1 Ambu bag anak 1

2 Ambu bag dewasa 1

3 ETT No. 3 1
4 ETT No. 3,5 1
5 ETT No. 4 1
6 ETT No. 4,5 1
7 ETT No. 5 1
8 ETT No. 5,5 1
9 ETT No. 6 1
10 ETT No. 6,5 1
11 ETT No. 7 1
12 ETT No. 7,5 1
13 Guedel 1 set 1
14 Masker NRM dewasa 1
15 Masker NRM anak 1
16 Makser RM dewasa 1
17 Nasal kanul oksigen anak 1
18 Nasal kanul oksigen dewasa 1
19 Suction No. 10 1
20 Suction No. 12 1
1 Aminophilin inj 24mg/1mL 1
2 Antrain Inj (metamizol) 1g/2mL) 1
3 Aqua pro injeksi 50mL 2
4 Aspilet 80mg tablet 5
5 Atropin sulfat 0,25mg/mL 6
6 Ca glukonas inj 100mg/mL 1
7 Cordaron (amiodaron) 150 mg/3mL 1
8 Dekstrosa 40% inj 25mL 2
9 Doburan (dobutamin) inj 250mg/5mL 2
10 Dopamin inj 200mg/5mL 2
11 Epinefrin 0,1% inj 1mg/mL 5
12 Furosemid inj 20mg/2mL 3
13 Invicolt (Heparin) inj 25.000iu 1
14 Isosorbid Dinitrat 5mg tablet 2
15 Indexon (Dexametason) inj 5mg/mL 2
16 KCl 7,46% inj 25mL 1
17 Lidocain 2% inj 20mg/2mL 5
18 MgSO4 40% inj 25 mL 2
19 Miloz (midazolam) inj 5mg/5mL 1
20 Nicardipine Inj (4mg/4mL) 1
21 Nitroglicerin (10mg/10mL) 1
22 Norefinefrin Inj (4mg/mL) 1
23 Stesolid (diazepam) inj 10mg/2mL 1
1 Alkohol Swab 10
2 Blood set 1
3 Cateter tip 1
4 Dextrose 10 % 500 mL 1
5 dextrose 5% 500 mL 1
 6 Foley Catheter No. 16 1
7 Foley Catheter No. 18 1
8 Infus set 1
9 Manitol 100 mL 1
10 NaCl 0.9 % 500mL 1
11 NaCl 0.9 % 100mL 1
12 NaCl 0.9 % 25mL 1
13 NaCl 0.9 % 25mL 1
14 NGT No. 6 1
15 NGT No. 8 2
16 NGT No. 10 2
17 NGT No. 12 2
18 NGT No. 16 1
19 RL 500 mL 1
20 Handscoon steril no.7 1
21 Laringoskop 1
22 Syring 1cc 2
23 Syring 3cc 5
24 Syring 5cc 5
25 Syring 10cc 5
26 Syring 20cc 1
27 Three Way Stop Cok 1
28 Transofix 1
29 Urine bag 1
30 Venflon 18 2
31 Venflon 20 2
32 Venflon 22 2
33 Venflon 24 2
34 Xylocain gel 1
 FORMULIR PENGONTROLAN TROLLEY EMERGENCY
INSTALASI FARMASI RSIA DHIA
Ruangan
Bulan

Exp. Tanggal Pengecekkan

No Nama Obat & BMHP Satuan Jumlah Ket.
Date

Laci 1
1 Aminophilin inj 24mg/1mL 1
2 Antrain Inj (metamizol) 1g/2mL) 1
3 Aqua pro injeksi 50mL 2
4 Aspilet 80mg tablet 5
5 Atropin sulfat 0,25mg/mL 6
6 Ca glukonas inj 100mg/mL 1
7 Cordaron (amiodaron) 150 mg/3m 1
8 Dekstrosa 40% inj 25mL 2
9 Doburan (dobutamin) inj 250mg/ 2
10 Dopamin inj 200mg/5mL 2
11 Epinefrin 0,1% inj 1mg/mL 5
12 Furosemid inj 20mg/2mL 3
13 Invicolt (Heparin) inj 25.000iu 1
14 Isosorbid Dinitrat 5mg tablet 2
15 Indexon (Dexametason) inj 5mg/ 2
16 KCl 7,46% inj 25mL 1
17 Lidocain 2% inj 20mg/2mL 5
18 MgSO4 40% inj 25 mL 2
19 Miloz (midazolam) inj 5mg/5mL 1
20 Nicardipine Inj (4mg/4mL) 1
21 Nitroglicerin (10mg/10mL) 1
22 Norefinefrin Inj (4mg/mL) 1
23 Stesolid (diazepam) inj 10mg/2mL 1

Laci 2
1 Alkohol Swab 10
2 Blood set 1
3 Cateter tip 1
4 Dextrose 10 % 500 mL 1
5 dextrose 5% 500 mL 1
6 Foley Catheter No. 16 1
7 Foley Catheter No. 18 1
8 Infus set 1
9 Manitol 100 mL 1
10 NaCl 0.9 % 500mL 1
11 NaCl 0.9 % 100mL 1
12 NaCl 0.9 % 25mL 1
13 NaCl 0.9 % 25mL 1
 14 NGT No. 6 1
15 NGT No. 8 2
16 NGT No. 10 2
17 NGT No. 12 2
18 NGT No. 16 1
19 RL 500 mL 1
20 Handscoon steril no.7 1
21 Laringoskop 1
22 Syring 1cc 2
23 Syring 3cc 5
24 Syring 5cc 5
25 Syring 10cc 5
26 Syring 20cc 1
27 Three Way Stop Cok 1
28 Transofix 1
29 Urine bag 1
30 Venflon 18 2
31 Venflon 20 2
32 Venflon 22 2
33 Venflon 24 2
34 Xylocain gel 1

Laci 3
1 Ambu bag anak 1
2 Ambu bag dewasa 1
3 ETT No. 3 1
4 ETT No. 3,5 1
5 ETT No. 4 1
6 ETT No. 4,5 1
7 ETT No. 5 1
8 ETT No. 5,5 1
9 ETT No. 6 1
10 ETT No. 6,5 1
11 ETT No. 7 1
12 ETT No. 7,5 1
13 Guedel 1 set 1
14 Masker NRM dewasa 1
15 Masker NRM anak 1
16 Makser RM dewasa 1
17 Nasal kanul oksigen anak 1
18 Nasal kanul oksigen dewasa 1
19 Suction No. 10 1
20 Suction No. 12 1
Tanda tangan petugas farmasi
Tanda tangan perawat
FORMULIR PEMAKAIAN OBAT DAN BMHP TROLLEY EMERGENCY
INSTALASI FARMASI RSIA DHIA