LAPORAN BULANAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

POSKESDES :
KODE PUSKESMAS : P6101030101 PELAPORAN BULAN : Januari th 2021 DOKUMEN NOMOR TANGGAL
PUSKESMAS : TEBAS PERMINTAAN BULAN : Februari th 2021 PUSKESMAS
KECAMATAN : TEBAS POL/PUSTU
KABUPATEN : SMBAS

STOK KET. (Rusak, ED/

No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
1 2 3 4 5 6 7=5+6 8 9=7-8 10 11 12 13
I. OBAT
1 Air Pro Injeksi 25 ml Bolus - - - -
2 Albendazol tablet 400 mg Tablet - - - -
3 Alopurinol tablet 100 mg Tablet - - - -
4 Ambroxol sirup 15 mg/ml Botol - - - -
5 Ambroxol tablet 30 mg Tablet - - - -
6 Aminofilina injeksi 24 mg/ml - 10 ml Ampul - - - -
7
Aminofilina tablet 200 mg Tablet - - - -
8 Amlodipin 5 mg Tablet - - - -
9 Asetilsistein 200 mg Tablet - - - -
10 Antasida
Antasida DOEN
DOEN suspensi
tablet kunyah,kombinasi: Botol - - - -

11
Mg-Hidroksida 200 mg + Al. Hidroksida. 200 Tablet - - - -

mg
Anti Bakteri DOEN salep kombinasi: Basitrasin
12 Pot - - - -
500 IU/g + Polimiksin 10.000 IU/g
Anti Diare Kombinasi Kaolin 986 mg+Pektin 40
13 Botol - - - -
mg
14
Anti Hemoroid DOEN kombinasi : Bismuth Supp - - - -
subgalat 150 mg + Heksaklorofen 2,5 mg
15 Anti malaria (DHP) Tablet - - - -
Antifungi DOEN kombinasi : Asam Benzoat 6 %
16 Pot - - - -
+ Asam Salisilat 3 %
Antimigren DOEN tablet kombinasi : Ergotamin
17
Tartrat 1 mg + Kofein 50 mg Tablet - - - -

18
Asam asetil salisilat (asetosal) Tablet - - - -
tablet/kapsul/kaplet 100 mg
19 Asam Askorbat (Vitamin C) tablet 50 mg Tablet - - - -
20 Asam askorbat (vitamin C) tablet 250 mg Tablet - - - -
21 Asam Folat tablet 0,4 mg Tablet - - - -
22 Asam Mefenamat 500 mg Kaplet - - - -
23 Asam Traneksamat 500 mg Tablet - - - -
24 Asam traneksamat injeksi 100 mg/ml Ampul - - - -
25 Atropin inj 0,25 mg / ml Ampul - - - -
26 Attapulgite 600 mg tablet Tablet - - - -
27 Bedak salisil serbuk 2% Box - - - -
28 Betahistin tablet 6 mg Tablet - - - -
29 Betametason krim0,1% Tube - - - -
30 Bisakodil suppositoria 10mg Supp - - - -
31 Bisakodil suppositoria 5 mg Supp - - - -
32 Bisakodil tablet 5 mg Tablet - - - -
33 Bisoprolol tablet 5 mg Tablet - - - -
34 Cetirizin sirup 5 mg/5 ml Botol - - - -
35 Cetirizine tablet 10 mg Tablet - - - -
36 Deksametason injeksi 5 mg/ml - 1 ml Ampul - - - -
37 Deksametason tablet 0,5 mg Tablet - - - -
38 Dietilkarbamazin Sitrat tablet 100 mg Tablet - - - -
39 Difenhidramin HCl inj 10 mg/ml - 1 ml Ampul - - - -
40 Digoksin tablet/kapsul/kaplet 0,25 mg Tablet - - - -
41 Doksisiklin tab 100 mg Tablet - - - -
42 Domperidon 10 mg Tablet - - - -
43 Domperidon suspensi 5 mg/5 ml Botol - - - -
Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1
44
mg/ml Ampul - - - -
45 Etil Klorida semprot Botol - - - -
46 Eugenol cairan Botol - - - -
47 Fenitoin injeksi 50 mg/ml (100 mg/2 ml) Ampul - - - -
48 Fenitoin Kapsul/Kaplet 100 mg Tablet - - - -
49 Fenoterol HBr solution 0,1% (Berotec Solution) Botol - - - -
50 Fenol Gliserol tetes telinga 10% Botol - - - -
51 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul - - - -
52 Fitomenodion (Vit.K1) tablet salut gula 10 mg Tablet - - - -

Flutikason propionat (micronized) 0,5 mg/dosis

53
(Flutikason propionat nebules 0,5 mg) Botol - - - -

54 Furosemid injeksi i.v./i.m. 10 mg/ml Ampul - - - -

55 Furosemid tablet 40 mg Tablet - - - -
56 Gabapentin tablet/kapsul/kaplet 300 mg Tablet - - - -
 STOK KET. (Rusak, ED/
No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
1 2 3 4 5 6 7=5+6 8 9=7-8 10 11 12 13
Garam Oralit I serbuk, kombinasi: Natrium
57
klorida 0,52 g + kalium klorida 0,30 g + Sachet - - - -
Trinatrium sitrat dihidrat 0,58 g + Glukosa
Anhidrat 2,70 g
58 Gemfibrozil tablet/kapsul/kaplet 300 mg Tablet - - - -
59 Gentamicin 0,1 % Salep Kulit Botol - - - -
60 Gentamisin injeksi 40 mg/2 ml Ampul - - - -
61 Gentamisin tetes mata 0,3% Botol - - - -
62 Gentian violet 1 o/o Botol - - - -
63 Glibenklamid tablet 5 mg Tablet - - - -
64 Gliklazid tablet/kapsul/kaplet 80 mg Tablet - - - -
65 Glimepiride tablet/kapsul/kaplet 2 mg Tablet - - - -
66 Gliseril Guaiakolat tablet 100 mg Tablet - - - -
67 Glukonas Kalsikus 10 % Injeksi Ampul - - - -
68 Glukosa larutan infus 5 % 500 ml Kolf - - - -
69 Hidroklorotiazid tab 25 mg Tablet - - - -
70 Hidrokortison krim 2,5 % Tube - - - -
71 Hyosine N-Butilbromide tab 10 mg Tablet - - - -
72 Ibuprofen Suspensi 100 mg/5 ml Botol - - - -
73 Ibuprofen tablet 200 mg Tablet - - - -
74 Ibuprofen tablet 400 mg Tablet - - - -
75 Isosorbit Dinitrat tablet sublingual 5 mg Tablet - - - -
Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500
76
mg Tablet - - - -
77 Kandesartan tablet/kapsul/kaplet 8 mg Tablet - - - -
78 Kaptopril tablet/kaplet scored 25 mg Tablet - - - -
79 Karbamazepin tablet/kapsul/kaplet 200 mg Tablet - - - -
80 Ketokonazol krim 2% Tube - - - -
81 Ketoprofen supositoria 100 mg Supp - - - -
82 Ketorolak inj 30 mg/ml Ampul - - - -
83 Klopidogrel tablet/kapsul/kaplet 75 mg Tablet - - - -
84 Kloramfenikol salep mata 1 % Botol - - - -
85 Kloramfenikol tetes mata 0,5 % Botol - - - -
86 Kloramfenikol tetes telinga 3 % (Reco TT) Botol - - - -

Klorfeniramina Maleat (CTM)

87
tablet/kapsul/kaplet 4 mg Tablet - - - -

88
kombinasi: ferro fumarat 60 mg + As. Folat 0,4 Tablet - - - -
mg tablet salut gula (tablet tambah darah)
89 Lidokain injeksi 2% (HCL) Ampul - - - -
Lidokain injeksi 2%(HCl) + Epinefrin 1:80.000-
90 Ampul - - - -
2mL
91 Loperamid 10 mg Tablet - - - -
92 Loratadin 10 mg Tablet - - - -
93 Magnesium sulfat injeksi 40% Bolus - - - -
94 Metamizol injeksi 500 mg/ml Ampul - - - -
95 Metformin HCl tablet/kapsul/kaplet 500 mg Tablet - - - -
96 Metildopa tablet salut 250 mg Tablet - - - -
97 Metilergametrin tablet salut 0,125 mg Tablet - - - -
98 Metilergametrin Maleat inj 0,200 mg-1 ml Ampul - - - -
99 Metilprednisolon inj 125 mg/2 mL Ampul - - - -
100 Metilprednisolon tablet/kapsul/kaplet 4mg Tablet - - - -
101 Metoclopramide injeksi 5 mg/ml Ampul - - - -
102 Metoklopramide sirup 5 mg/ 5 ml Botol - - - -
103 Metoklopramide tablet 10 mg Tablet - - - -
104 Miconazole krim 2% (Nitrat) Tube - - - -
105 Mineral Mix Sachet - - - -
106 Natrium Bikarbonat tablet 500 mg Tablet - - - -
107 Natrium diklofenak tablet 50 mg Tablet - - - -
108 Natrium Klorida larutan infus 0,9 % Steril Kolf - - - -
109 Nifedipin tablet 10 mg Tablet - - - -
110 Nistatin tablet Oral 500.000 IU/ g Tablet - - - -
111 Nistatin vaginal tablet 100.000 IU/ g Ovula - - - -
112 Nystatin drop Botol - - - -
Obat batuk Tablet Kombinasi
113 Tablet - - - -
Dextromethorphan
Obat HBr
batuk Syrup Kombinasi
114 Botol - - - -
Dextromethorphan HBr
115 Obat Batuk Hitam ( O.B.H ) sirup Botol - - - -
116 Oksitetrasiklin HCI salep kulit 3 % Tube - - - -
117 Oksitetrasiklin HCI salep mata 1 % Tube - - - -
118 Oksitosin inj 10 UI/ml Ampul - - - -
119 Omeprazol injeksi 40 mg/ 10 ml Ampul - - - -
120 Omeprazol kapsul 20 mg Kapsul - - - -
121 Ondansetron inj 2 mg/ml (4 mg/ 2 mL) Ampul - - - -
122 Ondansetron tablet 4 mg Tablet - - - -
 STOK KET. (Rusak, ED/
No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
1 2 3 4 5 6 7=5+6 8 9=7-8 10 11 12 13

123 Parasetamol drips (infus) 1000 mg/100 mL Botol - - - -

Parasetamol drop 100 mg/ml btl @15ml

124
(60mg/0,6ml) (G) Botol - - - -

125 Parasetamol sirup 120 mg / 5 ml Botol - - - -

126 Parasetamol tablet/kaplet 500 mg Tablet - - - -
127 Perak sulfadiazin krim 1% Tube - - - -
128 Permetrin Krim 5% Tube - - - -
129 Piracetam 400 mg Tablet - - - -
130 Piracetam Inj 1 g/5 ml Ampul - - - -
131 Pirantel tablet score (base) 125 mg Tablet - - - -
132 Pirazinamid 500 mg Tablet - - - -
133 Piridoksin (Vitamin B6) 10 mg (HCl) Tablet - - - -
134 Piroksikam 20 mg Tablet - - - -
135 Prednison tablet 5 mg Tablet - - - -
136 Primakuin tablet 15 mg Tablet - - - -
137 Propiltiourasil tablet100 mg Tablet - - - -
138 Propranolol tablet 10 mg Tablet - - - -
139 Ranitidin injeksi 25 mg/ml Ampul - - - -
140 Ranitidin tablet 150 mg Tablet - - - -
141 Retinol ( Vitamin A ) 100.000 IU kapsul lunak Kapsul - - - -
142 Retinol ( Vitamin A ) 200.000 IU kapsul lunak Kapsul - - - -
143 Ringer laktat larutan infus 500 ml Kolf - - - -
144 Salbutamol cairan ih 0,1% (Ventolin Nebules) Tablet - - - -
145 Salbutamol sirup Botol - - - -
146 Salbutamol tablet 4 mg Tablet - - - -

Salep 2 - 4 Kombinasi : Asam Salisilat 2 % +

147
Belerang Endap 4 % Pot - - - -

148 Sianokobalamin (vitamin B12) injeksi Ampul - - - -

149 Sianokobalamin (vitamin B12) tablet 50 mcg Tablet - - - -
150 Simvastatin tablet 10 mg Tablet - - - -
151 Sukralfat susp 500 mg/5 mL, 100 ml Botol - - - -
152 Sukralfat tablet 500 mg Tablet - - - -
153 Teofilin tablet 150 mg Tablet - - - -
154 Tiamin (Vitamin B1) tablet 50 mg Tablet - - - -
155 Valproat sirup 250 mg/5 ml Botol - - - -
156 Valproat tablet salut 250 mg Tablet - - - -
157 Vitamin B Kompleks tablet Tablet - - - -
158 Zinc Syrup 20 mg/5 ml Botol - - - -
159 Zinc tablet dispersible 20 mg Tablet - - - -
II. BMHP -
1 Alat suntik sekali pakai 50 ml Piece - - - -
2 Alat suntik sekali pakai 1 ml Piece - - - -
3 Alat suntik sekali pakai 10 ml Piece - - - -
4 Alat suntik sekali pakai 20 ml Piece - - - -
5 Alat suntik sekali pakai 3 ml Piece - - - -
6 Alat suntik sekali pakai 5 ml Piece - - - -
7
Alat Suntik Sekali Pakai Otomatis Rusak 0.05 Piece - - - -
ml
8 Alat Suntik Sekali Pakai Otomatis Rusak 0.5 ml Piece - - - -
9 Alkohol 70% Botol - - - -
10 Alkohol Swab Piece - - - -
11 Blood Lancet Piece - - - -
12 Blood Transfusion Set Piece - - - -
13 Cairan Antiseptika pencuci alat instrumen Botol - - - -
Cairan Antiseptika pencuci tangan tanpa
14
dibilas Botol - - - -
Cairan Antispetika pencuci tangan dengan
15
dibilas Botol - - - -
16 CATGUT CHROMIC SMI 2/0 HR 26 MM Sachet - - - -
17 CATGUT CHROMIC SMI 3/0 HR 26 MM Sachet - - - -
18 CATGUT PLAIN SMI 2/0 HR 26 MM Sachet - - - -
19 CATGUT PLAIN SMI 3/0 HR 26 MM Sachet - - - -
20 Folley Catheter 2 Way no. 16 Piece - - - -
21 Folley Catheter 2 Way no. 18 Piece - - - -
22 Folley Catheter 2 Way no. 22 Piece - - - -
23 Handschoon size M Piece - - - -
24 Handschoon size S Piece - - - -
25 Handshoon Obgyn Steril (Panjang) Pasang - - - -
26 Infus Set Anak (60 drops/ml) Piece - - - -
Infus Set Dewasa (20 drops/ml)
27 Piece - - - -
28 IV Catheter no. 16 G Piece - - - -
29 IV-Catheter no. 26 G Piece - - - -
30 IV-Catheter no. 18 G Piece - - - -
31 IV-Catheter no. 20 G Piece - - - -
 STOK KET. (Rusak, ED/
No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
1 2 3 4 5 6 7=5+6 8 9=7-8 10 11 12 13

32 IV-Catheter no. 22 G Piece - - - -

33 IV-Catheter no. 24 G Piece - - - -
34 Jelly (Gel Topikal) Tube - - - -
35 Kapas Pembalut Hidrofil DRC 250gr Roll - - - -
36 Kasa Hidrofil DRC 36m x 80cm Roll - - - -
37 Kasa Hydrophil Steril Uk. 18 x 22 Kotak - - - -
38 Kasa Pembalut Hidrofil DRC 4m x 10cm Roll - - - -
39 Kasa Steril DRC 16cm x 16cm (16 pads) Box - - - -
40 Lysol 1 liter Botol - - - -
41 Masker Nebulizer Anak Piece - - - -
42 Masker Nebulizer Dewasa Piece - - - -
43 Nasal Oksigen O2 cannula, size L Piece - - - -
44 Nasal Oksigen O2 cannula, size M Piece - - - -
45 Nasal Oksigen O2 cannula, size S Piece - - - -
46 Pembalut Elastis 10 cm x 4,55 m Roll - - - -
47 Plester Leukoplast Hospital 7.50cm x 4.5m Roll - - - -
48 Plester Polifix 10 cm x 5 m Roll - - - -
49 Povidone Iodine 300 ml Botol - - - -
50 Rivanol 300 cc Botol - - - -
51 Scalpel Blades Nomor 10 Piece - - - -
52 Silk Black Sachet - - - -
53 Surgical Mask Piece - - - -
54 Umbilical Cord Klem Steril Nylon Piece - - - -
55 Underpad Steril 60 x 90 cm Blister - - - -
56 Urine Bag with hanger Piece - - - -
III. REAGENSIA -
1 Gluco Protein tes Piece - - - -
2 HCG Strip Pregnancy Test Strip - - - -
3 Hexagon Syphilis tes Piece - - - -
4 HIV/AIDS Tes Strip Piece - - - -
5 Malaria Pf & Pv Cassette Strip - - - -
6 Rapid tes Dengue (IgG-IgM) Device Piece - - - -
7 Stik Asam Urat Test Strip 25's Strip - - - -
8 Stik Cholesterol Total Test Strip 10's Strip - - - -
9 Stik Glukosa Test Strip 50's Strip - - - -
V. LAIN-LAIN
1
2
3
4
5

Umum
Jumlah Kunjungan Resep BPJS Jumlah
Bayar Tidak
1 2 3 4 5

Mengetahui Yang Menyerahkan Yang Meminta

Kepala Puskesmas Tebas Petugas Farmasi Puskesmas Petugas Poskesdes/Putu ………………………………………

dr. RINI PUJIASTUTI KHAIRUN NISA

NIP. 198407142014072001 NIP. 198304022006042012 NIP. 198304022006042012
 LAPORAN BULANAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBA
POSKESDES :
KODE PUSKESMAS : P6101030101 PELAPORAN BULAN : Januari th 2021
PUSKESMAS : TEBAS PERMINTAAN BULAN : Februari th 2021
KECAMATAN : TEBAS
KABUPATEN : SMBAS

No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN

1 2 3 4 5 6 7=5+6
I. OBAT
1 Air Pro Injeksi 25 ml Bolus -
2 Albendazol tablet 400 mg Tablet -
3 Alopurinol tablet 100 mg Tablet -
4 Ambroxol sirup 15 mg/ml Botol -
5 Ambroxol tablet 30 mg Tablet -
6 Aminofilina injeksi 24 mg/ml - 10 ml Ampul -
7 Aminofilina tablet 200 mg Tablet -
8 Amlodipin 5 mg Tablet -
9 Asetilsistein 200 mg Tablet -
10 Antasida DOEN suspensi Botol -

11
Antasida DOEN tablet kunyah,kombinasi: Tablet -
Mg-Hidroksida 200 mg + Al. Hidroksida. 200 mg
Anti Bakteri DOEN salep kombinasi: Basitrasin 500 IU/g +
12
Polimiksin 10.000 IU/g Pot -

13 Anti Diare Kombinasi Kaolin 986 mg+Pektin 40 mg Botol -

Anti Hemoroid DOEN kombinasi : Bismuth subgalat 150 mg +
14 Supp -
Heksaklorofen 2,5 mg
15 Anti malaria (DHP) Tablet -
Antifungi DOEN kombinasi : Asam Benzoat 6 % + Asam Salisilat
16
3% Pot -

Antimigren DOEN tablet kombinasi : Ergotamin Tartrat 1 mg +

17 Tablet -
Kofein 50 mg
18 Asam asetil salisilat (asetosal) tablet/kapsul/kaplet 100 mg Tablet -
19 Asam Askorbat (Vitamin C) tablet 50 mg Tablet -
20 Asam askorbat (vitamin C) tablet 250 mg Tablet -
21 Asam Folat tablet 0,4 mg Tablet -
22 Asam Mefenamat 500 mg Kaplet -
23 Asam Traneksamat 500 mg Tablet -
24 Asam traneksamat injeksi 100 mg/ml Ampul -
25 Atropin inj 0,25 mg / ml Ampul -
26 Attapulgite 600 mg tablet Tablet -
27 Bedak salisil serbuk 2% Box -
28 Betahistin tablet 6 mg Tablet -
29 Betametason krim0,1% Tube -
30 Bisakodil suppositoria 10mg Supp -
31 Bisakodil suppositoria 5 mg Supp -
32 Bisakodil tablet 5 mg Tablet -
33 Bisoprolol tablet 5 mg Tablet -
34 Cetirizin sirup 5 mg/5 ml Botol -
35 Cetirizine tablet 10 mg Tablet -
36 Deksametason injeksi 5 mg/ml - 1 ml Ampul -
37 Deksametason tablet 0,5 mg Tablet -
38 Dietilkarbamazin Sitrat tablet 100 mg Tablet -
39 Difenhidramin HCl inj 10 mg/ml - 1 ml Ampul -
40 Digoksin tablet/kapsul/kaplet 0,25 mg Tablet -
41 Doksisiklin tab 100 mg Tablet -
42 Domperidon 10 mg Tablet -
43 Domperidon suspensi 5 mg/5 ml Botol -
44 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Ampul -
No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7=5+6
45 Etil Klorida semprot Botol -
46 Eugenol cairan Botol -
47 Fenitoin injeksi 50 mg/ml (100 mg/2 ml) Ampul -
48 Fenitoin Kapsul/Kaplet 100 mg Tablet -
49 Fenoterol HBr solution 0,1% (Berotec Solution) Botol -
50 Fenol Gliserol tetes telinga 10% Botol -
51 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml Ampul -
52 Fitomenodion (Vit.K1) tablet salut gula 10 mg Tablet -
53
Flutikason propionat (micronized) 0,5 mg/dosis (Flutikason Botol -
propionat nebules 0,5 mg)
54 Furosemid injeksi i.v./i.m. 10 mg/ml Ampul -
55 Furosemid tablet 40 mg Tablet -
56 Gabapentin tablet/kapsul/kaplet 300 mg Tablet -
Garam Oralit I serbuk, kombinasi: Natrium klorida 0,52 g +
57 kalium klorida 0,30 g + Trinatrium sitrat dihidrat 0,58 g + Sachet -
Glukosa Anhidrat 2,70 g
58 Gemfibrozil tablet/kapsul/kaplet 300 mg Tablet -
59 Gentamicin 0,1 % Salep Kulit Botol -
60 Gentamisin injeksi 40 mg/2 ml Ampul -
61 Gentamisin tetes mata 0,3% Botol -
62 Gentian violet 1 o/o Botol -
63 Glibenklamid tablet 5 mg Tablet -
64 Gliklazid tablet/kapsul/kaplet 80 mg Tablet -
65 Glimepiride tablet/kapsul/kaplet 2 mg Tablet -
66 Gliseril Guaiakolat tablet 100 mg Tablet -
67 Glukonas Kalsikus 10 % Injeksi Ampul -
68 Glukosa larutan infus 5 % 500 ml Kolf -
69 Hidroklorotiazid tab 25 mg Tablet -
70 Hidrokortison krim 2,5 % Tube -
71 Hyosine N-Butilbromide tab 10 mg Tablet -
72 Ibuprofen Suspensi 100 mg/5 ml Botol -
73 Ibuprofen tablet 200 mg Tablet -
74 Ibuprofen tablet 400 mg Tablet -
75 Isosorbit Dinitrat tablet sublingual 5 mg Tablet -
76 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 mg Tablet -
77 Kandesartan tablet/kapsul/kaplet 8 mg Tablet -
78 Kaptopril tablet/kaplet scored 25 mg Tablet -
79 Karbamazepin tablet/kapsul/kaplet 200 mg Tablet -
80 Ketokonazol krim 2% Tube -
81 Ketoprofen supositoria 100 mg Supp -
82 Ketorolak inj 30 mg/ml Ampul -
83 Klopidogrel tablet/kapsul/kaplet 75 mg Tablet -
84 Kloramfenikol salep mata 1 % Botol -
85 Kloramfenikol tetes mata 0,5 % Botol -
86 Kloramfenikol tetes telinga 3 % (Reco TT) Botol -
87 Klorfeniramina Maleat (CTM) tablet/kapsul/kaplet 4 mg Tablet -
kombinasi: ferro fumarat 60 mg + As. Folat 0,4 mg tablet salut
88 Tablet -
gula (tablet tambah darah)
89 Lidokain injeksi 2% (HCL) Ampul -
90 Lidokain injeksi 2%(HCl) + Epinefrin 1:80.000-2mL Ampul -
91 Loperamid 10 mg Tablet -
92 Loratadin 10 mg Tablet -
93 Magnesium sulfat injeksi 40% Bolus -
94 Metamizol injeksi 500 mg/ml Ampul -
95 Metformin HCl tablet/kapsul/kaplet 500 mg Tablet -
96 Metildopa tablet salut 250 mg Tablet -
97 Metilergametrin tablet salut 0,125 mg Tablet -
98 Metilergametrin Maleat inj 0,200 mg-1 ml Ampul -
No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7=5+6
99 Metilprednisolon inj 125 mg/2 mL Ampul -
100 Metilprednisolon tablet/kapsul/kaplet 4mg Tablet -
101 Metoclopramide injeksi 5 mg/ml Ampul -
102 Metoklopramide sirup 5 mg/ 5 ml Botol -
103 Metoklopramide tablet 10 mg Tablet -
104 Miconazole krim 2% (Nitrat) Tube -
105 Mineral Mix Sachet -
106 Natrium Bikarbonat tablet 500 mg Tablet -
107 Natrium diklofenak tablet 50 mg Tablet -
108 Natrium Klorida larutan infus 0,9 % Steril Kolf -
109 Nifedipin tablet 10 mg Tablet -
110 Nistatin tablet Oral 500.000 IU/ g Tablet -
111 Nistatin vaginal tablet 100.000 IU/ g Ovula -
112 Nystatin drop Botol -
113 Obat batuk Tablet Kombinasi Dextromethorphan HBr Tablet -
114 Obat batuk Syrup Kombinasi Dextromethorphan HBr Botol -
115 Obat Batuk Hitam ( O.B.H ) sirup Botol -
116 Oksitetrasiklin HCI salep kulit 3 % Tube -
117 Oksitetrasiklin HCI salep mata 1 % Tube -
118 Oksitosin inj 10 UI/ml Ampul -
119 Omeprazol injeksi 40 mg/ 10 ml Ampul -
120 Omeprazol kapsul 20 mg Kapsul -
121 Ondansetron inj 2 mg/ml (4 mg/ 2 mL) Ampul -
122 Ondansetron tablet 4 mg Tablet -
123 Parasetamol drips (infus) 1000 mg/100 mL Botol -
124 Parasetamol drop 100 mg/ml btl @15ml (60mg/0,6ml) (G) Botol -
125 Parasetamol sirup 120 mg / 5 ml Botol -
126 Parasetamol tablet/kaplet 500 mg Tablet -
127 Perak sulfadiazin krim 1% Tube -
128 Permetrin Krim 5% Tube -
129 Piracetam 400 mg Tablet -
130 Piracetam Inj 1 g/5 ml Ampul -
131 Pirantel tablet score (base) 125 mg Tablet -
132 Pirazinamid 500 mg Tablet -
133 Piridoksin (Vitamin B6) 10 mg (HCl) Tablet -
134 Piroksikam 20 mg Tablet -
135 Prednison tablet 5 mg Tablet -
136 Primakuin tablet 15 mg Tablet -
137 Propiltiourasil tablet100 mg Tablet -
138 Propranolol tablet 10 mg Tablet -
139 Ranitidin injeksi 25 mg/ml Ampul -
140 Ranitidin tablet 150 mg Tablet -
141 Retinol ( Vitamin A ) 100.000 IU kapsul lunak Kapsul -
142 Retinol ( Vitamin A ) 200.000 IU kapsul lunak Kapsul -
143 Ringer laktat larutan infus 500 ml Kolf -
144 Salbutamol cairan ih 0,1% (Ventolin Nebules) Tablet -
145 Salbutamol sirup Botol -
146 Salbutamol tablet 4 mg Tablet -
147 Salep 2 - 4 Kombinasi : Asam Salisilat 2 % + Belerang Endap 4 % Pot -
148 Sianokobalamin (vitamin B12) injeksi Ampul -
149 Sianokobalamin (vitamin B12) tablet 50 mcg Tablet -
150 Simvastatin tablet 10 mg Tablet -
151 Sukralfat susp 500 mg/5 mL, 100 ml Botol -
152 Sukralfat tablet 500 mg Tablet -
153 Teofilin tablet 150 mg Tablet -
154 Tiamin (Vitamin B1) tablet 50 mg Tablet -
155 Valproat sirup 250 mg/5 ml Botol -
 No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7=5+6
156 Valproat tablet salut 250 mg Tablet -
157 Vitamin B Kompleks tablet Tablet -
158 Zinc Syrup 20 mg/5 ml Botol -
159 Zinc tablet dispersible 20 mg Tablet -
II. BMHP
1 Alat suntik sekali pakai 50 ml Piece -
2 Alat suntik sekali pakai 1 ml Piece -
3 Alat suntik sekali pakai 10 ml Piece -
4 Alat suntik sekali pakai 20 ml Piece -
5 Alat suntik sekali pakai 3 ml Piece -
6 Alat suntik sekali pakai 5 ml Piece -
7 Alat Suntik Sekali Pakai Otomatis Rusak 0.05 ml Piece -
8 Alat Suntik Sekali Pakai Otomatis Rusak 0.5 ml Piece -
9 Alkohol 70% Botol -
10 Alkohol Swab Piece -
11 Blood Lancet Piece -
12 Blood Transfusion Set Piece -
13 Cairan Antiseptika pencuci alat instrumen Botol -
14 Cairan Antiseptika pencuci tangan tanpa dibilas Botol -
15 Cairan Antispetika pencuci tangan dengan dibilas Botol -
16 CATGUT CHROMIC SMI 2/0 HR 26 MM Sachet -
17 CATGUT CHROMIC SMI 3/0 HR 26 MM Sachet -
18 CATGUT PLAIN SMI 2/0 HR 26 MM Sachet -
19 CATGUT PLAIN SMI 3/0 HR 26 MM Sachet -
20 Folley Catheter 2 Way no. 16 Piece -
21 Folley Catheter 2 Way no. 18 Piece -
22 Folley Catheter 2 Way no. 22 Piece -
23 Handschoon size M Piece -
24 Handschoon size S Piece -
25 Handshoon Obgyn Steril (Panjang) Pasang -
26 Infus Set Anak (60 drops/ml) Piece -
Infus Set Dewasa (20 drops/ml)
27 Piece -
28 IV Catheter no. 16 G Piece -
29 IV-Catheter no. 26 G Piece -
30 IV-Catheter no. 18 G Piece -
31 IV-Catheter no. 20 G Piece -
32 IV-Catheter no. 22 G Piece -
33 IV-Catheter no. 24 G Piece -
34 Jelly (Gel Topikal) Tube -
35 Kapas Pembalut Hidrofil DRC 250gr Roll -
36 Kasa Hidrofil DRC 36m x 80cm Roll -
37 Kasa Hydrophil Steril Uk. 18 x 22 Kotak -
38 Kasa Pembalut Hidrofil DRC 4m x 10cm Roll -
39 Kasa Steril DRC 16cm x 16cm (16 pads) Box -
40 Lysol 1 liter Botol -
41 Masker Nebulizer Anak Piece -
42 Masker Nebulizer Dewasa Piece -
43 Nasal Oksigen O2 cannula, size L Piece -
44 Nasal Oksigen O2 cannula, size M Piece -
45 Nasal Oksigen O2 cannula, size S Piece -
46 Pembalut Elastis 10 cm x 4,55 m Roll -
47 Plester Leukoplast Hospital 7.50cm x 4.5m Roll -
48 Plester Polifix 10 cm x 5 m Roll -
49 Povidone Iodine 300 ml Botol -
50 Rivanol 300 cc Botol -
51 Scalpel Blades Nomor 10 Piece -
52 Silk Black Sachet -
 No. KODE NAMA SATUAN STOK AWAL PENERIMAAN PERSEDIAAN
1 2 3 4 5 6 7=5+6
53 Surgical Mask Piece -
54 Umbilical Cord Klem Steril Nylon Piece -
55 Underpad Steril 60 x 90 cm Blister -
56 Urine Bag with hanger Piece -
III. REAGENSIA
1 Gluco Protein tes Piece -
2 HCG Strip Pregnancy Test Strip -
3 Hexagon Syphilis tes Piece -
4 HIV/AIDS Tes Strip Piece -
5 Malaria Pf & Pv Cassette Strip -
6 Rapid tes Dengue (IgG-IgM) Device Piece -
7 Stik Asam Urat Test Strip 25's Strip -
8 Stik Cholesterol Total Test Strip 10's Strip -
9 Stik Glukosa Test Strip 50's Strip -
V. LAIN-LAIN
1
2
3
4
5
6
7
8
9
10

Umum
Jumlah Kunjungan Resep BPJS Jumlah
Bayar Tidak
1 2 3 4 5

Mengetahui Yang Menyerahkan

Kepala Puskesmas Tebas Petugas Farmasi Puskesmas

dr. RINI PUJIASTUTI KHAIRUN NISA

NIP. 198407142014072001 NIP. 198304022006042012
KAIAN DAN LEMBAR PERMINTAAN OBAT

: Januari th 2021 DOKUMEN NOMOR TANGGAL

: Februari th 2021 PUSKESMAS
POL/PUSTU

STOK KET. (Rusak, ED/

PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
8 9=7-8 10 11 12 13

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

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
 STOK KET. (Rusak, ED/
PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
8 9=7-8 10 11 12 13
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -

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

- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
 STOK KET. (Rusak, ED/
PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
8 9=7-8 10 11 12 13
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
 STOK KET. (Rusak, ED/
PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
8 9=7-8 10 11 12 13
- - -
- - -
- - -
- - -
-
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
 STOK KET. (Rusak, ED/
PEMAKAIAN SISA STOK PERMINTAAN PEMBERIAN
OPTIMUM Sampling, dll)
8 9=7-8 10 11 12 13
- - -
- - -
- - -
- - -
-
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

Yang Menyerahkan Yang Meminta

Petugas Farmasi Puskesmas Petugas Poskesdes/Putu ………………………………………

KHAIRUN NISA
NIP. 198304022006042012 NIP. 198304022006042012