LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS

PUSKESMAS : CIAMIS
KECAMATAN : CIAMIS
KABUPATEN : CIAMIS PELAPORAN BULAN/PERIODE :
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE :

NO NAMA OBAT SATUAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR

1 2 3 4 5 6 7 8
A. APBD / DAK
1 Abothyl btl 10 ml
Acetylcystein tab 200 mg Tablet
Allopurinol Tablet
2 Alopurinol tablet 100 mg Tablet
3 Albendazol tablet 400 mg Tablet
4 Ambroksol tablet 30 mg Tablet
Ambroksol tablet 30 mg Tablet
Ambroksol tablet 30 mg Tablet
5 Ambroksol syrup 15 mg Btl 60 ml
Ambroksol syrup 15 mg Btl 60 ml
6 Aminofilin tablet 200 mg Tablet
7 Aminofilin injeksi 24 mg/ml ampul
8 Amlodipin tablet 5 mg Tablet
Amlodipin tablet 5 mg Tablet
9 Amitripilin tablet salut 25 mg (HCL) Tablet
Amitripilin tablet salut 25 mg (HCL) Tablet
10 Aminofluid Bag
11 Amoksisilin kapsul 250 mg (B) Kapsul
Amoksisilin kapsul 250 mg (B) Kapsul
12 Amoksisilin kaplet 500 mg Kaplet
Amoksisilin kaplet 500 mg Kaplet
13 Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml
Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml
Amoksisilin sirup kering 250 mg/ 5 mg botol
14 Ampisilin injk i.m/ 1000 mg/ml Vial
15 Antalgin (Metampiron) injeksi 250 mg Ampul
16 Antalgin (Metampiron) tablet 500 mg Tablet
Antasida DOEN I tablet kunyah, kombinasi :Aluminium
17 Tablet
Hidroksida 200 mg + Magnesium Hidroksida 200 mg
Antasida DOEN I tablet kunyah, kombinasi :Aluminium
18 Tablet
Hidroksida 200 mg + Magnesium Hidroksida 200 mg
Antasida DOEN I tablet kunyah, kombinasi :Aluminium
Tablet
Hidroksida 200 mg + Magnesium Hidroksida 200 mg
1 2 3 4 5 6 7 8
Antasida DOEN II suspensi, kombinasi :Aluminium Hidroksida
19 Btl 60 ml
200 mg + Magnesium Hidroksida 200 mg
Antasida DOEN II suspensi, kombinasi :Aluminium Hidroksida
Btl 60 ml
200 mg + Magnesium Hidroksida 200 mg
Anti Bakteri DOEN salep kombinasi : Basitrasin 500 IU/g +
20 Tube
polimiksin 10.000 IU/g
Antifungi DOEN Kombinasi : Asam Benzoat 6% + Asam
21 Pot
Salisilat 3%
Antifungi DOEN Kombinasi : Asam Benzoat 6% + Asam
Pot
Salisilat 3%
Antihemoroid DOEN kombinasi : Bismut Subgalat 150 mg +
22 Supp
Heksaklorofen 250 mg
Antihemoroid DOEN kombinasi : Bismut Subgalat 150 mg +
Supp
Heksaklorofen 250 mg
23 Air untuk injeksi Vial
23 Air untuk injeksi Vial
24 Asam Asetil Salisilat tablet 100 mg Tablet
25 Asam Asetil Salisilat tablet 500 mg Tablet
26 Asam Askorbat (vitamin C) tablet 50 mg btl 100 Tablet
Asam Askorbat (vitamin C) tablet 50 mg KF Tablet
Asam Askorbat (vitamin C) tablet 50 mg KF Tablet
27 Asam Mefenamat kaplet 500 mg Kaplet
Asam Mefenamat kaplet 500 mg Kaplet
28 Asering b Botol 500 ml
29 Asiklovir tablet 200 mg Kaplet
30 Asiklovir tablet 400 mg Tablet
30 Asiklovir tablet 400 mg RAJAWALI Tablet
31 Asiklovir krim 5% Tube
Asiklovir krim 5% Tube
32 Azytromicin 500 mg Tablet
Besi (II) sulfat 200 mg + Asam Folat 0,25 mg tablet (tablet
33 Tablet
tambah darah kombinasi) (B)
34 Betametason krim 0,1 % Tube
Betametason krim 0,1 % Tube
Betametason krim 0,1 % Tube
35 Bisakodil 10 mg (DULCOLAX DEWASA) Supp
Bisakodil 10 mg (DULCOLAX DEWASA) Supp
Bisakodil 5 mg (DULCOLAX ANAK) Supp
36 Bisoprolol 2,5 mg (Concor 2,5 mg) Tablet
Bisoprolol 10 mg Tablet
37 Ca Glukonas injeksi ampul
Calcium Dibasic Phosphate 450 mg, DHA 100 mg, Omega 3
20 mg, Thiamine HCL 2 mg, Pyridoxine HCL 1.5 mg,
38 Tablet
Cyanocobalamine 5 mcg, Vitamin D3 400 IU, Nicotinamide 10
mg (CALCIMEGA)
Calcium Dibasic Phosphate 450 mg, DHA 100 mg, Omega 3
20 mg, Thiamine HCL 2 mg, Pyridoxine HCL 1.5 mg,
39 Tablet
Cyanocobalamine 5 mcg, Vitamin D3 400 IU, Nicotinamide 10
mg (CALCIMEGA)
1 2 3 4 5 6 7 8
40 Cefixim 100 mg kapsul
Cefixim 100 mg kapsul
41 Cefotaxime injeksi Vial
42 Ceftriaxone injeksi Vial
43 Cetirizin Tablet tablet
44 Chlorin 1000 ml
45 Deksametason Injeksi I.v. 5 mg/ml Ampul
Deksametason Injeksi I.v. 5 mg/ml Ampul
46 Deksametason tablet 0,5 mg Tablet
Deksametason tablet 0,5 mg Tablet
Deksametason tablet 0,5 mg Tablet
47 Deksklorfeniramin Maleat 2 mg (HISTAKLOR) Tablet
48 Diazepam Injeksi 5mg/ml Ampul
Diazepam Injeksi 5mg/ml Ampul
49 Diazepam Rektal enema 5 mg/2,5 ml Tube
50 Diazepam tablet 2 mg botol 100 Tablet
51 Diazepam tablet 5 mg Tablet
52 Difenhidramin Injeksi I.M. 10 mg/ml (HCL) Ampul
53 Digoksin tablet 0,25 mg Tablet
Digoksin tablet 0,25 mg Tablet
54 Dimenhidrinat tablet 50 mg Tablet
Disosmin 450 mg, Hesperidin 50 mg (DIOS) Tablet

DMP 10 mg, Dexchlorpheniramin maleat 2 mg (CORSAMYL) Tablet

55 Doksisiklin kapsul 100 mg Kapsul

56 Domperidon Syrup Botol
Domperidon Syrup Botol
Domperidon tablet 10 mg tablet
57 Efedrin tablet 25 mg (HCL) Tablet
58 Epinefrin (Adrenalin) injeksi 0,1% (sebagai HCL) Ampul
Epinefrin (Adrenalin) injeksi 0,1% (sebagai HCL) Ampul
59 Eritromicin 500 mg kap Tablet
59 Eritromicin 500 mg kap Tablet
60 Esomeprazole injeksi 40 mg Vial
61 Ethambutol 500 mg (1) Tablet
62 Ethambutol 500 mg (2) Tablet
63 Etanol 70 % Botol 100 ml
Etanol 70 % AFI FARMA Botol 100 ml
64 Etakridin larutan 0,1% Botol 300 ml
65 Famotidin tablet 20 mg Tablet
66 Fenitoin Natriun kapsul 30 mg Kapsul
67 Fenobarbital Injeksi I.m/I.v 50 mg/ml ampul
68 Fenobarbital tablet 30 mg Tablet
Fenobarbital tablet 30 mg Tablet
Fenobarbital tablet 30 mg Tablet
69 Fenoksimetil Penisilin tablet 500 mg Tablet
70 Fenol Gliserol tetes telinga 10% Botol
Fenol Gliserol tetes telinga 10% Botol
1 2 3 4 5 6 7 8
Fe (II) Fumarat (Fe=30 mg) 90 mg, Calsium Pantethonat 20
mg, Asam folat 1 mg, Vitamin B1 5 mg, Vitamin B6 5 mg,
71 Tablet
Vitamin B12 2 mcg, Mangan Sulfat 400 mcg, Cupri Sulfat
anhydrous 400 mcg (SOLVITRON)
Fe (II) Fumarat 250 mg, Mn Sulfat 0,2mg, Cu-Sulfat 0,2mg,
Tablet
Asam Folat 925 mcg, Vit B12 8 mc (SAMCOBION)
72 Fitomenadion (Vit. K1) injeksi 10 mg/ml Ampul
Fitomenadion 2 mg/ml inj ( Vitka Infant ) Ampul
73 Fitomenadion 2 mg/ml inj ( Vitka Infant ) Ampul
74 Fitomenadion 2mg/ml inj (B) Ampul
75 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet
75 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet
76 Flukonazol 150 mg Tablet
77 Fluoxetine 10 mg (ZAC) Tablet
78 Furosemid injeksi i.v/i.m 10 mg/ml Ampul
79 Furosemid tablet 40 mg Tablet
Furosemid tablet 40 mg Tablet
80 Garam Oralit Serbuk Kombinasi Sachet
81 Gemfibrozil 300 mg kapsul
81 Gemfibrozil 300 mg kapsul
82 Gentamisin injeksi 40 mg/ml ampul
83 Gentamisin salep kulit 0,1% Tube
Gentamisin salep kulit 0,1% (GENTALEX) Tube
84 Gentamisin Salep Mata Tube
Gentamisin Salep Mata Tube
85 Gentian Violet Larutan 1 % Botol 10 ml
86 Glibenklamida tablet 5 mg Tablet
Glibenklamida tablet 5 mg Tablet
87 Gliseril Gualakolat tablet 100 mg Tablet
Gliseril Gualakolat tablet 100 mg Tablet
88 Glukosa larutan infus 5% btl 500 ml
89 Griseofulvin tablet 125 mg, micronized Tablet
90 Haloperidol tablet 1,5 mg Tablet
Haloperidol tablet 1,5 mg Holi Tablet
91 Hidroklorotiazida tablet 25 mg ktk 100 Tablet
91 Hidroklorotiazida tablet 25 mg Tablet
92 Hidrokortison krim 2,5% Tube
Hidrokortison krim 2,5% Tube
93 Ibuprofen suspensi 100 mg/5ml btl m60 ml
94 Ibuprofen tablet 200 mg Tablet
95 Ibuprofen tablet 400 mg Tablet
96 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet
97 KAEN 3B Botol 500 ml
98 KAEN 3B b Botol 500 ml
99 Kalium Klorida 600 mg (KSR) Tablet
Kalium Klorida 600 mg (KSR) Tablet
100 Kalsium Laktat (Kalk) tablet 500 mg Tablet
101 Kalsium Laktat (Kalk) tablet 500 mg Tablet
102 Kaptopril tablet 12,5 mg Tablet
1 2 3 4 5 6 7 8
103 Kaptopril tablet 25 mg Tablet
104 Karbamazepin tablet 200 mg Tablet
Karbamazepin tablet 200 mg Tablet
105 Klindamicyn 150 mg Kapsul
106 Klindamicyn 300 mg kapsul
107 Ketokonazole tablet 200 mg Tablet
108 Kloramfenikol kapsul 250 mg Kapsul
109 Kloramfenikol kapsul 500 mg Kapsul
Kloramfenikol kapsul 500 mg Kapsul
110 Kloramfenikol Tetes Mata 0.5% (DECACETIN) btl. 5 ml
111 Kloramfenikol tetes telinga 3 % btl. 5 ml
112 Kloramfenikol tetes telinga 3 % (RECO) btl. 5 ml
113 Kloramfenikol salep mata 1 % Tube
Kloramfenikol salep mata 1 % Tube
114 Kloramfenikol salep kulit (BUFACETIN) Tube
Kloramfenikol salep kulit Tube
Kloramfenikol Suspensi 60 ml Botol
115 Kloraniramina mealeat (CTM) tablet 4 mg (B) Tablet
Kloraniramina mealeat (CTM) tablet 4 mg (B) Tablet
Kloraniramina mealeat (CTM) tablet 4 mg KF Tablet
116 Klorpromazin injeksi i.m 5 mg/ml-2ml (HCL) ampul
Klorpromazin injeksi i.m 5 mg/ml-2ml (HCL) ampul
117 Klorpromazin tablet salut 100 mg ( HCL ) Tablet
Klorpromazin tablet salut 100 mg ( HCL ) Tablet
118 Klozapine 25 MG Tablet
119 kodein tablet 10 mg Tablet
Kombinasi Deksametason 0,5 mg + Deksklorfeniramin Maleat
120 Tablet
2 mg (BIDAXTAM)
Kombinasi Tramadol HCl 37,5 mg + Parasetamol 325 mg
121 Tablet
(TRAMPARA)
Kombinasi Sefiksim 400 mg + Azitromisin 1000 mg Pet
Kotrimosazol Suspensi Kombinasi :Sulfametoksazol 200 mg +
122 botol 60 ml
Trimetoprim 40 mg/ 5 ml
Kotrimosazol Suspensi Kombinasi :Sulfametoksazol 200 mg +
botol 60 ml
Trimetoprim 40 mg/ 5 ml
Kotrimosazol DOEN I (dewasa) Kombinasi : Sulfametoksazol
123 Tablet
400 mg, Trimetoprim 80 mg
Kotrimosazol DOEN I (dewasa) Kombinasi : Sulfametoksazol
Tablet
400 mg, Trimetoprim 80 mg
Kotrimosazol DOEN II (pediatrik) Kombinasi : Sulfametoksazol
124 Tablet
100 mg, Trimetoprim 20 mg
125 Kotrimosazol 960 mg Tablet
126 Lansoprazole 30 mg kapsul
126 Lansoprazole 30 mg kapsul
127 Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2 ml Ampul
128 Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2 ml Ampul
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2 ml Ampul
129 Lidokain Injeksi Ampul
129 Lidokain Injeksi 2 % Marin Ampul
1 2 3 4 5 6 7 8
130 Lisol 1 liter Botol 1000 ml
Lisol 1 liter Botol 1000 ml
131 Loratadin tablet 10 mg Tablet
132 Magnesium Sulfat inj (IV) 20%-25 ml Vial
133 Meloxicam 15 mg tablet
Meloxicam 15 mg tablet
134 Metformin 500 mg tablet
Metformin 500 mg tablet
Metformin 500 mg tablet
135 Metildopa tablet
Metildopa tablet

136 Metilergometrin Maleat (Metilergometrin) tablet salut 0,125 mg Tablet

137 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul

Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul
138 Metilprednisolon tablet 4 mg Tablet
Metilprednisolon tablet 4 mg Tablet
139 Metoklopramid injeksi 5 mg/ml Ampul
140 Metoklopramid tablet 10 mg tablet
141 Metronidazol infus 500 mg/100 ml Botol
142 Metronidazol tablet 500 mg Tablet
Metronidazol tablet 500 mg Tablet
143 Mikonazole krim / salep 2% (nitrat) tube
Multivitamin syrup Psdii folium ext sicc 100 mg curcuma
144 Botol
domestica 50 mg piper bettle folium 50 mg (ANSTREP)
Multivitamin syrup pertumbuhan plus suplemen yang
145 mengandung Curcumin Vitamin B1 B2 B6 Lysin B12 Botol
(CURVIPLEX)
Multivitamin syrup tiap 5 mL mengandung vit A 2000IU, vit D
Botol
200IU, vit B1 3,2424 mg,vit B2 1,25 mg (SAMCOVIT)

Multivitamin yang mengandung Fe Fumarat 360 mg, asam

146 Tablet
folat 1,5 mg, vit.B12 0,015 mg, Vit.C 75 mg, Ch (VITALEX)

Multivitamin yang mengandung Vit.A 4000 IU B! 3 mg, B2 3

147 mg,B6 2 mg,B12 2mcg, C 50mg D 400IU E 10 mg Tablet
(PEHAVRAL)
Multivitamin yang mengandung Vit.A 6000 IU Vit D 400 IU, B1
10mg,B6 2 mg,B2 2,5mg, C 50mg B6 15mg Vit B12 4 mcg Tablet
kalsium (BUNDAVIN)
148 Natrium Bikarbonat tablet 500 mg Botol
149 Natrium Diklofenak 50 mg Tablet
Natrium Diklofenak 50 mg Tablet
150 Natrium Klorida larutan infus 0,9 % Botol
151 Nifedipin 10 mg (B) Tablet
152 Nistatin Vaginal tablet salut 100.000 IU/g Tablet
Nistatin Vaginal tablet salut 100.000 IU/g Tablet
153 OAT FDC KAT 1 Tablet
154 OAT FDC KAT 2 paket
155 OAT FDC KAT Anak paket
156 OAT FDC Sisispan paket
1 2 3 4 5 6 7 8
157 Obat Batuk hitam ( O.B.H.) HERBAKOF botol

Obat Batuk syrup yg mengandung dekstrometrophan HBR 10

158 Botol
mg GG 50 mg phenylpropanolamin HCL 12,5 mg (DEXTRAL)

Obat Batuk syrup yg mengandung dekstrometrophan HBR 10

158 mg GG 50 mg phenylpropanolamin HCL 12,5 mg Botol
(SAMCODRYL)
Obat cacing berbentuk permen 0,4 g ekstrak setara dengan
159 Tablet
caricae radix 8 g
Obat flu kombinasi parasetamol 250 mg, dekstrometrophan
160 Tablet
Hbr 15 mg,Phenilleprin HCL 2 mg, Gliseril Gu (LODECON)
Obat flu kombinasi parasetamol 500 mg, Fenolpropanolamin
161 Tablet
dan CTM (MOLEXFLU)
Obat flu kombinasi parasetamol 500 mg, Fenolpropanolamin
Tablet
dan CTM (MOLEXFLU)

Obat flu syr yg mengandung parasetamol 120 mg, Gliseril

162 Botol
guaikolat 25 mg, CTM 1 mg, Phelyleprin HCL 5 (SOLAPLUZ)

Obat flu syr yg mengandung parasetamol 120 mg, Gliseril

Botol
guaikolat 25 mg, CTM 1 mg, Phelyleprin HCL 5 (SOLAPLUZ)

Obat pencernaan setiap 1 gr mengandung rice starch

163 maltodextrin lactobacillus acidophilus W 55 Lactobacillus (L- Sachet
BIO)
Obat tetes mata Distilled witch hazel 13.0% v/v, Benzalkonium
164 chloride 0.005% w/v dalam larutan yang diberi dapar Bo (I - Botol
RINS)
Obat tetes mata kombinasi neomisin,deksametason, polimiksin
165 Botol
(ALLETROL TETES MATA)
166 Obat tetes Neomisin 3,5 mg + Deksametason 1 mg Botol

Obat wasir yang mengandung Graptolium 250mg, Ekstrak

167 Kapsul
curcuma domestica 25 mg, ekstrak centella asiat (NUWASIR)

Obat wasir yang mengandung Graptolium 250mg, Ekstrak

Kapsul
curcuma domestica 25 mg, ekstrak centella asiat (NUWASIR)

Obat yang mengandung sylimarin 70 mg cynarin 1,2

168 Kapsul
mg,curcumin 5 mg lycopene 5 mg (hepagard)
Obat yang mengandung sylimarin 70 mg cynarin 1,2
Kapsul
mg,curcumin 5 mg lycopene 5 mg (hepagard)
169 Oksitetrasiklin HCL salep kulit 3% Tube
170 Oksitetrasiklin HCL salep mata 1% Tube
171 Oksitosin injeksi 10 UI/ml-1 ml Ampul
172 Omeprazole kapsul 10 mg Kapsul
173 Ondansentron inj 4 mg/ 2 ml ampul
174 Paracetamol drop 100 mg /ml botol
Paracetamol drop 100 mg /ml botol
175 Paracetamol sirup 120 mg / 5 ml Botol 60 ml
175 Paracetamol sirup 120 mg / 5 ml Botol 60 ml
176 Paracetamol tablet 500 mg Tablet
177 Paracetamol tablet 500 mg Tablet
1 2 3 4 5 6 7 8
178 Papaperin tablet 40 mg Tablet
Per 5 mL : L-lysine HCl 200 mg, beta-caroten 1000 IU, vit B1
Botol
3 mg, vit B2 2 mg, vit B6 (LYTACUR)
179 Petidine injeksi 50 mg/ ml Ampul
180 Piracetam injeksi 1 gr/5ml Ampul
181 Piracetam tablet 400 mg Tablet
182 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet
Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet
183 Piroksikam tablet 20 mg Tablet
183 Piroksikam tablet 20 mg Tablet
183 Piroksikam tablet 20 mg Tablet
184 Povidon Iodida larutan 10 % Botol 30 ml
Povidon Iodida larutan 10 % Botol 30 ml
185 Povidon Iodida larutan 10 % Botol 60 ml
186 Povidon Iodida larutan 10 % Botol 300 ml
187 Prednison tablet 5 mg Tablet
Prednison tablet 5 mg Tablet
Prednison tablet 5 mg Tablet
188 Primakuin tablet 15 mg Tablet
189 Propanolol tablet 10 mg (HCL) Tablet
190 Ranitidin injeksi 25 mg/2 ml Ampul
191 Ranitidin tablet 150 mg HOLI tablet
Ranitidin tablet 150 mg tablet
192 Retinol (Vitamin A) kapsul lunak 100.000 IU kapsul
Retinol (Vitamin A) kapsul lunak 100.000 IU kapsul
Retinol (Vitamin A) kapsul lunak 100.000 IU kapsul
193 Retinol (Vitamin A) kapsul lunak 200.000 IU (B) Kapsul
Retinol (Vitamin A) kapsul lunak 200.000 IU (B) Kapsul
194 Ringer Laktat larutan infus Botol 500 ml
195 Risperidone 2 mg Tablet
196 Salbutamol tablet (sebagai sulfat) 2 mg KF Tablet
197 Salbutamol tablet (sebagai sulfat) 2 mg Tablet
198 Salbutamol syrup Botol
Salbutamol syrup Botol
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang endap
199 Pot
4%
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang endap
Pot
4%
200 Salisil bedak 2% Kotak 50 gram
Salisil bedak 2% Kotak 50 gram
201 Sefadroksil kapsul 500 mg kapsul
Sefadroksil kapsul 500 mg kapsul
202 Sefadroksil Syrup 125 mg/5 ml botol
Sefadroksil Syrup 125 mg/5 ml botol
203 Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU I) Vial
204 Serum Anti Difteri Vial
205 Sianokobalamin (Vitamin B12) injeksi 500 mcg Ampul
206 Simvastatin 10 mg tablet
1 2 3 4 5 6 7 8
207 Siproploksacin tablet 500 mg Tablet
208 Siproploksacin tablet 500 mg b Tablet
Tablet Ferous (II) fumarat 300 mg asam folat 2 mg mangan
209 Tablet
sulfat 0,2 mg copper sulfat 0,2 mg (HEMAFORT)
210 Tablet Tambah darah KF Tablet
Tablet Tambah Darah Ferro Fumarat 60 mg dan Asam Folat
Tablet
0,4 mg PHAPROS

Tetes mata per mL mgd Polimix B shulpate 600IU,Neomycin

Botol
sulphate3,5mg,Dexamethason 1mg (LYTROL)

211 Tetrasiklin kapsul 250 mg Kapsul

212 Tetagam (Human tetanus imunoglobulin) Vial
Tetagam (Human tetanus imunoglobulin) Vial
213 Tiamfenikol kapsul 500 mg Kapsul
214 Tiamin (vitamin B1) injeksi 100 mg/ml Ampul
215 Tiamin (vitamin B1) tablet 100 mg (HCL/Nitrat) Tablet
216 Tiamin (vitamin B1) tablet 100 mg (HCL/Nitrat) Tablet
Tiamin (vitamin B1) tablet 100 mg (HCL/Nitrat) Tablet
Tiamin (vitamin B1) tablet 100 mg (HCL/Nitrat) Tablet
217 Tramadol injeksi 50 mg/ml Ampul
218 Tramadol tablet 50 mg Tablet
219 Triheksifenidil tablet 2 mg Tablet
Triheksifenidil tablet 2 mg Tablet
220 Vitamin B Kompleks tablet HOLI Tablet
Vitamin B Kompleks tablet Tablet
Vitamin B1 100 mg, Vit B6 200 mg, Vit B12 200 mcg
Tablet
(CORSANEURON)
Vitamin Neurotropik Kombinasi Antalgin 250 mg B1 50 mg B6
221 Tablet
100 mg Vit B12 (IKANEURON)
Vitamin syr yg ngd Vit. A 2000 IU Vit.B1 1 mg, Vit.B12 0,5mg
222 Botol
vit.B6 1mg,B12 1 mcg, vit.C 10 mg, vit. (TRUVIT)
Vitamin syr yg ngd Vit. A 2000 IU Vit.B1 1 mg, Vit.B12 0,5mg
Botol
vit.B6 1mg,B12 1 mcg, vit.C 10 mg, vit. (TRUVIT)
Vit A (4000 IU), B1 (3 mg), B2 (3 mg), B6 (2 mg), B12 (2 mcg),
Tablet
Vit C (50 mg), Vit D (400 IU), Vit E (SOLVITRAL)
223 Zink tablet 20 mg Tablet
JUMLAH OBAT

BMHP
1 Abocath no.22 buah
2 Abocath no.24 buah
ADS 0,05 ml pcs
ADS 0,05 ml RAJAWALI pcs
3 Alat suntik 0,5 ml buah
4 Alat suntik 0,05 ml buah
5 Alat suntik 1 ml buah
6 Alat suntik sekali pakai 2,5 ml buah
7 Alat suntik sekali pakai 2,5 ml buah
Alat suntik 3 ml SRU buah
Alat suntik 3 ml SRU buah
1 2 3 4 5 6 7 8
8 Alat suntik sekali pakai 5 ml buah
9 Bisturi Aesculap buah
10 Catgut / Benang Bedah No. 3/0 buah
Catgut Chromic 3/0 baru pcs
Catgut Chromic SMI 3/0 HR 26 MM Rajawali pcs
Folley Catheter No 16 pcs
11 Infusion set anak Set /kantong
12 Infusion set dewasa Set /kantong
Infusion set dewasa Set /kantong
Infusion set dewasa Y-Type pcs
13 IV Catheter No. 18 B buah
14 IV Catheter No. 18 buah
15 IV Catheter No. 20 G buah
16 IV Catheter No. 22 G buah
17 IV Catheter No. 24 G buah
17 IV Catheter No. 24 F buah
Steracath IV Catheter 20G Alphatirta buah
18 Kapas Pembalut / Absorben 250 gram Bungkus
19 Kapas Pembalut / Absorben 250 gram (B) Bungkus
19 Kapas Pembalut Hidfrofil 250 gram (B) Bungkus
20 Kasa Kompres 40/40 steril Bungkus
21 Kasa Pembalut 2 m x 80 cm (B) Rol
Kasa Pembalut 2 m x 80 cm Rol
22 Kasa Utama 2 m x 80 cm (B) Rol
23 Kasa Pembalut Hidrofil 4 m x 15 cm elastic Rol
24 Kasa Steril Utama pcs
25 Masker Pcs
Masker Pcs
MMP Cathy IV Cannula 20 G pcs
MMP Cathy IV Cannula 22 G pcs
26 Paper tape 1,25 cm x 9,14 m Rol
27 Sarung Tangan Steril 7,5 pasang
28 Sarung Tangan ukuran S buah
29 Sarung Tangan ukuran M buah
30 Sarung Tangan ukuran L buah
31 Silk (Benang Bedah Sutera) No. 3/0 buah
32 Silk No. 3/0 buah
Surgical Silk 3/0 pcs
Surgical Face Mask Ear Loop (Masker MMP) pcs
Silk Black 3/0 HR 26 MM Rajawali pcs
33 Tranfusi set buah
34 Urin Bag buah
35 Wing Needle No. 23 G buah
36 Wing Needle No. 27 G buah
 1 2 3 4 5 6 7 8
OBAT GIGI
1 Devitalisasi Pasta (Non Arsen) pot
2 Etil Klorida spray Botol
3 Eugenol cairan Botol
4 Eugenol cairan b Botol
5 Glass Ionomer Cement ART Set
6 Kalsium Hidroksida Pasta tube
7 Klorfenol kamfer Menthol ( CHKM ) botol
8 Mummifying Pasta botol
9 Semen Seng Fosfat serbuk dan cairan botol
set @ 100 gram /
10 Temporary Stopping Fletcher (Fletcher) serbuk dan cairan
btl

Reagensia
1 Reagen Zeihl Nelsen kit
2 Slide kit
2 Pot Dahak buah
3 Reagen HBsAg buah
Jumlah Rp

B. BUFFER
1 Klorpromazine HCL 100 mg Tablet - - - - -
2 Clobazam 10 mg Tablet - - - - -
3 Clozapine 25 mg Tablet - - - - -
4 Fluoxetine 10 mg Tablet - - - - -
5 Klorpromazine HCL 100 mg Tablet - - - - -
6 Natrium Klorida larutan infus botol 500 ml - - - - -
7 Ringer Laktat botol 500 ml - - - - -
8 Risperidon 2 mg Tablet - - - - -
9 Trifluoferazine HCL 5 mg Tablet - - - - -
10 OAT - FDC kategori 2 Paket - - - - -
Jumlah Rp

C. PROGRAM
I. TB PARU (OAT FDC)
1 OAT - FDC kategori 1 Paket
OAT - FDC kategori 1 Paket
2 OAT - FDC kategori 2 Paket
3 OAT - FDC kategori Sisipan Paket
4 Obat Anti Tuberculosis - FDC anak Paket
5 Kombipak Katagori 1 Paket
6 Reagen ziehl nielsen Kit
7 Slide bok
8 Pot Dahak buah
9 Sound Timer box
 1 2 3 4 5 6 7 8

II. DIARE
1 Garam oralit untuk 200 ml air Sachet
Garam oralit untuk 200 ml air Sachet
2 Zinc* Tab 20 mg Tablet

III. KECACINGAN
1 Albendazol tablet 400 mg Tablet
Albendazol tablet 400 mg Tablet
Albendazol tablet 400 mg Tablet
2 Pirantel tab. Score (base) 125 mg Tablet

IV. GIZI
1 Retinol (Vitamin A) 100.000 IU Kapsul Kapsul
2 Retinol (Vitamin A) 200.000 IU Kapsul Kapsul
Retinol (Vitamin A) 200.000 IU Kapsul Kapsul

V.KUSTA
1 Mb dewasa blister
2 Mb anak blister
3 Pb anak blister
4 Pb dewasa blister

VI.IMUNISASI
1 ADS 0,05 ml pcs
ADS 0,05 ml pcs
2 ADS 0,5 ml pcs
3 ADS 0,5 ml pcs
4 ADS 5 ml pcs
ADS 5 ml pcs
5 BCG vial
BCG DAN PELARUT RUTIN vial
BCG DAN PELARUT b vial
6 Campak vial
7 DPT-HB-Hib vial
8 DPT-HB-Hib vial
DPT-HB-Hib ORI vial
DPT-HB-Hib rutin vial
DPT-HB-Hib rutin vial
9 DT vial
DT ORI vial
DT ORI vial
10 HB Uniject pouch
HB Uniject pouch
HB Uniject pouch
11 Meningitis Vaksin paket
12 Polio vial
Polio dan droper vial
13 Polio (IPV 10 dosis) vial
14 Polio (IPV 5 dosis) rutin vial
15 Polio (IPV 5 dosis) vial
Polio (IPV 5 dosis) vial
Polio (IPV 5 dosis) GAVI vial
Polio (IPV 5 dosis) vial
16 Td vial
 1 2 3 4 5 6 7 8
17 Td ORI rutin vial
18 Pelarut Campak vial
19 Droper Polio buah
20 Safety box pcs
Safety box pcs
MR dan pelarut rutin vial
21 MR dan pelarut vial
Measles Rubella (MR) vial
22 MR Plus Pelarut vial

VII. JIWA
1 Haloperidol Tablet 5 mg Tablet
2 Klorpromazine 100 mg Tablet
3 Karbamazepin Tablet
4 Haloperidol injeksi 5mg/ml ampul
5 Haloperidol Dekanoat injeksi 50 mg / ml ampul
6 Fluferazine Deconoat injeksi 25mg/ml (zkizonoat) ampul

VIII. KIA
1 Tablet Tambah Darah (Tablet Fe) tablet
2 Ca Glukonas injeksi 10 % ampul
3 Metilergometrin Maleat injeksi ampul
4 Oksitocin Injeksi 10 IU ampul
5 Retinol kapsul 100.000 IU Kapsul
6 Retinol kapsul 200.000 IU Kapsul
7 Magnesium sulfat inj (iv) 40% botol

VIII. DBD
1 BTI botol
2 Larvasida (abate) botol 1 kg
3 Bactivec botol

VIII. RABIES
1 Vaksin Anti Rabies vial

IX. HEPATITIS
1 Reagen Rapid HBsAg test
2 Rapid tes Anti HBS (Hepatitis B) test
3 Vaksin Hepatitis B Dewasa test

X. HIV/AIDS/IMS
1 Benzatin Penislin Injeksi 2,4 IU Vial
2 Kombipak paket Paket
Kombipak paket Paket
Kombipak paket Paket
3 Kotrimoksazole 480 mg Tablet
4 Pyrimethamine BP 25 mg Tablet
Rapid 2 HIV Fokus test
1 2 3 4 5 6 7 8
5 Rapid test HIV SD test
Rapid test HIV 1/2 Biometric (R3) test
5 Rapid test HIV 1/2 SD B test
Rapid test HIV 1/2 SD Baru test
6 Rapid test HIV intec test
7 Rapid test HIV ONCO test
8 Rapid test Syphilis test
Rapid test Syphilis test
9 Reagen syphlis test
RPR Syphilis b test
RPR Syphilis c test
10 Klindamisin kapsul 150 mg Kapsul
11 Klindamisin kapsul 300 mg Kapsul

Jumlah Rp
Jumlah Total Rp

UMUM
BPJS JUMLAH
BAYAR TIDAK BAYAR
JUMLAH KUNJUNGAN RESEP

Mengetahui / Menyetujui Yang Menyerahkan : Kepala Puskesmas Ciamis

Kepala Dinas Kesehatan Kabupaten Ciamis Petugas Gudang Farmasi Pkm Ciamis

……………………………………... ………………………… EVIE TRIYANTI, drg, MM IRMA SANDRA

NIP.198110182010012000 NIP. 19640323 198501 2 001
 FORM : LPLPO
DOKUMEN NOMOR TANGGAL
DINKES KABUPATEN

PUSKESMAS

HARGA JUMLAH HARGA

STOK OPTIMUM PERMINTAAN PEMBERIAN KET.
SATUAN RP (8x9)
9 10 11 12 13 14

17,393.00 - -
358.00 - -
99.00 - -
89.00 - -
350.00 - -
143.00 - -
162.00 -
198.00 - -
3,597.00 - -
4,372.50 - -
90.00 - -
3,345.00 - -
85.00 - -
70.00 - -
112.00 - -
167.00 - -
61,600.00 - -
180.00 - -
184.00 - -
190.00 - -
495.00 - -
2,090.00 - -
2,000.00 - -
3,628.00 - -
5,100.00 - -
1,540.00 - -
124.00 - -

62.00 - -

58.00 - -

54.00 - -
9 10 11 12 13 14

4,240.00 - -

1,995.00 - -

3,035.00 - -

4,323.00 - -

4,496.00 - -

3,045.00 - -

3,167.00 - -

2,302.00 - -
2,295.00 - -
116.00 - -
225.00 - -
39.00 - -
104.00 - -
105.00 - -
100.00 - -
103.00 - -
9,275.00 - -
236.00 - -
345.00 - -
380.00 - -
3,111.90 - -
3,135.00 - -
4,500.00 - -

42.00 - -

1,520.00 - -
1,349.00 - -
1,340.00 - -
5,800.00 - -
5,370.00 - -
6,000.00 - -
650.00 - -
2,950.00 - -
9,955.00 - -

693.00 - -

704.00 - -
 9 10 11 12 13 14
2,387.00 - -
2,838.00 - -
4,000.00 - -
9,548.00 - -
90.00 - -
25,300.00 - -
1,500.00 - -
1,097.00 - -
41.00 - -
32.00 - -
132.00 - -
192.50 - -
4,180.00 - -
1,735.00 - -
12,573.00 - -
86.00 - -
109.00 - -
1,095.00 - -
97.00 - -
104.00 - -
104.00 - -
4,587.00 - -

308.00 - -

270.00 - -
3,000.00 - -
2,700.00 - -
91.00 - -
35.00 - -
8,100.00 - -
1,408.00 - -
930.00 - -
750.00 - -
39,759.00 - -
1,100.00 - -
451.00 - -
4,541.67 - -
3,650.00 - -
2,550.00 - -
643.50 - -
69.00 - -
1,800.00 - -
61.00 - -
165.00 - -
171.00 - -
605.00 - -
2,500.00 - -
2,590.00 - -
 9 10 11 12 13 14

610.50 - -

423.50 - -

1,566.00 - -
3,682.00 - -
7,750.00 - -
3,417.00 - -
695.00 - -
710.00 - -
22,000.00 - -
2,970.00 - -
1,829.00 - -
78.00 - -
72.00 - -
325.00 - -
289.00 - -
371.00 - -
3,399.00 - -
3,542.00 - -
3,547.50 - -
2,830.00 - -
8,536.00 - -
2,970.00 - -
168.30 - -
119.00 - -
126.50 - -
187.00 - -
5,200.00 - -
224.00 - -
69.00 - -
61.00 - -
149.00 - -
155.00 - -
2,639.00 - -
2,475.00 - -
7,150.00 - -
95.00 - -
522.50 - -
115.50 - -
10,000.00 - -
10,050.00 - -
1,700.00 - -
1,755.00 - -
59.00 - -
56.00 - -
62.00 - -
 9 10 11 12 13 14
80.00 - -
228.00 - -
230.00 - -
361.00 - -
553.00 - -
300.00 - -
200.00 - -
1,048.00 - -
1,090.00 - -
3,250.00 - -
2,475.00 - -
6,930.00 - -
1,810.00 - -
1,881.00 - -
3,038.00 - -
3,008.00 - -
4,700.00 - -
51.00 - -
37.00 - -
22.00 - -
1,240.00 - -
1,243.00 - -
144.00 - -
157.00 - -
1,550.00 - -
370.00 - -

156.20 - -

5,280.00 - -

31,231.00 - -

2,145.00 - -

2,120.00 - -

129.00 - -

125.00 - -

70.00 - -

308.00 - -
303.00 - -
323.00 - -
1,845.00 - -
1,937.00 - -
1,152.00 - -
839.00 - -
1,144.00 - -
 9 10 11 12 13 14
43,000.00 - -
43,050.00 - -
123.00 - -
3,200.00 - -
1,188.00 - -
1,100.00 - -
100.00 - -
258.50 - -
96.00 - -
911.00 - -
946.00 - -

385.00 - -

2,959.00 - -
2,750.00 - -
143.00 - -
134.00 - -
3,395.00 - -
90.00 - -
9,950.00 - -
160.00 - -
330.00 - -
3,414.00 - -

10,175.00 - -

12,375.00 - -

15,290.00 - -

484.00 - -

929.50 - -

599.50 - -

187.00 - -
159.00 - -
115.00 - -
6,410.00 - -
99.00 - -
523.00 - -
560.00 - -
359,900.00 - -
1,297,889.00 - -
232,518.00 - -
160,000.00 - -
 9 10 11 12 13 14
11,990.00 - -

10,780.00 - -

8,195.00 - -

792.00 - -

858.00 - -

390.50 - -

412.50 - -

13,805.00 - -

13,750.00 - -

6,549.40 - -

25,146.00 - -

11,220.00 - -

11,220.00 - -

1,534.50 - -

1,523.50 - -

2,750.00 - -

2,776.40 - -

1,936.00 - -
3,520.00 - -
1,900.00 - -
361.10 - -
1,650.00 - -
14,157.00 - -
6,649.00 - -
1,010.00 - -
1,107.00 - -
49.00 - -
53.00 - -
 9 10 11 12 13 14
86.00 - -

12,980.00 - -

14,500.00 - -
5,390.00 - -
440.00 - -
123.00 - -
118.00 - -
213.40 - -
297.00 - -
293.70 - -
3,038.46 - -
9,975.00 - -
3,700.00 - -
18,892.85 - -
99.00 - -
73.00 - -
73.00 - -
98.00 - -
65.00 - -
1,155.00 - -
112.00 - -
105.00 - -
260.00 - -
284.00 - -
288.00 - -
459.00 - -
517.00 - -
7,150.00 - -
347.00 - -
63.00 - -
78.00 - -
4,446.00 - -
4,275.00 - -

2,527.00 - -

2,621.00 - -

4,180.00 - -
1,020.00 - -
1,001.00 - -
478.00 - -
4,185.00 - -
3,922.00 - -
462,000.00 - -
945,230.00 - -
900.00 - -
110.00 - -
 9 10 11 12 13 14
739.20 - -
281.00 - -

825.00 - -

50.00 - -

353.00 - -

6,490.00 - -

166.00 - -
170,000.00 - -
176,800.00 - -
913.00 - -
1,100.00 - -
91.00 - -
82.00 - -
86.00 - -
85.00 - -
2,395.00 - -
324.50 - -
91.00 - -
80.00 - -
89.00 - -
83.00 - -

825.00 - -

1,199.00 - -

11,709.50 - -

12,430.00 - -

929.50 - -

508.00 - -
- -
- -
- -
7,484.00 - -
7,484.00 - -
1,395 - -
1,582 - -
1,499.00 - -
1,395.00 - -
748.00 - -
659.07 - -
672.08 - -
672.08 - -
924.00 - -
 9 10 11 12 13 14
847.00 - -
3,000.00 - -
7,424.58 - -
7,466.67 - -
32,800.00 - -
7,787.50 - -
3,500.00 - -
4,400.00 - -
6,435.00 - -
8,061.00 - -
6,000.00 - -
5,500.00 - -
6,000.00 - -
5,500.00 - -
5,500.00 - -
4,547.75 - -
3,914.00 - -
6,000.00 - -
12,500.00 - -
24,257.79 - -
1,806.00 - -
9,451.50 - -
7,931.00 - -
7,300.00 - -
3,818.87 - -
343.75 - -
438.90 - -
379.48 - -
8,580.00 - -
8,580.00 - -
4,900.00 - -
5,037.00 - -
462.00 - -
462.00 - -
462.00 - -
20,325.00 - -
3,937.50 - -
3,862.50 - -
411.40 - -
19,700.00 - -
3,600.00 - -
4,418.70 - -
1,442.00 - -
1,442.00 - -
- -
 9 10 11 12 13 14
- -
735,900 - -
119,999 - -
52,800 - -
52,800 - -
766,370 - -
333,960 - -
114,400 - -
280,500 - -
200,420 - -

115,940 - -

- -
- -
304,000 - -
20,000 - -
1,750 - -
9,878 - -
- -
-

133 - -
7,650 - -
2,475 - -
1,166 - -
133 - -
4,700 - -
7,150 - -
1,781 - -
330 - -
1,199,900 - -
- -

359,980 - -
389,344 - -
1,199,985 - -
160,000 - -
214,985 - -
325,472 - -
276,500 - -
19,500 - -
1,750 - -
293,800 - -
9 10 11 12 13 14
-
-
257 - -
260 - -
508 - -
-
-
292 - -
403 - -
430 - -
18,600 - -
-
-
255 - -
459 - -
517 - -
-
-
31,760 - -
19,800 - -
8,052 - -
18,300 - -
-
-
1,590 - -
1,395 - -
1,195 - -
1,185 - -
1,640 - -
847 - -
59,950 - -
61,996 - -
66,154 - -
28,204 - -
78,991 - -
76,285 - -
78,991 - -
78,991 - -
84,282 - -
17,996 - -
17,996 - -
19,195 - -
20,900 - -
23,991 - -
25,597 - -
135,000 - -
19,954 - -
19,954 - -
245,025 - -
169,653 - -
139,000 - -
153,736 - -
144,540 - -
158,994 - -
16,500 - -
9 10 11 12 13 14
16,995 - -
- -
- -
18,625 - -
22,433 - -
155,813 - -
149,820 - -
166,265 - -
136,200 - -
-
-
88 - -
162 - -
230 - -
6,250 - -
101,300 - -
55,000 - -
- -
- -
350 - -
7,800 - -
2,684 - -
1,785 - -
288 - -
517 - -
3,796 - -
- -
- -
16,113 - -
58,795 - -
18,945 - -
- -
- -
165,000 - -
- -
- -
9,870 - -
19,800 - -
52,050 - -
- -
- -
14,500 - -
330,000 - -
30,000 - -
30,030 - -
149 - -
1,100 - -
14,470 - -
 9 10 11 12 13 14
22,330 - -
19,480 - -
14,340 - -
11,975 - -
22,358 - -
22,385 - -
26,527 - -
20,400 - -
27,900 - -
4,150 - -
4,120 - -
382 - -
527 - -
-
- -
- -

Ciamis,
Yang menerima :
Petugas Gudang Farmasi Pkm Ciamis Petugas Pustu/poskesdes

IRMA SANDRA
NIP. 19640323 198501 2 001