUSKESMAS 2018

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : OKTOBER 2,018 UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : NOVEMBER PUSKESMAS 442.3/ / Pkm 31-Oct-18
SISA PEMBERIAN
NO NAMA OBAT SATUAN STOK PENERIMA PERSEDIA PEMAKAIA STOK STOK OPT. PERMINT JUMLAH
AWAL AN AN N AKHIR AAN APBN ASKES APBD I APBD II PROGRAM LAIN LAIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
6 Aloporinol Tablet 100 mg Tablet 841 2,000 2,841 600 2,241
7 Aminofilin Tablet 200 mg Tablet - - - - - 1,000
11 Amoksilin Kaplet 500mg Kaplet 4,400 2,000 6,400 3,027 3,373 6,000
Hidroksida 500 IU / g + Alumunium Hidroksida
17
200 mg
Tablet 7,420 - 7,420 3,010 4,410

18 Basintrasin 500 IU / g Tube 73 - 73 30 43 100
19 Anti Hemoroid Doen Kombinasi Supp - 20 20 15 5 20
20 Antifungi DOEN Kombinasi : Pot 138 - 138 15 123

Asam Benzoat 6 % = Asam Salisilat 3 %

Hal 139
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

25 Asam Askrobat ( Vit . C ) 50 mg Tablet 1,136 2,000 3,136 2,136 1,000 3,000
38
( Plain & Cromoic)
Sachet 240 120 360 51 309
41 Deksametason Tablet 0,5 mg Tablet 2,362 2,000 4,362 1,890 2,472 2,000
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 75 - 75 15 60 100
51 Digoksin Tablet 0,25 mg Tablet - - - - -
54
Ampul 30 - 30 - 30

Hal 140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol 8 - 8 1 7
57 Etanol 70 % - 100ml Botol 22 - 22 4 18
59 Etil Krorida Semprot - 100 ml Botol - 6 6 - 6
73 Furosemid Tablet 40 mg Tablet 250 1,000 1,250 247 1,003
76 Garam Oralit 200 ml Air Sachet - 400 400 40 360
80 Glibenklamid Tablet 5 mg Tablet - 1,000 1,000 500 500 500
89 Haloperoidol 1,5 mg Tablet Tablet 190 - 190 35 155

Hal 141
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
93 Ibufropen Tablet 200 mg Tablet - 5,000 5,000 109 4,891
94 Ibufropen Tablet 400 mg Tablet 50 - 50 50 -
96 Infusion Set Dewasa Set 215 - 215 22 193
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 3,521 - 3,521 3,453 68 4,000
107 Kapas Pembalut / Absorben 250 Gram Bungkus - 10 10 1 9
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 50 - 50 - 50 -
117 Kloramfenikol Kapsul 250mg Kapsul 880 - 880 155 725 1,000
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol - 250 250 - 250
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 164 3,000 3,164 2,464 700 5,000

121
Tablet - - - - -


Hal 142
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 67 50 117 44 73 200
mg


143
Ampul 289 - 289 60 229

150 Metanol - 100 ml Botol - - - - -

151 Tablet Salut 0,125 gram Tablet - - - - - 500


Hal 143
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
161 Nistatin 500.000 IU / gram Tablet 962 - 962 - 962
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 285 - 285 34 251
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 202 - 202 20 182
176 Parasetamol Tablet 500 mg Tablet 450 5,000 5,450 4,530 920 10,000
184
Tablet - - - - -

187
Botol - - - - -

Hal 144
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
194 Prednison Tablet 5 mg Tablet 200 1,000 1,200 186 1,014
208 Salbutamol Tablet 2 mg Tablet 270 - 270 248 22 2,000
Salep 2 - 4 Kombinasi : Asamsalisilat 2 %
209 +Belerang Endap 4 % - 30 mg Pot 120 - 120 1 119
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 3 10 13 - 13
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml Ampul - - - - - 100
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 106 120 226 26 200

Hal 145
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

229
Tablet 57,456 - 57,456 2,957 54,499
230 Temporary Stooping Fletcher set - 6 6 - 6

241 Vitamin B Komplek Tablet Tablet 2,581 - 2,581 44 2,537
242 Acyclovir 200 mg Tablet 450 - 450 23 427
245 Amlodipin tab 5 mg tablet - 900 900 5 895
250 Captopril tablet 12.5 mg Tablet 3,566 - 3,566 1,490 2,076 2,000
251 Captopril tablet 25 mg Tablet - - - - - 3,000
252 Ciprofloksasin tablet 500 mg tablet - 1,200 1,200 520 680 3,000
255 Dimehydrinate 50 mg tablet tablet 820 - 820 270 550
256 Domperidone tablet 790 - 790 163 627
258 Etanol 70 % - 1000ml botol - - - - -

Hal 146
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
260 Handscoon no 7-7,5 Set - - - - -
267 Loratadine tab 10 mg tablet - - - - - 500
268 Masker set 250 - 250 - 250
272 Multivit Ibu Hamil / Hemafort kapsul 12,715 - 12,715 220 12,495
274 Omeprazole 20 mg tablet 200 - 200 50 150
275 Ranitidin tablet 150 mg tablet 590 100 690 190 500 1,000
276 Simvastatin tab 10 mg tab 80 90 170 40 130
279 Zink Tablet 1,045 - 1,045 180 865
285 Natrium Diklofenak Tablet 400 1,200 1,600 1,400 200 1,500
289 Hemorograd ( Antihemoroid ) Kotak 50 - 50 20 30 120
290 Pehacain,Lidocaine HCL,Epinephrine Ampul - - - - - 300
292 Kasa 16 X 16 Roll - - - - -

Hal 147
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
296 Metronidazole Suspensi 125 mg/5 ml Botol 35 - 35 5 30 100
297 Handscoon Steril no. 6.5 pcs 99 - 99 19 80 200
299 Handscoon Non Steril M pcs 1,000 - 1,000 600 400 1,000
300 Handscoon Non Steril L pcs 600 - 600 200 400
302 New Antides ( Attapulgit ) tablet 210 - 210 137 73 1,000
309 Metformin 500 mg tab 218 400 618 123 495
316 Seltifort Kid 60 ml Botol 32 - 32 - 32
317 Cetirizine Hcl 10 mg tab 4,050 - 4,050 967 3,083
318 Kasa 36 cm X 80 m Gulung 7 - 7 3 4
319 Omeprazole kaps 20 mg Caps 200 - 200 50 150
320 Ketokonazole 200 mg tab 970 - 970 90 880
321 Acetylystein 200 mg tab 740 960 1,700 1,145 555 3,840
322 Hand Rub 500 ml botol 40 - 40 - 40
323 Sianokobalamin 50 mg Tab - 100 100 - 100
324 Klindamicyn 150 mg Caps - 2,000 2,000 100 1,900
325 -
UMUM BPJS /
Kasep JUMLAH
# 2,434 # 684 3,118

Hal 148
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Indramayu
dr. H. Deden Bonni Koswara,MM Suryatno, S.Si., Apt. Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes H. Sahrudin, S.Kep., Ners.
NIP. 19740110 200212 1 008 NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 149
FORM : LPLPO
PUSKESMAS 2016

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : NOVEMBER UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : DESEMBER PUSKESMAS
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set 3,995 - 3,995 3,995 -
3 Alat Suntik Sekali Pakai 3 ml Set 6,932 - 6,932 6,932 -
4 Alat suntik Sekali Pakai 5 ml Set 3,636 - 3,636 3,636 -
5 Albendazol Tablet 400 mg Tablet 3,437 1,063 4,500 4,500 -
6 Aloporinol Tablet 100 mg Tablet 2,241 - 2,241 2,241 - 2,000
7 Aminofilin Tablet 200 mg Tablet - - - - - 1,000
10 Amoksilin Kapsul 250 mg Kapsul 1,296 3,000 4,296 4,296 -
11 Amoksilin Kaplet 500mg Kaplet 3,373 5,000 8,373 8,373 - 5,000
12 Amoksilin Sirup kering 125 mg / 5 ml Botol 211 - 211 211 - 300
15 Antalgin ( Matampiron ) Tanlet 500 mg Tablet - - - - - 5,000
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet 4,410 - 4,410 4,410 - 5,000
200 mg

18 Basintrasin 500 IU / g Tube 43 100 143 143 - 150
19 Anti Hemoroid Doen Kombinasi Supp 5 20 25 25 - 50

Hal 150
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

20 Asam Benzoat 6 % = Asam Salisilat 3 % Pot 123 - 123 123 - 130


25 Asam Askrobat ( Vit . C ) 50 mg Tablet 1,000 2,000 3,000 3,000 - 3,000
37 Betametasol Krim , 0,1 % - 5 mg Tube 201 - 201 201 - 240
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet 309 - 309 309 - 120
( Plain & Cromoic)
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul 100 - 100 100 -
41 Deksametason Tablet 0,5 mg Tablet 2,472 1,000 3,472 3,472 - 3,000
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul 60 30 90 90 -

Hal 151
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51 Digoksin Tablet 0,25 mg Tablet - - - - - 1,000
54
Ampul 30 - 30 30 -
55 Etakridin ( rifanol ) Larutan 0.1 % - 300 ml Botol 7 - 7 7 -
57 Etanol 70 % - 100ml Botol 18 - 18 18 -
59 Etil Krorida Semprot - 100 ml Botol 6 - 6 6 -
60 Eugenol Cairan - 10 ml Botol 3 - 3 3 -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul 210 - 210 210 -
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet 1,300 - 1,300 1,300 -
73 Furosemid Tablet 40 mg Tablet 1,003 - 1,003 1,003 -
76 Garam Oralit 200 ml Air Sachet 360 - 360 360 -
80 Glibenklamid Tablet 5 mg Tablet 500 300 800 800 -
83 Glukosa Larutan Infus 5 % Steril - 500 ml Botol 106 - 106 106 -

Hal 152
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
86 Griseofulvin Tablet 125 mg Mikronised Tablet 2,015 - 2,015 2,015 -
89 Haloperoidol 1,5 mg Tablet Tablet 155 - 155 155 -
92 Hidrokortison Krim 2,5 % Tube 153 - 153 153 - 160
93 Ibufropen Tablet 200 mg Tablet 4,891 - 4,891 4,891 - 5,000
95 Infusion Set Anak Set 381 - 381 381 -
96 Infusion Set Dewasa Set 193 - 193 193 -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet 500 - 500 500 -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet 68 4,000 4,068 4,068 - 4,500
107 Kapas Pembalut / Absorben 250 Gram Bungkus 9 - 9 9 -
110 Kasa Pembalut 2 m x 80 Cm Roll 100 - 100 100 -
113 Kasa Pembalut Hidrofil 4 m x 10 Cm Rol 50 - 50 50 -
117 Kloramfenikol Kapsul 250mg Kapsul 725 500 1,225 1,225 - 2,000

Hal 153
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
119 Kloramfenikol Tetes Telinga 3 % - 5 ml Botol 250 - 250 250 -
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet 700 3,000 3,700 3,700 - 4,000



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol 73 100 173 173 - 300
mg
131 Kotrimoksazol Tableti Kombinasi : Tablet 10,152 - 10,152 10,152 -


143 Lidokain Komp. Injeksi, kombinasi : Ampul 229 - 229 229 -



Hal 154
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul 100 - 100 100 -

156 Natrium Bikarbonat Tablet 500 mg Tablet 1,480 - 1,480 1,480 -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol 180 - 180 180 -
160 Nistatin 100.000 IU / gram Vaginal Tablet 246 - 246 246 -
161 Nistatin 500.000 IU / gram Tablet 962 - 962 962 -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube 89 - 89 89 - 250
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube 251 - 251 251 -
172 Oksitosin Injeksi IU/ml - 1 ml Ampul 182 - 182 182 - 50
174 Parasetamol sirup 120 mg/5 ml - 60 ml Botol - 300 300 300 -
176 Parasetamol Tablet 500 mg Tablet 920 2,000 2,920 2,920 - 10,000

Hal 155
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet 2,795 - 2,795 2,795 - 3,000
186 Plester 5 Yards x 2 inch Rol 44 - 44 44 -

187
Botol - - - - -

192 Povidon Lodida 10 % - 1000 ml Botol 7 - 7 7 -
194 Prednison Tablet 5 mg Tablet 1,014 - 1,014 1,014 -
202 Retinol (Vit.A) 100.000 IU Kapsul Kapsul 250 - 250 250 -
203 Retinol (Vit.A) 200.000 IU Kapsul Kapsul 1,190 - 1,190 1,190 -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol 96 - 96 96 -
208 Salbutamol Tablet 2 mg Tablet 22 500 522 522 - 600
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 119 - 119 119 -
210 Salisil Bedak 2 % - 50 gram Kotak 67 - 67 67 - 100

Hal 156
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
212 Semen Seng Fosfat Serbuk dan Cairan Botol 2 - 2 2 -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul 13 - 13 13 - 20
218 Sianokobalamin (Vit.B12) Injeksi 500 mcg / ml - Ampul - - - - - 200
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet 200 - 200 200 -

229
Tablet 54,499 - 54,499 54,499 -
230 Temporary Stooping Fletcher set 6 - 6 6 -

233 Tetrasiklin HCL Kapsul 500 mg Kapsul 3,355 - 3,355 3,355 -
235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet 3,059 1,000 4,059 4,059 -
241 Vitamin B Komplek Tablet Tablet 2,537 - 2,537 2,537 - 5,000
242 Acyclovir 200 mg Tablet 427 - 427 427 -
243 Acyclovir Krim Tube 132 - 132 132 - 250

Hal 157
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
245 Amlodipin tab 5 mg tablet 895 - 895 895 -
248 Antidiare Tablet - 500 500 500 -
250 Captopril tablet 12.5 mg Tablet 2,076 500 2,576 2,576 -
251 Captopril tablet 25 mg Tablet - 2,000 2,000 2,000 -
252 Ciprofloksasin tablet 500 mg tablet 680 - 680 680 - 3,000
255 Dimehydrinate 50 mg tablet tablet 550 - 550 550 -
256 Domperidone tablet 627 - 627 627 -
257 Domperidone syrup tablet 176 - 176 176 -
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
261 IV Catheter No 18 G set 109 - 109 109 -
268 Masker set 250 - 250 250 -
269 Metronidazol tablet 500 mg tablet 1,779 - 1,779 1,779 -
270 Miconazole cream 2 % tube 107 - 107 107 -
271 Multivit Anak Kurang Gizi / Vical botol 93 - 93 93 -
272 Multivit Ibu Hamil / Hemafort kapsul 12,495 - 12,495 12,495 -
273 Nifedipin tab 10 mg tablet 2,900 - 2,900 2,900 -
274 Omeprazole tablet 150 - 150 150 - 1,000
275 Ranitidin tablet 150 mg tablet 500 1,000 1,500 1,500 - 3,000
276 Simvastatin tab 10 mg tab 130 - 130 130 - 1,000

Hal 158
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet 865 - 865 865 - 2,000
281 Tes Kehamialan Set - - - - - 100
283 Piroksicam 10 mg tablet - - - - - 1,000
284 Propanolol 40 mg tablet 1,160 - 1,160 1,160 -
285 Natrium Diklofenak Tablet 200 1,500 1,700 1,700 - 2,000
289 Hemorograd ( Antihemoroid ) Kotak 30 - 30 30 -
290 Pehacain,Lidocaine HCL,Epinephrine Ampul - - - - -
292 Kasa 16 X 16 Roll - - - - -
296 Metronidazole Suspensi 125 mg/5 ml Botol 30 - 30 30 -
297 Handscoon Steril no. 6.5 pcs 80 50 130 130 -
298 Handscoon Non Steril S pcs 900 - 900 900 -
299 Handscoon Non Steril M pcs 400 300 700 700 -
300 Handscoon Non Steril L pcs 400 - 400 400 -
301 Autoclik Device OneMed pcs 2 - 2 2 -
302 New Antides ( Attapulgit ) tablet 73 - 73 73 - 1,000
303 Dextral Sirup - - -
304 Dulcolax Supp Dewasa 10 mg 9 - -
305 Dulcolax Supp anak - - -
306 Cefiksime Tab 100 mg - - -
307 Alat Suntik Sekali Pakai 10 cc 9 - -
308 Alat Suntik Sekali Pakai 20 cc 23 - -
309 Metformin 500 mg 495 - -
310 Herbakof Sirup - - -
311 Hanscoon Steril No. 7 295 - -

Hal 159
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
312 Otsu Water ( Air Untuk Injeksi ) - - -
313 Gentamicin Sulfat 0,5 % Tetes Mata 78 - -
314 Tropikal Anetesi - - -
315 Hustab P 4 mg / 5 ml Syr - - -
316 Seltifort Kid 60 ml 32 - -
317 Cetirizine Hcl 10 mg 3,083 5,000 -
318 Kasa 36 cm X 80 m 4 - -
319 Omeprazole kaps 20 mg 150 - -
320 Ketokonazole 200 mg 880 - -
321 Acetylystein 200 mg 555 960 -
322 Hand Rub 500 ml 40 - -
323 Sianokobalamin 50 mg 100 - -
324 Klindamicyn 150 mg 1,900 - -
325 Indramayu,
UMUM BPJS /
Kasep JUMLAH
# 1,185 524 1,709

Indramayu Lohbener

Hal 160
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

Hal 161
FORM : LPLPO
PUSKESMAS 2016

KAB./KOTA : INDRAMAYU LAPORAN BULAN/ PERIODE : DESEMBER UPTD FARMASI
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : JANUARI PUSKESMAS
PEMBERIAN
STOK SISA STOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
2 Alat Suntik Sekali Pakai 1 ml Set - - - - -
3 Alat Suntik Sekali Pakai 3 ml Set - - - - -
4 Alat suntik Sekali Pakai 5 ml Set - - - - -
6 Aloporinol Tablet 100 mg Tablet - - - - -
7 Aminofilin Tablet 200 mg Tablet - - - - -
10 Amoksilin Kapsul 250 mg Kapsul - - - - -
11 Amoksilin Kaplet 500mg Kaplet - - - - -
12 Amoksilin Sirup kering 125 mg / 5 ml Botol - - - - -
17 Hidroksida 500 IU / g + Alumunium Hidroksida Tablet - - - - -
200 mg

18 Basintrasin 500 IU / g Tube - - - - -

Hal 162
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

20 Asam Benzoat 6 % = Asam Salisilat 3 % Pot - - - - -


37 Betametasol Krim , 0,1 % - 5 mg Tube - - - - -
38 Catgut / Benang Bedah No. /0 - 3/0 Sachet - - - - -
( Plain & Cromoic)
40 Deksametason Injeksi 5 mg/ml - 1ml Ampul - - - - -
41 Deksametason Tablet 0,5 mg Tablet - - - - -
50 Difenhidramin HCL Injeksi 10 mg/ml - 1ml Ampul - - - - -

Hal 163
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
51 Digoksin Tablet 0,25 mg Tablet - - - - -
54
Ampul - - - - -
57 Etanol 70 % - 100ml Botol - - - - -
60 Eugenol Cairan - 10 ml Botol - - - - -
70 Fitomenadion(Vit.K10) Injeksi 10 mg / - ml Ampul - - - - -
71 Fitomenadion(Vit.K1) Tablet Salut 10mg Tablet - - - - -
73 Furosemid Tablet 40 mg Tablet - - - - -

Hal 164
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
86 Griseofulvin Tablet 125 mg Mikronised Tablet - - - - -
92 Hidrokortison Krim 2,5 % Tube - - - - -
95 Infusion Set Anak Set - - - - -
96 Infusion Set Dewasa Set - - - - -
101 Isosorbid Dinitrat 5 mg Tablet Sublingual Tablet - - - - -
105 Kalsium Laktat ( Kalk ) Tablet 500 mg Tablet - - - - -
110 Kasa Pembalut 2 m x 80 Cm Roll - - - - -

Hal 165
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
120 Klofeniranim Malet ( CTM ) Tablet 4 mg Tablet - - - - -



mg

130 Sulfametoksazol 200 mg+Trimetropin 40 mg/5 Botol - - - - -
mg
131 Kotrimoksazol Tableti Kombinasi : Tablet - - - - -


143 Lidokain Komp. Injeksi, kombinasi : Ampul - - - - -



Hal 166
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
150 Metanol - 100 ml Botol - - - - -

151
Tablet - - - - -
152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 m Ampul - - - - -

156 Natrium Bikarbonat Tablet 500 mg Tablet - - - - -
158 Natrium Klorida Larutan Infus 0,9 + % Steril - 5 Botol - - - - -
160 Nistatin 100.000 IU / gram Vaginal Tablet - - - - -
161 Nistatin 500.000 IU / gram Tablet - - - - -
170 Oksitetrasiklin HCL Salep Mata 1% - 3,5 g Tube - - - - -
171 Oksitetrasiklin HCL Salep 3 % - 5 g Tube - - - - -
172 Oksitosin Injeksi IU/ml - 1 ml Ampul - - - - -

Hal 167
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
185 Piridoksin HCL (vit.B6) Tablet 10 mg Tablet - - - - -
186 Plester 5 Yards x 2 inch Rol - - - - -

187
Botol - - - - -

194 Prednison Tablet 5 mg Tablet - - - - -
207 Ringer Laktat Larutan Infus Steril - 500 ml Botol - - - - -
209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot - - - - -
210 Salisil Bedak 2 % - 50 gram Kotak - - - - -

Hal 168
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
212 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
216 Serum Anti Tetanus Injeksi 1.500 IU / Ampul (A Ampul - - - - -
219 Slik (Benang Bedah Sutra) No. 3/0 Sachet - - - - -

229
Tablet - - - - -

235 Tiamin HCL/ Mononitrat (Vit.B1) Tablet 50 mg Tablet - - - - -
241 Vitamin B Komplek Tablet Tablet - - - - -
242 Acyclovir 200 mg Tablet - - - - -
243 Acyclovir Krim Tube - - - - -

Hal 169
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
249 Asam Mafenamat tab 500 mg Tablet - - - - -
250 Captopril tablet 12.5 mg Tablet - - - - -
251 Captopril tablet 25 mg Tablet - - - - -
257 Domperidone syrup tablet - - - - -
258 Etanol 70 % - 1000ml botol - - - - -
260 Handscoon no 7-7,5 Set - - - - -
261 IV Catheter No 18 G set - - - - -
268 Masker set - - - - -
269 Metronidazol tablet 500 mg tablet - - - - -
270 Miconazole cream 2 % tube - - - - -
271 Multivit Anak Kurang Gizi / Vical botol - - - - -
272 Multivit Ibu Hamil / Hemafort kapsul - - - - -
273 Nifedipin tab 10 mg tablet - - - - -
275 Ranitidin tablet 150 mg tablet - - - - -
276 Simvastatin tab 10 mg tab - - - - -

Hal 170
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
279 Zink Tablet - - - - -
284 Propanolol 40 mg tablet - - - - -
285 Natrium Diklofenak Tablet - - - - -
289 Hemorograd ( Antihemoroid ) Kotak - - - - -
290 Pehacain,Lidocaine HCL,Epinephrine Ampul - - - - -
291 - - - - -
292 - - - - -
293 - - - - -
294 - - - - -
295 - - - - -
296 - - - - -
297 - - - - -
298 - - - - -
299 #NAME? - #NAME? #NAME? -
300 Handscoon Non Steril M pcs - - - - -
301 Hansdcoon Non Steril L Pcs - - - - -
303 New Antides ( Attapulgit ) tablet - - - - -
305 Dulcolax Supp Dewasa 10 mg Supp - - - - -
UMUM BPJS /
Kasep JUMLAH
-

Hal 171
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Indramayu Lohbener
NIP. NIP 19650323 198603 1010 NIP. 19770929 200801 2 006 NIP 19750725 200604 1 010

59CF7000

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DATA DASAR

KEPALA UPTD PUKESMAS LOHBENER

Petugas Pengelola Obat

KEPALA DINAS KESEHATAN KAB. INDRAMAYU

KEPALA UPTD FARMASI KAB. INDRAMAYU

SISA STOK OBAT TIAP BULAN TAHUN 2018

Antasid DOEN Tablet,Kombinasi :Magnesium

Anti Bakteri DOEN Salep Kombinasi

19 Anti Hemoroid Doen Kombinasi Supp - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

21 Anti Migren DOEN Kombinasi : Tablet - - - - - - - - - - - - -

23 Aqua Pro Injeksi Steril, Bebas Prirogen - 20 ml Vial - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Kloroquin Fosfat Tablet 250 mg

122 Klorpromazin HCL Injeksi 25 mg/ml - 1 ml Ampul - - - - - - - - - - - - -

Kotrimoksazol Pediatrik Tablet,Kombinasi

Kotrimoksazol Suspensi Kombinasi :

Kotrimoksazol Tableti Kombinasi :

132 Kuinin Dihidroklorida Injeksi 25% - 2 ml Ampul - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

151 Metilergometri Maleat (Metilergometrin) Tablet - - - - - - - - - - - - -

152 Metilergometrin Maleat Injeksi 0,2000 mg - 1 Ampul 65 62 62 34 229 - - - - - - - 452

Pemakaian Obat PKM LOHBNER TAHUN 2016

Polikresulen (Kondensasi Metakresol Sulfonat

188 Polipeptida Kombinasi DOEN Larutan Infus - 50 Botol - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

229 Tablet Tambah Darah Kombinasi : Tablet - - - 12,763 22,200 - - - - - - - 34,963

230 Temporary Stooping Fletcher set - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes H. Sahrudin, S.Kep., Ners.

Pemakaian Obat PKM LOHBNER TAHUN 2016

REKAP PEMAKAIAN OBAT TIAP BULAN TAHUN 2018

Antasid DOEN Tablet,Kombinasi :Magnesium

18 Anti Bakteri DOEN Salep Kombinasi Tube 1 4 4 9 16 6 7 12 27 30 143 - 259

Pemakaian Obat PKM LOHBNER TAHUN 2016

20 Antifungi DOEN Kombinasi : Asam Benzoat 6 Pot 7 9 1 5 7 - - - 30 15 123 - 197

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

121 Kloroquin Fosfat Tablet 250 mg

Kotrimoksazol Pediatrik Tablet,Kombinasi

Kotrimoksazol Tableti Kombinasi :

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

184 Pirantel Pamoat Tablet 365 mg Tablet - - - - - - - - - - - - -

Pemakaian Obat PKM LOHBNER TAHUN 2016

209 Salep 2 - 4 Kombinasi : Asamsalisilat 2 % Pot 10 1 - 3 8 5 9 4 5 1 119 - 165

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Pemakaian Obat PKM LOHBNER TAHUN 2016

Hj. Uswatun Hasanah. S.ST.SKM.MH.Kes dr. Yulis Susanto

Pemakaian Obat PKM LOHBNER TAHUN 2016

PENERIMAAN OBAT TAHUN 2018

Antasid DOEN Tablet,Kombinasi :Magnesium

Anti Bakteri DOEN Salep Kombinasi

19 Anti Hemoroid Doen Kombinasi Supp 20 20 40

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