Format Lplpo 2020 Alehanuae

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)
KODE PUSKESMAS :
PUSKESMAS :
KECAMATAN :
KAB/KOTA :
PROPINSI :
SISA STOK PENERI- PERSE- PEMA-

NO NAMA OBAT SATUAN
HARI AWAL MAAN DIAAN KAIAN
1 2 3 4 5 6 7 8
A. O B A T - O B A T A N
1 Albendazol suspensi 200 mg / 5 ml Btl - -
2 Albendazol tablet 400 mg Tab - -
3 Alopurinol tablet 100 mg Tab 70 70
4 Alopurinol tablet 300 mg Tab - -
5 Alprazolam 0,25 mg Tab - -
7 Ambroxol 30 mg Tab 500 500
8 Ambroxol Sirup Tab 10 10
9 Aminofilin injeksi 24 mg/ml - 10 ml Amp - -
10 Aminofilin tablet 150 mg Tab - -
12 Amitriptilin hcl tablet salut 25 mg Tab - -
13 Amlodipin Tablet15 mg Tab 100 100
14 Amlodipin Tablet210 mg Tab 140 140
15 Amoksisilin1kapsul 250 mg Cps - -
16 Amoksisilin2kaplet 500 mg Kpl 300 300
17 Amoksisilin3sirup kering 125 mg/5 ml Vial 8 8
18 Amoksisilin2serbuk injeksi 1000 mg Btl - -
19 Amoksisillin drops 100 mg/mL Btl - -
20 Amoksisillin sirup forte 250 mg/ 5 ml Btl - -
21 Ampisilin Injeksi 1000 mg/Vial Vial - -
22 Ampisilin serbuk injeksi 500 mg / vial Vial - -
23 Antalgin (Metampiron) tablet 500 mg Tab - -
24 Antalgin Injeksi 1000 mg/2 ml Amp - -
25 Antasida doen tablet, kombinasi Tab 440 440
26 Antasida suspensi Btl 9 9
27 Antibakteri doen salep kombinasi Tube - -
28 Antifungi doen kombinasi (Whytefield) Pot - -
29 Antihemoroid doen kombinasi Supp - -
30 Antimalaria kombinasi Tab - -
31 Antimigrain doen kombinasi (Ergo + Koff) Tab - -
32 Tab
Antiparkinson Kombinasi (Benzerasid 25 mg, Levodopa 100mg) - -
Page 1 of 55
NO NAMA OBAT SATUAN
33 Aqua pro injeksi steril bebas pirogen Btl - -
34 Asam asetil salisilat ( Asetosal ) tablet 80 mg Tab - -
35 Asam askorbat (Vit.C) tablet 250 mg Tab - -
36 Asam askorbat (Vit.C) tablet 50 mg Tab 470 470
37 Asam folat tablet 0,4 mg Tab - -
38 Asam folat tablet 1 mg Tab - -
39 Asam Fusidat Krim (Fucilex) Tube - -
40 Asam Mefenamat 250 mg Tab - -
41 Asam Mefenamat 500 mg Tab 140 140
42 Asam Salisilat 5% Tab - -
43 Asam Traneksamat Injeksi Amp - -
44 Asiklovir krim 5 % Tube - -
45 Asiklovir tablet 200 mg Tab - -
47 Atapulgit tablet Tab - -
48 Atenolol tablet 50 mg Tab - -
49 Atropin sulfat injeksi 0,25 mg/ml - 1 ml Amp - -
50 Benzatin penisilin injeksi 1,2 jt UI / ml Amp - -
51 Betahistin Mesilat tablet 6 mg Tab - -
52 Betametasom krim 0,1 % Tube - -
53 Betametasom krim 0,5 mg/ gram Tube - -
54 Betametasom tetes mata 1 mg/ ml Btl - -
55 Bisacodil Suppositoria (Dulcolax Supp)15 mg Supp - -
57 Bisacodil tablet 5 mg Tab - -
58 Budesonid ( Pulmicort ) 0,5 mg/ml Amp - -
59 Captopril 12,5 mg Tab - -
60 Captopril 25 mg Tab - -
62 Ceftriaxone 1 g Vial - -
63 Cendo Liters Tetes mata 15 ml Btl - -
64 Cetirizem syrup 5 mg/ 5 ml Btl - -
65 Cetirizem tablet 10 mg Tab - -
66 Cifrofloxacin 500 mg Tab - -
67 Cimetidin tablet 200 mg Tab - -
68 Clindamicin 150 mg Tab - -
70 Clobazam tab.10 mg Tab - -
71 Clopidogrel 75 mg Tab - -
72 Clozapine 25 mg Tab - -
73 Codein 10 mg Tab - -
75 Deksametason injeksi 5 mg/ml - 1 ml Amp - -
76 Deksametason tablet 0,5 mg Tab 270 270
77 Diazepam inj. 5 mg / ml - 2 ml Amp - -
78 Diazepam larutan1rektal 5 mg/2,5 mL Amp - -
Page 2 of 55
NO NAMA OBAT SATUAN
80 Diazepam tablet 2 mg Tab - -
82 Dietylkarbamasin tablet 100 mg Tab - -
83 Difenhidramin hcl inj. 10 mg / ml - 1 ml Amp - -
84 Digoksin tablet 0,25 mg Tab - -
85 Diltiazem HCl tablet 30 mg Tab - -
86 Diltiazem serbuk injeksi 50 mg Vial - -
87 Dimenhidrinat tablet 50 mg Tab - -
88 Doksisiklin kapsul 100 mg Kaps - -
89 Domperiden suspensi 5 mg/5ml Btl - -
90 Domperidon Tablet 10 mg Tab - -
91 Epineprin hcl/bitatrat (adrenalin) inj. 0,1 % Amp - -
92 Ergokalsiferol (Vitamin D2) serb 10000 UI Tab - -
93 Ergotamin tablet 1 mg Tab - -
94 Eritromisin 250 mg Tab - -
96 Eritromisin sirup Btl - -
97 Ethambutol 250 mg Tab - -
100 Famotidin tab 20 mg Tab - -
101 Fenilbutazone tablet 200 mg Tab - -
102 Fenitoin Injeksi 50 mg/ ml Amp - -
103 Fenitoin Na kapsul 100 mg Kaps - -
104 Fenobarbital injeksi 50 mg/ml - 2 ml Amp - -
105 Fenobarbital tablet130 mg Tab - -
107 Fenoksimethyl Penisilin ( Penisilin V ) tablet 500 mg Tab - -
108 Fenol gliserol tetes telinga 10 % Btl - -
109 Ferro fumarat kapsul 300 mg Kaps - -
110 Ferro Sulfat syrup 15 mg/ 5 ml Btl - -
111 Ferro Sulfat tablet salut 300 mg Tab - -
112 Fitomenadion (Vit.K) Infant Injeksi 2 mg/ml Amp - -
113 Fitomenadion (Vit.K) injeksi 10 mg/ml Amp - -
114 Fitomenadion (Vit.K) tablet salut 10 mg Tab - -
115 Fluoksetin tablet 10 mg Tab - -
116 Fluoresein tetes mata 2,5 mg/ ml Btl - -
117 Framisetin Sulfat (tulle 1%) Pcs - -
118 Furosemid Injeksi 10 ml Vial - -
119 Furosemid tablet 40 mg Tab - -
120 Garam Oralit untuk 200 ml air Sach 13 13
121 Gentamicin 0,1 % Salep kulit Tube - -
122 Gentamicin tetes mata Btl - -
123 Gentian violet larutan 1 % Btl - -
124 Glibenklamid tablet 2,5 mg Tab - -
Page 3 of 55
NO NAMA OBAT SATUAN
125 Glibenklamid tablet 5 mg Tab 140 140
126 Glimepirid tablet 1 mg Tab - -
128 Glipisid tablet 5 mg Tab - -
129 Gliseril guayakolat tablet 100 mg Tab - -
130 Gliseril trinitat tablet sublingual 0,5 mg Tab - -
131 Gliserin tetes 10 mg/ ml Btl - -
132 Glukonas Kalsikus injeksi 100 mg/ ml (10%) Amp - -
133 Griseofulvin tablet 125 mg, micronized Tab - -
135 Haloperidol injeksi 5 mg/ ml Amp - -
136 Haloperidol injeksi 50 mg / mL Amp - -
137 Haloperidol tablet 0,5 mg Tab - -
139 Haloperidol tablet 2 mg Tab - -
141 Hidro Urea Krim 10% (Soft U Derm) Tube - -
142 Hidroklorotiazid (HCT) tablet 25 mg Tab - -
143 Hidrokortison krim 1 % Tube 8 8
144 Hiosina butil bromida 10 mg Tab 130 130
145 Ibuprofen syrup 100 mg/ 5 ml Btl - -
146 Ibuprofen tablet 200 mg Tab 130 130
147 Ibuprofen tablet 400 mg Tab - -
148 Ipratropium Bromida Inhaler padat 20 mg Btl - -
149 Ipratropium Bromida Nebulizer 0,025 % Btl - -
150 Isoniazid tablet 100 mg Tab - -
152 Isosorbid dinitrat tablet sublingual15 mg Tab - -
154 Kalamin lotio Btl - -
155 Kalsium karbonat tablet 500 mg Tab - -
156 Kalsium laktat (kalk) tablet 500 mg Tab 440 440
157 Karbamazepin sirup 100 mg / 5 ml Btl - -
158 Karbamazepin tablet 100 mg Tab - -
160 Karbo gliserin tetes telinga 10% Btl - -
161 Karbon aktif ( Norit ) Tab Tab - -
162 Ketamin injeksi2100 mg/ml Amp - -
163 Ketokonazole 200 mg Tab - -
164 Ketokonazole cream 2% 10 gr Tube - -
165 Ketorolac inj 30 mg Amp - -
166 Klofasimin kapsul 100 mg Kaps - -
167 Klonidine 0,15 mg Tab - -
168 Kloramfenikol kapsul 250 mg Kaps - -
169 Kloramfenikol salep kulit 2 % Tube 13 13
170 Kloramfenikol salep mata 1 % Tube - -
Page 4 of 55
NO NAMA OBAT SATUAN
171 Kloramfenikol Suspensi Btl - -
172 Kloramfenikol tetes mata 0,5 % Btl 7 7
173 Kloramfenikol tetes telinga 3 % Btl - -
174 Klorfeniramin maleat (CTM) tablet 4 mg Tab 240 240
175 Klorpromazin HCl tablet salut125 mg Tab - -
177 Klorpromazin Injeksi15 mg/ ml Amp - -
179 Kolkisin tablet 500 mcg Tab - -
180 Kombinasi (Amoksisilin 500 mg, Asam Klavulanat 125 mg) Tab
Palentin 625 mg tab - -
181 Kombinasi (Artemeter 20mg, Lumefantrin 120mg) Tab - -
182 Kombinasi (Artesunat 50mg, Amodiaquin 200mg) Tab - -
183 Kombinasi (As. Salisil, As. Benzoat, Sulfur) Salep 88 Pot - -
184 Kombinasi (Benserazid 25 mg, Levodopa 100 mg) tab Tab - -
185 Kombinasi (Besi II fumarat,Mangan,Tembaga,as.folat, Vit.C, Vit Tab
B12) Hemafort Tab - -
186 Kombinasi (Fluocinolone Asetonide, Neomisin Sulfat 5 mg) Tube
Fluocort N Cream - -
187 Kombinasi (Ipratropium Br 0,5 mg, Salbutamol 2,5 mg) Nebulizer Btl
(Combivent) - -
188 Kombinasi (Kaolin 550 mg, Pektin 20 mg ) Tab - -
189 Kombinasi (Methampiron, Papaverin HCl, Belladon Extract) Tab

Spasminal Tab - -
190 Kombinasi (Sulfadoksin 500 mg, pirimetamin 25 mg ) Tab - -
191 Kombinasi (Triprolidin HCl 2,5 mg, Pseudoefedrin 30 mg, PCT Tab
500 mg) Noza Tab - -
192 Kontrasepsi KB 3 bulan Kaps - -
193 Kontrasepsi oral kombinasi (Levonogestrel 150mcg & ethynil Tab
estradiol 30mcg) - -
194 Kontrasepsi, AKDR (iud) capper T Pcs - -
195 Kontrasepsi, Implant Etono gestrel Implant 68 mg Pcs - -
196 Kontrasepsi, Implant Levono gestrel Implant 2 rods, 75 mg (3- Pcs
4tahun) - -
197 Kotrimoksazol0suspensi Btl - -
198 Kotrimoksazol1pediatrik tablet Tab - -
199 Kotrimoksazol2dewasa tablet Tab - -
200 Kotrimoksazol3Forte Tablet Tab - -
201 Larutan Asering Btl - -
202 Larutan Dekstran 70 - infus 6 % steril Btl - -
203 Larutan Glukosa05 % Btl - -
205 Larutan KAEN 3B Btl - -
206 Larutan Natrium klorida (NaCl) 0,9 % Btl - -
207 Larutan Ringer laktat (RL) Btl - -
208 Lidokain Gel 2 % Btl - -
209 Lidokain Injeksi 2 % (HCl) Amp - -
210 Lidokain Injeksi 2 % + Ephineprin Amp - -
Page 5 of 55
NO NAMA OBAT SATUAN
211 Lidokain Injeksi 2 % + Ephineprin (Pehacain) Amp - -
212 Lidokain Injeksi 2% (HCI) + Epinefrin 1:80.000-2ML Amp - -
213 Lidokain Salep 5 % Tube - -
214 Lidokain Spray 10 % Btl - -
215 Lisinopril tablet 10 mg Tab - -
216 Loperamid tablet 2 mg Tab 160 160
217 Loratadin tablet 10 mg Tab - -
218 Magnesium Sulfat Injeksi 20% Btl - -
220 Magnesium Sulfat Serb,ktg 30 gram Vial - -
221 Mebendazol sirup 100 mg/ 5 ml Btl - -
222 Mebendazol tablet 100 mg Tab - -
224 Meloxicam 7,5 mg Tab - -
225 Metamizol Inj 500 mg/ml Amp - -
226 Metformin 500 mg Tab - -
227 Methochlorpramide injeksi 10 mg/2 ml Amp - -
228 Methochlorpramide Susp. Btl - -
229 Methochlorpramide tab15 mg Tab 170 170
230 Methochlorpramide tab210 mg Tab - -
231 Methyl Prednisolon tab 4 mg Tab - -
233 Metilergometrin maleat inj. 0,200 mg - 1 ml Amp - -
234 Metilergometrin maleat tab.salut 0,125 mg Tab - -
235 Metronidazol larutan infus 5 mg / ml Btl - -
236 Metronidazol sirup 125 mg / 5 ml Btl - -
237 Metronidazol tablet 250 mg Tab - -
239 Mikonazol krim / salep 2 % Tube - -
240 Mikonazol serb. 2 % Pot - -
241 N-Asetil Sistein 200 mg Tab - -
242 Natrium bikarbonat tablet 500 mg Tab - -
243 Natrium diklofenak tablet 25 mg Tab 140 140
244 Natrium diklofenak tablet 50 mg Tab - -
245 Natrium diklofenak tts mata 1 mg/ml Btl - -
246 Natrium flurosein tetes mata 2% Btl - -
247 Natrium tiosulfat inj. 25 % - 10 ml Amp - -
248 Nifedipin Tab.10 mg Tab - -
249 Nikotinamid tablet 20 mg Tab - -
250 Nistatin 100.000 iu/g tablet vaginal Tab - -
251 Nistatin 100.000 iu/ml susp Btl - -
252 Nistatin 500.000 iu tablet salut Tab - -
253 Norephinefrin injeksi 1 mg/ ml Amp - -
254 Obat Antituberkulosis kategori 1 dewasa (FDC) Tab - -
256 Obat Antituberkulosis Kategori Anak Tab - -
Page 6 of 55
NO NAMA OBAT SATUAN
257 Obat Antituberkulosis Kombipak Tab - -
258 Obat Antituberkulosis Sisipan Tab - -
259 Obat batuk hitam (OBH) cairan Btl - -
260 Ofloksasin Tablet 200 mg Tab - -
261 Oksimetasolin tetes hidung 0,050 % Btl - -
262 Oksitetrasiklin hcl salep kulit 3 % Tube - -
263 Oksitetrasiklin hcl salep mata 1 % Tube 12 12
264 Oksitosin injeksi 10 iu / ml - 1 ml Amp - -
265 Olopatadin tetes mata 0,1 % Btl - -
266 Omeprazole Injeksi 40 mg/ 10 ml Vial - -
267 Omeprazole kaps.20 mg Kaps - -
268 Papaverin tablet Tab - -
269 Parasetamol Drops Btl - -
270 Parasetamol sirup 120 mg/ 5ml Btl 12 12
271 Parasetamol tablet 500 mg Tab 430 430
272 Peditox Solution Btl - -
273 Perak Sulphadiazine 10 mg Tube - -
274 Permetrin Cream 5% Tube - -
275 Piracetam injeksi 1 g/5 ml Vial - -
276 Pirantel pamoat tablet 125 mg Tab - -
278 Pirantel suspensi 125 mg/5 ml Btl - -
279 Piridoksin hcl tablet 10 mg Tab 440 440
280 Piridoksin hcl tablet 25 mg Tab - -
281 Piridoksin injeksi 100 mg/ ml Amp - -
282 Pirosikam1tablet 10 mg Tab - -
283 Pirosikam2kapsul 20 mg Kaps - -
284 Povidon larutan 10 % 30 ml Btl - -
285 Povidon larutan 10 %160 ml Btl - -
287 Prazikuantel tablet 600 mg Tab - -
288 Prednison tablet 5 mg Tab - -
289 Primaquin tablet 15 mg Tab - -
290 Probenezid tablet 500 mg Tab - -
291 Prokain Benzil Penisilin G Inj 3 Jt Vial - -
292 Prokain Benzil Penisilin serbuk Inj 1 Jt UI / vial Vial - -
293 Propanolol Hcl tablet 10 mg Tab - -
295 Propiltiourasil tablet 100 mg Tab - -
296 Pyrazinamid 500 mg Tab - -
297 Quinin Injeksi Vial - -
298 Quinin Tab 250 mg Tab - -
299 Ranitidin inj. 50 mg/2 ml Amp - -
300 Ranitidin tablet 150 mg Tab - -
301 Retinol (Vit.A) Kapsul 100.000 iu Kaps - -
Page 7 of 55
NO NAMA OBAT SATUAN
303 Rifampisin tablet 300 mg Tab - -
304 Risperidone 2 mg Tab - -
305 Sacharum Lactis Bks - -
306 Salbutamol larutan Inhaler 0,5 % Btl - -
307 Salbutamol tablet 2 mg Tab 90 90
308 Salbutamol tablet 4 mg Tab - -
309 Salep 2-4 kombinasi Pot 3 3
310 Salisil bedak 2 % Ktk - -
311 Sefadroksil kapsul 500 mg Tab - -
312 Sefadroksil syrup kering 125 mg/ml Btl - -
313 Sianokobalamin1(Vit.B12) tablet 50 mg Tab 280 280
314 Sianokobalamin2(Vit.B12) inj. 500 mcg/ml Amp - -
315 Simvastatin 10 mg Tab 240 240
316 Simvastatin 20 mg Tab - -
317 Spironolakton tablet 25 mg Tab - -
318 Streptomisin serbuk injeksi 1000 mg Vial - -
319 Suplemen Multivitamin anak sirup (Corovit) Btl - -
320 Suplemen Multivitamin Dewasa ( Corovit ) Tab - -
Tablet Tambah Darah (Kombinasi) : Ferro Fumarat 60MG + As.
321 Folat 0,4Mg Tab - -
322 Tablet Tambah darah Neo Tab 140 140
323 TDF + 3TC + EFV (Obat HIV) Tab - -
324 Tetrakain tetes mata 0,5% Btl - -
325 Tetrasiklin hcl kapsul 250 mg Kaps - -
327 Thiamhpenikol 500 mg Kap - -
328 Tiamin hcl ( Vit.B1 ) inj. 100 mg/ml - 1 ml Amp - -
329 Tiamin hcl mononitrat (Vit.B1) tab. 50 mg Tab - -
330 Triheksifenidil hidroklorida tablet 2 mg Tab - -
331 Tuberkulin protein purified derifatif Inj 1 : 10 Vial - -
332 Ultrasoun galaktose mikropartikel 200-400 mg mikropar/ml Btl - -
333 Valproat sirup 250 mg / 5 ml Btl - -
334 Valproat tablet salut 250 mg (Depakote ER) Tab - -
336 Vitamin B Kompleks Injeksi Amp - -
337 Vitamin B Kompleks tablet Tab 460 460
338 Zidovudine kapsul 100 mg Kaps - -
339 Zinc serb. 10 mg Pot - -
340 Zinc Syr 20 mg/5 ml Btl - -
341 Zink 20 mg Tab - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
Page 8 of 55
NO NAMA OBAT SATUAN
342 - -
342 - -
342 - -
B. OBAT GIGI - -
1 Articulating paper (kertas pewarna penanda oklusi) Lbr - -
2 Betadin Kumur Btl - -
3 BIODINAMICA Frutti Flour Gel Btl Plstik - -
4 Bonding Btl - -
5 Carpule single-use needles (for syringe citoject) Pcs - -
6 Dentorit ( bhn tambal sementara ) Btl - -
7 Devitalisasi pasta ( non arsen ) Btl - -
8 Etching Btl - -
9 Etil klorida semprot Btl - -
10 Eugenol cairan Btl - -
11 Formokresol cairan Btl - -
12 Glass Ionomer cement Pkt - -
13 Kalsium hidroksida pasta Btl - -
14 Kenalog Tube - -
15 Klorfenol Kanfer Mentol (CHKM) Btl - -
16 Klorheksidine larutan 0,2% Btl - -
17 Klorheksidine larutan 15% Btl - -
18 Komposit resin Btl - -
19 Lidocain Inj + Carpule Ampl - -
20 Natrium hipoklorid cairan concentrat 5% untuk diencerkan Btl - -
21 Pasta pengisi saluran akar Btl - -
22 Polikresulen ( Albotil ) Btl - -
23 Qutta percha & peper point 15-40 mm Btl - -
25 Salcoseryl Pasta/Gingi Jelly Btl - -
26 Semen seng fosfat serbuk dan cairan Btl - -
27 Septocain (Articaine + Epinefrin) Injeksi Ampl - -
28 Spon Gelatin ( Hemospon ) Pcs - -
29 Tambalan Sementara (Cavit 3 M) Pkt - -
30 Tambalan Sinar A2 (Composit) Btl - -
32 Temporary stoping fletcher serbuk dan cair Set - -
33 Trikresol formalin ( T.K.F ) cairan Btl - -
34 - -
34 - -
34 - -
34 - -
34 - -
34 - -
C. VAKSIN - -
1 Serum antidifteri (A.D.S) Injeksi i.m 10000 UI / vial Dev - -
2 Serum antirabies injeksi 200 UI / ml Vial - -
Page 9 of 55
NO NAMA OBAT SATUAN
3 Serum antitetanus (ATS) inj 1500 IU/ml i.m (Biosat 1,5) Ampul - -
4 Serum antitetanus (ATS) injeksi 1500 UI Vial - -
5 Vaksin BCG injeksi Vial - -
6 Vaksin HPV (Human Papilloma Virus)-quadrivalent Vial - -
7 Vaksin jerap difteri tetanus (DT) injeksi Vial - -
8 Vaksin jerap difteri tetanus pertusis (DTP) injeksi Vial - -
9 Vaksin jerap tetanus (tetanus adsorbed toxoid) Inj Vial - -
10 Vaksin kombinasi DPT + hepatitis B Vial - -
11 Vaksin polio cairan steril 10 dosis Vial - -
12 Vaksin polio drops 10 dosis Vial - -
13 Vaksin rabies Vero Vial - -
14 Vaksin rabies, untuk manusia inj + booster Vial - -
15 Vaksin Tetanus toxoid injeksi Vial - -
16 - -
16 - -
16 - -
16 - -
16 - -
16 - -
D. BAHAN HABIS PAKAI - -
1 Abbocath No. 18 Pcs - -
6 Alat suntik sekali0pakai 0,5 ml Pcs - -
7 Alat suntik sekali1pakai 1 ml Pcs 20 20
8 Alat suntik sekali2pakai 2,5 ml / 3 ml Pcs 20 20
9 Alat suntik sekali3pakai 5 ml Pcs 20 20
10 Alat suntik sekali4pakai 10 ml Pcs - -
11 Alat suntik sekali4pakai 2,5 ml (Untuk Gigi) Pcs - -
12 Alat Ukur Lingkar Perut Btl - -
13 Alkohol Swab Lbr - -
14 Apron One Plastic Bag - -
15 Aqua gel 250 ml (Ultrasonic) Btl - -
16 Aseptic Gel + Dispenser Btl - -
17 Askina Soft Clear 7,5 x 5 Lbr - -
18 Autoclick Lancing Device Pcs - -
19 Basic Dressing Set Pcs - -
20 Blood Lancet Device Pcs - -
21 Borgol Plastik Pcs - -
22 Box Slide Pcs - -
23 Catgut Chromic 2/0 + jarum 1/2 GT 35 mm Pcs - -
25 Catgut Chromic 3/0 HR 20 MM Pcs - -
Page 10 of 55
NO NAMA OBAT SATUAN
29 CATGUT CHROMIC SMI 2/0 HR 37 MM Pcs - -
31 Catgut Plain 3/0 HR 20 MM Pcs - -
34 Celemek Dental (polibib) Pcs - -
35 Cervical Collar Universal (Penyangga Leher) Pcs - -
36 Chromic 2/0, 90 cm, 1/2Taper, 37 mm Pcs - -
37 Chromic 4/0, 75 cm, 3/8 CC, 16 mm Pcs - -
38 Cutimed Gel 15 gr Tube - -
39 Dek Glass Pcs - -
40 E-CARE SURGICAL TAPE 2 ( plester kertas ) Pcs - -
41 Elastic verband 10 cm x 4,57 m (4 inc) Roll - -
42 Foley Catheter No 12 Pcs - -
47 Hanschoen Non steril1S Psg - -
48 Hanschoen Non steril2M Psg - -
49 Hanschoen Non steril3L Psg - -
50 Hanschoen steril No. 6,5 Psg - -
51 Hanschoen steril No. 7 Psg - -
54 Infusion set anak Pcs - -
55 Infusion set dewasa Pcs - -
56 Jarum Hecting Kulit G-09 Lsn - -
62 Jarum Hecting Otot B-10 Lsn - -
66 Jarum Hecting Otot G-12 Lsn - -
68 Jelly Catheter Btl - -
69 Kaca Batang Pengaduk Tabung HB Sahli Pcs - -
70 Kanula Hidung1Bayi Disposible Pcs - -
71 Kanula Hidung2Anak Disposible Pcs - -
72 Kanula Hidung3Dewasa Disposible Pcs - -
Page 11 of 55
NO NAMA OBAT SATUAN
73 Kapas pembalut/adsorben 250 gram Pcs - -
75 Kasa Kompres 40/40 steril Roll - -
76 Kasa pembalut 2 m x 80 cm Pcs - -
77 Kasa pembalut hidrofil 36 x 80 cm Pcs - -
78 Kasa pembalut hidrofil 4 m x 10 cm Pcs - -
83 Kasa pembalut steril uk 16 x 16 Pcs - -
85 Kertas EKG Roll - -
86 Kertas Saring Lbr - -
87 Kertas Thermal Untuk MINDRAY Btl - -
88 Kertas USG Roll - -
89 Larutan Aquadest steril Btl - -
90 Larutan Aquadest (Waterone 1 liter) Btl - -
91 Larutan Aseptic Gel (Hand Rub 500 ml) Btl - -
93 Larutan Chlorin Btl - -
94 Larutan Etakridin (Rivanol) larutan 0,1 % Btl - -
95 Larutan Etanol (alkohol) 70 % 1 Liter Btl - -
96 Larutan Etanol (Alkohol) 96 % Btl - -
97 Larutan Lisol 1 liter Btl - -
98 Larutan Povidon 10% 30 ml Btl - -
99 Larutan Povidon 10%160 ml Btl - -
101 Larutan Surgical Scrub1(Hand Scrub 500 ml ) Btl - -
102 Larutan Surgical Scrub2(Hand Scrub 5000 ml) Btl - -
103 Masker MP 305 Pcs - -
104 Masker N95 Pcs - -
105 Masker Surgical ear loop Lbr - -
106 Micropipette Adjust Vol 5-50ul Pcs - -
109 Mitella Kain Pcs - -
110 Mukus Extractor Pcs - -
111 Obstetric Gloves Psg - -
112 Obstetric Gloves No. 6,5 Psg - -
113 Obstetric Gloves No. 7 Psg - -
115 Parafilm Roll - -
116 Pembalut Siku (Arm Sling M) Lbr - -
117 Pengaduk Dahak Bks - -
118 Pipet Tetes Pcs - -
Page 12 of 55
NO NAMA OBAT SATUAN
119 Plastik Klip1Kecil Bks - -
120 Plastik Klip2Sedang Bks - -
121 Plastik Klip3Besar Bks - -
122 Plastik Klip4Besar 12 x 20 cm Bks - -
123 Plester 2,50 X 4,5 CM Roll - -
124 Plester 5 yard x 2 inch Roll - -
125 Plester 7,5 yard x 2 inch Roll - -
126 Plester Fiksasi Kateter IV 6 x 8cm Roll - -
127 Plester fiksasi penutup luka Lebar 5cm x 5 m (Fixomul) Roll - -
128 Plester fiksasi penutup luka Lebar 15cm x 5m (Fixomul) Roll - -
130 Plester Penutup Luka Lebar Tulle 10 x 10cm (Cuticell Classic) Lbr - -
Plester Penutup Luka Lebar Tulle 7,5x20cm (Cuticell Oitment
132 Dressing) Lbr - -
133 Plesterin Bulat Pcs - -
134 Pot Dahak TB Pot - -
135 Pot Tinja Pot - -
136 Pot Urine Pot - -
137 Provein 5/0, 45 cm, 3/8RCPrem, 18 mm Pcs - -
138 Purple Cap Vacum Tube EDTA k3 3ml Btl - -
139 Regulator Oksigen (O2) Bh - -
140 Safety Box Bh - -
141 Sikat Tabung Pcs - -
142 Silk 3/0 + jarum 1/2, 24 mm, 75 cm Pcs - -
144 Silk 3/0,75cm,1/2 Taper, 26mm Pcs - -
146 Silk Black 4/0 HR 26 MM Pcs - -
147 Slide (Objeck Glass) Pcs - -
148 Spalk1Bayi Bh - -
149 Spalk2Anak Bh - -
150 Spalk3Kayu Bh - -
151 Steroform Bh - -
152 Stomach Tube FR 10 Pcs - -
154 Suction catheter No. 06 Pcs - -
158 Sungkup/Masker Oksigen1Bayi Pcs - -
159 Sungkup/Masker Oksigen2Anak Pcs - -
160 Sungkup/Masker Oksigen3Dewasa Pcs - -
161 Surgical blade No 10 Pcs - -
Page 13 of 55
NO NAMA OBAT SATUAN
171 Tabung Centrifuge 10 CC Pcs - -
172 Tabung HB Sahli Pcs - -
173 Tabung Reaksi Pcs - -
174 Tabung Reaksi 16 X 150 mm Pcs - -
175 Tabung Westegreen (Tabung LED) Pcs - -
176 Tanda Pengenal Pasien (Bayi) Pcs - -
177 Tanda Pengenal Pasien (Dewasa) Pcs - -
178 Three Way Stop Cock With Tube Pcs - -
179 Tip Blue Tip Micropipette Pcs - -
180 Tip White Micropipette Pcs - -
181 Tip Yellow Tip Micropipette Pcs - -
182 Tissue Dispenser Bh - -
183 Tissue Standar Livi Pcs - -
184 Umbical cord klem Nylon Pcs - -
185 Underpad Pcs - -
186 Urine Bag Pcs - -
187 Vicryil 5/0 (Vio) Pcs - -
188 Wing Needle 19 G x 1/2 Pcs - -
191 Wrapping Paper 60 gsm, 100x100 Pcs - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
E. REAGEN - -
1 Combur test urine Btl - -
2 Desinfektan High Level, Alkapharm Btl - -
3 EDTA Bubuk 50 gram Pot - -
4 Ether Alkohol 100 ml Btl - -
5 Formalin cair Btl - -
6 Gliserin Btl - -
7 Gliserin (LAB) Btl - -
8 Gluco dr Alat ( Included Strip) Set - -
9 Glukostrip Dr Btl - -
Page 14 of 55
NO NAMA OBAT SATUAN
10 Iodin Test 10 ml Btl - -
11 Larutan Anisol Btl - -
12 Larutan Asam Sulfosalisilat 20 % Btl - -
13 Larutan BaCl 2 Btl - -
14 Larutan benedict Btl - -
15 Larutan boor ( Burowi ) 100 ml Btl - -
17 Larutan EDTA 10% 100 ml Btl - -
18 Larutan Emersion Oil 100 cc Btl - -
19 Larutan eosin 2 % Btl - -
20 Larutan etanol asam ( HCl Alkohol ) 3% Btl - -
21 Larutan Fouchet Btl - -
22 Larutan gabbet Btl - -
23 Larutan giemsa stain Btl - -
24 Larutan H2O2 3 % 100 cc Btl - -
25 Larutan Hayem Btl - -
26 Larutan HCl 0,1 N / Asam Klorida Btl - -
27 Larutan karbol fuksin Btl - -
28 Larutan KOH 10 % Btl - -
29 Larutan Lugol Btl - -
30 Larutan Metanol Btl - -
31 Larutan metilen biru Btl - -
32 Larutan Natrium Citrat 3,8 % Btl - -
33 Larutan Pewarna Giensa 100 ml Btl - -
34 Larutan Schlesinger Btl - -
35 Larutan Spiritus Btl - -
36 Larutan Sulfosalisilat Acid 20 % Btl - -
37 Larutan turk Btl - -
38 Larutan Ziehl-Neelsen Btl - -
39 Rapid Test Chikunguya Set - -
40 Rapid Test Dengue Duo NS1 Dev - -
42 Rapid Test Dengue IgG/IgM Dev - -
43 Rapid Test HBsAg Dev - -
44 Rapid Test HIV 1 / 23,0 Dev - -
45 Rapid Test HIV R2 Dev - -
46 Rapid Test Malaria Dev - -
47 Rapid Test Salmonella Dev - -
48 Rapid Test Syphilis Dev - -
49 Reagen Hematology Analyzer Beckman Coulter Pkt - -
50 Reagen Hematology Analyzer Drew D3 - USA Pkt - -
51 Reagen Spektrofotometer Kenza Max/Biolabo Pkt - -
52 Reagen Spektrofotometer Type 5010 Pkt - -
53 - Cholesterol Kit - -
Page 15 of 55
NO NAMA OBAT SATUAN
54 - Trigliserida GPO Kit - -
55 - HDL Cholesterol PEG Kit - -
56 - Glucosa Kit - -
57 - Ureum/urea Kit - -
58 - Asam urat Kit - -
59 - SGOT (AST) Kit - -
60 - SGPT (ALT) Kit - -
61 - Chemistry Control, N (Lyophilized) Kit - -
62 Reagen Hematology Analizer MINDRAY Pkt - -
63 -Diluent 20 liter Pack - -
64 -Lyse 500 ml Btl - -
65 -Prob Cleanser 17 ml Btl - -
66 -Kontrol 3 ml Btl - -
67 Reagen Kimia Klinik (Fotometer) Pkt - -
68 -Albumin Kit - -
69 -ALT/GPT Kit - -
70 -AST/GOT Kit - -
71 -Urit Acid/Asam Urat Kit - -
72 -Ureum Kit - -
73 -Creatinin Kit - -
74 -Cholesterol Kit - -
75 -Glukosa Kit - -
76 Strip Asam Urat 25's (NESCO) Strip - -
77 Strip Cholesterol 10's (AUTOCHECK) Strip - -
78 Strip Glucose 25's (AUTOCHECK) Strip - -
79 Strip Gula Darah 25's (NESCO) Strip - -
80 Strip Haemoglobin 4 x 50 Test (HaemoCue Hb 201+) Strip - -
81 Strip Haemoglobin Catridge HbA1c 10's Strip - -
82 Strip Kolestrol 10's (NESCO) Strip - -
83 Strip pemeriksaan Asam Urat Strip - -
84 Strip pemeriksaan Asam Urat (BENE CHECK PLUS) Strip - -
85 Strip pemeriksaan Asam Urat (Sinocare EA-12) Strip - -
86 Strip pemeriksaan Cholesterol (BENE CHECK PLUS) Strip - -
87 Strip pemeriksaan Cholesterol (Mission Ultra) Strip - -
88 Strip pemeriksaan Cotinin Strip - -
89 Strip pemeriksaan Glukosa (ACCU Check Performa) Strip - -
90 Strip Urine Aution Stick 10 AE Strip - -
91 Test Golongan Darah ABO Dev - -
92 Test Kehamilan Strip - -
93 Test Tuberculin Strip - -
94 Widal Set - -
95 - -
95 - -
95 - -
Page 16 of 55
NO NAMA OBAT SATUAN
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
JUMLAH
KUNJUNGAN
RESEP UMUM KIS A
Kepala Pusksmas…………
( ………….…….………… )
Catatan :
Jumlah Kunjungan Resep = Jumlah Penulisan Resep per Pasien dalam Sebulan !!!
Page 17 of 55
AN LEMBAR PERMINTAAN OBAT
LPLPO)
BULAN : 5
TAHUN : 2020
EXP. SISA STOCK PERMIN- PEMBERI

KET
DATE STOCK OPT. TAAN AN
9 10 11 12 13 14
-
-
70
-
-
-
500
10
-
-
-
-
100
140
-
300
8
-
-
-
-
-
-
-
440
9
-
-
-
-
-
Page 18 of 55
KET
-
-
-
470
-
-
-
-
140
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
270
-
-
Page 19 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
13
-
-
-
-
Page 20 of 55
KET
140
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
8
130
-
130
-
-
-
-
-
-
-
-
-
440
-
-
-
-
-
-
-
-
-
-
-
-
13
-
Page 21 of 55
KET
-
7
-
240
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 22 of 55
KET
-
-
-
-
-
160
-
-
-
-
-
-
-
-
-
-
-
-
170
-
-
-
-
-
-
-
-
-
-
-
-
-
140
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 23 of 55
KET
-
-
-
-
-
-
12
-
-
-
-
-
-
12
430
-
-
-
-
-
-
-
440
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 24 of 55
KET
-
-
-
-
90
-
3
-
-
-
280
-
240
-
-
-
-
-
-
140
-
-
-
-
-
-
-
-
-
-
-
-
-
-
460
-
-
-
-
-
-
-
-
-
-
-
Page 25 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 26 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
20
20
20
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 27 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 28 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 29 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 30 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 31 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 32 of 55
KET
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Page 33 of 55
KET
-
-
-
-
-
-
-
-
-
-
ASKES JUMLAH
Yang Menerima
( ………….…….………… )
Page 34 of 55
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)
KODE PUSKESMAS :
PUSKESMAS : BULAN : 1
KECAMATAN : TAHUN : 2020
KAB/KOTA :
PROPINSI :
SISA STOK PENERI- PERSE- PEMA- EXP. SISA STOCK PERMIN- PEMBERI
NO NAMA OBAT SATUAN KET
HARI AWAL MAAN DIAAN KAIAN DATE STOCK OPT. TAAN AN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
A. O B A T - O B A T A N
1 Albendazol suspensi 200 mg / 5 ml Btl - -
2 Albendazol tablet 400 mg Tab - -
7 Ambroxol 30 mg Tab - -
8 Ambroxol Sirup Tab - -
9 Aminofilin injeksi 24 mg/ml - 10 ml Amp - -
12 Amitriptilin hcl tablet salut 25 mg Tab - -
13 Amlodipin Tablet15 mg Tab - -
14 Amlodipin Tablet210 mg Tab - -
15 Amoksisilin1kapsul 250 mg Cps - -
16 Amoksisilin2kaplet 500 mg Kpl - -
17 Amoksisilin3sirup kering 125 mg/5 ml Vial - -
18 Amoksisilin2serbuk injeksi 1000 mg Btl - -
19 Amoksisillin drops 100 mg/mL Btl - -
20 Amoksisillin sirup forte 250 mg/ 5 ml Btl - -
21 Ampisilin Injeksi 1000 mg/Vial Vial - -
22 Ampisilin serbuk injeksi 500 mg / vial Vial - -
23 Antalgin (Metampiron) tablet 500 mg Tab - -
24 Antalgin Injeksi 1000 mg/2 ml Amp - -
25 Antasida doen tablet, kombinasi Tab - -
Page 35 of 55
26 Antasida suspensi Btl - -
27 Antibakteri doen salep kombinasi Tube - -
28 Antifungi doen kombinasi (Whytefield) Pot - -
29 Antihemoroid doen kombinasi Supp - -
30 Antimalaria kombinasi Tab - -
31 Antimigrain doen kombinasi (Ergo + Koff) Tab - -
32 Tab
Antiparkinson Kombinasi (Benzerasid 25 mg, Levodopa 100mg) - -
33 Aqua pro injeksi steril bebas pirogen Btl - -
34 Asam asetil salisilat ( Asetosal ) tablet 80 mg Tab - -
37 Asam folat tablet 0,4 mg Tab - -
38 Asam folat tablet 1 mg Tab - -
39 Asam Fusidat Krim (Fucilex) Tube - -
42 Asam Salisilat 5% Tab - -
43 Asam Traneksamat Injeksi Amp - -
44 Asiklovir krim 5 % Tube - -
47 Atapulgit tablet Tab - -
48 Atenolol tablet 50 mg Tab - -
49 Atropin sulfat injeksi 0,25 mg/ml - 1 ml Amp - -
50 Benzatin penisilin injeksi 1,2 jt UI / ml Amp - -
51 Betahistin Mesilat tablet 6 mg Tab - -
52 Betametasom krim 0,1 % Tube - -
53 Betametasom krim 0,5 mg/ gram Tube - -
54 Betametasom tetes mata 1 mg/ ml Btl - -
57 Bisacodil tablet 5 mg Tab - -
58 Budesonid ( Pulmicort ) 0,5 mg/ml Amp - -
59 Captopril 12,5 mg Tab - -
62 Ceftriaxone 1 g Vial - -
Page 36 of 55
63 Cendo Liters Tetes mata 15 ml Btl - -
64 Cetirizem syrup 5 mg/ 5 ml Btl - -
65 Cetirizem tablet 10 mg Tab - -
66 Cifrofloxacin 500 mg Tab - -
67 Cimetidin tablet 200 mg Tab - -
70 Clobazam tab.10 mg Tab - -
71 Clopidogrel 75 mg Tab - -
72 Clozapine 25 mg Tab - -
75 Deksametason injeksi 5 mg/ml - 1 ml Amp - -
76 Deksametason tablet 0,5 mg Tab - -
77 Diazepam inj. 5 mg / ml - 2 ml Amp - -
82 Dietylkarbamasin tablet 100 mg Tab - -
83 Difenhidramin hcl inj. 10 mg / ml - 1 ml Amp - -
84 Digoksin tablet 0,25 mg Tab - -
85 Diltiazem HCl tablet 30 mg Tab - -
86 Diltiazem serbuk injeksi 50 mg Vial - -
87 Dimenhidrinat tablet 50 mg Tab - -
88 Doksisiklin kapsul 100 mg Kaps - -
89 Domperiden suspensi 5 mg/5ml Btl - -
90 Domperidon Tablet 10 mg Tab - -
91 Epineprin hcl/bitatrat (adrenalin) inj. 0,1 % Amp - -
92 Ergokalsiferol (Vitamin D2) serb 10000 UI Tab - -
93 Ergotamin tablet 1 mg Tab - -
96 Eritromisin sirup Btl - -
100 Famotidin tab 20 mg Tab - -
Page 37 of 55
101 Fenilbutazone tablet 200 mg Tab - -
102 Fenitoin Injeksi 50 mg/ ml Amp - -
103 Fenitoin Na kapsul 100 mg Kaps - -
104 Fenobarbital injeksi 50 mg/ml - 2 ml Amp - -
107 Fenoksimethyl Penisilin ( Penisilin V ) tablet 500 mg Tab - -
108 Fenol gliserol tetes telinga 10 % Btl - -
109 Ferro fumarat kapsul 300 mg Kaps - -
110 Ferro Sulfat syrup 15 mg/ 5 ml Btl - -
111 Ferro Sulfat tablet salut 300 mg Tab - -
112 Fitomenadion (Vit.K) Infant Injeksi 2 mg/ml Amp - -
113 Fitomenadion (Vit.K) injeksi 10 mg/ml Amp - -
114 Fitomenadion (Vit.K) tablet salut 10 mg Tab - -
115 Fluoksetin tablet 10 mg Tab - -
116 Fluoresein tetes mata 2,5 mg/ ml Btl - -
118 Furosemid Injeksi 10 ml Vial - -
119 Furosemid tablet 40 mg Tab - -
120 Garam Oralit untuk 200 ml air Sach - -
121 Gentamicin 0,1 % Salep kulit Tube - -
122 Gentamicin tetes mata Btl - -
123 Gentian violet larutan 1 % Btl - -
124 Glibenklamid tablet 2,5 mg Tab - -
125 Glibenklamid tablet 5 mg Tab - -
128 Glipisid tablet 5 mg Tab - -
129 Gliseril guayakolat tablet 100 mg Tab - -
130 Gliseril trinitat tablet sublingual 0,5 mg Tab - -
131 Gliserin tetes 10 mg/ ml Btl - -
132 Glukonas Kalsikus injeksi 100 mg/ ml (10%) Amp - -
135 Haloperidol injeksi 5 mg/ ml Amp - -
136 Haloperidol injeksi 50 mg / mL Amp - -
Page 38 of 55
141 Hidro Urea Krim 10% (Soft U Derm) Tube - -
142 Hidroklorotiazid (HCT) tablet 25 mg Tab - -
143 Hidrokortison krim 1 % Tube - -
144 Hiosina butil bromida 10 mg Tab - -
145 Ibuprofen syrup 100 mg/ 5 ml Btl - -
148 Ipratropium Bromida Inhaler padat 20 mg Btl - -
149 Ipratropium Bromida Nebulizer 0,025 % Btl - -
154 Kalamin lotio Btl - -
155 Kalsium karbonat tablet 500 mg Tab - -
156 Kalsium laktat (kalk) tablet 500 mg Tab - -
157 Karbamazepin sirup 100 mg / 5 ml Btl - -
160 Karbo gliserin tetes telinga 10% Btl - -
161 Karbon aktif ( Norit ) Tab Tab - -
162 Ketamin injeksi2100 mg/ml Amp - -
163 Ketokonazole 200 mg Tab - -
164 Ketokonazole cream 2% 10 gr Tube - -
165 Ketorolac inj 30 mg Amp - -
166 Klofasimin kapsul 100 mg Kaps - -
167 Klonidine 0,15 mg Tab - -
168 Kloramfenikol kapsul 250 mg Kaps - -
169 Kloramfenikol salep kulit 2 % Tube - -
170 Kloramfenikol salep mata 1 % Tube - -
171 Kloramfenikol Suspensi Btl - -
172 Kloramfenikol tetes mata 0,5 % Btl - -
173 Kloramfenikol tetes telinga 3 % Btl - -
174 Klorfeniramin maleat (CTM) tablet 4 mg Tab - -
Page 39 of 55
179 Kolkisin tablet 500 mcg Tab - -
180 Kombinasi (Amoksisilin 500 mg, Asam Klavulanat 125 mg) Tab
Palentin 625 mg tab - -
181 Kombinasi (Artemeter 20mg, Lumefantrin 120mg) Tab - -
182 Kombinasi (Artesunat 50mg, Amodiaquin 200mg) Tab - -
183 Kombinasi (As. Salisil, As. Benzoat, Sulfur) Salep 88 Pot - -
184 Kombinasi (Benserazid 25 mg, Levodopa 100 mg) tab Tab - -
185 Kombinasi (Besi II fumarat,Mangan,Tembaga,as.folat, Vit.C, Vit Tab
B12) Hemafort Tab - -
186 Kombinasi (Fluocinolone Asetonide, Neomisin Sulfat 5 mg) Tube
Fluocort N Cream - -
187 Kombinasi (Ipratropium Br 0,5 mg, Salbutamol 2,5 mg) Nebulizer Btl
(Combivent) - -
188 Kombinasi (Kaolin 550 mg, Pektin 20 mg ) Tab - -
189 Kombinasi (Methampiron, Papaverin HCl, Belladon Extract) Tab

Spasminal Tab - -
190 Kombinasi (Sulfadoksin 500 mg, pirimetamin 25 mg ) Tab - -
191 Kombinasi (Triprolidin HCl 2,5 mg, Pseudoefedrin 30 mg, PCT Tab
500 mg) Noza Tab - -
192 Kontrasepsi KB 3 bulan Kaps - -
193 Kontrasepsi oral kombinasi (Levonogestrel 150mcg & ethynil Tab
estradiol 30mcg) - -
194 Kontrasepsi, AKDR (iud) capper T Pcs - -
195 Kontrasepsi, Implant Etono gestrel Implant 68 mg Pcs - -
196 Kontrasepsi, Implant Levono gestrel Implant 2 rods, 75 mg (3- Pcs
4tahun) - -
197 Kotrimoksazol0suspensi Btl - -
198 Kotrimoksazol1pediatrik tablet Tab - -
199 Kotrimoksazol2dewasa tablet Tab - -
200 Kotrimoksazol3Forte Tablet Tab - -
201 Larutan Asering Btl - -
202 Larutan Dekstran 70 - infus 6 % steril Btl - -
205 Larutan KAEN 3B Btl - -
206 Larutan Natrium klorida (NaCl) 0,9 % Btl - -
207 Larutan Ringer laktat (RL) Btl - -
208 Lidokain Gel 2 % Btl - -
Page 40 of 55
209 Lidokain Injeksi 2 % (HCl) Amp - -
210 Lidokain Injeksi 2 % + Ephineprin Amp - -
211 Lidokain Injeksi 2 % + Ephineprin (Pehacain) Amp - -
212 Lidokain Injeksi 2% (HCI) + Epinefrin 1:80.000-2ML Amp - -
213 Lidokain Salep 5 % Tube - -
214 Lidokain Spray 10 % Btl - -
215 Lisinopril tablet 10 mg Tab - -
216 Loperamid tablet 2 mg Tab - -
217 Loratadin tablet 10 mg Tab - -
220 Magnesium Sulfat Serb,ktg 30 gram Vial - -
221 Mebendazol sirup 100 mg/ 5 ml Btl - -
224 Meloxicam 7,5 mg Tab - -
225 Metamizol Inj 500 mg/ml Amp - -
226 Metformin 500 mg Tab - -
227 Methochlorpramide injeksi 10 mg/2 ml Amp - -
228 Methochlorpramide Susp. Btl - -
233 Metilergometrin maleat inj. 0,200 mg - 1 ml Amp - -
234 Metilergometrin maleat tab.salut 0,125 mg Tab - -
235 Metronidazol larutan infus 5 mg / ml Btl - -
236 Metronidazol sirup 125 mg / 5 ml Btl - -
239 Mikonazol krim / salep 2 % Tube - -
240 Mikonazol serb. 2 % Pot - -
241 N-Asetil Sistein 200 mg Tab - -
242 Natrium bikarbonat tablet 500 mg Tab - -
245 Natrium diklofenak tts mata 1 mg/ml Btl - -
246 Natrium flurosein tetes mata 2% Btl - -
Page 41 of 55
247 Natrium tiosulfat inj. 25 % - 10 ml Amp - -
248 Nifedipin Tab.10 mg Tab - -
249 Nikotinamid tablet 20 mg Tab - -
250 Nistatin 100.000 iu/g tablet vaginal Tab - -
251 Nistatin 100.000 iu/ml susp Btl - -
252 Nistatin 500.000 iu tablet salut Tab - -
253 Norephinefrin injeksi 1 mg/ ml Amp - -
256 Obat Antituberkulosis Kategori Anak Tab - -
257 Obat Antituberkulosis Kombipak Tab - -
258 Obat Antituberkulosis Sisipan Tab - -
259 Obat batuk hitam (OBH) cairan Btl - -
260 Ofloksasin Tablet 200 mg Tab - -
261 Oksimetasolin tetes hidung 0,050 % Btl - -
262 Oksitetrasiklin hcl salep kulit 3 % Tube - -
263 Oksitetrasiklin hcl salep mata 1 % Tube - -
264 Oksitosin injeksi 10 iu / ml - 1 ml Amp - -
265 Olopatadin tetes mata 0,1 % Btl - -
266 Omeprazole Injeksi 40 mg/ 10 ml Vial - -
267 Omeprazole kaps.20 mg Kaps - -
268 Papaverin tablet Tab - -
269 Parasetamol Drops Btl - -
270 Parasetamol sirup 120 mg/ 5ml Btl - -
271 Parasetamol tablet 500 mg Tab - -
272 Peditox Solution Btl - -
273 Perak Sulphadiazine 10 mg Tube - -
274 Permetrin Cream 5% Tube - -
275 Piracetam injeksi 1 g/5 ml Vial - -
278 Pirantel suspensi 125 mg/5 ml Btl - -
281 Piridoksin injeksi 100 mg/ ml Amp - -
282 Pirosikam1tablet 10 mg Tab - -
283 Pirosikam2kapsul 20 mg Kaps - -
284 Povidon larutan 10 % 30 ml Btl - -
Page 42 of 55
287 Prazikuantel tablet 600 mg Tab - -
288 Prednison tablet 5 mg Tab - -
289 Primaquin tablet 15 mg Tab - -
290 Probenezid tablet 500 mg Tab - -
291 Prokain Benzil Penisilin G Inj 3 Jt Vial - -
292 Prokain Benzil Penisilin serbuk Inj 1 Jt UI / vial Vial - -
295 Propiltiourasil tablet 100 mg Tab - -
296 Pyrazinamid 500 mg Tab - -
297 Quinin Injeksi Vial - -
298 Quinin Tab 250 mg Tab - -
299 Ranitidin inj. 50 mg/2 ml Amp - -
300 Ranitidin tablet 150 mg Tab - -
303 Rifampisin tablet 300 mg Tab - -
304 Risperidone 2 mg Tab - -
305 Sacharum Lactis Bks - -
306 Salbutamol larutan Inhaler 0,5 % Btl - -
309 Salep 2-4 kombinasi Pot - -
310 Salisil bedak 2 % Ktk - -
311 Sefadroksil kapsul 500 mg Tab - -
312 Sefadroksil syrup kering 125 mg/ml Btl - -
313 Sianokobalamin1(Vit.B12) tablet 50 mg Tab - -
314 Sianokobalamin2(Vit.B12) inj. 500 mcg/ml Amp - -
317 Spironolakton tablet 25 mg Tab - -
318 Streptomisin serbuk injeksi 1000 mg Vial - -
319 Suplemen Multivitamin anak sirup (Corovit) Btl - -
320 Suplemen Multivitamin Dewasa ( Corovit ) Tab - -
Tablet Tambah Darah (Kombinasi) : Ferro Fumarat 60MG + As.
321 Folat 0,4Mg Tab - -
322 Tablet Tambah darah Neo Tab - -
Page 43 of 55
323 TDF + 3TC + EFV (Obat HIV) Tab - -
324 Tetrakain tetes mata 0,5% Btl - -
327 Thiamhpenikol 500 mg Kap - -
328 Tiamin hcl ( Vit.B1 ) inj. 100 mg/ml - 1 ml Amp - -
329 Tiamin hcl mononitrat (Vit.B1) tab. 50 mg Tab - -
330 Triheksifenidil hidroklorida tablet 2 mg Tab - -
331 Tuberkulin protein purified derifatif Inj 1 : 10 Vial - -
332 Ultrasoun galaktose mikropartikel 200-400 mg mikropar/ml Btl - -
333 Valproat sirup 250 mg / 5 ml Btl - -
336 Vitamin B Kompleks Injeksi Amp - -
337 Vitamin B Kompleks tablet Tab - -
338 Zidovudine kapsul 100 mg Kaps - -
339 Zinc serb. 10 mg Pot - -
340 Zinc Syr 20 mg/5 ml Btl - -
341 Zink 20 mg Tab - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
342 - -
B. OBAT GIGI - -
1 Articulating paper (kertas pewarna penanda oklusi) Lbr - -
2 Betadin Kumur Btl - -
3 BIODINAMICA Frutti Flour Gel Btl Plstik - -
4 Bonding Btl - -
5 Carpule single-use needles (for syringe citoject) Pcs - -
6 Dentorit ( bhn tambal sementara ) Btl - -
7 Devitalisasi pasta ( non arsen ) Btl - -
8 Etching Btl - -
Page 44 of 55
9 Etil klorida semprot Btl - -
10 Eugenol cairan Btl - -
11 Formokresol cairan Btl - -
12 Glass Ionomer cement Pkt - -
13 Kalsium hidroksida pasta Btl - -
14 Kenalog Tube - -
15 Klorfenol Kanfer Mentol (CHKM) Btl - -
16 Klorheksidine larutan 0,2% Btl - -
17 Klorheksidine larutan 15% Btl - -
18 Komposit resin Btl - -
19 Lidocain Inj + Carpule Ampl - -
20 Natrium hipoklorid cairan concentrat 5% untuk diencerkan Btl - -
21 Pasta pengisi saluran akar Btl - -
22 Polikresulen ( Albotil ) Btl - -
25 Salcoseryl Pasta/Gingi Jelly Btl - -
26 Semen seng fosfat serbuk dan cairan Btl - -
27 Septocain (Articaine + Epinefrin) Injeksi Ampl - -
28 Spon Gelatin ( Hemospon ) Pcs - -
29 Tambalan Sementara (Cavit 3 M) Pkt - -
32 Temporary stoping fletcher serbuk dan cair Set - -
33 Trikresol formalin ( T.K.F ) cairan Btl - -
34 - -
34 - -
34 - -
34 - -
34 - -
34 - -
C. VAKSIN - -
1 Serum antidifteri (A.D.S) Injeksi i.m 10000 UI / vial Dev - -
2 Serum antirabies injeksi 200 UI / ml Vial - -
3 Serum antitetanus (ATS) inj 1500 IU/ml i.m (Biosat 1,5) Ampul - -
4 Serum antitetanus (ATS) injeksi 1500 UI Vial - -
5 Vaksin BCG injeksi Vial - -
6 Vaksin HPV (Human Papilloma Virus)-quadrivalent Vial - -
Page 45 of 55
7 Vaksin jerap difteri tetanus (DT) injeksi Vial - -
8 Vaksin jerap difteri tetanus pertusis (DTP) injeksi Vial - -
9 Vaksin jerap tetanus (tetanus adsorbed toxoid) Inj Vial - -
10 Vaksin kombinasi DPT + hepatitis B Vial - -
11 Vaksin polio cairan steril 10 dosis Vial - -
12 Vaksin polio drops 10 dosis Vial - -
13 Vaksin rabies Vero Vial - -
14 Vaksin rabies, untuk manusia inj + booster Vial - -
15 Vaksin Tetanus toxoid injeksi Vial - -
16 - -
16 - -
16 - -
16 - -
16 - -
16 - -
D. BAHAN HABIS PAKAI - -
6 Alat suntik sekali0pakai 0,5 ml Pcs - -
8 Alat suntik sekali2pakai 2,5 ml / 3 ml Pcs - -
11 Alat suntik sekali4pakai 2,5 ml (Untuk Gigi) Pcs - -
12 Alat Ukur Lingkar Perut Btl - -
13 Alkohol Swab Lbr - -
14 Apron One Plastic Bag - -
15 Aqua gel 250 ml (Ultrasonic) Btl - -
16 Aseptic Gel + Dispenser Btl - -
17 Askina Soft Clear 7,5 x 5 Lbr - -
18 Autoclick Lancing Device Pcs - -
19 Basic Dressing Set Pcs - -
20 Blood Lancet Device Pcs - -
21 Borgol Plastik Pcs - -
22 Box Slide Pcs - -
Page 46 of 55
34 Celemek Dental (polibib) Pcs - -
35 Cervical Collar Universal (Penyangga Leher) Pcs - -
36 Chromic 2/0, 90 cm, 1/2Taper, 37 mm Pcs - -
37 Chromic 4/0, 75 cm, 3/8 CC, 16 mm Pcs - -
38 Cutimed Gel 15 gr Tube - -
39 Dek Glass Pcs - -
40 E-CARE SURGICAL TAPE 2 ( plester kertas ) Pcs - -
41 Elastic verband 10 cm x 4,57 m (4 inc) Roll - -
47 Hanschoen Non steril1S Psg - -
48 Hanschoen Non steril2M Psg - -
49 Hanschoen Non steril3L Psg - -
54 Infusion set anak Pcs - -
55 Infusion set dewasa Pcs - -
Page 47 of 55
68 Jelly Catheter Btl - -
69 Kaca Batang Pengaduk Tabung HB Sahli Pcs - -
70 Kanula Hidung1Bayi Disposible Pcs - -
71 Kanula Hidung2Anak Disposible Pcs - -
72 Kanula Hidung3Dewasa Disposible Pcs - -
75 Kasa Kompres 40/40 steril Roll - -
76 Kasa pembalut 2 m x 80 cm Pcs - -
85 Kertas EKG Roll - -
86 Kertas Saring Lbr - -
87 Kertas Thermal Untuk MINDRAY Btl - -
88 Kertas USG Roll - -
89 Larutan Aquadest steril Btl - -
90 Larutan Aquadest (Waterone 1 liter) Btl - -
93 Larutan Chlorin Btl - -
94 Larutan Etakridin (Rivanol) larutan 0,1 % Btl - -
95 Larutan Etanol (alkohol) 70 % 1 Liter Btl - -
96 Larutan Etanol (Alkohol) 96 % Btl - -
97 Larutan Lisol 1 liter Btl - -
98 Larutan Povidon 10% 30 ml Btl - -
Page 48 of 55
101 Larutan Surgical Scrub1(Hand Scrub 500 ml ) Btl - -
102 Larutan Surgical Scrub2(Hand Scrub 5000 ml) Btl - -
103 Masker MP 305 Pcs - -
104 Masker N95 Pcs - -
105 Masker Surgical ear loop Lbr - -
109 Mitella Kain Pcs - -
110 Mukus Extractor Pcs - -
111 Obstetric Gloves Psg - -
113 Obstetric Gloves No. 7 Psg - -
115 Parafilm Roll - -
116 Pembalut Siku (Arm Sling M) Lbr - -
117 Pengaduk Dahak Bks - -
118 Pipet Tetes Pcs - -
119 Plastik Klip1Kecil Bks - -
120 Plastik Klip2Sedang Bks - -
121 Plastik Klip3Besar Bks - -
122 Plastik Klip4Besar 12 x 20 cm Bks - -
123 Plester 2,50 X 4,5 CM Roll - -
124 Plester 5 yard x 2 inch Roll - -
125 Plester 7,5 yard x 2 inch Roll - -
126 Plester Fiksasi Kateter IV 6 x 8cm Roll - -
127 Plester fiksasi penutup luka Lebar 5cm x 5 m (Fixomul) Roll - -
Plester Penutup Luka Lebar Tulle 7,5x20cm (Cuticell Oitment
132 Dressing) Lbr - -
133 Plesterin Bulat Pcs - -
134 Pot Dahak TB Pot - -
135 Pot Tinja Pot - -
136 Pot Urine Pot - -
Page 49 of 55
137 Provein 5/0, 45 cm, 3/8RCPrem, 18 mm Pcs - -
138 Purple Cap Vacum Tube EDTA k3 3ml Btl - -
139 Regulator Oksigen (O2) Bh - -
140 Safety Box Bh - -
141 Sikat Tabung Pcs - -
146 Silk Black 4/0 HR 26 MM Pcs - -
147 Slide (Objeck Glass) Pcs - -
148 Spalk1Bayi Bh - -
149 Spalk2Anak Bh - -
150 Spalk3Kayu Bh - -
151 Steroform Bh - -
158 Sungkup/Masker Oksigen1Bayi Pcs - -
159 Sungkup/Masker Oksigen2Anak Pcs - -
160 Sungkup/Masker Oksigen3Dewasa Pcs - -
171 Tabung Centrifuge 10 CC Pcs - -
172 Tabung HB Sahli Pcs - -
173 Tabung Reaksi Pcs - -
174 Tabung Reaksi 16 X 150 mm Pcs - -
Page 50 of 55
175 Tabung Westegreen (Tabung LED) Pcs - -
176 Tanda Pengenal Pasien (Bayi) Pcs - -
177 Tanda Pengenal Pasien (Dewasa) Pcs - -
178 Three Way Stop Cock With Tube Pcs - -
179 Tip Blue Tip Micropipette Pcs - -
180 Tip White Micropipette Pcs - -
181 Tip Yellow Tip Micropipette Pcs - -
182 Tissue Dispenser Bh - -
183 Tissue Standar Livi Pcs - -
184 Umbical cord klem Nylon Pcs - -
185 Underpad Pcs - -
186 Urine Bag Pcs - -
187 Vicryil 5/0 (Vio) Pcs - -
191 Wrapping Paper 60 gsm, 100x100 Pcs - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
192 - -
E. REAGEN - -
1 Combur test urine Btl - -
2 Desinfektan High Level, Alkapharm Btl - -
3 EDTA Bubuk 50 gram Pot - -
4 Ether Alkohol 100 ml Btl - -
5 Formalin cair Btl - -
6 Gliserin Btl - -
7 Gliserin (LAB) Btl - -
8 Gluco dr Alat ( Included Strip) Set - -
9 Glukostrip Dr Btl - -
10 Iodin Test 10 ml Btl - -
11 Larutan Anisol Btl - -
12 Larutan Asam Sulfosalisilat 20 % Btl - -
Page 51 of 55
13 Larutan BaCl 2 Btl - -
14 Larutan benedict Btl - -
17 Larutan EDTA 10% 100 ml Btl - -
18 Larutan Emersion Oil 100 cc Btl - -
19 Larutan eosin 2 % Btl - -
20 Larutan etanol asam ( HCl Alkohol ) 3% Btl - -
21 Larutan Fouchet Btl - -
22 Larutan gabbet Btl - -
23 Larutan giemsa stain Btl - -
24 Larutan H2O2 3 % 100 cc Btl - -
25 Larutan Hayem Btl - -
26 Larutan HCl 0,1 N / Asam Klorida Btl - -
27 Larutan karbol fuksin Btl - -
28 Larutan KOH 10 % Btl - -
29 Larutan Lugol Btl - -
30 Larutan Metanol Btl - -
31 Larutan metilen biru Btl - -
32 Larutan Natrium Citrat 3,8 % Btl - -
33 Larutan Pewarna Giensa 100 ml Btl - -
34 Larutan Schlesinger Btl - -
35 Larutan Spiritus Btl - -
36 Larutan Sulfosalisilat Acid 20 % Btl - -
37 Larutan turk Btl - -
38 Larutan Ziehl-Neelsen Btl - -
39 Rapid Test Chikunguya Set - -
42 Rapid Test Dengue IgG/IgM Dev - -
43 Rapid Test HBsAg Dev - -
44 Rapid Test HIV 1 / 23,0 Dev - -
45 Rapid Test HIV R2 Dev - -
46 Rapid Test Malaria Dev - -
47 Rapid Test Salmonella Dev - -
48 Rapid Test Syphilis Dev - -
Page 52 of 55
49 Reagen Hematology Analyzer Beckman Coulter Pkt - -
50 Reagen Hematology Analyzer Drew D3 - USA Pkt - -
51 Reagen Spektrofotometer Kenza Max/Biolabo Pkt - -
52 Reagen Spektrofotometer Type 5010 Pkt - -
53 - Cholesterol Kit - -
54 - Trigliserida GPO Kit - -
55 - HDL Cholesterol PEG Kit - -
56 - Glucosa Kit - -
57 - Ureum/urea Kit - -
58 - Asam urat Kit - -
59 - SGOT (AST) Kit - -
60 - SGPT (ALT) Kit - -
61 - Chemistry Control, N (Lyophilized) Kit - -
62 Reagen Hematology Analizer MINDRAY Pkt - -
63 -Diluent 20 liter Pack - -
64 -Lyse 500 ml Btl - -
65 -Prob Cleanser 17 ml Btl - -
66 -Kontrol 3 ml Btl - -
67 Reagen Kimia Klinik (Fotometer) Pkt - -
68 -Albumin Kit - -
69 -ALT/GPT Kit - -
70 -AST/GOT Kit - -
71 -Urit Acid/Asam Urat Kit - -
72 -Ureum Kit - -
73 -Creatinin Kit - -
74 -Cholesterol Kit - -
75 -Glukosa Kit - -
76 Strip Asam Urat 25's (NESCO) Strip - -
77 Strip Cholesterol 10's (AUTOCHECK) Strip - -
78 Strip Glucose 25's (AUTOCHECK) Strip - -
79 Strip Gula Darah 25's (NESCO) Strip - -
80 Strip Haemoglobin 4 x 50 Test (HaemoCue Hb 201+) Strip - -
81 Strip Haemoglobin Catridge HbA1c 10's Strip - -
82 Strip Kolestrol 10's (NESCO) Strip - -
83 Strip pemeriksaan Asam Urat Strip - -
84 Strip pemeriksaan Asam Urat (BENE CHECK PLUS) Strip - -
Page 53 of 55
85 Strip pemeriksaan Asam Urat (Sinocare EA-12) Strip - -
86 Strip pemeriksaan Cholesterol (BENE CHECK PLUS) Strip - -
87 Strip pemeriksaan Cholesterol (Mission Ultra) Strip - -
88 Strip pemeriksaan Cotinin Strip - -
89 Strip pemeriksaan Glukosa (ACCU Check Performa) Strip - -
90 Strip Urine Aution Stick 10 AE Strip - -
91 Test Golongan Darah ABO Dev - -
92 Test Kehamilan Strip - -
93 Test Tuberculin Strip - -
94 Widal Set - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
95 - -
JUMLAH
KUNJUNGAN
RESEP UMUM KIS ASKES JUMLAH
Yang Menerima
Kepala Pusksmas…………
Page 54 of 55
( ………….…….………… ) ( ………….…….………… )
Catatan :
Jumlah Kunjungan Resep = Jumlah Penulisan Resep per Pasien dalam Sebulan !!!
Page 55 of 55

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

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189 Kombinasi (Methampiron, Papaverin HCl, Belladon Extract) Tab

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189 Kombinasi (Methampiron, Papaverin HCl, Belladon Extract) Tab

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