Monitoring Survey Por Fika

FORMULIR PELAPORAN INDIKATOR PERESEPEN ISPA NON PNEUMONIA
UPTD PUSKESMAS : BUNGARAYA

KABUPATEN : SIAK BULAN : JANUARI
PROPINSI : RIAU TAHUN : 2018
Jumlah Antibiotik Lama Pemakaian

Tgl No Nama Umur Nama Obat Dosis Obat
Item Obat Ya/Tidak ( hari )
(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-12-2017 1 Sugianto 39 th 3 tdk Hustab 3x1 X
Vit C 50 mg 3x1 X
Dexamethason 3x1 X
27-12-2017 2 Warka 56 th 2 tdk GG 3x1 VI

Vit C 50 mg 3x1 VI
28-12-2017 3 Sumini 37 th 3 tdk Parasetamol 500 mg 3x1 X

Vit C 50 mg 3x1 X
Ctm 3x1 X
29-12-2017 4 Suhariyanto 35 th 4 tdk Ambroxol 3x1 X

Ctm 3x1 X
Ibuprofen 400 mg 2x1 X
Vit B Comp 2x1 X
30-12-2017 5 Adminah 25 th 3 tdk Loratadin 2x1 X

GG 3x1 X
Ranitidin 2x1 X
01-01-2018 6 Septiani 11 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
03-01-2018 7 Shifatul azkia 2,3 th 4 tdk GG Mf Pulv X II

Ctm 3 x 1 bks II
Vit C 50 mg II
Parasetamol syr 3 x 1 cth I
04-01-2018 8 Sariyamah 21 th 3 tdk Ambroxol 3x1 X
Vit C 50 mg 3x1 X
Parasetamol 500 mg 3x1 X
05-01-2018 9 Saniah 6,8 th 4 tdk Parasetamol 500 mg 3 x 1/2 V

Ambroxol 3 x 1/2 V
Ctm 3 x 1/2 V
Vit C 50 mg 1x1 V
06-01-2018 10 Ziki 8 th 4 ya Ctm 3 x 1/2 V

Ambroxol 3 x 1/2 V
Amoxicillin 250 mg 3x1 XV
Vit C 50 mg 2x1 X
08-01-2018 11 Tayan 58 th 4 ya Ambroxol 3x1 X

Dexamethason 2x1 X
Ranitidin 2x1 X
09-01-2018 12 Osmar 49 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
10-01-2018 13 Bustomi 3,9 th 2 tdk GG Mf Pulv X III

Ctm 3 x 1 bks III
12-01-2018 14 Siti fatimah 41 th 4 tdk Vit C 50 mg 3x1 X

Ambroxol 3x1 X
Ctm 3x1 X
13-01-2018 15 Heri kiswanto 31 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
14-01-2018 16 Hesti 29 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
16-01-2018 17 Amalia 7 th 5 ya Parasetamol 500 mg 3 x 1/2 V
Ambroxol 3 x 1/2 V
Ctm 3 x 1/2 V
Vit C 50 mg 2x1 X
17-01-2018 18 Selnida 37 th 4 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X
18-01-2018 19 Darki 40 th 4 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X
19-01-2018 20 Edi sugiono 37 th 4 tdk Ibuprofen 200 mg 2x1 VI

Ranitidin 2x1 VI
Vit B Complex 2x1 VI
GG 2x1 VI
20-01-2018 21 Suryanti 37 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
22-01-2018 22 Alvadina 17 th 4 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X
Total Item Obat 76 3
Rerata Item Obat/ Lembar R/ 3.45
22
Persentase AB 13.64
Jumlah Obat Generik 65
KETERANGAN :
N = Jumlah Pasien
A = Jumlah Item Obat = A/n
B = Jumlah Pasien yg mendapat Antibiotik = B / n x 100 %
C = Jumlah Pasien yg mendapat injeksi = C / n x 100 %
D = Jumlah Obat Generik = D / A x 100 %
IKATOR PERESEPEN ISPA NON PNEUMONIA
Sesuai
Pedoman Ya/
Tidak
(10)
FORMULIR PELAPORAN INDIKATOR PERESEPEN DIARE NON SPESIFIK
Jumlah Item Antibiotik Lama Pemakaian

Tgl No Nama Umur Nama Obat Dosis
Obat Ya/ Tidak ( Hari )
(1) (2) (3) (4) (5) (6) (7) (8) (9)
29-12-2017 1 Salsabila 16 bln 3 ya Cotrimoksazol syr 2 x 1 cth I
Probiokid 3 x 1/2 III
Parasetamol syr 3 x 1/2 cth I
01-01-2018 2 Eko 29 th 5 tdk Neo diaform 3x1 X

GG 3x1 X
Oralit Suc V
Ranitidin 2x1 VI
Hyorex 2x1 VI
03-01-2018 3 Rafli abiyanto 1,6 th 6 ya Oralit Suc IV

Domperidon syr 3 x 1/4 cth I
Parasetamol syr 3 x 3/4 cth I
Cotrimoksazol syr 2 x 3/4 cth I
Probiokid 1x1 III
Zinc 1x1 X
04-01-2018 4 Intan 42 th 4 tdk Oralit Suc V

Ranitidin 2x1 VI
Loperamid 2-1-1 VI
Vit B Comp 3x1 X
05-01-2018 5 Anwar fauzi 2,4 th 3 tdk Oralit Suc V

Probiokid 1x1 III
Zinc 1x1 X
08-01-2018 6 Octa adelia 2,2 th 4 tdk Probiokid 1x1 III

Zinc 1x1 X
Oralit suc IV
06-01-2018 7 M. Ikhwan 1,10 th 6 tdk Oralit Suc V
Zinc 1x1 X
Probiokid 1x1 III
Antasid Mf Pulv X II
3 x 1 bks
Ambroxol Mf Pulv X II
Ctm 3 x 1 bks II
09-01-2018 8 Lailatul 2 th 3 tdk Oralit Suc IV

Zinc 1x1 X
Probiokid 1x1 III
10-01-2018 9 Arif abdul 2 th 4 tdk Oralit Suc V

Probiokid 1x1 III
Zinc 1x1 X
11-01-2018 10 Shaquilla rifdah 5,6 th 5 tdk Oralit Suc VIII

Zinc 1x1 X
Probiokid 1x1 III
Antasid Mf Pulv X III
3 x 1 bks ac
Parasetamol syr 3 x I 1/2 cth I
14-01-2018 11 Lailatul fitria 2 th 1 tdk Probiokid 2 x 1/2 bks III
17-01-2018 12 M. Mahmud 9 th 5 tdk Oralit Suc V

Zinc 1x1 V
Domperidon syr 3 x 1 cth I
Probiokid 1x1 III
Antasid 3 x 1/2 V
18-01-2018 13 Imam safii 52 th 5 ya Oralit Suc VIII

Ranitidin 2x1 VI
Loperamid 2-1-1 VI
Cotrimoksazol 480 2x2 XX
19-01-2018 14 Evan 2,11 th 2 ya Cotrimoksazol syr 2 x 1 cth I
Probiokid 3 x 1/2 III
21-01-2018 15 Toni 6,6 th 5 ya Domperidon syr 3 x 1/2 cth I

Oralit Suc VIII
Probiokid 1x1 III
Zinc 1x1 X
Cotrimoksazol 480 2x1 X

15
Persentase AB 33.33
KETERANGAN :
N = Jumlah Pasien
ATOR PERESEPEN DIARE NON SPESIFIK
Sesuai
Pedoman
Ya/Tidak
(10)
FORMULIR PELAPORAN INDIKATOR PERESEPEN MYALGIA
Lama
Jumlah Item Injeksi
Tgl No Nama Umur Nama Obat Dosis Pemakaian (
Obat Ya/Tidak
hari )
(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-12-2018 1 Suwardiah 55 th 2 tdk Ibuprofen 400 mg 3x1 X
Antasid 3 x 1 ac X
08-01-2018 2 Sutiani 28 th 3 tdk Na diklofenak 25 mg 2x1 X

Dexamethason 2x1 X
Ranitidin 2x1 X
09-01-2018 3 Jumali 37 th 3 tdk Dexamethason 3x1 XV

Piroxicam 10 mg 2x1 X
Ranitidin 2x1 X
10-01-2018 4 Suratun 62 th 4 tdk Na Diklofenak 25 mg 2x1 X

Vit B complex 2x1 X
Vit C 50 mg 3x1 X
Allopurinol 100 mg 1x1 X
12-01-2018 5 Khairiyah 60 th 3 tdk Ibuprofen 200 mg 3x1 X

Omeprazole 2 x 1 ac VI
Vit B Complex 3x1 X
13-01-2018 6 Kanari 52 th 3 tdk Na diklofenak 25 mg 2x1 X

Vit B Complex 2x1 X
Ranitidin 2x1 X
20-01-2018 7 Arifin 29 th 2 tdk Na diklofenak 50 mg 2x1 X

Ranitidin 2x1 X
7
Persentase Injeksi 0.00
KETERANGAN :
N = Jumlah Pasien
AN INDIKATOR PERESEPEN MYALGIA
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : FEBRUARI

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-01-2018 1 Gito 41 th 4 tdk Parasetamol 500 mg 3x1 VI
Ambroxol 30 mg 3x1 X
Loratadin 1x1 VI
Vit C 50 mg 2x1 X
24-01-2018 2 Arman 30 th 3 tdk Parasetamol 500 mg 3x1 X

Ctm 4 mg 3x1 X
25-01-2018 3 Febiola 21 th 4 ya Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
Amoxicillin 500 mg 3x1 XII
26-01-2018 4 Lagiem 37 th 3 tdk GG 3x1 X

Ctm 4 mg 3x1 X
Dexamethason 0,5 mg 3 x 1 X
27-01-2018 5 Dika ardiansyah 8 th 2 tdk Parasetamol 500 mg 3 x 1/2 V

Ctm 4 mg 3 x 1/2 V
29-01-2018 6 Sonali gea 31 th 4 tdk Parasetamol 500 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
30-01-2018 7 Erikson 22 th 3 tdk Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
31-01-2018 8 Susilo 40 th 4 tdk Parasetamol 500 mg 3x1 X
Vit B Complex 3x1 X
Ranitidin 2x1 VI
Ctm 4 mg 3x1 X
01-02-2018 9 Sutarno 26 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 4 mg 3x1 X
02-02-2018 10 Putri 5 bln 3 tdk GG Mf Pulv X I

Ctm 4 mg 3 x 1 bks I
Parasetamol drops I
03-02-2018 11 Rijan 87 th 4 ya Parasetamol 500 mg 3x1 X

Vit C 50 mg 3x1 X
05-02-2018 12 Rio rinaldo 16 th 3 ya GG 3x1 X

Ctm 4 mg 3x1 X
06-02-2018 13 May meri 39 th 2 tdk Parasetamol 500 mg 3x1 X

Ctm 4 mg 3x1 X
07-02-2018 14 Kirno 40 th 5 ya Parasetamol 500 mg 3x1 X

Loratadin 1x1 V
Ranitidin 2x1 X
Dexamethason 2x1 VI
08-02-2018 15 Sutardi 49 th 4 ya Loratadin 2x1 X

Dexamethason 3x1 X
Ranitidin 2x1 X
09-02-2018 16 Wahyu sutrisno 32 th 5 ya Amoxicillin 500 mg 3x1 XV

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
10-02-2018 17 Ahmad farid 10 bln 3 tdk GG Mf Pulv X II
Ctm 3 x 1 bks II
Vit C 50 mg II
12-02-2018 18 Sutardi 50 th 2 tdk Loratadin 1x1 X

GG 3x1 XV
13-03-2018 19 M. Rifai 2,6 th 4 tdk GG Mf Pulv X II

Ctm 3 x 1 bks II
Vit C 50 mg II
Dhavit syr 1 x 1 cth I
14-02-2018 20 Ari Budi 7 th 4 ya GG 3 x 1/2 V

Ctm 3 x 1/2 V
Dexamethason 0,5 mg 3 x 1/2 V
Amoxicillin syr 3 x I 1/2 cth II
15-02-2018 21 Iwan 23 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 4 mg 3x1 X
17-02-2018 22 Yani 29 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 4 mg 3x1 X
19-02-2018 23 M. Syaiful 5,6 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

GG 3 x 1/2 V
Ctm 4 mg 3 x 1/2 V
20-02-018 24 Rohmatul 17 th 1 tdk Hustab 3x1 X

24
Persentase AB 29.17
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
25-01-2018 1 Erlina 15 th 4 ya Cotrimoksazol syr 3x1 XII
Probiokid 3x1 VI
Ranitidin 2x1 VI
29-01-2018 2 Yosi 8 bln 5 tdk Oralit Suc IV

Probiokid 1x1 IV
Zinc 1x1 X
Ambroxol Mf Pulv X I
Loratadin 2 x 1 bks I
30-01-2018 3 Rafael 2 th 4 tdk Oralit Suc VIII

Probiokid 1x1 III
Zinc 1x1 X
31-01-2018 4 Rizki 11 bln 3 ya Probiokid 3 x 1/2 III

Zinc 1x1 X
Cotrimoksazol syr 2 x 1 cth I
03-02-2018 5 Kholidah 39 th 4 tdk Ranitidin 2x1 VI

Vit C 50 mg 3x1 X
Oralit Suc VI
Guanistrep syr 3 x 2 cth I
05-02-2018 6 Sutiman 36 th 6 ya Neo diaform 3x1 VI
Hyorex 3x1 VI
Oralit Suc IV
Ranitidin 2x1 X
Asam tranexamat 2x1 VI
07-02-2018 7 Lela 2,5 th 3 tdk Probiokid 1x1 III

Zinc 1x1 X
Oralit Suc III
08-02-2018 8 Agustina 40 th 3 tdk Vit B1 3x1 X

Vit B6 3x1 X
10-02-2018 9 Fais ardiansyah 2 th 6 tdk Zinc 1x1 X

Probiokid 1x1 III
Oralit suc VIII
Dhavit syr 1 x 1/2 cth I
Domperidon syr 3 x I cth I
Ctm Mf Pulv X II
3 x 1 bks
12-02-2018 10 Elisabet 1,8 th 5 tdk Dhavit syr 1 x 1/2 cth I

Probiokid 1x1 III
Zinc 1x1 X
Oralit Suc III
Parasetamol drops 3 x 0,8 ml I
13-02-2018 11 Sukadi 89 th 3 tdk Antasid 3 x 1 ac X

Oralit suc VII
14-02-2018 12 Lukman nul hakim 25 th 3 ya Cotrimoksazol 480 2x2 XII

Zinc 1x1 X
Papaverin 3x1 VI
15-02-2018 13 Nikolas 1 th 3 tdk Oralit Suc V

Domperidon syr 3 x 1,2 ml I
Zinc 1x1 X
17-02-2018 14 Aiko 1,5 th 2 ya Probiokid 3 x 1/2 III
Cotrimoksazol susp 2 x 1 cth I
19-02-2018 15 Aris munandar 25 th 3 ya Cotrimoksazol 480 2x2 XII

Oralit Suc V
Antasid 3 x 1 ac X
20-02-2018 16 Aiko 1,5 th 3 tdk Zinc 1x1 X

Probiokid suc V
Oralit 3 x 1/2 III

16
Persentase AB 37.50
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman
Ya/Tidak
(10)
Lama Sesuai
Jumlah Item Injeksi
Tgl No Nama Umur Nama Obat Dosis Pemakaian ( pedoman
Obat Ya/Tidak
hari ) Ya/Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
23-01-2018 1 Sumaji 53 th 3 tdj Piroxicam 10 mg 2x1 VI
Vit B Complex 3x1 X
Antasid 3 x 1 ac X
24-01-2018 2 Arifin 30 th 2 tdk Ibuprofen 400 mg 2x1 X

Vit B Complex 2x1 X
31-01-2018 3 Norasih 43 th 2 tdk Vit B Complex 3x1 X

Parasetamol 500 mg 3 x 1 X
12-02-2018 4 Fatimah 42 th 2 tdk Na diklofenak 50 mg 2x1 X

Ranitidin 2x1 X
20-02-2018 5 Nukman halim 32 th 2 tdk Parasetamol 500 mg 3 x 1 X

Mecobalamin 3x1 X

5
N = Jumlah Pasien
KABUPATEN : SIAK BULAN : MARET
Sesuai
Tgl No Nama Umur Nama Obat Dosis Obat Pedoman Ya/
Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
23-02-2018 1 Ridwan 7 th 1 tdk Hustab 3 x 1/2 V
24-02-2018 2 Pio ronaldo 16 th 3 tdk Loratadin 2x1 X

Ranitidin 2x1 X
Dexamethason 2x1 X
27-02-2018 3 Albion 10 th 4 ya Ambroxol 3x1 X

Vit C 50 mg 3x1 X
Amoxicillin 500 mg 3x1 X
28-02-2018 4 Bustomi 4 th 3 tdk Ambroxol Mf Pulv X III

Loratadin 2 x 1 bks II
Dhavit syr 1 x 1 cth I
01-03-2018 5 Nurul anisa 3,9 th 4 ya Ambroxol Mf Pulv X III

Methyl prednisolon 3 x 1 bks III
Loratadin
Amoxicillin syr 3 x 1 cth I
02-03-2018 6 Hendro 51 th 4 tdk Ambroxol 3x1 X

Antasid 3x1 X
Ranitidin 2x1 X
03-03-2018 7 Hafizah 7,6 th 3 tdk GG 3x1 X

Loratadin 1x1 V
Dexamethason 2x1 VI
05-03-2018 8 Alfiatur rohmanian 4,10 th 4 ya Parasetamol syr 4 x I 1/4 cth I
Loratadin Mf Pulv X II
Salbutamol 2 mg 2 x 1 bks II
Cotrimoksazol syr 2 x I 1/2 cth I
06-03-2018 9 Doni 31 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Loratadin 1x1 V
07-03-2018 10 Arifin zai 40 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Loratadin 1x1 V
08-03-2018 11 Siti 30 th 3 ya Amoxicillin 500 mg 3x1 XV

Vit B Complex 3x1 X
09-03-2018 12 Suminah 48 th 5 tdk Salbutamol 2 mg 3x1 X

Loratadin 1x1 V
Dexamethason 3x1 X
GG 3x1 X
10-03-2018 13 Tinus hulu 36 th 2 tdk Ambroxol 3x1 X

12-03-2018 14 Eko haryono 29 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Loratadin 1x1 V
13-03-2018 15 Ismayanto 36 th 2 tdk Vit B Complex 2x1 VI

14-03-2018 16 Agus iswanto 27 th 2 tdk Loratadin 1x1 X

Dexamethason 3x1 X
15-03-2018 17 Tusiman 25 th 3 ya Amoxicillin 500 mg 3x1 XII

Ctm 3x1 X
16-03-2018 18 Sakri 85 th 3 tdk Ambroxol 3x1 X

Parasetamol 3x1 X
Ctm 3x1 X
17-03-2018 19 Sri mawarni 45 th 4 ya Parasetamol 500 mg 3x1 X

GG 3x1 X
Loratadin 1x1 V
18-03-2018 20 Arifin 30 th 2 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
3/19/2018 21 Nurul 34 th 2 tdk Ambroxol 3x1 X

Ctm 3x1 X
22-03-2018 22 Rifa'i 14 th 4 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
Dexamethason 3x1 X
Salbutamol 4 mg 3x1 VI

22
Persentase AB 27.27
KETERANGAN :
N = Jumlah Pasien
Jumlah Item Antibiotik

Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
26-02-2018 1 Syakila N 6 bln 2 tdk Oralit Suc
Zinc 1 x 1/2
28-02-2018 2 Jalil 1,2 th 2 tdk Probiokid 1x1

Zinc 1x1
01-03-2018 3 Azizah 7 bln 3 tdk Oralit suc

Guanistrep syr 3 x 1/2 cth
Zinc 1x1
02-03-2018 4 Friska 7 bln 2 tdk Oralit Suc

Guanistrep syr 3 x 1/2 cth
05-03-2018 5 Supriatun 37 th 3 tdk Neo diaform 3x1

Ranitidin 2x1
Oralit Suc
20-03-2018 6 Lelo fernando 27 th 2 tdk Oralit Suc

Neo diaform 3x1
21-03-2018 7 Sujeni 34 th 2 tdk Neo diaform 3x1

Parasetamol 500 mg 3x1
22-03-2018 8 Alisa putri 2,9 th 4 tdk Oralit Suc

Zinc 1x1
Probiokid 1x1
Parasetamol syr 3 x 1 cth
8
Persentase AB 0.00
KETERANGAN :
N = Jumlah Pasien
INDIKATOR PERESEPEN DIARE NON SPESIFIK
Sesuai
Lama Pemakaian
Pedoman
( Hari )
Ya/Tidak
(9) (10)
VII
V
V
X
V
I
X
V
I
X
X
III
V
VI
X
X
IV
X
III
I
Jumlah Item Injeksi Lama Pemakaian

Obat Ya/Tidak ( hari )
(1) (2) (3) (4) (5) (6) (7) (8) (9)
06-03-2018 1 Indra 33 th 3 tdk Ibuprofen 400 mg 2x1 X
Vit B1 2x1 X
Ranitidin 2x1 X
09-03-2018 2 Sulaiman 37 th 2 tdk Na diklofenak 50 mg 2x1 X

Vit B Complex 2x1 X
19-03-2018 3 Darino 57 th 2 tdk Asam mefenamat 500 mg 3x1 X

Ranitidin 2x1 X
22-03-2018 4 Desmiyanti 26 th 2 tdk Vit B Complex 3x1 X

Total Item Obat 9 0

4
7/15/2017 7 Nurlaili 41 th 3 tdk
N = Jumlah Pasien
INDIKATOR PERESEPEN MYALGIA
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : APRIL
Sesuai
Tgl No Nama Umur Nama Obat Dosis Obat Pedoman Ya/
Tidak
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
23-03-2018 1 Fadilah 6 th 2 tdk Ambroxol 3 x 1/2 V
Ctm 3 x 1/2 V
24-03-2018 2 Nazar habibi 11 th 3 ya GG 3x1 X

Dexamethason 3x1 X
26-03-2018 3 Fadil 8 th 4 tdk Ambroxol 3 x 1/2 V

Ctm 3 x 1/2 V
Parasetamol 500 mg 3 x 1/2 V
Vit C 50 mg 2x1 X
28-03-2018 4 Siswono 47 th 3 ya Parasetamol 500 mg 3x1 X

GG 3x1 X
29-03-2018 5 Suraji 28 th 3 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
GG 3x1 X
31-03-2018 6 Rumini 43 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
02-04-2018 7 Sri mawarni 45 th 3 tdk Cetirizin 2x1 XX

Methylprednisolon 2x1 XX
Ranitidin 2x1 XX
03-04-2018 8 Selamet 34 th 3 tdk Parasetamol 500 mg 3x1 X
GG 3x1 X
Ctm 3x1 X
04-04-2018 9 Yatiar 42 th 3 tdk Parasetamol 500 mg 3x1 X

Cetirizin 1x1 V
Vit C 50 mg 3x1 X
05-04-2018 10 Amanda 10 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

Ambroxol 3 x 1/2 V
Vit C 50 mg 2x1 X
06-04-2018 11 Lilis 37 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Ranitidin 2x1 VI
07-04-2018 12 Mursinah 35 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
09-04-2018 13 Novita sari 9 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

GG 3 x 1/2 V
Ctm 3 x 1/2 V
10-04-2018 14 Kasilah 50 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 VI
Ctm 3x1 X
11-04-2018 15 Juliana 18 th 2 tdk GG 3x1 X

Ctm 3x1 X
12-04-2018 16 Zainudin 23 th 3 tdk Ibuprofen 400 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
13-04-2018 17 Eza 3 bln 3 ya Parasetamol drop 4 x 0,6 ml I

Amoxicillin syr 3 x 1/2 cth I
Loratadin Mf Pulv VIII 1/2
2 x 1 bks
16-04-2018 18 Diandra 6,2 th 3 ya GG 3 x 1/2 V
Dexamethason 3 x 1/2 V
17-04-2018 19 Ahmad yusrizal 5,6 th 3 tdk Parasetamol 500 mg 3x1 X

Dexamethason 3x1 X
Cetirizin 2x1 VI
18-04-2018 20 Suryati 46 th 4 tdk Ambroxol 3x1 X

Cetirizin 1x1 V
Antasid 3 x 1 ac X
19-04-2018 21 Azam 1,6 th 3 tdk Parasetamol syr 3 x 1 cth I

GG Mf Pulv X II
Cetirizin 2 x 1 bks I
20-04-2018 22 Shalu 1,1 th 3 tdk Cetirizin Mf Pulv X II

GG 2 x 1 bks I
Parasetamol 500 mg Mf Pulv X II
3 x 1 bks
21-04-2018 23 Legiem 37 th 3 ya Ambroxol 3x1 X

Cetirizin 1x1 V

23
Persentase AB 21.74
KETERANGAN :
N = Jumlah Pasien

(1) (2) (3) (4) (5) (6) (7) (8) (9)
24-03-2018 1 Fiki aji saputra 7 th 3 tdk Oralit Suc VI
Zinc 1x1 X
Probiokid 1x1 VI
26-03-2018 2 Darto 40 th 4 tdk Loratadin 1x1 V

Oralit Suc V
02-04-2018 3 Arman maulana 3,7 th 4 tdk Parasetamol syr 3 x I 1/4 cth I

Oralit Suc IV
Zinc 1x1 X
Probiokid 1x1 III
05-04-2018 4 Abdul latif 30 th 5 tdk Parasetamol 500 mg 3x1 X

Ranitidin 2x1 VI
Oralit Suc VI
06-04-2018 5 Nurkholis 63 th 4 tdk Neo diaform 3x1 X

Oralit Suc VI
Antasid 3x1 X
09-04-2018 6 Hotyani 34 th 3 ya Zinc 1x1 X

Cotrimoksazol 480 2x2 XII
Oralit Suc V
10-04-2018 7 Pasrah 31 th 3 tdk Papaverin 2x1 VI
Antasid 3x1 X
Oralit Suc V
16-04-2018 8 Zafran 6 th 3 ya Cotrimoksazol syr 2 x I 1/2 cth I

Probiokid 1x1 III
Ibuprofen syr 3 x I 1/2 cth I
17-04-2018 9 Andrea stefano 7 th 3 ya Probiokid 1x1 III

Cotrimoksazol 480 2x1 VIII
Cetirizin 2 x 1/2 IV
19-04-2018 10 Cartini 26 th 3 ya Cotrimoksazol 480 2x2 XII

Zinc 1x1 V
Antasid 3x1 X

10
Persentase AB 40.00
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman
Ya/Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-03-2018 1 Hadi hermawan 35 th 2 tdk Na diklofenak 50 mg 2x1 X
Methylprednisolon 2x1 X
29-03-2018 2 Agus sukamto 52 th 3 tdk Ibuprofen 400 mg 2x1 X

Ranitidin 2x1 X
Vit B Complex 2x1 X
31-03-2018 3 Eva yusanti 38 th 2 tdk Ibuprofen 200 mg 3x1 X

Vit B Complex 3x1 X
03-04-2018 4 Dina 31 th 2 tdk Parasetamol 500 mg 3x1 X

Vit B Complex 3x1 X
04-04-2018 5 Disun 31 th 3 tdk Ranitidin 2x1 VI

Vit B Complex 3x1 X
10-04-2018 6 Satna 35 th 2 tdk Asam mefenamat 500 mg 3 x 1 X

Vit B Complex 3x1 X
11-04-2018 7 Parijo 45 th 3 tdk Amlodipine 10 mg 1x1 X

Captopril 25 mg 2x1 XX
Mecobalamin 2x1 XX
16-04-2018 8 Partini 37 th 4 tdk Ibuprofen 400 mg 3x1 X

Vit B Complex 3x1 X
GG 3x1 X
Antasid doen 3 x 1 ac X
8
KETERANGAN :
N = Jumlah Pasien
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : MEI

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-04-2018 1 Aria rizki A 7 th 3 ya Cetirizin 1 x 1/2 III
Methyl prednisolon 3 x 1/2 V
24-04-2018 2 Mudra 6 th 2 tdk Ambroxol 30 mg 3 x 1/2 V

Cetirizin 1 x 1/2 III
25-04-2018 3 Rangga aji 6,5 th 2 ya Hustab 3 x 1/2 V

26-04-2018 4 Murnisah 35 th 1 tdk Hustab 3x1 X
27-04-2018 5 Kasman 50 th 2 tdk Cetirizin 1x1 V

Parasetamol 500 mg 2 x 1 kp VI
28-04-2018 6 Herman 28 th 3 tdk Parasetamol 500 mg 3 x 1 kp X

GG 3x1 X
Cetirizin 2x1 X
30-04-2018 7 Palil 66 th 4 tdk Ambroxol 30 mg 3x1 X

Ctm 3x1 X
Vit C 50 mg 3x1 X
Parasetamol 500 mg 3 x 1 kp X
02-05-2018 8 Sumarno 43 th 5 tdk Ambroxol 30 mg 3x1 X

Cetirizin 1x1 V
Ranitidin 2x1 VI
amlodipine 5 mg 1x1 X
03-05-2018 9 Rifki maulana 6 th 1 tdk Hustab 3 x 1/2 X
04-05-2018 10 Shirin sakira 7 th 3 tdk Parasetamol 500 mg Mf Pulv X IV

Dexamethason 3 x 1 bks III
GG III
05-05-2018 11 Zulfikar 35 th 3 tdk GG 3x1 X

Cetirizin 1x1 III
08-05-2018 12 Pujianto 34 th 2 tdk GG 3x1 X

09-05-2018 13 Saniah 34 th 3 tdk Parasetamol 500 mg 3x1 X

Alerfed 3x1 X
Vit C 50 mg 3x1 X
11-05-2018 14 Yayan 47 th 2 tdk Ambroxol 30 mg 3x1 X

Cetirizin 1x1 V
12-05-2018 15 Amanda 11 th 3 tdk Parasetamol 500 mg 3x1 X

GG 2x1 X
Cetirizin 1x1 III
14-05-2018 16 Sugito 37 th 2 tdk Ambroxol 3x1 X

Vit B Complex 2x1 X
15-05-2018 17 Surianto 32 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Cetirizin 1x1 V
16-05-2018 18 Riswanto 45 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Cetirizin 2x1 VI
17-05-2018 19 Kamto kijaya 7 th 4 tdk GG 3 x 1/2 V

Antasid 3 x 1/2 ac V
18-05-2018 20 Yuni marlina 24 th 4 ya Parasetamol 500 mg 3x1 X
Cetirizin 1x1 III
Vit C 50 mg 3x1 X
19-05-2018 21 Fahmi saputra 12 th 4 tdk Ambroxol 30 mg 3x1 X

Cetirizin 1x1 V
Salbutamol 2 mg 2 x 1 kp VI
Dexamethason 3x1 VI
21-05-2018 22 Erikson 22 th 2 tdk Ambroxol 30 mg 3x1 X

Vit B Complex 3x1 X

22
Persentase AB 13.64
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
23-04-2018 1 Zulfikar 35 th 3 tdk Neo diaform 3x2
Oralit Suc
Parasetamol 500 mg 3 x 1 kp
24-04-2018 2 Pratini 46 th 3 tdk Oralit Suc

Neo diaform 3x2
Antasid 3 x ac
25-04-2018 3 Daslam 48 th 3 tdk Oralit Suc

Ranitidin 2x1
Neo diaform 3x2
27-04-2018 4 Hulman sianipar 32 th 5 tdk Neo diaform 3x2

Papav hcl 3x1
Oralit Suc
Vit B6 3x1
Ranitidin 2x1
07-05-2018 5 Parlindungan siburian 37 th 3 ya Cotrimoksazol 480 2x2

Hyorex 3x1
Antasid 3 x 1 ac
08-05-2018 6 Ramadhan 19 th 3 ya Cotrimoksazol 480 2x2

Hyorex Suc
Ibuprofen 400 mg 2x1
09-05-2018 7 Abidin 49 th 5 ya Cotrimoksazol 480 2x2
Oralit Suc
Ranitidin 2x1
Vit B Complex 3x1
Probiokid 1x1

7
Persentase AB 42.86
KETERANGAN :
N = Jumlah Pasien
INDIKATOR PERESEPEN DIARE NON SPESIFIK
Sesuai
Lama Pemakaian
Pedoman
( Hari )
Ya/Tidak
(9) (10)
X
IV
VI
VI
X
X
VI
X
X
VI
VI
IV
VI
VI
XII
IV
VI
XII
VI
VI
XX
VIII
X
X
III

(1) (2) (3) (4) (5) (6) (7) (8) (9)
26-04-2018 1 Yakun 40 th 4 ya Na diklofenak 50 mg 2x1 VI
Ranitidin 2x1 VI
Dexamethason 3x1 X
Ciprofloxacin 500 mg 2x1 VI
27-04-2018 2 Turiah 41 th 2 tdk Na diklofenak 50 mg 2x1 VI

Ranitidin 2x1 VI
03-05-2018 3 Poltak simbolon 31 th 2 tdk Asam mefenamat 500 mg 3 x 1 X

Vit B Complex 2x1 X
08-05-2018 4 Nikson 40 th 2 tdk Ibuprofen 400 mg 2x1 X

Vit B Complex 2x1 X
09-05-2018 5 Ulfa 42 th 2 tdk Na diklofenak 50 mg 2x1 X

Vit B Complex 3x1 X
11-05-2018 6 Suparman 42 th 2 tdk Na diklofenak 50 mg 2x1 X

Vit B Complex 2x1 X
12-05-2018 7 Siten 50 th 2 tdk Na diklofenak 50 mg 2x1 VI

Ranitidin 2x1 VI
15-05-2018 8 Muhtar 54 th 2 tdk Amlodipine 5 mg 1x1 XV

Ibuprofen 400 mg 2x1 XX
17-05-2018 9 Suparman 41 th 3 tdk Ibuprofen 400 mg 2x1 X
Ranitidin 2x1 X
Vit B Complex 2x1 X
21-05-2018 10 Aprival 41 th 3 tdk Asam mefenamat 500 mg 3 x 1 X

Dexamethason 3x1 X
Vit C 50 mg 3x1 X

10
KETERANGAN :
N = Jumlah Pasien
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : JUNI

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-05-2018 1 Elfi 6 th 2 ya Hustab 3 x 1/2 V
24-05-2018 2 Rina 5.5 th 2 ya Hustab 3 x 1/2 V

25-05-2018 3 Septiani 11 th 4 tdk GG 2x1 X

Cetirizin 2x1 X
Dexamethason 2x1 X
Ranitidin 2x1 X
26-05-2018 4 Nina 9 th 2 tdk GG 3 x 1/2 V

28-05-2018 5 Bambang 33 th 4 tdk Ambroxol 2x1 VI

Cetirizin 1x1 III
Parasetamol 500 mg 2x1 VI
Vit C 50 mg 2x1 VI
30-05-2018 6 Irgi 11 th 1 tdk Ambroxol 3x1 X
31-05-2018 7 Nadifa 5 th 4 ya Amoxicillin 250 mg 3x1 X

Parasetamol 500 mg 4 x 1/2 X
Cetirizin 1x1 III
GG 3 x 1/2 V
02-06-2018 8 Ratnawilis 38 th 3 tdk Cetirizin 1x1 V

Methylprednisolon 2x1 VI
Ambroxol 2x1 VI
04-06-2018 9 Najib Fajri 8 th 4 ya Parasetamol 500 mg 4 x 1/2 VIII
Cetirizin 1 x 1/2 II
Ambroxol 2 x 1/2 IV
05-06-2018 10 Febrianto 20 th 2 tdk Cetirizin 1x1 V

Vit B complex 2x1 VI
06-06-2018 11 Samingun 27 th 4 ya Parasetamol 500 mg 2x1 VI

Ambroxol 30 mg 2x1 VI
Cefadroxil 500 mg 2x1 X
Vit C 50 mg 2x1 VI
07-06-2018 12 Novita sari 23 th 4 tdk Ambroxol 2x1 VI

Cetirizin 1x1 V
Vit C 50 mg 2x1 VI
08-06-2018 13 Parinah 43 th 2 tdk Hustab 3x1 X

Vit C 50 mg 2x1 X
09-06-2018 14 Mirnawati 45 th 4 tdk Ambroxol 3x1 X

Antasid doen 3x1 X
Salbutamol 2 mg 3 x 1 kp X
21-06-2018 15 Riskia 7 th 5 ya Cetirizin 1 x 1/2 III

Vit C 50 mg 2x1 X
Ambroxol 3 x 1/2 V
22-06-2018 16 Aima 9 th 2 tdk Ambroxol 30 mg 3x1 VI

Ctm 3x1 VI
16
Persentase AB 37.50
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-05-2018 1 Fatih 13 th 4 tdk Garam Oralit Suc V
Probiokid 2x1 VI
Ranitidin th VI
Papav hcl 2x1 VI
24-05-2018 2 Sutiman 36 th 4 ya Papav hcl 2x1 VI

Anti hemoroid 1x1 III
Garam Oralit Suc V
Cotrimoksazol 480 2x2 XII
28-05-2018 3 Suhodo 37 th 4 tdk Garam Oralit Suc V

Neo Diaform 3x2 X
Antasid doen 3 x 1 ac VI
31-05-2018 4 Tuni fitriani 19 th 5 tdk Parasetamol 3x1 X

Ranitidin 2x1 VI
Garam Oralit Suc VI
Neo Diaform 3x2 X
Antasid doen 3 x 1 ac X
04-06-2018 5 Hitler 60 th 5 ya Parasetamol 500 mg 2x1 VI

Ranitidin 2x1 X
Neo Diaform 3x2 X
Garam Oralit Suc V
07-06-2018 6 Gandi 22 th 4 tdk Neo Diaform 3x2 X
Ranitidin 2x1 VI
Garam Oralit Suc V
Vit B Complex 3x1 X
09-06-2018 7 Mi'roj 35 th 4 tdk Parasetamol 500 mg 3x1 X

Ranitidin 2x1 X
Vit B6 3x2 X
Garam Oralit Suc IV
21-06-2018 8 Eko Haryono 29 th 6 ya Neo Diaform 3x2 X

Garam Oralit Suc IV
Spasmolit 2x1 VI
Paraseramol 500 mg 3 x 1 kp VI
Ranitidin 2x1 X
22-06-2018 9 M. Firmansyah 1 th 6 tdk Garam Oralit Suc VI

Zinc 1x1 X
Probiokid 1x1 III
Ambroxol Mf Pulv X II
Ctm 3 x 1 bks II

9
Persentase AB 33.33
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman
Ya/Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-05-2018 1 Arman 31 th 2 tdk Asam mefenamat 500 mg 2x1 X
Vit B Complex 2x1 X
24-05-2018 2 Relli 65 th 3 tdk Na diklofenak 50 mg 2x1 X

Ranitidin 2x1 X
Vit B Complex 2x1 X
26-05-2018 3 Arlik zebua 32 th 2 tdk Asam mefenamat 500 mg 3 x 1 kp VI

28-05-2018 4 Hasnan 60 th 2 tdk Na diklofenak 50 mg 2x1 X

30-05-2018 5 Relli 65 th 2 tdk Na Diklofenak 50 mg 2x1 X

Ranitidin 2x1 VI
31-05-2018 6 Andi sihombing 25 th 2 tdk Ibuprofen 400 mg 3x1 X

Vit B Complex 3x1 X
02-06-2018 7 Meiliza 27 th 3 tdk Ibuprofen 400 mg 2x1 X

Vit B1 2x1 X
Vit B6 2x1 X
04-06-2018 8 Carles simbolon 24 th 2 tdk Ibuprofen 400 mg 2x1 X

Vit B Complex 2x1 X
08-06-2018 9 Kuswati 38 th 2 tdk Parasetamol 500 mg 2x1 VI

Vit B Complex 2x1 X
09-06-2018 10 Poltak S 31 th 2 tdk Asam mefenamat 500 mg 2x1 X
Vit B Complex 2x1 X

10
KETERANGAN :
N = Jumlah Pasien
NDIKATOR PERESEPEN MYALGIA
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : JULI

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-06-2018 1 Arman 46 th 4 tdk Ctm 3x1 X
amlodipine 5 mg 1x1 V
25-06-2018 2 Moh Solihin 32 th 5 ya Parasetamol 500 mg 3x1 X

Ctm 3x1 X
Vit C 50 mg 3x1 X
26-06-2018 3 Abdullah 50 th 4 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
GG 3x1 X
Dexamethason 3x1 X
28-06-2018 4 Suhodo 37 th 2 ya Hustab 3x1 X

29-06-2018 5 Murni 30 th 4 ya Ambroxol 3x1 X

Ctm 3x1 X
Vit C 50 mg 3x1 X
30-06-2018 6 Jubaidah 19 th 4 ya Ambroxol 30 mg 3x1 X

Ctm 3x1 X
Vit C 50 mg 3x1 X
02-07-2018 7 Dwi warisman 28 th 4 tdk Parasetamol 500 mg 3x1 VI
Vit C 50 mg 3x1 VI
Ctm 3x1 VI
03-07-2018 8 Yuda 6 th 3 tdk GG Mf Pulv X IV

Ctm 3 x 1 bks IV
Dexamethason IV
04-07-2018 9 Munjiyah 43 th 2 tdk Hustab 3x1 X

05-07-2018 10 Bunadi 31 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
06-07-2018 11 Rido pratama 20 th 3 tdk GG 3x1 X

Ctm 3x1 X
07-07-2018 12 Khoirul zanah 9 th 3 tdk Parasetamol 500 mg 3 x 1/2 X

Ctm 3 x 1/2 V
09-07-2018 13 Nurmayadi 23 th 3 tdk Parasetamol 500 mg 3x1 X

Vit C 50 mg 3x1 X
10-07-2018 14 Lisman 31 th 4 ya Ctm 3x1 X

Dexamethason 3x1 X
Antasid doen 3x1 X
11-07-2018 15 Ayu safitri 15 th 2 ya Hustab 3x1 X

12-07-2018 16 Rosmina 29 th 1 ya Hustab 3x1 X

13-07-2018 17 Istirokha 40 th 2 tdk Hustab 3x1 X
Vit B Complex 3x1 X
14-07-2018 18 Putri 7 th 4 tdk Domperidon syr 3 x 1 cth I

GG 3 x 1/2 V
Ctm 3 x 1/2 V
16-07-2018 19 Samin 43 th 5 ya Parasetamol 500 mg 3x1 X

Ctm 3x1 X
Vit B Complex 2x1 X
Antasid 3 x 1 ac X
17-07-2018 20 Abdul azis 8 th 4 ya Parasetamol 500 mg 3 x 1/2 V

Ctm 3 x 1/2 V
Ambroxol 30 mg 2 x 1/2 V
18-07-2018 21 Setiani 18 th 4 tdk Ambroxol 30 mg 3x1 X

Vit C 50 mg 3x1 X
Ctm 3x1 X
19-07-2018 22 Wahid 11 th 4 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
Vit C 50 mg 3x1 X
20-07-2018 23 Lina 33 th 2 ya Hustab 3x1 X

21-07-2018 24 Wahid 11 th 5 ya Amoxicillin 500 mg 3x1 X

Ctm 3x1 VI
Vit C 50 mg 3x1 VI
24
Persentase AB 45.83
Jumlah Obat Generik 76 92.68
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
25-06-2018 1 Misri 33 th 3 tdk Neo diaform 3x2 X
Oralit Suc IV
Ranitidin 2x1 X
30-06-2018 2 Lukman 26 th 5 ya Neo daform 3x2 X

Ranitidin 2x1 VI
Oralit Suc V
03-07-2018 3 Nuraisyah 3,11 th 4 tdk Oralit Suc V

Zinc sulfat syr 1 x 1 cth I
04-07-2018 4 Saniah 34 th 4 tdk Oralit Suc V

Neo diaform 3x1 X
Vit B Complex 3x1 X
05-07-2018 5 Kevin khoirul ichsan 6 th 3 ya Cotrimoksazol 480 2x1 VIII

Oralit Suc III
Zinc 1x1 X
07-07-2018 6 Kholikah 6 th 4 ya Cotrimoksazol syr 2 x 2 cth I

Zinc 1x1 X
Oralit Suc IV
10-07-2018 7 Fauziah 5,4 th 3 tdk Domperidon syr 3 x 1/3 cth I
Zinc 1x1 X
Oralit Suc III
11-07-2018 8 Ismanto 36 th 4 tdk Ranitidin 2x1 VI

Oralit Suc VI
Spasmolit 3x1 VI

8
Persentase AB 37.50
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman
Ya/Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-06-2018 1 Carles simamora 24 th 2 tdk Ibuprofen 400 mg 2x1 X
Vit B Complex 2x1 X
28-06-2018 2 Sarwoto 32 th 2 tdk Ibuprofen 400 mg 3x1 X

Vit B Complex 3x1 X
09-07-2018 3 Sunengsih 31 th 2 tdk Na Diklofenak 25 mg 2x1 X

Vit B Complex 2x1 X
10-07-2018 4 Karsim 54 th 2 tdk Na diklofenak 50 mg 2x1 VI

Ranitidin 2x1 VI
12-07-2018 5 Suparman 41 th 4 tdk Na Diklofenak 50 mg 3x1 X

Ranitidin 2x1 VI
Oralit Suc V
13-07-2018 6 Asa 43 th 2 tdk Ranitidin 2x1 X

Na Diklofenak 50 mg 2x1 X
16-07-2018 7 Febrianus 23 th 3 tdk Ibuprofen 400 mg 2x1 VI

Ranitidin 2x1 VI
17-07-2018 8 Wakinem 70 th 3 tdk Na diklofenak 50 mg 2x1 X

Methylprednisolon 4 mg 2x1 XV
Ranitidin 2x1 X
18-07-2018 9 Rinaldi lenong 38 th 2 tdk Ibuprofen 400 mg 2x1 X
Vit B Complex 2x1 X
19-07-2018 10 Sutiman 36 th 2 tdk Ibuprofen 400 mg 2x1 X

Vit B Complex 2x1 X
21-07-2018 11 Hadimun 42 th 3 tdk Na Diklofenak 50 mg 2x1 VI

Ranitidin 2x1 VI

11
KETERANGAN :
N = Jumlah Pasien
Sesuai
pedoman
Ya/Tidak
(10)
KABUPATEN : SIAK BULAN : AGUSTUS

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-07-2018 1 Basuri 46 th 4 tdk Parasetamol 500 mg 3x1 X
GG 3x1 X
Ctm 3x1 X
Vit B Complex 3x1 X
24-07-2018 2 Runani 44 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
25-07-2018 3 Ahmad khadafi 10 bln 3 tdk Parasetamol syr 4 x 1 cth I

GG Mf Pulv X II
Ctm 3 x 1 bks II
26-07-2018 4 Cayem 60 th 4 ya Ambroxol 3x1 X

Vit C 50 mg 3x1 X
27-07-2018 5 Fitria mustika 22 th 3 ya Ambroxol 30 mg 3x1 X

Vit C 50 mg 3x1 XV
28-07-2018 6 Abi 7 th 2 tdk Ctm 3 x 1/2 V

Vit C 50 mg 2x1 X
30-07-2018 7 Azura 8 th 2 ya Hustab 3 x 1/2 V

31-07-2018 8 Ahmad fakih 13 th 1 tdk Hustab 3x1 X
01-08-2018 9 Fatmawati 38 th 2 tdk GG 3x1 X

Vit C 50 mg 2x1 VI
02-08-2018 10 Nurul janah 18 th 4 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
Antasida doen 3x1 X
03-08-2018 11 Salsa 8 th 4 ya Parasetamol 500 mg 3 x 1/2 V

GG 3 x 1/2 V
Ctm 3 x 1/2 V
04-08-2018 12 Darin 5 th 3 tdk Parasetamol syr 3 x I 1/2 cth I

Ambroxol 30 mg 3 x 1/2 V
Vit C 50 mg 2x1 X
06-08-2018 13 Hanafi 8 th 4 tdk Ambroxol 30 mg 3 x 1/2 V

Ctm 3 x 1/2 V
Vit C 50 mg 2x1 X
07-08-2018 14 Wahyu 9 th 2 tdk Parasetamol 500 mg 3 x 1/2 V

Ctm 3 x 1/2 V
08-08-2018 15 Febi eka supriyani 20 th 3 tdk Hustab 3x1 X

Antasida doen 3x1 X
Ranitidin 2x1 VI
09-08-2018 16 Alfiatur rohmaniah 5 th 1 tdk Baby cough syr 3 x I1/4 cth I
10-08-2018 17 Egi ferdiansyah 6 th 4 ya Parasetamol 500 mg 3 x 1/2 V

GG 3 x 1/2 V
Ctm 3 x 1/2 V
11-08-2018 18 Putra ramadhan 10 th 4 ya Parasetamol 500 mg 3x1 X
GG 3x1 X
Ctm 3x1 X
13-08-2018 19 Agus bahri 40 th 4 tdk Ambroxol 30 mg 3x1 X

Ranitidin 2x1 VI
Domperidon 3x1 X
13-08-2018 20 Agus bahri 40 th 4 tdk Ambroxol 30mg 3x1 X

Ranitidin 2x1 VI
Domperidon 3x1 X
14-08-2018 21 Lilis 5,3 th 4 tdk Parasetamol syr 3 x I 1/2 cth I

Ambroxol 30 mg Mf Pulv X IV
Ctm 3 x 1 bks IV
Vit C 50 mg IV
15-08-2018 22 Misnawati 19 th 4 ya Parasetamol 500 mg 3x1 X

Vit C 50 mg 3x1 X
Ctm 3x1 X
16-08-2018 23 M. Azka maulana 1,1 th 4 tdk Parasetamol syr 3 x 1 cth I

GG Mf Pulv X II
Ctm 3 x 1 bks II
Vit C 50 mg II
18-08-2018 24 Rafika 28 th 3 tdk Ambroxol 30 mg 3x1 X

Ctm 3x1 X
Vit B Complex 3x1 X
20-08-2018 25 Barlin 5 th 4 ya Parasetamol syr 4 x I 1/2 cth I

GG Mf Pulv X III
Ctm 3 x 1 bks III
21-08-2018 26 Febri 7 th 4 ya Cotrimoksazol 480 mg 2x1 VIII
GG 3 x 1/2 V
Ctm 3 x 1/2 V

26
Persentase AB 30.77
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)
Lama
Tgl No Nama Umur Nama Obat Dosis Pemakaian (
Obat Ya/ Tidak
Hari )
(1) (2) (3) (4) (5) (6) (7) (8) (9)
26-07-2018 1 Murniati 32 th 4 tdk Spasmolit 3x1 X
Garam Oralit Suc VII
Loperamid 2-1-1 IV
Ranitidin 2x1 VI
27-07-2018 2 Ilham 42 th 4 tdk Loperamid 2-1-1 IV

Spasmolit 3x1 X
Ranitidin 2x1 VI
Garam Oralit Suc VII
28-07-2018 3 Susi sarini 26 th 3 ya Garam oralit Suc VII

Loperamid 2-1-1 IV
02-08-2018 4 Komariah 33 th 3 ya Cotrimoksazol 480 2x2 XII

Garam Oralit Suc VI
Antasid 3 x 1 ac X
06-08-2018 5 Gandi kurniawan 21 th 4 tdk Loperamid 2-1-1 X

Ranitidin 2x1 VI
Garam oralit Suc VII
Spasmolit 3x1 X
11-08-2018 6 Rehan 5,6 th 3 ya Cotrimoksazol syr 2 x I 1/2 cth I

Oralit Suc III
6
Persentase AB 50.00
KETERANGAN :
N = Jumlah Pasien
KATOR PERESEPEN DIARE NON SPESIFIK
Sesuai
Pedoman
Ya/Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-07-2018 1 Jemadi 44 th 2 tdk Na diklofenak 25 mg 2x1 VI
Ranitidin 2x1 VI
30-07-2018 2 M. Idris 77 th 4 tdk Ibuprofen 200 3x1 X

Ranitidin 2x1 VI
Vit B Complex 3x1 X
Ctm 3x1 X
07-08-2018 3 Nukman 32 th 1 tdk Ibuprofen 400 mg 2x1 VI
15-08-2018 4 Pairah 47 th 3 tdk Ibuprofen 200 mg 3x1 X

Vit B Complex 3x1 X
Ranitidin 2x1 VI
16-08-2018 5 Masniar 42 th 2 tdk Ibuprofen 200 mg 3x1 X

Vit B Complex 3x1 X

5
KETERANGAN :
N = Jumlah Pasien
N INDIKATOR PERESEPEN MYALGIA
Sesuai
pedoman
Ya/Tidak
(10)
PUSKESMAS : BUNGARAYA
KABUPATEN : SIAK BULAN : SEPTEMBER

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23-08-2018 1 Wastiman 47 th 2 tdk Hustab 3x1 X
Vit C 50 mg 3x1 X
24-08-2018 2 Asa 46 th 4 tdk Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
25-08-2018 3 Sri Jumainah 24 th 3 tdk Ctm 4 mg 3x1 X

GG 100 mg 3x1 X
27-08-2018 4 Maniatun 42 th 3 tdk Parasetamol 500 mg 3x1 X

GG 100 mg 3x1 X
Ctm 4 mg 3x1 X
28-08-2018 5 Sunarno 35 th 2 tdk Vit C 50 mg 3x1 X

Ctm 4 mg 3x1 X
29-08-2018 6 Fadilah 7 th 3 tdk GG 100 mg 3 x 1/2 V

Ctm 4 mg 3 x 1/2 V
30-08-2018 7 Awang 48 th 3 tdk Parasetamol 500 mg 3x1 X

GG 100 mg 3x1 X
Ctm 4 mg 3x1 X
31-08-2018 8 Muslim 39 th 4 ya Parasetamol 500 mg 3x1 X
Vit C 50 mg 3x1 X
01-09-2018 9 Andini 6 th 4 tdk Ambroxol 30 mg 3 x 1/2 V

Ctm 4 mg 3 x 1/2 V
Vit C 50 mg 2x1 X
03-09-2018 10 Aulia 6 th 3 ya Ctm 4 mg 3 x 1/2 V

04-09-2018 11 Rheynada 12 th 3 tdk Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
05-09-2018 12 Rafa nurohman 4,3 th 5 ya Parasetamol syr 3 x I 1/2 cth I

Amoxicillin syr 3 x I 1/2 cth I
GG Mf Pulv X III
Ctm 3 x 1 bks III
Vit C 50 mg III
06-09-2018 13 Hadi nughroho 5,6 th 4 ya GG Mf Pulv X III

Ctm 3 x 1 bks III
Parasetamol 500 mg III
Amoxicillin syr 3 x I 1/2 cth I
07-09-2018 14 Saniah 31 th 3 tdk Ctm 4 mg 3x1 X

GG 100 mg 3x1 X
08-09-2018 15 Alief 7 th 2 tdk Parasetamol 500 mg 3 x 1/2 V

Vit B Complex 3 x 1/2 V
GG 3 x 1/2 V
10-09-2018 16 Susniani 30 th 3 tdk Ambroxol 30 mg 3x1 X
Cetirizin 10 mg 1x1 V
12-09-2018 17 Asrofi 17 th 4 tdk Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit B Complex 2x1 X
13-09-2018 18 Martin 25 th 3 tdk Ctm 4 mg 3x1 X

GG 100 mg 3x1 X
14-09-2018 19 Meliana jufita sari 6 th 4 ya Ctm 4 mg 3 x 1/2 V

GG 100 mg 3 x 1/2 V
15-09-2018 20 Sauli sihotang 57 th 3 tdk Parasetamol 500 mg 3x1 X

GG 100 mg 3x1 X
Ctm 4 mg 3x1 X
17-09-2018 21 Mulyani 69 th 2 tdk GG 100 mg 3x1 X

Ctm 4 mg 3x1 X
18-09-2018 22 Robi surono 40 th 3 tdk Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
19-09-2018 23 Sodiah 22 th 5 ya Ambroxol 30 mg 3x1 X

Ctm 4 mg 3x1 X
Vit C 50 mg 3x1 X
26
Persentase AB 30.77
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
24/03/2017 1 Fais 17bln 4 tdk Ranitidin Mf Pulv X
Vit B6 3 x 1 bks
Zirkum kids syr 1 x 1 cth
Oralit Suc
06/04/2017 2 Imam syafii 48 th 3 tdk Guanistrep syr 3 x 2 cth kp

Oralit Suc
Ranitidin 2x1
08/04/2017 3 Subahan 13 th 4 ya Cotrimoksazol 480 2x2

Antasid 3 x 1 ac
Vit B6 3 x 1 ac
Oralit Suc
10/04/2017 4 Alya 10 bln 4 ya Parasetamol syr 4 x 3/4 cth

Cotrimoksazol syr 2 x 1/2 cth
Zirkum kids syr 1 x 1/2 cth
Oralit Suc
11/04/2017 5 Elyana safitri 3,8 th 3 tdk Zirkum kids syr 1 x 1 cth

Oralit Suc
Antasid Mf Pulv X
3 x 1 ac
12/04/2017 6 Keyla 9 th 3 tdk Oralit Suc

Guanistrep syr 3 x 1 cth kp
Antasid 3 x 1/2
15/04/2017 7 Meiriana BR Nainggolan 37 th 4 tdk Oralit Suc
Guanistrep syr 3 x 2 cth kp
Ranitidin 2x1
Ondancentron 4 mg 3 x 1 ac
17/04/2017 8 Aida fitri 1,7 th 3 tdk Oralit Suc

Domperidon syr 3 x 3/4 cth
4/18/2017 9 Tarminah 60 th 3 ya Cotrimoksazol 480 2x2

Hyorex 3x1
19/04/2017 10 Debi 37 bln 4 tdk Parasetamol syr 4 x 1 cth

Zinc 1x1
Oralit Suc
Domperidon syr 3 x 3/4 cth ac
20/04/2017 11 Alifa 2 th 1 tdk Peptin syr 3 x 1 cth

11
Persentase AB 27.27
KETERANGAN :
N = Jumlah Pasien
N INDIKATOR PERESEPEN DIARE NON SPESIFIK
Lama Sesuai
Pemakaian ( Pedoman
Hari ) Ya/Tidak
(9) (10)
II
II
I
II
I
V
X
XVI
X
X
VI
I
I
I
V
I
V
II1/2
V
I
V
X
I
X
X
IV
I
I
XII
X
VI
I
X
IV
I
I

(1) (2) (3) (4) (5) (6) (7) (8) (9)
3/23/2017 1 Sami 52 th 2 tdk Meloxicam 7,5 mg 1x1 X
Amlodipine 10 mg 1x1 X
4/4/2017 2 Watimah 28 th 1 tdk Vit B Complex 3x1 X
4/6/2017 3 Charles 24 th 2 tdk Na diklofenak 25 mg 2x1 X

Vit B Complex 2x1 X
17/04/2017 4 Marmiyati 57 th 3 tdk Allopurinol 300 mg 1 x 1/2 V

Ranitidin 2x1 X
19/04/2017 5 Suwandi 40 th 2 tdk Na diklofenak 25 mg 2x1 X

Ranitidin 2x1 X

5
KETERANGAN :
N = Jumlah Pasien
N INDIKATOR PERESEPEN MYALGIA
Sesuai
pedoman
Ya/Tidak
(10)

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23/05/2017 1 Poniaman 47 th 4 ya Cefixime 100 mg 2x1 X
Loratadin 1x1 V
Ambroxol 3x1 X
Vit C 50 mg 3x1 X
24/05/2017 2 Sabila 7 bln 5 ya Parasetamol syr 4 x 1 cth I

Amoxicillin syr 3 x 3/4 cth I
GG Mf Pulv X II
Ctm 3 x 1 bks II
Vit C 50 mg II
26/05/2017 3 Desvi kurnia 8 th 2 tdk Intibrox syr 3 x 1 cth I

Loratadin 1 x 1/2 III
27/05/2017 4 Arifin 29 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
30/05/2017 5 Linda lestari 9 th 4 ya Parasetamol 500 mg 3x1 VI

Ambroxol 2x1 V
Loratadin 2x1 III
31/05/2017 6 Nurmadi 56 th 4 ya GG 3x1 VI

Loratadin 2x1 IV
Cefixime 100 mg 2x1 IV
Vit K 3x1 VI
02/06/2017 7 Suminah 36 th 4 tdk Parasetamol 500 mg 3x1 X
GG 3x1 X
Methylprednisolon 3x1 X
Vit B Complex 3x1 X
03/06/2017 8 Arjuna 5,6 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

Methylprednisolon 2 x 1/2 IV
05/06/2017 9 Sugianto 16 th 3 tdk Ambroxol 3x1 X

Ctm 3x1 X
06/06/2017 10 Febriyanto 26 th 4 tdk Parasetamol 500 mg 3x1 X

Ctm 3x1 X
Ambroxol 3x1 X
Vit B Complex 3x1 X
07/06/2017 11 Kamarul fikri 25 th 3 tdk Parasetamol 500 mg 2x1 VI

Loratadin 1x1 V
Vit B Complex 2x1 X
08/08/2017 12 Lia 8 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

GG 3 x 1/2 V
Ctm 3 x 1/2 V
09/06/2017 13 Edi setiawan 30 th 4 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
10/06/2017 14 Akmal 4,11 th 3 tdk Ambroxol Mf Pulv X III

Ctm 3 x 1 bks III
Vical syr 1 x 1 cth I
12/03/2017 15 Teguh santoso 42 th 3 tdk Parasetamol 500 mg 2x1 X

Vit B Complex 2x1 X
13/06/2017 16 Assyifa jaya aira 5 bln 3 tdk Ambroxol Mf Pulv X I
Ctm 3 x 1 bks I
Vit C 50 mg I
14/06/2017 17 Bambang R 32 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
15/06/2017 18 Amel indriyani 7 th 2 tdk Loratadin Mf Pulv X IV

Methylprednisolon 3 x 1 bks IV
6/16/2017 19 Zaki almajid 3,5 th 2 tdk Ambroxol Mf Pulv X' V

Ctm 3 x 1 bks V
6/17/2017 20 Fikri hamim arrasyid 1,5 th 4 ya Parasetamol syr 3 x 1 cth I

Erytromisin syr 3 x 3/4 cth I
Ctm Mf Pulv X III
GG 3 x 1 bks III
19/06/2017 21 Suparman 40 th 3 tdk Parasetamol 500 mg 2x1 X

GG 3x1 X
Vit B Complex 2x1 X
20/06/2017 22 Olik 27 th 3 tdk Ambroxol 2x1 X

Loratadin 1x1 V
Vit B Complex 2x1 X
21/06/2017 23 Amelani safitri 35 bln 4 tdk Ambroxol Mf Pulv X II1/2

Ctm 2 x 1 bks II
Salbutamol 2 mg II
Caviplex drops 1 x 1 cth I
22/06/2017 24 Khanida 50 th 3 tdk GG 2x1 X

Ranitidin 2x1 X
Loratadin 2x1 X
24
Persentase AB 20.83
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
26/05/2017 1 Imam syafii 50 th 6 ya Oralit Suc
Hyorex 3x1
Ranitidin 2x1
Cotrimoksazol 480 2x2
Guanistrep syr 3 x 2 cth
27/05/2017 2 Lukman nul hakim 25 th 3 ya Cotrimoksazol 480 2x2

Oralit Suc
Ranitidin 2x1
05/06/2017 3 Saroh 5 th 3 tdk Oralit Suc

Parasetamol 500 mg 3 x 1/2
15/06/2017 4 M. Riadi 27 th 3 ya Cotrimoksazol 480 2x2

Ctm 2x1
Antasid 2x1
16/06/2017 5 Mujane hafiz 4,5 th 3 tdk Parasetamol syr 3 x 1 cth

Zinc 1x1
Oralit Suc
19/06/2017 6 Umi Khomairiyatul 18 th 3 tdk Guanistrep syr 3 x 2 cth

Antasid 3 x 1 ac
Oralit Suc
22/06/2017 7 Puspita sari 6 th 2 ya Cotrimoksazol syr 2 x I 1/2 cth

Parasetamol syr 3 x I 1/2 cth
7
Persentase AB 57.14
KETERANGAN :
N = Jumlah Pasien
Lama Sesuai
Pemakaian ( Pedoman
Hari ) Ya/Tidak
(9) (10)
X
I
X
V
VI
I
XII
IV
VI
V
V
I
XII
X
X
I
X
IV
I
X
V
I
I
Jumlah Item Injeksi

Obat Ya/Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
6/12/2017 1 Khaidil fadli 27 th 2 tdk Asam mefenamat 500 mg 2 x 1
Vit B Complex 2x1
6/13/2017 2 Sri rahayu 42 th 2 tdk Parasetamol 500 mg 2x1

Vit B Complex 2x1
6/22/2017 3 Lastri 47 th 2 tdk Vit B1 2x1

Vit B6 2x1
Total Item Obat 6 0

3
KETERANGAN :
N = Jumlah Pasien
ORAN INDIKATOR PERESEPEN MYALGIA
Sesuai
Lama Pemakaian
pedoman
( hari )
Ya/Tidak
(9) (10)
X
X
X
X
XX
XX
KABUPATEN : SIAK BULAN : NOVEMBER

(1) (2) (3) (4) (5) (6) (7) (8) (9)
23/10/2017 1 Arsila 6 th 3 tdk Parasetamol 500 mg 3 x 1/2 V
Ctm 3 x 1/2 V
Vit C 50 mg 2x1 X
24/10/2017 2 Doni 31 th 3 ya Noza 3x1 VI

Vit C 50 mg 3x1 X
25/10/2017 3 Khairunisa 11 th 4 ya Parasetamol 500 mg 4 x 1/2 VIII

Loratadin 1 x 1/2 III
Domperidon 2 x 1/2 ac II
26/10/2017 4 Suripah 34 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
27/10/2017 5 Hartini 37 th 3 tdk GG 3x1 X

Loratadin 2x1 VI
Vit C 50 mg 3x1 X
28/10/2017 6 Murniati 32 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Ctm 3x1 X
30/10/2017 7 Habibi 5,8 th 4 tdk Parasetamol 500 mg 3 x 1/2 VI

GG 3 x 1/2 VI
Ctm 3 x 1/2 VI
Vit C 50 mg 3 x 1/2 VI
31/10/2017 8 Wakidah 30 th 3 tdk Antasid 3x1 X
GG 3x1 X
Vit B6 3x1 X
01/11/2017 9 Darin 47 th 2 tdk Noza 3x1 VI

Vit C 50 mg 3x1 X
02/11/2017 10 Atoli zebua 26 th 3 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Ctm 3x1 X
03/11/2017 11 Tugiran toro 39 th 3 ya Noza 3x1 X

Vit C 50 mg 3x1 X
04/11/2017 12 Hartini 57 th 3 ya Amoxicillin 500 mg 3x1 XV

GG 3x1 X
Vit B Complex 3x1 X
06/11/2017 13 Basuri 46 th 3 tdk Parasetamol 500 mg 3x1 VI

Ctm 3x1 VI
07/11/2017 14 Linda 20 th 2 tdk Hustab 3x1 X

Vit C 50 mg 3x1 X
08/11/2017 15 Marse 39 th 3 tdk Parasetamol 500 mg Mf Pulv X II 1/2

3 x 1 bks
Ambroxol Mf Pulv X III
Loratadin 2 x 1 bks I
09/11/2017 16 Poiman 45 th 3 tdk Loratadin 2x1 X

Dexamethason 3x1 X
Ranitidin 2x1 X
10/11/2017 17 Dola 33 th 3 ya Noza 3x1 X

Vit C 50 mg 3x1 X
11/11/2017 18 Zulfikar 34 th 2 tdk Noza 3x1 X
Vit C 50 mg 3x1 X
13/11/2017 19 Anwar awaludin 14 th 4 ya Amoxicillin 500 mg 3x1 XV

Parasetamol 500 mg 3 x 1 1/2 XV
GG 3x1 X
Ctm 3x1 X
15/11/2017 20 Imam faizan 23 th 2 tdk Ctm 3x1 X

GG 3x1 X
11/16/2017 21 Naura 9 th 5 tdk Parasetamol 500 mg 4 x 1/2 VI

Ctm 2x1 V
GG 2x1 V
Vit C 50 mg 2x1 V
Antasid syr 3 x 1 cth ac I
11/17/2017 22 Sarwono 32 th 3 tdk Parasetamol 500 mg 3x1 X

GG 3x1 X
Vit C 50 mg 3x1 X
18/11/2017 23 Adila nisa 9 bln 1 tdk Hustab syr 2 x 1/4 cth I
20/11/2017 24 Ali munawar 49 th 3 tdk Loratadin 1x1 V

Ambroxol 3x1 X
Vit C 50 mg 3x1 X
21/11/2017 25 Indra lesmana 35 th 4 tdk Parasetamol 500 mg 3x1 X

Ambroxol 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X
22/11/2017 26 Isna 7,5 th 4 tdk Parasetamol 500 mg 3 x 1/2 V

Ambroxol 3 x 1/2 V
Ctm 2x1 V
Vit C 50 mg 2x1 X
26
Persentase AB 23.08
KETERANGAN :
N = Jumlah Pasien
Sesuai
Pedoman Ya/
Tidak
(10)

Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
24/11/2017 1 Imam hambali 29 th 4 tdk Oralit Suc
Hyorex 2x1
Ranitidin 2x1
25/11/2017 2 Erina zahira 4 th 4 tdk Probiokids 1x1

Zinc 1x1
Vit B6 Mf Pulv X
3 x 1 bks ac
Parasetamol syr 3 x I 1/4 cth
28/11/2017 3 Zakia 4 th 1 tdk Probiokids 1x1
30/11/2017 4 Jumanji 26 th 3 tdk Antasid 3x1

Neo diaform 3x1
Hyorex 3x1
31/11/2017 5 Ananda afriansyah 5,6 th 2 tdk Guanistrep syr 3 x 1 cth

Probiokids 1x1
01/11/2017 6 Darin 4,4 th 3 tdk Probiokids 1x1

Oralit Suc
Domperidon syr 3 x 1/4 cth
02/11/2017 7 Perikles gultom 48 th 5 tdk Ranitidin 2x1

Ambroxol 3x1
Domperidon 3x1
Oralit Suc
09/11/2017 8 lelo fernando 27 th 2 tdk Neo diaform 3x1
11/11/2017 9 Ini casini 41 th 4 tdk Guanistrep syr 3 x 2 cth

Oralit Suc
Ranitidin 2x1

9
Persentase AB 0.00
KETERANGAN :
N = Jumlah Pasien
Lama Sesuai
Pemakaian ( Pedoman
Hari ) Ya/Tidak
(9) (10)
IV
VI
X
VI
III
V
III
III
X
X
X
I
III
III
V
I
VI
X
X
X
V
VI
VI
I
V
VI
Jumlah Item Injeksi

Obat Ya/Tidak
(1) (2) (3) (4) (5) (6) (7) (8)
11/7/2017 1 Ahmad yani 41 th 2 tdk Ibuprofen 400 mg 2x1
Vit C 50 mg 3x1
11/9/2017 2 Asmida 43 th 3 tdk Ibuprofen 400 3x1

Vit B Complex 3x1
Ranitidin 2x1
15/11/2017 3 Tukini 59 th 2 tdk Ibuprofen 200 mg 3x2

Vit B Complex 3x1
17/11/2017 4 Sadimin 37 th 2 tdk Ibuprofen 400 mg 3x1

Antasid doen 3x1
Total Item Obat 9 0

4
KETERANGAN :
N = Jumlah Pasien
ORAN INDIKATOR PERESEPEN MYALGIA
: NOVEMBER
Sesuai
Lama Pemakaian
pedoman
( hari )
Ya/Tidak
(9) (10)
VI
X
X
X
X
XX
X
X
X
FORMULIR PELAPORAN INDIKATOR PERESEPEN ISPA NON P
KABUPATEN : SIAK
PROPINSI : RIAU
Jumlah Antibiotik
Tgl No Nama Umur
Item Obat Ya/Tidak
(1) (2) (3) (4) (5) (6)
23-11-2017 1 Sodikun 34 th 3 ya
24-11-2017 2 Darman H 25 th 3 tdk
25-11-2017 3 Yulinar 55 th 3 tdk
27-11-2017 4 Edi Suhandri 36 th 3 tdk
28-11-2017 5 Triana 35 th 4 ya
29-11-2017 6 Asharun janah 5,11 th 5 ya
30-11-2017 7 Ahmad wahibun 45 th 4 tdk
02-12-2017 8 Suripto 36 th 3 tdk
04-12-2017 9 Syafrizal 42 th 3 tdk
05-12-2017 10 Sukin 33 th 3 tdk

06-12-2017 11 Niazerni zalukhu 10 th 5 tdk
07-12-2017 12 Assyfa 5,5 th 4 tdk
08-12-2017 13 Raihan ganda S 7 th 3 ya
09-12-2017 14 Nikson 40 th 5 ya
12-12-2017 Sumiati 28 th 3 tdk
13-12-2017 Carles simamora 24 th 2 ya
14-12-2017 Turiah 41 th 4 ya
15-12-2017 Siti nurlela 38 th 2 tdk
16-12-2017 Suripah 38 th 4 ya
18-12-2017 Indra 12 th 4 tdk

26
Persentase AB 23.08
KETERANGAN :
N = Jumlah Pasien
OR PERESEPEN ISPA NON PNEUMONIA
BULAN : DESEMBER
TAHUN : 2017
Sesuai
Lama Pemakaian
Nama Obat Dosis Obat Pedoman Ya/
( hari )
Tidak
(7) (8) (9) (10)
Ambroxol 3x1 X
Loratadin 1x1 X
GG 3x1 VI
Ctm 3x1 VI
GG 3x1 X
Ctm 3x1 X
Vit B Complex 3x1 X
GG 3x1 VI
Vit C 50 mg 3x1 VI
Loratadin 1x1 III

Loratadin 1x1 V
Ambroxol 3x1 X
Amoxicillin syr 3 x I 3/4 cth II

Ambroxol 3 x 1/2 V
Ctm 3 x 1/2 V
Vit C 50 mg 3 x 1/2 V
Ambroxol 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X
Ctm 3x1 X
GG 3x1 X
Ctm 3x1 X
GG 3x1 X
Hustab 3x1 X
Vit C 50 mg 3x1 X
Ibuprofen 200 2x1 X
Ctm 3 x 1/2 V
Parasetamol 500 mg 4 x 1/2 VI
GG 3 x 1/2 V
Ranitidin 2 x 1/2 V
Vit B6 2x1 X
Parasetamol 500 mg 3 x 1/2 IV

Ambroxol 3 x 1/2 V
Ctm 3 x 1/2 V
Vit C 50 mg 2x1 X
Ambroxol 3 x 1/2 V
Vit C 50 mg 2x1 X

Ambroxol 3x1 X
Ctm 3x1 X
Vit C 50 mg 3x1 X

Ctm 3x1 X
GG 3x1 X
Ambroxol 3x1 X
Ambroxol 3x1 X
Loratadin 1x1 IV
Vit C 50 mg 3x1 X
Hustab 3x1 X
Vit C 50 mg 3x1 X
GG 3x1 X
Vit C 50 mg 2x1 X
Loratadin 1x1 V

Ambroxol 3 x 1/2 V
Vit C 50 mg 3 x 1/2 V
Ctm 3 x 1/2 V
/ A x 100 %
FORMULIR PELAPORAN INDIKATOR PERESEPEN DIARE NO
KABUPATEN : SIAK
PROPINSI : RIAU

Tgl No Nama Umur
Obat Ya/ Tidak
(1) (2) (3) (4) (5) (6)
23-11-2017 1 Cahaya 20 bln 3 tdk
24-11-2017 2 Ahmad alfikri 9,9 th 3 ya
27-11-2017 3 Iqbal 9 bln 4 tdk
28-11-2017 4 Intan 7 th 2 tdk
02-12-2017 5 Adila 5 bln 5 ya
05-12-2017 6 Asep 36 th 3 tdk
12-12-2017 Abizar 1 th 1 tdk
15-12-2017 M. Kholid 1,1 th 4 tdk
16-12-2017 Faisn ardiansyah 21 bln 5 ya

18-12-2017 Suyati 33 th 2 tdk

9
Persentase AB 0.00
KETERANGAN :
N = Jumlah Pasien
OR PERESEPEN DIARE NON SPESIFIK
BULAN : DESEMBER
TAHUN : 2017
Lama Sesuai
Nama Obat Dosis Pemakaian ( Pedoman
Hari ) Ya/Tidak
(7) (8) (9) (10)
Zinc 1x1 X
Probiokid 1x1 III
Oralit Suc III
Zinc 1x1 X
Cotrimoksazol 480 2x1 X
Antasid 3 x 1/2 ac V
Pyrexin 80 mg Sue I
Baby cough syr 3 x 1 cth I
Probiokid 1x1 II
Zinc 1x1 X
Antasid 3 x 1/2 V
Probiokid 1x1 III
Cotrimoksazol susp 2 x 1 cth I

Parasetamol 500 mg Mf Pulv X II
GG 3 x 1 bks II
Ctm II
Probiokid 1x1 III
Hyorex 3x1 X
Oralit Suc VI
Neo diaform 3x1 X
Probiokids 1x1 III
Probiokid 1 x 1/2 II
Zinc 1x1 X
Oralit suc IV
Amoxicilllin syr 3 x 3/4 cth I

Oralit Suc V
Zinc 1x1 X
Probiokid 1x1 III
Ambroxol Mf Pulv X I1/2
Ctm 3 x 1 bks I1/2
Lansoprazole 1x1 V
Vit B Complex 2x1 X
/ A x 100 %
FORMULIR PELAPORAN INDIKATOR PERESEPEN MYA
KABUPATEN : SIAK
PROPINSI : RIAU
Jumlah Item Injeksi

Tgl No Nama Umur
Obat Ya/Tidak
(1) (2) (3) (4) (5) (6)
30-11-2017 1 Salim 76 th 2 tdk
Total Item Obat 9 0

4
KETERANGAN :
N = Jumlah Pasien
DIKATOR PERESEPEN MYALGIA
BULAN : DESEMBER
TAHUN : 2017
Sesuai
Lama Pemakaian
Nama Obat Dosis pedoman
( hari )
Ya/Tidak
(7) (8) (9) (10)
Na diklofenak 25 mg 2x1 X
Vit B Complex 3x1 X
/ n x 100 %
/ A x 100 %

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FORMULIR PELAPORAN INDIKATOR PERESEPEN ISPA NON PNEUMONIA

UPTD PUSKESMAS : BUNGARAYA

Jumlah Antibiotik Lama Pemakaian

27-12-2017 2 Warka 56 th 2 tdk GG 3x1 VI

28-12-2017 3 Sumini 37 th 3 tdk Parasetamol 500 mg 3x1 X

29-12-2017 4 Suhariyanto 35 th 4 tdk Ambroxol 3x1 X

30-12-2017 5 Adminah 25 th 3 tdk Loratadin 2x1 X

01-01-2018 6 Septiani 11 th 3 tdk Parasetamol 500 mg 3x1 X

03-01-2018 7 Shifatul azkia 2,3 th 4 tdk GG Mf Pulv X II

05-01-2018 9 Saniah 6,8 th 4 tdk Parasetamol 500 mg 3 x 1/2 V

06-01-2018 10 Ziki 8 th 4 ya Ctm 3 x 1/2 V

08-01-2018 11 Tayan 58 th 4 ya Ambroxol 3x1 X

09-01-2018 12 Osmar 49 th 3 tdk Parasetamol 500 mg 3x1 X

10-01-2018 13 Bustomi 3,9 th 2 tdk GG Mf Pulv X III

12-01-2018 14 Siti fatimah 41 th 4 tdk Vit C 50 mg 3x1 X

13-01-2018 15 Heri kiswanto 31 th 3 tdk Parasetamol 500 mg 3x1 X

14-01-2018 16 Hesti 29 th 3 tdk Parasetamol 500 mg 3x1 X

17-01-2018 18 Selnida 37 th 4 tdk Parasetamol 500 mg 3x1 X

18-01-2018 19 Darki 40 th 4 tdk Parasetamol 500 mg 3x1 X

19-01-2018 20 Edi sugiono 37 th 4 tdk Ibuprofen 200 mg 2x1 VI

20-01-2018 21 Suryanti 37 th 3 tdk Parasetamol 500 mg 3x1 X

22-01-2018 22 Alvadina 17 th 4 tdk Parasetamol 500 mg 3x1 X

Jumlah Item Antibiotik Lama Pemakaian

01-01-2018 2 Eko 29 th 5 tdk Neo diaform 3x1 X

03-01-2018 3 Rafli abiyanto 1,6 th 6 ya Oralit Suc IV

04-01-2018 4 Intan 42 th 4 tdk Oralit Suc V

05-01-2018 5 Anwar fauzi 2,4 th 3 tdk Oralit Suc V

08-01-2018 6 Octa adelia 2,2 th 4 tdk Probiokid 1x1 III

09-01-2018 8 Lailatul 2 th 3 tdk Oralit Suc IV

10-01-2018 9 Arif abdul 2 th 4 tdk Oralit Suc V

11-01-2018 10 Shaquilla rifdah 5,6 th 5 tdk Oralit Suc VIII

14-01-2018 11 Lailatul fitria 2 th 1 tdk Probiokid 2 x 1/2 bks III

17-01-2018 12 M. Mahmud 9 th 5 tdk Oralit Suc V

18-01-2018 13 Imam safii 52 th 5 ya Oralit Suc VIII

21-01-2018 15 Toni 6,6 th 5 ya Domperidon syr 3 x 1/2 cth I

Total Item Obat 61 5

08-01-2018 2 Sutiani 28 th 3 tdk Na diklofenak 25 mg 2x1 X

09-01-2018 3 Jumali 37 th 3 tdk Dexamethason 3x1 XV

10-01-2018 4 Suratun 62 th 4 tdk Na Diklofenak 25 mg 2x1 X

12-01-2018 5 Khairiyah 60 th 3 tdk Ibuprofen 200 mg 3x1 X

13-01-2018 6 Kanari 52 th 3 tdk Na diklofenak 25 mg 2x1 X

20-01-2018 7 Arifin 29 th 2 tdk Na diklofenak 50 mg 2x1 X

Jumlah Antibiotik Lama Pemakaian

24-01-2018 2 Arman 30 th 3 tdk Parasetamol 500 mg 3x1 X

25-01-2018 3 Febiola 21 th 4 ya Parasetamol 500 mg 3x1 X

26-01-2018 4 Lagiem 37 th 3 tdk GG 3x1 X

27-01-2018 5 Dika ardiansyah 8 th 2 tdk Parasetamol 500 mg 3 x 1/2 V

29-01-2018 6 Sonali gea 31 th 4 tdk Parasetamol 500 mg 3x1 X

30-01-2018 7 Erikson 22 th 3 tdk Ambroxol 30 mg 3x1 X

01-02-2018 9 Sutarno 26 th 3 tdk Parasetamol 500 mg 3x1 X

02-02-2018 10 Putri 5 bln 3 tdk GG Mf Pulv X I

03-02-2018 11 Rijan 87 th 4 ya Parasetamol 500 mg 3x1 X

05-02-2018 12 Rio rinaldo 16 th 3 ya GG 3x1 X

06-02-2018 13 May meri 39 th 2 tdk Parasetamol 500 mg 3x1 X

07-02-2018 14 Kirno 40 th 5 ya Parasetamol 500 mg 3x1 X

08-02-2018 15 Sutardi 49 th 4 ya Loratadin 2x1 X

09-02-2018 16 Wahyu sutrisno 32 th 5 ya Amoxicillin 500 mg 3x1 XV

12-02-2018 18 Sutardi 50 th 2 tdk Loratadin 1x1 X

13-03-2018 19 M. Rifai 2,6 th 4 tdk GG Mf Pulv X II

14-02-2018 20 Ari Budi 7 th 4 ya GG 3 x 1/2 V

15-02-2018 21 Iwan 23 th 3 tdk Parasetamol 500 mg 3x1 X

17-02-2018 22 Yani 29 th 3 tdk Parasetamol 500 mg 3x1 X

19-02-2018 23 M. Syaiful 5,6 th 3 tdk Parasetamol 500 mg 3 x 1/2 V

20-02-018 24 Rohmatul 17 th 1 tdk Hustab 3x1 X