LAPORANPEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

SUB UNIT

PUSKESMAS : PUSKESMAS GAYAM

SUB UNIT : PUSTU KALOWANG
PELAPORAN BULAN / PERIODE :
NOMOR DOKUMEN : --------------

Sediaan Padat
Stok Penerim Persedia Pemakai Stok Perminta Pembe
NO Nama Obat Satuan Ket.
Awal aan an an Akhir an rian
1 2 3 4 5 6 7 8 10 11 12
1 Ambroxol 30 mg Tablet Tablet 80 0 80 50 30 100
2 Amoxiciilin 500 mg Tablet 20 100 120 80 40 100
3 Antalgin 500 mg Tablet Tablet 30 100 130 100 30 100
4 Antasida 500 mg Tablet Tablet 20 100 120 90 30 100
5 Asam Folat 1 mg Tablet Tablet - -
6 Asam Mefenamat 500 mg Tablet Tablet 70 0 70 60 10 100
7 Captopril 25 mg Tablet 20 100 120 80 40 100
8 CotRimoxazole Dewasa Tablet 480 mg Tablet 80 0 80 60 20 100
9 Dexamethasone Tabet Tablet 20 100 120 90 30 100
10 Dimenhidrinate Tablet 50 mg Tablet 50 0 50 30 20 100
11 Efedrine Tablet 25 mg Tablet - -
12 Furosemide Tablet 40 mg Tablet - -
13 Garam Oralit Tablet - -
14 Glycerylguaiacolat Tablet 100 mg Tablet 10 100 110 80 30 100
15 Ibuprofen 400 mg Tablet 20 100 120 90 30 100
Kalsium Laktat 500 mg (Kalk) tablet
16 Tablet 40 100 140 80 60 100
500 mg
17 Klorfeniramin Maleat (CTM) 4 mg Tablet 10 100 110 70 40 100
18 Lexadium Tablet Tablet - -
19 Lexavit Tablet (Multivitamin) Tablet - -
20 Metilergometrin Maleat Tablet Tablet - -
21 Metoclorpramide tablet 10 mg Tablet - -
22 Metronidazole tablet 500 mg Tablet 80 0 80 50 30 100
23 Pantrin (Pyrantel) tablet 250 mg Tablet - -
24 Papaverina Tablet Tablet - -
25 Paracetamol 500 mg Tablet Tablet 20 100 120 100 20 100
26 Prednison Tablet 5 mg Tablet 10 100 110 80 30 100
27 Pyridoxine Hcl tablet 10 mg Tablet - -
28 Retinol (Vitamin A 100.000 IU) Tablet - -
29 Retinol (Vitamin A 200.000 IU) Tablet - -
30 Salbutamol 4 mg Tablet Tablet 80 0 80 70 10 100
31 Tablet Tambah Darah Tablet 30 100 130 100 30 100
32 Vitamin C 50 mg Tablet Tablet - -
33 Zinc Tablet 20 mg Tablet 70 0 70 50 20 100
34 - -
35 - -
36 - -
37 - -
38 - -
39 - -
40 - -
41 - -
42 - -
43 - -
44 - -
45 - -
46 - -
47 - -
48 - -

Sediaan Cair
 1 Dextral Syrup Botol 1 5 6 5 1 5
2 Ambroxol Syrup Botol 2 5 7 6 1 5
3 Cotrimoksazole Syrup 240 mg/60ml Botol 2 5 7 5 2 5
4 Fenol Glycerol Tetes Telinga 10% 5 ml Botol - -
5 Glucosa Larutan Infus 5% Botol - -
6 Lytacur Syrup (Multivitamin) Botol - -
7 Molexflu Syrup Botol 2 5 7 5 2 5
8 NaCl 0,9% 500 ml Botol - -
9 Obat Batuk Hitan (OBH) syrup Botol - -
10 Paracetamol syrup 120 mg/5 ml Botol 2 7 9.00 5 4.00 7
11 Pirantel suspensi 125 mg/5 ml Botol - -
12 Polikrosulen cairan (Aptil) 36% Botol - -
13 Ringer Laktat Infus Botol - -
14 Zinckid Syrup Botol 3 5 8 4 4 5
15 - -
16 - -
17 - -
18 - -
19 - -

Sediaan Parenteral
1 Antalgin Injeksi 250 ml/ 2 ml Ampul - -
2 Aqua untuk injeksi 25 ml Fls - -
Cyanocobalamin (Vitamin B12) Injeksi
3 Ampul 10 50 60 45 15 50
Dexamethasone
500 mcg/ml Injeksi 5 mg/ml - 1
4 Ampul 5 30 35 20 15 30
Diphenhidramine Hcl Injeksi 10
ml
5 Ampul 7 30 37 27 10 30
mg/ml - 1 ml
6 Fitomenadion Injeksi 2ml/ml Ampul - -
7 Lidocain Injeksi 2% Ampul 1 5 6 5 1 7
8 Ranitidin Injeksi 25 mg/ml Ampul - -
9 - -
10 - -
11 - -
12 - -
13 - -
14 - -

Sesiaan Salep, Krim dan Obat Topikal

Antihemoroid Doen Kombinasi
1 Supps - -
(Superhoid) 2 gr
2 Acyclovir Cream 5% Tube - -
3 Chloramfenicol Salep Mata 1% Tube 2 5 7 3 4 5
Gentamycin Salep Kulit 0,1%
4 Tube 2 5 7 5 2 5
(Gentalex)
5 Hydrocortisone Cream 2,5 mg Tube 1 5 6 4 2 5
6 Levertran Salep (Salep Luka Bakar) Pot - -
7 Miconazole Cream 2% Tube 3 2 5 3 2 5
8 Oxytetracycline Hcl Salep Kulit 3% Tube 3 3 6 5 1 5
9 Salep 2-4 Pot - -
10 - -
11 - -
12 - -
13 - -
14 - -
15 - -
16 - -

Antiseptik
1 Alkohol 70 % 100 ml Botol - - 1
2 Ethakridin (Rivanol) Lrutan 0,1 % 300 Botol - -
3 Gentian Violet Larutan 1% Botol - -
4 H2O2 Botol - -
5 PK Serbuk Botol - -
6 Povidon Iodine Larutan 10% 1000 ml Botol - -
7 Povidon Iodine Larutan 10% 300 ml Botol 2 5 7 4 3 5
8 - -
9 - -
10 - -
11 - -

Psikotropika
1 - -
2 - -
3 - -
4 - -

Bahan Medis Habis Pakai

1 Alat Suntik Sekali Pakai 1 ml Pcs - -
2 Alat Suntik Sekali Pakai 10 ml Pcs - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 10 100 110 90 20 100
4 Alat Suntik Sekali Pakai 5 ml Pcs - -
5 Alat Suntik Sekali Pakai 50 ml Pcs - -
Benang Non Absorb 3/0 (Premilene)
6 Pcs 1 2 3 2 1 3
75 cm
7 Benang Non Absorb 3/0 (Silk) 75 cm Pcs 1 2 3 1 2 3
8 Infusion Set Anak Pcs 2
9 Infusion Set Dewasa Pcs - - 2
10 Infusion Set Paediatric Pcs - -
11 IV Cathether No. 18 Pcs - - 1
12 IV Cathether No. 20 Pcs - - 2
13 IV Cathether No. 22 Pcs - - 2
14 IV Cathether No. 24 Pcs - -
15 Kasa Steril 2 5 7 4 3 10
16 Kasa Pembalut 40 x 80 cm Pcs - -
17 Masker Tali Pcs - - 1
18 Plester 5 x 4,5 m Pcs - -
19 Sarung tangan Biasa Ukuran L Pcs - -
20 Sarung tangan Biasa Ukuran M Pcs - - 1
21 Sarung tangan Biasa Ukuran S Pcs - -
22 Sarung tangan Steril No.6,5 Pcs - -
23 Sarung tangan Steril No.7 Pcs - -
24 - -
25 - -
26 - -
27 - -
28 - -
29 - -
30 - -
31 - -
32 - -
33 - -

Mengetahui Yang Menyerahkan Yang Menerima

Kepala Puskesmas Gayam Pengelola Obat Puskesmas Petugas Sub Unit

Hj. IDA ROYANI, A.Md.Keb ________________________ RIRIN SARASWATI, S.Kep.Ns

NIP. 19691009 198901 2 002 NIP : NIP. 19770517 200701 2015
 Sediaan Cair

1 Dextral Syrup Botol - -

2 Ambroxol Syrup Botol - -
3 Cotrimoksazole Syrup 240 mg/60ml Botol - -
4 Fenol Glycerol Tetes Telinga 10% 5 ml Botol - -
5 Glucosa Larutan Infus 5% Botol - -
6 Lytacur Syrup (Multivitamin) Botol - -
7 Molexflu Syrup Botol - -
8 NaCl 0,9% 500 ml Botol - -
9 Obat Batuk Hitan (OBH) syrup Botol - -
10 Paracetamol syrup 120 mg/5 ml Botol - -
11 Pirantel suspensi 125 mg/5 ml Botol - -
12 Polikrosulen cairan (Aptil) 36% Botol - -
13 Ringer Laktat Infus Botol - -
14 Zinckid Syrup Botol - -
15 - -
16 - -
17 - -
18 - -
19 - -

Sediaan Parenteral

1 Antalgin Injeksi 250 ml/ 2 ml Ampul - -

2 Aqua untuk injeksi 25 ml Fls - -
Cyanocobalamin (Vitamin B12) Injeksi
3 Ampul - -
500 mcg/ml
4 Dexamethasone Injeksi 5 mg/ml - 1 ml Ampul - -
Diphenhidramine Hcl Injeksi 10 mg/ml -
5 Ampul - -
1 ml
6 Fitomenadion Injeksi 2ml/ml Ampul - -
7 Lidocain Injeksi 2% Ampul - -
8 Ranitidin Injeksi 25 mg/ml Ampul - -

9 - -
10 - -
11 - -
12 - -
13 - -
14 - -

Sesiaan Salep, Krim dan Obat Topikal

Antihemoroid Doen Kombinasi
1 Supps -
(Superhoid) 2 gr -
2 Acyclovir Cream 5% Tube - -
3 Chloramfenicol Salep Mata 1% Tube - -
4 Gentamycin Salep Kulit 0,1% (Gentalex) Tube - -
5 Hydrocortisone Cream 2,5 mg Tube - -
6 Levertran Salep (Salep Luka Bakar) Pot - -
7 Miconazole Cream 2% Tube - -
8 Oxytetracycline Hcl Salep Kulit 3% Tube - -
9 Salep 2-4 Pot - -
10 - -
11 - -
12 - -
13 - -
14 - -
15 - -
16 - -
 Antiseptik

1 Alkohol 70 % 100 ml Botol - -

2 Ethakridin (Rivanol) Lrutan 0,1 % 300 ml Botol - -
3 Gentian Violet Larutan 1% Botol - -
4 H2O2 Botol - -
5 PK Serbuk Botol - -
6 Povidon Iodine Larutan 10% 1000 ml Botol - -
7 Povidon Iodine Larutan 10% 300 ml Botol - -
8 - -
9 - -
10 - -
11 - -

Psikotropika

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

Bahan Medis Habis Pakai

1 Alat Suntik Sekali Pakai 1 ml Pcs - -

2 Alat Suntik Sekali Pakai 10 ml Pcs - -
3 Alat Suntik Sekali Pakai 3 ml Pcs - -
4 Alat Suntik Sekali Pakai 5 ml Pcs - -
5 Alat Suntik Sekali Pakai 50 ml Pcs - -
Benang Non Absorb 3/0 (Premilene) 75
6 Pcs -
cm -
7 Benang Non Absorb 3/0 (Silk) 75 cm Pcs - -
8 Infusion Set Anak Pcs - -
9 Infusion Set Dewasa Pcs - -
10 Infusion Set Paediatric Pcs - -
11 IV Cathether No. 18 Pcs - -
12 IV Cathether No. 20 Pcs - -
13 IV Cathether No. 22 Pcs - -
14 IV Cathether No. 24 Pcs - -
15 Kasa Steril - -
16 Kasa Pembalut 40 x 80 cm Pcs - -
17 Masker Tali Pcs - -
18 Plester 5 x 4,5 m Pcs - -
19 Sarung tangan Biasa Ukuran L Pcs - -
20 Sarung tangan Biasa Ukuran M Pcs - -
21 Sarung tangan Biasa Ukuran S Pcs - -
22 Sarung tangan Steril No.6,5 Pcs - -
23 Sarung tangan Steril No.7 Pcs - -
24 - -
25 - -
26 - -
27 - -
28 - -
29 - -
30 - -
31 - -
32 - -
33 - -

Mengetahui Yang Menyerahkan Yang Menerima

Kepala Puskesmas Gayam Pengelola Obat Puskesmas Petugas Sub Unit

--------------------------------- --------------------------------- ---------------------------------

NIP : NIP : NIP :
 LAPORANPEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
SUB UNIT

PUSKESMAS : PUSKESMAS GAYAM

SUB UNIT : PONKESDES PANCOR
PELAPORAN BULAN / PERIODE : OKTOBER 2018
NOMOR DOKUMEN : --------------

Sediaan Padat
Stok Stok
NO Nama Obat Satuan Penerimaan Persediaan Pemakaian Permintaan Pemberian Ket.
Awal Akhir

1 2 3 4 5 6 7 8 10 11 12

1 Ambroxol 30 mg Tablet Tablet 0 0 0 0 0 200

2 Amoxiciilin 500 mg Tablet 0 0 0 0 0 200

3 Antalgin 500 mg Tablet Tablet 0 0 0 0 0 200

4 Antasida 500 mg Tablet Tablet 0 0 0 0 0 200

5 Asam Folat 1 mg Tablet Tablet 0 0

6 Asam Mefenamat 500 mg Tablet Tablet 0 0
7 Captopril 25 mg Tablet 0 0 30 30 0 200

8 Cotimoxazole Dewasa Tablet 480 mg Tablet 0 0 0 0 0 200

9 Dexamethasone Tabet Tablet 0 100 100 70 30 200

10 Dimenhidrinate Tablet 50 mg Tablet 0 0 0 0 0 200

11 Efedrine Tablet 25 mg Tablet 0 0

12 Furosemide Tablet 40 mg Tablet 0 0 0 0 0 100

13 Garam Oralit Tablet 0

14 Glycerylguaiacolat Tablet 100 mg Tablet 0 0

15 Ibuprofen 400 mg Tablet 0 0 0 0 0 200
Kalsium Laktat 500 mg (Kalk) tablet
16 Tablet 0 0 0 0 200
500 mg 0
17 Klorfeniramin Maleat (CTM) 4 mg Tablet 0 0 50 30 20 200

18 Lexadium Tablet Tablet 0 0

19 Lexavit Tablet (Multivitamin) Tablet 0 0
20 Metilergometrin Maleat Tablet Tablet 0 0
21 Metoclorpramide tablet 10 mg Tablet 0 0 0 0 0 200

22 Metronidazole tablet 500 mg Tablet 0 0 0 0 0 200

23 Pantrin (Pyrantel) tablet 250 mg Tablet 0 0

24 Papaverina Tablet Tablet 0 0
25 Paracetamol 500 mg Tablet Tablet 0 0 0 0 0 200

26 Prednison Tablet 5 mg Tablet 0 0 0 0 0 200

27 Pyridoxine Hcl tablet 10 mg Tablet 0 0

28 Retinol (Vitamin A 100.000 IU) Tablet 0 0
29 Retinol (Vitamin A 200.000 IU) Tablet 0 0
30 Salbutamol 4 mg Tablet Tablet 0 0 0 0 0 200

31 Tablet Tambah Darah Tablet 100 0 100 70 30 200

32 Vitamin C 50 mg Tablet Tablet 0 0
33 Zinc Tablet 20 mg Tablet 0 0
34 Kasa gulung 0 0
35 amlodipin 5 mg Tablet 20 90 110 60 50 100

36 Ibuprofen 400 mg Tablet 20 0 20 20 0 200

37 alluporinol 100 mg Tablet 0 100 100 100 0 200

38 molexflu Tablet 20 150 170 150 20 200

39 hustab Tablet 0 0 0 0 0 200

40 becofrot Tablet 0 100 100 100 0 200

41 hemafrot tablet 0 0 0 0 0 200

42 0 0
43 0 0
44 0 0
45 0 0
46 0 0
47 0 0
48 0 0

Sediaan Cair

1 Dextral Syrup Botol 0 0

2 Ambroxol Syrup Botol 0 0
3 Cotrimoksazole Syrup 240 mg/60ml Botol 0 0
4 Fenol Glycerol Tetes Telinga 10% 5 ml Botol 0 0
5 Glucosa Larutan Infus 5% Botol 0 0
6 Lytacur Syrup (Multivitamin) Botol 0 0
7 Molexflu Syrup Botol 0 0
8 NaCl 0,9% 500 ml Botol 0 0
9 Obat Batuk Hitan (OBH) syrup Botol 0 0
10 Paracetamol syrup 120 mg/5 ml Botol 0 0
11 Pirantel suspensi 125 mg/5 ml Botol 0 0
12 Polikrosulen cairan (Aptil) 36% Botol 0 0
13 Ringer Laktat Infus Botol 0 0
14 Zinckid Syrup Botol 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0

Sediaan Parenteral

1 Antalgin Injeksi 250 ml/ 2 ml Ampul 0 0 0 0 0 200

2 Aqua untuk injeksi 25 ml Fls 0 0

Cyanocobalamin (Vitamin B12) Injeksi
3 Ampul 0 20 20 20 0 200
500 mcg/ml
4 Dexamethasone Injeksi 5 mg/ml - 1 ml Ampul 0 0
Diphenhidramine Hcl Injeksi 10 mg/ml -
5 Ampul 0 10 10 10 0 200
1 ml
6 Fitomenadion Injeksi 2ml/ml Ampul 0 0 0 0 0 200

7 Lidocain Injeksi 2% Ampul 0 0 0 0 0 50

8 Ranitidin Injeksi 25 mg/ml Ampul 0 0 0 0 0 0

9 inj.B1 100 mg/ml Ampul 0 10 10 10 0 200

10 0 0
11 0 0
12 0 0
13 0 0
14 0 0

Sesiaan Salep, Krim dan Obat Topikal

Antihemoroid Doen Kombinasi
1 Supps 0
(Superhoid) 2 gr 0
2 Acyclovir Cream 5% Tube 0 0
3 Chloramfenicol Salep Mata 1% Tube 0 0 0 0 0 10
4 Gentamycin Salep Kulit 0,1% (Gentalex) Tube 2 0 2 2 0 10
5 Hydrocortisone Cream 2,5 mg Tube 2 0 2 2 0 10
6 Levertran Salep (Salep Luka Bakar) Pot 0 0
7 Miconazole Cream 2% Tube 0 0 0 0 0 10
8 Oxytetracycline Hcl Salep Kulit 3% Tube 0 0 0 0 0 10
9 Salep 2-4 Pot 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0

Antiseptik

1 Alkohol 70 % 100 ml Botol 0 1 1 1 0 1

2 Ethakridin (Rivanol) Lrutan 0,1 % 300 ml Botol 0 0
3 Gentian Violet Larutan 1% Botol 0 0
4 H2O2 Botol 0 0
5 PK Serbuk Botol 0 0
6 Povidon Iodine Larutan 10% 1000 ml Botol 0 0
7 Povidon Iodine Larutan 10% 300 ml Botol 0 0
8 0 0
9 0 0
10 0 0
11 0 0

Psikotropika

1 0 0
2 0 0
3 0 0
4 0 0

Bahan Medis Habis Pakai

1 Alat Suntik Sekali Pakai 1 ml Pcs 0 0

2 Alat Suntik Sekali Pakai 10 ml Pcs 0 0
3 Alat Suntik Sekali Pakai 3 ml Pcs 0 50 50 50 0 200
4 Alat Suntik Sekali Pakai 5 ml Pcs 0 50 50 50 0 200
5 Alat Suntik Sekali Pakai 50 ml Pcs 0 0
Benang Non Absorb 3/0 (Premilene) 75
6 Pcs 0
cm 0
7 Benang Non Absorb 3/0 (Silk) 75 cm Pcs 0 0
8 Infusion Set Anak Pcs 0 0
9 Infusion Set Dewasa Pcs 0 0
10 Infusion Set Paediatric Pcs 0 0
11 IV Cathether No. 18 Pcs 0 0
12 IV Cathether No. 20 Pcs 0 0
13 IV Cathether No. 22 Pcs 0 0
14 IV Cathether No. 24 Pcs 0 0
15 Kasa Steril 0 0
16 Kasa Pembalut 40 x 80 cm Pcs 0 0
17 Masker Tali Pcs 0 0
18 Plester 5 x 4,5 m Pcs 0 0
19 Sarung tangan Biasa Ukuran L Pcs 0 0
20 Sarung tangan Biasa Ukuran M Pcs 0 0
21 Sarung tangan Biasa Ukuran S Pcs 0 0
22 Sarung tangan Steril No.6,5 Pcs 0 0
23 Sarung tangan Steril No.7 Pcs 0 0
24 Kapas gulung gulung 0 0 0 0 0 1
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
32 0 0
33 0 0

Mengetahui Yang Menyerahkan Yang Menerima

Kepala Puskesmas Gayam Pengelola Obat Puskesmas Petugas Sub Unit

--------------------------------- --------------------------------- ---------------------------------

NIP : NIP : NIP :
 LAPORANPEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
SUB UNIT

PUSKESMAS : PUSKESMAS GAYAM

SUB UNIT : PONKESDES PANCOR
PELAPORAN BULAN / PERIODE OKTOBER 2018
NOMOR DOKUMEN : --------------

Sediaan Padat
Stok Stok
NO Nama Obat Satuan Penerimaan Persediaan Pemakaian Permintaan Pemberian Ket.
Awal Akhir

1 2 3 4 5 6 7 8 10 11 12

1 Ambroxol 30 mg Tablet Tablet 40 40 40 0

2 Amoxiciilin 500 mg Tablet 0 0
3 Antalgin 500 mg Tablet Tablet 0 0 0
4 Antasida 500 mg Tablet Tablet 0 0
5 Asam Folat 1 mg Tablet Tablet 0 0
6 Asam Mefenamat 500 mg Tablet Tablet 0 0
7 Captopril 25 mg Tablet 0 0
8 Cotimoxazole Dewasa Tablet 480 mg Tablet

9 Dexamethasone Tabet Tablet 0 0

10 Dimenhidrinate Tablet 50 mg Tablet 0 0 0
11 Efedrine Tablet 25 mg Tablet 0 0
12 Furosemide Tablet 40 mg Tablet 0 0
13 Garam Oralit Tablet 0

14 Glycerylguaiacolat Tablet 100 mg Tablet 0 0

15 Ibuprofen 400 mg Tablet 0 0
Kalsium Laktat 500 mg (Kalk) tablet
16 Tablet 0 0
500 mg
17 Klorfeniramin Maleat (CTM) 4 mg Tablet 0 0
18 Lexadium Tablet Tablet 0 0
19 Lexavit Tablet (Multivitamin) Tablet 0 0
20 Metilergometrin Maleat Tablet Tablet 0 0
21 Metoclorpramide tablet 10 mg Tablet 0 0
22 Metronidazole tablet 500 mg Tablet 0 0
23 Pantrin (Pyrantel) tablet 250 mg Tablet 0 0
24 Papaverina Tablet Tablet 0 0
25 Paracetamol 500 mg Tablet Tablet 0 0
26 Prednison Tablet 5 mg Tablet 0 0
27 Pyridoxine Hcl tablet 10 mg Tablet 0 0
28 Retinol (Vitamin A 100.000 IU) Tablet 0 0
29 Retinol (Vitamin A 200.000 IU) Tablet 0 0
30 Salbutamol 4 mg Tablet Tablet 0 0
31 Tablet Tambah Darah Tablet 0 0
32 Vitamin C 50 mg Tablet Tablet 0 0
33 Zinc Tablet 20 mg Tablet 0 0
34 Kasa gulung 0 0
35 Amlodipin 5 mg 0 0
36 Ibuprofen 200 mg 0 0
37 Alupurinol 0 0
38 Molexflu 0 0
39 HUSTAB 0 0
40 BECEFROT 0 0
41 HEMAFORT
42 0 0
43 0 0
44 0 0
45 0 0
46 0 0
47 0 0
48 0 0

Sediaan Cair

1 Dextral Syrup Botol 3 3 3 0

2 Ambroxol Syrup Botol 0 0
3 Cotrimoksazole Syrup 240 mg/60ml Botol 0 0
4 Fenol Glycerol Tetes Telinga 10% 5 ml Botol 0 0
5 Glucosa Larutan Infus 5% Botol 0 0
6 Lytacur Syrup (Multivitamin) Botol 0 0
7 Molexflu Syrup Botol 0 0
8 NaCl 0,9% 500 ml Botol 0 0
9 Obat Batuk Hitan (OBH) syrup Botol 0 0
10 Paracetamol syrup 120 mg/5 ml Botol 0 0
11 Pirantel suspensi 125 mg/5 ml Botol 0 0
12 Polikrosulen cairan (Aptil) 36% Botol 0 0
13 Ringer Laktat Infus Botol 0 0
14 Zinckid Syrup Botol 0 0
15 Antasida syrup 0 0
16 Amox syup 0 0
17 Cefad syrup 0 0
18 cotrim syr 0 0
19 ibuprofen syr 0 0

Sediaan Parenteral

1 Antalgin Injeksi 250 ml/ 2 ml Ampul 10 10 10 0 100

2 Aqua untuk injeksi 25 ml Fls 0 0

Cyanocobalamin (Vitamin B12) Injeksi
3 Ampul 0 0
500 mcg/ml
4 Dexamethasone Injeksi 5 mg/ml - 1 ml Ampul 0 0
Diphenhidramine Hcl Injeksi 10 mg/ml -
5 Ampul 0 0
1 ml
6 Fitomenadion Injeksi 2ml/ml Ampul 0 0
7 Lidocain Injeksi 2% Ampul 0 0
8 Ranitidin Injeksi 25 mg/ml Ampul 0 0

9 B1 INJEKSI 100 mg/ml Ampul 0 0

10 0 0
11 0 0
12 0 0
13 0 0
14 0 0

Sesiaan Salep, Krim dan Obat Topikal

Antihemoroid Doen Kombinasi
1 Supps 0
(Superhoid) 2 gr 0
2 Acyclovir Cream 5% Tube 0 0
3 Chloramfenicol Salep Mata 1% Tube 0 0
4 Gentamycin Salep Kulit 0,1% (Gentalex) Tube 0 0
5 Hydrocortisone Cream 2,5 mg Tube 0 0 0
6 Levertran Salep (Salep Luka Bakar) Pot 0 0
7 Miconazole Cream 2% Tube 0 0
8 Oxytetracycline Hcl Salep Kulit 3% Tube 0 0 0
9 Salep 2-4 Pot 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0

Antiseptik

1 Alkohol 70 % 100 ml Botol 0 0

2 Ethakridin (Rivanol) Lrutan 0,1 % 300 ml Botol 0 0
3 Gentian Violet Larutan 1% Botol 0 0
4 H2O2 Botol 0 0
5 PK Serbuk Botol 0 0
6 Povidon Iodine Larutan 10% 1000 ml Botol 0 0
7 Povidon Iodine Larutan 10% 300 ml Botol 0 0
8 0 0
9 0 0
10 0 0
11 0 0

Psikotropika

1 0 0
2 0 0
3 0 0
4 0 0

Bahan Medis Habis Pakai

1 Alat Suntik Sekali Pakai 1 ml Pcs 0 0

2 Alat Suntik Sekali Pakai 10 ml Pcs 0 0
3 Alat Suntik Sekali Pakai 3 ml Pcs 0 0 0
4 Alat Suntik Sekali Pakai 5 ml Pcs 0 0
5 Alat Suntik Sekali Pakai 50 ml Pcs 0 0
Benang Non Absorb 3/0 (Premilene) 75
6 Pcs 0
cm 0
7 Benang Non Absorb 3/0 (Silk) 75 cm Pcs 0 0
8 Infusion Set Anak Pcs 0 0
9 Infusion Set Dewasa Pcs 0 0
10 Infusion Set Paediatric Pcs 0 0
11 IV Cathether No. 18 Pcs 0 0
12 IV Cathether No. 20 Pcs 0 0
13 IV Cathether No. 22 Pcs 0 0
14 IV Cathether No. 24 Pcs 0 0
15 Kasa Steril 0 0
16 Kasa Pembalut 40 x 80 cm Pcs 0 0
17 Masker Tali Pcs 0 0
18 Plester 5 x 4,5 m Pcs 0 0
19 Sarung tangan Biasa Ukuran L Pcs 0 0
20 Sarung tangan Biasa Ukuran M Pcs 0 0
21 Sarung tangan Biasa Ukuran S Pcs 0 0
22 Sarung tangan Steril No.6,5 Pcs 0 0
23 Sarung tangan Steril No.7 Pcs 0 0
24 KAPAS GULUNG 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
32 0 0
33 0 0

Mengetahui Yang Menyerahkan Yang Menerima

Kepala Puskesmas Gayam Pengelola Obat Puskesmas Petugas Sub Unit

--------------------------------- --------------------------------- ---------------------------------

NIP : NIP : NIP :