LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LPLPO)

KODE PUSKESMAS : ________________________

PUSKESMAS : ________________________ BULAN : ________________
KECAMATAN : ________________________ TAHUN : ________________
KABUPATEN : ________________________ MASUK TGL. : ________________
PROPINSI : ________________________

No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
1 101 Acon Stik for Plano Test kotak
2 102 Acyclovir krim tube
3 103 Acyclovir tablet - 200 mg tablet
4 104 Acyclovir tablet - 400 mg tablet
5 105 Air raksa dental use botol
6 106 Alat Suntik 10 ml set
7 107 Alat suntik sekali pakai 1 ml set
8 108 Alat suntik sekali pakai 2,5 ml set
9 109 Alat suntik sekali pakai 5 ml set
10 110 Albendazol tablet 400 mg tablet
11 113 Alkohol 95 % botol
12 114 Alkohol Swab dos
13 115 Alopurinol tablet tablet
14 116 Alpara tablet
15 117 Ambroxol sirup 60 ml botol
16 118 Ambroxol tablet 30 mg tablet
17 119 Aminofilina injeksi 24mg/ml-10ml ampul
18 120 Aminofilina tablet 200 mg tablet
19 121 Amitriptilina HCL tablet 25 mg tablet
20 122 Amlodipin 10 mg tablet
21 123 Amoksilin Forte Sirup Kering botol
22 124 Amoksilin kaplet - 500 mg kaplet
23 125 Amoksilin kapsul - 250 mg kapsul
24 126 Amoksilin Sirup Kering botol
25 127 Ampisilina injeksi 1 gram vial
26 128 Antalgin injeksi 24 mg/ml-10ml ampul
27 129 Antalgin tablet 500mg tablet
28 130 Antasi DOEN II Suspensi,Kombi botol
29 131 Antasida Doen tablet tablet
30 132 Anti Hemmoroid Suppositoria supp
Antibakteri DOEN (Basitrasin +
31 133 tube
Polimiksin)
Antifungi DOEN (As Benzoat 3%+As
32 134 pot
Salisilat 6%)DOEN (Ergotamina Trt +
Antimigren
33 135 tablet
Kofeina)
Antrain injeksi 2ml /5
34 136 ampul
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
35 137 Aqua pro injeksi steril - 20 ml ampul
36 138 Aquadest steril - 1000 ml botol
37 139 Aquadest steril - 500 ml botol
38 Air utk Irigra Lar Infus 1000 ml botol
39 140 Aquagel Sterile Jely 82 gr tube
40 141 Asam Askorbat (vit C) tablet 50 mg tablet
41 143 Asam Mefenamat kaplet 500 mg kaplet
42 144 Asam tranexamat injeksi 100mg/ml ampul
43 145 AsamTraneksamat HCL tablet 500mg tablet
44 146 Aseptic Gel + Disp 500 ml botol
45 147 Asetosal tablet 100 mg tablet
46 149 Asetosal tablet 80 mg tablet
47 Attapulgit 600 mg tablet
48 150 Attapulgit 630 mg tablet
49 151 Atropina Sulfat injeksi ampul
50 153 Autodisposable Syringe 0,05 ml set
Autodisposable Syringe 0,5 ml
51 154 set
(Soloshot)
Autodisposable Syringe 5 ml
52 157 set
(Soloshot)
53 158 Azitromicin 250 mg tab tablet
54 201 Bahan tumpatan sementara/Caviton botol
55 203 Becefort tablet tablet
56 205 Benzatin Bensil Pen.inj 2,4 juta IU vial
57 207 Betahistin Mesilat 6 mg tablet
58 208 Betametason krim tube
59 209 Betametason N crem tube
60 210 Bisakodil Supp 10mg supp
61 213 Bisoprolol tablet 5 mg tablet
62 214 Bist Mess No.24 set
63 215 Blood Lancet set
64 217 Bonding Liq botol
65 219 Bunofa 400 kaplet
66 301 Calcium Gluconas infus botol
67 Captopril tablet 12,5 mg tablet
68 302 Captopril tablet 25 mg tablet
69 Captopril tablet 50 mg tablet
70 Cover Glass 18 x 18 cm set
71 303 Carpiaton 100 mg tablet
72 304 Catgut Chrom 2/0 + jarum sachet
73 305 Catgut Chrom 3/0 + jarum sachet
74 306 Catgut Plain 2/0 + jarum sachet
75 307 Catgut Plain 3/0 + jarum sachet
76 308 Cefadroxil kapsul 500 mg kapsul
77 309 Cefixime 100mg tablet
78 310 Cefotaxim injeksi vial
79 311 Ceftriaxone 1.Og inj Kering vial
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
80 313 Cendo Lyteer botol
81 314 Cetirizine Kapsul 10mg kapsul
Chlorhexidine gluconat 0,2% /
82 315 botol
ASEPTAN
Chlorhexidine gluconat 4% 500 cc +
83 316 botol
dispenser / ONE
Chlorhexidine SCROB
gluconat 0,5 W/v 70 % botol
84
/ ASEPTAN
85 317 Cimetidin tablet 200 mg tablet
86 318 Clorin / One Clean botol
87 320 Composit Light Curing A2 syringe
88 321 Composit Light Curing A3 syringe
89 322 Composit Light Curing A3,5 syringe
90 323 Corsafen 500 mg kapsul
91 324 Cover Glass pcs
92 325 Cresopen (obat gigi) botol
93 326 Cyprofloxacin kapsul 500 mg kapsul
94 Clobazam 10 mg tablet
95 Clozapin 25 mg tablet
Daryan Tulle :Flamisetin Sulfat 10 x
96 402 lembar
10 cm
97 403 Decullin tablet 30mg tablet
98 404 Deksametason Injeksi 5mg/ml ampul
99 405 Deksametason tablet 0,5 mg tablet
100 406 Demacolin tablet tablet
101 Dentin Conditioner / Mini Pack
102 407 Depo Progestin Injeksi 3 bln vial
Dermazin salep kulit 1% - 25gram
103 408 tube
/BioplaN
104 409 Devitalisasi pasta botol
105 411 Dextran infus - 500 ml botol
106 412 Dextrofen Sirup botol
107 413 Diazepam Injeksi 5mg/ml-2ml ampul
108 414 Diazepam tablet 2 mg tablet
109 415 Diazepam tablet 5 mg tablet
110 416 Diethylcarbamazine tablet
111 417 Difenhidramina HCL injeksi 10 mg ampul
112 418 Digoksina tablet 0,25 mg tablet
113 419 Doksisiklin kapsul 100 mg kapsul
114 420 Domperidon tablet 10 mg tablet
115 Dulcolax supp Adult 10 mg / Bisakadil supp
Epinefrina HCL/Bitart injeksi 0.1% -
116 504 ampul
l ml
117 505 Erithromicin kaplet 500 mg kaplet
118 506 Erithromicin kapsul 250 mg kapsul
119 507 Erithromicin sirup - 60 ml Kering botol
120 509 Etanol 70% - 1000 ml botol
121 510 Etching+bonding Liquit SDI set
122 513 Etil Klorida semprot botol
123 514 Eugenol Cairan - 10 ml botol
124 601 Farmoten 12,5 mg tablet
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
125 602 Feeding tube No. 10 set
126 603 Feeding tube No. 16 set
127 604 Feeding tube No. 5 set
128 605 Feeding tube No. 8 set
129 606 Fenitoina Natrium kapsul 100 mg kapsul
130 607 Fenobarbital Injeksi 50mg/ml-2ml ampul
131 608 Fenobarbital tablet 30 mg tablet
132 610 Fenoksimetil Penisilina tablet 500 mg tablet
133 612 Fitomenadion injeksi 10mg/ml ampul
134 613 Fitomenadion injeksi 2 mg/ml ampul
135 614 Fitomenadion tablet 10 mg tablet
136 615 Flagil / Metronidazol Ovuo 500mg Tablet
137 Fluoksetin 10 mg tablet
138 616 Fluconazole 150 mg tablet
139 617 Fluoride Sediaan Topical/Clinpro Whit botol
140 618 Folley Catheter No. 14 set
141 619 Folley Catheter No. 16 set
142 620 Folley Catheter No. 18 set
143 622 Furosemida tablet 40 mg tablet
144 623 Furosemide 10mg/ml injeksi ampul
145 701 Garam Oralit untuk 200 ml air kantong
146 704 Gentamycin injeksi 80 mg/2 ml vial
147 705 Gentamycin salep kulit tube
148 706 Gentamycin salep mata tube
149 707 Gentamycin tetes mata botol
150 708 Gentian violet larutan 1% botol
151 710 Glass Ionomer Cement set
152 711 Glibenklamida tablet 5 mg tablet
153 Glimepiride 1 mg tablet
154 712 Glimepiride 2 mg tablet
155 713 Gliseril Guayakolat tablet 100 mg tablet
156 714 Gliserin 1 liter botol
157 715 Gliserin 100 ml botol
158 720 Glukosa infus 0,225% - 500 ml botol
159 721 Glukosa lar. infus 10% steril botol
160 722 Glukosa lar. infus 40% steril ampul
161 723 Glukosa lar. infus 5% steril botol
162 724 Griseofulvin tablet 125mg tablet
163 Griseofulvin tablet 500 mg
164 802 Haloperidol tablet 0.5 mg tablet
165 803 Haloperidol tablet 1.5 mg tablet
166 804 Haloperidol tablet 2 mg tablet
167 805 Halopuridol tablet 5 mg tablet
168 Haldol Decanoat 50 mg / ml inj ampul
169 Haloperidol / lodomer Drops 15ml botol
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
170 808 Hidrogen Peroksida / H2O2 botol
171 809 Hidroklortiazida tab 25 mg tablet
172 810 Hidrokortison Krim 2,5% tube
173 901 Ibuprofen suspensi 100 mg/ 5ml botol
174 902 Ibuprofen tablet 200 mg tablet
175 903 Ibuprofen tablet 400 mg tablet
176 904 Imipramine 25 mg tablet
177 906 Infusion set anak set
178 907 Infusion set dewasa set
179 IV Catether No.18 biji
180 IV Catether No.20 biji
181 IV Catether No.22 biji
182 IV Catether No.24 biji
183 Iodina Test Test Kit
184 909 Isoniazid 100 mg kaplet
185 Isoniazid 300 mg kaplet
186 910 Isosorbid Dinitrat tablet 5 mg tablet
187 1101 KA-EN 3B infus - 500 ml botol
188 1103 Kalsium Hidroksida pasta tube
189 1104 Kalsium Laktat tablet 500mg. tablet
190 1105 Kapas pembalut abs 250 gram rol
191 1106 Karbamazepin tablet 200 mg tablet
192 1108 Kasa Hidrofil 16x16 box
193 1109 Kasa kompres steril 40cm/40cm bungkus
194 1110 Kasa pembalut 2 m x 80 cm bungkus
195 1111 Kasa Pembalut 4x10 cm rol
196 1112 Kasa pembalut hidrofil 4mx 3cm rol
197 1113 Kasa pembalut hidrofil 4mx15cm rol
198 1115 Ketokonazol tablet tablet
199 Ketokonazol Krim 2 % Tube
200 1116 Klindamycin kapsul 150 mg kapsul
201 1117 Klindamycin kapsul 300 mg kapsul
202 1119 Kloramfenikol kapsul 250 mg kapsul
203 1120 Kloramfenikol Salep Mata 1% tube
Kloramfenikol sirup - 125 mg/ml
204 1121 botol
-60ml
205 1122 Kloramfenikol tetes mata 0,5% - 5 ml botol
206 1123 Kloramfenikol tetes telinga 3% botol
207 1124 Klorfeniramina Maleat tablet 4mg tablet
208 1125 Klorpromazina HCL inj 25 mg/ml-1ml ampul
209 1126 Klorpromazina HCL tab salut 100 mg tablet
210 1127 Klorpromazina HCL tab salut 25 mg tablet
211 1128 Kodeina tablet. 10mg tablet
212 1129 Kotrimoksazol sirup botol
213 1130 Kotrimoksazol tablet Adult tablet
214 Kotrimoksazol tablet Forte tablet
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
215 1132 Kuinina Sulfat tablet tablet
216 Kombipak Kategori 1 Paket
217 1201 Lanzoprazol kapsul 30 mg kapsul
218 1214 Laxadin sirup 60 ml botol
219 Leukoplast Hospital 7.50 cm x 4.5 m rol
220 1215 Levofloksasin tablet 500 mg tablet
221 1216 Lidocain 2% injeksi ampul
222 1217 Lidokaina Comp. Injeksi 2% ampul
223 1218 Lisol - 1000 ml botol
224 1219 Loperamide tablet - 2mg tablet
225 1220 Loratadin tablet
226 1222 Lytacur 60 ml botol
227 Levotiroksin tab 100mcg tablet
228 Lexavit Kaplet kaplet
229 1301 Magnesium Sulfat injeksi 20% ampul
230 1302 Magnesium Sulfat injeksi 40% ampul
231 1303 Maltodextrin tablet / TABURIA tablet
232 1304 Masker disposable biji
233 1305 Masker Oksigen Dewasa biji
234 1306 Masker Surgical ear loop'50 biji
235 1307 Masker Surgical Plus 3 Ply Plus Earlo biji
236 1308 Masker Surgical tie on'50 biji
237 Masker Disposable (N95)
238 1309 Mebendazol sirup 100 mg/ 5 ml botol
239 1310 Mebendazol tablet 100 mg tablet
240 1315 Meloksikam tablet 15 mg tablet
241 1316 Meloksikam tablet 7,5 mg tablet
242 1317 Metamizole / Norages injeksi 500mg ampul
243 1318 Metaneuron tablet tablet
244 1320 Metformin H Cl tablet 500 mg tablet
245 1321 Metformin HCL tablet 850mg tablet
246 1322 Methylpredhisolon 8 mg tablet
Metilergometrina injeksi 0,2 mg/ml
247 1324 ampul
-1 ml
248 1325 Metilergometrina Maleat tablet tablet
249 1326 Metoclopramide 5 mg tablet
250 1327 Metoklopramid 10 mg tablet
251 1328 Metoklopramid Syrup 60 ml botol
252 1329 Metronidazol 500mg infus vial
253 1330 Metronidazol tablet 250 mg tablet
254 1331 Metronidazol tablet 500 mg tablet
255 1332 Meylon injeksi ampul
256 1334 Mineral mix sachet
257 1336 Monoklorkamfer Mentol cairan botol
258 1337 Mummifying pasta botol
Na ClO 5.,25 % dan CaOCl212 /
259 1401 botol
BYCLIN
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
260 1403 Nasaflam 100 mg tablet
261 1405 Natrium Bikarbonat tablet 500 mg tablet
262 1406 Natrium Diklofenak 50 mg tablet
263 1407 Natrium Klorida larutan infus 0.9% botol
264 1412 Neo Kaominal sirup botol
265 1413 Neurobat injeksi ampul
266 1415 Neurosanbe 5000 tablet tablet
267 1416 Nifedipin 10 mg tablet tablet
268 1417 Nistatin 100.000 IU suspensi botol
269 1418 Nistatin 100.000 IU/g tablet vaginal tablet
270 1419 Nistatin 500.000 IU/g tablet oral tablet
271 1501 Obat Antituberkulosis kat - Anak paket
272 1502 Obat Antituberkulosis kat - I paket
273 1503 Obat Antituberkulosis kat -II paket
274 1504 Obat Batuk Hitam cairan 100ml botol
275 1505 OBAT KUSTA M B anak strip
276 1506 OBAT KUSTA M B dewasa strip
277 1507 OBAT KUSTA P B anak strip
278 1508 OBAT KUSTA P B dewasa strip
279 1509 Obat Malaria tablet tablet
280 1510 OBH Tropica Exta Mentol 60 ml botol
281 1511 OBH Tropica Plus Anak Jeruk 60 ml botol
282 1512 OBH Tropica Plus Mentol 60 ml botol
283 1513 Obyek Glass pcs
284 1515 Oksigen Gas dalam tabung - 1m3 tabung
285 1516 Oksigen Gas dalam tabung - 6m3 tabung
286 1518 Oksitetrasiklina HCL salep kulit 3 % tube
287 1519 Oksitetrasiklina HCL salep mata 1% tube
288 1520 Oksitosina injeksi 10 IU/ml-1ml ampul
289 1521 Omeprazol kapsul kapsul
290 1522 Ondansetron tab 4 mg tablet
291 1523 Ondansetron tab 4 mg/2 ml Inj - Ktk 5 ampul
292 Oxyflow Nasal Oxygen Anak biji
293 Oxyflow Nasal Oxygen Dewasa biji
294 Oxyflow Nasal Oxygen Bayi biji
295 1603 Paracetamol Drop botol
296 1604 Parasetamol sirup 120 mg/5ml botol
297 1606 Parasetamol tablet 500 mg tablet
298 1609 Permetrin Krim 5% / Scabimite tube
299 1610 Petidina HCL injeksi 50 mg/ml-2ml ampul
300 1612 Pewarna Ziehl-Neesen / 1 set botol
301 1614 Piracetam 800 mg tablet tablet
302 1615 Piracetam inj 1 gram/5ml ampul
303 1616 Pirantel Pamoat tablet 125 mg tablet
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
304 1617 Pirantel Susp 125mg / 5 ml botol
305 1618 Piridoksina HCL tablet 10mg tablet
306 Piridoksina HCL tablet 25 mg
307 1619 Piroxicam 20 mg kapsul
308 1621 Plester 5 yard x 2 inch rol
309 1622 Plester Flexible non woven 5 x 5 rol
310 1623 Plester Kain Roll 1,25cm x 4,5m rol
311 1624 Plester Kain Roll 2,5cm x 4,5m rol
312 1625 PM-ASI Biskuit bungkus
313 1626 PMT Untuk BUMIL bungkus
314 1627 PMT-AS biskuit bungkus
Polikresulen ( Metakresolsulfonat ) -
315 1628 botol
10 ml
316 1630 Prednison tablet 5 mg tablet
317 1635 Prokaina Pen. G injeksi 3 juta IU vial
318 1636 Propanolol HCL tablet 10 mg tablet
319 1637 Propanolol HCL tablet 40 mg tablet
320 1638 Propiltiourasil tablet 100 mg tablet
321 1701 Ranitidin 150 mg tablet
322 1702 Ranitidin 50 mg / 2 ml Inj ampul
323 1703 RDT Malaria card
324 1716 Renadinac 25 mg kaplet
325 1718 Retinol kap. lunak 100.000 IU kapsul
326 1719 Retinol kap. lunak 200.000 IU kapsul
327 1723 Ringer Asetat infus - 500ml botol
Ringer Laktat + Glucose 5% infus-
328 1724 botol
500ml
329 1725 Ringer Laktat Larutan infus - 500 ml botol
330 1726 Risperidone 2 mg tablet
331 1801 Safe Glove Exam L set
332 1802 Safe Glove Exam M set
333 1803 Safe Glove Exam S set
334 1804 Safety box set
335 1805 Sakaneuron tablet tablet
336 1806 Salbutamol 2 mg tablet
337 1807 Salbutamol 4 mg tablet
Salep 2-4 DOEN (As.Salisilat 2%
338 1808 pot
+Belerang Endap 4%)
339 1809 Salisil Bedak 2% - 50 gram kotak
340 1810 Sarung Tangan Obgyn ( STERIL ) set
341 1812 Semen Seng Fosfat set
342 1813 Semillas Non Woven 5x500cm rol
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
343 1815 Serum Anti Bisa Ular injeksi (ABU I) vial
344 1816 Serum Anti Dipteri injeksi 20.000 IU vial
345 1817 Serum Anti Tetanus injeksi 1.500 IU ampul
346 1818 Serum Anti Tetanus injeksi 20.000 IU vial
347 1819 Serum Kontrol kit
348 1820 Sianokobalamina (Vit B12) injeksi ampul
349 1821 Sikzonoate injeksi 25 mg /ml ampul
350 1822 Silk no 2/0, 24x13x60 cm sachet
351 1823 Silk no 3/0, 24x13x60 cm sachet
352 1824 Silver Amalgam serbuk 65-75% botol
353 1825 Simvastatin tablet 10 mg tablet
354 Spashi - Injeksi ampul
355 Spasminal tablet tablet
356 1830 Spironolactone 25 mg tablet
357 1831 Spons Gelatin cubicles 1x1x1cm biji
358 1834 Stesolid Rectal 10 mg/2,5 ml tube
359 1835 Stesolid Rectal 5 mg/2,5 ml tube
360 1837 Stolax /Bisakodil Supp 10mg tablet
361 1841 Sulfasetamida tetes mata 15% botol
362 1842 Surgical glove no. 6 set
363 1843 Surgical Glove No. 7 set
364 1844 Surgical Glove No. 7,5 set
365 1845 Surgical Glove No. 8 set
366 Semilas Non Woven 10x 500cm rol
Tablet Tambah Darah (Besi II Sulfat)
367 1901 tablet
tab.300mg
368 1903 Temporary Stopping Fletcher set
369 1904 Teosal tablet tablet
370 1911 Tetrasiklina HCl kapsul 500 mg kapsul
371 1912 Thiampenicol Sirup botol
372 1913 Thiamphenicol 500 mg kapsul
373 1914 Three way Stop Cock pcs
374 1915 Tiamina (Vit B1) tablet 100 mg tablet
375 1916 Tiamina (Vit B1) tablet 50 mg tablet
376 1917 Tiamina HCL injeksi 100mg/ml ampul
377 1919 Topical Anastesi Gel/Prime Gel
378 1920 Tramadol injiksi 50 mg/ml ampul
379 1921 Tramadol kapsul 50 mg tablet
380 1922 Transfusion set set
381 1923 Trifluoperazin 5 mg / Stesoli tab tablet
382 1924 Trigliserida ( 3X50 ST ) kit
383 1925 Triheksifenidil Hcl tablet - 2 mg tablet
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
Trikresol Formalin (Forinokresol)
384 1926 botol
cairan - 10 ml
385 2002 Umbilical Cord biji
386 2003 Underpad biji
387 2004 Urine bag set
388 2005 Uriscan Gen 11 / 10 Parameter botol
389 2006 Uriscan Glucose 1 kit
390 2007 Uriscan GP2 for Reduksi + Albumin kit
391 USG Gel 250 ml Botol
392 USG Gel 5 liter Botol
393 2101 Vaselin Alba botol
394 2102 Ventolin / Salbutamol Inhaler 0,5 % botol
Ventolin Nebules /Salbutamol
395 2103 ampul
Cairan 2,5 mg
396 Voluven - Koloid HES BM 130.000 LarBotol
397 2201 Vitamin B Kompleks tablet tablet
398 2302 Wida D5 1/2 NS botol
399 2303 Wing Needle bayi no.25 biji
400 2501 Yodium Povidon 10% - 30 ml botol
401 2502 Yodium Povidon 10% - 300 ml botol
402 Yodium Povidon 1000 ml
403 2602 ZINC tablet 20 mg tablet
404 2603 Zircum KID sirup botol
405 2604 Zoralin tablet
406 PROGRAM IMUNISASI
407 2701 Pelarut BCG ampul
408 2704 Vaksin MR ampul
409 2706 Vaksin DPT Hb - Hib / PENTABIO vial
410 2707 Vaksin Polio bOPV 10 Dosis ampul
411 2708 Vaksin DT vial
412 2709 Vaksin HB Unijeck vial
413 Vaksin Polio IPV 5 Dosis ampul
414 2711 Vaksin Td vial
415 2712 Vaksin TT vial
416 2713 Vaksin Meningitis vial
417
418
419 PROGRAM IMS
420 2801 Alcohol Swab
421 2802 Cotton Applicators Sterile
422 2803 Cover Glass
423 2804 Hand Gloves
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
424 2805 Immersion Oil
425 2806 Kertas PH 3,8 - 4,2
426 2807 KOH 10%
427 2808 Methylated Spirit
428 2809 Methylen Blue 0.3%
429 2810 Nacl 0.9%
430 2811 Object Glass
431 2812 Reagen Sifilis RPR/kit (10ml untk 500 test)
432 2813 Reagen Sifilis TPHA
433 2814 Vaculab/Tabung darah plastic tutup merah
434 2815 Xylol
435 2816 Yellow dan Blue Tip
436 Reagen Rapid syphilis/Standar Diagno @ 100
437 Performa Test Strips/ Stik GDA ACCU
438 Safe-T Pro Uno
439 Focus TPHA Test
440 Total Hardness: 12-537 mg/ L CaCO3
441 Stip Glukosa Merk Easytouch
442 Stip Urid Acid Merk Easytouch
443 Stip Colesterol Merk Easytouch
444 Asam Cuka 25 %
445 Autocheck total Kolesterol 10 Strip
446 Spekulum Disposble
447 Cotton swab
448 Larutan Chlorine
449 Sputum Pot pct
450 Paket Alat Deteksi Resiko Kehamilan Paket
451 Catridge TCM PCS
452 Gluco Protein Piece
453 Tube EDTA plh 13x75 3,0 blblce lav set
454 Ultra Once Test Hamil Piece
455 3002 Widal Salmonella Thypi O Antigen A vial
456 3003 Widal Salmonella Thypi O Antigen B vial
457 3004 Widal Salmonella Thypi O Antigen C vial
458 3005 Widal Salmonella Thypi O vial
459 3006 Widal Salmonella Thypi H Antigen A vial
460 3007 Widal Salmonella Thypi H Antigen B vial
461 3008 Widal Salmonella Thypi H Antigen C vial
462 3009 Widal Salmonella Thypi H vial
463 3010 Control Positive Polyvalent vial
464 3011 Control Negatif Polyvalent box
465 3012 HBsAg Strip Tes box
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
466 3013 HBsAb Strip Tes box
467 3014 Determine HIV box
468 3015 Rapid Syphilis box
469 3016 ICT Malaria box
470 3018 Golongan Darah Anti A vial
471 3019 Golongan Darah Anti B vial
472 3020 Golongan Darah Anti AB vial
473 3021 Golongan Darah Anti D vial
474 709 Reagen Giemsa + Buffer Giemds botol
475 1836 Stick Urine 10 PM stick
476 1839 Strip Urine 11 PM tube
477 1840 Strip Urine 3 PM tube
478
479
480
481
482
483 Pengecatan
484 3101 Brilliant Cresyl Blue 1 % botol
485 3102 Giemsa botol
486 3103 Larutan Drabkin botol
487 3104 Larutan Eosin 2 % botol
488 3105 Larutan Turk botol
489 3106 Oil Imersion botol
490 3107 Pewarna Gram set
Pewarna Rapid/ sediaan apus darah
491 3108 set
tepi/MDT
492 3109 Pewarna Ziehl Nellsen set
493 3110 Xylol botol
494 PROGRAM HIV
495 1905 Tes HIV I (Oncoprobe ) set
496 1906 Tes HIV II ( Intech Triline ) ) set
497 1907 Tes HIV III (Vikia ) set
498 Reagen I SD Bioline HIV 1/2
499 Reagen I Intec One Step Anti HIV Tri Line Tes Carrd
500 Reagen Penghitung CD 4
501 Reagen Penghitung CD 4 Control
502 Catridge TCM PCS
503 Efavirenz (EFV) 600mg
504 Nevirapine ( NVP ) 200mg
 No. No. STOK PENERIMA PERSEDIA PEMAKAI SISA STOK PERMINTA PEMBERIAN
NAMA OBAT SATUAN KET.
URUT KODE AWAL AN AN AN STOK OPT. AN DAK BPJS PROG LAIN-2 TOTAL
1 2 3 4 5 6 7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15 16 17
Zidofudine ( ZDV ) 300mg +
505
Lamivudine ( 3TC ) 150mg
Tenofovir 300+Lamivudin
506
300+Efavien 600 Dewasa
Zidofudine ( ZDV ) 60mg +
507 Lamivudine 30mg+Nevirapine 50mg
( Triple FDC ) Anak
508 Zidofudine (ZDV ) 100 mg tablet tablet
509 Tenofovir 300 mg tablet tablet
510 Efavirenz (EFV) 200 mg
Tenofovir 300 mg + Emcitritabine
511 tablet
200 (FCT)
512 Abacavir (ABC) 300 mg tablet
513 Lamivudine 150 mg tablet tablet
514 Right Sign
Verorab Serum

UMUM BPJS LAIN-LAIN JUMLAH

KUNJUNGAN RESEP
-----------------,---------------------------------

Mengetahui/menyetujui Yang menyerahkan Yang melaporkan/meminta Yang menerima

Kepala Instalasi Farmasi Sie Penyimpanan & Penyaluran Kepala Puskesmas Pengelola Obat Puskesmas
Kabupaten Jember IFK Jember ……………………………………

____________________________
NIP. NIP. NIP. NIP.
 KOP PUSKESMAS

BERITA ACARA STOK OPNAME OBAT DAN PERBEKALAN KESEH

PUSKESMAS ………………………………..

Pada tanggal…..bln….s/d….. Bln….2017, telah melaksanakan Stok Opname seluruh barang p

kesehatan seseuai daftar di bawah ini

STOK
NO. NO. AWAL
URUT
NAMA OBAT SATUAN PER 1
LPLPO
JAN 2017

1 2 3 4

1 101 Air raksa dental use botol -

2 102 Alat suntik sekali pakai 1 ml set -
3 103 Alat suntik sekali pakai 2,5 ml set -
4 104 Alat suntik sekali pakai 5 ml set -
5 105 Albendazol tablet 400 mg tablet -
6 106 Alopurinol tablet tablet -
7 107 Aminofilina tablet 200 mg tablet -
8 108 Aminofilina injeksi 24mg/ml-10ml ampul -
9 109 Amitriptilina HCL tablet 25 mg tablet -
10 110 Amoksilin Sirup Kering botol -
11 111 Amoksilin kapsul - 250 mg kapsul -
12 112 Amoksilin kaplet - 500 mg kaplet -
13 113 Ampisilina Sirup Kering botol -
14 114 Antalgin tablet 500mg tablet -
15 115 Antalgin injeksi 24 mg/ml-10ml ampul -
16 116 Antasida Doen tablet tablet -
17 117 Antibakteri DOEN (Basitrasin + Polimiksin) tube -
18 118 Anti Hemmoroid Suppositoria supp -
Antifungi DOEN (As Benzoat 3%+As Salisilat -
19 119 pot
6%)
20 120 Antimigren DOEN (Ergotamina Trt + Kofeina) tablet -
21 121 Aqua pro injeksi steril - 20 ml ampul -
22 122 Aquadest steril - 500 ml botol -
23 123 Asam Askorbat (vit C) tablet 250 mg tablet -
24 124 Asam Askorbat (vit C) tablet 50 mg tablet -
25 125 Asetosal tablet 100 mg tablet -
26 126 Asetosal tablet 500 mg tablet -
27 127 Atropina Sulfat injeksi ampul -
28 128 Atropina Sulfat tablet 0,5 mg tablet -
29 201 Benzatin Bensil Pen.inj 1,2 juta 1U vial -
30 202 Benzatin Bensil Pen.inj 2,4 juta IU vial -
31 203 Besi sirup botol -
32 204 Betametason krim tube -
33 301 Catgut Chrom 2/0 + jarum sachet -
34 404 Deksametason Injeksi 5mg/ml ampul -
35 405 Deksametason tablet 0,5 mg tablet -
36 406 Dekstrometorfan HBr sirup botol -
37 407 Dekstrometorfan HBr tablet 15 mg tablet -
38 408 Devitalisasi pasta botol -
39 409 Diazepam Injeksi 5mg/ml-2ml ampul -
40 410 Diazepam tablet 2 mg tablet -
41 411 Diazepam tablet 5 mg tablet -
42 412 Difenhidramina HCL injeksi 10 mg ampul -
43 413 Digoksina tablet 0,25 mg tablet -
44 501 Efedrina HCL tablet 25mg tablet -
45 502 Ekstrak Belladon tablet 10mg tablet -
46 503 Epinefrina HCL/Bitart injeksi 0.1% - l ml ampul -
47 504 Etakridina larutan 0,1%-300ml botol -
48 505 Etanol 70% - 1000 ml botol -
49 506 Etil Klorida semprot botol -
50 507 Eugenol Cairan - 10 ml botol -
51 601 Fenitoina Natrium kapsul 100mg kapsul -
52 602 Fenitoina Natrium kapsul 30 mg kapsul -
53 603 Fenobarbital Injeksi 50mg/ml-2ml ampul -
54 604 Fenobarbital tablet 100 mg tablet -
55 605 Fenobarbital tablet 30 mg tablet -
56 606 Fenoksimetil Penisilina tablet 250 mg tablet -
57 607 Fenoksimetil Penisilina tablet 500 mg tablet -
58 608 Fitomenadion injeksi 10mg/ml ampul -
59 609 Fitomenadion tablet 10 mg tablet -
60 610 Fitomenadion injeksi 2 mg/ml ampul -
61 611 Furosemida tablet 40 mg tablet -
62 701 Gameksan emulsi 1% - 100 ml botol -
63 702 Garam Oralit untuk 200 ml air kantong -
64 703 Gentian violet larutan 1% botol -
65 704 Glass Ionomer Cement set -
66 705 Glibenklamida tablet 5 mg tablet -
67 706 Gliseril Guayakolat tablet 100 mg tablet -
68 707 Glukosa lar. infus 10% steril botol -
69 708 Glukosa lar. infus 40% steril ampul -
70 709 Glukosa lar. infus 5% steril botol -
71 710 Griseofulvin tablet 125mg tablet -
72 801 Haloperidol tablet 0.5 mg tablet -
73 802 Haloperidol tablet 1.5 mg tablet -
74 803 Hidroklortiazida tab 25mg tablet -
75 804 Hidrokortison Krim 2,5% tube -
76 901 Ibuprofen tablet 200 mg tablet -
 77 902 Ibuprofen tablet 400 mg tablet -
78 903 Infusion set anak set -
79 904 Infusion set dewasa set -
80 905 Iodiol kapsul lunak kapsul -
81 906 Isosorbid Dinitrat tablet 5 mg tablet -
82 1101 Kalium Permanganat serbuk botol -
83 1102 Kalsium Hidroksida pasta tube -
84 1103 Kalsium Laktat tablet 500mg. tablet -
85 1104 Kapas Alkohol (Isopas) kotak -
86 1105 Kapas pembalut abs 250 gram rol -
87 1106 Karbamazepin tablet 200 mg tablet -
88 1107 Kasa kompres steril 40cm/40cm bungkus -
89 1108 Kasa pembalut 2 m x 80 cm bungkus -
90 1109 Kasa pembalut hidrofil 4mx15cm rol -
91 1110 Kasa pembalut hidrofil 4mx 3cm rol -
92 1111 Kloramfenikol kapsul 250 mg kapsul -
93 1112 Kloramfenikol Salep Mata 1% tube -
94 1113 Kloramfenikol tetes telinga 3% botol -
95 1114 Klorfeniramina Maleat tablet 4mg tablet -
96 1115 Klorpromazina HCL inj 25 mg/ml-1ml ampul -
97 1116 Klorpromazina HCL tab salut 100 mg tablet -
98 1117 Klorpromazina HCL tab salut 25 mg tablet -
99 1118 Kodeina tablet. 10mg tablet -
100 1119 Komb. Pirimetamin 25 mg + Sulfadoksin tablet tablet -
101 1120 Kotrimoksazol tablet Pediatrik tablet -
102 1121 Kotrimoksazol sirup botol -
103 1122 Kotrimoksazol tablet Adult tablet -
104 1123 Kuinina Dihidroklorida injeksi ampul -
105 1124 Kuinina Sulfat tablet tablet -
106 1201 Larutan Benedict - 100 ml botol -
107 1202 Larutan Eosin 2 % - 100 ml botol -
108 1203 Larutan Etanol Asam - 100 ml botol -
109 1204 Larutan Giemsa Stain - 100 ml botol -
110 1205 Larutan Karbol Fuksin - 100 ml botol -
111 1206 Larutan Kinyoun - 100 ml botol -
112 1207 Larutan Gabbet - 100 ml botol -
113 1208 Larutan Metilen Biru - 100 ml botol -
114 1209 Larutan Turk - 100 ml botol -
115 1210 Lidokaina Comp. Injeksi 2% ampul -
116 1211 Lisol - 1000 ml botol -
117 1301 Magnesium Sulfat injeksi 20% ampul -
118 1302 Magnesium Sulfat injeksi 40% ampul -
119 1303 Magnesium Sulfat serbuk 30 gram sachet -
120 1304 Mebendazol sirup 100mg/5 ml botol -
121 1305 Mebendazol tablet 100 mg tablet -
122 1306 Metanol - 100 ml botol -
123 1307 Metilergometrina Maleat tablet tablet -
124 1308 Metilergometrina injeksi 0,2 mg/ml - 1 ml ampul -
125 1309 Metronidazol tablet 250 mg tablet -
126 1310 Metronidazol tablet 500 mg tablet -
127 1311 Monoklorkamfer Mentol cairan botol -
128 1312 Mummifying pasta botol -
129 1401 Natrium Bikarbonat tablet 500 mg tablet -
130 1402 Natrium Klorida larutan infus 0.9% botol -
131 1403 Nistatin 100.000 IU/g tablet vaginal tablet -
132 1404 Nistatin 500.000 IU/g tablet oral tablet -
133 1501 Obat Antituberkulosis kat - I paket -
134 1502 Obat Antituberkulosis kat -II paket -
135 1503 Obat Antituberkulosis kat -III paket -
136 1504 Obat Antituberkulosis kat -Sisipan paket -
137 1505 Obat Antituberkulosis kat - Anak paket -
138 1506 Obat Batuk Hitam cairan 100ml botol -
139 1507 Oksigen Gas dalam tabung - 6m3 tabung -
140 1508 Oksitetrasiklina HCl injeksi 50 mg/ml vial -
141 1509 Oksitetrasiklina HCL salep kulit 3 % tube -
142 1510 Oksitetrasiklina HCL salep mata 1% tube -
143 1511 Oksitosina injeksi 10 IU/ml-1ml ampul -
144 1601 Parasetamol sirup 120 mg/5ml botol -
145 1602 Parasetamol tablet 100 mg tablet -
146 1603 Parasetamol tablet 500 mg tablet -
147 1604 Perfenazin tablet 16 mg tablet -
148 1605 Perfenazin tablet 4 mg tablet -
149 1606 Petidina HCL injeksi 50 mg/ml-2ml ampul -
150 1607 Pirantel Pamoat tablet 125mg tablet -
151 1608 Piridoksina HCL tablet 10mg tablet -
152 1609 Plester 5 yard x 2 inch rol -
153 1610 Polikresulen ( Metakresolsulfonat ) - 10 ml botol -
154 1611 Prednison tablet 5 mg tablet -
155 1612 Primakina tablet 15 mg tablet -
156 1613 Prokaina Pen. G injeksi 3 juta IU vial -
157 1614 Propiltiourasil tablet 100 mg tablet -
158 1615 Propanolol HCL tablet 10 mg tablet -
159 1616 Propanolol HCL tablet 40 mg tablet -
160 1801 Reserpina tablet 0,25 mg tablet -
161 1802 Retinol kap. lunak 100.000 IU kapsul -
162 1803 Retinol kap. lunak 200.000 IU kapsul -
163 1804 Rifampisin Tablet 600 mg tablet -
164 1805 Rifampisin Kapsul 300 mg kapsul -
165 1806 Rifampisin Kapsul 450 mg kapsul -
166 1807 Ringer Laktat Larutan infus - 500 ml botol -
167 1901 Salbutamol tablet tablet -
Salep 2-4 DOEN (As.Salisilat 2%+Belerang -
168 1902 pot
Endap 4%)
169 1903 Salisil Bedak 2% - 50 gram kotak -
170 1904 Semen Seng Fosfat set -
171 1905 Serum Anti Bisa Ular injeksi (ABU I) vial -
172 1906 Serum Anti Dipteri injeksi 20.000 IU vial -
173 1907 Serum Anti Tetanus injeksi 1.500 IU ampul -
174 1908 Serum Anti Tetanus injeksi 20.000 IU vial -
175 1909 Sianokobalamina (Vit B12) injeksi ampul -
176 1910 Silk no 2/0, 24x13x60 cm sachet -
177 1911 Silver Amalgam serbuk 65-75% botol -
178 1912 Spons Gelatin cubicles 1x1x1cm biji -
179 1913 Streptomisina Sulfat injeksi 1gram vial -
180 1914 Sulfadimidin tablet 500 mg tablet -
181 1915 Sulfasetamida tetes mata 15% botol -
182 2001 Tablet Tambah Darah (Besi II Sulfat) tab.300mg tablet -
183 2002 Temporary Stopping Fletcher set -
184 2003 Tetrasiklina HCl kapsul 250mg kapsul -
185 2004 Tetrasiklina HCl kapsul 500 mg kapsul -
186 2005 Tiamina HCL injeksi 100mg/ml ampul -
187 2006 Tiamina (Vit B1) tablet 50 mg tablet -
188 2007 Triheksilfenidil Hcl tablet - 2 mg tablet -
189 2008 Trikresol Formalin (Forinokresol) cairan - 10 ml botol -
190 2201 Vitamin B Kompleks tablet tablet -
191 2501 Yodium Povidon 10% - 30 ml botol -
192 2502 Yodium Povidon 10% - 300 ml botol -
193 1029 Acyclovir krim tube -
194 1030 Acyclovir tablet - 200 mg tablet -
195 1031 Acyclovir tablet - 400 mg tablet -
196 1032 Alkohol 95 % botol -
197 1033 Alkohol Swab dos -
198 1034 Ambroxol sirup 60 ml botol -
199 1035 Ambroxol tablet 30 mg tablet -
200 1036 Amlodipin 10 mg tablet -
201 1037 Amphotericin B 50mg / vial vial -
202 1038 Ampisilina injeksi 1 gram vial -
203 1039 Ancla Ds botol -
204 1040 Antasi DOEN II Suspensi,Kombi botol -
205 1041 Aquadest steril - 1000 ml botol -
206 1042 Asam Mefenamat kaplet 500 mg kaplet -
207 1043 Asam tranexamat injeksi 100mg/ml ampul -
208 1044 AsamTraneksamat HCL tablet 500mg tablet -
209 1045 Azitromicin 250 mg tab tablet -
210 1046 Azitromicin 500 mg tab tablet -
211 205 Betahistin Mesilat 6 mg tablet -
212 206 Betametason N crem tube -
213 207 Bexicom Kaplet Kaplet -
214 208 Bidicef 500 mg kapsul -
215 209 Bidicef DS Syrup botol -
216 210 Biomin-AFZ tablet -
217 211 Bisoprolol tablet 5 mg tablet -
218 212 Bist Mess No.24 set -
219 213 Blood Lancet set -
220 214 Bunofa 400 kaplet -
221 215 Buscopan injeksi ampul -
222 302 Calcium Gluconas infus botol -
223 303 Captopril tablet 25 mg tablet -
224 304 Carpiaton 100 mg tablet -
225 305 Cefadroxil kapsul 500 mg kapsul -
226 306 Cefixime 100mg tablet -
227 307 Cefotaxim injeksi vial -
228 308 Cetirizine Kapsul 10mg kapsul -
229 309 Chlorhexidine gluconat 0,2% / ASEPTAN botol -
Chlorhexidine gluconat 4% 500 cc + dispenser / -
230 310 botol
ONE SCROB
231 311 Cimetidin tablet 200 mg tablet -
232 312 Clorin / One Clean botol -
233 313 Colfin Syrup botol -
234 314 Composit Light Curing A2 syringe -
235 315 Composit Light Curing A3 syringe -
236 316 Composit Light Curing A3,5 syringe -
237 317 Coredryl sirup botol -
238 318 Corsafen 500 mg kapsul -
239 319 Cotrimoxazole 480 mg / 5 ml / vial vial -
240 320 Cresopen (obat gigi) botol -
241 321 Cronitin tablet tablet -
242 322 Cyprofloxacin kapsul 500 mg kapsul -
243 414 Decullin tablet 30mg tablet -
244 414 Demacolin tablet tablet -
245 415 Dercason krem tube -
246 416 Dermazin salep kulit 1% - 25gram /BioplaN tube -
247 417 Dextran infus - 500 ml botol -
248 418 Diethylcarbamazine tablet -
249 419 Doksisiklin kapsul 100 mg kapsul -
250 420 Domperidon tablet 10 mg tablet -
251 508 Envios - FB botol -
252 509 Erithromicin kaplet 500 mg kaplet -
253 510 Erithromicin kapsul 250 mg kapsul -
254 511 Erithromicin sirup - 60 ml botol -
255 512 Etching+bonding Liquit SDI set -
256 513 Ethambutol 250 mg tablet -
257 514 Ethambutol 500 mg tablet -
258 612 Fenol Gliserol tetes telinga botol -
259 613 Fluconazole 150 mg tablet -
260 614 Folinic Acid 5 mg tablet -
261 615 Formaten 25 mg tablet -
262 616 Farmoten 12,5 mg tablet -
263 711 Gastrusid Blister tablet -
264 712 Gastrusid sirup - 60ml botol -
265 713 Gentamycin injeksi 80mg/2ml vial -
266 714 Gentamycin salep kulit tube -
267 715 Gentamycin tetes mata botol -
268 716 Gliseril 1 liter botol -
269 717 Gludepatic tablet -
270 718 Glukosa infus 0,225% - 500 ml botol -
271 805 Hidrogen Peroksida / H2O2 botol -
272 806 Holimol Kaplet Kaplet -
273 907 Ibuprofen suspensi 100mg/ 5ml botol -
274 1125 KA-EN 3B infus - 500 ml botol -
275 1126 Ketokonazol tablet tablet -
276 1127 Klindamycin Injeksi 150 mg /4 ml ampul -
277 1128 Klindamycin kapsul 150 mg kapsul -
278 1129 Klindamycin kapsul 300 mg kapsul -
279 1130 Kloramfenikol injeksi 1gram vial -
280 1131 Kloramfenikol sirup - 125 mg/ml -60ml botol -
281 1132 Kloramfenikol tetes mata 0,5% - 5 ml botol -
282 1212 Lanzoprazol kapsul 30 mg kapsul -
283 1213 Laxadin sirup 60 ml botol -
284 1214 Levofloksasin tablet 500 mg tablet -
285 1215 Lidocain 2% injeksi ampul -
286 1216 Lisinopril tablet - 5mg tablet -
287 1217 Livron B-Plex tablet -
288 1218 Loperamide tablet - 2mg tablet -
289 1313 Maltodextrin tablet / TABURIA tablet -
290 1314 Meloksikam tablet 15 mg tablet -
291 1315 Meloksikam tablet 7,5 mg tablet -
292 1316 Metamizole / Norages injeksi 500mg ampul -
293 1317 Metaneuron tablet tablet -
294 1318 Metformin H Cl tablet 500 mg tablet -
295 1319 Metformin HCL tablet 850mg tablet -
296 1320 Methylpredhisolon 16mg tablet -
297 1321 Metidrol tablet -
298 1322 Metoklopramid injeksi 5mg/ml ampul -
299 1323 Metoklopramid Syrup 60ml botol -
300 1324 Metoklopramid tablet 10 mg tablet -
301 1325 Metronidazol 500mg infus vial -
302 1326 Meylon injeksi ampul -
303 1327 Miconazol 2% salep kulit tube -
304 1405 Na ClO 5.,25 % dan CaOCl212 / BYCLIN botol -
305 1406 Nasaflam 100 mg tablet -
306 1407 Nasaflam 50 mg tablet -
307 1408 Natrium Diklofenak 50 mg tablet -
308 1409 Neo Kaominal sirup botol -
309 1410 Neuralgin Rx kaplet -
310 1411 Neurobat injeksi / Bioneuron ampul -
311 1412 Neurotropic Plus kaplet -
312 1413 Neuroval kaplet kaplet -
313 1414 Nifedipin 200 mg tablet tablet -
314 1512 OBAT KUSTA M B anak strip -
315 1513 OBAT KUSTA M B dewasa strip -
316 1514 OBAT KUSTA P B anak strip -
317 1515 OBAT KUSTA P B dewasa strip -
318 1516 Omeprazol kapsul kapsul -
319 1617 Papaverine injeksi 40mg/ml ampul -
320 1618 Papaverine tablet 40 mg tablet -
321 1619 Paracetamol Drop botol -
322 1620 Piracetam inj 1 gram/5ml ampul -
323 1621 Piroxicam 20 mg kapsul -
324 1622 Prenase Caps kaplet -
325 1623 Prenatin Plus tablet -
326 1624 Procurma Plus Syrup botol -
327 1625 Pyrimethamine 25 mg tablet -
328 1808 Renadinac 25 mg kaplet -
329 1809 Ringer Asetat infus - 500ml botol -
330 1810 Ringer Laktat + Glucose 5% infus-500ml botol -
331 1916 Sakaneuron tablet tablet -
332 1917 Salbutamol tablet 4 mg tablet -
333 1918 Scabicid salep kulit tube -
334 1919 Simvastatin tablet 10 mg tablet -
335 1920 Solvita sirup - 60 ml botol -
336 1921 Solvitral kaplet kaplet -
337 1922 Sotatic tablet -
338 1923 Spasmal tablet tablet -
339 1924 Stesolid Rectal 5 mg/2,5 ml tube -
340 1925 Sulfadiazin tablet 500 mg tablet -
341 2009 Tamiflu (Oseltamivir) kapsul kapsul -
342 2010 Teosal tablet tablet -
343 2011 Thiampenicol Sirup botol -
344 2012 Thiamphenicol 500 mg kapsul -
345 2013 Tramadol injiksi 50mg/ml ampul -
346 2014 Tramadol kapsul 50 mg tablet -
347 2101 Ulsikur/ Ulcumet injeksi 200mg ampul -
348 2202 Vical suspensi 60 ml botol -
349 2301 Wida D5 1/2 NS botol -
350 2401 Xylomidon inj vial -
351 2601 ZINC tablet 20mg tablet -
352 2602 Zoralin tablet -
353 216 Bidan Kid set -
354 323 Catgut Chrom 3/0 + jarum sachet -
355 324 Catgut Plain 2/0 + jarum sachet -
356 325 Catgut Plain 3/0 + jarum sachet -
357 326 Celemek buah -
358 617 Feeding tube No. 10 set -
359 618 Feeding tube No. 16 set -
360 619 Feeding tube No. 5 set -
361 620 Feeding tube No. 8 set -
362 621 Folley Catheter No. 14 set -
363 622 Folley Catheter No. 16 set -
364 623 Folley Catheter No. 18 set -
365 719 Gynaecology gloves/ OBGYN set -
366 1001 Jarum Jahit Bedah No. 12 biji -
367 1002 Jarum Jahit Bedah No. 13 biji -
368 1003 Jarum Jahit Bedah No. 14 biji -
369 1133 Kasa Hidrofil 16x16 box -
370 1134 Kassa Pembalut 4x10cm rol -
371 1328 Masker disposable biji -
372 1329 Masker Oksigen Dewasa biji -
373 1330 Masker Surgical ear loop'50 biji -
374 1331 Masker Surgical tie on'50 biji -
375 1332 Medicut No. 18 biji -
376 1333 Medicut No. 20 biji -
377 1334 Medicut No. 22 biji -
378 1335 Medicut No. 24 biji -
379 1415 Nelato Catether No. 12 set -
380 1416 Nelato Catether No. 14 set -
381 1417 Nelato Catether No. 16 set -
382 1418 Nelato Catether No. 18 set -
383 1517 Oksigen Gas dalam tabung - 1m3 tabung -
384 1626 Plaster Flexible non woven 5 x 5 rol -
385 1627 Plaster Kain Roll 1,25cm x 4,5m rol -
386 1628 Plaster Kain Roll 2,5cm x 4,5m rol -
387 1926 Sarung Tangan Obgyn ( STERIL ) set -
388 1927 Silk no 3/0, 24x13x60 cm sachet -
389 1928 Sketsel set -
390 1929 Spuit 10 ml set -
391 1930 Surgical glove no. 6 set -
392 1931 Surgical Glove No. 7 set -
393 1932 Surgical Glove No. 7,5 set -
394 1933 Surgical Glove No. 8 set -
395 2015 Timbangan Dacin biji -
396 2016 Transfusion set set -
397 2102 Underpad biji -
398 2103 Urine bag set -
399 2302 Wing Needle bayi no.25 biji -
400 1047 Autodisposable Syringe 0,05 ml set -
401 1048 Autodisposable Syringe 0,5 ml (Soloshot) set -
402 1049 Autodisposable Syringe 10 ml set -
403 1050 Autodisposable Syringe 2 ml (Soloshot) set -
404 1051 Autodisposable Syringe 5 ml (Soloshot) set -
405 1034 Safety box set -
406 1336 Mineral mix sachet -
407 1337 MP-ASI biskuit sachet -
408 1629 PMT Untuk BUMIL dos -
409 2203 VINERAL Biskuit kotak -
410 2204 VINERAL SOYA Susu kotak -
411 2205 VINERAL Susu kotak -
412 421 Depo Progestin Injeksi 3 bln Vial -
413 908 Implant KB / Levenogestrel 75 mg Vial -
414 909 IUD set -
415 1630 Pil Kontrasepsi (Microdiol) strip -
416 1035 Spuit KB vial -
417 1052 ALAT SUNTIK 1 ML set -
418 1135 KONDOM biji -
419 1136 KONDOM LAKI-LAKI biji -
420 1137 KONDOM PEREMPUAN RING biji -
421 1138 KONDOM PEREMPUAN SPONS biji -
422 1219 LUBLIKAN biji -
423 1053 Acon Stik for Plano Test kotak -
424 1054 Albumin Kit -
425 1055 Alkali Phospatse Kit -
426 217 Billrubin Kit -
427 218 Brilliant Green Lactose Broth 500 gr MERCH botol -
428 219 Buffer Wright Kit -
429 220 BUN ( 4X50 ST ) Kit -
430 327 CHLORINE REAGEN TEST DPD 1"100 kotak -
431 328 CHLORINE REAGEN TEST DPD 3"100 kotak -
432 329 Cholesterol ( 3X50 ST ) Kit -
433 515 EDTA box -
434 720 Giemsa + Buffer Giemds botol 5 ml -
435 721 Gluco DR box -
436 722 Glucocard box -
437 723 Glukosa ( 3X100 ST ) Kit -
438 724 Golongan Darah Kit -
439 807 H Cl 0,1 N Kit -
440 808 HbsAg rapid botol -
441 809 Hemoglobin (500 ml/btl) botol -
442 1139 Kertas PH kotak -
443 1220 Lactose Broth 500 gram MERCK botol -
444 1221 Larutan Drapkin Kit -
445 1222 Larutan Hayem botol -
446 1223 Larutan HIPOCHLORIT 500 ml Kit -
447 1224 Larutan Wright / Pewarna Wright Kit -
448 1419 Na F Kristal botol -
449 1420 Natrium Chlorida 500 ml botol -
450 1518 Oil Imersion boto -
451 1630 Pepton For Water Buffer 500 gr MERCK botol -
452 1631 PEWARNA ZIEHL NIELSEN / 1 set set -
453 1632 Pewarna Gram / 1 set bot -
454 1633 Pewarna Ziehl-Neesen / 1 set botol -
455 1634 Plano Test Stik Blue Cross @50 box -
456 1811 RAPID Test Siphilis box -
457 1812 Reagen Bilirubin Total (Diazonium ) Kit -
458 1813 Reagen BUN ( Enzymatic ) set -
459 1814 Reagen Cholesterol ( CHOD-PAP ) Kit -
460 1815 Reagen Creatinin ( Picrate ) set -
461 1816 Reagen Determine HIV 100 test box -
462 1817 Reagen Glukosa ( GOD-PAP ) Kit -
463 1818 Reagen Hematologi (Analyzer) set -
- Isotonac 18 Liter galon -
- Hemolinec 1.5 Liter galon -
-Cleanac 5 Liter galon -
464 1819 Reagen Oncoprobe HIV 25 test box -
465 1820 Reagen SD HIV 0,5 Bioline 0,3 30 test box -
466 1821 Reagen SGOT ( 5X20 ST ) Kit -
467 1822 Reagen SGOT ( IFCC ) Kit -
468 1823 Reagen SGPT ( 5X20 ST ) Kit -
469 1824 Reagen SGPT ( IFCC ) Kit -
470 1825 Reagen Uric Acid ( Urease ) Kit -
471 1826 Reagen Urine strip box -
472 1827 Reangen Stik gula darah / Gluco M strip isi 25 box -
473 1828 Rees Ecker Kit -
474 1829 RPR Determane Siphilis box -
475 1830 RPR Test Kit RPR 500 Clos Shield Kit -
476 1036 Sodium Thiosulfat 1,000 gram botol -
477 2017 Teripton Glucose Extract Agar Kit -
478 2018 TES KEHAMILAN box -
479 2019 Tes Kehamilan / ACON box -
480 2020 Total Protein set -
481 2021 Trigliserida ( 3X50 ST ) Kit -
482 2022 Tyroid Rapid Test set -
483 2104 Uric Acid ( 3X50 ST ) Kit -
484 2105 Uriscan Gen 11 / 10 Parameter botol -
485 2106 Uriscan Glucose 1 Kit -
486 2107 Uriscan GP2 for Reduksi + Albumin Kit -
487 2303 Widal Kit -
488 2402 Xilol botol -
489 Gliserin 100ml botol -
490 Furosemide 10mg/ml injeksi ampul -
491 Ceftriaxone 1.Og inj Kering Vial -
492 Tiamina (Vit B1) tablet 100 mg tablet -
493 Isoniazid 100 mg tablet -
494 Novagesic 500mg kaplet kaplet -
495 Novatrim 480mg kaplet kaplet -
496 Novastan 500mg kaplet kaplet -
495 Novamag kaplet kaplet -
LAB.PUSKESMAS -
Reagen Hematology Sysmex -
Reagen Hematology Urit -
Aquabidest -
Reagen Golongan Darangan Darah -
Blood Lancet ( GEA ) -
Stick Urine 10 PM -
Planotest Strip -
RPR Test -
TPHA Test -
HIV Card -
Siphylis Card -
KOH 10% -
Methylen Blue 0,3% -
NaOH 0,1N -
HCI 0,1 N -
Eosin -
PH Paper Test -
Lactose Broth -
Brilliant Green Lactose Broth -
Aquadest -
Alkohol 70% -
Sikzonoate 25mg /ml ampul -
Obat Malaria tablet -
Susu SGM 3 400 gram kotak -
Susu SGM 4 400 gram kotak -
 Imipramine 25 mg Tablet -
Risperidone 2mg Tablet -
Trifluoperazin 5 mg / Stesoli tab Tablet -
Stolax /Bisakodil Supp 10mg Tablet -
Ventolin / Salbutamol Inhaler 0,5 % Botol -
Flagil / Metronidazol Ovuo 500mg Tablet -
Atapulgit 630 mg tablet -
Spironolactone 25 mg tablet -
Amoksilin Forte Sirup Kering botol -
Haloperidol 2 mg tablet -
Tetrakain / Pantocain 0,5 % Tts Mata botol -
Zircum KID sirup -
SUSU BENDERA -
Pirantel Susp 125mg / 5 ml botol -
Ondansetron tab 4 mg tablet -
1 BCG Ampul -
2 POLIO Botol -
3 DPT HB COMB0 Vial -
4 DPT Hb - Hib / PENTABIO Vial -
5 CAMPAK Vial -
6 TT Vial -
7 HB Unijeck Vial -
8 Pelarut BCG Ampul -
9 Pelarut Campak Ampul -
10 Pipet Polio Set -
11 DT Vial
12 Td Vial

Glimepiride 2 mg tablet
Metoclopramide 5 mg tablet
Umbilical Cord biji
Masker Surgical Plus 3 Ply Plus Earloop biji
Daryan Tulle :Flamisetin Sulfat 10 x 10 cm sachet
Lytacur 60 ml botol
Aseptic Gel + Disp 500 ml botol
Tes HIV I (Oncoprobe ) set
Tes HIV II ( Intech Triline ) ) set
Tes HIV III (Vikia ) set
OBH Tropica Plus Anak Jeruk 60 ml botol
OBH Tropica Exta Mentol 60 ml botol
Alpara tablet
OBH Tropica Plus Mentol 60 ml botol
Neurosanbe 5000 tablet tablet
Ranitidin 50 mg / 2 ml Inj ampul
Nistatin 100.000 IU suspensi botol
 Stesolid Rectal 10 mg/2,5 ml tube
Ondansetron tab 4 mg/2 ml Inj - Ktk 5 ampul

LABORAT PUSKESMAS 2014

1 Darah Kontrol set
2 Tabung K3 EDTA Box
3 RDT Malaria card
4 Reagen Widal Set ( O, H, AO,BO,AH,BH ) set
5 Serum Kontrol kit
6 Strip Urine 3 PM tube
7 Strip Urine 11 PM tube
8 Hemocue ( Tube ) tube
1 Sprei Karet Premium 90x200x15 pcs
2 Jas Operasi Water Rep pcs
3 Washlap 15x20 pcs
4 Sepatu Tertutup pcs
5 Topi Tali pcs
6 Duk 140 x 180 cm pcs
7 Duk 90 x 125 cm pcs
8 Duk 50 x 60 cm pcs
9 Duk Lubang Bulat 90x125 cm pcs
10 Duk Lubang Bulat 60x90 cm pcs
11 Duk Lubang Bulat 50x60 cm pcs

Mengetahui
Kepala Puskesmas

_____________________________
NIP
P PUSKESMAS

DAN PERBEKALAN KESEHATAN

……………………..

Stok Opname seluruh barang pakai habis dan perbekalan

PENERIMA PEMAKAIAN JUMLAH

SISA SELISIH
AN ( JAN - ( JAN - DES FISIK KET
STOK STOK
DES 2017 ) 2017 ) BARANG

5 6 7=(4+5)-6 8 9 = ( 8-7 ) 10
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Jember,………………………………
Pengelola Obat Puskesmas

_____________________________
NIP.
 LAPORAN OBAT RUSAK DAN KADALUWARSA DI PUSKESMAS
TAHUN 2017

PUSKESMAS : ……...………………

KEADAAN BARANG
No.
No. LPLPO
NAMA OBAT SATUAN JUMLAH RUSAK /
KADALUWARSA

1 2 3 4 5 6

……………………, ……………

Mengetahui, Yang melaporkan

Kepala Puskesmas Pengelola Obat Puskesm

------------------------------------- ---------------------------------
..................................... .....................................
NIP. NIP.
KESMAS

KEADAAN BARANG
TGL.
KADALUWARSA

……………, …………………….

Yang melaporkan
ngelola Obat Puskesmas

--------------------------------
....................................
P.
 STOK OPNAME PUSKESMAS,.......
Contoh Blangko Stok Opname Puskesmas

KODE PUSKESMAS :
PUSKESMAS :
KECAMATAN :
KABUPATEN :
PROPINSI :

NO. GUDANG APOTIK

NO. URUT NAMA OBAT SATUAN
KODE

Keterangan : 1. Kolom 5 ( Gudang ) sisa stok per tgl 31 Desember 2017

2. Kolom 6 s/d 16 Sisa stok LPLPO Desember 2017
3. Kolom 17 Jumlah dari kolom 5 s/d kolom 16
4. Kolom 18 sisa Stok LPLPO Puskesmas Bln Desember 2017
5. Kolom 19 dan 20 Selisih antara Kolom 17 dan 18

Mengetahui
Kepala Puskesmas........................

..........................................................
PNAME PUSKESMAS,.....................................................................................

BULAN :
TAHUN :

PERAWATA PUSTU....... POLINDE. POLINDE....

BP GIGI BP UMUM KIA LABORAT UGD PUSTU A
N . .....

Jember
Petugas
Puskesm

.............
BULAN :
TAHUN :

SELISIH
JUMLAH SISA LPLPO
KURANG LEBIH

Jember,......................
Petugas Pengelola Obat
Puskesmas..................

....................................
 LAPORAN PEMAKAIAN DAN LEMBA
(CITO)

KODE PUSKESMAS : ________________________

PUSKESMAS : ________________________
KECAMATAN : ________________________
KABUPATEN : ________________________
PROPINSI : ________________________

No. PENERIMA
No. URUT NAMA OBAT SATUAN STOK AWAL
KODE AN
1 2 3 4 5 6

Mengetahui/menyetujui Yang menyerahkan

Kepala Instalasi Farmasi Sie Penyimpanan & Penyalur
Kabupaten Jember IFK Jember

NIP. NIP.
MAKAIAN DAN LEMBAR PERMINTAAN OBAT
(CITO)

BULAN : ________________
TAHUN : ________________
MASUK TGL. : ________________

PERSEDIAA PEMAKAIA SISA STOK PERMINT PEMBERIAN

N N STOK OPT. AAN DAK BPJS PROG LAIN-2
7 ( 5+6 ) 8 9 ( 7-8 ) 10 11 ( 8+Bln lalu ) 12 13 14 15

-----------------,---------------------------------

Yang menyerahkan Yang melaporkan/meminta Yang menerima

Sie Penyimpanan & Penyaluran Kepala Puskesmas Pengelola Obat Puskesmas
IFK Jember ……………………………………

____________________________
NIP. NIP.
 : ________________
: ________________
: ________________

N
KET.
TOTAL
16 17

-----,---------------------------------

Yang menerima
engelola Obat Puskesmas