LAPORAN PELAYANAN OBAT UNTUK PESERTA JKN DI RUMAH SAKIT

DIREKTORAT PELAYANAN KEFARMASIAN

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

Nama Rumah Sakit : RSUD Kab. Dompu

Tipe Rumah Sakit : C
Alamat Rumah Sakit : Jl. Kesehatan No 1 Dompu NTB
Kabupaten / Kota : Dompu
Provinsi : NTB
Nama Ka. Instalasi Farmasi : apt. Vera Arimbi, S,Si
Jumlah Apoteker : 12 Orang
No. Telepon / HP : 081236742084
Bulan* : Januari 2022
Tahun : 2022

Nama Obat Jumlah Jumlah Penggunaan

No. Bentuk Sediaan Kekuatan Stok Awal Harga per item Total Harga
Generik Bermerek Penerimaan Rawat Jalan Rawat Inap IGD OK Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
Acetosal 80 mg Tablet 80 mg 0 0 382 -
Acyclovir 400 Tablet 400 mg 1100 0 0 0 0 0 - -
Albendazol Tablet 100 0 100 0 0 100 - -
Albiotin Tablet 0 0 0 0 0 0 - -
Alopurinol tablet 100 mg Tablet 100 mg 4500 0 0 0 0 0 86 -
Alopurinol tablet 300 mg Tablet Tablet 300 mg 1500 1000 500 300 0 1800 200 360,000
Alprazolam 0,5 mg tab Tablet tablet 0.5 mg 4100 0 500 0 0 500 - -
Alzim tab 5 mg Tablet tablet 5 mg 1890 0 0 0 0 0 8,415 -
Ambroxol 30 mg tab Tablet tablet 30 mg 0 0 180 0 0 180 330 59,400
Aminofilin 150 mg tab Tablet tablet 150 mg 0 0 0 0 0 0 - -
Amitriptilin 25mg Tablet tablet 25 mg 700 0 0 0 0 0 - -
Amlodipine 10 mg tab Tablet tablet 10 mg 0 0 0 0 0 0 275 -
Amlodipine 5 mg tab Tablet tablet 5 mg 11740 0 0 0 0 0 53 -
Amoksisilin kaplet 500 mg Tablet tablet 500 mg 2000 3800 1500 600 0 5900 421 2,484,910
Anemolat Tablet 500 400 400 600 0 1400 220 308,000
Antasida DOEN tab Tablet 0 0 200 0 0 200 54 10,703
Aricept Evess 10 mg (Donepezil HCl) Tablet tablet 10 mg 504 0 0 0 0 0 - -
Arimidex Tablet 0 0 0 0 0 0 - -
Aromasin Tablet 0 0 0 0 0 0 - -
Asam Folat Tablet 0 0 0 0 0 0 - -
Asam Mafenamat 500 mg Tablet tablet 500 mg 7200 0 0 0 0 0 110 -
Asam Traneksamat tab Tablet tablet 500 mg 2500 600 500 1000 0 2100 2,199 4,617,900
Asetil sistein Tablet tablet 300 mg 0 0 0 0 0 0 - -
Atorvastatin 10 mg Tablet tablet 10 mg 2880 1500 0 200 0 0 200 323 64,600
Atorvastatin 20 mg Tablet tablet 20 mg 2160 1500 300 200 300 0 800 467 373,600
Avodart Tablet 960 0 360 0 0 360 0 -
Azitromicin Tablet tablet 500 mg 3300 0 30 0 0 30 - -
Bamgetol 200 mg Tablet tablet 500 mg 3000 0 200 200 0 400 2,265 906,162
Becomzet Kapsul 0 1400 0 200 0 1600 - -
Betahistin Tablet tablet 6,25 mg 2600 500 0 300 0 800 1430 1,144,000
Biosanbe Kapsul 3600 1900 1000 600 0 3500 660 2,310,000
Bisoprolol 2,5 mg Tablet tablet 2,5 mg 100 100 0 0 0 100 - -
Bisoprolol 5 mg Tablet tablet 5 mg 2880 0 0 0 0 0 -
Buferce (vit C 1000) Tablet effervesent 1000 mg 0 0 0 0 0 0 - -
Buffect 200 mg(Ibuprofen 200 mg) Tablet tablet 200 mg 0 1200 0 0 0 0 0 374 -
Calgae Kaplet 1980 0 0 0 0 0 - -
Calsium Laktat (Kalk) Tablet 0 0 0 0 0 0 - -
Candesartan 16 mg Tablet tablet 16 mg 2470 0 0 0 0 0 319 -
Candesartan 8 mg Tablet tablet 8 mg 4,260 3000 150 800 90 0 1040 212 220,480
Captopril Tablet 12,5 mg Tablet tablet 12.5 mg 3900 870 500 270 0 1640 74 121,360
Captopril Tablet 25 mg Tablet tablet 25 mg 700 300 0 200 0 500 74 37,162
Carbamazepin Tablet 0 0 400 400 0 800 - -
Cefadroxyl 500 mg Tablet tablet 500 mg 900 1400 1400 200 0 3000 839 2,518,108
Cefixime 100 mg Tablet tablet 100 mg 11800 2500 3100 600 0 6200 386 2,396,216
Cefixime 200 mg Tablet tablet 200 mg 11600 10000 2000 1000 1800 0 4800 749 3,595,200
Cetirizine 10 mg Tablet tablet 10 mg 14900 2500 3100 600 0 6200 50 310,000
 Channa Kapsul 0 0 0 0 0 0 - -
Chloroquin 200 mg Tablet tablet 200 mg 100 0 0 0 0 0 - -
Chlorpromazine HCl Tablet 0 0 0 0 0 0 - -
Cilostazol 100mg Tablet tablet 100 mg 0 0 0 0 0 0 - -
Ciprofloksasin kap 500 mg Tablet tablet 500 mg 4400 700 700 500 0 1900 250 475,000
Citaz Tablet 0 650 200 400 0 600 5,000 2,999,990
Citicolin Tab Tablet tablet 500 mg 0 0 0 0 0 0 - -
Clindamicin tab 300 mg Tablet Tablet 300 mg 0 0 0 0 0 0 - -
Clobazam 10 mg Tablet tablet 10 mg 0 0 0 0 0 0 - -
Clopidogrel 7,5mg Tablet tablet 7,5 mg 7500 0 0 0 0 0 - -
Coclcin colchicine Tablet 2100 0 0 0 - -
Codein 20mg Tablet tablet 20 mg 10200 900 900 0 0 1800 - -
Cotrimoxazol 480 mg Tablet tablet 480 mg 5800 0 0 0 0 0 - -
CTM (Chlorpheniramin Maleat) Tablet tablet 4 mg 0 0 300 0 0 300 - -
Curcuma Tablet 1800 0 0 0 0 0 - -
Curcuma Force Tablet 10560 500 800 400 0 1700 - -
Dehidroartemisin Piperaquin (DHP) Tablet 0 0 0 0 0 0 - -
Deksametason tablet 0,5 mg Tablet tablet 0.5 mg 1600 0 0 0 0 0 - -
Diazepam tab 5 mg Tablet tablet 5 mg 300 900 200 400 0 1500 - -
Digoksin tablet 0,25 mg Tablet tablet 0.25 mg 800 0 0 0 0 0 - -
Divalpi 250 mg Tablet tablet 250 mg 1000 0 0 0 0 0 - -
Domperidon 10 mg Tablet tablet 10 mg 1000 400 300 0 0 700 - -
Doxiciclyne 100 mg Tablet tablet 100 mg 0 300 200 200 0 700 - -
Erytromicin kap 500 mg Tablet tablet 500 mg 0 0 0 0 0 0 - -
Estazor Bpjs 250 mg (UCDA) Kapsul tablet 250 mg 990 0 0 0 0 0 - -
Ethambutol Tablet 0 0 60 90 0 150 - -
Euthyrox 100mg Tablet tablet 100 mg 300 0 0 0 0 0 - -
Exjade 250 mg Tablet tablet 250 mg 0 200 0 0 0 200 - -
Ezol Tablet 56 0 0 0 0 0 - -
Farmadol (Paracetamol 500 mg) Tablet tablet 500 mg 20000 10000 2500 3600 1200 0 7300 289 2,107,875
Farneltic Tablet 90 0 0 0 0 - -
Fasgo 500 tab Tablet tablet 500 mg 14800 4000 5800 5000 0 14800 400 5,920,000
Fastor (Atorvastatin) 20 mg Tablet tablet 20 mg 4500 2490 300 450 0 0 750 10,780 8,085,000
Favipiravir Tablet Tablet 300 mg 900 0 0 0 0 0 13,044 -
Favipiravir Bantuan Tablet Tablet 300 mg 0 0 0 0 0 0 - -
Fenofibrat / trolip Tablet 480 300 90 90 0 480 573 275,040
Fluconazole 150 mg Tablet tablet 150 mg 80 80 0 0 0 80 18,799 1,503,928
Fluimucil Granule 200 mg (Asetil 2460
Saset serbuk 200 mg 270 390 420 0 1080 3,300 3,564,000
Sistein)
Flunarizine Tablet tablet 5 mg 1100 300 0 700 0 1000 1,980 1,980,000
Folacit 400mcg Tablet tablet 400 mcg 6400 1000 1000 0 0 2000 660 1,320,000
Furosemid tablet 40 mg Tablet tablet 40 mg 5600 0 800 0 0 800 153 122,400
Gabapentin Tablet Tablet 300 mg 90 1500 90 0 0 0 90 643 57,870
Gastrul (Misoprostol) Tablet tablet 200 microgram 660 0 0 0 0 0 - -
Gemfibrozil kaps 300 mg Tablet kapsul 300 mg 0 0 0 0 0 0 - -
Glimepiride 1 mg Tablet tablet 1 mg 1500 300 0 0 0 300 194 58,080
Glimepiride 2 MG Tablet tablet 2 mg 2200 500 0 0 0 500 123 61,441
Glivec 100 mg Tablet tablet 100 mg 0 0 0 0 0 0 - -
Griseofulvin 125 mg Tablet tablet 125 mg 0 0 0 0 0 0 - -
Haloperidol 5 mg Tablet tablet 5 mg 200 0 0 0 0 0 - -
Harnal 0,2 mg Tablet tablet 0,2 mg 0 0 0 0 0 0 - -
Hesmin Kaps Kapsul 0 0 0 0 0 0 - -
Ibuprofen 400 mg Tablet tablet 400 mg 0 0 0 0 0 0 - -
Imatinib 100mg Tablet tablet 100 mg 0 0 0 0 0 0 - -
Inbumin 250 mg Tablet tablet 250 mg 0 990 0 0 0 0 0 5,486 -
Incetyl Kapsul kapsul 200 mg 0 0 0 0 0 0 - -
ISDN 5 mg / Isonat Tablet tablet 5 mg 0 0 0 0 0 0 - -
Isoniazid (INH) Tablet 500 0 0 0 0 0 - -
Kalxetin 10 mg Tablet tablet 10 mg 570 0 150 0 0 150 479 71,850
Kalxetin 20 mg Tablet tablet 20 mg 0 0 0 0 0 0 - -
Ketonazole 200 mg tab Tablet tablet 200 mg 1000 0 0 0 0 0 - -
Ketoprofen tab 100 mg Tablet tablet 100 mg 1850 0 0 200 0 200 1,108 221,600
KSR 600 mg Tablet tablet 600 mg 3200 0 0 0 0 0 - -
Lanzoprazole 30 mg Tablet tablet 30 mg 4180 700 2060 900 0 3660 495 1,811,700
Lapibal 500 mcg Tablet tablet 500 mcg 4800 12000 2800 1200 900 0 4900 2,723 13,340,250
L-cisin 0,5 mg Tablet tablet 0,5 mg 0 1470 0 0 0 0 0 3,960 -
Levofloxacin 500 mg Tablet tablet 500 mg 600 300 0 0 0 300 755 226,500
Lodia (Loperamid) Tablet tablet 2 mg 0 0 0 0 0 0 - -
Loratadine 10 mg Tablet tablet 10 mg 6950 0 200 200 0 400 66 26,400
Lorazepam 1 mg Tablet tablet 1 mg 1000 0 0 0 0 0 - -
Mecobalamin kap Kaplet tablet 500 mcg 5000 300 0 0 0 300 - -
Meloxicam 15 mg Tablet tablet 15 mg 4500 500 500 0 0 1000 770 770,000
Meloxicam 7,5 mg Tablet tablet 7,5 mg 1100 800 300 0 0 1100 854 939,658
Mesola 4 mg Tablet tablet 4 mg 0 0 0 0 0 0 - -
Mestinon Tablet 0 0 0 0 0 0 - -
Metformin 500 mg Tablet tablet 500 mg 9000 1600 1600 0 0 3200 191 611,200
Methyl Ergometrin 0,125 mg Tablet tablet 0,125 mg 3000 0 0 0 0 0 - -
Metronidazole 500 mg Tablet tablet 500 mg 0 1100 200 700 200 0 1100 260 286,000
Metyl Prednisolon 4 mg Tablet tablet 4 mg 39900 1900 1000 1600 0 4500 102 459,000
Metyl Prednisolon 8 mg Tablet tablet 8 mg 0 0 0 0 0 0 -
Myonep Bpjs Tablet 3100 2000 1500 400 300 0 2200 4,240 9,327,648
N Ace Kapsul kapsul 200 mg 1320 420 600 300 0 1320 2,144 2,830,080
Narmig 25 mg (cinnarizine) Tablet tablet 25 mg 0 0 0 0 0 0 - -
Natrium Diklofenak 25 mg Tablet tablet 25 mg 800 800 0 0 0 800 114 91,200
Natrium Diklofenak 50 mg Tablet tablet 50 mg 900 4000 700 0 200 0 900 108 97,200
Nifedipin 10 mg Tablet tablet 10 mg 400 0 0 100 0 100 105 10,500
Nitrokaf Retard Kapsul tablet 2,5 mg 1800 600 0 0 0 600 1,640 984,000
OAT Kategori Anak Paket 0 0 0 0 0 0 - -
OAT Kategori I Paket 0 0 0 0 0 0 - -
Omeprazole Tablet kapsul 20 mg 10800 2600 2700 1400 0 6700 129 864,300
Ondancentron 4 mg Tablet tablet 4 mg 2100 50 0 200 0 250 - -
Oralit serbuk Saset 300 0 0 0 0 0 - -
Oseltamivir 75 mg Bantuan Tablet tablet 75 mg 300 0 0 0 0 0 - -
Paracetamol 500 mg Tablet tablet 500 mg 0 0 0 0 0 0 - -
Phenitoin 100 Kapsul Kapsul kapsul 100 mg 100 100 0 0 0 100 1,353 135,300
Phenobarbital 30 mg (Phental) Tablet tablet 30 mg 0 0 0 0 0 0 - -
Piracetam 1200 mg Tablet tablet 1200 mg 0 0 0 0 0 0 - -
Piracetam 400 mg Tablet tablet 400 mg 0 0 0 0 0 0 - -
Piracetam 800 mg Tablet tablet 800 mg 0 0 0 0 0 0 - -
Pirazinamida Tablet 0 0 0 0 0 0 - -
Piroxicam tablet 20 mg Tablet tablet 20 mg 1300 500 0 200 0 700 - -
Pottasium Diklofenak 25 mg Tablet tablet 25 mg 5000 1300 800 200 0 2300 - -
Pradaxa 110mg Tablet tablet 110 mg 750 0 0 0 0 0 - -
Prednison tablet 5 mg Tablet tablet 5 mg 800 200 0 0 0 200 - -
Primaquin Tab Tablet 0 0 0 0 0 0 - -
Probiokid serbuk Saset 160 500 0 80 80 0 160 6,941 1,110,534
Profero Tablet 1410 0 900 240 0 1140 - -
Propanolol 10 mg Tablet tablet 10 mg 700 500 300 100 100 0 500 59 29,502
Propanolol 40 mg Tablet tablet 40 mg 0 0 0 0 0 0 - -
Propiltiourasil (PTU) 100 mg Tablet tablet 100 mg 0 2000 0 0 0 0 0 405 -
Ramipril 2,5 mg Tablet tablet 2.5 mg 1700 1000 0 0 0 0 0 240 -
Ramipril 5 mg Tablet tablet 5 mg 0 0 0 0 0 0 - -
Ranitidin tab Tablet tablet 150 mg 3300 5000 800 900 400 0 2100 85 178,500
Rhodium Tablet 1290 0 0 0 0 0 - -
Rifampicin 450 mg Tablet tablet 450 mg 500 0 0 0 0 0 - -
Risperidone 2 mg Tablet tablet 2 mg 200 0 0 0 0 0 - -
Salbutamol 2 mg Tablet tablet 2 mg 0 0 0 0 0 0 - -
Salbutamol 4 mg Tablet tablet 4 mg 300 0 0 200 0 200 - -
Scopamin + Hiosin (Gitas Plus) Tablet 850 1650 300 150 400 0 850 4,928 4,188,800
Sebivo 600 mg Tablet tablet 600 mg 0 0 0 0 0 0 - -
Sifrol 0,75 Tablet tablet 0,75 mg 0 0 0 0 0 0 - -
Simarc / Warfarin Tablet 0 0 0 0 0 0 - -
Simvastatin 10 mg Tablet tablet 10 mg 16400 400 700 0 0 1100 - -
Simvastatin 20 mg Tablet tablet 20 mg 5300 300 600 300 0 1200 - -
Sistenol ( Asetil Sistein +
Kaplet 1080 0 720 360 0 1080 - -
Parasetamol )
Solaneuron Tablet 0 0 0 0 0 0 - -
Spironolakton 100 mg Tablet tablet 100 mg 700 0 0 0 0 0 - -
Spironolakton 25 mg Tablet tablet 25 mg 600 300 0 0 0 300 - -
Stalevo Tablet 0 0 0 0 0 0 - -
Sucralfate / ulsidex Tablet tablet 500 mg 0 3000 0 0 0 0 0 222 -
Tablet Tambah Darah (Ferro Sulfat) Tablet 3200 0 0 0 0 0 - -
Tamofen 10 mg Tablet tablet 10 mg 1020 0 0 0 0 0 - -
Tasdiar 2 mg Tablet tablet 2 mg 0 0 0 0 0 0 - -
Tasigna 150 mg Kapsul tablet 150 mg 224 0 0 0 0 0 - -
Telmisartan 80 mg Tablet tablet 80 mg 0 0 0 0 0 0 - -
Tenofovir Disoproxil Tablet 150 90 0 0 0 90 - -
Tramadol tab Tablet 0 0 0 0 0 0 - -
Triamcinolone 4 mg Tablet tablet 4 mg 0 0 0 0 0 0 - -
Trihexipenidyl / arkin Tablet 0 0 0 0 0 0 - -
Trisela 10 mg Tablet tablet 10 mg 0 0 0 0 0 0 - -
Trogil Tablet tablet 500 mg 0 0 0 0 0 0 - -
Tyarit tab Tablet 0 0 0 0 0 0 - -
Tykerb 250 (Lapatinib) Tablet tablet 250 mg 140 0 0 0 0 0 - -
 Urief 4 mg Tablet tablet 4 mg 1000 400 100 100 0 600 - -
Urinter Tablet 1800 0 0 0 0 0 - -
Vioxy FM Tablet 90 0 0 0 0 0 - -
Vip Albumin Tablet 2040 600 1290 0 0 1890 - -
Vitamin B Complex Tablet 0 0 0 0 0 0 - -
Vitamin B6 Tablet 1600 0 500 0 0 500 - -
Vitamin C 250 mg Tablet tablet 250 mg 0 0 0 0 0 0 - -
Zink Dispersibel Tablet 800 1000 0 0 400 0 400 253 101,200
Invitec (Misoprostol) Tablet 0 0 400 0 400 - -
Bracer tab tablet 60 0 3,280 -
Bedaquilin Tablet 0 0 0 0 0 0 -
Cycloserin (Closerin 250 mg) Tablet tablet 250 mg 200 0 0 0 0 0 -
Lamprene (Clofazimin 100 mg) Tablet tablet 100 mg 0 0 0 0 0 0 -
Linezoid 600 mg Tablet tablet 600 mg 0 0 0 0 0 0 -
Moximed (Moxyfloxacin 400 mg) Tablet tablet 400 mg 170 0 0 0 0 0 -
DHP Firmal Kotak 0 0 0 0 0 0 -
Primaquin Tablet 0 0 0 0 0 0 -
Ambroxol Syr Botol 60 ml syrup 30 mg/ 5 ml 0 0 0 0 0 0 3,465 -
Amoksisilin Sirup Kering Botol 60 ml syrup kering 125 mg/5 ml 80 0 0 0 0 0 -
Antasida Suspensi Botol 60 ml 0 0 0 30 0 30 4950 148,500
Asam Valproat syr Botol 60 ml 151 0 0 0 0 0 -
Cefadroxyl Syr Botol 60 ml syrup kering 125 mg/5 ml 249 48 0 10 0 58 3,913 226,979
Cefixime Syr Botol 60 ml syrup kering 100 mg/5 ml 75 50 40 40 0 130 4,947 643,114
Cetirizine syr Botol 60 ml syrup Kering 5 mg/5 ml 0 0 50 25 0 75 -
Cotrimoxazol Suspensi Botol 60 ml syrup kering 240 mg/5 ml 22 0 0 0 0 0 -
Domperidon Botol 60 ml syrup 10 mg/5 ml 100 0 0 10 0 10 -
Erlamor syr Botol 60 ml 0 0 15 20 0 35 -
Erytromicin Syr Botol 60 ml syrup kering 250 mg/5 ml 0 0 0 0 0 0 -
Ferro K drop Botol 60 ml drop 0 0 0 0 0 0 -
Ibuprofen Syr Botol 60 ml syrup 100 mg/ 5 ml 5 0 0 0 0 0 -
Laxasium syr Laxasium syr Botol 60 ml 0 0 0 5 0 5 -
Maagel Syr Botol 60 ml 0 0 0 0 0 0 -
Molafate Syr Botol 60 ml 0 0 0 0 0 0 -
Opilax syr Botol 60 ml 103 0 0 0 0 0 -
Paracetamol syr Botol 60 ml syrup 120 mg/5 ml 197 0 24 24 0 48 -
Pralax 100 ml Botol 100 ml 179 0 103 93 0 196 -
Sukralfat syr Botol 60 ml syrup 500 mg/5ml 650 0 0 0 0 0 -
ZinkPro Syr Botol 60 ml 0 150 200 200 0 550 -
Amikasin Sulfate 250 mg/ ml Ampul Injeksi 250 mg/ml 0 220 0 0 0 0 0 9,900 -
Aminofilin Inj. Ampul injeksi 25 mg/ml 0 0 0 0 0 0 3,783 -
Amiodaron Ampul injeksi 50 mg/ml 50 0 0 0 0 0 6,063 -
Ampicilin Injeksi Ampul Injeksi 1 gr 70 0 0 0 0 0 - -
Anti Tetanus 1500 iu (ATS) Ampul injeksi 1500 iu 0 0 60 0 0 60 138,924 8,335,443
Apidra Solostar Pen Injeksi 100 IU/ml 400 0 0 0 0 0 - -
Aqua pro injeksi Vial 25 ml 286 140 85 0 0 225 - -
Asam Traneksamat 500 mg Ampul Injeksi 500 mg/ml 3470 0 0 0 0 0 2,199 -
Atropin Sulfat0,25 mg/ml Ampul Injeksi 0,25 mg/ml 70 0 650 200 0 850 - -
Bactesyn Ampul Injeksi 0.75 gr 60 0 0 0 0 0 14,891 -
Berotec Inhaler inhaler MDI 100 mcg/Puff 10 ml 83 0 45 0 0 45 86,929 3,911,793
Bunascan Ampul Injeksi 5 mg/5 ml 90 10 3 10 0 23 67,155 1,544,554
Calsium Gluconax Ampul Injeksi 100 mg/ml 0 0 0 0 90 90 18,150 1,633,500
Cebactam Ampul Injeksi 1 gr 140 0 0 0 0 0 107,478 -
Cefoperazone Vial Injeksi 1 gr 0 0 120 20 0 140 - -
Cefotaxime 1 g Vial Injeksi 1 gr 3368 0 1276 700 0 1976 5,699 11,261,422
Ceftriaxone 1 g Vial Injeksi 1 gr 4662 0 2616 676 0 3292 5,699 18,761,437
Chloramfenicol (chlorbiotic) Ampul Injeksi 1 gr 0 0 0 0 0 0 - -
Citicolin 250mg/ 2ml Ampul Injeksi 250 mg/2 ml 2350 0 800 200 0 1000 5,599 5,599,099
Combivent Ampul Inhalasi 0,5 mg+2.5 mg 0 0 0 0 0 0 - -
Cortidex Ampul Injeksi 5 mg/1 ml 0 0 0 0 0 0 - -
Covifor ( Remdesivir ) vial Injeksi 100 mg/vial 0 0 0 0 0 0 - -
Desrem 100 mg ( Remdesivir ) Vial Injeksi 100 mg/vial 20 0 0 0 0 0 - -
Dexametason Inj Ampul Injeksi 5 mg/1 ml 1400 0 700 300 0 1000 1,441 1,440,901
Dextrosa injeksi 40 % steril Vial 25 ml Injeksi 40 %/25 ml 178 0 0 0 0 0 20,295 -
Diazepam (valisanbe) Inj Ampul Injeksi 5 mg/ml 230 100 0 0 30 0 30 - -
Dipenhydramin Inj Ampul Injeksi 10 mg/ml 0 0 0 0 0 0 - -
Diviti PFS 2,5mg/0,5ml vial Injeksi 2,5 mg/0,5 ml 0 0 0 0 0 0 - -
Dobutamin/ Inotrop Ampul Injeksi 250 mg/5 ml 35 0 0 0 0 0 - -
Dopamin Ampul Injeksi 20 mg/ml 10 0 0 0 0 0 - -
0 0 0 0 - -
Efedrin HCl Ampul Injeksi 50 mg/ml 300 0 0 0 0 0 - -
Epinefrin Inj. Ampul Injeksi 1 mg/ml 100 0 0 0 100 100 1,590 158,955
 Ezelin vial Insulin 100 UI/ml 0 50 0 10 0 0 10 89,000 890,000
Farbion Inj. Ampul Injeksi 5000/ml 4920 0 1500 900 0 2400 5,445 13,066,811
Farbivent 2,5 ml Ampul Inhalasi 0,5 mg+2.5 mg 90 0 0 90 0 90 9,680 871,200
Farelax Ampul Injeksi 10 mg/ml 20 0 0 0 0 0 - -
Fartison 100 mg Ampul Injeksi 100 mg/ml 0 0 0 0 10 10 60,500 605,000
Fartolin Ampul Inhalasi 1 mg/ml 160 0 0 0 0 0 - -
Fendex 50 mg Ampul injeksi 50 mg/ml 400 0 100 50 0 150 53,514 8,027,027
Fentanyl 0,05 mg Ampul injeksi 0,05 mg/ml 200 0 0 150 175 325 28,273 9,188,716
Flutias inhaler inhaler Inhalasi 125 mcg/puff 28 10 0 10 0 20 - -
Furosemid Inj. Ampul Injeksi 10 mg/ml 650 0 350 300 0 650 - -
Gentamycine 40 mg/ ml Inj. Ampul Injeksi 40 mg/ml 120 0 70 0 20 90 - -
Gitas Ampul Injeksi 20 mg/ml 50 30 0 45 0 0 45 22,022 990,990
Halotan Ampul Inhalasi 250 ml 0 - -
Induxin Ampul Injeksi 10 IU/ml 2100 1000 0 400 250 700 1350 6,534 8,820,900
Infimycin Inj Ampul Injeksi 500 mgvial 0 0 0 0 0 - -
Isoflurane Ampul Inhalasi 250 ml 1 0 0 0 0 0 - -
Jubi-R ( Remdesivir ) Vial Injeksi 100 mg/vial 0 0 0 0 0 0 - -
KCl Botol 25 ml Injeksi 25 ml 141 0 0 0 0 0 - -
Ketamin 100 mg Ampul Injeksi 100 mg/ml 0 0 0 0 0 0 - -
Ketamin 50 mg Ampul injeksi 50 mg/ml 0 4 0 0 0 4 4 - -
Ketorolac 10 mg/ml Ampul Injeksi 10 mg/ml 0 1500 0 0 0 0 0 2,000 -
Ketorolac 30 Inj. Ampul Injeksi 30 mg/ml 24 0 24 0 0 24 2,084 50,017
Lanzoprazole vial Injeksi 30 mg/ml 1484 0 528 120 0 648 99,000 64,152,000
Lapibal Ampul 960 870 0 500 250 0 750 21,175 15,881,250
Lasacom Ampul 5140 60 800 500 0 1360 9,405 12,790,126
Levemir FlexPen Ampul 10 0 10 0 0 10 89,000 889,999
Levica 50 mg Ampul 0 0 0 0 0 0 - -
Levosol ( Norepinefrin ) Ampul 0 5 0 5 0 0 5 - -
Lidodex Ampul 0 0 - -
Lidokain HCl Ampul 400 0 0 400 0 400 891 356,360
Lidokain kombinasi Ampul 30 480 0 0 0 0 0 847 -
LOLA (L-Ornithin L-Aspartate) Ampul 0 0 0 0 0 0 - -
Mecobalamin 500mcg/1ml Ampul 0 0 0 0 0 0 - -
Megabal Ampul 50 0 0 0 0 0 - -
Meropenem 1 gr Ampul Injeksi 1 gr/ml 343 0 130 0 0 130 - -
Metoclopramide Hcl 10 mg/2 ml Ampul Injeksi 10 mg/2 ml 0 0 0 0 0 0 - -
Metyl prednisolon Ampul Injeksi 125 mg/ml 135 500 0 107 100 10 217 10,912 2,367,904
Meylon (Natrium Bicarbonat) Ampul 0 0 0 0 0 0 - -
MgSO4 20 % vial Injeksi 20%/25 ml 0 0 0 0 0 0 - -
MgSO4 40 % Botol 25 ml Injeksi 40 %/25 ml 0 30 0 0 0 0 0 - -
Morfin 10 mg Ampul Injeksi 10 mg/ml 90 0 12 18 0 30 - -
N - Asetil Sisteil Inhalasi 300mg/3ml Ampul Inhalasi 300 mg/3 ml 120 0 0 0 0 0 - -
Neostigmine 0.5mg Ampul Injekis 0,5 mg/ml 0 0 0 0 0 0 - -
Nicardipine 10 mg Ampul Injeksi 10 mg/ml 0 0 0 0 0 0 - -
Novomix-30 Flexpen Pen Insulin 100 UI/ml 5 0 0 0 0 0 - -
Novorapid FlexPen Pen Insulin 100 UI/ml 60 0 0 0 0 0 - -
Oksitosin Inj. Ampul 200 60 0 0 0 60 - -
Omeprazole Inj Ampul Injeksi 850 3000 0 698 794 0 1492 5,346 7,976,232
Ondancentron 4mg/ 2ml Inj Ampul Injeksi 4 mg/ml 2585 150 0 800 700 150 1650 873 1,440,450
Ondancentron 8mg/ 4 ml Inj Ampul Injeksi 8 mg/ml 0 0 0 0 0 0 - -
Peinlos 400mg Vial Injeksi 400 mg/ml 400 0 325 75 0 400 - -
Petidin 50 mg Inj. Ampul injeksi 50 mg/ml 570 0 0 0 0 0 - -
Phenitoin Ampul 0 500 0 0 30 0 30 2,596 77,880
Phenobarbital Inj (Phental) Ampul 0 0 0 - -
Piracetam 3 gr Inj. Ampul Injeksi 3 gr/ 410 256 0 350 60 0 410 1,001 410,410
Pospargin Inj Ampul 200 300 0 50 50 100 200 4,356 871,200
Prohem Ampul 770 0 0 50 75 125 - -
Prove - C 1000 mg/ml Ampul Injeksi 1000 mg/ml 40 0 0 0 0 0 1,788 -
Ranitidin Inj. Ampul 1690 2050 0 880 560 250 1690 1,542 2,606,021
Recofolf Ampul 50 0 0 0 10 10 - -
Rocuronium Bromide 50 mg Ampul injeksi 50 mg/ml 0 0 0 0 0 0 - -
Ryzodeg pen 5 0 0 0 0 0 - -
SABU (Serum Anti Bisa Ular) Ampul 0 33 0 3 7 0 10 517,132 5,171,320
Sansulin Pen 0 0 0 0 0 0 - -
Sansulin Log G Pen 0 0 0 0 0 0 - -
Sansulin Log G Dispopen pen 70 150 60 10 0 0 70 89,580 6,270,578
Sedacum ( Midazolam ) Ampul 70 0 0 0 0 0 - -
Seretide Inhaler Botol 25 0 0 0 0 0 - -
Sevodex 250 ml Ampul Inhalasi 250 ml 0 2 0 0 0 0 0 2,524,500 -
Sharox 750mg Inj vial Injeksi 750 mg/ml 222 0 100 0 0 100 - -
Sibital injeksi Ampul 0 0 0 0 0 0 - -
 Streptomysin Vial 112 0 0 0 0 0 - -
Terrel Botol 0 0 0 0 0 0 - -
Tetagam Ampul 5 60 0 0 0 0 0 207,900 -
Tofedex (Dexketoprofen) Ampul 400 250 0 5 5 0 10 51,728 517,275
Topazol Ampul 290 240 0 200 50 0 250 97,829 24,457,125
Tramadol Inj. Ampul 540 0 20 0 0 20 -
Tramus Inj Ampul 0 25 0 0 0 0 0 51,425 -
Umaron Ampul 55 5 0 0 0 5 - -
Vasola vial 140 0 65 55 0 120 - -
Ventolin Nebules 2,5 mg Ampul Inhalasi 0,5 mg+2.5 mg 0 0 0 0 0 0 - -
Zoladex Ampul 1 0 0 0 0 0 - -
Meprovent INH Ampul 0 1000 0 0 0 0 0 3,677 -
VAR Verorab AntiRabies Ampul 0 5 0 5 0 0 5 - -
Artesunate Ampul 0 1 0 1 0 0 1 - -
Midazolam Ampul 0 0 0 0 0 0 - -
Fentanil 100 mcg Ampul Injeksi 100 mcg/ml 0 0 0 0 0 0 - -
Bupivacain Ampul 0 25 0 0 0 0 0 - -
Quanacain Ampul 0 105 0 0 0 25 25 55,000 1,375,000
Esomeprazol 40 mg inj Vial Injeksi 40 mg/ml 0 1000 0 0 0 0 0 7,787 -
1 Acyclovir SK tube 0 0 0 0 0 0 - -
2 Akilen Akilen botol 0 20 0 0 0 0 0 61,578 -
3 Betametasone SK tube 0 0 0 0 0 0 1,520 -
4 Cendo Lyteer TM Cendo Lyteer TM botol 40 40 0 0 0 40 24,750 990,000
5 Cendo Xitrol TM Cendo Xitrol TM botol 0 0 0 0 0 0 - -
6 Cloramphenicol SM tube 120 0 0 0 24 24 - -
7 Erladerm SK Erladerm SK tube 2 0 0 0 0 0 - -
8 Ethil Klorida botol 0 0 0 0 0 0 - -
9 Forumen Ear Drop Forumen Ear Drop botol 0 30 0 0 0 0 0 25,938 -
10 Gentamicin SK tube 0 20 0 15 5 0 20 4,500 90,000
Hydrocortisone ZK tube 168 24 0 0 0 24 - -
Inmatrol TM botol 41 20 0 10 0 30 - -
Isotic Adretor TM botol 0 0 0 0 0 0 - -
Ketokonazole ZK tube 1 0 0 0 0 0 - -
Mikonazole ZK tube 0 0 0 0 0 0 - -
Ottopain TT botol 20 20 0 0 0 0 0 57,750 -
Polidemisin TM botol 0 0 0 0 0 0 - -
Tarivid TT botol 50 10 0 0 0 10 - -
Anti Hemoroid supp 150 0 50 0 0 50 3,249 162,473
Dulcolax supp anak supp 30 0 0 18 0 18 - -
Dulcolax supp dws (Stolac) supp 100 0 100 0 0 100 - -
Kaltrofen supp supp 2900 2000 0 1000 250 350 1600 10,200 16,320,480
Pronalges supp 0 0 0 0 0 0 - -
Albapure 20% 100 ml botol 3 0 3 0 0 3 - -
Benutrion botol 0 0 0 0 0 0 52,400 -
Ciprofloksasin botol 0 100 0 0 0 0 0 10,019 -
Floxaris botol 0 0 0 0 0 0 - -
Gabaxa (L-Alanyl-L glutimin) botol 130 0 48 24 0 72 - -
Human Albumin 20 % 100ml botol 0 0 0 0 0 0 - -
Human Albumin 20 % 50ml botol 0 10 0 0 0 0 0 445,000 -
Levofloxacin botol 52 0 0 0 0 0 - -
Metronidazole botol 84 3103 0 0 84 0 84 5,885 494,340
Moxifloxacin 400 mg/ 250 ml botol Injeksi 400 mg/250 ml 32 0 24 8 0 32 - -
Octalbin 20% 100 ml botol 0 10 0 0 0 0 0 905,000 -
Octalbin 25% 100ml botol 0 0 0 0 0 0 - -
Octalbin 25% 50ml botol 0 0 0 0 0 0 - -
Paracetamol botol 800 1669 0 360 440 0 800 8,882 7,105,560
Resfar (Asetil Sistein) botol 364 0 0 0 0 0 - -
Sanmol botol 220 0 96 72 0 168 - -
Tamoliv (paracetamol) botol 0 840 0 120 120 0 240 12,100 2,904,000
Dianeal PD-4 1,58 Dextwin botol 0 1 0 0 0 0 0 -

Keterangan :
*Pengumpulan data perbulan, selama periode triwulan:

1. Tahun 2021, (bulan_#### - bulan_####) Kolom 1 : Nomor urut

mohon diisi nama bulannya sesuai Kolom 2 dan 3 Nama obat, ditulis dengan nama kandungan zat aktif di kolom generik apabila tersedia produk generiknya, atau ditulis dengan nama dagangnya
rentang bulan yg diminta :
di kolom bermerek apabila tersedia produk bermereknya
Kolom 4 : Bentuk sediaan (tablet, sirup, kaplet, dll)
Kolom 5 : Kekuatan (dalam mg, mg/mL, UI, dll) (dalam satuan unit terkecil)
Kolom 6. : Jumlah stok awal periode pelaporan (dalam satuan unit terkecil)
Kolom 7 : Jumlah total penerimaan obat dari awal sampai dengan akhir triwulan periode pelaporan (dalam satuan unit terkecil)
Kolom 8 : Jumlah penggunaan obat di Layanan Rawat Jalan dan IGD (dalam 1 periode pelaporan, dalam satuan unit terkecil)
Kolom 9 Jumlah penggunaan obat di Layanan Rawat Inap mencakup rawat inap, ICU, ICCU, NICU, PICU
:
(dalam 1 periode pelaporan, dalam satuan unit terkecil)
Kolom 10 : Total Jumlah penggunaan obat (kolom nomor 8 + kolom nomor 9)
Kolom 11 : Harga beli rumah sakit per item (HNA obat + ppn), dalam satuan unit terkecil
Kolom 12 : Total harga (kolom nomor 10 x kolom nomor 11)