Cetak

LAPORAN PERSEDIAAN CETAK
DINAS KESEHATAN KAB. LUMAJANG

PUSKESMAS SUKODONO
UNTUK PERIODE TAHUN 2022
Saldo Awal 01 Januari 2022 Pengadaan 01 Januari - 31 Januari 2022 Penggun

Nilai
No. Nama Persediaan Jumlah Harga/Satuan Persediaan Jumlah Harga/Satuan Nilai Pengadaan Jumlah
Satuan Awal Satuan
Barang Barang Barang
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
1 Amplop Coklat Berlogo 8 pak 42,350.00 338,800 - pak 42,350.00 - -
2 Bagan Skreening PE 2 rim 302,500.00 605,000 - rim 302,500.00 - 2
3 Blangko Bon Pemesanan Barang 2 Rangkap 10 bendel 13,860.00 138,600 - bendel 13,860.00 - -
4 Blangko Konseling Obat 3 bendel 44,000.00 132,000 - bendel 44,000.00 - -
5 Blangko KS 2 rim 151,250.00 302,500 - rim 151,250.00 - 2
6 Blangko Rujukan 6 bendel 40,700.00 244,200 - bendel 40,700.00 - 1
7 Blangko Surat Calon Pengantin Wanita 4 bendel 20,350.00 81,400 - bendel 20,350.00 - 2
8 Blangko Surat Keterangan Sakit 3 bendel 10,560.00 31,680 - bendel 10,560.00 - -
9 Blanko Hasil Lab DL 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
10 Blanko Hasil Lab UL 1 rim 151,250.00 151,250 - rim 151,250.00 - -
11 Buku Register Kunjungan 20 bendel 77,000.00 1,540,000 - bendel 77,000.00 - 10
12 Catatan keperawatan /kebidanan 9 rim 142,500.00 1,282,500 - rim 142,500.00 - 1
13 Catatan penunjang klinis 6 rim 142,500.00 855,000 - rim 142,500.00 - 2
14 Daftar Tilik Penapisan KB 18 bendel 20,350.00 366,300 - bendel 20,350.00 - -
15 Form Skrining Lansia 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
16 Format monitoring rujukan 9 rim 142,500.00 1,282,500 - rim 142,500.00 - -
17 Formulir persetujuan /penolakan tindakan 4 rim 142,500.00 570,000 - rim 142,500.00 - -
18 Inform Concent KB 2 rim 302,500.00 605,000 - rim 302,500.00 - -
19 Karcis Rawat Inap 26 bendel 18,700.00 486,200 - bendel 18,700.00 - -
20 Karcis Rawat Jalan 56 bendel 13,860.00 776,160 - bendel 13,860.00 - 10
21 Lembar Asuhan Bidan / Perawat 6 rim 302,500.00 1,815,000 - rim 302,500.00 - -
22 Lembar Klaim BPJS 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
23 Lembar Laporan Pembedahan 1 rim 151,250.00 151,250 - rim 151,250.00 - -
24 Lembar Odontogram 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
25 Lembar Permintaan Obat 30 bendel 12,100.00 363,000 - bendel 12,100.00 - -
26 Lembar Rawat Jalan 10 rim 302,500.00 3,025,000 - rim 302,500.00 - 5
27 Lembar RM NO 01 13 rim 302,500.00 3,932,500 - rim 302,500.00 - -
29 Map Personal Rekam Medis 235 map 5,500.00 1,292,500 - map 5,500.00 - -
30 Pengkajian awal klinis 2 rim 240,000.00 480,000 - rim 240,000.00 - 1
31 Register Lansia 12 buku 49,500.00 594,000 - buku 49,500.00 - 12
32 Register PIO 10 buku 40,700.00 407,000 - buku 40,700.00 - 2
33 register rawat jalan 10 bk 150,000.00 1,500,000 - bk 150,000.00 - 1
34 Rekam medis /catatan medis 8 rim 240,000.00 1,920,000 - rim 240,000.00 - -
35 Rencana pemulangan pasien rawat inap 8 rim 142,500.00 1,140,000 - rim 142,500.00 - -
36 Resep Dokter 30 bendel 12,100.00 363,000 - bendel 12,100.00 - 15
37 RM catatan keperawatan/ kebidanan 5 rim 240,000.00 1,200,000 - rim 240,000.00 - 2
38 RM catatan penunjang klinis 12 rim 142,500.00 1,710,000 - rim 142,500.00 - -
39 RM pengkajian awal klinis 3 rim 240,000.00 720,000 - rim 240,000.00 - -
40 RM ringkasan keluar 8 rim 142,500.00 1,140,000 - rim 142,500.00 - 1
41 Rujukan Internal 20 bendel 20,350.00 407,000 - bendel 20,350.00 - -
42 Stop map status pasien 1,000 bh 9,000.00 9,000,000 - bh 9,000.00 - -
43 Surat keterangan sehat 18 bendel 20,350.00 366,300 - bendel 20,350.00 - 1
MUTASI DARI DINAS KESEHATAN
1,644 44,945,640 - - 74
Mengetahui,
UPT. Kepala Puskesmas Sukodono
dr. Rina Yulya Agustin

NIP. 19800814 201001 2 016
ERSEDIAAN CETAK
TAN KAB. LUMAJANG
MAS SUKODONO
RIODE TAHUN 2022
Penggunaan 01 Januari - 31 Januari 2022 Saldo Akhir 31 Januari 2022
Nilai Sisa Nilai

Harga/Satuan Penggunaan Jumlah Harga/Satuan Persediaan Ket.
Satuan Satuan
Barang
(Rp) (Rp) (Rp) (Rp)
12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 8 pak 42,350.00 338,800.00

rim 302,500.00 605,000 - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 302,500.00 - rim 151,250.00 -
bendel 40,700.00 40,700 5 bendel 40,700.00 203,500.00
bendel 20,350.00 40,700 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - 3 bendel 10,560.00 31,680.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 770,000 10 bendel 77,000.00 770,000.00
rim 142,500.00 142,500 8 rim 142,500.00 1,140,000.00
rim 142,500.00 285,000 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 26 bendel 18,700.00 486,200.00
bendel 13,860.00 138,600 46 bendel 13,860.00 637,560.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 151,250 - rim 151,250.00 -
bendel 12,100.00 - 30 bendel 12,100.00 363,000.00
rim 302,500.00 1,512,500 5 rim 302,500.00 1,512,500.00
rim 302,500.00 - 13 rim 302,500.00 3,932,500.00
rim 302,500.00 - 10 rim 302,500.00 3,025,000.00
map 5,500.00 - 235 map 5,500.00 1,292,500.00
rim 240,000.00 240,000 1 rim 240,000.00 240,000.00
buku 49,500.00 594,000 - buku 49,500.00 -
buku 40,700.00 81,400 8 buku 40,700.00 325,600.00
bk 150,000.00 150,000 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
bendel 12,100.00 181,500 15 bendel 12,100.00 181,500.00
rim 240,000.00 480,000 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 142,500 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 20,350 17 bendel 20,350.00 345,950.00
6,332,250 1,570 38,613,390
Lumajang, 31 Januari 2022
Pengurus Barang
UPT. Puskesmas Sukodono
Yessy Gladiani Sutrisno

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Februari 2022 Pengadaan 01 Februari - 28 Februari 2022 Penggunaan

Nilai
Barang Satuan Awal Barang Satuan Barang
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
2 Bagan Skreening PE - rim 302,500.00 - - rim 302,500.00 - -
5 Blangko KS - rim 151,250.00 - - rim 151,250.00 - -
6 Blangko Rujukan 5 bendel 40,700.00 203,500 - bendel 40,700.00 - -
7 Blangko Surat Calon Pengantin Wanita 2 bendel 20,350.00 40,700 - bendel 20,350.00 - -
9 Blanko Hasil Lab DL - rim 151,250.00 - - rim 151,250.00 - -
11 Buku Register Kunjungan 10 bendel 77,000.00 770,000 - bendel 77,000.00 - -
12 Catatan keperawatan /kebidanan 8 rim 142,500.00 1,140,000 - rim 142,500.00 - -
13 Catatan penunjang klinis 4 rim 142,500.00 570,000 - rim 142,500.00 - -
15 Form Skrining Lansia - rim 151,250.00 - - rim 151,250.00 - -
17 Formulir persetujuan /penolakan tindakan 4 rim 142,500.00 570,000 - rim 142,500.00 - 1
22 Lembar Klaim BPJS - rim 151,250.00 - - rim 151,250.00 - -
24 Lembar Odontogram - rim 151,250.00 - - rim 151,250.00 - -
26 Lembar Rawat Jalan 5 rim 302,500.00 1,512,500 - rim 302,500.00 - -
27 Lembar RM NO 01 13 rim 302,500.00 3,932,500 - rim 302,500.00 - 1
29 Map Personal Rekam Medis 235 map 5,500.00 1,292,500 - map 5,500.00 - 135
31 Register Lansia - buku 49,500.00 - - buku 49,500.00 - -
32 Register PIO 8 buku 40,700.00 325,600 - buku 40,700.00 - -
33 register rawat jalan 9 bk 150,000.00 1,350,000 - bk 150,000.00 - -
37 RM catatan keperawatan/ kebidanan 3 rim 240,000.00 720,000 - rim 240,000.00 - -
39 RM pengkajian awal klinis 3 rim 240,000.00 720,000 - rim 240,000.00 - 2
40 RM ringkasan keluar 7 rim 142,500.00 997,500 - rim 142,500.00 - -
43 Surat keterangan sehat 17 bendel 20,350.00 345,950 - bendel 20,350.00 - -
1,570 38,613,390 - - 161
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Februari - 28 Februari 2022 Saldo Akhir 28 Februari 2022
Nilai Sisa Nilai

Satuan Barang Satuan
(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 8 pak 42,350.00 338,800.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 5 bendel 40,700.00 203,500.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - 3 bendel 10,560.00 31,680.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 10 bendel 77,000.00 770,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 142,500 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 26 bendel 18,700.00 486,200.00
bendel 13,860.00 83,160 40 bendel 13,860.00 554,400.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 - 30 bendel 12,100.00 363,000.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
rim 302,500.00 302,500 12 rim 302,500.00 3,630,000.00
rim 302,500.00 907,500 7 rim 302,500.00 2,117,500.00
map 5,500.00 742,500 100 map 5,500.00 550,000.00
rim 240,000.00 240,000 - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
bendel 12,100.00 145,200 3 bendel 12,100.00 36,300.00
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 480,000 1 rim 240,000.00 240,000.00
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 - 17 bendel 20,350.00 345,950.00
3,043,360 1,409 35,570,030
Lumajang, 28 Februari 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Maret 2022 Pengadaan 01 Maret - 03 Maret 2022 Pengguna

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
20 Karcis Rawat Jalan 40 bendel 13,860.00 554,400 - bendel 13,860.00 - -
29 Map Personal Rekam Medis 100 map 5,500.00 550,000 - map 5,500.00 - -
30 Pengkajian awal klinis - rim 240,000.00 - - rim 240,000.00 - -
36 Resep Dokter 3 bendel 12,100.00 36,300 - bendel 12,100.00 - -
39 RM pengkajian awal klinis 1 rim 240,000.00 240,000 - rim 240,000.00 - -
1,409 35,570,030 - - -
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Maret - 03 Maret 2022 Saldo Akhir 03 Maret 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 8 pak 42,350.00 338,800.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 5 bendel 40,700.00 203,500.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - 3 bendel 10,560.00 31,680.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 10 bendel 77,000.00 770,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 26 bendel 18,700.00 486,200.00
bendel 13,860.00 - 40 bendel 13,860.00 554,400.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 - 30 bendel 12,100.00 363,000.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
rim 302,500.00 - 12 rim 302,500.00 3,630,000.00
rim 302,500.00 - 7 rim 302,500.00 2,117,500.00
map 5,500.00 - 100 map 5,500.00 550,000.00
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
bendel 12,100.00 - 3 bendel 12,100.00 36,300.00
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - 1 rim 240,000.00 240,000.00
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 - 17 bendel 20,350.00 345,950.00
- 1,409 35,570,030
Lumajang, 03 Maret 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Januari 2022 Pengadaan 01 Januari - 03 Maret 2022 Penggunaa

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
2 Bagan Skreening PE 2 rim 302,500.00 605,000 - rim 302,500.00 - 2
5 Blangko KS 2 rim 151,250.00 302,500 - rim 151,250.00 - 2
7 Blangko Surat Calon Pengantin Wanita 4 bendel 20,350.00 81,400 - bendel 20,350.00 - 2
9 Blanko Hasil Lab DL 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
11 Buku Register Kunjungan 20 bendel 77,000.00 1,540,000 - bendel 77,000.00 - 10
13 Catatan penunjang klinis 6 rim 142,500.00 855,000 - rim 142,500.00 - 2
15 Form Skrining Lansia 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
17 Formulir persetujuan /penolakan tindakan 4 rim 142,500.00 570,000 - rim 142,500.00 - 1
22 Lembar Klaim BPJS 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
24 Lembar Odontogram 1 rim 151,250.00 151,250 - rim 151,250.00 - 1
29 Map Personal Rekam Medis 235 map 5,500.00 1,292,500 - map 5,500.00 - 135
31 Register Lansia 12 buku 49,500.00 594,000 - buku 49,500.00 - 12
32 Register PIO 10 buku 40,700.00 407,000 - buku 40,700.00 - 2
33 register rawat jalan 10 bk 150,000.00 1,500,000 - bk 150,000.00 - 1
37 RM catatan keperawatan/ kebidanan 5 rim 240,000.00 1,200,000 - rim 240,000.00 - 2
40 RM ringkasan keluar 8 rim 142,500.00 1,140,000 - rim 142,500.00 - 1
1,644 44,945,640 - - 235
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Januari - 03 Maret 2022 Saldo Akhir 03 Maret 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 8 pak 42,350.00 338,800.00

rim 302,500.00 605,000 - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 302,500.00 - rim 151,250.00 -
bendel 40,700.00 40,700 5 bendel 40,700.00 203,500.00
bendel 20,350.00 40,700 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - 3 bendel 10,560.00 31,680.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 770,000 10 bendel 77,000.00 770,000.00
rim 142,500.00 142,500 8 rim 142,500.00 1,140,000.00
rim 142,500.00 285,000 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 142,500 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 26 bendel 18,700.00 486,200.00
bendel 13,860.00 221,760 40 bendel 13,860.00 554,400.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 151,250 - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 151,250 - rim 151,250.00 -
bendel 12,100.00 - 30 bendel 12,100.00 363,000.00
rim 302,500.00 1,512,500 5 rim 302,500.00 1,512,500.00
rim 302,500.00 302,500 12 rim 302,500.00 3,630,000.00
rim 302,500.00 907,500 7 rim 302,500.00 2,117,500.00
map 5,500.00 742,500 100 map 5,500.00 550,000.00
rim 240,000.00 480,000 - rim 240,000.00 -
buku 49,500.00 594,000 - buku 49,500.00 -
buku 40,700.00 81,400 8 buku 40,700.00 325,600.00
bk 150,000.00 150,000 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
bendel 12,100.00 326,700 3 bendel 12,100.00 36,300.00
rim 240,000.00 480,000 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 480,000 1 rim 240,000.00 240,000.00
rim 142,500.00 142,500 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 20,350 17 bendel 20,350.00 345,950.00
9,375,610 1,409 35,570,030
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 04 Maret 2022 Pengadaan 04 Maret - 31 Maret 2022 Pengguna

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
8 Blangko Surat Keterangan Sakit 3 bendel 10,560.00 31,680 - bendel 10,560.00 - 3
19 Karcis Rawat Inap 26 bendel 18,700.00 486,200 - bendel 18,700.00 - 8
25 Lembar Permintaan Obat 30 bendel 12,100.00 363,000 - bendel 12,100.00 - 4
29 Map Personal Rekam Medis 100 map 5,500.00 550,000 - map 5,500.00 - -
1,409 35,570,030 - - 43
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 04 Maret - 31 Maret 2022 Saldo Akhir 31 Maret 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 8 pak 42,350.00 338,800.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 40,700 4 bendel 40,700.00 162,800.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 31,680 - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 10 bendel 77,000.00 770,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 149,600 18 bendel 18,700.00 336,600.00
bendel 13,860.00 277,200 20 bendel 13,860.00 277,200.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 48,400 26 bendel 12,100.00 314,600.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
rim 302,500.00 302,500 11 rim 302,500.00 3,327,500.00
rim 302,500.00 605,000 5 rim 302,500.00 1,512,500.00
map 5,500.00 - 100 map 5,500.00 550,000.00
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
bendel 12,100.00 36,300 - bendel 12,100.00 -
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 240,000 - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 - 17 bendel 20,350.00 345,950.00
1,731,380 1,366 33,838,650
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 April 2022 Pengadaan 01 April - 30 April 2022 Penggun

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
1 Amplop Coklat Berlogo 8 pak 42,350.00 338,800 - pak 42,350.00 - 3
8 Blangko Surat Keterangan Sakit - bendel 10,560.00 - - bendel 10,560.00 - -
29 Map Personal Rekam Medis 100 map 5,500.00 550,000 - map 5,500.00 - 26
35 Rencana pemulangan pasien rawat inap 8 rim 142,500.00 1,140,000 - rim 142,500.00 - 2
36 Resep Dokter - bendel 12,100.00 - - bendel 12,100.00 - -
39 RM pengkajian awal klinis - rim 240,000.00 - - rim 240,000.00 - -
1,366 33,838,650 - - 37
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 April - 30 April 2022 Saldo Akhir 30 April 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 127,050.00 5 pak 42,350.00 211,750.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 4 bendel 40,700.00 162,800.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 10 bendel 77,000.00 770,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 18 bendel 18,700.00 336,600.00
bendel 13,860.00 - 20 bendel 13,860.00 277,200.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 36,300 23 bendel 12,100.00 278,300.00
rim 302,500.00 907,500 2 rim 302,500.00 605,000.00
rim 302,500.00 - 11 rim 302,500.00 3,327,500.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
map 5,500.00 143,000 74 map 5,500.00 407,000.00
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 285,000 6 rim 142,500.00 855,000.00
bendel 12,100.00 - - bendel 12,100.00 -
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 - 17 bendel 20,350.00 345,950.00
1,498,850 1,329 32,339,800
Lumajang, 30 April 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Mei 2022 Pengadaan 01 Mei - 31 Mei 2022 Penggu

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
26 Lembar Rawat Jalan 2 rim 302,500.00 605,000 - rim 302,500.00 - -
29 Map Personal Rekam Medis 74 map 5,500.00 407,000 - map 5,500.00 - 74
35 Rencana pemulangan pasien rawat inap 6 rim 142,500.00 855,000 - rim 142,500.00 - -
1,329 32,339,800 - - 90
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Mei - 31 Mei 2022 Saldo Akhir 31 Mei 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 5 pak 42,350.00 211,750.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 4 bendel 40,700.00 162,800.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 10 bendel 77,000.00 770,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 18 bendel 18,700.00 336,600.00
bendel 13,860.00 138,600 10 bendel 13,860.00 138,600.00
rim 302,500.00 - 6 rim 302,500.00 1,815,000.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 24,200 21 bendel 12,100.00 254,100.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
rim 302,500.00 - 11 rim 302,500.00 3,327,500.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
map 5,500.00 407,000 - map 5,500.00 -
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 6 rim 142,500.00 855,000.00
bendel 12,100.00 - - bendel 12,100.00 -
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 81,400 13 bendel 20,350.00 264,550.00
651,200 1,239 31,688,600
Lumajang, 31 Mei 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Juni 2022 Pengadaan 01 Juni - 30 Juni 2022 Penggun

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
11 Buku Register Kunjungan 10 bendel 77,000.00 770,000 - bendel 77,000.00 - 1
21 Lembar Asuhan Bidan / Perawat 6 rim 302,500.00 1,815,000 - rim 302,500.00 - 3
26 Lembar Rawat Jalan 2 rim 302,500.00 605,000 - rim 302,500.00 - 2
29 Map Personal Rekam Medis - map 5,500.00 - - map 5,500.00 - -
1,239 31,688,600 - - 9
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Juni - 30 Juni 2022 Saldo Akhir 30 Juni 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 5 pak 42,350.00 211,750.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 4 bendel 40,700.00 162,800.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 77,000 9 bendel 77,000.00 693,000.00
rim 142,500.00 - 8 rim 142,500.00 1,140,000.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 18 bendel 20,350.00 366,300.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 18 bendel 18,700.00 336,600.00
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
rim 302,500.00 907,500 3 rim 302,500.00 907,500.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 - 21 bendel 12,100.00 254,100.00
rim 302,500.00 605,000 - rim 302,500.00 -
rim 302,500.00 - 11 rim 302,500.00 3,327,500.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
map 5,500.00 - - map 5,500.00 -
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 6 rim 142,500.00 855,000.00
bendel 12,100.00 - - bendel 12,100.00 -
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 20 bendel 20,350.00 407,000.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 61,050 10 bendel 20,350.00 203,500.00
1,650,550 1,230 30,038,050
Lumajang, 30 Juni 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Juli 2022 Pengadaan 01 Juli - 31 Juli 2022 Penggu

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
14 Daftar Tilik Penapisan KB 18 bendel 20,350.00 366,300 - bendel 20,350.00 - 4
21 Lembar Asuhan Bidan / Perawat 3 rim 302,500.00 907,500 - rim 302,500.00 - -
26 Lembar Rawat Jalan - rim 302,500.00 - - rim 302,500.00 - -
41 Rujukan Internal 20 bendel 20,350.00 407,000 - bendel 20,350.00 - 1
1,230 30,038,050 - - 19
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Juli - 31 Juli 2022 Saldo Akhir 31 Juli 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 5 pak 42,350.00 211,750.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 40,700 3 bendel 40,700.00 122,100.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 - 9 bendel 77,000.00 693,000.00
rim 142,500.00 142,500 7 rim 142,500.00 997,500.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 81,400 14 bendel 20,350.00 284,900.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 18 bendel 18,700.00 336,600.00
bendel 13,860.00 138,600 - bendel 13,860.00 -
rim 302,500.00 - 3 rim 302,500.00 907,500.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 24,200 19 bendel 12,100.00 229,900.00
rim 302,500.00 - - rim 302,500.00 -
rim 302,500.00 - 11 rim 302,500.00 3,327,500.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
map 5,500.00 - - map 5,500.00 -
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 - 8 rim 240,000.00 1,920,000.00
rim 142,500.00 - 6 rim 142,500.00 855,000.00
bendel 12,100.00 - - bendel 12,100.00 -
rim 240,000.00 - 3 rim 240,000.00 720,000.00
rim 142,500.00 - 12 rim 142,500.00 1,710,000.00
rim 240,000.00 - - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 20,350 19 bendel 20,350.00 386,650.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 - 10 bendel 20,350.00 203,500.00
447,750 1,211 29,590,300
Lumajang, 31 Juli 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 Agustus 2022 Pengadaan 01 Agustus - 31 Agustus 2022 Penggunaan

Nilai
(Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11
PENGADAAN
11 Buku Register Kunjungan 9 bendel 77,000.00 693,000 - bendel 77,000.00 - 2
12 Catatan keperawatan /kebidanan 7 rim 142,500.00 997,500 - rim 142,500.00 - -
20 Karcis Rawat Jalan - bendel 13,860.00 - 40 bendel 13,764.00 550,560.00 5
21 Lembar Asuhan Bidan / Perawat 3 rim 302,500.00 907,500 - rim 302,500.00 - -
26 Lembar Rawat Jalan - rim 302,500.00 - - rim 302,500.00 - -
34 Rekam medis /catatan medis 8 rim 240,000.00 1,920,000 - rim 240,000.00 - 2
37 RM catatan keperawatan/ kebidanan 3 rim 240,000.00 720,000 - rim 240,000.00 - 1
38 RM catatan penunjang klinis 12 rim 142,500.00 1,710,000 - rim 142,500.00 - 2
1,211 29,590,300.00 40 550,560.00 25
Mengetahui,

NIP. 19800814 201001 2 016
N PERSEDIAAN CETAK
HATAN KAB. LUMAJANG
ESMAS SUKODONO
PERIODE TAHUN 2022
Penggunaan 01 Agustus - 31 Agustus 2022 Saldo Akhir 31 Agustus 2022
Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

12 13 14 15=3+7-11 16 17 19
18=15x17
pak 42,350.00 - 5 pak 42,350.00 211,750.00

rim 302,500.00 - - rim 302,500.00 -
bendel 13,860.00 - 10 bendel 13,860.00 138,600.00
bendel 44,000.00 - 3 bendel 44,000.00 132,000.00
rim 151,250.00 - - rim 151,250.00 -
bendel 40,700.00 - 3 bendel 40,700.00 122,100.00
bendel 20,350.00 - 2 bendel 20,350.00 40,700.00
bendel 10,560.00 - - bendel 10,560.00 -
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
bendel 77,000.00 154,000 7 bendel 77,000.00 539,000.00
rim 142,500.00 - 7 rim 142,500.00 997,500.00
rim 142,500.00 - 4 rim 142,500.00 570,000.00
bendel 20,350.00 - 14 bendel 20,350.00 284,900.00
rim 151,250.00 - - rim 151,250.00 -
rim 142,500.00 - 9 rim 142,500.00 1,282,500.00
rim 142,500.00 - 3 rim 142,500.00 427,500.00
rim 302,500.00 - 2 rim 302,500.00 605,000.00
bendel 18,700.00 - 18 bendel 18,700.00 336,600.00
bendel 13,764.00 68,820 35 bendel 13,764.00 481,740.00
rim 302,500.00 - 3 rim 302,500.00 907,500.00
rim 151,250.00 - - rim 151,250.00 -
rim 151,250.00 - 1 rim 151,250.00 151,250.00
rim 151,250.00 - - rim 151,250.00 -
bendel 12,100.00 108,900 10 bendel 12,100.00 121,000.00
rim 302,500.00 - - rim 302,500.00 -
rim 302,500.00 302,500 10 rim 302,500.00 3,025,000.00
rim 302,500.00 - 5 rim 302,500.00 1,512,500.00
map 5,500.00 - - map 5,500.00 -
rim 240,000.00 - - rim 240,000.00 -
buku 49,500.00 - - buku 49,500.00 -
buku 40,700.00 - 8 buku 40,700.00 325,600.00
bk 150,000.00 - 9 bk 150,000.00 1,350,000.00
rim 240,000.00 480,000 6 rim 240,000.00 1,440,000.00
rim 142,500.00 - 6 rim 142,500.00 855,000.00
bendel 12,100.00 - - bendel 12,100.00 -
rim 240,000.00 240,000 2 rim 240,000.00 480,000.00
rim 142,500.00 285,000 10 rim 142,500.00 1,425,000.00
rim 240,000.00 - - rim 240,000.00 -
rim 142,500.00 - 7 rim 142,500.00 997,500.00
bendel 20,350.00 - 19 bendel 20,350.00 386,650.00
bh 9,000.00 - 1,000 bh 9,000.00 9,000,000.00
bendel 20,350.00 61,050 7 bendel 20,350.00 142,450.00
1,700,270.00 1,226 28,440,590.00
Lumajang, 31 Agustus 2022
Pengurus Barang

NIP. 19950701 202012 2 011
PUSKESMAS SUKODONO
Saldo Awal 01 September 2022 Pengadaan 01 September - 30 September 2022 Penggunaan 01 September - 30 September 2022 Saldo Akhir 30 September 2022
Nilai
Nilai
No. Nama Persediaan Jumlah Harga/Satuan Persediaan Jumlah Harga/Satuan Nilai Pengadaan Jumlah Harga/Satuan Penggunaan Jumlah Harga/Satuan
Satuan Awal Satuan Satuan Satuan
Barang Barang Barang Barang
(Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15=3+7-11 16 17
PENGADAAN
1 Amplop Coklat Berlogo 5 pak 42,350 211,750 10 Pak 42,624 426,240 - Pak 42,624 - 15 Pak 42,624
2 Bagan Skreening PE - rim 302,500 - 1 rim 166,500 166,500 1 rim 166,500 166,500 - rim 166,500
3 Blangko Bon Pemesanan Barang 2 Rangkap 10 bendel 13,860 138,600 15 Bendel 22,866 342,990 - Bendel 22,866 - 25 Bendel 22,866
4 Blangko Konseling Obat 3 bendel 44,000 132,000 - bendel 44,000 - - bendel 44,000 - 3 bendel 44,000
5 Blangko KS - rim 151,250 - - rim 151,250 - - rim 151,250 - - rim 151,250
6 Blangko Permintaan Lab - rim 166,500 - 2 rim 166,500 333,000 - rim 166,500 - 2 rim 166,500
7 Blangko Rujukan 3 bendel 40,700 122,100 10 Bendel 53,613 536,130 - Bendel 53,613 - 13 Bendel 53,613
8 Blangko Surat Calon Pengantin Wanita 2 bendel 20,350 40,700 5 Bendel 20,313 101,565 2 Bendel 20,313 40,626 5 Bendel 20,313
9 Blangko Surat Keterangan Sakit - bendel 10,560 - 75 Bendel 10,545 790,875 5 Bendel 10,545 52,725 70 Bendel 10,545
10 Blangko Vaksinasi Covid-19 - Rim 166,500 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
11 Blangko Vaksinasi Covid-19 untuk anak - Rim 166,500 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
12 Blangko Vaksinasi Covid-19 untuk bumil - Rim 166,500 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
13 Blanko hasil Lab - rim 166,500 - 2 rim 166,500 333,000 - rim 166,500 - 2 rim 166,500
14 Blanko Hasil Lab DL - rim 151,250 - 2 Rim 166,500 333,000 - Rim 166,500 - 2 Rim 166,500
15 Blanko Hasil Lab UL 1 rim 151,250 151,250 1 Rim 166,500 166,500 - Rim 166,500 - 2 Rim 166,500
16 Bukti pelayanan BPJS Untuk Puskesmas - Rim 166,500 - 2 Rim 166,500 333,000 - Rim 166,500 - 2 Rim 166,500
17 Bukti pelayanan BPJS Untuk Rujuk - Rim 166,500 - 2 Rim 166,500 333,000 - Rim 166,500 - 2 Rim 166,500
18 Buku Register Kunjungan 7 bendel 77,000 539,000 - bendel 77,000 - 1 bendel 77,000 77,000 6 bendel 77,000
19 Catatan keperawatan /kebidanan 7 rim 142,500 997,500 - rim 142,500 - 1 rim 142,500 142,500 6 rim 142,500
20 Catatan penunjang klinis 4 rim 142,500 570,000 - rim 142,500 - 2 rim 142,500 285,000 2 rim 142,500
21 Cetak Etiket Putih - Rim 166,500 - 5 Rim 166,500 832,500 5 Rim 166,500 832,500 - Rim 166,500
22 Cetak Kartu Stok warna Biru - Rim 166,500 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
23 Cetak Kartu Stok warna kuning - Rim 166,500 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
24 Cetak Kartu Stok warna Putih - Rim 166,500 - 4 Rim 166,500 666,000 - Rim 166,500 - 4 Rim 166,500
25 Daftar Tilik Penapisan KB 14 bendel 20,350 284,900 20 Bendel 20,313 406,260 - Bendel 20,313 - 34 Bendel 20,313
26 Form Skrining Lansia - rim 151,250 - 2 Rim 233,100 466,200 - Rim 233,100 - 2 Rim 233,100
27 Format monitoring rujukan 9 rim 142,500 1,282,500 - rim 142,500 - - rim 142,500 - 9 rim 142,500
28 Formulir persetujuan /penolakan tindakan 3 rim 142,500 427,500 - rim 142,500 - 3 rim 142,500 427,500 - rim 142,500
29 Inform Concent KB (1) 2 rim 302,500 605,000 - Rim 233,100 - - Rim 233,100 - 2 Rim 233,100
30 Inform Concent KB (2) - Rim 233,100 - 5 Bendel 46,620 233,100 - Bendel 46,620 - 5 Bendel 46,620
31 Karcis Rawat Inap 18 bendel 18,700 336,600 - Bendel 18,700 - - Bendel 18,700 - 18 Bendel 18,700
32 Karcis Rawat Jalan 35 bendel 13,764 481,740 260 Bendel 13,764 3,578,640 15 Bendel 13,764 206,460 280 Bendel 13,764
33 Kartu Ibu - Rim 233,100 - 20 Bendel 46,620 932,400 2 Bendel 46,620 93,240 18 Bendel 46,620
34 Kartu Persalinan - rim 233,100 - 2 rim 233,100 466,200 - rim 233,100 - 2 rim 233,100
35 kohort anak - Buku 27,473 - 13 Buku 27,473 357,143 - Buku 27,473 - 13 Buku 27,473
36 kohort bayi - Buku 27,473 - 13 Buku 27,473 357,143 - Buku 27,473 - 13 Buku 27,473
37 kohort ibu - Buku 27,473 - 13 Buku 27,473 357,143 - Buku 27,473 - 13 Buku 27,473
38 Lembar Asuhan Bidan / Perawat 3 rim 302,500 907,500 8 Rim 233,100 1,864,800 - Rim 233,100 - 11 Rim 233,100
39 Lembar Klaim BPJS - rim 151,250 - 1 Rim 166,500 166,500 - Rim 166,500 - 1 Rim 166,500
40 Lembar Laporan Pembedahan 1 rim 151,250 151,250 - rim 151,250 - - rim 151,250 - 1 rim 151,250
41 Lembar Odontogram - rim 151,250 - 2 Rim 166,500 333,000 1 Rim 166,500 166,500 1 Rim 166,500
42 Lembar Permintaan Obat 10 bendel 12,100 121,000 - bendel 12,100 - - bendel 12,100 - 10 bendel 12,100
43 Lembar Pernyataan - Rim 166,500 - 2 Rim 166,500 333,000 1 Rim 166,500 166,500 1 Rim 166,500
44 Lembar Rawat Jalan - rim 302,500 - 15 Rim 233,100 3,496,500 2 Rim 233,100 466,200 13 Rim 233,100
45 Lembar RM NO 01 10 rim 302,500 3,025,000 - rim 302,500 - 1 rim 302,500 302,500 9 rim 302,500
46 Lembar RM NO 03 5 rim 302,500 1,512,500 5 Rim 233,100 1,165,500 - Rim 233,100 - 10 Rim 233,100
47 Map Personal Rekam Medis - map 5,500 - - map 5,500 - - map 5,500 - - map 5,500
48 MTBM - Rim 233,100 - 3 Rim 233,100 699,300 - Rim 233,100 - 3 Rim 233,100
49 MTBS - Rim 233,100 - 5 Rim 233,100 1,165,500 - Rim 233,100 - 5 Rim 233,100
50 Partograf - Rim 233,100 - 2 Rim 233,100 466,200 - Rim 233,100 - 2 Rim 233,100
51 Pengkajian awal klinis - rim 240,000 - - rim 240,000 - - rim 240,000 - - rim 240,000
52 Register Covid - Bendel 53,613 - 1 Bendel 53,613 53,613 - Bendel 53,613 - 1 Bendel 53,613
53 Register Laboratorium - Bendel 54,945 - 5 Bendel 54,945 274,725 - Bendel 54,945 - 5 Bendel 54,945
54 Register Lansia - buku 49,500 - - buku 49,500 - - buku 49,500 - - buku 49,500
55 Register PIO 8 buku 40,700 325,600 - buku 40,700 - - buku 40,700 - 8 buku 40,700
56 Register Ranap - Bendel 54,945 - 5 Bendel 54,945 274,725 - Bendel 54,945 - 5 Bendel 54,945
57 register rawat jalan (Gilut) 9 bk 150,000 1,350,000 - bk 150,000 - - bk 150,000 - 9 bk 150,000
58 Register Rawat Jalan (Umum) - Bendel 54,945 - 20 Bendel 54,945 1,098,900 - Bendel 54,945 - 20 Bendel 54,945
59 Register Rawat Jalan Gizi - Bendel 53,613 - 2 Bendel 53,613 107,226 - Bendel 53,613 - 2 Bendel 53,613
60 Register Triple Eliminasi - Bendel 53,613 - 2 Bendel 53,613 107,226 - Bendel 53,613 - 2 Bendel 53,613
61 Rekam medis /catatan medis 6 rim 240,000 1,440,000 - rim 240,000 - - rim 240,000 - 6 rim 240,000
62 Rencana pemulangan pasien rawat inap 6 rim 142,500 855,000 - rim 142,500 - - rim 142,500 - 6 rim 142,500
63 Resep Dokter (Hijau) - bendel 13,764 - 200 bendel 13,764 2,752,800 23 bendel 13,764 316,572 177 bendel 13,764
64 Resep Dokter (Putih) - bendel 12,100 - 194 bendel 10,578 2,052,216 30 bendel 10,578 317,353 164 bendel 10,578
65 Resume Medik BPJS - Rim 166,500 - 2 Rim 166,500 333,000 - Rim 166,500 - 2 Rim 166,500
66 Resume Medis Persalinan - Rim 166,500 - 2 Rim 166,500 333,000 - Rim 166,500 - 2 Rim 166,500
67 RM catatan keperawatan/ kebidanan 2 rim 240,000 480,000 - rim 240,000 - - rim 240,000 - 2 rim 240,000
68 RM catatan penunjang klinis 10 rim 142,500 1,425,000 - rim 142,500 - - rim 142,500 - 10 rim 142,500
69 RM pengkajian awal klinis - rim 240,000 - - rim 240,000 - - rim 240,000 - - rim 240,000
70 RM ringkasan keluar 7 rim 142,500 997,500 - rim 142,500 - 1 rim 142,500 142,500 6 rim 142,500
71 Rujukan Internal 19 bendel 20,350 386,650 20 Bendel 20,313 406,260 2 Bendel 20,313 40,626 37 Bendel 20,313
72 Stop map status pasien 1,000 bh 9,000 9,000,000 - bh 9,000 - - bh 9,000 - 1,000 bh 9,000
73 Surat keterangan sehat 7 bendel 20,350 142,450 30 Bendel 20,313 609,390 - Bendel 20,313 - 37 Bendel 20,313
1,226 28,440,590 1,015 31,774,409 98 4,242,802 2,143
Lumajang, 30 September 2022
Mengetahui, Pengurus Barang

UPT. Kepala Puskesmas Sukodono UPT. Puskesmas Sukodono
dr. Rina Yulya Agustin Yessy Gladiani Sutrisno

NIP. 19800814 201001 2 016 NIP. 19950701 202012 2 011
AN PERSEDIAAN CETAK
EHATAN KAB. LUMAJANG
KESMAS SUKODONO
PERIODE TAHUN 2022
Saldo Akhir 30 September 2022
Sisa Nilai
Persediaan Ket.
(Rp)
19
18=15x17
639,360
-
571,650
132,000
-
333,000
696,969
101,565
738,150
166,500
166,500
166,500
333,000
333,000
333,000
333,000
333,000
462,000
855,000
285,000
-
166,500
166,500
666,000
690,642
466,200
1,282,500
-
466,200
233,100
336,600
3,853,920
839,160
466,200
357,143
357,143
357,143
2,564,100
166,500
151,250
166,500
121,000
166,500
3,030,300
2,722,500
2,331,000
-
699,300
1,165,500
466,200
-
53,613
274,725
-
325,600
274,725
1,350,000
1,098,900
107,226
107,226
1,440,000
855,000
2,436,228
1,734,863
333,000
333,000
480,000
1,425,000
-
855,000
751,581
9,000,000
751,581
55,422,062
Lumajang, 30 September 2022
Pengurus Barang

NIP. 19950701 202012 2 011

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LAPORAN PERSEDIAAN CETAK

DINAS KESEHATAN KAB. LUMAJANG

Saldo Awal 01 Januari 2022 Pengadaan 01 Januari - 31 Januari 2022 Penggun

MUTASI DARI DINAS KESEHATAN

dr. Rina Yulya Agustin

Penggunaan 01 Januari - 31 Januari 2022 Saldo Akhir 31 Januari 2022

Nilai Sisa Nilai

pak 42,350.00 - 8 pak 42,350.00 338,800.00

6,332,250 1,570 38,613,390

Lumajang, 31 Januari 2022

Yessy Gladiani Sutrisno

Saldo Awal 01 Februari 2022 Pengadaan 01 Februari - 28 Februari 2022 Penggunaan

MUTASI DARI DINAS KESEHATAN

1,570 38,613,390 - - 161

dr. Rina Yulya Agustin

Penggunaan 01 Februari - 28 Februari 2022 Saldo Akhir 28 Februari 2022

Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

pak 42,350.00 - 8 pak 42,350.00 338,800.00

3,043,360 1,409 35,570,030

Lumajang, 28 Februari 2022

Yessy Gladiani Sutrisno

Saldo Awal 01 Maret 2022 Pengadaan 01 Maret - 03 Maret 2022 Pengguna

MUTASI DARI DINAS KESEHATAN

dr. Rina Yulya Agustin

Penggunaan 01 Maret - 03 Maret 2022 Saldo Akhir 03 Maret 2022

Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

pak 42,350.00 - 8 pak 42,350.00 338,800.00

Lumajang, 03 Maret 2022

Yessy Gladiani Sutrisno

Saldo Awal 01 Januari 2022 Pengadaan 01 Januari - 03 Maret 2022 Penggunaa

MUTASI DARI DINAS KESEHATAN

1,644 44,945,640 - - 235

dr. Rina Yulya Agustin

Penggunaan 01 Januari - 03 Maret 2022 Saldo Akhir 03 Maret 2022

Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

pak 42,350.00 - 8 pak 42,350.00 338,800.00

9,375,610 1,409 35,570,030

Lumajang, 03 Maret 2022

Yessy Gladiani Sutrisno

Saldo Awal 04 Maret 2022 Pengadaan 04 Maret - 31 Maret 2022 Pengguna

MUTASI DARI DINAS KESEHATAN

dr. Rina Yulya Agustin

Penggunaan 04 Maret - 31 Maret 2022 Saldo Akhir 31 Maret 2022

Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

pak 42,350.00 - 8 pak 42,350.00 338,800.00

1,731,380 1,366 33,838,650

Lumajang, 04 Maret 2022

Yessy Gladiani Sutrisno

Saldo Awal 01 April 2022 Pengadaan 01 April - 30 April 2022 Penggun

MUTASI DARI DINAS KESEHATAN

dr. Rina Yulya Agustin

Penggunaan 01 April - 30 April 2022 Saldo Akhir 30 April 2022

Nilai Sisa Nilai

(Rp) (Rp) (Rp) (Rp)

pak 42,350.00 127,050.00 5 pak 42,350.00 211,750.00

1,498,850 1,329 32,339,800

Lumajang, 30 April 2022

Yessy Gladiani Sutrisno

Saldo Awal 01 Mei 2022 Pengadaan 01 Mei - 31 Mei 2022 Penggu