SURAT KEPUTUSAN
KEPALA KLINIK PRATAMA DENANTI
Nomor : SK/KPD/ /2023
TENTANG
FORMULARIUM OBAT
Menimbang : a. bahwa Obat adalah salah satu unsur penunjang yang penting dalam
pelayanan kesehatan di Klinik;
b. bahwa dalam upaya meningkatkan mutu pelayanan kesehatan di Klinik,
perlu diadakan pemilihan jenis Obat yang tepat;
c. jenis Obat terpilih perlu disusun dalam suatu Formularium yang
penggunaannya ditetapkan oleh Kepala Klinik Pratama Denanti.
MEMUTUSKAN
Ditetapkan di : Cimahi
Pada Tanggal :
b. Cepalosporin
Cefadroxil Kapsul 500 mg
Syrup 125mg/5mg, 250mg/5mg
Cefixime Kapsul 100 mg, 200 mg
Syrup 100mg/5mL
Ceftriaxone Injeksi 1 g
c. Kloramfenikol
Thiamfenikol Kapsul 500 mg
Syrup 125mg/5mL
d. Makrolida
Azitromycin Kapsul 500 mg
e. penisilin
Amoxicillin Tablet 500 mg
Syrup 125mg/5mL, 250/5mL
Drop 100mg/ml
f. Tetracycline
Doxycycline Kapsul 100 mg
g. Clindamycin
Clindamycin Kapsul 150 mg, 300 mg
h. Sulfonamida
Kombinasi : Sulfamethoxazole + Tablet 400 mg/80 mg
Trimetropim (Cotrimoxazole) Syrup 200 mg/40 mg
i. Fluoroquinolone
Ciprofloxacin Tablet 500 mg
Levofloxacin Tablet 100 mg
B ANTI FUNGI
Griseofulvin Tablet 120 mg
Ketoconazole Tablet 200 mg
Nystatin Ovula Ovula
Nystatin Drop Botol 100.000 IU/mL
C ANTI PROTOZOA
Metronidazole Tablet 500 mg
D ANTI VIRUS
Acyclovir Tablet 200 mg, 400 mg
Cream 5%
E ANTI HELMINTIK
Pirantel Pamoat Tablet 125 mg, 250 mg
Suspensi 125 mg/mL
II KARDIOVASKULAR
A DIURETIKUM
Furosemide Tablet 40 mg
B ANTI ANGINA
ISDN Tablet 5 mg
C ANTI ARITMIA
Digoksin Tablet 0,25 mg
D ANTIHIPERTENSI
Amlodipine Tablet 5 mg, 10 mg
Captropil Tablet 12,5 mg, 25 mg, 50 mg
Candesartan Tablet 8 mg, 16 mg
Bisoprolol Tablet 5 mg
Nifedipine Tablet 10 mg
E ANTIHIPERLIPIDEMIA
Simvastatin Tablet 10 mg, 20 mg
Atorvastatin Tablet 10 mg, 20 mg
F ANTI PLATELET
Asam asetil salisilat Tablet 80 mg
ANALGESIK, ANTIPIRETIK,
III ANTIINFLAMASI NON STEROID,
ANTIPIRAI
ANALGETIK NON NARKOTIK,
A ANTIPIRETIK, ANTI INFLAMASI
NON STEROID
Paracetamol Tablet 500 mg, 650 mg
Syrup 120mg/5mL, 160mg/5mL,
250mg/5mL
Asam Mefenamat Tablet 250 mg, 500 mg
Ibuprofen Tablet 200 mg, 400 mg
Suspensi 100mg/5mL, 200 mg/5mL
Piroxicam Tablet 10 mg, 20 mg
Meloxicam Tablet 7,5 mg, 15 mg
Natrium diclofenak Tablet 25 mg, 50 mg
Pottasium diclofenak Tablet 50 mg
Ketorolac Injeksi i.v 30 mg,mL
Kombinasi : Paracetamol + Ibuprofen + Tablet 350mg/200mg/50mg
Caffeine
Kombinasi : Metampirone + Vit B1 + Tablet 500mg/150mg/10mg/ 10mcg
Vit B6 + Vit B12
B ANTI PIRAI
Allopurinol Tablet 100 mg, 300 mg
Colchicine Tablet 500 mcg
C NYERI NEUROPATIK
Gabapentin Kapsul 100 mg
Pregabalin Kapsul 75 mg
Mecobalamine Kapsul 500 mg
Glucosamine 250 mg Tablet 250 mg, 500 mg
Kombinasi : Thyamin mg + pyridoxine Tablet 100mg/200mg/200mg
mg + Cyanocobalamin Tablet 100mg/100mg/5000mcg
Injeksi i.v 100mg/100mg/ 5000mcg
Kombinasi : Metampirone + Vit B1 + Tablet 500mg/150mg/10mg/ 10mcg
Vit B6 + Vit B12
IV ANESTETIK
A ANESTETIK LOKAL
Lidocain HCl 2%
V1 ANTIEPILEPSI, ANTIKONVULSI
Diazepam Tablet 2 mg
Larutan Rektal 5mg/tube 2,5 mL
Pregabalin Capsul 75 mg
IX SALURAN PERNAFASAN
A ANTITUSIF
Codeine Phospate Tablet 10 mg
B EKSPEKTORAN
Glyceryl Guaicolate (Guaifenesin) Tablet 10 mg
C MUKOLITIK
Bromhexine Tablet 8 mg
Ambroxol Tablet 30 mg
Syrup 15mg/5mL
Drop 15mg/5mL
Acetylcysteine Kapsul 200 mg
D DEKONGESTAN
Pseudoephedrine Drop Drop 7,5mg/0,8mL
KOMBINASI ANTITUSIF,
E EKSPEKTORAN DEKONGESTAN
DAN ANTIHISTAMIN
Pseudoephedrine + Triprolidine Syrup 30mg/1,25mg per 5 mL
(Flutrop) Tablet 30mg/2,5mg
Pseudoephedrine Sulfat + Loratadine Kapsul 60 mg/5mg
(Rhinos SR)
KOMBINASI PARACETAMOL,
ANTITUSIF, EKSPEKTORAN
F
DEKONGESTAN, MUKOLITIK,
DAN ANTIHISTAMIN
Paracetamol + Phenylpropanolamine Tablet 500mg/12,5mg/2mg/ 15mg
HCl + CTM + Dextromethorphan
(Alpara, Calortusin, Brocon)
Paracetamol + Gliseril guaicolat + Tablet 500mg/50mg/15mg/15mg /1mg
Phenylpropanolamine HCl + (Flucadex)
Dextromethorphan + CTM Syrup 250mg/50mg/7,5mg/ 7,5mg /7,5
mg/0,5mg per 5 mL (Flucadex)
Syrup 160mg/25mg/3,5mg/
3,5mg/0,5mg (Flutop C)
Paracetamol + Phenylpropanolamine Tablet 500mg/15mg/2mg/50mg
HCl + CTM + Gliceryl Guaicolat Syrup 125mg/3,5mg/0,5mg/ 12,5mg per
(Flutamol) 5 mL
G ANTIASMA
Salbutamol Tablet 2 mg, 4 mg
Syrup 2 mg/5mL
Salbutamol + Guaifenesin Syrup 2mg/75mg per 5 mL
Teofilin + Salbutamol Sulfate Tablet 130mg/1,25mg
X SALURAN PENCERNAAN
A ANTASIDA DAN ANTIULKUS
Antasida doen kombinasi : Tablet Kunyah
Al(OH)3/Mg(OH) + Mg(OH)2 Suspensi
Ranitidine Tablet 150 mg
Injeksi.i.v.amp 25 mg/mL
Lansoprazole Tablet 30 mg
Omeprazole Tablet 20 mg
Pantoprazole Inj. 40mg/10mL
Sucralfate suspensi Suspensi 500mg/5mL
B ANTIEMETIK
Dimendidrinat Tablet 50 mg
Domperidone Tablet 10 mg
Syrup 5mg/5mL
Drops. 5mg/5mL
Metoclopramide Tablet 10 mg
Syrup 5mg/5mL
Ondancentron Tablet 4 mg
Inj 2mg/mL
C ANTIDIARE
Attapulgit Tablet 600 mg
Attapulgit + Pectin Tablet 650mg/50mg
Garam Oralit : NaCl 0,52 g, KCl 0,30 g, Serbuk untuk 200 mL air
trinatrium sitrat dihidrat 0,58 g, glukosa
anhidrat 2,70 g
Kombinasi Kaolin + Pektin Syrup 986mg/40mg per 5 mL
Zinc Tablet Dispersible 20 mg
Syr 20mg/5mL, 10mg/5mL, btl 60 mL
Drops 10mg/mL
Loperamide Tablet 2 mg
Probiotic Sacchet
D ANTISPASMODIKUM
Hyoscine Butylbromide Tablet 10 mg
Kombinasi Hyoscine Butylbromide + Tablet 10 mg/500 mg
Paracetamol
E LAKSATIF
Bisakodil Tablet Salut 5mg
Kombinasi : Paraffin liquid + Suspensi 1,5g/75mg/1g
Phenolphthalein + Glycerol
Lactulosa Syrup 3,335 g/5mL
Na lauryl sulfate 45mg + Na Citrate Enema
450mg + Sorbic acid 5mg +
Sorbitol,4,465mg + PEG-400 625mg
F ANTIHEMOROID
Graptophyllum pictum folia 90mg + Kapsul
sophora japonica flos 85 mg + rubia
cardifolia radix 10mg + coleus
atropurpureus folia 10mg + sanguisorba
afficinalis radix 20m + kaempferia
angustifolia rhizoma 10mg + curcuma
heyneana rhizoma 25mg (Ambeven)
Benzokain 1,0% + ZnO 2% + Alukol Suppositoria
0,25% dalam massa hidrofil (Superhoid)
B KORTIKOSTEROID
Dexamethasone 0,5 mg Tablet 0,5 mg, 0,75 mg
Methyl Prednisolone 4 mg Tablet 4 mg, 8 mg, 16 mg
Prednison Tablet 5 mg
OBAT PENYAKIT
XII
KULIT/TOPIKAL
A ANTIMIKROBA
Acyclovir Krim 5%, tube 5g
Chloramfenicol Salep 2%
Clindamycin Phospate Krim 10mg/g tube 10g
Gentamycin Salep 0,1% tube 5g
ANTIBIOTIK +
B
KORTIKOSTEROID
Neomycin 0,5% + Fluocinolone Krim 5 g
acetonide 0,025%
Neomycin 5 mg + Betametasone 1 mg Krim 5 g
C ANTIFUNGI
Ketoconazole Krim 2% 5g, 10g
Miconazole Krim 2% 10g
Klotrimazole Krim 1% tube 10g
ANTIINFLAMASI dan
D
ANTIPRURITIK
Clindamycin Tube 10 g
Betametasone Krim 0,1% tube 5 g
Flucinolone acetonide Krim 0,25mg tube 10 g
Hydrocortisone Krim 1% tube 5g, 2,5% tube 5g
Mometasone Furoat 0,1% Krim 0,1% tube 5g, 10g
Triamicolon acetonide Salep 0,1% tube 5g
E ANTISKABIES
Permetrin 5% Krim tube 30 g
Lotion 30 mL
Salep 2-4 : Asam Salisilat 2% + Ointment, pot 30g
Belerang Endap 4%
F LAIN-LAIN
Bedak Salisil Serbuk 2% 60g
Heparin Gel 200 IU tube 20g
Diclofenac sodium Gel 1% tube 20g
LARUTAN ELEKTROLIT,
XV
NUTRISI dan LAIN-LAIN
A ORAL
Garam Oralit : NaCl 0,52 g, KCl 0,30 g, Serbuk untuk 200 mL air
trinatrium sitrat dihidrat 0,58 g, glukosa
anhidrat 2,70 g
Zinc Tablet Dispersible 20 mg
Syr 20mg/5mL, 10mg/5mL, btl 60 mL
Drops 10mg/mL
Lacto-B
B PARENTERAL
Larutan Mengandung Elektrolit
Natrium Chlorida Larutan Infus 0,9% botol 500 mL
Ringer Lactat Larutan Infus botol 500 mL
Ditetapkan di : Cimahi
Pada Tanggal :
Kepala FKTP Klinik Denanti,