.2020 - Format Baru LPLPO Dan LB2 Rutin Nias Barat2

PEMERINTAH KABUPATEN NIAS BARAT
DINAS KESEHATAN
Jl. Soekarno-Hatta No.1 Blok A-3 Lahomi Kode Pos : 22863
email : kesehatanniasbarat@gmail.com
:
NAMA PUSKESMAS BULAN :
:
KECAMATAN TAHUN : 2020
LAPORAN PEMAKAIAN DAN PERMINTAAN OBAT (LPLPO) TAHUN 2020

PEMAKAIAN KEBUTUHAN
TANGGAL KEBUTUHAN STOK PERMINTAAN PERSETUJUAN TANGGAL Sumber
NO NAMA BARANG Satuan 3 BULAN SISA STOK
PER BULAN KADALUARSA OPTIMAL (per bulan) ( 3 bulan ) KADALUARSA Dana
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
1) OBAT
1 Air untuk injeksi botol

2 Air untuk irigasi inf 1000 ml botol
3 Asetil sistein kapsul 200 mg tablet
4 Albendazol suspensi 200 mg/5 ml botol 300.00
5 Albendazol tablet 400 mg tablet -
6 Alopurinol tablet 100 mg tablet 250 -
7 Alopurinol tablet 300 mg tablet 220 -
8 Alprazolam tablet 0,5 mg tablet
9 Ambroxol sirup 15 mg/ml botol -
10 Ambroxol tablet 30 mg tablet 900 150.00
11 Amitriptilin tab sal selaput 25 mg tablet
12 Aminofilin tablet 150 mg tablet
13 Aminofillin Injeksi 24 mg/ml ampul
14 Aminofillin tablet 200 mg tablet
15 Amlodipin tablet 10 mg tablet
17 Amoksisilin drops botol
18 Amoksisilin kaplet 250 mg kaplet
20 Amoksisilin sirup kering 125 mg/5 ml botol
21 Ampisilin sirup kering 125 mg/5 ml botol
23 Antasida DOEN II suspensi botol
24 Antasida DOEN tablet kunyah tablet
1
PEMAKAIAN
KEBUTUHAN TANGGAL KEBUTUHAN STOK PERMINTAAN TANGGAL Sumber
NO NAMA BARANG Satuan 3 BULAN PER BULAN SISA STOK KADALUARSA OPTIMAL (per bulan) ( 3 bulan ) PERSETUJUAN KADALUARSA Dana
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
Antimalaria, Kombinasi (DHP):

25 dihidroartemisin 40 mg + Piperakuin 320 tablet
mg tab sal selaput (DHP FRIMAL)
26 Asam Asetilsalisilat (asetosal/aspirin) tablet tablet

80 mg (MINIASPI 80)
27 Asam Askorbat (Vitamin C) tablet 50 mg tablet
28 Asam Folat 1 mg tablet tablet
29 Asam Mefenamat kaplet 500 mg kaplet
30 Asam traneksamat injeksi 100 mg/ml ampul
32 Asiklovir krim 5% tube
33 Asiklovir salep mata 3% (LACYVIR) tube
34 Atapulgit tablet 650 mg (NEW DIAGON) tablet
35 Atropin Injeksi i.m./i.v./s.k. 0,25 mg/ml ampul
36 Betahistin Mesilat tablet 6 mg tablet
37 Betametason krim 0,1 % tube
38 Betametason krim 0,5 mg/g tube
39 Bisakodil suppositoria 10 mg (DULCOLAX) suppo
40 Deksametason injeksi i.v. 5 mg/ml ampul
41 Deksametason tablet 0,5 mg tablet
42 Diazepam enema 5 mg/2,5 mL (STESOLID) tube
43 Diazepam injeksi 5mg/ml ampul
44 Diazepam tablet 2 mg tablet
46 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul
47 Digoksin tablet 0,25 mg tablet
48 Diltiazem HCl tablet 30 mg tablet
49 Doksisiklin kapsul 100 mg kapsul
50 Domperidon suspensi 5 mg / 5ml botol
51 Domperidon tablet 10 mg tablet
52 Ekstrak Kurkuma + Multivitamin sirup botol

(CURBION KIDS)
53 Ekstrak Kurkuma tablet (CURCUMA) tablet
54 Ekstrak Plasenta + Neomisin sulfat salep tube

(BIOPLACENTON)
55 Epinefrin (adrenalin) injeksi 0,1 % (sebagai ampul

HCL)
56 Eritromisin kapsul 250 mg kapsul
57 Eritromisin sirup kering 200 mg/5 ml botol
58 Eritromisin tablet 500 mg tablet
59 Fenoterol HBr 0,1 % larutan inhalasi botol
60 Fitomenadion (Vit K1) injeksi 2 mg/ml ampul
2
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
61 Fitomenadion (Vit K1) tablet salut gula 10 tablet

mg
62 Furosemid injeksi i.v/i.m 10 mg/ml ampul
63 Furosemid tablet 40 mg tablet
64 Garam Oralit bungkus
65 Gentamisin injeksi 40 mg/ml ampul
66 Gentamisin salep kulit 0,1% tube
67 Gentamisin salep mata 0,3% tube
68 Gentamisin tetes mata 0,3% botol
69 Glibenklamida tablet 5 mg tablet
70 Gliseril Guaiakolat tablet 100 mg tablet
71 Glukosa Larutan Infus 5 % Steril botol
72 Griseofulvin tablet 125mg tablet
73 Hidrokortison krim 2,5% tube
74 Hyoscine-N-Butilbromide injeksi 20 mg/ml ampul
75 Hyoscine-N-Butilbromide tablet 10 mg tablet

76 Ibuprofen 200 mg tablet tablet
78 Ibuprofen suspensi 200mg/5ml botol
79 Ipratropium + Salbutamol larutan inhalasi vial

(COMBIVENT UDV)
80 Isosorbid Dinitrat (ISDN) tablet 5mg tablet
81 Kalsium Laktat tablet 500 mg tablet
82 Kaptopril tablet 12,5 mg tablet
83 Kaptopril tablet 25 mg tablet
84 Karbimazol tablet 5 mg tablet

(NEO MERCAZOLE)
85 Ketokonazol krim 2 % tube
86 Ketokonazol tablet 200 mg tablet
87 Ketoprofen suppositoria 100 mg suppo

(SUPRAFENID)
88 Ketorolac injeksi 30 mg ampul
89 Klindamisin kapsul 150 mg kapsul
91 Kloramfenikol salep kulit 2% tube

(BUFACETINE)
92 Klorfeniramina Maleat (CTM) tablet 4 mg tablet
93 Kodein tablet 10 mg tablet
94 Kombinasi Salep 2-4 : asam salisilat 2% + tablet

belerang endap 4%
95 Kotrimoksazol DOEN I (dewasa) tablet 480 tablet

mg
3
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
Kotrimoksazole DOEN suspensi (anak), tiap

96 5 ml : sulfametoksazol 200 mg + botol
trimetoprim 40 mg
97 Levofloksasin tetes mata 0.5% (OPTIFLOX) botol
98 Lidokain injeksi 2% ampul
99 Lidokain injeksi 2% (HCl) + Epinefrin ampul

(1 : 80.000) - 2ml
100 Loratadin tablet 10 mg tablet
101 Metformin HCl tablet 500 mg tablet
103 Metilergometrin maleat injeksi 0.2 mg/ml ampul
104 Metilprednisolon tablet 4 mg tablet
105 Metoklopramid drop 2 mg/mL (GAVISTAL) botol
106 Metronidazol infus 5 mg/ml botol
107 Metronidazol Suspensi 125 mg/ 5 ml botol
108 Metronidazol tablet 500mg tablet
109 Mikonazole Krim 2 % tube
110 Minyak Ikan (COD LIVER OIL) kapsul
111 Multivitamin + DHA tablet (PRE NATAL) tablet
112 Multivitamin + Zinc tablet (CETOP ZINC) tablet
113 Natrium Bikarbonat tab 500 mg (BicNat) tablet
114 Natrium diklofenak tab 50 mg tablet
115 Natrium Klorida larutan infus 0,9 % (NaCl) botol
116 Obat Anti Tuberculosis FDC Kategori Anak paket
117 Obat Anti Tuberculosis FDC Kategori II paket
118 Oksimetazolin tetes hidung 0,025% botol

(ILLIADIN)
119 Oksitetrasiklin HCl salep mata 1 % tube
120 Oksitosin injeksi 10 IU/ml vial
121 Omeprazol injeksi 40 mg / 10 ml vial
122 Omeprazol kapsul 20 mg kapsul
123 Ondansetron injeksi 4 mg / 2 ml ampul
124 Parasetamol drops botol
125 Parasetamol infus 10 mg/ml botol
126 Parasetamol sirup 120 mg/5 ml botol
127 Parasetamol tablet 500 mg tablet
128 Piracetam inj 1g/5 ml ampul
129 Pirantel suspensi 125 mg/ 5 ml botol
130 Pirantel tablet score (base) 250 mg tablet

(PANTRIN)
131 Piridoksin (Vit B6) tablet 10mg tablet
132 Propranolol tablet 10 mg tablet
133 Propanolol tablet 40 mg tablet
4
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
134 Ranitidin injeksi 25mg/2ml ampul
135 Ranitidin tablet 150 mg tablet
136 Ringer Laktat larutan infus botol
137 Salbutamol Inhaler 100 mcg/dose botol

(SALBULIN)
138 Salbutamol sir 2 mg/5 Ml botol
139 Salbutamol tablet 2 mg tablet
141 Sefadroksil kapsul 250 mg kapsul
142 Seftriakson injeksi 1 gram vial
143 Serum anti bisa ular A.B.U. I inj (i.m./i.v) vial

(BIOSAVE)
144 Serum antitetanus (A.T.S) inj 1500 IU/mL vial

(i.m) (BIOSAT 1,5)
145 Setirizin sirup 5 mg/ 5 ml botol
146 Sianokobalamin (Vit B12) injeksi 500 mcg ampul
147 Sianokobalamin (Vit B12) tablet 50 mcg tablet
148 Simvastatin tablet 10 mg tablet
149 Siprofloksasin tablet 500 mg tablet
150 Spironolakton tablet 25 mg tablet
151 Streptomisin sulfat serbuk inj 1000 mg vial
152 Sukralfat sirup 500 mg/5ml botol
153 Tetrasiklin kapsul 500mg kapsul
154 Tiamin (Vitamin B1) tablet 50 mg tablet
155 Tramadol inj 50 mg/ml ampul
156 Tripolidin HCl + Pseudoefedrin HCl Sirup botol

(PROTIFED)
157 Vitamin B Kompleks injeksi (MERSIBION) ampul
158 Vitamin B Kompleks tablet tablet
159 Zinc sirup 20 mg/5ml botol
160 Zinc tablet 20 mg tablet
5
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
2) BMHP
1 Alat suntik sekali pakai 0,05 ml pcs

3 Alat suntik sekali pakai 1 ml pcs
8 Alat suntik sekali pakai 50 ml botol
9 Alkohol 70% 100 cc botol
12 Apron Plastik Disposible pcs
13 Aseptic Gel 500 cc + dispenser botol
14 Blood Lancet pcs
15 Bracket Hand Wash Plastik botol
16 Catgut Chromic 2/0 + jarum 1/2 GT pcs
18 Catgut PETERS SURGICALS PETER SILK 4/0, pcs

½ TP 16 mm, 75cm-2PTR5192E
19 Catgut PETERS SURGICALS PETER SILK 4/0, pcs

3/8 RC 20 mm, 75cm-2PTR5217E
20 Catgut Plain 2/0 + jarum 1/2 GT pcs
21 Catgut Plain 3/0 + jarum 1/2GT pcs
22 Catgut Silk 2/0 + jarum 1/2 GT pcs
24 Chlorhexidine 0.5%+Alkohol 70% Spray botol

100cc
25 Connecting Tube pcs
26 Desinfektan 1 Liter Botol
27 Devitalisasi Pasta (Non Arsen) 6 gram tube
28 Duk Lubang Bulat 50 x 60 cm pcs
29 ECG Paper (210mm) roll
30 EKG Elektroda pcs
31 Foley Catheter 2 Way No.16 pcs
33 Hidrogen Peroksida cairan 50% botol
34 ID band bayi pcs
35 ID band ibu (dewasa ) pcs
6
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
36 Infusion set anak pcs
37 Infusion set dewasa pcs
38 IV Catheter No. 18G pcs
43 Jelli Onemed USG Gel 250 ml pcs
44 Kapas Alkohol pcs
45 Kapas Pembalut / absorben 250 gram bungkus
46 Kasa Hidrofil 40 x 80 rol
47 Kasa Hidrofil 4yard x 15cm (3.6mx15cm) rol
49 Kasa Hidrofil 4yard x 5 cm (3.6mx5cm) rol
50 Kasa hydrophil steril uk. 18 cm x 22 cm pouch
51 Kasa Steril 7.5 x 7.5 cm, 8 ply 1 x 5’s bungkus
52 Lysol Concentrat 1 L botol
53 Masker pcs
54 Masker Oksigen Anak pcs
55 Masker Oksigen Dewasa pcs
56 Nald 23G pcs
57 Nald 27G pcs
58 Naso Gastric Tube 40 cm (No.6) pcs
63 Naso Gastric Tube 100 cm (No.10) Pcs
64 Naso Gastric Tube Levin Tube 125 cm pcs

(No.12)
65 Naso Gastric Tube Levin Tube 125 cm pcs

(No.14)
66 Naso Gastric Tube Stomach Tube 85 cm pcs

(No.12)
67 Naso Gastric Tube Stomach Tube 85 cm pcs

(No.14)
Nebulizer - INTERSURGICAL Cirrus
68 nebuliser (with Ecolite mask kid and tube pcs
for paediatric)
Nebulizer - INTERSURGICAL Cirrus
69 pcs
nebuliser ( T-piece Kit 22mm for Adult
7
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
70 Neonatal IV Arm Board pcs
71 Object Glass pcs
72 Pediatric IV Arm Board pcs
73 Pembalut Elastis Uk 7,5 cm x 4,55 m pcs
74 Pembersih Enzim Sachet 25 mg bungkus

(ALKHAZYME)
75 Plaster flexible non woven 5 cm x 5 m rol
77 Plaster flexible non woven 15 cm x 5m rol
79 Plaster Paper Tape 5 cm x 9.14 m pcs
80 Plaster steril Transparent untuk pcs

pemasangan IV Catheter
81 Povidon Iodida larutan 10% 30 ml botol
82 Povidon Iodida larutan 10 % 300ml botol
83 Povidon Iodida larutan 10 % 1000 ml botol
84 Rapid Tes DBD set
85 RDT Malaria set
86 Rivanol larutan 0,1% botol
87 Safety Box 5 liter pcs
88 Sarung tangan steril No. 6,5 pasang
89 Sarung tangan steril No. 7 pasang
91 Sarung tangan non steril L pcs
92 Sarung tangan non steril M pcs
93 Sarung tangan non steril S pcs
94 Selang Oksigen Anak pcs
95 Selang Oksigen Dewasa pcs
96 Sendok Obat Sirup 5 cc pcs
97 Softpad (Underpad) Nonsteril 60x90 cm bungkus
98 Spuit Disposable 100cc pcs
99 Strip tes asam urat pcs
100 Strip tes gula darah pcs
101 Strip tes hemoglobin pcs
102 Strip tes kolesterol total pcs
103 Suction Catheter No. 6 pcs
106 Surgical blade (Pisturi) pcs
107 Tes gula darah, kolesterol, asam urat pcs
108 Tes hamil urine/HCG test pcs
8
PEMAKAIAN
TERAKHIR
1 2 3 4 5 6 7 8 = 5 + 10% (5)+ 10% (5) 9 10 11 12
109 Threeway For IV Catheter pcs
110 Umbilical Cord Klem pcs
111 Urine bag bungkus
Umum BPJS Inap Total
JUMLAH KUNJUNGAN PASIEN/RESEP (3bulan)
*Permintaan
…………. , ………………………….
Mengetahui : Yang Melaporkan :

Kepala Puskesmas Hinako Pengelola Obat Puskesmas …………………
Kabupaten Nias Barat, Kabupaten Nias Barat,
..................................................................... ........................................................
NIP. NIP.
Lahomi, 20 Januari 2020
Mengetahui : Disetujui Oleh : Disusun Oleh :

Kepala Dinas Kesehatan Kepala Bidang Sumber Daya Kesehatan Kepala Seksi Kefarmasian, Alkes dan PKRT
Kabupaten Nias Barat, Dinas Kesehatan Kabupaten Nias Barat, Dinas Kesehatan Kabupaten Nias Barat,
RAHMATI DAELI, SKM, MKM IWAN S. GAURIFA, S.Kep., M.Kes. IRMA L. H. SINAGA, S.Farm., Apt.
Pembina Tk. I Penata Tk. I Penata Muda Tk. I
NIP. 19630816 198803 1 014 NIP. 19871120 201001 1 013 NIP. 19860315 201403 2 002
9
DINAS KESEHATAN
NAMA PUSKESMAS/ PUSTU/ POSKESDES

:
BULAN : LB2
KECAMATAN : TAHUN :
LAPORAN BULANAN PEMAKAIAN OBAT DAN BMHP (LB2) RUTIN
SALDO AWAL (Awal Bulan) PENERIMAAN PENGELUARAN SISA STOK (Akhir Bulan)
NO NAMA BARANG Sumber Satuan

Dana
JUMLAH HARGA TOTAL (Rp) JUMLAH HARGA TOTAL (Rp) JUMLAH HARGA TOTAL (Rp) JUMLAH HARGA TOTAL (Rp) TANGGAL
SATUAN SATUAN (Rp) SATUAN SATUAN (Rp) SATUAN SATUAN (Rp) SATUAN SATUAN (Rp) KADALUARSA
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1) OBAT -
1 Air untuk injeksi botol

2 Air untuk irigasi inf 1000 ml botol
3 Asetil sistein kapsul 200 mg tablet
4 Albendazol suspensi 200 mg/5 ml botol
5 Albendazol tablet 400 mg tablet
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam tablet 0,5 mg tablet
9 Ambroxol sirup 15 mg/ml botol
10 Ambroxol tablet 30 mg tablet
11 Amitriptilin tab sal selaput 25 mg tablet
12 Aminofilin tablet 150 mg tablet
13 Aminofillin Injeksi 24 mg/ml ampul
14 Aminofillin tablet 200 mg tablet
17 Amoksisilin drops botol
20 Amoksisilin sirup kering 125 mg/5 ml botol
23 Antasida DOEN II suspensi botol
24 Antasida DOEN tablet kunyah tablet
Antimalaria, Kombinasi (DHP):
25 dihidroartemisin 40 mg + Piperakuin 320 mg tablet
tab sal selaput (DHP FRIMAL)
Asam Asetilsalisilat (asetosal/aspirin) tablet

26 80 mg (MINIASPI 80) tablet
27 Asam Askorbat (Vitamin C) tablet 50 mg tablet

28 Asam Folat 1 mg tablet tablet
29 Asam Mefenamat kaplet 500 mg kaplet
10

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

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

32 Asiklovir krim 5% tube
33 Asiklovir salep mata 3% (LACYVIR) tube
34 Atapulgit tablet 650 mg (NEW DIAGON) tablet
35 Atropin Injeksi i.m./i.v./s.k. 0,25 mg/ml ampul
36 Betahistin Mesilat tablet 6 mg tablet
37 Betametason krim 0,1 % tube
38 Betametason krim 0,5 mg/g tube
39 Bisakodil suppositoria 10 mg (DULCOLAX) suppo
40 Deksametason injeksi i.v. 5 mg/ml ampul
41 Deksametason tablet 0,5 mg tablet
42 Diazepam enema 5 mg/2,5 mL (STESOLID) tube
43 Diazepam injeksi 5mg/ml ampul
46 Difenhidramin injeksi i.m. 10 mg/ml (HCl) ampul
47 Digoksin tablet 0,25 mg tablet
48 Diltiazem HCl tablet 30 mg tablet
49 Doksisiklin kapsul 100 mg kapsul
50 Domperidon suspensi 5 mg / 5ml botol
51 Domperidon tablet 10 mg tablet
Ekstrak Kurkuma + Multivitamin sirup
52 (CURBION KIDS) botol
53 Ekstrak Kurkuma tablet (CURCUMA) tablet

Ekstrak Plasenta + Neomisin sulfat salep
54 (BIOPLACENTON) tube
Epinefrin (adrenalin) injeksi 0,1 % (sebagai

55 HCL) ampul
56 Eritromisin kapsul 250 mg kapsul

57 Eritromisin sirup kering 200 mg/5 ml botol
58 Eritromisin tablet 500 mg tablet
59 Fenoterol HBr 0,1 % larutan inhalasi botol
60 Fitomenadion (Vit K1) injeksi 2 mg/ml ampul
61 Fitomenadion (Vit K1) tablet salut gula 10 mg tablet
62 Furosemid injeksi i.v/i.m 10 mg/ml ampul

63 Furosemid tablet 40 mg tablet
64 Garam Oralit bungkus
65 Gentamisin injeksi 40 mg/ml ampul
66 Gentamisin salep kulit 0,1% tube
67 Gentamisin salep mata 0,3% tube
68 Gentamisin tetes mata 0,3% botol
69 Glibenklamida tablet 5 mg tablet
70 Gliseril Guaiakolat tablet 100 mg tablet
71 Glukosa Larutan Infus 5 % Steril botol
72 Griseofulvin tablet 125mg tablet
73 Hidrokortison krim 2,5% tube
12

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
74 Hyoscine-N-Butilbromide injeksi 20 mg/ml ampul

75 Hyoscine-N-Butilbromide tablet 10 mg tablet
78 Ibuprofen suspensi 200mg/5ml botol
Ipratropium + Salbutamol larutan inhalasi
79 (COMBIVENT UDV) vial
80 Isosorbid Dinitrat (ISDN) tablet 5mg tablet

81 Kalsium Laktat tablet 500 mg tablet
82 Kaptopril tablet 12,5 mg tablet
83 Kaptopril tablet 25 mg tablet
84 Karbimazol tablet 5 mg tablet

(NEO MERCAZOLE)
85 Ketokonazol krim 2 % tube
86 Ketokonazol tablet 200 mg tablet
Ketoprofen suppositoria 100 mg
87 (SUPRAFENID) suppo
88 Ketorolac injeksi 30 mg ampul

91 Kloramfenikol salep kulit 2% (BUFACETINE) tube
92 Klorfeniramina Maleat (CTM) tablet 4 mg tablet
93 Kodein tablet 10 mg tablet
Kombinasi Salep 2-4 : asam salisilat 2% +
94 belerang endap 4% tablet
Kotrimoksazol DOEN I (dewasa) tablet 480

95 mg tablet
Kotrimoksazole DOEN suspensi (anak), tiap 5

96 ml : sulfametoksazol 200 mg + trimetoprim botol
40 mg
97 Levofloksasin tetes mata 0.5% (OPTIFLOX) botol
98 Lidokain injeksi 2% ampul
Lidokain injeksi 2% (HCl) + Epinefrin (1 :
99 80.000) - 2ml ampul
100 Loratadin tablet 10 mg tablet

103 Metilergometrin maleat injeksi 0.2 mg/ml ampul
104 Metilprednisolon tablet 4 mg tablet
105 Metoklopramid drop 2 mg/mL (GAVISTAL) botol
106 Metronidazol infus 5 mg/ml botol
107 Metronidazol Suspensi 125 mg/ 5 ml botol
108 Metronidazol tablet 500mg tablet
109 Mikonazole Krim 2 % tube
110 Minyak Ikan (COD LIVER OIL) kapsul
111 Multivitamin + DHA tablet (PRE NATAL) tablet
112 Multivitamin + Zinc tablet (CETOP ZINC) tablet
113 Natrium Bikarbonat tab 500 mg (BicNat) tablet
114 Natrium diklofenak tab 50 mg tablet
13

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
115 Natrium Klorida larutan infus 0,9 % (NaCl) botol

116 Obat Anti Tuberculosis FDC Kategori Anak paket
117 Obat Anti Tuberculosis FDC Kategori II paket
Oksimetazolin tetes hidung 0,025%
118 (ILLIADIN) botol
119 Oksitetrasiklin HCl salep mata 1 % tube

120 Oksitosin injeksi 10 IU/ml vial
121 Omeprazol injeksi 40 mg / 10 ml vial
122 Omeprazol kapsul 20 mg kapsul
123 Ondansetron injeksi 4 mg / 2 ml ampul
124 Parasetamol drops botol
125 Parasetamol infus 10 mg/ml botol
126 Parasetamol sirup 120 mg/5 ml botol
127 Parasetamol tablet 500 mg tablet
128 Piracetam inj 1g/5 ml ampul
129 Pirantel suspensi 125 mg/ 5 ml botol
Pirantel tablet score (base) 250 mg
130 (PANTRIN) tablet
131 Piridoksin (Vit B6) tablet 10mg tablet

132 Propranolol tablet 10 mg tablet
133 Propanolol tablet 40 mg tablet
134 Ranitidin injeksi 25mg/2ml ampul
135 Ranitidin tablet 150 mg tablet
136 Ringer Laktat larutan infus botol
Salbutamol Inhaler 100 mcg/dose
137 (SALBULIN) botol
138 Salbutamol sir 2 mg/5 Ml botol

141 Sefadroksil kapsul 250 mg kapsul
142 Seftriakson injeksi 1 gram vial
Serum anti bisa ular A.B.U. I inj (i.m./i.v)
143 (BIOSAVE) vial
Serum antitetanus (A.T.S) inj 1500 IU/mL

144 (i.m) (BIOSAT 1,5) vial
145 Setirizin sirup 5 mg/ 5 ml botol

146 Sianokobalamin (Vit B12) injeksi 500 mcg ampul
147 Sianokobalamin (Vit B12) tablet 50 mcg tablet
148 Simvastatin tablet 10 mg tablet
149 Siprofloksasin tablet 500 mg tablet
150 Spironolakton tablet 25 mg tablet
151 Streptomisin sulfat serbuk inj 1000 mg vial
152 Sukralfat sirup 500 mg/5ml botol
153 Tetrasiklin kapsul 500mg kapsul
154 Tiamin (Vitamin B1) tablet 50 mg tablet
155 Tramadol inj 50 mg/ml ampul
14

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Tripolidin HCl + Pseudoefedrin HCl Sirup

156 (PROTIFED) botol
157 Vitamin B Kompleks injeksi (MERSIBION) ampul

158 Vitamin B Kompleks tablet tablet
159 Zinc sirup 20 mg/5ml botol
160 Zinc tablet 20 mg tablet
15

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
2) BMHP

8 Alat suntik sekali pakai 50 ml botol
12 Apron Plastik Disposible pcs
13 Aseptic Gel 500 cc + dispenser botol
14 Blood Lancet pcs
15 Bracket Hand Wash Plastik botol
Catgut PETERS SURGICALS PETER SILK 4/0,
18 ½ TP 16 mm, 75cm-2PTR5192E pcs

19 3/8 RC 20 mm, 75cm-2PTR5217E pcs
20 Catgut Plain 2/0 + jarum 1/2 GT pcs

21 Catgut Plain 3/0 + jarum 1/2GT pcs
Chlorhexidine 0.5%+Alkohol 70% Spray
24 100cc botol
25 Connecting Tube pcs

26 Desinfektan 1 Liter Botol
27 Devitalisasi Pasta (Non Arsen) 6 gram tube
28 Duk Lubang Bulat 50 x 60 cm pcs
29 ECG Paper (210mm) roll
30 EKG Elektroda pcs
33 Hidrogen Peroksida cairan 50% botol
34 ID band bayi pcs
35 ID band ibu (dewasa ) pcs
36 Infusion set anak pcs
37 Infusion set dewasa pcs
16

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

43 Jelli Onemed USG Gel 250 ml pcs
44 Kapas Alkohol pcs
45 Kapas Pembalut / absorben 250 gram bungkus
46 Kasa Hidrofil 40 x 80 rol
49 Kasa Hidrofil 4yard x 5 cm (3.6mx5cm) rol
50 Kasa hydrophil steril uk. 18 cm x 22 cm pouch
51 Kasa Steril 7.5 x 7.5 cm, 8 ply 1 x 5’s bungkus
52 Lysol Concentrat 1 L botol
53 Masker pcs
54 Masker Oksigen Anak pcs
55 Masker Oksigen Dewasa pcs
56 Nald 23G pcs
57 Nald 27G pcs
63 Naso Gastric Tube 100 cm (No.10) Pcs
64 Naso Gastric Tube Levin Tube 125 cm (No.12) pcs
65 Naso Gastric Tube Levin Tube 125 cm (No.14) pcs
Naso Gastric Tube Stomach Tube 85 cm

66 (No.12) pcs
Naso Gastric Tube Stomach Tube 85 cm

67 (No.14) pcs
Nebulizer - INTERSURGICAL Cirrus nebuliser

68 (with Ecolite mask kid and tube for pcs
paediatric)

69 ( T-piece Kit 22mm for Adult pcs
70 Neonatal IV Arm Board pcs

71 Object Glass pcs
72 Pediatric IV Arm Board pcs
73 Pembalut Elastis Uk 7,5 cm x 4,55 m pcs
Pembersih Enzim Sachet 25 mg
74 (ALKHAZYME) bungkus

77 Plaster flexible non woven 15 cm x 5m rol
79 Plaster Paper Tape 5 cm x 9.14 m pcs
80 Plaster steril Transparent untuk pemasangan pcs

IV Catheter
17

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
81 Povidon Iodida larutan 10% 30 ml botol

82 Povidon Iodida larutan 10 % 300ml botol
83 Povidon Iodida larutan 10 % 1000 ml botol
84 Rapid Tes DBD set
85 RDT Malaria set
86 Rivanol larutan 0,1% botol
87 Safety Box 5 liter pcs
89 Sarung tangan steril No. 7 pasang
91 Sarung tangan non steril L pcs
92 Sarung tangan non steril M pcs
93 Sarung tangan non steril S pcs
94 Selang Oksigen Anak pcs
95 Selang Oksigen Dewasa pcs
96 Sendok Obat Sirup 5 cc pcs
97 Softpad (Underpad) Nonsteril 60x90 cm bungkus
98 Spuit Disposable 100cc pcs
99 Strip tes asam urat pcs
100 Strip tes gula darah pcs
101 Strip tes hemoglobin pcs
102 Strip tes kolesterol total pcs
106 Surgical blade (Pisturi) pcs
107 Tes gula darah, kolesterol, asam urat pcs
108 Tes hamil urine/HCG test pcs
109 Threeway For IV Catheter pcs
110 Umbilical Cord Klem pcs
111 Urine bag bungkus
18

Dana
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
DAFTAR 10 PENYAKIT TERTINGGI BULAN ………….

1
2
3
4
5
6
7
8
9
10
JUMLAH KUNJUNGAN PASIEN/RESEP BULAN………….

1. UMUM :
2. BPJS : ................. , ..........................................

Kepala Puskesmas ......................................... Pengelola Obat ..............................
Kabupaten Nias Barat, Kabupaten Nias Barat,
..................................................................... ........................................................
NIP.
Lahomi, 20 Januari 2020
Mengetahui : Disetujui Oleh : Disusun Oleh :

Kepala Dinas Kesehatan Kabupaten Nias Barat, Kepala Bidang Sumber Daya Kesehatan Kepala Seksi Kefarmasian, Alkes dan PKRT
Dinas Kesehatan Kabupaten Nias Barat, Dinas Kesehatan Kabupaten Nias Barat,
RAHMATI DAELI, SKM., M.KM IWAN S. GAURIFA, S.Kep., M.Kes. IRMA L. H. SINAGA, S.Farm., Apt.
Pembina Tk. I Penata Tk. I Penata Muda Tk. I
NIP. 19630816 198803 1 014 NIP. 19871120 201001 1 013 NIP. 19860315 201403 2 002
19
DINAS KESEHATAN
LAPORAN MUTASI OBAT DAN BMHP (NON PROGRAM) TAHUN 2019

DI INSTALASI FARMASI KABUPATEN NIAS BARAT
Gagal Pengadaan Barang belum masuk obat nonKatalog Obat Kimia Farma belum masuk
Barang sedang otw sudah masuk obat gizi
PENGELUARAN SISA STOK
SALDO AWAL ( per 1 Januari 2019) PENERIMAAN (DAK 2019)
No NAMA BARANG Sumber Dana Satuan
DAK 2019 SISA 2018 DAK 2019 ( per 31 Desember 2019) SISA 2018 (per 30 Juni 2019)
JUMLAH JUMLAH JUMLAH HARGA JUMLAH HARGA SATUAN JUMLAH HARGA JUMLAH HARGA
HARGA SATUAN (Rp) TOTAL (Rp) HARGA SATUAN (Rp) TOTAL (Rp) TOTAL (Rp) TOTAL (Rp) TOTAL (Rp) TOTAL (Rp)
SATUAN SATUAN SATUAN SATUAN (Rp) SATUAN (Rp) SATUAN SATUAN (Rp) SATUAN SATUAN (Rp)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
1) OBAT
1 Air untuk injeksi (OTSU - WI) DAK 2018 botol 90 2,860.00 257,400.00 - 0 2,860.00 - 80 2,860.00 228,800.00 90 2,860.00 257,400.00
2 Air untuk irigasi inf 1000 ml (WIDA WI UNICAP) DAK 2019 botol 120 11,235.000 0 120 11,235.00 1,348,200.00
3 Albendazol suspensi 200 mg/5 ml botol - - 0 - - - - - -

4 Albendazol tablet 400 mg DAK 2018 tablet 4,800 423.00 2,030,400.00 - 2,200 423.00 930,600.00 - - - 2,600 423.00 1,099,800.00
DAK 2019 tablet 5,000 423.000 2,115,000.00 0 5,000 423.00 2,115,000.00
5 Alopurinol tablet 100 mg DAK 2017 tablet 111,100 108.00 11,998,800.00 - 105,400 108.00 11,383,200.00 - - - 5,700 108.00 615,600.00
DAK 2019 tablet 60,000 104.000 6,240,000.00 0 60,000 104.00 6,240,000.00
6 Alopurinol tablet 300 mg Buffer 2018 tablet 200 210.00 42,000.00 - 200 210.00 42,000.00 - - - 0 210.00 -
7 Alprazolam tablet 0,5 mg tablet - - 0 - - - - - -
8 Ambroxol sirup 15 mg/ml DAK2018non botol 3,934 5,280.00 20,771,520.00 - 1,285 5,280.00 6,784,800.00 - - - 2,649 5,280.00 13,986,720.00
9 Ambroxol tablet 30 mg DAK2018non tablet 86,900 280.00 24,332,000.00 - 39,900 280.00 11,172,000.00 - - - 47,000 280.00 13,160,000.00
10 Amitriptilin tab sal selaput 25 mg DAK 2019 tablet 2,000 168.000 336,000.00 0 2,000 168.00 336,000.00
11 Amlodipin tablet 10 mg DAK 2019 tablet - 90,000 94.000 8,460,000.00 0 - 90,000 94.00 8,460,000.00 - -
12 Amlodipin tablet 5 mg DAK 2019 tablet - 90,000 78.000 7,020,000.00 0 - 78,300 78.00 6,107,400.00 - -
13 Amoksisilin drops DAK 2019 botol 13,500.00 1,200 13,500.000 16,200,000.00 0 1,200 13,500.00 16,200,000.00
14 Amoksisilin kaplet 250 mg DAK 2018 kaplet 49,400 190.00 9,386,000.00 - 17,100 190.00 3,249,000.00 - - - 32,300 190.00 6,137,000.00
15 Amoksisilin kaplet 500 mg Buffer 2018 kaplet 24,000 191.00 4,584,000.00 - 21,700 191.00 4,144,700.00 - - - 2,300 191.00 439,300.00
DAK 2019 kaplet 300,000 261.000 78,300,000.00 0 247,200 261.00 64,519,200.00
16 Amoksisilin sirup kering 125 mg/5 ml DAK 2017 botol 1,325 1,920.00 2,544,000.00 - 1,215 1,920.00 2,332,800.00 - - - 110 1,920.00 211,200.00
17 Amoksisilin sirup kering 250 mg/5 ml DAK 2019 botol 5,000 3,670.000 18,350,000.00 0 5,000 3,670.00 18,350,000.00
18 Antasida DOEN II suspensi DAK 2019 botol - 5,000 2,189.000 10,945,000.00 0 - - 4,230 2,189.00 9,259,470.00 - -
19 Antasida DOEN tablet kunyah DAU 2016 tablet 60,000 63.53 3,811,620.00 - 28,500 63.53 1,810,519.50 - - - 31,500 63.53 2,001,100.50
DAK 2019 tablet 300,000 60.000 18,000,000.00 0 300,000 60.00 18,000,000.00
Buffer 2018 tablet 46,200 59.00 2,725,800.00 - 46,200 59.00 2,725,800.00 - - - 0 - -
Antimalaria, Kombinasi (DHP): dihidroartemisin 40
20 mg + Piperakuin 320 mg tab sal selaput (DHP DAK 2019 tablet - 900 2,134.000 1,920,600.00 0 - - 900 2,134.00 1,920,600.00 - -
FRIMAL)
Asam Asetilsalisilat (asetosal/aspirin) tablet 80 mg
21 DAK 2019 tablet 10,000 105.000 1,050,000.00 0 10,000 105.00 1,050,000.00
(MINIASPI 80)
22 Asam Askorbat (Vitamin C) tablet 50 mg DAK 2018 tablet 56,100 110.00 6,171,000.00 - 44,700 110.00 4,917,000.00 - - - 11,400 110.00 1,254,000.00
DAK 2019 tablet 50,000 110.000 5,500,000.00 0 45,800 110.00 5,038,000.00
23 Asam Folat 1 mg tablet DAK 2019 tablet - 3,000 79.000 237,000.00 0 - - 3,000 79.00 237,000.00 - -
24 Asam Mefenamat kaplet 500 mg DAK 2017 kaplet 95,500 102.00 9,741,000.00 - 93,800 102.00 9,567,600.00 - - - 1,700 102.00 173,400.00
Buffer 2018 kaplet 68,700 102.00 7,007,400.00 - 52,500 102.00 5,355,000.00 - - - 16,200 102.00 1,652,400.00
25 Asam Traneksamat injeksi 100 mg/ml DAU 2016 ampul 115 2,489.00 286,235.00 - 115 2,489.00 286,235.00 - - - 0 - -
26 Asam traneksamat injeksi 50 mg/ml DAK 2018 ampul 950 1,813.00 1,722,350.00 - 0 1,813.00 - - - - 950 1,813.00 1,722,350.00
27 Asam Traneksamat kapsul 500 mg DAK 2019 kapsul - - 0 - - - - - - -
28 Asiklovir krim 5% DAK2018non tube 873 4,950.00 4,321,350.00 - 240 4,950.00 1,188,000.00 131 4,950.00 648,450.00 633 4,950.00 3,133,350.00
29 Asiklovir salep mata 3% (LACYVIR) DAK 2018 tube 39 19,900.00 776,100.00 - 30 19,900.00 597,000.00 - - - 9 19,900.00 179,100.00
DAK 2019 tube 1,008 19,900.000 20,059,200.00 0 969 19,900.00 19,283,100.00
30 Asiklovir tablet 200 mg tablet - - 0 - - - - - - -
31 Asiklovir tablet 400 mg DAK 2019 tablet - - 0 - - - - - - -
32 Atapulgit tablet (NEW DIAGON) DAK 2019 tablet - 60,000 230.000 13,800,000.00 0 - - 55,900 230.00 12,857,000.00 - -
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
33 Atropin Injeksi i.m./i.v./s.k. 0,25 mg/ml ampul - - 0 - - - - - - -

34 Betahistin Mesilat tablet 6 mg DAK 2017 tablet 18,180 151.00 2,745,180.00 - 2,610 151.00 394,110.00 1,420 151.00 214,420.00 15,570 151.00 2,351,070.00
35 Betametason krim 0,1 % DAK 2018 tube 4,990 1,340.00 6,686,600.00 - 0 1,340.00 - - - - 4,990 1,340.00 6,686,600.00
36 Betametason krim 0,5 mg/g Buffer 2018 tube 2,184 3,388.00 7,399,392.00 - 274 3,388.00 928,312.00 - - - 1,910 3,388.00 6,471,080.00
37 Bisakodil suppositoria 10 mg DAK 2019 suppo 600 5,900.000 3,540,000.00 0 600 5,900.00 3,540,000.00
38 Bisakodil 5 mg tablet tablet - - 0 - - - - - - -
39 Bromheksin tablet 8 mg tablet - - 0 - - - - - - -
40 Citicoline injeksi 250 mg/ 2 ml ampul 0 - - 0 - - - - - - -
41 Deksametason injeksi i.v. 5 mg/ml Buffer 2018 ampul 2,374 1,647.00 3,909,978.00 - 0 1,647.00 - - - - 2,374 1,647.00 3,909,978.00
DAK 2018 ampul 5,000 1,152.00 5,760,000.00 - 335 1,152.00 385,920.00 - - - 4,665 1,152.00 5,374,080.00
DAK 2019 ampul 20,000 1,152.000 23,040,000.00 0 20,000 1,152.00 23,040,000.00
42 Deksametason tablet 0,5 mg DAK 2018 tablet 200,000 33.00 6,600,000.00 - 3,600 33.00 118,800.00 - - - 196,400 33.00 6,481,200.00
43 Diazepam enema 5 mg/2,5 mL (STESOLID) DAK 2019 tube 200 13,202.000 2,640,400.00 0 200 13,202.00 2,640,400.00
44 Diazepam injeksi 5mg/ml DAK 2018 ampul 200 1,822.00 364,400.00 - 0 1,822.00 - - - - 200 1,822.00 364,400.00
DAK 2019 ampul 500 1,822.000 911,000.00 0 500 1,822.00 911,000.00
45 Diazepam tablet 2 mg DAK 2019 tablet - 10,000 86.000 860,000.00 0 - - 10,000 86.00 860,000.00 - -
46 Diazepam tablet 5 mg DAK 2019 tablet 114.00 10,000 114.000 1,140,000.00 0 10,000 114.00 1,140,000.00
47 Difenhidramin injeksi i.m. 10 mg/ml (HCl) DAK 2018 ampul 244 1,151.00 280,844.00 - 70 1,151.00 80,570.00 - - - 174 1,151.00 200,274.00
DAK 2019 ampul 990 1,228.000 1,215,720.00 0 990 1,228.00 1,215,720.00
48 Digoksin tablet 0,25 mg DAK 2019 tablet - 10,000 104.000 1,040,000.00 0 - - 10,000 104.00 1,040,000.00 - -
49 Diltiazem HCl tablet 30 mg tablet - - 0 - - - - - - -
50 Doksisiklin kapsul 100 mg DAK 2018 kapsul 1,300 264.00 343,200.00 - 300 264.00 79,200.00 - - - 1,000 264.00 264,000.00
51 Domperidone drops 5 mg/mL DAK 2019 botol 0 - - -
52 Domperidon suspensi 5 mg / 5ml DAK 2018 botol 350 2,781.00 973,350.00 - 210 2,781.00 584,010.00 - - - 140 2,781.00 389,340.00
DAK 2019 botol 1,000 2,781.000 2,781,000.00 0 1,000 2,781.00 2,781,000.00
53 Domperidon tablet 10 mg DAK 2018 tablet 46,900 86.00 4,033,400.00 - 2,200 86.00 189,200.00 - - - 44,700 86.00 3,844,200.00
DAK 2019 tablet 20,000 86.000 1,720,000.00 0 20,000 86.00 1,720,000.00
Ekstrak Keji Beling + Kumis Kucing + Tempuyung
54 DAK2018non kapsul 1,900 720.00 1,368,000.00 - 1,500 720.00 1,080,000.00 - - - 400 720.00 288,000.00
kapsul (KEJI BELING)
Ekstrak Kurkuma + Multivitamin sirup (CURBION
55 DAK2018non botol 1,295 7,150.00 9,259,250.00 - 435 7,150.00 3,110,250.00 - - - 860 7,150.00 6,149,000.00
KIDS)
56 Ekstrak Kurkuma tablet (CURCUMA) DAK2018non tablet 11,300 1,470.00 16,611,000.00 - 5,500 1,470.00 8,085,000.00 - - - 5,800 1,470.00 8,526,000.00
57 Ekstrak Phyllanthus niruri kaspul (STIMUNO) DAK2018non kapsul 430 3,844.00 1,652,920.00 - 430 3,844.00 1,652,920.00 - - - 0 - -
Ekstrak Plasenta + Neomisin sulfat salep

58 DAK2018non tube 180 22,500.00 4,050,000.00 - 36 22,500.00 810,000.00 - - - 144 22,500.00 3,240,000.00
(BIOPLACENTON)
59 Epinefrin (adrenalin) injeksi 0,1 % (sebagai HCL) DAK 2018 ampul 500 1,408.00 704,000.00 - 0 1,408.00 - - - - 500 1,408.00 704,000.00
60 Ergokalsiferol (vitamin D3/D2) kapsul 50.000 IU kapsul - - 0 - - - - - - -
61 Eritromisin kapsul 250 mg kapsul 0 - - 0 - - - - - - -

62 Eritromisin sirup kering 200 mg/5 ml Buffer 2018 botol 50 6,303.00 315,150.00 - 39 6,303.00 245,817.00 - - - 11 6,303.00 69,333.00
63 Eritromisin tablet 500 mg Buffer 2018 tablet 2,900 751.00 2,177,900.00 - 1,400 751.00 1,051,400.00 - - - 1,500 751.00 1,126,500.00
64 Eugenol cairan DAK 2019 botol 1,250 21,091.000 0 1,250 21,091.00 26,363,750.00
65 Fenoterol HBr 0,1 % larutan inhalasi botol - - 0 - - - - - - -
66 Fitomenadion (Vit K1) injeksi 2 mg/ml DAK 2019 ampul - 600 3,867.000 2,320,200.00 0 - - 600 3,867.00 2,320,200.00 - -
67 Fitomenadion (Vit K1) tablet salut gula DAK 2018 tablet 200 747.00 149,400.00 - 200 747.00 149,400.00 - - - 0 - -
10 mg DAK 2019 tablet 5,000 797.000 3,985,000.00 0 5,000 797.00 3,985,000.00
68 Furosemid injeksi i.v/i.m 10 mg/ml DAK 2018 ampul 465 1,333.00 619,845.00 - 436 1,333.00 581,188.00 - - - 29 1,333.00 38,657.00
DAK 2019 ampul 500 1,333.000 666,500.00 0 500 1,333.00 666,500.00
69 Furosemid tablet 40 mg DAK 2018 tablet 28,800 77.00 2,217,600.00 - 1,200 77.00 92,400.00 22,800 77.00 1,755,600.00 27,600 77.00 2,125,200.00
DAK 2019 tablet 20,000 82.000 1,640,000.00 0 20,000 82.00 1,640,000.00
70 Garam Oralit DAK 2018 bungkus 5,000 257.00 1,285,000.00 - 1,400 257.00 359,800.00 - - - 3,600 257.00 925,200.00
71 Gentamisin injeksi 40 mg/ml DAK 2018 ampul 105 3,685.00 386,925.00 - 0 3,685.00 - - - - 105 3,685.00 386,925.00
72 Gentamisin salep kulit 0,1% tube - - 0 - - - - - - -
73 Gentamisin salep mata 0,3% DAK 2019 tube - 2,616 2,810.000 7,350,960.00 0 - - 2,160 2,810.00 6,069,600.00 - -
74 Gentamisin tetes mata 0,3% DAK 2019 botol - 480 4,452.000 2,136,960.00 0 - - 480 4,452.00 2,136,960.00 - -
21
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
75 Glibenklamida tablet 5 mg DAU 2016 tablet 6,800 140.00 952,000.00 - 3,300 140.00 462,000.00 600 140.00 84,000.00 3,500 140.00 490,000.00
DAK 2018 tablet 5,000 125.00 625,000.00 - 0 125.00 - 5,000 DAK 2018 - 5,000 125.00 625,000.00
76 Gliseril Guaiakolat tablet 100 mg DAK2018non tablet 107,800 220.00 23,716,000.00 - 22,300 220.00 4,906,000.00 - - - 85,500 220.00 18,810,000.00
77 Glukosa Larutan Infus 5 % Steril DAU 2016 botol 1,624 6,481.62 10,526,153.51 - 1,295 6,481.62 8,393,700.00 - - - 329 6,481.62 2,132,453.51
DAK 2018 botol 477 6,900.00 3,291,300.00 - 120 6,900.00 828,000.00 - - - 357 6,900.00 2,463,300.00
DAK 2019 botol 500 7,363.000 3,681,500.00 0 500 7,363.00 3,681,500.00
78 Haloperidol Tablet 0,5 mg Buffer 2015 tablet 800 61.00 48,800.00 - 800 61.00 48,800.00 - - - 0 - -
79 Hidroklorotiazid (HCT) tab 25 mg DAK 2019 tablet 10,000 163.000 1,630,000.00 0 10,000 163.00 1,630,000.00
80 Hidrokortison krim 2,5% DAK 2019 tube - 4,800 2,475.000 11,880,000.00 0 - - 4,800 2,475.00 11,880,000.00 - -
81 Hyoscine-N-Butilbromide injeksi 20 mg/ml DAK2018non ampul 295 12,900.00 3,805,500.00 - 0 12,900.00 - - - - 295 12,900.00 3,805,500.00
82 Hyoscine-N-Butilbromide tablet 10 mg tablet - - 0 - - - - - - -

83 Ibuprofen 200 mg tablet DAK 2018 tablet 6,800 108.00 734,400.00 - 3,800 108.00 410,400.00 - - - 3,000 108.00 324,000.00
84 Ibuprofen 400 mg tablet tablet - - 0 - - - - - - -
85 Ibuprofen suspensi 100mg/5ml DAK 2019 botol 1,000 2,776.000 0 890 2,776.00 2,470,640.00
86 Ibuprofen suspensi 200mg/5ml DAK 2019 botol 4,945.00 - 2,000 4,945.000 9,890,000.00 0 4,945.00 - 2,000 4,945.00 9,890,000.00 4,945.00 -
87 Ikhtamol salep 10 % tube - - 0 - - - - - - -
Ipratropium + Salbutamol larutan inhalasi
88 DAK 2019 vial - 300 4,550.000 1,365,000.00 0 - - 300 4,550.00 1,365,000.00 - -
(COMBIVENT)
89 Irbesartan tablet/kapsul/kaplet 150 mg DAK 2018 tablet 1,020 410.00 418,200.00 - 810 410.00 332,100.00 - - - 210 410.00 86,100.00
90 Isoniazid (INH) Tablet 100 mg Buffer 2018 tablet 9,800 78.00 764,400.00 - 9,800 78.00 764,400.00 - - - 0 - -
91 Isosorbid Dinitrat (ISDN) tablet sublingual 5mg DAK 2018 tablet 3,600 89.00 320,400.00 - 1,200 89.00 106,800.00 1,200 89.00 106,800.00 2,400 89.00 213,600.00
92 Kalium Diklofenak tablet 25 mg tablet - - 0 - - - - - - -

93 Kalium Diklofenak tablet 50 mg tablet - - 0 - - - - - - -
94 Kalsium Laktat 500 mg tablet DAK 2017 tablet 197,000 57.00 11,229,000.00 - 197,000 57.00 11,229,000.00 - - - 0 - -
DAK 2019 63.00 100,000 63.000 6,300,000.00 0 63.00 - 99,000 63.00 6,237,000.00
95 Kaolin + Pektin suspensi botol - - 0 - - - - - - -
96 Kaptopril tablet 12,5 mg DAU 2016 tablet 133,300 62.89 8,383,617.86 - 33,300 62.89 2,094,332.14 - - - 100,000 62.89 6,289,285.71
DAK 2018 tablet 20,000 64.00 1,280,000.00 - 0 64.00 - - - - 20,000 64.00 1,280,000.00
DAK 2019 tablet 30,000 68.000 2,040,000.00 0 30,000 68.00 2,040,000.00
97 Kaptopril tablet 25 mg DAK 2016 tablet 81,300 71.00 5,772,300.00 - 17,800 71.00 1,263,800.00 - - - 63,500 71.00 4,508,500.00
DAK 2018 tablet 19,300 77.00 1,486,100.00 - 11,700 77.00 900,900.00 - - - 7,600 77.00 585,200.00
98 Kaptopril tablet 50 mg tablet - - 0 - - - - - - -
99 Karbazokrom natrium sulfat injeksi 5mg/ml ampul - - 0 - - - - - - -
100 Karbimazol tablet 5 mg DAK 2018 tablet 9,800 1,120.00 10,976,000.00 - 700 1,120.00 784,000.00 - - - 9,100 1,120.00 10,192,000.00
DAK 2019 tablet 18,000 1,195.000 21,510,000.00 0 18,000 1,195.00 21,510,000.00
101 Ketokonazol krim 2 % Buffer 2018 tube 82 2,596.00 212,872.00 - 82 2,596.00 212,872.00 - - - 0 - -
DAK 2019 tube 1,000 2,518.000 2,518,000.00 0 1,000 2,518.00 2,518,000.00
102 Ketokonazol tablet 200 mg DAK 2018 tablet 4,300 278.00 1,195,400.00 - 2,000 278.00 556,000.00 - - - 2,300 278.00 639,400.00
DAK 2019 tablet 10,000 297.000 2,970,000.00 0 10,000 297.00 2,970,000.00
103 Ketoprofen suppositoria 100 mg DAK 2019 suppo - 130 2,380.000 309,400.00 0 - - 130 2,380.00 309,400.00 - -
104 Ketorolac injeksi 30 mg DAK 2018 ampul 968 1,045.00 1,011,560.00 - 145 1,045.00 151,525.00 - - - 823 1,045.00 860,035.00
DAK 2019 ampul 3,000 1,089.000 3,267,000.00 0 3,000 1,089.00 3,267,000.00
105 Klindamisin kapsul 150 mg DAK 2018 kapsul 4,100 729.00 2,988,900.00 - 3,050 729.00 2,223,450.00 - - - 1,050 729.00 765,450.00
106 Klindamisin kapsul 300 mg DAK 2017 kapsul 200 589.00 117,800.00 - 200 589.00 117,800.00 - - - 0 - -
107 Kloramfenikol kapsul 250mg kapsul - - 0 - - - - - - -
108 Kloramfenikol salep kulit 2% DAK 2017 tube 368 3,107.00 1,143,376.00 - 128 3,107.00 397,696.00 - - - 240 3,107.00 745,680.00
(BUFACETINE) Buffer 2018 tube 91 3,107.00 282,737.00 - 91 3,107.00 282,737.00 - - - 0 3,107.00 -
DAK 2018 tube 960 3,138.00 3,012,480.00 - 0 3,138.00 - - - - 960 3,138.00 3,012,480.00
DAK 2019 tube 1,920 3,349.000 6,430,080.00 0 1,920 3,349.00 6,430,080.00
109 Kloramfenikol salep mata 1% tube - - 0 - - - - - - -
110 Kloramfenikol suspensi 125 mg/5 ml botol - - 0 - - - - - - -
111 Kloramfenikol tetes telinga 3 % botol - - 0 - - - - - - -
112 Klorfeniramina Maleat (CTM) tablet 4 mg DAK 2017 tablet 193,800 37.00 7,170,600.00 - 22,200 37.00 821,400.00 - - - 171,600 37.00 6,349,200.00
DAK 2019 tablet 100,000 25.000 2,500,000.00 0 100,000 25.00 2,500,000.00
Buffer 2018 tablet 183,200 37.00 6,778,400.00 - 400 37.00 14,800.00 - - - 182,800 37.00 6,763,600.00
113 Klorpromazin (CPZ) tablet salut (HCl) tablet - - 0 - - - - - - -
22
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
114 Kodein tablet 10 mg DAK 2018 tablet 5,000 600.00 3,000,000.00 - 0 600.00 - - - - 5,000 600.00 3,000,000.00
Kombinasi tablet salut : Besi (II) sulfat 7H2O 200
tablet - - 0 - - - - - - -
mg Asam folat 0,25 mg
Kombinasi Salep 2-4 : asam salisilat 2% +
115 DAK 2019 pot 5,000 2,938.000 14,690,000.00 0 5,000 2,938.00 14,690,000.00
belerang endap 4%
116 Kotrimoksazol DOEN I tablet 480mg DAK 2019 tablet - 100,000 133.000 13,300,000.00 0 - - 100,000 133.00 13,300,000.00 - -
117 Kotrimoksazole DOEN suspensi Buffer 2018 botol 140 2,364.00 330,960.00 - 140 2,364.00 330,960.00 - - - 0 - -
DAK 2019 botol 2,190.00 - 500 2,190.000 1,095,000.00 0 2,190.00 - 500 2,190.00 1,095,000.00 2,190.00 -
118 Lansoprazol kapsul 30 mg DAK 2019 kapsul - - 0 - - - - - - -
119 Levofloksasin tts mata 0.5% (OPTIFLOX) DAK 2019 botol 96 19,000.000 1,824,000.00 0 96 19,000.00 1,824,000.00
120 Lidokain injeksi 2% DAK 2018 ampul 880 1,203.00 1,058,640.00 - 275 1,203.00 330,825.00 - - - 605 1,203.00 727,815.00
DAK 2019 ampul 5,000 1,284.000 6,420,000.00 0 5,000 1,284.00 6,420,000.00
Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 -
121 DAK 2019 ampul 1,291.00 - 600 1,291.000 774,600.00 0 1,291.00 - 600 1,291.00 774,600.00 1,291.00 -
2ml
122 Loperamide tablet 2 mg tablet - - 0 - - - - - - -
123 Loratadin 10 mg DAK 2019 tablet 10,000 133.000 1,330,000.00 0 10,000 133.00 1,330,000.00
124 Magnesium sulfat injeksi 20% Buffer 2018 vial 739 3,200.00 2,364,800.00 - 739 3,200.00 2,364,800.00 - - - 0 - -
125 Magnesium sulfat injeksi 40% DAK 2014 vial 675 14,500.00 9,787,500.00 - 675 14,500.00 9,787,500.00 - - - 0 - -
Buffer 2018 vial 859 3,650.00 3,135,350.00 - 859 3,650.00 3,135,350.00 - - - 0 - -
126 Metformin HCl tablet 500 mg DAK 2019 tablet - 10,000 106.000 1,060,000.00 0 - - 10,000 106.00 1,060,000.00 - -
127 Metformin HCl tablet 850 mg DAK 2018 tablet 8,900 163.00 1,450,700.00 - 3,900 163.00 635,700.00 - - - 5,000 163.00 815,000.00
128 Metilergometrin maleat injeksi 0.2 mg/ml DAK 2018 ampul 500 3,102.00 1,551,000.00 - 0 3,102.00 - - - - 500 3,102.00 1,551,000.00
DAK 2019 ampul 500 3,102.000 1,551,000.00 0 500 3,102.00 1,551,000.00
129 Metilergometrin maleat tablet salut 0,125 mg tablet - - 0 - - - - - - -
130 Metilprednisolon tablet 4 mg DAK 2019 tablet 60,000 146.000 8,760,000.00 0 60,000 146.00 8,760,000.00
131 Metoklopramid drop 2 mg/mL DAK 2018 botol 185 3,990.00 738,150.00 - 40 3,990.00 159,600.00 - - - 145 3,990.00 578,550.00
(GAVISTAL) DAK 2019 botol 300 3,990.000 1,197,000.00 0 300 3,990.00 1,197,000.00
132 Metoklopramide injeksi 5mg/ml DAK 2017 ampul 20 6,303.00 126,060.00 - 20 6,303.00 126,060.00 - - - 0 - -
DAK 2019 0 - - -
133 Metronidazol infus 5 mg/ml DAK 2018 vial 840 8,250.00 6,930,000.00 - 68 8,250.00 561,000.00 - - - 772 8,250.00 6,369,000.00
134 Metronidazol Suspensi 125 mg/ 5 ml DAK 2018 botol 440 3,950.00 1,738,000.00 - 168 3,950.00 663,600.00 - - - 272 3,950.00 1,074,400.00
DAK 2019 botol 2,000 3,950.000 7,900,000.00 0 2,000 3,950.00 7,900,000.00
135 Metronidazol tablet 500mg DAK 2019 tablet - - 0 - - - - - - -
136 Mikonazole Krim 2 % DAK 2018 tube 978 3,585.00 3,506,130.00 - 64 3,585.00 229,440.00 - - - 914 3,585.00 3,276,690.00
DAK 2019 tube 2,400 3,585.000 8,604,000.00 0 2,400 3,585.00 8,604,000.00
137 Mineral Mix sachet - - 0 - - - - - - -
138 Multivitamin + DHA tablet (PRE NATAL) DAK2018non tablet 1,500 3,850.00 5,775,000.00 - 1,500 3,850.00 5,775,000.00 - - - 0 - -
139 Multivitamin + Zinc tablet (CETOP ZINC) DAK2018non tablet 4,000 3,300.00 13,200,000.00 - -900 3,300.00 - 2,970,000.00 - - - 4,900 3,300.00 16,170,000.00
140 N-asetil sistein kapsul 200 mg DAK 2018 kapsul 30,000 357.00 10,710,000.00 - 3,000 357.00 1,071,000.00 - - - 27,000 357.00 9,639,000.00
DAK 2019 kapsul 275,000 381.000 104,775,000.00 0 275,000 381.00 104,775,000.00
141 Natrium Bikarbonat tab 500 mg DAK 2017 tablet 123,300 63.80 7,866,540.00 - 10,500 63.80 669,900.00 - - - 112,800 63.80 7,196,640.00
142 Natrium diklofenak tab 25 mg tablet - - 0 - - - - - - -
143 Natrium diklofenak tab 50 mg DAK 2018 tablet 44,050 127.00 5,594,350.00 - 13,850 127.00 1,758,950.00 - - - 30,200 127.00 3,835,400.00
DAK 2019 tablet 300,000 136.000 40,800,000.00 0 300,000 136.00 40,800,000.00
144 Natrium Klorida larutan infus 0,9 % DAU 2016 botol 1,243 6,235.93 7,751,258.68 - 750 6,235.93 4,676,946.11 - - - 493 6,235.93 3,074,312.57
(NaCl) Buffer 2018 botol 200 6,410.00 1,282,000.00 - 0 6,410.00 - - - - 200 6,410.00 1,282,000.00
DAK 2019 botol 10,000 6,840.000 68,400,000.00 0 10,000 6,840.00 68,400,000.00
145 Nifedipine tablet 10mg tablet - - 0 - - - - - - -
146 Nistatin 100.000 IU/ml drop botol - - 0 - - - - - - -
147 Obat Anti Tuberculosis FDC Kategori Anak DAK 2019 paket 10 260,526.000 2,605,260.00 0 10 260,526.00 2,605,260.00
148 Obat Anti Tuberculosis FDC Kategori II DAK 2019 paket 30 1,454,232.000 43,626,960.00 0 30 1,454,232.00 43,626,960.00
149 Obat Batuk Hitam (OBH) cairan paket - - 0 - - - - - - -
150 Oksimetazolin tetes hidung 0,025% (ILLIADIN) DAK 2019 botol 150 34,177.000 5,126,550.00 0 150 34,177.00 5,126,550.00
151 Oksitetrasiklin HCl salep mata 1 % DAK 2019 tube - 5,000 2,774.000 13,870,000.00 0 - - 5,000 2,774.00 13,870,000.00 - -
152 Oksitosin injeksi 10 IU/ml DAK 2019 ampul - 3,000 1,199.000 3,597,000.00 0 - - 3,000 1,199.00 3,597,000.00 - -
23
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
153 Omeprazol injeksi 40 mg / 10 ml DAK 2018 vial 225 9,999.00 2,249,775.00 - 40 9,999.00 399,960.00 - - - 185 9,999.00 1,849,815.00
DAK 2019 600 10,670.000 6,402,000.00 0 600 10,670.00 6,402,000.00
154 Omeprazol kapsul 20 mg DAK 2018 kapsul 22,800 134.00 3,055,200.00 - 11,330 134.00 1,518,220.00 - - - 11,470 134.00 1,536,980.00
DAK 2019 189,000 143.000 27,027,000.00 0 189,000 143.00 27,027,000.00
155 Ondansetron injeksi 4 mg / 2 ml DAK 2019 ampul - 500 1,153.000 576,500.00 0 - - 500 1,153.00 576,500.00 - -
156 Ondansetron tablet 4 mg tablet - - 0 - - - - - - -
Parasetamol + Fenilpropalamin + CTM sirup
157 DAK2018non botol 340 10,300.00 3,502,000.00 - 310 10,300.00 3,193,000.00 - - - 30 10,300.00 309,000.00
(MOLEXFLU)
158 Parasetamol + Guafenisin + CTM sirup botol - - 0 - - - - - - -
159 Parasetamol drops DAK 2018 botol 28 6,981.00 195,468.00 - 28 6,981.00 195,468.00 - - - 0 - -
DAK 2019 botol 1,000 6,981.000 6,981,000.00 0 1,000 6,981.00 6,981,000.00
160 Parasetamol infus 10 mg/Ml DAK 2019 botol 1,800 12,389.000 22,300,200.00 0 1,800 12,389.00 22,300,200.00
161 Parasetamol sirup 120 mg/5 ml DAU 2016 botol 6,583 1,171.77 7,713,753.04 - 251 1,171.77 294,113.93 - - - 6,332 1,171.77 7,419,639.10
Buffer 2018 botol 1,230 1,119.00 1,376,370.00 - 1,230 1,119.00 1,376,370.00 - - - 0 - -
DAK 2019 botol 6,000 1,148.000 6,888,000.00 0 6,000 1,148.00 6,888,000.00
162 Parasetamol tablet 500 mg Buffer 2018 tablet 25,100 51.00 1,280,100.00 - 16,700 51.00 851,700.00 - - - 8,400 51.00 428,400.00
163 Perak Sulfadiazin krim 1 % tube - - 0 - - - - - - -
164 Piracetam inj 1g/5 ml DAK 2017 ampul 170 7,408.50 1,259,445.00 - 10 7,408.50 74,085.00 - - - 160 7,408.50 1,185,360.00
165 Piracetam inj 3g/5 ml ampul - - 0 - - - - - - -
166 Piracetam tab 400 mg tablet - - 0 - - - - - - -
167 Piracetam tab 800 mg tablet - - 0 - - - - - - -
168 Pirantel suspensi 125 mg/ 5 ml DAK 2018 botol 355 10,100.00 3,585,500.00 - 220 10,100.00 2,222,000.00 - - - 135 10,100.00 1,363,500.00
DAK 2019 botol 500 10,778.000 0 500 10,778.00 5,389,000.00
169 Pirantel tablet score (base) 250 mg (PANTRIN) DAK 2019 tablet - 5,000 1,008.000 5,040,000.00 0 - - 5,000 1,008.00 5,040,000.00 - -
170 Piridoksin (Vit B6) injeksi 100mg/ml ampul - - 0 - - - - - - -

171 Piridoksin (Vit B6) tablet 10mg Buffer 2018 tablet 5,700 124.00 706,800.00 - 5,700 124.00 706,800.00 - - - 0 - -
DAK 2018 tablet 10,000 129.00 1,290,000.00 - 5,000 129.00 645,000.00 - - - 5,000 129.00 645,000.00
DAK 2019 tablet 20,000 138.000 2,760,000.00 0 20,000 138.00 2,760,000.00
172 Prednison tablet 5 mg Buffer 2018 tablet 116,500 82.00 9,553,000.00 - 116,500 82.00 9,553,000.00 - - - 0 - -
173 Probenesid tablet 500 mg (PROBENID) DAK 2018 tablet 1,900 1,913.00 3,634,700.00 - 1,900 1,913.00 3,634,700.00 - - - 0 - -
174 Propranolol tablet 10 mg DAK 2018 tablet 21,200 56.00 1,187,200.00 - 4,900 56.00 274,400.00 - - - 16,300 56.00 912,800.00
DAK 2019 tablet 70,000 60.000 0 70,000 60.00 4,200,000.00
175 Propanolol tablet 40 mg tablet - - 0 - - - - - - -
176 Propilitiuorasil tablet 100 mg tablet - - 0 - - - - - - -
177 Ranitidin injeksi 25mg/2ml DAK 2018 ampul 938 1,155.00 1,083,390.00 10,000 1,188.000 11,880,000.00 160 1,155.00 184,800.00 10,000 1,188.00 11,880,000.00 778 1,155.00 898,590.00
178 Ranitidin tablet 150 mg Buffer 2018 tablet 5,000 100.00 500,000.00 - 5,000 100.00 500,000.00 - - - 0 - -
DAK2018non tablet 20,000 320.00 6,400,000.00 - 13,200 320.00 4,224,000.00 - - - 6,800 320.00 2,176,000.00
179 Reserpin tablet 0,25 mg tablet - - 0 - - - - - - -
180 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul - - 0 - - - - - - -
181 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul - - 0 - - - - - - -
182 Ringer Laktat larutan infus DAK 2018 botol 807 7,150.00 5,770,050.00 - 570 7,150.00 4,075,500.00 - - - 237 7,150.00 1,694,550.00
DAK 2019 botol 20,000 7,630.000 152,600,000.00 0 20,000 7,630.00 152,600,000.00
183 Salbutamol Inhaler 100 mcg/dose (SALBULIN) DAK 2020 botol 200 32,120.000 6,424,000.00 0 200 32,120.00 6,424,000.00
184 Salbutamol sir 2 mg/5 mL DAK 2019 botol 2,000 4,446.000 8,892,000.00 0 2,000 4,446.00 8,892,000.00
185 Salbutamol tablet 2 mg DAK 2018 tablet 3,800 63.00 239,400.00 - 2,900 63.00 182,700.00 - - - 900 63.00 56,700.00
DAK 2019 tablet 50,000 67.000 3,350,000.00 0 50,000 67.00 3,350,000.00
186 Salbutamol tablet 4 mg DAK 2018 tablet 4,700 74.00 347,800.00 - 2,200 74.00 162,800.00 - - - 2,500 74.00 185,000.00
187 Salisil bedak 2% bungkus - - 0 - - - - - - -
188 Sefadroksil kapsul 250 mg DAK 2019 kapsul - 10,000 711.000 7,110,000.00 0 - - 10,000 711.00 7,110,000.00 - -
189 Sefadroksil sirup kering 125 mg/5 ml botol - - 0 - - - - - - -
190 Sefotaksim injeksi 1 gram vial - - 0 - - - - - - -
191 Seftriakson injeksi 1 gram DAK 2018 vial 115 4,684.00 538,660.00 - 0 4,684.00 - - - - 115 4,684.00 538,660.00
DAK 2019 vial 3,000 4,998.000 14,994,000.00 0 3,000 4,998.00 14,994,000.00
Serum anti bisa ular A.B.U. I inj (i.m./i.v)
192 DAK 2019 vial 20 512,204.000 10,244,080.00 0 20 512,204.00 10,244,080.00
(BIOSAVE)
Serum antitetanus (A.T.S) inj 1500 IU/mL (i.m)

193 DAK 2019 vial 200 130,999.000 26,199,800.00 0 200 130,999.00 26,199,800.00
(BIOSAT 1,5)
194 Setirizin sirup 5 mg/ 5 ml DAK 2018 botol 440 2,907.00 1,279,080.00 - 310 2,907.00 901,170.00 - - - 130 2,907.00 377,910.00
24
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
DAK 2019 5,000 2,973.000 0 5,000 2,973.00 14,865,000.00

195 Setirizin tablet 10 mg tablet - - 0 - - - - - - -
196 Sianokobalamin (Vit B12) injeksi 500 mcg DAK 2018 ampul 1,000 1,065.00 1,065,000.00 - 700 1,065.00 745,500.00 - - - 300 1,065.00 319,500.00
DAK 2019 ampul 20,000 1,136.000 22,720,000.00 0 20,000 1,136.00 22,720,000.00

197 Sianokobalamin (Vit B12) tablet 50 mcg DAK 2018 tablet 96,300 47.00 4,526,100.00 - 20,900 47.00 982,300.00 - - - 75,400 47.00 3,543,800.00
DAK 2019 tablet 100,000 50.000 5,000,000.00 0 100,000 50.00 5,000,000.00
198 Simvastatin tablet 10 mg DAK 2018 tablet 25,200 110.00 2,772,000.00 - 7,680 110.00 844,800.00 - - - 17,520 110.00 1,927,200.00
DAK 2019 tablet 18,000 117.000 2,106,000.00 0 18,000 117.00 2,106,000.00
199 Spironolakton tablet 25 mg DAK 2019 tablet 10,000 208.000 2,080,000.00 0 10,000 208.00 2,080,000.00
200 Siprofloksasin tablet 500 mg Buffer 2018 tablet 10,400 247.00 2,568,800.00 - 7,100 247.00 1,753,700.00 - - - 3,300 247.00 815,100.00
201 Streptomisin sulfat serbuk inj 1000 mg DAK 2019 vial 1,120 5,460.000 6,115,200.00 0 1,120 5,460.00 6,115,200.00
202 Sukralfat sirup 500 mg/5ml DAK 2018 botol 270 6,989.00 1,887,030.00 - 251 6,989.00 1,754,239.00 - - - 19 6,989.00 132,791.00
DAK 2019 botol 800 6,989.000 5,591,200.00 0 800 6,989.00 5,591,200.00
203 Tetrasiklin kapsul 500mg DAK 2019 kapsul - 10,000 323.000 3,230,000.00 0 - - 10,000 323.00 3,230,000.00 - -
204 Tiamin (Vitamin B1) injeksi 100 mg/ml ampul - - 0 - - - - - - -
205 Tiamin (Vitamin B1) tablet 50 mg DAK 2015 tablet 44,000 75.97 3,342,834.44 - 32,200 75.97 2,446,347.02 - - - 11,800 75.97 896,487.42
Buffer 2018 tablet 12,800 89.00 1,139,200.00 - 12,800 89.00 1,139,200.00 - - - 0 - -
DAK 2019 tablet 20,000 92.000 1,840,000.00 0 20,000 92.00 1,840,000.00
206 Tramadol inj 50 mg/ml DAK 2017 ampul 870 1,720.00 1,496,400.00 - 15 1,720.00 25,800.00 - - - 855 1,720.00 1,470,600.00
207 Tramadol kapsul 50mg kapsul - - 0 - - - - - - -
208 Triheksifenidil tablet 2 mg tablet - - 0 - - - - - - -
209 DAK2018non botol 160 11,750.00 1,880,000.00 - 41 11,750.00 481,750.00 - - - 119 11,750.00 1,398,250.00
(PROTIFED)
210 Vitamin B Kompleks injeksi DAK2018non ampul 2,470 7,150.00 17,660,500.00 - 445 7,150.00 3,181,750.00 - - - 2,025 7,150.00 14,478,750.00
DAK2019non ampul 0 - - - -
211 Vitamin B Kompleks tablet Buffer 2018 tablet 7,600 121.00 919,600.00 - 7,600 121.00 919,600.00 - - - 0 - -
DAK 2018 tablet 100,000 123.00 12,300,000.00 - 8,800 123.00 1,082,400.00 - - - 91,200 123.00 11,217,600.00
DAK 2019 tablet 800,000 123.000 98,400,000.00 0 - 800,000 123.00 98,400,000.00
212 Zinc sirup 20 mg/5ml DAK 2018 botol 270 3,122.00 842,940.00 - 99 3,122.00 309,078.00 - - - 171 3,122.00 533,862.00
DAK 2019 botol 5,000 3,322.000 16,610,000.00 0 - 5,000 3,322.00 16,610,000.00 -
213 Zinc tablet 20 mg DAK 2018 tablet 4,000 551.00 2,204,000.00 - 1,600 551.00 881,600.00 - - - 2,400 551.00 1,322,400.00
DAK 2019 tablet 551.00 20,000 551.000 11,020,000.00 0 551.00 - 20,000 551.00 11,020,000.00 0 551.00 -
1 Ambroxol sirup 15 mg/ml DAK2019non botol - 2,750 4,860.000 13,365,000.00 0 - - 2,750 4,860.00 13,365,000.00 0 - -
2 Deksametason tablet 0,5 mg DAK2019non tablet - 25,000 250.000 6,250,000.00 0 - - 25,000 250.00 6,250,000.00 0 - -
Ekstrak Kurkuma + Multivitamin sirup (CURBION
3 DAK2019non botol - 2,000 6,500.000 13,000,000.00 0 - - 2,000 6,500.00 13,000,000.00 0 - -
KIDS)
4 Ekstrak Kurkuma tablet (CURCUMA) DAK2019non tablet - 5,000 1,500.000 7,500,000.00 0 - - 1,000 1,500.00 1,500,000.00 0 - -
5 Metronidazol tablet 500 mg DAK2019non tablet - 30,000 550.000 16,500,000.00 0 - - 30,000 550.00 16,500,000.00 0 - -
6 Minyak Ikan DAK2019non kapsul - 50,000 278.000 13,900,000.00 0 - - 50,000 278.00 13,900,000.00 0 - -
7 Multivitamin + DHA tablet (PRE NATAL) DAK2019non tablet - 8,500 3,900.000 33,150,000.00 0 - - 8,500 3,900.00 33,150,000.00 0 - -
8 Multivitamin + Zinc tablet (CETOP ZINC) DAK2019non tablet - 10,000 3,100.000 31,000,000.00 0 - - 10,000 3,100.00 31,000,000.00 0 - -
9 Paracetamol tablet 500 mg DAK2019non tablet - 100,000 300.000 30,000,000.00 0 - - 100,000 300.00 30,000,000.00 0 - -
10 DAK2019non botol 200 10,500.000 2,100,000.00 0 - - 200 10,500.00 2,100,000.00 0 - -
(PROTIFED)
11 Vitamin Bcom injeksi DAK2019non ampul - 2,200 6,650.000 14,630,000.00 0 - - 2,200 6,650.00 14,630,000.00 0 - -
TOTAL PENERIMAAN OBAT DAK TOTAL PENGELUARAN TOTAL PENGELUARAN OBAT TOTAL SISA STOK OBAT TOTAL SISA STOK OBAT
TOTAL SALDO AWAL OBAT 499,894,139.53 1,176,478,870.00 - 204,791,545.70 - 295,102,593.82
2019 OBAT DAK 2019 SISA 2018 DAK 2019 SISA 2018
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
2) BMHP
1 Alat suntik sekali pakai 0,05 ml pcs - - 0 - - - - - -

2 Alat suntik sekali pakai 0,5 ml DAU 2016 pcs 10,170 1,759.00 17,889,030.00 - 1,055 1,759.00 1,855,745.00 - - - 9,115 1,759.00 16,033,285.00
3 Alat suntik sekali pakai 1 ml DAK 2019 pcs - 1,000 1,074.039 1,074,039.00 0 - - 1,000 1,074.04 1,074,039.00 - -
4 Alat suntik sekali pakai 10 ml DAK 2017 pcs 755 1,627.50 1,228,762.50 - 265 1,627.50 431,287.50 - - - 490 1,627.50 797,475.00
5 Alat suntik sekali pakai 2,5 ml DAK 2015 pcs 5,810 825.50 4,796,155.00 - 3,560 825.50 2,938,780.00 - - - 2,250 825.50 1,857,375.00
6 Alat suntik sekali pakai 3 ml DAK 2019 pcs - 20,000 1,083.0916 21,661,832.00 0 20,000 1,083.09 21,661,832.00 - -
7 Alat suntik sekali pakai 5 ml DAK 2018 pcs 7,870 862.50 6,787,875.00 - 360 862.50 310,500.00 - - - 7,510 862.50 6,477,375.00
DAK 2019 pcs 10,000 1,207.7484 12,077,484.00 0 10,000 1,207.75 12,077,484.00
8 Alat suntik sekali pakai 50 ml DAK 2019 pcs 300 4,507.370 1,352,211.00 0 300 4,507.37 1,352,211.00
9 Alkohol 70% 100 cc DAK 2018 botol 169 6,500.00 1,098,500.00 - 27 6,500.00 175,500.00 - - - 142 6,500.00 923,000.00
10 Alkohol 70% 300 cc DAK 2018 botol 967 11,600.00 11,217,200.00 - 107 11,600.00 1,241,200.00 - - - 860 11,600.00 9,976,000.00
11 Alkohol 70% 1000 cc DAK 2018 botol 220 25,300.00 5,566,000.00 - 61 25,300.00 1,543,300.00 - - - 159 25,300.00 4,022,700.00
DAK 2019 botol 300 30,000.000 9,000,000.00 0 300 30,000.00 9,000,000.00
12 Apron Plastik Disposible DAK 2019 pcs - 3,000 2,904.440 8,713,320.00 0 - - 3,000 2,904.44 8,713,320.00 - -
13 Aseptic Gel 500 cc + dispenser DAK 2019 botol 600 26,400.000 15,840,000.00 0 600 26,400.00 15,840,000.00
14 Blood Lancet DAK 2019 pcs - 10,000 123.464 1,234,640.00 0 - - 10,000 123.46 1,234,640.00 - -
15 Bracket Hand Wash Plastik DAK 2019 pcs 230 20,240.000 4,655,200.00 0 230 20,240.00 4,655,200.00
16 Catgut Chromic 2/0 + jarum 1/2 GT DAU 2016 pcs 359 6,420.83 2,305,079.17 - 0 6,420.83 - - - - 359 6,420.83 2,305,079.17
17 Catgut Chromic 3/0 + jarum 1/2 GT DAU 2016 pcs 444 6,420.83 2,850,850.00 - 72 6,420.83 462,300.00 - - - 372 6,420.83 2,388,550.00
18 Catgut Plain 2/0 + jarum 1/2 GT DAK 2018 pcs 264 6,420.83 1,695,100.00 - 130 6,420.83 834,708.33 - - - 134 6,420.83 860,391.67
DAK 2019 pcs 480 6,420.83333333 3,082,000.00 0 480 6,420.83 3,082,000.00
19 Catgut Plain 3/0 + jarum 1/2GT DAK 2018 pcs 240 6,420.83 1,541,000.00 - 150 6,420.83 963,125.00 - - - 90 6,420.83 577,875.00
DAK 2019 pcs 480 6,420.833 3,082,000.00 0 480 6,420.83 3,082,000.00
Catgut PETERS SURGICALS PETER SILK 4/0, ½

20 DAK 2019 pcs 180 32,500.000 5,850,000.00 0 180 32,500.00 5,850,000.00
TP 16 mm, 75cm-2PTR5192E

21 DAK 2019 pcs 180 34,000.000 6,120,000.00 0 180 34,000.00 6,120,000.00
3/8 RC 20 mm, 75cm-2PTR5217E
Catgut PETERS SURGICALS FILAPEAU 5/0, 3/8

22 DAK 2019 pcs 180 40,000.000 7,200,000.00 0 180 40,000.00 7,200,000.00
RC 12 mm, 90cm-2PTR7004E
23 Connecting Tube DAK 2017 Pcs 200 24,750.00 4,950,000.00 - 0 24,750.00 - - - - 200 24,750.00 4,950,000.00
24 Desinfektan 1 Liter DAK 2017 Botol 6 2,972,970.00 17,837,820.00 - 6 2,972,970.00 17,837,820.00 - - - 0 - -
25 ECG Paper (210mm) DAK 2017 roll 5 194,400.00 972,000.00 - 5 194,400.00 972,000.00 - - - 0 - -
26 EKG Elektroda DAK 2012 pcs 2,100 2,838.00 5,959,800.00 - 0 2,838.00 - - - - 2,100 2,838.00 5,959,800.00
27 Foley Catheter 2 Way No.16 DAK 2017 pcs 145 13,750.00 1,993,750.00 - 35 13,750.00 481,250.00 - - - 110 13,750.00 1,512,500.00
28 Foley Catheter 2 Way No.18 DAK 2017 Pcs 111 13,750.00 1,526,250.00 - 35 13,750.00 481,250.00 - - - 76 13,750.00 1,045,000.00
29 Hidrogen Peroksida cairan 50% DAK 2018 botol 18 77,000.00 1,386,000.00 - 12 77,000.00 924,000.00 - - - 6 77,000.00 462,000.00
30 ID band bayi DAK 2012 pcs 8,200 1,720.00 14,104,000.00 - 400 1,720.00 688,000.00 - - - 7,800 1,720.00 13,416,000.00
31 ID band ibu (dewasa ) DAK 2012 pcs 8,600 1,720.00 14,792,000.00 - 400 1,720.00 688,000.00 - - - 8,200 1,720.00 14,104,000.00
32 Infusion set anak DAK 2015 pcs 1,557 4,445.00 6,920,865.00 - 160 4,445.00 711,200.00 - - - 1,397 4,445.00 6,209,665.00
Buffer 2018 pcs 200 7,920.00 1,584,000.00 - 0 7,920.00 - - - - 200 7,920.00 1,584,000.00
DAK 2019 pcs 1,500 6,606.300 9,909,450.00 0 1,500 6,606.30 9,909,450.00
33 Infusion set dewasa DAK 2015 pcs 1,963 4,064.00 7,977,632.00 - 595 4,064.00 2,418,080.00 - - - 1,368 4,064.00 5,559,552.00
DAK 2019 pcs 2,200 6,217.120 13,677,664.00 0 2,200 6,217.12 13,677,664.00
34 IV Catheter No. 18G DAK 2018 pcs 500 16,087.50 8,043,750.00 - 100 16,087.50 1,608,750.00 - - - 400 16,087.50 6,435,000.00
26
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
DAK 2019 500 7,657.940 3,828,970.00 0 500 7,657.94 3,828,970.00

35 IV Catheter No. 20G Buffer 2018 pcs 281 8,700.00 2,444,700.00 - 281 8,700.00 2,444,700.00 - - - 0 - -
DAK 2018 pcs 500 16,087.50 8,043,750.00 - 110 16,087.50 1,769,625.00 - - - 390 16,087.50 6,274,125.00
DAK 2019 1,000 7,657.940 7,657,940.00 0 1,000 7,657.94 7,657,940.00
DAK 2018 pcs 1,000 16,087.50 16,087,500.00 - 305 16,087.50 4,906,687.50 - - - 695 16,087.50 11,180,812.50
DAK 2019 1,500 7,611.580 11,417,370.00 0 1,500 7,611.58 11,417,370.00
DAK 2018 pcs 2,000 16,087.50 32,175,000.00 - 320 16,087.50 5,148,000.00 - - - 1,680 16,087.50 27,027,000.00
DAK 2019 1,500 7,611.580 11,417,370.00 0 1,500 7,611.58 11,417,370.00
38 IV Catheter No. 26G DAK 2018 pcs 500 14,823.60 7,411,800.00 - 200 14,823.60 2,964,720.00 - - - 300 14,823.60 4,447,080.00
DAK 2019 500 9,827.100 4,913,550.00 0 500 9,827.10 4,913,550.00
39 Jarum Hecting Cutting 1/2 Circle no. 10 DAK 2012 pcs 36 3,062.00 110,232.00 - 36 3,062.00 110,232.00 - - - 0 - -
40 Jarum Hecting Cutting 1/2 Circle no. 14 DAK 2012 pcs 72 3,062.00 220,464.00 - 72 3,062.00 220,464.00 - - - 0 - -
41 Jarum Hecting Rounded 1/2 Circle no.10 pcs - 0 - - - -
42 Jarum Hecting Rounded 1/2 Circle no.14 DAK 2012 pcs 48 3,062.00 146,976.00 - 48 3,062.00 146,976.00 - - - 0 - -
43 Jelli Onemed USG Gel 250 ml DAK 2019 tube 240 15,100.800 3,624,192.00 0 240 15,100.80 3,624,192.00
44 Kapas Alkohol DAK 2017 pcs 37,600 137.50 5,170,000.00 - 1,520 137.50 209,000.00 - - - 36,080 137.50 4,961,000.00
DAK 2019 pcs 20,000 141.5688 2,831,376.00 0 20,000 141.57 2,831,376.00
45 Kapas Pembalut / absorben 250 gram DAU 2016 bgks 57 10,109.03 576,214.71 - 37 10,109.03 374,034.11 - - - 20 10,109.03 202,180.60
Buffer 2018 bgks 100 24,000.00 2,400,000.00 - 0 24,000.00 - - - - 100 24,000.00 2,400,000.00
46 Kasa Hidrofil 40 x 80 Buffer 2018 rol 5 110,250.00 551,250.00 - 5 110,250.00 551,250.00 - - - 0 - -
47 Kasa Hidrofil 4yard x 15cm (3.6mx15cm) DAK 2012 rol 50 2,838.00 141,900.00 - 50 2,838.00 141,900.00 - - - 0 - -
48 Kasa Hidrofil 4yard x 10cm (3.6mx10cm) DAK 2012 rol 10 2,020.00 20,200.00 - 10 2,020.00 20,200.00 - - - 0 - -
49 Kasa Hidrofil 3yard x 10cm (3.6mx10cm) DAK 2019 rol 5,000 1,669.800 8,349,000.00 0 5,000 1,669.80 8,349,000.00
50 Kasa Hidrofil 3yard x 5 cm (3.6mx5cm) DAK 2019 rol 5,000 1,707.600 8,538,000.00 0 5,000 1,707.60 8,538,000.00 -
51 Kasa hydrophil steril uk. 18 cm x 22 cm DAK 2018 kotak 916 718.75 658,375.00 - -9,440 718.75 - 6,785,000.00 - - - 10,356 718.75 7,443,375.00
52 Kasa Steril 7.5 x 7.5 cm, 8 ply 1 x 5’s DAK 2019 pack 1,000 3,615.140 3,615,140.00 0 1,000 3,615.14 3,615,140.00
53 Lubricating Jelly sachet 5 gram sachet - - 0 - - - - - - -
54 Lysol Concentrat DAU 2016 botol 2 49,200.00 98,400.00 - 2 49,200.00 98,400.00 - - - 0 - -
DAK 2019 botol 200 49,200.000 9,840,000.00 0 200 49,200.00 9,840,000.00
55 Masker DAK 2018 pcs 40,300 379.50 15,293,850.00 - 1,850 379.50 702,075.00 - - - 38,450 379.50 14,591,775.00
56 Masker Oksigen Anak DAK 2018 pcs 50 28,336.00 1,416,800.00 - 5 28,336.00 141,680.00 - - - 45 28,336.00 1,275,120.00
57 Masker Oksigen Dewasa DAK 2018 pcs 50 28,336.00 1,416,800.00 - 5 28,336.00 141,680.00 - - - 45 28,336.00 1,275,120.00
58 Mucus Extractor pcs - - 0 - - - - - - -
59 Nald 23G pcs - - 0 - - - - - - -
60 Nald 27G pcs - - 0 - - - - - - -
61 Naso Gastric Tube 40 cm (No.6) DAK 2017 pcs 25 8,495.00 212,375.00 - 15 8,495.00 127,425.00 - - - 10 8,495.00 84,950.00
62 Naso Gastric Tube 40 cm (No.8) DAK 2017 pcs 35 8,495.00 297,325.00 - 0 8,495.00 - - - - 35 8,495.00 297,325.00
67 Naso Gastric Tube Levin Tube 125 cm (No.12) DAK 2017 Pcs 22 10,312.50 226,875.00 - 5 10,312.50 51,562.50 - - - 17 10,312.50 175,312.50
68 Naso Gastric Tube Levin Tube 125 cm (No.14) DAK 2017 Pcs 27 10,312.50 278,437.50 - 0 10,312.50 - - - - 27 10,312.50 278,437.50
69 Naso Gastric Tube Stomach Tube 85 cm (No.12) DAK 2017 Pcs 23 8,495.00 195,385.00 - 5 8,495.00 42,475.00 - - - 18 8,495.00 152,910.00
70 Naso Gastric Tube Stomach Tube 85 cm (No.14) DAK 2017 Pcs 23 8,495.00 195,385.00 - 0 8,495.00 - - - - 23 8,495.00 195,385.00

71 DAK 219 pcs 108 21,881.481 2,363,200.00 0 108 21,881.48 2,363,200.00
(with Ecolite mask kid and tube for paediatric)
Nebulizer - INTERSURGICAL Cirrus nebuliser ( T-

72 DAK 219 pcs 120 25,400.000 3,048,000.00 0 120 25,400.00 3,048,000.00
piece Kit 22mm for Adult
73 Neonatal IV Arm Board buah 0 - - 0 - - - - - - -
74 Object Glass DAU 2016 pcs 3,600 281.18 1,012,258.00 - 0 281.18 - - - - 3,600 281.18 1,012,258.00
75 Pediatric IV Arm Board DAK 2012 buah 380 14,700.00 5,586,000.00 - 100 14,700.00 1,470,000.00 - - - 280 14,700.00 4,116,000.00
76 Pembalut Elastis Uk 7,5 cm x 4,55 m DAU 2016 pcs 307 27,830.00 8,543,810.00 - 115 27,830.00 3,200,450.00 - - - 192 27,830.00 5,343,360.00
27
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
77 Pembersih Enzim Sachet 25 mg DAK 2017 bungkus 9 881,100.00 7,929,900.00 - 5 881,100.00 4,405,500.00 - - - 4 881,100.00 3,524,400.00
(ALKAZYME) DAK 2019 sachet 2,500 32,040.000 80,100,000.00 0 2,500 32,040.00 80,100,000.00
78 Plaster flexible non woven 5 cm x 5 m DAK 2018 rol 79 27,324.00 2,158,596.00 - 0 27,324.00 - - - - 79 27,324.00 2,158,596.00
79 Plaster flexible non woven 5 cm x 10 m DAK 2019 rol 600 54,615.740 32,769,444.00 0 600 54,615.74 32,769,444.00
80 Plaster flexible non woven 10 cm x 5 m rol - - 0 - - - - - - -
81 Plaster flexible non woven 10 cm x 10 m DAK 2019 rol 600 85,443.920 51,266,352.00 0 600 85,443.92 51,266,352.00
82 Plaster flexible non woven 15 cm x 5m rol - - 0 - - - - - - -
83 Plaster flexible non woven 20 cm x 5 m rol - - 0 - - - - - - -
84 Plaster Paper Tape 5 cm x 9.14 m DAK 2017 Rol 79 18,437.50 1,456,562.50 - 40 18,437.50 737,500.00 - - - 39 18,437.50 719,062.50
Plaster steril Transparent untuk pemasangan IV
85 DAU 2016 pcs 329 2,360.54 776,617.66 - 200 2,360.54 472,108.00 - - - 129 2,360.54 304,509.66
Catheter
86 Plester 5 yards x 2 inch rol - - 0 - - - - - - -
87 Povidon Iodida larutan 10% 30 ml DAK 2019 botol - 650 3,480.000 2,262,000.00 0 - - 650 3,480.00 2,262,000.00 - -
88 Povidon Iodida larutan 10 % 300ml botol - - 0 - - - - - - -
89 Povidon Iodida larutan 10 % 1000 ml botol - - 0 - - - - - - -
90 Rapid Tes DBD (SERENITY) DAK 2019 box - 750 22,887.0133333 17,165,260.00 0 - - 750 22,887.01 17,165,260.00 - -
91 RDT Malaria DAK 2018 set 200 53,480.00 10,696,000.00 - 25 53,480.00 1,337,000.00 - - - 175 53,480.00 9,359,000.00
RDT Malaria (SERENITY) DAK 2019 box 750 17,905.467 13,429,100.00 0 750 17,905.47 13,429,100.00
92 Rivanol larutan 0,1% DAK 2018 pcs 690 3,600.00 2,484,000.00 - 41 3,600.00 147,600.00 - - - 649 3,600.00 2,336,400.00
93 Safety Box 5 liter pcs - - 0 - - - - - - -
94 Sarung tangan steril No. 6,5 DAK 2019 pasang - 1,000 9,603.840 9,603,840.00 0 - - 1,000 9,603.84 9,603,840.00 - -
95 Sarung tangan steril No. 7 DAK 2019 pasang - 600 9,603.840 5,762,304.00 0 - - 600 9,603.84 5,762,304.00 - -
96 Sarung tangan steril No. 7,5 DAK 2019 pasang - 1,000 9,603.840 9,603,840.00 0 - - 1,000 9,603.84 9,603,840.00 - -
97 Sarung Tangan Steril Chirugic No. 7.5 DAK 2017 Pcs 161 9,500.00 1,529,500.00 - 161 9,500.00 1,529,500.00 - - - 0 - -
98 Sarung tangan non steril L DAK 2019 pcs - 10,000 590.480 5,904,800.00 0 - - 10,000 590.48 5,904,800.00 - -
99 Sarung tangan non steril M DAK 2018 pcs 5,000 409.63 2,048,150.00 - 4,500 409.63 1,843,335.00 - - - 500 409.63 204,815.00
DAK 2019 pcs 20,000 590.480 11,809,600.00 0 20,000 590.48 11,809,600.00
100 Sarung tangan non steril S DAK 2019 pcs - 20,000 590.480 11,809,600.00 0 - - 20,000 590.48 11,809,600.00 - -
101 Sarung tangan non steril XS DAK 2019 5,000 574.8274 2,874,137.00 0 5,000 574.83 2,874,137.00
102 Sarung tangan obgyn steril (obgyn glove) DAK 2019 pasang 200 22,264.000 4,452,800.00 0 200 22,264.00 4,452,800.00
103 Selang Oksigen Anak DAK 2015 set 383 11,500.00 4,404,500.00 - 100 11,500.00 1,150,000.00 - - - 283 11,500.00 3,254,500.00
104 Selang Oksigen Dewasa DAK 2015 set 383 11,500.00 4,404,500.00 - 100 11,500.00 1,150,000.00 - - - 283 11,500.00 3,254,500.00
105 Sendok Obat Sirup 5 cc DAK 2015 pcs 37,200 338.79 12,603,103.45 - 110 338.79 37,267.24 - - - 37,090 338.79 12,565,836.21
106 Silk 2/0 + jarum 1/2 GT DAU 2016 pcs 103 5,270.83 542,895.83 - 36 5,270.83 189,750.00 - - - 67 5,270.83 353,145.83
107 Silk 3/0 + jarum 1/2 GT DAU 2016 pcs 1,043 5,270.83 5,497,479.17 - 36 5,270.83 189,750.00 - - - 1,007 5,270.83 5,307,729.17
108 Softpad (Underpad) 60x90 cm Nonsteril DAK 2019 pcs 400 4,786.760 1,914,704.00 0 400 4,786.76 1,914,704.00
109 Strip tes asam urat HUMASENS DAK 2018 strip 650 22,252.00 14,463,800.00 - 400 22,252.00 8,900,800.00 - - - 250 22,252.00 5,563,000.00
Strip tes asam urat AUTOCHECK DAK 2019 strip 2,500 3,816.600 9,541,500.00 0 2,500 3,816.60 9,541,500.00
Strip tes asam urat BENECHECK DAK 2019 strip 450 6,333.33333333 2,850,000.00 0 450 6,333.33 2,850,000.00
110 Strip tes gula darah HUMASENS DAK 2018 strip 1,200 5,156.00 6,187,200.00 - 700 5,156.00 3,609,200.00 - - - 500 5,156.00 2,578,000.00
Strip tes gula darah AUTOCHECK DAK 2019 strip 2,500 2,991.600 7,479,000.00 0 2,500 2,991.60 7,479,000.00
Strip tes gula darah BENECHECK DAK 2019 strip 950 3,463.15789474 3,290,000.00 0 950 3,463.16 3,290,000.00
111 Strip tes kolesterol total HUMASENS DAK 2018 strip 940 27,495.00 25,845,300.00 - 320 27,495.00 8,798,400.00 - - - 620 27,495.00 17,046,900.00
Strip tes kolesterol total AUTOCHECK DAK 2019 strip 1,250 15,223.200 19,029,000.00 0 1,250 15,223.20 19,029,000.00
Strip tes kolesterol total BENECHECK DAK 2019 strip 130 26,153.8461538 3,400,000.00 0 130 26,153.85 3,400,000.00
28
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
112 Suction Catheter No. 6 DAU 2016 pcs 417 4,997.00 2,083,749.00 - 15 4,997.00 74,955.00 - - - 402 4,997.00 2,008,794.00
115 Surgical blade DAK 2019 pcs - 3,000 623.130 1,869,390.00 0 - - 3,000 623.13 1,869,390.00 - -
116 Surgical blade No. 11 pcs - - 0 - - - - - - -
117 Tes gula darah, kolesterol, asam urat DAU 2016 set 2 877,950.00 1,755,900.00 - 2 877,950.00 1,755,900.00 - - - 0 - -
118 Tes gula urine pcs - - 0 - - - - - - -
119 Tes hamil urine/HCG test DAK 2019 pcs - 1,000 2,229.850 2,229,850.00 0 - - 1,000 2,229.85 2,229,850.00 - -
120 Tes Hepatitis Darah set - - 0 - - - - - - -
121 Threeway For IV Catheter DAK 2013 pcs 6,960 13,524.86 94,133,012.42 - 6,960 13,524.86 94,133,012.42 - - - 0 - -
122 Umbilical Cord Klem DAK 2019 pcs - 500 1,495.000 747,500.00 0 - - 500 1,495.00 747,500.00 - -
123 Urine bag DAU 2016 pcs 240 3,450.00 828,000.00 - 240 3,450.00 828,000.00 - - - 0 - -
DAK 2019 pcs 100 7,057.700 705,770.00 - 100 7,057.70 705,770.00
- -
TOTAL PENGELUARAN BMHP DAK TOTAL PENGELUARAN BMHP SISA TOTAL SISA STOK BMHP DAK TOTAL SISA STOK BMHP SISA
TOTAL SALDO AWAL BMHP 466,769,593.90 TOTAL PENERIMAAN BMHP DAK 2019 517,137,969.00 - 190,399,369.60 517,137,969.00 276,370,224.30
2019 2018 2019 2018
TOTAL PENGELUARAN TOTAL PENGELUARAN DAK TOTAL SISA STOK SISA TOTAL SISA STOK DAK
TOTAL KESELURUHAN OBAT & BMHP TOTAL SALDO AWAL 966,663,733.43 TOTAL PENERIMAAN DAK 2019 1,693,616,839.00 - 395,190,915.30 - 571,472,818.13
SISA 2018 2019 2018 2019
Lahomi, 6 November 2019

Kepala Dinas Kesehatan Kabupaten Nias Barat, Kepala Seksi Kefarmasian, Alat Kesehatan, dan PKRT
Dinas Kesehatan Kabupaten Nias Barat,
RAHMATI DAELI, SKM, MKM IRMA L. H. SINAGA, S.Farm., Apt.

Pembina Tk. I (IV/b) Penata Muda Tk. I (III/b)
NIP. 19630816 198803 1 014 NIP. 19860315 201403 2 002
29
Page 30 of 40
DAFTAR OBAT SESUAI FORMULARIUM NASIONAL

PUSKESMAS :
KECAMATAN :
KABUPATEN : NIAS BARAT
Harga Satuan VOLUME

Jumlah Harga
No. NAMA OBAT & BMHP Satuan e-katalog per: KEMASAN KEBUTUHAN
(Rupiah)
23/10/2017 (Jumlah)
1 2 3 4 5 6 4x6 = 7
1 Air untuk injeksi botol Rp -

2 Albendazol suspensi 200 mg/5 ml botol Rp 4,041
3 Albendazol tablet 400 mg tablet Rp 411
4 Alopurinol tablet 100 mg tablet Rp 108
5 Alopurinol tablet 300 mg tablet Rp 210
6 Amilorid tablet 5 mg tablet Rp -
7 Aminofillin Injeksi 24 mg/ml ampul Rp 2,998
8 Aminofilin tablet 150 mg tablet Rp -
9 Aminofillin tablet 200 mg tablet Rp 92
10 Amitriptilin tablet salut selaput 25 mg tablet Rp -
11 Amlodipin tablet 5 mg tablet Rp 88
12 Amlodipin tablet 10 mg tablet Rp 106
13 Amoksisilin drops 100 mg/ ml botol Rp -
14 Amoksisilin sirup kering 125 mg / 5 ml botol Rp 1,920
15 Amoksisilin sirup kering 250 mg / 5 ml botol Rp 3,642
16 Amoksisilin tablet 250 mg tablet Rp 185
17 Amoksisilin tablet 500 mg tablet Rp 191
18 Ampisilin serbuk injeksi 250 mg (i.m/i.v) vial Rp -
19 Ampisilin serbuk injeksi 1000 mg (i.v.) vial Rp -
20 Antasida tablet kunyah, kombinasi aluminium hidroksida 200 mg + tablet Rp 59

magnesium hidroksida 200 mg
21 Antasida suspensi, kombinasi aluminium hidroksida 200 mg + botol Rp 1,962

magnesium hidroksida 200 mg
22 Antihemoroid suppositoria, kombinasi : bismut subgalat + heksaklorofen suppo Rp -

+ lidokain + seng oksida + sup ad suspensi
23 Antifungi salep, kombinasi asam benzoat 6 % + asam salisilat 3 % tube Rp 4,540
24 Antimalaria tablet, kombinasi : Pirimetamin 25 mg + Sulfadoksin 500 mg tablet Rp 593
Antimalaria tablet, kombinasi: Dihidroartemisin 40 mg + piperakuin 320

25 Rp -
mg
26 Antimalaria Falsiparum tablet, kombinasi: Artemether 20 mg + tablet Rp -

Lumefantrin 120 mg
27 Aquadest cairan 500 ml botol Rp -
28 Articulating paper kertas warna penanda oklusi lembar Rp -
29 Asam asetilsalisilat (asetosal) tablet 80 mg tablet Rp 94
30 Asam Askorbat (Vitamin C) tablet 50 mg tablet Rp 109
31 Asam Askorbat (Vitamin C) tablet 250 mg tablet Rp 114
32 Asam Folat tablet 0,4 mg tablet Rp 60
33 Asam Folat tablet 1 mg tablet Rp 70
34 Asam Folat tablet 5 mg tablet Rp -
35 Asam Mefenamat kapsul 250 mg kapsul Rp -
36 Asam Mefenamat kapsul 500 mg kapsul Rp 102
37 Asam salisilat salep 3 % tube Rp -
38 Asam salisilat salep 5 % tube Rp -
39 Asam salisilat larutan 0,1 % botol Rp -
40 Asiklovir tablet 200 mg tablet Rp 245
41 Asiklovir tablet 400 mg tablet Rp 380
42 Atapulgit tablet tablet Rp 142
43 Atenol tablet 50 mg tablet Rp 310
44 Atropin Injeksi i.m./i.v./s.k. 0,25 mg/ml (sulfat) ampul Rp 1,540
45 Atropin tablet 0,5 mg tablet Rp 1,040
46 Bahan tumpatan sementara lar serbuk Rp 11,235
47 Bedak salisil serbuk 2 % bungkus Rp 1,040
48 Benzatin benzil penisilin inj 1,2 jt IU/ml (i.m.) vial Rp 11,235
49 Benzatin benzil penisilin inj 2,4 jt IU/ml (i.m.) vial Rp 15,225
50 Benserazid 25 mg + levodopa 100 mg tablet tablet Rp 1,200
51 Benserazid 25 mg + levodopa 100 mg tablet dispersible tablet Rp -
Page 31 of 40
52 Betametason krim 0,05% tube Rp 1,349

53 Betametason tetes mata 1 mg/ml botol Rp -
54 Bisakodil 5 mg tablet tablet Rp 306
55 Bisakodil sup 5 mg suppo Rp 5,800
56 Bisakodil sup 10 mg suppo Rp 5,800
57 Budesonid serbuk ih 100 mcg/dosis vial Rp -
58 Budesonid serbuk ih 200 mcg/dosis vial Rp 105,000
59 Budesonid cairan ih 0,25 mg/ml botol Rp 121,000
60 Budesonid cairan ih 0,5 mg/ml botol Rp 121,000
61 Coal tar larutan 5% botol Rp -
62 Deksametason asetat 0,1% + thymol 5% + paraklorphenol 30% + campor botol Rp -

64%, cairan perawatan gigi
63 Copper T set set
64 Dapson tablet 100 mg tablet Rp -
65 Deksametason injeksi 5 mg/ml (i.v./i.m.) ampul Rp 1,647
66 Deksametason tablet 0,5 mg tablet Rp 43
67 Diazepam injeksi 5mg/ml (i.v./i.m.) ampul Rp -
68 Diazepam tablet 2 mg tablet Rp -
69 Diazepam tablet 5 mg tablet Rp 105
70 Diazepam enema 5 mg/2.5 ml tube Rp 12,696
71 Diazepam enema 10 mg/2.5ml tube Rp 18,456
72 Dietilkarbamazin tablet 100 mg tablet Rp 164
73 Difenhidramin injeksi i.v./I.m. 10 mg/ml (HCL) ampul Rp 1,115
74 Difenhidramin 2 % + kalamin 5 % + zinc 10 % + gliserin 5 % lotion kulit Rp -

botol
75 Digoksin tablet 0,25 mg tablet Rp 107
76 Diltiazem tablet 30 mg tablet Rp 135
77 Diltiazem serbuk injeksi 50 mg vial
78 Dimenhidrinat tablet 50 mg tablet Rp 107
79 Doksisiklin kapsul 100 mg kapsul Rp 273
80 Domperidon sirup 5 mg / 5ml botol Rp 3,105
81 Domperidon tablet 10 mg tablet Rp 95
82 Epinefrin (adrenalin) injeksi 0,1 % (sebagai HCL) i.v./s.k./i.m. ampul Rp 1,749
83 Ergokalsiferol (vitamin D3/D2) kapsul 50.000 IU kapsul Rp -
84 Ergokalsiferol (vitamin D3/D2) suspensi 10.000 IU/mL kapsul Rp -
85 Ergotamin tablet 1 mg tablet Rp -
86 Ergotamin 1 mg + kafein 50 mg tablet Rp 167
87 Eritromisin kapsul 250 mg kapsul Rp 587
88 Eritomisin tablet 500 mg tablet Rp 751
89 Eritromisin sirup kering 200 mg/5 ml botol Rp 6,303
90 Etambutol tablet 250 mg tablet Rp 359
91 Etambutol tablet 400 mg tablet Rp -
92 Etambutol tablet 500 mg tablet Rp 505
93 Etanol 70 % cairan botol Rp -
94 Etil klorida spray 100 ml botol Rp -
95 Etonogestrel implan 68 mg Rp -
96 Eugenol cairan botol Rp -
97 Fenitoin kapsul 30 mg kapsul Rp 142
98 Fenitoin kapsul 100 mg kapsul Rp 152
99 Fenitoin injeksi 50 mg / ml ampul Rp 4,956
100 Fenobarbital tablet 30 mg tablet Rp 165
101 Fenobarbital tablet 100 mg tablet Rp -
Page 32 of 40
102 Fenoksimetil penisilin tablet 250 mg tablet Rp 368

103 Fenoksimetil penisilin tablet 500 mg tablet Rp 635
104 Ferrakrilum cairan 1 % botol Rp -
105 Ferro sulfat sirup 150 mg/ 5 ml botol Rp -
106 Ferro sulfat 200 mg + asam folat 0,25 mg tablet Rp -
107 Ferro sulfat tablet salut 300 mg tablet Rp -
108 Ferro sulfat 60 mg + asam folat 0,4 mg tablet salut tablet Rp 370
109 Ferro sulfat 180 mg + asam folat 0,4 mg tablet salut tablet Rp -
110 Ferro fumarat kapsul lunak 300 mg kapsul Rp -
111 Fitomenadion (Vit K1) tablet salut gula 10 mg tablet Rp 721
112 Fitomedion injeksi 2 mg/ml (i.m.) ampul Rp 3,728
113 Fitomedion injeksi 10 mg/ml (i.m.) ampul Rp 4,167
114 Flufenazin injeksi 25 mg/ ml (i.m.) ampul Rp 57,500
115 Fluoksetin kapsul 20 mg kapsul Rp 225
116 Fluor tablet 0,5 mg tablet Rp -
117 Fluor kaplet 1 mg kaplet Rp -
118 Fluor sedian topikal tube Rp -
119 Fluoresein tetes mata 2,5 mg/ml botol Rp -
120 Framisetin sulfat tulle 1 % bungkus Rp 8,990
121 Furosemid tablet 40 mg tablet Rp 81
122 Furosemide injeksi i.v/i.m 10 mg/ml ampul Rp -
123 Galactose microparticle 200-400 mg micropart / ml utk USG Rp -
124 Garam oralit kombinasi natrium klorida 0,52 g + kalium klorida 0,30 g + saset Rp 265
trinatrium sitrat dihidrat 0,58 g + glukosa anhidrat 2,7 g serbuk
125 Glass Ionomer ART ser Set Rp -
126 Glass Ionomer ART lar Rp -
127 Glass Ionomer ART cocoa butter 5 g Rp -
128 Glibenklamida tablet 2,5 mg tablet Rp -
129 Glibenklamida tablet 5 mg tablet Rp -
130 Glimepirid tablet 1 mg tablet Rp 199
131 Glimepirid tablet 2 mg tablet Rp 231
132 Glipizid tablet 5 mg tablet Rp -
133 Gliseril trinitrat tablet 0,5 mg tablet Rp 1,418
134 Gliserin drops 10 mg/ml botol Rp -
135 Gliserin cairan obat luar 100 mg/ ml botol Rp -
136 Griseofulvin tablet 125mg tablet Rp 245
137 Griseofulvin tablet 250 mg tablet Rp 1,705
138 Gutta percha dan paper points 15 - 40 mm Rp -
139 Gutta percha dan paper points 45 - 80 mm Rp -
140 Haloperidol tablet 1,5 mg tablet Rp 63
141 Haloperidol tablet 2 mg tablet Rp 94
142 Haloperidol tablet 5 mg tablet Rp 74
143 Haloperidol drops 2 mg/ ml botol Rp 18,100
144 Haloperidol injeksi 5 mg/ml (i.m.) ampul Rp 4,000
145 Haloperidol injeksi 50 mg/ml ampul Rp 97,500
146 Hidrogen peroksida cairan 3 % botol Rp -
147 Hidroklorotiazid tab 25 mg tablet Rp 156
148 Hidrokortison krim 2,5% tube Rp 2,640
149 Hidrokortison serbuk injeksi 100 mg vial Rp -
150 Hiosina butilbromida tab 10 mg tablet Rp -
152 Human tetanus imunoglobulin injeksi 250 IU (i.m.) ampul Rp 170,000
153 Human tetanus imunoglobulin injeksi 500 IU (i.m.) ampul Rp 1,950,000
154 Ibuprofen 200 mg tablet tablet Rp 105
155 Ibuprofen 400 mg tablet tablet Rp 112
156 Ibuprofen suspensi 100mg/5ml botol Rp 2,550
157 Ibuprofen suspensi 200mg/5ml botol Rp 5,191
Page 33 of 40
158 Ipratropium bromida ih 20 mcg/puff botol Rp 83,500

159 Ipratropium bromida cairan ih 0,025 % botol Rp -
160 Ipratropium bromida 0,5 % + salbutamol 2,5 % cairan ih botol Rp 5,700
161 Isoniazid tablet 100 mg tablet Rp 78
162 Isoniazid tablet 300 mg tablet Rp 170
163 Isosorbid Dinitrat tablet 5mg tablet Rp 93
164 Kalamin lotio botol Rp -
165 Kalsium hidroksida bubuk pasta Rp -
166 Kalsium glukonat injeksi 10% ampul Rp 9,955
167 Kalsium karbonat tablet 500 mg Tablet Rp 430
168 Kalsium laktat tablet 500 mg tablet Rp 57
169 Kaolin 550 mg + pektin 20 mg tablet tablet Rp -
170 Kaptopril tablet 12,5 mg tablet Rp 62
171 Kaptopril tablet 25 mg tablet Rp 81
172 Kaptopril tablet 50 mg tablet Rp 124
173 Karbamazepin tablet 200 mg (*100mg) tablet Rp 230
174 Karbamazepin sirup 100 mg/ 5 ml botol Rp -
175 Karbon aktif tablet 0,5 mg tablet Rp -
176 Karbogliserin tetes telinga 10% botol Rp 2,500
177 Ketamin injeksi 50 mg/ml (i.v.) ampul Rp -
178 Ketamin injeksi 100 mg/ml (i.v.) ampul Rp 51,750
179 Ketokonazol krim 2 % tube Rp 2,596
180 Ketokonazol scalp sol 2 % botol Rp 26,400
181 Ketokonazol tablet 200 mg tablet Rp 288
182 Klindamisin kapsul 150 mg kapsul Rp -
183 Klindamisin kapsul 300 mg kapsul Rp 589
184 Klofazimin micronized kapsul 50 mg kapsul Rp -
185 Klofazimin micronized kapsul 100 mg kapsul Rp -
186 Klorfenol kamfer mentol (CHKM) botol Rp -
187 Klorheksidin larutan 0,2 % botol Rp -
188 Klorheksidin larutan 15 % botol Rp -
189 Kloramfenikol kapsul 500 mg (*250 mg) kapsul Rp 1,100
190 Kloramfenikol salep kulit 2 % tube Rp 3,107
191 Kloramfenikol salep mata 1 % tube Rp 1,810
192 Kloramfenikol suspensi 125 mg/5 ml botol Rp 4,841
193 Kloramfenikol tetes mata 0,5 % botol Rp 3,500
194 Kloramfenikol tetes mata 1 % botol Rp -
195 Kloramfenikol tetes telinga botol Rp -
196 Klorfeniramin tablet 4 mg tablet Rp 37
197 Klortalidon tablet 50 mg tablet Rp -
198 Klopormazin tablet salut 25 mg tablet Rp -
199 Klorpromazin tablet salut selaput 100 mg tablet Rp 148
200 Klorpromazin injeksi 5 mg/ml (i.v.) ampul Rp 1,456
201 Klorpromazin injeksi 25 mg/ml (i.m.) ampul Rp 1,291
202 Kodein tablet 10 mg tablet Rp 577
203 Kodein tablet 20 mg tablet Rp 1,312
204 Kolkisin tab 500 mcg tablet Rp 2,750
205 Komposit resin set
Kombinasi (DHP) dihidroartemisin 40 mg + piperakuin 320 mg tablet
206 salut selaput tablet Rp 2,160
Kombinasi larutan deksametason asetat 0,1% + thymol 5% +

207 tablet Rp -
paraklorphenol 30% + campor 64%
Kombinasi: triamsinolon asetonit + dementilklortetrasiklin

208 tube Rp -
pasta
209 Kombinasi levonorgestrel 150 meg + etinilestradiol 30 meg Rp 1,350
Kombinasi larutan lidokain + medisinal creosote phenol + eugenol +
210 botol Rp -
benzil alkohol
Kombinasi lotion: difenhidramin 2% + kalamin 5% + zinc 10% + gliserin

211 botol Rp -
5%
Page 34 of 40
212 Kombinasi benserazid 25 mg + levodopa 100 mg tablet Rp 1,200

213 Kotrimoksazol (dewasa) Kombinasi tablet 480 mg tablet Rp 131
214 Kotrimoksazol forte (dewasa) Kombinasi tablet 960 mg tablet Rp 323
215 Kotrimoksazol (dewasa) Kombinasi susp. 240 mg / 5ml botol Rp 2,364
216 Kuinin tablet 200 mg tablet Rp 704
217 Kuinin tablet 222 mg tablet Rp -
218 Kuinin tablet 250 mg tablet Rp -
219 Kuinin injeksi 25% (i.v.) ampul Rp -
220 Larutan mengandung elektrolit botol Rp 11,000
221 Larutan mengandung karbohidrat botol Rp 6,900
222 Larutan mengandung elektrolit + karbohidrat botol Rp 8,025
223 Levonorgestrel implan 2 rods, 75 mg (3-4 tahun) pcs Rp -
224 Lidokain injeksi 2% (infiltr/p.v.) ampul Rp 1,169
225 Lidokain injeksi 2% + epinefrin 1:80.000 injeksi 2 ml ampul Rp 2,037
226 Lidokain gel 2% botol Rp 40,000
227 Lidokain spray oral 10% botol Rp 170,400
228 Lidokain + medisinal creosote phenol + eugnol + benzil alkohol (cairan) botol Rp -
229 Lidokain salep 5 % tube Rp -
230 Loratadin tablet 10 mg tablet Rp 125
232 Lugol lar Rp -
233 Magnesium sulfat serbuk vial Rp -
234 Magnesium sulfat injeksi 20% (i.v.) ampul Rp 3,200
235 Magnesium sulfat injeksi 40% (i.v.) ampul Rp 3,650
236 Mebendazol tab 100 mg tablet Rp -
237 Mebendazol tab 500 mg tablet Rp 8,800
238 Mebendazol suspensi 100 mg/ 5 ml botol Rp -
239 Medroksi progesteron asetat injeksi 150 mg/ml ampul Rp 5,680
240 Metenamin mandelat (heksamin mandelat ) tablet salut enterik 500 mg tablet Rp -
241 Metformin tablet 500 mg tablet Rp 98
242 Metformin tablet 850 mg tablet Rp 169
243 Metilergometrin maleat injeksi 0.2 mg/ml ampul Rp 2,992
244 Metilergometrin maleat tablet salut 0,125 mg tablet Rp -
245 Metilprednisolon tablet 4 mg tablet Rp 160
246 Metoklopramid tablet 5 mg tablet Rp 123
247 Metoklopramid tablet 10 mg tablet Rp 87
248 Metronidazol tablet 250 mg tablet Rp 92
249 Metronidazol tablet 500 mg tablet Rp 114
250 Metronidazol Suspensi 125 mg/ 5 ml botol Rp 3,800
251 Metronidazol infus 5 mg/ml botol Rp 8,525
253 Mikonazol krim 2 % Tube Rp -
254 Mikonazol serbuk 2 % vial Rp 2,950
255 N-asetil sistein kapsul 200 mg kapsul Rp -
256 Natrium Bikarbonat tab 500 mg tablet Rp -
257 Natrium diklofenak tab 25 mg tablet Rp 140
258 Natrium diklofenak tab 50 mg tablet Rp 122
259 Natrium diklofenak tetes mata 1 mg/ml botol Rp -
260 Natrium hipoklorit cairan konsentrat 5 % botol Rp -
261 Natrium tiosulfat injeksi 25% (i.v.) ampul Rp -
262 Nifedipine tablet 10mg tablet Rp 110
263 Nikotinamid tablet 20 mg tablet Rp -
264 Nistatin tablet sal gula 500.000 iu tablet Rp 803
265 Nistatin suspensi 100.000 IU/ml drop botol Rp -
266 Nistatin tab vaginal 100.000 IU botol Rp 572
267 Nitrofuratoin tablet 50 mg tablet Rp -
Page 35 of 40
268 OAT - FDC kategori 4 dewasa paket

269 OAT - FDC kategori 2 dewasa paket
270 OAT - FDC kategori 3 anak paket
271 OAT - FDC kategori 2 anak paket
272 OAT - Kombipak paket
273 OAT - Kombipak II dewasa paket
274 OAT - Kombipak III dewasa paket
275 OAT - Kombipak A anak paket
276 OAT - Kombipak B anak paket
277 Oksitosin injeksi 10 IU/ml ampul Rp 1,900
278 Oksimetazolin tetes hidung 0,025% botol Rp 32,900
279 Oksimetazolin tetes hidung 0,050% botol Rp 34,650
280 Olopatadin tetes mata 0,1 % botol Rp 72,500
281 Omeprazol kapsul 20 mg kapsul Rp 144
282 Omeprazol serbuk injeksi 40 mg ampul Rp 12,998
283 Paraformaldehid tablet 1 g tablet Rp -
284 Parasetamol tab 500 mg tablet Rp 51
285 Parasetamol drops 100 mg/ml botol Rp -
286 Parasetamol sirup 120 mg/5 ml botol Rp 1,013
287 Pasta devitalisasi (non arsen) pasta
288 Pasta pengisi saluran akar
289 Permetrin krim 5 % Tube Rp 12,155
290 Perak nitrat lar 20 % botol Rp -
291 Perak Sulfadiazin krim 1 % Tube Rp 20,700
292 Pirantel pamoat suspensi 125 mg/ 5 ml botol Rp 9,885
293 Pirantel pamoat tablet 125 mg tablet Rp 288
294 Pirantel pamoat tablet 250 mg tablet Rp -
295 Pirazinamid tablet 500 mg tablet Rp 236
296 Piridoksin (Vit B6) injeksi 100mg/ml ampul Rp -
297 Piridoksin (Vit B6) tablet 10 mg tablet Rp 124
298 Piridoksin (Vit B6) tablet 25 mg tablet Rp -
299 Podofilin tingtur 25 % botol Rp -
300 Povidon iodin larutan 100 mg/ ml botol Rp -
301 Prazikuantel tablet 600 mg tablet Rp -
302 Prednison tablet 5 mg tablet Rp 82
303 Primakuin tablet 15 mg tablet Rp 235
304 Propranolol tablet 10 mg tablet Rp 57
305 Probenesid tablet 500 mg tablet Rp 1,849
306 Prokain benzil penisilin serbuk injeksi 3 juta IU (i.m.) vial Rp -
307 Propilitiuorasil tablet 100 mg tablet Rp -
308 Ranitidin tablet 150 mg tablet Rp 100
309 Retinol (Vitamin A) 100.000 IU kapsul lunak kapsul Rp 298
310 Retinol (Vitamin A) 200.000 IU kapsul lunak kapsul Rp 531
311 Rifampisin kapsul 300 mg kapsul Rp 786
312 Risperidon tablet 2 mg tablet Rp 347
313 Salbutamol tablet 2 mg tablet Rp 78
314 Salbutamol tablet 4 mg tablet Rp 80
315 Salbutamol cairan ih 1 mg/ ml botol Rp 450
316 Alat hirup Salbutamol serbuk inhaler 200 mcg/kapsul botol Rp 6,550
317 Salep 2-4, kombinasi : asam salisilat 2% + belerang endap 4% tube Rp 2,654
318 Serum anti bisa ular A.B.U.I injeksi (i.m./i.v.) ampul Rp 462,000
319 Serum anti bisa ular A.B.U.II injeksi (i.m./i.v.) ampul Rp -
320 Serum antidifteri (A.D.S.) injeksi 10.000 IU/ml (i.m.) ampul Rp -
321 Serum antidifteri (A.D.S.) injeksi 20.000 IU/ml (i.m.) ampul Rp -
322 Serum anti rabies injeksi 10.000 IU/ml ampul Rp -
323 Serum anti rabies injeksi 20.000 - 40.000 IU/ml ampul Rp -
Page 36 of 40
324 ampul Rp 126,500

Serumantitetanus (ATS) untuk pencegahan injeksi 1500 IU/mL (i.m.)
325 ampul Rp -
Serumantitetanus (ATS) untuk pencegahan injeksi 5000 IU/mL (i.m.)
326 ampul Rp -
Serumantitetanus (ATS) untuk pengobatan injeksi 10.000 IU/mL (i.m.)
327 ampul Rp -
Serumantitetanus (ATS) untuk pengobatan injeksi 20.000 IU/mL (i.m.)
328 Setirizin sirup 5 mg/ 5 ml botol Rp 3,200
330 Sianokobalamin (Vit B12) injeksi 500 mcg ampul Rp 1,157
331 Sianokobalamin (Vit B12) tablet 50 mcg tablet Rp 52
332 Simvastatin tablet 10 mg tablet Rp 113
333 Simvastatin tablet 20 mg tablet Rp 239
334 Siprofloksasin tablet sal selaput 500 mg tablet Rp 247
335 Siprofloksasin tetes mata 3 mg/ml botol Rp -
336 Spironolakton tablet 25 mg tablet Rp 244
337 Streptomisin serbuk injeksi 1000 mg vial Rp -
338 Surgical ginggival pack pasta pack
339 Terbutalin injeksi 0,5 mg/ml (s.k./i.v.) ampul Rp 11,500
340 Terbutalin injeksi 2,5 mg/ml ampul Rp -
342 Tetrakain tetes mata 0,5 % botol Rp -
343 Tetrasiklin kapsul 250mg kapsul Rp 174
344 Tetrasiklin kapsul 500mg kapsul Rp 319
345 Tiamin (Vitamin B1) tablet 50 mg tablet Rp 84
346 Triamsinolon asetonit + dementilklortetrasiklin (pasta) botol Rp -
347 Triheksifenidil tablet 2 mg tablet Rp 80
348 Tuberkulin protein purified derivative serb inj 2 TU /0,1 mL ampul Rp -
349 Urea krim 20 % Tube Rp 6,809
350 Valproat tablet sal enterik 250 mg tablet Rp 1,750
351 Valproat tablet lepas lambat 250 mg tablet Rp 2,840
352 Valproat tablet lepas lambat 500 mg tablet Rp 5,700
353 Valproat sirup 250 mg/ 5 ml botol Rp 22,987
354 Vaksin BCG serbuk injeksi 0,75 mg/ml + pelarut (i.k.) vial Rp 59,950
355 Vaksin campak serbuk injeksi + pelarut (s.k.) vial Rp 28,232
356 Vaksin kombinasi DPT-HB-Hib injeksi (i.m.) vial Rp 76,285
357 Vaksin jerap difteri tetanus (DT) injeksi 40/15 if per mil vial Rp 17,798
358 Vaksin jerap difteri tetanus (Td) injeksi 4/15 if per mL (i.m.) vial Rp 16,500
359 Vaksin jerap difteri tetanus pertusis (DTP) injeksi (i.m.) vial Rp -
360 Vaksin jerap tetanus (tetanus adsorbed toxoid) injeksi vial Rp -
361 Vaksin polio t-OPV drops 10 dosis vial Rp -
362 Vaksin polio IPV injeksi 0,5 mL (i.m.) vial Rp 153,736
363 Vaksin rabies serbuk injeksi + booster (s.k.) vial Rp -
364 Vaksin rabies serbuk injeksi 2,5 IU (s.k.) vial Rp -
365 Vitamin B Kompleks tablet tablet Rp 121
366 Zinc serbuk 10 mg vial Rp -
367 Zinc sirup 10 mg/ml (Interbat) botol Rp 6,600
368 Zinc sirup 20 mg/ 5 ml (Meprofarm) botol Rp 4,789
369 Zinc tablet dispersibel 20 mg tablet Rp 539
............, ..................................2017
Mengetahui / Menyetujui : Yang merencanakan:

Kepala Puskesmas......................... Petugas Pengelola Obat
Kabupaten Nias Barat, Turut Merencanakan: Puskesmas..........................
Dokter Puskesmas...................................,
.................................................... ...............................................................
NIP. ............................................................... NIP.
NIP.
* Buat 2 (dua) rangkap untuk arsip :

1. Dinas Kesehatan (asli)
2. Puskesmas /UPT ybs.
Lampiran Radiogram:
Nomor: 005/3264/Bangda
Tanggal: 16 Juli 2019
Format Tabel
Data Informasi Terkait IRTP Untuk Pengajuan DAK Non
Jumlah IRTP (hingga Jumlah Nomor P- IRT Jumlah Tenaga Penyuluh Keamanan P
Provinsi Kab/Kota (Dinkes/Puskesmas/BPOM hingga ta
tahun 2019) yang diterbitkan
Total
Format Tabel
TP Untuk Pengajuan DAK Non Fisik 2020
Tenaga Penyuluh Keamanan Pangan/PKP

s/Puskesmas/BPOM hingga tahun 2019 Jumlah Tenaga DFI Jumlah Jumlah Anggaran
PKP (Dinkes/Puskesmas/ Anggaran Pemda Kab/Kota
BPOM hingga tahun2019) Pemda terkait Kegiatan
Kab/Kota Sampling/
dalam rangka Monitoring/
Penerbitan Pengawasan Pos-
izin IRTP Market IRTP
Lampiran Radiogram:
Nomor: 005/3264/Bangda
Tanggal: 16 Juli 2019
Keterangan:
Kolom nomor 1 = Nama Provinsi
Kolom nomor 2 = Nama Kabupaten/Kota
Kolom nomor 3 = Jumlah Sumber Daya Manusia yang bertugas melakukan pengawasan sarana pelayanan kefarmasian
Kolom nomor 4 = Jumlah sarana Apotek di Kabupaten/Kota
Kolom nomor 5 = Jumlah sarana Toko Obat d Kabupaten/Kota
Kolom nomor 6 = Besarnya jumlah alokasi anggaran selama tiga tahun terakhir (2017, 2018 dan 2019) untuk kegiatan pengaw
kolom nomor 7 = Rincian kegiatan untuk setiap alokasi anggaran yang berkaitan dengan pengawasan sarana pelayanan kefarm
kolom nomor 8 = Besarnya biaya transport antar kecamatan dengan nilai paling rendah
Kolom nomor 9 = Besarnya biaya transport antar kecamatan dengan nilai paling tinggi
elayanan kefarmasian
2019) untuk kegiatan pengawasan sarana pelayanan kefarmasian

asan sarana pelayanan kefarmasian

.2020 - Format Baru LPLPO Dan LB2 Rutin Nias Barat2

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.2020 - Format Baru LPLPO Dan LB2 Rutin Nias Barat2

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PEMERINTAH KABUPATEN NIAS BARAT

LAPORAN PEMAKAIAN DAN PERMINTAAN OBAT (LPLPO) TAHUN 2020

1 Air untuk injeksi botol

Antimalaria, Kombinasi (DHP):

26 Asam Asetilsalisilat (asetosal/aspirin) tablet tablet

52 Ekstrak Kurkuma + Multivitamin sirup botol

54 Ekstrak Plasenta + Neomisin sulfat salep tube

55 Epinefrin (adrenalin) injeksi 0,1 % (sebagai ampul

61 Fitomenadion (Vit K1) tablet salut gula 10 tablet

74 Hyoscine-N-Butilbromide injeksi 20 mg/ml ampul

75 Hyoscine-N-Butilbromide tablet 10 mg tablet

79 Ipratropium + Salbutamol larutan inhalasi vial

84 Karbimazol tablet 5 mg tablet

87 Ketoprofen suppositoria 100 mg suppo

91 Kloramfenikol salep kulit 2% tube

94 Kombinasi Salep 2-4 : asam salisilat 2% + tablet

95 Kotrimoksazol DOEN I (dewasa) tablet 480 tablet

Kotrimoksazole DOEN suspensi (anak), tiap

99 Lidokain injeksi 2% (HCl) + Epinefrin ampul

118 Oksimetazolin tetes hidung 0,025% botol

130 Pirantel tablet score (base) 250 mg tablet

137 Salbutamol Inhaler 100 mcg/dose botol

143 Serum anti bisa ular A.B.U. I inj (i.m./i.v) vial

144 Serum antitetanus (A.T.S) inj 1500 IU/mL vial

156 Tripolidin HCl + Pseudoefedrin HCl Sirup botol

1 Alat suntik sekali pakai 0,05 ml pcs

18 Catgut PETERS SURGICALS PETER SILK 4/0, pcs

19 Catgut PETERS SURGICALS PETER SILK 4/0, pcs

24 Chlorhexidine 0.5%+Alkohol 70% Spray botol

64 Naso Gastric Tube Levin Tube 125 cm pcs

65 Naso Gastric Tube Levin Tube 125 cm pcs

66 Naso Gastric Tube Stomach Tube 85 cm pcs

67 Naso Gastric Tube Stomach Tube 85 cm pcs

74 Pembersih Enzim Sachet 25 mg bungkus

80 Plaster steril Transparent untuk pcs

Umum BPJS Inap Total

JUMLAH KUNJUNGAN PASIEN/RESEP (3bulan)

Mengetahui : Yang Melaporkan :

Lahomi, 20 Januari 2020

Mengetahui : Disetujui Oleh : Disusun Oleh :

NAMA PUSKESMAS/ PUSTU/ POSKESDES

LAPORAN BULANAN PEMAKAIAN OBAT DAN BMHP (LB2) RUTIN

NO NAMA BARANG Sumber Satuan

1 Air untuk injeksi botol

Asam Asetilsalisilat (asetosal/aspirin) tablet

27 Asam Askorbat (Vitamin C) tablet 50 mg tablet

NO NAMA BARANG Sumber Satuan

30 Asam traneksamat injeksi 100 mg/ml ampul

NO NAMA BARANG Sumber Satuan

31 Asam traneksamat injeksi 50 mg/ml ampul

53 Ekstrak Kurkuma tablet (CURCUMA) tablet

Epinefrin (adrenalin) injeksi 0,1 % (sebagai

56 Eritromisin kapsul 250 mg kapsul

61 Fitomenadion (Vit K1) tablet salut gula 10 mg tablet

62 Furosemid injeksi i.v/i.m 10 mg/ml ampul

NO NAMA BARANG Sumber Satuan

74 Hyoscine-N-Butilbromide injeksi 20 mg/ml ampul

80 Isosorbid Dinitrat (ISDN) tablet 5mg tablet

84 Karbimazol tablet 5 mg tablet

88 Ketorolac injeksi 30 mg ampul

Kotrimoksazol DOEN I (dewasa) tablet 480

Kotrimoksazole DOEN suspensi (anak), tiap 5

100 Loratadin tablet 10 mg tablet