PEMERINTAH KABUPATEN GARUT

DINAS KESEHATAN
UPT PUSKESMAS MALANGBONG
Jalan Alun-alun Timur No. 5 Kecamatan Malangbong Garut
Tlp. (0262) 421038 Email : puskesmas_malangbong@yahoo.com

EVALUASI KESESUAIAN PERESEPAN DENGAN FORMULARIUM

Puskesmas : Malangbong Bulan : Januari
Kabupaten : Garut Tahun : 2018
Provinsi : Jawa Barat Form 1

Umur Jml item obat di R/ yg tdk Sesuai Formularium

Jml item obat di R/ yg Jml item obat di R/ yg tdk masuk
Tgl No Nama Jml item obat dlm R/ masuk Formularium PKM dlm
L P masuk Formularium PKM Formularium PKM Ya Tidak
1 bln
1 2 3 4 5 6 7 8 9 10 11
1 Evi 25 th 3 3 0
2 Ahmad 2 th 2 1 1
1/2/2018 3 Juhara 61 th 3 3 0
4 Nayla 7 th 3 3 0
5 Cua 70 th 4 3 1
1 Mei Seida 34 th 2 2 0
2 M. Aryanda 8 th 2 2 0
1/3/2018 3 Nia 45 th 3 3 0
4 Nunung 47 th 2 2 0
5 Maemunah 69 th 3 3 0
1 Rosita 48 th 2 2 0
2 M. Nuril 2 th 3 3 0
1/4/2018 3 Delia 7 th 2 2 0
4 Siti Patimah 4 bln 3 3 0
5 Hendrik 11 th 3 3 0
1 M. Rendi 9 th 4 4 0
2 Ina 29 th 2 2 0
1/5/2018 3 Imas 41 th 3 3 0
4 M. akbar 3,5 th 4 4 0
5 Puji 20 th 3 3 0
1 Putri 16 th 4 4 0
2 Syarif 39 th 4 4 0
1/6/2018 3 Siti Nurmilah 34 th 2 2 0
4 Soleha 19 th 4 4 0
5 Endang 29 th 3 3 0
 1 Fitriyani 3 th 2 2 0
2 Hilman 11 th 3 3 0
1/8/2018 3 Aah 64 th 3 3 0
4 Alis 8 th 2 1 1
5 Wini 42 th 2 2 0
1 Enung 11 th 3 2 1
2 Nazam 11 th 2 2 0
1/9/2018 3 Ilham 4 th 4 4 0
4 Saadah 56 th 4 4 0
5 Yanti 14 th 4 4 0
1 Eli 58 th 4 4 0
2 Empat 54 th 3 3 0
1/10/2018 3 Wari 23 th 4 4 0
4 Agus 21 th 2 2 0
5 Siti Rukoyah 37 th 3 3 0
1 Eet 29 th 4 4 0
2 Zaki 11 th 3 2 1
1/11/2018 3 Deti 29 th 2 2 0
4 Rohanah 43 th 3 3 0
5 Imam 54 th 3 3 0
1 Rizal 17 th 4 4 0
2 Pupu 23 th 3 3 0
1/12/2018 3 Neng Reni 11 th 1 1 0
4 Sela 18 th 3 3 0
5 Sopa 8 th 3 3 0
1 Heni 32 th 2 2 0
2 Siti Komariah 24 th 2 2 0
1/13/2018 3 Ai 21 th 3 3 0
4 Wahyudin 50 th 3 3 0
5 Aura 5 th 3 3 0
1 Zahra 8 th 2 2 0
2 Rindi 17 th 3 3 0
1/15/2018 3 Elsa 12 th 2 2 0
4 Cucu 20 th 2 2 0
5 Siti Maemunah 37 th 3 3 0
1 Teti 25 th 2 2 0
2 Fatimah 20 th 3 3 0
1/16/2018 3 Tengku 40 th 2 2 0
4 Diana 19 th 2 2 0
5 Wariah 60 th 4 4 0
1 Fatma 2,5 th 3 3 0
2 Atep 15 th 3 3 0
1/17/2018 3 Aso 70 th 1 1 0
4 Bama 80 th 3 3 0
5 Asep 37 th 2 2 0
1 Aang 41 th 4 4 0
2 Kokom 40 th 3 3 0
1/18/2018 3 Cicih 35 th 1 1 0
4 Jajang 50 th 1 1 0
5 Dede bagas 31 th 3 3 0
1 Noval 6 th 2 2 0
2 Baehaki 34 th 3 3 0
1/19/2018 3 Habsah 42 th 3 3 0
4 M. Sasa 3,5 th 3 3 0
5 Hari 22 th 2 2 0
1 Yandi 17 th 2 2 0
2 Junaedi 45 th 3 3 0
1/20/2018 3 M. Kim 2 th 1 1 0
4 Dede Enah 32 th 3 3 0
5 M. Azka 3 th 2 2 0
1 Papat 23 th 2 2 0
2 Denden 16 th 2 2 0
1/22/2018 3 Syeril 9 bln 2 2 0
4 Syifa 6 th 3 3 0
5 Yayah 52 th 3 3 0
1 M. Ilham 23 th 2 2 0
2 Wawan 29 th 4 4 0
1/23/2018 3 Ida 37 th 2 2 0
4 Saepul 32 th 2 2 0
5 Rahma 9 th 3 3 0
1 Ayi 15 th 3 3 0
2 Dede 13 th 3 2 1
1/24/2018 3 Saidah 23 th 4 4 0
4 Uu 47 th 4 3 1
5 Nani 50 th 4 3 1
1 Ameliana 1,5 th 2 2 0
2 Uju 60 th 3 3 0
1/25/2018 3 Sari 79 th 3 3 0
4 Akipa 3,5 th 2 2 0
5 Ade Dadin 41 th 4 4 0
1 Titin 44 th 3 3 0
2 Nazwa 3 th 2 2 0
1/26/2018 3 Rifki 11 bln 3 3 0
4 Atin 12 th 2 2 0
5 Herman 34 th 3 3 0
1 Hendrayana 24 th 2 2 0
2 Hani 29 th 1 1 0
1/27/2018 3 Cucu 33 th 1 1 0
4 Engkus 55 th 2 2 0
5 Apong 49 th 3 3 0
1 Mae 68 th 3 3 0

1/28/2018
 2 Elis 33 th 2 2 0
1/28/2018 3 Jejen 55 th 4 3 1
4 Pipih 48 th 3 3 0
5 Nia 27 th 3 3 0
1 Neng 7 th 4 4 0
2 Ela 40 th 2 2 0
1/29/2018 3 Esih 48 th 2 2 0
4 Bayu 21 th 3 3 0
5 H. Solehudin 62 th 3 3 0
1 Mumun 47 th 3 3 0
2 Engkoy 70 th 3 3 0
1/30/2018 3 Yuli 25 th 3 2 1
4 Muhamad S 68 th 4 4 0
5 Zahratunisa 10 th 3 2 1
1 Julaeha 12 th 3 2 1
2 Fatimah 42 th 3 2 1
1/31/2018 3 Nazwa 9 th 3 3 0
4 Farhan 12 th 1 1 0
5 Beri 38 th 1 1 0
JUMLAH 368 355 13 13 96.47% 3.53%

Mengetahui, Malangbong, 31 Januari 2018

Penanggung Jawab UKP Pengelola Obat

drg. Dian Vicktorina Loka Gian S. Nurseto, S.Si.,Apt

NIP. 197402092003122002
 PEMERINTAH KABUPATEN GARUT
DINAS KESEHATAN
UPT PUSKESMAS MALANGBONG
Jalan Alun-alun Timur No. 5 Kecamatan Malangbong Garut
Tlp. (0262) 421038 Email : puskesmas_malangbong@yahoo.com

EVALUASI KESESUAIAN PERESEPAN DENGAN FORMULARIUM

Puskesmas : Malangbong Bulan : Februari

Kabupaten : Garut Tahun : 2018
Provinsi : Jawa Barat Form 1

Umur Jml item obat di R/ yg tdk Sesuai Formularium

Jml item obat di R/ yg Jml item obat di R/ yg tdk masuk
Tgl No Nama Jml item obat dlm R/ masuk Formularium PKM dlm
L P masuk Formularium PKM Formularium PKM Ya Tidak
1 bln
1 2 3 4 5 6 7 8 9 10 11
1 Ajiji 76 th 2 2 0
2 Asep 3 th 2 1 1
2/1/2018 3 Rafa 2 th 3 3 0
4 Nina 21 th 4 4 0
5 Lutfi 1 th 2 2 0
1 Fajar 4 th 3 3 0
2 Melati 9 th 3 3 0
2/2/2018 3 Isah 57 th 2 1 1
4 Septia 6 th 3 2 1
5 Enung 59 th 4 4 0
1 Deni 43 th 3 3 0
2 Salwa 19 bln 1 1 0
2/3/2018 3 Joni 12 th 3 3 0
4 Arsila 16 bln 3 3 0
5 Titi 43 th 2 2 0
1 Badru 20 th 4 4 0
2 Oji 21 th 4 4 0
2/5/2018 3 Ayu 17 bln 2 2 0
4 Suryana 52 th 3 3 0
5 M. Satrya 8 th 3 3 0
1 Neni 30 th 2 2 0
2 Cicih 43 th 3 3 0
2/6/2018 3 Ari 7 th 3 3 0
4 Ruhiat 30 th 3 3 0
5 Entik 41 th 2 2 0
1 Yuyun 28 th 3 3 0
2 Ima 29 th 4 4 0
2/7/2018 3 Novi 11 th 3 3 0
2/7/2018
4 M. Hasbi 5 th 4 4 0
5 Suhendi 75 th 4 4 0
1 Yulia N. 18 th 3 3 0
2 Fatmawati 50 th 4 4 0
2/8/2018 3 Denina 4 th 3 3 0
4 Enok 50 th 4 4 0
5 Nelsa 7 th 3 3 0
1 Ineu 33 th 3 3 0
2 M. Revi 14 th 4 4 0
2/9/2018 3 Ade Saepudin 50 th 2 2 0
4 Ade Masitoh 35 th 2 2 0
5 Lilis Sinta 13 th 2 2 0
1 Serli 18 th 3 3 0
2 Wati 43 th 3 3 0
2/10/2018 3 Abdul Rosid 17 th 2 2 0
4 Ruhiat 35 th 2 1 1
5 N. Mila 16 th 2 2 0
1 Eman 55 th 3 3 0
2 Erina 17 th 3 3 0
2/12/2018 3 Nurhayati 42 th 4 4 0
4 Ase K. 40 th 4 4 0
5 Yanti 35 th 3 3 0
1 Rizki 10 th 3 3 0
2 Nining 45 th 3 3 0
2/13/2018 3 Yuyu 37 th 4 4 0
4 Asep 43 th 4 4 0
5 Cecep 56 th 3 3 0
1 Selvi 16 th 1 1 0
2 Dimas 4 th 3 3 0
2/14/2018 3 Dedi 66 th 3 3 0
4 Aman K. 43 th 3 3 0
5 Cucu 40 th 3 3 0
1 Apon 57 th 3 3 0
2 Ai Rosita 33 th 3 3 0
2/15/2018 3 Siti Ukaenah 38 th 3 3 0
4 Lastri 24 th 2 2 0
5 Titik 53 th 3 3 0
1 Najwa 14 th 3 3 0
2 Siti Maesaroh 22 th 3 3 0
2/17/2018 3 Nai 36 th 2 2 0
4 Rani 34 th 3 3 0
5 Dedah 36 th 3 3 0
1 Sinta 20 th 3 3 0
2 Surtiah 40 th 2 2 0
2/19/2018
2/19/2018 3 Siti Rosmina 21 th 4 4 0
4 Elis 36 th 3 3 0
5 Ai Siti H. 30 th 3 3 0
1 M. Harun 69 th 2 2 0
2 Yuni M. 16 th 2 2 0
2/20/2018 3 Arul 15 th 4 4 0
4 Agus 60 th 3 3 0
5 M. Baehaki 24 th 4 4 0
1 Uju 60 th 1 1 0
2 Sela 17 th 2 2 0
2/21/2018 3 Aldi 22 th 1 1 0
4 Kokom 47 th 1 1 0
5 Jajang 50 th 1 1 0
1 Anih 54 th 1 1 0
2 Anis 42 th 4 4 0
2/22/2018 3 Kaka 42 th 2 2 0
4 Salsa 19 th 3 3 0
5 Restu 14 th 3 3 0
1 Hasbi 33 th 2 2 0
2 Isah 58 th 2 2 0
2/23/2018 3 Sinta 18 th 4 4 0
4 Aat 46 th 2 2 0
5 Indra Jaya 27 th 2 2 0
1 Aang 30 th 2 2 0
2 Nurdin 40 th 2 2 0
2/24/2018 3 Arya 14 th 2 2 0
4 Neng Uci 31 th 3 3 0
5 Jaman 69 th 1 1 0
1 Yani 42 th 2 2 0
2 Hasanah 18 th 3 3 0
2/26/2018 3 Popon 60 th 3 3 0
4 Rukmini 75 th 3 3 0
5 Rita 42 th 2 2 0
1 Andri Candra 46 th 3 3 0
2 Engkus 61 th 3 3 0
2/27/2018 3 M. Rezia 15 th 2 2 0
4 M. Asep 12 th 2 2 0
5 Aep S. 38 th 3 3 0
1 Ujang 25 th 2 2 0
2 Siti Jenab 43 th 3 3 0
2/28/2018 3 Ai Yanyan 22 th 3 3 0
4 Rahmat 44 th 4 4 0
5 Abdul Fakih 21 th 3 3 0
JUMLAH 316 312 4 4 98.73% 1.27%
 Mengetahui, Malangbong, 28 Februari 2018
Penanggung Jawab UKP Pengelola Obat

drg. Dian Vicktorina Loka

NIP. 197402092003122002 Gian S. Nurseto, S.Si.,Apt
 PEMERINTAH KABUPATEN GARUT
DINAS KESEHATAN kabupaten
UPT PUSKESMAS MALANGBONG
Jalan Alun-alun Timur No. 5 Kecamatan Malangbong Garut
Tlp. (0262) 421038 Email : puskesmas_malangbong@yahoo.com

EVALUASI KESESUAIAN PERESEPAN DENGAN FORMULARIUM

Puskesmas : Malangbong Bulan : Maret

Kabupaten : Garut Tahun : 2018
Provinsi : Jawa Barat Form 1

Umur Jml item obat di R/ yg tdk Sesuai Formularium

Jml item obat di R/ yg Jml item obat di R/ yg tdk masuk
Tgl No Nama Jml item obat dlm R/ masuk Formularium PKM dlm
L P masuk Formularium PKM Formularium PKM Ya Tidak
1 bln
1 2 3 4 5 6 7 8 9 10 11
1 Soni 32 th 2 2 0
2 Didin 44 th 4 4 0
3/1/2018 3 Usep 47 th 3 3 0
4 Asep 40 th 3 3 0
5 Lala 15 th 1 1 0
1 Yani 35 th 2 2 0
2 Meli 22 th 2 2 0
3/2/2018 3 Sri W. 18 th 4 4 0
4 Ulva 20 th 2 2 0
5 Yulia 33 th 3 3 0
1 D. Elsa 13 th 2 2 0
2 M. Wildan 20 bln 3 3 0
3/3/2018 3 Endah 30 th 2 2 0
4 Jahri 55 th 3 3 0
5 Ucu Aisah 23 th 2 2 0
1 M. Adnan 10 bln 3 3 0
2 Raisa 2 th 2 2 0
1/5/2018 3 Hani 31 th 2 2 0
4 Abdurrohman 35 th 2 2 0
5 Papat 23 th 3 3 0
1 Cicih 63 th 3 3 0
2 Fitri 10 th 4 4 0
1/6/2018 3 Cucu C. 28 th 4 4 0
4 Wida 3 th 4 4 0
5 Alia 4,5 th 3 3 0
1 Wini 43 th 4 4 0
2 M. Subhan 7 th 2 2 0
1/7/2018 3 Denden 33 th 3 3 0
1/7/2018
4 Atikah 27 th 4 4 0
5 Aep 38 th 5 5 0
1 Mikaila 2 th 4 4 0
2 Asih 45 th 2 2 0
1/8/2018 3 Desmira 2,2 th 3 3 0
4 Ainun 8 bln 1 1 0
5 M. Rizki 16 bln 2 2 0
1 Caca 8 th 3 3 0
2 Maesaroh 31 th 2 2 0
1/9/2018 3 Yulia 34 th 1 1 0
4 Ranti 10 bln 2 2 0
5 Arsy 11 bln 2 2 0
1 Risna 3 bln 1 1 0
2 Desti 5 th 3 3 0
1/10/2018 3 Nurasifa 2,5 th 3 3 0
4 Yeni 46 th 1 1 0
5 Indah 18 th 3 3 0
1 M. Rupsan 9 th 4 4 0
2 Sri Lia 7 th 3 3 0
1/12/2018 3 Alipa 3,5 th 3 3 0
4 M. Alfahmi 1,5 th 3 3 0
5 Wini 39 th 3 3 0
1 Isah 73 th 2 2 0
2 Ila N. 20 th 3 3 0
1/13/2018 3 M. Iksan 2,5 th 2 2 0
4 Manah 56 th 2 2 0
5 Injagi 18 th 3 3 0
1 Siti Patimah 14 bln 2 2 0
2 Siti 25 th 2 2 0
1/14/2018 3 M. Haikal 3 th 1 1 0
4 Ai Siti 33 th 2 2 0
5 Teten 50 th 2 2 0
1 Mahyar 50 th 4 4 0
2 Wahyu 58 th 2 2 0
1/15/2018 3 Nurul H. 10 th 2 2 0
4 Deni R. 35 th 3 3 0
5 Ajeng 22 th 4 4 0
1 Siti Nurjanah 40 th 3 3 0
2 Iwan 48 th 2 2 0
1/16/2018 3 Tuti 41 th 4 4 0
4 Opi Sopian 41 th 4 4 0
5 Sri Wahyuni 8 th 4 4 0
1 Irod 70 th 3 3 0
2 Iboh 72 th 3 3 0
1/19/2018
1/19/2018 3 M. Farhan 8 th 2 2 0
4 Imam 25 th 2 2 0
5 Ujang Dedi 41 th 2 2 0
1 Oneng 29 th 2 2 0
2 Aditya 10 th 2 2 0
1/20/2018 3 Apong 57 th 3 3 0
4 Empat 61 th 2 2 0
5 Ai Nurjanah 48 th 3 3 0
1 Salsa 11 th 2 2 0
2 Ai Kumiati 21 th 3 3 0
1/21/2018 3 Nadira 3 th 3 3 0
4 Nia 46 th 3 3 0
5 Juju 56 th 4 4 0
1 Ripki D. 7 th 2 2 0
2 Irsa 14 th 4 4 0
1/22/2018 3 Uka 62 th 2 2 0
4 Mala 45 th 3 3 0
5 Ani 23 th 2 2 0
1 Enok 51 th 3 3 0
2 Popon 27 th 4 4 0
1/23/2018 3 Sopiah 40 th 3 3 0
4 Sandi 25 th 2 2 0
5 Euis 54 th 3 3 0
1 Meli 38 th 2 2 0
2 Elis Rahayu 37 th 3 3 0
1/24/2018 3 Dinar 11 th 2 2 0
4 Asep 6 th 3 3 0
5 Sulaeman 55 th 3 3 0
1 Hairul 5,5 th 2 2 0
2 Siti Komariah 24 th 2 2 0
1/26/2018 3 Resa 19 th 3 3 0
4 Entik 50 th 3 3 0
5 Dedi 66 th 2 2 0
1 Santi 30 th 2 2 0
2 Hasanah 19 th 1 1 0
1/27/2018 3 Siti Sopiah 27 th 2 2 0
4 Ai Mulyani 25 th 3 3 0
5 Cicih 38 th 2 2 0
1 Seli 23 th 2 2 0
2 Sopian 43 th 4 4 0
1/28/2018 3 M. Razhesh 6 th 2 2 0
4 M. Adam 8 th 3 3 0
5 Yudin 54 th 3 3 0
1 Kamilah 15 th 3 3 0

1/29/2018
 2 Hindun 24 th 3 3 0
1/29/2018 3 Mega 23 th 4 4 0
4 Husnul 31 th 3 3 0
5 Geri 25 th 3 3 0
1 Dadan 27 th 3 3 0
2 Nurita 23 th 3 3 0
1/31/2018 3 Anisa 20 th 3 3 0
4 Yupi 3 th 2 2 0
5 Sidqi 2,5 th 2 2 0
JUMLAH 333 333 0 0 100.00% 0.00%

Mengetahui, Malangbong, 31 Maret 2018

Penanggung Jawab UKP Pengelola Obat

drg. Dian Vicktorina Loka Gian S. Nurseto, S.Si.,Apt

NIP. 197402092003122002
 PEMERINTAH KABUPATEN GARUT
DINAS KESEHATAN kabupaten
UPT PUSKESMAS MALANGBONG
Jalan Alun-alun Timur No. 5 Kecamatan Malangbong Garut
Tlp. (0262) 421038 Email : puskesmas_malangbong@yahoo.com

EVALUASI KESESUAIAN PERESEPAN DENGAN FORMULARIUM

% Rerata item obat / % Rerata item obat / Capaian (%)

No Bulan/Tahun lembar resep yang lembar resep yang tidak
sesuai formularium sesuai formularium
Sesuai Tidak Sesuai
Formularium Formularium
(1) (2) (3) (4) (5) (6)
1 Jan-18 96% 4%
2 Feb-18 99% 1% 98% 2%
3 Mar-18 100% 0%

Mengetahui, Malangbong, 31 Maret 2018

Penanggung Jawab UKP Pengelola Obat

drg. Dian Vicktorina Loka Gian S. Nurseto, S.Si.,Apt

NIP. 197402092003122002