LPLPO KP - Klagen APBD 2021

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD PUSKESMAS
( LPLPO APBD )
PUSTU/PONKESDES/POLINDES : UGD
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :

PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE :
PERMIN PEMBERIAN
JMLAH
NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT. KET
PEMBERIAN
TAAN APBD BPJS PROGRAM LAIN-2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
OBAT-OBATAN :
1 Adona AC - 17 tablet / Saldona tablet tablet - -

2 Adona AC Injeksi 5 mg / ml - 2 ml ampul - -
3 Albuthyl Ovula supp - -
4 Alopurinol tablet 100 mg tablet - -
6 Alprazolam 0,5 mg tablet tablet - -
7 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
8 Ambroxol tablet 30 mg tablet - -
9 Aminofilin tablet scored 150 mg tablet - -
11 Aminofilina injeksi 24 mg / ml ampul - -
12 Amitriptilin tablet salut 25 mg ( HCl ) tablet - -
13 Amlodipine tablet 10 mg tablet - -
15 Amoksisilin Sirup Kering 125 mg / 5 ml botol @ 60 ml - -
17 Amoksisilin kaplet 500 mg tablet - -
18 Amoksisilin kapsul 250 mg tablet - -
19 Amoksisilin Serbuk injeksi 1000 mg vial - -
20 Ampisilina sirup kering 125 mg/5ml botol - -
Antalgin ( Metamisol )injeksi 500 mg / ml - 2 ml (
21 ampul @ 2 ml - -
Novalgin / Antrain / Santagesik )
22 Antalgin ( Metampiron ) tablet 500 mg tablet - -
23 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - -
Antasida DOEN I tablet kunyah, kombinasi :
24 Aluminium Hidroksida 200 mg ; Magnesium tablet - -
Antasida
HidroksidaDOEN
200 mgII suspensi, kombinasi :
25 Aluminium Hidroksida 200 mg/ml ; Magnesium botol @ 60 ml - -
Hidroksida 200 mg/ml
26 Antifungi DOEN pot @ 30 gr - -
27 Antihemoroid DOEN supp - -
28 Antimigren DOEN tablet tablet - -
29 Antiparkinson DOEN tablet tablet - -
30 Aqua pro Injeksi steril, bebas pirogen botol @ 25 ml - -
31 Aquadest steril botol @ 1000 ml - -
32 Asam Asetilsalisilat (Asetosal) tablet 100 mg tablet - -
35 Asam Askorbat ( Vitamin C ) tablet 250 mg tablet - -
37 Asam Mefenamat kaplet 500 mg tablet - -
38 Asam traneksamat injeksi 100 mg/ml ampul - -
40 Aseptik Gel 500 cc + dispenser botol @ 500 ml - -
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Asvex tablet tablet - -
44 Atapulgit tablet 600 mg tablet - -
45 Atorvastatin 20 mg tablet tablet - -
46 Atropin Sulfat injeksi 0,25 mg / ml - 1 ml ampul - -
47 Atropin Sulfat tablet 0,5 mg tablet - -
48 Atropin Sulfat tetes mata 0,5% botol - -
49 Azitromisiin tablet 250 mg tablet - -
50 Azitromisin tablet 500 mg tablet - -
51 Batugin Elixir Sirup ( Fitofarmaka ) botol - -
52 Becom - C tablet tablet - -
53 Bedak salisil serbuk 2 % kotak - -
54 Benzatin Benzil Penisillin Injeksi 2.4 Jt IU/vial ampul - -
55 Betadin Gargle 100 ml / Molexdin obat kumur botol - -
56 Betahistin Mesilat tablet 6 mg tablet - -
57 Betametason krim 0.1% ( sebagai valerat ) tube 5 gr - -
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -
Bisacodil suppositoria 10 mg ( Stolax / Dulcolax
60 supp - -
supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -
63 Borak Gliserin 5% botol @ 15 ml - -
Bromhexin tablet ( Bronex tablet ; Novaheksin
64 tablet - -
tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml - -
66 Cendo Lyters botol - -
67 Centabio Jelly / Bioplacenton Jelly tube @ 20 gr - -
68 Curcuma tablet tablet - -
69 Deksametason injeksi 5 mg / ml ampul @ 1 ml - -
70 Deksametason tablet 0,5 mg tablet - -
Denomix Cream - Desoksimetason 0,25 %,
71 Tube - -
neomycin sulfate 0.5%
72 Desoksimetason krim 0,25 % tube @ 15 gr - -
73 Dextrofen Syrup botol @ 60 ml - -
74 Diazepam injeksi 5 mg / ml - 2 ml ampul - -
75 Diazepam rectal tube (Stesolid rectal Tube) tube @ 2,5 ml - -
76 Diazepam tablet 2 mg tablet - -
78 Difenhidramin HCl injeksi 10 mg / ml ampul - -
79 Digoksin tablet 0,25 mg tablet - -
80 Dimenhidrinat tablet 50 mg tablet - -
81 Doksisiklin tablet 100 mg kapsul - -
82 Domperidone sirup 5 mg/5ml botol @ 60 ml - -
83 Domperidone tablet 10 mg tablet - -
84 Efedrin HCl tablet 25 mg tablet - -
85 Ekstrak Belladon tablet 10 mg tablet - -
86 Elkana Sirup botol - -
87 Epinefrina HCl ( Adrenalin ) injeksi 1 mg/ml ampul - -
88 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml - -
89 Eritromisin kapsul 250 mg kapsul - -
91 Etynil estradiol (Lynoral tablet 0,05 mg) tablet - -
92 Fenobarbital tablet 30 mg tablet - -
93 Fenofibrat kapsul 100 mg kapsul - -
95 Fenol Gliserol tetes telinga 10% botol - -
96 Fitomenadion ( Vitamin K1 ) injeksi 10 mg /ml ampul - -
Fitomenadion ( Vitamin K1 ) tablet salut gula 10
97 tablet - -
mg
98 Fludane Plus Sirup botol @ 60 ml - -
99 Fludane Tablet tablet - -
100 Fluocinolone Acetonide (Dermasolon) tube @ 5 gram - -
101 Fluor tablet 0,5 mg tablet - -
102 Furosemid tablet 40 mg tablet - -
103 Gelofusin Infus botol @ 500 ml - -
104 Gemfibrosil kapsul 300 mg kapsul - -
106 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -
Gentamisin salep mata 0,3 % (Genoint salep
107 tube - -
mata)
108 Gentamisin tetes mata 0,3 % botol - -
109 Gentian Violet larutan 1 % botol @10 ml - -
110 Glibenklamid tablet 5 mg tablet - -
111 Glimepiride tablet 2 mg tablet - -
113 Gliseril Guaiakolat tablet 100 mg tablet - -
114 Glukosa 5% - 1/2 NS botol @ 500 ml - -
116 Glukosa larutan infus 10 % steril botol @ 25 ml - -
119 Griseofulvin tablet 125 mg tablet - -
121 Hemorogard kapsul kapsul - -
122 Hidroklorotiazid ( HCT ) tablet 25 mg tablet - -
123 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20 mg/ml (Spasi
124 ampul - -
injeksi)
125 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -
126 Ibuprofen tablet 200 mg tablet - -
128 Ichtiyol Zalf pot @ 15 gr - -
129 Ipratropium bromida nebulazer 0,025 ampul - -
130 Isosorbid Dinitrat tablet sublingual 5 mg tablet - -
131 KA-EN 3 B Otsu infus botol @ 500 ml - -
132 Kalium Diklofenak tablet 50 mg tablet - -
133 Kalsium Laktat ( Kalk ) tablet 500 mg tablet - -
134 Kaptopril tablet scored 25 mg tablet - -
135 Kaptopril tablet scored 12,5 mg tablet - -
136 Ketokonazol krim 2 % tube 10 gr - -
137 Ketokonazol tablet 200 mg tablet - -
138 Ketoprofen supositoria 100 mg ( Protofen supp ) supp - -
139 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -
140 Klindamisin kapsul 150 mg kapsul - -
Kloramfenikol injeksi 1000 mg (Colsancetin
142 vial - -
injeksi 1000 mg )
143 Kloramfenikol kapsul 250 mg kapsul - -
145 Kloramfenikol salep kulit 2 % (BUFACETINE) tube - -
146 Kloramfenikol salep mata 1 % tube - -
147 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml - -
148 Kloramfenikol tetes Mata 0.5 % botol @ 5 ml - -
149 Kloramfenikol tetes telinga 1 % botol @ 10 ml - -
150 Klorfeniramin Maleat ( CTM ) tablet 4 mg tablet - -
151 Kodein HCl tablet 10 mg tablet - -
152 Kotrimoksazol Dewasa tablet tablet - -
153 Kotrimoksazol Pediatrik tablet tablet - -
154 Kotrimoksazol Suspensi botol @ 60 ml - -
155 Lactodia / Lacto B sachet - -
156 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit ( Na 130 mEq,
157 Cl 109 mEq , Ca 3 mEq , Asetat 28 mEq ) / botol @ 500 ml - -
Asering 500
Larutan ml larutanelektrolit
mengandung infus steril
(Ringer Laktat
158 botol @ 500 ml - -
larutan infus steril / Wida RL )
159 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) + Epinefrin 1 : 80.000
160 ampul @ 2 ml - -
- 2 ml
161 Linkomisina kapsul 500 mg kapsul - -
162 Loperamida tablet 2 mg tablet - -
163 Loratadin tablet 10 mg tablet - -
164 Meloksikam tablet 15 mg tablet - -
165 Metformin HCl tablet 500 mg tablet - -
166 Methyl Prednisolon 4 mg tablet tablet - -
167 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml - -
168 Metoklopropamid tablet 10 mg tablet - -
169 Metronidazol ovula ovula - -
170 Metronidazol tablet 250 mg tablet - -
171 Miconazol krim 2 % ( Nitrat ) tube - -
172 N-Acetyl systeine tablet 200 mg tablet - -
173 Natrium Diklofenak tablet 50 mg tablet - -
174 Natrium Klorida larutan infus 0,9% steril botol @ 500 ml - -
175 Neo Kauminal suspensi botol @ 60 ml - -
176 Neuralgin - RX tablet tablet - -
177 Neurosanbe 5000 mg tablet / Ikaneuron 5000 tablet - -
Neurosanbe injeksi / Mersibion Injeksi 5000 /
178 ampul - -
Sohobion 5000 Injeksi
179 Neurovit E tablet / Nervitone - E tablet - -
180 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg Sediaan lepas lambat
181 tablet - -
(Adalat OROS)
Nifedipin tablet 30 mg Sediaan lepas lambat
182 tablet - -
(Adalat OROS)
183 Nistatin tablet salut 500.000 IU / g tablet - -
184 Nistatin vaginal tablet 100.000 IU / g tablet - -
185 Noretisteron tablet 5 mg (Primolut N tablet) tablet - -
186 Obat Batuk Hitam ( O.B.H. ) Generik botol @ 100 ml - -
187 Obat Batuk Hitam ( O.B.H. ) Paten botol @ 100 ml - -
188 Ofloxaxin tablet 200 mg tablet - -
189 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml - -
190 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -
191 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr - -
192 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml - -
193 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml - -
194 Omeprazole tablet 20 mg tablet - -
195 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -
196 Ondansetron tablet 4 mg tablet - -
198 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -
199 Papaverin Tablet 40 mg tablet - -
200 Parasetamol drop 100 mg/ml ( 60 mg / 0,6 ml ) botol @ 15 ml - -
201 Parasetamol sirup 120 mg / 5 ml botol - -
202 Parasetamol tablet 100 mg tablet - -
204 Pehavral tablet tablet - -
205 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml - -
206 Pilokarpin HCl / Nitrat tetes mata 2% botol - -
207 Piracetam 1200 mg tablet tablet - -
208 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
210 Piracetam tablet 800 mg tablet - -
211 Piridoksin HCl ( Vitamin B6 ) tablet 10 mg tablet - -
212 Piroxicam tablet 10 mg tablet - -
214 Ponflu tablet tablet - -
215 Prednison tablet 5 mg tablet - -
216 Prolipid kaplet tablet - -
217 Propiltiourasil tablet 100 mg tablet - -
218 Propranolol HCl tablet 40 mg tablet - -
219 Proris suppositoria supp - -
220 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
221 Ranitidin tablet 150 mg tablet - -
222 Reserpin tablet 0,25 mg tablet - -
223 Rifampisin kapsul 300 mg kapsul - -
224 Salbutamol Inhaler (Salbulin) pcs - -
225 Salbutamol tablet 2 mg ( sebagai sulfat ) tablet - -
Salep 2-4 , kombinasi : Asam Salisilat 2 % +
226 pot @ 30 gr - -
Belerang endap 4 %
Scabicid krim / Scabimite Cream 10 - Permetrin
227 tube - -
krim 5 %
228 Sefadroksil kapsul 500 mg kapsul - -
229 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml - -
230 Sefiksim kapsul 100 mg kapsul - -
232 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml - -
233 Sefotaksim injeksi 1 gr vial @ 1 gr - -
234 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr - -
235 Serum Anti Bisa Ular Polivalen injeksi I vial - -
236 Serum Anti Tetanus Injeksi 1.500 IU / amp vial - -
237 Serum Anti Tetanus Injeksi 20.000 IU / vial vial - -
238 Setirizin sirup 5 mg / 5 ml botol - -
239 Setirizin tablet 10 mg tablet - -
240 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg ampul - -
241 Sianokobalamin (Vitamin B12) tablet 50 mcg tablet - -
242 Silver Sulfadiazin Cream Tube - -
243 Simetidin tablet 200 mg tablet - -
244 Simvastatin tablet 10 mg tablet - -
246 Siprofloksasin kapsul 500 mg ( sebagai HCl ) kapsul - -
247 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml - -
248 Spasi Plus tablet / Scopma Plus tablet - -
249 Spasminal tablet tablet - -
250 Sucralfate suspensi 500 mg / 5 ml botol - -
251 Sulfasetamida Natrium tetes mata 15 % botol - -
252 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus Imunoglobulin
253 Unit - -
Injeksi I.M. 250 UI
254 Tetrakain HCl tetes mata 0,5% botol - -
255 Tetrasiklin HCl kapsul 500 mg kapsul - -
256 Thiamfenikol kapsul 500 mg kapsul - -
257 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml - -
258 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1ml ampul - -
Tiamin HCl / Mononitrat (Vitamin B1) tablet 50
259 tablet - -
mg
260 Truvit Syrup botol @ 60 ml - -
261 Ventolin Nebules 2,5 mg ampul - -
262 Vitamin B Kompleks tablet tablet - -
263 Xylocaine 10 % Spray botol - -
264 Xylocaine 2 % Jelly syringe - -
265 Zenirex Sirup botol @ 60 ml - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
3 Fenitoin Natrium kapsul 100 mg kapsul - -
5 Fluoxetine (Napres) tablet - -
6 Haloperidol 5 mg / ml (Lodomer) ampul - -
Haloperidol injeksi 50 mg/ml ( Haldol Decanoas
7 ampul - -
)
8 Haloperidol tablet 0,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -
11 Karbamazepin tablet 200 mg tablet - -
12 Klorpromazin HCl tablet salut 100 mg tablet - -
14 Klorpromazin injeksi 5 mg/ ml ampul - -
15 Risperidon tablet 1 mg tablet - -
17 Sikzonoat Inj / Flupenaziin Inj ampul - -
18 Trifluoperasin tablet 5 mg tablet - -
19 Triheksifenidil Hidroklorida tablet 2 mg tablet - -
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi (II) sulfat 7H2O
5 200 mg Asam Folat 0,25 mg ( tablet tambah tablet - -
darah )
6 Mineral Mix 8 gr sase - -
7 Retinol ( Vitamin A ) kapsul 100.000 IU kapsul - -
Retinol ( Vitamin A ) kapsul 200.000 IU kapsul
8 kapsul - -
lunak
9 Taburia sachet - -
10 Zink sirup 20 mg/5ml ( Zircum Kid Sirup ) botol @ 60 ml - -
PROGRAM KECACINGAN : - -
1 Albendazol suspensi 200 mg / 5 ml botol - -
2 Albendazol tablet 400 mg tablet - -
3 Dietilkarbamazin Sitrat tablet 100 mg tablet - -
4 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml - -
5 Pirantel tablet score ( base ) 125 mg tablet - -
PROGRAM KIA : - -
1 Ampisilin Injeksi 1000 mg/ml Vial - -
2 Fenobarbital Inj 50 mg / ml ampul - -
Fitomenadion ( Vitamin K1 ) injeksi 2 mg / ml
3 ampul - -
( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul - -
5 Kalsium Glukonat injeksi i.v 10 % ( 100 mg/ml ) ampul - -
6 Magnesium Sulfat injeksi ( IV ) 20 % - 25 ml botol @ 25 ml - -
Metilergometrin Maleat (Metilergometrin) tablet
8 tablet - -
salut 0,125 mg
9 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 1 ml - -
10 Procain Benzil Penisilin 3.000.000 I.U vial - -
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
PROGRAM TBC : - -
1 Isoniazide tablet 100 mg tablet - -
3 OAT - FDC Kategori 1 - 3 PAKET paket - -
4 OAT - FDC Kategori 2 PAKET paket - -
5 OAT - FDC Kategori anak PAKET paket - -
6 OAT Sisipan paket - -
7 OAT-Kombipak Kategori 1 anak paket - -
8 OAT-Kombipak Kategori 1 dewasa paket - -
9 OAT - FDC TB / HIV Fase Awal paket - -
10 OAT - FDC TB / HIV Fase Lanjutan paket - -
11 Pirazinamida tablet 500 mg tablet - -
PROGRAM FLU BURUNG : - -
1 Tamiflu tablet - -
PROGRAM DIARE : - -
1 Garam Oralit untuk 200 ml air sase - -
2 Zink tablet disperible 20 mg tablet - -
PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Klorokuin Fosfat tablet 250 mg tablet - -
2 Kuinin ( Kina ) tablet 200 mg tablet - -
3 Kuinin injeksi i.v 25% ( sebagai 2 HCl ) ampul - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Efavirenz (EFV) 200 mg tablet - -
4 Lamivudine (3TC) 150 mg tablet - -
5 Levotiroksin tab 100 µg tablet - -
6 Lopinavir 200 mg + Ritonavir 50 mg (Aluvia) tablet - -
7 Nevirapine (NVP) 200 mg tablet - -
8 Tenofovir 300 mg (TDF) tablet - -
Tenofovir 300 mg (TDF) + Emcitritabine 200 mg
9 tablet - -
(FTC)
Tenofovir 300 mg (TDF) + Lamivudine (3TC)
10 300 mg + Efavirenz (EFV) 600 mg (Triple FDC) tablet - -
Dewasa
11 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg + Lamivudine (3TC)
12 tablet - -
150 mg
Zidofudine 60 mg + Lamivudine 300 mg +
13 tablet - -
Nevirapine 50 mg (Triple FDC) Anak
- -
BAHAN GIGI : - -
1 1470IK Z250XT Syr Intro Kit kotak - -
2 Air raksa dental use botol - -
3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -
6 Cresotin Liquid II Technodent kotak - -
7 Cressophate botol - -
8 Cressophen botol - -
9 Devitalisasi Pasta ( Non Arsen ) botol - -
10 Endoseal Kotak - -
11 Etil Klorida semprot ( Duta Kaisar ) botol - -
12 Eugenol cairan botol - -
13 Glass Ionomer Cement ( GC IX ) botol - -
14 Jarum Sitoject biji - -
15 Kalsium Hidroksida Pasta ( hydcal ) botol - -
16 Monoklorkamfer Mentol Cairan ( CHKM ) botol - -
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
19 Semen Seng Fosfat serbuk dan cairan botol - -
20 Silver Amalgam serbuk 65 - 75 % botol 30 gr - -
21 Spons Gelatin Cubicles 1 x 1 x 1 cm biji - -
22 Temporary Stopping Fletcher ( Fletcher ) set - -
23 Trikresol Formalin (TKF) cairan botol - -
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS PAKAI ( BMHP ) - -
1 Alat Laboratorium Malaria Paket - -
2 Alat suntik sekali pakai 1 ml tuberculin set - -
3 Alat suntik sekali pakai 10 ml set - -
6 Alkohol Swab pcs - -
7 Askina Calgitrol 15 gram tube - -
8 Askina Gel 15 gram tube - -
9 Blood Lancet biji - -
10 Blood transfision set set - -
11 Catgut / Benang Bedah No. 2/0 - 3/0 biji - -
12 Etakridin ( Rivanol ) larutan 0,1% botol - -
13 Etanol 70 % 100 ml botol - -
14 Etanol 70% 1000 ml botol - -
15 Folleycatheter Silicon 2 way 14 - 18 biji - -
16 Hans Coen Nitril Non steril / Sarung Tangan Biji - -
17 Hans Coen Non steril / Sarung Tangan biji - -
18 Hans Coen Obgyn (Jayamas) pasang - -
19 Hans Coen steril / Sarung Tangan pasang - -
20 Hypafix 5 x 5 (Fixomull stretch 5 cm x 5 m) rol - -
21 Infusion set anak set - -
22 Infusion set dewasa set - -
23 IV Dressing 6 x 7 S lembar - -
24 IV. Chateter No. 14 s/d 24 set - -
25 IV. Chateter No. 24 set - -
27 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji - -
28 Jarum Suntik 22G s/d 25 G biji - -
29 Jarum Suntik 26G biji - -
30 Kapas Pembalut / Absorben 250 gram rol - -
31 Kasa Kompres 40 / 40 steril rol - -
32 Kasa Pembalut 2 m x 80 cm rol - -
33 Kasa Pembalut Hidrofil 4 m x 15 cm rol - -
35 Kasa Steril 16 Cm X 16 Cm (16 Pads) Pads - -
36 Lisol, mengandung Kresol tersabun 50% botol - -
37 Lomatulle / Bioplacentulle lembar - -
38 Masker Earloop/ Tie On biji - -
39 Masker N 95 set - -
40 Masker Nebulizer Set Anak Piece - -
41 Masker Nebulizer Set Dewasa Piece - -
42 Masker Oxygen Anak - Oxyflow Piece - -
43 Masker Oxygen Anak NR Mask biji - -
44 Masker Oxygen Dewasa - Oxyflow Piece - -
45 Masker Oxygen Dewasa NR Mask biji - -
46 Plester 1,25 cm x 4,5 m rol - -
47 Plesterin - plester bulat non wofen box @ 200 pcs - -
48 Pot Dahak Steril Pot - -
49 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml - -
51 Prontosan Gel 30 gram botol - -
53 Prontosan Sol 350 ml botol - -
54 Safety Box 5 Liter Pcs - -
55 Scalp Vein no. 25 biji - -
56 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol - -
57 Stabimed 1 L botol - -
58 Surgical Blade / Mess No. 11 biji - -
Umbilical cord klem nylon steril (Claim
59 biji - -
Umbilical)
60 Underpad biji - -
61 Urine Bag standard steril 2 Lt ( T valve ) biji - -
62 USG Gel botol @ 250 ml - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL Assay (Cartridge HIV
2 Test - -
Viral Load)
3 Human Hexagon Syphillis Kit - -
4 Iodina Test test kit - -
Rapid Syphilis/Standar Diagnostic (Alere)
5 Piece - -
Bioline
6 Rapid Test Anti HCV Test - -
7 Rapid Test Syphilis Test - -
8 RDT DBD Dengue Combo Verotec Test - -
9 Reagen 2 (FOCUS) Kit - -
10 Reagen 2 (Oncoprobe / IR - 100 C) Kit - -
11 Reagen 2 KHB Test - -
12 Reagen 3 (Biomerieux / Vikia HIV 1/2) Kit - -
13 Reagen 3 Diagnostar Test - -
14 Reagen CD 4 Control Kit - -
15 Reagen CD 4 Mobile Kit - -
16 Reagen HIV Right Sign Kit - -
Reagen I (Intec One Step Anti HIV (1&2) Tri
17 Kit - -
Line Test (ard)
Reagen I (Standart Diagnostic (SD) Bioline HIV
18 Kit - -
1/2)
19 Reagen Rapid Tes Hbs Ag Test - -
20 Reagen Test Anti Hbs Test - -
21 Reagen Zn Paket - -
RPR Syphilis/Titer (Plasmatec/RPR Tes Kit,
22 Piece - -
RPR 0/012)
- -
TAMBAHAN : - -
1 Hyaloph tetes mata - -
2 Ketac universal HMA3 - -
3 kaca slide - -
4 Becefort - -
5 Hand rub - -
6 NaCl 0,9% 100 cc - -
7 Nacl 0,9% 25 cc - -
BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI ASKES MANDIRI
Gresik, 8 Desember 2020
Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN YANG MENERIMA
KEPALA DINASEHATAN KAB. GRESIK PETUGAS GUDANG PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES
(……………………………………..) (Sunarti,A.Md.Farm.) (drg.Jon Sudiro Hendrata) (.......................................................)
NIP.19840403 2011012 013 NIP.19610823 198901 1 003
Yang Melayani :…………………….. Yang Memeriksa :……………………..

LAPORAN PEM
PUSTU/PONKESDES/POLINDES
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
1 Adona AC - 17 tablet / Saldona tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml
3 Albuthyl Ovula
4 Alopurinol tablet 100 mg
6 Alprazolam 0,5 mg tablet
7 Ambroxol sirup 15 mg / ml
8 Ambroxol tablet 30 mg
9 Aminofilin tablet scored 150 mg
11 Aminofilina injeksi 24 mg / ml
12 Amitriptilin tablet salut 25 mg ( HCl )
13 Amlodipine tablet 10 mg
15 Amoksisilin Sirup Kering 125 mg / 5 ml
17 Amoksisilin kaplet 500 mg
18 Amoksisilin kapsul 250 mg
19 Amoksisilin Serbuk injeksi 1000 mg
20 Ampisilina sirup kering 125 mg/5ml
Antalgin ( Metamisol )injeksi 500 mg / ml - 2 ml

21
( Novalgin / Antrain / Santagesik )
22 Antalgin ( Metampiron ) tablet 500 mg
23 Antalgin injeksi 250 mg / ml - 2 ml
Antasida DOEN I tablet kunyah, kombinasi : Aluminium

24
Hidroksida 200 mg ; Magnesium Hidroksida 200 mg
Antasida DOEN II suspensi, kombinasi : Aluminium
25 Hidroksida 200 mg/ml ; Magnesium Hidroksida 200
mg/ml
26 Antifungi DOEN
27 Antihemoroid DOEN
28 Antimigren DOEN tablet
29 Antiparkinson DOEN tablet
30 Aqua pro Injeksi steril, bebas pirogen
31 Aquadest steril
32 Asam Asetilsalisilat (Asetosal) tablet 100 mg
35 Asam Askorbat ( Vitamin C ) tablet 250 mg
37 Asam Mefenamat kaplet 500 mg
38 Asam traneksamat injeksi 100 mg/ml
40 Aseptik Gel 500 cc + dispenser
41 Asiklovir krim 5 %
42 Asiklovir tablet 400 mg
43 Asvex tablet
44 Atapulgit tablet 600 mg
45 Atorvastatin 20 mg tablet
46 Atropin Sulfat injeksi 0,25 mg / ml - 1 ml
47 Atropin Sulfat tablet 0,5 mg
48 Atropin Sulfat tetes mata 0,5%
49 Azitromisiin tablet 250 mg
50 Azitromisin tablet 500 mg
51 Batugin Elixir Sirup ( Fitofarmaka )
52 Becom - C tablet
53 Bedak salisil serbuk 2 %
54 Benzatin Benzil Penisillin Injeksi 2.4 Jt IU/vial
55 Betadin Gargle 100 ml / Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg
57 Betametason krim 0.1% ( sebagai valerat )
58 Betason - N krim
59 Bisacodil ( Bicolak ) tablet
60 Bisacodil suppositoria 10 mg ( Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg

62 Bisoprolol tablet 5 mg
63 Borak Gliserin 5%
64 Bromhexin tablet ( Bronex tablet ; Novaheksin tablet)
65 Bronchitin Expektoran Sirup
66 Cendo Lyters
67 Centabio Jelly / Bioplacenton Jelly
68 Curcuma tablet
69 Deksametason injeksi 5 mg / ml
70 Deksametason tablet 0,5 mg
Denomix Cream - Desoksimetason 0,25 %, neomycin

71
sulfate 0.5%
72 Desoksimetason krim 0,25 %
73 Dextrofen Syrup
74 Diazepam injeksi 5 mg / ml - 2 ml
75 Diazepam rectal tube (Stesolid rectal Tube)
76 Diazepam tablet 2 mg
78 Difenhidramin HCl injeksi 10 mg / ml
79 Digoksin tablet 0,25 mg

80 Dimenhidrinat tablet 50 mg
81 Doksisiklin tablet 100 mg
82 Domperidone sirup 5 mg/5ml
83 Domperidone tablet 10 mg
84 Efedrin HCl tablet 25 mg
85 Ekstrak Belladon tablet 10 mg
86 Elkana Sirup
87 Epinefrina HCl ( Adrenalin ) injeksi 1 mg/ml
88 Erithromisin sirup 200 mg / 5 ml
89 Eritromisin kapsul 250 mg
91 Etynil estradiol (Lynoral tablet 0,05 mg)
92 Fenobarbital tablet 30 mg
93 Fenofibrat kapsul 100 mg
95 Fenol Gliserol tetes telinga 10%
96 Fitomenadion ( Vitamin K1 ) injeksi 10 mg /ml
97 Fitomenadion ( Vitamin K1 ) tablet salut gula 10 mg

98 Fludane Plus Sirup
99 Fludane Tablet
100 Fluocinolone Acetonide (Dermasolon)
101 Fluor tablet 0,5 mg
102 Furosemid tablet 40 mg
103 Gelofusin Infus
104 Gemfibrosil kapsul 300 mg
106 Gentamisin Salep Kulit 0,1 %
107 Gentamisin salep mata 0,3 % (Genoint salep mata)
108 Gentamisin tetes mata 0,3 %
109 Gentian Violet larutan 1 %
110 Glibenklamid tablet 5 mg
111 Glimepiride tablet 2 mg
113 Gliseril Guaiakolat tablet 100 mg
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS

116 Glukosa larutan infus 10 % steril
119 Griseofulvin tablet 125 mg
121 Hemorogard kapsul
122 Hidroklorotiazid ( HCT ) tablet 25 mg
123 Hidrokortison krim 2,5 %
124 Hiosin Butil Bromid injeksi 20 mg/ml (Spasi injeksi)
125 Ibuprofen Sirup 100 mg / 5 mg
126 Ibuprofen tablet 200 mg
128 Ichtiyol Zalf
129 Ipratropium bromida nebulazer 0,025
130 Isosorbid Dinitrat tablet sublingual 5 mg
131 KA-EN 3 B Otsu infus
132 Kalium Diklofenak tablet 50 mg
133 Kalsium Laktat ( Kalk ) tablet 500 mg

134 Kaptopril tablet scored 25 mg
135 Kaptopril tablet scored 12,5 mg
136 Ketokonazol krim 2 %
137 Ketokonazol tablet 200 mg
138 Ketoprofen supositoria 100 mg ( Protofen supp )
139 Ketorolac injeksi 10 mg/ml
140 Klindamisin kapsul 150 mg
Kloramfenikol injeksi 1000 mg (Colsancetin injeksi 1000

142
mg )
143 Kloramfenikol kapsul 250 mg
145 Kloramfenikol salep kulit 2 % (BUFACETINE)
146 Kloramfenikol salep mata 1 %
147 Kloramfenikol suspensi 125 mg / 5 ml
148 Kloramfenikol tetes Mata 0.5 %
149 Kloramfenikol tetes telinga 1 %
150 Klorfeniramin Maleat ( CTM ) tablet 4 mg
151 Kodein HCl tablet 10 mg

152 Kotrimoksazol Dewasa tablet
153 Kotrimoksazol Pediatrik tablet
154 Kotrimoksazol Suspensi
155 Lactodia / Lacto B
156 Lansoprazol tablet 30 mg

Larutan mengandung elektrolit ( Na 130 mEq, Cl 109
157 mEq , Ca 3 mEq , Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
Larutan mengandung elektrolit (Ringer Laktat larutan
158
infus steril / Wida RL )
159 Lidokain injeksi 2% ( HCl)
160 Lidokain injeksi 2% ( HCl) + Epinefrin 1 : 80.000 - 2 ml
161 Linkomisina kapsul 500 mg
162 Loperamida tablet 2 mg
163 Loratadin tablet 10 mg
164 Meloksikam tablet 15 mg
165 Metformin HCl tablet 500 mg
166 Methyl Prednisolon 4 mg tablet
167 Metoklopropamid injeksi 5 mg / ml
168 Metoklopropamid tablet 10 mg
169 Metronidazol ovula

170 Metronidazol tablet 250 mg
171 Miconazol krim 2 % ( Nitrat )
172 N-Acetyl systeine tablet 200 mg
173 Natrium Diklofenak tablet 50 mg
174 Natrium Klorida larutan infus 0,9% steril
175 Neo Kauminal suspensi
176 Neuralgin - RX tablet
177 Neurosanbe 5000 mg tablet / Ikaneuron 5000
Neurosanbe injeksi / Mersibion Injeksi 5000 / Sohobion

178
5000 Injeksi
179 Neurovit E tablet / Nervitone - E
180 Nifedipin tablet 10 mg
Nifedipin tablet 20 mg Sediaan lepas lambat (Adalat

181
OROS)
182
OROS)
183 Nistatin tablet salut 500.000 IU / g
184 Nistatin vaginal tablet 100.000 IU / g
185 Noretisteron tablet 5 mg (Primolut N tablet)
186 Obat Batuk Hitam ( O.B.H. ) Generik
187 Obat Batuk Hitam ( O.B.H. ) Paten

188 Ofloxaxin tablet 200 mg
189 Oksimetazolin tetes hidung 0,025 %
190 Oksitetrasiklin HCl salep 3 %
191 Oksitetrasiklin HCl salep mata 1 %
192 Oksitosin injeksi 10 IU / ml - 1 ml
193 Omeprazole injeksi 40 mg / 10 ml
194 Omeprazole tablet 20 mg
195 Ondansetron injeksi 4 mg/2ml
196 Ondansetron tablet 4 mg
198 Papaverin injeksi 40 mg / 1 ml
199 Papaverin Tablet 40 mg
200 Parasetamol drop 100 mg/ml ( 60 mg / 0,6 ml )
201 Parasetamol sirup 120 mg / 5 ml
202 Parasetamol tablet 100 mg
204 Pehavral tablet
205 Petidin HCl injeksi 50 mg / ml - 2 ml

206 Pilokarpin HCl / Nitrat tetes mata 2%
207 Piracetam 1200 mg tablet
208 Piracetam injeksi 1 g / 5 ml
210 Piracetam tablet 800 mg
211 Piridoksin HCl ( Vitamin B6 ) tablet 10 mg
212 Piroxicam tablet 10 mg
214 Ponflu tablet
215 Prednison tablet 5 mg
216 Prolipid kaplet
217 Propiltiourasil tablet 100 mg
218 Propranolol HCl tablet 40 mg
219 Proris suppositoria
220 Ranitidin injeksi 25 mg / ml
221 Ranitidin tablet 150 mg
222 Reserpin tablet 0,25 mg
223 Rifampisin kapsul 300 mg

224 Salbutamol Inhaler (Salbulin)
225 Salbutamol tablet 2 mg ( sebagai sulfat )
Salep 2-4 , kombinasi : Asam Salisilat 2 % + Belerang

226
endap 4 %
Scabicid krim / Scabimite Cream 10 - Permetrin krim 5
227
%
228 Sefadroksil kapsul 500 mg
229 Sefadroksil Sirup Kering 125 mg / 5 ml
230 Sefiksim kapsul 100 mg
232 Sefiksim sirup kering 100 mg / 5 ml
233 Sefotaksim injeksi 1 gr
234 Seftriakson serbuk injeksi 1 gr / vial
235 Serum Anti Bisa Ular Polivalen injeksi I
236 Serum Anti Tetanus Injeksi 1.500 IU / amp
237 Serum Anti Tetanus Injeksi 20.000 IU / vial
238 Setirizin sirup 5 mg / 5 ml
239 Setirizin tablet 10 mg
240 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg
241 Sianokobalamin (Vitamin B12) tablet 50 mcg

242 Silver Sulfadiazin Cream
243 Simetidin tablet 200 mg
244 Simvastatin tablet 10 mg
246 Siprofloksasin kapsul 500 mg ( sebagai HCl )
247 Solotio Perhydrol ( H2O2 ) 3 %
248 Spasi Plus tablet / Scopma Plus
249 Spasminal tablet
250 Sucralfate suspensi 500 mg / 5 ml
251 Sulfasetamida Natrium tetes mata 15 %
252 Tensigard kapsul
TETAGAM - Human Tetanus Imunoglobulin Injeksi I.M.

253
250 UI
254 Tetrakain HCl tetes mata 0,5%
255 Tetrasiklin HCl kapsul 500 mg
256 Thiamfenikol kapsul 500 mg
257 Thiamfenikol sirup 125 mg / 5 ml
258 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1ml
259 Tiamin HCl / Mononitrat (Vitamin B1) tablet 50 mg

260 Truvit Syrup
261 Ventolin Nebules 2,5 mg
262 Vitamin B Kompleks tablet
263 Xylocaine 10 % Spray
264 Xylocaine 2 % Jelly
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :
1 Clobazam 10 Mg tab
2 Clozapin 25 mg tablet
3 Fenitoin Natrium kapsul 100 mg
5 Fluoxetine (Napres)
6 Haloperidol 5 mg / ml (Lodomer)
7 Haloperidol injeksi 50 mg/ml ( Haldol Decanoas )
8 Haloperidol tablet 0,5 mg

10 Haloperidol tablet 5 mg
11 Karbamazepin tablet 200 mg
12 Klorpromazin HCl tablet salut 100 mg
14 Klorpromazin injeksi 5 mg/ ml
15 Risperidon tablet 1 mg
17 Sikzonoat Inj / Flupenaziin Inj
18 Trifluoperasin tablet 5 mg
19 Triheksifenidil Hidroklorida tablet 2 mg
PROGRAM GIZI :
1 Asam Folat tablet 0,4 mg
2 Asam Folat tablet 1 mg
3 Besi Sirup
4 Iodiol kapsul lunak
Kombinasi tablet salut : Besi (II) sulfat 7H2O 200 mg

5
Asam Folat 0,25 mg ( tablet tambah darah )
6 Mineral Mix 8 gr
7 Retinol ( Vitamin A ) kapsul 100.000 IU

8 Retinol ( Vitamin A ) kapsul 200.000 IU kapsul lunak
9 Taburia
10 Zink sirup 20 mg/5ml ( Zircum Kid Sirup )
PROGRAM KECACINGAN :
1 Albendazol suspensi 200 mg / 5 ml
2 Albendazol tablet 400 mg
3 Dietilkarbamazin Sitrat tablet 100 mg
4 Pirantel suspensi 125 mg / 5 ml
5 Pirantel tablet score ( base ) 125 mg
PROGRAM KIA :
1 Ampisilin Injeksi 1000 mg/ml
2 Fenobarbital Inj 50 mg / ml

3
( Neonatus )
4 Gentamisin Inj 40 mg / ml
5 Kalsium Glukonat injeksi i.v 10 % ( 100 mg/ml )
6 Magnesium Sulfat injeksi ( IV ) 20 % - 25 ml
Metilergometrin Maleat (Metilergometrin) tablet salut

8
0,125 mg
9 Metilergometrin Maleat injeksi 0,200 mg-1 ml
10 Procain Benzil Penisilin 3.000.000 I.U
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
1 Isoniazide tablet 100 mg
3 OAT - FDC Kategori 1 - 3 PAKET
4 OAT - FDC Kategori 2 PAKET
5 OAT - FDC Kategori anak PAKET
6 OAT Sisipan
7 OAT-Kombipak Kategori 1 anak
8 OAT-Kombipak Kategori 1 dewasa
9 OAT - FDC TB / HIV Fase Awal
10 OAT - FDC TB / HIV Fase Lanjutan

11 Pirazinamida tablet 500 mg
PROGRAM FLU BURUNG :
1 Tamiflu
PROGRAM DIARE :
1 Garam Oralit untuk 200 ml air
2 Zink tablet disperible 20 mg
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
1 Klorokuin Fosfat tablet 250 mg
2 Kuinin ( Kina ) tablet 200 mg
3 Kuinin injeksi i.v 25% ( sebagai 2 HCl )
PROGRAM HIV :
1 Abacavir (ABC) 300 mg
2 Efavirenz (EFV) 200 mg
4 Lamivudine (3TC) 150 mg

5 Levotiroksin tab 100 µg
6 Lopinavir 200 mg + Ritonavir 50 mg (Aluvia)
7 Nevirapine (NVP) 200 mg
8 Tenofovir 300 mg (TDF)
9 Tenofovir 300 mg (TDF) + Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) + Lamivudine (3TC) 300 mg +

10
Efavirenz (EFV) 600 mg (Triple FDC) Dewasa
11 Zidofudine (ZDV) 100 mg
12 Zidofudine (ZDV) 300 mg + Lamivudine (3TC) 150 mg
Zidofudine 60 mg + Lamivudine 300 mg + Nevirapine

13
50 mg (Triple FDC) Anak
BAHAN GIGI :
1 1470IK Z250XT Syr Intro Kit
2 Air raksa dental use
3 Cavit - G
4 Caviton White
5 Composit resin ( solare )
6 Cresotin Liquid II Technodent
7 Cressophate
8 Cressophen
9 Devitalisasi Pasta ( Non Arsen )
10 Endoseal
11 Etil Klorida semprot ( Duta Kaisar )
12 Eugenol cairan
13 Glass Ionomer Cement ( GC IX )
14 Jarum Sitoject
15 Kalsium Hidroksida Pasta ( hydcal )
16 Monoklorkamfer Mentol Cairan ( CHKM )
17 Mummifying Pasta
18 Pehacain Inj
19 Semen Seng Fosfat serbuk dan cairan
20 Silver Amalgam serbuk 65 - 75 %
21 Spons Gelatin Cubicles 1 x 1 x 1 cm
22 Temporary Stopping Fletcher ( Fletcher )
23 Trikresol Formalin (TKF) cairan
24 Tumpatan komposit kit

BAHAN MEDIS HABIS PAKAI ( BMHP )
1 Alat Laboratorium Malaria
2 Alat suntik sekali pakai 1 ml tuberculin
3 Alat suntik sekali pakai 10 ml
6 Alkohol Swab
7 Askina Calgitrol 15 gram
8 Askina Gel 15 gram
9 Blood Lancet
10 Blood transfision set
11 Catgut / Benang Bedah No. 2/0 - 3/0
12 Etakridin ( Rivanol ) larutan 0,1%
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml
15 Folleycatheter Silicon 2 way 14 - 18
16 Hans Coen Nitril Non steril / Sarung Tangan
17 Hans Coen Non steril / Sarung Tangan

18 Hans Coen Obgyn (Jayamas)
19 Hans Coen steril / Sarung Tangan
20 Hypafix 5 x 5 (Fixomull stretch 5 cm x 5 m)
21 Infusion set anak
22 Infusion set dewasa
23 IV Dressing 6 x 7 S
24 IV. Chateter No. 14 s/d 24
25 IV. Chateter No. 24
27 Jarum Jahit ( Bedah ) No. 9 s/d 14
28 Jarum Suntik 22G s/d 25 G
29 Jarum Suntik 26G
30 Kapas Pembalut / Absorben 250 gram
31 Kasa Kompres 40 / 40 steril
32 Kasa Pembalut 2 m x 80 cm
33 Kasa Pembalut Hidrofil 4 m x 15 cm
35 Kasa Steril 16 Cm X 16 Cm (16 Pads)

36 Lisol, mengandung Kresol tersabun 50%
37 Lomatulle / Bioplacentulle
38 Masker Earloop/ Tie On
39 Masker N 95
40 Masker Nebulizer Set Anak
41 Masker Nebulizer Set Dewasa
42 Masker Oxygen Anak - Oxyflow
43 Masker Oxygen Anak NR Mask
44 Masker Oxygen Dewasa - Oxyflow
45 Masker Oxygen Dewasa NR Mask
46 Plester 1,25 cm x 4,5 m
47 Plesterin - plester bulat non wofen
48 Pot Dahak Steril
49 Povidon Iodida Larutan 10% 30 ml
51 Prontosan Gel 30 gram
53 Prontosan Sol 350 ml

54 Safety Box 5 Liter
55 Scalp Vein no. 25
56 Silk ( Benang Bedah Sutera ) No. 3 / 0
57 Stabimed 1 L
58 Surgical Blade / Mess No. 11
59 Umbilical cord klem nylon steril (Claim Umbilical)
60 Underpad
61 Urine Bag standard steril 2 Lt ( T valve )
62 USG Gel
REAGEN :
1 Cartridge Genexpert
Cepheid Xpert HIV - 1 VL Assay (Cartridge HIV Viral

2
Load)
3 Human Hexagon Syphillis
4 Iodina Test
5 Rapid Syphilis/Standar Diagnostic (Alere) Bioline
6 Rapid Test Anti HCV
7 Rapid Test Syphilis

8 RDT DBD Dengue Combo Verotec
9 Reagen 2 (FOCUS)
10 Reagen 2 (Oncoprobe / IR - 100 C)
11 Reagen 2 KHB
12 Reagen 3 (Biomerieux / Vikia HIV 1/2)
13 Reagen 3 Diagnostar
14 Reagen CD 4 Control
15 Reagen CD 4 Mobile
16 Reagen HIV Right Sign
Reagen I (Intec One Step Anti HIV (1&2) Tri Line Test
17
(ard)
18 Reagen I (Standart Diagnostic (SD) Bioline HIV 1/2)
19 Reagen Rapid Tes Hbs Ag
20 Reagen Test Anti Hbs
21 Reagen Zn
RPR Syphilis/Titer (Plasmatec/RPR Tes Kit, RPR

22
0/012)
TAMBAHAN :
1 Hyaloph tetes mata

2 Ketac universal HMA3
3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc
Mengetahui/Menyetujui,
KEPALA DINASEHATAN KAB. GRESIK

(……………………………………..)
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN O
( LPLPO APBD )
: PONED
:WRINGINANOM
: GRESIK PELAPORAN BULAN / PERIODE :
: JAWA TIMUR PERMINTAAN BULAN / PERIODE :
SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN
3 4 5 6 7
tablet
- -
ampul
- -
supp
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
vial
- -
botol
- -
ampul @ 2 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr
- -
supp
- -
tablet
- -
tablet
- -
botol @ 25 ml
- -
botol @ 1000 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
ampul
- -
botol @ 500 ml
- -
tube @ 5 gr
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
botol
- -
tablet
- -
tablet
- -
botol
- -
tablet
- -
kotak
- -
ampul
- -
botol
- -
tablet
- -
tube 5 gr
- -
tube
- -
tablet
- -
supp
- -
tablet
- -
tablet
- -
botol @ 15 ml
- -
tablet
- -
botol @ 50 ml
- -
botol
- -
tube @ 20 gr
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
Tube
- -
tube @ 15 gr
- -
botol @ 60 ml
- -
ampul
- -
tube @ 2,5 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
botol
- -
ampul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
botol
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tube @ 5 gram
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
kapsul
- -
kapsul
- -
tube @ 5 gr
- -
tube
- -
botol
- -
botol @10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
kapsul
- -
tablet
- -
tube
- -
ampul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
pot @ 15 gr
- -
ampul
- -
tablet
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tube 10 gr
- -
tablet
- -
supp
- -
ampul @ 1 ml
- -
kapsul
- -
kapsul
- -
vial
- -
kapsul
- -
kapsul
- -
tube
- -
tube
- -
botol @ 60 ml
- -
botol @ 5 ml
- -
botol @ 10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
sachet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml
- -
ampul @ 2 ml
- -
kapsul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
ovula
- -
tablet
- -
tube
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 100 ml
- -
botol @ 100 ml
- -
tablet
- -
botol @ 10 ml
- -
tube @ 5 gr
- -
tube @ 3,5 gr
- -
ampul @ 1 ml
- -
vial @ 10 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
botol @ 15 ml
- -
botol
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
botol
- -
tablet
- -
ampul @ 5 ml
- -
ampul @ 15 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
supp
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
kapsul
- -
pcs
- -
tablet
- -
pot @ 30 gr
- -
tube
- -
kapsul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
botol @ 30 ml
- -
vial @ 1 gr
- -
vial @ 1 gr
- -
vial
- -
vial
- -
vial
- -
botol
- -
tablet
- -
ampul
- -
tablet
- -
Tube
- -
tablet
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 100 ml
- -
tablet
- -
tablet
- -
botol
- -
botol
- -
kapsul
- -
Unit
- -
botol
- -
kapsul
- -
kapsul
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol
- -
syringe
- -
botol @ 60 ml
- -
- -
- -
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
tablet
- -
ampul
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
- -
tablet
- -
tablet
- -
botol
- -
kapsul
- -
tablet
- -
sase
- -
kapsul
- -
kapsul
- -
sachet
- -
botol @ 60 ml
- -
- -
botol
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
- -
Vial
- -
ampul
- -
ampul
- -
ampul
- -
ampul
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
tablet
- -
ampul @ 1 ml
- -
vial
- -
- -
blister
- -
blister
- -
blister
- -
blister
- -
- -
tablet
- -
tablet
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
tablet
- -
tablet
- -
- -
tablet
- -
- -
sase
- -
tablet
- -
- -
vial
- -
- -
tablet
- -
tablet
- -
ampul
- -
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
- -
- -
kotak
- -
botol
- -
botol
- -
kotak
- -
Kit
- -
kotak
- -
botol
- -
botol
- -
botol
- -
Kotak
- -
botol
- -
botol
- -
botol
- -
biji
- -
botol
- -
botol
- -
botol
- -
ampul @ 2 ml
- -
botol
- -
botol 30 gr
- -
biji
- -
set
- -
botol
- -
set
- -
- -
- -
Paket
- -
set
- -
set
- -
set
- -
set
- -
pcs
- -
tube
- -
tube
- -
biji
- -
set
- -
biji
- -
botol
- -
botol
- -
botol
- -
biji
- -
Biji
- -
biji
- -
pasang
- -
pasang
- -
rol
- -
set
- -
set
- -
lembar
- -
set
- -
set
- -
set
- -
biji
- -
biji
- -
biji
- -
rol
- -
rol
- -
rol
- -
rol
- -
rol
- -
Pads
- -
botol
- -
lembar
- -
biji
- -
set
- -
Piece
- -
Piece
- -
Piece
- -
biji
- -
Piece
- -
biji
- -
rol
- -
box @ 200 pcs
- -
Pot
- -
botol @ 30 ml
- -
botol @ 60 ml
- -
botol
- -
botol
- -
botol
- -
Pcs
- -
biji
- -
rol
- -
botol
- -
biji
- -
biji
- -
biji
- -
biji
- -
botol @ 250 ml
- -
- -
- -
Test
- -
Test
- -
Kit
- -
test kit
- -
Piece
- -
Test
- -
Test
- -
Test
- -
Kit
- -
Kit
- -
Test
- -
Kit
- -
Test
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Test
- -
Test
- -
Paket
- -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
(Sunarti,A.Md.Farm.)
NIP.19840403 2011012 013
Yang Melayani :……………………..

PERMINTAAN OBAT APBD PUSKESMAS
APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
STOK AKHIR STOK OPT.
TAAN APBD BPJS PROGRAM
8 9 10 11 12 13
NON BPJS JUMLAH
YANG MEMINTA / MELAPORKAN YAN
PIMPINAN PUSKESMAS PETUGAS P

(drg.Jon Sudiro Hendrata) (...................
NIP.19610823 198901 1 003
Yang Memeriksa :……………………..

N
JMLAH
KET
PEMBERIAN
LAIN-2
14 15 16
resik, 8 Desember 2020
YANG MENERIMA
PETUGAS PUSTU/PONKESDES
(.......................................................)
LAPORAN PEM
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
3 Albuthyl Ovula

21

24
mg/ml
26 Antifungi DOEN
31 Aquadest steril
43 Asvex tablet
52 Becom - C tablet
58 Betason - N krim

66 Cendo Lyters
68 Curcuma tablet

71
sulfate 0.5%
73 Dextrofen Syrup

86 Elkana Sirup

99 Fludane Tablet
103 Gelofusin Infus
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS

128 Ichtiyol Zalf


142
mg )


158


178
5000 Injeksi

181
OROS)
182
OROS)

204 Pehavral tablet

214 Ponflu tablet
216 Prolipid kaplet


226
endap 4 %
227
%


253
250 UI

260 Truvit Syrup
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :

PROGRAM GIZI :
3 Besi Sirup

5
6 Mineral Mix 8 gr

9 Taburia
PROGRAM KIA :

3
( Neonatus )

8
0,125 mg
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
6 OAT Sisipan

1 Tamiflu
PROGRAM DIARE :
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
PROGRAM HIV :


10

13
BAHAN GIGI :
3 Cavit - G
4 Caviton White
7 Cressophate
8 Cressophen
10 Endoseal
12 Eugenol cairan
14 Jarum Sitoject
17 Mummifying Pasta
18 Pehacain Inj

6 Alkohol Swab
9 Blood Lancet
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml

29 Jarum Suntik 26G

39 Masker N 95
48 Pot Dahak Steril

57 Stabimed 1 L
60 Underpad
62 USG Gel
REAGEN :

2
Load)
4 Iodina Test

9 Reagen 2 (FOCUS)
11 Reagen 2 KHB
17
(ard)
21 Reagen Zn

22
0/012)
TAMBAHAN :

3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc

(……………………………………..)
( LPLPO APBD )
: LEBANI SUKO
:WRINGINANOM
3 4 5 6 7
tablet
- -
ampul
- -
supp
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
vial
- -
botol
- -
ampul @ 2 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr
- -
supp
- -
tablet
- -
tablet
- -
botol @ 25 ml
- -
botol @ 1000 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
ampul
- -
botol @ 500 ml
- -
tube @ 5 gr
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
botol
- -
tablet
- -
tablet
- -
botol
- -
tablet
- -
kotak
- -
ampul
- -
botol
- -
tablet
- -
tube 5 gr
- -
tube
- -
tablet
- -
supp
- -
tablet
- -
tablet
- -
botol @ 15 ml
- -
tablet
- -
botol @ 50 ml
- -
botol
- -
tube @ 20 gr
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
Tube
- -
tube @ 15 gr
- -
botol @ 60 ml
- -
ampul
- -
tube @ 2,5 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
botol
- -
ampul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
botol
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tube @ 5 gram
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
kapsul
- -
kapsul
- -
tube @ 5 gr
- -
tube
- -
botol
- -
botol @10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
kapsul
- -
tablet
- -
tube
- -
ampul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
pot @ 15 gr
- -
ampul
- -
tablet
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tube 10 gr
- -
tablet
- -
supp
- -
ampul @ 1 ml
- -
kapsul
- -
kapsul
- -
vial
- -
kapsul
- -
kapsul
- -
tube
- -
tube
- -
botol @ 60 ml
- -
botol @ 5 ml
- -
botol @ 10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
sachet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml
- -
ampul @ 2 ml
- -
kapsul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
ovula
- -
tablet
- -
tube
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 100 ml
- -
botol @ 100 ml
- -
tablet
- -
botol @ 10 ml
- -
tube @ 5 gr
- -
tube @ 3,5 gr
- -
ampul @ 1 ml
- -
vial @ 10 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
botol @ 15 ml
- -
botol
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
botol
- -
tablet
- -
ampul @ 5 ml
- -
ampul @ 15 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
supp
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
kapsul
- -
pcs
- -
tablet
- -
pot @ 30 gr
- -
tube
- -
kapsul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
botol @ 30 ml
- -
vial @ 1 gr
- -
vial @ 1 gr
- -
vial
- -
vial
- -
vial
- -
botol
- -
tablet
- -
ampul
- -
tablet
- -
Tube
- -
tablet
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 100 ml
- -
tablet
- -
tablet
- -
botol
- -
botol
- -
kapsul
- -
Unit
- -
botol
- -
kapsul
- -
kapsul
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol
- -
syringe
- -
botol @ 60 ml
- -
- -
- -
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
tablet
- -
ampul
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
- -
tablet
- -
tablet
- -
botol
- -
kapsul
- -
tablet
- -
sase
- -
kapsul
- -
kapsul
- -
sachet
- -
botol @ 60 ml
- -
- -
botol
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
- -
Vial
- -
ampul
- -
ampul
- -
ampul
- -
ampul
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
tablet
- -
ampul @ 1 ml
- -
vial
- -
- -
blister
- -
blister
- -
blister
- -
blister
- -
- -
tablet
- -
tablet
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
tablet
- -
tablet
- -
- -
tablet
- -
- -
sase
- -
tablet
- -
- -
vial
- -
- -
tablet
- -
tablet
- -
ampul
- -
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
- -
- -
kotak
- -
botol
- -
botol
- -
kotak
- -
Kit
- -
kotak
- -
botol
- -
botol
- -
botol
- -
Kotak
- -
botol
- -
botol
- -
botol
- -
biji
- -
botol
- -
botol
- -
botol
- -
ampul @ 2 ml
- -
botol
- -
botol 30 gr
- -
biji
- -
set
- -
botol
- -
set
- -
- -
- -
Paket
- -
set
- -
set
- -
set
- -
set
- -
pcs
- -
tube
- -
tube
- -
biji
- -
set
- -
biji
- -
botol
- -
botol
- -
botol
- -
biji
- -
Biji
- -
biji
- -
pasang
- -
pasang
- -
rol
- -
set
- -
set
- -
lembar
- -
set
- -
set
- -
set
- -
biji
- -
biji
- -
biji
- -
rol
- -
rol
- -
rol
- -
rol
- -
rol
- -
Pads
- -
botol
- -
lembar
- -
biji
- -
set
- -
Piece
- -
Piece
- -
Piece
- -
biji
- -
Piece
- -
biji
- -
rol
- -
box @ 200 pcs
- -
Pot
- -
botol @ 30 ml
- -
botol @ 60 ml
- -
botol
- -
botol
- -
botol
- -
Pcs
- -
biji
- -
rol
- -
botol
- -
biji
- -
biji
- -
biji
- -
biji
- -
botol @ 250 ml
- -
- -
- -
Test
- -
Test
- -
Kit
- -
test kit
- -
Piece
- -
Test
- -
Test
- -
Test
- -
Kit
- -
Kit
- -
Test
- -
Kit
- -
Test
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Test
- -
Test
- -
Paket
- -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
NIP.19840403 2011012 013

APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
8 9 10 11 12 13
NON BPJS JUMLAH

NIP.19610823 198901 1 003

N
JMLAH
KET
PEMBERIAN
LAIN-2
14 15 16
YANG MENERIMA
(.......................................................)
LAPORAN PEM
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
3 Albuthyl Ovula

21

24
mg/ml
26 Antifungi DOEN
31 Aquadest steril
43 Asvex tablet
52 Becom - C tablet
58 Betason - N krim

66 Cendo Lyters
68 Curcuma tablet

71
sulfate 0.5%
73 Dextrofen Syrup

86 Elkana Sirup

99 Fludane Tablet
103 Gelofusin Infus
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS

128 Ichtiyol Zalf


142
mg )


158


178
5000 Injeksi

181
OROS)
182
OROS)

204 Pehavral tablet

214 Ponflu tablet
216 Prolipid kaplet


226
endap 4 %
227
%


253
250 UI

260 Truvit Syrup
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :

PROGRAM GIZI :
3 Besi Sirup

5
6 Mineral Mix 8 gr

9 Taburia
PROGRAM KIA :

3
( Neonatus )

8
0,125 mg
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
6 OAT Sisipan

1 Tamiflu
PROGRAM DIARE :
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
PROGRAM HIV :


10

13
BAHAN GIGI :
3 Cavit - G
4 Caviton White
7 Cressophate
8 Cressophen
10 Endoseal
12 Eugenol cairan
14 Jarum Sitoject
17 Mummifying Pasta
18 Pehacain Inj

6 Alkohol Swab
9 Blood Lancet
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml

29 Jarum Suntik 26G

39 Masker N 95
48 Pot Dahak Steril

57 Stabimed 1 L
60 Underpad
62 USG Gel
REAGEN :

2
Load)
4 Iodina Test

9 Reagen 2 (FOCUS)
11 Reagen 2 KHB
17
(ard)
21 Reagen Zn

22
0/012)
TAMBAHAN :

3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc

(……………………………………..)
( LPLPO APBD )
: LEBANI WARAS
:WRINGINANOM
3 4 5 6 7
tablet
- -
ampul
- -
supp
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
vial
- -
botol
- -
ampul @ 2 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr
- -
supp
- -
tablet
- -
tablet
- -
botol @ 25 ml
- -
botol @ 1000 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
ampul
- -
botol @ 500 ml
- -
tube @ 5 gr
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
botol
- -
tablet
- -
tablet
- -
botol
- -
tablet
- -
kotak
- -
ampul
- -
botol
- -
tablet
- -
tube 5 gr
- -
tube
- -
tablet
- -
supp
- -
tablet
- -
tablet
- -
botol @ 15 ml
- -
tablet
- -
botol @ 50 ml
- -
botol
- -
tube @ 20 gr
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
Tube
- -
tube @ 15 gr
- -
botol @ 60 ml
- -
ampul
- -
tube @ 2,5 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
botol
- -
ampul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
botol
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tube @ 5 gram
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
kapsul
- -
kapsul
- -
tube @ 5 gr
- -
tube
- -
botol
- -
botol @10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
kapsul
- -
tablet
- -
tube
- -
ampul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
pot @ 15 gr
- -
ampul
- -
tablet
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tube 10 gr
- -
tablet
- -
supp
- -
ampul @ 1 ml
- -
kapsul
- -
kapsul
- -
vial
- -
kapsul
- -
kapsul
- -
tube
- -
tube
- -
botol @ 60 ml
- -
botol @ 5 ml
- -
botol @ 10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
sachet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml
- -
ampul @ 2 ml
- -
kapsul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
ovula
- -
tablet
- -
tube
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 100 ml
- -
botol @ 100 ml
- -
tablet
- -
botol @ 10 ml
- -
tube @ 5 gr
- -
tube @ 3,5 gr
- -
ampul @ 1 ml
- -
vial @ 10 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
botol @ 15 ml
- -
botol
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
botol
- -
tablet
- -
ampul @ 5 ml
- -
ampul @ 15 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
supp
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
kapsul
- -
pcs
- -
tablet
- -
pot @ 30 gr
- -
tube
- -
kapsul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
botol @ 30 ml
- -
vial @ 1 gr
- -
vial @ 1 gr
- -
vial
- -
vial
- -
vial
- -
botol
- -
tablet
- -
ampul
- -
tablet
- -
Tube
- -
tablet
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 100 ml
- -
tablet
- -
tablet
- -
botol
- -
botol
- -
kapsul
- -
Unit
- -
botol
- -
kapsul
- -
kapsul
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol
- -
syringe
- -
botol @ 60 ml
- -
- -
- -
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
tablet
- -
ampul
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
- -
tablet
- -
tablet
- -
botol
- -
kapsul
- -
tablet
- -
sase
- -
kapsul
- -
kapsul
- -
sachet
- -
botol @ 60 ml
- -
- -
botol
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
- -
Vial
- -
ampul
- -
ampul
- -
ampul
- -
ampul
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
tablet
- -
ampul @ 1 ml
- -
vial
- -
- -
blister
- -
blister
- -
blister
- -
blister
- -
- -
tablet
- -
tablet
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
tablet
- -
tablet
- -
- -
tablet
- -
- -
sase
- -
tablet
- -
- -
vial
- -
- -
tablet
- -
tablet
- -
ampul
- -
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
- -
- -
kotak
- -
botol
- -
botol
- -
kotak
- -
Kit
- -
kotak
- -
botol
- -
botol
- -
botol
- -
Kotak
- -
botol
- -
botol
- -
botol
- -
biji
- -
botol
- -
botol
- -
botol
- -
ampul @ 2 ml
- -
botol
- -
botol 30 gr
- -
biji
- -
set
- -
botol
- -
set
- -
- -
- -
Paket
- -
set
- -
set
- -
set
- -
set
- -
pcs
- -
tube
- -
tube
- -
biji
- -
set
- -
biji
- -
botol
- -
botol
- -
botol
- -
biji
- -
Biji
- -
biji
- -
pasang
- -
pasang
- -
rol
- -
set
- -
set
- -
lembar
- -
set
- -
set
- -
set
- -
biji
- -
biji
- -
biji
- -
rol
- -
rol
- -
rol
- -
rol
- -
rol
- -
Pads
- -
botol
- -
lembar
- -
biji
- -
set
- -
Piece
- -
Piece
- -
Piece
- -
biji
- -
Piece
- -
biji
- -
rol
- -
box @ 200 pcs
- -
Pot
- -
botol @ 30 ml
- -
botol @ 60 ml
- -
botol
- -
botol
- -
botol
- -
Pcs
- -
biji
- -
rol
- -
botol
- -
biji
- -
biji
- -
biji
- -
biji
- -
botol @ 250 ml
- -
- -
- -
Test
- -
Test
- -
Kit
- -
test kit
- -
Piece
- -
Test
- -
Test
- -
Test
- -
Kit
- -
Kit
- -
Test
- -
Kit
- -
Test
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Test
- -
Test
- -
Paket
- -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
NIP.19840403 2011012 013

APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
8 9 10 11 12 13
NON BPJS JUMLAH

NIP.19610823 198901 1 003

N
JMLAH
KET
PEMBERIAN
LAIN-2
14 15 16
YANG MENERIMA
(.......................................................)
LAPORAN PEM
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
3 Albuthyl Ovula

21

24
mg/ml
26 Antifungi DOEN
31 Aquadest steril
43 Asvex tablet
52 Becom - C tablet
58 Betason - N krim

66 Cendo Lyters
68 Curcuma tablet

71
sulfate 0.5%
73 Dextrofen Syrup

86 Elkana Sirup

99 Fludane Tablet
103 Gelofusin Infus
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS

128 Ichtiyol Zalf


142
mg )


158


178
5000 Injeksi

181
OROS)
182
OROS)

204 Pehavral tablet

214 Ponflu tablet
216 Prolipid kaplet


226
endap 4 %
227
%


253
250 UI

260 Truvit Syrup
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :

PROGRAM GIZI :
3 Besi Sirup

5
6 Mineral Mix 8 gr

9 Taburia
PROGRAM KIA :

3
( Neonatus )

8
0,125 mg
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
6 OAT Sisipan

1 Tamiflu
PROGRAM DIARE :
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
PROGRAM HIV :


10

13
BAHAN GIGI :
3 Cavit - G
4 Caviton White
7 Cressophate
8 Cressophen
10 Endoseal
12 Eugenol cairan
14 Jarum Sitoject
17 Mummifying Pasta
18 Pehacain Inj

6 Alkohol Swab
9 Blood Lancet
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml

29 Jarum Suntik 26G

39 Masker N 95
48 Pot Dahak Steril

57 Stabimed 1 L
60 Underpad
62 USG Gel
REAGEN :

2
Load)
4 Iodina Test

9 Reagen 2 (FOCUS)
11 Reagen 2 KHB
17
(ard)
21 Reagen Zn

22
0/012)
TAMBAHAN :

3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc

(……………………………………..)
( LPLPO APBD )
: SUMENGKO
:WRINGINANOM
3 4 5 6 7
tablet
- -
ampul
- -
supp
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
vial
- -
botol
- -
ampul @ 2 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr
- -
supp
- -
tablet
- -
tablet
- -
botol @ 25 ml
- -
botol @ 1000 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
ampul
- -
botol @ 500 ml
- -
tube @ 5 gr
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
botol
- -
tablet
- -
tablet
- -
botol
- -
tablet
- -
kotak
- -
ampul
- -
botol
- -
tablet
- -
tube 5 gr
- -
tube
- -
tablet
- -
supp
- -
tablet
- -
tablet
- -
botol @ 15 ml
- -
tablet
- -
botol @ 50 ml
- -
botol
- -
tube @ 20 gr
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
Tube
- -
tube @ 15 gr
- -
botol @ 60 ml
- -
ampul
- -
tube @ 2,5 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
tablet
- -
botol
- -
ampul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
botol
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
tube @ 5 gram
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
kapsul
- -
kapsul
- -
tube @ 5 gr
- -
tube
- -
botol
- -
botol @10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
kapsul
- -
tablet
- -
tube
- -
ampul
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
pot @ 15 gr
- -
ampul
- -
tablet
- -
botol @ 500 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tube 10 gr
- -
tablet
- -
supp
- -
ampul @ 1 ml
- -
kapsul
- -
kapsul
- -
vial
- -
kapsul
- -
kapsul
- -
tube
- -
tube
- -
botol @ 60 ml
- -
botol @ 5 ml
- -
botol @ 10 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
sachet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml
- -
ampul @ 2 ml
- -
kapsul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
ovula
- -
tablet
- -
tube
- -
tablet
- -
tablet
- -
botol @ 500 ml
- -
botol @ 60 ml
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
botol @ 100 ml
- -
botol @ 100 ml
- -
tablet
- -
botol @ 10 ml
- -
tube @ 5 gr
- -
tube @ 3,5 gr
- -
ampul @ 1 ml
- -
vial @ 10 ml
- -
tablet
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
ampul @ 1 ml
- -
tablet
- -
botol @ 15 ml
- -
botol
- -
tablet
- -
tablet
- -
tablet
- -
ampul @ 2 ml
- -
botol
- -
tablet
- -
ampul @ 5 ml
- -
ampul @ 15 ml
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
supp
- -
ampul @ 2 ml
- -
tablet
- -
tablet
- -
kapsul
- -
pcs
- -
tablet
- -
pot @ 30 gr
- -
tube
- -
kapsul
- -
botol @ 60 ml
- -
kapsul
- -
kapsul
- -
botol @ 30 ml
- -
vial @ 1 gr
- -
vial @ 1 gr
- -
vial
- -
vial
- -
vial
- -
botol
- -
tablet
- -
ampul
- -
tablet
- -
Tube
- -
tablet
- -
tablet
- -
tablet
- -
kapsul
- -
botol @ 100 ml
- -
tablet
- -
tablet
- -
botol
- -
botol
- -
kapsul
- -
Unit
- -
botol
- -
kapsul
- -
kapsul
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol @ 60 ml
- -
ampul
- -
tablet
- -
botol
- -
syringe
- -
botol @ 60 ml
- -
- -
- -
- -
tablet
- -
tablet
- -
kapsul
- -
kapsul
- -
tablet
- -
ampul
- -
ampul
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
ampul
- -
tablet
- -
tablet
- -
- -
tablet
- -
tablet
- -
botol
- -
kapsul
- -
tablet
- -
sase
- -
kapsul
- -
kapsul
- -
sachet
- -
botol @ 60 ml
- -
- -
botol
- -
tablet
- -
tablet
- -
botol @ 60 ml
- -
tablet
- -
- -
Vial
- -
ampul
- -
ampul
- -
ampul
- -
ampul
- -
botol @ 25 ml
- -
botol @ 25 ml
- -
tablet
- -
ampul @ 1 ml
- -
vial
- -
- -
blister
- -
blister
- -
blister
- -
blister
- -
- -
tablet
- -
tablet
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
paket
- -
tablet
- -
tablet
- -
- -
tablet
- -
- -
sase
- -
tablet
- -
- -
vial
- -
- -
tablet
- -
tablet
- -
ampul
- -
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
tablet
- -
- -
- -
kotak
- -
botol
- -
botol
- -
kotak
- -
Kit
- -
kotak
- -
botol
- -
botol
- -
botol
- -
Kotak
- -
botol
- -
botol
- -
botol
- -
biji
- -
botol
- -
botol
- -
botol
- -
ampul @ 2 ml
- -
botol
- -
botol 30 gr
- -
biji
- -
set
- -
botol
- -
set
- -
- -
- -
Paket
- -
set
- -
set
- -
set
- -
set
- -
pcs
- -
tube
- -
tube
- -
biji
- -
set
- -
biji
- -
botol
- -
botol
- -
botol
- -
biji
- -
Biji
- -
biji
- -
pasang
- -
pasang
- -
rol
- -
set
- -
set
- -
lembar
- -
set
- -
set
- -
set
- -
biji
- -
biji
- -
biji
- -
rol
- -
rol
- -
rol
- -
rol
- -
rol
- -
Pads
- -
botol
- -
lembar
- -
biji
- -
set
- -
Piece
- -
Piece
- -
Piece
- -
biji
- -
Piece
- -
biji
- -
rol
- -
box @ 200 pcs
- -
Pot
- -
botol @ 30 ml
- -
botol @ 60 ml
- -
botol
- -
botol
- -
botol
- -
Pcs
- -
biji
- -
rol
- -
botol
- -
biji
- -
biji
- -
biji
- -
biji
- -
botol @ 250 ml
- -
- -
- -
Test
- -
Test
- -
Kit
- -
test kit
- -
Piece
- -
Test
- -
Test
- -
Test
- -
Kit
- -
Kit
- -
Test
- -
Kit
- -
Test
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Kit
- -
Test
- -
Test
- -
Paket
- -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
NIP.19840403 2011012 013

APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
8 9 10 11 12 13
NON BPJS JUMLAH

NIP.19610823 198901 1 003

N
JMLAH
KET
PEMBERIAN
LAIN-2
14 15 16
YANG MENERIMA
(.......................................................)
LAPORAN PEM
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
3 Albuthyl Ovula
21
24

mg/ml
26 Antifungi DOEN
31 Aquadest steril
43 Asvex tablet
52 Becom - C tablet
58 Betason - N krim
66 Cendo Lyters
68 Curcuma tablet
71
sulfate 0.5%
73 Dextrofen Syrup
86 Elkana Sirup
99 Fludane Tablet
103 Gelofusin Infus
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS
128 Ichtiyol Zalf
142
mg )
158
178
5000 Injeksi
181
OROS)
182
OROS)
204 Pehavral tablet
214 Ponflu tablet
216 Prolipid kaplet
226
endap 4 %
227
%
253
250 UI
260 Truvit Syrup
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :
PROGRAM GIZI :
3 Besi Sirup
5
6 Mineral Mix 8 gr
9 Taburia
PROGRAM KIA :
3
( Neonatus )
8
0,125 mg
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
6 OAT Sisipan
1 Tamiflu
PROGRAM DIARE :
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
PROGRAM HIV :

10


13
BAHAN GIGI :
3 Cavit - G
4 Caviton White
7 Cressophate
8 Cressophen
10 Endoseal
12 Eugenol cairan
14 Jarum Sitoject
17 Mummifying Pasta
18 Pehacain Inj

6 Alkohol Swab
9 Blood Lancet
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml
29 Jarum Suntik 26G
39 Masker N 95
48 Pot Dahak Steril
57 Stabimed 1 L
60 Underpad
62 USG Gel
REAGEN :
2
Load)
4 Iodina Test
9 Reagen 2 (FOCUS)
11 Reagen 2 KHB
17
(ard)

21 Reagen Zn
22
0/012)
TAMBAHAN :
3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc
(……………………………………..)
( LPLPO APBD )
: KEDUNG ANYAR
:WRINGINANOM
3 4 5 6 7
tablet - -
ampul - -
supp - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
botol @ 60 ml - -
tablet - -
tablet - -
vial - -
botol - -
ampul @ 2 ml
- -
tablet - -
ampul @ 2 ml - -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr - -
supp - -
tablet - -
tablet - -
botol @ 25 ml - -
botol @ 1000 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
ampul - -
botol @ 500 ml - -
tube @ 5 gr - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
botol - -
tablet - -
tablet - -
botol - -
tablet - -
kotak - -
ampul - -
botol - -
tablet - -
tube 5 gr - -
tube - -
tablet - -
supp
- -
tablet - -
tablet - -
botol @ 15 ml - -
tablet
- -
botol @ 50 ml - -
botol - -
tube @ 20 gr - -
tablet - -
ampul @ 1 ml - -
tablet - -
Tube
- -
tube @ 15 gr - -
botol @ 60 ml - -
ampul - -
tube @ 2,5 ml - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
kapsul - -
botol @ 60 ml - -
tablet - -
tablet - -
tablet - -
botol - -
ampul - -
botol @ 60 ml - -
kapsul - -
kapsul - -
tablet - -
tablet - -
kapsul - -
kapsul - -
botol - -
ampul - -
tablet
- -
botol @ 60 ml - -
tablet - -
tube @ 5 gram - -
tablet - -
tablet - -
botol @ 500 ml - -
kapsul - -
kapsul - -
tube @ 5 gr - -
tube
- -
botol - -
botol @10 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
botol @ 500 ml - -
botol @ 500 ml - -
botol @ 25 ml - -
botol @ 25 ml - -
botol @ 500 ml - -
tablet - -
tablet - -
kapsul - -
tablet - -
tube - -
ampul
- -
botol @ 60 ml - -
tablet - -
tablet - -
pot @ 15 gr - -
ampul - -
tablet - -
botol @ 500 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tube 10 gr - -
tablet - -
supp - -
ampul @ 1 ml - -
kapsul - -
kapsul - -
vial
- -
kapsul - -
kapsul - -
tube - -
tube - -
botol @ 60 ml - -
botol @ 5 ml - -
botol @ 10 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
sachet - -
tablet - -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml - -
ampul @ 2 ml
- -
kapsul - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul @ 2 ml - -
tablet - -
ovula - -
tablet - -
tube - -
tablet - -
tablet - -
botol @ 500 ml - -
botol @ 60 ml - -
tablet - -
tablet - -
ampul
- -
tablet - -
tablet - -
tablet
- -
tablet
- -
tablet - -
tablet - -
tablet - -
botol @ 100 ml - -
botol @ 100 ml - -
tablet - -
botol @ 10 ml - -
tube @ 5 gr - -
tube @ 3,5 gr - -
ampul @ 1 ml - -
vial @ 10 ml - -
tablet - -
ampul @ 2 ml - -
tablet - -
tablet - -
ampul @ 1 ml - -
tablet - -
botol @ 15 ml - -
botol - -
tablet - -
tablet - -
tablet - -
ampul @ 2 ml - -
botol - -
tablet - -
ampul @ 5 ml - -
ampul @ 15 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
supp - -
ampul @ 2 ml - -
tablet - -
tablet - -
kapsul - -
pcs - -
tablet - -
pot @ 30 gr
- -
tube
- -
kapsul - -
botol @ 60 ml - -
kapsul - -
kapsul - -
botol @ 30 ml - -
vial @ 1 gr - -
vial @ 1 gr - -
vial - -
vial - -
vial - -
botol - -
tablet - -
ampul - -
tablet - -
Tube - -
tablet - -
tablet - -
tablet - -
kapsul - -
botol @ 100 ml - -
tablet - -
tablet - -
botol - -
botol - -
kapsul - -
Unit
- -
botol - -
kapsul - -
kapsul - -
botol @ 60 ml - -
ampul - -
tablet - -
botol @ 60 ml - -
ampul - -
tablet - -
botol - -
syringe - -
botol @ 60 ml - -
- -
- -
- -
tablet - -
tablet - -
kapsul - -
kapsul - -
tablet - -
ampul - -
ampul - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
- -
tablet - -
tablet - -
botol - -
kapsul - -
tablet
- -
sase - -
kapsul - -
kapsul
- -
sachet - -
botol @ 60 ml - -
- -
botol - -
tablet - -
tablet - -
botol @ 60 ml - -
tablet - -
- -
Vial - -
ampul - -
ampul
- -
ampul - -
ampul - -
botol @ 25 ml - -
botol @ 25 ml - -
tablet
- -
ampul @ 1 ml - -
vial - -
- -
blister - -
blister - -
blister - -
blister - -
- -
tablet - -
tablet - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
tablet - -
tablet - -
- -
tablet - -
- -
sase - -
tablet - -
- -
vial - -
- -
tablet - -
tablet - -
ampul - -
- -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet
- -
tablet
- -
tablet - -
tablet
- -
tablet
- -
- -
- -
kotak - -
botol - -
botol - -
kotak - -
Kit - -
kotak - -
botol - -
botol - -
botol - -
Kotak - -
botol - -
botol - -
botol - -
biji - -
botol - -
botol - -
botol - -
ampul @ 2 ml - -
botol - -
botol 30 gr - -
biji - -
set - -
botol - -
set - -
- -
- -
Paket - -
set - -
set - -
set - -
set - -
pcs - -
tube - -
tube - -
biji - -
set - -
biji - -
botol - -
botol - -
botol - -
biji - -
Biji - -
biji - -
pasang - -
pasang - -
rol - -
set - -
set - -
lembar - -
set - -
set - -
set - -
biji - -
biji - -
biji - -
rol - -
rol - -
rol - -
rol - -
rol - -
Pads - -
botol - -
lembar - -
biji - -
set - -
Piece - -
Piece - -
Piece - -
biji - -
Piece - -
biji - -
rol - -
box @ 200 pcs - -
Pot - -
botol @ 30 ml - -
botol @ 60 ml - -
botol - -
botol - -
botol - -
Pcs - -
biji - -
rol - -
botol - -
biji - -
biji - -
biji - -
biji - -
botol @ 250 ml - -
- -
- -
Test - -
Test
- -
Kit - -
test kit - -
Piece - -
Test - -
Test - -
Test - -
Kit - -
Kit - -
Test - -
Kit - -
Test - -
Kit - -
Kit - -
Kit - -
Kit
- -
Kit
- -
Test - -
Test - -
Paket - -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
NIP.19840403 2011012 013
APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
8 9 10 11 12 13
NON BPJS JUMLAH


NIP.19610823 198901 1 003
N JMLAH
KET
LAIN-2 PEMBERIAN
14 15 16
YANG MENERIMA
(.......................................................)
LAPORAN PEM
KECAMATAN
KABUPATEN
PROVINSI
NO NAMA OBAT
1 2
OBAT-OBATAN :
3 Albuthyl Ovula
21
24

mg/ml
26 Antifungi DOEN
31 Aquadest steril
43 Asvex tablet
52 Becom - C tablet
58 Betason - N krim
66 Cendo Lyters
68 Curcuma tablet
71
sulfate 0.5%
73 Dextrofen Syrup
86 Elkana Sirup
99 Fludane Tablet
103 Gelofusin Infus
114 Glukosa 5% - 1/2 NS
115 Glukosa 5% - 1/4 NS
128 Ichtiyol Zalf
142
mg )
158
178
5000 Injeksi
181
OROS)
182
OROS)
204 Pehavral tablet
214 Ponflu tablet
216 Prolipid kaplet
226
endap 4 %
227
%
253
250 UI
260 Truvit Syrup
265 Zenirex Sirup
OBAT PROGRAM
PROGRAM JIWA :
PROGRAM GIZI :
3 Besi Sirup
5
6 Mineral Mix 8 gr
9 Taburia
PROGRAM KIA :
3
( Neonatus )
8
0,125 mg
PROGRAM KUSTA :
1 MB Anak
2 MB Dewasa
3 PB Anak
4 PB Dewasa
PROGRAM TBC :
6 OAT Sisipan
1 Tamiflu
PROGRAM DIARE :
PROGRAM DIPHTERI :
1 Serum ADS 20.000
PROGRAM MALARIA :
PROGRAM HIV :

10


13
BAHAN GIGI :
3 Cavit - G
4 Caviton White
7 Cressophate
8 Cressophen
10 Endoseal
12 Eugenol cairan
14 Jarum Sitoject
17 Mummifying Pasta
18 Pehacain Inj

6 Alkohol Swab
9 Blood Lancet
13 Etanol 70 % 100 ml
14 Etanol 70% 1000 ml
29 Jarum Suntik 26G
39 Masker N 95
48 Pot Dahak Steril
57 Stabimed 1 L
60 Underpad
62 USG Gel
REAGEN :
2
Load)
4 Iodina Test
9 Reagen 2 (FOCUS)
11 Reagen 2 KHB
17
(ard)

21 Reagen Zn
22
0/012)
TAMBAHAN :
3 kaca slide
4 Becefort
5 Hand rub
6 NaCl 0,9% 100 cc
7 Nacl 0,9% 25 cc
(……………………………………..)
( LPLPO APBD )
: PASINAN
:WRINGINANOM
3 4 5 6 7
tablet - -
ampul - -
supp - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
botol @ 60 ml - -
tablet - -
tablet - -
vial - -
botol - -
ampul @ 2 ml
- -
tablet - -
ampul @ 2 ml - -
tablet
- -
botol @ 60 ml
- -
pot @ 30 gr - -
supp - -
tablet - -
tablet - -
botol @ 25 ml - -
botol @ 1000 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
ampul - -
botol @ 500 ml - -
tube @ 5 gr - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
botol - -
tablet - -
tablet - -
botol - -
tablet - -
kotak - -
ampul - -
botol - -
tablet - -
tube 5 gr - -
tube - -
tablet - -
supp
- -
tablet - -
tablet - -
botol @ 15 ml - -
tablet
- -
botol @ 50 ml - -
botol - -
tube @ 20 gr - -
tablet - -
ampul @ 1 ml - -
tablet - -
Tube
- -
tube @ 15 gr - -
botol @ 60 ml - -
ampul - -
tube @ 2,5 ml - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
kapsul - -
botol @ 60 ml - -
tablet - -
tablet - -
tablet - -
botol - -
ampul - -
botol @ 60 ml - -
kapsul - -
kapsul - -
tablet - -
tablet - -
kapsul - -
kapsul - -
botol - -
ampul - -
tablet
- -
botol @ 60 ml - -
tablet - -
tube @ 5 gram - -
tablet - -
tablet - -
botol @ 500 ml - -
kapsul - -
kapsul - -
tube @ 5 gr - -
tube
- -
botol - -
botol @10 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
botol @ 500 ml - -
botol @ 500 ml - -
botol @ 25 ml - -
botol @ 25 ml - -
botol @ 500 ml - -
tablet - -
tablet - -
kapsul - -
tablet - -
tube - -
ampul
- -
botol @ 60 ml - -
tablet - -
tablet - -
pot @ 15 gr - -
ampul - -
tablet - -
botol @ 500 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tube 10 gr - -
tablet - -
supp - -
ampul @ 1 ml - -
kapsul - -
kapsul - -
vial
- -
kapsul - -
kapsul - -
tube - -
tube - -
botol @ 60 ml - -
botol @ 5 ml - -
botol @ 10 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
botol @ 60 ml - -
sachet - -
tablet - -
botol @ 500 ml
- -
botol @ 500 ml
- -
ampul @ 2 ml - -
ampul @ 2 ml
- -
kapsul - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul @ 2 ml - -
tablet - -
ovula - -
tablet - -
tube - -
tablet - -
tablet - -
botol @ 500 ml - -
botol @ 60 ml - -
tablet - -
tablet - -
ampul
- -
tablet - -
tablet - -
tablet
- -
tablet
- -
tablet - -
tablet - -
tablet - -
botol @ 100 ml - -
botol @ 100 ml - -
tablet - -
botol @ 10 ml - -
tube @ 5 gr - -
tube @ 3,5 gr - -
ampul @ 1 ml - -
vial @ 10 ml - -
tablet - -
ampul @ 2 ml - -
tablet - -
tablet - -
ampul @ 1 ml - -
tablet - -
botol @ 15 ml - -
botol - -
tablet - -
tablet - -
tablet - -
ampul @ 2 ml - -
botol - -
tablet - -
ampul @ 5 ml - -
ampul @ 15 ml - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
supp - -
ampul @ 2 ml - -
tablet - -
tablet - -
kapsul - -
pcs - -
tablet - -
pot @ 30 gr
- -
tube
- -
kapsul - -
botol @ 60 ml - -
kapsul - -
kapsul - -
botol @ 30 ml - -
vial @ 1 gr - -
vial @ 1 gr - -
vial - -
vial - -
vial - -
botol - -
tablet - -
ampul - -
tablet - -
Tube - -
tablet - -
tablet - -
tablet - -
kapsul - -
botol @ 100 ml - -
tablet - -
tablet - -
botol - -
botol - -
kapsul - -
Unit
- -
botol - -
kapsul - -
kapsul - -
botol @ 60 ml - -
ampul - -
tablet - -
botol @ 60 ml - -
ampul - -
tablet - -
botol - -
syringe - -
botol @ 60 ml - -
- -
- -
- -
tablet - -
tablet - -
kapsul - -
kapsul - -
tablet - -
ampul - -
ampul - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
ampul - -
tablet - -
tablet - -
- -
tablet - -
tablet - -
botol - -
kapsul - -
tablet
- -
sase - -
kapsul - -
kapsul
- -
sachet - -
botol @ 60 ml - -
- -
botol - -
tablet - -
tablet - -
botol @ 60 ml - -
tablet - -
- -
Vial - -
ampul - -
ampul
- -
ampul - -
ampul - -
botol @ 25 ml - -
botol @ 25 ml - -
tablet
- -
ampul @ 1 ml - -
vial - -
- -
blister - -
blister - -
blister - -
blister - -
- -
tablet - -
tablet - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
paket - -
tablet - -
tablet - -
- -
tablet - -
- -
sase - -
tablet - -
- -
vial - -
- -
tablet - -
tablet - -
ampul - -
- -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet - -
tablet
- -
tablet
- -
tablet - -
tablet
- -
tablet
- -
- -
- -
kotak - -
botol - -
botol - -
kotak - -
Kit - -
kotak - -
botol - -
botol - -
botol - -
Kotak - -
botol - -
botol - -
botol - -
biji - -
botol - -
botol - -
botol - -
ampul @ 2 ml - -
botol - -
botol 30 gr - -
biji - -
set - -
botol - -
set - -
- -
- -
Paket - -
set - -
set - -
set - -
set - -
pcs - -
tube - -
tube - -
biji - -
set - -
biji - -
botol - -
botol - -
botol - -
biji - -
Biji - -
biji - -
pasang - -
pasang - -
rol - -
set - -
set - -
lembar - -
set - -
set - -
set - -
biji - -
biji - -
biji - -
rol - -
rol - -
rol - -
rol - -
rol - -
Pads - -
botol - -
lembar - -
biji - -
set - -
Piece - -
Piece - -
Piece - -
biji - -
Piece - -
biji - -
rol - -
box @ 200 pcs - -
Pot - -
botol @ 30 ml - -
botol @ 60 ml - -
botol - -
botol - -
botol - -
Pcs - -
biji - -
rol - -
botol - -
biji - -
biji - -
biji - -
biji - -
botol @ 250 ml - -
- -
- -
Test - -
Test
- -
Kit - -
test kit - -
Piece - -
Test - -
Test - -
Test - -
Kit - -
Kit - -
Test - -
Kit - -
Test - -
Kit - -
Kit - -
Kit - -
Kit
- -
Kit
- -
Test - -
Test - -
Paket - -
Piece
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
BPJS
YANG MENYERAHKAN
PETUGAS GUDANG
NIP.19840403 2011012 013
APBD )
/ PERIODE :
/ PERIODE :
PERMIN PEMBERIAN
8 9 10 11 12 13
NON BPJS JUMLAH


NIP.19610823 198901 1 003
N JMLAH
KET
LAIN-2 PEMBERIAN
14 15 16
YANG MENERIMA
(.......................................................)
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD PUSK
( LPLPO APBD )
PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : JANUARI 2021
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : PEBRUARI 2021
NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT.
1 2 3 4 5 6 7 8 9
OBAT-OBATAN :
4 Alopurinol tablet 100 mg tablet 130 130 100 30
14 Amlodipine tablet 5 mg tablet 30 30 20 10
17 Amoksisilin kaplet 500 mg tablet 80 80 80 -
21 ampul @ 2 ml
( Novalgin / Antrain / Santagesik ) - -
24 tablet
200 200 90 110
25 Hidroksida 200 mg/ml ; Magnesium Hidroksida 200 botol @ 60 ml
mg/ml - -
42 Asiklovir tablet 400 mg tablet 20 20 10 10
60 Bisacodil suppositoria 10 mg ( Stolax / Dulcolax supp ) supp
- -
64 Bromhexin tablet ( Bronex tablet ; Novaheksin tablet) tablet
- -
71 Tube
sulfate 0.5% - -
97 Fitomenadion ( Vitamin K1 ) tablet salut gula 10 mg tablet
- -
107 Gentamisin salep mata 0,3 % (Genoint salep mata) tube
- -
124 Hiosin Butil Bromid injeksi 20 mg/ml (Spasi injeksi) ampul
- -
140 Klindamisin kapsul 150 mg kapsul 60 60 10 50
142 vial
mg ) - -
145 Kloramfenikol salep kulit 2 % (BUFACETINE) tube 3 3 3 -
150 Klorfeniramin Maleat ( CTM ) tablet 4 mg tablet 90 90 20 70
157 mEq , Ca 3 mEq , Asetat 28 mEq ) / Asering 500 ml botol @ 500 ml
larutan infus steril - -
158 botol @ 500 ml
infus steril / Wida RL ) - -
160 Lidokain injeksi 2% ( HCl) + Epinefrin 1 : 80.000 - 2 ml ampul @ 2 ml
- -
173 Natrium Diklofenak tablet 50 mg tablet 420 420 200 220
178 ampul
5000 Injeksi - -
181 tablet
OROS) - -
182 tablet
OROS) - -
201 Parasetamol sirup 120 mg / 5 ml botol 13 13 9 4
225 Salbutamol tablet 2 mg ( sebagai sulfat ) tablet 90 90 20 70
226 pot @ 30 gr
endap 4 % - -
227 tube
% - -
241 Sianokobalamin (Vitamin B12) tablet 50 mcg tablet 250 250 80 170
244 Simvastatin tablet 10 mg tablet 320 320 110 110
253 Unit
250 UI - -
259 Tiamin HCl / Mononitrat (Vitamin B1) tablet 50 mg tablet - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
7 Haloperidol injeksi 50 mg/ml ( Haldol Decanoas ) ampul - -
PROGRAM GIZI : - -
5 tablet
Asam Folat 0,25 mg ( tablet tambah darah ) - -
8 Retinol ( Vitamin A ) kapsul 200.000 IU kapsul lunak kapsul
- -
PROGRAM KIA : - -
3 ampul
( Neonatus ) - -
8 tablet
0,125 mg - -
PROGRAM KUSTA : - -
PROGRAM TBC : - -
PROGRAM DIARE : - -
PROGRAM HIV : - -
9 Tenofovir 300 mg (TDF) + Emcitritabine 200 mg (FTC) tablet
- -

10 tablet
- -
12 Zidofudine (ZDV) 300 mg + Lamivudine (3TC) 150 mg tablet
- -
13 tablet
50 mg (Triple FDC) Anak - -
- -
BAHAN GIGI : - -
- -
33 Kasa Pembalut Hidrofil 4 m x 15 cm rol 2 2 2 -
34 Kasa Pembalut Hidrofil 4 m x 3 cm rol 2 2 2 -
56 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol 2 2 1 1
59 Umbilical cord klem nylon steril (Claim Umbilical) biji - -
- -
REAGEN : - -
2 Test
Load) - -
5 Rapid Syphilis/Standar Diagnostic (Alere) Bioline Piece - -
17 Kit
(ard) - -
18 Reagen I (Standart Diagnostic (SD) Bioline HIV 1/2) Kit
- -
22 Piece
0/012) - -
- -
TAMBAHAN : - -
3 kaca slide - -
4 Becefort - -
5 Hand rub - -
6 NaCl 0,9% 100 cc - -
7 Nacl 0,9% 25 cc - -

31 182
130 3 18
Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MEL

KEPALA DINASEHATAN KAB. GRESIK PETUGAS GUDANG PIMPINAN PUSKE
(……………………………………..) (Sunarti,A.Md.Farm.) (drg.Jon Sudiro Hen

NIP.19840403 2011012 013 NIP.19610823 198901

AT APBD PUSKESMAS
PERMIN PEMBERIAN JMLAH

KET
TAAN APBD BPJS PROGRAM LAIN-2 PEMBERIAN
10 11 12 13 14 15 16
100
100
100
5
3
100
JUMLAH
182
Gresik,15 JAN 2021

ANG MEMINTA / MELAPORKAN YANG MENERIMA
PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES
(drg.Jon Sudiro Hendrata) (.......................................................)

NIP.19610823 198901 1 003

( LPLPO APBD )
: KEPUH
PUSTU/PONKESDES/POLINDES KLAGEN
PELAPORAN BULAN /
KABUPATEN : GRESIK
PERIODE : April 21
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : Apri
Mei
PERMI JMLAH
SISA PENERI PERSE PEMAK STOK STOK PEMBERIAN
NO NAMA OBAT SAT. N PEMBE KET
AWAL MAAN DIAAN AIAN AKHIR OPT. PROGR
TAAN APBD BPJS LAIN-2 RIAN
AM
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
OBAT-OBATAN :
4 Alopurinol tablet 100 mg tablet 20 200 10 20 300
13 Amlodipine tablet 10 mg tablet 10 200 10 10 300
14 Amlodipine tablet 5 mg tablet
15 Amoksisilin Sirup Kering 125 mg / 5 ml botol @ 60 ml - - 10
17 Amoksisilin kaplet 500 mg tablet 20 300 320 10 10 300
21 ampul @ 2 ml - -
24 Antasida DOEN II suspensi, kombinasi : Aluminium tablet 30 300 330 10 300
25 Hidroksida 200 mg/ml ; Magnesium Hidroksida 200 botol @ 60 ml - - 5
26 mg/ml
Antifungi DOEN pot @ 30 gr - - 3
41 Asiklovir krim 5 % tube @ 5 gr - - 5
42 Asiklovir tablet 400 mg tablet 10 100 110 10 300
44 Atapulgit tablet 600 mg tablet 100 300 400 10 300
60 Bisacodil suppositoria 10 mg ( Stolax / Dulcolax supp ) supp - -
64 Bromhexin tablet ( Bronex tablet ; Novaheksin tablet) tablet - -
71 Tube - -
sulfate 0.5%
97 Fitomenadion ( Vitamin K1 ) tablet salut gula 10 mg tablet - -
107 Gentamisin salep mata 0,3 % (Genoint salep mata) tube - -
124 Hiosin Butil Bromid injeksi 20 mg/ml (Spasi injeksi) ampul - -
139 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - - 25
140 Klindamisin kapsul 150 mg kapsul 50 50 50
142 vial - -
mg )
145 Kloramfenikol salep kulit 2 % (BUFACETINE) tube 3 3 3 -
146 Kloramfenikol salep mata 1 % tube - - 15
150 Klorfeniramin Maleat ( CTM ) tablet 4 mg tablet 70 100 170 10 70 100
156 Lansoprazol tablet 30 elektrolit
Larutan mengandung mg ( Na 130 mEq, Cl 109 tablet 60 60 60 300
157 mEq , Ca 3 mEq , Asetat 28 mEq ) / Asering 500 ml botol @ 500 ml - -
158 larutan infus steril botol @ 500 ml - -
160 Lidokain injeksi 2% ( HCl) + Epinefrin 1 : 80.000 - 2 ml ampul @ 2 ml - -
162 Loperamida tablet 2 mg tablet - - 300
173 Natrium Diklofenak tablet 50 mg tablet 160 200 360 10 160 300
178 ampul - -
5000 Injeksi
181 tablet - -
OROS)
182 tablet - -
OROS)
186 Obat Batuk Hitam ( O.B.H. ) Generik botol @ 100 ml - - 20
201 Parasetamol sirup 120 mg / 5 ml botol 20 20 20
203 Parasetamol tablet 500 mg tablet - - 300
204 Pehavral tablet tablet - - 300
213 Piroxicam tablet 20 mg tablet - - 300
214 Ponflu tablet tablet - - 300
225 Salbutamol tablet 2 mg ( sebagai sulfat ) tablet 70 70 70 300
226 pot @ 30 gr - -
endap 4%
227 tube - -
%
241 Sianokobalamin (Vitamin B12) tablet 50 mcg tablet 250 250 80 170
244 Simvastatin tablet 10 mg tablet 90 150 240 10 90 300
245 Simvastatin tablet 20 mg tablet 190 100 290 20 190 300
249 Spasminal tablet tablet - - 300
253 Unit - -
250 UI
256 Thiamfenikol kapsul 500 mg kapsul - - 300
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
PROGRAM GIZI : - -
5 tablet - -
8 Retinol ( Vitamin A ) kapsul 200.000 IU kapsul lunak kapsul - -
PROGRAM KIA : - -
3 ampul - -
( Neonatus )
8 tablet - -
0,125 mg
PROGRAM KUSTA : - -
PROGRAM TBC : - -
PROGRAM DIARE : - -
PROGRAM HIV : - -
9 Tenofovir 300 mg (TDF) + Emcitritabine 200 mg (FTC) tablet - -
10 tablet - -
12 Zidofudine (ZDV) 300 mg + Lamivudine (3TC) 150 mg tablet - -
13 tablet - -
- -
BAHAN GIGI : - -
- -
33 Kasa Pembalut Hidrofil 4 m x 15 cm rol 2 2 -
34 Kasa Pembalut Hidrofil 4 m x 3 cm rol 2 2 -
56 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol 2 2 2 2
- -
REAGEN : - -
2 Test - -
Load)
17 Kit - -
(ard)
18 Reagen I (Standart Diagnostic (SD) Bioline HIV 1/2) Kit - -
22 Piece - -
0/012)
- -
TAMBAHAN : - -
3 kaca slide - -
4 Becefort - -
5 Hand rub - -
6 NaCl 0,9% 100 cc - -
7 Nacl 0,9% 25 cc - -

JUMLAH KUNJUNGAN PBI ASKES MANDIRI
RESEP 5 85
65 15
Gresik,06 April 2021
Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN YANG MENERIMA
KEPALA DINASEHATAN KAB. GRESIK PETUGAS GUDANG PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES
(……………………………………..) (Sunarti,A.Md.Farm.) (drg.Jon Sudiro Hendrata) (.......................................................)
NIP.19840403 2011012 013 NIP.19610823 198901 1 003

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD PUSK
( LPLPO APBD )
PUSTU/PONKESDES/POLINDES : SUMBER WARU
KABUPATEN : GRESIK PElAPORAN BULAN / PERIODE :
NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR
1 2 3 4 5 6 7 8
OBAT-OBATAN :
4 Alopurinol tablet 100 mg tablet 180 180 60 120
13 Amlodipine tablet 10 mg tablet 160 160 10 150
21 ampul @ 2 ml
24 tablet
50 50 50 -
mg/ml 8 8 2 6
- -
- -
71 Tube
sulfate 0.5% - -
- -
- -
111 Glimepiride tablet 2 mg tablet 130 130 20 110
- -
132 Kalium Diklofenak tablet 50 mg tablet
133 Kalsium Laktat ( Kalk ) tablet 500 mg tablet 110 110 10 100
135 Kaptopril tablet scored 12,5 mg tablet 260 260 50 210
137 Ketokonazol tablet 200 mg tablet
142 vial
mg ) - -
158 botol @ 500 ml
- -
165 Metformin HCl tablet 500 mg tablet 170 170 170 -
173 Natrium Diklofenak tablet 50 mg tablet 250 250 60 190
178 ampul
5000 Injeksi - -
181 tablet
OROS) - -
182 tablet
OROS) - -
226 pot @ 30 gr
endap 4 % - -
227 tube
% - -
253 Unit
250 UI - -
262 Vitamin B Kompleks tablet tablet 70 70 50 20
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
PROGRAM GIZI : - -
5 tablet
- -
PROGRAM KIA : - -
3 ampul
( Neonatus ) - -
8 tablet
0,125 mg - -
PROGRAM KUSTA : - -
PROGRAM TBC : - -
PROGRAM DIARE : - -
PROGRAM HIV : - -
- -
10 tablet
- -
- -
13 tablet
50 mg (Triple FDC) Anak -
- -
BAHAN GIGI : - -
- -
- -
REAGEN : - -
2 Test
Load) - -
17 Kit
(ard) - -
- -
22 Piece
0/012) - -
- -
TAMBAHAN : - -
3 kaca slide - -
4 Becefort - -
5 Hand rub - -
6 NaCl 0,9% 100 cc - -
7 Nacl 0,9% 25 cc - -
BPJS NON BPJS

Mengetahui/Menyetujui, YANG MENYERAHKAN

KEPALA DINASEHATAN KAB. GRESIK PETUGAS GUDANG
(……………………………………..) (Sunarti,A.Md.Farm.)
NIP.19840403 2011012 013

MINTAAN OBAT APBD PUSKESMAS
BD )
2021

STOK OPT. KET
9 10 11 12 13 14 15 16
JUMLAH

YANG MEMINTA / MELAPORKAN YANG MENERIMA
PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES
(drg.Jon Sudiro Hendrata) (.......................................................)

NIP.19610823 198901 1 003

( LPLPO APBD )
PUSTU/PONKESDES/POLINDES : SEMBUNG
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :

NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT. KET
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
OBAT-OBATAN :
21 ampul @ 2 ml
24 tablet
- -
mg/ml - -
- -
- -
71 Tube
sulfate 0.5% - -
- -
- -
- -
142 vial
mg ) - -
158 botol @ 500 ml
- -
173 Natrium Diklofenak tablet 50 mg tablet - -
178 ampul
5000 Injeksi - -
181 tablet
OROS) - -
182 tablet
OROS) - -
226 pot @ 30 gr
endap 4 % - -
227 tube
% - -
253 Unit
250 UI - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
PROGRAM GIZI : - -
5 tablet
- -
PROGRAM KIA : - -
3 ampul
( Neonatus ) - -
8 tablet
0,125 mg - -
PROGRAM KUSTA : - -
PROGRAM TBC : - -
PROGRAM DIARE : - -
PROGRAM HIV : - -
- -
10 tablet
- -
- -
13 tablet
50 mg (Triple FDC) Anak - -
- -
BAHAN GIGI : - -
- -
- -
REAGEN : - -
2 Test
Load) - -
17 Kit
(ard) - -
- -
22 Piece
0/012) - -
- -
TAMBAHAN : - -
3 kaca slide - -
4 Becefort - -
5 Hand rub - -
6 NaCl 0,9% 100 cc - -
7 Nacl 0,9% 25 cc - -

Gresik, 8
Desember 2020
YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN YANG MENERIMA
PETUGAS GUDANG PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES
(Sunarti,A.Md.Farm.) (drg.Jon Sudiro Hendrata) (.......................................................)
NIP.19840403 2011012 013 NIP.19610823 198901 1 003

LPLPO KP - Klagen APBD 2021

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD PUSKESMAS

KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :

1 Adona AC - 17 tablet / Saldona tablet tablet - -

BPJS NON BPJS JUMLAH

Gresik, 8 Desember 2020

Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN YANG MENERIMA

(……………………………………..) (Sunarti,A.Md.Farm.) (drg.Jon Sudiro Hendrata) (.......................................................)

NIP.19840403 2011012 013 NIP.19610823 198901 1 003

Yang Melayani :…………………….. Yang Memeriksa :……………………..

1 Adona AC - 17 tablet / Saldona tablet

4 Alopurinol tablet 100 mg

5 Alopurinol tablet 300 mg

6 Alprazolam 0,5 mg tablet

9 Aminofilin tablet scored 150 mg

10 Aminofilin tablet scored 200 mg

12 Amitriptilin tablet salut 25 mg ( HCl )

15 Amoksisilin Sirup Kering 125 mg / 5 ml

16 Amoksisilin Sirup Kering 250 mg / 5 ml

17 Amoksisilin kaplet 500 mg

18 Amoksisilin kapsul 250 mg

19 Amoksisilin Serbuk injeksi 1000 mg

20 Ampisilina sirup kering 125 mg/5ml

Antalgin ( Metamisol )injeksi 500 mg / ml - 2 ml

22 Antalgin ( Metampiron ) tablet 500 mg

23 Antalgin injeksi 250 mg / ml - 2 ml

Antasida DOEN I tablet kunyah, kombinasi : Aluminium

28 Antimigren DOEN tablet

29 Antiparkinson DOEN tablet

30 Aqua pro Injeksi steril, bebas pirogen

32 Asam Asetilsalisilat (Asetosal) tablet 100 mg

33 Asam Asetilsalisilat (Asetosal) tablet 500 mg

34 Asam Asetilsalisilat (Asetosal) tablet 80 mg

35 Asam Askorbat ( Vitamin C ) tablet 250 mg

36 Asam Askorbat ( Vitamin C ) tablet 50 mg

37 Asam Mefenamat kaplet 500 mg

38 Asam traneksamat injeksi 100 mg/ml

39 Asam traneksamat injeksi 50 mg/ml

40 Aseptik Gel 500 cc + dispenser

42 Asiklovir tablet 400 mg

46 Atropin Sulfat injeksi 0,25 mg / ml - 1 ml

47 Atropin Sulfat tablet 0,5 mg

48 Atropin Sulfat tetes mata 0,5%

49 Azitromisiin tablet 250 mg

50 Azitromisin tablet 500 mg

51 Batugin Elixir Sirup ( Fitofarmaka )

53 Bedak salisil serbuk 2 %

54 Benzatin Benzil Penisillin Injeksi 2.4 Jt IU/vial

55 Betadin Gargle 100 ml / Molexdin obat kumur

56 Betahistin Mesilat tablet 6 mg

57 Betametason krim 0.1% ( sebagai valerat )

59 Bisacodil ( Bicolak ) tablet

60 Bisacodil suppositoria 10 mg ( Stolax / Dulcolax supp )

61 Bisoprolol tablet 2,5 mg

64 Bromhexin tablet ( Bronex tablet ; Novaheksin tablet)

65 Bronchitin Expektoran Sirup

67 Centabio Jelly / Bioplacenton Jelly

70 Deksametason tablet 0,5 mg