LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKESMAS

( LPLPO JKN )
PUSTU/PONKESDES/POLINDES ; UGD

KECAMATAN :WRINGINANOM

KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :

PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE :

NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR STOK OPT. KET

3
1 2 4 5 6 7 8 9 10

OBAT-OBATAN :

1 Adona AC - 17 tablet tablet

- -

2 Adona AC Injeksi 5 mg / ml - 2 ml ampul

- -

3 Albendazol suspensi 200 mg / 5 ml botol

- -

4 Albendazol tablet 400 mg tablet

- -

5 Albuthyl Ovula supp

- -

6 Alopurinol tablet 100 mg tablet

- -

7 Alopurinol tablet 300 mg tablet

- -

8 Alprazolam 0,5 mg tablet tablet

- -

9 Ambroxol sirup 15 mg / ml botol @ 60 ml

- -

10 Ambroxol tablet 30 mg tablet

- -

11 Aminofilin tablet scored 200 mg tablet

- -

12 Aminofilina injeksi 24 mg / ml ampul

- -

13 Amitriptilin tablet salut 25 mg ( HCl ) tablet

- -

14 Amlodipine tablet 10 mg tablet

- -

15 Amlodipine tablet 5 mg tablet

- -
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml - -
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml - -

18 Amoksisilin kaplet 500 mg tablet

- -

19 Amoksisilin kapsul 250 mg tablet

- -

20 Amoksisilin Serbuk injeksi 1000 mg vial

- -
Amoxillin + As.Klavulanat 625 mg
21 tablet
kapsul - -

22 Ampisilina sirup kering 125 mg/5ml botol

- -

23 Antalgin ( Metampiron ) tablet 500 mg tablet

- -

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml

- -
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik ) - -
Antasida DOEN I tablet kunyah,
26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium
Antasida DOEN IIHidroksida
suspensi, 200 mg - -
kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200 - -
mg/ml
28 Antifungi DOEN pot @ 30 gr
- -

29 Antihemoroid DOEN supp

- -

30 Antimigren DOEN tablet tablet

- -

31 Antiparkinson DOEN tablet tablet

- -

32 Aqua pro Injeksi steril, bebas pirogen botol

- -

33 Aquadest steril botol @ 1000 ml

- -
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg - -
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg - -
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg - -

37 Asam Folat tablet 0,4 mg tablet

- -

38 Asam Folat tablet 1 mg tablet

- -

39 Asam Mefenamat kaplet 500 mg tablet

- -

40 Asam traneksamat injeksi 100 mg/ml ampul

- -

41 Asam traneksamat injeksi 50 mg/ml ampul

- -
42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
- -

43 Asiklovir krim 5 % tube @ 5 gr

- -

44 Asiklovir tablet 400 mg tablet

- -

45 Atapulgit tablet 600 mg tablet

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

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 % tablet

- -
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial - -

55 Besi Sirup botol

- -
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur - -

57 Betahistin Mesilat tablet 6 mg tablet

- -
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat ) - -

59 Betason - N krim tube

- -

60 Bisacodil ( Bicolak ) tablet tablet

- -
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp ) - -

62 Bisoprolol tablet 5 mg tablet

- -

63 Borak Gliserin 5% botol @ 15 ml

- -
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet) - -

65 Bronchitin Expektoran Sirup botol @ 50 ml

- -

66 Centabio Jelly / Bioplacenton Jelly tablet

- -

67 Curcuma tablet tablet

- -

68 Deksametason injeksi 5 mg / ml ampul @ 1 ml

- -

69 Deksametason tablet 0,5 mg tablet

- -

70 Desoksimetason krim 0,25 % tube @ 15 gr

- -

71 Diazepam injeksi 5 mg / ml - 2 ml ampul

- -
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube) - -

73 Diazepam tablet 2 mg tablet

- -

74 Dietilkarbamazin Sitrat tablet 100 mg tablet

- -

75 Difenhidramin HCl injeksi 10 mg / ml ampul

- -

76 Digoksin tablet 0,25 mg tablet

- -

77 Dimenhidrinat tablet 50 mg tablet

- -

78 Doksisiklin tablet 100 mg tablet

- -

79 Domperidone sirup 5 mg/5ml botol @ 60 ml

- -

80 Domperidone tablet 10 mg tablet

- -

81 Efedrin HCl tablet 25 mg tablet

- -

82 Ekstrak Belladon tablet 10 mg tablet

- -

83 Elkana Sirup tablet

- -
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml - -

85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml

- -

86 Eritromisin kapsul 500 mg kapsul

- -

87 Etakridin ( Rivanol ) larutan 0,1% botol

- -

88 Etanol 70 % 100 ml botol

- -

89 Etanol 70% 1000 ml botol

- -
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg) - -

91 Fenitoin Natrium kapsul 100 mg kapsul

- -

92 Fenitoin Natrium kapsul 30 mg kapsul

- -

93 Fenobarbital tablet 30 mg tablet

- -
94 Fenofibrat kapsul 100 mg kapsul
- -

95 Fenofibrat kapsul 300 mg kapsul

- -
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg - -

97 Fenol Gliserol tetes telinga 10% botol

- -
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml - -
Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg - -

101 Fludane Plus Sirup botol @ 60 ml

- -

102 Fluor tablet 0,5 mg tablet

- -

103 Furosemid tablet 40 mg tablet

- -

104 Garam Oralit untuk 200 ml air sase

- -

105 Gelofusin Infus botol @ 500 ml

- -

106 Gemfibrosil kapsul 300 mg kapsul

- -

107 Gemfibrosil kapsul 600 mg kapsul

- -

108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr

- -

109 Gentamisin tetes mata 0,3 % botol

- -

110 Gentian Violet larutan 1 % botol @10 ml

- -

111 Glibenklamid tablet 5 mg tablet

- -

112 Glimepiride tablet 2 mg tablet

- -

113 Gliseril Guaiakolat tablet 100 mg tablet

- -

114 Glukosa 5% - 1/2 NS botol @ 500 ml

- -

115 Glukosa 5% - 1/4 NS botol @ 500 ml

- -

116 Glukosa larutan infus 10 % steril botol @ 25 ml

- -

117 Glukosa larutan infus 40 % steril botol @ 25 ml

- -

118 Glukosa larutan infus 5 % steril botol @ 500 ml

- -

119 Griseofulvin tablet 125 mg tablet

- -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) - -

121 Haloperidol tablet 0,5 mg tablet

- -

122 Haloperidol tablet 1,5 mg tablet

- -

123 Haloperidol tablet 5 mg tablet

- -

124 Hemobion tablet tablet

- -

125 Hemorogard kapsul kapsul

- -

126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet

- -

127 Hidrokortison krim 2,5 % tube

- -
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi) - -

129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml

- -

130 Ibuprofen tablet 200 mg tablet

- -

131 Ibuprofen tablet 400 mg tablet

- -

132 Ichtiyol Zalf pot @ 15 gr

- -

133 Iodiol kapsul lunak kapsul

- -

134 Ipratropium bromida nebulazer 0,025 ampul

- -

135 Isoniazide tablet 100 mg tablet

- -
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg - -

137 KA-EN 3 B Otsu infus botol @ 500 ml

- -

138 Kalium Diklofenak tablet 50 mg tablet

- -
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml ) - -

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

- -

141 Kaptopril tablet scored 25 mg tablet

- -

142 Kaptopril tablet scored 12,5 mg tablet

- -

143 Karbamazepin tablet 200 mg tablet

- -

144 Ketokonazol krim 2 % tube 10 gr

- -

145 Ketokonazol tablet 200 mg tablet

- -
 Ketoprofen supositoria 100 mg
146 supp
( Protofen supp ) - -

147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml

- -

148 Klindamisin kapsul 150 mg kapsul

- -
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg ) - -

150 Kloramfenikol kapsul 250 mg kapsul

- -

151 Kloramfenikol salep mata 1 % tube

- -

152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml

- -

153 Kloramfenikol tetes Mata botol @ 5 ml

- -

154 Kloramfenikol tetes telinga 3 % botol @ 10 ml

- -
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg - -

156 Klorheksidin larutan 15 % botol

- -

157 Klorokuin Fosfat tablet 250 mg tablet

- -

158 Klorpromazin HCl tablet salut 100 mg tablet

- -

159 Klorpromazin HCl tablet salut 25 mg tablet

- -

160 Klorpromazin injeksi 5 mg/ ml ampul

- -

161 Kodein HCl tablet 10 mg tablet

- -
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah ) - -

163 Kotrimoksazol Dewasa tablet tablet

- -

164 Kotrimoksazol Pediatrik tablet tablet

- -

165 Kotrimoksazol Suspensi botol @ 60 ml

- -

166 Kuinin ( Kina ) tablet 200 mg tablet

- -
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
) - -

168 Lactodia / Lacto B sachet

- -

169 Lansoprazol tablet 30 mg tablet

- -
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RLmengandung
Larutan ) elektrolit ( Na - -
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml - -
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
- -
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml - -

174 Linkomisina kapsul 500 mg kapsul

- -
Lisol, mengandung Kresol tersabun
175 botol
50% - -

176 Loperamida tablet 2 mg tablet

- -

177 Loratadin tablet 10 mg tablet

- -

178 Lysmin Plus Sirup botol @ 60 ml

- -
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml - -
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml - -

181 MB Anak blister

- -

182 MB Dewasa blister

- -

183 Mebendazol tablet 100 mg tablet

- -

184 Meloksikam tablet 15 mg tablet

- -

185 Metformin HCl tablet 500 mg tablet

- -
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg - -
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml - -

188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml

- -

189 Metoklopropamid tablet 10 mg tablet

- -

190 Metronidazol ovula ovula

- -

191 Metronidazol tablet 250 mg tablet

- -

192 Miconazol krim 2 % ( Nitrat ) tube

- -

193 Mineral Mix 8 gr sase

- -

194 Natrium Diklofenak tablet 50 mg tablet

- -
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril - -

196 Neo Kauminal suspensi botol @ 60 ml

- -

197 Neuralgin - RX tablet tablet

- -
198 Neurosanbe 5000 mg tablet tablet
- -

199 Neurosanbe injeksi ampul

- -

200 Neurovit E tablet tablet

- -

201 Nifedipin tablet 10 mg tablet

- -

202 Nistatin tablet salut 500.000 IU / g tablet

- -

203 Nistatin vaginal tablet 100.000 IU / g tablet

- -

204 Nodiar tablet tablet

- -
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet) - -

206 OAT - FDC Kategori 1 - 3 PAKET paket

- -

207 OAT - FDC Kategori 2 PAKET paket

- -

208 OAT Kategori anak PAKET paket

- -

209 OAT Sisipan paket

- -

210 OAT-Kombipak Kategori 1 anak paket

- -

211 OAT-Kombipak Kategori 1 dewasa paket

- -

212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml

- -
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup - -

214 Ofloxaxin tablet 200 mg tablet

- -

215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml

- -

216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr

- -

217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr

- -

218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml

- -

219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml

- -

220 Omeprazole tablet 20 mg tablet

- -

221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml

- -

222 Ondansetron tablet 4 mg tablet

- -

223 Ondansetron tablet 8 mg tablet

- -

224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml

- -

225 Papaverin Tablet 40 mg tablet

- -
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml ) - -

227 Parasetamol sirup 120 mg / 5 ml botol

- -

228 Parasetamol tablet 100 mg tablet

- -

229 Parasetamol tablet 500 mg tablet

- -

230 PB Anak blister

- -

231 PB Dewasa blister

- -

232 Pehavral tablet tablet

- -

233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

- -

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

- -

235 Piracetam 1200 mg tablet Kotak

- -

236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml

- -

237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml

- -

238 Piracetam tablet 800 mg tablet

- -

239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml

- -

240 Pirantel tablet score ( base ) 125 mg tablet

- -

241 Pirazinamida tablet 500 mg tablet

- -
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg - -

243 Piroxicam tablet 10 mg tablet

- -

244 Piroxicam tablet 20 mg tablet

- -

245 Polikresulen cairan ( Aptil ) botol

- -

246 Ponflu tablet tablet

- -

247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

- -

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

- -

249 Prednison tablet 5 mg tablet

- -
250 Primakuin tablet 15 mg tablet
- -

251 Prolipid kaplet tablet

- -

252 Propiltiourasil tablet 100 mg tablet

- -

253 Propranolol HCl tablet 40 mg tablet

- -

254 Proris suppositoria supp

- -

255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml

- -

256 Ranitidin tablet 150 mg tablet

- -

257 Reserpin tablet 0,25 mg tablet

- -
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU - -
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak - -

260 Rifampisin kapsul 300 mg tablet

- -

261 Risperidon tablet 1 mg tablet

- -
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat ) - -
Salep 2-4 , kombinasi : Asam Salisilat
263 pot @ 30 gr
2 % + Belerang endap 4 % - -

264 Scabicid krim tube

- -

265 Sefadroksil kapsul 500 mg kapsul

- -

266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml

- -

267 Sefiksim kapsul 100 mg kapsul

- -

268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml

- -

269 Sefotaksim injeksi 1 gr vial @ 1 gr

- -

270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr

- -

271 Serum ADS 20.000 vial

- -
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I - -
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp - -
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial - -

275 Setirizin sirup 5 mg / 5 ml botol

- -

276 Setirizin tablet 10 mg tablet

- -
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg - -
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg - -

279 Simetidin tablet 200 mg tablet

- -

280 Simvastatin tablet 10 mg tablet

- -

281 Simvastatin tablet 20 mg tablet

- -
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl ) - -

283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml

- -

284 Spasi Plus tablet tablet

- -

285 Spasminal tablet tablet

- -
Sulfasetamida Natrium tetes mata 15
286 botol
% - -

287 Supralivron tablet tablet

- -

288 Taburia sachet

- -

289 Tamiflu tablet

- -

290 Tensigard kapsul kapsul

- -

291 Tetrakain HCl tetes mata 0,5% botol

- -

292 Tetrasiklin HCl kapsul 250 mg kapsul

- -

293 Tetrasiklin HCl kapsul 500 mg kapsul

- -

294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml

- -

295 Thiamfenikol kapsul 500 mg kapsul

- -
Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml - -
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg - -

298 Trifluoperasin tablet 5 mg tablet

- -

299 Triheksifenidil Hidroklorida tablet 2 mg tablet

- -

300 Ventolin Nebules 2,5 mg ampul

- -

301 Vical Sirup botol @ 60 ml

- -
302 Vitamin B Kompleks tablet tablet
- -

303 Zenirex Sirup botol @ 60 ml

- -
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup ) - -

305 Zink tablet disperible 20 mg tablet

- -

- -

BAHAN GIGI :
- -

306 Air raksa dental use botol

- -

307 Cavit - G botol

- -

308 Composit resin ( solare ) Kit

- -

309 Devitalisasi Pasta ( Non Arsen ) botol

- -

310 Etil Klorida semprot ( Duta Kaisar ) botol

- -

311 Eugenol cairan botol

- -

312 Glass Ionomer Cement ( GC IX ) botol

- -

313 Kalsium Hidroksida Pasta ( hydcal ) botol

- -
Monoklorkamfer Mentol Cairan
314 botol
( CHKM ) - -

315 Mummifying Pasta botol

- -

316 Semen Seng Fosfat serbuk dan cairan botol

- -

317 Silver Amalgam serbuk 65 - 75 % botol 30 gr

- -

318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

- -
Temporary Stopping Fletcher
319 set
( Fletcher ) - -

320 Trikresol Formalin (TKF) cairan botol

- -

321 Tumpatan komposit kit set

- -

322 Cressophen botol

- -

323 Cressophate botol

- -

- -
BAHAN MEDIS HABIS PAKAI
( BMHP ) - -

324 Alat suntik sekali pakai 1 ml tuberculin set

- -

325 Alat suntik sekali pakai 3 ml set

- -

326 Alat suntik sekali pakai 5 ml set

- -

327 Blood Lancet biji

- -

328 Blood transfision set set

- -

329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

- -

330 Folleycatheter Silicon 2 way 14 - 18 biji

- -

331 Hans Coen steril / Sarung Tangan pasang

- -

332 Hypafix 5 x 5 rol

- -

333 Infusion set anak set

- -

334 Infusion set dewasa set

- -

335 IV. Chateter No. 14 s/d 24 set

- -

336 IV. Chateter No. 26 set

- -

337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji

- -

338 Jarum Suntik 22G s/d 25 G biji

- -

339 Jarum Suntik 26G biji

- -

340 Kapas Pembalut / Absorben 250 gram rol

- -

341 Kasa Kompres 40 / 40 steril rol

- -

342 Kasa Pembalut 2 m x 80 cm rol

- -

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

- -

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

- -

345 Lomatulle lembar

- -

346 Masker Earloop/ Tie On biji

- -

347 Masker N 95 set

- -

348 Plester 1,25 cm x 4,5 m rol

- -

349 Scalp Vein no. 25 biji

- -
350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol
- -

351 Surgical Blade / Mess No. 11 biji

- -
Umbilical cord klem nylon steril (Claim biji
352
Umbilical) - -

353 Underpad biji

- -
Urine Bag standard steril 2 Lt ( T
354 biji
valve ) - -

- -

REAGEN LABORATORIUM
- -

355 Amonia 10 % botol

- -

356 Asam Asetat 6 % botol

- -

357 Asam Klorida 0,1 N botol

- -

358 Asam Sulfosalisilat 20% botol

- -

359 Cholesterol Strip Easy Touch botol

- -

360 Cholesterol Strip Nesco botol

- -

361 Clever Check Strip 50 test botol

- -

362 Contronorm Plus 5 x 5 ml botol

- -

363 G O T - AST Starter 8 x 15 ml botol

- -

364 G P T - ALT Starter 8 x 15 ml botol

- -

365 Glucose GOD PAP botol

- -

366 Golda Tulip Anti - A botol

- -

367 Golda Tulip Anti - B botol

- -

368 Golda Tulip Anti AB botol

- -

369 Golda Tulip Anti D/Rhesus botol

- -

370 HBs Ag Intec Strip 50 botol

- -

371 HDL Cholesterol 6 x 40 ml botol

- -

372 Hemoglobin 1000 ml botol

- -

373 Kolesterol CHOD-PAP 8 X 20 ml botol

- -

374 Kreatinin - Jaffe 400 ml botol

- -

375 Larutan Giemsa Stain botol

- -

376 Larutan Karbol Fuksin botol

- -

377 Larutan Metilen Biru botol

- -

378 Larutan Turk botol

- -

379 LDL Cholesterol 6 x 50 ml botol

- -

380 Metanol botol

- -

381 Natrium Chlorida 0,9 % botol

- -

382 Pewarna Gram 1 % botol

- -
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu - -

384 Rees Ecker botol

- -

385 Sclessinger botol

- -

386 Stik HCG Strip Answer 50 botol

- -

387 Stik urine combine 10 test M botol

- -

388 Stik urine 10 parameter botol

- -

389 Stik urine 3 parameter botol

- -

390 Strip Hb Mission Plus botol

- -

391 Trigliserida GPO - PAP 8 x 20 ml biji

- -

392 Urea Col 1 x 100 ml biji

- -

393 Uric Acid Strip Easy Touch biji

- -

394 Uric Acid Strip Nesco biji

- -

395 Uricase-PAP 8 x 20 ml botol

- -

396 VDRL botol

- -

397 Widal ( Slam O Paratyphi A ) botol

- -

398 Widal ( Slam O Paratyphi B ) botol

- -

399 Widal ( Slam Typhi H ) botol

- -
400 Widal ( Slam Typhi O ) botol
- -
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set - -

- -

OBAT TAMBAHAN :
- -

1 Acitral / antasid + simetikon tube

- -

2 Akarbose 100 mg ampul

- -

3 Alat suntik 10 ml biji

- -

4 Alat suntik 20 ml biji

- -

5 Alat suntik 50 ml biji

- -

6 Alkohol Swabs pcs

- -

7 Alletrol Tetes Mata botol

- -

8 Amiodaron inj 50 mg/ml ampul

- -

9 Ampicillin Injeksi 1 gram vial

- -

10 Aqua Gel 150's G sachet sachet

- -

11 Arm Sling Comfort (M/L) pcs

- -

12 Artikulating paper pcs

- -
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi - -

14 Aseptik Gel 5 Liter botol

- -

15 Askina calgitrol gel 15 g tube

- -

16 Askina gel 15 g tube

- -

17 Asvex tablet tablet

- -

18 Biolysin Sirup botol

- -

19 Bisoprolol 2,5 mg tablet

- -
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml - -

21 Budesonid inhaler (Pulmicort) pcs

- -
Budesonid repsules (Pulmicort
22 pcs
Repsule) - -
Budesonide-formoterol 160/4,5
23 pcs
(symbicort) - -

24 Carpule needle L Ject biji

- -

25 Carpule posicain 100 biji

- -

26 Catgut 3/0 + 1/2 biji

- -

27 Catgut Chromic tanpa needle biji

- -

28 Catgut No. 2/0 - 100 m biji

- -

29 Cell Pack biji

- -

30 Cellclean biji
- -

31 Cervical Collar Universal pcs

- -

32 Cevitron pink kotak

- -

33 Cevitron putih kotak

- -

34 Chloramex 250 mg tablet tablet

- -

35 Cliad / Braxidin tablet

- -

36 Clopigrogel tablet 75 mg tablet

- -

37 Colergis tablet
- -

38 Combivent UDV vial

- -

39 Contronorm Plus 5 x 4 mL pcs

- -

40 Cotton rol rol

- -

41 Cover Glass biji

- -

42 Curcumex tablet tablet

- -

43 Deculin 15 mg tablet
- -

44 Dekstrofen syrup botol

- -

45 Demacolin Syrup botol

- -

46 Demacolin Tablet tablet

- -
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs) - -

48 Dermafix 10 x 15 cm rol
- -
49 Dermafix 10 x 20 cm rol
- -

50 Dermafix S IV 6x7 cm rol

- -

51 Dermafix SS 10 x 10 cm rol
- -

52 Dermafix T 10 x 12 cm rol
- -

53 Dermafix T 10 x 25 cm rol
- -

54 Dermafix T 10 x 8 cm rol
- -

55 Dermafix T 6 x 7 cm rol
- -

56 Dextral Tablet tablet

- -

57 Duk lubang steril 25x30 cm piece

- -

58 Duk lubang steril 50x50 cm piece

- -

59 Eightchek / Kontrol Hema (H, L, N) biji

- -

60 Elite Cement botol

- -

61 Endoseal biji
- -

62 Eryclone ( Anti AB ) botol

- -

63 Female Catheter biji

- -

64 Fenitoin injeksi 50 mg / ml ampul

- -

65 Flukonazol tablet
- -

66 Fluocinolon acetonid / dermasolon tube

- -

67 Folleycatheter Silicon 2 way 08 - 12 biji

- -

68 Furosemid injeksi 10mg/ml ampul

- -

69 Gabapentin 300 mg kapsul

- -
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata) - -

71 Glimepiride 3 mg tablet
- -

72 Glimepiride 4 mg tablet
- -

73 Glucosa strip easy touch biji

- -

74 Glucose biji
- -

75 Glukosa strip on call plus biji

- -

76 Gula Darah Stik biji

- -
Hans Coen Non steril / Sarung
77 biji
Tangan - -

78 Hb Hemoglobin strip quick check biji

- -

79 Hypafix 15 x 5 rol
- -

80 Hypafix 20 x 5 rol
- -

81 Hypafix 5 cm x 1 m rol
- -

82 ID Band Anak biji

- -

83 ID Band Dewasa biji

- -

84 Insulin Rapid Acting (Novorapid) piece

- -

85 Isosorbid Dinitrat injeksi 1 mg/ml ampul

- -

86 IV Film 6 x 8 cm pcs
- -

87 Jarum jahit (bedah) MANI No. 12 biji

- -

88 Jarum jahit (bedah) MANI No. 14 biji

- -

89 Jarum Suntik Terumo No. 23 biji

- -

90 Kasa 3,6 M x 15 cm rol

- -

91 Kasa Hidrofil 40 x 80 cm rol

- -

92 Kasa steril 16 x 16 cm rol

- -

93 Kertas Lakmus Merah biji

- -

94 Kertas saring biji

- -

95 Kertas Termal USG biji

- -

96 Ketorolac injeksi 30 mg / ml ampul

- -

97 Klindamisin kapsul 300 mg kapsul

- -

98 Kloramfenikol 500 mg kapsul kapsul

- -

99 Kloramfenikol salep kulit tube

- -

100 Komposit A2 biji

- -
101 Komposit A3 biji
- -

102 Komposit Nexcon A3 biji

- -

103 Komposit Voco A3 biji

- -

104 Komposit Voco Incisal biji

- -

105 Konik ECG gel botol

- -

106 Laktulosa syrup botol

- -

107 Masker Nebulizer Anak piece

- -

108 Masker Nebulizer Dewasa piece

- -

109 Mata bur no 1 biji

- -

110 Mata bur no 2 biji

- -

111 Mata bur set biji

- -

112 Matovit tablet tablet

- -

113 Maxiflow anak biji

- -

114 Maxiflow bayi biji

- -

115 Maxiflow dewasa biji

- -

116 Mersibion injeksi ampul

- -

117 Metilprednisolon 4 mg tablet

- -

118 Metilprednisolon inj 500mg/8ml ampul

- -

119 Metilprednisolon injeksi 125mg/ml ampul

- -

120 Metronidazole 500mg tablet tablet

- -

121 Metronidazole infus 500mg/100 ml botol

- -

122 Mitella piece

- -

123 Mucus Extraction pcs

- -

124 My Jelly 82 gram tube

- -

125 Nasal dan Masker Oksigen Anak pcs

- -

126 Nasal dan Masker Oksigen Dewasa pcs

- -

127 Nebulizer canula Adult piece

- -

128 Nebulizer canula Child piece

- -

129 Needle carpule biji

- -

130 Needle no 25 biji

- -

131 Nierbeken Disposible 25 cm pcs

- -

132 Nistatin suspensi 100.000 IU / ml botol

- -

133 Norepinephrine bitartat injeksi 1 mg/ml ampul

- -

134 Novomix Flexpen biji

- -

135 Object Glass biji

- -

136 Oksigen canula adult biji

- -

137 Oksigen canula child biji

- -

138 Paracetamol drip (infus) 1g / 100 mL botol

- -
Parasetamol suppositoria - Pamol
139 suppo
Supp - -

140 Pehacain injeksi ampul

- -

141 Pembalut hamil piece

- -

142 Plesterin Bulat Soft isi 200 piece

- -

143 Plesterin Roll 20 cm x 5 m rol

- -

144 Povidone iodine 60 ml botol

- -

145 Probenid tab 500 mg tablet

- -

146 Prontosan wound gel botol

- -

147 Prontosan wound irigation botol

- -

148 Psidii 500 mg kapsul kapsul

- -

149 Psidii sirup botol

- -

150 Risperidon tablet 2 mg tablet

- -

151 Safety Box 12 L piece

- -

152 Safety Box 5 Lt OM piece

- -
153 Salbutamol 4 mg tablet
- -

154 Sarung Tangan Gynaecolog pasang

- -

155 Sikzonoat Inj / Flupenaziin Inj ampul

- -

156 Silk No. 2/0 - 100 m rol

- -

157 Slem / Mucus Extractor biji

- -

158 Spalk 10 x 5 cm biji

- -

159 Spalk 100 x 10 piece

- -

160 Spalk 15 x 5 piece

- -

161 Spalk 20 x 5 cm biji

- -

162 Spalk 4 x 12 cm biji

- -

163 Spalk 40 x 8 x 7 cm biji

- -

164 Spalk 60 x 10 piece

- -

165 Spalk 80 x 10 x 8 cm biji

- -

166 Spironolacton tab 100 mg tablet

- -

167 Spironolacton tab 25mg tablet

- -

168 Stik Asam Urat biji

- -

169 Stik Gula Darah biji

- -

170 Stik Kolesterol biji

- -

171 Stromatolyser piece

- -

172 Suction catheter no 12 biji

- -

173 Sukralfat suspensi botol

- -

174 Superpatch jumbo biji

- -

175 Surgical gown non woven steril pcs

- -

176 Surgical gown spunlace biji

- -

177 Tensocrepe 3 inch biji

- -

178 Tensocrepe 4 inch biji

- -

179 Tensocrepe 6 inch biji

- -

180 Terbutalin repsules (bricasma repsule) ampul

- -
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler) - -

182 Test Kehamilan piece

- -

183 Test Kesuburan (Baby Test) piece

- -

184 Tremenza Syrup botol

- -

185 Tremenza Tablet tablet

- -

186 Triamcinolon injeksi 10 mg/ml ampul

- -

187 Truvit syrup botol

- -

188 Ultrasonic gel botol

- -

189 Urea pcs

- -

190 Uricase pcs

- -

191 USC Gel 250 ml botol

- -

192 Vaculab EDTA 3 ml piece

- -

193 Vaculab non EDTA 3 ml plain pcs

- -

194 Valsartan 80 mg tablet

- -

195 Yellow Tip pcs

- -

196 Zinc Syrup 10 mg / ml botol

- -

197 Coparcetin tab tablet

- -

198 Curbiplex sirup BOtol

- -

199 Fultrop tablet tablet

- -

200 Fultrop SIRUP BOtol

- -

201 Molexflu syr botol

- -

202 APD coverall

- -

203 Isolation Gown

- -

204 nurse/dokter cap

- -
 205 shoes cover
- -

206 Hemaviton cardio

- -

207 Coparcetin sirup botol

- -

208 Plesterin roll 10 cm x 5 m

- -
Aseptik gel 1 L/Hand Foam sanitiser
209 botol
600 ml - -

210 Cavilpex tablet

- -
211 Etanol 96% botol
- -

- -

BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI ASKES MANDIRI

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

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

 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES ; PONED
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : LEBANI SUKO

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : LEBANI WARAS

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
 Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
 Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
 Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml

188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml

189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket

212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml

Obat Batuk Hitam ( O.B.H. ) Indo Plus

213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

 YANG MENYERAHKAN

PETUGAS GUDANG

(Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-
-

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

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-

-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-
-

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

-
-

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-
-

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

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-

-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-
-

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

-
-

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

NON BPJS JUMLAH

MANDIRI
YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS

(drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH
 Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES

(.......................................................)
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKESMAS
( LPLPO JKN )
PUSTU/PONKESDES/POLINDES : KEPUHKLAGEN
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : APRIL 2021
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : MEI 2021

NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN STOK AKHIR PERMINTAAN PEMBERIAN

1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet - -
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul - -
3 Albendazol suspensi 200 mg / 5 ml botol
- -
4 Albendazol tablet 400 mg tablet - -
5 Albuthyl Ovula supp - -
6 Alopurinol tablet 100 mg tablet - -
7 Alopurinol tablet 300 mg tablet - -
8 Alprazolam 0,5 mg tablet tablet - -
9 Ambroxol sirup 15 mg / ml botol @ 60 ml 2 2 2 5
10 Ambroxol tablet 30 mg tablet 60 60 100
11 Aminofilin tablet scored 200 mg tablet - -
12 Aminofilina injeksi 24 mg / ml ampul - -
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
- -
14 Amlodipine tablet 10 mg tablet - -
15 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml 7 10 17 1 10
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml - -
18 Amoksisilin kaplet 500 mg tablet - -
19 Amoksisilin kapsul 250 mg tablet - -
20 Amoksisilin Serbuk injeksi 1000 mg vial
- -
Amoxillin + As.Klavulanat 625 mg
21 tablet
kapsul - -
22 Ampisilina sirup kering 125 mg/5ml botol
- -
23 Antalgin ( Metampiron ) tablet 500 mg tablet
230 100 330 ‾ 100
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - -
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik ) - -

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg
- -
Antasida DOEN II suspensi,
kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml - -
28 Antifungi DOEN pot @ 30 gr - -
29 Antihemoroid DOEN supp - -
30 Antimigren DOEN tablet tablet - -
31 Antiparkinson DOEN tablet tablet - -
32 Aqua pro Injeksi steril, bebas pirogen botol
- -
33 Aquadest steril botol @ 1000 ml - -
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg - -
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg - -
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg - -
37 Asam Folat tablet 0,4 mg tablet - -
38 Asam Folat tablet 1 mg tablet - -
39 Asam Mefenamat kaplet 500 mg tablet 70 100 70 ‾ 100
40 Asam traneksamat injeksi 100 mg/ml ampul
- -
41 Asam traneksamat injeksi 50 mg/ml ampul
- -
42 Aseptik Gel 500 cc + dispenser botol @ 500 ml - -
43 Asiklovir krim 5 % tube @ 5 gr 13 5 18 ‾ 5
44 Asiklovir tablet 400 mg tablet - -
45 Atapulgit tablet 600 mg tablet - -
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml - -
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 % tablet - -
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial - -
55 Besi Sirup botol - -
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur - -
57 Betahistin Mesilat tablet 6 mg tablet - -
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat ) - -
59 Betason - N krim tube - -
60 Bisacodil ( Bicolak ) tablet tablet - -
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp ) - -
62 Bisoprolol tablet 5 mg tablet - -
63 Borak Gliserin 5% botol @ 15 ml - -
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet) - -
65 Bronchitin Expektoran Sirup botol @ 50 ml -
66 Centabio Jelly / Bioplacenton Jelly tablet - -
67 Curcuma tablet tablet - -
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml - -
69 Deksametason tablet 0,5 mg tablet 44 200 44 100
70 Desoksimetason krim 0,25 % tube @ 15 gr - -
71 Diazepam injeksi 5 mg / ml - 2 ml ampul - -
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube) - -
73 Diazepam tablet 2 mg tablet - -
74 Dietilkarbamazin Sitrat tablet 100 mg tablet
- -
75 Difenhidramin HCl injeksi 10 mg / ml ampul
- -
76 Digoksin tablet 0,25 mg tablet - -
77 Dimenhidrinat tablet 50 mg tablet - -
78 Doksisiklin tablet 100 mg tablet - -
79 Domperidone sirup 5 mg/5ml botol @ 60 ml - -
80 Domperidone tablet 10 mg tablet - -
81 Efedrin HCl tablet 25 mg tablet - -
82 Ekstrak Belladon tablet 10 mg tablet - -
83 Elkana Sirup tablet - -
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml - -
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml - -
86 Eritromisin kapsul 500 mg kapsul - -
87 Etakridin ( Rivanol ) larutan 0,1% botol - -
88 Etanol 70 % 100 ml botol - -
89 Etanol 70% 1000 ml botol - -
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg) - -
91 Fenitoin Natrium kapsul 100 mg kapsul - -
92 Fenitoin Natrium kapsul 30 mg kapsul - -
93 Fenobarbital tablet 30 mg tablet - -
94 Fenofibrat kapsul 100 mg kapsul - -
95 Fenofibrat kapsul 300 mg kapsul - -
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg - -
97 Fenol Gliserol tetes telinga 10% botol - -
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml - -
Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg - -
101 Fludane Plus Sirup botol @ 60 ml - -
102 Fluor tablet 0,5 mg tablet - -
103 Furosemid tablet 40 mg tablet - -
104 Garam Oralit untuk 200 ml air sase - -
105 Gelofusin Infus botol @ 500 ml - -
106 Gemfibrosil kapsul 300 mg kapsul - -
107 Gemfibrosil kapsul 600 mg kapsul - -
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -
109 Gentamisin tetes mata 0,3 % botol - -
110 Gentian Violet larutan 1 % botol @10 ml 12 3 12 3
111 Glibenklamid tablet 5 mg tablet - -
112 Glimepiride tablet 2 mg tablet - -
113 Gliseril Guaiakolat tablet 100 mg tablet 266 100 266 100
114 Glukosa 5% - 1/2 NS botol @ 500 ml - -
115 Glukosa 5% - 1/4 NS botol @ 500 ml - -
116 Glukosa larutan infus 10 % steril botol @ 25 ml - -
117 Glukosa larutan infus 40 % steril botol @ 25 ml - -
118 Glukosa larutan infus 5 % steril botol @ 500 ml - -
119 Griseofulvin tablet 125 mg tablet - -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) - -
121 Haloperidol tablet 0,5 mg tablet - -
122 Haloperidol tablet 1,5 mg tablet - -
123 Haloperidol tablet 5 mg tablet - -
124 Hemobion tablet tablet - -
125 Hemorogard kapsul kapsul - -
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
- -
127 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi) - -
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -
130 Ibuprofen tablet 200 mg tablet - -
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr 6 4 6 4
133 Iodiol kapsul lunak kapsul - -
134 Ipratropium bromida nebulazer 0,025 ampul
- -
135 Isoniazide tablet 100 mg tablet - -
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg - -
137 KA-EN 3 B Otsu infus botol @ 500 ml - -
138 Kalium Diklofenak tablet 50 mg tablet - -
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml ) - -
140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet
- -
141 Kaptopril tablet scored 25 mg tablet 40 100 140 100
142 Kaptopril tablet scored 12,5 mg tablet - -
143 Karbamazepin tablet 200 mg tablet - -
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp ) - -
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -
148 Klindamisin kapsul 150 mg kapsul - -
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg ) - -
150 Kloramfenikol kapsul 250 mg kapsul - -
151 Kloramfenikol salep mata 1 % tube - -
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
- -
153 Kloramfenikol tetes Mata botol @ 5 ml - -
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml - - -
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg - -
156 Klorheksidin larutan 15 % botol - -
157 Klorokuin Fosfat tablet 250 mg tablet - -
158 Klorpromazin HCl tablet salut 100 mg tablet
- -
159 Klorpromazin HCl tablet salut 25 mg tablet
- -
160 Klorpromazin injeksi 5 mg/ ml ampul - -
161 Kodein HCl tablet 10 mg tablet - -
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah ) - -
163 Kotrimoksazol Dewasa tablet tablet - -
164 Kotrimoksazol Pediatrik tablet tablet - -
165 Kotrimoksazol Suspensi botol @ 60 ml - -
166 Kuinin ( Kina ) tablet 200 mg tablet - -
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
) - -
168 Lactodia / Lacto B sachet - -
169 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL ) - -
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril - -
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml - -
174 Linkomisina kapsul 500 mg kapsul - -
Lisol, mengandung Kresol tersabun
175 botol
50% - -
176 Loperamida tablet 2 mg tablet 100 10 10
177 Loratadin tablet 10 mg tablet - -
178 Lysmin Plus Sirup botol @ 60 ml - -
 Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml - -
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml - -
181 MB Anak blister - -
182 MB Dewasa blister - -
183 Mebendazol tablet 100 mg tablet - -
184 Meloksikam tablet 15 mg tablet - -
185 Metformin HCl tablet 500 mg tablet - -
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg - -
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml - -
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml - -
189 Metoklopropamid tablet 10 mg tablet - -
190 Metronidazol ovula ovula - -
191 Metronidazol tablet 250 mg tablet - -
192 Miconazol krim 2 % ( Nitrat ) tube - -
193 Mineral Mix 8 gr sase - -
194 Natrium Diklofenak tablet 50 mg tablet - -
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril - -
196 Neo Kauminal suspensi botol @ 60 ml 2 2 8
197 Neuralgin - RX tablet tablet 170 100 270 100
198 Neurosanbe 5000 mg tablet tablet - -
199 Neurosanbe injeksi ampul - -
200 Neurovit E tablet tablet - -
201 Nifedipin tablet 10 mg tablet - -
202 Nistatin tablet salut 500.000 IU / g tablet - -
203 Nistatin vaginal tablet 100.000 IU / g tablet
- -
204 Nodiar tablet tablet - -
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet) - -
206 OAT - FDC Kategori 1 - 3 PAKET paket
- -
207 OAT - FDC Kategori 2 PAKET paket - -
208 OAT Kategori anak PAKET paket - -
209 OAT Sisipan paket - -
210 OAT-Kombipak Kategori 1 anak paket - -
211 OAT-Kombipak Kategori 1 dewasa paket
- -
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml - -
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup 20 20 20
214 Ofloxaxin tablet 200 mg tablet - -
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
- -
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr - -
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml 400 400 400
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml - -
220 Omeprazole tablet 20 mg tablet - -
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml 100 100 100
222 Ondansetron tablet 4 mg tablet - -
223 Ondansetron tablet 8 mg tablet - -
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -
225 Papaverin Tablet 40 mg tablet - -
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml ) - -
227 Parasetamol sirup 120 mg / 5 ml botol 4 4 6
228 Parasetamol tablet 100 mg tablet - -
229 Parasetamol tablet 500 mg tablet 116 300 116 100
230 PB Anak blister - -
231 PB Dewasa blister - -
232 Pehavral tablet tablet - -
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml
- -
234 Pilokarpin HCl / Nitrat tetes mata 2% botol
- -
235 Piracetam 1200 mg tablet Kotak - -
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml - -
238 Piracetam tablet 800 mg tablet - -
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml - -
240 Pirantel tablet score ( base ) 125 mg tablet
- -
241 Pirazinamida tablet 500 mg tablet - -
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg - -
243 Piroxicam tablet 10 mg tablet - -
244 Piroxicam tablet 20 mg tablet 30 30 100
245 Polikresulen cairan ( Aptil ) botol - -
246 Ponflu tablet tablet - -
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml
- -
248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml
- -
249 Prednison tablet 5 mg tablet - -
250 Primakuin tablet 15 mg tablet - -
251 Prolipid kaplet tablet - -
252 Propiltiourasil tablet 100 mg tablet - -
253 Propranolol HCl tablet 40 mg tablet - -
254 Proris suppositoria supp - -
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
256 Ranitidin tablet 150 mg tablet - -
257 Reserpin tablet 0,25 mg tablet - -
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU - -
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak - -
260 Rifampisin kapsul 300 mg tablet - -
261 Risperidon tablet 1 mg tablet - -
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat ) - -
Salep 2-4 , kombinasi : Asam Salisilat
263 pot @ 30 gr
2 % + Belerang endap 4 %
- -
264 Scabicid krim tube - -
265 Sefadroksil kapsul 500 mg kapsul - -
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
- -
267 Sefiksim kapsul 100 mg kapsul - -
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
- -
269 Sefotaksim injeksi 1 gr vial @ 1 gr - -
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
- -
271 Serum ADS 20.000 vial - -
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I - -
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp - -
 Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial - -
275 Setirizin sirup 5 mg / 5 ml botol - -
276 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg - -
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg - -
279 Simetidin tablet 200 mg tablet - -
280 Simvastatin tablet 10 mg tablet - -
281 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl ) - -
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml - -
284 Spasi Plus tablet tablet - -
285 Spasminal tablet tablet - -
Sulfasetamida Natrium tetes mata 15
286 botol
% - -
287 Supralivron tablet tablet - -
288 Taburia sachet - -
289 Tamiflu tablet - -
290 Tensigard kapsul kapsul - -
291 Tetrakain HCl tetes mata 0,5% botol - -
292 Tetrasiklin HCl kapsul 250 mg kapsul - -
293 Tetrasiklin HCl kapsul 500 mg kapsul - -
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml - -
295 Thiamfenikol kapsul 500 mg kapsul 190 190 100
Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml - -
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg - -
298 Trifluoperasin tablet 5 mg tablet - -
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
- -
300 Ventolin Nebules 2,5 mg ampul - -
301 Vical Sirup botol @ 60 ml - -
302 Vitamin B Kompleks tablet tablet - -
303 Zenirex Sirup botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup ) - -
305 Zink tablet disperible 20 mg tablet - -
- -
BAHAN GIGI : - -
306 Air raksa dental use botol - -
307 Cavit - G botol - -
308 Composit resin ( solare ) Kit - -
309 Devitalisasi Pasta ( Non Arsen ) botol - -
310 Etil Klorida semprot ( Duta Kaisar ) botol
- -
311 Eugenol cairan botol - -
312 Glass Ionomer Cement ( GC IX ) botol - -
313 Kalsium Hidroksida Pasta ( hydcal ) botol
- -
Monoklorkamfer Mentol Cairan
314 botol
( CHKM ) - -
315 Mummifying Pasta botol - -
Semen Seng Fosfat serbuk dan
316 botol
cairan - -
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr - -
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji
- -
Temporary Stopping Fletcher
319 set
( Fletcher ) - -
320 Trikresol Formalin (TKF) cairan botol - -
321 Tumpatan komposit kit set - -
322 Cressophen botol - -
323 Cressophate botol - -
- -
BAHAN MEDIS HABIS PAKAI
( BMHP ) - -
324 Alat suntik sekali pakai 1 ml tuberculin set
- -
325 Alat suntik sekali pakai 3 ml set - -
326 Alat suntik sekali pakai 5 ml set - -
327 Blood Lancet biji - -
328 Blood transfision set set - -
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji
- -
330 Folleycatheter Silicon 2 way 14 - 18 biji
- -
331 Hans Coen steril / Sarung Tangan pasang - -
332 Hypafix 5 x 5 rol - -
333 Infusion set anak set - -
334 Infusion set dewasa set - -
335 IV. Chateter No. 14 s/d 24 set - -
336 IV. Chateter No. 26 set - -
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji - -
338 Jarum Suntik 22G s/d 25 G biji - -
339 Jarum Suntik 26G biji - -
340 Kapas Pembalut / Absorben 250 gram rol
- -
341 Kasa Kompres 40 / 40 steril rol - -
342 Kasa Pembalut 2 m x 80 cm rol - -
343 Kasa Pembalut Hidrofil 4 m x 15 cm rol
- -
344 Kasa Pembalut Hidrofil 4 m x 3 cm rol
- -
345 Lomatulle lembar - -
346 Masker Earloop/ Tie On biji - -
347 Masker N 95 set - -
348 Plester 1,25 cm x 4,5 m rol - -
349 Scalp Vein no. 25 biji - -
350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol
- -
351 Surgical Blade / Mess No. 11 biji - -
Umbilical cord klem nylon steril (Claim biji
352
Umbilical) - -
353 Underpad biji - -
Urine Bag standard steril 2 Lt ( T
354 biji
valve ) - -
- -
REAGEN LABORATORIUM - -
355 Amonia 10 % botol - -
356 Asam Asetat 6 % botol - -
357 Asam Klorida 0,1 N botol - -
358 Asam Sulfosalisilat 20% botol - -
359 Cholesterol Strip Easy Touch botol - -
360 Cholesterol Strip Nesco botol - -
361 Clever Check Strip 50 test botol - -
362 Contronorm Plus 5 x 5 ml botol - -
363 G O T - AST Starter 8 x 15 ml botol - -
364 G P T - ALT Starter 8 x 15 ml botol - -
365 Glucose GOD PAP botol - -
366 Golda Tulip Anti - A botol - -
367 Golda Tulip Anti - B botol - -
368 Golda Tulip Anti AB botol - -
369 Golda Tulip Anti D/Rhesus botol - -
370 HBs Ag Intec Strip 50 botol - -
371 HDL Cholesterol 6 x 40 ml botol - -
372 Hemoglobin 1000 ml botol - -
373 Kolesterol CHOD-PAP 8 X 20 ml botol - -
374 Kreatinin - Jaffe 400 ml botol - -
375 Larutan Giemsa Stain botol - -
376 Larutan Karbol Fuksin botol - -
377 Larutan Metilen Biru botol - -
378 Larutan Turk botol - -
379 LDL Cholesterol 6 x 50 ml botol - -
380 Metanol botol - -
381 Natrium Chlorida 0,9 % botol - -
382 Pewarna Gram 1 % botol - -
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu - -
384 Rees Ecker botol - -
385 Sclessinger botol - -
386 Stik HCG Strip Answer 50 botol - -
387 Stik urine combine 10 test M botol - -
388 Stik urine 10 parameter botol - -
389 Stik urine 3 parameter botol - -
390 Strip Hb Mission Plus botol - -
391 Trigliserida GPO - PAP 8 x 20 ml biji - -
392 Urea Col 1 x 100 ml biji - -
393 Uric Acid Strip Easy Touch biji - -
394 Uric Acid Strip Nesco biji - -
395 Uricase-PAP 8 x 20 ml botol - -
396 VDRL botol - -
397 Widal ( Slam O Paratyphi A ) botol - -
398 Widal ( Slam O Paratyphi B ) botol - -
399 Widal ( Slam Typhi H ) botol - -
400 Widal ( Slam Typhi O ) botol - -
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set - -
- -
OBAT TAMBAHAN : - -
1 Acitral / antasid + simetikon tube - -
2 Akarbose 100 mg ampul - -
3 Alat suntik 10 ml biji - -
4 Alat suntik 20 ml biji - -
5 Alat suntik 50 ml biji - -
6 Alkohol Swabs pcs - -
7 Alletrol Tetes Mata botol 5 5 5
8 Amiodaron inj 50 mg/ml ampul - -
9 Ampicillin Injeksi 1 gram vial - -
10 Aqua Gel 150's G sachet sachet - -
11 Arm Sling Comfort (M/L) pcs - -
12 Artikulating paper pcs - -
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi - -
14 Aseptik Gel 5 Liter botol - -
15 Askina calgitrol gel 15 g tube - -
16 Askina gel 15 g tube - -
17 Asvex tablet tablet - -
18 Biolysin Sirup botol - -
19 Bisoprolol 2,5 mg tablet - -
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml - -
21 Budesonid inhaler (Pulmicort) pcs - -
Budesonid repsules (Pulmicort
22 pcs
Repsule) - -
Budesonide-formoterol 160/4,5
23 pcs
(symbicort) - -
24 Carpule needle L Ject biji - -
25 Carpule posicain 100 biji - -
26 Catgut 3/0 + 1/2 biji - -
27 Catgut Chromic tanpa needle biji - -
28 Catgut No. 2/0 - 100 m biji - -
29 Cell Pack biji - -
30 Cellclean biji - -
31 Cervical Collar Universal pcs - -
32 Cevitron pink kotak - -
33 Cevitron putih kotak - -
34 Chloramex 250 mg tablet tablet - -
35 Cliad / Braxidin tablet - -
36 Clopigrogel tablet 75 mg tablet - -
37 Colergis tablet - -
38 Combivent UDV vial - -
39 Contronorm Plus 5 x 4 mL pcs - -
40 Cotton rol rol - -
41 Cover Glass biji - -
42 Curcumex tablet tablet - -
43 Deculin 15 mg tablet - -
44 Dekstrofen syrup botol 3 3 7
45 Demacolin Syrup botol -
46 Demacolin Tablet tablet 20 200 220 200
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs) - -
48 Dermafix 10 x 15 cm rol - -
49 Dermafix 10 x 20 cm rol - -
50 Dermafix S IV 6x7 cm rol - -
51 Dermafix SS 10 x 10 cm rol - -
52 Dermafix T 10 x 12 cm rol - -
53 Dermafix T 10 x 25 cm rol - -
54 Dermafix T 10 x 8 cm rol - -
55 Dermafix T 6 x 7 cm rol - -
56 Dextral Tablet tablet - -
57 Duk lubang steril 25x30 cm piece - -
58 Duk lubang steril 50x50 cm piece - -
59 Eightchek / Kontrol Hema (H, L, N) biji - -
60 Elite Cement botol - -
61 Endoseal biji - -
62 Eryclone ( Anti AB ) botol - -
63 Female Catheter biji - -
64 Fenitoin injeksi 50 mg / ml ampul - -
65 Flukonazol tablet - -
66 Fluocinolon acetonid / dermasolon tube
- -
67 Folleycatheter Silicon 2 way 08 - 12 biji
- -
68 Furosemid injeksi 10mg/ml ampul - -
69 Gabapentin 300 mg kapsul - -
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata) - -
71 Glimepiride 3 mg tablet - -
72 Glimepiride 4 mg tablet - -
73 Glucosa strip easy touch biji - -
74 Glucose biji - -
75 Glukosa strip on call plus biji - -
76 Gula Darah Stik biji - -
Hans Coen Non steril / Sarung
77 biji
Tangan - -
78 Hb Hemoglobin strip quick check biji - -
79 Hypafix 15 x 5 rol - -
80 Hypafix 20 x 5 rol - -
81 Hypafix 5 cm x 1 m rol - -
82 ID Band Anak biji - -
83 ID Band Dewasa biji - -
84 Insulin Rapid Acting (Novorapid) piece - -
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul - -
86 IV Film 6 x 8 cm pcs - -
87 Jarum jahit (bedah) MANI No. 12 biji - -
88 Jarum jahit (bedah) MANI No. 14 biji - -
89 Jarum Suntik Terumo No. 23 biji - -
90 Kasa 3,6 M x 15 cm rol - -
91 Kasa Hidrofil 40 x 80 cm rol - -
92 Kasa steril 16 x 16 cm rol - -
93 Kertas Lakmus Merah biji - -
94 Kertas saring biji - -
95 Kertas Termal USG biji - -
96 Ketorolac injeksi 30 mg / ml ampul - -
97 Klindamisin kapsul 300 mg kapsul - -
98 Kloramfenikol 500 mg kapsul kapsul - -
99 Kloramfenikol salep kulit tube - -
100 Komposit A2 biji - -
101 Komposit A3 biji - -
102 Komposit Nexcon A3 biji - -
103 Komposit Voco A3 biji - -
104 Komposit Voco Incisal biji - -
105 Konik ECG gel botol - -
106 Laktulosa syrup botol - -
107 Masker Nebulizer Anak piece - -
108 Masker Nebulizer Dewasa piece - -
109 Mata bur no 1 biji - -
110 Mata bur no 2 biji - -
111 Mata bur set biji - -
112 Matovit tablet tablet - -
113 Maxiflow anak biji - -
114 Maxiflow bayi biji - -
115 Maxiflow dewasa biji - -
116 Mersibion injeksi ampul - -
117 Metilprednisolon 4 mg tablet - -
118 Metilprednisolon inj 500mg/8ml ampul - -
119 Metilprednisolon injeksi 125mg/ml ampul - -
120 Metronidazole 500mg tablet tablet - -
121 Metronidazole infus 500mg/100 ml botol
- -
122 Mitella piece - -
123 Mucus Extraction pcs - -
124 My Jelly 82 gram tube - -
125 Nasal dan Masker Oksigen Anak pcs - -
126 Nasal dan Masker Oksigen Dewasa pcs
- -
127 Nebulizer canula Adult piece - -
128 Nebulizer canula Child piece - -
129 Needle carpule biji - -
130 Needle no 25 biji - -
131 Nierbeken Disposible 25 cm pcs - -
132 Nistatin suspensi 100.000 IU / ml botol - -
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml - -
134 Novomix Flexpen biji - -
135 Object Glass biji - -
136 Oksigen canula adult biji - -
137 Oksigen canula child biji - -
138 Paracetamol drip (infus) 1g / 100 mL botol
- -
Parasetamol suppositoria - Pamol
139 suppo
Supp - -
140 Pehacain injeksi ampul - -
141 Pembalut hamil piece - -
142 Plesterin Bulat Soft isi 200 piece - -
143 Plesterin Roll 20 cm x 5 m rol - -
144 Povidone iodine 60 ml botol - -
145 Probenid tab 500 mg tablet - -
146 Prontosan wound gel botol - -
147 Prontosan wound irigation botol - -
148 Psidii 500 mg kapsul kapsul - -
149 Psidii sirup botol - -
150 Risperidon tablet 2 mg tablet - -
151 Safety Box 12 L piece - -
152 Safety Box 5 Lt OM piece - -
153 Salbutamol 4 mg tablet - -
154 Sarung Tangan Gynaecolog pasang - -
155 Sikzonoat Inj / Flupenaziin Inj ampul - -
156 Silk No. 2/0 - 100 m rol - -
157 Slem / Mucus Extractor biji - -
158 Spalk 10 x 5 cm biji - -
159 Spalk 100 x 10 piece - -
160 Spalk 15 x 5 piece - -
161 Spalk 20 x 5 cm biji - -
162 Spalk 4 x 12 cm biji - -
163 Spalk 40 x 8 x 7 cm biji - -
164 Spalk 60 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
166 Spironolacton tab 100 mg tablet - -
167 Spironolacton tab 25mg tablet - -
168 Stik Asam Urat biji - -
169 Stik Gula Darah biji - -
170 Stik Kolesterol biji - -
171 Stromatolyser piece - -
172 Suction catheter no 12 biji - -
173 Sukralfat suspensi botol - -
174 Superpatch jumbo biji - -
175 Surgical gown non woven steril pcs - -
176 Surgical gown spunlace biji - -
177 Tensocrepe 3 inch biji - -
178 Tensocrepe 4 inch biji - -
179 Tensocrepe 6 inch biji - -
Terbutalin repsules (bricasma
180 ampul
repsule) - -
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler) - -
182 Test Kehamilan piece - -
183 Test Kesuburan (Baby Test) piece - -
184 Tremenza Syrup botol - -
185 Tremenza Tablet tablet - -
186 Triamcinolon injeksi 10 mg/ml ampul - -
187 Truvit syrup botol - -
188 Ultrasonic gel botol - -
189 Urea pcs - -
190 Uricase pcs - -
191 USC Gel 250 ml botol - -
192 Vaculab EDTA 3 ml piece - -
193 Vaculab non EDTA 3 ml plain pcs - -
194 Valsartan 80 mg tablet - -
195 Yellow Tip pcs - -
196 Zinc Syrup 10 mg / ml botol - -
197 Coparcetin tab tablet - -
198 Curbiplex sirup BOtol - -
199 Fultrop tablet tablet - -
200 Fultrop SIRUP BOtol - -
201 Molexflu syr botol - -
202 APD coverall - -
203 Isolation Gown - -
204 nurse/dokter cap - -

205 shoes cover

- -

206 Hemaviton cardio

- -

207 Coparcetin sirup botol

- - -

208 Plesterin roll 10 cm x 5 m

- -
Aseptik gel 1 L/Hand Foam sanitiser
209 botol
600 ml - -

210 Cavilpex tablet

- -
211 Etanol 96% botol
- -

- -

BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI ASKES MANDIRI

5 85
65 15

Gresik, 06 April 2021

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

Yang Melayani :…………………….. Yang Memeriksa :……………………..
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKESMAS
( LPLPO JKN )
PUSTU/PONKESDES/POLINDES : KEPUHKLAGEN
KECAMATAN :WRINGINANOM
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. KET

1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet - -
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul - -
3 Albendazol suspensi 200 mg / 5 ml botol
- -
4 Albendazol tablet 400 mg tablet - -
5 Albuthyl Ovula supp - -
6 Alopurinol tablet 100 mg tablet - -
7 Alopurinol tablet 300 mg tablet - -
8 Alprazolam 0,5 mg tablet tablet - -
9 Ambroxol sirup 15 mg / ml botol @ 60 ml 4 4 2 2
10 Ambroxol tablet 30 mg tablet 140 140 40 100
11 Aminofilin tablet scored 200 mg tablet - -
12 Aminofilina injeksi 24 mg / ml ampul - -
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
- -
14 Amlodipine tablet 10 mg tablet - -
15 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml 10 10 2 8
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml - -
18 Amoksisilin kaplet 500 mg tablet - -
19 Amoksisilin kapsul 250 mg tablet - -
20 Amoksisilin Serbuk injeksi 1000 mg vial
- -
Amoxillin + As.Klavulanat 625 mg
21 tablet
kapsul - -
22 Ampisilina sirup kering 125 mg/5ml botol
- -
23 Antalgin ( Metampiron ) tablet 500 mg tablet
240 240 10 230
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - -
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik ) - -

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg
- -
Antasida DOEN II suspensi,
kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml - -
28 Antifungi DOEN pot @ 30 gr - -
29 Antihemoroid DOEN supp - -
30 Antimigren DOEN tablet tablet - -
31 Antiparkinson DOEN tablet tablet - -
32 Aqua pro Injeksi steril, bebas pirogen botol
- -
33 Aquadest steril botol @ 1000 ml - -
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg - -
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg - -
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg - -
37 Asam Folat tablet 0,4 mg tablet - -
38 Asam Folat tablet 1 mg tablet - -
39 Asam Mefenamat kaplet 500 mg tablet 170 170 50 120
40 Asam traneksamat injeksi 100 mg/ml ampul
- -
41 Asam traneksamat injeksi 50 mg/ml ampul
- -
42 Aseptik Gel 500 cc + dispenser botol @ 500 ml - -
43 Asiklovir krim 5 % tube @ 5 gr 14 14 1 13
44 Asiklovir tablet 400 mg tablet - -
45 Atapulgit tablet 600 mg tablet - -
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml - -
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 60 60 60 -
53 Bedak salisil serbuk 2 % tablet - -
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial - -
55 Besi Sirup botol - -
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur - -
57 Betahistin Mesilat tablet 6 mg tablet - -
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat ) - -
59 Betason - N krim tube - -
60 Bisacodil ( Bicolak ) tablet tablet - -
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp ) - -
62 Bisoprolol tablet 5 mg tablet - -
63 Borak Gliserin 5% botol @ 15 ml - -
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet) - -
65 Bronchitin Expektoran Sirup botol @ 50 ml 4 4 2 2
66 Centabio Jelly / Bioplacenton Jelly tablet - -
67 Curcuma tablet tablet - -
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml - -
69 Deksametason tablet 0,5 mg tablet 190 190 60 130
70 Desoksimetason krim 0,25 % tube @ 15 gr - -
71 Diazepam injeksi 5 mg / ml - 2 ml ampul - -
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube) - -
73 Diazepam tablet 2 mg tablet - -
74 Dietilkarbamazin Sitrat tablet 100 mg tablet
- -
75 Difenhidramin HCl injeksi 10 mg / ml ampul
- -
76 Digoksin tablet 0,25 mg tablet - -
77 Dimenhidrinat tablet 50 mg tablet - -
78 Doksisiklin tablet 100 mg tablet - -
79 Domperidone sirup 5 mg/5ml botol @ 60 ml - -
80 Domperidone tablet 10 mg tablet - -
81 Efedrin HCl tablet 25 mg tablet - -
82 Ekstrak Belladon tablet 10 mg tablet - -
83 Elkana Sirup tablet - -
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml - -
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml - -
86 Eritromisin kapsul 500 mg kapsul - -
87 Etakridin ( Rivanol ) larutan 0,1% botol - -
88 Etanol 70 % 100 ml botol - -
89 Etanol 70% 1000 ml botol - -
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg) - -
91 Fenitoin Natrium kapsul 100 mg kapsul - -
92 Fenitoin Natrium kapsul 30 mg kapsul - -
93 Fenobarbital tablet 30 mg tablet - -
94 Fenofibrat kapsul 100 mg kapsul - -
95 Fenofibrat kapsul 300 mg kapsul - -
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg - -
97 Fenol Gliserol tetes telinga 10% botol - -
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml - -
Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg - -
101 Fludane Plus Sirup botol @ 60 ml - -
102 Fluor tablet 0,5 mg tablet - -
103 Furosemid tablet 40 mg tablet - -
104 Garam Oralit untuk 200 ml air sase - -
105 Gelofusin Infus botol @ 500 ml - -
106 Gemfibrosil kapsul 300 mg kapsul - -
107 Gemfibrosil kapsul 600 mg kapsul - -
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -
109 Gentamisin tetes mata 0,3 % botol - -
110 Gentian Violet larutan 1 % botol @10 ml 19 19 3 16
111 Glibenklamid tablet 5 mg tablet - -
112 Glimepiride tablet 2 mg tablet - -
113 Gliseril Guaiakolat tablet 100 mg tablet 280 280 20 260
114 Glukosa 5% - 1/2 NS botol @ 500 ml - -
115 Glukosa 5% - 1/4 NS botol @ 500 ml - -
116 Glukosa larutan infus 10 % steril botol @ 25 ml - -
117 Glukosa larutan infus 40 % steril botol @ 25 ml - -
118 Glukosa larutan infus 5 % steril botol @ 500 ml - -
119 Griseofulvin tablet 125 mg tablet - -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) - -
121 Haloperidol tablet 0,5 mg tablet - -
122 Haloperidol tablet 1,5 mg tablet - -
123 Haloperidol tablet 5 mg tablet - -
124 Hemobion tablet tablet - -
125 Hemorogard kapsul kapsul - -
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
- -
127 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi) - -
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -
130 Ibuprofen tablet 200 mg tablet - -
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr 7 7 7
133 Iodiol kapsul lunak kapsul - -
134 Ipratropium bromida nebulazer 0,025 ampul
- -
135 Isoniazide tablet 100 mg tablet - -
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg - -
137 KA-EN 3 B Otsu infus botol @ 500 ml - -
138 Kalium Diklofenak tablet 50 mg tablet - -
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml ) - -
140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet
- -
141 Kaptopril tablet scored 25 mg tablet 210 210 50 160
142 Kaptopril tablet scored 12,5 mg tablet - -
143 Karbamazepin tablet 200 mg tablet - -
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp ) - -
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -
148 Klindamisin kapsul 150 mg kapsul - -
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg ) - -
150 Kloramfenikol kapsul 250 mg kapsul - -
151 Kloramfenikol salep mata 1 % tube - -
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
- -
153 Kloramfenikol tetes Mata botol @ 5 ml - -
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml 5 5 5 -
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg - -
156 Klorheksidin larutan 15 % botol - -
157 Klorokuin Fosfat tablet 250 mg tablet - -
158 Klorpromazin HCl tablet salut 100 mg tablet
- -
159 Klorpromazin HCl tablet salut 25 mg tablet
- -
160 Klorpromazin injeksi 5 mg/ ml ampul - -
161 Kodein HCl tablet 10 mg tablet - -
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah ) - -
163 Kotrimoksazol Dewasa tablet tablet - -
164 Kotrimoksazol Pediatrik tablet tablet - -
165 Kotrimoksazol Suspensi botol @ 60 ml - -
166 Kuinin ( Kina ) tablet 200 mg tablet - -
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
) - -
168 Lactodia / Lacto B sachet - -
169 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL ) - -
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril - -
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml - -
174 Linkomisina kapsul 500 mg kapsul - -
Lisol, mengandung Kresol tersabun
175 botol
50% - -
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet - -
178 Lysmin Plus Sirup botol @ 60 ml - -
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml - -
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml - -
181 MB Anak blister - -
182 MB Dewasa blister - -
183 Mebendazol tablet 100 mg tablet - -
184 Meloksikam tablet 15 mg tablet - -
185 Metformin HCl tablet 500 mg tablet - -
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg - -
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml - -
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml - -
189 Metoklopropamid tablet 10 mg tablet - -
190 Metronidazol ovula ovula - -
191 Metronidazol tablet 250 mg tablet - -
192 Miconazol krim 2 % ( Nitrat ) tube - -
193 Mineral Mix 8 gr sase - -
194 Natrium Diklofenak tablet 50 mg tablet - -
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril - -
196 Neo Kauminal suspensi botol @ 60 ml 9 9 7 2
197 Neuralgin - RX tablet tablet 400 400 120 280
198 Neurosanbe 5000 mg tablet tablet - -
199 Neurosanbe injeksi ampul - -
200 Neurovit E tablet tablet - -
201 Nifedipin tablet 10 mg tablet - -
202 Nistatin tablet salut 500.000 IU / g tablet - -
203 Nistatin vaginal tablet 100.000 IU / g tablet
- -
204 Nodiar tablet tablet - -
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet) - -
206 OAT - FDC Kategori 1 - 3 PAKET paket
- -
207 OAT - FDC Kategori 2 PAKET paket - -
208 OAT Kategori anak PAKET paket - -
209 OAT Sisipan paket - -
210 OAT-Kombipak Kategori 1 anak paket - -
211 OAT-Kombipak Kategori 1 dewasa paket
- -
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml - -
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup - -
214 Ofloxaxin tablet 200 mg tablet - -
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
- -
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr - -
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml - -
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml - -
220 Omeprazole tablet 20 mg tablet - -
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -
222 Ondansetron tablet 4 mg tablet - -
223 Ondansetron tablet 8 mg tablet - -
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -
225 Papaverin Tablet 40 mg tablet - -
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml ) - -
227 Parasetamol sirup 120 mg / 5 ml botol - -
228 Parasetamol tablet 100 mg tablet - -
229 Parasetamol tablet 500 mg tablet 350 350 110 240
230 PB Anak blister - -
231 PB Dewasa blister - -
232 Pehavral tablet tablet - -
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml
- -
234 Pilokarpin HCl / Nitrat tetes mata 2% botol
- -
235 Piracetam 1200 mg tablet Kotak - -
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml - -
238 Piracetam tablet 800 mg tablet - -
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml - -
240 Pirantel tablet score ( base ) 125 mg tablet
- -
241 Pirazinamida tablet 500 mg tablet - -
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg - -
243 Piroxicam tablet 10 mg tablet - -
244 Piroxicam tablet 20 mg tablet 120 120 50 70
245 Polikresulen cairan ( Aptil ) botol - -
246 Ponflu tablet tablet - -
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml
- -
248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml
- -
249 Prednison tablet 5 mg tablet - -
250 Primakuin tablet 15 mg tablet - -
251 Prolipid kaplet tablet - -
252 Propiltiourasil tablet 100 mg tablet - -
253 Propranolol HCl tablet 40 mg tablet - -
254 Proris suppositoria supp - -
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
256 Ranitidin tablet 150 mg tablet - -
257 Reserpin tablet 0,25 mg tablet - -
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU - -
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak - -
260 Rifampisin kapsul 300 mg tablet - -
261 Risperidon tablet 1 mg tablet - -
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat ) - -
Salep 2-4 , kombinasi : Asam Salisilat
263 pot @ 30 gr
2 % + Belerang endap 4 %
- -
264 Scabicid krim tube - -
265 Sefadroksil kapsul 500 mg kapsul - -
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
- -
267 Sefiksim kapsul 100 mg kapsul - -
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
- -
269 Sefotaksim injeksi 1 gr vial @ 1 gr - -
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
- -
271 Serum ADS 20.000 vial - -
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I - -
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp - -
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial - -
275 Setirizin sirup 5 mg / 5 ml botol - -
276 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg - -
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg - -
279 Simetidin tablet 200 mg tablet - -
280 Simvastatin tablet 10 mg tablet - -
281 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl ) - -
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml - -
284 Spasi Plus tablet tablet - -
285 Spasminal tablet tablet - -
Sulfasetamida Natrium tetes mata 15
286 botol
% - -
287 Supralivron tablet tablet - -
288 Taburia sachet - -
289 Tamiflu tablet - -
290 Tensigard kapsul kapsul - -
291 Tetrakain HCl tetes mata 0,5% botol - -
292 Tetrasiklin HCl kapsul 250 mg kapsul - -
293 Tetrasiklin HCl kapsul 500 mg kapsul - -
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml - -
295 Thiamfenikol kapsul 500 mg kapsul 180 180 180
Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml - -
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg - -
298 Trifluoperasin tablet 5 mg tablet - -
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
- -
300 Ventolin Nebules 2,5 mg ampul - -
301 Vical Sirup botol @ 60 ml - -
302 Vitamin B Kompleks tablet tablet - -
303 Zenirex Sirup botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup ) - -
305 Zink tablet disperible 20 mg tablet - -
- -
BAHAN GIGI : - -
306 Air raksa dental use botol - -
307 Cavit - G botol - -
308 Composit resin ( solare ) Kit - -
309 Devitalisasi Pasta ( Non Arsen ) botol - -
310 Etil Klorida semprot ( Duta Kaisar ) botol
- -
311 Eugenol cairan botol - -
312 Glass Ionomer Cement ( GC IX ) botol - -
313 Kalsium Hidroksida Pasta ( hydcal ) botol
- -
Monoklorkamfer Mentol Cairan
314 botol
( CHKM ) - -
315 Mummifying Pasta botol - -
316 Semen Seng Fosfat serbuk dan cairan botol
- -
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr - -
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji
- -
Temporary Stopping Fletcher
319 set
( Fletcher ) - -
320 Trikresol Formalin (TKF) cairan botol - -
321 Tumpatan komposit kit set - -
322 Cressophen botol - -
323 Cressophate botol - -
- -
BAHAN MEDIS HABIS PAKAI
( BMHP ) - -
324 Alat suntik sekali pakai 1 ml tuberculin set
- -
325 Alat suntik sekali pakai 3 ml set - -
326 Alat suntik sekali pakai 5 ml set - -
327 Blood Lancet biji - -
328 Blood transfision set set - -
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji
- -
330 Folleycatheter Silicon 2 way 14 - 18 biji
- -
331 Hans Coen steril / Sarung Tangan pasang - -
332 Hypafix 5 x 5 rol - -
333 Infusion set anak set - -
334 Infusion set dewasa set - -
335 IV. Chateter No. 14 s/d 24 set - -
336 IV. Chateter No. 26 set - -
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji - -
338 Jarum Suntik 22G s/d 25 G biji - -
339 Jarum Suntik 26G biji - -
340 Kapas Pembalut / Absorben 250 gram rol
- -
341 Kasa Kompres 40 / 40 steril rol - -
342 Kasa Pembalut 2 m x 80 cm rol - -
343 Kasa Pembalut Hidrofil 4 m x 15 cm rol
- -
344 Kasa Pembalut Hidrofil 4 m x 3 cm rol
- -
345 Lomatulle lembar - -
346 Masker Earloop/ Tie On biji - -
347 Masker N 95 set - -
348 Plester 1,25 cm x 4,5 m rol - -
349 Scalp Vein no. 25 biji - -
350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol
- -
351 Surgical Blade / Mess No. 11 biji - -
Umbilical cord klem nylon steril (Claim biji
352
Umbilical) - -
353 Underpad biji - -
Urine Bag standard steril 2 Lt ( T
354 biji
valve ) - -
- -
REAGEN LABORATORIUM - -
355 Amonia 10 % botol - -
356 Asam Asetat 6 % botol - -
357 Asam Klorida 0,1 N botol - -
358 Asam Sulfosalisilat 20% botol - -
359 Cholesterol Strip Easy Touch botol - -
360 Cholesterol Strip Nesco botol - -
361 Clever Check Strip 50 test botol - -
362 Contronorm Plus 5 x 5 ml botol - -
363 G O T - AST Starter 8 x 15 ml botol - -
364 G P T - ALT Starter 8 x 15 ml botol - -
365 Glucose GOD PAP botol - -
366 Golda Tulip Anti - A botol - -
367 Golda Tulip Anti - B botol - -
368 Golda Tulip Anti AB botol - -
369 Golda Tulip Anti D/Rhesus botol - -
370 HBs Ag Intec Strip 50 botol - -
371 HDL Cholesterol 6 x 40 ml botol - -
372 Hemoglobin 1000 ml botol - -
373 Kolesterol CHOD-PAP 8 X 20 ml botol - -
374 Kreatinin - Jaffe 400 ml botol - -
375 Larutan Giemsa Stain botol - -
376 Larutan Karbol Fuksin botol - -
377 Larutan Metilen Biru botol - -
378 Larutan Turk botol - -
379 LDL Cholesterol 6 x 50 ml botol - -
380 Metanol botol - -
381 Natrium Chlorida 0,9 % botol - -
382 Pewarna Gram 1 % botol - -
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu - -
384 Rees Ecker botol - -
385 Sclessinger botol - -
386 Stik HCG Strip Answer 50 botol - -
387 Stik urine combine 10 test M botol - -
388 Stik urine 10 parameter botol - -
389 Stik urine 3 parameter botol - -
390 Strip Hb Mission Plus botol - -
391 Trigliserida GPO - PAP 8 x 20 ml biji - -
392 Urea Col 1 x 100 ml biji - -
393 Uric Acid Strip Easy Touch biji - -
394 Uric Acid Strip Nesco biji - -
395 Uricase-PAP 8 x 20 ml botol - -
396 VDRL botol - -
397 Widal ( Slam O Paratyphi A ) botol - -
398 Widal ( Slam O Paratyphi B ) botol - -
399 Widal ( Slam Typhi H ) botol - -
400 Widal ( Slam Typhi O ) botol - -
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set - -
- -
OBAT TAMBAHAN : - -
1 Acitral / antasid + simetikon tube - -
2 Akarbose 100 mg ampul - -
3 Alat suntik 10 ml biji - -
4 Alat suntik 20 ml biji - -
5 Alat suntik 50 ml biji - -
6 Alkohol Swabs pcs - -
7 Alletrol Tetes Mata botol 10 10 3 7
8 Amiodaron inj 50 mg/ml ampul - -
9 Ampicillin Injeksi 1 gram vial - -
10 Aqua Gel 150's G sachet sachet - -
11 Arm Sling Comfort (M/L) pcs - -
12 Artikulating paper pcs - -
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi - -
14 Aseptik Gel 5 Liter botol - -
15 Askina calgitrol gel 15 g tube - -
16 Askina gel 15 g tube - -
17 Asvex tablet tablet - -
18 Biolysin Sirup botol - -
19 Bisoprolol 2,5 mg tablet - -
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml - -
21 Budesonid inhaler (Pulmicort) pcs - -
Budesonid repsules (Pulmicort
22 pcs
Repsule) - -
Budesonide-formoterol 160/4,5
23 pcs
(symbicort) - -
24 Carpule needle L Ject biji - -
25 Carpule posicain 100 biji - -
26 Catgut 3/0 + 1/2 biji - -
27 Catgut Chromic tanpa needle biji - -
28 Catgut No. 2/0 - 100 m biji - -
29 Cell Pack biji - -
30 Cellclean biji - -
31 Cervical Collar Universal pcs - -
32 Cevitron pink kotak - -
33 Cevitron putih kotak - -
34 Chloramex 250 mg tablet tablet - -
35 Cliad / Braxidin tablet - -
36 Clopigrogel tablet 75 mg tablet - -
37 Colergis tablet - -
38 Combivent UDV vial - -
39 Contronorm Plus 5 x 4 mL pcs - -
40 Cotton rol rol - -
41 Cover Glass biji - -
42 Curcumex tablet tablet - -
43 Deculin 15 mg tablet - -
44 Dekstrofen syrup botol 9 9 3 6
45 Demacolin Syrup botol -
46 Demacolin Tablet tablet 180 180 70 110
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs) - -
48 Dermafix 10 x 15 cm rol - -
49 Dermafix 10 x 20 cm rol - -
50 Dermafix S IV 6x7 cm rol - -
51 Dermafix SS 10 x 10 cm rol - -
52 Dermafix T 10 x 12 cm rol - -
53 Dermafix T 10 x 25 cm rol - -
54 Dermafix T 10 x 8 cm rol - -
55 Dermafix T 6 x 7 cm rol - -
56 Dextral Tablet tablet - -
57 Duk lubang steril 25x30 cm piece - -
58 Duk lubang steril 50x50 cm piece - -
59 Eightchek / Kontrol Hema (H, L, N) biji - -
60 Elite Cement botol - -
61 Endoseal biji - -
62 Eryclone ( Anti AB ) botol - -
63 Female Catheter biji - -
64 Fenitoin injeksi 50 mg / ml ampul - -
65 Flukonazol tablet - -
66 Fluocinolon acetonid / dermasolon tube
- -
67 Folleycatheter Silicon 2 way 08 - 12 biji
- -
68 Furosemid injeksi 10mg/ml ampul - -
69 Gabapentin 300 mg kapsul - -
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata) - -
71 Glimepiride 3 mg tablet - -
72 Glimepiride 4 mg tablet - -
73 Glucosa strip easy touch biji - -
74 Glucose biji - -
75 Glukosa strip on call plus biji - -
76 Gula Darah Stik biji - -
Hans Coen Non steril / Sarung
77 biji
Tangan - -
78 Hb Hemoglobin strip quick check biji - -
79 Hypafix 15 x 5 rol - -
80 Hypafix 20 x 5 rol - -
81 Hypafix 5 cm x 1 m rol - -
82 ID Band Anak biji - -
83 ID Band Dewasa biji - -
84 Insulin Rapid Acting (Novorapid) piece - -
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul - -
86 IV Film 6 x 8 cm pcs - -
87 Jarum jahit (bedah) MANI No. 12 biji - -
88 Jarum jahit (bedah) MANI No. 14 biji - -
89 Jarum Suntik Terumo No. 23 biji - -
90 Kasa 3,6 M x 15 cm rol - -
91 Kasa Hidrofil 40 x 80 cm rol - -
92 Kasa steril 16 x 16 cm rol - -
93 Kertas Lakmus Merah biji - -
94 Kertas saring biji - -
95 Kertas Termal USG biji - -
96 Ketorolac injeksi 30 mg / ml ampul - -
97 Klindamisin kapsul 300 mg kapsul - -
98 Kloramfenikol 500 mg kapsul kapsul - -
99 Kloramfenikol salep kulit tube - -
100 Komposit A2 biji - -
101 Komposit A3 biji - -
102 Komposit Nexcon A3 biji - -
103 Komposit Voco A3 biji - -
104 Komposit Voco Incisal biji - -
105 Konik ECG gel botol - -
106 Laktulosa syrup botol - -
107 Masker Nebulizer Anak piece - -
108 Masker Nebulizer Dewasa piece - -
109 Mata bur no 1 biji - -
110 Mata bur no 2 biji - -
111 Mata bur set biji - -
112 Matovit tablet tablet - -
113 Maxiflow anak biji - -
114 Maxiflow bayi biji - -
115 Maxiflow dewasa biji - -
116 Mersibion injeksi ampul - -
117 Metilprednisolon 4 mg tablet - -
118 Metilprednisolon inj 500mg/8ml ampul - -
119 Metilprednisolon injeksi 125mg/ml ampul - -
120 Metronidazole 500mg tablet tablet - -
121 Metronidazole infus 500mg/100 ml botol
- -
122 Mitella piece - -
123 Mucus Extraction pcs - -
124 My Jelly 82 gram tube - -
125 Nasal dan Masker Oksigen Anak pcs - -
126 Nasal dan Masker Oksigen Dewasa pcs
- -
127 Nebulizer canula Adult piece - -
128 Nebulizer canula Child piece - -
129 Needle carpule biji - -
130 Needle no 25 biji - -
131 Nierbeken Disposible 25 cm pcs - -
132 Nistatin suspensi 100.000 IU / ml botol - -
133 Norepinephrine bitartat injeksi 1 mg/ml ampul
- -
134 Novomix Flexpen biji - -
135 Object Glass biji - -
136 Oksigen canula adult biji - -
137 Oksigen canula child biji - -
138 Paracetamol drip (infus) 1g / 100 mL botol
- -
Parasetamol suppositoria - Pamol
139 suppo
Supp - -
140 Pehacain injeksi ampul - -
141 Pembalut hamil piece - -
142 Plesterin Bulat Soft isi 200 piece - -
143 Plesterin Roll 20 cm x 5 m rol - -
144 Povidone iodine 60 ml botol - -
145 Probenid tab 500 mg tablet - -
146 Prontosan wound gel botol - -
147 Prontosan wound irigation botol - -
148 Psidii 500 mg kapsul kapsul - -
149 Psidii sirup botol - -
150 Risperidon tablet 2 mg tablet - -
151 Safety Box 12 L piece - -
152 Safety Box 5 Lt OM piece - -
153 Salbutamol 4 mg tablet - -
154 Sarung Tangan Gynaecolog pasang - -
155 Sikzonoat Inj / Flupenaziin Inj ampul - -
156 Silk No. 2/0 - 100 m rol - -
157 Slem / Mucus Extractor biji - -
158 Spalk 10 x 5 cm biji - -
159 Spalk 100 x 10 piece - -
160 Spalk 15 x 5 piece - -
161 Spalk 20 x 5 cm biji - -
162 Spalk 4 x 12 cm biji - -
163 Spalk 40 x 8 x 7 cm biji - -
164 Spalk 60 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
166 Spironolacton tab 100 mg tablet - -
167 Spironolacton tab 25mg tablet - -
168 Stik Asam Urat biji - -
169 Stik Gula Darah biji - -
170 Stik Kolesterol biji - -
171 Stromatolyser piece - -
172 Suction catheter no 12 biji - -
173 Sukralfat suspensi botol - -
174 Superpatch jumbo biji - -
175 Surgical gown non woven steril pcs - -
176 Surgical gown spunlace biji - -
177 Tensocrepe 3 inch biji - -
178 Tensocrepe 4 inch biji - -
179 Tensocrepe 6 inch biji - -
180 Terbutalin repsules (bricasma repsule) ampul
- -
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler) - -
182 Test Kehamilan piece - -
183 Test Kesuburan (Baby Test) piece - -
184 Tremenza Syrup botol - -
185 Tremenza Tablet tablet - -
186 Triamcinolon injeksi 10 mg/ml ampul - -
187 Truvit syrup botol - -
188 Ultrasonic gel botol - -
189 Urea pcs - -
190 Uricase pcs - -
191 USC Gel 250 ml botol - -
192 Vaculab EDTA 3 ml piece - -
193 Vaculab non EDTA 3 ml plain pcs - -
194 Valsartan 80 mg tablet - -
195 Yellow Tip pcs - -
196 Zinc Syrup 10 mg / ml botol - -
197 Coparcetin tab tablet - -
198 Curbiplex sirup BOtol - -
199 Fultrop tablet tablet - -
200 Fultrop SIRUP BOtol - -
201 Molexflu syr botol - -
202 APD coverall - -
203 Isolation Gown - -
204 nurse/dokter cap - -

205 shoes cover

- -

206 Hemaviton cardio

- -

207 Coparcetin sirup botol

3 3 3 -

208 Plesterin roll 10 cm x 5 m

- -
Aseptik gel 1 L/Hand Foam sanitiser
209 botol
600 ml - -

210 Cavilpex tablet

- -
211 Etanol 96% botol
- -

- -

BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI ASKES MANDIRI

31 182
130 3 18

Gresik, 15 Januari 2021

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

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

 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKESMAS
( LPLPO JKN )
PUSTU/PONKESDES/POLINDES : KEPUHKLAGEN
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : PEBRUARI
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : MARET 2021

NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN

1 2 3 4 5 6 7
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet - -
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul - -
3 Albendazol suspensi 200 mg / 5 ml botol - -
4 Albendazol tablet 400 mg tablet - -
5 Albuthyl Ovula supp - -
6 Alopurinol tablet 100 mg tablet - -
7 Alopurinol tablet 300 mg tablet - -
8 Alprazolam 0,5 mg tablet tablet - -
9 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
10 Ambroxol tablet 30 mg tablet - -
11 Aminofilin tablet scored 200 mg tablet - -
12 Aminofilina injeksi 24 mg / ml ampul - -
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet - -
14 Amlodipine tablet 10 mg tablet - -
15 Amlodipine tablet 5 mg tablet - -
16 Amoksisilin Sirup Kering 125 mg / 5 ml botol @ 60 ml
- -
17 Amoksisilin Sirup Kering 250 mg / 5 ml botol @ 60 ml
- -
18 Amoksisilin kaplet 500 mg tablet - -
19 Amoksisilin kapsul 250 mg tablet - -
20 Amoksisilin Serbuk injeksi 1000 mg vial - -
21 Amoxillin + As.Klavulanat 625 mg kapsul tablet
- -
22 Ampisilina sirup kering 125 mg/5ml botol - -
23 Antalgin ( Metampiron ) tablet 500 mg tablet - -
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - -
Antalgin ( Metamisol )injeksi 500 mg / ml -
25 ampul @ 2 ml
2 ml ( Novalgin / Antrain / Santagesik )
- -
 Antasida DOEN I tablet kunyah,
26 kombinasi : Aluminium Hidroksida 200 mg tablet
; Magnesium Hidroksida 200 mg
- -

Antasida DOEN II suspensi, kombinasi :

27 Aluminium Hidroksida 200 mg/ml ; botol @ 60 ml
Magnesium Hidroksida 200 mg/ml
- -
28 Antifungi DOEN pot @ 30 gr - -
29 Antihemoroid DOEN supp - -
30 Antimigren DOEN tablet tablet - -
31 Antiparkinson DOEN tablet tablet - -
32 Aqua pro Injeksi steril, bebas pirogen botol - -
33 Aquadest steril botol @ 1000 ml - -
Asam Asetilsalisilat (Asetosal) tablet 100
34 tablet
mg - -
Asam Asetilsalisilat (Asetosal) tablet 500
35 tablet
mg - -
36 Asam Askorbat ( Vitamin C ) tablet 50 mg tablet
- -
37 Asam Folat tablet 0,4 mg tablet - -
38 Asam Folat tablet 1 mg tablet - -
39 Asam Mefenamat kaplet 500 mg tablet - -
40 Asam traneksamat injeksi 100 mg/ml ampul - -
41 Asam traneksamat injeksi 50 mg/ml ampul - -
42 Aseptik Gel 500 cc + dispenser botol @ 500 ml - -
43 Asiklovir krim 5 % tube @ 5 gr - -
44 Asiklovir tablet 400 mg tablet - -
45 Atapulgit tablet 600 mg 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 % tablet - -
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial - -
55 Besi Sirup botol - -
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur - -
57 Betahistin Mesilat tablet 6 mg tablet - -
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat ) - -
59 Betason - N krim tube - -
60 Bisacodil ( Bicolak ) tablet tablet - -
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp ) - -
62 Bisoprolol tablet 5 mg tablet - -
63 Borak Gliserin 5% botol @ 15 ml - -
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet) - -
65 Bronchitin Expektoran Sirup botol @ 50 ml - -
66 Centabio Jelly / Bioplacenton Jelly tablet - -
67 Curcuma tablet tablet - -
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml - -
69 Deksametason tablet 0,5 mg tablet - -
70 Desoksimetason krim 0,25 % tube @ 15 gr - -
71 Diazepam injeksi 5 mg / ml - 2 ml ampul - -
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube) - -
73 Diazepam tablet 2 mg tablet - -
74 Dietilkarbamazin Sitrat tablet 100 mg tablet - -
75 Difenhidramin HCl injeksi 10 mg / ml ampul - -
76 Digoksin tablet 0,25 mg tablet - -
77 Dimenhidrinat tablet 50 mg tablet - -
78 Doksisiklin tablet 100 mg tablet - -
79 Domperidone sirup 5 mg/5ml botol @ 60 ml - -
80 Domperidone tablet 10 mg tablet - -
81 Efedrin HCl tablet 25 mg tablet - -
82 Ekstrak Belladon tablet 10 mg tablet - -
83 Elkana Sirup tablet - -
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml - -
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml - -
86 Eritromisin kapsul 500 mg kapsul - -
87 Etakridin ( Rivanol ) larutan 0,1% botol - -
88 Etanol 70 % 100 ml botol - -
89 Etanol 70% 1000 ml botol - -
90 Etynil estradiol (Lynoral tablet 0,05 mg) tablet
- -
91 Fenitoin Natrium kapsul 100 mg kapsul - -
92 Fenitoin Natrium kapsul 30 mg kapsul - -
93 Fenobarbital tablet 30 mg tablet - -
94 Fenofibrat kapsul 100 mg kapsul - -
95 Fenofibrat kapsul 300 mg kapsul - -
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg - -
97 Fenol Gliserol tetes telinga 10% botol - -
Fitomenadion ( Vitamin K1 ) injeksi 10 mg
98 ampul
/ml - -
Fitomenadion ( Vitamin K1 ) injeksi 2 mg /
99 ampul
ml ( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet salut
100 tablet
gula 10 mg - -
101 Fludane Plus Sirup botol @ 60 ml - -
102 Fluor tablet 0,5 mg tablet - -
103 Furosemid tablet 40 mg tablet - -
104 Garam Oralit untuk 200 ml air sase - -
105 Gelofusin Infus botol @ 500 ml - -
106 Gemfibrosil kapsul 300 mg kapsul - -
107 Gemfibrosil kapsul 600 mg kapsul - -
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -
109 Gentamisin tetes mata 0,3 % botol - -
110 Gentian Violet larutan 1 % botol @10 ml - -
111 Glibenklamid tablet 5 mg tablet - -
112 Glimepiride tablet 2 mg tablet - -
113 Gliseril Guaiakolat tablet 100 mg tablet - -
114 Glukosa 5% - 1/2 NS botol @ 500 ml - -
115 Glukosa 5% - 1/4 NS botol @ 500 ml - -
116 Glukosa larutan infus 10 % steril botol @ 25 ml - -
117 Glukosa larutan infus 40 % steril botol @ 25 ml - -
118 Glukosa larutan infus 5 % steril botol @ 500 ml - -
119 Griseofulvin tablet 125 mg tablet - -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) - -
121 Haloperidol tablet 0,5 mg tablet - -
122 Haloperidol tablet 1,5 mg tablet - -
123 Haloperidol tablet 5 mg tablet - -
124 Hemobion tablet tablet - -
125 Hemorogard kapsul kapsul - -
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet - -
127 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi) - -
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -
130 Ibuprofen tablet 200 mg tablet - -
131 Ibuprofen tablet 400 mg tablet - -
132 Ichtiyol Zalf pot @ 15 gr - -
133 Iodiol kapsul lunak kapsul - -
134 Ipratropium bromida nebulazer 0,025 ampul - -
135 Isoniazide tablet 100 mg tablet - -
136 Isosorbid Dinitrat tablet sublingual 5 mg tablet
- -
137 KA-EN 3 B Otsu infus botol @ 500 ml - -
138 Kalium Diklofenak tablet 50 mg tablet - -
Kalsium Glukonat injeksi i.v 10 % ( 100
139 ampul
mg/ml ) - -
140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet - -
141 Kaptopril tablet scored 25 mg tablet - -
142 Kaptopril tablet scored 12,5 mg tablet - -
143 Karbamazepin tablet 200 mg tablet - -
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100 mg ( Protofen
146 supp
supp ) - -
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -
148 Klindamisin kapsul 150 mg kapsul - -
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg ) - -
150 Kloramfenikol kapsul 250 mg kapsul - -
151 Kloramfenikol salep mata 1 % tube - -
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
- -
153 Kloramfenikol tetes Mata botol @ 5 ml - -
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml - -
155 Klorfeniramin Maleat ( CTM ) tablet 4 mg tablet
- -
156 Klorheksidin larutan 15 % botol - -
157 Klorokuin Fosfat tablet 250 mg tablet - -
158 Klorpromazin HCl tablet salut 100 mg tablet - -
159 Klorpromazin HCl tablet salut 25 mg tablet - -
160 Klorpromazin injeksi 5 mg/ ml ampul - -
161 Kodein HCl tablet 10 mg tablet - -
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah ) - -
163 Kotrimoksazol Dewasa tablet tablet - -
164 Kotrimoksazol Pediatrik tablet tablet - -
165 Kotrimoksazol Suspensi botol @ 60 ml - -
166 Kuinin ( Kina ) tablet 200 mg tablet - -
167 Kuinin injeksi i.v 25% ( sebagai 2 HCl ) ampul
- -
168 Lactodia / Lacto B sachet - -
169 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit (Ringer
170 botol @ 500 ml
Laktat larutan infus steril / Wida RL )
- -
Larutan mengandung elektrolit ( Na 130
mEq, Cl 109 mEq , Ca 3 mEq , Asetat 28
171 botol @ 500 ml
mEq ) / Asering 500 ml larutan infus
steril - -
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) + Epinefrin 1 :
173 ampul @ 2 ml
80.000 - 2 ml - -
174 Linkomisina kapsul 500 mg kapsul - -
175 Lisol, mengandung Kresol tersabun 50% botol
- -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Lysmin Plus Sirup botol @ 60 ml - -
Magnesium Sulfat injeksi ( IV ) 20 % - 25
179 botol @ 25 ml
ml - -
Magnesium Sulfat injeksi ( IV ) 40 % - 25
180 botol @ 25 ml
ml - -
181 MB Anak blister - -
182 MB Dewasa blister - -
183 Mebendazol tablet 100 mg tablet - -
184 Meloksikam tablet 15 mg tablet - -
185 Metformin HCl tablet 500 mg tablet - -
Metilergometrin Maleat (Metilergometrin)
186 tablet
tablet salut 0,125 mg
- -
Metilergometrin Maleat injeksi 0,200 mg-1
187 ampul @ 1 ml
ml - -
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml - -
189 Metoklopropamid tablet 10 mg tablet - -
190 Metronidazol ovula ovula - -
191 Metronidazol tablet 250 mg tablet - -
192 Miconazol krim 2 % ( Nitrat ) tube - -
193 Mineral Mix 8 gr sase - -
194 Natrium Diklofenak tablet 50 mg tablet - -
195 Natrium Klorida larutan infus 0,9% steril botol @ 500 ml
- -
196 Neo Kauminal suspensi botol @ 60 ml - -
197 Neuralgin - RX tablet tablet - -
198 Neurosanbe 5000 mg tablet tablet - -
199 Neurosanbe injeksi ampul - -
200 Neurovit E tablet tablet - -
201 Nifedipin tablet 10 mg tablet - -
202 Nistatin tablet salut 500.000 IU / g tablet - -
203 Nistatin vaginal tablet 100.000 IU / g tablet - -
204 Nodiar tablet tablet - -
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet) - -
206 OAT - FDC Kategori 1 - 3 PAKET paket - -
207 OAT - FDC Kategori 2 PAKET paket - -
208 OAT Kategori anak PAKET paket - -
209 OAT Sisipan paket - -
210 OAT-Kombipak Kategori 1 anak paket - -
211 OAT-Kombipak Kategori 1 dewasa paket - -
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml - -
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup - -
214 Ofloxaxin tablet 200 mg tablet - -
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml - -
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr - -
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml - -
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml - -
220 Omeprazole tablet 20 mg tablet - -
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -
222 Ondansetron tablet 4 mg tablet - -
223 Ondansetron tablet 8 mg tablet - -
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -
225 Papaverin Tablet 40 mg tablet - -
 Parasetamol drop 100 mg/ml ( 60 mg /
226 botol @ 15 ml
0,6 ml ) - -
227 Parasetamol sirup 120 mg / 5 ml botol - -
228 Parasetamol tablet 100 mg tablet - -
229 Parasetamol tablet 500 mg tablet - -
230 PB Anak blister - -
231 PB Dewasa blister - -
232 Pehavral tablet tablet - -
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml - -
234 Pilokarpin HCl / Nitrat tetes mata 2% botol - -
235 Piracetam 1200 mg tablet Kotak - -
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml - -
238 Piracetam tablet 800 mg tablet - -
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml - -
240 Pirantel tablet score ( base ) 125 mg tablet - -
241 Pirazinamida tablet 500 mg tablet - -
242 Piridoksin HCl ( Vitamin B6 ) tablet 10 mg tablet
- -
243 Piroxicam tablet 10 mg tablet - -
244 Piroxicam tablet 20 mg tablet - -
245 Polikresulen cairan ( Aptil ) botol - -
246 Ponflu tablet tablet - -
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml - -
248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml - -
249 Prednison tablet 5 mg tablet - -
250 Primakuin tablet 15 mg tablet - -
251 Prolipid kaplet tablet - -
252 Propiltiourasil tablet 100 mg tablet - -
253 Propranolol HCl tablet 40 mg tablet - -
254 Proris suppositoria supp - -
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
256 Ranitidin tablet 150 mg tablet - -
257 Reserpin tablet 0,25 mg tablet - -
258 Retinol ( Vitamin A ) kapsul 100.000 IU kapsul
- -
Retinol ( Vitamin A ) kapsul 200.000 IU
259 kapsul
kapsul lunak - -
260 Rifampisin kapsul 300 mg tablet - -
261 Risperidon tablet 1 mg tablet - -
262 Salbutamol tablet 2 mg ( sebagai sulfat ) tablet
- -
Salep 2-4 , kombinasi : Asam Salisilat 2
263 pot @ 30 gr
% + Belerang endap 4 % - -
264 Scabicid krim tube - -
265 Sefadroksil kapsul 500 mg kapsul - -
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
- -
267 Sefiksim kapsul 100 mg kapsul - -
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml - -
269 Sefotaksim injeksi 1 gr vial @ 1 gr - -
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr - -
271 Serum ADS 20.000 vial - -
272 Serum Anti Bisa Ular Polivalen injeksi I vial
- -
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp - -
Serum Anti Tetanus Injeksi 20.000 IU /
274 vial
vial - -
275 Setirizin sirup 5 mg / 5 ml botol - -
276 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg - -
Sianokobalamin (Vitamin B12) tablet 50
278 tablet
mcg - -
279 Simetidin tablet 200 mg tablet - -
280 Simvastatin tablet 10 mg tablet - -
281 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg ( sebagai
282 kapsul
HCl ) - -
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml - -
284 Spasi Plus tablet tablet - -
285 Spasminal tablet tablet - -
286 Sulfasetamida Natrium tetes mata 15 % botol
- -
287 Supralivron tablet tablet - -
288 Taburia sachet - -
289 Tamiflu tablet - -
290 Tensigard kapsul kapsul - -
291 Tetrakain HCl tetes mata 0,5% botol - -
292 Tetrasiklin HCl kapsul 250 mg kapsul - -
293 Tetrasiklin HCl kapsul 500 mg kapsul - -
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml - -
295 Thiamfenikol kapsul 500 mg kapsul - -
296 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1ml ampul
- -
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg - -
298 Trifluoperasin tablet 5 mg tablet - -
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
- -
300 Ventolin Nebules 2,5 mg ampul - -
301 Vical Sirup botol @ 60 ml - -
302 Vitamin B Kompleks tablet tablet - -
303 Zenirex Sirup botol @ 60 ml - -
304 Zink sirup 20 mg/5ml ( Zircum Kid Sirup ) botol @ 60 ml
- -
305 Zink tablet disperible 20 mg tablet - -
- -
BAHAN GIGI : - -
306 Air raksa dental use botol - -
307 Cavit - G botol - -
308 Composit resin ( solare ) Kit - -
309 Devitalisasi Pasta ( Non Arsen ) botol - -
310 Etil Klorida semprot ( Duta Kaisar ) botol - -
311 Eugenol cairan botol - -
312 Glass Ionomer Cement ( GC IX ) botol - -
313 Kalsium Hidroksida Pasta ( hydcal ) botol - -
314 Monoklorkamfer Mentol Cairan ( CHKM ) botol
- -
315 Mummifying Pasta botol - -
316 Semen Seng Fosfat serbuk dan cairan botol
- -
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr - -
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji - -
319 Temporary Stopping Fletcher ( Fletcher ) set
- -
320 Trikresol Formalin (TKF) cairan botol - -
321 Tumpatan komposit kit set - -
322 Cressophen botol - -
323 Cressophate botol - -
- -
BAHAN MEDIS HABIS PAKAI ( BMHP )
- -
324 Alat suntik sekali pakai 1 ml tuberculin set - -
325 Alat suntik sekali pakai 3 ml set - -
326 Alat suntik sekali pakai 5 ml set - -
327 Blood Lancet biji - -
328 Blood transfision set set - -
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji - -
330 Folleycatheter Silicon 2 way 14 - 18 biji - -
331 Hans Coen steril / Sarung Tangan pasang - -
332 Hypafix 5 x 5 rol - -
333 Infusion set anak set - -
334 Infusion set dewasa set - -
335 IV. Chateter No. 14 s/d 24 set - -
336 IV. Chateter No. 26 set - -
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji - -
338 Jarum Suntik 22G s/d 25 G biji - -
339 Jarum Suntik 26G biji - -
340 Kapas Pembalut / Absorben 250 gram rol
- -
341 Kasa Kompres 40 / 40 steril rol - -
342 Kasa Pembalut 2 m x 80 cm rol - -
343 Kasa Pembalut Hidrofil 4 m x 15 cm rol - -
344 Kasa Pembalut Hidrofil 4 m x 3 cm rol - -
345 Lomatulle lembar - -
346 Masker Earloop/ Tie On biji - -
347 Masker N 95 set - -
348 Plester 1,25 cm x 4,5 m rol - -
349 Scalp Vein no. 25 biji - -
350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol
- -
351 Surgical Blade / Mess No. 11 biji - -
Umbilical cord klem nylon steril (Claim biji
352
Umbilical) - -
353 Underpad biji - -
354 Urine Bag standard steril 2 Lt ( T valve ) biji
- -
- -
REAGEN LABORATORIUM - -
355 Amonia 10 % botol - -
356 Asam Asetat 6 % botol - -
357 Asam Klorida 0,1 N botol - -
358 Asam Sulfosalisilat 20% botol - -
359 Cholesterol Strip Easy Touch botol - -
360 Cholesterol Strip Nesco botol - -
361 Clever Check Strip 50 test botol - -
362 Contronorm Plus 5 x 5 ml botol - -
363 G O T - AST Starter 8 x 15 ml botol - -
364 G P T - ALT Starter 8 x 15 ml botol - -
365 Glucose GOD PAP botol - -
366 Golda Tulip Anti - A botol - -
367 Golda Tulip Anti - B botol - -
368 Golda Tulip Anti AB botol - -
369 Golda Tulip Anti D/Rhesus botol - -
370 HBs Ag Intec Strip 50 botol - -
371 HDL Cholesterol 6 x 40 ml botol - -
372 Hemoglobin 1000 ml botol - -
373 Kolesterol CHOD-PAP 8 X 20 ml botol - -
374 Kreatinin - Jaffe 400 ml botol - -
375 Larutan Giemsa Stain botol - -
376 Larutan Karbol Fuksin botol - -
377 Larutan Metilen Biru botol - -
378 Larutan Turk botol - -
379 LDL Cholesterol 6 x 50 ml botol - -
380 Metanol botol - -
381 Natrium Chlorida 0,9 % botol - -
382 Pewarna Gram 1 % botol - -
383 Reagen Gol Darah (Anti A,B,AB)+Kartu botol
- -
384 Rees Ecker botol - -
385 Sclessinger botol - -
386 Stik HCG Strip Answer 50 botol - -
387 Stik urine combine 10 test M botol - -
388 Stik urine 10 parameter botol - -
389 Stik urine 3 parameter botol - -
390 Strip Hb Mission Plus botol - -
391 Trigliserida GPO - PAP 8 x 20 ml biji - -
392 Urea Col 1 x 100 ml biji - -
393 Uric Acid Strip Easy Touch biji - -
394 Uric Acid Strip Nesco biji - -
395 Uricase-PAP 8 x 20 ml botol - -
396 VDRL botol - -
397 Widal ( Slam O Paratyphi A ) botol - -
398 Widal ( Slam O Paratyphi B ) botol - -
399 Widal ( Slam Typhi H ) botol - -
400 Widal ( Slam Typhi O ) botol - -
401 Ziel Nelson ( ZN Set ) Pewarna BTA set botol
- -
 - -
OBAT TAMBAHAN : - -
1 Acitral / antasid + simetikon tube - -
2 Akarbose 100 mg ampul - -
3 Alat suntik 10 ml biji - -
4 Alat suntik 20 ml biji - -
5 Alat suntik 50 ml biji - -
6 Alkohol Swabs pcs - -
7 Alletrol Tetes Mata botol - -
8 Amiodaron inj 50 mg/ml ampul - -
9 Ampicillin Injeksi 1 gram vial - -
10 Aqua Gel 150's G sachet sachet - -
11 Arm Sling Comfort (M/L) pcs - -
12 Artikulating paper pcs - -
Asam Asetilsalisilat (Asetosal) tablet 80
13 tablet
mg / Miniaspi - -
14 Aseptik Gel 5 Liter botol - -
15 Askina calgitrol gel 15 g tube - -
16 Askina gel 15 g tube - -
17 Asvex tablet tablet - -
18 Biolysin Sirup botol - -
19 Bisoprolol 2,5 mg tablet - -
20 Bricasma, Terbutaline injeksi 0,5 mg/ml ampul
- -
21 Budesonid inhaler (Pulmicort) pcs - -
22 Budesonid repsules (Pulmicort Repsule) pcs
- -
Budesonide-formoterol 160/4,5
23 pcs
(symbicort) - -
24 Carpule needle L Ject biji - -
25 Carpule posicain 100 biji - -
26 Catgut 3/0 + 1/2 biji - -
27 Catgut Chromic tanpa needle biji - -
28 Catgut No. 2/0 - 100 m biji - -
29 Cell Pack biji - -
30 Cellclean biji - -
31 Cervical Collar Universal pcs - -
32 Cevitron pink kotak - -
33 Cevitron putih kotak - -
34 Chloramex 250 mg tablet tablet - -
35 Cliad / Braxidin tablet - -
36 Clopigrogel tablet 75 mg tablet - -
37 Colergis tablet - -
38 Combivent UDV vial - -
39 Contronorm Plus 5 x 4 mL pcs - -
40 Cotton rol rol - -
41 Cover Glass biji - -
42 Curcumex tablet tablet - -
43 Deculin 15 mg tablet - -
44 Dekstrofen syrup botol - -
45 Demacolin Syrup botol - -
46 Demacolin Tablet tablet - -
47 Dental Cotoon 8 mm (20 ikat @ 50 pcs) rol
- -
48 Dermafix 10 x 15 cm rol - -
49 Dermafix 10 x 20 cm rol - -
50 Dermafix S IV 6x7 cm rol - -
51 Dermafix SS 10 x 10 cm rol - -
52 Dermafix T 10 x 12 cm rol - -
53 Dermafix T 10 x 25 cm rol - -
54 Dermafix T 10 x 8 cm rol - -
55 Dermafix T 6 x 7 cm rol - -
56 Dextral Tablet tablet - -
57 Duk lubang steril 25x30 cm piece - -
58 Duk lubang steril 50x50 cm piece - -
59 Eightchek / Kontrol Hema (H, L, N) biji - -
60 Elite Cement botol - -
61 Endoseal biji - -
62 Eryclone ( Anti AB ) botol - -
63 Female Catheter biji - -
64 Fenitoin injeksi 50 mg / ml ampul - -
65 Flukonazol tablet - -
66 Fluocinolon acetonid / dermasolon tube - -
67 Folleycatheter Silicon 2 way 08 - 12 biji - -
68 Furosemid injeksi 10mg/ml ampul - -
69 Gabapentin 300 mg kapsul - -
Gentamisin salep mata 0,3 % (Genoint
70 tube
salep mata) - -
71 Glimepiride 3 mg tablet - -
72 Glimepiride 4 mg tablet - -
73 Glucosa strip easy touch biji - -
74 Glucose biji - -
75 Glukosa strip on call plus biji - -
76 Gula Darah Stik biji - -
77 Hans Coen Non steril / Sarung Tangan biji
- -
78 Hb Hemoglobin strip quick check biji - -
79 Hypafix 15 x 5 rol - -
80 Hypafix 20 x 5 rol - -
81 Hypafix 5 cm x 1 m rol - -
82 ID Band Anak biji - -
83 ID Band Dewasa biji - -
84 Insulin Rapid Acting (Novorapid) piece - -
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul - -
86 IV Film 6 x 8 cm pcs - -
87 Jarum jahit (bedah) MANI No. 12 biji - -
88 Jarum jahit (bedah) MANI No. 14 biji - -
89 Jarum Suntik Terumo No. 23 biji - -
90 Kasa 3,6 M x 15 cm rol - -
91 Kasa Hidrofil 40 x 80 cm rol - -
92 Kasa steril 16 x 16 cm rol - -
93 Kertas Lakmus Merah biji - -
94 Kertas saring biji - -
95 Kertas Termal USG biji - -
96 Ketorolac injeksi 30 mg / ml ampul - -
97 Klindamisin kapsul 300 mg kapsul - -
98 Kloramfenikol 500 mg kapsul kapsul - -
99 Kloramfenikol salep kulit tube - -
100 Komposit A2 biji - -
101 Komposit A3 biji - -
102 Komposit Nexcon A3 biji - -
103 Komposit Voco A3 biji - -
104 Komposit Voco Incisal biji - -
105 Konik ECG gel botol - -
106 Laktulosa syrup botol - -
107 Masker Nebulizer Anak piece - -
108 Masker Nebulizer Dewasa piece - -
109 Mata bur no 1 biji - -
110 Mata bur no 2 biji - -
111 Mata bur set biji - -
112 Matovit tablet tablet - -
113 Maxiflow anak biji - -
114 Maxiflow bayi biji - -
115 Maxiflow dewasa biji - -
116 Mersibion injeksi ampul - -
117 Metilprednisolon 4 mg tablet - -
118 Metilprednisolon inj 500mg/8ml ampul - -
119 Metilprednisolon injeksi 125mg/ml ampul - -
120 Metronidazole 500mg tablet tablet - -
121 Metronidazole infus 500mg/100 ml botol - -
122 Mitella piece - -
123 Mucus Extraction pcs - -
124 My Jelly 82 gram tube - -
125 Nasal dan Masker Oksigen Anak pcs - -
126 Nasal dan Masker Oksigen Dewasa pcs - -
127 Nebulizer canula Adult piece - -
128 Nebulizer canula Child piece - -
129 Needle carpule biji - -
130 Needle no 25 biji - -
131 Nierbeken Disposible 25 cm pcs - -
132 Nistatin suspensi 100.000 IU / ml botol - -
133 Norepinephrine bitartat injeksi 1 mg/ml ampul
- -
134 Novomix Flexpen biji - -
135 Object Glass biji - -
136 Oksigen canula adult biji - -
137 Oksigen canula child biji - -
138 Paracetamol drip (infus) 1g / 100 mL botol - -
139 Parasetamol suppositoria - Pamol Supp suppo
- -
140 Pehacain injeksi ampul - -
141 Pembalut hamil piece - -
142 Plesterin Bulat Soft isi 200 piece - -
143 Plesterin Roll 20 cm x 5 m rol - -
144 Povidone iodine 60 ml botol - -
145 Probenid tab 500 mg tablet - -
146 Prontosan wound gel botol - -
147 Prontosan wound irigation botol - -
148 Psidii 500 mg kapsul kapsul - -
149 Psidii sirup botol - -
150 Risperidon tablet 2 mg tablet - -
151 Safety Box 12 L piece - -
152 Safety Box 5 Lt OM piece - -
153 Salbutamol 4 mg tablet - -
154 Sarung Tangan Gynaecolog pasang - -
155 Sikzonoat Inj / Flupenaziin Inj ampul - -
156 Silk No. 2/0 - 100 m rol - -
157 Slem / Mucus Extractor biji - -
158 Spalk 10 x 5 cm biji - -
159 Spalk 100 x 10 piece - -
160 Spalk 15 x 5 piece - -
161 Spalk 20 x 5 cm biji - -
162 Spalk 4 x 12 cm biji - -
163 Spalk 40 x 8 x 7 cm biji - -
164 Spalk 60 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
166 Spironolacton tab 100 mg tablet - -
167 Spironolacton tab 25mg tablet - -
168 Stik Asam Urat biji - -
169 Stik Gula Darah biji - -
170 Stik Kolesterol biji - -
171 Stromatolyser piece - -
172 Suction catheter no 12 biji - -
173 Sukralfat suspensi botol - -
174 Superpatch jumbo biji - -
175 Surgical gown non woven steril pcs - -
176 Surgical gown spunlace biji - -
177 Tensocrepe 3 inch biji - -
178 Tensocrepe 4 inch biji - -
179 Tensocrepe 6 inch biji - -
180 Terbutalin repsules (bricasma repsule) ampul
- -
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler) - -
182 Test Kehamilan piece - -
183 Test Kesuburan (Baby Test) piece - -
184 Tremenza Syrup botol - -
185 Tremenza Tablet tablet - -
186 Triamcinolon injeksi 10 mg/ml ampul - -
187 Truvit syrup botol - -
188 Ultrasonic gel botol - -
189 Urea pcs - -
190 Uricase pcs - -
191 USC Gel 250 ml botol - -
192 Vaculab EDTA 3 ml piece - -
193 Vaculab non EDTA 3 ml plain pcs - -
194 Valsartan 80 mg tablet - -
195 Yellow Tip pcs - -
196 Zinc Syrup 10 mg / ml botol - -
197 Coparcetin tab tablet - -
198 Curbiplex sirup BOtol - -
199 Fultrop tablet tablet - -
200 Fultrop SIRUP BOtol - -
 201 Molexflu syr botol - -
202 APD coverall - -
203 Isolation Gown - -
204 nurse/dokter cap - -

205 shoes cover

- -

206 Hemaviton cardio

- -

207 Coparcetin sirup botol

- -

208 Plesterin roll 10 cm x 5 m

- -
Aseptik gel 1 L/Hand Foam sanitiser 600
209 botol
ml - -

210 Cavilpex tablet

- -
211 Etanol 96% botol
- -

BPJS

JUMLAH KUNJUNGAN RESEP PBI ASKES MANDIRI

YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN

PETUGAS GUDANG PIMPINAN PUSKESMAS

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

NIP.19840403 2011012 013 NIP.19610823 198901 1 003

Yang Melayani :…………………….. Yang Memerik

AT JKN PUSKESMAS

RIODE : PEBRUARI
RIODE : MARET 2021

STOK AKHIR STOK OPT. KET

8 9 10
NON BPJS JUMLAH

Gresik, 28 Februari 2021

YANG MENERIMA

PETUGAS PUSTU/PONKESDES

(.......................................................)

Yang Memeriksa : ……………………………..

 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : SUMBER RAME

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : PASINAN
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

AP
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES :SEMBUNG
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : KEDUNG ANYAR

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

 A
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

RAN BULAN / PERIODE :
AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN P
( LPLPO JKN )
PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN
KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE :

NO NAMA OBAT SAT. SISA AWAL PENERIMAAN PERSEDIAAN

1 2 3 4 5 6
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet -
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul -
3 Albendazol suspensi 200 mg / 5 ml botol
-
4 Albendazol tablet 400 mg tablet -
5 Albuthyl Ovula supp -
6 Alopurinol tablet 100 mg tablet -
7 Alopurinol tablet 300 mg tablet -
8 Alprazolam 0,5 mg tablet tablet -
9 Ambroxol sirup 15 mg / ml botol @ 60 ml -
10 Ambroxol tablet 30 mg tablet -
11 Aminofilin tablet scored 200 mg tablet -
12 Aminofilina injeksi 24 mg / ml ampul -
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
-
14 Amlodipine tablet 10 mg tablet -
15 Amlodipine tablet 5 mg tablet -
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml -
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml -
18 Amoksisilin kaplet 500 mg tablet -
19 Amoksisilin kapsul 250 mg tablet -
20 Amoksisilin Serbuk injeksi 1000 mg vial
-
Amoxillin + As.Klavulanat 625 mg
21 tablet
kapsul -
22 Ampisilina sirup kering 125 mg/5ml botol
-
23 Antalgin ( Metampiron ) tablet 500 mg tablet
-
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml -
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik ) -

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg
-
Antasida DOEN II suspensi,
kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml -
28 Antifungi DOEN pot @ 30 gr -
29 Antihemoroid DOEN supp -
30 Antimigren DOEN tablet tablet -
31 Antiparkinson DOEN tablet tablet -
32 Aqua pro Injeksi steril, bebas pirogen botol
-
33 Aquadest steril botol @ 1000 ml -
 Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg -
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg -
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg -
37 Asam Folat tablet 0,4 mg tablet -
38 Asam Folat tablet 1 mg tablet -
39 Asam Mefenamat kaplet 500 mg tablet -
40 Asam traneksamat injeksi 100 mg/ml ampul
-
41 Asam traneksamat injeksi 50 mg/ml ampul
-
42 Aseptik Gel 500 cc + dispenser botol @ 500 ml -
43 Asiklovir krim 5 % tube @ 5 gr -
44 Asiklovir tablet 400 mg tablet -
45 Atapulgit tablet 600 mg tablet -
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml -
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 % tablet -
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial -
55 Besi Sirup botol -
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur -
57 Betahistin Mesilat tablet 6 mg tablet -
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat ) -
59 Betason - N krim tube -
60 Bisacodil ( Bicolak ) tablet tablet -
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp ) -
62 Bisoprolol tablet 5 mg tablet -
63 Borak Gliserin 5% botol @ 15 ml -
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet) -
65 Bronchitin Expektoran Sirup botol @ 50 ml -
66 Centabio Jelly / Bioplacenton Jelly tablet -
67 Curcuma tablet tablet -
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml -
69 Deksametason tablet 0,5 mg tablet -
70 Desoksimetason krim 0,25 % tube @ 15 gr -
71 Diazepam injeksi 5 mg / ml - 2 ml ampul -
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube) -
73 Diazepam tablet 2 mg tablet -
74 Dietilkarbamazin Sitrat tablet 100 mg tablet
-
75 Difenhidramin HCl injeksi 10 mg / ml ampul
-
76 Digoksin tablet 0,25 mg tablet -
77 Dimenhidrinat tablet 50 mg tablet -
78 Doksisiklin tablet 100 mg tablet -
79 Domperidone sirup 5 mg/5ml botol @ 60 ml -
80 Domperidone tablet 10 mg tablet -
81 Efedrin HCl tablet 25 mg tablet -
82 Ekstrak Belladon tablet 10 mg tablet -
83 Elkana Sirup tablet -
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml -
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml -
86 Eritromisin kapsul 500 mg kapsul -
87 Etakridin ( Rivanol ) larutan 0,1% botol -
88 Etanol 70 % 100 ml botol -
89 Etanol 70% 1000 ml botol -
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg) -
91 Fenitoin Natrium kapsul 100 mg kapsul -
92 Fenitoin Natrium kapsul 30 mg kapsul -
93 Fenobarbital tablet 30 mg tablet -
94 Fenofibrat kapsul 100 mg kapsul -
95 Fenofibrat kapsul 300 mg kapsul -
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg -
97 Fenol Gliserol tetes telinga 10% botol -
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml -
Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus ) -
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg -
101 Fludane Plus Sirup botol @ 60 ml -
102 Fluor tablet 0,5 mg tablet -
103 Furosemid tablet 40 mg tablet -
104 Garam Oralit untuk 200 ml air sase -
105 Gelofusin Infus botol @ 500 ml -
106 Gemfibrosil kapsul 300 mg kapsul -
107 Gemfibrosil kapsul 600 mg kapsul -
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr -
109 Gentamisin tetes mata 0,3 % botol -
110 Gentian Violet larutan 1 % botol @10 ml -
111 Glibenklamid tablet 5 mg tablet -
112 Glimepiride tablet 2 mg tablet -
113 Gliseril Guaiakolat tablet 100 mg tablet -
114 Glukosa 5% - 1/2 NS botol @ 500 ml -
115 Glukosa 5% - 1/4 NS botol @ 500 ml -
116 Glukosa larutan infus 10 % steril botol @ 25 ml -
117 Glukosa larutan infus 40 % steril botol @ 25 ml -
118 Glukosa larutan infus 5 % steril botol @ 500 ml -
119 Griseofulvin tablet 125 mg tablet -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) -
121 Haloperidol tablet 0,5 mg tablet -
122 Haloperidol tablet 1,5 mg tablet -
123 Haloperidol tablet 5 mg tablet -
124 Hemobion tablet tablet -
125 Hemorogard kapsul kapsul -
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
-
127 Hidrokortison krim 2,5 % tube -
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi) -
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml -
130 Ibuprofen tablet 200 mg tablet -
131 Ibuprofen tablet 400 mg tablet -
132 Ichtiyol Zalf pot @ 15 gr -
133 Iodiol kapsul lunak kapsul -
134 Ipratropium bromida nebulazer 0,025 ampul
-
135 Isoniazide tablet 100 mg tablet -
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg -
137 KA-EN 3 B Otsu infus botol @ 500 ml -
138 Kalium Diklofenak tablet 50 mg tablet -
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml ) -
140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet
-
141 Kaptopril tablet scored 25 mg tablet -
142 Kaptopril tablet scored 12,5 mg tablet -
143 Karbamazepin tablet 200 mg tablet -
144 Ketokonazol krim 2 % tube 10 gr -
145 Ketokonazol tablet 200 mg tablet -
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp ) -
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml -
148 Klindamisin kapsul 150 mg kapsul -
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg ) -
150 Kloramfenikol kapsul 250 mg kapsul -
151 Kloramfenikol salep mata 1 % tube -
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
-
153 Kloramfenikol tetes Mata botol @ 5 ml -
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml -
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg -
156 Klorheksidin larutan 15 % botol -
157 Klorokuin Fosfat tablet 250 mg tablet -
158 Klorpromazin HCl tablet salut 100 mg tablet
-
159 Klorpromazin HCl tablet salut 25 mg tablet
-
160 Klorpromazin injeksi 5 mg/ ml ampul -
161 Kodein HCl tablet 10 mg tablet -
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah ) -
163 Kotrimoksazol Dewasa tablet tablet -
164 Kotrimoksazol Pediatrik tablet tablet -
165 Kotrimoksazol Suspensi botol @ 60 ml -
166 Kuinin ( Kina ) tablet 200 mg tablet -
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
) -
168 Lactodia / Lacto B sachet -
169 Lansoprazol tablet 30 mg tablet -
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL ) -
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril -
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml -
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml -
174 Linkomisina kapsul 500 mg kapsul -
 Lisol, mengandung Kresol tersabun
175 botol
50% -
176 Loperamida tablet 2 mg tablet -
177 Loratadin tablet 10 mg tablet -
178 Lysmin Plus Sirup botol @ 60 ml -
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml -
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml -
181 MB Anak blister -
182 MB Dewasa blister -
183 Mebendazol tablet 100 mg tablet -
184 Meloksikam tablet 15 mg tablet -
185 Metformin HCl tablet 500 mg tablet -
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg -
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml -
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml -
189 Metoklopropamid tablet 10 mg tablet -
190 Metronidazol ovula ovula -
191 Metronidazol tablet 250 mg tablet -
192 Miconazol krim 2 % ( Nitrat ) tube -
193 Mineral Mix 8 gr sase -
194 Natrium Diklofenak tablet 50 mg tablet -
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril -
196 Neo Kauminal suspensi botol @ 60 ml -
197 Neuralgin - RX tablet tablet -
198 Neurosanbe 5000 mg tablet tablet -
199 Neurosanbe injeksi ampul -
200 Neurovit E tablet tablet -
201 Nifedipin tablet 10 mg tablet -
202 Nistatin tablet salut 500.000 IU / g tablet -
203 Nistatin vaginal tablet 100.000 IU / g tablet
-
204 Nodiar tablet tablet -
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet) -
206 OAT - FDC Kategori 1 - 3 PAKET paket
-
207 OAT - FDC Kategori 2 PAKET paket -
208 OAT Kategori anak PAKET paket -
209 OAT Sisipan paket -
210 OAT-Kombipak Kategori 1 anak paket -
211 OAT-Kombipak Kategori 1 dewasa paket
-
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml -
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup -
214 Ofloxaxin tablet 200 mg tablet -
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
-
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr -
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr -
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml -
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml -
220 Omeprazole tablet 20 mg tablet -
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml -
222 Ondansetron tablet 4 mg tablet -
223 Ondansetron tablet 8 mg tablet -
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml -
225 Papaverin Tablet 40 mg tablet -
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml ) -
227 Parasetamol sirup 120 mg / 5 ml botol -
228 Parasetamol tablet 100 mg tablet -
229 Parasetamol tablet 500 mg tablet -
230 PB Anak blister -
231 PB Dewasa blister -
232 Pehavral tablet tablet -
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml
-
234 Pilokarpin HCl / Nitrat tetes mata 2% botol
-
235 Piracetam 1200 mg tablet Kotak -
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml -
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml -
238 Piracetam tablet 800 mg tablet -
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml -
240 Pirantel tablet score ( base ) 125 mg tablet
-
241 Pirazinamida tablet 500 mg tablet -
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg -
243 Piroxicam tablet 10 mg tablet -
244 Piroxicam tablet 20 mg tablet -
245 Polikresulen cairan ( Aptil ) botol -
246 Ponflu tablet tablet -
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml
-
248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml
-
249 Prednison tablet 5 mg tablet -
250 Primakuin tablet 15 mg tablet -
251 Prolipid kaplet tablet -
252 Propiltiourasil tablet 100 mg tablet -
253 Propranolol HCl tablet 40 mg tablet -
254 Proris suppositoria supp -
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml -
256 Ranitidin tablet 150 mg tablet -
257 Reserpin tablet 0,25 mg tablet -
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU -
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak -
260 Rifampisin kapsul 300 mg tablet -
261 Risperidon tablet 1 mg tablet -
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat ) -
Salep 2-4 , kombinasi : Asam Salisilat
263 pot @ 30 gr
2 % + Belerang endap 4 %
-
264 Scabicid krim tube -
265 Sefadroksil kapsul 500 mg kapsul -
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
-
267 Sefiksim kapsul 100 mg kapsul -
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
-
269 Sefotaksim injeksi 1 gr vial @ 1 gr -
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
-
271 Serum ADS 20.000 vial -
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I -
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp -
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial -
275 Setirizin sirup 5 mg / 5 ml botol -
276 Setirizin tablet 10 mg tablet -
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg -
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg -
279 Simetidin tablet 200 mg tablet -
280 Simvastatin tablet 10 mg tablet -
281 Simvastatin tablet 20 mg tablet -
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl ) -
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml -
284 Spasi Plus tablet tablet -
285 Spasminal tablet tablet -
Sulfasetamida Natrium tetes mata 15
286 botol
% -
287 Supralivron tablet tablet -
288 Taburia sachet -
289 Tamiflu tablet -
290 Tensigard kapsul kapsul -
291 Tetrakain HCl tetes mata 0,5% botol -
292 Tetrasiklin HCl kapsul 250 mg kapsul -
293 Tetrasiklin HCl kapsul 500 mg kapsul -
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml -
295 Thiamfenikol kapsul 500 mg kapsul -
Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml -
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg -
298 Trifluoperasin tablet 5 mg tablet -
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
-
300 Ventolin Nebules 2,5 mg ampul -
301 Vical Sirup botol @ 60 ml -
302 Vitamin B Kompleks tablet tablet -
303 Zenirex Sirup botol @ 60 ml -
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup ) -
305 Zink tablet disperible 20 mg tablet -
-
BAHAN GIGI : -
306 Air raksa dental use botol -
307 Cavit - G botol -
308 Composit resin ( solare ) Kit -
309 Devitalisasi Pasta ( Non Arsen ) botol -
310 Etil Klorida semprot ( Duta Kaisar ) botol
-
311 Eugenol cairan botol -
312 Glass Ionomer Cement ( GC IX ) botol -
313 Kalsium Hidroksida Pasta ( hydcal ) botol
-
Monoklorkamfer Mentol Cairan
314 botol
( CHKM ) -
315 Mummifying Pasta botol -
Semen Seng Fosfat serbuk dan
316 botol
cairan -
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr -
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji
-
Temporary Stopping Fletcher
319 set
( Fletcher ) -
320 Trikresol Formalin (TKF) cairan botol -
321 Tumpatan komposit kit set -
322 Cressophen botol -
323 Cressophate botol -
-
BAHAN MEDIS HABIS PAKAI
( BMHP ) -
324 Alat suntik sekali pakai 1 ml tuberculin set
-
325 Alat suntik sekali pakai 3 ml set -
326 Alat suntik sekali pakai 5 ml set -
327 Blood Lancet biji -
328 Blood transfision set set -
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji
-
330 Folleycatheter Silicon 2 way 14 - 18 biji
-
331 Hans Coen steril / Sarung Tangan pasang -
332 Hypafix 5 x 5 rol -
333 Infusion set anak set -
334 Infusion set dewasa set -
335 IV. Chateter No. 14 s/d 24 set -
336 IV. Chateter No. 26 set -
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji -
338 Jarum Suntik 22G s/d 25 G biji -
339 Jarum Suntik 26G biji -
340 Kapas Pembalut / Absorben 250 gram rol
-
341 Kasa Kompres 40 / 40 steril rol -
342 Kasa Pembalut 2 m x 80 cm rol -
343 Kasa Pembalut Hidrofil 4 m x 15 cm rol
-
344 Kasa Pembalut Hidrofil 4 m x 3 cm rol
-
345 Lomatulle lembar -
346 Masker Earloop/ Tie On biji -
347 Masker N 95 set -
348 Plester 1,25 cm x 4,5 m rol -
349 Scalp Vein no. 25 biji -
350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol
-
351 Surgical Blade / Mess No. 11 biji -
Umbilical cord klem nylon steril (Claim biji
352
Umbilical) -
353 Underpad biji -
Urine Bag standard steril 2 Lt ( T
354 biji
valve ) -
-
REAGEN LABORATORIUM -
355 Amonia 10 % botol -
356 Asam Asetat 6 % botol -
357 Asam Klorida 0,1 N botol -
358 Asam Sulfosalisilat 20% botol -
359 Cholesterol Strip Easy Touch botol -
360 Cholesterol Strip Nesco botol -
361 Clever Check Strip 50 test botol -
362 Contronorm Plus 5 x 5 ml botol -
363 G O T - AST Starter 8 x 15 ml botol -
364 G P T - ALT Starter 8 x 15 ml botol -
365 Glucose GOD PAP botol -
366 Golda Tulip Anti - A botol -
367 Golda Tulip Anti - B botol -
368 Golda Tulip Anti AB botol -
369 Golda Tulip Anti D/Rhesus botol -
370 HBs Ag Intec Strip 50 botol -
371 HDL Cholesterol 6 x 40 ml botol -
372 Hemoglobin 1000 ml botol -
373 Kolesterol CHOD-PAP 8 X 20 ml botol -
374 Kreatinin - Jaffe 400 ml botol -
375 Larutan Giemsa Stain botol -
376 Larutan Karbol Fuksin botol -
377 Larutan Metilen Biru botol -
378 Larutan Turk botol -
379 LDL Cholesterol 6 x 50 ml botol -
380 Metanol botol -
381 Natrium Chlorida 0,9 % botol -
382 Pewarna Gram 1 % botol -
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu -
384 Rees Ecker botol -
385 Sclessinger botol -
386 Stik HCG Strip Answer 50 botol -
387 Stik urine combine 10 test M botol -
388 Stik urine 10 parameter botol -
389 Stik urine 3 parameter botol -
390 Strip Hb Mission Plus botol -
391 Trigliserida GPO - PAP 8 x 20 ml biji -
392 Urea Col 1 x 100 ml biji -
393 Uric Acid Strip Easy Touch biji -
394 Uric Acid Strip Nesco biji -
395 Uricase-PAP 8 x 20 ml botol -
396 VDRL botol -
397 Widal ( Slam O Paratyphi A ) botol -
398 Widal ( Slam O Paratyphi B ) botol -
399 Widal ( Slam Typhi H ) botol -
400 Widal ( Slam Typhi O ) botol -
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set -
-
OBAT TAMBAHAN : -
1 Acitral / antasid + simetikon tube -
2 Akarbose 100 mg ampul -
3 Alat suntik 10 ml biji -
4 Alat suntik 20 ml biji -
5 Alat suntik 50 ml biji -
6 Alkohol Swabs pcs -
7 Alletrol Tetes Mata botol -
8 Amiodaron inj 50 mg/ml ampul -
9 Ampicillin Injeksi 1 gram vial -
10 Aqua Gel 150's G sachet sachet -
11 Arm Sling Comfort (M/L) pcs -
12 Artikulating paper pcs -
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi -
14 Aseptik Gel 5 Liter botol -
15 Askina calgitrol gel 15 g tube -
16 Askina gel 15 g tube -
17 Asvex tablet tablet -
18 Biolysin Sirup botol -
19 Bisoprolol 2,5 mg tablet -
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml -
21 Budesonid inhaler (Pulmicort) pcs -
Budesonid repsules (Pulmicort
22 pcs
Repsule) -
Budesonide-formoterol 160/4,5
23 pcs
(symbicort) -
24 Carpule needle L Ject biji -
25 Carpule posicain 100 biji -
26 Catgut 3/0 + 1/2 biji -
27 Catgut Chromic tanpa needle biji -
28 Catgut No. 2/0 - 100 m biji -
29 Cell Pack biji -
30 Cellclean biji -
31 Cervical Collar Universal pcs -
32 Cevitron pink kotak -
33 Cevitron putih kotak -
34 Chloramex 250 mg tablet tablet -
35 Cliad / Braxidin tablet -
36 Clopigrogel tablet 75 mg tablet -
37 Colergis tablet -
38 Combivent UDV vial -
39 Contronorm Plus 5 x 4 mL pcs -
40 Cotton rol rol -
41 Cover Glass biji -
42 Curcumex tablet tablet -
43 Deculin 15 mg tablet -
44 Dekstrofen syrup botol -
45 Demacolin Syrup botol -
46 Demacolin Tablet tablet -
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs) -
48 Dermafix 10 x 15 cm rol -
49 Dermafix 10 x 20 cm rol -
50 Dermafix S IV 6x7 cm rol -
51 Dermafix SS 10 x 10 cm rol -
52 Dermafix T 10 x 12 cm rol -
53 Dermafix T 10 x 25 cm rol -
54 Dermafix T 10 x 8 cm rol -
55 Dermafix T 6 x 7 cm rol -
56 Dextral Tablet tablet -
57 Duk lubang steril 25x30 cm piece -
58 Duk lubang steril 50x50 cm piece -
59 Eightchek / Kontrol Hema (H, L, N) biji -
60 Elite Cement botol -
61 Endoseal biji -
62 Eryclone ( Anti AB ) botol -
63 Female Catheter biji -
64 Fenitoin injeksi 50 mg / ml ampul -
65 Flukonazol tablet -
66 Fluocinolon acetonid / dermasolon tube
-
67 Folleycatheter Silicon 2 way 08 - 12 biji
-
68 Furosemid injeksi 10mg/ml ampul -
69 Gabapentin 300 mg kapsul -
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata) -
71 Glimepiride 3 mg tablet -
72 Glimepiride 4 mg tablet -
73 Glucosa strip easy touch biji -
74 Glucose biji -
75 Glukosa strip on call plus biji -
76 Gula Darah Stik biji -
Hans Coen Non steril / Sarung
77 biji
Tangan -
78 Hb Hemoglobin strip quick check biji -
79 Hypafix 15 x 5 rol -
80 Hypafix 20 x 5 rol -
81 Hypafix 5 cm x 1 m rol -
82 ID Band Anak biji -
83 ID Band Dewasa biji -
84 Insulin Rapid Acting (Novorapid) piece -
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul -
86 IV Film 6 x 8 cm pcs -
87 Jarum jahit (bedah) MANI No. 12 biji -
88 Jarum jahit (bedah) MANI No. 14 biji -
89 Jarum Suntik Terumo No. 23 biji -
90 Kasa 3,6 M x 15 cm rol -
91 Kasa Hidrofil 40 x 80 cm rol -
92 Kasa steril 16 x 16 cm rol -
93 Kertas Lakmus Merah biji -
94 Kertas saring biji -
95 Kertas Termal USG biji -
96 Ketorolac injeksi 30 mg / ml ampul -
97 Klindamisin kapsul 300 mg kapsul -
98 Kloramfenikol 500 mg kapsul kapsul -
99 Kloramfenikol salep kulit tube -
100 Komposit A2 biji -
101 Komposit A3 biji -
102 Komposit Nexcon A3 biji -
103 Komposit Voco A3 biji -
104 Komposit Voco Incisal biji -
105 Konik ECG gel botol -
106 Laktulosa syrup botol -
107 Masker Nebulizer Anak piece -
108 Masker Nebulizer Dewasa piece -
109 Mata bur no 1 biji -
110 Mata bur no 2 biji -
111 Mata bur set biji -
112 Matovit tablet tablet -
113 Maxiflow anak biji -
114 Maxiflow bayi biji -
115 Maxiflow dewasa biji -
116 Mersibion injeksi ampul -
117 Metilprednisolon 4 mg tablet -
118 Metilprednisolon inj 500mg/8ml ampul -
119 Metilprednisolon injeksi 125mg/ml ampul -
120 Metronidazole 500mg tablet tablet -
121 Metronidazole infus 500mg/100 ml botol
-
122 Mitella piece -
123 Mucus Extraction pcs -
124 My Jelly 82 gram tube -
125 Nasal dan Masker Oksigen Anak pcs -
126 Nasal dan Masker Oksigen Dewasa pcs
-
127 Nebulizer canula Adult piece -
128 Nebulizer canula Child piece -
129 Needle carpule biji -
130 Needle no 25 biji -
131 Nierbeken Disposible 25 cm pcs -
132 Nistatin suspensi 100.000 IU / ml botol -
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml -
134 Novomix Flexpen biji -
135 Object Glass biji -
136 Oksigen canula adult biji -
137 Oksigen canula child biji -
138 Paracetamol drip (infus) 1g / 100 mL botol
-
Parasetamol suppositoria - Pamol
139 suppo
Supp -
140 Pehacain injeksi ampul -
141 Pembalut hamil piece -
142 Plesterin Bulat Soft isi 200 piece -
143 Plesterin Roll 20 cm x 5 m rol -
144 Povidone iodine 60 ml botol -
145 Probenid tab 500 mg tablet -
146 Prontosan wound gel botol -
147 Prontosan wound irigation botol -
148 Psidii 500 mg kapsul kapsul -
149 Psidii sirup botol -
150 Risperidon tablet 2 mg tablet -
151 Safety Box 12 L piece -
152 Safety Box 5 Lt OM piece -
153 Salbutamol 4 mg tablet -
154 Sarung Tangan Gynaecolog pasang -
155 Sikzonoat Inj / Flupenaziin Inj ampul -
156 Silk No. 2/0 - 100 m rol -
157 Slem / Mucus Extractor biji -
158 Spalk 10 x 5 cm biji -
159 Spalk 100 x 10 piece -
160 Spalk 15 x 5 piece -
161 Spalk 20 x 5 cm biji -
162 Spalk 4 x 12 cm biji -
163 Spalk 40 x 8 x 7 cm biji -
164 Spalk 60 x 10 piece -
165 Spalk 80 x 10 x 8 cm biji -
166 Spironolacton tab 100 mg tablet -
167 Spironolacton tab 25mg tablet -
168 Stik Asam Urat biji -
169 Stik Gula Darah biji -
170 Stik Kolesterol biji -
171 Stromatolyser piece -
172 Suction catheter no 12 biji -
173 Sukralfat suspensi botol -
174 Superpatch jumbo biji -
175 Surgical gown non woven steril pcs -
176 Surgical gown spunlace biji -
177 Tensocrepe 3 inch biji -
178 Tensocrepe 4 inch biji -
179 Tensocrepe 6 inch biji -
Terbutalin repsules (bricasma
180 ampul
repsule) -
 Terbutalin turbuhaler (bricasma
181 piece
turbuhaler) -
182 Test Kehamilan piece -
183 Test Kesuburan (Baby Test) piece -
184 Tremenza Syrup botol -
185 Tremenza Tablet tablet -
186 Triamcinolon injeksi 10 mg/ml ampul -
187 Truvit syrup botol -
188 Ultrasonic gel botol -
189 Urea pcs -
190 Uricase pcs -
191 USC Gel 250 ml botol -
192 Vaculab EDTA 3 ml piece -
193 Vaculab non EDTA 3 ml plain pcs -
194 Valsartan 80 mg tablet -
195 Yellow Tip pcs -
196 Zinc Syrup 10 mg / ml botol -
197 Coparcetin tab tablet -
198 Curbiplex sirup BOtol -
199 Fultrop tablet tablet -
200 Fultrop SIRUP BOtol -
201 Molexflu syr botol -
202 APD coverall -
203 Isolation Gown -
204 nurse/dokter cap -

205 shoes cover

-

206 Hemaviton cardio

-

207 Coparcetin sirup botol

-

208 Plesterin roll 10 cm x 5 m

-
Aseptik gel 1 L/Hand Foam sanitiser
209 botol
600 ml -

210 Cavilpex tablet

-
211 Etanol 96% botol
-

BPJS

JUMLAH KUNJUNGAN RESEP PBI ASKES

 YANG MENYERAHKAN

PETUGAS GUDANG

(Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

INTAAN OBAT JKN PUSKESMAS
)

LAPORAN BULAN / PERIODE :

MINTAAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT. KET

7 8 9 10

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-

-
-
-
-
-

-
-
-

-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-

-
-
-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

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

-
-
-
-
-

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

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

BPJS NON BPJS JUMLAH

MANDIRI
YANG MEMINTA / MELAPORKAN YANG MENERIMA

PIMPINAN PUSKESMAS PETUGAS PUSTU/PONKESDES

(drg.Jon Sudiro Hendrata) (.......................................................)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)
 LAPORAN PEMAKAIAN DA

PUSTU/PONKESDES/POLINDES : KEPUH KLAGEN

KECAMATAN :WRINGINANOM
KABUPATEN : GRESIK
PROVINSI : JAWA TIMUR

NO NAMA OBAT SAT.

1 2 3
OBAT-OBATAN :
1 Adona AC - 17 tablet tablet
2 Adona AC Injeksi 5 mg / ml - 2 ml ampul
3 Albendazol suspensi 200 mg / 5 ml botol
4 Albendazol tablet 400 mg tablet
5 Albuthyl Ovula supp
6 Alopurinol tablet 100 mg tablet
7 Alopurinol tablet 300 mg tablet
8 Alprazolam 0,5 mg tablet tablet
9 Ambroxol sirup 15 mg / ml botol @ 60 ml
10 Ambroxol tablet 30 mg tablet
11 Aminofilin tablet scored 200 mg tablet
12 Aminofilina injeksi 24 mg / ml ampul
13 Amitriptilin tablet salut 25 mg ( HCl ) tablet
14 Amlodipine tablet 10 mg tablet
15 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125 mg / 5
16 botol @ 60 ml
ml
Amoksisilin Sirup Kering 250 mg / 5
17 botol @ 60 ml
ml
18 Amoksisilin kaplet 500 mg tablet
19 Amoksisilin kapsul 250 mg tablet
20 Amoksisilin Serbuk injeksi 1000 mg vial

Amoxillin + As.Klavulanat 625 mg

21 tablet
kapsul

22 Ampisilina sirup kering 125 mg/5ml botol

23 Antalgin ( Metampiron ) tablet 500 mg tablet

24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml
Antalgin ( Metamisol )injeksi 500 mg /
25 ml - 2 ml ( Novalgin / Antrain / ampul @ 2 ml
Santagesik )

Antasida DOEN I tablet kunyah,

26 kombinasi : Aluminium Hidroksida 200 tablet
mg ; Magnesium Hidroksida 200 mg

Antasida DOEN II suspensi,

kombinasi : Aluminium Hidroksida 200
27 botol @ 60 ml
mg/ml ; Magnesium Hidroksida 200
mg/ml
28 Antifungi DOEN pot @ 30 gr
29 Antihemoroid DOEN supp
30 Antimigren DOEN tablet tablet
31 Antiparkinson DOEN tablet tablet
32 Aqua pro Injeksi steril, bebas pirogen botol
33 Aquadest steril botol @ 1000 ml
Asam Asetilsalisilat (Asetosal) tablet
34 tablet
100 mg
Asam Asetilsalisilat (Asetosal) tablet
35 tablet
500 mg
Asam Askorbat ( Vitamin C ) tablet 50
36 tablet
mg
37 Asam Folat tablet 0,4 mg tablet
38 Asam Folat tablet 1 mg tablet
39 Asam Mefenamat kaplet 500 mg tablet
40 Asam traneksamat injeksi 100 mg/ml ampul

41 Asam traneksamat injeksi 50 mg/ml ampul

42 Aseptik Gel 500 cc + dispenser botol @ 500 ml
43 Asiklovir krim 5 % tube @ 5 gr
44 Asiklovir tablet 400 mg tablet
45 Atapulgit tablet 600 mg tablet
Atropin Sulfat injeksi 0,25 mg / ml - 1
46 ampul
ml
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 % tablet
Benzatin Benzil Penisillin Injeksi 2.4 Jt
54 ampul
IU/vial
55 Besi Sirup botol
Betadin Gargle 100 ml / Molexdin obat
56 botol
kumur
57 Betahistin Mesilat tablet 6 mg tablet
Betametason krim 0.1% ( sebagai
58 tube 5 gr
valerat )
59 Betason - N krim tube
60 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg ( Stolax
61 supp
supp )
62 Bisoprolol tablet 5 mg tablet
63 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex tablet ;
64 tablet
Novaheksin tablet)
65 Bronchitin Expektoran Sirup botol @ 50 ml
66 Centabio Jelly / Bioplacenton Jelly tablet
67 Curcuma tablet tablet
68 Deksametason injeksi 5 mg / ml ampul @ 1 ml
69 Deksametason tablet 0,5 mg tablet
70 Desoksimetason krim 0,25 % tube @ 15 gr
71 Diazepam injeksi 5 mg / ml - 2 ml ampul
Diazepam rectal tube (Stesolid rectal
72 tube @ 2,5 ml
Tube)
73 Diazepam tablet 2 mg tablet
74 Dietilkarbamazin Sitrat tablet 100 mg tablet

75 Difenhidramin HCl injeksi 10 mg / ml ampul

76 Digoksin tablet 0,25 mg tablet
77 Dimenhidrinat tablet 50 mg tablet
78 Doksisiklin tablet 100 mg tablet
79 Domperidone sirup 5 mg/5ml botol @ 60 ml
80 Domperidone tablet 10 mg tablet
81 Efedrin HCl tablet 25 mg tablet
82 Ekstrak Belladon tablet 10 mg tablet
83 Elkana Sirup tablet
Epinefrina HCl ( Adrenalin ) injeksi 1
84 ampul
mg/ml
85 Erithromisin sirup 200 mg / 5 ml botol @ 60 ml
86 Eritromisin kapsul 500 mg kapsul
87 Etakridin ( Rivanol ) larutan 0,1% botol
88 Etanol 70 % 100 ml botol
89 Etanol 70% 1000 ml botol
Etynil estradiol (Lynoral tablet 0,05
90 tablet
mg)
91 Fenitoin Natrium kapsul 100 mg kapsul
92 Fenitoin Natrium kapsul 30 mg kapsul
93 Fenobarbital tablet 30 mg tablet
94 Fenofibrat kapsul 100 mg kapsul
95 Fenofibrat kapsul 300 mg kapsul
Fenoksimetil Penisilina ( Penisilin V )
96 tablet
tablet 500 mg
97 Fenol Gliserol tetes telinga 10% botol
Fitomenadion ( Vitamin K1 ) injeksi 10
98 ampul
mg /ml
 Fitomenadion ( Vitamin K1 ) injeksi 2
99 ampul
mg / ml ( Neonatus )
Fitomenadion ( Vitamin K1 ) tablet
100 tablet
salut gula 10 mg
101 Fludane Plus Sirup botol @ 60 ml
102 Fluor tablet 0,5 mg tablet
103 Furosemid tablet 40 mg tablet
104 Garam Oralit untuk 200 ml air sase
105 Gelofusin Infus botol @ 500 ml
106 Gemfibrosil kapsul 300 mg kapsul
107 Gemfibrosil kapsul 600 mg kapsul
108 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
109 Gentamisin tetes mata 0,3 % botol
110 Gentian Violet larutan 1 % botol @10 ml
111 Glibenklamid tablet 5 mg tablet
112 Glimepiride tablet 2 mg tablet
113 Gliseril Guaiakolat tablet 100 mg tablet
114 Glukosa 5% - 1/2 NS botol @ 500 ml
115 Glukosa 5% - 1/4 NS botol @ 500 ml
116 Glukosa larutan infus 10 % steril botol @ 25 ml
117 Glukosa larutan infus 40 % steril botol @ 25 ml
118 Glukosa larutan infus 5 % steril botol @ 500 ml
119 Griseofulvin tablet 125 mg tablet
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas )
121 Haloperidol tablet 0,5 mg tablet
122 Haloperidol tablet 1,5 mg tablet
123 Haloperidol tablet 5 mg tablet
124 Hemobion tablet tablet
125 Hemorogard kapsul kapsul
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet
127 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20 mg/ml
128 ampul
(Spasi injeksi)
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml
130 Ibuprofen tablet 200 mg tablet
131 Ibuprofen tablet 400 mg tablet
132 Ichtiyol Zalf pot @ 15 gr
133 Iodiol kapsul lunak kapsul
134 Ipratropium bromida nebulazer 0,025 ampul
135 Isoniazide tablet 100 mg tablet
Isosorbid Dinitrat tablet sublingual 5
136 tablet
mg
137 KA-EN 3 B Otsu infus botol @ 500 ml
138 Kalium Diklofenak tablet 50 mg tablet
Kalsium Glukonat injeksi i.v 10 %
139 ampul
( 100 mg/ml )

140 Kalsium Laktat ( Kalk ) tablet 500 mg tablet

141 Kaptopril tablet scored 25 mg tablet
142 Kaptopril tablet scored 12,5 mg tablet
143 Karbamazepin tablet 200 mg tablet
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100 mg
146 supp
( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml
148 Klindamisin kapsul 150 mg kapsul
Kloramfenikol injeksi 1000 mg
149 ampul
(Colsancetin injeksi 1000 mg )
150 Kloramfenikol kapsul 250 mg kapsul
151 Kloramfenikol salep mata 1 % tube
152 Kloramfenikol suspensi 125 mg / 5 ml botol @ 60 ml
153 Kloramfenikol tetes Mata botol @ 5 ml
154 Kloramfenikol tetes telinga 3 % botol @ 10 ml
Klorfeniramin Maleat ( CTM ) tablet 4
155 tablet
mg
156 Klorheksidin larutan 15 % botol
157 Klorokuin Fosfat tablet 250 mg tablet
158 Klorpromazin HCl tablet salut 100 mg tablet

159 Klorpromazin HCl tablet salut 25 mg tablet

160 Klorpromazin injeksi 5 mg/ ml ampul
161 Kodein HCl tablet 10 mg tablet
Kombinasi tablet salut : Besi (II) sulfat
162 7H2O 200 mg Asam Folat 0,25 mg tablet
( tablet tambah darah )
163 Kotrimoksazol Dewasa tablet tablet
164 Kotrimoksazol Pediatrik tablet tablet
165 Kotrimoksazol Suspensi botol @ 60 ml
166 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25% ( sebagai 2 HCl
167 ampul
)
168 Lactodia / Lacto B sachet
169 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
170 (Ringer Laktat larutan infus steril / botol @ 500 ml
Wida RL )
Larutan mengandung elektrolit ( Na
130 mEq, Cl 109 mEq , Ca 3 mEq ,
171 botol @ 500 ml
Asetat 28 mEq ) / Asering 500 ml
larutan infus steril
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml
Lidokain injeksi 2% ( HCl) + Epinefrin
173 ampul @ 2 ml
1 : 80.000 - 2 ml
174 Linkomisina kapsul 500 mg kapsul
Lisol, mengandung Kresol tersabun
175 botol
50%
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Lysmin Plus Sirup botol @ 60 ml
Magnesium Sulfat injeksi ( IV ) 20 % -
179 botol @ 25 ml
25 ml
Magnesium Sulfat injeksi ( IV ) 40 % -
180 botol @ 25 ml
25 ml
181 MB Anak blister
182 MB Dewasa blister
183 Mebendazol tablet 100 mg tablet
184 Meloksikam tablet 15 mg tablet
185 Metformin HCl tablet 500 mg tablet
Metilergometrin Maleat
186 (Metilergometrin) tablet salut 0,125 tablet
mg
Metilergometrin Maleat injeksi 0,200
187 ampul @ 1 ml
mg-1 ml
188 Metoklopropamid injeksi 5 mg / ml ampul @ 2 ml
189 Metoklopropamid tablet 10 mg tablet
190 Metronidazol ovula ovula
191 Metronidazol tablet 250 mg tablet
192 Miconazol krim 2 % ( Nitrat ) tube
193 Mineral Mix 8 gr sase
194 Natrium Diklofenak tablet 50 mg tablet
Natrium Klorida larutan infus 0,9%
195 botol @ 500 ml
steril
196 Neo Kauminal suspensi botol @ 60 ml
197 Neuralgin - RX tablet tablet
198 Neurosanbe 5000 mg tablet tablet
199 Neurosanbe injeksi ampul
200 Neurovit E tablet tablet
201 Nifedipin tablet 10 mg tablet
202 Nistatin tablet salut 500.000 IU / g tablet
203 Nistatin vaginal tablet 100.000 IU / g tablet
204 Nodiar tablet tablet
Noretisteron tablet 5 mg (Primolut N
205 tablet
tablet)

206 OAT - FDC Kategori 1 - 3 PAKET paket

207 OAT - FDC Kategori 2 PAKET paket
208 OAT Kategori anak PAKET paket
209 OAT Sisipan paket
210 OAT-Kombipak Kategori 1 anak paket
211 OAT-Kombipak Kategori 1 dewasa paket
212 Obat Batuk Hitam ( O.B.H. ) cairan botol @ 100 ml
Obat Batuk Hitam ( O.B.H. ) Indo Plus
213 botol @ 100 ml
sirup
214 Ofloxaxin tablet 200 mg tablet
215 Oksimetazolin tetes hidung 0,025 % botol @ 10 ml
216 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
217 Oksitetrasiklin HCl salep mata 1 % tube @ 3,5 gr
218 Oksitosin injeksi 10 IU / ml - 1 ml ampul @ 1 ml
219 Omeprazole injeksi 40 mg / 10 ml vial @ 10 ml
220 Omeprazole tablet 20 mg tablet
221 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
222 Ondansetron tablet 4 mg tablet
223 Ondansetron tablet 8 mg tablet
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
225 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml ( 60
226 botol @ 15 ml
mg / 0,6 ml )
227 Parasetamol sirup 120 mg / 5 ml botol
228 Parasetamol tablet 100 mg tablet
229 Parasetamol tablet 500 mg tablet
230 PB Anak blister
231 PB Dewasa blister
232 Pehavral tablet tablet
233 Petidin HCl injeksi 50 mg / ml - 2 ml ampul @ 2 ml

234 Pilokarpin HCl / Nitrat tetes mata 2% botol

235 Piracetam 1200 mg tablet Kotak
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
237 Piracetam injeksi 3 g / 15 ml ampul @ 15 ml
238 Piracetam tablet 800 mg tablet
239 Pirantel suspensi 125 mg / 5 ml botol @ 60 ml
240 Pirantel tablet score ( base ) 125 mg tablet
241 Pirazinamida tablet 500 mg tablet
Piridoksin HCl ( Vitamin B6 ) tablet 10
242 tablet
mg
243 Piroxicam tablet 10 mg tablet
244 Piroxicam tablet 20 mg tablet
245 Polikresulen cairan ( Aptil ) botol
246 Ponflu tablet tablet
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 ml

248 Povidon Iodida Larutan 10% 300 ml botol @ 60 ml

249 Prednison tablet 5 mg tablet
250 Primakuin tablet 15 mg tablet
251 Prolipid kaplet tablet
252 Propiltiourasil tablet 100 mg tablet
253 Propranolol HCl tablet 40 mg tablet
254 Proris suppositoria supp
255 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
256 Ranitidin tablet 150 mg tablet
257 Reserpin tablet 0,25 mg tablet
Retinol ( Vitamin A ) kapsul 100.000
258 kapsul
IU
Retinol ( Vitamin A ) kapsul 200.000
259 kapsul
IU kapsul lunak
260 Rifampisin kapsul 300 mg tablet
261 Risperidon tablet 1 mg tablet
Salbutamol tablet 2 mg ( sebagai
262 tablet
sulfat )

Salep 2-4 , kombinasi : Asam Salisilat

263 pot @ 30 gr
2 % + Belerang endap 4 %

264 Scabicid krim tube

265 Sefadroksil kapsul 500 mg kapsul
266 Sefadroksil Sirup Kering 125 mg / 5 ml botol @ 60 ml
267 Sefiksim kapsul 100 mg kapsul
268 Sefiksim sirup kering 100 mg / 5 ml botol @ 30 ml
269 Sefotaksim injeksi 1 gr vial @ 1 gr
270 Seftriakson serbuk injeksi 1 gr / vial vial @ 1 gr
271 Serum ADS 20.000 vial
Serum Anti Bisa Ular Polivalen injeksi
272 vial
I
Serum Anti Tetanus Injeksi 1.500 IU /
273 vial
amp
Serum Anti Tetanus Injeksi 20.000
274 vial
IU / vial
275 Setirizin sirup 5 mg / 5 ml botol
276 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12 ) injeksi
277 ampul
500 mcg
Sianokobalamin (Vitamin B12) tablet
278 tablet
50 mcg
279 Simetidin tablet 200 mg tablet
280 Simvastatin tablet 10 mg tablet
281 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
282 kapsul
( sebagai HCl )
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml
284 Spasi Plus tablet tablet
285 Spasminal tablet tablet
Sulfasetamida Natrium tetes mata 15
286 botol
%
287 Supralivron tablet tablet
288 Taburia sachet
289 Tamiflu tablet
290 Tensigard kapsul kapsul
291 Tetrakain HCl tetes mata 0,5% botol
292 Tetrasiklin HCl kapsul 250 mg kapsul
293 Tetrasiklin HCl kapsul 500 mg kapsul
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml
295 Thiamfenikol kapsul 500 mg kapsul
 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-
296 ampul
1ml
Tiamin HCl / Mononitrat (Vitamin B1)
297 tablet
tablet 50 mg
298 Trifluoperasin tablet 5 mg tablet
299 Triheksifenidil Hidroklorida tablet 2 mg tablet
300 Ventolin Nebules 2,5 mg ampul
301 Vical Sirup botol @ 60 ml
302 Vitamin B Kompleks tablet tablet
303 Zenirex Sirup botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum Kid
304 botol @ 60 ml
Sirup )
305 Zink tablet disperible 20 mg tablet

BAHAN GIGI :
306 Air raksa dental use botol
307 Cavit - G botol
308 Composit resin ( solare ) Kit
309 Devitalisasi Pasta ( Non Arsen ) botol
310 Etil Klorida semprot ( Duta Kaisar ) botol
311 Eugenol cairan botol
312 Glass Ionomer Cement ( GC IX ) botol
313 Kalsium Hidroksida Pasta ( hydcal ) botol

Monoklorkamfer Mentol Cairan

314 botol
( CHKM )
315 Mummifying Pasta botol
Semen Seng Fosfat serbuk dan
316 botol
cairan
317 Silver Amalgam serbuk 65 - 75 % botol 30 gr
318 Spons Gelatin Cubicles 1 x 1 x 1 cm biji

Temporary Stopping Fletcher

319 set
( Fletcher )
320 Trikresol Formalin (TKF) cairan botol
321 Tumpatan komposit kit set
322 Cressophen botol
323 Cressophate botol

BAHAN MEDIS HABIS PAKAI

( BMHP )

324 Alat suntik sekali pakai 1 ml tuberculin set

325 Alat suntik sekali pakai 3 ml set
326 Alat suntik sekali pakai 5 ml set
327 Blood Lancet biji
328 Blood transfision set set
329 Catgut / Benang Bedah No. 2/0 - 3/0 biji

330 Folleycatheter Silicon 2 way 14 - 18 biji

331 Hans Coen steril / Sarung Tangan pasang
332 Hypafix 5 x 5 rol
333 Infusion set anak set
334 Infusion set dewasa set
335 IV. Chateter No. 14 s/d 24 set
336 IV. Chateter No. 26 set
337 Jarum Jahit ( Bedah ) No. 9 s/d 14 biji
338 Jarum Suntik 22G s/d 25 G biji
339 Jarum Suntik 26G biji
340 Kapas Pembalut / Absorben 250 gram rol

341 Kasa Kompres 40 / 40 steril rol

342 Kasa Pembalut 2 m x 80 cm rol

343 Kasa Pembalut Hidrofil 4 m x 15 cm rol

344 Kasa Pembalut Hidrofil 4 m x 3 cm rol

345 Lomatulle lembar

346 Masker Earloop/ Tie On biji
347 Masker N 95 set
348 Plester 1,25 cm x 4,5 m rol
349 Scalp Vein no. 25 biji

350 Silk ( Benang Bedah Sutera ) No. 3 / 0 rol

351 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon steril (Claim biji
352
Umbilical)
353 Underpad biji
Urine Bag standard steril 2 Lt ( T
354 biji
valve )

REAGEN LABORATORIUM
355 Amonia 10 % botol
356 Asam Asetat 6 % botol
357 Asam Klorida 0,1 N botol
358 Asam Sulfosalisilat 20% botol
359 Cholesterol Strip Easy Touch botol
360 Cholesterol Strip Nesco botol
361 Clever Check Strip 50 test botol
362 Contronorm Plus 5 x 5 ml botol
363 G O T - AST Starter 8 x 15 ml botol
364 G P T - ALT Starter 8 x 15 ml botol
365 Glucose GOD PAP botol
366 Golda Tulip Anti - A botol
367 Golda Tulip Anti - B botol
368 Golda Tulip Anti AB botol
369 Golda Tulip Anti D/Rhesus botol
370 HBs Ag Intec Strip 50 botol
371 HDL Cholesterol 6 x 40 ml botol
372 Hemoglobin 1000 ml botol
373 Kolesterol CHOD-PAP 8 X 20 ml botol
374 Kreatinin - Jaffe 400 ml botol
375 Larutan Giemsa Stain botol
376 Larutan Karbol Fuksin botol
377 Larutan Metilen Biru botol
378 Larutan Turk botol
379 LDL Cholesterol 6 x 50 ml botol
380 Metanol botol
381 Natrium Chlorida 0,9 % botol
382 Pewarna Gram 1 % botol
Reagen Gol Darah (Anti A,B,AB)
383 botol
+Kartu
384 Rees Ecker botol
385 Sclessinger botol
386 Stik HCG Strip Answer 50 botol
387 Stik urine combine 10 test M botol
388 Stik urine 10 parameter botol
389 Stik urine 3 parameter botol
390 Strip Hb Mission Plus botol
391 Trigliserida GPO - PAP 8 x 20 ml biji
392 Urea Col 1 x 100 ml biji
393 Uric Acid Strip Easy Touch biji
394 Uric Acid Strip Nesco biji
395 Uricase-PAP 8 x 20 ml botol
396 VDRL botol
397 Widal ( Slam O Paratyphi A ) botol
398 Widal ( Slam O Paratyphi B ) botol
399 Widal ( Slam Typhi H ) botol
400 Widal ( Slam Typhi O ) botol
Ziel Nelson ( ZN Set ) Pewarna BTA
401 botol
set

OBAT TAMBAHAN :
1 Acitral / antasid + simetikon tube
2 Akarbose 100 mg ampul
3 Alat suntik 10 ml biji
4 Alat suntik 20 ml biji
5 Alat suntik 50 ml biji
6 Alkohol Swabs pcs
7 Alletrol Tetes Mata botol
8 Amiodaron inj 50 mg/ml ampul
9 Ampicillin Injeksi 1 gram vial
10 Aqua Gel 150's G sachet sachet
11 Arm Sling Comfort (M/L) pcs
12 Artikulating paper pcs
Asam Asetilsalisilat (Asetosal) tablet
13 tablet
80 mg / Miniaspi
14 Aseptik Gel 5 Liter botol
15 Askina calgitrol gel 15 g tube
16 Askina gel 15 g tube
17 Asvex tablet tablet
18 Biolysin Sirup botol
19 Bisoprolol 2,5 mg tablet
Bricasma, Terbutaline injeksi 0,5
20 ampul
mg/ml
21 Budesonid inhaler (Pulmicort) pcs
Budesonid repsules (Pulmicort
22 pcs
Repsule)
Budesonide-formoterol 160/4,5
23 pcs
(symbicort)
24 Carpule needle L Ject biji
25 Carpule posicain 100 biji
26 Catgut 3/0 + 1/2 biji
27 Catgut Chromic tanpa needle biji
28 Catgut No. 2/0 - 100 m biji
29 Cell Pack biji
30 Cellclean biji
31 Cervical Collar Universal pcs
32 Cevitron pink kotak
33 Cevitron putih kotak
34 Chloramex 250 mg tablet tablet
35 Cliad / Braxidin tablet
36 Clopigrogel tablet 75 mg tablet
37 Colergis tablet
38 Combivent UDV vial
39 Contronorm Plus 5 x 4 mL pcs
40 Cotton rol rol
41 Cover Glass biji
42 Curcumex tablet tablet
43 Deculin 15 mg tablet
44 Dekstrofen syrup botol
45 Demacolin Syrup botol
46 Demacolin Tablet tablet
Dental Cotoon 8 mm (20 ikat @ 50
47 rol
pcs)
48 Dermafix 10 x 15 cm rol
49 Dermafix 10 x 20 cm rol
50 Dermafix S IV 6x7 cm rol
51 Dermafix SS 10 x 10 cm rol
52 Dermafix T 10 x 12 cm rol
53 Dermafix T 10 x 25 cm rol
54 Dermafix T 10 x 8 cm rol
55 Dermafix T 6 x 7 cm rol
56 Dextral Tablet tablet
57 Duk lubang steril 25x30 cm piece
58 Duk lubang steril 50x50 cm piece
59 Eightchek / Kontrol Hema (H, L, N) biji
60 Elite Cement botol
61 Endoseal biji
62 Eryclone ( Anti AB ) botol
63 Female Catheter biji
64 Fenitoin injeksi 50 mg / ml ampul
65 Flukonazol tablet
66 Fluocinolon acetonid / dermasolon tube

67 Folleycatheter Silicon 2 way 08 - 12 biji

68 Furosemid injeksi 10mg/ml ampul
69 Gabapentin 300 mg kapsul
Gentamisin salep mata 0,3 %
70 tube
(Genoint salep mata)
71 Glimepiride 3 mg tablet
72 Glimepiride 4 mg tablet
73 Glucosa strip easy touch biji
74 Glucose biji
75 Glukosa strip on call plus biji
76 Gula Darah Stik biji
Hans Coen Non steril / Sarung
77 biji
Tangan
78 Hb Hemoglobin strip quick check biji
79 Hypafix 15 x 5 rol
80 Hypafix 20 x 5 rol
81 Hypafix 5 cm x 1 m rol
82 ID Band Anak biji
83 ID Band Dewasa biji
84 Insulin Rapid Acting (Novorapid) piece
85 Isosorbid Dinitrat injeksi 1 mg/ml ampul
86 IV Film 6 x 8 cm pcs
87 Jarum jahit (bedah) MANI No. 12 biji
88 Jarum jahit (bedah) MANI No. 14 biji
89 Jarum Suntik Terumo No. 23 biji
90 Kasa 3,6 M x 15 cm rol
91 Kasa Hidrofil 40 x 80 cm rol
92 Kasa steril 16 x 16 cm rol
93 Kertas Lakmus Merah biji
94 Kertas saring biji
95 Kertas Termal USG biji
96 Ketorolac injeksi 30 mg / ml ampul
97 Klindamisin kapsul 300 mg kapsul
98 Kloramfenikol 500 mg kapsul kapsul
99 Kloramfenikol salep kulit tube
100 Komposit A2 biji
101 Komposit A3 biji
102 Komposit Nexcon A3 biji
103 Komposit Voco A3 biji
104 Komposit Voco Incisal biji
105 Konik ECG gel botol
106 Laktulosa syrup botol
107 Masker Nebulizer Anak piece
108 Masker Nebulizer Dewasa piece
109 Mata bur no 1 biji
110 Mata bur no 2 biji
111 Mata bur set biji
112 Matovit tablet tablet
113 Maxiflow anak biji
114 Maxiflow bayi biji
115 Maxiflow dewasa biji
116 Mersibion injeksi ampul
117 Metilprednisolon 4 mg tablet
118 Metilprednisolon inj 500mg/8ml ampul
119 Metilprednisolon injeksi 125mg/ml ampul
120 Metronidazole 500mg tablet tablet
121 Metronidazole infus 500mg/100 ml botol
122 Mitella piece
123 Mucus Extraction pcs
124 My Jelly 82 gram tube
125 Nasal dan Masker Oksigen Anak pcs
126 Nasal dan Masker Oksigen Dewasa pcs
127 Nebulizer canula Adult piece
128 Nebulizer canula Child piece
129 Needle carpule biji
130 Needle no 25 biji
131 Nierbeken Disposible 25 cm pcs
132 Nistatin suspensi 100.000 IU / ml botol
Norepinephrine bitartat injeksi 1
133 ampul
mg/ml
134 Novomix Flexpen biji
135 Object Glass biji
136 Oksigen canula adult biji
137 Oksigen canula child biji
138 Paracetamol drip (infus) 1g / 100 mL botol

Parasetamol suppositoria - Pamol

139 suppo
Supp
140 Pehacain injeksi ampul
141 Pembalut hamil piece
142 Plesterin Bulat Soft isi 200 piece
143 Plesterin Roll 20 cm x 5 m rol
144 Povidone iodine 60 ml botol
145 Probenid tab 500 mg tablet
146 Prontosan wound gel botol
147 Prontosan wound irigation botol
148 Psidii 500 mg kapsul kapsul
149 Psidii sirup botol
150 Risperidon tablet 2 mg tablet
151 Safety Box 12 L piece
152 Safety Box 5 Lt OM piece
153 Salbutamol 4 mg tablet
154 Sarung Tangan Gynaecolog pasang
155 Sikzonoat Inj / Flupenaziin Inj ampul
156 Silk No. 2/0 - 100 m rol
157 Slem / Mucus Extractor biji
158 Spalk 10 x 5 cm biji
159 Spalk 100 x 10 piece
160 Spalk 15 x 5 piece
161 Spalk 20 x 5 cm biji
162 Spalk 4 x 12 cm biji
163 Spalk 40 x 8 x 7 cm biji
164 Spalk 60 x 10 piece
165 Spalk 80 x 10 x 8 cm biji
166 Spironolacton tab 100 mg tablet
167 Spironolacton tab 25mg tablet
168 Stik Asam Urat biji
169 Stik Gula Darah biji
170 Stik Kolesterol biji
171 Stromatolyser piece
172 Suction catheter no 12 biji
173 Sukralfat suspensi botol
174 Superpatch jumbo biji
175 Surgical gown non woven steril pcs
176 Surgical gown spunlace biji
177 Tensocrepe 3 inch biji
178 Tensocrepe 4 inch biji
179 Tensocrepe 6 inch biji
Terbutalin repsules (bricasma
180 ampul
repsule)
Terbutalin turbuhaler (bricasma
181 piece
turbuhaler)
182 Test Kehamilan piece
183 Test Kesuburan (Baby Test) piece
184 Tremenza Syrup botol
185 Tremenza Tablet tablet
186 Triamcinolon injeksi 10 mg/ml ampul
187 Truvit syrup botol
188 Ultrasonic gel botol
189 Urea pcs
190 Uricase pcs
191 USC Gel 250 ml botol
192 Vaculab EDTA 3 ml piece
193 Vaculab non EDTA 3 ml plain pcs
194 Valsartan 80 mg tablet
195 Yellow Tip pcs
196 Zinc Syrup 10 mg / ml botol
197 Coparcetin tab tablet
198 Curbiplex sirup BOtol
199 Fultrop tablet tablet
200 Fultrop SIRUP BOtol
201 Molexflu syr botol
202 APD coverall
203 Isolation Gown
204 nurse/dokter cap

205 shoes cover

206 Hemaviton cardio

207 Coparcetin sirup botol

208 Plesterin roll 10 cm x 5 m

Aseptik gel 1 L/Hand Foam sanitiser

209 botol
600 ml

210 Cavilpex tablet

211 Etanol 96% botol

JUMLAH KUNJUNGAN RESEP

YANG MENYERAHKAN

PETUGAS GUDANG
 (Sunarti,A.Md.Farm.)

NIP.19840403 2011012 013

Yang Melayani :……………………..

RAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN PUSKE
( LPLPO JKN )

PELAPORAN BULAN / PERIODE :

PERMINTAAN BULAN / PERIODE :

SISA AWAL PENERIMAAN PERSEDIAAN

4 5 6

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

BPJS

AH KUNJUNGAN RESEP PBI ASKES

TAAN OBAT JKN PUSKESMAS

RAN BULAN / PERIODE :

AAN BULAN / PERIODE :

PEMAKAIAN STOK AKHIR STOK OPT.

7 8 9

-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-

-
-

-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-

-
-
-

-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-

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

-
-
-
-
-
-

-
-

-
-
-
-
-
-

-
-

-
-
-

-
-
-
-
-
-

-
-
-

-
-
-

-
-
-

-
-
-
-

-
-
-

-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-

-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-

-
-

-
-
-
-
-
-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-

-
-
-
-

-
-

-
-
-

-
-
-
-

-
-
-
-

-
-
-
-
-
-
-
-
-
-
-

-
-

-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-

-
-

-
-

-
-
-
-
-
-

-
-
-
-
-

-
-
-
-
-
-
-
-
-
-

-
-
-

-
-
-
-
-
-

-
-

-
-

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

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

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

-
-
-
-
-
-
-

-
-

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

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

-
-
-

-
-
-
-
-
-
-

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

-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
-
-

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

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

-
 -

NON BPJS JUMLAH

MANDIRI

YANG MEMINTA / MELAPORKAN

PIMPINAN PUSKESMAS
 (drg.Jon Sudiro Hendrata)

NIP.19610823 198901 1 003

Yang Memeriksa :……………………..

KET

10
JUMLAH

Gresik, 8
Desember
2020

YANG MENERIMA

PETUGAS PUSTU/PONKESDES
(.......................................................)