LAPORAN PEMAKAIAN OBAT BLUD

TAHUN ANGGARAN 2020 & 2021

KODE PUSKESMAS : HALAMAN
PUSKESMAS : PATEBON I LB2
KECAMATAN : PATEBON BULAN APRIL
KABUPATEN/KODYA: KENDAL TAHUN 2022
PROPINSI : JAWA TENGAH
STOCK HARGA TOTAL NO EXPIRE
NO NAMA OBAT SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN SISA HARGA
AWAL SATUAN HARGA BATCH DATE
1 ASAM MEFENAMAT 500 mg TAB 600 - 600 100 500 30,520 305 152,600 210336120 MART-23
2 BIOPRADYN TAB 400 - 400 100 300 96,500 965 289,500 F3321019 AGST-24
3 BORAKS 10% GLISERIN 8ML(GOM) - - - - - 4,200 4,200 - U05072 7/1/2024
4 CEFADROXIL 500mg KAP 1,400 - 1,400 400 1,000 76,364 764 763,640 51B0609 2/1/2024
5 CIPROFLOXACIN 500mg TAB 2,000 - 2,000 - 2,000 40,909 409 818,180 TSD14949 3/1/2025
6 COTRYMOXAZOLE 480 mg TAB 2,100 - 2,100 200 1,900 30,909 309 587,271 9613 MART-25
7 DEXAMETHASONE/IFIDEX 0,5 mg TAB 500 - 500 - 500 16,000 160 80,000 1507025 7/1/2025
8 ERLAMYCETIN SM Tube 10 - 10 - 10 9,000 9,000 90,000 454202 11/1/2023
9 ERLAMYCETIN TM BTL 24 - 24 10 14 13,172 13,172 184,408 D.0756013 MART-23
10 FLUTAMOL KAP 700 - 700 300 400 53,315 533 213,260 HP028 AGST-23
11 FOLAXIN 400MCG/ASAM FOLAT 400MCG TAB 300 - 300 100 200 23,091 231 46,182 ARE016001 1/1/2026
12 FUROSEMID 40MG TAB 2,800 - 2,800 - 2,800 27,600 276 772,800 29013 AGST-26
13 GLIBENCLAMIDE 5MG TAB 1,600 - 1,600 900 700 16,250 163 113,750 20GD1280 1/1/2023
14 GLIMEPIRIDE 2MG TAB 1,400 - 1,400 - 1,400 65,149 651 912,086 51L4106 10/1/2022
15 GUANISTREP SYR BTL 75 - 75 25 50 7,954 7,954 397,700 107211 7/1/2025
16 IBUPROFEN 200MG TAB 1,400 - 1,400 400 1,000 29,500 295 295,000 30013 AGST-26
17 KALSIUM LAKTAT / TRIMAKAL TAB 1,900 - 1,900 - 1,900 25,454 255 483,626 B9007 2/1/2024
18 METRONIDAZOLE 500MG TAB 1,200 - 1,200 200 1,000 26,727 267 267,270 C20060 3/1/2024
19 NATRIUM DICLOFENAK 50MG TAB 2,200 - 2,200 - 2,200 23,125 231 508,750 11810 LN 12/1/2023
20 OBH SYR ITRASAL BTL 60 - 60 20 40 7,773 7,773 310,920 111158 11/1/2025
21 PARASETAMOL 500mg TAB 5,400 - 5,400 - 5,400 29,500 295 1,593,000 93814 9/1/2026
22 PHENOL GLISEROL TT BTL 35 - 35 11 24 8,182 8,182 196,368 20LF027 6/1/2022
23 PIRACETAM 400mg TAB 300 - 300 - 300 43,940 439 131,820 KPG46750 6/1/2023
24 PIROXICAM 10 MG TAB 2,000 - 2,000 600 1,400 21,000 210 294,000 62215 Sep-26
25 RANITIDIN 150MG TAB 2,300 - 2,300 Err:522 Err:522 24,700 247 Err:522 HTRNTB15844 Sep-23
26 SIMVASTATIN 10 MG TAB 900 - 900 - 900 44,500 445 400,500 52FD346 May-24
27 SUPERHOID / ANTI HEMOROID SUPP SUPP 57 - 57 6 51 33,582 5,597 285,447 C21085 MART-24
28 VITAMIN B1 '1000 TAB 23,000 - 23,000 1,000 22,000 30,752 31 676,544 14105005 May-24
29 VITAMIN B6 '250 TAB 1,500 - 1,500 250 1,250 14,090 56 70,450 210720 Jul-23
30 VITAMIN BC '250 TAB 3,000 - 3,000 1,250 1,750 33,055 132 231,385 821044 AGST-23
31 VITAMIN SYRUP (MOMILEN IMUSIVE 60ml) BTL 15 - 15 15 - 18,488 18,488 - 2402 APRL-22
TOTAL 13,305,520
 LAPORAN PEMAKAIAN BAHAN MEDIS HABIS PAKAI BLUD
TAHUN ANGGARAN 2020 & 2021
KODE PUSKESMAS : HALAMAN
PUSKESMAS : PATEBON I LB2
KECAMATAN : PATEBON BULAN APRIL
KABUPATEN/KODYA: KENDAL TAHUN 2022
PROPINSI : JAWA TENGAH
STOCK PENERIMAA PERSEDIAA PEMAKAIA HARGA TOTAL NO EXPIRE
NO NAMA OBAT SATUAN SISA HARGA
AWAL N N N SATUAN HARGA BATCH DATE
1 ANTI A / GOLONGAN DARAH VLS 1 - 1 - 1 159,090 159,090 159,090 1010341 11/30/2022
2 ANTI B / GOLONGAN DARAH VLS 1 - 1 - 1 159,090 159,090 159,090 1020341 11/30/2022
3 BLOOD LANCET@100 PCS 200 - 200 - 200 25,300 253 50,600
4 DIRUI BCC-3600 LYSE (500mL) PACK 1 - 1 - 1 2,750,000 2,750,000
5 DIRUI BCC-3600 DILUENT (20L) PACK 1 - 1 - 1 1,815,000 1,815,000
6 DIRUI BCC-3600 CLEANSER (500mL) PACK 1 - 1 - 1 2,420,000 2,420,000
7 EASY TOUCH ASAM URAT@25 PCS 75 - 75 - 75 125,000 5,000 375,000 UAS18530C6E 4/30/2021
8 EASY TOUCH CHOLESTEROL@10 PCS 20 - 20 10 10 187,000 18,700 187,000 CHS19827B9C 2/28/2021
9 HCG RIGHT SIGN STRIP@50 PCS 100 - 100 10 90 105,000 2,100 189,000
10 KARTU GOLONGAN DARAH PCS 200 - 200 - 200 45,000 450 90,000
11 KASSA 16x16 ADINDA PCS 7 - 7 - 7 9,900 69,300
12 MAXTER STERIL 6,5 PCS 200 - 200 - 200 13,100 2,620,000
13 NESCO CHOLESTROL@10 PCS 20 - 20 10 10 203,000 20,300 203,000
14 NESCO CHOLESTROL@10 PCS 40 50 90 20 70 180,000 18,000 1,260,000
15 NESCO GLUCOSE@25 PCS 250 - 250 125 125 100,000 4,000 500,000
16 NESCO URIC ACID @ 25 PCS 100 - 100 25 75 148,000 5,920 444,000
17 SAFE GLOVE S PCS 3,800 - 3,800 - 3,600 105,000 1,050 3,780,000
18 SAFE GLOVE M PCS 1,600 - 1,600 - 1,600 105,000 1,050 1,680,000
19 SPUIT 1 CC PCS 100 - 100 30 70 197,500 1,975 138,250
20 SPUIT 3 CC PCS 500 - 500 - 500 145,000 1,450 725,000
21 STRIP URIN VERYPY 3'P @100 PCS 100 - 100 100 - 120,000 1,200 -
22 TABUNG EDTA 3ML PCS 300 - 300 - 300 150,000 1,500 450,000
23 TEST STRIP HB QUICK CHECK @ 50 PCS 50 250 300 100 200 517,000 10,340 2,068,000 HBM1020033 10/7/2022
24 TORNIQUET PCS 1 - 1 - 1 33,000 33,000 33,000
25 TIMER KURZZEITMESSER UNIT 1 - 1 - 1 77,000 77,000 77,000
26 THERMOMETER DIGITAL KULKAS PCS 1 - 1 - 1 99,000 99,000 99,000
27 WIDEAL FOTRES AH VIAL 1 - 1 - 1 100,000 100,000 100,000
TOTAL 22,441,330
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LPLPO)
KODE PUSKESMAS : HALAMAN :1
PUSKESMAS : PATEBON I LB2 :
KECAMATAN S: PATEBON BULAN : MEI
KABUPATEN/KODYA A: KENDAL TAHUN : 2022
T
PROPINSI U: JAWA TENGAH
A
N
NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 4 5 6 7 8 9 10 11 12 13 14 15 11
1 ABU (DAK) vial 1 - - - 1 512,204.00 512,204 Sep-23 4,700,319
2 Acycovir 200 mg tab - - - - - 130.00 -
3 Acycovir 400 mg tab - - - - - 249.00 -
4 Acyclovir cream (APBD 2 21) tube 70 - - - 70 5,225.00 365,750 Oct-24 7,818
5 ADS 0,05 ml (prop '21) - - - - - 1,640.00 -
6 Alat suntik 10 ml piece - - - - - 932.16
7 Alat suntik 1 ml (DAK) piece - - - - - 1,430.00 - Nov-23 181001
8 Alat suntik 2,5 ml pcs - - - - - 660.00
9 Alat suntik 3 ml (DAK) pcs - - - - - 1,138.00 - Mar-23 181302
10 Alat suntik 3 ml (DAK) 900 - 900 - 900 650.00 585,000.00 Mart-26 21D1508J
11 Alat Suntik 5 ml (DAK) pcs - - - - - 1,600.00 #VALUE!
12 Alat tes kehamilan pcs - - - - - 1,320.00
13 Albendazol 400 mg (prop '21) tab 211 - - - 211 402.00 53,865.99 AGST-23 1108083
14 Alkohol swab (DAK 20) lembar 300 - - - - 176.24 #VALUE! Feb-22 122177
15 Alkohol swab (DAK 21) 1,000 - 1,000 100 900 120.00 108,000.00 Jun-24 1072188
16 Allopurinol 100 mg (DAK 2020) tablet 1,500 - 1,500 200 1,300 105.00 136,500.00 Feb-23 A01601
17 Ambroxol 30 mg (APBD 2 21) tab 2,300 3,000 5,300 400 4,900 2,000 187.00 916,300.00 45,231 2111.07.146
18 Ambroxol sirup (APBD 2 21) botol 150 - 150 - 150 5,197.50 779,625.00 Nov-23 2111-14-184
19 Aminophillin 150 mg tab - - - - - 138.99
20 Aminophillin 200 mg (DAK) tab 200 - 200 - 200 95.00 19,000.00 Sep-22 19CJ002
21 Aminophillin Inj 24 mg/ml-10 ml ampul - - - - - 3,345.00
22 Amitriptilin tab salut 25 mg (HCl) tab - - - - - 112.00
23 Amlodipin 5 mg (DAK 21) tablet 1,500 3,000 4,500 900 3,600 3,000 53.00 190,800.00 AGST-23 O81331
24 Amoxicillin 500 mg (DAK 2021) kaplet 600 5,000 5,600 1,200 4,400 3,000 201.00 884,400.00 Apr-22 B90394
25 Amoxicillin Forte 250 mg/ 5 ml (DAK 21) botol 170 - 170 170 - 3,498.00 - 45,536 10729
26 Amoxycillin Sirup Kering 125 mg/ 5 ml btl - - - - - 2,223.00
27 Ampicillin 1 gram vial - - - - - 8,237.00
28 Anak FDC Triple tab - - - - - 740.15
29 Antalgin 500 mg/Metamizole Na 500mg(APBD 2 21) tab 2,700 2,000 4,700 - 4,700 2,000 374.00 1,757,800.00 Dec-24 211,201,142
30 Antasida DOEN (DAK 2020) tablet 600 5,000 5,600 2,000 3,600 3,000 58.00 208,800.00 Aug-23 AO1600
31 Antasida DOEN suspensi (DAK 21) botol 170 - 170 10 160 1,679.00 268,640.00 Jul-24 G29101
32 Anti bakteri DOEN Kombinasi tube - - - - - 3,035.00 -
33 Antifungi DOEN Kombinasi pot - 144 144 24 120 48 4,496.00 539,519.76 Sep-22 185J002C
 S
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NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 4 5 6 7 8 9 11 12 13 14 15 11
34 Antihemoroid supp - - - - - 3,166.90
35 Antimigren tab - - - - - 173.00
36 Aqua pro injeksi (DAK 2020) ampul 50 - - - 50 2,860.00 143,000.00 Mar-23 1100320002
37 Asam Ascorbat 50 mg (PROP) tab - - - - - 105.00 - Apr-22
38 Asam Folat (DAK 21) tab 1800 - 1,800 300 1500 42.00 63,000.00 AGST-23 2108.01.365
39 Asam Mefenamat 500 mg (DAK 21) kaplet 2900 3,000 5,900 1,200 4700 2,000 111.00 521,700.00 Sep-23 HTMECA15858
40 Asam Tranexamat injeksi 5 % ampul - - - - - 2,445.00 -
41 Atropine Sulfat Inj (DAK) ampul - - - - - 1,639.00 -
42 ATS 1500 IU (DAK) ampul - - - - - 130,999.00 - MART-2022 4200720
43 Attapulgite (DAK) tab 2800 - - - - 220.00 - May-25 O157005
44 Azytromycin 500 mg tab - - - - - 1,900.00
45 Baju Pelindung pcs - - - - - 30,000.00
46
Benecheck Plus Multi Monitoring System 3'in 1/alat GCU unit - - - - - 198,025.13

47 Benzatin Penisilin 2.4 jt vial - - - - 14,500.00

48 Betahistine (DAK 21) tablet 60 390 450 - 450 600 4,945.00 2,225,250.00 Jun-23 A 9217FY
49 Betametason Cream 1 %-5 g (DAK) tube - 25 25 25 - 25 1,430.00 - MART-22 C00092T
50 Bisakodil 10 mg suppositoria /Dulcolax/Stolax supp - - - - - - 5,370.00 - Apr-22 AB9967
51 Bisakodil 5 mg suppositoria / Dulcolax supp - - - - - 5,999.95
52 Bisakodil 5 mg tablet salut enterik tab - - - - - - 300.00
53 Bisturi Aesculap Blades B- Braun No. 12 pcs - - - - - 3,150.00 - `4506995293
54 Blood Lancet ktk - - - - - 15,950.00 -
55 Blood Transfusion Set Nipro pcs - - - - - 13,420.00
56 Buku Petunjuk Teknis Penggunaan Alat Deteksi Dini Ibu
pcs - - - - 22,000.00
Hamil Pelayanan Antenatal Bagi Bidan (Prop. 2016) -
57 Calcii glukonas ampul - - - - - 9,955.00 - Mar-21 97KH0038
58 Captopril 12,5 mg tablet 300 - 300 300 - 66.00 - Oct-23 K82265B
59 Captopril 25 mg tablet - - - - - 68.00
60 Carbamazepine 200 mg (PROP. 2020) tab 0 300 300 - 300 300 245.00 73,500.00 NOV22 A90981
61 Cat gut Plain 3/0 70C + jarum 1/2 25M R (PHSDA) pcs - - - - - 24,583.33 - May-25
62 Cat Gut Plain suture needle 3/0 (DAK 21) 1 - 1 - 1 84,000.00 84,000.00 Jun-25 CP73030B0
63 Cat Gut Chromic 3/0 + jarum 1/2 GT 35 mm pcs - - - - - 5,750.25 - May-25 2,004,053
64 Cat gut Chromic 3/0 75C + jarum 1/2 22 M R (CHPFA) pcs - - - - - 22,500.00 - May-25 2,004,053
65 Cat Gut Chromic 3/0 with needle serenity(DAK21) 2 - 2 1 1 78,000.00 78,000.00 Jun-25 CC73030B3
66 CD 4 Control buah - - - - - 660,000.00
67 CD 4 POC test - - - - - 158,400.00
68 Cefadroxil 500 mg kapsul - - - - - 450.00
69 Cefadroxil sirup kering 125 mg/ 5 ml botol - - - - - 3,992.00
70 Cetirizine 10 mg (DAK) kapsul 0 1,500 1,500 200 1,300 500 89.98 116,974.00 Apr-22 20RBSG16
71 Chlorpromazine 100 mg tab 1 - 1 1 - 157.00 - Apr-22 A91133
72 Ciprofloksasin 500 mg tablet - - - - - 265.00
73 Clindamycin 150 mg (DAK) tab - - - - - 759.00 - Apr-22 EDD292
74 Clonidine 0,15 mg tab - - - - - 139.00
75 Clozapine 25mg 154 - 154 154 - 1,121.00 - Jan-23 52HO319
76 Corsaneuron tab - - - - - 756.00
77 Cover Glass 24 x 24 mm jayamas Onelab pcs - - - - - 144.61
 S
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NO NAMA OBAT 0 PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
300 MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2### (2) 5 6 7 8 9 10 11 12 13 14 15 11
78 CTM (APBD 2) tablet 4,300 3,000 7,300 2,000 5,300 54.00 286,200.00 Jun-24 604021
79 Cuticell 10 x 10 cm piece - - - - - 5,520.00
80
Cuticell classic 10 cm x 40 cm BSN Medical GMBH Germany
piece 16 - 16 2 14 14,689.00 205,646.00 Jul-22 832,643

81 Dehydro Artemsin 40 mg + Piperaquin 320 mg (DHP) tab - - - - - 2,160.00

82 Dewasa FDC Triple : Tenofovir 300 mg + Lamivudine 300
tab - - - - 2,638.47
mg + Efavirenz 600 mg -
83 Dexametason 0,5 mg (APBD 2 21) tab 2,000 3,000 5,000 1,700 3,300 3,000 137.50 453,750.00 Oct-25 2110062
84 Dexametason Injeksi 5 mg / ml-1 ml ampul - - - - - 1,096.92 - F8E396
85 Dextral kaplet - - - - - 506.00
86 Diazepam 10 mg RT/Stesolid RT 10 mg/ 2,5 ml rectal tube - - - - - 18,279.00
87 Diazepam 2 mg tab 359 - 359 359 - 86.00 - Jun-23 A3114 JS
88 Diazepam 5 mg tab 100 - 100 100 - 108.00 - Jul-25 A11202
89 Diazepam 5 mg RT/ Stesolid RT 5 mg/ 2,5 ml rectal tube - - - - - 12,573.00
90 Diazepam injeksi 5 mg/ ml ampul - - - - - 1,735.00
91 Digoxin 0,25 mg tablet 0 - - - 0 104.00 - Feb-21 A8606BW
92 Dimenhydrinate 50 mg (DAK) tab 500 - 500 - 500 112.00 56,000.00 May-24 F91585B
93 Diphenhidramin injeksi ampul - - - - - 1,095.00 - Oct-21 26342020-2
94 Doksisiklin 100 mg kapsul tablet - - - - - 280.00
95 Domperidon 10 mg (APBD 2) tablet - 1,000 1,000 1,000 - 222.00 -
96 Domperidone maleat10 mg (DAK '21) 300 - 300 300 - 71.00 - Jul-24 JG0831
97 Domperidon susp. botol - - - - - 2,700.00
98 Duviral ( Zidovudine 300 mg + Lamivudine 150 mg ) tab - - - - - 3,700.00
99 E Care Hand Scrub 5 liter galon - - - - - 640,800.00
100 E-care antiseptik Hand rub 5 lt galon - - - - - 580,000.00
101 Efavirens 600 mg tab - - - - - 6,630.00
102 Ephineprine Injeksi 0,1 %-1 ml (DTT 2) ampul 1 - 1 - 1 7,908.67 7,908.67 Dec-22 26344011-2
103 Erytromicin 250 mg tab - - - - - 546.00
104 Erytromicin 500 mg kapsul - - - - - 730.00
105 Erytromicin sirup botol - - - - - 6,150.00
106 Etakridin 300 ml Jayamas Onemed botol - - - - - 3,000.00
107 Etambutol tab salut 500 mg (HCl) tab - - - - - 410.00
108 Etanol 70% (Alkhohol) 1 liter (DTT 2) btl 6 - 6 - 6 45,000.00 270,000.00 Jan-23 1001828
109 Eugenol cairan botol - - - - - 18,100.00
110 Euthyrox tab - - - - - 735.00
111 Fasolon Cream (APBD2 21) 50 - 50 10 40 22,000.00 880,000.00 N0V-25
111 FDC Anak (PROP) paket 1 - 1 1 - 248,120.00 - Oct-22 20PK2012
112 FDC Kat. 2 paket - - - - - 1,199,985.00
113 FDC Kat. I paket 0 - - - - 415,467.00
114 Fenitoin 100 mg tab - - - - - 157.99 - Sep-21 390901
115 Fenobarbital 30 mg tab 130 - 130 130 - 171.00 - Apr-22 172244B
116 Fenobarbital inj 50 mg/ml- 2 ml ampulS - - - - - 1,857.00
117 Fenoksimetil Penisilin 500 mg A
tab - - - - - 605.00
T
118 Fenol Glicerol TT 10 % ( Karbogliserin TT 10 % )(DAK) btl
U - - - - - 2,764.00 - Apr-22 18LB017
119 Flutamol suppA - 2,000 2,000 500 1,500 2,640.00
N
NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 3 5 6 7 8 9 10 11 12 13 14 15 11
120 Fitomenadion 10 mg tablet - - - - - 748.00 - Jan-23 36381002
121 Fitomenadion 2 mg/ml- 1 ml (DAK) ampul 31 - 31 - 31 3,681.99 114,141.69 Apr-22 36478020
122 Foleycath, 2 way latex foley cath.No. 16 piece - - - - - 11,530.00
123 Foleycath, 2 way latex foley cath.No. 18(DAK 21) piece 4 - 4 - 4 9,680.00 38,720.00 Jul-26 9082188
124 Furosemid 40 mg tab - - - - - 78.00
125 Garam Oralit Kombinasi sachet - - - - - 257.00
126 Gemfibrosil 300 mg kapsul - - - - - 380.00 -
127 Gentamicin 40 mg/ml injeksi ampul - - - - - 3,509.00
128 Gentamicin Salep Kulit 0.1 %(DAK 21) tube 70 - 70 30 40 7,623.00 304,920.00 AGST-24 10628
129 GG / Guaifenesin 100 mg tab - - - - - 129.80 - Agst-22 190822
130 Glibenklamide 5 mg (DAK) tab 2,000 - 2,000 - 2,000 119.00 238,000.00 Oct-22 20GD1188
131 Glimepiride 1 mg tab - - - - - 174.00
132 Glukosa 5 % (DAK) btl 10 - 10 - 10 7,362.30 73,623.00 Feb-23 200314
133 Griseofulvin 125 mg (DAK 21) tab 700 - 700 400 300 210.00 63,000.00 Feb-24 B90350B
134 Hazmat (APD LEVEL 3 ) 4 - 4 - 4 40,000.00 160,000.00
135 Halloperidol 0,5 mg tab - - - - - 56.00
136 Halloperidol 5 mg tab 313 - 313 313 - 60.00 - Jul-24 A11078
137 Haloperidol 2 mg drop ( Lodomer) botol 125 - 125 125 - 18,900.00 - 45,261 A02538
138 Haloperidol Dekanoat inj 50 mg/ml (Haldol Decanoas inj) ampul - - - - - 101,300.00
139 Hydrex Surgical Scrub 5 liter galon - - - - - 836,160.00
140 Hydrochlortiazid 25 mg tab 0 - - - - 149.00 - May-21 E160424B
141 Hydrocortisone 2.5 % cream (DAK) tube 72 - 72 10 62 2,325.00 144,150.00 AGST-25 H12183W
142 Hyperhep B-Hepatitis B imunoglubolin vial - - - - - 1,324,986.30
143 Ibuprofen 200 mg tab - - - - - 105.00
144 Ibuprofen sirup botol - - - - - 2,720.30
145 Infus set anak pcs 40 - 40 - 40 3,597.00 143,880.00
146 Infusset dewasa (DAK) pcs 49 - 49 - 49 5,800.00 284,200.00 Mar-24 19110301
147
Intec Products/ One Step Anti HIV ( 1&2 ) Tri-Line Test Card test - - - - - 11,300.00

148 Iodins test botol - - - - - 5,275.00

149 Isoniazid 100 mg tab - - - - - 145.00
150 Isoniazide 300 mg tab - - - - - 173.00
151 Isosorbide Dinitrat tab 0 - - - - - 89.00 - Oct-21 A235959 JU
152 IV Catheter pcs - - - - - 8,750.00
a. IV Catheter No 18 (APBD 2) pcs 24 - 24 10 14 8,750.00 122,500.00 Sep-22 17K27G8261
b. IV Catheter No 20 pcs - - - - - 4,749.00
c. IV Catheter No 22 pcs - - - - - 4,224.00
d. IV Catheter No 24 (APBD 2 ) pcs 14 - 14 - 14 8,750.00 122,500.00 Dec-24 19N24G8302
153 Kalsium Lactat 500 mg (DAK 21) tablet 2,600 3,000 5,600 800 4800 60.00 288,000.00 AGST-24 A11261
154 Kapas Pembalut Hidrofil DRC 250 gr (DAK 20) roll 1 - 1 - 1 20,600.00 20,600.00 Jan-23 140119
155 Kartu golongan darah kotak
S - - - - - 27,500.00
156 Kasa Hidrofil DRC 2 m x 80 cm A
pcs - - - - - 9,870.00
T
157 Kasa Hidrofil DRC 36 m x 80 cm roll
U - 5 5 4 1 136,500.00 136,500.00 Mart-22 S20318
158 Kasa Pembalut Hidrofil DRC 3,6 m x 10 cm A
roll - - - - - 2,415.00
N
NO NAMA OBAT - PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
70 MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 3 5 6 7 8 9 10 11 12 13 14 15 11
159 Kasa Pembalut Hidrofil DRC 4m x 10 cm rol 0 - - - - 2,300.00 - 20616
160 Kasa Steril DRC 16 cm x 16 cm ( 16 pads ) pcs 200 100 300 300 - 100 8,000.00 - Jul-22 `040117
161 Ketokenazole 2 % krim tube 45 - 45 20 25 2,517.90 62,947.50 Nov-23 K91687T
162 Ketokenazole 200 mg tab - - - - - 280.00
163 Ketoprofen 100 mg / Suprafenid supp - - - - - 2,380.00
164 Ketorolac 30 mg inj ampul - - - - - 1,100.00
165 Khloramfenicol Salep Kulit 2 % (DAK 20) tube - - - - - 3,241.70 - Feb-22 2907
166 Khloramfenicol susp. 125 mg/ 5 ml btl - - - - - 5,015.00
167 Khloramfenikol 1 % Salep Mata 5 gram (DAK) tube 31 48 79 65 14 2,006.40 28,089.60 Oct-22 J919244W
168 Khloramfenikol 250 mg kapsul - - - - - 310.00
169 Khloramfenikol 500 mg (DAK 20) kapsul - - - - - 1,163.00 -
170 Khloramfenikol Tetes Mata /RECO TM (DAK 21) botol - - - - 50 8,250.00 - Feb-23 90881006
171 Kombipak Azytromycin-Cefixime paket - - - - - 30,030.00
172 Kotrimoksazole dewasa kombinasi tablet 0 - - - - 125.00 - Maret 2021 170324123
173 Kotrimoksazole suspensi (DAK 20 ) botol 10 - 10 10 - 2,052.00 - Oct-22 A92908
174 Lamivudine 150 mg tab - - - - - 1,560.00
175 Larutan Metanol 100 ml btl - - - - - 23,584.00
176 Leukoplast rol - - - - - 35,532.00
177 Levofloxacin 500 mg kaplet - - - - - 495.00
178 Lidocain Comp. 2 % injeksi 2 ml (DAK ) ampul 60 - 60 30 30 1,228.99 36,869.70 Apr-24 36815001
179 Lisol 1 liter btl - - - - - 49,862.00
180 Lodecon Forte tab - - - - - 1,089.00
181 Loperamide tablet - - - - - 85.00
182 Loratadine 10 mg tablet - - - - - 134.00
 183 Masker Bedah (DAK 21) pcs 1000 - 1,000 - 1000 760.00 760,000.00 Jun-25 30072025
184 Masker 3 M 1860 N95 kotak - - - - - 396,500.00
185 Masker 30 M 1870 + Aura N95 kotak - - - - - 426,500.00
186 Masker jilbab earloop pcs - - - - - 440.00
187 Masker N95 pcs - - - - - 6,512.00 -
188 Masker KN95 (DAK 21) - - - - - 9,153.00 -
189 Metformin HCl tab 500 mg (PROP 21) tablet 1,300 - 1,300 300 1,000 102.00 102,000.00 Sep-22 HTMFNA05586

190 Methilergometrin Maleat 0,125 mg tab - - - - - 211.00 Feb-21 18CB009

191 Methilergometrin Maleat Inj. 0.2mg/ ml ampul - 25 25 - 25 2,684.00
192 Methylprednisolon 4 mg (DAK) tablet 2600 - 2,600 300 2300 143.00 328,900.00 Sep-23 HTMPSD15238
193 Metoklopramide 10 mg tab - - - - - 90.00 Juni 2021 WF049G
194 Metronidazol infus botol - - - - 8,110.00
195 Metronidazole 500 mg kaplet - - - - - 133.00
196 MgSO4 20 % pcs - - - - - 3,327.50
197 MgSO4 40 % (DAK 20 ) 0 - - - - 3,796.00 - Feb-22
198 Miconazole cream 2 % (DAK ) tube 24 192 216 106 110 3,413.30 375,463.00 45,170 191843W
199 Mineral Mix sachet - - - - - 2,920.00
200 Miniaspi 80 mg ( Asam Asetilsalisilat 80 mg ) tab
S 0 - - - - 99.00 - Mart-21 170502
201 A - - - -
Mucus Extractor 25 ml Serenity Size 10 FR pcs
T
0 6,900.00 - Juni 2021 20160620
202 Natrium Diklofenak 25 mg (DAK 21) tablet
U 550 3,000 3,550 750 2,800 2,000 115.00 322,000.00 MART-23 36364014
203 A - 15 15 -
Natrium Klorida 0.9 % (DAK 20) botol
N
15 6,839.80 - Feb-25 400306
NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 4 5 6 7 8 9 10 11 12 13 14 15 11
204 Nevirapine 200 mg tab - - - - - 2,940.00
205 Nifedipin tab tablet 1,300 - 1,300 600 700 111.99 78,393.00 May-23 F91469B
206 Novadiar sirup botol - - - - - 6,800.00
207 Nystatin 100.000 IU tab vag - - - - - 560.00
208 OAT Kat. I Dewasa Kombipak (PROP 20) paket - - - - - 415,467.00 - Sep-23 J02957J
209 OBH botol - - - - - 4,995.50
210 Object Glass 7101 Jayamas Onelab kotak/72 pcs 4 - 4 - 4 17,604.00 70,416.00
211 Object Glass Frosted kotak - - - - - 20,000.00
212 Oksigen Canula Size (DTT 2) pcs 27 - 27 - 27 4,966.00 134,082.00 Feb-25 4200202
213 Oksigen Canula Size S/XS pcs - - - - -
214 Oksigen Canula Size M pcs - - - - -
215 Oksigen Canula Size L pcs - - - - -
216 Omegdiar (DAK 21) 800 - 800 400 400 275.00 110,000.00 May-23 O521044
217 Omeprazole 20 mg (DAK 21) kapsul 800 - 800 200 600 129.00 77,400.00 Sep-23 KOPZB10641
218 Oncoprobe ( HIV 1 dan 2 Antibody ) Rapid test 4th
generation IR-100
test - - - - - 56,650.00

219 Ondansetron 4 mg tab - - - - - 472.00

220 Ondansetron 4 mg injeksi iv/ im ampul - - - - - 1,070.00
221 Osetalmivir kapsul - - - - - 129.72
222 Oxitosin Injeksi 10 IU/ml- 1 ml (DAK ) ampul 5 - 5 - 5 1,199.00 5,995.00 Feb-23 9620B0067A
223 Oxytetracyclin Salep Mata tube 0 - - Err:522 Err:522 2,500.00 Err:522 Feb-22 B90119W
224 Papaverin HCl tab - - - Err:522 Err:522 308.00
225 Paracetamol 500 mg (APBD 2 21) tablet 4000 3,000 7,000 2,500 4500 3,000 247.50 1,113,750.00 AGST-24 A11279
226 Parasetamol sirup ( DAK 21) botol 355 - 355 45 310 1,160.00 359,600.00 APRL-24 A10673
227 Paedilac sachet 0 - - - - 6,750.00 - Dec-21
Permethrin 5% (APBD2 21) 85 - 85 20 65 11,466.00 745,290.00 Sep-23
228 Pharmafix 5 m x500 (DAK 21) rol 10 - 10 1 9 31,900.00 287,100.00 Feb-26 15C21
229 Piroxicam 20 mg kapsul - - - - - 163.90
230 Ponflu sirup botol - - - - - 19,200.00
231 Povidon Iodida 10 % 60 ml botol - - - - - 4,620.00 - Jan-23 2011004
232 Povidone Iodium 10% 30 ml botol - - - - - 2,000.00
233 Povidone Iodium 10% 300 ml (DAK) btl 1 - 1 1 - 16,500.00 - Feb-25 20110012
234 PP UD 2TU 1,5 ML (Test Mantoux) vial - - - - - 625,900.00
235 Prednison 5 mg tablet - - - - - 73.00
236 Propanolol 10 mg (DAK) tab 200 - 200 200 - 58.00 - Jun-22 1906084
237 Pyrantel 125 mg tab - - - - - 291.00
238 Pyrazinamide 500 mg kaplet - - - - - 237.00
239 Pyridoksin HCl 10 mg / Vitamin B6(APBD 2 21) tab 3,500 2,000 5,500 1,000 4,500 2,000 137.50 618,750.00 Nov-25 2111042
240 Pyridoksin HCl 25 mg / Vitamin B6 tab - - - - - 60.00
241 Ranitidin 150 mg tab(DAK 21) tablet 1300 - 1,300 600 700 85.00 59,500.00 Sep-23 HTRNB15805
242 Ranitidine 50 mg/ 2 ml injeksi ampul - - - - - 1,155.00
243 Rapid 1 HIV ( SD ) test - - - - - 11,975.00
244 Rapid 2 HIV ( Fokus ) test - - - - - 13,235.00
245 Rapid 3 HIV ( Vikia ) test - - - - - 19,822.19
246 Rapid Test HBsAg SD S
test - - - - - 9,850.00 -
A
247 RDT Leptospirosis test
T - - - - - 66,000.00
248 U
Reagent Boule M-series Diluid (900 cycle) 20 L galon
A - - - - - 4,174,000.00
N
NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 4 5 6 7 8 9 10 11 12 13 14 15 11
249 Reagent Boule M-series Lyze (900 cycle) 5 L galon - - - - - 6,451,000.00
250 Reagen Colesterol 6 x 100 ml + std kit/ktk - - - - - 3,552,250.00
251
Reagent Cleaning Kit (Hypodal enzyn,Cleaner,Detergen) Kit - - - - - 6,261,000.00

252 Reagen Glucosa 6 x 100 ml + std kit/ktk - - - - - 2,087,250.00

253 Reagent Lugol botol - - - - - 30,000.00
254 Reagen Trigliserides 6 x 50 ml +std kit/ktk - - - - - 3,809,250.00
255 Reagen Uric Acid 6 x 50 ml +std kit/ktk - - - - - 2,823,250.00
256 Reagen Zn(DAK) paket - - - - - 228,800.00 -
257 Rifampicin 300 mg kapsul - - - - - 683.00
258 Ringer Laktat 500 ml(DAK 20) btl 3 20 23 23 - 7,629.60 - Feb-25 300326
259 Risperidon 2 mg - - - - - 123.00 - Jul-25 52H0319
260 RPR Syphilis test - - - - - 4,150.00
261 Safety Box 5 liter Jayamas Onemed pcs - - - - - 23,398.00 -
262 Salbutamol 2 mg (DAK) tab 500 - 500 100 400 66.90 26,760.00 Jul-23 H92032B
263 Salbutamol 4 mg tab - - - - - 70.00
264 Salep 2-4 Kombinasi 30 g pot 0 - - - 0 2,796.00 - May-24 4,803,061
265 Salisil Bedak 2% 50 g kotak - - - - - 1,020.00
266 Sarung Tangan Non Steril Master Exam Uk.M( DAK '21 ) pcs - - - - - 1,489.16 - May-26 121213865
267 Sarung Tangan Non Steril Master Exam Uk.L( DAK '21 ) 300 - 300 - 300 1,489.16 446,748.00 May-26 121313924
268 Sarung Tangan Non Steril Master Exam Uk.S( DAK '21 ) 200 - 200 - 200 1,489.16 297,832.00 Mar-26 712115318
269
Sarung tangan steril gynecolog-6.5 ( Elbow Length ) Remedi
pasang - - - - - 17,400.00 -

270
Sarung tangan steril gynecolog-7 ( Elbow Length ) Remedi pasang - - - - - 17,400.00

271 Sarung Tangan Steril no. 6,5 (DAK 21) pairs 130 - 130 30 100 7,905.00 790,500.00 Oct-25 2020-337W5
272 Sarung Tangan Steril no. 7 (DAK 21) 100 - 100 50 50 7,905.00 395,250.00 Mar-26 2021-092W5
273 Sarung Tangan Steril PF No. 7,5 pairs - - - - - 7,905.00 -
274 Scabimite 5 % tube - - - - - 11,825.00
275 Solvitral vial - 2,000 2,000 100 1,900 4,200.00
276 Sianokobalamin (Vit. B12) Injeksi 500mcg/ ml ampul - - - - - 1,077.00
277 Sikzonoate inj 25 mg ampul - - - - - 59,800.00
278 Silk 3/0 + jarum 1/2 GT 35 mm pcs - - - - - (ED) 3,147.222 - MART-22 21603200430
279 Silk 3/0 75C + jarum 1/2 17M R (Demesilk) (SHLDA) pcs - - - - - 20,833.33
280 Simvastatin 10 mg tablet 0 - - - - 117.00 - Nov-21 A8792KW
281 Simvastatin 20 mg (DAK 21) tablet 850 - 850 850 - 150.00 - MART-23 D10519BJ
282 Slide Box kotak - - - - - 57,100.00
283 Softpad ( Underpad ) 60 x 90 cm Non Steril Jayamas
Onemed
pcs 150 - 150 - 150 41,624.00 6,243,600.00 Mar-22 101,130,319

284 Stick Chlolesterol Test Strip 20's (Humasens) ktk@20 - - - - - 541,899.99

285 Stick Cholestrol tes strip 10's (Benecheck) ktk@10 - - - - - 251,046.90
286 Stick Glucose tes strip 50's (Benecheck) ktk@50
S - - - - - 161,046.90
287 Stick Glucose Test strip 50's (Humasens) A
ktk@50 - - - - - 249,800.00
T
288 Stick uric acid test strip 25's (Humasens) ktk@25
U - - - - - 548,300.00
289 Syphilis Rapid SD A
test 350 - 350 50 300 20,400.00 6,120,000.00 Oct-21 QSY1018035
N
NO NAMA OBAT STOK PENERI PERSE PEMA SISA STOK PERMIN PEMBERIAN KET HARGA TOTAL EXPIRE BATCH/
AWAL MAAN DIAAN KAIAN OPT TAAN INPRES PHB APBD LAIN JML SATUAN HARGA DATE LOT
1 2
### 4 5 6 7 8 9 10 11 12 13 14 15 11
 290 Tempat penampungan urine pcs - - - - - 165.00
291 Tenovofir (TDF) 300 mg tab - - - - - 4,212.00
292 Tetracyclin HCl 500 mg kapsul - - - - - 303.00
293 Tetracyclin HCl 250 mg kapsul - - - - - 174.00
294 Thiamin (Vit. B1) 50 mg (APBD 2 21) tablet 4,500 2,000 6,500 600 5,900 2,000 258.50 1,525,150.00 Nov-25 2111009
295 Tranfuse set serenity ( DAK 21 ) 40 - - - 40 9,355.50 374,220.00 May-26 11210501
296 Triheksifenidil 2 mg (DAK 21) tab 273 500 773 773 0 63.00 - Jun-24 A11009
297 Truvit sirup botol - - - - - 10,840.00
298 TTD (DAK) tablet 13,580 - 13,580 4,280 9,300 226.00 2,101,800.00 APRL-23 A10725
299 Tube EDTA pcs - - - - - 1,138.00 - Jun-23 30071888
300 Umbilical Cord Nylon pcs 10 - 10 - 10 1,300.00 13,000.00 Nov-23 `03101788
301 Urine Bag SR (DAK 21) pcs 49 - 49 - 49 6,336.00 310,464.00
302 USG Gel 250 ml Jayamas Onemed botol 2 - 2 - 2 16,000.00 32,000.00 Jul-23 10903010278
303 Vaksin Anti Rabies ( VAR ) / Verorab vial - - - - - 165,000.00
304 Ventolin Nebules 2,5 mg ampul - - - - - 4,000.00
305 HIV INTEC (DAK) pcs 100 - 100 40 60 - 14,300.00 858,000.00
306 Vikia HBsAg/ Reagen Hepatitis pcs - - - - - 21,500.00 - Mar-21
307 Vikia HIV 1/2 pcs - - - - - 19,480.00 - Dec-20 1007212320
308 VIOREX galon - - - - - 649,999.00 -
309 Vit. B. Complex tab - - - - - 89.00 - Jul-21 `1808001
310 Vitamin A 100.000 IU(biru) (DAK) caps lunak 950 - 950 - 950 306.00 290,700.00 Jul-22 20KG006
311 Vitamin A 200.000 IU(merah)(DAK) caps lunak 2383 - 2,383 - 2383 552.00 1,315,416.00 Jul-22 20KG013
312 Zidovudine tab - - - - - 1,768.00
313 Zink Dipersible 20 mg tablet - - - - - 524.00
314 Albendazol suspensi 200mg/5ml(prop. '21) botol - - - - - 4,000.00 - Jul-22 2,006,038
315 RAPIDAN tester HBsAg (DAK) pcs - - - - - 4,600.00 -
316 Handsanitizer 1000ml (PROP) botol - - - - - -
317 Handsanitizer (donasi) - - - - -
318 Rapid Virochek HIV 1/2 (prop. 21) pcs 75 - 75 50 25 8,094.00 202,350.00
319 Rapid Virochek HBsAg (prop. 21) 175 - 175 25 150 9,850.00 1,477,500.00
320 Rapid KHB HIV Pcs - - - -
321 RDT (Antigen Lyher) 150 - 150 - 150 97,450.00 14,617,500.00 Jan-23 2,107,037
322 Syphilis Trepocheck (PROP) Pcs - - - - - - 9,000.00 -
323 ADS 0,5 (PROP vaksin 21) - - - - - 1,190.00 -
ADS 0,3 (PROP vaksin 21) - - - - - 1,255.00 -
ADS 3 ML (PROP vaksin 21) - - - - - 569.00 -
NaCl - - - - - 3,280.00 -
324 ALKOHOLSWAB (prop vaksin'21) - - - - - 79.00 -
325 Kartu Vaksin (APBD 2 '21) bks - - - - - 2,000.00 -
326 Safety Box (prop vaksin'21) - - - - - 13,600.00 -
327 VTM (Prop 21) 5 - 5 - 5 24,000.00 120,000.00
Pot Dahak - - - - -
328 Kapas Pembalut Hidrofil DRC 100 gr (prop vaksin'21) bks 2 - 2 1 1 7,205.00 7,205.00 Jul-24 47051
JUMLAH TOTAL #VALUE!
MENGETAHUI / MENYETUJUI YANG MENYERAHKAN YANG MEMINTA/MELAPORKAN YANG MENERIMA
KEPALA DINKES DATI II KEPALA GFK PEMIMPIN PUSKESMAS PETUGAS PUSKESMAS

PARNO, S.Pd.I, M.H Pry Hartini, S.Farm.,Apt dr. ISTIAWATI ARSYADANI FAUZI, S.Farm., Apt
NIP : 19821001 201101 1 012 NIP:19830911 201101 2 007 NIP.197207122006042032 NIP.199504182022031008
38,949,108.76

38,948,704.75

404.01

#VALUE!
 3,305,424.00

-
2,159,504.67

2,254,734.69

2,016,269.80
 3,660,276.00

14,320,690.00

23,245,305.00
#VALUE!
 PEMERINTAHAN KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT.01/01 Kec. Patebon, Kab. Kendal Kode Pos 51351
Email : [email protected]
LAPORAN PEMASUKAN DAN PENGELUARAN PSIKOTROPIKA

Persediaan Pemasukan Jumlah Pengelua

No Nama Sediaan Satuan Keseluruhan Untuk
Awal Bulan Tanggal Dari Jumlah
(4+7) Pembuatan

1 2 3 4 5 6 7 8 9
1 CLOZAPINE 25 MG TAB 449 449 0
2 DIAZEPAM TABLET 2 MG TAB 359 359 -

3 DIAZEPAM TABLET 5 MG TAB 100 100 -

4 DIAZEPAM INJEKSI 5 MG/ML-2 ML AMP

5 HALOPERIDOL 0,5 MG TAB TAB

6 HALOPERIDOL 5 MG TAB TAB 973 973 -

7 HALOPERIDOL DECANOAT INJ 50 MG/ML AMP

8 KHLORPROMAZIN HCL TABLET 25 MG TAB

9 KHLORPROMAZIN HCL TABLET 100 MG TAB 1 1 -

10 KHLORPROMAZIN HCL INJEKSI AMP

11 LODOMER DROPS BTL 125 125 -

12 NEUROVAL TABLET / OPINEURON TAB TAB

13 PHENOBARBITAL INJ 50 MG/ML-2ML AMP

14 PHENOBARBITAL TABLET 30 MG TAB 130 130 -

15 RISPERIDON 2 MG TAB 300 300 -

16 STESOLID RECTAL TUBE 10 MG/2,5 ML RC

17 STESOLID RECTAL TUBE 5 MG/2,5 ML RC
18 TRIHEXYPHENIDIL HCL 2 MG TABLET TAB 933 5/13/2022 IPF 500 1,433 -

19 SIKZONOATE INJ 25 MG AMP

MENGETAHUI
KEPALA PUSKESMAS PATEBON I

dr. ISTIAWATI
NIP.197207122006042032
AN KABUPATEN KENDAL
S KESEHATAN
MAS PATEBON I
01 Kec. Patebon, Kab. Kendal Kode Pos 51351
[email protected]
DAN PENGELUARAN PSIKOTROPIKA

Pengeluaran Persediaan
Untuk Jumlah Akhir Bulan Keterangan
Lain-lain (9+10) (8-11)

10 11 12 13
295 295 154
- - 359
- - 100

970 970 3

- - 1

1 1 124

- - 130
- - 300

1,010 1,010 423

PETUGAS PENGELOLA OBAT

ARSYADANI FAUZI
NIP. 199504182022031008
 PEMERINTAHAN KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT.01/01 Kec. Patebon, Kab. Kendal Kode Pos 51351
Email : [email protected]

FORM PEMANTAUAN KETERSEDIAAN OBAT DAN VAKSIN INDIKATOR DI PUSKESMAS

PERIODE PELAPORAN APRIL BULAN APRIL
NAMA PUSKESMAS : PUSKESMAS PATEBON I PENANGGUNGJAWAB FARMASI : dr. ISTIAWATI
KAB/KOTA : KENDAL NO HP
PROVINSI : JAWA TENGAH EMAIL : [email protected]
BENTUK KETERSEDIAAN
KODE NAMA OBAT KET
SEDIAAN ADA/TIDAK
1 2 3 4 5
1 ALBENDAZOL TABLET 400 MG TABLET 1
2 AMOKSILIN 500 MG KAPLET TABLET 1
3 AMOKSILIN SYRUP 1
4 DEKSAMETASON TABLET 0,5 MG TABLET 1
5 DIAZEPAM INJ 5 MG/ML-1 ML INJEKSI 0
6 EPINEFRIN HCL/BITARTRANTN (ADRENALIN) INJ 0,1%-1ML INJEKSI 1
7 FITOMENADION (VIT K ) INJEKSI 10MG/ML-1ML INJEKSI 1
8 FUROSEMID TABLET 40 MG/HIDROKLOROTIAZID TABLET 1
9 GARAM ORALIT UNTUK 200 ML AIR SERBUK 0
10 GLIBENKLAMID TABLET 5 MG TABLET 1
11 KAPTOPRIL TABLET 1
MAGNESIUM SULFAT INJEKSI ( IV ) 20 % - 25 ML/MAGNESIUM
12 INJEKSI 0
SULFAT INJEKSI ( IV ) 40 % 25 ML
13 METIL ERGOMETRIN MALEAT INJEKSI 0,200 MG - 1 ML INJEKSI 0
14 OBAT ANTI TUBERCOLUSIS DEWASA TABLET 1
15 OKSITOSIN INJEKSI 10 IU/ML - 1 ML INJEKSI 1
16 PARASETAMOL TABLET 500 MG TABLET 1
17 TABLET TAMBAH DARAH KOMBINASI TABLET 0
18 VAKSIN BCG INJEKSI 1
19 VAKSIN DPT-HB-Hib INJEKSI 1
20 VAKSIN Td INJEKSI 1

MENGETAHUI
KEPALA PUSKESMAS PATEBON I PETUGAS PUSKESMAS

dr. ISTIAWATI ARSYADANI FAUZI

NIP.197207122006042032 NIP: 199504182022031008
 PEMERINTAH KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT. 01/01 Kec. Patebon Kab. Kendal Kode Pos 51351
Email : [email protected]

OBAT WAJIB APOTIK

KODE PUSKESMAS:
PUSKESMAS : PATEBON I
KECAMATAN : PATEBON I
KABUPATEN/KODYA
: KENDAL
PROPINSI : JAWA TENGAH
KELAS SATU STOK PENERI PERSE PEMA
KODE NAMA OBAT SISA
TERAPI AN AWAL MAAN DIAAN KAIAN

1 2 3 4 5 6 7 8 9

1 ALBENDAZOL TABLET 400 MG 6.1.1 TAB 500 - 500 289 211

2 AMOKSILIN SIRUP KERING 125 MG/5 ML 6.2.1 BTL 0 - - - -
3 AMOKSILIN SIRUP KERING 250 MG/5 ML 6.2.1 BTL 250 - 250 40 210
4 AMOKSILIN 500 MG KAPLET 6.2.1 KAP 1,900 3,000 4,900 3,100 1,800
5 CAPTOPRIL TABLET 12,5 MG TAB 800 - 800 200 600
6 DEKSAMETASON TABLET 0,5 MG 16.4 TAB 0 - - - 0
7 DIAZEPAM INJ 5 MG/ML-1 ML 5 AMP - - - - -
EPINEFRIN HCL/BITARTRANTN (ADRENALIN) INJ 0,1%-
8
1ML
3 AMP 1 - 1 - 1
9 OAT KAT. I DEWASA KOMBIPAK 6.2.4 PKT 4 - 4 1 3
10 FDC ANAK 6.2.4 PKT 1 - 1 - 1
11 FITOMENADION (VIT K ) INJEKSI 2MG/ML-1ML 10.2 AMP 31 - 31 - 31
12 FUROSEMID TABLET 40 MG 14 TAB - - - - -
13 GARAM ORALIT UNTUK 200 ML AIR 201 ZAK - - - - -
14 GLIBENKLAMID TABLET 5 MG 16.1.1 TAB 1200 1,000 2,200 200 2,000
15 MAGNESIUM SULFAT INJEKSI ( IV ) 20 % - 25 ML 5 VIAL - - - - -
16 MAGNESIUM SULFAT INJEKSI ( IV ) 40 % 25 ML 5 ML - - - - -

17 METIL ERGOMETRIN MALEAT INJEKSI 0,200 MG - 1 ML 22.1 AMP - - - - -

 PEMERINTAH KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT. 01/01 Kec. Patebon Kab. Kendal Kode Pos 51351
Email : [email protected]

OBAT WAJIB APOTIK

KODE PUSKESMAS:
PUSKESMAS : PATEBON I
KECAMATAN : PATEBON I
KABUPATEN/KODYA
: KENDAL
PROPINSI : JAWA TENGAH
KELAS SATU STOK PENERI PERSE PEMA
KODE NAMA OBAT SISA
TERAPI AN AWAL MAAN DIAAN KAIAN

1 2 3 4 5 6 7 8 9

18 OKSITOSIN INJEKSI 10 IU/ML - 1 ML 22.1 AMP 5 - 5 - 5

19 PARASETAMOL TABLET 500 MG 1.2 TAB 4000 3,000 7,000 2,500 4500
20 TABLET TAMBAH DARAH KOMBINASI 10.1 TAB 13,580 - 13,580 4,280 9,300
21 VAKSIN BCG 27.2 AMP 20 - 20 - 20
22 TD 29 AMP 15 - 15 - 15

MENGETAHUI / MENYETUJUI YANG MENYERAHKAN YANG MEMINTA/MELAPORKAN

KEPALA DINKES DATI II KEPALA GFK PEMIMPIN PUSKESMAS

PARNO, S.Pd.I, M.H Pry Hartini, S.Farm.,Apt dr. ISTIAWATI

NIP : 1973 0223 1993 02 1 001 NIP:19830911 201101 2 007 NIP. 197207122006042032
H KABUPATEN KENDAL
AS KESEHATAN
SMAS PATEBON I
. 01/01 Kec. Patebon Kab. Kendal Kode Pos 51351
: [email protected]

AT WAJIB APOTIK
LB2
BULAN : MARET
TAHUN : 2022

STOK PERMINTAA PEMBERIAN

KET
OPT N INPRES PHB APBD LAIN JML

10 11 12 13 14 15 16 17

-
-
-
-
-
-
-
-

-
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-
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-

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H KABUPATEN KENDAL
AS KESEHATAN
SMAS PATEBON I
. 01/01 Kec. Patebon Kab. Kendal Kode Pos 51351
: [email protected]

WAJIB APOTIK
LB2
BULAN : APRIL
TAHUN : 2022

STOK PEMBERIAN
PERMINTAA KET
OPT N INPRES PHB APBD LAIN JML

10 11 12 13 14 15 16 17

-
-
-
-
-

YANG MEMINTA/MELAPORKAN YANG MENERIMA

PEMIMPIN PUSKESMAS PETUGAS PUSKESMAS

dr. ISTIAWATI ARSYADANI FAUZI, S.Farm., Apt

NIP. 197207122006042032 NIP : 199504182022031008

 PEMERINTAHAN KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT.01/01 Kec. Patebon, Kab. Kendal Kod
Email : [email protected]

LAPORAN PEMASUKAN DAN PENGELUARAN NARKOTIKA

Persediaan Pemasukan Jumlah

NO Nama sediaan Satuan Keseluruhan
Awal Bulan Tanggal Dari Jumlah
(4+7)
1 2 3 4 5 6 7 8
1 NIHIL - - - - -

MENGETAHUI
KEPALA PUSKESMAS PATEBON I

dr. ISTIAWATI
NIP.197207122006042032
TAHAN KABUPATEN KENDAL
DINAS KESEHATAN
ESMAS PATEBON I
T.01/01 Kec. Patebon, Kab. Kendal Kode Pos 51351
: [email protected]

ASUKAN DAN PENGELUARAN NARKOTIKA

Pengeluaran Persediaan
Untuk Jumlah Akhir Bulan Keterangan
Pembuatan Lain-lain (9+10) (8-11)
9 10 11 12 13
- - - -

PETUGAS PENGELOLA OBAT

ARSYADANI FAUZI
NIP : 199504182022031008
 PEMERINTAHAN KABUPATEN KENDAL
DINAS KESEHATAN
PUSKESMAS PATEBON I
Jl. Laut Desa Pidodokulon RT.01/01 Kec. Patebon, Kab. Kendal Kode Po
Email : [email protected]

LAPORAN PEMAKAIAN OBAT PREKURSOR

Persediaan
No Nama sediaan Satuan Penerimaan Jumlah
Awal

1 2 3 4 5 (6=4+5)

1 ANTIMIGRAIN DOEN KOMBINASI TAB - - -

2 CARBAMAZEPIN 200 MG TAB 0 - -
3 DEXTRAL TAB TAB - - -
4 LODEXON FORTE TABLET TAB - - -
5 METILERGOMETRIN MALEAT INJEKSI AMP - - -
6 METILERGOMETRIN MALEAT TABLET TAB - - -
7 PONFLU SYRUP BTL - - -

MENGETAHUI
KEPALA PUSKESMAS PATEBON I

dr. ISTIAWATI
NIP.197207122006042032
HAN KABUPATEN KENDAL
NAS KESEHATAN
SMAS PATEBON I
1/01 Kec. Patebon, Kab. Kendal Kode Pos 51351
[email protected]

MAKAIAN OBAT PREKURSOR

Pemakaian Persediaan Akhir Keterangan

7 (8=6-7) 9
- -
- 0
- - -
- -
- - -
- - -
- - -

PETUGAS PENGELOLA OBAT

ARSYADANI FAUZI
NIP : 199504182022031008