LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LPLPO)

PUSKESMAS :
KECAMATAN :
KABUPATEN :
DAERAH ISTIMEWA :

No Nama Barang Persediaan Satuan Keterangan

1 2 3 4
OBAT
1 Acyclovir krim 5 % tube
2 Acyclovir tablet 200 mg tablet
3 Acyclovir tablet 400 mg tablet
4 Albendazol tablet 400 mg tablet
5 Albendazole suspensi botol
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Ambroksol syrup botol
9 Ambroxol tablet 30 mg tablet
10 Aminofilin tablet 200 mg tablet
11 Aminofilina injeksi 24 mg/ml - 10 ml ampul
12 Amitriptilin HCl tablet salut 25 mg tablet
13 Amlodipin 10 mg tablet
14 Amlodipine 5 mg tablet tablet
15 Amoksilin Forte sirup 250mg/5ml botol
16 Amoxicillin kaplet 500 mg tablet
17 Amoxicillin sirup kering 125 mg/5ml botol
18 Ampicillin injeksi 1 gr amp

19 Antasida DOEN tab,kombinasi: tablet

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

20 Antasida suspensi botol

Anti Bakteri DOEN salep kombinasi:
21 Basitrasin 500 IU/g + Polimiksin 10.000 IU/g tube

22 Anti Hemoroid DOEN Kombinasi suppo

23 Anti Scabies krim 10 gr tube
24 Anti Spasmodik injeksi ampul
Anti Spasmodik tablet: Hyoscine-N-Butylbromide
25 tablet
10 mg (Spashi®)

26 Antifungi DOEN Kombinasi: pot

Asam Benzoat 6% + Asam Salisilat 3%

27 Antimigren: tablet
Ergotamin Tartrat 1 mg + Kofein 50 mg
Antiparkinson DOEN tablet kombinasi :
28 Benserazid 25 mg Levodopa 100 mg tablet

29 Aqua pro Injeksi steril, bebas pirogen botol

30 Aquadest Steril botol
31 Asam Askorbat (Vit C) tablet 250 mg tablet
32 Asam Askorbat (Vit C) tablet 50 mg tablet
33 Asam folat tablet 1 mg tablet
34 Asam Mefenamat 500 mg kaplet tablet
35 Asering plabot 500 mL plabot
36 Asetosal tablet 80 mg tablet
37 Asetylsistein tablet
38 Atapulgit tablet 600 mg tablet
39 Atropin sulfat inj 0,25mg/ml ampul
40 Atropine 0.5 mg Tablet tablet
41 Betametason krim 0.1% tube
42 Bisacodyl Suppo 10 mg suppo
43 Bisacodyl Suppo 5 mg suppo
44 Bisacodyl tablet 5 mg tablet
45 Calcusol® kapsul kapsul
46 Captopril 12,5 mg tablet
47 Carbo-adsorbent tablet 250 mg tablet
48 Cefadroksil kapsul 500 mg kapsul
49 Cimetidin tablet 200 mg tablet
50 Obat Anti Vertigo (Cinarizine / Betahistin) tablet
51 Ciprofloksasin Kapsul 500 mg kapsul
52 Codein tablet
53 Curcuma® degree degree
54 Deksametason injeksi 5 mg/ml - 1 ml ampul
55 Deksametason tablet 0,5 mg tablet
56 Dekstran 70 - larutan infus 6% steril botol
57 Diazepam 5 mg / 2,5 ml lar rectal (Stesolid®) susp
58 Diazepam injeksi 5 mg/ml - 2 ml ampul
59 Diazepam tablet 2 mg tablet
60 Diazepam tablet 5 mg tablet
61 Dietilkarbamazin Sitrat 100mg tablet tablet
62 Difenhidramin HCl inj 10 mg/ml-1 ml ampul
63 Digoksin tablet 0,25 mg tablet
64 Diltiazem Hcl tablet 25 mg tablet
65 Dimenhidrinat 50 mg tablet tablet
66 Doksisiklin 100 mg kapsul kapsul
67 Domperidon syrup 5mg/5ml botol
68 Domperidon tablet 10 mg tablet
69 Efedrin HCl tablet 25 mg tablet
70 Epineprin injeksi 0.1% ( adrenalin injeksi ) ampul
71 Eritromisin 250 mg tablet
72 Eritromisin sirup 200 mg/5 mL botol
73 Etambutol 250 mg tablet
74 Etambutol 500 mg tablet
75 Etanol 70 % botol
76 Fenitoin Injeksi 100 mg/2 mL amp
77 Fenitoin Natrium kapsul 100 mg kapsul
78 Fenobarbital injeksi 50 mg/ml - 1 ml ampul
79 Fenobarbital tablet 30 mg tablet
80 Fenoksimetil Penisilina tablet 250 mg tablet
81 Fenoksimetil Penisilina tablet 500 mg tablet
82 Fenol Gliserol tetes telinga 10% botol
83 Fitomenadion (Vit.K1) injeksi ampul

84 Fitomenadion (Vit.K1) tablet salut gula 10 mg tablet

85 Fluoxetin 10 mg kapsul kapsul

86 Fluticasone Propionate 0.5 mg dalam 2ml NaCl nebules

87 Furosemid injeksi 10mg/ml ampul

88 Furosemid tablet 40 mg tablet
89 Garam Oralit untuk 200 ml air sachet
90 Gemfibrozil 300 mg tablet
91 Gentamisin salb kulit 1% tube
92 Glibenklamid tablet 5 mg tablet
93 Glimepirid tablet 2 mg tablet
94 Glukosa larutan infus 10 % steril botol
95 Glukosa larutan infus 40 % steril botol
96 Glukosa larutan infus 5 % steril botol
97 Griseofulvin tablet 125 mg, micronized tablet
98 Haloperidol tablet 0,5 mg tablet
99 Haloperidol tablet 1,5 mg tablet
100 Haloperidol tablet 5 mg tablet
101 Hidroklorotiazid (HCT) tablet 25 mg tablet
102 Hidrokortison krim 2,5 % tube
103 Ibuprofen sirup 200 mg/ 5mL botol
104 Ibuprofen suspensi 100mg/5ml botol
105 Ibuprofen tablet 200 mg tablet
106 Ibuprofen tablet 400 mg tablet
107 INH 100 mg tablet
108 INH 300 mg tab tablet
109 Isosorbid Dinitrat tablet sublingual 5 mg tablet
110 Kalamin lotion botol
111 Kalium Declovenak 50 mg tablet
112 Kalium Permanganat serbuk pot
113 Kalsium Glukonat Inj 100 mg/mL amp
114 Kalsium Laktat (Kalk) tablet 500 mg tablet
115 kaolin + pectin tablet tablet
116 Kaolin-Pektin 760mg syrup botol
117 Kaptopril tablet 25 mg tablet
118 Karbamazepin tablet 200 mg tablet
119 Ketamin injeksi 1000 mg/ 10 mL vial
120 Ketokonazol crem 2 % tube
121 Ketokonazol tablet tablet
122 Ketoprofen 100 mg Suppositoria suppo
123 Klindamicin 150 mg kapsul kapsul
124 Klonidin 0,15 mg tablet tablet
125 Kloramfenikol kapsul 250 mg kapsul
126 Kloramfenikol salb kulit 2% tube
127 Kloramfenikol salb mata 1 % tube
128 Kloramfenikol syrup 125mg/5ml botol
129 Kloramfenikol tetes mata 0.5% botol
130 Kloramfenikol tetes telinga 3 % botol
131 Klorfeniramin Maleat (CTM) tablet 4 mg tablet
132 Klorokuin 250mg tablet tablet
133 Klorpromazin HCl injeksi 25 mg/ml - 2 ml ampul
134 Klorpromazin HCl tablet salut 100 mg tablet
135 Klorpromazin HCl tablet salut 25 mg tablet
136 kotrimoksazol forte tablet
Kotrimoksazol Suspensi komb: Sulfametoksazol
137 200 mg botol
+ Trimetoprim 40 mg / 5 ml

Kotrimoksazol tablet kombinasi:

138 Sulfametoksazol 400 mg
+ Trimetoprim 80 mg tablet

139 Kotrimoksazol tablet pediatrik, kombinasi: tablet

Sulfametoksazol 100 mg + Trimetoprim 20 mg

140 Kuinin (Kina) tablet 200 mg tablet

141 Lidocain Injeksi non adrenalin ampul
142 Lidokain 2% jelly 10 gr syringe
Lidokain komp. injeksi, Kombinasi:
143 Lidokain HCl 2% + Epinefrin 1:80.000 - 2 ml ampul

144 Loratadin tablet 10 mg tablet

145 Magnesium Sulfat Injeksi ( IV ) 40%-25 ml botol
146 Metformin Hcl tablet 500 mg tablet
147 Metil Prednisolone tablet 4 mg tablet
148 Metilergometrin Maleat inj 0,200 mg-1 ml ampul

149 Metilergometrin Maleat tablet salut 0,125 mg tablet

150 Metoclopramid 10 mg tablet tablet

151 Metoclopramid Hcl injeksi ampul
152 Metronidazol 500 mg Suppositoria Suppo
153 Metronidazol larutan infus 500 mg /ml botol
154 Metronidazol ovula ovula
155 Metronidazol sirup 125 mg/ 5mL botol
156 Metronidazol tablet 250 mg tablet
157 Metronidazol tablet 500 mg tablet
158 Mikonazol crem tube
159 Mikronutrien Ibu Hamil Tablet tablet
160 Multivitamin + Tambah Darah tab/cap tablet
161 Multivitamin Syrup PKD botol
162 Multivitamin Syrup Program Gizi botol
163 Natrium Bikarbonat tablet 500 mg tablet
164 Natrium Diklofenac 50 mg tablet tablet
165 Natrium Diklofenak tablet 25 mg tablet
166 Natrium Klorida larutan infus 0,9 % steril botol
167 Neurotropik tablet tablet
168 Nifedipin tablet 10 mg tablet
169 Nistatin 500.000 IU tablet tablet
170 Nistatin suspensi 100000Ui/ml botol
171 Nistatin tablet Vagina 100.000 IU suppo
172 OAT Kategori Anak FDC paket
173 OAT Kategori I FDC paket
174 OAT Kategori II FDC paket
175 OAT Sisipan FDC paket
176 Obat Flu Kombinasi Anak Sirup botol
177 Obat Flu Kombinasi Anak Tablet tablet
178 Obat Flu Kombinasi Dewasa Tablet tablet
179 Obat Flu Kombinasi Infant Sirup botol
180 Obat Flu Kombinasi Infant Tablet tablet
181 Obat Peluruh Batu Ginjal tablet
182 Obat Pencernaan Kombinasi Syr botol

183 Obat Sal Cerna : Antasida 200 mg; dimeticone 40 tablet

mg kaplet (Berlocid®)
Obat Tetes Mata Kombinasi: Polymyxin B sulfate
184 6.000 IU; neomycin sulfate 3.5 mg; sodium botol
sulphate 1 mg
185 Oksitosin injeksi 10 IU/ml - 1 ml ampul
186 Omeprazole kapsul 20 mg kapsul
187 Oseltamivir Phosphate tablet (Tamiflu®) tablet
188 Parasetamol drops botol
189 Parasetamol sirup 120 mg/5 ml botol
190 Parasetamol Suppositoria suppo
191 Parasetamol tablet 500 mg tablet
192 Perak Sulfadiazin krim tube
193 Piracetam tablet 800 mg tablet
194 Pirantel Pamoat tablet 125 mg tablet
195 Pirazinamid 500 mg tablet tablet
196 Piridoksin HCl (Vit.B6) tablet 10 mg tablet
197 Piroksikam 20 mg tablet
198 Povidon Iodida 1 % MW/Kumur botol
199 Povidon Iodida 10 % 30 ml botol
200 Povidon Iodida 10 % 300 ml botol
201 Prednison tablet 5 mg tablet
202 Primakuin 15 mg tablet
203 Propiltiourasil tablet 100 mg tablet
204 Propranolol HCl tablet 10 mg tablet
205 Ranitidin injeksi 25mg/2ml ampul
 206 Ranitidin tablet 150 mg tablet
207 Resperidone 2 mg tablet
208 Retinol ( Vit A ) 100.000.IU softcap
209 Retinol ( Vit A ) 200.000.IU softcap
210 Riffampisin 600 mg tablet tablet
211 Ringer Laktat larutan infus steril botol
212 Salbutamol 2 mg tablet tablet
213 Salbutamol 4 mg tablet tablet

214 Salbutamol Sulphate Nebules 2.5 mg / 2.5 ml ampul

(Ventolin®)
Salep 2-4 , Kombinasi:
215 Asam Salisilat 2% + Belerang Endap 4% pot

216 Salep Kortikosteroid Kombinasi Antibiotik tube

217 Salisil Bedak 2 % botol
Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU
218 ampul
I)

219 Serum Anti Tetanus (ATS) Injeksi 1.500 IU/ampul ampul

220 Setirizin sirup 5mg/ml botol

221 Sianokobalamin (Vit.B12) 50 mcg tablet tablet
222 Sianokobalamin (Vit.B12) injeksi 500 mcg-ml ampul
223 Simvastatin tablet 10 mg tablet
224 Spironolakton tablet 25 mg tablet
225 Streptomicin injeksi ampul
226 Tablet Tambah Darah tablet
227 Tablet Zink Dispersible tablet
228 Tetrasiklin HCl kapsul 250 mg kapsul
229 Tetrasiklin HCl kapsul 500 mg kapsul
230 Tiamin HCl Mononitrat (Vit.B1) tablet 50 mg tablet
231 Triheksifenidil Hidroklorida tablet 2 mg tablet
232 Vitamin B Kompleks tablet tablet
233 Zinc sirup 10 mg/mL botol
234 Bisoprolol Fumarate 5 mg tablet
235 Oksitetrasiklin salb kulit 3 % tube
236 Lidokain spray oral 10% botol
237 Zidovudine (ZDV) 100mg tablet
238 Lamivudine (3TC) 150mg tablet
239 Efavirenz (EFV) 200mg tablet
240 Nevirapine (NVP) 200mg tablet
241 Tenofovir (TDF) 300mg tablet
242 ZDV/3TC (300/150mg) tablet
243 TDC/3TC/EFV (300/300/600mg) tablet
244 Flufenazin inj 25 mg/mL (i.m.) inj
245 Haloperidol drops 2 mg/mL drops
246 Haloperidol inj 50 mg/mL inj
247 Valproat tab lepas lambat 250 mg tab
248 Omeprazol serb inj 40 mg serb inj
 249 Efavirenz (EFV) 600mg tablet

BAHAN MEDIS PAKAI HABIS

250 Alat suntik sekali pakai 1 ml pcs
251 Alat suntik sekali pakai 10 ml pcs
252 Alat suntik sekali pakai 3 ml pcs
253 Alat suntik sekali pakai 5 ml pcs
254 Alkohol swab lbr
255 Antiseptik dan Disinfektan Gel botol
256 Aqua DM pcs
257 Bayclin® (Klorin 5.25%) 4 Liter botol
258 Benang sutra hitam 2/0 roll
259 Benang sutra hitam 3/0 roll
260 Catgut Chromic Benang Bedah 3/0 roll
261 Catgut Plain Benang Bedah 3/0 roll
262 Daryantule® (Kasa Pembalut ukuran 10x10 cm
direndam dlm 1% Framicetin SO4) lembar
263 Foly Cateter No 16 pcs
264 Foly Cateter No 18 pcs
265 Infusion set anak pcs
266 Infusion set dewasa pcs
267 IV Catheter No. 16 pcs
268 IV Catheter No. 18 G pcs
269 IV Catheter No. 20 G pcs
270 IV Catheter No. 22 G pcs
271 IV Catheter No. 24 G pcs
272 Jarum Jahit pcs
273 Jelly Lubricant Steril tube
274 Kantong Urin pcs
275 Kapas Pembalut / Absorben 250 gram pcs
276 Kasa 16 x 16 pcs
277 Kasa hidrofil 40 x 80 cm elastis roll
278 Kasa Kompres 40/40 steril pcs
279 Kasa Pembalut 2 m x 80 cm pcs
280 Kasa Pembalut Hidrofil 4 m x 15 cm elastic pcs
281 Kasa Pembalut Hidrofil 4 m x 3 cm elastic pcs
282 Kertas EKG CARDIOLINE® set
283 Kertas EKG FUKUDA® set
284 Klem Umbilical pcs
285 Lysol® (kresol tersabun 50%) botol
286 Masker Nebulizer Anak set
287 Masker Nebulizer Dewasa set
288 Masker Wajah Ear Loop pcs
289 Masker Wajah Tali pcs
290 Pembalut Gips pcs
291 Perhidrol botol
292 Pisau Bedah No .11 pcs
 293 Plester 5 yards x 2 inch roll
294 Pot Dahak pcs
295 Sarung Tangan non steril No. 7 set
296 Sarung Tangan Persalinan (panjang) set
297 Sarung Tangan Sanitasi (orange) set
298 Sarung Tangan Steril No.6,5 set
299 Sarung Tangan Steril No.7 set
300 Sarung Tangan Steril No.7,5 set
301 Sarung Tangan Steril No.8 set
302 Selang Oksigen Anak pcs
303 Selang Oksigen Bayi pcs
304 Selang Oksigen Dewasa pcs
305 Sendok sirup pcs
Silk Benang Bedah Sutera No. 3/0 dengan jarum
306 bedah set
307 Spalk pcs
308 Tissue kotak
309 Tranfusi set pcs
Ultra Sonique Gel 260 gr® (Gel Lubrikasi USG)
310 botol
Ultra Sonique Gel 5 L® (Refill Gel Lubrikasi USG)
311 botol
312 Underpad 60 x 90 pcs
313 Masker N95 pcs
314 Ferrakrilum cairan 1% cairan
315 Klorheksidin lar 0,2% lar
316

BAHAN KEDOKTERAN GIGI

316 Air Raksa Dental Use pcs
317 Bahan Pengisi Saluran Akar pcs
318 Arkansas Bur Hijau pcs
319 Arkansas Bur Putih pcs
320 Artikulating Papper pcs
321 Bahan Tambalan Sinar BONDING pcs
322 Bahan Tambalan Sinar ETCHING pcs
323 Bahan Tambalan Sinar SOLARE A2.5 Anterior pcs
324 Bahan Tambalan Sinar SOLARE A3.5 pcs
325 Bahan Tambalan Sinar SOLARE A3 pcs
326 Bor Poilsh composite pcs
327 Caviton pcs
328 Celluloid Strip kotak

329 Dentocain® Mepivacaine HCL 3% carpule 1.8 ml carpule

330 Devitalisasi Pasta (Non Arsen) botol
331 Disposible Dental Needle pcs
332 Etil Klorida spray botol
333 Eugenol cairan botol
 334 Finishing Strip strip
335 Gelas Kumur Disposible pcs
336 Glass Ionomer Cement kotak
337 Bahan Tumpatan Sementara (Fill Temp) pot
338 Glass Ionomer Cement ART Fuji VII botol
339 Iod Gliserin kotak
340 Iodofom pcs
341 Kalsium Hidroksida Pasta kotak
342 Klorfenol kamfer Menthol ( CHKM ) kotak
343 Mata Bor High speed Fissure pcs
344 Mata Bor High Speed Inverted pcs
345 Mata Bor High Speed Round pcs
346 Mata Bor Low speed set
347 MD Cleanser kotak
348 Microbrush set
349 Occo Liquid botol
350 Saliva ejector disposible pcs
351 Semen Seng Fosfat serbuk dan cairan set
352 Silver Amalgam pcs
353 Smear Layer Removal pot
354 Spon Gelatin cublices 1x1x1 cm pcs
Temporary Stopping Fletcher (Fletcher)
355 serbuk dan cairan set
356 Tri Kresol Formalin (TKF) botol

BAHAN LABORATORIUM
356 Antikoagulan EDTA serbuk botol
357 Antisera gol. Darah A botol
358 Antisera gol. Darah B botol
359 Antisera gol. Darah AB botol
360 Antisera gol. Darah D botol
361 Antisera Widal Ty H botol
362 Antisera Widal Ty O botol
363 Reagen strip, HBsAg strip
364 Reagen strip, PP (HCG) test strip
365 Reagen strip, HIV strip
366 Reagen strip, Urin 2 parameter strip
367 Reagen strip, Urin 3 parameter strip
368 Reagen strip, Urin 10 parameter strip
369 Tabung Vacutainer Non Koagulan pcs
370 Tabung Vacutainer Dengan Koagulan pcs
371 Jarum Vacutainer pcs
372 Reagen Kontrol Gula Darah vial
373 Reagen Kontrol Asam Urat vial
374 Reagen Kontrol Kolesterol vial
375 Reagen Kontrol Trigliserid vial
376 Reagen Strip Gula Darah strip
377 Reagen Strip Asam Urat strip
378 Reagen Strip Kolesterol strip
379 Reagen Strip Trigliserid strip
380 Reagen Strip Haemoglobin strip
381 Holder Vacutainer pcs
382 Biolarvasida (Program DBD)/Bactivec botol
383 Insektisida (Program DBD) botol
384 Reagen Strip Leptospirosis strip
385 Pewarna Zein Nelson botol
386 Regaen Strip Dengue NS1 strip
387 Reagen Strip Dengue IgG / IgM strip
388 Reagen Test Iodium strip
389 Reagen Sipilis set
390 Pewarna Gram A-B-C-D paket
391 DHP -Frimal ( Program ) tablet
392 Fluconazole 150 mg ( program) tablet
393 Coverplast tranparan pcs
394 Abate kg
395 Haloperidol drop 2mg botol
396 Sikzonat injeksi 25 mg ampul
397 Asam Valproat 250 mg (DEPAKOTE) tab
398 Vaksin Rabies (VERORAB) ampul
399 Haloperidol inj 50 mg/mL ampul
400 Anti HBs (SD BIOLINE) kit
401 Masker Hijab (P2 PM) pcs
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
Keterangan