Cijagang LPLPO 2022

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS
PUSKESMAS : CIJAGANG DOKUMEN NOMOR TANGGAL
KECAMATAN : CIKALONGKULON PUSKESMAS
KABUPATEN : CIANJUR DINAS KESEHATAN
PELAPORAN BULAN : November 2018 SIE. FARWASMAMIN 42/SBBK/XII/18 11/12/2018
PERMINTAAN BULAN : Desember 2018
Laporan Mutasi Obat JKN PKM
NO NAMA OBAT SATUAN Stok Awal Penerimaan

Jumlah
Pemakaian
Stok Stok
Permintaan
PEMBERIAN Bulan : Desember 2017
Persediaan akhir Optimum
DAU BPJS PROGRAM DAK Lain-lain Jumlah
Stok Awal Penerimaan Pemakaian Stok Akhir
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Acyclovir tab 200mg TABLET 0 0 0 0 400 0 0 0
2 Acyclovir tab 400mg TABLET 200 200 400 200 200 400 100 100 0 0
3 Air Raksa Dental Use BOTOL 0 0 0 0 0 0 0
4 Alat Suntik Sekali Pakai 1 ml SET 50 50 100 100 0 100 25 25 0 0
8 Albendazol tab TABLET 0 0 0 0 100 0 0 0
9 Alkohol Swab KOTAK 0 1 1 1 0 10 1 1 0 0
10 Alopurinol Tablet 100 mg TABLET 100 200 300 200 100 300 200 200 0 0
11 Ambroxol syrup 15mg/5ml BOTOL 0 15 15 15 0 300 15 15 0 0
12 Ambroxol tab 30 mg TABLET 0 200 200 200 0 500 200 200 0 0
13 Aminofilin Injeksi 24 mg/ ml AMPUL 5 0 5 5 0 0 0 0
14 Aminofilin Tablet 200 mg TABLET 50 0 50 50 0 0 0 0
15 Amitriptilin HCL 25 mg TABLET 0 0 0 0 100 100 100 0 0
16 Amlodipin Tablet 10 mg TABLET 0 300 300 300 0 600 300 300 0 0
17 Amlodipin Tablet 5 mg TABLET 0 300 300 300 0 600 300 300 0 0
18 Amoksisilin 250 mg KAPSUL 200 500 700 500 200 500 500 500 0 0
19 Amoksisilin 500 mg TABLET 1000 3000 4000 3500 500 8000 1500 1500 0 0
20 Amoksisilin + Asam Klavulanat TABLET 0 0 0 0 500 0 0 0
21 Amoksisilin Syrup 125 mg/ 5 ml BOTOL 0 240 240 240 0 250 120 120 0 0
22 Ampisilin Kaplet 500 mg Kaplet 0 0 0 0 0 0 0
23 Ampisillin Serbuk 1.000 mg injeksi VIAL 0 0 0 0 0 0 0
24 Antalgin Injeksi 250 mg/ ml AMPUL 0 0 0 0 0 0 0
25 Antalgin tab (Metampiron) 500 mg TABLET 0 0 0 0 200 0 0 0
26 Antasida DOEN I tablet kunyah TABLET 0 2000 2000 2000 0 2000 2000 2000 0 0
27 Antasida DOEN II suspensi, Botol 0 100 100 100 0 200 100 100 0 0
28 Anti Bakteri DOEN salep kombinasi TUBE 0 25 25 15 10 10 25 25 0 0
29 Anti fungi DOEN Kombinasi POT 18 24 42 20 22 10 24 24 0 0
30 Anti Hemoroid Doen Kombinasi SUP 30 20 50 50 0 30 20 20 0 0
31 Antihemoroid Kapsul Kapsul 0 0 0 0 200 0 0 0
32 Antimigren tablet: Ergotamin Tartrat 1 mg + TABLET 0 0 0 0 200 0 0 0
33 Aqua Proinjeksi Steril VIAL 0 0 0 0 50 0 0 0
34 Asam Asetil Salisilat Tablet 100mg TABLET 0 0 0 0 100 0 0 0
35 Asam Askorbat 50 mg TABLET 200 1000 1200 1200 0 1600 400 400 0 0
36 Asam Mefenamat 500 mg TABLET 400 1000 1400 1400 0 1000 1000 1000 0 0
37 Asam Traneksamat injeksi 100 mg/ml Ampul 14 0 14 14 0 50 10 10 0 0
38 Atropin Sulfat Injeksi 0,25 mg AMPUL 14 0 14 10 4 0 0 0
39 Bekarbon TABLET 0 0 0 0 0 0 0
40 Benzatin B. P. Injek 2,4 juta UI VIAL 0 0 0 0 0 0 0
41 Betametason Krim 0,1 %- 5 mg TUBE 0 25 25 25 75 25 25 0 0
42 Bisakodil Suppositoria 10 mg Supp 5 6 11 10 1 50 6 6 0 0
43 Bisakodil Suppositoria 5 mg Supp 0 12 12 8 4 50 6 6 0 0
44 Bisaprolol tab 5mg TABLET 0 0 0 0 100 0 0 0
45 Bromhexin Syrup Botol 0 0 0 0 100 0 0 0
46 Bromhexin Tablet 8 mg TABLET 0 0 0 0 1000 0 0 0
47 Ca-Glukonas injeksi IV 10% Ampul 14 10 24 20 4 25 24 24 0 0
48 Captopril Tablet 25 mg TABLET 0 1000 1000 1000 0 1500 1000 1000 0 0
49 Catgut Chromic No.2/0 Sachet 5 15 20 20 0 15 15 15 0 0
50 Catgut Chromic No.3/0 Sachet 3 15 18 18 0 15 15 15 0 0
51 Catgut plain No.2/0 Sachet 0 7 7 7 0 15 7 7 0 0
52 Catgut Plain No.3/0 Sachet 0 15 15 10 5 15 15 15 0 0
53 Cefadroxil Kapsul 500 mg KAPSUL 200 400 600 600 0 800 400 400 0 0
54 Cetirizin Tablet 10mg TABLET 0 500 500 500 0 1000 500 500 0 0
55 Cimetidine Tablet 200 mg TABLET 0 0 0 0 100 0 0 0
56 Clindamycin Kapsul 150mg KAPSUL 100 200 300 100 200 200 200 200 0 0
57 Clindamycin Kapsul 300mg KAPSUL 350 200 550 250 300 300 100 100 0 0
58 Clobazam Tablet 10 mg TABLET 0 0 0 0 100 100 100 0 0
59 Clozapin 25 mg TABLET 700 0 700 100 600 100 100 100 0 0
60 Codein 20 mg TABLET 0 0 0 0 200 0 0 0
61 Cyprofloxacin Tablet 500 mg TABLET 700 0 700 500 200 500 500 500 0 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 30 0 30 30 0 50 30 30 0 0
63 Deksametason Tablet 0,5 mg TABLET 0 2000 2000 2000 0 2000 1500 1500 0 0
64 Devitalisasi Pasa Non Arsen BOTOL 0 0 0 0 0 0 0
65 Dextran 6% BOTOL 0 0 0 0 0 0 0
66 Diazepam Injeksi 5 mg/ ml- 2 ml AMPUL 24 0 24 15 9 10 10 10 0 0
67 Diazepam Rectal Tube 5mg Tube 0 0 0 0 15 0 0 0
68 Diazepam Tablet 2 mg TABLET 0 0 0 0 100 0 0 0
70 Difenhidramin HCL Injeksi AMPUL 100 0 100 45 55 20 30 30 0 0
71 Digoxin 0,25 mg TABLET 100 100 200 120 80 200 100 100 0 0
72 Domperidon Syrup Botol 0 10 10 10 0 30 15 15 0 0
73 Domperidon Tablet 10mg TABLET 0 100 100 100 0 200 100 100 0 0
74 Doxycilkin 100 mg kapsul KAPSUL 200 0 200 100 100 0 0 0
75 Efedrin HCL 25 mg TABLET 0 0 0 0 200 0 0 0
76 Ekstrak Belladone 10 mg TABLET 0 0 0 0 0 0 0
77 Epinefrin (Adrenalin) injeksi 0,1 % AMPUL 40 0 40 10 30 0 0 0
78 Eritromisin sirup 200 mg/ 5 ml BOTOL 60 0 60 30 30 50 15 15 0 0
79 Erythromicin 250 mg KAPSUL 200 0 200 110 90 200 200 200 0 0
80 Erythromicin 500 mg KAPSUL 100 0 100 100 0 200 100 100 0 0
81 Etakridine ( Rivanol ) 0,1 % BOTOL 1 2 3 3 0 3 2 2 0 0
82 Etambutol 500 mg TABLET 0 0 0 0 0 0 0
83 Etanol 70 % 100 ml BOTOL 0 0 0 0 10 0 0 0
84 Etanol 70 % 1000 ml BOTOL 1 2 3 3 0 3 1 1 0 0
85 Etil Klorida Semprot BOTOL 0 0 0 0 5 0 0 0
86 Eugenol Cairan BOTOL 1 0 1 1 0 10 1 1 0 0
87 Extrak Plasenta dan Neomisin Jeli tuBE 8 10 18 18 0 20 0 0 0
88 Fenilbutazone Tablet 200 mg TABLET 0 0 0 0 0 0 0
89 Fenobarbital Injeksi 50 mg/ ml AMPUL 23 0 23 23 0 0 0 0
90 Fenobarbital Tablet 30 mg TABLET 0 0 0 0 0 0 0
91 Fenoksimetil Penisilina 250 mg TABLET 0 0 0 0 0 0 0
92 Fenoksimetil Penisilina 500 mg TABLET 0 0 0 0 0 0 0
93 Fenolgliserol TT 10 % 5 ml BOTOL 26 0 26 26 0 10 24 24 0 0
94 Fitomenadion Injeksi 10 mg/ ml AMPUL 0 0 0 0 10 0 0 0
95 Fitomenadion Injeksi 2 mg/ ml AMPUL 40 0 40 20 20 10 30 30 0 0
96 Fitomenadion Salut Gula 10 mg TABLET 0 100 100 100 0 100 100 100 0 0
97 Fluoksetin 10 mg TABLET 0 0 0 0 0 0 0
98 Folley Catheter No. 18 Buah 5 10 15 10 5 10 10 10 0 0
99 Folley Catheter No. 20 Buah 6 10 16 10 6 10 10 10 0 0
100 Forinokresol (TKF) 10 ml BOTOL 0 0 0 0 0 0 0
101 Furosemid Tablet 40 mg TABLET 0 200 200 200 0 200 200 200 0 0
102 Garam Oralit 200 ml Air SASE 200 300 500 500 0 400 300 300 0 0
103 Gentamisin injeksi 40 mg/ ml AMPUL 0 0 0 0 0 0 0
104 Gentamisin Salep Kulit 0.1% TUBE 0 12 12 12 0 36 12 12 0 0
105 Gentian Violet Larutan 1 % 10 ml BOTOL 0 0 0 0 50 0 0 0
106 Glass Ionomer Cement ( Fuji GC IX ) BOTOL 0 1 1 1 0 2 1 1 0 0
107 Glibenklamid 5 mg TABLET 700 0 700 400 300 100 100 100 0 0
108 Gliseril Guayakolat 100 mg TABLET 0 0 0 0 2000 0 0 0
109 Gliseril Guayakolat Syrup Botol 0 0 0 0 100 0 0 0
110 Gliserin lar. 50% BOTOL 0 5 5 5 0 5 5 5 0 0
111 Glukosa Larutan Infus 10% Steril BOTOL 0 7 7 3 4 7 7 7 0 0
112 Glukosa Larutan Infus 40% Steril VIAL 0 7 7 5 2 7 7 7 0 0
113 Glukosa Larutan Infus 5% Steril BOTOL 30 0 30 2 28 0 0 0
114 Griseofulvin 125 mg, micronized TABLET 100 100 200 100 100 200 0 0 0
115 Haloperidol 0,5mg TABLET 300 0 300 300 200 200 200 0 0
116 Haloperidol 1,5 mg TABLET 219 0 219 219 200 100 100 0 0
117 Haloperidol 5 mg TABLET 0 0 0 0 200 0 0 0
118 Haloperidol injeksi 5 mg/ml AMPUL 5 0 5 5 10 5 5 0 0
119 Haloperidol injeksi 50 mg/ml AMPUL 0 0 0 0 10 0 0 0
120 Hand Sanitizer Botol 5 0 5 5 0 0 0 0
121 Hidrogen Peroksida Lar. 3 % BOTOL 8 0 8 8 0 10 5 5 0 0
122 Hidroklorotiazid ( HCT ) 25 mg TABLET 50 100 150 100 50 100 100 100 0 0
123 Hidrokortison Krim 2,5 % TUBE 0 48 48 48 0 72 48 48 0 0
124 Hyoscine N Butilbromide 10 mg TABLET 200 200 400 400 0 300 200 200 0 0
125 Ibuprofen 200 mg TABLET 0 400 400 400 0 500 400 400 0 0
126 Ibuprofen 400 mg TABLET 0 0 0 0 1000 0 0 0
127 Ibuprofen suspensi 200mg/5ml BOTOL 0 20 20 20 0 100 15 15 0 0
128 Infusion Set Anak SET 20 25 45 26 19 25 25 25 0 0
129 Infusion Set Dewasa SET 10 25 35 30 5 25 25 25 0 0
130 Isoniazid 300 mg TABLET 0 0 0 0 0 0 0
131 Isosorbid dinitrat 5 mg TABLET 100 100 200 100 100 200 200 200 0 0
132 IV Catheter/abocath No. 18 Buah 6 5 11 11 0 30 5 5 0 0
133 IV Catheter/abocath No. 20 Buah 10 20 30 30 0 25 20 20 0 0
134 IV Catheter/abocath No.22 Buah 0 15 15 15 0 25 15 15 0 0
135 IV Catheter/abocath No.24 Buah 0 10 10 10 0 25 10 10 0 0
136 Kalium Diklofenak 50 mg TABLET 0 0 0 0 400 0 0 0
137 Kalsium Hidroksida Pasta KOTAK 0 0 0 0 10 1 1 0 0
138 Kalsium Laktat 500 mg TABLET 400 300 700 500 200 300 300 300 0 0
139 Kapas Pembalut 250 mg ROL 2 0 2 2 0 10 1 1 0 0
140 Karbamazepin 200 mg TABLET 200 0 200 200 0 0 0
141 Kasa Kompres 16x16 steril KOTAK 5 20 25 20 5 25 10 10 0 0
142 Kasa Pembalut 36 mx 80 cm ROL 0 1 1 1 0 3 1 1 0 0
143 Kasa Pembalut Hidrofil 4 m x 10 cm ROL 30 0 30 20 10 10 10 10 0 0
144 Kasa Pembalut Hidrofil 4 m x 5 cm ROL 10 0 10 10 0 10 10 10 0 0
145 Ketokonazol 200 mg TABLET 0 100 100 100 0 500 100 100 0 0
146 Ketokonazol Krim 2 % Tube 15 g 0 25 25 25 0 50 25 25 0 0
147 Kloramfenikol 250 mg KAPSUL 0 200 200 100 100 300 200 200 0 0
148 Kloramfenikol SM TUBE 0 0 0 0 50 24 24 0 0
149 Kloramfenikol TM 0.5 % 5 ml BOTOL 0 0 0 0 25 0 0 0
150 Kloramfenikol TT 3 % 5 ml BOTOL 0 0 0 0 25 0 0 0
151 Klorfeniramin Maleat (CTM) 4 mg TABLET 0 1000 1000 1000 0 2000 1500 1500 0 0
152 Klorfenol kamfer Mentol(CHKM) Cairan BOTOL 0 0 0 0 0 0 0
153 Klorin Cair Lar. 5% BOTOL 1 2 3 3 0 2 1 1 0 0
154 Klorpromazine tab 100mg TABLET 500 100 600 600 100 0 0 0
155 Klorpromazine tab 25mg TABLET 0 0 0 0 300 0 0 0
156 Komb : Pirimetamin+sulfadoxin TABLET 0 0 0 0 0 0 0
157 Komposit Resin Botol 10 ml 0 0 0 0 0 0 0
158 Kontrasepsi injek depo/ KB 3 bln vial 0 0 0 0 100 20 20 0 0
159 Kontrasepsi Oral (Pil KB) Blister 300 0 300 200 100 0 0 0
160 Kotrimoksazole Suspensi BOTOL 0 100 100 100 0 180 100 100 0 0
161 Kotrimoksazole Tablet Dewasa TABLET 0 200 200 100 100 500 200 200 0 0
162 Larutan Benedict 100 ml BOTOL 0 0 0 0 0 0 0
163 Larutan Eosin 2 % 100 ml BOTOL 0 0 0 0 0 0 0
164 Larutan Etanol asam 100 ml BOTOL 0 0 0 0 0 0 0
165 Larutan Giemsa stain 100 ml BOTOL 0 0 0 0 0 0 0
166 Larutan Iodine Test BOTOL 0 0 0 0 0 0 0
167 Larutan Karbol Fuksin 100 ml BOTOL 0 0 0 0 0 0 0
168 Larutan Metilen Biru BOTOL 0 0 0 0 0 0 0
169 Larutan Turk BOTOL 0 0 0 0 0 0 0
170 Laxadin Syrup Botol 0 10 10 10 0 10 0 0 0
171 Levertrans Salep POT 0 0 0 0 10 0 0 0
172 Lidokain Injeksi 2% AMPUL 0 50 50 28 22 100 50 50 0 0
173 Lidokain Jeli 2% Syringe 0 0 0 0 3 0 0 0
174 Lidokain Komp Injeksi AMPUL 75 0 75 20 55 0 0 0
175 Lisol BOTOL 1L 1 2 3 3 0 2 2 2 0 0
176 Loratadin tab 10mg TABLET 0 100 100 50 50 200 100 100 0 0
177 Lubricating Jeli (Aquagel) Tube 0 2 2 2 0 5 0 0 0
178 Magnesium Sulfat Injeksi 20 % VIAL 0 5 5 5 0 10 0 0 0
179 Magnesium Sulfat Injeksi 40 % VIAL 0 5 5 5 0 10 0 0 0
180 Masker 3 Fly earloop Buah 0 50 50 50 0 100 50 50 0 0
181 Masker N95 Single valve Buah 10 0 10 10 0 10 5 5 0 0
182 Mebendazol tablet 100mg TABLET 0 0 0 0 100 0 0 0
183 Meloxicam 15mg TABLET 0 0 0 0 300 0 0 0
184 Metformin HCl Tablet 500mg TABLET 200 0 200 100 100 0 0 0
185 Metil Prednisolon 4 mg TABLET 0 200 200 100 100 500 200 200 0 0
186 Metildopa tab sal 250 mg TABLET 0 0 0 0 400 0 0 0
187 Metilergometrin Maleat Inj. 0,200 AMPUL 165 0 165 165 0 10 10 10 0 0
188 Metilergometrin Maleat tab 0,125 mg TABLET 300 0 300 150 150 0 0 0
189 Metisoprinol TABLET 0 0 0 0 0 0 0
190 Metoklopramide 10 mg TABLET 0 300 300 250 50 400 200 200 0 0
191 Metoklopramide Drop 5mg/ml BOTOL 10 10 20 20 0 10 10 10 0 0
192 Metoklopramide injeksi 5mg/ml AMPUL 0 0 0 0 0 0 0
193 Metoklopramide syrup 5mg/ml BOTOL 3 0 3 3 0 20 15 15 0 0
194 Metronidazol Larutan infus 5mg/ml BOTOL 0 0 0 0 0 0 0
195 metronidazol ovula Ovula 39 0 39 30 9 50 30 30 0 0
196 Metronidazol suppositoria 500mg Supp 0 0 0 0 20 0 0 0
197 Metronidazole 250 mg TABLET 0 0 0 0 300 0 0 0
198 Metronidazole 500 mg TABLET 0 300 300 300 0 500 200 200 0 0
199 Mikonazol krim 2% TUBE 0 24 24 24 0 48 24 24 0 0
200 Mometason Furoat Krim 0.1% Tube 10g 0 10 10 10 0 30 0 0 0
201 Multivitamin Syrup Botol 0 0 0 0 48 0 0 0
202 Multivitamin tablet Caplet 0 200 200 200 0 700 200 200 0 0
203 Mummifying Fasta BOTOL 0 0 0 0 0 0 0
204 Narium Tiroksin 100 µg TABLET 0 0 0 0 0 0 0
205 Natrium Bikarbonat 500 mg TABLET 0 0 0 0 200 0 0 0
206 Natrium bikarbonat injeksi VIAL 0 0 0 0 0 0 0
207 Natrium Diklofenak 50 mg TABLET 0 200 200 200 0 500 200 200 0 0
208 Natrium Fusidat Krim tube 0 0 0 0 10 0 0 0
209 Natrium Klorida Infus 0,9 % Steril BOTOL 63 0 63 63 0 0 0 0
210 Nipedifin 10 mg TABLET 0 0 0 0 200 0 0 0
211 Nistatin 100.000 IU/ Gram Vaginal TABLET 65 0 65 65 0 0 0 0
212 OAT FDC 1,3 PAKET 0 10 10 10 0 10 10 10 0 0
213 OAT Kategori 1 PAKET 0 0 0 0 0 0 0
214 OAT Kategori 2/FDC 2 PAKET 0 0 0 0 0 0 0
215 OAT Kategori 3 PAKET 0 0 0 0 0 0 0
216 OAT Kategori Anak PAKET 0 5 5 5 0 5 5 5 0 0
217 OAT Sisipan PAKET 0 0 0 0 0 0 0
218 Obat Batuk Hitam ( OBH ) 100 ml BOTOL 0 0 0 0 100 0 0 0
219 Obat Batuk Pilek Kombinasi Syrup BOTOL 0 0 0 0 50 0 0 0
220 Obat Batuk Pilek Kombinasi Tablet TABLET 0 0 0 0 500 0 0 0
221 Obat Diare Syrup (Kombinasi Attapulgit 700 TABLET 0 0 0 0 24 0 0 0
222 Obat Diare Tablet TABLET 0 100 100 100 0 500 0 0 0
223 Obat Flu Kombinasi Tablet TABLET 0 100 100 100 0 400 100 100 0 0
224 Ofloxacin tab 400mg TABLET 0 0 0 0 0 0 0
225 Oksigen Kaleng Botol 0 2 2 2 0 2 2 2 0 0
226 Oksimetazolin Tetes Hidung 0,025% Botol 0 0 0 0 10 0 0 0
227 Oksitetrasiklin HCL Inj 1m 50 mg VIAL 0 0 0 0 0 0 0
228 Oksitetrasiklin HCL SK 1 % 3,5 Gr TUBE 0 0 0 0 48 0 0 0
229 Oksitetrasiklin HCL SM 1 % 3,5 Gr TUBE 0 25 25 25 0 48 25 25 0 0
230 Oksitosin Injeksi 10 IU/ ml AMPUL 190 0 190 100 90 0 0 0
231 Omeprazol injeksi 40 mg/ 10 ml AMPUL 0 10 10 10 0 50 20 20 0 0
232 Omeprazol Kapsul 20 mg KAPSUL 0 60 60 60 0 300 60 60 0 0
233 Ondansetron 4 mg TABLET 0 36 36 36 0 180 36 36 0 0
234 Ondansetron inj 4 mg/ 2 mL Ampul 0 20 20 20 0 25 20 20 0 0
235 Papaverin 40 mg/ ml injeksi AMPUL 0 0 0 0 0 0 0
236 Parasetamol Drops BOTOL 91 0 91 90 1 50 56 56 0 0
237 Parasetamol Syrup 120 mg/ ml BOTOL 0 100 100 100 0 300 100 100 0 0
238 Parasetamol tablet 100 mg TABLET 0 100 100 100 0 300 100 100 0 0
239 Parasetamol tablet 500 mg TABLET 1000 10000 11000 9000 2000 10000 5000 5000 0 0
240 Pembalut Gips Rol 1 0 1 1 0 3 0 0 0
241 Permetrin Krim 5% (Scabimite) TUBE 0 10 10 10 0 100 10 10 0 0
242 Pirantel Pamoat 125 mg TABLET 250 0 250 200 50 0 0 0
243 Pirantel Suspensi 125mg/5ml BOTOL 20 0 20 20 0 0 0 0
244 Piridoksin HCL 10 mg TABLET 0 500 500 500 0 500 500 500 0 0
245 Piroxicam 20 mg KAPSUL 0 200 200 200 0 500 200 200 0 0
246 Plester 6 Yards x 2 Inch ROL 0 1 1 1 0 5 1 1 0 0
247 Polikresulen 360 mg 10 ml BOTOL 0 0 0 0 20 0 0 0
248 Povidon Iodida 10 % 30 ml BOTOL 2 10 12 12 0 10 10 10 0 0
249 Povidon Iodida 10 % 300 ml BOTOL 0 5 5 5 0 5 4 4 0 0
250 PP test Buah 170 0 170 170 0 100 60 60 0 0
251 Prednison 5 mg TABLET 0 500 500 500 0 500 500 500 0 0
252 Prokain Benzil Penisili 3 Jt IU VIAL 0 0 0 0 0 0 0
253 Propiltiourasil tablet 100mg TABLET 100 0 100 100 0 0 0 0
254 Propranolol HCL 40 mg TABLET 150 0 150 150 0 0 0 0
255 Pyrazinamide 500 mg TABLET 0 0 0 0 0 0 0
256 Ranitidin Injek Ampul 72 0 72 70 2 100 40 40 0 0
257 Ranitidin tablet 150mg TABLET 0 1000 1000 1000 0 1000 1000 1000 0 0
258 Reserpin 0,25 mg TABLET 0 0 0 0 0 0 0
259 Retinol (Vit. A) 100.000 IU KAPSUL 0 0 0 0 100 0 0 0
260 Retinol (Vit. A) 200.000 IU KAPSUL 0 0 0 0 100 0 0 0
261 Rifampisin 300 mg KAPSUL 0 0 0 0 0 0 0
264 Risperidon Tablet 2 mg TABLET 200 0 200 200 0 200 100 100 0 0
265 RL Larutan infus Steril 500ml BOTOL 20 100 120 120 0 100 100 100 0 0
266 Sacharum Lactis kaleng 0 0 0 0 2 0 0 0
267 Salbutamol 2 mg TABLET 0 100 100 100 0 500 100 100 0 0
268 Salbutamol 4 mg TABLET 0 100 100 100 0 500 100 100 0 0
269 Salbutamol Cairan inhalasi 0,1 % Botol plastik 8 5 13 13 0 50 5 5 0 0
270 Salbutamol Inhalasi /Aerosol 100 mcg/dosis Botol 0 0 0 0 5 0 0 0
271 Salep 2-4 Komb. POT 0 24 24 24 0 0 0 0
272 Salisil Bedak 2 % 50 Gram KOTAK 0 0 0 0 100 0 0 0
273 Sarung tangan Gynecology Pasang 15 0 15 15 0 0 0 0
274 Sarung tangan No. 6.5 Pasang 10 0 10 10 0 10 10 10 0 0
275 Sarung tangan No. 7 Pasang 10 0 10 10 0 10 10 10 0 0
276 Sarung tangan No. 7.5 Pasang 5 0 5 5 0 10 10 10 0 0
277 Sarung Tangan Periksa L Buah 0 100 100 100 0 200 100 100 0 0
278 Sarung Tangan Periksa M Buah 0 100 100 100 0 200 100 100 0 0
279 Sefiksim syrup kering 100mg/5ml BOTOL 0 10 10 10 0 50 10 10 0 0
280 Sefixime 100 mg TABLET 0 100 100 100 0 500 100 100 0 0
281 Semen Seng Fosfat Serbuk + Cair BOTOL 0 1 1 1 0 1 1 1 0 0
282 Serum ABU Injek. 5 ml (ABU I ) VIAL 5 ml 0 0 0 0 0 0 0
283 Serum ADS 20.000 iu VIAL 5 ml 0 0 0 0 0 0 0
284 Serum ATS Injek. 1.500 IU AMPUL 16 0 16 16 0 0 0 0
285 Serum ATS Injek. 20.000 IU VIAL 0 0 0 0 0 0 0
286 Sianokobalamin Injeksi 500mcg/ ml AMPUL 20 0 20 20 0 100 100 100 0 0
287 Silk No 3/0( Benang Bedah Sutera) SACHET 52 0 52 34 18 10 36 36 0 0
288 Silver Amalgam serbuk 65-75 % BOTOL 0 0 0 0 0 0 0
289 Simvastatin 10mg TABLET 30 60 90 90 0 150 60 60 0 0
290 Stomach Tube No. 12 Buah 0 0 0 0 0 0 0
291 Strip Test Asam Urat Pak 25 0 0 0 0 1 0 0 0
292 Strip Test Glukosa Pak 50 0 0 0 0 1 0 0 0
293 Strip Test Kolesterol Pak 10 0 0 0 0 1 0 0 0
294 Sulfasetamida Na. TM 15 % 5ml BOTOL 0 0 0 0 25 0 0 0
295 Tablet Tambah Darah Dewasa TABLET 1000 39300 40300 5000 35300 39300 0 mcai 0 0
296 Tablet Tambah Darah Dewasa 2 (Hemafort) TABLET 0 0 0 0 1000 0 0 0
297 Temporary Stopping Fletcher SET 0 1 1 1 0 1 1 1 0 0
298 Test HIV I (Vikia) Buah 0 0 0 0 0 0 0
299 Test HIV II (intec) Buah 0 0 0 0 0 0 0
300 Test HIV III (Onco) Buah 0 0 0 0 0 0 0
301 Test Siphylis Buah 0 0 0 0 0 0 0
302 Tetrasiklin HCL 250 mg KAPSUL 100 0 100 50 50 200 100 100 0 0
303 Tetrasiklin HCL 500 mg KAPSUL 100 100 200 50 150 200 100 100 0 0
304 Thiamfenikol kap 500mg KAPSUL 100 100 200 200 0 300 0 0 0
305 Thiamfenikol Syrup BOTOL 30 0 30 25 5 50 0 0 0
306 Thiamin HCL (Vit. B1 ) Injek.100 mg AMPUL 0 30 30 30 0 100 0 0 0
307 Thiamin HCL (Vit. B1) 100 mg TABLET 0 0 0 0 1000 0 0 0
308 Thiamin HCL (Vit. B1) 50 mg TABLET 0 300 300 300 0 1000 300 300 0 0
309 Tramadol tablet 50mg TABLET 0 0 0 0 100 0 0 0
310 Trifluoferazin 5 mg TABLET 0 0 0 0 0 0 0
311 Trihexyphenidil HCL 2 mg KAPSUL 100 100 200 200 0 200 100 100 0 0
312 Umbilical cord klem Buah 135 0 135 40 95 0 0 0
313 Urea Krim 10 % (Soft U Derm) TUBE 0 10 10 10 0 10 0 0 0
314 Urine Bag BUAH 0 0 0 0 10 0 0 0
315 Vaksin Anti Rabies Vero KUUR 0 0 0 0 0 0 0
316 Vitamin B. Komplek TABLET 0 500 500 500 0 2000 200 200 0 0
317 Vitamin B12 tablet 50mg TABLET 0 100 100 100 0 1000 300 300 0 0
318 Vitamin Neurotropik TABLET 0 0 0 0 1000 0 0 0
319 Wing Needle No.25,27 BUAH 15 0 15 15 0 20 20 20 0 0
320 Zink dispersibel tablet TABLET 200 500 700 700 0 1000 500 500 0 0
321 Asetil Sistein Kapsul 200 mg Tablet 2350 240 2590 1100 1490 500 240 240 0 0
322 Betahistin Maesylate Tablet 170 120 290 290 0 150 150 150 0 0
323 Bioplasenton Tule 10x10 kotak 0 5 5 5 0 10 3 3 0 0
324 Bisturi No. 10,15, 20 buah 25 0 25 15 10 10 0 0 0
325 Cetirizin Syrup Botol 0 15 15 15 0 30 15 15 0 0
326 Dehidroartemisin +piperaquin TABLET 0 0 0 0 0 0 0
327 Gentamisin TM Botol 0 24 24 24 0 48 24 24 0 0
328 Hiosin N Butil Bromida injeksi AMPUL 190 0 190 45 145 50 20 20 0 0
329 Kaca Slide Buah 0 0 0 0 0 0 0
330 Kontrasepsi Suntik KB I bulan vial 0 0 0 0 20 0 0 0
331 Masker Tali Buah 0 50 50 50 0 100 50 50 0 0
332 Primakuin TABLET 0 0 0 0 0 0 0
333 Tabung EDTA Buah 0 0 0 0 0 0 0
334 Vaksin BCG Vial 18 10 28 28 0 20 20 20 0 0
335 Vaksin HB Uniject Vial 35 20 55 45 10 30 30 30 0 0
336 Vaksin DPT-HB/HIB Vial 22 40 62 47 15 50 50 50 0 0
337 Vaksin Polio (bOPV) Vial 36 40 76 70 6 60 20 20 0 0
338 Vaksin Polio IPV 5 Dosis Vial 30 0 30 14 16 10 10 10 0 0
339 Vaksin Campak Vial 0 0 0 0 0 0 0
340 Vaksin Td Vial 10 20 30 20 10 30 30 30 0 0
341 Pelarut BCG Vial 18 10 28 28 0 20 20 20 0 0
342 Pelarut Campak Vial 0 0 0 0 0 0 0
343 Dropper Polio Buah 60 0 60 60 0 60 60 60 0 0
344 Vaksin Polio IPV 10 Dosis Vial 0 0 0 0 0 0 0
345 Vaksin Campak MR Vial 20 20 40 40 0 20 20 20 0 0
346 Pelarut Campak MR Vial 20 20 40 40 0 20 20 20 0 0
347 Nistatin Drops Botol 15 10 25 25 30 10 10 0 0
348 Ichtiol Salep Pot 17 0 17 17 20 10 10 0 0
349 Tensi ABN 0 0 0 0 0 2 2
350 Cholesterol ET 0 0 0 0 0 10 10
351 Gula ET 0 0 0 0 0 10 10
352 Handscoon 0 0 0 0 0 200 200
353 Delle 0 0 0 0 0 1 1
354 Spuit 3 CC 0 0 0 0 0 500 500
Mengetahui/menyetujui, Yang menyerahkan, Yang meminta, Yang Menerima,

Kepala Dinas Kesehatan Kab. Cianjur Kepala Seksi Kefarmasian Kepala Puskesmas Petugas Puskesmas
…………………………………………. Meita Triwendyarti, S.Si, Apt, MH Javed S Mataputung, SAP Yuni maria
NIP. …………………………………… NIP 19760505 200604 2 025 NIP 19720913 199403 1 002 NIP 19720603 199503 2 004
PUSKESMAS
KECAMATAN : CIKALONGKULON
PELAPORAN BULAN : November 2021 SIE. FARWASMAMIN 02/SBBK/XII/2021 ###
PERMINTAAN BULAN : Desember 2021
Jumlah Stok Stok PEMBERIAN

NO NAMA OBAT SATUAN Stok Awal Penerimaan Pemakaian Permintaan
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Acyclovir tab 200mg TABLET 0 0 0 0 500 0
3 Air Raksa Dental Use BOTOL 0 0 0 0 0
4 Alat Suntik Sekali Pakai 1 ml SET 300 0 300 300 0 500 500 500
6 Alat Suntik Sekali Pakai 5 ml SET 155 200 355 355 0
8 Albendazol tab TABLET 0 4000 4000 4000 0
9 Albendazol Syr Botol 0 0 0 0 0
10 Alkohol Swab KOTAK 10 48 58 19 39 0
11 Alopurinol Tablet 100 mg TABLET 0 1000 1000 200 800 0
12 Aminofilin Injeksi 24 mg/ ml AMPUL 0 0 0 0 0
13 Aminofilin Tablet 200 mg TABLET 0 0 0 0 0
14 Amitriptilin HCL 25 mg TABLET 0 200 200 10 190 0
15 Amlodipin Tablet 10 mg TABLET 1100 1000 2100 500 1600 0
17 Amoksisilin 250 mg KAPSUL 0 0 0 0 3000 0
18 Amoksisilin 500 mg TABLET 3800 0 3800 3800 0
19 Amoksisilin + Asam Klavulanat TABLET 0 0 0 0 0
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 240 240 480 120 120 300 300 300
21 Ampisillin Serbuk 1.000 mg injeksi VIAL 0 0 0 0 0
SBBK LAIN-LAIN (AMPRAHAN DILUAR DISTRIBUSI)
Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET
1 2 3 4 5 6
22 Antasida DOEN I tablet kunyah TABLET 700 2000 2700 1700 1000 1500 1500 1500
23 Antasida DOEN II suspensi, Botol 0 200 200 200 0 300 300 300
24 Anti Bakteri DOEN salep kombinasi TUBE 0 0 0 0 0
25 Anti fungi DOEN Kombinasi POT 0 0 0 0 20 0
26 Anti Hemoroid Doen Kombinasi SUP 0 50 50 10 40 0
27 Antihemoroid Kapsul Kapsul 0 0 0 0 0
28 Antimigren tablet: Ergotamin Tartrat 1 mg + Ko TABLET 0 0 0 0 0
29 Aqua Proinjeksi Steril VIAL 10 0 10 10 0 0
30 Asam Askorbat 50 mg (Vit C) TABLET 800 2000 2800 2800 0 2000 2000 2000
31 Asam Askorbat 500 mg (Vit C) TABLET 0 0 0 0 0
32 Asam Mefenamat 500 mg TABLET 1200 2000 3200 1900 1300 2000 2000 2000
33 Asam Traneksamat injeksi 100 mg/ml Ampul 0 0 0 0 0
34 Asetil Sistein Kapsul 200 mg Tablet 0 300 300 300 0
35 Atropin Sulfat Injeksi 0,25 mg AMPUL 0 0 0 0 0
36 Benzatin B. P. Injek 2,4 juta UI VIAL 0 0 0 0 0
37 Betahistin Maesylate Tablet 0 0 0 0 1000 0
38 Betametason Krim 0,1 %- 5 mg TUBE 0 48 48 48 0 240 240 240
39 Bioplasenton Tule 10x10 kotak 0 0 0 0 20 0
40 Bisakodil Suppositoria 10 mg Supp 0 0 0 0 0
42 Bisturi No. 10,15, 20 buah 0 0 0 0 0
43 Ca-Glukonas injeksi IV 10% Ampul 0 0 0 0 50 0
44 Captopril Tablet 12.5 mg TABLET 700 500 1200 200 1000 0
45 Captopril Tablet 25 mg TABLET 900 500 1400 600 800 0
46 Captopril Tablet 50 mg TABLET 0 0 0 0 0
47 Catgut Chromic No.2/0 Sachet 24 0 24 24 0
49 Catgut plain No.2/0 Sachet 48 0 48 48 0
50 Catgut Plain No.3/0 Sachet 48 0 48 48 0
51 Cefadroxil Kapsul 500 mg KAPSUL 0 0 0 0 500 0
52 Cefixime + Azithromisin kombipak Box 0 0 0 0 0
53 Cetirizin Tablet 10mg TABLET 0 0 0 0 0
54 Cetirizin Syrup Botol 50 50 100 50 50 50 50 50
55 Clindamycin Kapsul 150mg KAPSUL 0 0 0 0 500 0
57 Clobazam Tablet 10 mg TABLET 125 0 125 15 110 100 0
58 Clozapin 25 mg TABLET 0 0 0 0 200 200 200
59 Codein 20 mg TABLET 0 0 0 0 0
60 Cyprofloxacin Tablet 500 mg TABLET 0 0 0 0 500 0
61 Dehidroartemisin +piperaquin TABLET 0 0 0 0 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 80 0 80 15 65 100 100 100
63 Deksametason Tablet 0,5 mg TABLET 0 0 0 0 2000 2000 2000
64 Devitalisasi Pasa Non Arsen BOTOL 0 0 0 0 0
65 Dextran 6% BOTOL 0 0 0 0 50 0
66 Diazepam Injeksi 5 mg/ ml- 2 ml AMPUL 19 0 19 2 17 0
67 Diazepam Rectal Tube 5mg Tube 20 0 20 1 19 0
70 Difenhidramin HCL Injeksi AMPUL 30 0 30 20 10 60 60 60
71 Digoxin 0,25 mg TABLET 0 0 0 0 0
72 Domperidon Syrup Botol 90 0 90 90 0
73 Domperidon Tablet 10mg TABLET 500 0 500 400 100 0
74 Doxycilkin 100 mg kapsul KAPSUL 0 0 0 0 0
75 Ekstrak Belladone 10 mg TABLET 0 0 0 0 0
76 Epinefrin (Adrenalin) injeksi 0,1 % AMPUL 0 0 0 0 0
77 Eritromisin sirup 200 mg/ 5 ml BOTOL 10 50 60 25 35 50 50 50
78 Erythromicin 250 mg KAPSUL 0 0 0 0 500 0
80 Etakridine ( Rivanol ) 0,1 % BOTOL 0 0 0 0 0
81 Etambutol 250mg TABLET 0 0 0 0 0
82 Etambutol 500 mg TABLET 0 0 0 0 0
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
85 Etil Klorida Semprot BOTOL 0 0 0 0 3 0
86 Eugenol Cairan BOTOL 0 0 0 0 0
87 Extrak Plasenta dan Neomisin Jeli tuBE 0 0 0 0 0
88 Fenobarbital Injeksi 50 mg/ ml AMPUL 0 0 0 0 0
89 Fenobarbital Tablet 30 mg TABLET 140 0 140 140 0
90 Fenoksimetil Penisilina 250 mg TABLET 0 0 0 0 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 48 0 48 24 24 24 24 24
93 Fitomenadion Injeksi 10 mg/ ml AMPUL 0 0 0 0 0
94 Fitomenadion Injeksi 2 mg/ ml AMPUL 50 0 50 20 30 0
95 Fitomenadion Salut Gula 10 mg TABLET 0 0 0 0 0
96 Flufenazine decanoat inj 25mg/ml AMPUL 0 0 0 0 0
97 Flukonazole Tablet 150 mg tablet 0 0 0 0 500 0
98 Folley Catheter No. 18 Buah 0 0 0 0 0
100 Forinokresol (TKF) 10 ml BOTOL 0 0 0 0 0
101 Furosemid Tablet 40 mg TABLET 0 0 0 0 0
102 Garam Oralit 200 ml Air SASE 900 0 900 100 800 0
103 Gentamisin injeksi 40 mg/ ml AMPUL 0 0 0 0 0
104 Gentamisin Salep Kulit 0.1% TUBE 0 0 0 0 50 0
105 Gentamisin TM Botol 0 0 0 0 50 0
106 Glass Ionomer Cement ( Fuji GC IX ) BOTOL 0 0 0 0 0
107 Glibenklamid 5 mg TABLET 600 0 600 600 0
108 Gliseril Guayakolat 100 mg TABLET 0 0 0 0 2000 0
109 Gliseril Guayakolat Syrup Botol 0 0 0 0 50 0
110 Gliserin lar. 50% BOTOL 0 0 0 0 0
111 Glukosa Larutan Infus 10% Steril BOTOL 0 0 0 0 0
112 Glukosa Larutan Infus 40% Steril VIAL 0 0 0 0 0
114 Griseofulvin 125 mg, micronized TABLET 0 0 0 0 0
115 Haloperidol 0,5mg TABLET 690 0 690 690 0
116 Haloperidol 1,5 mg TABLET 226 0 226 10 216 0
117 Haloperidol 5 mg TABLET 360 0 360 10 350 0
118 Haloperidol injeksi 5 mg/ml AMPUL 0 0 0 0 0
120 Hand Sanitizer Botol 10 0 10 5 5 0
121 Hidrogen Peroksida Lar. 3 % BOTOL 0 0 0 0 0
122 Hidroklorotiazid ( HCT ) 25 mg TABLET 0 0 0 0 0
123 Hidrokortison Krim 2,5 % TUBE 0 0 0 0 98 0
124 Hyoscine N Butilbromide 10 mg TABLET 0 0 0 0 0
125 Hiosin N Butil Bromida injeksi AMPUL 0 0 0 0 0
126 Ibuprofen 200 mg TABLET 0 0 0 0 2000 0
127 Ibuprofen 400 mg TABLET 0 0 0 0 2000 1000 1000
128 Ibuprofen suspensi 200mg/5ml BOTOL 50 0 50 50 0 100 0
129 Ichtiol Salep Pot 0 0 0 0 50 0
130 Infusion Set Anak SET 16 0 16 16 0 0
131 Infusion Set Dewasa SET 280 0 280 30 250 0
132 Isoniazid 300 mg TABLET 0 0 0 0 0
133 IV Catheter/abocath No. 18 Buah 50 0 50 50 0
134 IV Catheter/abocath No. 20 Buah 106 0 106 16 90 0
135 IV Catheter/abocath No.22 Buah 100 0 100 20 80 0
137 Kaca Slide Buah 0 0 0 0 0
138 Kalsium Hidroksida Pasta KOTAK 0 0 0 0 0
139 Kalsium Laktat 500 mg TABLET 0 0 0 0 500 0
140 Kapas Pembalut 250 mg ROL 2 0 2 2 0 0
141 Karbamazepin 200 mg TABLET 270 0 270 10 260 0
142 Kasa Kompres 16x16 steril KOTAK 2 0 2 2 0 0
143 Kasa Pembalut 36 mx 80 cm ROL 0 0 0 0 0
144 Kasa Pembalut Hidrofil 4 m x 10 cm ROL 0 0 0 0 0
146 Ketokonazol 200 mg TABLET 0 0 0 0 500 200 200
147 Ketokonazol Krim 2 % Tube 15 g 44 0 44 44 0
148 Kloramfenikol 250 mg KAPSUL 0 0 0 0 0
149 Kloramfenikol SM TUBE 0 0 0 0 50 0
150 Kloramfenikol Salep Kulit Tube 38 24 62 12 50 0
151 Kloramfenikol TM 0.5 % 5 ml BOTOL 0 0 0 0 0
152 Kloramfenikol TT 3 % 5 ml BOTOL 0 0 0 0 0
153 Klorfeniramin Maleat (CTM) 4 mg TABLET 200 4000 4200 2400 1800 2000 2000 2000
154 Klorfenol kamfer Mentol(CHKM) Cairan BOTOL 0 0 0 0 0
155 Klorin Cair Lar. 5% BOTOL 0 0 0 0 0
156 Klorin / Alkazhym Sachet BUAH 0 0 0 0 0
157 Klorpromazine tab 100mg TABLET 0 0 0 0 0
159 Komb : Pirimetamin+sulfadoxin TABLET 0 0 0 0 0
160 Komposit Resin Botol 10 ml 0 0 0 0 0
161 Kontrasepsi Suntik KB I bulan vial 0 0 0 0 0
162 Kontrasepsi injek depo/ KB 3 bln vial 0 0 0 0 0
163 Kontrasepsi Oral (Pil KB) Blister 0 0 0 0 0
164 Kotrimoksazole Suspensi BOTOL 70 0 70 20 50 0
165 Kotrimoksazole Tablet 480 mg TABLET 0 0 0 0 0
166 Kotrimoksazole Tablet 960 mg TABLET 300 500 800 500 300 0
167 Larutan Iodine Test BOTOL 0 0 0 0 0
168 Lidokain Injeksi 2% AMPUL 50 100 150 30 120 0
169 Lidokain Jeli 2% Syringe 0 0 0 0 0
170 Lidokain Komp Injeksi AMPUL 0 60 60 5 55 0
171 Lisol BOTOL 1L 0 0 0 0 0
172 Loratadin tab 10mg TABLET 0 0 0 0 500 0
173 Lubricating Jeli (Aquagel) Tube 0 0 0 0 0
174 Magnesium Sulfat Injeksi 20 % VIAL 0 0 0 0 0
175 Magnesium Sulfat Injeksi 40 % VIAL 3 0 3 3 0 0
176 Masker 3 Fly earloop Buah 0 1000 700 700 0 1000 1000 1000
177 Masker Tali Buah 0 0 0 0 0
178 Masker N95 Single valve Buah 20 40 60 40 20 40 40 40
179 Mebendazol tablet 100mg TABLET 0 0 0 0 0
180 Metformin HCl Tablet 500mg TABLET 0 600 600 200 400 0
181 Metil Prednisolon 4 mg TABLET 0 500 500 200 300 500 500 500
182 Metildopa tab sal 250 mg TABLET 0 0 0 0 0
183 Metilergometrin Maleat Inj. 0,200 AMPUL 145 0 145 15 130 0
184 Metilergometrin Maleat tab 0,125 mg TABLET 700 0 700 700 0 0
185 Metoklopramide 10 mg TABLET 0 300 300 200 100 200 200 200
186 Metoklopramide Drop 5mg/ml BOTOL 0 0 0 0 50 0
187 Metoklopramide injeksi 5mg/ml AMPUL 0 0 0 0 0
188 Metoklopramide syrup 5mg/ml BOTOL 0 0 0 0 50 0
189 Metronidazol Larutan infus 5mg/ml BOTOL 0 0 0 0 0
190 metronidazol ovula Ovula 0 0 0 0 0
191 Metronidazol suppositoria 500mg Supp 0 0 0 0 0
192 Metronidazole 250 mg TABLET 0 0 0 0 0
194 Metronidazole Suspensi 125mg/mL BOTOL 0 0 0 0 0
195 Mikonazol krim 2% TUBE 48 0 48 48 0
196 Mometason Furoat Krim 0.1% Tube 10g 0 0 0 0 0
197 Multivitamin Syrup Botol 0 0 0 0 50 0
198 Multivitamin tablet Caplet 0 180 180 180 0 0
199 Mummifying Fasta BOTOL 0 0 0 0 0
200 Narium Tiroksin 100 µg TABLET 0 0 0 0 0
201 Natrium Bikarbonat 500 mg TABLET 0 0 0 0 0
202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

203 Natrium Diklofenak 50 mg TABLET 400 1000 1400 400 1000 0
204 Natrium Klorida Infus 0,9 % Steril BOTOL 50 0 50 10 40 0
205 Nipedifin 10 mg TABLET 0 0 0 0 0
206 Nistatin Suspensi Botol 0 0 0 0 50 0
207 Nistatin 100.000 IU/ Gram Vaginal TABLET 0 0 0 0 0
208 OAT FDC 1,3 PAKET 0 8 8 8 0 0
209 OAT Kategori 1 ( kombipak ) PAKET 0 0 0 0 0
210 OAT Kategori 2/FDC 2 PAKET 0 4 4 4 0 0
211 OAT Kategori Anak PAKET 0 4 4 4 0 0
OAT KAT 1 DOSIS HARIAN 0 0 0 0
212 Obat Diare Syrup (Kombinasi Attapulgit 700mg TABLET 0 0 0 0 50 0
213 Obat Diare Tablet TABLET 0 0 0 0 500 0
214 Ofloxacin tab 400mg TABLET 0 0 0 0 0
215 Oksigen Kaleng Botol 0 0 0 0 0
216 Oksimetazolin Tetes Hidung 0,025% Botol 0 0 0 0 0
217 Oksitetrasiklin HCL Inj 1m 50 mg VIAL 0 0 0 0 0
218 Oksitetrasiklin HCL SK 1 % 3,5 Gr TUBE 0 0 0 0 0
219 Oksitetrasiklin HCL SM 1 % 3,5 Gr TUBE 0 0 0 0 50 50 50
220 Oksitosin Injeksi 10 IU/ ml AMPUL 251 0 251 11 240 0
221 Omeprazol injeksi 40 mg/ 10 ml AMPUL 0 0 0 0 0
222 Omeprazol Kapsul 20 mg KAPSUL 0 400 400 200 200 600 400 400
223 Ondansetron 4 mg TABLET 0 0 0 0 0
224 Ondansetron inj 4 mg/ 2 mL Ampul 0 0 0 0 0
225 Papaverin 40 mg/ ml injeksi AMPUL 0 0 0 0 0
226 Parasetamol Drops BOTOL 45 0 45 45 0
227 Parasetamol Syrup 120 mg/ ml BOTOL 0 0 0 0 200 200 200
228 Parasetamol tablet 100 mg TABLET 0 0 0 0 0
229 Parasetamol tablet 500 mg TABLET 83600 0 83600 33500 50100 0
230 Permetrin Krim 5% (Scabimite) TUBE 30 0 30 30 0 50 30 30
231 Pirantel Pamoat 125 mg TABLET 0 0 0 0 0
232 Pirantel Suspensi 125mg/5ml BOTOL 0 0 0 0 0
233 Piridoksin HCL 10 mg TABLET 0 0 0 0 0
234 Piroxicam 20 mg KAPSUL 0 0 0 0 0
235 Plester 6 Yards x 2 Inch ROL 10 0 10 10 0 0
236 Povidon Iodida 10 % 30 ml BOTOL 0 10 10 10 0
237 Povidon Iodida 10 % 300 ml BOTOL 0 5 5 2 3 0
238 PP test Buah 50 0 50 50 0 0
239 Prednison 5 mg TABLET 200 0 200 200 0 0
240 Propiltiourasil tablet 100mg TABLET 0 0 0 0 0
241 Pyrazinamide 500 mg TABLET 0 0 0 0 0
242 Ranitidin Injek Ampul 0 0 0 0 0
243 Ranitidin tablet 150mg TABLET 0 1000 1000 1000 0 2000 300 300
244 Reagen Rapid Tes HBSAG/SD Pcs 181 0 181 181 0
245 Reagen ZN Kit 0 0 0 0 4 0
246 Retinol (Vit. A) 100.000 IU KAPSUL 0 0 0 0 0
248 Rifampisin 300 mg KAPSUL 0 0 0 0 0
251 Risperidon Tablet 2 mg TABLET 189 0 189 62 127 200 200 200
252 RL Larutan infus Steril 500ml BOTOL 140 0 140 40 100 100 100 100
253 Salbutamol 2 mg TABLET 0 200 200 100 100 0
254 Salbutamol 4 mg TABLET 0 200 200 200 0
255 Salbutamol Cairan inhalasi 0,1 % Botol plastik 0 0 0 0 20 20 20
256 Salep 2-4 Komb. POT 0 50 50 20 30 0
257 Salisil Bedak 2 % 50 Gram KOTAK 0 0 0 0 50 0
258 Sarung tangan Gynecology Pasang 0 0 0 0 0
259 Sarung Tangan Gynecology Elbow No.6,5 Pasang 0 0 0 0 0
260 Sarung Tangan Gynecology Elbow No.7 Pasang 0 0 0 0 0
262 Sarung tangan No. 6.5 Pasang 15 0 15 15 0
263 Sarung tangan No. 7 Pasang 20 0 20 20 0
265 Sarung Tangan Periksa L Buah 500 0 500 300 200 2000 2000 2000
266 Sarung Tangan Periksa M Buah 0 0 0 0 1000 0
267 Sarung Tangan Periksa S Buah 0 200 200 200 0 0
268 Sefiksim syrup kering 100mg/5ml BOTOL 0 0 0 0 50 0
269 Sefixime 100 mg TABLET 0 0 0 0 500 0
270 Semen Seng Fosfat Serbuk + Cair BOTOL 0 0 0 0 0
271 Sianokobalamin Injeksi 500mcg/ ml (Vit B12) AMPUL 0 0 0 0 100 100 100
272 Silk No 3/0( Benang Bedah Sutera) SACHET 0 0 0 0 0
273 Simvastatin 10mg TABLET 0 500 500 200 300 0
274 Stomach Tube No. 12 Buah 0 0 0 0 0
275 Strip Test Asam Urat Pak 25 4 0 4 4 0
276 Strip Test Glukosa Pak 50 0 0 0 0 0
277 Strip Test Kolesterol Pak 10 0 0 0 0 0
278 Tablet Tambah Darah Dewasa TABLET 0 100000 100000 100000 0 0
279 Tablet Tambah Darah Dewasa 2 (Hemafort) TABLET 0 0 0 0 0
280 Tabung EDTA Buah 0 0 0 0 0
281 Temporary Stopping Fletcher SET 0 0 0 0 0
282 Test HIV 1/2 SD/ R1 Test 150 0 150 150 0 ED
283 Test HIV Fokus (II)/ R2 Test 0 0 0 0 0
284 Test HIV I (Vikia)/ R3 Buah 396 0 396 396 0
285 Test Siphylis Buah 566 0 566 566 0
286 Tetrasiklin HCL 250 mg KAPSUL 0 0 0 0 0
288 Thiamfenikol kap 500mg KAPSUL 0 0 0 0 0
289 Thiamfenikol Syrup BOTOL 0 0 0 0 0
290 Thiamin HCL (Vit. B1 ) Injek.100 mg AMPUL 0 0 0 0 0
291 Thiamin HCL (Vit. B1) 100 mg TABLET 0 0 0 0 0
293 Tramadol tablet 50mg TABLET 0 0 0 0 0
294 Trifluoferazin 5 mg TABLET 0 0 0 0 0
295 Trihexyphenidil HCL 2 mg KAPSUL 418 0 418 29 389 0
296 Umbilical cord klem Buah 0 0 0 0 0
297 Urea Krim 10 % (Soft U Derm) TUBE 0 0 0 0 0
298 Urine Bag BUAH 20 0 20 20 0
299 Vaksin Anti Rabies Vero KUUR 0 0 0 0 0
300 Vitamin B. Komplek TABLET 0 1500 1500 1500 0 2000 1500 1500
301 Vitamin B12 tablet 50mg TABLET 0 1000 1000 600 400 0
302 Vitamin Neurotropik TABLET 0 0 0 0 0
303 Wing Needle No.25,27 BUAH 0 0 0 0 0
304 Zink dispersibel tablet TABLET 1000 0 1000 200 800 0
305 Vaksin BCG Vial 50 0 50 30 20 30 0
306 Pelarut BCG Vial 50 0 50 30 20 30 0
307 Vaksin HB Uniject Vial 150 0 150 56 94 56 0
308 Vaksin DPT-HB/HIB Vial 110 0 110 38 72 40 0
309 Vaksin Polio (bOPV) Vial 50 0 50 50 0 50 50 50
310 Dropper Polio Buah 50 0 50 50 0 50 50 50
311 Vaksin Polio IPV 5 Dosis Vial 0 0 0 0 0
312 Vaksin Campak Vial 0 0 0 0 0
313 Pelarut Campak Vial 0 0 0 0 0
314 Vaksin Polio IPV 10 Dosis Vial 80 0 80 10 70 0
315 Vaksin Campak MR Vial 157 0 157 50 107 50 0
316 Pelarut Campak MR Vial 187 0 187 80 107 50 0
317 Vaksin Td Vial 50 0 50 42 8 0
318 Alat Suntik 5ml Pcs 107 0 107 107 0 0
319 Alat Suntik 0,5ml Pcs 855 0 855 355 500 0
320 Alat Suntik 0,05ml Test 0 0 0 0 0
321 Safety Box Buah 9 0 9 9 0
322 Pot Dahak Pot 60 0 60 20 40 0
323 Vaksin Hepatitis B ig Syringe 2 2 4 2 2 0
324 Serum ABU Injek. 5 ml (ABU I ) VIAL 5 ml 0 0 0 0 0
325 Serum ATS Injek. 1.500 IU AMPUL 0 0 0 0 0
326 Autoclick Lancing Device Kotak 0 0 0 0 0
327 Blood Lancet No. 26G Kotak 0 0 0 0 0
328 Sharp Continer 7L Pcs 0 0 0 0 0
329 RPR Sypilis Pcs 0 0 0 0 0
330 Alat Suntik Tuberculin Pcs 0 0 0 0 0
331 Centrifuse (HIV) Unit 0 0 0 0 0
332 Holder standard yellow bulk CE Pcs 0 0 0 0 0
333 Tube PLN PLH 13X75 4.0 PLBL RD Pcs 0 0 0 0 0
334 Needle Flashback BOX 0 0 0 0 0
335 CGXMTB/RIF-50-XPERT MTB/RIF 50 Pcs 0 0 0 0 0
336 Surgical Gown Non Woven Pcs 0 0 0 0 0
337 RAK TABUNG REAKSI MULTIPURPOSE Pcs 0 0 0 0 0
Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

0
0
0
…………………………………………. apt. Meita Triwendiyarti S.Si.MH Dasep Sumawiharja, S.Kep.Ners apt. Flora Sekar Pertiwi, S.Farm
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001
PUSKESMAS
PELAPORAN BULAN : Desember 2021 SIE. FARWASMAMIN 55/SBBK/I/2022 10 January 2022
PERMINTAAN BULAN : Januari 2022

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
5 Alat Suntik Sekali Pakai 3 ml SET 70 100 170 70 100 0
8 Albendazol tab TABLET 4000 0 4000 3800 200 0
10 Alkohol Swab KOTAK 39 0 39 39 0
11 Alopurinol Tablet 100 mg TABLET 800 0 800 500 300 1000 1000 1000
14 Amitriptilin HCL 25 mg TABLET 190 0 190 20 170 0
17 Amoksisilin 250 mg KAPSUL 0 0 0 0 0
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 120 300 420 420 0 600 600 600
1 2 3 4 5 6
23 Antasida DOEN II suspensi, Botol 0 300 300 200 100 300 300 300
24 Anti Bakteri DOEN salep kombinasi TUBE 0 0 0 0 0
25 Anti fungi DOEN Kombinasi POT 0 0 0 0 0
29 Aqua Proinjeksi Steril VIAL 0 0 0 0 0
33 Asam Traneksamat injeksi 100 mg/ml Ampul 0 0 0 0 0
34 Asetil Sistein Kapsul 200 mg Tablet 300 0 300 300 0 1000 600 600
40 Bisakodil Suppositoria 10 mg Supp 0 0 0 0 50 50 50
41 Bisakodil Suppositoria 5 mg Supp 0 0 0 0 12 12 12
42 Bisturi No. 10,15, 20 buah 0 0 0 0 0
44 Captopril Tablet 12.5 mg TABLET 1200 0 1200 200 1000 1500 1500 1500
45 Captopril Tablet 25 mg TABLET 800 0 800 300 500 2000 2000 2000
51 Cefadroxil Kapsul 500 mg KAPSUL 0 0 0 0 0
54 Cetirizin Syrup Botol 50 50 100 50 50 200 0
57 Clobazam Tablet 10 mg TABLET 110 0 110 10 100 0
58 Clozapin 25 mg TABLET 0 200 200 10 190 0
60 Cyprofloxacin Tablet 500 mg TABLET 0 0 0 0 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 65 100 165 40 125 0
63 Deksametason Tablet 0,5 mg TABLET 0 2000 2000 2000 0 3000 3000 3000
65 Dextran 6% BOTOL 0 0 0 0 50 0
67 Diazepam Rectal Tube 5mg Tube 19 0 19 19 0
69 Diazepam Tablet 5 mg TABLET 250 100 350 25 325 0
70 Difenhidramin HCL Injeksi AMPUL 10 60 70 10 60 0
72 Domperidon Syrup Botol 90 0 90 90 100 100 100
73 Domperidon Tablet 10mg TABLET 100 0 100 100 0 500 0
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
85 Etil Klorida Semprot BOTOL 0 0 0 0 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 24 24 48 48 24 24 24
94 Fitomenadion Injeksi 2 mg/ ml AMPUL 30 0 30 30 30 30 30
97 Flukonazole Tablet 150 mg tablet 0 0 0 0 0
102 Garam Oralit 200 ml Air SASE 800 0 800 200 600 500 500 500
107 Glibenklamid 5 mg TABLET 600 0 600 100 500 0
111 Glukosa Larutan Infus 10% Steril BOTOL 0 0 0 0 40 20 20
112 Glukosa Larutan Infus 40% Steril VIAL 0 0 0 0 40 20 20
115 Haloperidol 0,5mg TABLET 690 0 690 30 660 0
120 Hand Sanitizer Botol 5 0 5 5 20 20 20
123 Hidrokortison Krim 2,5 % TUBE 0 0 0 0 0
126 Ibuprofen 200 mg TABLET 0 0 0 0 0
128 Ibuprofen suspensi 200mg/5ml BOTOL 0 0 0 0 0
129 Ichtiol Salep Pot 0 0 0 0 0
130 Infusion Set Anak SET 0 0 0 0 0
133 IV Catheter/abocath No. 18 Buah 50 0 50 15 35 50 50 50
136 IV Catheter/abocath No.24 Buah 50 0 50 15 35 50 50 50
137 Kaca Slide Buah 0 0 0 0 50 0
139 Kalsium Laktat 500 mg TABLET 0 0 0 0 0
140 Kapas Pembalut 250 mg ROL 0 0 0 0 0
141 Karbamazepin 200 mg TABLET 260 0 260 260 0
142 Kasa Kompres 16x16 steril KOTAK 0 0 0 0 0
147 Ketokonazol Krim 2 % Tube 15 g 44 0 44 32 12 60 48 48
149 Kloramfenikol SM TUBE 0 0 0 0 0
150 Kloramfenikol Salep Kulit Tube 50 0 50 50 0
162 Kontrasepsi injek depo/ KB 3 bln vial 0 0 0 0 50 0
164 Kotrimoksazole Suspensi BOTOL 50 0 50 20 30 0
166 Kotrimoksazole Tablet 960 mg TABLET 300 0 300 300 500 500 500
167 Larutan Iodine Test BOTOL 0 0 0 0 2 2 2
168 Lidokain Injeksi 2% AMPUL 120 0 120 20 100 0
170 Lidokain Komp Injeksi AMPUL 55 0 55 25 30 0
171 Lisol BOTOL 1L 0 0 0 0 0
172 Loratadin tab 10mg TABLET 0 0 0 0 0
178 Masker N95 Single valve Buah 20 40 60 40 20 40 40 40
180 Metformin HCl Tablet 500mg TABLET 400 0 400 400 0
183 Metilergometrin Maleat Inj. 0,200 AMPUL 130 0 130 130 0
184 Metilergometrin Maleat tab 0,125 mg TABLET 0 0 0 0 0
185 Metoklopramide 10 mg TABLET 100 200 300 100 200 0
186 Metoklopramide Drop 5mg/ml BOTOL 0 0 0 0 0
188 Metoklopramide syrup 5mg/ml BOTOL 0 0 0 0 0
195 Mikonazol krim 2% TUBE 48 0 48 10 38 0
197 Multivitamin Syrup Botol 0 0 0 0 0
198 Multivitamin tablet Caplet 0 0 0 0 0

203 Natrium Diklofenak 50 mg TABLET 1000 0 1000 1000 0
204 Natrium Klorida Infus 0,9 % Steril BOTOL 40 0 40 40 0
206 Nistatin Suspensi Botol 0 0 0 0 0
208 OAT FDC 1,3 PAKET 0 0 0 0 15 10 10
210 OAT Kategori 2/FDC 2 PAKET 0 0 0 0 0
212 OAT KAT 1 DOSIS HARIAN PAKET 0 0 0 0 0
213 Obat Diare Syrup (Kombinasi Attapulgit 700mg TABLET 0 0 0 0 0
214 Obat Diare Tablet TABLET 0 0 0 0 0
220 Oksitetrasiklin HCL SM 1 % 3,5 Gr TUBE 0 50 50 25 25 0
221 Oksitosin Injeksi 10 IU/ ml AMPUL 240 0 240 240 0
224 Ondansetron 4 mg TABLET 0 0 0 0 0
225 Ondansetron inj 4 mg/ 2 mL Ampul 0 0 0 0 0
228 Parasetamol Syrup 120 mg/ ml BOTOL 0 200 200 200 0 400 400 400
230 Parasetamol tablet 500 mg TABLET 50100 0 50100 7300 42800 5000 2000 2000 ED Januari 2022
234 Piridoksin HCL 10 mg TABLET 0 0 0 0 0
236 Plester 6 Yards x 2 Inch ROL 0 0 0 0 0
238 Povidon Iodida 10 % 300 ml BOTOL 3 0 3 1 2 5 3 3
239 PP test Buah 0 0 0 0 50 50 50
240 Prednison 5 mg TABLET 0 0 0 0 3000 500 500
243 Ranitidin Injek Ampul 0 0 0 0 100 0
245 Reagen Rapid Tes HBSAG/SD Pcs 181 0 181 161 20 0
246 Reagen ZN Kit 0 0 0 0 10 10 10
247 Retinol (Vit. A) 100.000 IU KAPSUL 0 0 0 0 550 550 550
248 Retinol (Vit. A) 200.000 IU KAPSUL 0 0 0 0 3350 3350 3350
252 Risperidon Tablet 2 mg TABLET 127 200 327 150 177 300 0
ED Januari 2022
253 RL Larutan infus Steril 500ml BOTOL 100 100 200 200 100 100 100
254 Salbutamol 2 mg TABLET 100 0 100 100 0 500 0
255 Salbutamol 4 mg TABLET 200 0 200 200 0 500 500 500
256 Salbutamol Cairan inhalasi 0,1 % Botol plastik 0 20 20 20 0
257 Salep 2-4 Komb. POT 30 0 30 30 0 50 20 20
258 Salisil Bedak 2 % 50 Gram KOTAK 0 0 0 0 30 10 10
266 Sarung Tangan Periksa L Buah 200 2000 2200 1800 400 2000 500 500
267 Sarung Tangan Periksa M Buah 0 0 0 0 2000 200 200
268 Sarung Tangan Periksa S Buah 0 0 0 0 0
269 Sefiksim syrup kering 100mg/5ml BOTOL 0 0 0 0 100 0
270 Sefixime 100 mg TABLET 0 0 0 0 0
272 Sianokobalamin Injeksi 500mcg/ ml (Vit B12) AMPUL 0 100 100 100 0
276 Strip Test Asam Urat Pak 25 4 0 4 1 3 0
279 Tablet Tambah Darah Dewasa TABLET 0 0 0 0 0
283 Test HIV 1/2 SD/ R1 Test 150 0 150 150 0 0 ED
285 Test HIV I (Vikia)/ R3 Buah 396 0 396 161 235 0
286 Test Siphylis Buah 566 0 566 161 405 0
292 Thiamin HCL (Vit. B1) 100 mg TABLET 0 0 0 0 1000 0
293 Thiamin HCL (Vit. B1) 50 mg TABLET 0 0 0 0 1000 1000 1000
294 Tramadol tablet 50mg TABLET 0 0 0 0 200 0
299 Urine Bag BUAH 20 0 20 5 15 0
302 Vitamin B12 tablet 50mg TABLET 400 0 400 400 0 1000 0
303 Vitamin Neurotropik TABLET 0 0 0 0 1000 0
305 Zink dispersibel tablet TABLET 800 0 800 400 400 1000 1000 1000
306 Vaksin BCG Vial 20 0 20 20 0 100 0
307 Pelarut BCG Vial 20 0 20 20 0 100 0
308 Vaksin HB Uniject Vial 94 0 94 61 33 100 0
310 Vaksin Polio (bOPV) Vial 0 50 50 50 0 100 100 100
311 Dropper Polio Buah 0 50 50 50 0 100 100 100
312 Vaksin Polio IPV 5 Dosis Vial 0 0 0 0 50 50 50
315 Vaksin DT Vial 70 0 70 41 29 50 0
316 Vaksin Campak MR Vial 107 0 107 40 67 100 100 100
317 Pelarut Campak MR Vial 107 0 107 40 67 100 100 100
318 Vaksin Td Vial 8 0 8 8 50 0
319 Alat Suntik 5ml Pcs 0 0 0 0 0
320 Alat Suntik 0,5ml Pcs 500 0 500 500 0 0
323 Pot Dahak Pot 40 0 40 20 20 0
324 Vaksin Hepatitis B ig Syringe 2 0 2 1 1 0

0
0
0
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001
PUSKESMAS
PELAPORAN BULAN : Januari 2022 SIE. FARWASMAMIN 68/SBBK/II/2022 ###
PERMINTAAN BULAN : Februari 2022

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
14 Amitriptilin HCL 25 mg TABLET 170 0 170 170 200 200 200
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 0 600 600 420 180 300 0
1 2 3 4 5 6
23 Antasida DOEN II suspensi, Botol 100 300 400 200 200 200 0
24 Anti Bakteri DOEN salep kombinasi TUBE 0 0 0 0 100 0
26 Anti Hemoroid Doen Kombinasi SUP 30 0 30 30 0
30 Asam Askorbat 50 mg (Vit C) TABLET 1400 1000 2400 1000 1400 0
33 Asam Traneksamat injeksi 100 mg/ml Ampul 0 0 0 0 50 0
34 Asetil Sistein Kapsul 200 mg Tablet 0 600 600 300 300 600 0
40 Bisakodil Suppositoria 10 mg Supp 0 50 50 10 40 0
42 Bisturi No. 10,15, 20 buah 0 0 0 0 0
54 Cetirizin Syrup Botol 50 0 50 50 100 0
55 Clindamycin Kapsul 150mg KAPSUL 0 0 0 0 0
57 Clobazam Tablet 10 mg TABLET 100 0 100 100 100 0
58 Clozapin 25 mg TABLET 190 0 190 190 100 100 100
62 Deksametason Injeksi 5 mg/ ml AMPUL 125 0 125 25 100 100 0
65 Dextran 6% BOTOL 0 0 0 0 0
66 Diazepam Injeksi 5 mg/ ml- 2 ml AMPUL 16 0 16 7 9 30 30 30
72 Domperidon Syrup Botol 90 100 190 90 100 0
74 Doxycilkin 100 mg kapsul KAPSUL 0 0 0 0 500 0
80 Etakridine ( Rivanol ) 0,1 % BOTOL 0 0 0 0 73 73 73
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 48 24 72 72 0
101 Furosemid Tablet 40 mg TABLET 0 0 0 0 500 0
114 Griseofulvin 125 mg, micronized TABLET 0 0 0 0 300 0
116 Haloperidol 1,5 mg TABLET 151 0 151 6 145 200 200 200
117 Haloperidol 5 mg TABLET 330 0 330 330 0
123 Hidrokortison Krim 2,5 % TUBE 0 0 0 0 48 0
128 Ibuprofen suspensi 200mg/5ml BOTOL 0 0 0 0 100 0
135 IV Catheter/abocath No.22 Buah 70 0 70 70 0
141 Karbamazepin 200 mg TABLET 260 0 260 260 100 100 100
144 Kasa Pembalut Hidrofil 4 m x 10 cm ROL 0 0 0 0 30 30 30
145 Kasa Pembalut Hidrofil 4 m x 5 cm ROL 0 0 0 0 30 30 30
147 Ketokonazol Krim 2 % Tube 15 g 12 48 60 24 36 0
150 Kloramfenikol Salep Kulit Tube 50 0 50 50 0
162 Kontrasepsi injek depo/ KB 3 bln vial 0 0 0 0 0
164 Kotrimoksazole Suspensi BOTOL 30 0 30 30 0 100 100 100
166 Kotrimoksazole Tablet 960 mg TABLET 300 500 800 300 500 0
168 Lidokain Injeksi 2% AMPUL 100 0 100 100 0
170 Lidokain Komp Injeksi AMPUL 30 0 30 30 0
171 Lisol BOTOL 1L 0 0 0 0 0
176 Masker 3 Fly earloop Buah 300 1000 1300 300 1000 0
178 Masker N95 Single valve Buah 20 40 60 40 20 0
180 Metformin HCl Tablet 500mg TABLET 400 0 400 200 200 400 400 400
185 Metoklopramide 10 mg TABLET 200 0 200 100 100 300 0
193 Metronidazole 500 mg TABLET 100 300 400 100 300 0
198 Multivitamin tablet Caplet 0 0 0 0 0

203 Natrium Diklofenak 50 mg TABLET 1000 0 1000 500 500 0
204 Natrium Klorida Infus 0,9 % Steril BOTOL 40 0 40 10 30 0
208 OAT FDC 1,3 PAKET 0 10 10 10 0 0
211 OAT Kategori Anak PAKET 0 0 0 0 0
220 Oksitetrasiklin HCL SM 1 % 3,5 Gr TUBE 25 0 25 25 0 0
224 Ondansetron 4 mg TABLET 0 0 0 0 50 0
225 Ondansetron inj 4 mg/ 2 mL Ampul 0 0 0 0 50 0
227 Parasetamol Drops BOTOL 45 0 45 15 30 120 96 96
230 Parasetamol tablet 500 mg TABLET 42800 2000 44800 44800 0 5000 2000 2000 ED 12.000
234 Piridoksin HCL 10 mg TABLET 0 0 0 0 1000 600 600
235 Piroxicam 20 mg KAPSUL 0 0 0 0 1000 0
236 Plester 6 Yards x 2 Inch ROL 0 0 0 0 10 5 5
239 PP test Buah 0 50 50 50 0
243 Ranitidin Injek Ampul 0 0 0 0 0
246 Reagen ZN Kit 0 10 10 10 0 0
247 Retinol (Vit. A) 100.000 IU KAPSUL 0 550 550 550 0 0
248 Retinol (Vit. A) 200.000 IU KAPSUL 0 3350 3350 3350 0 0
252 Risperidon Tablet 2 mg TABLET 177 0 177 46 131 0
256 Salbutamol Cairan inhalasi 0,1 % Botol plastik 20 0 20 5 15 10 10 10
257 Salep 2-4 Komb. POT 0 20 20 20 0 50 30 30
266 Sarung Tangan Periksa L Buah 400 500 900 900 0
267 Sarung Tangan Periksa M Buah 0 200 200 200 0
269 Sefiksim syrup kering 100mg/5ml BOTOL 0 0 0 0 0
272 Sianokobalamin Injeksi 500mcg/ ml (Vit B12) AMPUL 100 0 100 100 0
274 Simvastatin 10mg TABLET 0 0 0 0 0
283 Test HIV 1/2 SD/ R1 Test 0 0 0 0 0
299 Urine Bag BUAH 15 0 15 15 0
302 Vitamin B12 tablet 50mg TABLET 0 0 0 0 0
306 Vaksin BCG Vial 0 0 0 0 200 200 200
307 Pelarut BCG Vial 0 0 0 0 200 200 200
308 Vaksin HB Uniject Vial 33 0 33 33 0
310 Vaksin Polio (bOPV) Vial 0 100 100 100 0
311 Dropper Polio Buah 0 100 100 100 0
315 Vaksin DT Vial 29 0 29 29 0
316 Vaksin Campak MR Vial 67 100 167 167 0
317 Pelarut Campak MR Vial 67 100 167 167 0
318 Vaksin Td Vial 8 0 8 8 0
320 Alat Suntik 0,5ml Pcs 0 0 0 0 0
322 Safety Box Buah 9 0 9 9 0 0
323 Pot Dahak Pot 20 0 20 10 10 0
324 Vaksin Hepatitis B ig Syringe 1 0 1 1 0

0
0
0
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001
PUSKESMAS
PELAPORAN BULAN : Februari 2022 SIE. FARWASMAMIN 43/SBBK/III/2022 ###
PERMINTAAN BULAN : Maret 2022

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
7 Alat Suntik Sekali Pakai 10 ml SET 80 0 80 80 200 200 200
8 Albendazol tab TABLET 200 0 200 200 0 0
10 Alkohol Swab KOTAK 30 0 30 30 0 50 0
14 Amitriptilin HCL 25 mg TABLET 170 200 370 370 0
15 Amlodipin Tablet 10 mg TABLET 500 0 500 200 300 2000 1000 1000
18 Amoksisilin 500 mg TABLET 3800 0 3800 3800 0 5000 0
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 180 0 180 180 0 600 0
1 2 3 4 5 6
23 Antasida DOEN II suspensi, Botol 200 0 200 200 0 500 0
27 Antihemoroid Kapsul Kapsul 0 0 0 0 200 0
34 Asetil Sistein Kapsul 200 mg Tablet 300 0 300 300 0 600 0
37 Betahistin Maesylate Tablet 0 0 0 0 0
38 Betametason Krim 0,1 %- 5 mg TUBE 96 48 144 96 48 114 0
39 Bioplasenton Tule 10x10 kotak 0 0 0 0 0
42 Bisturi No. 10,15, 20 buah 0 0 0 0 0
43 Ca-Glukonas injeksi IV 10% Ampul 0 0 0 0 0
44 Captopril Tablet 12.5 mg TABLET 1300 0 1300 1300 0
47 Catgut Chromic No.2/0 Sachet 24 0 24 24 0 0
48 Catgut Chromic No.3/0 Sachet 48 0 48 24 24 0
49 Catgut plain No.2/0 Sachet 48 0 48 24 24 0
50 Catgut Plain No.3/0 Sachet 48 0 48 24 24 0
57 Clobazam Tablet 10 mg TABLET 100 0 100 100 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 100 0 100 50 50 100 0
69 Diazepam Tablet 5 mg TABLET 323 0 323 323 0
72 Domperidon Syrup Botol 100 0 100 100 0 200 0
73 Domperidon Tablet 10mg TABLET 0 0 0 0 0
77 Eritromisin sirup 200 mg/ 5 ml BOTOL 50 100 150 50 100 0
78 Erythromicin 250 mg KAPSUL 0 0 0 0 0
80 Etakridine ( Rivanol ) 0,1 % BOTOL 0 73 73 73 0 0
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 72 0 72 48 24 48 0
107 Glibenklamid 5 mg TABLET 500 0 500 100 400 0
108 Gliseril Guayakolat 100 mg TABLET 0 0 0 0 0
109 Gliseril Guayakolat Syrup Botol 0 0 0 0 0
111 Glukosa Larutan Infus 10% Steril BOTOL 20 0 20 5 15 20 20 20
115 Haloperidol 0,5mg TABLET 660 0 660 10 650 0
140 Kapas Pembalut 250 mg ROL 0 0 0 0 5 0
145 Kasa Pembalut Hidrofil 4 m x 5 cm ROL 0 30 30 5 25 0
146 Ketokonazol 200 mg TABLET 0 0 0 0 0
150 Kloramfenikol Salep Kulit Tube 50 0 50 26 24 72 48 48
166 Kotrimoksazole Tablet 960 mg TABLET 500 0 500 300 200 500 500 500
168 Lidokain Injeksi 2% AMPUL 100 0 100 50 50 200 0
170 Lidokain Komp Injeksi AMPUL 30 0 30 10 20 60 0
171 Lisol BOTOL 1L 0 0 0 0 0
178 Masker N95 Single valve Buah 20 0 20 20 0 40 0
181 Metil Prednisolon 4 mg TABLET 0 500 500 500 0 2000 0
182 Metildopa tab sal 250 mg TABLET 0 0 0 0 1000 0
185 Metoklopramide 10 mg TABLET 100 0 100 100 0 500 0
187 Metoklopramide injeksi 5mg/ml AMPUL 0 0 0 0 50 0
198 Multivitamin tablet Caplet 0 0 0 0 1000 1000 1000

203 Natrium Diklofenak 50 mg TABLET 500 0 500 500 0
204 Natrium Klorida Infus 0,9 % Steril BOTOL 30 0 30 10 20 60 0
208 OAT FDC 1,3 PAKET 0 0 0 0 10 0
220 Oksitetrasiklin HCL SM 1 % 3,5 Gr TUBE 0 0 0 0 0
221 Oksitosin Injeksi 10 IU/ ml AMPUL 240 0 240 240 100 0
230 Parasetamol tablet 500 mg TABLET 0 2000 2000 2000 0 5000 0
234 Piridoksin HCL 10 mg TABLET 0 600 600 400 200 600 200 200
236 Plester 6 Yards x 2 Inch ROL 0 5 5 5 0 0
239 PP test Buah 50 0 50 50 0
246 Reagen ZN Kit 0 0 0 0 0
257 Salep 2-4 Komb. POT 0 30 30 30 0 30 0
266 Sarung Tangan Periksa L Buah 900 0 900 900 0 0
267 Sarung Tangan Periksa M Buah 200 0 200 200 0 1000 0
272 Sianokobalamin Injeksi 500mcg/ ml (Vit B12) AMPUL 100 0 100 30 70 0
277 Strip Test Glukosa Pak 50 0 0 0 0 5 0
278 Strip Test Kolesterol Pak 10 0 0 0 0 5 0
283 Test HIV 1/2 SD/ R1 Test 0 0 0 0 0
294 Tramadol tablet 50mg TABLET 0 0 0 0 600 0
296 Trihexyphenidil HCL 2 mg KAPSUL 247 0 247 247 300 300 300
299 Urine Bag BUAH 15 0 15 15 0 0
305 Zink dispersibel tablet TABLET 1200 0 1200 700 500 1000 1000 1000
306 Vaksin BCG Vial 0 200 200 200 0
307 Pelarut BCG Vial 0 200 200 200 0
309 Vaksin DPT-HB/HIB Vial 0 200 200 200 0
315 Vaksin DT Vial 29 0 29 29 0
323 Pot Dahak Pot 10 0 10 10 0 0

0
0
0
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001
PUSKESMAS
PELAPORAN BULAN : Maret 2022 SIE. FARWASMAMIN 15/SBBK/IV/2022 ###
PERMINTAAN BULAN : April 2022

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
10 Alkohol Swab KOTAK 0 0 0 0 50 48 48
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 0 0 0 0 600 0
1 2 3 4 5 6
23 Antasida DOEN II suspensi, Botol 0 0 0 0 500 0
27 Antihemoroid Kapsul Kapsul 0 0 0 0 200 0
34 Asetil Sistein Kapsul 200 mg Tablet 0 0 0 0 600 0
37 Betahistin Maesylate Tablet 0 0 0 0 0
38 Betametason Krim 0,1 %- 5 mg TUBE 48 0 48 48 0 114 0
39 Bioplasenton Tule 10x10 kotak 0 0 0 0 0
42 Bisturi No. 10,15, 20 buah 0 0 0 0 0
43 Ca-Glukonas injeksi IV 10% Ampul 0 0 0 0 0
44 Captopril Tablet 12.5 mg TABLET 1300 0 1300 1300 0
50 Catgut Plain No.3/0 Sachet 24 0 24 24 0 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 50 0 50 50 0
63 Deksametason Tablet 0,5 mg TABLET 1000 3000 4000 800 3200 0
70 Difenhidramin HCL Injeksi AMPUL 0 0 0 0 0
72 Domperidon Syrup Botol 0 0 0 0 0
73 Domperidon Tablet 10mg TABLET 0 0 0 0 0
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 24 0 24 24 48 0
94 Fitomenadion Injeksi 2 mg/ ml AMPUL 30 60 90 90 60 60 60
99 Folley Catheter No. 20 Buah 10 0 10 10 30 20 20
107 Glibenklamid 5 mg TABLET 400 0 400 400 1000 1000 1000
108 Gliseril Guayakolat 100 mg TABLET 0 0 0 0 0
109 Gliseril Guayakolat Syrup Botol 0 0 0 0 0
111 Glukosa Larutan Infus 10% Steril BOTOL 15 20 35 35 20 20 20
112 Glukosa Larutan Infus 40% Steril VIAL 20 0 20 1 19 0
120 Hand Sanitizer Botol 23 0 23 23 0
146 Ketokonazol 200 mg TABLET 0 0 0 0 0
150 Kloramfenikol Salep Kulit Tube 24 48 72 48 24 72 48 48
166 Kotrimoksazole Tablet 960 mg TABLET 200 500 700 300 400 500 500 500
167 Larutan Iodine Test BOTOL 2 0 2 2 0 0
168 Lidokain Injeksi 2% AMPUL 50 0 50 50 200 200 200
171 Lisol BOTOL 1L 0 0 0 0 0
176 Masker 3 Fly earloop Buah 0 1000 1000 1000 1000 1000 1000
178 Masker N95 Single valve Buah 0 0 0 0 40 40 40
183 Metilergometrin Maleat Inj. 0,200 AMPUL 130 0 130 130 100 0
185 Metoklopramide 10 mg TABLET 0 0 0 0 0
195 Mikonazol krim 2% TUBE 38 0 38 29 9 0

203 Natrium Diklofenak 50 mg TABLET 500 0 500 100 400 1000 0
208 OAT FDC 1,3 PAKET 0 0 0 0 10 0
214 Obat Diare Tablet TABLET 0 0 0 0 1000 0
221 Oksitosin Injeksi 10 IU/ ml AMPUL 240 0 240 60 180 300 0
228 Parasetamol Syrup 120 mg/ ml BOTOL 0 0 0 0 300 0
230 Parasetamol tablet 500 mg TABLET 0 0 0 0 5000 3000 3000 ED 12.000
234 Piridoksin HCL 10 mg TABLET 200 200 400 200 200 600 200 200
239 PP test Buah 50 0 50 10 40 0
245 Reagen Rapid Tes HBSAG/SD Pcs 20 0 20 20 0 50 50 50
253 RL Larutan infus Steril 500ml BOTOL 120 100 220 220 300 300 300
257 Salep 2-4 Komb. POT 0 0 0 0 30 30 30
266 Sarung Tangan Periksa L Buah 0 0 0 0 0
283 Test HIV 1/2 SD/ R1 Test 0 0 0 0 150 150 150
285 Test HIV I (Vikia)/ R3 Buah 235 0 235 36 199 0
286 Test Siphylis Buah 405 0 405 36 369 150 150 150
296 Trihexyphenidil HCL 2 mg KAPSUL 247 300 547 170 377 200 200 200
299 Urine Bag BUAH 0 0 0 0 0
301 Vitamin B. Komplek TABLET 500 3000 3500 1300 2200 0
306 Vaksin BCG Vial 200 0 200 14 186 0
307 Pelarut BCG Vial 200 0 200 14 186 0
308 Vaksin HB Uniject Vial 33 0 33 33 0 0
309 Vaksin DPT-HB/HIB Vial 200 0 200 44 156 0
310 Vaksin Polio (bOPV) Vial 100 0 100 44 56 0
311 Dropper Polio Buah 100 0 100 44 56 0
315 Vaksin DT Vial 29 0 29 29 0
316 Vaksin Campak MR Vial 167 0 167 26 141 0
317 Pelarut Campak MR Vial 167 0 167 26 141 0
318 Vaksin Td Vial 8 0 8 8 0 0
323 Pot Dahak Pot 0 0 0 0 0
324 Vaksin Hepatitis B ig Syringe 1 0 1 1 2 2 2

0
0
0
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001
PUSKESMAS
PELAPORAN BULAN : April 2022 SIE. FARWASMAMIN
PERMINTAAN BULAN : Mei 2022

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
11 Alopurinol Tablet 100 mg TABLET 2200 1000 3200 200 3000 0
15 Amlodipin Tablet 10 mg TABLET 800 1000 1800 600 1200 1000 0
16 Amlodipin Tablet 5 mg TABLET 1200 1500 2700 300 2400 1000 0
20 Amoksisilin Syrup 250 mg/ 5 ml BOTOL 0 0 0 0 300 0
1 2 3 4 5 6
22 Antasida DOEN I tablet kunyah TABLET 3000 4000 7000 2500 4500 2000 0
23 Antasida DOEN II suspensi, Botol 0 0 0 0 400 0
28 Antimigren tablet: Ergotamin Tartrat 1 mg + Ko TABLET 0 0 0 0 500 0
32 Asam Mefenamat 500 mg TABLET 3200 2000 5200 5200 500 0
34 Asetil Sistein Kapsul 200 mg Tablet 0 0 0 0 2000 0
38 Betametason Krim 0,1 %- 5 mg TUBE 0 0 0 0 98 0
42 Bisturi No. 10,15, 20 buah 0 0 0 0 50 0
51 Cefadroxil Kapsul 500 mg KAPSUL 0 0 0 0 500 0
52 Cefixime + Azithromisin kombipak Box 0 0 0 0 500 0
53 Cetirizin Tablet 10mg TABLET 0 0 0 0 1000 0
58 Clozapin 25 mg TABLET 227 0 227 227 0
60 Cyprofloxacin Tablet 500 mg TABLET 0 0 0 0 500 0
62 Deksametason Injeksi 5 mg/ ml AMPUL 50 0 50 50 100 0
63 Deksametason Tablet 0,5 mg TABLET 3200 0 3200 3200 2000 0
64 Devitalisasi Pasa Non Arsen BOTOL 0 0 0 0 1 0
66 Diazepam Injeksi 5 mg/ ml- 2 ml AMPUL 37 0 37 37 0
71 Digoxin 0,25 mg TABLET 0 0 0 0 500 0
72 Domperidon Syrup Botol 0 0 0 0 100 0
74 Doxycilkin 100 mg kapsul KAPSUL 0 0 0 0 200 0
77 Eritromisin sirup 200 mg/ 5 ml BOTOL 50 100 150 150 0
83 Etanol 70 % 100 ml BOTOL 4 0 4 4 0
84 Etanol 70 % 1000 ml BOTOL 4 0 4 4 0
85 Etil Klorida Semprot BOTOL 0 0 0 0 5 0
86 Eugenol Cairan BOTOL 0 0 0 0 1 0
92 Fenolgliserol TT 10 % 5 ml BOTOL 24 0 24 24 0
101 Furosemid Tablet 40 mg TABLET 0 0 0 0 500 0
102 Garam Oralit 200 ml Air SASE 700 0 700 700 0
106 Glass Ionomer Cement ( Fuji GC IX ) BOTOL 0 0 0 0 1 0
114 Griseofulvin 125 mg, micronized TABLET 0 0 0 0 500 0
116 Haloperidol 1,5 mg TABLET 200 0 200 200 0
117 Haloperidol 5 mg TABLET 304 0 304 304 0
120 Hand Sanitizer Botol 23 0 23 23 0
131 Infusion Set Dewasa SET 100 0 100 100 0
143 Kasa Pembalut 36 mx 80 cm ROL 0 0 0 0 30 0
146 Ketokonazol 200 mg TABLET 0 0 0 0 500 0
147 Ketokonazol Krim 2 % Tube 15 g 12 24 36 36 24 0
148 Kloramfenikol 250 mg KAPSUL 0 0 0 0 500 0
149 Kloramfenikol SM TUBE 0 0 0 0 50 0
150 Kloramfenikol Salep Kulit Tube 24 48 72 72 48 0
151 Kloramfenikol TM 0.5 % 5 ml BOTOL 0 0 0 0 50 0
152 Kloramfenikol TT 3 % 5 ml BOTOL 0 0 0 0 50 0
153 Klorfeniramin Maleat (CTM) 4 mg TABLET 1100 2000 3100 3100 2000 0
157 Klorpromazine tab 100mg TABLET 0 0 0 0 200 0
158 Klorpromazine tab 25mg TABLET 0 0 0 0 200 0
164 Kotrimoksazole Suspensi BOTOL 150 200 350 350 0
168 Lidokain Injeksi 2% AMPUL 50 200 250 250 0
171 Lisol BOTOL 1L 0 0 0 0 2 0
172 Loratadin tab 10mg TABLET 0 0 0 0 500 0
176 Masker 3 Fly earloop Buah 1000 1000 2000 2000 0
178 Masker N95 Single valve Buah 0 40 40 40 40 0
180 Metformin HCl Tablet 500mg TABLET 200 0 200 200 0 400 0
185 Metoklopramide 10 mg TABLET 0 0 0 0 500 0
187 Metoklopramide injeksi 5mg/ml AMPUL 0 0 0 0 50 0
193 Metronidazole 500 mg TABLET 200 0 200 200 0 500 0
195 Mikonazol krim 2% TUBE 9 0 9 9 0 48 0
196 Mometason Furoat Krim 0.1% Tube 10g 0 0 0 0 50 0
197 Multivitamin Syrup Botol 0 0 0 0 100 0
201 Natrium Bikarbonat 500 mg TABLET 0 0 0 0 500 0

203 Natrium Diklofenak 50 mg TABLET 400 0 400 400 0 1000 0
208 OAT FDC 1,3 PAKET 0 0 0 0 0
211 OAT Kategori Anak PAKET 0 0 0 0 0
223 Omeprazol Kapsul 20 mg KAPSUL 0 600 600 600 0 1000 0
228 Parasetamol Syrup 120 mg/ ml BOTOL 0 0 0 0 0
230 Parasetamol tablet 500 mg TABLET 0 3000 3000 3000 0 5000 0
231 Permetrin Krim 5% (Scabimite) TUBE 0 30 30 30 0 30 0
234 Piridoksin HCL 10 mg TABLET 200 200 400 400 400 0
237 Povidon Iodida 10 % 30 ml BOTOL 4 0 4 4 0 10 0
239 PP test Buah 40 0 40 10 30 50 0
244 Ranitidin tablet 150mg TABLET 0 500 500 500 0 1000 0
252 Risperidon Tablet 2 mg TABLET 265 300 565 565 0
253 RL Larutan infus Steril 500ml BOTOL 220 300 520 520 0
256 Salbutamol Cairan inhalasi 0,1 % Botol plastik 30 20 50 50 0
257 Salep 2-4 Komb. POT 0 30 30 30 0 50 0
258 Salisil Bedak 2 % 50 Gram KOTAK 16 20 36 36 0 50 0
266 Sarung Tangan Periksa L Buah 0 0 0 0 2000 0
273 Silk No 3/0( Benang Bedah Sutera) SACHET 0 0 0 0 50 0
276 Strip Test Asam Urat Pak 25 0 0 0 0 0
283 Test HIV 1/2 SD/ R1 Test 0 150 150 150 0
289 Thiamfenikol kap 500mg KAPSUL 0 0 0 0 500 0
290 Thiamfenikol Syrup BOTOL 0 0 0 0 100 0
296 Trihexyphenidil HCL 2 mg KAPSUL 377 200 577 577 0
299 Urine Bag BUAH 0 0 0 0 0
301 Vitamin B. Komplek TABLET 2200 0 2200 2200 2000 0
302 Vitamin B12 tablet 50mg TABLET 0 0 0 0 2000 0
305 Zink dispersibel tablet TABLET 1200 0 1200 1200 0
306 Vaksin BCG Vial 186 0 186 186 0
307 Pelarut BCG Vial 186 0 186 186 0
309 Vaksin DPT-HB/HIB Vial 156 0 156 156 0
315 Vaksin DT Vial 29 0 29 29 0
323 Pot Dahak Pot 0 0 0 0 0

0
0
0
NIP. …………………………………… NIP 19760505 200604 2 025 NIP. 19720729 199503 1 001

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

NO NAMA OBAT SATUAN Stok Awal Penerimaan

206 Natrium bikarbonat injeksi VIAL 0 0 0 0 0 0 0

Mengetahui/menyetujui, Yang menyerahkan, Yang meminta, Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

Jumlah Stok Stok PEMBERIAN

Jumlah NO.SBBK Tanggal Penerima Yang Menyerahkan KET

202 Natrium bikarbonat injeksi VIAL 0 0 0 0 0

Mengetahui/menyetujui, Yang Menyerahkan Yang Meminta Yang Menerima,

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