PERKUMPULAN PERHIMPUNAN SANTO BORROMEUS

“KLINIK PRATAMA “UNPAR”

JL. Menjangan No. 14 Bandung 40132 INDONESIA
2015
Telp 022 8260238

FORM EVALUASI PENGGUNAAN OBAT

DI KLINIK PRATAMA UNPAR

NAMA KLINIK : KLINIK PRATAMA UNPAR

ALAMAT :JL.MENJANGAN NO.14 CIUMBULEUIT, BANDUNG
BULAN : OKTOBER - DESEMBER
TAHUN : 2022

BENTUK KEKUATAN KESESUAIAN JUMLAH

SEDIAAN DOSIS DG FORNAS PENGADAAN

NO. NAMA OBAT (Ya / Tidak )

1 ACYCLOVIR crem 5 gr 5% TUBE TUBE YA 1.00
2 ALLETROL TETES MATA ED ED YA 1.00
3 AMOXYCILLIN DROP DROP DROP ,100MG/ML YA 1.00
4 AMOXYCILLIN SIRUP 250 MG/5 ML SIRUP 250 MG/5 ML YA 1.00
5 ANTASIDA DOEN SIRUP SIRUP YA 1.00
6 BACTOPRIM COMBI SIRUP 240MG/ 5 ML SIRUP 240MG/ 5 ML TIDAK 1.00
7 BETASON CREM 5 GRAM TUBE YA 1.00
8 BIOVITON SIRUP SIRUP YA 1.00
9 BUFACOMB ORAL BASE CR TUBE YA 1.00
10 CALOREX SIRUP 60 ML SIRUP YA 1.00
11 CEFIXIME SIRUP 100MG/5 ML SIRUP 100MG/5 ML YA 1.00
12 CHLORAMPHENICOL TETES MATA DROP YA 1.00
13 COMTUSI STRAW SIRUP SIRUP YA 1.00
14 DENOMIX CREAM 10 GR TUBE YA 1.00
15 DEXAMETHASON INJEKSI 5 MG/ML AMPUL 5 MG/ML YA 1.00
16 ERLAMYCETIN PLUS TM TETES MATA YA 1.00
17 ETALYSIN SIR (MULTIVITAMIN) SIRUP YA 1.00
18 GLISEND EXPECTORANT SIRUP 60 ML SIRUP YA 1.00
19 GRAFADON DROPS DROP 60 mg/ml YA 1.00
20 GUANISTREP SIRUP 60 ML SIRUP YA 1.00
21 LIDOKAIN COMPOSITUM INJEKSI AMPUL 20MG YA 1.00
22 MAGTEN SUSPENSI SIRUP 400mg/ 5ml YA 1.00
23 MUSIN SUSPENSI 120 ML SIRUP 500mg/5ml TIDAK 1.00
24 NON WOVEN ADHESIVE PLASTER 1 X 1 MASTER PCS YA 1.00
25 OBH ITRASAL 100 ML SIRUP YA 1.00
26 PARACETAMOL SIRUP 120 MG/5ML SIRUP 120 MG/5ML YA 1.00
27 POT 50 ML TUTUP BENING PCS YA 1.00
28 SUKRALFAT SIRUP 500 MG/5 ML 100 ML SIRUP 500 mg/5ml YA 1.00
29 XEPAMOL SIRUP @ 60 ML SIRUP 250 MG/5ML YA 1.00
30 BETAMETASON CREAM 5G TUBE YA 2.00
31 BETASON N CREM 5 GR TUBE YA 2.00
32 CENDO XITROL ED 0.6ML MINI DOSE @5 TETES MATA YA 2.00
33 CETIRIZIN SIRUP E CATALOG SIRUP 5mg / 5ml YA 2.00
34 COTRIMOXAZOL SIRUP 240 MG/ 5ML SIRUP YA 2.00
35 DARYANTULLE LEMBAR YA 2.00
36 DISP SYRINGE 3ML TP DISPSPUIT 3ml YA 2.00
37 DOMPERIDON SIRUP 5 MG/5 ML SIRUP 5 MG/5 ML YA 2.00
TETES
ERLAMYCETIN PLUS TT 2.00
38 TELINGA YA
39 GENOINT EYE OINT SALEP MATA YA 2.00
40 HIDROKORTISON 1% CREM 5 GR SALEP MATA 1% YA 2.00
41 KONIGEN CREAM TUBE YA 2.00
42 LIDOKAIN INJEKSI 2% AMPUL 20 mg YA 2.00
43 PROMEDRYL SIRUP(PCT,GG,CTM) SIRUP YA 2.00
44 SALBUVEN EXPECTORANT SIRUP TIDAK 2.00
 PERKUMPULAN PERHIMPUNAN SANTO BORROMEUS
“KLINIK PRATAMA “UNPAR”
JL. Menjangan No. 14 Bandung 40132 INDONESIA
2015
Telp 022 8260238

45 SUCRALFAT SIRUP 100 ML SIRUP YA 2.00

46 AMOXYCILLIN SIRUP 125 MG/5 ML SIRUP 125 MG/5 ML YA 3.00
47 BROXFION SIRUP 15MG/5 ML SIRUP 15MG/5 ML YA 3.00
48 CYCLOGESTON VIAL INJEKSI YA 3.00

49 ONDANSETRON HCL INJEKSI 8MG/4ML @5 INJEKSI 8MG/4ML YA 3.00

50 CEFADROXIL SIRUP 125MG/5ML SIRUP 125MG/5ML YA 4.00
51 MORITA DENTAL NEEDLE PCS YA 4.00
52 PERMETHRIN SALEP TUBE YA 4.00
53 THIAMPHENICOL capsul 500 mg KAPSUL 500 mg YA 4.00
54 TRANABAT TABLET TABLET YA 4.00
55 AZITHROMYCIN 500MG TABLET TABLET 500 mg YA 5.00
56 DISP SPUIT 5 CC TOP POINT DISPSPUIT YA 5.00
57 KETOROLAC 30 MG INJEKSI INJEKSI YA 5.00
58 LEVOFLOXACIN 500 MG (KF) TABLET 500 mg YA 5.00
59 VITAMIN C 500 MG TABLET @ 100 TAB TABLET 500 mg YA 5.00
60 LERZIN SIRUP 60 ML SIRUP 5mg/5ml YA 6.00
61 VENTOLIN NEBULES 2,5 MG @ 20AMP AMPUL 2,5mg YA 6.00
62 AMLODIPINE 10MG@100 E CATALOG TABLET 10 mg YA 7.00
63 FUROSEMIDE TABLET 40 MG @ 100 TAB TABLET 40mg YA 7.00
64 OTTOPAN SIRUP 60 ML SIRUP 120 MG/5ML YA 7.00
65 PEHACAIN INJEKSI INJEKSI 20 mg YA 7.00
66 HANDSCHOEN L LEMBAR YA 8.00
67 JOVIAL SACCHET @ 20 SACCH/ BOX SACCHET YA 8.00
68 NEEDLE 24 PCS YA 9.00
69 PACETIK BP SIRUP SIRUP 120mg/5ml YA 9.00
70 HANDSCHOEN NON STERIL S SAFEGUARD LEMBAR YA 10.00
71 MELOXICAM TABLET 15MG TABLET 15 mg YA 10.00
72 MUCOTEIN TABLET @ 20 TAB TABLET 30 mg YA 10.00
73 NORMUDAL TAB TABLET 2 mg YA 10.00
74 PONSTELAX TAB 500MG TABLET 500 mg TIDAK 10.00
75 RIBUNAL TABLET (IBUPROFEN) TABLET 400 mg YA 10.00
76 RINDOBION KAPLET TABLET YA 10.00
77 GENTAMICINE CREM 5 GR TUBE YA 11.00
78 ORALIT 200MG sacch SACCHET 200 mg YA 11.00
79 COHISTAN SIRUP 100 ML SIRUP YA 12.00
80 SPASMINAL TABLET TABLET 500 mg YA 14.00
81 HISTIGO TABLET TABLET 6 mg YA 16.00
82 PRONEURON TABLET TABLET 500 mg, 2 mg YA 16.00
83 ROXIDENE 20MG (PIROKSIKAM) KAPSUL 20MG YA 16.00
84 COTRIMOXAZOL TABLET 480 MG TABLET 480MG YA 18.00
85 SUPRAMOX 500MG KAPSUL TABLET 500 mg YA 18.00
86 METRONIDAZOLE TABLET 500 MG TABLET 500 mg YA 19.00
87 AMLODIPIN TABLET 10 MG @30 LDS TABLET 10mg YA 20.00
88 D-VIT 1000 TABLET 1000 mcg YA 20.00
89 IRBESARTAN 300MG E CATALOG TABLET 300mg YA 20.00
90 KETOCONAZOLE 200MG @100 TAB TABLET 200 mg YA 20.00
91 ANTASIDA DOEN TABLET TABLET 200mg,200mg YA 21.00
92 ETABION ( MULTIVITAMIN FE) KAPSUL 375 mg YA 22.00
93 SPASMAL TABLET @ 100 TABLET TABLET 500 mg,30mg,5mg YA 24.00
94 VITAMIN B KOMPLEKS TABLET TABLET YA 24.00
95 AMOXYCILLIN TABLET 500MG TABLET 500 mg YA 25.00
96 KIMSMED DISPOSYBLE SYRINGE 3 ML PCS 3ml YA 25.00
97 NASAMEX FORTE TABLET TABLET YA 26.00
98 CTM 4 MG TABLET @100 TABLET TABLET 4mg YA 28.00
99 SWAB ANTIGEN CLUNGENE IND COVID-19 PCS YA 28.00
100 ONDANSETRON 4 MG @50 TABLET 4mg YA 29.00
101 TRIFEDRIN @ 30 TABLET TABLET 30m, 2,5mg YA 29.00
102 AMLODIPINE 5 MG @100 ENSEVAL (REG) TABLET 5mg YA 30.00
103 EPERISONE TABLET (NOVELL) TABLET 10mg YA 30.00
 PERKUMPULAN PERHIMPUNAN SANTO BORROMEUS
“KLINIK PRATAMA “UNPAR”
JL. Menjangan No. 14 Bandung 40132 INDONESIA
2015
Telp 022 8260238

104 METOCLOPRAMIDE TABLET 10 MG TABLET 10 mg YA 30.00

105 SALBUTAMOL TABLET 2 MG TABLET 2mg YA 30.00
106 SALBUTAMOL TABLET 4 MG TABLET 4mg YA 32.00
107 INFLO 18G X32MM PCS YA 33.00
108 VIRON KAPLET TABLET 500mg, YA 33.00
109 CAPTOPRIL TABLET 25 MG TABLET 25mg YA 34.00
110 ACETYLCYSTEINE 200 MG CAPSUL KAPSUL 200 mg YA 36.00
111 INFLO 22G X 1" PCS YA 36.00
112 RANITIDIN TABLET 150 MG TABLET 150 MG YA 36.00
113 PARACETAMOL TABLET 500 MG TABLET 500 mg YA 37.00
114 AMLODIPIE 10MG@50 E CATALOG TABLET 10 MG YA 40.00
115 AMLODIPINE 10 MG @100 TAB TABLET 10 MG YA 40.00
116 MEZAC 50 TABLET @ 50 TAB/BOX TABLET 50 MG YA 40.00
117 AMBROXOL tablet 30 mg TABLET 30 MG YA 41.00
118 DOMPERIDON tablet 10 mg TABLET 10 MG YA 43.00
119 FLUZEP TABLET TABLET 500mg, YA 43.00
120 DOMPERIDONE TAB E CATALOG TABLET 10 MG YA 50.00
121 LAPROTON 20MG ( LANSOPRAZOLE) NEW KAPSUL 20 MG YA 50.00
122 THERABEX TABLET 50mg TIDAK 50.00
123 ZINC TABLET 20 MG TABLET 20MG YA 52.00
124 LANSOPRAZOLE capsul 20 mg KAPSUL 20 MG YA 55.00
125 MELOXICAM TABLET 7,5 MG TABLET 7,5 MG YA 55.00
126 ETABROXOL TAB TABLET 30 MG YA 58.00
127 MECOBALAMIN CAPSUL 500 MCG KAPSUL 500 mCg YA 58.00
128 CEFIXIME CAPSUL 100 MG KAPSUL 100 MG YA 60.00
129 SUMAGESIC TABLET 600 MG TABLET 600 mg YA 64.00
130 BETAHISTINE TABLET 6 MG TABLET 6 MG YA 66.00
131 ONESWAB (ALKOHOL SWAB) ONE MED LEMBAR YA 73.00
132 IRBESARTAN 150 MG @ 50 KAPSUL TABLET 150MG YA 80.00
133 DEXTEEM PLUS TABLET 2mg,05mg YA 91.00
134 WICOLD TABLET @100 TABLET/BOX TABLET 500mg, YA 93.00
135 ETHAMBUTOL tablet 500 mg TABLET 500 mg YA 100.00
136 HANDSCHOEN NON STERIL M ALTAMED LEMBAR YA 102.00
137 OBATINE TABLET 500mg, YA 107.00
138 GRAFADON TABLET ( PARACETAMOL) TABLET 500 mg YA 108.00
139 AMOXYCILLIN 500 MG TABLET KF TABLET 500 mg YA 111.00
140 CIPROFLOXACIN TABLET 500 MG TABLET 500 mg YA 111.00
141 LORATADINE 10 MG TAB@50 LDS TABLET 10mg YA 112.00
142 TRACODIA TABLET (LOPERAMIDE) TABLET 2 mg YA 116.00
143 AMLODIPIN 5MG @300 E-CATALOG TABLET 5 mg YA 125.00
144 METHYLPREDNISOLON TABLET 4 MG TABLET 4 mg YA 128.00
145 TAGYT TABLET 600 mg, 50mg YA 143.00
146 IBUPROFEN 400 MG TAB TABLET 400 mg YA 147.00
147 FLACOID TABLET (DEXAMETHASONE ) TABLET 0,5mg YA 163.00
148 BACTORIM FORTE TAB TABLET 960mg YA 167.00
149 ASAM MEFENAMAT TABLET 500MG TABLET 500 mg YA 173.00
150 CETIRIZIN TABLET 10MG @ 100 TABLET TABLET 10 mg YA 188.00
151 OMEPRAZOLE CAPSUL @ 100 TABLET 30 mg YA 200.00
152 CLINDAMYCIN 300MG @ 100 KAPSUL KAPSUL 300 mg YA 204.00
153 CEBEX CAPLET TABLET 500mg, YA 205.00
154 NODROF ANTITUSIF TABLET TABLET 500mg, YA 212.00
155 PROMEDRYL SIRUP(PCT,GG,CTM) SIRUP 120mg/5ml YA 306.00
156 CEFADROXIL CAPSUL 500 MG TABLET 500 mg YA 313.00
157 DEGIROL TABLET HISAP TABLET 0,25mg YA 331.00
158 DEXAMETHASON TABLET 0,5 MG TABLET 0,5 MG YA 343.00
159 ENZYPLEX TABLET TABLET YA 346.00
160 NODROF EXPECTORAN TABLET 500mg, YA 346.00
161 CEFIXIME 200 MG @100 PROMED TABLET 200 mg YA 385.00
162 ALAXAN FR TABLET TABLET 375/200 YA 497.00
 PERKUMPULAN PERHIMPUNAN SANTO BORROMEUS
“KLINIK PRATAMA “UNPAR”
JL. Menjangan No. 14 Bandung 40132 INDONESIA
2015
Telp 022 8260238

Presentase kesesuaian dg Fornas : Jumlah Item Obat yg sesuai dg Fornas X 100 %

Jumlah Item Obat yg tersedia di Klinik

= 157
200 X 100 %

= 78.5%

PRESENTASE KESESUAIAN DG FORNAS

KETERANGAN:

Kolom 1 : Nomor urut

Kolom 2 : Nama Obat,ditulis dg Nama Generik atau Nama Dagang jika Ada

Kolom 3 : Bentuk sediaan Tablet,Kapsul,Sirup,drop,sacchet /kekuatan Dosis dalam mg,mg/ml

Kolom 4 : Kesesuaian dg Fornas bilaitem obat tercantum dlmfornas tulis YA = 1 TIDAK = 0

Kolom 5 : TotalPengguunaan Obat

Presentase kesesuaian dg Fornas : Jumlah Item Obat yg sesuai dg Fornas X 100 %

Jumlah Item Obat yg tersediadiKlinik

Form diisi dengan data per triwulan

Bandung, .11 Januari .2023

Apoteker KP UNPAR
Q Apoteker : Mega Bulan M,.SFarm,Apt
SIPA :19720623/SIPA_32.73/2021/2152