LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN

PUSKESMAS : TELUK LINGGA PELAPORAN BULAN

KECAMATAN : SANGATTA UTARA PERMINTAAN BULAN/PERIODE
KABUPATEN : KUTAI TIMUR

PEMA
STOK PENERIM PERSEDIA KAIAN
NO NAMA OBAT SATUAN AWAL AAN AN

1 2 3 4 5 6 7
1 Allilestrenol 5 mg Tablet
2 Allopurinol 100 mg Tablet 700 700 400
3 Allopurinol 300 mg Tablet - -
4 Ambroksol 30 mg Tablet - -
5 Aminofilin 150 mg Tablet - -
6 Aminofilin 200 mg Tablet - -
7 Amitriphyllin 25 mg Tablet 50 50 10
8 Amlodipin 10 mg Tablet 1,400 3,000 4,400 3,500
9 Amlodipin 5 mg Tablet 900 3,000 3,900 1,200
10 Amoksisilin 250 mg Tablet - -
11 Amoksisilin 500 mg Tablet 600 5,000 5,600 3,900
12 Antasida Tablet - -
13 Artemether-Lumafantrin (Kombinasi) Tablet - -
14 Asam asetil salisilat (asetosal) 100 mg Tablet - -
15 Asam asetil salisilat (asetosal) 80 mg Tablet - -
16 Asam askorbat (vitamin C) 250 mg Tablet - -
17 Asam askorbat (vitamin C) 50 mg Tablet - 4,000 4,000 3,400
18 Asam folat 0,4 mg Tablet - -
19 Asam folat 1 mg Tablet - - -
20 Asam folat 5 mg Tablet - -
21 Asam Mefenamat 250 mg Capsul - -
22 Asam Mefenamat 500 mg Tablet 1,700 1,000 2,700 1,400
23 Asam traneksamat 500 mg Tablet - -
24 Asam ursodeoksikolat 250 mg Kapsul - - -
25 Asiklovir 200 mg Tablet 800 800 150
26 Asiklovir 400 mg Tablet 500 500 200
27 Attapulgit Tablet - -
28 Atenolol 50 mg Tablet - -
29 Atorvastatin 20 mg Tablet - -
30 Atropin sulfat 0,5 mg Tablet - -
31 Benserazid-levodopa (kombinasi) Tablet - -
32 Betahistin 24 mg Tablet - -
33 Betahistin 6 mg Tablet 210 200 410 410
34 Bisakodil 5 mg Tablet 120 120 30
35 Bisoprolol 5 mg Tablet - -
36 Bromheksin 8 mg tablet - -
37 Dapson 100 mg Tablet - -
38 Deksametason 0,5 mg Tablet 700 8,000 8,700 7,100
39 Dekstrometorfan 15 mg Tablet - -
Dekstrometorfan-Gliseril guaikolat-PPA-
40 Tablet
CTM kombinasi - -
41 Diazepam 2 mg Tablet -
42 Diazepam 5 mg Tablet 78 78 9
43 Digoksin 0,25 mg Tablet 400 400 300
44 diltiazem 30 mg Tablet 200 200 100
45 Dimenhidrinat 50 mg Tablet 139 139 39
46 Domperidon 10 mg Tablet 300 500 800 400
47 Efedrin 25 mg Tablet - -
48 Ekstrak graptofili-sitrus bioflavonoid kapsul - -
49 Ekstrak kurkuma 20 mg tablet - -
50 Ergokalsiferol (Vit D2) 50 mg Tablet - -
51 Ergotamin 1 mg Tablet - -
52 Ergotamin-Kafein (kombinasi) Tablet - -
53 Eritromisin 250 mg Capsul - -
54 Eritromisin 500 mg tablet - -
55 Etambutol 250 mg Tablet - -
56 Etambutol 400 mg Tablet - -
57 famotidin 20 mg Tablet - -
58 Fenitoin 100 mg Kapsul - - -
59 Fenitoin 30 mg Kapsul - -
60 Fenobarbital 100 mg Tablet - -
61 Fenobarbital 30 mg Tablet - - -
62 Fenoksimetil penisilin (Penisilin V) 250 mg Tablet - -
63 Fenoksimetil penisilin (Penisilin V) 500 mg Tablet - -
64 Ferro fumarat 300 mg kapsul - -
Ferro glukonat-Vit C-asam folat-vit B12-
65 Kupri sulfat-Mangan sulfat-sorbitol Tablet
kombinasi - -
66 Ferro sulfat-asam folat (kombinasi) Tablet 360 - 360 360
67 Fitomenadion (Vit K1) 10 mg Tablet 100 100 100
68 Fluoksetin 10 mg Kapsul - -
69 Fluoksetin 20 mg Kapsul 60 60 -
70 Furosemid 40 mg Tablet 200 200 -
71 Gabapentin 300 mg Tablet - -
72 Glibenklamid 2,5 mg Tablet - -
73 Glibenklamid 5 mg Tablet 400 2,000 2,400 500
 74 Glimipiride 1 mg Tablet - -
75 Glimipiride 2 mg Tablet 2,000 2,000 -
76 Glipizid 5mg Tablet - -
77 Gliseril guaikolat 100 mg/guafenesin Tablet - 1,500 1,500 1,500
78 Gliseril trinitrat 0,5 mg Tablet - -
79 Griseofulvin 125 mg Tablet 200 200 100
80 Griseofulvin 250 mg Tablet - -
81 Griseofulvin 500 mg Tablet - -
82 Haloperidol 1,5 mg Tablet - -
83 Haloperidol 2 mg Tablet - -
84 Haloperidol 5 mg Tablet - -
85 Hidroklortiazid 25 mg Tablet 300 200 500 300
86 Hiosin butilbromida 10 mg Tablet - -
87 Hiosin butilbromida-parasetamol komb Tablet - -
88 Ibuprofen 200 mg Tablet - -
89 Ibuprofen 400 mg Tablet 1,600 1,000 2,600 1,500
90 Irbesartan 300 mg Tablet - -
91 Isoksuprin 20 mg Tablet - -
92 Isoniazid 100 mg Tablet - -
93 Isoniazid 300 mg Tablet - -
94 Isosorbid Dinitrat 5 mg Tablet 700 700 500
95 Kalium diklofenak 50 mg Tablet - -
96 Kalium klorida 600 mg Tablet - -
97 Kalsium karbonat 500 mg Tablet - -
98 Kalsium Laktat (Kalk) 500 mg Tablet 1,300 1,500 2,800 2,000
99 Kaolin-pektin komb Tablet - -
100 Kaptopril 12,5 mg Tablet - -
101 Kaptopril 25 mg Tablet 300 2,000 2,300 1,100
102 Kaptopril 50 mg Tablet - -
103 Karbamazepin 100 mg Tablet - -
104 Karbamazepin 200 mg Tablet - -
105 Karbon aktif 0,5 mg Tablet - -
106 Ketokonazol 200 mg Tablet 200 200 100
107 Ketoprofen 50 mg Tablet - -
108 Klindamisin 150 mg Kapsul - -
109 Klindamisin 300 mg Kapsul - -
110 Klofazimin 100 mg Kapsul - -
111 Klofazimin 50 mg Kapsul - -
112 Klopidogrel 75 mg Tablet - -
113 Kloramfenikol 250 mg kapsul - -
114 Kloramfenikol 500 mg Kapsul - -
115 Klorfeniramin 4 mg Tablet 800 7,000 7,800 4,600
116 Klorpromazin 100 mg Tablet - -
117 Klorpromazin 25 mg Tablet - -
118 Klortalidon 50 mg Tablet - -
119 Klozapin 100 mg Tablet - -
120 Klozapin 25 mg Tablet - -
121 Kodein 10 mg Tablet 125 125 10
122 Kodein HCL 10 mg Tablet - -
123 Kodein HCL 20 mg Tablet - -
124 Kolkisin 500 mcg Tablet - -
125 Kotrimoksazol 480 mg Tablet - -
126 Kotrimoksazol forte 960 mg tablet - -
Laktobasilus-bifidobakterium longun-
127 sachet
streptokokus serbuk kombinasi - -
128 Lansoprazole 30 mg Kapsul - -
129 Levofloksasin sal selaput 500 mg Tablet - -
130 Lisonopril 10 mg Tablet - -
131 Loperamid 2 mg/ Novadium tablet Tablet 450 200 650 200
132 Loratadin 10 mg Tablet - 1,500 1,500 500
133 Lorazepam 0,5 mg Tablet - -
134 Lorazepam 1 mg Tablet - -
135 Lorazepam 2 mg Tablet - -
136 Mebendazol 100 mg Tablet - -
137 Mebendazol 500 mg Tablet - -
138 Mebhidrolin napadisilat 50 mg tablet - -
139 Meloksikam 15 mg Tablet - - -
140 Meloksikam 7,5 mg Tablet - -
141 Metenamin mandelat sal enterik 500 mg Tablet - -
142 Metformin 500 mg Kaplet - -
143 Metformin 850 mg Tablet - -
144 Methysoprinol 500 mg Tablet - -
145 Metil Ergometrin 0,125 mg Tablet 50 50 -
146 Metildopa 250 mg Tablet - -
147 Metilprednisolon 16 mg Tablet 120 600 720 270
148 Metilprednisolon 4 mg Tablet - 900 900 900
149 Metilprednisolon 8 mg Tablet - -
150 Metoklopramid 10 mg Tablet - - -
151 Metoklopramid 5 mg Tablet 100 100 -
152 Metronidazol 250 mg Tablet - -
153 Metronidazol 500 mg Tablet - 200 200 200
154 Misoprostol 200 mcg tablet - -
155 n-Asetil sistein 200 mg kapsul 600 3,000 3,600 1,440
156 Natrium bikarbonat 500 mg Tablet - -
157 Natrium Diclofenak 25 mg Tablet 1,000 2,000 3,000 2,600
158 Natrium Diclofeak 50 mg Tablet - -
159 Nifedipin 10 mg Tablet 200 200 -
160 Nistatin sal gula 500.000 IU Tablet - - -
161 Nitrofurantoin 50 mg Tablet - -
162 Omeprazole 20 mg Kapsul - - -
163 Ondansetron 4 mg Tablet 144 144 -
164 Papaverin 40 mg Tablet - -
165 Parasetamol 500 mg Tablet 600 4,000 4,600 3,900
Parasetamol-gliseril gualikolat-PPA-CTM
166 tablet
kombinasi - -
167 Piracetam 800 mg Tablet - -
168 Pirantel Pamoat 125 mg Tablet - -
169 Pirantel Pamoat 250 mg Tablet - -
170 Piridoksin (Vit B6) 10 mg Tablet 1,600 2,000 3,600 1,600
171 Piridoksin (Vit B6) 25 mg Tablet - -
172 Piroksikam 10 mg Capsul - -
173 Piroksikam 20 mg Capsul - -
174 Prazikuantel 600 mg Tablet - -
175 Probenesid 500 mg Tablet - -
176 Propanolol 10 mg Tablet - -
177 Propiltiourasil 100 mg Tablet - -
178 Pseudoefedrin 30 mg tablet - -
179 Ranitidin 150 mg Tablet - -
180 Rifampisin 300 mg Kapsul - -
181 Risperidon 1 mg Tablet - -
182 Risperidon 2 mg Tablet 370 370 10
183 Salbutamol 2 mg Tablet - -
184 Salbutamol 4 mg Tablet 600 2,000 2,600 500
185 Sefadroksil 250 mg Kapsul - -
186 Sefadroksil 500 mg Kapsul 900 2,000 2,900 1,600
187 Sefiksim sal selaput 100 mg Tablet - - -
188 Sefiksim sal selaput 200 mg Tablet - -
189 Setirizin tab 10 mg Tablet - 2,000 2,000 1,000
190 Sianokobalamin (vit B12) 50 mcg Tablet 200 3,000 3,200 2,200
191 Simetidin 200 mg Tablet -
192 Simvastatin 10 mg Tablet 500 1,200 1,700 800
193 Simvastatin 20 mg Tablet 150 500 650 650
194 Simvastatin 40 mg Tablet - -
195 Siprofloksasin sal selaput 500 mg Tablet - - -
196 Sitikolin 500 mg Tablet 40 40 -
197 Spironolakton 100 mg Tablet - -
198 Spironolakton 25 mg Tablet - -
199 Sukralfat 500 mg Tablet - -
200 Teofilin 100 mg Tablet - -
201 Tetrasiklin 250 mg kapsul - -
202 Tetrasiklin 500 mg Kapsul - -
203 Tiamfenikol 500 mg Tablet - - -
204 Tiamin (Vit B1) 50 mg Tablet 800 3,000 3,800 600
205 Tramadol tab 50 mg tablet 300 300 250
206 Triheksifenidil 2 mg Tablet 225 225 60
 207 Valproat lepas lambat 250 mg Tablet - -
208 Valproat lepas lambat 500 mg Tablet - -
209 Valproat sal enterik 250 mg Tablet - -
210 Valsiklovir 500 mg Tablet - -
Vit A-vit D-vit B1-vit B2-Vit B6-Vit B12-
nikotinamid-vit C-vit E-Kalsium pantotenat-
211 Biotin-asamfilat-Ferro fumarat-asam tablet
glutamat-Zink-Mangan-Fluor-Iodium
kombinasi - - -
Vit B1 100 mg-Vit B6 200 mg-Vit B12 200
212 tablet
mcg kombinasi - -
213 Vitamin B Kompleks Tablet 5,000 5,000 2,000
OBAT JENIS SYRUP - -
1 Ambroksol drop 15 mg/ml botol - -
2 Ambroksol sy 15 mg/5 ml Botol 106 106 106
3 Amoksisilin drops 100 mg/ml Botol - -
4 Amoksisilin Syrup Kering 125 mg/5ml Botol - -
5 Amoksisilin Syrup Kering 250 mg/5ml Botol - -
6 Antasida Suspensi Botol - - -
7 Domperidon drop 5 mg/ml botol - -
8 Domperidon Syrup 5 mg/5ml Botol 50 50 10
9 Ergokalsiferol (vit D2) susp 10.000 IU/ml botol - -
10 Eritromisin Sy kering 200 mg / 5 ml Botol - -
11 Ferro sulfat sy 150 mg/5ml botol - -
12 Haloperidol drop 2 mg/ml botol - -
13 Ibuprofen syrup 100mg/5 ml Botol 30 30 30
14 Ibuprofen syrup 200mg/5ml Botol - -
15 Kaolin-pektin kombinasi sirup botol - -
16 Karbamazepin sy 100 mg/ 5 ml Botol - -
17 Kloramfenikol Suspensi 125 mg/5 ml Botol 50 50 -
18 Kotrimoksazol Suspensi 240 mg/ 5 ml Botol 23 23 12
19 laktulosa sy 3,335 gr/5 ml botol 25 25 -
20 Lugol larutan botol - -
21 Mebendazol sy 100 mg /5 ml Botol - -
22 Metadon sy 50 mg/5ml botol - -
23 Methysoprinol sy 250 mg/5 ml botol - -
24 Metoklopramid sy 5 mg/5 ml (lexapram syr) Botol - - -
25 Metoklopramid drop 2 mg/ml (Gavistal drops Botol - -
26 Metronidazol suspensi 125 mg / 5 ml botol - -
27 Nistatin susp 100.000 IU/ml botol - -
28 Obat Batuk Hitam Sy Botol - - -
29 Parasetamol 120 mg / 5 ml Syrup Botol - -
30 Parasetamol Drops 100 mg/ml Botol - -
Parasetamol-CTM-guaifenesin-PPA sirup
31 botol
kombinasi - -
 32 Pirantel pamoat susp 125 mg / 5 ml Botol - -
33 Pseudoefedrin drop 7,5 mg/0,8 ml botol - -
34 Pseudoefedrin sy 30 mg/5 ml botol - -
35 Salbutamol sy 2 mg/5 ml botol 10 10 -
36 Salbutamol-Guaifenesin kombinasi sy botol - -
37 sefadroksil syr kering 125 mg/5 ml Botol - -
38 sefadroksil syr kering 250 mg/5 ml Botol - -
39 Sefiksim sy 100 mg / 5 ml Botol - -
40 Setrizin Syrup 5 mg/5ml Botol - - -
41 Sukralfat Susp 500 mg/5 ml Botol - -
42 Tiamfenikol sy 125 mg/5 ml botol - -
43 Valproat sy 250 mg/ 5 ml Botol - -
vit A-vit D-vit B1-vit B2-Vit B6-Vit B12-
nikotinamid-vit C-vit E-Kalsium pantotenat-
44 Biotin-asamfilat-Ferro fumarat-asam botol
glutamat-Zink-Mangan-Fluor-Iodium
kombinasi syrup - -
45 Zink drop 10 mg/ml botol - -
46 zink syrup 10 mg/5 ml botol - -
BAHAN MEDIS HABIS PAKAI DAN BAHAN LABORATORIUM - -
1 Air untuk Injeksi 25 ml Botol 6 6 -
2 Alat Suntik sekali pakai 1 ml pieces 1,080 1,080 430
3 Alat suntik sekali pakai 10 ml kotak - -
4 Alat Suntik sekali pakai 2,5 ml kotak - -
5 Alat suntik sekali pakai 3 ml pieces 459 459 69
6 Alat suntik sekali pakai 5 ml kotak 219 219 -
7 alkohol swab kotak 1 1 1
8 Benang cat gut chromic 2/0 sachet 12 12 -
9 Benang cat gut plain 3/0 sachet 24 24 -
10 Benang Suture Silk 2/0 Pcs 36 36 -
11 Benang Suture Silk 3/0 Sachet - -
12 Benang suture silk 4/0 sachet - -
13 Blood lancet kotak 3 3 -
14 crepe/bandage 7,5 cm x 4,5 cm pcs - -
15 Etakridin laktat 0,1% botol - -
16 Etanol cairan 70% botol 19 19 4
17 Handschon ginekologi kotak - -
18 Handschon non steril (S) kotak 6 6 6
19 Handschon non steril (M) kotak 5 5 1
20 Handschon non steril (L) kotak 5 5 4
21 Handschon steril uk.7 kotak 5 5 -
22 Hidrogen peroksida cairan 3% botol 4 4 -
23 Imersi oil 100 cc botol - -
24 Infusion set Anak Set 90 90 -
25 Infusion set Dewasa Set 49 49 12
26 IV cath no 20 pcs 100 100 -
 27 IV cath no 18 pcs 95 95 -
28 IV cath no 22 pcs 53 53 8
29 IV cath no 24 pcs 69 69 6
30 IV cath no 26 pcs - -
31 Jarum Bedah set - -
32 K.Y. Jelly tube - -
33 Kalsium hipoklorit serbuk botol - -
34 Kapas 250 mg Bungkus - -
35 Kapas 1000 gram Bungkus 1 1 -
36 Kapas Berlemak 500 mg Bungkus - -
37 Kapas Kompres 40/40 steril Kotak - -
38 Kasa gulung 40 x 80 cm Rol 3 3 1
39 Kasa Pembalut 2 M x 80 CM Rol - -
40 Kasa Pembalut Hidropil 4M x 15 CM Rol - -
41 Kasa Pembalut Hidropil 4M x 3 CM Rol - -
42 Kasa steril 16x16 kotak 13 13 1
43 Klorheksidin lar 15% botol - -
44 Masker earloop kotak - - -
45 Masker kerudung/hijab kotak 37 37 15
46 Masker N95 kotak - -
47 needle 24G x 25 mm kotak 100 100 -
48 needle 26G x 13 mm kotak 90 90 -
49 NGT no 16 pcs 1 1 -
50 NGT no 18 pcs 1 1 -
51 Nonwoven fixation 20 cm x 5 M roll 1 1 1
52 Oksigen ih tabung - -
53 Plester uk 5 cm roll - -
54 Povidon Iodin lar 300 mg/ml botol 2 2 -
55 PP Test kotak - 100 100 50
56 selang oksigen anak pcs 3 3 -
57 selang oksigen dewasa pcs 3 3 2
58 selang oksigen neonatus pcs 4 4 -
59 Strip asam urat botol 3 3 3
60 Strip Glukosa botol 3 3 3
61 Strip kolesterol botol - - -
62 surgical blade (bisturi) kotak - - -
63 tongue spatel (kayu) kotak - -
64 urine bag pcs - -
65 urine cath no 18 pcs 2 2 -
66 urine cath no 16 pcs 2 2 -
OBAT SUNTIK / INJEKSI / INHALASI ( AMPUL / VIAL ) - -
1 Aminofilin Injeksi 24 mg/ml Ampul 10 10 -
2 ampisilin serbuk inj 1000 mg vial - -
3 ampisilin serbuk inj 250 mg vial - -
4 asam traneksamat 100 mg/ml Ampul - -
 5 Asam traneksamat 50 mg/ml Ampul - -
6 Atropin Injeksi 0,25 mg/ml Ampul - -
7 Benzatin benzil penisilin 1,2 juta IU/ml Vial - -
8 Benzatin benzil penisilin 2,4 juta IU/ml Vial - -
9 Budesonid cairan ih 0,25 mg/ml Ampul - -
10 Budesonid cairan ih 0,5 mg/ml Ampul - -
11 Budesonid serb ih 100 mcg/dosis spray - -
12 Budesonid serb ih 200 mcg/dosis spray - -
13 D5 1/2 NS infus Botol - -
14 D5 1/4 NS infus Botol - -
15 Deksametason Injeksi 5 mg/ml Ampul 154 154 -
16 Diazepam Injeksi 5 mg/ml Ampul 19 19 -
17 Difenhidramin Injeksi 10 mg/ml Ampul 33 33 -
18 Diltiazem serb inj 50 mg vial - -
19 Dopamin inj 40 mg/ml Ampul - -
20 Epinefrin Injeksi 0,1 % ml Ampul - - -
21 Esomeprazole serb inj 40 mg Ampul - -
22 fenitoin inj 50 mg/ml Ampul - -
23 Fitomenadion (Vit K1) Injeksi 10 mg/ml Ampul 49 49 -
24 Flufenazin inj 25 mg/ml Ampul - -
25 Furosemid inj 10 mg/ml Ampul - -
26 Glukosa 10 % Infus Botol - -
27 Glukosa 40 % Infus Botol 6 6 -
28 Glukosa 5 % Infus Botol 20 20 -
29 Haloperidol inj 5 mg/ml (Lodomer) Ampul - -
30 Haloperidol inj 50 mg/ml (Haldol) Ampul 15 15 -
31 Hepatitis B Imunoglobulin Inj 150 IU/1,5 ml Ampul - -
32 Hepatitis B Imunoglobulin Inj 220 IU/ml Ampul 1 1 -
33 Hidrokortison serb inj 100 mg vial - -
34 Hiosin butilbromida inj 20 mg/ml Ampul - -
35 Human tetanus imunoglobulin inj 250 IU Ampul - -
36 Human tetanus imunoglobulin inj 500 IU Ampul - -
37 Ipratropium bromida aerosol 20 mcg/puf spray - -
38 Ipratropium bromida cairan ih 0,025% Ampul - -
39 Ipratropium bromida-salbutamol cairan ih Ampul - -
40 Isoksuprin 2 mg/10 ml Ampul - -
41 KA-EN 3A infus botol - -
42 KA-EN 3B infus botol - -
43 Kanamisin serb injeksi 1000 mg vial - -
44 Ketamin inj 100 mg/ml Ampul - -
45 Ketamin inj 50 mg/ml Ampul - -
46 Ketoprofen inj 25 mg/ml Ampul - -
47 Ketorolac inj 25 mg/ml Ampul - -
48 Klonidin inj 150 mcg/ml Ampul - -
49 Klorpromazin Injeksi 25 mg/ml Ampul - -
 50 Klorpromazin Injeksi 5 mg/ml Ampul - -
51 Lidocain inj 2% Ampul 19 19 -
52 Lidokain 2% + epinefrin inj 2 ml Ampul 88 88 32
53 Magnesium Sulfat 20 % flakon 12 12 -
54 Metamizol inj 500 mg/ml Ampul - -
55 Metoklopramid Inj 5 mg/ml Ampul - -
56 Nalokson inj 0,4 mg/ml Ampul - -
57 Natrium Klorida 0,9% infus Botol 20 20 -
58 Natrium Tiosulfat inj 25% Ampul - -
59 Omeprazole serb inj 40 mg Ampul - -
60 Ondansetron inj 4 mg/ml Ampul 99 99 2
61 Papaverin Injeksi Ampul - -
62 Parasetamol 1000 mg infus 100 ml botol - - -
63 Petidin Injeksi 50 mg/2 ml Ampul - -
64 Piridoksin (vit B6) inj 50 mg/ml Ampul - -
65 Prokain benzil penisilin serb inj 3 juta IU vial - -
66 Ranitidin Injeksi 25 mg/ml Ampul 100 100 7
67 Ringer asetat infus botol - -
68 Ringer laktat infus Botol 20 20 -
69 Salbutamol cairan ih 1 mg/ml Ampul - -
70 Sefotaksim serb inj 1000 mg vial - -
71 Sefotaksim serb inj 500 mg Vial - -
72 Seftriakson serb inj 1000 mg vial - -
73 Serum Anti Bisa Ular I Injeksi 50 ml Ampul - -
74 Serum anti rabies inj 100 IU/ml Ampul - -
75 Serum anti rabies inj 200-400 IU/ml Ampul - -
76 Serum anti tetanus (ATS) inj 1.500 IU/ml Ampul - -
77 Serum anti tetanus (ATS) inj 10.000 IU/ml Ampul - -
78 Serum anti tetanus (ATS) inj 20.000 IU/ml Ampul - -
79 Serum anti tetanus (ATS) inj 5.000 IU/ml Ampul - -
80 sianokobalamin (vit B12) Inj 500 mcg/ml Ampul - - -
81 Sitikolin inj 250 mg/2 ml Ampul - -
82 Streptomisin serb injeksi 1000 mg vial - -
83 Terbutalin cairan ih 2,5 mg/ml Ampul - -
84 Terbutalin inj 0,5 mg/ml Ampul - -
85 Tetanus toxoid inj/ Tetagam inj Ampul - -
86 Tramadol inj 100 mg/2 ml Ampul 8 8 1
87 Triamsinolon asetonid inj 10 mg/ml Ampul - -
88 Tuberkulin serb inj 2 TU/0,1 ml Ampul - -
Vit B1 100 mg-Vit B6 100 mg-Vit B12 5000
89 Ampul
mcg kombinasi injeksi - - -
OBAT LUAR ( TUBE,POT DAN SUPPO ) - -
1 Asiklovir salep Kulit 5% Tube 75 75 50
Anti Bakteri Komb : Basitrasin+Polimiksin
2 tube
salep kulit 50 50 100 75
 Anti fungi komb : as benzoat+as salisilat
3 tube
salep kulit - -
4 Anti Hemoroid kombinasi Suppo - -
5 Asam asetat tetes telinga 2% botol - -
6 Asam salisilat lar 0,1% Botol - -
7 Asam salisilat salep kulit 10% tube - -
8 Asam salisilat salep kulit 2% tube - -
9 Asam salisilat salep kulit 5% tube - -
10 Atropin tetes mata 1% botol - -
11 Bedak Salisil serb 2% Botol 40 40 -
Betametason 0,1%+Neomisin sulfat 0,5%
12 tube
salep kulit kombinasi - -
13 Betametason krim 0,05 % Tube - -
14 Betametason krim 0,1 % tube - -
15 Betametason salep 0,1 % tube - -
16 Betametason tetes mata 1 mg/ml botol - -
17 Bisakodil 10 mg suppo - -
18 Bisakodil 5 mg Suppo - -
19 Boraks gliserin cairan botol - -
20 desoksimetason salp 0,25 % tube - -
21 Diazepam enema 10 mg/ 2,5 ml suppo - -
22 Diazepam enema 5 mg/ 2,5 ml suppo 5 5 -
23 Diklofenak dietilamin gel 10 mg/gr tube - -
24 Fenol Gliserol tetes telinga 10 % Botol - 72 72 24
25 Fluoresein tts mata 2,5 mg/ml botol - -
26 Framisetin sulfat tulle 1% lembar - -
27 Gentamicin salep mata 0,3% tube - -
28 Gentamicin Tetes Mata 0,3% Tube 24 48 72 72
29 Gentamisin salep Kulit 0,1% Tube - -
30 Gentian Violet Larutan 1 % Botol - -
31 Gliserin cairan obat luar 100mg/ml botol - -
32 Heparin sodium gel 20.000 IU/100 gr tube 5 5 -
33 Hidrokortison 2,5 % Cream Tube 24 120 144 144
34 Ichtammolum salep kulit pot - -
35 Kalamin lotio Botol - -
36 Kalium Permagnat Serbuk Pot - -
37 Karbogliserin tetes telinga 10% botol - -
38 Ketokonazol 2 % Krim Tube 50 50 31
39 Ketokonazol scalp sol 2% botol - - -
40 Ketoprofen 100 mg rectal / Suprafenid supp Suppo 10 10 -
41 Kloramfenikol tetes telinga - -
42 Kloramphenicol SalEp Mata 1% Tube - -
43 Kloramphenicol Salep kulit 2%/Bufacetin cr tube - -
44 Kloramphenicol tetes mata 0,5% botol - -
45 Kloramphenicol tetes mata 1% botol - -
 46 Klotrimazol tab vaginal 100 mg Tablet - -
47 Lidokain gel 2% tube - -
48 liquor carbonis detergens lar 5% botol - -
49 Mentol-eugenol-metil salisilat krim/molakri tube - 12 12 12
Metronidazol 500 mg + Nistatin 100.000 IU
50 suppo
kombinasi - -
51 Metronidazol ovula 500 mg ovula 380 380 55
52 Metronidazol sup 500 mg tube - -
53 Mikonazole Krim 2% Tube - 24 24 24
54 Mikonazole serbuk 2%/ Mycorine powder botol 3 3 -
55 Mometason furoat 0,1 % cream Tube - -
56 Natrium diklofenak tts mata 1 mg/ml botol - -
57 Natrium fusidat salep 2% tube - -
Natrium klorida-Kalium klorida tetes mata
58 botol
kombinasi - -
59 Neomisin-Basitrasin powder botol 2 2 -
60 Nistatin tab vaginal 100.000 IU Tablet - - -
61 Ofloksasin tetes telinga 3% botol 2 2 -
62 Oksimetazolin tetes hidung 0,025% botol - -
63 Oksimetazolin tetes hidung 0,05% botol - -
64 Olopatadin tetes mata 0,1% Botol - -
65 Parasetamol rectal 125 mg/2,5 ml suppo 7 7 2
66 Parasetamol rectal 250mg/2,5 ml suppo 2 10 12 1
67 Perak sulfadiazin krim 1% Tube - -
68 Permetrin krim 5% tube - -
69 Pilokarpin tetes mata 2% botol - -
70 Plasenta extract-Neomisin salep kulit Tube - -
71 Podofilin tingtur 25% botol - -
Polimiksin-Neomisin-deksametason tetes
72 botol
mata kombinasi - -
Polimiksin-Neomisin-Fludrokortison-
73 botol
Lidokain tetes telinga kombinasi - -
74 Povidon Iodin mouthwash 100 ml botol - -
75 Salep 2-4 Pot 48 48 4
76 Siprofloksasin tetes mata 3% botol - -
77 Tetrakain 0,5% tetes mata botol - -
78 Tetrasiklin salep kulit 3% tube - -
Thymol 10 mg, ol. methae 20 mg,
79 botol
champora 60 mg tetes telinga - -
80 Timolol tetes mata 0,25% botol - -
81 Timolol tetes mata 0,5% botol - -
82 Triamsinolon asetonid 1 mg ointment kulit tube - -
83 Urea krim 10% tube - -
84 Urea krim 20% tube - -
OBAT PROGRAM ( PAKET,SET,BUNGKUS) - -
1 Albendazol susp 200 mg/ 5 ml Botol - -
2 Albendazol 400 mg Tablet - -
3 Ampisilin injeksi 1000 mg vial - -
4 Artesunat inj 60 mg Vial - -
5 ARV efavirenz 200 mg Tablet - -
6 ARV efavirenz 600 mg Tablet - -
7 ARV kombinasi FDC anak Tablet - -
8 ARV lamivudin150 mg Tablet - -
9 ARV lopinavir-ritonavir Tablet - -
10 ARV nefirapin 200 mg Kapsul - -
11 ARV tenofovir 300 mg Tablet - -
12 ARV tenofovir-emtrisitabin Tablet - -
13 ARV tenofovir-lamivudin-efavirenz Tablet - -
14 ARV zidofudin 100 Kapsul - -
15 ARV zidovudin-lamivudin Tablet - -
16 Azithromicyn 500 mg Tablet 60 60 60
17 DHP (Dihidroartemisin-piperakuin) komb Tablet 90 90 -
18 Dietil Karbamazin 100 mg Tablet - -
19 Doksisiklin 100 mg Kapsul 100 500 600 300
20 Fenobarbital Injeksi 50 mg/ml Ampul 30 30 30
21 Ferro Sulfat sal selaput 300 mg tablet 2,010 2,010 600
22 Fitomenadion (Vit K1) Injeksi 2 mg/ml Ampul - -
23 Garam Oralit Kombinasi serbuk Bungkus 500 1,000 1,500 700
24 Gentamisin inj 40 mg/ml Ampul 30 30 -
25 Kalsium glukonat inj 10% Ampul - -
26 Kontrasepsi AKDR Copper T set - -
27 Kontrasepsi AKDR IUD Cu T 380 A set - -
28 Kontrasepsi AKDR IUD levonorgestrel set - -
29 Kontrasepsi implan etonogestrel implan - -
30 Kontrasepsi implan levonogestrel implan - -
31 Kontrasepsi oral kombinasi Tablet - -
32 Kontrasepsi oral linestrenol 0,5 mg tablet - -
Kontrasepsi parenteral medroksi
33 vial
progesteron asetat inj 150 mg/3 ml - -
34 Kontrasepsi parenteral siklofem vial - -
35 Kuinin 200 mg Tablet - -
36 Kuinin inj 25% Ampul - -
37 Levotiroksin 50 mcg tablet - -
38 Magnesium Sulfat 40% flakon - -
39 Metil Ergometrin 0,2 mg/ml Ampul - - -
40 Metronidazol infus 5 mg/ml Botol - -
41 Mineral mix sachet - -
42 OAT anak 2KDT (FDC) Tablet - -
43 OAT anak 3KDT (FDC) Tablet - - -
44 OAT anak Kombipak A paket - -
45 OAT anak Kombipak B paket - -
 46 OAT dewasa 2KDT (FDC) Tablet - -
47 OAT dewasa 4KDT (FDC) Tablet - 30 30 4
48 OAT dewasa Kombipak II paket - -
49 OAT dewasa Kombipak III paket - -
50 Oksitosin Injeksi 10 IU/ml Ampul - - -
51 Prednison 5 mg Tablet - -
52 Primakuin 15 mg Tablet 151 151 -
53 Retinol (Vit A) 100.000 IU kapsul - -
54 Retinol (Vit A) 200.000 IU kapsul - -
55 Tetrasiklin salep mata 1% tube - -
56 Vaksin BCG inj 0,75 mg/ml + pelarut Ampul - -
57 Vaksin bivalen OPV drop 10 dosis - -
58 Vaksin Campak inj + pelarut Ampul - -
59 Vaksin DT inj 40/15 If per ml Ampul - -
60 Vaksin hepatitis rekombinan 0,5 ml Uniject - -
61 Vaksin kombinasi DPT-HB-Hib Inj Ampul - -
62 Vaksin Measless Rubella Inj 0,5 ml Ampul - -
63 Vaksin polio IPV inj 0,5 ml Ampul - -
64 Vaksin rabies inj + booster Ampul - -
65 Vaksin rabies inj 2,5 IU Ampul - -
66 Vaksin Td Inj 15/4 lf per ml Ampul - -
67 Zink 20 mg Tablet 200 1,000 1,200 600
OBAT GIGI / PERAWATAN GIGI - -
1 articulating paper - -
2 Aquadest 500 ml botol - -
3 Bahan tumpatan sementara lar/serbuk - -
4 Etil Klorida Spray 100 ml botol - -
5 Eugenol Cairan - -
6 Ferrakrilum cairan 1% - -
7 Fluor topikal - -
8 formokresol cairan - -
9 Glass Ionomer ART serb/larutan - -
10 Gutta percha-paper points 15-40 mm - -
11 Gutta percha-paper points 45-80 mm - -
12 Kalsium Hidroksida Pasta - -
13 Klorfenol kamfer mentol (CHKM) cairan - -
14 Klorheksidin lar 0,2% - -
Kombinasi : deksametason asetat-thymol-
15 paraklorfenol-campor - -
Kombinasi : lidokain-medisinal creosote
16 phenol-eugenol-benzil alkohol - -
Kombinasi : tramsinolon asetonid -
17 dementilklortetrasiklin pasta - -
18 Komposit resin set - -
19 Lidokain salep 5% tube - -
20 Lidokain spray oral 10% botol - -
21 Natrium hipoklorit 5% - -
22 Pasta devitalisasi (non arsen) - -
23 Pasta pengisi saluran akar - -
24 surgical ginggival pack pasta - -
- -
1 Albendazol tablet chewable Tablet 100 100 -
2 Alleterol OTM Botol - -
3 Alvogil - -
4 Antalgin 500 mg/ Metamizol 500 mg Tablet 400 2,000 2,400 800
5 Arsen - -
6 Art Fuji(glass Ionomert) - -
7 Asam Fucidat cr/Fucilex cr tube 60 60 -
8 Atroven Inhaler pieces - - -
9 Avamys Inhaler pieces 4 4 -
10 Berotec Inhaler pieces 1 1 -
11 Betablock tab Tablet 150 150 150
12 Bioplacenton Tulle box'10 1 1 -
13 Bioron injeksi Ampul - - -
14 Bisolvon drops btl 2 2 -
15 Borraginol Supp suppo 12 12 7
16 Bronsolvan Tab Tablet 500 500 500
17 Calporosis Tablet Tablet - -
18 CHKM - -
19 Chlorpromazin Inj 25 mg/mL Ampul 150 150 -
20 Clobazam Tablet Tablet 300 300 -
21 Combivent UDV pieces 20 20 -
22 Concor Tablet 1,25 mg Tablet 50 50 -
23 Concor Tablet 10 mg Tablet 120 120 90
24 Corvit - -
25 Curaspon Dental - -
26 Deg Glass pieces 5 5 1
27 Dentroit - -
28 Devitalisasi Pasta - -
29 Ecodine 300 ml Botol 1 1 1
30 Faktu Supp suppo -
31 Fartolin syr Botol - - -
32 Febrinex syr Botol 19 19 5
33 Flixotide Inhaler pieces - - -
34 Gentamycin injeksi Ampul 30 30 -
35 Gliquidon tablet Tablet 300 300 -
36 Masker Tali box - -
37 MDT MB strip - -
38 Mummfying Pasta - -
39 Nerilon cr tube - -
 40 Nifudiar syr botol - -
41 Nitroglycerin tab Tablet - -
42 Noza Tablet Tablet - -
43 Ofloksasin Tablet Tablet - -
44 Oxytetracylin cream Tube - -
45 Oxytetracylin eye oint tube -
46 Pehacain Injeksi Ampul 60 100 160 60
47 Recodryl Injeksi Ampul - - -
48 Selang O2 + Sungkup Anak pieces 4 4 -
49 Selang O2 + Sungkup Dewasa pieces 4 4 -
50 Skizonoate injeksi Ampul 25 25 -
51 Soft U derm cream tube 15 15 15
52 Synarcus cr tube - -
53 Thyrozol Tablet 10 mg Tablet - -
54 Urinter Kapsul kapsul 100 100 -

UMUM JAMKESDA
Tidak BPJS
Bayar Bayar JKP sktm
JUMLAH KUJUNGAN RESEP

Yang Meminta Mengetahui/ Menyetujui

Kepala UPT.Puskesmas Kepala Dinkes II/ GFK

dr. Suriani …………………………………………

NIP 19621226 199903 2 001 NIP:
N LEMBAR PERMINTAAN OBAT PUSKESMAS
FORM : LPLPO PUSKESMAS
ORAN BULAN : SEPTEMBER 2019 NO / TGL DOKUMEN
NTAAN BULAN/PERIODE : OKTOBER 2019 GFK
PUSK
DINKES

SISA PERMI PEMBERIAN KETERA

STOK NTAAN INPRES ASKES APBD APBD LAIN JUMLAH NGAN
I II LAIN Masa ED
8 9 10 11 12

300 400
500
3,000

40
900 3,000
2,700 -

1,700 4,000
3,000

100
3,000
600 4,000
500
- 500

1,300 1,000
100
-
650
300 200
500

50
 - 500
90 -

1,600 7,000

500

69
100 retur 300
100 retur 100
100
400 200
3,000

1,000

100
100

300

- 100

- 3,000
100

60
200

1,900 -
2,000 -

- 6,000

100 100

100
100
100
200
200 300
500
200
300
1,100 1,000

200 retur 500

2,000

100
800 2,500
100
1,000
1,200 1,500

100
100
100
100 100
500

500
500
3,200 5,000
100
100
 115

500

100

450 200
1,000 -

1,000
- 500
500

5,000

50

450 500
- 2,000
1,000
-
100

- 200

2,160

400 2,500
1,000
200
- 100

- 1,500
 144
100
700 4,000

500

100

2,000 -

1,000

360

2,100

1,300 1,000
- 500
300
1,000 500
1,000 2,000
1,000
900 1,000
- 1,500

- 1,000
40
100
100
1,000

- 500
3,200 -
50 retur 250
165
 - 1,000

1,000
3,000 1,000

- expire Oct-19

300
300
- 200

40 -

50
50

50
11 50
25

12
- 25
400
100
 50
50
10

100
100
50
- 100
100
50

100

50

6
650

390 -
219
- 3
12
24
36

15

- 20
4
1 5
5
4

90
37
100
95
45
63

12
1
-
22

100
90
1
1
- 3

3
2
50 50
3
1 2
4
- 3
- 3
- 3
-

2
2

10
154
19
33

49

6
20

15

12
19
56
12

20

97

93

20

25 50

25 75
 50

40

50
50
50

12
12

5
5 -

48 -

25
- 100
25
50

5
- 200
12

20

19 50
-
10
25
25
25
25
25
 3

- 24

325

- 50
3

2
-
2

5
11
3
25

44 -
 - retur 60
90

300 200
-
1,410 3,000

800
30

-
 26 -

- 25

151

600
 100
50

1,600 -

60
-
4
1
- retur 150
1
-
2
5 20
- retur 500

150
300
20
50
30 retur 90

- -

-
14
-
30
300
 1,000

100
-
4
4
25
- retur

100

Jumlah Total Item Obat Jumlah Item % Penggunaan

Dalam R/ Obat Generik Obat Generik

0 0 0 0.00%

Yang Menyerahkan Yang Menerima

Petugas GFK Petugas Puskesmas

…………………………………… Kurnia Rizki Ramadani, S.Farm., Apt.

NIP. NRTK2D. 6408.19950217.2018.9576