DAFTAR OBAT TROLI EMERGENSI

RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan :April

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat inj 2 Apr-20
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Mar-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Feb-20
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj/ Indop inj 2 May-21
13 Ephedrine HCL inj 2 Apr-20
14 Ephineprin HCL inj (KULKAS) 15 Nov 20
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental/ Sibital inj 2 Apr-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 Apr-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Apr-20
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Oct-20
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34
35
ORAL
1 Aspilet 10 tab Apr-21
2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
 Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2 Extension Tube 2 Aug-23
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Abbocath 26 Oct-22
4 Alkohol Swab 5
5 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
6 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
7 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
8 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
9 Three way (stop cock) ekor/non ekor 2/2 Jan-20
10 Abbocath 26 2
11 Urine Bag 2 Apr-24
12 Hypafix 1 Oct-23
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Feb-21
2 Infus D5% 1 Feb-22
3 Infus widahes /Ha-Es 130 1 Jul-20
4 Infus RL 2 Apr-21
5 InfusNaCl 1 Apr-20
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Oct-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan : Mei

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat inj 2 Apr-20
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Mar-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Feb-20
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj/ Indop inj 2 May-21
13 Ephedrine HCL inj 2 Apr-20
14 Ephineprin HCL inj (KULKAS) 15 Nov 20
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental/ Sibital inj 2 Apr-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 Apr-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Apr-20
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Oct-20
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34
35
ORAL
1 Aspilet 10 tab Apr-21
2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2 Extension Tube 2 Aug-23
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Abbocath 26 Oct-22
4 Alkohol Swab 5
5 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
6 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
7 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
8 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
9 Three way (stop cock) ekor/non ekor 2/2 Jan-20
10 Abbocath 26 2
11 Urine Bag 2 Apr-24
12 Hypafix 1 Oct-23
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Feb-21
2 Infus D5% 1 Feb-22
3 Infus widahes /Ha-Es 130 1 Jul-20
4 Infus RL 2 Apr-21
5 InfusNaCl 1 Apr-20
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Oct-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan : Juni

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat inj 2 Apr-20
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Mar-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Feb-20
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj/ Indop inj 2 May-21
13 Ephedrine HCL inj 2 Apr-20
14 Ephineprin HCL inj (KULKAS) 15 Nov 20
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental/ Sibital inj 2 Apr-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 Apr-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Apr-20
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Oct-20
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34
35
ORAL
1 Aspilet 10 tab Apr-21
2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2 Extension Tube 2 Aug-23
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Abbocath 26 Oct-22
4 Alkohol Swab 5
5 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
6 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
7 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
8 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
9 Three way (stop cock) ekor/non ekor 2/2 Jan-20
10 Abbocath 26 2
11 Urine Bag 2 Apr-24
12 Hypafix 1 Oct-23
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Feb-21
2 Infus D5% 1 Feb-22
3 Infus widahes /Ha-Es 130 1 Jul-20
4 Infus RL 2 Apr-21
5 InfusNaCl 1 Apr-20
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Oct-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan : Juli

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat inj 2 Apr-20
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Mar-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Feb-20
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj/ Indop inj 2 May-21
13 Ephedrine HCL inj 2 Apr-20
14 Ephineprin HCL inj (KULKAS) 15 Nov 20
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental/ Sibital inj 2 Apr-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 Apr-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Apr-20
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Oct-20
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34
35
ORAL
1 Aspilet 10 tab Apr-21
2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2 Extension Tube 2 Aug-23
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Abbocath 26 Oct-22
4 Alkohol Swab 5
5 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
6 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
7 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
8 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
9 Three way (stop cock) ekor/non ekor 2/2 Jan-20
10 Abbocath 26 2
11 Urine Bag 2 Apr-24
12 Hypafix 1 Oct-23
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Feb-21
2 Infus D5% 1 Feb-22
3 Infus widahes /Ha-Es 130 1 Jul-20
4 Infus RL 2 Apr-21
5 InfusNaCl 1 Apr-20
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Oct-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan : Agustus

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat inj 2 Apr-20
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Mar-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Feb-20
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj/ Indop inj 2 May-21
13 Ephedrine HCL inj 2 Apr-20
14 Ephineprin HCL inj (KULKAS) 15 Nov 20
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental/ Sibital inj 2 Apr-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 Apr-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Apr-20
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Oct-20
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34
35
ORAL
1 Aspilet 10 tab Apr-21
2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2 Extension Tube 2 Aug-23
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Abbocath 26 Oct-22
4 Alkohol Swab 5
5 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
6 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
7 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
8 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
9 Three way (stop cock) ekor/non ekor 2/2 Jan-20
10 Abbocath 26 2
11 Urine Bag 2 Apr-24
12 Hypafix 1 Oct-23
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Feb-21
2 Infus D5% 1 Feb-22
3 Infus widahes /Ha-Es 130 1 Jul-20
4 Infus RL 2 Apr-21
5 InfusNaCl 1 Apr-20
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Oct-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : ICU
RS Siti Khodijah Pekalongan
Bulan : September

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 1 May-22
2 Amiodaron/ Tyarit inj 2 Jan-21
3 Aquabidest 25 ml (WFI) 2 Jul-21
4 Asam Tranexamat inj 2 Sep-21
5 Atrophine Sulfat 0,25 mg inj 15 Jun-20
6 Calcii Gluconas inj 1 Jun-21
7 D40% 2 Jul-21
8 Dexametason inj 1 Feb-21
9 Diazepam/ Stesolid inj 2 Nov 22
10 Digoxin / Fargoxin inj 2 Mar-21
11 Dobutamin inj 1 Jan-22
12 Dopamin Guilini/ Cetadop inj 2 Jan-21
13 Ephedrine HCL inj 2 Apr-21
14 Ephineprin HCL inj (KULKAS) 15 Nov-21
15 Fasorbid/ ISDN inj 5 May-21
16 Fenobarbital/ Phental inj 2 Mar-20
17 Fentanyl inj 4 Jun-21
18 Furosemid / Farsix inj 5 May-21
19 KCL 7,46 % 1 Jan-21
20 Ketamin inj 1 Mar-20
21 Lidocain inj 2 Jul-21
22 Methylergometrine inj (KULKAS) 1 Jun-20
23 Meylon 2 Oct-20
24 MgSO4 40% (LASA) 2 Nov 20
25 Nairet inj 2 Apr-20
26 Natrium Phenytoin 1 Dec-21
27 Norephineprine/ Vascon inj 2 Feb-21
28 Oxytocin inj (KULKAS) 1 Mar-22
29 Pethidina inj 1 Oct-21
30 Recofol 2 May-20
31 Rocuronium inj 2 Jan-20
32 Sedacum inj 6 Apr-21
33 Stesolid 10 mg supp (KULKAS) 1 Mar-22
34 Nicardipine 2 Mar-21
35
ORAL
1 Aspilet 10 tab Apr-21
 2 Clopidrogel 5 tab Aug-20
3 Dopamet 4 tab Dec-20
4 ISDN 4 tab Apr-21
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH TGL ED
1 Feeding tube 8/10 1/1 Jun-19
2
3 Guedel No.5/6/6,5/8/9/10 1/1/1/1/1/1.
4 Laringoskop dewasa/anak 1/1
5 Masker ambubag anak 1
6 Masker ambubag dewasa 1
7 NGT no. 12/14/16 1/1/1 Sep 22, Mei 23, Okt 23
8 NRM Dewasa/Anak 1/1
Feb-22, Jul-22, Jan-22,
9 ET no. 2,5/3,0/3,5/4,0 1/1/1/1
Nov-19
10 ET no. 5,0/5,5/6,5/7,0/ 7,5/8,0 1/1/1/1/2/1
11 Masker O2 anak/dewasa 1/1
12 Nasal canul O2 dewasa/anak/bayi 1/1/1
13 Suction catheter 6/8/10/12/14 1/1/1/1/1.
14 Sarung Tangan Intouch 7/7,5/8 Jun 22, Mei 22, Jun 22
15 Transfusion Set 2 Apr-24
Paraf Petugas Farmasi
Paraf Petugas Ruangan
LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Jul-23
2 Abbocath 24 2 Aug-23
3 Abbocath 26 2 Mar-23
Mar-23, Mei-22, Feb-23,
4 Folley Catheter no. 8/10/12/14/16/18 1/1/1/1/1/1.
Mei-23, Mei-21
5 infusion set makro otsuka/gea 2/5 Mar 24, Feb 22
6 Infusion set mikro otsuka/gea 2/1 Ags 23, Jan 20
Feb-24, Mar-24, Oct-22,
7 Spuit1cc/3cc/5cc/10cc/20cc/ 50cc 2/2/2/2/2/2
Apr-24, Feb-24, Apr-24
8 Three way (stop cock) ekor 2 Mar-24
9 Transfusion Set 2 May-20
10 Urine Bag 2 Aug-23
11 Stomacth Tube 14/16 2/2. Apr-23 , Apr-24
12 IV 3000 3 Dec-21
Extension Tube 2 Mar-24
 NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Apr-21
2 Infus D5% 1 Mar-22
3 Infus widahes /Ha-Es 130
4 Infus RL 2 Jul-24
5 InfusNaCl 1 Sep-21
6 Infus Assering 1 Apr-21
7 Infus Manitol 20% 1 Jul-22
InfusTerastarch 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : April

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : Mei

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : Juni

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : Juli

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : Agustus

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MARWAH
RS Siti Khodijah Pekalongan
Bulan : September

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Mar-21
2 Amiodaron/ Cordarone/ Tyarit inj 2 Jan-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Feb-21
7 Dexametasone/ Cortidex inj 3 Apr-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 1 May-21
11 Ephedrine HCL inj 1 Sep-21
12 Ephineprin HCL inj (KULKAS) 2 Nov-20
13 Fenobarbital/ Sibital inj 1 Mar-20
14 Fentanyl inj 2 Dec-20
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 MgSO4 40% 2 Feb-20
21 Nairet/ Bricasma/ Terbutalin inj 2 Apr-20
22 Natrium Phenytoin inj 2 Dec-21
23 Nicardipin inj 1 Apr-20
24 Norephineprine/ Vascon inj 2 Apr-20
25 Recofol inj 1 Dec-19
26 Rocum inj (kulkas) 1 Apr-20
27 Sedacum inj 1 Dec-20
28 WFI 25 ml 2 Oct-21
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab May-20
3 Farsorbid 5 tab Feb-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA OBAT JUMLAH TGL ED
1 Ambubag Dewasa 1
2 Extension Tube 3
3 Guedel No. 5/6 1/1.
4 Laringoskop 1
5 Masker ambubag Anak 1
6 Masker ambubag Neonatus 1
7 NGT no. 12/14/16/18 1/1/1/1
8 NRM Dewasa 1
9 ET 5/5,5/6,5/7,5/8 1/1/1/1/1
10 Hypafix 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16/20 1/1/1
5 infusion set makro 1
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/50mL 3/3/3.
8 Suction Catheter 10/12 1/1
9 Tranfusion set 1
10 Urine Bag 1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1
2 Infus D5% 1
3 Infus widahes / Ha-Es 130 0
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : April

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan

NO NAMA ALKES JUMLAH TGL ED

1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
 6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : Mei

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan

NO NAMA ALKES JUMLAH TGL ED

1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
 6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : Juni

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan

NO NAMA ALKES JUMLAH TGL ED

1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
 6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : Juli

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan

NO NAMA ALKES JUMLAH TGL ED

1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
 6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : Agustus\

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan

NO NAMA ALKES JUMLAH TGL ED

1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
 6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : MINA
RS Siti Khodijah Pekalongan
Bulan : September

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Dec-19
2 Amiodaron Inj 1 Feb-20
3 Aquabidest 25 ml (WFI) 2 Oct-21
4 Asam Tranexamat Inj 1 Mar-22
5 Atrophine Sulfat 0,25 mg inj 2 Jan-20
6 Calcii Gluconas inj 2 Feb-20
7 D40% 2 Dec-20
8 Dexametason inj 2 Apr-20
9 Diazepam/ Stesolid inj 1 Nov-22
10 Dobutamin/ Doburan inj 2 May-20
11 Dopamin Guilini/ Indoop inj 2 May-21
12 Ephedrine HCL inj 2 Jul-20
13 Ephineprin HCL inj (KULKAS) 6 Nov-20
14 Fentanyl inj 1 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methylprednisolon inj 1 Sep-20
19 Nairet inj 1 Jan-20
20 Natrium Phenytoin inj 2 Dec-21
21 Nicardipin inj 1 Apr-20
22 Norephineprine inj 1 Sep-20
23 Rocum inj 1 Apr-20
24 Sedacum inj 1 Apr-21
25 Sibital inj/ Phental Inj 1 Mar-20
26 Stesolid 5 mg supp (KULKAS) 1 Mar-22
Paraf Petugas Farmasi
Paraf Petugas Ruangan
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20/24 2/2. Apr-20, Sep-21
2 Alkohol Swab 5 Mar-23
3 Folley Catheter no. 10/8 1/1. 02 Agst 20
4 infusion set makro 1
5 Infusion set mikro 1.
6 Spuit 10mL/5mL/3mL 3/3/3.
7 Tranfusion set 1 Aug-23
8 Extension Tube 2 May-23
9 Urine Bag 1 Aug-23
10 NGT (Stomach tube) no. 12/14/16/18 1/1/1/1 May-20
11 Nasal Oxigen Canul 1
12 Nebulizer Salter Anak 1
13 Masker NRM Anak Balon 2

NO NAMA INFUS JUMLAH TGL ED

1 Infus D10% 1 Jul-20
2 Infus D5% 1 Feb-22
3 Infus RL 1 Apr-24
4 InfusNaCl 1 May-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : April

NO NAMA OBAT JUMLAH

1 Aminophilin inj 2
2 Amiodaron/ Cordarone/ Tyarit inj 2
3 Asam Tranexamat/ Transamin 2
4 Atrophine Sulfat 0,25 mg inj 2
5 Calcii Gluconas inj 1
6 D 40% 2
7 Dexametasone/ Cortidex inj 3
8 Diazepam/ Stesolid inj 1
9 Dobutamin/ Doburan/ Dobuject inj 2
10 Dopamin Guilini/ Indoop inj 3
11 Ephedrine HCL inj 2
12 Ephineprin HCL inj (KULKAS) 1
13 Fenobarbital/ Sibital / Penthal inj 2
14 Fentanyl inj 2
15 Furosemid/ Farsix/ Lasix inj 2
16 Ketamin inj 1
17 Lidocain inj 2
18 Methyl prednisolon inj 1
19 Meylon 2
20 Nairet/ Bricasma/ Terbutalin inj 2
21 Natrium Phenytoin inj 2
22 Nicardipin inj 1
23 Norephineprine/ Vascon inj 2
24 Rocum inj (kulkas) 1
25 Sedacum inj 2
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2
28
29
30
ORAL
1 Aspilet 10 tab
2 Clopidrogel 6 tab
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 2 ( AIRWAY & BREATHING)

NO NAMA ALKES JUMLAH
1 Extension Tube 2
 2 NGT NO 12 1
3 NGT NO 14 1
4 NGT NO 16 1
5 Suction cathether 12 1
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2
9 Sarung tangan Intouch Powder 7.5 2
10 Connecting Tube 1
11 Oxigen Nasal Dewasa 2
12 Colostomy Bag 2
13 Tree Way 1
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH
1 Abbocath 20 2
2 Abbocath 24 2
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2
5 infusion set makro 2
6 Infusion set mikro 1.
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
8 Tranfusion set 2
9 Urine Bag 1
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH
1 Infus D10% 1
2 Infus D5% 1
3 Infus Terrastrach 1
Infus RD 1
4 Infus RL 1
5 InfusNaCl 1
6 Infus Manitol 1
Paraf Petugas Farmasi
Paraf Petugas Ruangan
FAH
longan
l

TGL ED
Apr-20
Feb-20
Apr-20
Jun-20
Feb-20
Jan-20
Mar-21
Nov-22
Jan-22
May-21
Jul-20
Sep-20
Mar-20
Jun-21
Apr-20
Apr-20
Jul-21
Oct-21
Aug-20
Jan-20
Dec-21
Apr-20
Sep-20

Jun-20

Mar-20

Oct-20
Ags 20

EATHING)
TGL ED
May-23
 Sep-22
Jan-23
Apr-23
Feb-22

Mar-22
Jan-21
Jun-23
May-23

May-23

TION)
TGL ED
Oct-21
Sep-21

Feb 2022, Juli 2022

May-23

30 Nov 22, 31 Mar 22, 30

Nov 22, 30 April 23
Aug-23
Aug-23

TGL ED
Jun-20

Feb-20
May-20
Jul-23
Aug-23
Jul-20
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : Mei

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Apr-20
2 Amiodaron/ Cordarone/ Tyarit inj 2 Feb-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Jan-20
7 Dexametasone/ Cortidex inj 3 Mar-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 3 May-21
11 Ephedrine HCL inj 2 Jul-20
12 Ephineprin HCL inj (KULKAS) 1 Sep-20
13 Fenobarbital/ Sibital / Penthal inj 2 Mar-20
14 Fentanyl inj 2 Jun-21
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 Nairet/ Bricasma/ Terbutalin inj 2 Jan-20
21 Natrium Phenytoin inj 2 Dec-21
22 Nicardipin inj 1 Apr-20
23 Norephineprine/ Vascon inj 2 Sep-20
24 Rocum inj (kulkas) 1
25 Sedacum inj 2 Jun-20
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2 Mar-20
28
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab Ags 20
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA ALKES JUMLAH TGL ED
1 Extension Tube 2 May-23
2 NGT NO 12 1 Sep-22
3 NGT NO 14 1 Jan-23
4 NGT NO 16 1 Apr-23
5 Suction cathether 12 1 Feb-22
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2 Mar-22
9 Sarung tangan Intouch Powder 7.5 2 Jan-21
10 Connecting Tube 1 Jun-23
11 Oxigen Nasal Dewasa 2 May-23
12 Colostomy Bag 2
13 Tree Way 1 May-23
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Oct-21
2 Abbocath 24 2 Sep-21
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2 Feb 2022, Juli 2022
5 infusion set makro 2 May-23
6 Infusion set mikro 1.
30 Nov 22, 31 Mar 22, 30
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
Nov 22, 30 April 23
8 Tranfusion set 2 Aug-23
9 Urine Bag 1 Aug-23
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Jun-20
2 Infus D5% 1
3 Infus Terrastrach 1 Feb-20
Infus RD 1 May-20
4 Infus RL 1 Jul-23
5 InfusNaCl 1 Aug-23
6 Infus Manitol 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : Juni

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Apr-20
2 Amiodaron/ Cordarone/ Tyarit inj 2 Feb-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Jan-20
7 Dexametasone/ Cortidex inj 3 Mar-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 3 May-21
11 Ephedrine HCL inj 2 Jul-20
12 Ephineprin HCL inj (KULKAS) 1 Sep-20
13 Fenobarbital/ Sibital / Penthal inj 2 Mar-20
14 Fentanyl inj 2 Jun-21
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 Nairet/ Bricasma/ Terbutalin inj 2 Jan-20
21 Natrium Phenytoin inj 2 Dec-21
22 Nicardipin inj 1 Apr-20
23 Norephineprine/ Vascon inj 2 Sep-20
24 Rocum inj (kulkas) 1
25 Sedacum inj 2 Jun-20
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2 Mar-20
28
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab Ags 20
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA ALKES JUMLAH TGL ED
1 Extension Tube 2 May-23
2 NGT NO 12 1 Sep-22
3 NGT NO 14 1 Jan-23
4 NGT NO 16 1 Apr-23
5 Suction cathether 12 1 Feb-22
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2 Mar-22
9 Sarung tangan Intouch Powder 7.5 2 Jan-21
10 Connecting Tube 1 Jun-23
11 Oxigen Nasal Dewasa 2 May-23
12 Colostomy Bag 2
13 Tree Way 1 May-23
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Oct-21
2 Abbocath 24 2 Sep-21
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2 Feb 2022, Juli 2022
5 infusion set makro 2 May-23
6 Infusion set mikro 1.
30 Nov 22, 31 Mar 22, 30
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
Nov 22, 30 April 23
8 Tranfusion set 2 Aug-23
9 Urine Bag 1 Aug-23
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Jun-20
2 Infus D5% 1
3 Infus Terrastrach 1 Feb-20
Infus RD 1 May-20
4 Infus RL 1 Jul-23
5 InfusNaCl 1 Aug-23
6 Infus Manitol 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : Juli

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Apr-20
2 Amiodaron/ Cordarone/ Tyarit inj 2 Feb-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Jan-20
7 Dexametasone/ Cortidex inj 3 Mar-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 3 May-21
11 Ephedrine HCL inj 2 Jul-20
12 Ephineprin HCL inj (KULKAS) 1 Sep-20
13 Fenobarbital/ Sibital / Penthal inj 2 Mar-20
14 Fentanyl inj 2 Jun-21
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 Nairet/ Bricasma/ Terbutalin inj 2 Jan-20
21 Natrium Phenytoin inj 2 Dec-21
22 Nicardipin inj 1 Apr-20
23 Norephineprine/ Vascon inj 2 Sep-20
24 Rocum inj (kulkas) 1
25 Sedacum inj 2 Jun-20
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2 Mar-20
28
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab Ags 20
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA ALKES JUMLAH TGL ED
1 Extension Tube 2 May-23
2 NGT NO 12 1 Sep-22
3 NGT NO 14 1 Jan-23
4 NGT NO 16 1 Apr-23
5 Suction cathether 12 1 Feb-22
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2 Mar-22
9 Sarung tangan Intouch Powder 7.5 2 Jan-21
10 Connecting Tube 1 Jun-23
11 Oxigen Nasal Dewasa 2 May-23
12 Colostomy Bag 2
13 Tree Way 1 May-23
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Oct-21
2 Abbocath 24 2 Sep-21
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2 Feb 2022, Juli 2022
5 infusion set makro 2 May-23
6 Infusion set mikro 1.
30 Nov 22, 31 Mar 22, 30
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
Nov 22, 30 April 23
8 Tranfusion set 2 Aug-23
9 Urine Bag 1 Aug-23
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Jun-20
2 Infus D5% 1
3 Infus Terrastrach 1 Feb-20
Infus RD 1 May-20
4 Infus RL 1 Jul-23
5 InfusNaCl 1 Aug-23
6 Infus Manitol 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : Agustus

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Apr-20
2 Amiodaron/ Cordarone/ Tyarit inj 2 Feb-20
3 Asam Tranexamat/ Transamin 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Jan-20
7 Dexametasone/ Cortidex inj 3 Mar-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin/ Doburan/ Dobuject inj 2 Jan-22
10 Dopamin Guilini/ Indoop inj 3 May-21
11 Ephedrine HCL inj 2 Jul-20
12 Ephineprin HCL inj (KULKAS) 1 Sep-20
13 Fenobarbital/ Sibital / Penthal inj 2 Mar-20
14 Fentanyl inj 2 Jun-21
15 Furosemid/ Farsix/ Lasix inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 Nairet/ Bricasma/ Terbutalin inj 2 Jan-20
21 Natrium Phenytoin inj 2 Dec-21
22 Nicardipin inj 1 Apr-20
23 Norephineprine/ Vascon inj 2 Sep-20
24 Rocum inj (kulkas) 1
25 Sedacum inj 2 Jun-20
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2 Mar-20
28
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab Ags 20
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA ALKES JUMLAH TGL ED
1 Extension Tube 2 May-23
2 NGT NO 12 1 Sep-22
3 NGT NO 14 1 Jan-23
4 NGT NO 16 1 Apr-23
5 Suction cathether 12 1 Feb-22
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2 Mar-22
9 Sarung tangan Intouch Powder 7.5 2 Jan-21
10 Connecting Tube 1 Jun-23
11 Oxigen Nasal Dewasa 2 May-23
12 Colostomy Bag 2
13 Tree Way 1 May-23
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Oct-21
2 Abbocath 24 2 Sep-21
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2 Feb 2022, Juli 2022
5 infusion set makro 2 May-23
6 Infusion set mikro 1.
30 Nov 22, 31 Mar 22, 30
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
Nov 22, 30 April 23
8 Tranfusion set 2 Aug-23
9 Urine Bag 1 Aug-23
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Jun-20
2 Infus D5% 1
3 Infus Terrastrach 1 Feb-20
Infus RD 1 May-20
4 Infus RL 1 Jul-23
5 InfusNaCl 1 Aug-23
6 Infus Manitol 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan
12

10

0
Clopidrogel 6 tab Ags 20
Aspilet 10 tab 44105
WFI 25 ml 2 43891
Stesolid 10 mg supp (KULKAS) 0
Sedacum inj 2 43983
Vascon inj 2 44075 3
Nicardipin inj 1 43922 Paraf Petugas Farmasi
Natrium Phenytoin inj 2 44531 Paraf Petugas Ruangan
Nairet inj 2 43831
Meylon 2 44044
Methyl prednisolon inj 1 44470
Lidocain inj 2 44378
Ketamin inj 1 43922
Furosemid inj 2 43922
Fentanyl inj 2 44348
Penthal inj 2 43891
Ephineprin HCL inj (KULKAS) 1 44136
Ephedrine HCL inj 2 44013
Cetadop inj 3 44317
Dobutamin inj 2 43952
Diazepam/ Stesolid inj 1 44866
Dexametasone inj 3 44256
D 40% 2 43837
Calcii Gluconas inj 1 43862
Atrophine Sulfat 0,25 mg inj 2 43983
Asam Tranexamat inj 2 43922
Amiodaron inj 2 44166
Aminophilin inj 2 43922
NAMA OBAT JUMLAH TGL ED
 RUANG : AROFAH
RS Siti Khodijah Pekalongan
Bulan : September

NO NAMA OBAT JUMLAH TGL ED

1 Aminophilin inj 2 Apr-20
2 Amiodaron inj 2 Dec-20
3 Asam Tranexamat inj 2 Apr-20
4 Atrophine Sulfat 0,25 mg inj 2 Jun-20
5 Calcii Gluconas inj 1 Feb-20
6 D 40% 2 Jan-20
7 Dexametasone inj 3 Mar-21
8 Diazepam/ Stesolid inj 1 Nov-22
9 Dobutamin inj 2 May-20
10 Cetadop inj 3 May-21
11 Ephedrine HCL inj 2 Jul-20
12 Ephineprin HCL inj (KULKAS) 1 Nov-20
13 Penthal inj 2 Mar-20
14 Fentanyl inj 2 Jun-21
15 Furosemid inj 2 Apr-20
16 Ketamin inj 1 Apr-20
17 Lidocain inj 2 Jul-21
18 Methyl prednisolon inj 1 Oct-21
19 Meylon 2 Aug-20
20 Nairet inj 2 Jan-20
21 Natrium Phenytoin inj 2 Dec-21
22 Nicardipin inj 1 Apr-20
23 Vascon inj 2 Sep-20
24
25 Sedacum inj 2 Jun-20
26 Stesolid 10 mg supp (KULKAS) 0
27 WFI 25 ml 2 Mar-20
28
29
30
ORAL
1 Aspilet 10 tab Oct-20
2 Clopidrogel 6 tab Ags 20
3
Paraf Petugas Farmasi
Paraf Petugas Ruangan
 LACI 2 ( AIRWAY & BREATHING)
NO NAMA ALKES JUMLAH TGL ED
1 Extension Tube 2 May-23
2 NGT NO 12 1 Sep-22
3 NGT NO 14 1 Jan-23
4 NGT NO 16 1 Apr-23
5 Suction cathether 12 1 Feb-22
6 NRM Dewasa 2
7 Cuti Cell
8 Sarung tangan Intouch Powder 7 2 Mar-22
9 Sarung tangan Intouch Powder 7.5 2 Jan-21
10 Connecting Tube 1 Jun-23
11 Oxigen Nasal Dewasa 2 May-23
12 Colostomy Bag 2
13 Tree Way 1 May-23
14 Hypafix 1
15
Paraf Petugas Farmasi
Paraf Petugas Ruangan

LACI 3 (CIRCULATION)
NO NAMA ALKES JUMLAH TGL ED
1 Abbocath 20 2 Oct-21
2 Abbocath 24 2 Sep-21
3 Alkohol Swab 5
4 Folley Catheter no. 14/16 2/2 Feb 2022, Juli 2022
5 infusion set makro 2 May-23
6 Infusion set mikro 1.
30 Nov 22, 31 Mar 22, 30
7 Spuit 10mL/5mL/3mL/1mL 2/2/2/2
Nov 22, 30 April 23
8 Tranfusion set 2 Aug-23
9 Urine Bag 1 Aug-23
10 ET 5/5,5/7,5 1/1/1
NO NAMA INFUS JUMLAH TGL ED
1 Infus D10% 1 Jun-20
2 Infus D5% 1
3 Infus Terrastrach 1 Feb-20
Infus RD 1 May-20
4 Infus RL 1 Jul-23
5 InfusNaCl 1 Aug-23
6 Infus Manitol 1 Jul-20
Paraf Petugas Farmasi
Paraf Petugas Ruangan