Lplpo JKN Apt 2020

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
( LPLPO )
PUSKESMAS :
KECAMATAN :
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : DESEMBER 2016
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : JANUARI 2017
PENERIM PERSEDIA PEMAKAI STOK STOK PERMIN PEMBERIAN

NO NAMA OBAT SAT. SISA AWAL
AAN AN AN AKHIR OPT. TAAN APBD BPJS
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
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 - -
16 Amoksisilin Sirup Kering 125 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 kapsul - -
22 Ampisilina sirup kering 125 mg/5ml botol - -
23 Antalgin ( Metampiron ) tablet 500 mg tablet - -
1 2 3 4 5 6 7 8 9 10 11 12
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - -
Antalgin ( Metamisol )injeksi 500 mg / ml - 2 ml
25 ampul @ 2 ml
( Novalgin / Antrain / Santagesik ) - -
Antasida DOEN I tablet kunyah, kombinasi :
26 Aluminium Hidroksida 200 mg ; Magnesium tablet
Hidroksida 200 mg - -
Antasida DOEN II suspensi, kombinasi :
27 Aluminium Hidroksida 200 mg/ml ; Magnesium botol @ 60 ml
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 @ 25 ml - -
33 Aquadest steril botol @ 1000 ml - -
34 Asam Asetilsalisilat (Asetosal) tablet 100 mg tablet - -
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 - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
53 Bedak salisil serbuk 2 % kotak - -
54 Benzatin Benzil Penisillin Injeksi 2.4 Jt IU/vial ampul - -
55 Besi Sirup botol - -
56 Betadin Gargle 100 ml / Molexdin obat kumur botol - -
57 Betahistin Mesilat tablet 6 mg tablet - -
58 Betametason krim 0.1% ( sebagai valerat ) tube 5 gr - -
59 Betason - N krim tube - -
60 Bisacodil ( Bicolak ) tablet tablet - -
61 Bisacodil suppositoria 10 mg ( Stolax supp ) supp - -
62 Bisoprolol tablet 5 mg tablet - -
63 Borak Gliserin 5% botol @ 15 ml - -
Bromhexin tablet ( Bronex tablet ; Novaheksin
64 tablet
tablet) - -
65 Bronchitin Expektoran Sirup botol @ 50 ml - -
66 Centabio Jelly / Bioplacenton Jelly tube @ 20 gr - -
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 - -
72 Diazepam rectal tube (Stesolid rectal Tube) tube @ 2,5 ml - -
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 kapsul - -
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 botol - -
84 Epinefrina HCl ( Adrenalin ) injeksi 1 mg/ml ampul - -
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
93 Fenobarbital tablet 30 mg tablet - -
94 Fenofibrat kapsul 100 mg kapsul - -
Fenoksimetil Penisilina ( Penisilin V ) tablet 500
96 tablet
mg - -
97 Fenol Gliserol tetes telinga 10% botol - -
98 Fitomenadion ( Vitamin K1 ) injeksi 10 mg /ml ampul - -
Fitomenadion ( Vitamin K1 ) injeksi 2 mg / ml
99 ampul
( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet salut gula 10
100 tablet
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 - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
116 Glukosa larutan infus 10 % steril botol @ 25 ml - -
119 Griseofulvin tablet 125 mg tablet - -
Haloperidol injeksi 50 mg/ml ( Haldol
120 ampul
Decanoas ) - -
121 Haloperidol tablet 0,5 mg tablet - -
123 Haloperidol tablet 5 mg tablet - -
124 Hemobion tablet kapsul - -
125 Hemorogard kapsul kapsul - -
126 Hidroklorotiazid ( HCT ) tablet 25 mg tablet - -
127 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20 mg/ml (Spasi
128 ampul
injeksi) - -
129 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -
130 Ibuprofen tablet 200 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 - -
139 Kalsium Glukonat injeksi i.v 10 % ( 100 mg/ml ) ampul - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
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 (Colsancetin
149 vial
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 - -
160 Klorpromazin injeksi 5 mg/ ml ampul - -
161 Kodein HCl tablet 10 mg tablet - -
Kombinasi tablet salut : Besi (II) sulfat 7H2O
162 200 mg Asam Folat 0,25 mg ( tablet tambah tablet
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 Laktat
170 botol @ 500 ml
larutan infus steril / Wida RL ) - -
Larutan mengandung elektrolit ( Na 130 mEq,
171 Cl 109 mEq , Ca 3 mEq , Asetat 28 mEq ) / botol @ 500 ml
Asering 500 ml larutan infus steril - -
172 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
1 2 3 4 5 6 7 8 9 10 11 12
Lidokain injeksi 2% ( HCl) + Epinefrin 1 : 80.000
173 ampul @ 2 ml
- 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 - -
179 Magnesium Sulfat injeksi ( IV ) 20 % - 25 ml botol @ 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 (Metilergometrin) tablet
186 tablet
salut 0,125 mg - -
187 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 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 - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
204 Nodiar tablet tablet - -
205 Noretisteron tablet 5 mg (Primolut N 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 - -
213 Obat Batuk Hitam ( O.B.H. ) Indo Plus sirup botol @ 100 ml - -
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 - -
224 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -
225 Papaverin Tablet 40 mg tablet - -
226 Parasetamol drop 100 mg/ml ( 60 mg / 0,6 ml ) botol @ 15 ml - -
227 Parasetamol sirup 120 mg / 5 ml botol - -
228 Parasetamol tablet 100 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 tablet - -
236 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
245 Polikresulen cairan ( Aptil ) botol - -
246 Ponflu tablet tablet - -
247 Povidon Iodida Larutan 10% 30 ml botol @ 30 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 kapsul
259 kapsul
lunak - -
260 Rifampisin kapsul 300 mg kapsul - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
273 Serum Anti Tetanus Injeksi 1.500 IU / amp vial - -
274 Serum Anti Tetanus Injeksi 20.000 IU / vial vial - -
275 Setirizin sirup 5 mg / 5 ml botol - -
276 Setirizin tablet 10 mg tablet - -
277 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg ampul
- -
278 Sianokobalamin (Vitamin B12) tablet 50 mcg tablet - -
279 Simetidin tablet 200 mg tablet - -
280 Simvastatin tablet 10 mg tablet - -
282 Siprofloksasin kapsul 500 mg ( sebagai HCl ) kapsul - -
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 - -
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) tablet 50
297 tablet - -
mg
298 Trifluoperasin tablet 5 mg tablet - -
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
327 Blood Lancet biji - -
1 2 3 4 5 6 7 8 9 10 11 12
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 - -
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
352 biji - -
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 - -
1 2 3 4 5 6 7 8 9 10 11 12
357 Asam Klorida 0,1 N botol - -
358 Asam Sulfosalisilat 20% botol - -
359 Cholesterol Strip Easy Touch tub - -
360 Cholesterol Strip Nesco tub - -
361 Clever Check Strip 50 test box - -
362 Contronorm Plus 5 x 5 ml vial - -
363 G O T - AST Starter 8 x 15 ml Kit - -
364 G P T - ALT Starter 8 x 15 ml Kit - -
365 Glucose GOD PAP Kit - -
366 Golda Tulip Anti - A vial - -
367 Golda Tulip Anti - B vial - -
368 Golda Tulip Anti AB vial - -
369 Golda Tulip Anti D/Rhesus vial - -
370 HBs Ag Intec Strip 50 box - -
371 HDL Cholesterol 6 x 40 ml Kit - -
372 Hemoglobin 1000 ml botol - -
373 Kolesterol CHOD-PAP 8 X 20 ml Kit - -
374 Kreatinin - Jaffe 400 ml Kit - -
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 Kit - -
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 box - -
387 Stik urine combine 10 test M biji - -
388 Stik urine 10 parameter box - -
1 2 3 4 5 6 7 8 9 10 11 12
390 Strip Hb Mission Plus box - -
391 Trigliserida GPO - PAP 8 x 20 ml Kit - -
392 Urea Col 1 x 100 ml kit - -
393 Uric Acid Strip Easy Touch tub - -
394 Uric Acid Strip Nesco tub - -
395 Uricase-PAP 8 x 20 ml kit - -
396 VDRL botol - -
397 Widal ( Slam O Paratyphi A ) vial - -
398 Widal ( Slam O Paratyphi B ) vial - -
399 Widal ( Slam Typhi H ) vial - -
400 Widal ( Slam Typhi O ) vial - -
401 Ziel Nelson ( ZN Set ) Pewarna BTA set botol - -
- -
OBAT TAMBAHAN : - -
- -
Gentamisin salep mata 0,3 % (Genoint salep
1 - -
mata) tube
2 Sikzonoat Inj / Flupenaziin Inj ampul - -
3 Hans Coen Non steril / Sarung Tangan biji - -
4 Fluoxetine (Napres) tablet - -
5 Clobazam 10 Mg tab tablet - -
7 Becefort Tablet tablet - -
8 Fludane Tablet tablet - -
9 Prontosan Sol 350 ml botol - -
10 Prontosan Gel 50 gram botol - -
11 Stabimed 1 L botol - -
12 Askina Calgitrol 15 gram tube - -
13 Askina Gel 15 gram tube - -
Denomix Cream - Desoksimetason 0,25 %,
14 neomycin sulfate 0.5% Tube - -
15 Scabimite Cream 10 - Permetrin krim 5 % Tube - -
1 2 3 4 5 6 7 8 9 10 11 12
TETAGAM - Human Tetanus Imunoglobulin
16 Unit - -
Injeksi I.M. 250 UI
17 Pehacain Inj ampul @ 2 ml - -
18 Jarum Sitoject biji - -
RPR Syphilis/Titer (Plasmatec/RPR Tes Kit,
19 Piece - -
RPR 0/012)
Rapid Syphilis/Standar Diagnostic (Alere)
20 Piece
Bioline - -
21 Nevirapine (NVP) 200 mg tablet - -
22 Efavirenz (EFV) 600 mg tablet - -
23 Tenofovir 300 mg (TDF) tablet - -
Zidofudine (ZDV) 300 mg + Lamivudine (3TC)
24 tablet - -
150 mg
25 Lamivudine (3TC) 150 mg tablet - -
Tenofovir 300 mg (TDF) + Lamivudine (3TC)
26 300 mg + Efavirenz (EFV) 600 mg (Triple FDC) tablet
Dewasa - -
Reagen I (Standart Diagnostic (SD) Bioline HIV
27 Kit
1/2) - -
28 Kit - -
1/2)
Reagen I (Intec One Step Anti HIV (1&2) Tri
29 Kit
Line Test (ard) - -
30 Reagen 2 (Oncoprobe / IR - 100 C) Kit - -
32 Reagen 3 (Biomerieux / Vikia HIV 1/2) Kit - -
34 Truvit Syrup botol @ 60 ml - -
35 Ikaneuron 5000 tablet - -
36 Scopma Plus tablet - -
37 Procain Benzil Penisilin 3.000.000 I.U vial - -
38 Gentamisin Inj 40 mg / ml ampul - -
39 Fenobarbital Inj 50 mg / ml ampul - -
40 Nervitone - E tablet - -
1 2 3 4 5 6 7 8 9 10 11 12
41 Dextrofen Syrup botol @ 60 ml - -
42 Asvex tablet tablet - -
43 Mersibion Injeksi 5000 ampul - -
44 Levotiroksin tab 100 µg tablet - -
45 Clozapin 25 mg tablet tablet - -
47 Iodina Test test kit - -
48 Zidofudine (ZDV) 100 mg tablet - -
Tenofovir 300 mg (TDF) + Emcitritabine 200
49 tablet - -
mg (FTC)
50 Alkohol Swab pcs - -
51 Alat Laboratorium Malaria Paket - -
52 Haloperidol 5 mg / ml (Lodomer) ampul - -
53 Minyak Kayu Putih botol - -
54 Balsem Cap Lang pot - -
56 Visto Tetes Mata botol - -
58 Fluocinolone Acetonide (Synarcus Cream) tube @ 5 gram - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
1 2 3 4 5 6 7 8 9 10 11 12
BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN PBI ASKES MANDIRI
RESEP 0
Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN

KEPALA DINASEHATAN KAB. GRESIK KEPALA UPPF PIMPINAN PUSKESMAS
(……………………………………..) (………………………………….) (………………………………...)
Yang Melayani :…………………….. Yang Memeriksa :……………………..

EMBERIAN JMLAH
KET
PROGRAM LAIN-2 PEMBERIAN
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
EMBERIAN JMLAH
KET
13 14 15 16
Gresik, ............................................................
YANG MENERIMA
PETUGAS PUSKESMAS
(............................................................)
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS
( LPLPO )
PUSKESMAS :
KECAMATAN :
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE :
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE :
PERMIN PEMBERIAN JMLAH

SISA PENERIM PERSEDIA PEMAKAI STOK STOK
NO NAMA OBAT SAT. PEMBERIA KET
AWAL AAN AN AN AKHIR OPT. TAAN APBD BPJS PROGRAM LAIN-2 N
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
OBAT-OBATAN :
1 Adona AC - 17 tablet / Saldona tablet tablet - -
21 Amoxillin + As.Klavulanat 625 mg kapsul kapsul - -
25 ampul @ 2 ml
( Novalgin / Antrain / Santagesik ) - -
Antasida DOEN I tablet kunyah, kombinasi :
26 Aluminium Hidroksida 200 mg ; Magnesium tablet
Hidroksida 200 mg - -
Antasida DOEN II suspensi, kombinasi :
27 Aluminium Hidroksida 200 mg/ml ; Magnesium botol @ 60 ml
Hidroksida 200 mg/ml - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 Aqua pro Injeksi steril, bebas pirogen botol @ 25 ml - -
53 Bedak salisil serbuk 2 % kotak - -
64 tablet
tablet) - -
66 Centabio Jelly / Bioplacenton Jelly tube @ 20 gr - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
78 Doksisiklin tablet 100 mg kapsul - -
83 Elkana Sirup botol - -
96 tablet
mg - -
99 ampul
( Neonatus ) - -
Fitomenadion ( Vitamin K1 ) tablet salut gula 10
100 tablet
mg - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
120 ampul
Decanoas ) - -
124 Hemobion tablet kapsul - -
128 ampul
injeksi) - -
146 supp
supp ) - -
149 vial
injeksi 1000 mg ) - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Kombinasi tablet salut : Besi (II) sulfat 7H2O
162 200 mg Asam Folat 0,25 mg ( tablet tambah tablet
darah ) - -
170 botol @ 500 ml
larutan infus steril / Wida RL ) - -
Larutan mengandung elektrolit ( Na 130 mEq,
171 Cl 109 mEq , Ca 3 mEq , Asetat 28 mEq ) / botol @ 500 ml
Asering 500 ml larutan infus steril - -
173 ampul @ 2 ml
- 2 ml - -
178 Lysmin Plus Sirup / Truvit Syrup botol @ 60 ml - -
186 tablet
salut 0,125 mg - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
198 Neurosanbe 5000 mg tablet / Ikaneuron 5000 tablet - -
199 Neurosanbe injeksi / Mersibion Injeksi 5000 ampul - -
200 Neurovit E tablet / Nervitone - E tablet - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
235 Piracetam 1200 mg tablet tablet - -
259 kapsul
lunak - -
260 Rifampisin kapsul 300 mg kapsul - -
263 pot @ 30 gr
Belerang endap 4 % - -
Scabicid krim / Scabimite Cream 10 - Permetrin
264 tube
krim 5 % - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
277 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg ampul
- -
284 Spasi Plus tablet / Scopma Plus tablet - -
297 tablet
mg - -
- -
BAHAN GIGI : - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
- -
Umbilical cord klem nylon steril (Claim
352 biji - -
Umbilical)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
- -
- -
359 Cholesterol Strip Easy Touch tub - -
360 Cholesterol Strip Nesco tub - -
361 Clever Check Strip 50 test box - -
362 Contronorm Plus 5 x 5 ml vial - -
363 G O T - AST Starter 8 x 15 ml Kit - -
364 G P T - ALT Starter 8 x 15 ml Kit - -
365 Glucose GOD PAP Kit - -
366 Golda Tulip Anti - A vial - -
367 Golda Tulip Anti - B vial - -
368 Golda Tulip Anti AB vial - -
369 Golda Tulip Anti D/Rhesus vial - -
370 HBs Ag Intec Strip 50 box - -
371 HDL Cholesterol 6 x 40 ml Kit - -
373 Kolesterol CHOD-PAP 8 X 20 ml Kit - -
374 Kreatinin - Jaffe 400 ml Kit - -
379 LDL Cholesterol 6 x 50 ml Kit - -
386 Stik HCG Strip Answer 50 box - -
387 Stik urine combine 10 test M biji - -
390 Strip Hb Mission Plus box - -
391 Trigliserida GPO - PAP 8 x 20 ml Kit - -
392 Urea Col 1 x 100 ml kit - -
393 Uric Acid Strip Easy Touch tub - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
394 Uric Acid Strip Nesco tub - -
395 Uricase-PAP 8 x 20 ml kit - -
396 VDRL botol - -
397 Widal ( Slam O Paratyphi A ) vial - -
398 Widal ( Slam O Paratyphi B ) vial - -
399 Widal ( Slam Typhi H ) vial - -
400 Widal ( Slam Typhi O ) vial - -
- -
OBAT TAMBAHAN : - -
- -
1 1470IK Z250XT Syr Intro Kit kotak - -
2 Alat Laboratorium Malaria Paket - -
3 Alkohol Swab pcs - -
6 Askina Calgitrol 15 gram tube - -
7 Askina Gel 15 gram tube - -
9 Atorvastatin 20 mg tablet tablet - -
10 Balsem Cap Lang pot - -
11 Becefort Tablet tablet - -
12 Caviton White kotak - -
13 Cendo Lyters botol - -
14 Clobazam 10 Mg tab tablet - -
15 Clozapin 25 mg tablet tablet - -
16 Cresotin Liquid II Technodent kotak - -
Denomix Cream - Desoksimetason 0,25 %,
17 - -
neomycin sulfate 0.5% Tube
18 Dextrofen Syrup botol @ 60 ml - -
20 Efavirenz (EFV) 600 mg tablet - -
21 Fenobarbital Inj 50 mg / ml ampul - -
22 Fludane Tablet tablet - -
23 Fluocinolone Acetonide (Synarcus Cream) tube @ 5 gram - -
24 Fluoxetine (Napres) tablet - -
25 Gentamisin Inj 40 mg / ml ampul - -
26
mata) tube - -
27 Haloperidol 5 mg / ml (Lodomer) ampul - -
29 Human Hexagon Syphillis Kit - -
30 Iodina Test test kit - -
31 Jarum Sitoject biji - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 Kasa Steril 16 Cm X 16 Cm (16 Pads) Pads - -
34 Lamivudine (3TC) 150 mg tablet - -
35 Levotiroksin tab 100 µg tablet - -
36 Lopinavir 200 mg + Ritonavir 50 mg (Aluvia) tablet - -
37 Minyak Kayu Putih botol - -
38 Nevirapine (NVP) 200 mg tablet - -
39 Novabion Kapsul - -
40 Pehacain Inj ampul @ 2 ml - -
41 Procain Benzil Penisilin 3.000.000 I.U vial - -
42 Prontosan Gel 50 gram botol - -
43 Prontosan Sol 350 ml botol - -
Rapid Syphilis/Standar Diagnostic (Alere)
44 Piece - -
Bioline
45 Reagen 2 (FOCUS) Kit - -
50 Reagen HIV Right Sign Kit - -
Reagen I (Intec One Step Anti HIV (1&2) Tri
51 Kit
Line Test (ard) - -
52 Kit
1/2) - -
53 Kit
1/2) - -
54 Recovit Plus Tablet tablet - -
RPR Syphilis/Titer (Plasmatec/RPR Tes Kit,
56 Piece
RPR 0/012) - -
57 Safety Box 5 Liter Pcs - -
59 Stabimed 1 L botol - -
60 Tenofovir 300 mg (TDF) tablet - -
Tenofovir 300 mg (TDF) + Emcitritabine 200
61 tablet
mg (FTC) - -
Tenofovir 300 mg (TDF) + Lamivudine (3TC)
62 300 mg + Efavirenz (EFV) 600 mg (Triple FDC) tablet
Dewasa - -
TETAGAM - Human Tetanus Imunoglobulin
63 Unit
Injeksi I.M. 250 UI - -
64 Visto Tetes Mata botol - -
65 Zidofudine (ZDV) 100 mg tablet - -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Zidofudine (ZDV) 300 mg + Lamivudine (3TC)
66 tablet - -
150 mg
Zidofudine 60 mg + Lamivudine 300 mg +
67 tablet
Nevirapine 50 mg (Triple FDC) Anak - -
BPJS NON BPJS JUMLAH

JUMLAH KUNJUNGAN PBI ASKES MANDIRI
RESEP 0
Gresik, ............................................................
Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN YANG MENERIMA
KEPALA DINASEHATAN KAB. GRESIK KEPALA UPPF PIMPINAN PUSKESMAS PETUGAS PUSKESMAS
(……………………………………..) (………………………………….) (………………………………...) (............................................................)
Yang Melayani :…………………….. Yang Memeriksa :……………………..

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT JKN
( LPLPO JKN )
UNIT : KAMAR OBAT
PUSKESMAS : DADAP KUNING
KECAMATAN : CERME
KABUPATEN : GRESIK Jan-20

NO NAMA OBAT SAT. KET
AWAL AAN AN AN AKHIR OPT.
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
21 Amoxillin + As.Klavulanat 625 mg kapsul tablet - -
25 Antasida ampul @ 2 ml - -
( NovalginDOEN I tablet
/ Antrain kunyah, kombinasi
/ Santagesik ) :
26 Aluminium Hidroksida
Antasida DOEN 200 mg
II suspensi, ; Magnesium
kombinasi : tablet - -
27 Hidroksida 200 mg
Aluminium Hidroksida 200 mg/ml ; Magnesium botol @ 60 ml - -
28 Hidroksida 200 mg/ml
Antifungi DOEN pot @ 30 gr - -
32 Aqua pro Injeksi steril, bebas pirogen botol - -
1 2 3 4 5 6 7 8 9 10
53 Bedak salisil serbuk 2 % tablet - -
64 tablet - -
tablet)
66 Centabio Jelly / Bioplacenton Jelly tablet - -
78 Doksisiklin tablet 100 mg tablet - -
83 Elkana Sirup tablet - -
96 tablet - -
mg
99 ampul - -
(Fitomenadion
Neonatus ) ( Vitamin K1 ) tablet salut gula 10
100 tablet - -
mg
1 2 3 4 5 6 7 8 9 10
120 ampul - -
Decanoas )
124 Hemobion tablet tablet - -
128 ampul - -
injeksi)
146 supp - -
supp )
149 ampul - -
injeksi 1000 mg )
161 Kodein HCltablet
Kombinasi tabletsalut
10 mg: Besi (II) sulfat 7H2O tablet - -
162 200 mg Asam Folat 0,25 mg ( tablet tambah tablet - -
163 darah )
Kotrimoksazol Dewasa tablet tablet - -
1 2 3 4 5 6 7 8 9 10
170 Larutan mengandung elektrolit botol @ 500 ml - -
larutan infus steril / Wida RL ) ( Na 130 mEq,
171 Cl 109 mEq , Ca 3 mEq , Asetat 28 mEq ) / botol @ 500 ml - -
172 Asering
Lidokain500 ml larutan
injeksi infus steril
2% ( HCl) ampul @ 2 ml - -
173 ampul @ 2 ml - -
- 2 ml
186 tablet - -
salut 0,125 mg
1 2 3 4 5 6 7 8 9 10
235 Piracetam 1200 mg tablet Kotak - -
259 kapsul - -
lunak
260 Rifampisin kapsul 300 mg tablet - -
263 pot @ 30 gr - -
Belerang endap 4 %
277 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg ampul - -
1 2 3 4 5 6 7 8 9 10
297 tablet - -
mg
- -
BAHAN GIGI : - -
- -
1 2 3 4 5 6 7 8 9 10
Umbilical cord klem nylon steril (Claim biji
352 - -
Umbilical)
- -
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 - -
373 Kolesterol CHOD-PAP 8 X 20 ml botol - -
374 Kreatinin - Jaffe 400 ml botol - -
379 LDL Cholesterol 6 x 50 ml botol - -
386 Stik HCG Strip Answer 50 botol - -
387 Stik urine combine 10 test M botol - -
388 Stik urine 10 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 - -
1 2 3 4 5 6 7 8 9 10
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 - -
- -
OBAT TAMBAHAN : - -
1 Acitral / antasid + simetikon tube - -
2 Akarbose 100 mg ampul - -
3 Alat suntik 10 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 mg /
13 tablet - -
Miniaspi
14 Aseptik Gel 5 Liter botol - -
15 Askina calgitrol gel 15 g tube - -
16 Askina gel 15 g tube - -
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 - -
23 Budesonide-formoterol 160/4,5 (symbicort) pcs - -
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 - -
50 Dermafix S IV 6x7 cm rol - -
51 Dermafix SS 10 x 10 cm rol - -
1 2 3 4 5 6 7 8 9 10
52 Dermafix T 10 x 12 cm rol - -
56 Dextral Tablet tablet - -
57 Duk lubang steril 25x30 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 - -
68 Furosemid injeksi 10mg/ml ampul - -
69 Gabapentin 300 mg kapsul - -
70 tube - -
mata)
71 Glimepiride 3 mg tablet - -
73 Glucosa strip easy touch biji - -
74 Glucose biji - -
75 Glukosa strip on call plus biji - -
76 Gula Darah Stik biji - -
78 Hb Hemoglobin strip quick check biji - -
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 - -
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 - -
98 Kloramfenikol 500 mg kapsul kapsul - -
99 Kloramfenikol salep kulit tube - -
100 Komposit A2 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 - -
1 2 3 4 5 6 7 8 9 10
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 - -
151 Safety Box 12 L piece - -
152 Safety Box 5 Lt OM piece - -
153 Salbutamol 4 mg tablet - -
154 Sarung Tangan Gynaecolog pasang - -
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 - -
163 Spalk 40 x 8 x 7 cm biji - -
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 - -
1 2 3 4 5 6 7 8 9 10
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 - -
180 Terbutalin repsules (bricasma repsule) ampul - -
181 Terbutalin turbuhaler (bricasma turbuhaler) piece - -
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 - -
GRESIK, .....................................
MENGETAHUI YANG MELAPORKAN
KEPALA PUSKESMAS PENGELOLA OBAT PUSKESMAS
(…………………..........................…………………..) (……………….............................………………...)
( LPLPO JKN )
UNIT : KAMAR OBAT
KECAMATAN : CERME
KABUPATEN : GRESIK Feb-20

1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
/ Santagesik ) :
1 2 3 4 5 6 7 8 9 10
64 tablet - -
tablet)
96 tablet - -
mg
99 ampul - -
(Fitomenadion
100 tablet - -
mg
1 2 3 4 5 6 7 8 9 10
120 ampul - -
Decanoas )
128 ampul - -
injeksi)
146 supp - -
supp )
149 ampul - -
injeksi 1000 mg )
163 darah )
1 2 3 4 5 6 7 8 9 10
172 Asering
2% ( HCl) ampul @ 2 ml - -
173 ampul @ 2 ml - -
- 2 ml
186 tablet - -
salut 0,125 mg
1 2 3 4 5 6 7 8 9 10
259 kapsul - -
lunak
263 pot @ 30 gr - -
Belerang endap 4 %
1 2 3 4 5 6 7 8 9 10
297 tablet - -
mg
- -
BAHAN GIGI : - -
- -
1 2 3 4 5 6 7 8 9 10
352 - -
Umbilical)
- -
396 VDRL botol - -
1 2 3 4 5 6 7 8 9 10
- -
OBAT TAMBAHAN : - -
13 tablet - -
Miniaspi
26 Catgut 3/0 + 1/2 biji - -
28 Catgut No. 2/0 - 100 m biji - -
1 2 3 4 5 6 7 8 9 10
70 tube - -
mata)
74 Glucose biji - -
90 Kasa 3,6 M x 15 cm rol - -
1 2 3 4 5 6 7 8 9 10
156 Silk No. 2/0 - 100 m rol - -
159 Spalk 100 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
1 2 3 4 5 6 7 8 9 10
189 Urea pcs - -
190 Uricase pcs - -
GRESIK, .....................................
(…………………..........................…………………..) (……………….............................………………...)
( LPLPO JKN )
UNIT : KAMAR OBAT
KECAMATAN : CERME
KABUPATEN : GRESIK Mar-20

1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
/ Santagesik ) :
1 2 3 4 5 6 7 8 9 10
64 tablet - -
tablet)
96 tablet - -
mg
99 ampul - -
(Fitomenadion
100 tablet - -
mg
1 2 3 4 5 6 7 8 9 10
120 ampul - -
Decanoas )
128 ampul - -
injeksi)
146 supp - -
supp )
149 ampul - -
injeksi 1000 mg )
163 darah )
1 2 3 4 5 6 7 8 9 10
172 Asering
2% ( HCl) ampul @ 2 ml - -
173 ampul @ 2 ml - -
- 2 ml
186 tablet - -
salut 0,125 mg
1 2 3 4 5 6 7 8 9 10
259 kapsul - -
lunak
263 pot @ 30 gr - -
Belerang endap 4 %
1 2 3 4 5 6 7 8 9 10
297 tablet - -
mg
- -
BAHAN GIGI : - -
- -
1 2 3 4 5 6 7 8 9 10
352 - -
Umbilical)
- -
396 VDRL botol - -
1 2 3 4 5 6 7 8 9 10
- -
OBAT TAMBAHAN : - -
13 tablet - -
Miniaspi
26 Catgut 3/0 + 1/2 biji - -
28 Catgut No. 2/0 - 100 m biji - -
1 2 3 4 5 6 7 8 9 10
70 tube - -
mata)
74 Glucose biji - -
90 Kasa 3,6 M x 15 cm rol - -
1 2 3 4 5 6 7 8 9 10
156 Silk No. 2/0 - 100 m rol - -
159 Spalk 100 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
1 2 3 4 5 6 7 8 9 10
189 Urea pcs - -
190 Uricase pcs - -
GRESIK, .....................................
(…………………..........................…………………..) (……………….............................………………...)
( LPLPO JKN )
UNIT : SUKOANYAR
KECAMATAN : CERME
KABUPATEN : GRESIK april

1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
/ Santagesik ) :
1 2 3 4 5 6 7 8 9 10
64 tablet - -
tablet)
96 tablet - -
mg
99 ampul - -
(Fitomenadion
100 tablet - -
mg
1 2 3 4 5 6 7 8 9 10
113 Gliseril Guaiakolat tablet 100 mg tablet 100 100 10 90
120 ampul - -
Decanoas )
128 ampul - -
injeksi)
146 supp - -
supp )
149 ampul - -
injeksi 1000 mg )
163 darah )
1 2 3 4 5 6 7 8 9 10
172 Asering
2% ( HCl) ampul @ 2 ml - -
173 ampul @ 2 ml - -
- 2 ml
186 tablet - -
salut 0,125 mg
201 Nifedipin tablet 10 mg tablet 100 100 10 90
213 Obat Batuk Hitam ( O.B.H. ) Indo Plus sirup botol @ 100 ml 5 5 3 2
1 2 3 4 5 6 7 8 9 10
229 Parasetamol tablet 500 mg tablet 100 100 40 60
259 kapsul - -
lunak
263 pot @ 30 gr - -
Belerang endap 4 %
1 2 3 4 5 6 7 8 9 10
297 tablet - -
mg
- -
BAHAN GIGI : - -
- -
1 2 3 4 5 6 7 8 9 10
352 - -
Umbilical)
- -
396 VDRL botol - -
1 2 3 4 5 6 7 8 9 10
- -
OBAT TAMBAHAN : - -
13 tablet - -
Miniaspi
26 Catgut 3/0 + 1/2 biji - -
28 Catgut No. 2/0 - 100 m biji - -
1 2 3 4 5 6 7 8 9 10
70 tube - -
mata)
74 Glucose biji - -
90 Kasa 3,6 M x 15 cm rol - -
1 2 3 4 5 6 7 8 9 10
156 Silk No. 2/0 - 100 m rol - -
159 Spalk 100 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
1 2 3 4 5 6 7 8 9 10
189 Urea pcs - -
190 Uricase pcs - -
196 Zinc Syrup 10 mg / ml botol 3 3 1 2
197 molexflu
GRESIK, .....................................
(…………………..........................…………………..) (……………….............................………………...)
( LPLPO JKN )
UNIT : SUKOANYAR
KECAMATAN : CERME
KABUPATEN : GRESIK mei

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 - - -
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 - 100 100 40 60
24 Antalgin injeksi 250 mg / ml - 2 ml ampul @ 2 ml - - -
25 Antasida ampul @ 2 ml - - -
/ Santagesik ) :
kombinasi : tablet - - -
Aluminium Hidroksida 200 mg/ml ; Magnesium botol @ 60 ml - - -
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 - - -
34 Asam Asetilsalisilat (Asetosal) tablet 100 mg tablet - - -
35 Asam Asetilsalisilat (Asetosal) tablet 500 mg tablet - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
51 Batugin Elixir Sirup ( Fitofarmaka ) botol - - -
52 Becom - C tablet tablet - - -
53 Bedak salisil serbuk 2 % tablet - - -
54 Benzatin Benzil Penisillin Injeksi 2.4 Jt IU/vial ampul - - -
55 Besi Sirup botol - - -
56 Betadin Gargle 100 ml / Molexdin obat kumur botol - - -
57 Betahistin Mesilat tablet 6 mg tablet - - -
58 Betametason krim 0.1% ( sebagai valerat ) tube 5 gr - - -
59 Betason - N krim tube - - -
60 Bisacodil ( Bicolak ) tablet tablet - - -
61 Bisacodil suppositoria 10 mg ( Stolax supp ) supp - - -
62 Bisoprolol tablet 5 mg tablet - - -
63 Borak Gliserin 5% botol @ 15 ml - - -
64 tablet - - -
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 - - -
72 Diazepam rectal tube (Stesolid rectal Tube) tube @ 2,5 ml - - -
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 - - -
84 Epinefrina HCl ( Adrenalin ) injeksi 1 mg/ml ampul - - -
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 - - -
96 tablet - - -
mg
97 Fenol Gliserol tetes telinga 10% botol - - -
98 Fitomenadion ( Vitamin K1 ) injeksi 10 mg /ml ampul - - -
99 ampul - - -
(Fitomenadion
100 tablet - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
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 90 100 190 60 130
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 - - -
119 Griseofulvin tablet 125 mg tablet - - -
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 - - -
128 ampul - - -
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 - - -
139 Kalsium Glukonat injeksi i.v 10 % ( 100 mg/ml ) ampul - - -
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 - - -
146 supp - - -
supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - - -
148 Klindamisin kapsul 150 mg kapsul - - -
149 ampul - - -
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 - - -
10 mg: Besi (II) sulfat 7H2O tablet - - -
162 200 mg Asam Folat 0,25 mg ( tablet tambah tablet - - -
163 darah )
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 - - -
1 2 3 4 5 6 7 8 9 10
169 Lansoprazol tablet 30 mg tablet - - -
170 Larutan mengandung elektrolit botol @ 500 ml - - -
171 Cl 109 mEq , Ca 3 mEq , Asetat 28 mEq ) / botol @ 500 ml - - -
172 Asering
2% ( HCl) ampul @ 2 ml - - -
173 ampul @ 2 ml - - -
- 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 - - -
179 Magnesium Sulfat injeksi ( IV ) 20 % - 25 ml botol @ 25 ml - - -
180 Magnesium Sulfat injeksi ( IV ) 40 % - 25 ml botol @ 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 - - -
186 tablet - - -
salut 0,125 mg
187 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 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 - - -
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 90 100 190 20 170
202 Nistatin tablet salut 500.000 IU / g tablet - - -
203 Nistatin vaginal tablet 100.000 IU / g tablet - - -
204 Nodiar tablet tablet - - -
205 Noretisteron tablet 5 mg (Primolut N 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 - - -
213 Obat Batuk Hitam ( O.B.H. ) Indo Plus sirup botol @ 100 ml 2 2 (1) 3
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 - - -
226 Parasetamol drop 100 mg/ml ( 60 mg / 0,6 ml ) botol @ 15 ml - - -
227 Parasetamol sirup 120 mg / 5 ml botol - - -
1 2 3 4 5 6 7 8 9 10
228 Parasetamol tablet 100 mg tablet - - -
229 Parasetamol tablet 500 mg tablet 60 60 - 60
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 - - -
259 kapsul - - -
lunak
260 Rifampisin kapsul 300 mg tablet - - -
261 Risperidon tablet 1 mg tablet - - -
262 Salbutamol tablet 2 mg ( sebagai sulfat ) tablet - - -
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 - - -
273 Serum Anti Tetanus Injeksi 1.500 IU / amp vial - - -
274 Serum Anti Tetanus Injeksi 20.000 IU / vial vial - - -
275 Setirizin sirup 5 mg / 5 ml botol - - -
276 Setirizin tablet 10 mg tablet - - -
277 Sianokobalamin ( Vitamin B12 ) injeksi 500 mcg ampul - - -
278 Sianokobalamin (Vitamin B12) tablet 50 mcg tablet - - -
279 Simetidin tablet 200 mg tablet - - -
280 Simvastatin tablet 10 mg tablet - - -
281 Simvastatin tablet 20 mg tablet - - -
282 Siprofloksasin kapsul 500 mg ( sebagai HCl ) kapsul - - -
283 Solotio Perhydrol ( H2O2 ) 3 % botol @ 100 ml - - -
284 Spasi Plus tablet tablet - - -
285 Spasminal tablet tablet - - -
286 Sulfasetamida Natrium tetes mata 15 % botol - - -
1 2 3 4 5 6 7 8 9 10
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 - - -
297 tablet - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
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 - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
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 - - -
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 - - -
13 tablet - - -
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 - - -
23 Budesonide-formoterol 160/4,5 (symbicort) pcs - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
52 Dermafix T 10 x 12 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 - - -
70 tube - - -
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 - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
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 - - -
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 - - -
1 2 3 4 5 6 7 8 9 10
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 - - -
180 Terbutalin repsules (bricasma repsule) ampul - - -
181 Terbutalin turbuhaler (bricasma turbuhaler) piece - - -
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 2 2 2
GRESIK, .....................................
(…………………..........................…………………..) (……………….............................………………...)
( LPLPO JKN )
UNIT : NGEMBUNG
KECAMATAN : CERME
KABUPATEN : GRESIK JULI 2020
SISA PENERI PERSED PEMAK STOK PERMIN PEMBE

NO NAMA OBAT SAT. AWAL MAAN IAAN AIAN AKHIR TAAN RIAN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
10 Ambroxol tablet 30 mg tablet 40 100 140 40 100
21 Amoxillin + As.Klavulanat 625 mg kapsu tablet - -
23 Antalgin ( Metampiron ) tablet 500 mg tablet 90 100 190 140 50
25 Antalgin ( Metamisol )injeksi 500 mg /ampulml @ 2 ml - -
26 Antasida DOEN I tablet kunyah, kombin tablet - -
27 Antasida DOEN II suspensi, kombinasibotol @ 60 ml - -
34 Asam Asetilsalisilat (Asetosal) tablet 1 tablet - -
36 Asam Askorbat ( Vitamin C ) tablet 50 tablet - -
39 Asam Mefenamat kaplet 500 mg tablet 100 100 80 20
46 Atropin Sulfat injeksi 0,25 mg / ml - 1 ampul - -
53 Bedak salisil serbuk 2 % tablet 5 5 2 3
54 Benzatin Benzil Penisillin Injeksi 2.4 Jt I ampul - -
56 Betadin Gargle 100 ml / Molexdin obat botol - -
58 Betametason krim 0.1% ( sebagai valeratube 5 gr - -
61 Bisacodil suppositoria 10 mg ( Stolax sup supp - -
64 Bromhexin tablet ( Bronex tablet ; Nova tablet - -
69 Deksametason tablet 0,5 mg tablet 50 100 150 50 100
72 Diazepam rectal tube (Stesolid rectal Ttube @ 2,5 ml - -
84 Epinefrina HCl ( Adrenalin ) injeksi 1 m ampul - -
96 Fenoksimetil Penisilina ( Penisilin V ) t tablet - -
98 Fitomenadion ( Vitamin K1 ) injeksi 10 ampul - -
99 Fitomenadion ( Vitamin K1 ) injeksi 2 mg ampul - -
100 Fitomenadion ( Vitamin K1 ) tablet salu tablet - -
113 Gliseril Guaiakolat tablet 100 mg tablet 150 100 250 80 170
120 Haloperidol injeksi 50 mg/ml ( Haldol ampul - -
128 Hiosin Butil Bromid injeksi 20 mg/ml (Sp ampul - -
131 Ibuprofen tablet 400 mg tablet 70 100 170 80 90
136 Isosorbid Dinitrat tablet sublingual 5 m tablet - -
139 Kalsium Glukonat injeksi i.v 10 % ( 100 ampul - -
146 Ketoprofen supositoria 100 mg ( Protof supp - -
149 Kloramfenikol injeksi 1000 mg (Colsance ampul - -
152 Kloramfenikol suspensi 125 mg / 5 mlbotol @ 60 ml - -
155 Klorfeniramin Maleat ( CTM ) tablet 4 tablet - -
162 Kombinasi tablet salut : Besi (II) sulf tablet - -
170 Larutan mengandung elektrolit (Ringer botol
La @ 500 ml - -
171 Larutan mengandung elektrolit ( Na 130 botol @ 500 ml - -
173 Lidokain injeksi 2% ( HCl) + Epinefrin 1ampul
: @ 2 ml - -
179 Magnesium Sulfat injeksi ( IV ) 20 % - b2otol @ 25 ml - -
180 Magnesium Sulfat injeksi ( IV ) 40 % - b2otol @ 25 ml - -
186 Metilergometrin Maleat (Metilergometri tablet - -
187 Metilergometrin Maleat injeksi 0,200 ammpul @ 1 ml - -
195 Natrium Klorida larutan infus 0,9% steri
botol @ 500 ml - -
201 Nifedipin tablet 10 mg tablet 140 140 40 100
205 Noretisteron tablet 5 mg (Primolut N ta tablet - -
213 Obat Batuk Hitam ( O.B.H. ) Indo Plusbotol
si @ 100 ml 4 4 1 3
226 Parasetamol drop 100 mg/ml ( 60 mg botol/ 0 @ 15 ml - -
229 Parasetamol tablet 500 mg tablet 70 200 270 120 150
242 Piridoksin HCl ( Vitamin B6 ) tablet 10 tablet - -
262 Salbutamol tablet 2 mg ( sebagai sulfat tablet - -
263 Salep 2-4 , kombinasi : Asam Salisilat pot @ 30 gr - -
266 Sefadroksil Sirup Kering 125 mg / 5 mlbotol @ 60 ml - -
273 Serum Anti Tetanus Injeksi 1.500 IU / vial - -
274 Serum Anti Tetanus Injeksi 20.000 IU / v vial - -
277 Sianokobalamin ( Vitamin B12 ) injeksi ampul - -
278 Sianokobalamin (Vitamin B12) tablet 5 tablet - -
282 Siprofloksasin kapsul 500 mg ( sebagai kapsul - -
294 Thiamfenikol sirup 125 mg / 5 ml botol @ 60 ml 5 5 - 5
295 Thiamfenikol kapsul 500 mg kapsul 9 9 1 8
296 Tiamin HCl (Vit.B1) injeksi 100 mg/ml-1 ampul - -
297 Tiamin HCl / Mononitrat (Vitamin B1) t tablet - -
303 Zenirex Sirup botol @ 60 ml 3 3 1 2
304 Zink sirup 20 mg/5ml ( Zircum Kid Sirupbotol @ 60 ml - -
- -
BAHAN GIGI : - -
314 Monoklorkamfer Mentol Cairan ( CHKM botol - -
319 Temporary Stopping Fletcher ( Fletcher set - -
- -
352 Umbilical cord klem nylon steril (Claim biji - -
- -
396 VDRL botol - -
- -
OBAT TAMBAHAN : - -
23 Budesonide-formoterol 160/4,5 (symbic pcs - -
26 Catgut 3/0 + 1/2 biji - -
28 Catgut No. 2/0 - 100 m biji - -
70 Gentamisin salep mata 0,3 % (Genoint s tube - -
74 Glucose biji - -
90 Kasa 3,6 M x 15 cm rol - -
156 Silk No. 2/0 - 100 m rol - -
159 Spalk 100 x 10 piece - -
165 Spalk 80 x 10 x 8 cm biji - -
181 Terbutalin turbuhaler (bricasma turbuha piece - -
189 Urea pcs - -
190 Uricase pcs - -
197 curbeplek syr 3 3 1 2
198 coparcetin syr 4 5 9 3 6
GRESIK, .........................
(…………………..........................…………………..) (……………….............................………………...)

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT PUSKESMAS

PENERIM PERSEDIA PEMAKAI STOK STOK PERMIN PEMBERIAN

BPJS NON BPJS JUMLAH

Mengetahui/Menyetujui, YANG MENYERAHKAN YANG MEMINTA / MELAPORKAN

(……………………………………..) (………………………………….) (………………………………...)

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

PERMIN PEMBERIAN JMLAH

BPJS NON BPJS JUMLAH

(……………………………………..) (………………………………….) (………………………………...) (............................................................)

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

SISA PENERIM PERSEDIA PEMAKAI STOK STOK

SISA PENERIM PERSEDIA PEMAKAI STOK STOK

SISA PENERIM PERSEDIA PEMAKAI STOK STOK

SISA PENERIM PERSEDIA PEMAKAI STOK STOK

SISA PENERIM PERSEDIA PEMAKAI STOK STOK

SISA PENERI PERSED PEMAK STOK PERMIN PEMBE

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