LAPORAN PEMAK

PUSKESMAS :
KECAMATAN :
KABUPATEN : PIDIE
PROVINSI : ACEH

NO Nama Obat Kemasan Stok Awal

1 2 3 4
1 Air Raksa dental use botol
2 Abocath No. 20 pcs
3 Abocath No. 22 pcs
4 Abocath No. 24 pcs
5 Abocath No. 26 pcs
6 Acyclovir 200 mg ktk 10x10 tablet
7 Acyclovir 400 mg ktk 10x10 tablet
8 Alat suntik sekali pakai 1 ml pcs
9 Alat suntik sekali pakai 2.5 ml pcs
10 Alat suntik sekali pakai 3 ml pcs
11 Alat suntik sekali pakai 5 ml pcs
12 Albendazol Tab 400 mg tablet
13 Alkohol Swab Lembar
14 Alopurinol tablet 100 mg tablet
15 Alprazolam 0,5 mg tablet
16 Aminofilin injeksi 24 mg / ml - 10 ml ampul
17 Aminofilin tablet 200 mg 100 tablet
18 Amitriptilin HCL tablet salut 25 mg 100 tablet
19 Amlodipin 10 mg. tablet
20 Amoksisilin kaplet 500 mg 100 kaplet
21 Amoksisilin sirup kering 125 mg/5 ml botol
22 Amoksisilin sirup kering Forte 250 mg/5 mg botol
23 Antalgin (Metampiron) tablet 500 mg tablet
24 Antasida DOEN sirup botol
25 Antasida DOEN tablet tablet
26 Anti bakteri DOEN salap Basitrasin 25 tube @ 5 g
27 Anti hemoroid DOEN kombinasi supp
28 Antifungi DOEN kombinasi : 3 - 6 24 pot @ 30 g
29 Antimigren DOEN kombinasi (Ergotamin) tablet
Antiparkinson kombinasi : Benserazid 25 mg
30 tablet
Levodopa 100 mg (Levopar)
31 Artemeter Inj. 80 mg/ml. (Artem) ampul
32 Asam askorbat (vit.C) tablet 50 mg tablet
33 Asam Folat 0,4 mg tablet
34 Asam Mefenamat tablet 500 mg tablet
35 Asam Valproat 250 mg tablet
36 Asiklovir krim 5% tube
37 Attapulgit tablet ( Puralex ) tablet
38 Betahistin 6 mg tablet
39 Betametson krim 0,1% 24 tube @5 g
40 Bisakodil Supp 10 mg. ( Dulcolax ) supp
41 Bisakodil Supp 5 mg. ( Dulcolax ) supp
42 Bisoprolol 2,5 mg (Concord) tablet
43 bisoprolol 5 mg tablet
44 Bisturi (Scalpel Blades) 23 pcs
45 Captopril 12.5 mg. tablet
46 Captopril 25 mg tablet
47 Cat gut/benang bedah No. 3/0 (chromic) pcs
48 Cefixime 100 mg Kapsul
49 Cefotaxime inj 1 gr vial
50 Cetirizin 10 mg tab 50 tab/ktk
51 Cetirizin 5 mg / 5 ml botol
52 Clozapine 25 mg tab tablet
53 Deksametason injeksi 5 mg/ml - 1 ml ampul
54 Deksametason tablet 0,5 mg tablet
55 Diazepam injeksi 5 mg/ml - 2 ml ampul
56 Diazepam rektal 5 mg/ 2,5 ml (Stesolid) tube
57 Diazepam tablet 2 mg tablet
58 Diazepam tablet 5 mg tablet
59 Difenhidramin HCL injeksi 10 mg/ml - 1 ml ampul
60 Digoksin tablet 0,25 mg. tablet
61 Diltiazem HCl 30 mg tablet tablet
62 Doksisiklin 100 mg Kaps. Kapsul
63 Domperidon Sirup botol
64 Domperidon tablet 10 mg. tablet
65 Ekstrak Belladona tab 10 mg 1000/btl
66 Eritromisin kapsul 500mg ktk 10 x 10 tab.
67 Eritromisin sirup 200mg/5ml btl 60 ml
68 Etakridin (Rivanol) larutan 0,1% botol
69 Etanol 70% 1000 ml
70 Etanol 70% 100 ml
71 Etil klorida semprot 100 ml
72 Eugenol cairan botol
73 Fenitoin natrium kapsul 100 mg Kapsul
74 Fenobarbital Inj. I.m. 50 mg / ml - 2 ml ampul
75 Fenobarbital tablet 30 mg tablet
76 Fenol gliserol tts telinga 10% botol
77 Fitomenadion (vit.K1) Injeksi 10 mg / ml ampul
 78 Fitomenadion (vit.K1) tab. salut gula 10 mg tablet
79 Flufenazin Inj. I.m 25 mg / ml (Sikzonoat) ampul
80 Folley Catheter No 16 Buah
81 Folley Catheter No 18 Buah
82 Furosemid tablet 40 mg tablet
83 Furosemide Inj. 10 mg/ml. ampul
84 Fusidic Acid (Fusycom Cream) 5 gr tube
85 Gabapentine 100 mg (Alpintin) Kapsul
86 Gameksan emulsi 1% btl 30 ml.
87 Garam oralit untuk 200 ml air sachet
88 Gentamisin Salap mata 0,3% tube
89 Gentamisin Sulfat salep kulit 0,1 % tube
90 Gentamisin Sulfat tetes mata 0,3% botol
91 Gentian Violet larutan 1% botol
92 Glass lonomer cement (GC IX) Set
93 Glibenklamid tablet 5 mg tablet
94 Glimepirid tablet
95 Gliseril Guayakolat 100 mg tablet
96 Glukosa 5 % - Nacl 0,225 % 500 ml
97 Glukosa 5 % - Nacl 0,45 % btl 500 ml.
98 Glukosa 5 % - Nacl 0,9 % btl 500 ml.
99 Glukosa larutan infus 40% steril btl 500 ml.
100 Glukosa larutan infus 5% steril btl 500 ml.
101 Griseofulvin tablet 125 mg, Micronized tablet
102 Haloperidol tablet 0,5 mg tablet
103 Haloperidol tablet 1,5 mg tablet
104 Haloperidol tablet 5 mg tablet
105 Handscoon Steril No 6,5 50 Pasang/ktk
106 Handscoon Steril No 7,5 50 Pasang/ktk
107 Handscoon Ukuran L 100 pcs/ktk
108 Handscoon Ukuran M 100 pcs/ktk
109 Handscoon Ukuran S 100 pcs/ktk
110 Hidrokortoson krim 1 % tube
111 Hidrokortoson krim 2,5 % tube
112 Hodroklorotiazid (HCT) tablet 25 mg tablet
113 Ibuprofen susp. 60 ml. botol
114 Ibuprofen tablet 200 mg tablet
115 Ibuprofen tablet 400 mg tablet
116 Infusion set anak Set
117 Infusion set dewasa Set
118 Isosorbit Dinitrat tablet Sublingual 5 ml tablet
119 Kalium Klorida tab. 600 mg (KSR) tablet
120 Kalsium Hidroksida pasta Buah
121 Kalsium laktat (Kalk) tablet 500 mg tablet
122 Kapas pembalut/Hidrofil DRC 250 gram Bungkus
123 Karbamazepin tablet 200 mg tablet
124 Kasa kompres 16/16 steril Bungkus
125 Kasa pembalut Hidrofil 4 m x 10 cm Rol
126 Ketokonazol krim 2% tube
127 Ketokonazol tablet 200 mg. ktk 5 x 10 tab.
128 Ketoprofrem Supositoria 100 mg supp
129 Ketorolac Inj 30 mg/ml ampul
130 Kloplidogrel 75 mg Kapsul
131 Klindamisin 150 mg tablet
132 Kloramfenikol susp. 125 mg/ml botol
133 Kloramfinekol kapsul 250 mg Kapsul
134 Kloramfinekol salap mata 1% tube
135 Kloramfinekol tetes telinga 3% botol
136 Klorfeniramin Maleat (CTM) tablet 4 mg tablet
137 Klorfenol Kanfer Mentol (CHKM) botol
138 Klorokuin tablet 150 mg tablet
139 klorpromazin HCL Inj. 25 mg/ml ampul
140 Klorpromazin HCL tablet salut 100 mg tablet
141 Klorpromazin HCL tablet salut 25 mg tablet
142 Kodein 10 mg tablet
143 kodein 20 mg tablet
144 Kotrimoksazol suspensi botol
145 Kotrimoksazol tablet 480 mg tablet
146 Kotrimoksazol tablet pediatrik 120 mg tablet
147 Kuinin (Kina) tablet 200 mg tablet
148 Laktulosa sirup 3.335 gr/ 5ml botol
149 Lansoprazol 30 mg. kaps. Kapsul
150 Lidokain HCL inj. 2% Epinefrin 1:80000 ampul
151 Loperamide tab 2 mg tablet
152 Loratadin tablet 10 mg. tablet
153 Lubricating Jelly 82 gram botol
154 Masker pcs
155 Mebendazol tablet 100 mg tablet
156 Meloksikam 7,5 mg tablet
157 Metformin 500 mg tablet
158 Metilergometrin maleat tab. salut 0,125 mg tablet
159 Metilergometrin maleat inj. 0,200 mg - 1 ml ampul
160 Metilprednisolon 4 mg tablet
161 Metoklopramid tablet 10 mg. tablet
162 Metronidazol tablet 250 mg tablet
163 Mikonazol krim / salap 2% nitrat tube
164 Mummifying pasta botol
165 Natrium bikarbonat tablet 500 mg tablet
166 Natrium Diklofenac 50 mg tablet
167 Natrium klorida larutan infus 0,9% steril botol 500 ml
168 Nifedipin tablet
169 Nistatin tablet salut 100.000 IU tablet
170 Nistatin tablet salut 500.000 IU tablet
171 Oksitetrasiklin HCL inj. I.m 50 mg/ml - 10 ml vial
172 Oksitetrasiklin HCL salap mata 1% tube
173 Oksitetrasiklin HCL salap 3% tube
174 Omeprazol 20 mg. kaps. Kapsul
175 Ondansetron 4 mg tablet
176 Parasetamol sirup 120 mg/5 ml botol
177 Parasetamol tablet 100 mg. tablet
178 Parasetamol tablet 500 mg tablet
179 Parasetamol tetes 60 mg / 0,6 ml drop
180 Permetrin Cream 5 % (scabimite cr. 10 gr) tube
181 Pirantel tablet 125 mg tablet
182 Piridoksin HCL(Vit.B6) tablet 10 mg tablet
183 Pirocicam 20 mg kaplet
184 Plester (2,5 cm x 4,5 m) rol
185 Plester (5 cm x 4,5 m) rol
186 Povidon lodida 10% botol
187 Prednison tablet 5 mg tablet
188 Primakuin tablet 15 mg tablet
189 Propiltiorasil (PTU) tab tablet
190 Propranolol HCL tablet 40 mg tablet
191 Ranitidin Inj. 25 mg/ml. ampul
192 Ranitidin tab 150 mg tablet
193 Ringer laktat larutan infus steril botol
194 Risperidon 2 mg tablet
195 Salap 2 - 4, kombinasi : pot
196 Salbutamol tablet 2 mg tablet
197 Salisil bedak 2% Bungkus
198 Sefadroksil kapsul 500 mg. Kapsul
199 Serum Anti Bisa Ular (ABU I) Inj. vial
200 Serum Anti tetanus Inj. 20.000 IU (ATS) ampul
201 Serum Anti tetanus Inj.1.500 IU (ATS) ampul
202 Sianokobalamin (Vit.B12) 50 mcg tablet
203 Sianokobalamin (Vit.B12) inj. 500 mcg/ml-1ml ampul
204 Silk (Benang bedang Sutera) No. 3/0 pcs
205 Simetidin tablet 200 mg. tablet
206 Simvastatin tablet 10 mg. tablet
207 Siprofloksasin tablet 500 mg tablet
208 Spironolakton 25 mg. tablet
209 Sukralfat 500 (ulsidek) tab tablet
210 Sukralfat 500 mg/ 5 ml botol
211 Sulfasetamida Natrium tetes mata 15% botol
212 Tablet Tambah Darah besi II sulfat tablet
213 Temporary Stopping Fletcher (Fletcher) set/ 100 g
214 Teofilin150 mg (Bronsolvan) tablet
215 Tetrasiklin HCL kapsul 250 mg Kapsul
216 Tetrasiklin HCL kapsul 500 mg Kapsul
217 Tiamfenikol kapsul 500 mg. Kapsul
218 Tiamin HCL (vit.B1) injeksi 100 mg/ml - 1 ml ampul
219 Tiamin HCL/Mononitrat (vit.B1) tablet 50 mg tablet
220 Tramadol kapsul 50 mg. 50 kaps.
221 Triheksifenidil Hidroklorida tablet 2 mg tablet
222 Urine bag buah
223 Valsartan 80 mg tablet
224 Vitamin B Komplek tablet tablet
225 Vitamin Sirup botol
226 Zink Sirup ( Zircum Kid) botol
227 Zink tablet 20 mg. tablet
228 Masker Oxygen Anak Pcs
229 Masker Oxygen Bayi Pcs
230 Masker Oxygen Dewasa Pcs
231 Selang Oxygen Anak Pcs
232 Selang Oxygen Bayi Pcs
233 Selang Oxygen Dewasa Pcs
234 Depakote ER botol

MENGETAHUI/MENYETUJUI: YANG MENYERAHKAN:

KEPALA DINAS KESEHATAN KEPALA INSTALASI FARMASI
KABUPATEN PIDIE DINAS KESEHATAN PIDIE

dr. H. FAJRIMAN, Sp.S., M.Si., Med. ULIA MAKSUM, S. Farm., APT

NIP. 19700909 2000112 1 003 NIP. 19851007 200904 2 010
 LAPORAN PEMAKAIAN DAN LEMBARAN PERMINTAAN OBAT (LPLPO)
T A H U N 2017

PELAPORAN PERIODE
PERMINTAAN PERIODE :

Penerimaan Persediaan Pemakaian Sisa Stock Stok Optimum

5 6 7 8
 YANG MENYERAHKAN: YANG MEMINTA/MELAPORKAN:
KEPALA INSTALASI FARMASI KEPALA PUSKESMAS,
DINAS KESEHATAN PIDIE ……………………………..

ULIA MAKSUM, S. Farm., APT …………………………….

NIP. 19851007 200904 2 010 NIP.
DOKUMEN NOMOR TANGGAL
IFK
PUSKESMAS

Pemberian
Permintaan KET
DAK LAIN-LAIN

9 15 17
 SIGLI, ……………………………..20….
/MELAPORKAN: YANG MENERIMA:
SKESMAS, PETUGAS PENGELOLA OBAT
…………….. PUSKESMAS,...............

………………. ……………………………….
NIP.
 LAPORAN PEMAKAIAN DAN LEMBARAN PERMINTAAN OBAT (LPLPO)
T A H U N 2017
PUSKESMAS : UJONG RIMBA DOKUMEN
KECAMATAN : MUTIARA TIMUR IFK
KABUPATEN : PIDIE PELAPORAN PERIODE : NOVEMBER PUSKESMAS
PROVINSI : ACEH PERMINTAAN PERIODE : DESEMBER

Stok
NO Nama ObatK emasan PenerimaanPersediaPemakaianS isa Stock
Stok Optimum
Permintaan
Awal
an
1 2 3 4 5 6 7 8 9
1 Air Raksa botol 0 0 0 0 0 -
2 Abocath Nopcs 7 7 0 7 0 (7)
3 Abocath Nopcs 8 8 0 8 0 (8)
4 Abocath Nopcs 8 8 0 8 0 (8)
5 Abocath Nopcs 0 0 0 0 0 -
6 Acyclovir ktk 10x10 t 0 300 300 300 0 570 570
7 Acyclovir ktk 10x10 t 100 100 0 100 0 (100)
8 Alat suntik pcs 0 0 0 0 0 -
9 Alat suntik pcs 27 27 4 23 8 (15)
10 Alat suntik pcs 27 27 20 7 38 31
11 Alat suntik pcs 12 12 2 10 4 (6)
12 Albendazoltablet 0 0 0 0 0 -
13 Alkohol SwLembar 400 400 0 400 0 (400)
14 Alopurinol tablet 1400 1400 1200 200 2280 2,080
15 Alprazolamtablet 0 0 0 0 0 -
16 Aminofilin ampul 0 0 0 0 0 -
17 Aminofilin 100 tablet 0 0 0 0 0 -
18 Amitriptili 100 tablet 195 195 0 195 0 (195)
19 Amlodipin tablet 308 300 608 308 300 585 285
20 Amoksisili 100 kaplet 800 6000 6800 5900 900 11210 10,310
21 Amoksisilinbotol 0 0 0 0 0 -
22 Amoksisilinbotol 0 0 0 0 0 -
23 Antalgin ( tablet 0 0 0 0 0 -
24 Antasida Dbotol 0 0 0 0 0 -
25 Antasida Dtablet 0 0 0 0 0 -
26 Anti bakter25 tube @ 0 0 0 0 0 -
27 Anti hemorsupp 0 0 0 0 0 -
28 Antifungi D24 pot @ 3 0 0 0 0 0 -
29 Antimigrentablet 0 0 0 0 0 -
30 Antiparkin tablet 0 0 0 0 0 -
31 Artemeter Iampul 0 0 0 0 0 -
32 Asam askorb tablet 600 7000 7600 6700 900 12730 11,830
33 Asam Folattablet 0 300 300 180 120 342 222
34 Asam Mefen tablet 700 700 700 0 1330 1,330
35 Asam Valprtablet 0 0 0 0 0 -
36 Asiklovir k tube 0 0 0 0 0 -
37 Attapulgit ttablet 0 0 0 0 0 -
38 Betahistin tablet 0 0 0 0 0 -
39 Betametson24 tube @5 24 144 168 168 0 319 319
40 Bisakodil Ssupp 6 6 0 6 0 (6)
41 Bisakodil Ssupp 0 0 0 0 0 -
42 Bisoprolol tablet 0 0 0 0 0 -
43 bisoprolol tablet 0 0 0 0 0 -
44 Bisturi (Sc pcs 10 10 0 10 0 (10)
45 Captopril 1tablet 150 150 50 100 95 (5)
46 Captopril tablet 148 148 0 148 0 (148)
47 Cat gut/be pcs 80 80 11 69 21 (48)
48 Cefixime 1Kapsul 0 0 0 0 0 -
49 Cefotaximevial 0 0 0 0 0 -
50 Cetirizin 1 50 tab/ktk 500 500 500 0 950 950
51 Cetirizin 5 botol 0 0 0 0 0 -
52 Clozapine tablet 0 0 0 0 0 -
53 Deksametas ampul 37 37 0 37 0 (37)
54 Deksametas tablet 1600 6000 7600 5720 1880 10868 8,988
55 Diazepam in ampul 0 0 0 0 0 -
56 Diazepam re tube 5 5 0 5 0 (5)
57 Diazepam tablet 143 143 13 130 25 (105)
58 Diazepam tablet 0 0 0 0 0 -
59 Difenhidramampul 0 0 0 0 0 -
60 Digoksin tatablet 0 0 0 0 0 -
61 Diltiazem Htablet 0 0 0 0 0 -
62 DoksisiklinKapsul 0 0 0 0 0 -
63 Domperidon botol 50 50 0 50 0 (50)
64 Domperidon tablet 342 342 42 300 80 (220)
65 Ekstrak Be1000/btl 0 0 0 0 0 -
66 Eritromisi ktk 10 x 10 0 0 0 0 0 -
67 Eritromisi btl 60 ml 0 0 0 0 0 -
68 Etakridin ( botol 2 2 0 2 0 (2)
69 Etanol 70 1000 ml 0 0 0 0 0 -
70 Etanol 70 100 ml 0 0 0 0 0 -
71 Etil klorid 100 ml 0 0 0 0 0 -
72 Eugenol cabotol 25 25 3 22 6 (16)
73 Fenitoin n Kapsul 0 0 0 0 0 -
74 Fenobarbitalampul 0 0 0 0 0 -
 75 Fenobarbitatablet 99 99 64 35 122 87
76 Fenol glisebotol 0 0 0 0 0 -
77 Fitomenadioampul 0 0 0 0 0 -
78 Fitomenadiotablet 100 100 27 73 51 (22)
79 Flufenazin ampul 0 0 0 0 0 -
80 Folley Cat Buah 0 0 0 0 0 -
81 Folley Cat Buah 91 91 0 91 0 (91)
82 Furosemid tablet 0 0 0 0 0 -
83 Furosemideampul 0 0 0 0 0 -
84 Fusidic Ac tube 0 0 0 0 0 -
85 GabapentinKapsul 0 0 0 0 0 -
86 Gameksanbtl 30 ml. 113 113 0 113 0 (113)
87 Garam oralisachet 5 5 5 0 10 10
88 Gentamisintube 0 30 30 21 9 40 31
89 Gentamisintube 0 0 0 0 0 -
90 Gentamisinbotol 0 0 0 0 0 -
91 Gentian Viobotol 25 25 15 10 29 19
92 Glass lonoSet 0 0 0 0 0 -
93 Glibenklamitablet 0 0 0 0 0 -
94 Glimepirid tablet 100 100 200 30 170 57 (113)
95 Gliseril G tablet 0 0 0 0 0 -
96 Glukosa 5 500 ml 0 0 0 0 0 -
97 Glukosa 5 btl 500 ml. 0 0 0 0 0 -
98 Glukosa 5 btl 500 ml. 5 5 0 5 0 (5)
99 Glukosa larbtl 500 ml. 0 0 0 0 0 -
100 Glukosa larbtl 500 ml. 10 10 0 10 0 (10)
101 Griseofulvitablet 251 200 451 80 371 152 (219)
102 Haloperidoltablet 75 200 275 130 145 247 102
103 Haloperidoltablet 0 0 0 0 0 -
104 Haloperidoltablet 250 250 150 100 285 185
105 Handscoon50 Pasang/ 100 100 0 100 0 (100)
106 Handscoon50 Pasang/ 0 0 0 0 0 -
107 Handscoon100 pcs/ktk 0 0 0 0 0 -
108 Handscoon100 pcs/ktk 240 240 10 230 19 (211)
109 Handscoon100 pcs/ktk 0 0 0 0 0 -
110 Hidrokorto tube 0 0 0 0 0 -
111 Hidrokorto tube 0 0 0 0 0 -
112 Hodroklorottablet 810 810 0 810 0 (810)
113 Ibuprofen sbotol 15 15 10 5 19 14
114 Ibuprofen tablet 500 500 498 2 946 944
115 Ibuprofen tablet 800 2500 3300 2518 782 4784 4,002
116 Infusion seSet 0 0 0 0 0 -
117 Infusion s Set 9 9 0 9 0 (9)
118 Isosorbit Ditablet 40 40 10 30 19 (11)
119 Kalium Klotablet 0 0 0 0 0 -
120 Kalsium HiBuah 0 0 0 0 0 -
121 Kalsium laktablet 0 1500 1500 1018 482 1934 1,452
122 Kapas pemb Bungkus 4 4 0 4 0 (4)
123 Karbamazep tablet 100 100 80 20 152 132
124 Kasa kompre Bungkus 120 120 0 120 0 (120)
125 Kasa pemba Rol 30 30 3 27 6 (21)
126 Ketokonazotube 1 50 51 51 0 97 97
127 Ketokonazoktk 5 x 10 t 0 0 0 0 0 500
128 Ketoprofre supp 0 0 0 0 0 -
129 Ketorolac Iampul 0 0 0 0 0 -
130 Kloplidogr Kapsul 0 0 0 0 0 -
131 Klindamisi tablet 0 0 0 0 0 -
132 Kloramfenibotol 5 5 0 5 0 (5)
133 KloramfineKapsul 0 0 0 0 0 -
134 Kloramfinetube 0 0 0 0 0 -
135 Kloramfinekbotol 0 0 0 0 0 -
136 Klorfenira tablet 600 10000 10600 8800 1800 16720 14,920
137 Klorfenol botol 0 0 0 0 0 -
138 Klorokuin ttablet 0 0 0 0 0 -
139 klorpromazampul 0 0 0 0 0 -
140 Klorpromaztablet 126 126 126 0 239 239
141 Klorpromaztablet 0 0 0 0 0 -
142 Kodein 10 tablet 128 128 3 125 6 (119)
143 kodein 20 tablet 0 0 0 0 0 -
144 Kotrimoksabotol 142 142 54 88 103 15
145 Kotrimoksatablet 200 200 159 41 302 261
146 Kotrimoksaz tablet 0 0 0 0 0 -
147 Kuinin (Kintablet 0 0 0 0 0 -
148 Laktulosa sbotol 24 24 0 24 0 (24)
149 LansoprazoKapsul 745 1000 1745 1585 160 3012 2,852
150 Lidokain HC ampul 0 0 0 0 0 -
151 Loperamidetablet 0 0 0 0 0 -
152 Loratadin ttablet 0 0 0 0 0 -
153 Lubricatingbotol 0 0 0 0 0 -
154 Masker pcs 100 100 50 50 95 45
155 Mebendazol tablet 0 0 0 0 0 -
156 Meloksikamtablet 0 0 0 0 0 -
157 Metformin tablet 247 247 215 32 409 377
158 Metilergome tablet 0 0 0 0 0 -
159 Metilergome ampul 0 0 0 0 0 -
160 Metilpredn tablet 0 0 0 0 0 -
161 Metoklopratablet 0 0 0 0 0 -
162 Metronidaztablet 54 54 54 0 103 103
163 Mikonazol ktube 0 0 0 0 0 -
164 Mummifyingbotol 0 0 0 0 0 -
165 Natrium bi tablet 1000 1000 1000 0 1900 1,900
166 Natrium Ditablet 800 1500 2300 2050 250 3895 3,645
167 Natrium klobotol 500 m 0 0 0 0 0 -
168 Nifedipin tablet 124 100 224 88 136 167 31
169 Nistatin ta tablet 0 0 0 0 0 -
170 Nistatin ta tablet 100 100 10 90 19 (71)
171 Oksitetrasivial 0 0 0 0 0 -
172 Oksitetras tube 0 0 0 0 0 -
173 Oksitetrasitube 0 0 0 0 0 -
174 OmeprazolKapsul 0 0 0 0 0 -
175 Ondansetr tablet 0 0 0 0 0 -
176 Parasetamobotol 0 0 0 0 0 -
177 Parasetamotablet 0 0 0 0 0 -
178 Parasetamotablet 0 0 0 0 0 -
179 Parasetamol drop 0 0 0 0 0 -
180 Permetrin Ctube 0 0 0 0 0 -
181 Pirantel ta tablet 21 21 16 5 30 25
182 Piridoksin tablet 1520 1000 2520 2020 500 3838 3,338
183 Pirocicam kaplet 0 0 0 0 0 -
184 Plester (2, rol 0 0 0 0 0 -
185 Plester (5 rol 0 0 0 0 0 -
186 Povidon lo botol 0 0 0 0 0 -
187 Prednison tablet 0 0 0 0 0 -
188 Primakuin tablet 0 0 0 0 0 -
189 Propiltiora tablet 361 361 52 309 99 (210)
190 Propranolotablet 0 0 0 0 0 -
191 Ranitidin I ampul 42 42 0 42 0 (42)
192 Ranitidin t tablet 396 1500 1896 1296 600 2462 1,862
193 Ringer laktabotol 19 19 13 6 25 19
194 Risperidontablet 10 10 0 10 0 (10)
195 Salap 2 - 4pot 17 17 11 6 21 15
196 Salbutamoltablet 600 600 490 110 931 821
197 Salisil bed Bungkus 0 0 0 0 0 -
198 SefadroksiKapsul 0 0 0 0 0 -
199 Serum Antivial 0 0 0 0 0 -
200 Serum Antiampul 0 0 0 0 0 -
201 Serum Antiampul 0 0 0 0 0 -
202 Sianokobaltablet 0 0 0 0 0 -
203 Sianokobalampul 16 16 0 16 0 (16)
 204 Silk (Bena pcs 36 36 0 36 0 (36)
205 Simetidin t tablet 0 0 0 0 0 -
206 Simvastatintablet 470 470 410 60 779 719
207 Siprofloksatablet 0 1000 1000 500 500 950 450
208 Spironolaktablet 0 0 0 0 0 -
209 Sukralfat 5tablet 0 0 0 0 0 -
210 Sukralfat 5botol 0 0 0 0 0 -
211 Sulfasetambotol 0 0 0 0 0 -
212 Tablet Tambtablet 0 0 0 0 0 -
213 Temporary set/
S 100 g 0 0 0 0 0 -
214 Teofilin150tablet 0 0 0 0 0 -
215 Tetrasikli Kapsul 0 0 0 0 0 -
216 Tetrasikli Kapsul 0 0 0 0 0 -
217 TiamfenikoKapsul 0 0 0 0 0 -
218 Tiamin HCLampul 0 0 0 0 0 -
219 Tiamin HCL/ tablet 175 5000 5175 4375 800 8313 7,513
220 Tramadol k50 kaps. 0 0 0 0 0 -
221 Triheksifentablet 0 0 0 0 0 -
222 Urine bag buah 0 0 0 0 0 -
223 Valsartan tablet 0 0 0 0 0 -
224 Vitamin B tablet 1700 5000 6700 4700 2000 8930 6,930
225 Vitamin Sirbotol 0 0 0 0 0 -
226 Zink Sirup botol 34 34 3 31 6 (25)
227 Zink tablet tablet 440 440 40 400 76 (324)
228 Masker OxPcs 5 5 0 5 0 (5)
229 Masker OxPcs 0 0 0 0 0 -
230 Masker OxPcs 10 10 0 10 0 (10)
231 Selang OxPcs 0 0 0 0 0 -
232 Selang OxyPcs 0 0 0 0 0 -
233 Selang OxPcs 0 0 0 0 0 -
234 Depakote botol 100 100 0 100 0 (100)

MENGETAHUI/MENYETUJUI: YANG MENYERAHKAN: YANG MEMINTA/MELAPORKAN:

KEPALA DINAS KESEHATAN KEPALA INSTALASI FARMASI KEPALA PUSKESMAS,
KABUPATEN PIDIE DINAS KESEHATAN PIDIE UJONG RIMBA

dr. H. FAJRIMAN, Sp.S., M.Si., Med. RATNA DEWI, SKM dr. MARHAMAH
NIP. 19700909 2000112 1 003 NIP. 19721019 200003 2 005 NIP. 19821012 200904 2 003
N OBAT (LPLPO)

NOMOR TANGGAL

PUSKESMAS

Pemberian
KET
D A K LAIN-LAIN
15 17
 SIGLI, Desember 2017
YANG MENERIMA:
PETUGAS PENGELOLA OBAT
PUSKESMAS, UJONG RIMBA

ERLINA NURDIN, AMKL

NIP. 19780606 200504 2 003
 LAP

PUSKESMAS :
KECAMATAN :
KABUPATEN : PIDIE
PROVINSI : ACEH

NO Nama Obat Kemasan Januari Februari

1 2 3 4 5
1 Air Raksa dental use botol
2 Abocath No. 20 pcs
3 Abocath No. 22 pcs
4 Abocath No. 24 pcs
5 Abocath No. 26 pcs
6 Acyclovir 200 mg ktk 10x10 tablet
7 Acyclovir 400 mg ktk 10x10 tablet
8 Alat suntik sekali pakai 1 ml pcs
9 Alat suntik sekali pakai 2.5 ml pcs
10 Alat suntik sekali pakai 3 ml pcs
11 Alat suntik sekali pakai 5 ml pcs
12 Albendazol Tab 400 mg tablet
13 Alkohol Swab Lembar
14 Alopurinol tablet 100 mg tablet
15 Alprazolam 0,5 mg tablet
16 Aminofilin injeksi 24 mg / ml - 10 ml ampul
17 Aminofilin tablet 200 mg 100 tablet
18 Amitriptilin HCL tablet salut 25 mg 100 tablet
19 Amlodipin 10 mg. tablet
20 Amoksisilin kaplet 500 mg 100 kaplet
21 Amoksisilin sirup kering 125 mg/5 ml botol
22 Amoksisilin sirup kering Forte 250 mg/5 mg botol
23 Antalgin (Metampiron) tablet 500 mg tablet
24 Antasida DOEN sirup botol
25 Antasida DOEN tablet tablet
26 Anti bakteri DOEN salap Basitrasin 25 tube @ 5 g
27 Anti hemoroid DOEN kombinasi supp
28 Antifungi DOEN kombinasi : 3 - 6 24 pot @ 30 g
29 Antimigren DOEN kombinasi (Ergotamin) tablet
Antiparkinson kombinasi : Benserazid 25 mg
30 tablet
Levodopa 100 mg (Levopar)
31 Artemeter Inj. 80 mg/ml. (Artem) ampul
32 Asam askorbat (vit.C) tablet 50 mg tablet
33 Asam Folat 0,4 mg tablet
34 Asam Mefenamat tablet 500 mg tablet
35 Asam Valproat 250 mg tablet
36 Asiklovir krim 5% tube
37 Attapulgit tablet ( Puralex ) tablet
38 Betahistin 6 mg tablet
39 Betametson krim 0,1% 24 tube @5 g
40 Bisakodil Supp 10 mg. ( Dulcolax ) supp
41 Bisakodil Supp 5 mg. ( Dulcolax ) supp
42 Bisoprolol 2,5 mg (Concord) tablet
43 bisoprolol 5 mg tablet
44 Bisturi (Scalpel Blades) 23 pcs
45 Captopril 12.5 mg. tablet
46 Captopril 25 mg tablet
47 Cat gut/benang bedah No. 3/0 (chromic) pcs
48 Cefixime 100 mg Kapsul
49 Cefotaxime inj 1 gr vial
50 Cetirizin 10 mg tab 50 tab/ktk
51 Cetirizin 5 mg / 5 ml botol
52 Clozapine 25 mg tab tablet
53 Deksametason injeksi 5 mg/ml - 1 ml ampul
54 Deksametason tablet 0,5 mg tablet
55 Diazepam injeksi 5 mg/ml - 2 ml ampul
56 Diazepam rektal 5 mg/ 2,5 ml (Stesolid) tube
57 Diazepam tablet 2 mg tablet
58 Diazepam tablet 5 mg tablet
59 Difenhidramin HCL injeksi 10 mg/ml - 1 ml ampul
60 Digoksin tablet 0,25 mg. tablet
61 Diltiazem HCl 30 mg tablet tablet
62 Doksisiklin 100 mg Kaps. Kapsul
63 Domperidon Sirup botol
64 Domperidon tablet 10 mg. tablet
65 Ekstrak Belladona tab 10 mg 1000/btl
66 Eritromisin kapsul 500mg ktk 10 x 10 tab.
67 Eritromisin sirup 200mg/5ml btl 60 ml
68 Etakridin (Rivanol) larutan 0,1% botol
69 Etanol 70% 1000 ml
70 Etanol 70% 100 ml
71 Etil klorida semprot 100 ml
72 Eugenol cairan botol
73 Fenitoin natrium kapsul 100 mg Kapsul
74 Fenobarbital Inj. I.m. 50 mg / ml - 2 ml ampul
75 Fenobarbital tablet 30 mg tablet
76 Fenol gliserol tts telinga 10% botol
 77 Fitomenadion (vit.K1) Injeksi 10 mg / ml ampul
78 Fitomenadion (vit.K1) tab. salut gula 10 mg tablet
79 Flufenazin Inj. I.m 25 mg / ml (Sikzonoat) ampul
80 Folley Catheter No 16 Buah
81 Folley Catheter No 18 Buah
82 Furosemid tablet 40 mg tablet
83 Furosemide Inj. 10 mg/ml. ampul
84 Fusidic Acid (Fusycom Cream) 5 gr tube
85 Gabapentine 100 mg (Alpintin) Kapsul
86 Gameksan emulsi 1% btl 30 ml.
87 Garam oralit untuk 200 ml air sachet
88 Gentamisin Salap mata 0,3% tube
89 Gentamisin Sulfat salep kulit 0,1 % tube
90 Gentamisin Sulfat tetes mata 0,3% botol
91 Gentian Violet larutan 1% botol
92 Glass lonomer cement (GC IX) Set
93 Glibenklamid tablet 5 mg tablet
94 Glimepirid tablet
95 Gliseril Guayakolat 100 mg tablet
96 Glukosa 5 % - Nacl 0,225 % 500 ml
97 Glukosa 5 % - Nacl 0,45 % btl 500 ml.
98 Glukosa 5 % - Nacl 0,9 % btl 500 ml.
99 Glukosa larutan infus 40% steril btl 500 ml.
100 Glukosa larutan infus 5% steril btl 500 ml.
101 Griseofulvin tablet 125 mg, Micronized tablet
102 Haloperidol tablet 0,5 mg tablet
103 Haloperidol tablet 1,5 mg tablet
104 Haloperidol tablet 5 mg tablet
105 Handscoon Steril No 6,5 50 Pasang/ktk
106 Handscoon Steril No 7,5 50 Pasang/ktk
107 Handscoon Ukuran L 100 pcs/ktk
108 Handscoon Ukuran M 100 pcs/ktk
109 Handscoon Ukuran S 100 pcs/ktk
110 Hidrokortoson krim 1 % tube
111 Hidrokortoson krim 2,5 % tube
112 Hodroklorotiazid (HCT) tablet 25 mg tablet
113 Ibuprofen susp. 60 ml. botol
114 Ibuprofen tablet 200 mg tablet
115 Ibuprofen tablet 400 mg tablet
116 Infusion set anak Set
117 Infusion set dewasa Set
118 Isosorbit Dinitrat tablet Sublingual 5 ml tablet
119 Kalium Klorida tab. 600 mg (KSR) tablet
120 Kalsium Hidroksida pasta Buah
121 Kalsium laktat (Kalk) tablet 500 mg tablet
122 Kapas pembalut/Hidrofil DRC 250 gram Bungkus
123 Karbamazepin tablet 200 mg tablet
124 Kasa kompres 16/16 steril Bungkus
125 Kasa pembalut Hidrofil 4 m x 10 cm Rol
126 Ketokonazol krim 2% tube
127 Ketokonazol tablet 200 mg. ktk 5 x 10 tab.
128 Ketoprofrem Supositoria 100 mg supp
129 Ketorolac Inj 30 mg/ml ampul
130 Kloplidogrel 75 mg Kapsul
131 Klindamisin 150 mg tablet
132 Kloramfenikol susp. 125 mg/ml botol
133 Kloramfinekol kapsul 250 mg Kapsul
134 Kloramfinekol salap mata 1% tube
135 Kloramfinekol tetes telinga 3% botol
136 Klorfeniramin Maleat (CTM) tablet 4 mg tablet
137 Klorfenol Kanfer Mentol (CHKM) botol
138 Klorokuin tablet 150 mg tablet
139 klorpromazin HCL Inj. 25 mg/ml ampul
140 Klorpromazin HCL tablet salut 100 mg tablet
141 Klorpromazin HCL tablet salut 25 mg tablet
142 Kodein 10 mg tablet
143 kodein 20 mg tablet
144 Kotrimoksazol suspensi botol
145 Kotrimoksazol tablet 480 mg tablet
146 Kotrimoksazol tablet pediatrik 120 mg tablet
147 Kuinin (Kina) tablet 200 mg tablet
148 Laktulosa sirup 3.335 gr/ 5ml botol
149 Lansoprazol 30 mg. kaps. Kapsul
150 Lidokain HCL inj. 2% Epinefrin 1:80000 ampul
151 Loperamide tab 2 mg tablet
152 Loratadin tablet 10 mg. tablet
153 Lubricating Jelly 82 gram botol
154 Masker pcs
155 Mebendazol tablet 100 mg tablet
156 Meloksikam 7,5 mg tablet
157 Metformin 500 mg tablet
158 Metilergometrin maleat tab. salut 0,125 mg tablet
159 Metilergometrin maleat inj. 0,200 mg - 1 ml ampul
160 Metilprednisolon 4 mg tablet
161 Metoklopramid tablet 10 mg. tablet
162 Metronidazol tablet 250 mg tablet
163 Mikonazol krim / salap 2% nitrat tube
164 Mummifying pasta botol
165 Natrium bikarbonat tablet 500 mg tablet
166 Natrium Diklofenac 50 mg tablet
167 Natrium klorida larutan infus 0,9% steril botol 500 ml
168 Nifedipin tablet
169 Nistatin tablet salut 100.000 IU tablet
170 Nistatin tablet salut 500.000 IU tablet
171 Oksitetrasiklin HCL inj. I.m 50 mg/ml - 10 ml vial
172 Oksitetrasiklin HCL salap mata 1% tube
173 Oksitetrasiklin HCL salap 3% tube
174 Omeprazol 20 mg. kaps. Kapsul
175 Ondansetron 4 mg tablet
176 Parasetamol sirup 120 mg/5 ml botol
177 Parasetamol tablet 100 mg. tablet
178 Parasetamol tablet 500 mg tablet
179 Parasetamol tetes 60 mg / 0,6 ml drop
180 Permetrin Cream 5 % (scabimite cr. 10 gr) tube
181 Pirantel tablet 125 mg tablet
182 Piridoksin HCL(Vit.B6) tablet 10 mg tablet
183 Pirocicam 20 mg kaplet
184 Plester (2,5 cm x 4,5 m) rol
185 Plester (5 cm x 4,5 m) rol
186 Povidon lodida 10% botol
187 Prednison tablet 5 mg tablet
188 Primakuin tablet 15 mg tablet
189 Propiltiorasil (PTU) tab tablet
190 Propranolol HCL tablet 40 mg tablet
191 Ranitidin Inj. 25 mg/ml. ampul
192 Ranitidin tab 150 mg tablet
193 Ringer laktat larutan infus steril botol
194 Risperidon 2 mg tablet
195 Salap 2 - 4, kombinasi : pot
196 Salbutamol tablet 2 mg tablet
197 Salisil bedak 2% Bungkus
198 Sefadroksil kapsul 500 mg. Kapsul
199 Serum Anti Bisa Ular (ABU I) Inj. vial
200 Serum Anti tetanus Inj. 20.000 IU (ATS) ampul
201 Serum Anti tetanus Inj.1.500 IU (ATS) ampul
202 Sianokobalamin (Vit.B12) 50 mcg tablet
203 Sianokobalamin (Vit.B12) inj. 500 mcg/ml-1ml ampul
204 Silk (Benang bedang Sutera) No. 3/0 pcs
205 Simetidin tablet 200 mg. tablet
206 Simvastatin tablet 10 mg. tablet
207 Siprofloksasin tablet 500 mg tablet
208 Spironolakton 25 mg. tablet
209 Sukralfat 500 (ulsidek) tab tablet
210 Sukralfat 500 mg/ 5 ml botol
211 Sulfasetamida Natrium tetes mata 15% botol
212 Tablet Tambah Darah besi II sulfat tablet
213 Temporary Stopping Fletcher (Fletcher) set/ 100 g
214 Teofilin150 mg (Bronsolvan) tablet
215 Tetrasiklin HCL kapsul 250 mg Kapsul
216 Tetrasiklin HCL kapsul 500 mg Kapsul
217 Tiamfenikol kapsul 500 mg. Kapsul
218 Tiamin HCL (vit.B1) injeksi 100 mg/ml - 1 ml ampul
219 Tiamin HCL/Mononitrat (vit.B1) tablet 50 mg tablet
220 Tramadol kapsul 50 mg. 50 kaps.
221 Triheksifenidil Hidroklorida tablet 2 mg tablet
222 Urine bag buah
223 Valsartan 80 mg tablet
224 Vitamin B Komplek tablet tablet
225 Vitamin Sirup botol
226 Zink Sirup ( Zircum Kid) botol
227 Zink tablet 20 mg. tablet
228 Masker Oxygen Anak Pcs
229 Masker Oxygen Bayi Pcs
230 Masker Oxygen Dewasa Pcs
231 Selang Oxygen Anak Pcs
232 Selang Oxygen Bayi Pcs
233 Selang Oxygen Dewasa Pcs
234 Depakote ER botol
 MENGETAHUI/MENYETUJUI: YANG MENYERAHKAN:
KEPALA DINAS KESEHATAN KEPALA INSTALASI FARMASI
KABUPATEN PIDIE DINAS KESEHATAN PIDIE

dr. H. FAJRIMAN, Sp.S., M.Si., Med. ULIA MAKSUM, S. Farm., APT

NIP. 19700909 2000112 1 003 NIP. 19851007 200904 2 010
 LAPORAN PEMAKAIAN DAN LEMBARAN PERMINTAAN OBAT (LPLPO)
T A H U N 2017
DOKUMEN
IFK
PELAPORAN PERIODE PUSKESMAS
PERMINTAAN PERIODE :

Maret April Mei Juni Juli

6 7 8 9
 NYERAHKAN: YANG MEMINTA/MELAPORKAN:
TALASI FARMASI KEPALA PUSKESMAS,
SEHATAN PIDIE ……………………………..

M, S. Farm., APT …………………………….

07 200904 2 010 NIP.
BAT (LPLPO)

NOMOR TANGGAL

Agustus September Oktober November Desember

15
 SIGLI, ……………………………..20….
YANG MENERIMA:
PETUGAS PENGELOLA OBAT
PUSKESMAS,...............

……………………………….
NIP.
Jumlah

17