LB.

PUSKESMAS : Rawat Inap Jangga Baru BULAN : 0 1

KECAMATAN : Batin XXIV TAHUN : 2 0 2 2

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
PENERI- STOK PERMIN-
NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN NO. BATCH
JKN APBD LAIN JUMLAH PENGADAAN Exp

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 108 - 108 23 85 (7)
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 2,239 2,239 361 1,878 (651)
5 Alupurinol Tab 300mg Tablet 200 200 - 200 (200)
6 Aminofilin injeksi 24 mg/ml Amp 60 60 1 59 (56)
7 Aminofilin tablet 200 mg Tablet 200 200 37 163 (37)
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,636 1,636 61 1,575 (1,368)
9 Amlodipin tablet 10 mg Tablet 7,413 7,413 2,002 5,411 1,396
10 Amlodipin tablet 5 mg Tablet 5,000 5,000 685 4,315 (1,986)
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 113 113 24 89 (7)
14 Amoksisilin Tablet 500 mg Tablet 5,656 5,656 1,021 4,635 (1,164)
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 3,409 3,409 794 2,615 85
17 Antasida DOEN II Suspensi Kombinasi Botol 222 222 28 194 (99)
18 Antifungi DOEN Kombinasi Tube 89 89 - 89 (89)
19 Antihemoroid Kombinasi sup Sup 212 212 212 (212)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 556 556 175 381 214
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 860 860 280 580 372 1,000
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 6,364 6,364 580 5,784 (3,812)
24 Asam Folat 1 mg Tablet 620 620 538 82 1,747 2,000
25 Asam Mefenamat tablet 500 mg Tablet 5,693 5,693 388 5,305 (3,986)
26 Asiklovir Tablet 200 mg Tablet 993 993 194 799 (139)
27 Asiklovir Tablet 400 mg Tablet 785 785 156 629 (99)
28 Atapulgit Tablet Tablet 1,490 1,490 16 1,474 (1,420)
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 72 72 8 64 (37)
33 Betametason Krim 0,05 % Tube 205 205 56 149 41 200
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 247 247 - 247 (247)
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 109 109 24 85 (3)
37 Deksametason Tablet 0,5 mg Tablet 2,295 2,295 540 1,755 81
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 4 4 - 4 (4)
42 Diazepam Tablet 2 mg Tablet 808 808 108 700 (333)
43 Diazepam Tablet 5 mg Tablet 600 600 50 550 (380)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 66 66 45 21 132 300
46 Digoksin Tablet 0,25 mg tablet 765 765 - 765 (765)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 970 970 2 968 (961)
49 Domperidon 10 mg Tablet Tablet 644 644 459 185 1,376 2,000
50 Domperidon 5mg/5ml Sirup Botol 80 80 3 77 (67)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp 6 6 - 6 (6)
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet 500 500 15 485 (434)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol 18 18 - 18 (18)
57 Etil Klorida Semprot 100 ml Botol - - - - - 50
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,495 1,495 41 1,454 (1,315)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 126 126 19 107 (42)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 333 333 22 311 (236)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 20 20 20 - 68 40
68 Furosemid Tablet 40 mg Tablet 706 706 53 653 (473)
69 Garam Oralit I Serbuk Kombinasi Bks 152 152 46 106 50
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 948 948 - 948 (948)
72 Glimepirid 2 mg Tablet 2,435 2,435 526 1,909 (121)
73 Griseofulvin Tablet 125 mg Tablet 490 490 10 480 (446)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
77 Hidroklorotiazida Tablet 25 mg Tablet 943 943 171 772 (191)
78 Hidrokortison Krim 2,5 % Tube 106 106 39 67 66 100
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 846 846 39 807 (674)
80 Ibuprofen Sirup 100 mg/5 ml Botol 101 101 - 101 (101)
81 Ibuprofen Tablet 200 mg Amp 1,399 1,399 461 938 629 1,500
82 Ibuprofen Tablet 400 mg Tablet 775 775 667 108 2,160 3,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,007 1,007 - 1,007 (1,007)
84 Kalsium glukonat inj 10% Botol 3 3 - 3 (3)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 2,062 2,062 49 2,013 (1,846)
87 Kaptopril Tablet 25 mg Tablet 1,811 1,811 13 1,798 (1,754)
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - -
90 Ketokonazol tab 200 mg Tablet 889 889 145 744 (251)
91 Klindamisin 300 mg Tablet 460 460 - 460 (460)
92 Klindamisin kap 150mg Tablet - - - - -
93 Kloramfenikol kapsul 250 mg Tablet 718 718 - 718 (718)
94 Kloramfenikol Salep Mata 1 % Tube 95 95 - 95 (95)
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - -
99 Klorfeniramin Tablet 4 mg Tablet - - - - - 5,000
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 663 663 113 550 (166)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 832 832 59 773 (572)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 65 65 3 62 (52)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - - 500
108 Loratadin 10 mg tablet Tablet 3,765 3,765 608 3,157 (1,090)
109 Magnesium Sulfat Injeksi 20% Botol - - - -
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 18,226 18,226 123 18,103 (17,685)
115 Metformin 850 mg Kapsul 1,783 1,783 - 1,783 (1,783)
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,578 2,578 - 2,578 (2,578)
118 Metilprednisolon tab 4 mg Tablet - - - - - 3,000
119 Metoklopramid Tablet 10 mg Tablet 1,378 1,378 43 1,335 (1,189)
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,400 1,400 35 1,365 (1,246)
124 Mikonazol Krim 2% (Nitrat) Tube 194 194 11 183 (146)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 4,884 4,884 - 4,884 (4,884)
127 Natrium Diklofenak Tablet 50 mg Tablet 1,280 1,280 98 1,182 (849)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 818 818 248 570 273
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet 172 172 - 172 (172)
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet 152 152 29 123 (24)
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 218 218 218 (218)
134 Omeprazol tablet 20 mg Tablet 4,163 4,163 - 4,163 (4,163)
135 Parasetamol Sirup 120 mg / 5 ml Botol 63 63 63 - 214 300
136 Parasetamol Tablet 500 mg Tablet 5,218 5,218 3,004 2,214 8,000 10,000
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube 5 5 5 - 17
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 2,148 2,148 - 2,148 (2,148)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 3,845 3,845 654 3,191 (967)
142 Povidon Iodida 100 mg/ml 30 ml Botol 24 24 6 18 2
143 Povidon Iodida 100 mg/ml 300 ml Botol 22 22 4 18 (4)
144 Prednison Tablet 5 mg Tablet 1,628 1,628 979 649 2,680 2,000
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,149 1,149 - 1,149 (1,149)
149 Propilitiourasil Tablet 100 mg Tablet 609 609 - 609 (609)
150 Ranitidin Tablet 150 mg Tablet 1,585 1,585 301 1,284 (261)
151 Risperidon 2 mg Tablet - - - - -
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 2,225 2,225 - 2,225 (2,225)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 1,900 1,900 80 1,820 (1,548)
154 Salep 2 - 4 Kombinasi Tube 62 62 - 62 (62)
155 Sefadroksil Kapsul 500 mg Tablet 888 888 8 880 (853)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial - - - - -
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 12 12 12 (12)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 132 132 12 120 (79)
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,305 1,305 - 1,305 (1,305)
160 Simvastatin Tablet 10 mg Tablet 1,285 1,285 85 1,200 (911)
161 Simvastatin Tablet 20 mg Tablet 657 657 - 657 (657)
162 Siprofloksasin Tablet scored 500 mg Tablet 4,449 4,449 - 4,449 (4,449)
163 Spironolakton 25 mg tablet Tablet 938 938 36 902 (780)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - - - -
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 2,324 2,324 1,009 1,315 2,116
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 10,658 10,658 - 10,658 (10,658)
173 Zink sir 10 mg/ml Botol 86 86 - 86 (86)
174 Zink tablet dispersi 20 mg Tablet 874 874 - 874 (874)
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - - -
1 Ambroxol Sirup 15 mg/ml Botol 7 - 7 7 - 24 200
2 Ambroxol Tablet 30 mg Tablet 141 141 141 - 479 5,000
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 100 100 - 100 (100)
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 83 83 8 75 (48)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 46 46 2 44 (37)
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 27 27 - 27 (27)
15 Fenol Gliserol Tetes Telinga 10 % Botol 55 55 - 55 (55)
16 Gentamisin Injeksi 40 mg/ml Amp 37 37 - 37 (37)
17 Gentamisin Salep Kulit 0,1 % Botol 48 48 37 11 115
18 Gliseril Guaiakolat Tablet 100 mg Tablet 2,668 2,668 1,085 1,583 2,106 3,000
19 Glukosa Larutan Infus 10 % Steril Botol 9 9 - 9 (9)
20 Glukosa Larutan Infus 5 % Steril Botol 59 59 - 59 (59)
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 4,497 4,497 2,842 1,655 8,008 3,000
23 Ketorolac inj 30mg/ml Amp - - - - - 200
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 80 20 100 77 23 239 500
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 8 8 8 - 27 200
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 58 58 - 58 (58)
39 Oksitetrasiklin Salep Kulit 3 % Tube - - - - - 200
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 2,189 2,189 - 2,189 (2,189)
44 Propanolol tablet 40 mg Tablet - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 214 214 209 5 706 700
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 160 100 260 84 176 110 1,000
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 71 71 49 22 145 200
51 Setirizin Tablet 10mg Tablet 478 478 478 - 1,625 3,000
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 78 78 67 11 217 200
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 82 82 54 28 156 200
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 857 - 857 58 799 (602)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,938 1,938 1,665 273 5,388 1,000
4 Alat Suntik Sekali Pakai 5 ml Pcs 2,205 2,205 - 2,205 (2,205)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 42 42 - 42 (42)
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 47 47 - 47 (47)
8 Foley Catheter No. 18 Pcs 21 21 7 14 10
9 Hanscoond no 6,5 Pcs - - - - - 200
10 Hanscoond no 7,5 Pcs - - - - -
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 190 190 - 190 (190)
13 Infusion Set Dewasa Pcs 487 487 202 285 402
14 IV Catheter No. 18. G Pcs 150 150 11 139 (102)
15 IV Catheter No. 20 G Pcs 124 124 100 24 316 100
16 IV Catheter No. 22 G Pcs 191 191 - 191 (191)
17 IV Catheter No. 24 G Pcs 258 258 - 258 (258)
18 Jarum Jahit Kulit Pcs - - - - -
19 Jarum Jahit Otot Pcs - - - - -
20 Kapas Pembalut / Absorben 250 gr Pcs 20 20 7 13 11
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 - 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 104 104 59 45 156
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 18 18 - 18 (18)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 35 35 5 30 (13)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol - - - - -
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 75 75 32 43 66 108
33 Urine Bag Pcs 32 32 13 19 25 60
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - - -
A. MALARIA - - - -
1 Obat Anti Malaria (ACT) Tablet - - - - - -
2 Primaquin Tablet Tablet - - - - - -
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep - - - - -
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - - -
1 OAT FDC kategori 1 Paket - - - - - -
2 OAT FDC kategori 2 Paket - - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - -
2 Haloperidol tab 5 mg Tablet 4,920 4,920 120 4,800 (4,392)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp 2 2 2 - 7
5 Risperidon Tablet Tablet 2,075 2,075 220 1,855 (1,107)
6 Triheksifenidil HCLTablet 2 mg Tablet 4,405 4,405 250 4,155 (3,305)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,985 1,985 240 1,745 (929)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - - -
1 BCG Amp 11 3 14 3 11 (1)
2 POLIO 10 DS Pcs 40 10 50 10 40 (6)
3 CAMPAK Amp - - - -
4 IPV - - - -
5 HB UNIJEK 42 5 47 5 42 (25)
6 Td Amp 38 38 - 38 (38)
7 DPT HB-Hib Amp 22 10 32 10 22 12
8 TT Amp - - - -
9 Dt Amp 7 7 - 7 (7)
10 POLIO 20 DS Pcs - - - -
11 VAR (vaksin rabies ) Vial - - - -
12 ADS 0,05 ml Pcs 209 209 - 209 (209)
13 ADS 0,5 ml Pcs 321 321 - 321 (321)
14 ADS 5 ml Pcs 55 55 - 55 (55)
15 VAKSIN MR Amp 54 10 64 10 54 (20)
E. KIA - - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - - -
1 Tablet tambah darah Tablet 25,000 - 25,000 25,000 - 85,000
2 Vit A Biru 100.000 IU Tablet - - - - - -
3 Vit A Merah 200.000 IU Tablet 16,800 16,800 16,800 - 57,120
4 Iodin test Pcs - - - - -
G. DIARE - - - -
1 Garam Oralit 200 mg Bks 175 - 175 - 175 (175)
2 Zinc Tablet 20 mg Tablet - - - -
H. FILARIASIS - - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - -
2 Parasetamol 500 mg Tablet - - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - - -
1 Blood Lancet Pcs - - - - - -
2 Reagen TB Botol - - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs - - - - -
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks - - - - -
H. KUSTA - - - -
1 MB Adult - - - - - -
2 MB (MDTDMB) child - - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - - -
1 Rapid Test Merk :SD - - - - - -
2 Fokus (HIV ke 2) - - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - - -
1 Gentamisin Tetes mata Botol - - - - - -
2 Gentian Violet Botol - - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 16 16 4 12 2
16 Guaifenisin Tablet - - - - -
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs 40 40 40 (40)
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 16 16 6 10 10
31 Surgical Blade no. 10-24 Pcs - - - - -
32 Leucoplast Rol 13 13 - 13 (13)
33 Uniflex 7,5 x 4,5cm Rol 12 12 - 12 (12)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
 38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
45 Handscoon (M) Pcs 0 - - - -
46 Handscoon (L) Pcs 0 - - - -
47 Desinfektan Spray Botol 226 226 5 221 (204)
48 Lansoprazole Kapsul 0 - - - - 3000
49 Betahistine HCL Tablet 2644 2,644 164 2,480 (1,922)
50 Candesartan 8 mg Tablet 8815 8,815 60 8,755 (8,551)
51 Candesartan 16 mg Tablet 8853 8,853 101 8,752 (8,409)
52 Etanol cairan 70 % 1000ml Botol 17 17 7 10 14
53 Handscoon size 7 Pcs 200 200 200 - 680
54 Asam Askorbat (Vitamin C) Tablet 500 mg Tablet 500 500 10 490 (456)
55 0 - - -
56 0 - - -
57 0 - - -
58 0 - - -
59 0 - - -
60 0 - - -

UMUM
JAMKESDA JKN UKS KIR JUMLAH
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor, Yang Menerima,
Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas Petugas Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga Masykur, S. Farm
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010 NRPK.05.7.0510987

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
KET

17
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 85 - 85 13 72 (30)
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 1,878 1,878 92 1,786 (1,492)
5 Alupurinol Tab 300mg Tablet 200 200 10 190 (158)
6 Aminofilin injeksi 24 mg/ml Amp 59 59 - 59 (59)
7 Aminofilin tablet 200 mg Tablet 163 163 6 157 (138)
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,575 1,575 14 1,561 (1,516)
9 Amlodipin tablet 10 mg Tablet 5,411 5,411 795 4,616 (2,072)
10 Amlodipin tablet 5 mg Tablet 4,315 4,315 108 4,207 (3,861)
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 89 89 47 42 108 200
14 Amoksisilin Tablet 500 mg Tablet 4,635 4,635 2,790 1,845 7,083 8,000
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 2,615 2,615 1,996 619 5,768 6,000
17 Antasida DOEN II Suspensi Kombinasi Botol 194 194 76 118 125 100
18 Antifungi DOEN Kombinasi Tube 89 89 10 79 (47)
19 Antihemoroid Kombinasi sup Sup 212 212 212 (212)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 381 381 49 332 (175)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 580 1,000 1,580 630 950 1,066 1,000
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 5,784 5,784 1,249 4,535 (538)
24 Asam Folat 1 mg Tablet 82 2,000 2,082 350 1,732 (612)
25 Asam Mefenamat tablet 500 mg Tablet 5,305 5,305 1,537 3,768 1,150 3,000
26 Asiklovir Tablet 200 mg Tablet 799 799 - 799 (799)
27 Asiklovir Tablet 400 mg Tablet 629 629 40 589 (461)
28 Atapulgit Tablet Tablet 1,474 1,474 162 1,312 (794)
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 64 64 2 62 (56)
33 Betametason Krim 0,05 % Tube 149 120 269 61 208 (13) 50
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 247 247 222 25 685 700
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 85 85 14 71 (26)
37 Deksametason Tablet 0,5 mg Tablet 1,755 1,755 581 1,174 685 1,000
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 4 4 - 4 (4)
42 Diazepam Tablet 2 mg Tablet 700 700 56 644 (465)
43 Diazepam Tablet 5 mg Tablet 550 550 30 520 (424)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 21 21 9 12 17
46 Digoksin Tablet 0,25 mg tablet 765 765 29 736 (643)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 968 - 968 (968)
49 Domperidon 10 mg Tablet Tablet 185 185 168 17 521 2,000
50 Domperidon 5mg/5ml Sirup Botol 77 77 12 65 (27)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp 6 6 - 6 (6)
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet 485 485 60 425 (233)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol 18 18 5 13 3
57 Etil Klorida Semprot 100 ml Botol - - - - -
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,454 1,454 1 1,453 (1,450)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 107 107 19 88 (27)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 311 311 90 221 67 1,000
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp - 50 50 - 50 (50)
68 Furosemid Tablet 40 mg Tablet 653 653 323 330 704
69 Garam Oralit I Serbuk Kombinasi Bks 106 106 106 - 339 400
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 948 948 171 777 (230)
72 Glimepirid 2 mg Tablet 1,909 1,909 362 1,547 (389)
73 Griseofulvin Tablet 125 mg Tablet 480 480 - 480 (480)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 772 772 40 732 (604) 1,000
78 Hidrokortison Krim 2,5 % Tube 67 120 187 25 162 (82)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 807 807 143 664 (206)
80 Ibuprofen Sirup 100 mg/5 ml Botol 101 101 44 57 84 100
81 Ibuprofen Tablet 200 mg Amp 938 1,500 2,438 1,027 1,411 1,875 2,000
82 Ibuprofen Tablet 400 mg Tablet 108 2,000 2,108 610 1,498 454 1,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,007 1,007 34 973 (864)
84 Kalsium glukonat inj 10% Botol 3 3 - 3 (3)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 2,013 2,013 242 1,771 (997)
87 Kaptopril Tablet 25 mg Tablet 1,798 1,798 20 1,778 (1,714)
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - - 50
90 Ketokonazol tab 200 mg Tablet 744 744 23 721 (647)
91 Klindamisin 300 mg Tablet 460 460 65 395 (187)
92 Klindamisin kap 150mg Tablet - - - - -
93 Kloramfenikol kapsul 250 mg Tablet 718 718 59 659 (470)
94 Kloramfenikol Salep Mata 1 % Tube 95 95 17 78 (24)
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - - 40
99 Klorfeniramin Tablet 4 mg Tablet - - - - -
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 550 550 150 400 80
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 773 773 347 426 684 1,000
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 62 62 6 56 (37)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - -
108 Loratadin 10 mg tablet Tablet 3,157 3,157 2,422 735 7,015 7,000
109 Magnesium Sulfat Injeksi 20% Botol - - - - -
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 18,103 18,103 512 17,591 (15,953)
115 Metformin 850 mg Kapsul 1,783 1,783 91 1,692 (1,401)
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,578 2,578 - 2,578 (2,578)
118 Metilprednisolon tab 4 mg Tablet - - - - -
119 Metoklopramid Tablet 10 mg Tablet 1,335 1,335 154 1,181 (688)
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,365 1,365 282 1,083 (181)
124 Mikonazol Krim 2% (Nitrat) Tube 183 183 12 171 (133)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 4,884 4,884 325 4,559 (3,519)
127 Natrium Diklofenak Tablet 50 mg Tablet 1,182 1,182 340 842 246 1,000
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 570 570 100 470 (150)
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet 172 172 90 82 206 100
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet 123 123 123 - 394 100
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 218 218 18 200 (142)
134 Omeprazol tablet 20 mg Tablet 4,163 4,163 499 3,664 (2,067)
135 Parasetamol Sirup 120 mg / 5 ml Botol - 500 500 130 370 46
136 Parasetamol Tablet 500 mg Tablet 2,214 15,600 17,814 7,301 10,513 12,850
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube - - - - -
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 2,148 2,148 - 2,148 (2,148)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 3,191 3,191 655 2,536 (440)
142 Povidon Iodida 100 mg/ml 30 ml Botol 18 18 7 11 11
143 Povidon Iodida 100 mg/ml 300 ml Botol 18 18 11 7 28
144 Prednison Tablet 5 mg Tablet 649 2,000 2,649 1,975 674 5,646 5,000
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,149 1,149 125 1,024 (624)
149 Propilitiourasil Tablet 100 mg Tablet 609 609 100 509 (189)
150 Ranitidin Tablet 150 mg Tablet 1,284 1,284 489 795 770 1,000
151 Risperidon 2 mg Tablet - - - - -
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 2,225 2,225 775 1,450 1,030 1,000
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 1,820 1,820 523 1,297 377
154 Salep 2 - 4 Kombinasi Tube 62 62 17 45 9
155 Sefadroksil Kapsul 500 mg Tablet 880 880 5 875 (859)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial - - - - -
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 12 12 12 - 38
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 120 120 108 12 334
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,305 1,305 180 1,125 (549)
160 Simvastatin Tablet 10 mg Tablet 1,200 1,200 130 1,070 (654)
161 Simvastatin Tablet 20 mg Tablet 657 657 125 532 (132)
162 Siprofloksasin Tablet scored 500 mg Tablet 4,449 4,449 638 3,811 (1,769)
163 Spironolakton 25 mg tablet Tablet 902 902 - 902 (902)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - - - -
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 1,315 1,315 390 925 323
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 10,658 10,658 2,739 7,919 846
173 Zink sir 10 mg/ml Botol 86 86 3 83 (73)
174 Zink tablet dispersi 20 mg Tablet 874 874 213 661 21
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - - - -
1 Ambroxol Sirup 15 mg/ml Botol - - - - -
2 Ambroxol Tablet 30 mg Tablet - - - - -
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 100 100 25 75 5
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 75 75 - 75 (75)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 44 44 44 - 141
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 27 27 7 20 2
15 Fenol Gliserol Tetes Telinga 10 % Botol 55 55 6 49 (30)
16 Gentamisin Injeksi 40 mg/ml Amp 37 37 1 36 (33)
17 Gentamisin Salep Kulit 0,1 % Botol 11 11 2 9 (3)
18 Gliseril Guaiakolat Tablet 100 mg Tablet 1,583 1,583 1,583 - 5,066
19 Glukosa Larutan Infus 10 % Steril Botol 9 9 9 - 29
20 Glukosa Larutan Infus 5 % Steril Botol 59 59 59 - 189
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 1,655 3,000 4,655 573 4,082 (2,248)
23 Ketorolac inj 30mg/ml Amp - - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 23 500 523 103 420 (90)
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol - - - - -
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 58 58 1 57 (54)
39 Oksitetrasiklin Salep Kulit 3 % Tube - 200 200 5 195 (179)
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 2,189 2,189 30 2,159 (2,063)
44 Propanolol tablet 40 mg Tablet - - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 5 840 845 44 801 (660)
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 176 1,000 1,176 276 900 (17)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 22 200 222 32 190 (88) 100
51 Setirizin Tablet 10mg Tablet - - - - - 1,000
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 11 200 211 - 211 (211)
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 28 200 228 18 210 (152) 60
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - - - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 799 799 9 790 (761) 200
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 273 2,000 2,273 560 1,713 79 500
4 Alat Suntik Sekali Pakai 5 ml Pcs 2,205 2,205 26 2,179 (2,096)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 42 42 12 30 8
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 47 47 5 42 (26)
8 Foley Catheter No. 18 Pcs 14 14 3 11 (1)
9 Hanscoond no 6,5 Pcs - - - - -
10 Hanscoond no 7,5 Pcs - - - - -
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 190 190 - 190 (190)
13 Infusion Set Dewasa Pcs 285 285 71 214 13
14 IV Catheter No. 18. G Pcs 139 139 - 139 (139)
15 IV Catheter No. 20 G Pcs 24 100 124 - 124 (124)
16 IV Catheter No. 22 G Pcs 191 191 50 141 19
17 IV Catheter No. 24 G Pcs 258 258 40 218 (90)
18 Jarum Jahit Kulit Pcs - - - - -
19 Jarum Jahit Otot Pcs - - - - -
20 Kapas Pembalut / Absorben 250 gr Pcs 13 13 1 12 (9)
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 - 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 45 45 15 30 18 50
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 18 18 4 14 (1)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 30 30 5 25 (9)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol - - - - -
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 43 108 151 24 127 (50)
33 Urine Bag Pcs 19 60 79 79 (79)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - - -
A. MALARIA - - - -
1 Obat Anti Malaria (ACT) Tablet - - - - -
2 Primaquin Tablet Tablet - - - - -
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep - - - - -
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - - -
1 OAT FDC kategori 1 Paket - - - - -
2 OAT FDC kategori 2 Paket - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - -
2 Haloperidol tab 5 mg Tablet 4,800 4,800 - 4,800 (4,800)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - -
5 Risperidon Tablet Tablet 1,855 1,855 200 1,655 (1,015)
6 Triheksifenidil HCLTablet 2 mg Tablet 4,155 4,155 200 3,955 (3,315)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,745 1,745 - 1,745 (1,745)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - - -
1 BCG Amp 11 5 16 8 8 18
2 POLIO 10 DS Pcs 40 10 50 22 28 42
3 CAMPAK Amp - - - - -
4 IPV - 5 5 - 5 (5)
5 HB UNIJEK 42 10 52 52 (52)
6 Td Amp 38 38 17 21 33
7 DPT HB-Hib Amp 22 10 32 23 9 65
8 TT Amp - - - - -
9 Dt Amp 7 7 - 7 (7)
10 POLIO 20 DS Pcs - - - - -
11 VAR (vaksin rabies ) Vial - - - - -
12 ADS 0,05 ml Pcs 209 209 33 176 (70)
13 ADS 0,5 ml Pcs 321 200 521 140 381 67
14 ADS 5 ml Pcs 55 55 11 44 (9)
15 VAKSIN MR Amp 54 10 64 14 50 (5)
E. KIA - - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - - -
1 Tablet tambah darah Tablet - - - - -
2 Vit A Biru 100.000 IU Tablet - - - - -
3 Vit A Merah 200.000 IU Tablet - - - - -
4 Iodin test Pcs - - - - -
G. DIARE - - - -
1 Garam Oralit 200 mg Bks 175 175 175 - 560
2 Zinc Tablet 20 mg Tablet - - - - -
H. FILARIASIS - - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - -
2 Parasetamol 500 mg Tablet - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - - -
1 Blood Lancet Pcs - - - - -
2 Reagen TB Botol - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs - - - - -
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks - - - - -
H. KUSTA - - - -
1 MB Adult - - - - -
2 MB (MDTDMB) child - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - - -
1 Rapid Test Merk :SD - - - - -
2 Fokus (HIV ke 2) - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - - -
1 Gentamisin Tetes mata Botol - - - - -
2 Gentian Violet Botol - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 12 12 2 10 (4)
16 Guaifenisin Tablet - - - - -
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs 40 40 40 - 128
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 10 10 10 (10)
31 Surgical Blade no. 10-24 Pcs - - - -
32 Leucoplast Rol 13 13 13 (13)
33 Uniflex 7,5 x 4,5cm Rol 12 12 12 (12)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - -
45 Handscoon (M) Pcs - - - - 400
46 Handscoon (L) Pcs - - - - 200
47 Desinfektan Spray Botol 221 221 221 (221)
48 Lansoprazole Kapsul - - - -
49 Betahistine HCL Tablet 2,480 2,480 304 2,176 (1,203)
50 Candesartan 8 mg Tablet 8,755 8,755 90 8,665 (8,377)
51 Candesartan 16 mg Tablet 8,752 8,752 150 8,602 (8,122)
52 Etanol cairan 70 % 1000ml Botol 10 10 2 8 (2)
53 Handscoon size 7 Pcs - - - - -
54 Asam Askorbat (Vitamin C) Tablet 500 mg Tablet 490 490 50 440 (280)
55 - - - -
56 - - - -
57 - - - -
58 - - - -
59 - - - -
60 - - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
104 70 340

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010
 LB.2

0 2
2 0 2 2

LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17
KIR JUMLAH
514

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 72 72 72 - 230.40 250
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 1,786 1,786 105 1,681 (1,345)
5 Alupurinol Tab 300mg Tablet 190 190 - 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 59 59 1 58 (55)
7 Aminofilin tablet 200 mg Tablet 157 157 - 157 (157)
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,561 1,561 11 1,550 (1,515)
9 Amlodipin tablet 10 mg Tablet 4,616 10,000 14,616 907 13,709 (10,807)
10 Amlodipin tablet 5 mg Tablet 4,207 15,000 19,207 436 18,771 (17,376)
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 42 240 282 44 238 (97)
14 Amoksisilin Tablet 500 mg Tablet 1,845 18,000 19,845 1,266 18,579 (14,528)
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 619 6,000 6,619 1,162 5,457 (1,739)
17 Antasida DOEN II Suspensi Kombinasi Botol 118 120 238 106 132 207
18 Antifungi DOEN Kombinasi Tube 79 79 11 68 (33)
19 Antihemoroid Kombinasi sup Sup 212 212 - 212 (212)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 332 332 22 310 (240)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 950 950 103 847 (517)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 4,535 4,535 1,849 2,686 3,231
24 Asam Folat 1 mg Tablet 1,732 1,732 489 1,243 322
25 Asam Mefenamat tablet 500 mg Tablet 3,768 3,000 6,768 4,302 2,466 11,300
26 Asiklovir Tablet 200 mg Tablet 799 1,000 1,799 - 1,799 (1,799)
27 Asiklovir Tablet 400 mg Tablet 589 1,000 1,589 130 1,459 (1,043)
28 Atapulgit Tablet Tablet 1,312 1,312 103 1,209 (879)
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 62 62 10 52 (20)
33 Betametason Krim 0,05 % Tube 208 208 - 208 (208)
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 25 25 25 - 80
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 71 71 16 55 (4)
37 Deksametason Tablet 0,5 mg Tablet 1,174 1,000 2,174 525 1,649 31
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 4 4 - 4 (4)
42 Diazepam Tablet 2 mg Tablet 644 644 - 644 (644)
43 Diazepam Tablet 5 mg Tablet 520 520 - 520 (520)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 12 12 12 - 38
46 Digoksin Tablet 0,25 mg tablet 736 736 15 721 (673)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 968 - 968 (968)
49 Domperidon 10 mg Tablet Tablet 17 17 17 - 54
50 Domperidon 5mg/5ml Sirup Botol 65 65 6 59 (40)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp 6 6 6 - 19
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet 425 500 925 20 905 (841)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol 13 13 7 6 16
57 Etil Klorida Semprot 100 ml Botol - - - - -
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,453 1,453 20 1,433 (1,369)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 88 88 44 44 97
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 221 221 51 170 (7)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 50 50 1 49 (46)
68 Furosemid Tablet 40 mg Tablet 330 330 25 305 (225)
69 Garam Oralit I Serbuk Kombinasi Bks - - - - -
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 777 777 73 704 (470)
72 Glimepirid 2 mg Tablet 1,547 1,547 792 755 1,779
73 Griseofulvin Tablet 125 mg Tablet 480 480 - 480 (480)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
77 Hidroklorotiazida Tablet 25 mg Tablet 732 2,000 2,732 23 2,709 (2,635)
78 Hidrokortison Krim 2,5 % Tube 162 162 9 153 (124)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 664 664 110 554 (202)
80 Ibuprofen Sirup 100 mg/5 ml Botol 57 100 157 32 125 (23)
81 Ibuprofen Tablet 200 mg Amp 1,411 2,000 3,411 451 2,960 (1,517)
82 Ibuprofen Tablet 400 mg Tablet 1,498 1,000 2,498 938 1,560 1,442
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 973 1,000 1,973 26 1,947 (1,864)
84 Kalsium glukonat inj 10% Botol 3 3 - 3 (3)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 1,771 1,771 27 1,744 (1,658)
87 Kaptopril Tablet 25 mg Tablet 1,778 1,778 43 1,735 (1,597)
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - 48 48 48 154
90 Ketokonazol tab 200 mg Tablet 721 721 43 678 (540)
91 Klindamisin 300 mg Tablet 395 395 125 270 130
92 Klindamisin kap 150mg Tablet - - - - -
93 Kloramfenikol kapsul 250 mg Tablet 659 659 2 657 (651)
94 Kloramfenikol Salep Mata 1 % Tube 78 78 13 65 (23)
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - -
99 Klorfeniramin Tablet 4 mg Tablet - - - - -
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 400 400 42 358 (224)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 426 1,000 1,426 1,151 275 3,408
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 56 56 5 51 (35)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - -
108 Loratadin 10 mg tablet Tablet 735 3,000 3,735 1,562 2,173 2,825
109 Magnesium Sulfat Injeksi 20% Botol - - - - -
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 17,591 17,591 666 16,925 (14,794)
115 Metformin 850 mg Kapsul 1,692 1,692 20 1,672 (1,608)
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,578 2,578 100 2,478 (2,158)
118 Metilprednisolon tab 4 mg Tablet - - - - -
119 Metoklopramid Tablet 10 mg Tablet 1,181 1,181 946 235 2,792
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,083 1,083 441 642 769
124 Mikonazol Krim 2% (Nitrat) Tube 171 171 44 127 14
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 4,559 4,559 116 4,443 (4,072)
127 Natrium Diklofenak Tablet 50 mg Tablet 842 1,000 1,842 415 1,427 (99)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 470 470 5 465 (449)
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet 82 100 182 - 182 (182)
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet - - - - -
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 200 200 200 - 640
134 Omeprazol tablet 20 mg Tablet 3,664 3,664 556 3,108 (1,329)
135 Parasetamol Sirup 120 mg / 5 ml Botol 370 370 43 327 (189)
136 Parasetamol Tablet 500 mg Tablet 10,513 15,600 26,113 3,135 22,978 (12,946)
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube - - - - -
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 2,148 2,148 - 2,148 (2,148)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 2,536 3,000 5,536 412 5,124 (3,806)
142 Povidon Iodida 100 mg/ml 30 ml Botol 11 11 11 - 35
143 Povidon Iodida 100 mg/ml 300 ml Botol 7 7 - 7 (7)
144 Prednison Tablet 5 mg Tablet 674 674 674 - 2,157
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,024 1,024 224 800 (83)
149 Propilitiourasil Tablet 100 mg Tablet 509 509 - 509 (509)
150 Ranitidin Tablet 150 mg Tablet 795 795 403 392 898
151 Risperidon 2 mg Tablet - - - - -
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 1,450 3,000 4,450 857 3,593 (851)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 1,297 2,000 3,297 443 2,854 (1,436)
154 Salep 2 - 4 Kombinasi Tube 45 45 24 21 56
155 Sefadroksil Kapsul 500 mg Tablet 875 875 91 784 (493)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial - - - - -
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial - - - - -
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 12 12 12 - 38
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,125 1,125 442 683 731
160 Simvastatin Tablet 10 mg Tablet 1,070 1,070 131 939 (520)
161 Simvastatin Tablet 20 mg Tablet 532 532 155 377 119
162 Siprofloksasin Tablet scored 500 mg Tablet 3,811 3,811 272 3,539 (2,669)
163 Spironolakton 25 mg tablet Tablet 902 902 700 202 2,038
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - - - -
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 925 3,000 3,925 218 3,707 (3,009)
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 7,919 7,919 1,442 6,477 (1,863)
173 Zink sir 10 mg/ml Botol 83 83 2 81 (75)
174 Zink tablet dispersi 20 mg Tablet 661 661 48 613 (459)
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - - -
1 Ambroxol Sirup 15 mg/ml Botol - - - - -
2 Ambroxol Tablet 30 mg Tablet - - - - -
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 75 75 - 75 (75)
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 75 75 3 72 (62)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol - - 14 (14) 59
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 20 20 - 20 (20)
15 Fenol Gliserol Tetes Telinga 10 % Botol 49 49 10 39 (7)
16 Gentamisin Injeksi 40 mg/ml Amp 36 36 2 34 (28)
17 Gentamisin Salep Kulit 0,1 % Botol 9 9 9 - 29 100
18 Gliseril Guaiakolat Tablet 100 mg Tablet - - - - -
19 Glukosa Larutan Infus 10 % Steril Botol - - - - -
20 Glukosa Larutan Infus 5 % Steril Botol - - - - -
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 4,082 4,082 617 3,465 (1,491)
23 Ketorolac inj 30mg/ml Amp - - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 420 420 48 372 (218)
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol - - - - -
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 57 57 7 50 (28)
39 Oksitetrasiklin Salep Kulit 3 % Tube 195 195 26 169 (86)
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 2,159 2,159 10 2,149 (2,117)
44 Propanolol tablet 40 mg Tablet - - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 801 801 242 559 215
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 900 500 1,400 241 1,159 (388)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 190 190 24 166 (89)
51 Setirizin Tablet 10mg Tablet - - - - -
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 211 211 83 128 138
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 210 210 38 172 (50)
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 790 200 990 206 784 (125)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,713 500 2,213 2,064 149 6,456
4 Alat Suntik Sekali Pakai 5 ml Pcs 2,179 2,179 32 2,147 (2,045)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 30 30 3 27 (17)
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 42 42 12 30 8
8 Foley Catheter No. 18 Pcs 11 11 11 - 35
9 Hanscoond no 6,5 Pcs - - - - -
10 Hanscoond no 7,5 Pcs - - - - -
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 190 190 - 190 (190)
13 Infusion Set Dewasa Pcs 214 214 - 214 (214)
14 IV Catheter No. 18. G Pcs 139 139 19 120 (59)
15 IV Catheter No. 20 G Pcs 124 124 15 109 (61)
16 IV Catheter No. 22 G Pcs 141 141 11 130 (95)
17 IV Catheter No. 24 G Pcs 218 218 - 218 (218)
18 Jarum Jahit Kulit Pcs - - - - -
19 Jarum Jahit Otot Pcs - - - - -
20 Kapas Pembalut / Absorben 250 gr Pcs 12 12 - 12 (12)
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 - 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 30 50 80 80 - 256
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 14 14 2 12 (6)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 25 25 19 6 55
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol - - - - -
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 127 127 - 127 (127)
33 Urine Bag Pcs 79 79 17 62 (8)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - - -
A. MALARIA - - - -
1 Obat Anti Malaria (ACT) Tablet - - - - -
2 Primaquin Tablet Tablet - - - - -
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep - - - - -
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - - -
1 OAT FDC kategori 1 Paket - - - - -
2 OAT FDC kategori 2 Paket - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - -
2 Haloperidol tab 5 mg Tablet 4,800 4,800 - 4,800 (4,800)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - -
5 Risperidon Tablet Tablet 1,655 1,655 60 1,595 (1,403)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,955 3,955 60 3,895 (3,703)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,745 1,745 70 1,675 (1,451)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - -
1 BCG Amp 8 5 13 - 13 (13)
2 POLIO 10 DS Pcs 28 10 38 38 (38)
3 CAMPAK Amp - - - -
4 IPV 5 5 10 10 (10)
5 HB UNIJEK 52 10 62 62 (62)
6 Td Amp 21 21 21 (21)
7 DPT HB-Hib Amp 9 10 19 19 (19)
8 TT Amp - - - -
9 Dt Amp 7 7 7 (7)
10 POLIO 20 DS Pcs - - - -
11 VAR (vaksin rabies ) Vial - - 160 (160)
12 ADS 0,05 ml Pcs 176 176 178 (178)
13 ADS 0,5 ml Pcs 381 200 581 581 (581)
14 ADS 5 ml Pcs 44 44 44 (44)
15 VAKSIN MR Amp 50 10 60 60 (60)
E. KIA - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - - -
1 Tablet tambah darah Tablet - - - -
2 Vit A Biru 100.000 IU Tablet - - - -
3 Vit A Merah 200.000 IU Tablet - - - - -
4 Iodin test Pcs - - - - -
G. DIARE - - - -
1 Garam Oralit 200 mg Bks - - - - -
2 Zinc Tablet 20 mg Tablet - - - - -
H. FILARIASIS - - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - -
2 Parasetamol 500 mg Tablet - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - - -
1 Blood Lancet Pcs - - - - -
2 Reagen TB Botol - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs - - - - -
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks - - - -
H. KUSTA - - - -
1 MB Adult - - - - -
2 MB (MDTDMB) child - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - - -
1 Rapid Test Merk :SD - - - - -
2 Fokus (HIV ke 2) - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - - -
1 Gentamisin Tetes mata Botol - - - - -
2 Gentian Violet Botol - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 10 10 5 5 11
16 Guaifenisin Tablet - - - - -
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs - - - - -
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 10 10 (10) 20 (52)
31 Surgical Blade no. 10-24 Pcs - - - - -
32 Leucoplast Rol 13 13 6 7 12
33 Uniflex 7,5 x 4,5cm Rol 12 12 - 12 (12)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
47 Handscoon (M) - 200 200 200 - 640
48 Handscoon (L) - 200 200 200 - 640
49 Desinfektan Spray 221 221 221 - 707
50 Lansoprazole - - 0 - -
51 Betahistine HCL 2,176 2,176 51 2,125 (1,962)
52 Candesartan 8 mg 8,665 8,665 50 8,615 (8,455)
53 Candesartan 16 mg 8,602 8,602 221 8,381 (7,674)
54 Etanol cairan 70 % 1000ml 8 8 1 7 (4)
55 Handscoon size 7 - - 0 - -
56 Asam Askorbat (Vitamin C) Tablet 500 mg 440 440 116 324 47
57 - - - -
58 - - - -
59 - - - -
60 - - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
 JUMLAH KUNJUNGAN RESEP

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

Asrofi, SKM Yayat Hariman, S.Farm dr. Rinaldy Sinaga

NIP. 197004211991031001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 3
2 0 2 1

OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17
KIR JUMLAH
 Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- PERSE- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol - - - - -
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - -
4 Alopurinol tablet 100 mg Tablet 1,681 300 1,981 114 865 (500) 1,000
5 Alupurinol Tab 300mg Tablet 190 190 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 58 (58)
7 Aminofilin tablet 200 mg Tablet 157 157 691 (534) 2,745 500
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,550 1,550 - 1,550 (1,550)
9 Amlodipin tablet 10 mg Tablet 13,709 2,000 15,709 887 14,822 (11,984)
10 Amlodipin tablet 5 mg Tablet 18,771 18,771 18,771 (18,771)
11 Amoksisilin 250 mg Tablet - - - -
12 Amoksisilin sir forte 250mg Botol - - - -
13 Amoksisilin sir 125mg/5 ml Botol 238 238 55 244 (68)
14 Amoksisilin Tablet 500 mg Tablet 18,579 18,579 1,372 5,304 (914)
15 Ampisilin serb inj 1000 mg/vial Vial - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 5,457 5,457 1,030 5,400 (2,104)
17 Antasida DOEN II Suspensi Kombinasi Botol 132 132 14 273 (228)
18 Antifungi DOEN Kombinasi Tube 68 68 1 77 (74)
19 Antihemoroid Kombinasi sup Sup 212 212 212 (212)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 825 825 825 (825)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 847 847 223 1,036 (322)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 2,686 2,000 4,686 852 2,140 586
24 Asam Folat 1 mg Tablet 1,243 1,243 130 1,260 (844)
25 Asam Mefenamat tablet 500 mg Tablet 2,466 2,466 601 6,196 (4,273)
26 Asiklovir Tablet 200 mg Tablet 1,397 1,397 1,397 (1,397)
27 Asiklovir Tablet 400 mg Tablet 1,459 500 1,959 1,140 (1,140)
28 Atapulgit Tablet Tablet 1,209 1,209 1,209 (1,209)
29 Atenolol 50 mg Tablet - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 7 (7) 100
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - -
32 Bedak Salisil serbuk 2% Bks 52 52 8 48 (22)
33 Betametason Krim 0,05 % Tube 208 208 13 37 5 200
34 Bisakodil sup 5 mg Botol - - - -
35 Bisaprolol 5mg Tablet - - 78 341 (91)
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 55 240 295 4 279 (266)
37 Deksametason Tablet 0,5 mg Tablet 1,649 1,649 14 4,136 (4,091)
38 Devitalisasi Pasta (Non Arsen) Botol - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 55 55 55 (55)
40 Diazepam rektal 10mg/2 ,5ml Amp 23 23 23 (23)
41 Diazepam rektal 5mg/2 ml Amp 4 4 4 (4)
42 Diazepam Tablet 2 mg Tablet 140 140 140 (140) 200
43 Diazepam Tablet 5 mg Tablet 163 163 163 (163) 300
44 Dietilkarbamazin tab 100mg Tablet - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp - - 10 232 (200)
46 Digoksin Tablet 0,25 mg tablet 721 721 721 (721) 1,000
47 Diltiazem hcl tab 30mg Tablet - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 968 968 (968)
49 Domperidon 10 mg Tablet Tablet - 1,500 1,500 748 1,473 921
50 Domperidon 5mg/5ml Sirup Botol 59 59 59 (59) 100
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp - - - -
52 Ergotamin tab 1mg Tablet - - - -
53 Eritromisin kapsul 250 mg Tablet - - -
54 Eritromisin Kapsul 500 mg Tablet 190 190 20 170 (106) 1,000
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 50 (50)
56 Etanol cairan 70 % Botol 6 6 6 (6)
57 Etil Klorida Semprot 100 ml Botol - - - -
58 Eugenol cairan Botol - - - -
59 Fenitoin Na kaps Tablet - - - -
60 Fenobarbital tablet 30 mg Tablet 1,433 1,433 1,624 (1,624)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 44 44 53 (53) 100
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 170 100 270 - 484 (484) 1,000
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - -
66 Fluor kaps 1 mg Kapsul - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 49 49 49 (49)
68 Furosemid Tablet 40 mg Tablet 305 305 974 (974)
69 Garam Oralit I Serbuk Kombinasi Bks - - 298 627 327
70 Glass Ionomer Cement Art Lar. Botol - - - -
71 Glibenklamida Tablet 5 mg Tablet 704 2,000 2,704 205 1,939 (1,283)
72 Glimepirid 2 mg Tablet 755 755 15 - 48 1,000
73 Griseofulvin Tablet 125 mg Tablet 480 480 50 (50) 1,000
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 2,709 500 3,209 52 967 (801)
78 Hidrokortison Krim 2,5 % Tube 153 153 153 (153)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 554 554 (554)
80 Ibuprofen Sirup 100 mg/5 ml Botol 125 125 4 78 (65)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 1,560 500 2,060 322 1,353 (323)
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,947 1,947 1,563 (1,563)
84 Kalsium glukonat inj 10% Botol 3 3 3 (3)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - -
86 Kaptopril Tablet 12,5 mg Tablet 1,744 1,000 2,744 310 2,277 (1,285)
87 Kaptopril Tablet 25 mg Tablet 1,735 1,000 2,735 239 2,589 (1,824)
88 Karbamazepin tab 100 mg Tablet - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - -
90 Ketokonazol tab 200 mg Tablet 678 678 130 275 141 2,000
91 Klindamisin 300 mg Tablet 270 270 270 (270)
92 Klindamisin kap 150mg Tablet - - - - 1,000
93 Kloramfenikol kapsul 250 mg Tablet 657 657 2 919 (913)
94 Kloramfenikol Salep Mata 1 % Tube 65 65 2 43 (37)
95 Kloramfenikol susp 125mg/5ml Botol - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - 200
99 Klorfeniramin Tablet 4 mg Tablet - - 1,104 8,547 (5,014)
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - -
103 Kodein tablet 10 mg Tablet 358 500 858 149 639 (162)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 275 275 242 1,297 (523)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 51 51 51 (51)
106 Kuinin Tab Tablet - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - 31 228 (129)
108 Loratadin 10 mg tablet Tablet 2,173 2,173 2,173 (2,173) 2,000
109 Magnesium Sulfat Injeksi 20% Botol - - - -
110 Magnesium Sulfat Injeksi 40% Botol 6 6 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - -
112 Mebendazol tab 100 mg Tablet - - - -
113 Mebendazol tab 500 mg Tablet - - - -
114 Metformin 500 mg Kapsul 16,925 16,925 16,925 (16,925) 2,000
115 Metformin 850 mg Kapsul 1,672 1,672 302 90 876 2,000
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,478 2,478 2,478 (2,478)
118 Metilprednisolon tab 4 mg Tablet - - - -
119 Metoklopramid Tablet 10 mg Tablet 235 235 39 451 (326) 1,000
120 Metrodinazol lar inf 5mg/ml Botol - - - -
121 Metrodinazol sir 125mg/ml Botol - - - -
122 Metronidazol Tablet 250 mg Tablet - - - -
123 Metronidazol tablet 500 mg Tablet 642 1,500 2,142 73 1,924 (1,690)
124 Mikonazol Krim 2% (Nitrat) Tube 127 127 10 89 (57)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - 100
126 Natrium Diklofenak Tablet 25 mg Tablet 4,443 4,443 340 2,985 (1,897)
127 Natrium Diklofenak Tablet 50 mg Tablet 1,427 1,427 280 4,350 (3,454)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - -
129 Nifedipin Tablet 10 mg Tablet 465 465 465 (465)
130 Nistatin Suspensi 100.000UI/ml Botol - - - -
131 Nistatin Vagina 500.000 Tablet Tablet 182 182 407 (225) 1,527 500
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet - - 8 (8) 34
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp - - 12 88 (50) 100
134 Omeprazol tablet 20 mg Tablet 3,108 3,108 266 1,226 (375) 100
135 Parasetamol Sirup 120 mg / 5 ml Botol 327 200 527 47 257 (107)
136 Parasetamol Tablet 500 mg Tablet 22,978 5,000 27,978 2,464 5,147 2,738
137 Parasetamol drops 100 mg / 1 ml Botol - - - -
138 Perak sulfadiazin krim1% Tube - - - -
139 Pirantel pamoat sus 125mg/5ml Botol - - -
140 Pirantel pamoat tab 125 mg Tablet 158 158 158 (158)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 5,124 5,124 193 8,031 (7,413)
142 Povidon Iodida 100 mg/ml 30 ml Botol 35 35 35 (35)
143 Povidon Iodida 100 mg/ml 300 ml Botol 7 7 4 12 1
144 Prednison Tablet 5 mg Tablet - 500 500 225 1,059 (339)
145 Primakuin Tablet 15 mg Tablet - - - -
146 Probenesid tab 500mg Tablet - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 529 529 529 (529)
149 Propilitiourasil Tablet 100 mg Tablet 509 509 8 118 (92) 1,000
150 Ranitidin Tablet 150 mg Tablet 392 392 515 1,835 (187)
151 Risperidon 2 mg Tablet - - 185 (185) 777 500
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 3,593 3,593 135 891 (459) 2,000
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 2,854 2,854 410 (410) 2,000
154 Salep 2 - 4 Kombinasi Tube 21 21 7 38 (16)
155 Sefadroksil Kapsul 500 mg Tablet 784 784 30 754 - 2,000
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial - - 3 (3) 13 5
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 28 28 28 (28)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp - - 25 289 (209)
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 683 683 51 1,919 (1,756)
160 Simvastatin Tablet 10 mg Tablet - - - 2,000
161 Simvastatin Tablet 20 mg Tablet 377 1,000 1,377 125 940 (540) 2,000
162 Siprofloksasin Tablet scored 500 mg Tablet 3,539 3,539 133 1,037 (611)
163 Spironolakton 25 mg tablet Tablet 202 202 202 (202)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - 50 830 (670)
166 Tetrasiksin 250 mg Tablet - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 3,707 3,707 112 1,320 (962)
168 Valproat sir 250 mg/ml Botol - - - -
169 Valproat tab sal 250mg Tablet - - - -
170 Valproat tab sal 500 mg Tablet - - - -
171 Verapamil 80mg Tablet - - - -
172 Vitamin B Kompleks Tablet Tablet 6,477 9,400 15,877 3,171 10,522 (375)
173 Zink sir 10 mg/ml Botol 81 81 2 79 (73) 100
174 Zink tablet dispersi 20 mg Tablet 613 613 1,404 (1,404)
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - -
1 Ambroxol Sirup 15 mg/ml Botol - - - 14 190 (145)
2 Ambroxol Tablet 30 mg Tablet - - 163 3,883 (3,361)
3 Antalgin Injeksi 250 mg Amp - - - - 100
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 75 75 75 (75) 100
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - -
6 Asetosal Tablet 100mg Tablet - - - -
7 Asiklovir Krim 5% Tube 72 72 72 (72)
8 Counterpain 15 mg Tube - - - -
9 Duvadilan Tablet - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - -
12 Etakridin Larutan 0,1 Botol (14) (14) (14) 14
13 Famotidine Tablet 40 mg Tablet - - - -
14 Fenobarbital inj Tablet 20 20 20 (20)
15 Fenol Gliserol Tetes Telinga 10 % Botol 39 39 5 103 (87)
16 Gentamisin Injeksi 40 mg/ml Amp 34 34 34 (34)
17 Gentamisin Salep Kulit 0,1 % Botol - - 11 7 28 100
18 Gliseril Guaiakolat Tablet 100 mg Tablet - - 222 7,963 (7,253) 3,000
19 Glukosa Larutan Infus 10 % Steril Botol - - - -
20 Glukosa Larutan Infus 5 % Steril Botol - - 6 4 15
21 Imersi Oil Botol - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 3,465 5,000 8,465 404 5,750 (4,457)
23 Ketorolac inj 30mg/ml Amp - - - - 100
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - -
25 Larutan Asam Asetat Botol - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - -
27 Larutan Benedict Botol - - - -
28 Larutan Eosin 2% Botol - - - -
29 Larutan Faucet Botol - - - -
30 Larutan Giemsa Stalin Botol - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - -
32 Larutan Resserccer Botol - - - -
33 Larutan Turk Botol - - - -
34 Lisol Botol - - - - 30
35 Natrium Klorida Larutan Infus 0,9% Botol 372 372 36 137 (22)
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol - - 10 135 (103)
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 74 74 74 (74)
39 Oksitetrasiklin Salep Kulit 3 % Tube 169 169 2 81 (75)
40 Parasetamol 100 mg Tablet - - - -
41 Pehacain inj Amp - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - -
43 Piroxicam 20mg Tablet 2,149 2,149 25 340 (260) 1,000
44 Propanolol tablet 40 mg Tablet - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 559 200 759 76 223 20
46 Reagen Golongan Darah Botol - - - - 100
47 Reagen TB Botol - - - - 100
48 Ringer Laktat Larutan Infus Steril Botol 1,159 500 1,659 88 480 (198)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - -
50 Setirizin Sirup 5 mg/5ml Botol 166 166 1 165 (162)
51 Setirizin Tablet 10mg Tablet - - 240 834 (66) 1,000
52 Simetidin Tablet 200 mg Tablet - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - -
54 Tablet Tambah Darah Tablet - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 128 128 8 120 (94)
57 Trombophob Jeli 15 g Tube - - - -
58 Ventolin Botol 172 20 192 8 56 (30)
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 670 - 670 670 (670)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 149 149 154 167 326
4 Alat Suntik Sekali Pakai 5 ml Pcs 783 783 783 (783)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 27 27 21 52 15
6 Elastis Verban 4 inci Pcs - - - -
7 Foley Catheter No. 16 Pcs 48 48 48 (48)
8 Foley Catheter No. 18 Pcs - 20 20 20 (20)
9 Hanscoond no 6,5 Pcs - - 31 69 30
10 Hanscoond no 7,5 Pcs - - 45 155 (11)
11 HCG test Pcs - - - -
12 Infusion Set Anak Pcs 310 310 310 (310)
13 Infusion Set Dewasa Pcs 214 214 85 104 168 500
14 IV Catheter No. 18. G Pcs 199 100 299 5 294 (278)
15 IV Catheter No. 20 G Pcs 109 109 109 (109)
16 IV Catheter No. 22 G Pcs 130 130 130 (130)
17 IV Catheter No. 24 G Pcs 218 218 218 (218)
18 Jarum Jahit Kulit Pcs - - - -
19 Jarum Jahit Otot Pcs - - - -
20 Kapas Pembalut / Absorben 250 gr Pcs 12 12 12 (12)
21 Kasa Pembalut 2 m x 80 cm Rol - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol - 100 100 100 (100)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 12 12 5 7 9
26 Kasa Kompres 40/40 Steril Rol - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 6 (6)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - -
29 Masker Rol - - 450 (450) 1,890
30 Pembalut Gips 4 Inci Rol - - - -
31 Plester 5 Yards x 2 inci Rol - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 127 127 8 119 (93)
33 Urine Bag Pcs 62 62 13 71 (29)
34 Wing Needle No.27 G Pcs - - - -
35 Handscoond 8 Pcs - - - -
36 Handscoond 7 Pcs - - - -
37 Plesterin Non Woven Pcs - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - -
41 Plester 5cm x 5m Pcs - - - -
IV OBAT PROGRAM - - -
A. MALARIA - - -
1 Obat Anti Malaria (ACT) Tablet - - - - -
2 Primaquin Tablet Tablet - - - - -
3 Kina tablet Tablet - - - -
4 RDT Malaria (First Respon) Pcs - - - -
5 Arterakina (DHP)=Dartep - - - -
6 Artehemeter Injeksi Amp - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - -
B. TUBERCULOSIS (TB) - - -
1 OAT FDC kategori 1 Paket - - - - -
2 OAT FDC kategori 2 Paket - - - - -
3 OAT Kategori Anak Paket - - - -
4 OAT Kombipak Paket - - - -
5 Masker Pcs - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - -
2 Haloperidol tab 5 mg Tablet 4,800 4,800 10 4,790 (4,758)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - -
5 Risperidon Tablet Tablet 1,595 1,595 75 1,520 (1,280)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,895 3,895 3,895 (3,895)
7 Clobazam tablet 10 mg Tablet - - - -
8 Clozapine 25 mg Tablet 1,675 1,675 30 1,645 (1,549)
9 Klorpromazine Tablet Tablet - - - -
10 Diazepam 5 mg Tablet - - - -
11 Asprazolam Tablet - - - -
D. VAKSIN - - -
1 BCG Amp 13 7 20 8 12 14
2 POLIO 10 DS Pcs 13 10 23 16 7 44
3 CAMPAK Amp - - - -
4 IPV 10 1 11 1 10 (7)
5 HB UNIJEK 62 62 24 38 39
6 Td Amp 21 21 21 (21)
7 DPT HB-Hib Amp 19 20 39 22 17 53
8 TT Amp - - - -
9 Dt Amp 18 18 5 13 3
10 POLIO 20 DS Pcs - - - -
11 VAR (vaksin rabies ) Vial 160 160 160 (160)
12 ADS 0,05 ml Pcs 178 178 48 130 24
13 ADS 0,5 ml Pcs 581 100 681 101 580 (257)
14 ADS 5 ml Pcs 44 44 11 33 2
15 VAKSIN MR Amp 60 60 14 46 (1)
E. KIA - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - -
5 Gentamicin inj 40mg/dl Amp - - - -
6 Tes Kehamilan Pcs - - - -
7 Tes Protein Urine Pcs - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - 100
9 Oksitosin inj IV/ml-1ml Amp - - - - 100
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - 10
11 Reagen Golongan Darah Botol - - - -
12 Hb Sahli Pcs - - - -
13 Oto Klik Pcs - - - -
14 Larutan Hcl Botol - - - -
15 Blood lancet Pcs - - - -
F. GIZI - - -
1 Tablet tambah darah Tablet - - - - -
2 Vit A Biru 100.000 IU Tablet 100 - 100 100 (100)
3 Vit A Merah 200.000 IU Tablet 3,950 3,950 100 3,850 (3,530)
4 Iodin test Pcs - - - -
G. DIARE - - -
1 Garam Oralit 200 mg Bks 300 - 300 50 250 (90)
2 Zinc Tablet 20 mg Tablet - - - - -
H. FILARIASIS - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - -
2 Parasetamol 500 mg Tablet - - - - -
3 Albendazol 200 mg Tablet - - - -
G.ALAT LABORATORIUM - - -
1 Blood Lancet Pcs - - - - - 500
2 Reagen TB Botol - - - - -
3 Slide Pcs - - - -
4 Pot Sputum Pcs 2,000 2,000 1,700 300 5,140
5 Metanol 100 ml Botol - - - -
6 Imersi Oil 60 ml Botol - - - -
7 Buffer Phosphat 7,2 Botol - - - -
8 Handscoon (M) Pcs - - - -
9 Alkohol asam 100 ML Botol - - - -
10 Masker Pcs - - - -
11 Giemsa Solution 60 ml Botol - - - -
12 Alkohol Swap Bks - - 500 (500)
H. KUSTA - - -
1 MB Adult - - - - -
2 MB (MDTDMB) child - - - - -
3 PB Adult - - - -
4 PB (MTDPB) child - - - -
I. HIV DAN SIFILIS - - -
1 Rapid Test Merk :SD - - - - -
2 Fokus (HIV ke 2) - - - - -
3 Rapid Test Merk : Vikia - - - -
4 Human Hexogon Syphilis - - - -
5 RPR Syphylis - - - -
TAMBAHAN - - -
1 Gentamisin Tetes mata Botol - - - - -
2 Gentian Violet Botol - - - - -
3 OAM Tablet - - - -
4 Glikonas Kalsikus inj 10% Botol - - - -
5 Bromheksin Tablet - - - - 3,000
6 sefadroxil Syr Botol - - - -
7 Kasa Elastis 4 inc Rol - - - -
8 Klindamisin Kap 150 mg Tablet - - - -
9 Glukosa Lar.40% Botol - - - -
10 Antiparkinson doen kombinasi Tablet - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - -
12 Aminofilin tab 150 mg Tablet - - - -
13 Mumfying pasta Botol - - - -
14 Safety box Pcs - - - - 50
15 fixomul Rol 9 9 9 (9)
16 Guaifenisin Tablet - - - - 3,000
17 Metro 500mg/Injeksi Amp - - - -
18 Ampisilin 100mg Tablet - - - -
19 Euthirox 50mg Tablet - - - -
20 Mineral mix Botol - - - -
21 Urine 2 Parameter Pcs - - - -
22 Urine 10 Parameter Pcs - - - -
23 strip autochek Pcs - - - -
24 strip glukose autochek Pcs - - - -
25 Masker N 95 Pcs 40 40 40 (40)
26 objek glass Pcs - - - -
27 Rapid HIV Pcs - - - -
28 Kolesterol Auto chek Pcs - - - -
29 Stip Cek Narkoba Pcs - - - -
30 CutiCell 10cm x 10M Rol 20 20 20 (20)
31 Surgical Blade no. 10-24 Pcs - - 5 (5) 21
32 Leucoplast Rol 7 7 3 4 6
33 Uniflex 7,5 x 4,5cm Rol 12 12 1 11 (8)
34 HB ig Pcs - - - -
35 RDT hepatitis B Pcs - - - -
36 RDT Syphilis Pcs - - - -
37 RDT HIV Pcs - - - -
38 Blood Slide Pcs - - - -
39 Oksitetra salp mata prog. KIA Tube - - - -
40 Anti Hb SAG Pcs - - - -
41 Metrodinazol 500mg/100ml Botol - - - -
42 Betadine Salp Tube - - 1 (1) 4
43 Gluko Protein Pcs - - - -
44 Reagen Sphylis Botol - - - -
45 Sarung Tangan Non Steril Size L 200 200 200 (200) 500
46 Sarung Tangan Non Steril Size M 300 300 300 (300) 1000
47 Spray Desinfektan 36 36 22 14 56
48 - - -
49 - - -
50 - - - -
51 2,125 2,125 2,125 (2,125)
52 8,615 8,615 8,615 (8,615)
53 8,381 8,381 8,381 (8,381)
54 7 7 7 (7)
55 - - - -
56 324 324 324 (324)
57 - - - -
 58 - - - -
59 - - - -
60 - - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
166 355

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

Asrofi, SKM Yayat Hariman, S.Farm dr. Rinaldy Sinaga

NIP. 197004211991031001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 4
2 0 2 1

T (LPLPO. LB.2)
PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17

Expired
Expired
KIR JUMLAH
521

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : RAWAT INAP JANGGA BARU BULAN :
KECAMATAN : BATANG HARI TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol - - - 16 (16) 80
2 Albendazol 400mg Tablet - - - - 0
3 Albendazol susp 200 mg/5ml Botol - - - - 0
4 Alopurinol tablet 100 mg Tablet 865 1,000 1,865 111 1,754 (1,310)
5 Alupurinol Tab 300mg Tablet 190 190 - 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 - 58 (58)
7 Aminofilin tablet 200 mg Tablet (534) (534) - (534) 534 1,000
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,550 1,550 100 1,450 (1,050) 1,000
9 Amlodipin tablet 10 mg Tablet 14,822 14,822 798 14,024 (10,832) 2,000
10 Amlodipin tablet 5 mg Tablet 18,771 18,771 - 18,771 (18,771)
11 Amoksisilin 250 mg Tablet - - - - 0
12 Amoksisilin sir forte 250mg Botol - - - - 0
13 Amoksisilin sir 125mg/5 ml Botol 244 244 10 234 (194)
14 Amoksisilin Tablet 500 mg Tablet 5,304 1,000 6,304 1,748 4,556 2,436
15 Ampisilin serb inj 1000 mg/vial Vial - - - - 0 100
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 5,400 5,400 310 5,090 (3,850)
17 Antasida DOEN II Suspensi Kombinasi Botol 273 273 14 259 (203)
18 Antifungi DOEN Kombinasi Tube 77 77 3 74 (62)
19 Antihemoroid Kombinasi sup Sup 212 212 - 212 (212)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - 0
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 825 825 103 722 (310)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 1,036 1,036 170 866 (186)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 2,140 2,140 773 1,367 1,725 3,000
24 Asam Folat 1 mg Tablet 1,260 1,260 140 1,120 (560)
25 Asam Mefenamat tablet 500 mg Tablet 6,196 6,196 541 5,655 (3,491)
26 Asiklovir Tablet 200 mg Tablet 1,397 1,397 - 1,397 (1,397)
27 Asiklovir Tablet 400 mg Tablet 1,140 1,140 - 1,140 (1,140)
28 Atapulgit Tablet Tablet 1,209 1,209 - 1,209 (1,209) 2,000
29 Atenolol 50 mg Tablet - - - - 0
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7) 100
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - 0 1,000
32 Bedak Salisil serbuk 2% Bks 48 48 21 27 57 80
33 Betametason Krim 0,05 % Tube 37 37 22 15 73 300
34 Bisakodil sup 5 mg Botol - - - - 0
35 Bisaprolol 5mg Tablet 341 341 20 321 (241)
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 279 279 20 259 (179)
37 Deksametason Tablet 0,5 mg Tablet 4,136 4,136 248 3,888 (2,896)
38 Devitalisasi Pasta (Non Arsen) Botol - - - - 0
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 55 55 - 55 (55)
40 Diazepam rektal 10mg/2 ,5ml Amp 23 23 1 22 (18)
41 Diazepam rektal 5mg/2 ml Amp 4 4 - 4 (4)
42 Diazepam Tablet 2 mg Tablet 140 140 51 89 115 200
43 Diazepam Tablet 5 mg Tablet 163 163 21 142 (58)
44 Dietilkarbamazin tab 100mg Tablet - - - - 0
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 232 232 19 213 (137)
46 Digoksin Tablet 0,25 mg tablet 721 721 - 721 (721) 2,000
47 Diltiazem hcl tab 30mg Tablet - - - - 0
48 Doksisiklin Kapsul 100 mg Tablet 968 968 - 968 (968)
49 Domperidon 10 mg Tablet Tablet 1,473 1,473 576 897 1,407 2,000
50 Domperidon 5mg/5ml Sirup Botol 59 59 - 59 (59) 100
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp - - 2 (2) 10
52 Ergotamin tab 1mg Tablet - - - - 0
53 Eritromisin kapsul 250 mg Tablet - - - - 0
54 Eritromisin Kapsul 500 mg Tablet 170 500 670 63 607 (355)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol 6 6 3 3 9
57 Etil Klorida Semprot 100 ml Botol - - 2 (2) 10
58 Eugenol cairan Botol - - - - 0
59 Fenitoin Na kaps Tablet - - - - 0
60 Fenobarbital tablet 30 mg Tablet 1,624 1,624 16 1,608 (1,544)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - 0
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - 0
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 53 53 53 (53) 100
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 484 484 31 453 (329)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - 0
66 Fluor kaps 1 mg Kapsul - - - - 0
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 49 49 1 48 (44)
68 Furosemid Tablet 40 mg Tablet 974 974 974 (974)
69 Garam Oralit I Serbuk Kombinasi Bks 627 627 15 612 (552)
70 Glass Ionomer Cement Art Lar. Botol - - - - 0
71 Glibenklamida Tablet 5 mg Tablet 1,939 1,939 420 1,519 161
72 Glimepirid 2 mg Tablet - - - - 0
73 Griseofulvin Tablet 125 mg Tablet 50 50 - 50 (50) 500
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - 0
75 Haloperidol Tablet 0,5 mg Tablet - - - - 0
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 967 967 125 842 (342)
78 Hidrokortison Krim 2,5 % Tube 153 153 29 124 (8) 200
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 554 - 554 (554)
80 Ibuprofen Sirup 100 mg/5 ml Botol 78 78 78 (78)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 - 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 1,353 1,353 452 901 907 4,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,563 1,563 20 1,543 (1,463)
84 Kalsium glukonat inj 10% Botol 3 3 - 3 (3)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - 0
86 Kaptopril Tablet 12,5 mg Tablet 2,277 2,277 380 1,897 (377)
87 Kaptopril Tablet 25 mg Tablet 2,589 2,589 199 2,390 (1,594)
88 Karbamazepin tab 100 mg Tablet - - - - 0
89 karbo Gliserin tetestelinga 10 % Botol - - - - 0
90 Ketokonazol tab 200 mg Tablet 275 275 7 268 (240) 2,000
91 Klindamisin 300 mg Tablet 270 270 - 270 (270)
92 Klindamisin kap 150mg Tablet - - 14 (14) 70 2,000
93 Kloramfenikol kapsul 250 mg Tablet 919 919 - 919 (919)
94 Kloramfenikol Salep Mata 1 % Tube 43 43 4 39 (23)
95 Kloramfenikol susp 125mg/5ml Botol - - - - 0
96 Kloramfenikol Tablet 500mg Tablet - - - - 0
97 Kloramfenikol Tetes Mata 1 % Botol - - - - 0 200
98 Kloramfenikol tetes telinga 1% Botol - - - - 0 200
99 Klorfeniramin Tablet 4 mg Tablet 8,547 8,547 2,402 6,145 3,463 3,500
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - 0
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - 0
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - 0
103 Kodein tablet 10 mg Tablet 639 639 120 519 (39)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,297 1,297 351 946 458 1,000
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 51 51 3 48 (36)
106 Kuinin Tab Tablet - - - - 0
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp 228 228 43 185 (13)
108 Loratadin 10 mg tablet Tablet 2,173 2,173 - 2,173 (2,173)
109 Magnesium Sulfat Injeksi 20% Botol - - - - 0
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - 0
112 Mebendazol tab 100 mg Tablet - - - - 0
113 Mebendazol tab 500 mg Tablet - - - - 0
114 Metformin 500 mg Kapsul 16,925 16,925 - 16,925 (16,925) 3,000
115 Metformin 850 mg Kapsul 90 90 90 - 360 3,000
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - 0
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,478 2,478 72 2,406 (2,118)
118 Metilprednisolon tab 4 mg Tablet - - - - 0 3,000
119 Metoklopramid Tablet 10 mg Tablet 451 500 951 26 925 (821)
120 Metrodinazol lar inf 5mg/ml Botol - - - - 0
121 Metrodinazol sir 125mg/ml Botol - - - - 0
122 Metronidazol Tablet 250 mg Tablet - - - - 0
123 Metronidazol tablet 500 mg Tablet 1,924 1,924 424 1,500 196
124 Mikonazol Krim 2% (Nitrat) Tube 89 89 16 73 (9)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - 0 2,000
126 Natrium Diklofenak Tablet 25 mg Tablet 2,985 2,985 62 2,923 (2,675)
127 Natrium Diklofenak Tablet 50 mg Tablet 4,350 4,350 - 4,350 (4,350)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - 0
129 Nifedipin Tablet 10 mg Tablet 465 465 5 460 (440)
130 Nistatin Suspensi 100.000UI/ml Botol - - - - 0
131 Nistatin Vagina 500.000 Tablet Tablet (225) 100 (125) - (125) 125
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (8) (8) (8) 8
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 88 88 4 84 (68) 200
134 Omeprazol tablet 20 mg Tablet 1,226 100 1,326 1,106 220 4,204 4,500
135 Parasetamol Sirup 120 mg / 5 ml Botol 257 257 87 170 178 200
136 Parasetamol Tablet 500 mg Tablet 5,147 10,000 15,147 3,499 11,648 2,348
137 Parasetamol drops 100 mg / 1 ml Botol - - - - 0
138 Perak sulfadiazin krim1% Tube - - - - 0
139 Pirantel pamoat sus 125mg/5ml Botol - - - 0
140 Pirantel pamoat tab 125 mg Tablet 158 158 3 155 (143)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 8,031 8,031 608 7,423 (4,991)
142 Povidon Iodida 100 mg/ml 30 ml Botol 35 35 - 35 (35)
143 Povidon Iodida 100 mg/ml 300 ml Botol 12 12 - 12 (12)
144 Prednison Tablet 5 mg Tablet 1,059 1,059 302 757 451 500
145 Primakuin Tablet 15 mg Tablet - - - - 0
146 Probenesid tab 500mg Tablet - - - - 0
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - 0
148 Propanolol Tablet 10 mg (HCl) Tablet 529 529 - 529 (529)
149 Propilitiourasil Tablet 100 mg Tablet 118 118 - 118 (118)
150 Ranitidin Tablet 150 mg Tablet 1,835 1,835 281 1,554 (430)
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 891 1,500 2,391 27 2,364 (2,256)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 410 410 410 (410) 1,500
154 Salep 2 - 4 Kombinasi Tube 38 38 13 25 27 48
155 Sefadroksil Kapsul 500 mg Tablet 754 754 - 754 (754) 2,000
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial (3) (3) - (3) 3
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 28 28 28 (28)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 289 289 10 279 (239)
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,919 1,919 80 1,839 (1,519)
160 Simvastatin Tablet 10 mg Tablet - - - - 0
161 Simvastatin Tablet 20 mg Tablet 940 940 81 859 (535)
162 Siprofloksasin Tablet scored 500 mg Tablet 1,037 1,037 257 780 248 1,000
163 Spironolakton 25 mg tablet Tablet 202 202 - 202 (202)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - 0
165 Tetrasiklin Kapsul 500 mg Tablet 830 830 20 810 (730)
166 Tetrasiksin 250 mg Tablet - - - - 0
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 1,320 1,320 443 877 895 1,500
168 Valproat sir 250 mg/ml Botol - - - - 0
169 Valproat tab sal 250mg Tablet - - - - 0
170 Valproat tab sal 500 mg Tablet - - - - 0
171 Verapamil 80mg Tablet - - - - 0
172 Vitamin B Kompleks Tablet Tablet 10,522 10,522 4,816 5,706 13,558
173 Zink sir 10 mg/ml Botol 79 79 - 79 (79)
174 Zink tablet dispersi 20 mg Tablet 1,404 1,404 1,404 (1,404) 2,000
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - - 0
1 Ambroxol Sirup 15 mg/ml Botol 190 - 190 44 146 30
2 Ambroxol Tablet 30 mg Tablet 3,883 3,883 494 3,389 (1,413)
3 Antalgin Injeksi 250 mg Amp - - - - 0
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 75 75 - 75 (75)
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - 0
6 Asetosal Tablet 100mg Tablet - - - - 0
7 Asiklovir Krim 5% Tube 72 72 1 71 (67)
8 Counterpain 15 mg Tube - - - - 0
9 Duvadilan Tablet - - - - 0
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - 0
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - 0
12 Etakridin Larutan 0,1 Botol (14) (14) - (14) 14
13 Famotidine Tablet 40 mg Tablet - - - - 0
14 Fenobarbital inj Tablet 20 20 - 20 (20)
15 Fenol Gliserol Tetes Telinga 10 % Botol 103 103 6 97 (73)
16 Gentamisin Injeksi 40 mg/ml Amp 34 34 - 34 (34)
17 Gentamisin Salep Kulit 0,1 % Botol 7 7 7 - 28
18 Gliseril Guaiakolat Tablet 100 mg Tablet 7,963 3,000 10,963 465 10,498 (8,638)
19 Glukosa Larutan Infus 10 % Steril Botol - - - - 0
20 Glukosa Larutan Infus 5 % Steril Botol 4 4 - 4 (4)
21 Imersi Oil Botol - - - - 0
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 5,750 5,750 1,079 4,671 (355)
23 Ketorolac inj 30mg/ml Amp - - - - 0
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - 0
25 Larutan Asam Asetat Botol - - - - 0
26 Larutan Asam Klorida 0,1 N Botol - - - - 0
27 Larutan Benedict Botol - - - - 0
28 Larutan Eosin 2% Botol - - - - 0
29 Larutan Faucet Botol - - - - 0
30 Larutan Giemsa Stalin Botol - - - - 0
31 Larutan Natrium Sitrat 3,8% Botol - - - - 0
32 Larutan Resserccer Botol - - - - 0
33 Larutan Turk Botol - - - - 0
34 Lisol Botol - - - - 0
35 Natrium Klorida Larutan Infus 0,9% Botol 137 137 57 80 148 160
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 135 135 59 76 160 200
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - 0
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 74 74 20 54 26 50
39 Oksitetrasiklin Salep Kulit 3 % Tube 81 81 9 72 (36)
40 Parasetamol 100 mg Tablet - - - - 0
41 Pehacain inj Amp - - - - 0
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - 0
43 Piroxicam 20mg Tablet 340 340 30 310 (190)
44 Propanolol tablet 40 mg Tablet - - - - 0
45 Ranitidin Injeksi 25 mg / 2 ml Amp 223 223 121 102 382 550
46 Reagen Golongan Darah Botol - - - - 0
47 Reagen TB Botol - - - - 0
48 Ringer Laktat Larutan Infus Steril Botol 480 480 200 280 520 520
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - 0
50 Setirizin Sirup 5 mg/5ml Botol 165 165 6 159 (135)
51 Setirizin Tablet 10mg Tablet 834 1,000 1,834 151 1,683 (1,079)
52 Simetidin Tablet 200 mg Tablet - - - - 0
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - 0
54 Tablet Tambah Darah Tablet - - - - 0
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - 0
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 120 120 17 103 (35) 50
57 Trombophob Jeli 15 g Tube - - - - 0 10
58 Ventolin Botol 56 56 25 31 69 80
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - - 0
1 Alat Suntik Sekali Pakai 1 ml Pcs 670 - 670 46 624 (440)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - 0
3 Alat Suntik Sekali Pakai 3 ml Pcs 167 2,000 2,167 290 1,877 (717)
4 Alat Suntik Sekali Pakai 5 ml Pcs 783 783 102 681 (273)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 52 52 2 50 (42)
6 Elastis Verban 4 inci Pcs - - - - 0
7 Foley Catheter No. 16 Pcs 48 48 17 31 37 40
8 Foley Catheter No. 18 Pcs 20 20 1 19 (15)
9 Hanscoond no 6,5 Pcs 69 69 54 15 201 250
10 Hanscoond no 7,5 Pcs 155 155 152 3 605 700
11 HCG test Pcs - - - - 0
12 Infusion Set Anak Pcs 310 310 59 251 (15)
13 Infusion Set Dewasa Pcs 104 450 554 54 500 (284)
14 IV Catheter No. 18. G Pcs 294 294 294 (294)
15 IV Catheter No. 20 G Pcs 109 109 96 13 371
16 IV Catheter No. 22 G Pcs 130 130 28 102 10
17 IV Catheter No. 24 G Pcs 218 218 2 216 (208)
18 Jarum Jahit Kulit Pcs - - 4 (4) 20
19 Jarum Jahit Otot Pcs - - 4 (4) 20
20 Kapas Pembalut / Absorben 250 gr Pcs 12 12 5 7 13
21 Kasa Pembalut 2 m x 80 cm Rol - - - - 0
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 - 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - 0
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 100 100 9 91 (55)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 7 7 - 7 (7)
26 Kasa Kompres 40/40 Steril Rol - - - - 0
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 - 6 (6)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - 0
29 Masker Rol (450) (450) - (450) 450 1,000
30 Pembalut Gips 4 Inci Rol - - - - 0
31 Plester 5 Yards x 2 inci Rol - - - - 0
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 119 119 10 109 (69) 200
33 Urine Bag Pcs 71 71 5 66 (46)
34 Wing Needle No.27 G Pcs - - - - 0
35 Handscoond 8 Pcs - - - - 0
36 Handscoond 7 Pcs - - - - 0
37 Plesterin Non Woven Pcs - - - - 0
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - 0
39 Poligyp 10 cm x 2,7 m Pcs - - - - 0
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - 0
41 Plester 5cm x 5m Pcs - - - - 0
IV OBAT PROGRAM - - - 0
A. MALARIA - - - 0
1 Obat Anti Malaria (ACT) Tablet - - - - - 0
2 Primaquin Tablet Tablet - - - - - 0
3 Kina tablet Tablet - - - - 0
4 RDT Malaria (First Respon) Pcs - - - - 0
5 Arterakina (DHP)=Dartep - - - - 0
6 Artehemeter Injeksi Amp - - - - 0
7 Kuinin Sulfat tablet 222 mg Tablet - - - - 0
B. TUBERCULOSIS (TB) - - - 0
1 OAT FDC kategori 1 Paket - - - - - 0
2 OAT FDC kategori 2 Paket - - - - - 0
3 OAT Kategori Anak Paket - - - - 0
4 OAT Kombipak Paket - - - - 0
5 Masker Pcs - - - - 0
C. PENYAKIT TIDAK MENULAR (PTM) - - - 0
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - 0
2 Haloperidol tab 5 mg Tablet 4,790 4,790 - 4,790 (4,790)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - 0
5 Risperidon Tablet Tablet 1,520 1,520 30 1,490 (1,370)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,895 3,895 20 3,875 (3,795)
7 Clobazam tablet 10 mg Tablet - - - - 0
8 Clozapine 25 mg Tablet 1,645 1,645 20 1,625 (1,545)
9 Klorpromazine Tablet Tablet - - - - 0
10 Diazepam 5 mg Tablet - - - - 0
11 Asprazolam Tablet - - - - 0
D. VAKSIN - - - 0
1 BCG Amp 12 6 18 14 4 52
2 POLIO 10 DS Pcs 7 20 27 27 - 108
3 CAMPAK Amp - - - - 0
4 IPV 10 10 - 10 (10)
5 HB UNIJEK 38 38 16 22 42
6 Td Amp 21 21 - 21 (21)
7 DPT HB-Hib Amp 17 30 47 38 9 143
8 TT Amp - - - - 0
9 Dt Amp 13 13 13 - 52
10 POLIO 20 DS Pcs - - - - 0
11 VAR (vaksin rabies ) Vial 160 160 160 - 640
12 ADS 0,05 ml Pcs 130 130 130 - 520
13 ADS 0,5 ml Pcs 580 100 680 264 416 640
14 ADS 5 ml Pcs 33 33 84 (51) 387
15 VAKSIN MR Amp 46 20 66 26 40 64
E. KIA - - 0
1 Glukanos kalsikus injeksi 10 % Amp - - - - - 0
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - 0
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - 0
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - 0
5 Gentamicin inj 40mg/dl Amp - - - - 0
6 Tes Kehamilan Pcs 8 8 8 - 32 100
7 Tes Protein Urine Pcs - 8 8 - 32 100
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - 0
9 Oksitosin inj IV/ml-1ml Amp - - - - 0
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - 0
11 Reagen Golongan Darah Botol - - - - 0
12 Hb Sahli Pcs - - - - 0
13 Oto Klik Pcs - - - - 0
14 Larutan Hcl Botol - - - - 0
15 Blood lancet Pcs - - - - 0
F. GIZI - - - 0
1 Tablet tambah darah Tablet - - - 393 (393) 1,965
2 Vit A Biru 100.000 IU Tablet 100 - 100 - 100 (100)
3 Vit A Merah 200.000 IU Tablet 3,850 3,850 - 3,850 (3,850)
4 Iodin test Pcs - - - - 0
G. DIARE - - - 0
1 Garam Oralit 200 mg Bks 250 - 250 250 (250)
2 Zinc Tablet 20 mg Tablet - - - - - 0
H. FILARIASIS - - - 0
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - 0
2 Parasetamol 500 mg Tablet - - - - - 0
3 Albendazol 200 mg Tablet - - - - 0
G.ALAT LABORATORIUM - - - 0
1 Blood Lancet Pcs - - - - - 0
2 Reagen TB Botol - - - - - 0
3 Slide Pcs - - - 0
4 Pot Sputum Pcs 1,700 1,700 1,700 (1,700)
5 Metanol 100 ml Botol - - - - 0
6 Imersi Oil 60 ml Botol - - - - 0
7 Buffer Phosphat 7,2 Botol - - - - 0
8 Handscoon (M) Pcs - - - - 0
9 Alkohol asam 100 ML Botol - - - - 0
10 Masker Pcs - - - - 0
11 Giemsa Solution 60 ml Botol - - 0
12 Alkohol Swap Bks 500 500 500 (500) 500
H. KUSTA - - - 0
1 MB Adult - - - - - 0
2 MB (MDTDMB) child - - - - - 0
3 PB Adult - - - - 0
4 PB (MTDPB) child - - - - 0
I. HIV DAN SIFILIS - - - 0
1 Rapid Test Merk :SD - - - - - 0
2 Fokus (HIV ke 2) - - - - - 0
3 Rapid Test Merk : Vikia - - - - 0
4 Human Hexogon Syphilis - - - - 0
5 RPR Syphylis - - - - 0
TAMBAHAN - - - 0
1 Gentamisin Tetes mata Botol - - - - - 0 100
2 Gentian Violet Botol - - - - - 0
3 OAM Tablet - - - - 0
4 Glikonas Kalsikus inj 10% Botol - - - - 0
5 Bromheksin Tablet - - - - 0
6 sefadroxil Syr Botol - - - - 0
7 Kasa Elastis 4 inc Rol - - - - 0
8 Klindamisin Kap 150 mg Tablet - - - - 0 1,000
9 Glukosa Lar.40% Botol - - - - 0
10 Antiparkinson doen kombinasi Tablet - - - - 0
11 benzatin Penisilin G I juta iu/Vial Vial - - - - 0
12 Aminofilin tab 150 mg Tablet - - - - 0
13 Mumfying pasta Botol - - - - 0
14 Safety box Pcs - - - - 0
15 fixomul Rol 9 9 3 6 6 10
16 Guaifenisin Tablet - - 45 (45) 225 3,000
17 Metro 500mg/Injeksi Amp - - - - 0
18 Ampisilin 100mg Tablet - - - - 0
19 Euthirox 50mg Tablet - - - - 0
20 Mineral mix Botol - - - - 0
21 Urine 2 Parameter Pcs - - - - 0
22 Urine 10 Parameter Pcs - - - - 0
23 strip autochek Pcs - - - - 0
24 strip glukose autochek Pcs - - - - 0
25 Masker N 95 Pcs 40 40 40 - 160 100
26 objek glass Pcs - - - - 0
27 Rapid HIV Pcs - - - - 0
28 Kolesterol Auto chek Pcs - - - - 0
29 Stip Cek Narkoba Pcs - - - - 0
30 CutiCell 10cm x 10M Rol 9 9 5 4 16 20
31 Surgical Blade no. 10-24 Pcs (5) (5) - (5) 5
32 Leucoplast Rol 4 4 - 4 (4)
33 Uniflex 7,5 x 4,5cm Rol 11 11 - 11 (11)
34 HB ig Pcs - - - - 0
35 RDT hepatitis B Pcs - - - - 0
36 RDT Syphilis Pcs - - - - 0
37 RDT HIV Pcs - - - - 0
38 Blood Slide Pcs - - - - 0
39 Oksitetra salp mata prog. KIA Tube - - - - 0
40 Anti Hb SAG Pcs - - - - 0
41 Metrodinazol 500mg/100ml Botol - - - - 0
42 Betadine Salp Tube (1) (1) - (1) 1
43 Gluko Protein Pcs - - - - 0
44 Reagen Sphylis Botol - - - - 0
45 Handscoon (M) Kotak 200 200 200 - 800 1000
46 Handscoon (L) 300 300 300 - 1,200 1000
47 Desinfektan Spray Botol 14 14 2 12 (4)
48 - - 0 - 0
49 - - 0 - 0
50 - - 0 - 0
51 2,125 2,125 2,125 (2,125)
52 8,615 8,615 8,615 (8,615)
53 8,381 8,381 8,381 (8,381)
54 7 7 7 (7)
55 - - - 0
56 324 324 324 (324)
57 - - - 0
 58 - - - 0
59 - - - 0
60 - - - 0

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 5
2 0 2 1

DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17
Expired
KIR JUMLAH

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol (16) - (16) 11 (27) 71
2 Albendazol 400mg Tablet - - - - 0
3 Albendazol susp 200 mg/5ml Botol - - - - 0
4 Alopurinol tablet 100 mg Tablet 1,754 1,754 600 1,154 1,246 1,500
5 Alupurinol Tab 300mg Tablet 190 190 - 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 - 58 (58)
7 Aminofilin tablet 200 mg Tablet (534) (534) - (534) 534
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 1,450 1,000 2,450 2,450 (2,450)
9 Amlodipin tablet 10 mg Tablet 14,024 1,200 15,224 1,024 14,200 (10,104) 2,000
10 Amlodipin tablet 5 mg Tablet 18,771 1,800 20,571 20,571 (20,571)
11 Amoksisilin 250 mg Tablet - - - - 0
12 Amoksisilin sir forte 250mg Botol - - - - 0
13 Amoksisilin sir 125mg/5 ml Botol 234 234 11 223 (179)
14 Amoksisilin Tablet 500 mg Tablet 4,556 4,556 2,800 1,756 9,444 5,000
15 Ampisilin serb inj 1000 mg/vial Vial - - - - 0
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 5,090 5,090 1,300 3,790 1,410 2,500
17 Antasida DOEN II Suspensi Kombinasi Botol 259 259 13 246 (194)
18 Antifungi DOEN Kombinasi Tube 74 74 3 71 (59)
19 Antihemoroid Kombinasi sup Sup 212 212 68 144 128
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - 0
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 722 722 62 660 (412)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 866 866 298 568 624 2,000
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 1,367 5,000 6,367 1,055 5,312 (1,092)
24 Asam Folat 1 mg Tablet 1,120 1,120 261 859 185 1,000
25 Asam Mefenamat tablet 500 mg Tablet 5,655 5,655 771 4,884 (1,800)
26 Asiklovir Tablet 200 mg Tablet 1,397 1,397 125 1,272 (772)
27 Asiklovir Tablet 400 mg Tablet 1,140 1,140 90 1,050 (690)
28 Atapulgit Tablet Tablet 1,209 1,209 - 1,209 (1,209)
29 Atenolol 50 mg Tablet - - - - 0
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - 0
32 Bedak Salisil serbuk 2% Bks 27 96 123 11 112 (68)
33 Betametason Krim 0,05 % Tube 15 15 12 3 45 100
34 Bisakodil sup 5 mg Botol - - - - 0
35 Bisaprolol 5mg Tablet 321 321 31 290 (166) 500
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 259 259 7 252 (224)
37 Deksametason Tablet 0,5 mg Tablet 3,888 3,888 959 2,929 907 1,500
38 Devitalisasi Pasta (Non Arsen) Botol - - - - 0
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 55 55 - 55 (55)
40 Diazepam rektal 10mg/2 ,5ml Amp 22 22 2 20 (12)
41 Diazepam rektal 5mg/2 ml Amp 4 4 - 4 (4)
42 Diazepam Tablet 2 mg Tablet 89 89 22 67 21 200
43 Diazepam Tablet 5 mg Tablet 142 142 48 94 98 800
44 Dietilkarbamazin tab 100mg Tablet - - - - 0
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 213 213 9 204 (168)
46 Digoksin Tablet 0,25 mg tablet 721 721 - 721 (721)
47 Diltiazem hcl tab 30mg Tablet - - - - 0
48 Doksisiklin Kapsul 100 mg Tablet 968 968 - 968 (968)
49 Domperidon 10 mg Tablet Tablet 897 897 744 153 2,823 2,800
50 Domperidon 5mg/5ml Sirup Botol 59 59 - 59 (59)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (2) (2) 4 (6) 22
52 Ergotamin tab 1mg Tablet - - - - 0
53 Eritromisin kapsul 250 mg Tablet - - - - 0
54 Eritromisin Kapsul 500 mg Tablet 607 607 107 500 (72)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol 3 3 7 (4) 32 20
57 Etil Klorida Semprot 100 ml Botol (2) (2) 1 (3) 7
58 Eugenol cairan Botol - - - - 0
59 Fenitoin Na kaps Tablet - - - - 0
60 Fenobarbital tablet 30 mg Tablet 1,608 1,608 3 1,605 (1,593)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - 0
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - 0
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 53 53 - 53 (53)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 453 453 31 422 (298)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - 0
66 Fluor kaps 1 mg Kapsul - - - - 0
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 48 48 - 48 (48)
68 Furosemid Tablet 40 mg Tablet 974 974 149 825 (229)
69 Garam Oralit I Serbuk Kombinasi Bks 612 612 - 612 (612)
70 Glass Ionomer Cement Art Lar. Botol - - - - 0
71 Glibenklamida Tablet 5 mg Tablet 1,519 1,519 544 975 1,201 2,000
72 Glimepirid 2 mg Tablet - - - - 0
73 Griseofulvin Tablet 125 mg Tablet 50 50 - 50 (50)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - 0
75 Haloperidol Tablet 0,5 mg Tablet - - - - 0
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
77 Hidroklorotiazida Tablet 25 mg Tablet 842 842 112 730 (282)
78 Hidrokortison Krim 2,5 % Tube 124 240 364 364 (364)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 554 - 554 (554)
 80 Ibuprofen Sirup 100 mg/5 ml Botol 78 78 9 69 (33)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 - 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 901 901 207 694 134 3,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,543 1,543 130 1,413 (893)
84 Kalsium glukonat inj 10% Botol 3 3 - 3 (3) 10
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - 0
86 Kaptopril Tablet 12,5 mg Tablet 1,897 1,897 227 1,670 (762)
87 Kaptopril Tablet 25 mg Tablet 2,390 2,390 691 1,699 1,065 1,500
88 Karbamazepin tab 100 mg Tablet - - - - 0
89 karbo Gliserin tetestelinga 10 % Botol - - - - 0
90 Ketokonazol tab 200 mg Tablet 268 268 70 198 82 2,000
91 Klindamisin 300 mg Tablet 270 270 - 270 (270)
92 Klindamisin kap 150mg Tablet (14) (14) - (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 919 919 9 910 (874)
94 Kloramfenikol Salep Mata 1 % Tube 39 39 1 38 (34)
95 Kloramfenikol susp 125mg/5ml Botol - - - - 0
96 Kloramfenikol Tablet 500mg Tablet - - - - 0
97 Kloramfenikol Tetes Mata 1 % Botol - - - - 0
98 Kloramfenikol tetes telinga 1% Botol - - - - 0
99 Klorfeniramin Tablet 4 mg Tablet 6,145 3,888 10,033 1,982 8,051 (123)
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - 0
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - 0
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - 0
103 Kodein tablet 10 mg Tablet 519 519 93 426 (54)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 946 1,000 1,946 241 1,705 (741)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 48 48 - 48 (48)
106 Kuinin Tab Tablet - - - - 0
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp 185 185 185 (185)
108 Loratadin 10 mg tablet Tablet 2,173 2,173 2,173 (2,173)
109 Magnesium Sulfat Injeksi 20% Botol - - - 0
110 Magnesium Sulfat Injeksi 40% Botol 6 6 6 (6) 10
111 Mebendazol sir 50mg/ml Botol - - - - 0
112 Mebendazol tab 100 mg Tablet - - - - 0
113 Mebendazol tab 500 mg Tablet - - - - 0
114 Metformin 500 mg Kapsul 16,925 16,925 - 16,925 (16,925) 3,000
115 Metformin 850 mg Kapsul - - - - 0 3,000
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - 0
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,406 2,406 20 2,386 (2,306)
118 Metilprednisolon tab 4 mg Tablet - - - - 0
119 Metoklopramid Tablet 10 mg Tablet 925 925 - 925 (925)
120 Metrodinazol lar inf 5mg/ml Botol - - - - 0
121 Metrodinazol sir 125mg/ml Botol - - - - 0
122 Metronidazol Tablet 250 mg Tablet - - - - 0
123 Metronidazol tablet 500 mg Tablet 1,500 1,500 20 1,480 (1,400)
124 Mikonazol Krim 2% (Nitrat) Tube 73 73 13 60 (8)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - 0
126 Natrium Diklofenak Tablet 25 mg Tablet 2,923 2,923 210 2,713 (1,873)
127 Natrium Diklofenak Tablet 50 mg Tablet 4,350 4,350 494 3,856 (1,880)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - 0
129 Nifedipin Tablet 10 mg Tablet 460 460 100 360 40
130 Nistatin Suspensi 100.000UI/ml Botol - - - - 0
131 Nistatin Vagina 500.000 Tablet Tablet (125) (125) - (125) 125
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (8) (8) 14 (22) 78
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 84 84 7 77 (49)
134 Omeprazol tablet 20 mg Tablet 220 900 1,120 20 1,100 (1,020)
135 Parasetamol Sirup 120 mg / 5 ml Botol 170 200 370 30 340 (220)
136 Parasetamol Tablet 500 mg Tablet 11,648 11,648 4,205 7,443 9,377
137 Parasetamol drops 100 mg / 1 ml Botol - - - - 0
138 Perak sulfadiazin krim1% Tube - - - - 0
139 Pirantel pamoat sus 125mg/5ml Botol - - - - 0
140 Pirantel pamoat tab 125 mg Tablet 155 155 - 155 (155)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 7,423 7,423 112 7,311 (6,863)
142 Povidon Iodida 100 mg/ml 30 ml Botol 35 35 2 33 (25)
143 Povidon Iodida 100 mg/ml 300 ml Botol 12 12 5 7 13
144 Prednison Tablet 5 mg Tablet 757 757 565 192 2,068 2,000
145 Primakuin Tablet 15 mg Tablet - - - - 0
146 Probenesid tab 500mg Tablet - - - - 0
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - 0
148 Propanolol Tablet 10 mg (HCl) Tablet 529 529 79 450 (134)
149 Propilitiourasil Tablet 100 mg Tablet 118 118 63 55 197 2,000
150 Ranitidin Tablet 150 mg Tablet 1,554 1,554 328 1,226 86 2,000
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 2,364 200 2,564 131 2,433 (1,909)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 410 410 20 390 (310) 2,000
154 Salep 2 - 4 Kombinasi Tube 25 25 19 6 70 60
155 Sefadroksil Kapsul 500 mg Tablet 754 754 - 754 (754)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial (3) (3) 2 (5) 13
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 28 28 28 (28)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 279 279 82 197 131 200
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,839 1,839 60 1,779 (1,539)
160 Simvastatin Tablet 10 mg Tablet - - - - 0 2,000
161 Simvastatin Tablet 20 mg Tablet 859 859 387 472 1,076 2,000
162 Siprofloksasin Tablet scored 500 mg Tablet 780 1,000 1,780 238 1,542 (590)
163 Spironolakton 25 mg tablet Tablet 202 202 - 202 (202) 2,000
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - 0
165 Tetrasiklin Kapsul 500 mg Tablet 810 810 80 730 (410)
166 Tetrasiksin 250 mg Tablet - - - - 0
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 877 1,500 2,377 269 2,108 (1,032)
168 Valproat sir 250 mg/ml Botol - - - - 0
169 Valproat tab sal 250mg Tablet - - - - 0
170 Valproat tab sal 500 mg Tablet - - - - 0
171 Verapamil 80mg Tablet - - - - 0
172 Vitamin B Kompleks Tablet Tablet 5,706 5,706 3,075 2,631 9,669
173 Zink sir 10 mg/ml Botol 79 79 2 77 (69)
174 Zink tablet dispersi 20 mg Tablet 1,404 1,404 652 752 1,856 3,000
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - 0
1 Ambroxol Sirup 15 mg/ml Botol 146 - 146 26 120 (16)
2 Ambroxol Tablet 30 mg Tablet 3,389 3,389 1,167 2,222 2,446 2,500
3 Antalgin Injeksi 250 mg Amp - - - - 0
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 75 50 125 50 50 150
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - 0
6 Asetosal Tablet 100mg Tablet - - - - 0
7 Asiklovir Krim 5% Tube 71 71 2 69 (61)
8 Counterpain 15 mg Tube - - - - 0
9 Duvadilan Tablet - - - - 0
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - 0
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - 0
12 Etakridin Larutan 0,1 Botol (14) 48 34 48 (48)
13 Famotidine Tablet 40 mg Tablet - - - - 0
14 Fenobarbital inj Tablet 20 20 - 20 (20)
15 Fenol Gliserol Tetes Telinga 10 % Botol 97 97 4 93 (77)
16 Gentamisin Injeksi 40 mg/ml Amp 34 34 1 33 (29)
17 Gentamisin Salep Kulit 0,1 % Botol - - - - 0
18 Gliseril Guaiakolat Tablet 100 mg Tablet 10,498 10,498 1,000 9,498 (5,498) 2,500
19 Glukosa Larutan Infus 10 % Steril Botol - - - 0
20 Glukosa Larutan Infus 5 % Steril Botol 4 4 - 4 (4)
21 Imersi Oil Botol - - - - 0
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 4,671 4,671 1,028 3,643 469
23 Ketorolac inj 30mg/ml Amp - - - - 0
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - 0
25 Larutan Asam Asetat Botol - - - - 0
26 Larutan Asam Klorida 0,1 N Botol - - - - 0
27 Larutan Benedict Botol - - - - 0
28 Larutan Eosin 2% Botol - - - - 0
29 Larutan Faucet Botol - - - - 0
30 Larutan Giemsa Stalin Botol - - - - 0
31 Larutan Natrium Sitrat 3,8% Botol - - - - 0
32 Larutan Resserccer Botol - - - - 0
33 Larutan Turk Botol - - - - 0
34 Lisol Botol - - - - 0
35 Natrium Klorida Larutan Infus 0,9% Botol 80 200 280 40 240 (80)
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 76 54 130 16 114 (50)
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - 100 100 100 (100)
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 54 54 2 52 (44)
39 Oksitetrasiklin Salep Kulit 3 % Tube 72 72 13 59 (7)
40 Parasetamol 100 mg Tablet - - - - 0
41 Pehacain inj Amp - - - - 0
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - 0
43 Piroxicam 20mg Tablet 310 310 11 299 (255)
44 Propanolol tablet 40 mg Tablet - - - - 0
45 Ranitidin Injeksi 25 mg / 2 ml Amp 102 600 702 130 572 (52)
46 Reagen Golongan Darah Botol - - - - 0
47 Reagen TB Botol - - - - 0
48 Ringer Laktat Larutan Infus Steril Botol 280 1,000 1,280 180 1,100 (380)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - 0
50 Setirizin Sirup 5 mg/5ml Botol 159 159 4 155 (139)
51 Setirizin Tablet 10mg Tablet 1,683 1,683 210 1,473 (633)
52 Simetidin Tablet 200 mg Tablet - - - - 0
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - 0
54 Tablet Tambah Darah Tablet - - - - 0
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - 0
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 103 103 8 95 (63)
57 Trombophob Jeli 15 g Tube - - - - 0
58 Ventolin Botol 31 80 111 4 107 (91)
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs - 0
1 Alat Suntik Sekali Pakai 1 ml Pcs 624 - 624 45 579 (399)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - 0
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,877 1,877 253 1,624 (612)
4 Alat Suntik Sekali Pakai 5 ml Pcs 681 681 184 497 239
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 50 50 7 43 (15)
6 Elastis Verban 4 inci Pcs - - - - 0
7 Foley Catheter No. 16 Pcs 31 40 71 6 65 (41)
8 Foley Catheter No. 18 Pcs 19 19 2 17 (9)
9 Hanscoond no 6,5 Pcs 15 15 15 - 60 500
10 Hanscoond no 7,5 Pcs 3 3 3 - 12 500
11 HCG test Pcs - - - - 0
12 Infusion Set Anak Pcs 251 251 - 251 (251)
13 Infusion Set Dewasa Pcs 500 500 10 490 (450)
14 IV Catheter No. 18. G Pcs 294 294 294 (294)
15 IV Catheter No. 20 G Pcs 13 13 56 (43) 267
16 IV Catheter No. 22 G Pcs 102 102 15 87 (27)
17 IV Catheter No. 24 G Pcs 216 216 1 215 (211)
18 Jarum Jahit Kulit Pcs (4) (4) 10 (14) 54
19 Jarum Jahit Otot Pcs (4) (4) 10 (14) 54
20 Kapas Pembalut / Absorben 250 gr Pcs 7 7 9 (2) 38
21 Kasa Pembalut 2 m x 80 cm Rol - - - - 0
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - 0
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 91 91 19 72 4
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 7 7 7 (7)
26 Kasa Kompres 40/40 Steril Rol - - - - 0
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 6 (6)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - 0
29 Masker Rol (450) 500 50 50 (50)
30 Pembalut Gips 4 Inci Rol - - - - 0
31 Plester 5 Yards x 2 inci Rol - - - - 0
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 109 144 253 14 239 (183)
33 Urine Bag Pcs 66 66 9 57 (21)
34 Wing Needle No.27 G Pcs - - - - 0
35 Handscoond 8 Pcs - - - - 0
36 Handscoond 7 Pcs - - - - 0
37 Plesterin Non Woven Pcs - - - - 0
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - 0
39 Poligyp 10 cm x 2,7 m Pcs - - - - 0
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - 0
41 Plester 5cm x 5m Pcs - - - - 0
IV OBAT PROGRAM - - 0
A. MALARIA - - 0
1 Obat Anti Malaria (ACT) Tablet - - - - - 0
2 Primaquin Tablet Tablet - - - - - 0
3 Kina tablet Tablet - - - - 0
4 RDT Malaria (First Respon) Pcs - - - - 0
5 Arterakina (DHP)=Dartep - - - - 0
6 Artehemeter Injeksi Amp - - - - 0
7 Kuinin Sulfat tablet 222 mg Tablet - - - - 0
B. TUBERCULOSIS (TB) - - 0
1 OAT FDC kategori 1 Paket - - - - - 0
2 OAT FDC kategori 2 Paket - - - - - 0
3 OAT Kategori Anak Paket - - - - 0
4 OAT Kombipak Paket - - - - 0
5 Masker Pcs - - - - 0
C. PENYAKIT TIDAK MENULAR (PTM) - - 0
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - 0
2 Haloperidol tab 5 mg Tablet 4,790 4,790 90 4,700 (4,340)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - 0
5 Risperidon Tablet Tablet 1,490 1,490 1,490 (1,490)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,875 3,875 3,875 (3,875)
7 Clobazam tablet 10 mg Tablet - - - - 0
8 Clozapine 25 mg Tablet 1,625 1,625 1,625 (1,625)
9 Klorpromazine Tablet Tablet - - - - 0
10 Diazepam 5 mg Tablet - - - - 0
11 Asprazolam Tablet - - - - 0
D. VAKSIN - - 0
1 BCG Amp 12 6 18 14 4 52
2 POLIO 10 DS Pcs 7 20 27 27 - 108
3 CAMPAK Amp - - - - 0
4 IPV 10 10 - 10 (10)
5 HB UNIJEK 38 38 16 22 42
6 Td Amp 21 21 - 21 (21)
7 DPT HB-Hib Amp 17 30 47 38 9 143
8 TT Amp - - - - 0
9 Dt Amp 13 13 13 - 52
10 POLIO 20 DS Pcs - - - - 0
11 VAR (vaksin rabies ) Vial 160 160 160 - 640
12 ADS 0,05 ml Pcs 130 130 130 - 520
13 ADS 0,5 ml Pcs 580 100 680 264 416 640
14 ADS 5 ml Pcs 33 33 84 (51) 387
15 VAKSIN MR Amp 46 20 66 26 40 64
E. KIA - - 0
1 Glukanos kalsikus injeksi 10 % Amp - - - - - 0
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - 0
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - 0
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - 0
5 Gentamicin inj 40mg/dl Amp - - - - 0
6 Tes Kehamilan Pcs - - - - 0
7 Tes Protein Urine Pcs - - - - 0
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - 0
9 Oksitosin inj IV/ml-1ml Amp - - - - 0
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - 0
11 Reagen Golongan Darah Botol - - - - 0
12 Hb Sahli Pcs - - - - 0
13 Oto Klik Pcs - - - - 0
14 Larutan Hcl Botol - - - - 0
15 Blood lancet Pcs - - - - 0
F. GIZI - - 0
1 Tablet tambah darah Tablet (393) - (393) 6,007 (6,400) 30,428
2 Vit A Biru 100.000 IU Tablet 100 - 100 100 (100)
3 Vit A Merah 200.000 IU Tablet 3,850 3,850 100 3,750 (3,350)
4 Iodin test Pcs - - - - 0
G. DIARE - - 0
1 Garam Oralit 200 mg Bks 250 - 250 - 250 (250)
2 Zinc Tablet 20 mg Tablet - - - - - 0
H. FILARIASIS - - 0
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - 0
2 Parasetamol 500 mg Tablet - - - - - 0
3 Albendazol 200 mg Tablet - - - - 0
G.ALAT LABORATORIUM - - - 0
1 Blood Lancet Pcs - - - - - 0
2 Reagen TB Botol - - - - - 0
3 Slide Pcs - - - - 0
4 Pot Sputum Pcs 1,700 1,700 1,700 (1,700)
5 Metanol 100 ml Botol - - - - 0
 6 Imersi Oil 60 ml Botol - - - - 0
7 Buffer Phosphat 7,2 Botol - - - - 0
8 Handscoon (M) Pcs - - - - 0
9 Alkohol asam 100 ML Botol - - - - 0
10 Masker Pcs - - - - 0
11 Giemsa Solution 60 ml Botol - - - - 0
12 Alkohol Swap Bks 500 500 500 (500)
H. KUSTA - - 0
1 MB Adult - - - - - 0
2 MB (MDTDMB) child - - - - - 0
3 PB Adult - - - - 0
4 PB (MTDPB) child - - - - 0
I. HIV DAN SIFILIS - - 0
1 Rapid Test Merk :SD - - - - - 0
2 Fokus (HIV ke 2) - - - - - 0
3 Rapid Test Merk : Vikia - - - - 0
4 Human Hexogon Syphilis - - - - 0
5 RPR Syphylis - - - - 0
TAMBAHAN - - 0
1 Gentamisin Tetes mata Botol - - - - - 0
2 Gentian Violet Botol - - - - - 0
3 OAM Tablet - - - - 0
4 Glikonas Kalsikus inj 10% Botol - - - - 0
5 Bromheksin Tablet - - - - 0
6 sefadroxil Syr Botol - - - - 0
7 Kasa Elastis 4 inc Rol - - - - 0
8 Klindamisin Kap 150 mg Tablet - - - - 0
9 Glukosa Lar.40% Botol - - - - 0
10 Antiparkinson doen kombinasi Tablet - - - - 0
11 benzatin Penisilin G I juta iu/Vial Vial - - - - 0
12 Aminofilin tab 150 mg Tablet - - - - 0
13 Mumfying pasta Botol - - - - 0
14 Safety box Pcs - - - - 0
15 fixomul Rol 6 24 30 2 28 (20) 50
16 Guaifenisin Tablet (45) (45) - (45) 45
17 Metro 500mg/Injeksi Amp - - - - 0
18 Ampisilin 100mg Tablet - - - - 0
19 Euthirox 50mg Tablet - - - - 0
20 Mineral mix Botol - - - - 0
21 Urine 2 Parameter Pcs - - - - 0
22 Urine 10 Parameter Pcs - - - - 0
23 strip autochek Pcs - - - - 0
24 strip glukose autochek Pcs - - - - 0
25 Masker N 95 Pcs - - - - 0
26 objek glass Pcs - - - - 0
27 Rapid HIV Pcs - - - - 0
28 Kolesterol Auto chek Pcs - - - - 0
29 Stip Cek Narkoba Pcs - - - - 0
30 CutiCell 10cm x 10M Rol 4 4 3 1 11
31 Surgical Blade no. 10-24 Pcs (5) 20 15 15 (15)
32 Leucoplast Rol 4 4 - 4 (4)
33 Uniflex 7,5 x 4,5cm Rol 11 11 11 (11)
34 HB ig Pcs - - - - 0
35 RDT hepatitis B Pcs - - - - 0
36 RDT Syphilis Pcs - - - - 0
37 RDT HIV Pcs - - - - 0
38 Blood Slide Pcs - - - - 0
39 Oksitetra salp mata prog. KIA Tube - - - - 0
40 Anti Hb SAG Pcs - - - - 0
41 Metrodinazol 500mg/100ml Botol - - - - 0
42 Betadine Salp Tube - - 0
43 Gluko Protein Pcs 8 8 - 8 (8)
44 Reagen Sphylis Botol - - - - 0
45 Handscoon (M) 100 100 100 (100) 1000
46 Handsccon (L) 100 100 100 (100) 1000
47 Desinfektan Spray 14 14 14 (14)
48 Lansoprazole 500 500 500 (500)
49 - -
50 - -
51 - -
52 - -
53 - -
54 - -
55 - -
56 - -
57 - -
58 - -
59 - -
60 - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
163 374

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris
 dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 6
2 0 2 1

LB.2)
PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17

Expired
Expired
KIR JUMLAH
537

Yang Menerima,
Petugas Puskesmas
 Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN : 0
KECAMATAN : Batin XXIV TAHUN : 2

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN
JKN

1 2 3 4 5 6 7 8 9 10 11
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol (27) - (27) 12 (39) 80
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - -
4 Alopurinol tablet 100 mg Tablet 1,154 1,200 2,354 2,354 (2,354)
5 Alupurinol Tab 300mg Tablet 190 190 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 58 (58)
7 Aminofilin tablet 200 mg Tablet (534) (534) (534) 534
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,450 2,450 2,450 (2,450)
9 Amlodipin tablet 10 mg Tablet 14,200 14,200 1,492 12,708 (7,710) 4,000
10 Amlodipin tablet 5 mg Tablet 20,571 20,571 648 19,923 (17,752) 1,000
11 Amoksisilin 250 mg Tablet - - - -
12 Amoksisilin sir forte 250mg Botol - - - -
13 Amoksisilin sir 125mg/5 ml Botol 223 223 87 136 155 100
14 Amoksisilin Tablet 500 mg Tablet 1,756 1,756 1,335 421 4,051 3,000
15 Ampisilin serb inj 1000 mg/vial Vial - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 3,790 3,000 6,790 2,069 4,721 2,210 3,000
17 Antasida DOEN II Suspensi Kombinasi Botol 246 246 40 206 (72)
18 Antifungi DOEN Kombinasi Tube 71 71 16 55 (1)
19 Antihemoroid Kombinasi sup Sup 144 144 144 (144)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 660 660 10 650 (617)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 568 1,000 1,568 170 1,398 (829)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 5,312 5,312 4,060 1,252 12,349 12,000
24 Asam Folat 1 mg Tablet 859 859 320 539 533 2,000
25 Asam Mefenamat tablet 500 mg Tablet 4,884 4,884 1,390 3,494 1,163 2,000
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 1,272 (1,272)
27 Asiklovir Tablet 400 mg Tablet 1,050 1,050 1,050 (1,050)
28 Atapulgit Tablet Tablet 1,209 1,209 1,209 (1,209)
29 Atenolol 50 mg Tablet - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - -
32 Bedak Salisil serbuk 2% Bks 112 112 112 (112)
33 Betametason Krim 0,05 % Tube 3 3 3 (3)
34 Bisakodil sup 5 mg Botol - - - -
35 Bisaprolol 5mg Tablet 290 300 590 257 333 528 600
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 252 252 252 (252)
37 Deksametason Tablet 0,5 mg Tablet 2,929 3,000 5,929 71 5,858 (5,620)
38 Devitalisasi Pasta (Non Arsen) Botol - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 55 55 55 (55)
40 Diazepam rektal 10mg/2 ,5ml Amp 20 20 20 (20)
41 Diazepam rektal 5mg/2 ml Amp 4 4 4 (4)
42 Diazepam Tablet 2 mg Tablet 67 67 30 37 64 200
43 Diazepam Tablet 5 mg Tablet 94 800 894 68 826 (598)
44 Dietilkarbamazin tab 100mg Tablet - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 204 204 23 181 (104)
46 Digoksin Tablet 0,25 mg tablet 721 721 721 (721)
47 Diltiazem hcl tab 30mg Tablet - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 968 968 (968)
49 Domperidon 10 mg Tablet Tablet 153 153 153 - 513 2,000
50 Domperidon 5mg/5ml Sirup Botol 59 59 59 (59)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (6) (6) 2 (8) 15
52 Ergotamin tab 1mg Tablet - - - -
53 Eritromisin kapsul 250 mg Tablet - - - -
54 Eritromisin Kapsul 500 mg Tablet 500 500 10 490 (457)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 50 (50)
56 Etanol cairan 70 % Botol (4) (4) 3 (7) 17
57 Etil Klorida Semprot 100 ml Botol (3) (3) (3) 3
58 Eugenol cairan Botol - - - -
59 Fenitoin Na kaps Tablet - - - -
60 Fenobarbital tablet 30 mg Tablet 1,605 1,605 23 1,582 (1,505)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 53 53 18 35 25 100
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 422 422 16 406 (352)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - -
66 Fluor kaps 1 mg Kapsul - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 48 48 1 47 (44)
68 Furosemid Tablet 40 mg Tablet 825 825 825 (825)
69 Garam Oralit I Serbuk Kombinasi Bks 612 612 142 470 6
70 Glass Ionomer Cement Art Lar. Botol - - - -
71 Glibenklamida Tablet 5 mg Tablet 975 500 1,475 803 672 2,018 3,000
72 Glimepirid 2 mg Tablet - - - -
73 Griseofulvin Tablet 125 mg Tablet 50 50 10 40 (7)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 730 730 345 385 771 1,000
78 Hidrokortison Krim 2,5 % Tube 364 364 67 297 (73)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 554 554 (554)
80 Ibuprofen Sirup 100 mg/5 ml Botol 69 69 6 63 (43)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 694 694 149 545 (46) 2,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,413 1,413 102 1,311 (969)
84 Kalsium glukonat inj 10% Botol 3 10 13 13 (13)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - -
86 Kaptopril Tablet 12,5 mg Tablet 1,670 1,670 403 1,267 83 1,000
87 Kaptopril Tablet 25 mg Tablet 1,699 1,699 515 1,184 541 1,000
88 Karbamazepin tab 100 mg Tablet - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - -
90 Ketokonazol tab 200 mg Tablet 198 198 65 133 85 2,000
91 Klindamisin 300 mg Tablet 270 270 270 (270)
92 Klindamisin kap 150mg Tablet (14) (14) (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 910 910 16 894 (840)
94 Kloramfenikol Salep Mata 1 % Tube 38 38 1 37 (34)
95 Kloramfenikol susp 125mg/5ml Botol - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - -
99 Klorfeniramin Tablet 4 mg Tablet 8,051 8,051 4,697 3,354 12,381 10,000
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - -
103 Kodein tablet 10 mg Tablet 426 426 52 374 (200)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,705 1,705 312 1,393 (348)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 48 48 7 41 (18)
106 Kuinin Tab Tablet - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp 185 185 161 24 515 300
108 Loratadin 10 mg tablet Tablet 2,173 2,173 14 2,159 (2,112)
109 Magnesium Sulfat Injeksi 20% Botol - 12 12 12 (12)
110 Magnesium Sulfat Injeksi 40% Botol 6 6 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - -
112 Mebendazol tab 100 mg Tablet - - - -
113 Mebendazol tab 500 mg Tablet - - - -
114 Metformin 500 mg Kapsul 16,925 16,925 16,925 (16,925)
115 Metformin 850 mg Kapsul - - - -
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 2,386 (2,386)
118 Metilprednisolon tab 4 mg Tablet - - - -
119 Metoklopramid Tablet 10 mg Tablet 925 925 237 688 106 1,000
120 Metrodinazol lar inf 5mg/ml Botol - - - -
121 Metrodinazol sir 125mg/ml Botol - - - -
122 Metronidazol Tablet 250 mg Tablet - - - -
123 Metronidazol tablet 500 mg Tablet 1,480 1,480 273 1,207 (292)
124 Mikonazol Krim 2% (Nitrat) Tube 60 60 16 44 10 50
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 2,713 2,713 2,713 (2,713)
127 Natrium Diklofenak Tablet 50 mg Tablet 3,856 3,856 1,209 2,647 1,403
128 Natrium tiosulfat inj 25% (i.v) Amp - - - -
129 Nifedipin Tablet 10 mg Tablet 360 360 44 316 (169)
130 Nistatin Suspensi 100.000UI/ml Botol - - - -
131 Nistatin Vagina 500.000 Tablet Tablet (125) (125) 6 (131) 151
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) (22) 22
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 77 77 14 63 (16)
134 Omeprazol tablet 20 mg Tablet 1,100 1,100 699 401 1,941 2,500
135 Parasetamol Sirup 120 mg / 5 ml Botol 340 340 97 243 82
136 Parasetamol Tablet 500 mg Tablet 7,443 7,443 2,810 4,633 4,781 10,000
137 Parasetamol drops 100 mg / 1 ml Botol - - - -
138 Perak sulfadiazin krim1% Tube - - - -
139 Pirantel pamoat sus 125mg/5ml Botol - - - -
140 Pirantel pamoat tab 125 mg Tablet 155 155 155 (155)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 7,311 7,311 735 6,576 (4,114)
142 Povidon Iodida 100 mg/ml 30 ml Botol 33 33 33 (33)
143 Povidon Iodida 100 mg/ml 300 ml Botol 7 7 2 5 2 10
144 Prednison Tablet 5 mg Tablet 192 192 192 - 643 1,000
145 Primakuin Tablet 15 mg Tablet - - - -
146 Probenesid tab 500mg Tablet - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 450 450 100 350 (15) 1,000
149 Propilitiourasil Tablet 100 mg Tablet 55 1,000 1,055 176 879 (289)
150 Ranitidin Tablet 150 mg Tablet 1,226 1,226 1,226 - 4,107 5,000
151 Risperidon 2 mg Tablet (185) (185) (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 2,433 2,433 375 2,058 (802)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 390 390 80 310 (42) 2,000
154 Salep 2 - 4 Kombinasi Tube 6 6 6 - 20 120
155 Sefadroksil Kapsul 500 mg Tablet 754 754 754 (754)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 (2)
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 28 28 11 17 20
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 197 200 397 100 297 38
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,779 1,779 1,779 (1,779)
160 Simvastatin Tablet 10 mg Tablet - - - - 3,000
161 Simvastatin Tablet 20 mg Tablet 472 472 472 - 1,581 3,000
162 Siprofloksasin Tablet scored 500 mg Tablet 1,542 1,542 326 1,216 (124)
163 Spironolakton 25 mg tablet Tablet 202 1,000 1,202 1,202 (1,202)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - -
165 Tetrasiklin Kapsul 500 mg Tablet 730 730 70 660 (426)
166 Tetrasiksin 250 mg Tablet - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 2,108 2,108 218 1,890 (1,160) 4,000
168 Valproat sir 250 mg/ml Botol - - - -
169 Valproat tab sal 250mg Tablet - - - -
170 Valproat tab sal 500 mg Tablet - - - -
171 Verapamil 80mg Tablet - - - -
172 Vitamin B Kompleks Tablet Tablet 2,631 2,631 4,858 (2,227) 18,501 10,000
173 Zink sir 10 mg/ml Botol 77 77 4 73 (60) 100
174 Zink tablet dispersi 20 mg Tablet 752 752 346 406 753 5,000
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) -
1 Ambroxol Sirup 15 mg/ml Botol 120 - 120 38 82 45 100
2 Ambroxol Tablet 30 mg Tablet 2,222 2,500 4,722 2,574 2,148 6,475 5,000
3 Antalgin Injeksi 250 mg Amp - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 50 50 17 33 24 100
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - -
6 Asetosal Tablet 100mg Tablet - - - -
7 Asiklovir Krim 5% Tube 69 69 5 64 (47)
8 Counterpain 15 mg Tube - - - -
9 Duvadilan Tablet - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - -
12 Etakridin Larutan 0,1 Botol 48 48 48 (48)
13 Famotidine Tablet 40 mg Tablet - - - -
14 Fenobarbital inj Tablet 20 20 20 (20)
15 Fenol Gliserol Tetes Telinga 10 % Botol 93 93 23 70 7
16 Gentamisin Injeksi 40 mg/ml Amp 33 33 4 29 (16)
17 Gentamisin Salep Kulit 0,1 % Botol - - - -
18 Gliseril Guaiakolat Tablet 100 mg Tablet 9,498 3,000 12,498 1,643 10,855 (5,351) 3,000
19 Glukosa Larutan Infus 10 % Steril Botol - - 5 (5) 22 20
20 Glukosa Larutan Infus 5 % Steril Botol 4 4 4 (4)
21 Imersi Oil Botol - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 3,643 3,643 1,313 2,330 2,069 3,000
23 Ketorolac inj 30mg/ml Amp - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - -
25 Larutan Asam Asetat Botol - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - -
27 Larutan Benedict Botol - - - -
28 Larutan Eosin 2% Botol - - - -
29 Larutan Faucet Botol - - - -
30 Larutan Giemsa Stalin Botol - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - -
32 Larutan Resserccer Botol - - - -
33 Larutan Turk Botol - - - -
34 Lisol Botol - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 240 240 45 195 (44)
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 114 114 67 47 177 216
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 157 157 157 (157)
39 Oksitetrasiklin Salep Kulit 3 % Tube 59 59 11 48 (11)
40 Parasetamol 100 mg Tablet - - - -
41 Pehacain inj Amp - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - -
43 Piroxicam 20mg Tablet 299 299 10 289 (256)
44 Propanolol tablet 40 mg Tablet - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 572 572 78 494 (233)
46 Reagen Golongan Darah Botol - - - -
47 Reagen TB Botol - - - -
48 Ringer Laktat Larutan Infus Steril Botol 1,100 1,100 240 860 (56)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - -
50 Setirizin Sirup 5 mg/5ml Botol 155 155 12 143 (103) 60
51 Setirizin Tablet 10mg Tablet 1,473 1,473 233 1,240 (459)
52 Simetidin Tablet 200 mg Tablet - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - -
54 Tablet Tambah Darah Tablet - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 95 95 45 50 101 200
57 Trombophob Jeli 15 g Tube - - - -
58 Ventolin Botol 107 107 11 96 (59)
III BAHAN MEDIS HABIS PAKAI (BMHP) Pcs -
1 Alat Suntik Sekali Pakai 1 ml Pcs 579 - 579 71 508 (270)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,624 1,624 424 1,200 220 500
4 Alat Suntik Sekali Pakai 5 ml Pcs 497 497 160 337 199 500
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 43 43 30 13 88 100
6 Elastis Verban 4 inci Pcs - - - -
7 Foley Catheter No. 16 Pcs 65 65 65 (65)
8 Foley Catheter No. 18 Pcs 17 17 14 3 44 30
9 Hanscoond no 6,5 Pcs 60 60 60 (60) 800
10 Hanscoond no 7,5 Pcs 12 800 812 400 412 928 800
11 HCG test Pcs - - - -
12 Infusion Set Anak Pcs 251 251 251 (251)
13 Infusion Set Dewasa Pcs 490 490 140 350 119 200
14 IV Catheter No. 18. G Pcs 294 294 31 263 (159)
15 IV Catheter No. 20 G Pcs (43) (43) 88 (131) 426 300
16 IV Catheter No. 22 G Pcs 87 87 66 21 200 100
17 IV Catheter No. 24 G Pcs 215 215 215 (215)
18 Jarum Jahit Kulit Pcs (14) (14) 10 (24) 58
19 Jarum Jahit Otot Pcs (14) (14) 10 (24) 58
20 Kapas Pembalut / Absorben 250 gr Pcs (2) (2) 5 (7) 24
21 Kasa Pembalut 2 m x 80 cm Rol - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 10 (10)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 72 72 33 39 72 100
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 7 7 6 1 19 50
26 Kasa Kompres 40/40 Steril Rol - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 6 (6)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - -
29 Masker Rol 50 50 50 (50)
30 Pembalut Gips 4 Inci Rol - - - -
31 Plester 5 Yards x 2 inci Rol - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 239 239 22 217 (143)
33 Urine Bag Pcs 57 57 17 40 17
34 Wing Needle No.27 G Pcs - - - -
35 Handscoond 8 Pcs - - - -
36 Handscoond 7 Pcs - - - -
37 Plesterin Non Woven Pcs - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - -
41 Plester 5cm x 5m Pcs - - - -
IV OBAT PROGRAM - -
A. MALARIA - -
1 Obat Anti Malaria (ACT) Tablet - - - - -
2 Primaquin Tablet Tablet 18 - 18 18 (18)
3 Kina tablet Tablet - - - -
4 RDT Malaria (First Respon) Pcs - - - -
5 Arterakina (DHP)=Dartep 5 5 5 (5)
6 Artehemeter Injeksi Amp - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - -
B. TUBERCULOSIS (TB) - -
1 OAT FDC kategori 1 Paket - - - - -
2 OAT FDC kategori 2 Paket - - - -
3 OAT Kategori Anak Paket - - - -
4 OAT Kombipak Paket - - - -
5 Masker Pcs - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - -
2 Haloperidol tab 5 mg Tablet 4,700 4,700 4,700 (4,700)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - -
5 Risperidon Tablet Tablet 1,490 1,490 30 1,460 (1,360)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,875 3,875 55 3,820 (3,636)
7 Clobazam tablet 10 mg Tablet - - - -
8 Clozapine 25 mg Tablet 1,625 1,625 30 1,595 (1,495)
9 Klorpromazine Tablet Tablet - - - -
10 Diazepam 5 mg Tablet - - - -
11 Asprazolam Tablet - - - -
D. VAKSIN - -
1 BCG Amp 8 10 18 9 9 21
2 POLIO 10 DS Pcs 12 20 32 15 17 33
3 CAMPAK Amp - - - -
4 IPV 10 10 10 (10)
5 HB UNIJEK 15 10 25 5 20 (3)
6 Td Amp 11 5 16 4 12 1
7 DPT HB-Hib Amp 14 14 13 1 43
8 TT Amp - - - -
9 Dt Amp - - - -
10 POLIO 20 DS Pcs - - - -
11 VAR (vaksin rabies ) Vial - - - -
12 ADS 0,05 ml Pcs 205 205 25 180 (96)
13 ADS 0,5 ml Pcs 293 100 393 100 293 42
14 ADS 5 ml Pcs 54 54 12 42 (2)
15 VAKSIN MR Amp 13 10 23 9 14 16
E. KIA - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - -
5 Gentamicin inj 40mg/dl Amp - - - -
6 Tes Kehamilan Pcs - - - -
7 Tes Protein Urine Pcs - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - -
11 Reagen Golongan Darah Botol - - - -
12 Hb Sahli Pcs - - - -
13 Oto Klik Pcs - - - -
14 Larutan Hcl Botol - - - -
15 Blood lancet Pcs - - - -
F. GIZI - -
1 Tablet tambah darah Tablet (6,400) 15,000 8,600 8,600 (8,600)
2 Vit A Biru 100.000 IU Tablet 100 1,200 1,300 1,300 (1,300)
3 Vit A Merah 200.000 IU Tablet 3,750 25,000 28,750 28,750 (28,750)
4 Iodin test Pcs - - - -
G. DIARE - -
1 Garam Oralit 200 mg Bks 250 - 250 250 (250)
2 Zinc Tablet 20 mg Tablet - - - - -
H. FILARIASIS - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - -
2 Parasetamol 500 mg Tablet - - - - -
3 Albendazol 200 mg Tablet - - - -
G.ALAT LABORATORIUM - -
1 Blood Lancet Pcs - - - - -
2 Reagen TB Botol - - - - -
3 Slide Pcs - - - -
4 Pot Sputum Pcs 1,700 1,700 1,700 (1,700)
5 Metanol 100 ml Botol - - - -
6 Imersi Oil 60 ml Botol - - - -
7 Buffer Phosphat 7,2 Botol - - - -
8 Handscoon (M) Pcs - - - -
9 Alkohol asam 100 ML Botol - - - -
10 Masker Pcs - - - -
11 Giemsa Solution 60 ml Botol - - - -
12 Alkohol Swap Bks 500 500 300 200 805
H. KUSTA - -
1 MB Adult - - - - -
2 MB (MDTDMB) child - - - - -
3 PB Adult - - - -
4 PB (MTDPB) child - - - -
I. HIV DAN SIFILIS - -
1 Rapid Test Merk :SD - - - - -
2 Fokus (HIV ke 2) - - - - -
3 Rapid Test Merk : Vikia - - - -
4 Human Hexogon Syphilis - - - -
5 RPR Syphylis - - - -
TAMBAHAN - -
1 Gentamisin Tetes mata Botol - - - - - 50
2 Gentian Violet Botol - - - - -
3 OAM Tablet - - - -
4 Glikonas Kalsikus inj 10% Botol - - - -
5 Bromheksin Tablet - - - -
6 sefadroxil Syr Botol - - - -
7 Kasa Elastis 4 inc Rol - - - -
8 Klindamisin Kap 150 mg Tablet - - - -
9 Glukosa Lar.40% Botol - - - -
10 Antiparkinson doen kombinasi Tablet - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - -
12 Aminofilin tab 150 mg Tablet - - - -
13 Mumfying pasta Botol - - - -
14 Safety box Pcs - - - -
15 fixomul Rol 28 28 6 22 (2)
16 Guaifenisin Tablet (45) (45) (45) 45 3,000
17 Metro 500mg/Injeksi Amp - - - -
18 Ampisilin 100mg Tablet - - - -
19 Euthirox 50mg Tablet - - - -
20 Mineral mix Botol - - - -
21 Urine 2 Parameter Pcs - - - -
22 Urine 10 Parameter Pcs - - - -
23 strip autochek Pcs - - - -
24 strip glukose autochek Pcs - - - -
25 Masker N 95 Pcs - - - -
26 objek glass Pcs - - - -
27 Rapid HIV Pcs - - - -
28 Kolesterol Auto chek Pcs - - - -
29 Stip Cek Narkoba Pcs - - - -
30 CutiCell 10cm x 10M Rol 1 20 21 21 (21)
31 Surgical Blade no. 10-24 Pcs - - - 50
32 Leucoplast Rol 4 4 4 - 13
33 Uniflex 7,5 x 4,5cm Rol 11 11 2 9 (2)
34 HB ig Pcs - - - -
35 RDT hepatitis B Pcs - - - -
36 RDT Syphilis Pcs - - - -
37 RDT HIV Pcs - - - -
38 Blood Slide Pcs - - - -
39 Oksitetra salp mata prog. KIA Tube - - - -
40 Anti Hb SAG Pcs - - - -
41 Metrodinazol 500mg/100ml Botol - - - -
42 Betadine Salp Tube - - - -
43 Gluko Protein Pcs 8 8 8 - 27 20
44 Reagen Sphylis Botol - - - - 20
45 Handscoon (M) 100 100 100 - 335 2000
46 Handsccon (L) - - - 2000
47 Desinfektan Spray 14 14 14 - 47
48 Lansoprazole 500 500 90 410 (109)
49 - - -
50 - - -
51 - - -
52 Etanol cairan 70 % 1000ml Botol 24 24 24 (24)
53 Handscoon size 7 100 100 100 (100)
54 - -
55 - -
56 - -
57 - -
 58 - -
59 - -
60 - -

UMUM
JAMKESDA JKN UKS KIR
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
196 366

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor, Yang M

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas Petugas P
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga Masyku
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010 NRPK.05.

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

7
0 2 1

AR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
APBD LAIN JUMLAH PENGADAAN Exp

12 13 14 15 16 17
 JUMLAH
556

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol (39) - (39) 20 (59) 126 100
2 Albendazol 400mg Tablet - - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 2,354 2,354 - 2,354 (2,354)
5 Alupurinol Tab 300mg Tablet 190 190 - 190 (190)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 - 58 (58)
7 Aminofilin tablet 200 mg Tablet (534) (534) - (534) 534
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,450 2,450 - 2,450 (2,450)
9 Amlodipin tablet 10 mg Tablet 12,708 12,708 596 12,112 (10,115) 3,000
10 Amlodipin tablet 5 mg Tablet 19,923 19,923 527 19,396 (17,631) 3,000
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 136 200 336 8 328 (301)
14 Amoksisilin Tablet 500 mg Tablet 421 421 901 (480) 3,498 10,000
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 4,721 3,000 7,721 330 7,391 (6,286)
17 Antasida DOEN II Suspensi Kombinasi Botol 206 206 27 179 (89)
18 Antifungi DOEN Kombinasi Tube 55 55 5 50 (33)
19 Antihemoroid Kombinasi sup Sup 144 144 - 144 (144)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 650 650 94 556 (241)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 1,398 1,398 97 1,301 (976)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 1,252 12,000 13,252 1,869 11,383 (5,122)
24 Asam Folat 1 mg Tablet 539 539 379 160 1,110 1,500
25 Asam Mefenamat tablet 500 mg Tablet 3,494 2,000 5,494 1,119 4,375 (626)
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 1,272 (1,272)
27 Asiklovir Tablet 400 mg Tablet 1,050 1,050 90 960 (659)
28 Atapulgit Tablet Tablet 1,209 1,209 - 1,209 (1,209)
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 7 - 7 (7)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 112 112 13 99 (55)
33 Betametason Krim 0,05 % Tube 3 3 3 - 10 300
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 333 333 70 263 (29)
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 252 252 26 226 (139)
37 Deksametason Tablet 0,5 mg Tablet 5,858 5,858 3,697 2,161 10,224
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 55 55 5 50 (33)
40 Diazepam rektal 10mg/2 ,5ml Amp 20 20 2 18 (11)
41 Diazepam rektal 5mg/2 ml Amp 4 4 2 2 5
42 Diazepam Tablet 2 mg Tablet 37 1,000 1,037 50 987 (820)
43 Diazepam Tablet 5 mg Tablet 826 826 5 821 (804)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 181 181 17 164 (107)
46 Digoksin Tablet 0,25 mg tablet 721 721 - 721 (721)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 968 - 968 (968)
49 Domperidon 10 mg Tablet Tablet - - - - -
50 Domperidon 5mg/5ml Sirup Botol 59 59 - 59 (59)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (8) (8) 2 (10) 17
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet 490 490 90 400 (99)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol (7) (7) 1 (8) 11
57 Etil Klorida Semprot 100 ml Botol (3) (3) 7 (10) 33 5
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,582 1,582 7 1,575 (1,552)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 35 35 12 23 17 200
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 406 406 20 386 (319)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 47 47 1 46 (43)
68 Furosemid Tablet 40 mg Tablet 825 825 29 796 (699)
69 Garam Oralit I Serbuk Kombinasi Bks 470 470 3 467 (457)
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 672 672 604 68 1,955 3,000
72 Glimepirid 2 mg Tablet - - - - -
73 Griseofulvin Tablet 125 mg Tablet 40 40 - 40 (40)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 385 300 685 685 (685) 3,000
78 Hidrokortison Krim 2,5 % Tube 297 297 27 270 (180)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 554 - 554 (554)
80 Ibuprofen Sirup 100 mg/5 ml Botol 63 63 4 59 (46)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 - 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 545 545 - 545 (545)
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,311 1,311 50 1,261 (1,094)
84 Kalsium glukonat inj 10% Botol 13 13 7 6 17
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 1,267 1,267 164 1,103 (554)
87 Kaptopril Tablet 25 mg Tablet 1,184 1,184 319 865 204 2,000
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - -
90 Ketokonazol tab 200 mg Tablet 133 133 80 53 215 1,000
91 Klindamisin 300 mg Tablet 270 270 - 270 (270)
92 Klindamisin kap 150mg Tablet (14) (14) - (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 894 894 66 828 (607)
94 Kloramfenikol Salep Mata 1 % Tube 37 37 8 29 (2)
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - -
99 Klorfeniramin Tablet 4 mg Tablet 3,354 4,320 7,674 1,567 6,107 (858)
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 374 374 22 352 (278)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,393 1,393 25 1,368 (1,284)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 41 41 2 39 (32)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp 24 24 24 - 80 300
108 Loratadin 10 mg tablet Tablet 2,159 2,159 - 2,159 (2,159)
109 Magnesium Sulfat Injeksi 20% Botol 12 12 12 (12)
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 16,925 16,925 - 16,925 (16,925) 3,000
115 Metformin 850 mg Kapsul - - - - - 3,000
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 2,386 (2,386)
118 Metilprednisolon tab 4 mg Tablet - - - - -
119 Metoklopramid Tablet 10 mg Tablet 688 100 788 567 221 1,678 2,000
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,207 1,207 182 1,025 (415)
124 Mikonazol Krim 2% (Nitrat) Tube 44 44 17 27 30
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 2,713 2,713 873 1,840 1,085 2,000
127 Natrium Diklofenak Tablet 50 mg Tablet 2,647 2,647 2,647 - 8,867 9,000
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 316 316 - 316 (316)
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet (131) (131) - (131) 131
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) (22) 22
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 63 63 63 (63) 200
134 Omeprazol tablet 20 mg Tablet 401 401 401 - 1,343 2,000
135 Parasetamol Sirup 120 mg / 5 ml Botol 243 243 21 222 (152)
136 Parasetamol Tablet 500 mg Tablet 4,633 3,500 8,133 3,386 4,747 6,596 10,000
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube - - - - -
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 155 155 3 152 (142)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 6,576 6,576 163 6,413 (5,867)
142 Povidon Iodida 100 mg/ml 30 ml Botol 33 33 2 31 (24)
143 Povidon Iodida 100 mg/ml 300 ml Botol 5 24 29 2 27 (20)
144 Prednison Tablet 5 mg Tablet - - - - -
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 350 1,000 1,350 100 1,250 (915)
149 Propilitiourasil Tablet 100 mg Tablet 879 879 100 779 (444)
150 Ranitidin Tablet 150 mg Tablet - - - - -
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 2,058 2,058 183 1,875 (1,262)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 310 310 - 310 (310)
154 Salep 2 - 4 Kombinasi Tube - - - - -
155 Sefadroksil Kapsul 500 mg Tablet 754 754 - 754 (754)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 (2)
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 17 17 17 (17)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 297 297 73 224 21
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,779 1,779 336 1,443 (317)
160 Simvastatin Tablet 10 mg Tablet - - - - -
161 Simvastatin Tablet 20 mg Tablet - - - - -
162 Siprofloksasin Tablet scored 500 mg Tablet 1,216 1,216 280 936 2 1,000
163 Spironolakton 25 mg tablet Tablet 1,202 1,202 20 1,182 (1,115)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet 660 660 110 550 (182)
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 1,890 1,890 450 1,440 68
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet (2,227) 18,800 16,573 2,391 14,182 (6,172)
173 Zink sir 10 mg/ml Botol 73 73 - 73 (73)
174 Zink tablet dispersi 20 mg Tablet 406 406 - 406 (406)
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - -
1 Ambroxol Sirup 15 mg/ml Botol 82 - 82 18 64 (4)
2 Ambroxol Tablet 30 mg Tablet 2,148 800 2,948 1,318 1,630 2,785 3,000
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 33 33 12 21 19 100
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 64 64 10 54 (21) 100
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 48 48 48 (48)
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 20 20 3 17 (7)
15 Fenol Gliserol Tetes Telinga 10 % Botol 70 70 - 70 (70)
16 Gentamisin Injeksi 40 mg/ml Amp 29 29 - 29 (29)
17 Gentamisin Salep Kulit 0,1 % Botol - - - - -
18 Gliseril Guaiakolat Tablet 100 mg Tablet 10,855 3,000 13,855 497 13,358 (11,693)
19 Glukosa Larutan Infus 10 % Steril Botol (5) (5) - (5) 5
20 Glukosa Larutan Infus 5 % Steril Botol 4 4 4 - 13
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 2,330 5,000 7,330 529 6,801 (5,029)
23 Ketorolac inj 30mg/ml Amp - - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 195 195 55 140 44
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 47 47 4 43 (30)
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 157 157 17 140 (83)
39 Oksitetrasiklin Salep Kulit 3 % Tube 48 48 6 42 (22)
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 289 289 10 279 (246)
44 Propanolol tablet 40 mg Tablet - - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 494 494 104 390 (42)
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 860 860 160 700 (164)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 143 50 193 12 181 (141)
51 Setirizin Tablet 10mg Tablet 1,240 1,240 410 830 544
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 50 50 - 50 (50)
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 96 96 19 77 (13)
III BAHAN MEDIS HABIS PAKAI (BMHP) - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 508 - 508 2 506 (499)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,200 500 1,700 174 1,526 (943)
4 Alat Suntik Sekali Pakai 5 ml Pcs 337 500 837 17 820 (763)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 13 120 133 7 126 (103)
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 65 65 5 60 (43)
8 Foley Catheter No. 18 Pcs 3 30 33 - 33 (33)
9 Hanscoond no 6,5 Pcs 60 60 60 - 202
10 Hanscoond no 7,5 Pcs 412 412 74 338 (89)
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 251 251 - 251 (251)
13 Infusion Set Dewasa Pcs 350 200 550 52 498 (324)
14 IV Catheter No. 18. G Pcs 263 263 263 (263)
15 IV Catheter No. 20 G Pcs (131) 300 169 16 153 (99)
16 IV Catheter No. 22 G Pcs 21 100 121 42 79 62
17 IV Catheter No. 24 G Pcs 215 215 13 202 (158)
18 Jarum Jahit Kulit Pcs (24) (24) - (24) 24
19 Jarum Jahit Otot Pcs (24) (24) - (24) 24
20 Kapas Pembalut / Absorben 250 gr Pcs (7) (7) 2 (9) 16
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol 10 10 10 - 34
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 39 100 139 11 128 (91)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 1 25 26 26 (26)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 - 6 (6)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol 50 50 50 (50)
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 217 217 7 210 (187)
33 Urine Bag Pcs 40 40 - 40 (40)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - -
A. MALARIA - - -
1 Obat Anti Malaria (ACT) Tablet - - - - - -
2 Primaquin Tablet Tablet 18 - 18 - 18 (18)
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep 5 5 - 5 (5)
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - -
1 OAT FDC kategori 1 Paket - - - - - -
2 OAT FDC kategori 2 Paket - - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - -
2 Haloperidol tab 5 mg Tablet 4,700 4,700 30 4,670 (4,570)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - -
5 Risperidon Tablet Tablet 1,460 1,460 20 1,440 (1,373)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,820 3,820 160 3,660 (3,124)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,595 1,595 75 1,520 (1,269)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - -
1 BCG Amp 9 10 19 9 10 20
2 POLIO 10 DS Pcs 17 20 37 19 18 46
3 CAMPAK Amp - - - - -
4 IPV 10 10 - 10 (10)
5 HB UNIJEK 20 20 9 11 19
6 Td Amp 12 10 22 5 17 (0)
7 DPT HB-Hib Amp 1 10 11 11 - 37
8 TT Amp - - - - -
9 Dt Amp - - - - -
10 POLIO 20 DS Pcs - - - - -
11 VAR (vaksin rabies ) Vial - - - - -
12 ADS 0,05 ml Pcs 180 180 50 130 38
13 ADS 0,5 ml Pcs 293 200 493 103 390 (45)
14 ADS 5 ml Pcs 42 42 10 32 2
15 VAKSIN MR Amp 14 20 34 12 22 18
E. KIA - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - -
1 Tablet tambah darah Tablet 8,600 - 8,600 - 8,600 (8,600)
2 Vit A Biru 100.000 IU Tablet 1,300 - 1,300 - 1,300 (1,300)
3 Vit A Merah 200.000 IU Tablet 28,750 28,750 - 28,750 (28,750)
4 Iodin test Pcs - - - - -
G. DIARE - - -
1 Garam Oralit 200 mg Bks 250 - 250 - 250 (250)
2 Zinc Tablet 20 mg Tablet - - - - - -
H. FILARIASIS - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - -
2 Parasetamol 500 mg Tablet - - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - -
1 Blood Lancet Pcs - - - - - -
2 Reagen TB Botol - - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs 1,700 1,700 1,000 700 2,650
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks 200 200 - 200 (200)
H. KUSTA - - -
1 MB Adult - - - - - -
2 MB (MDTDMB) child - - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - -
1 Rapid Test Merk :SD - - - - - -
2 Fokus (HIV ke 2) - - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - -
1 Gentamisin Tetes mata Botol - - - - - -
2 Gentian Violet Botol - - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 22 22 - 22 (22)
16 Guaifenisin Tablet (45) (45) - (45) 45
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs - - - - -
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 21 21 - 21 (21)
31 Surgical Blade no. 10-24 Pcs - 10 10 - 10 (10)
32 Leucoplast Rol - - - - -
33 Uniflex 7,5 x 4,5cm Rol 9 9 - 9 (9)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
45 Handscoon (M) - - 0 - -
46 Handscoon (L) - - 0 - -
47 Desinfektan Spray - - 0 - -
48 Lansoprazole 410 410 178 232 364 1000
49 Betahistine HCL - 900 900 0 900 (900)
50 - - - -
51 - - - -
52 Etanol cairan 70 % 1000ml 24 24 6 18 2
53 Handscoon size 7 100 100 100 (100)
54 - - - -
55 - - - -
56 - - - -
57 - - - -
 58 - - -
59 - - -
60 - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
125 303

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 8
2 0 2 1

DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17

Expired
Expired
KIR JUMLAH
428

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol (59) 120 61 - 61 (61)
2 Albendazol 400mg Tablet - - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 2,354 2,354 50 2,304 (2,137)
5 Alupurinol Tab 300mg Tablet 190 200 390 - 390 (390)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 - 58 (58)
7 Aminofilin tablet 200 mg Tablet (534) (534) - (534) 534 1,000
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,450 2,450 2 2,448 (2,441)
9 Amlodipin tablet 10 mg Tablet 12,112 10,000 22,112 568 21,544 (19,641)
10 Amlodipin tablet 5 mg Tablet 19,396 19,396 355 19,041 (17,852) 1,000
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 328 328 34 294 (180)
14 Amoksisilin Tablet 500 mg Tablet (480) 12,000 11,520 1,686 9,834 (4,186)
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 7,391 7,391 1,170 6,221 (2,302)
17 Antasida DOEN II Suspensi Kombinasi Botol 179 179 77 102 156 200
18 Antifungi DOEN Kombinasi Tube 50 50 7 43 (20)
19 Antihemoroid Kombinasi sup Sup 144 300 444 40 404 (270)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 556 556 - 556 (556)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 1,301 1,301 61 1,240 (1,036)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 11,383 11,383 1,743 9,640 (3,801)
24 Asam Folat 1 mg Tablet 160 160 - 160 (160) 1,000
25 Asam Mefenamat tablet 500 mg Tablet 4,375 4,375 1,381 2,994 1,632 2,000
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 - 1,272 (1,272)
27 Asiklovir Tablet 400 mg Tablet 960 960 100 860 (525)
28 Atapulgit Tablet Tablet 1,209 1,209 - 1,209 (1,209) 2,000
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 7 10 17 - 17 (17)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 99 99 9 90 (60)
33 Betametason Krim 0,05 % Tube - - - - - 200
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 263 263 95 168 150
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 226 226 13 213 (169)
37 Deksametason Tablet 0,5 mg Tablet 2,161 2,161 458 1,703 (169)
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 2 2 - 2 (2)
42 Diazepam Tablet 2 mg Tablet 987 987 14 973 (926)
43 Diazepam Tablet 5 mg Tablet 821 821 75 746 (495)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 164 164 10 154 (121)
46 Digoksin Tablet 0,25 mg tablet 721 721 - 721 (721)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 968 1,000 1,968 30 1,938 (1,838)
49 Domperidon 10 mg Tablet Tablet - 1,000 1,000 200 800 (130)
50 Domperidon 5mg/5ml Sirup Botol 59 59 - 59 (59)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (10) (10) - (10) 10
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet 400 400 400 - 1,340 1,000
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50)
56 Etanol cairan 70 % Botol (8) (8) 1 (9) 12
57 Etil Klorida Semprot 100 ml Botol (10) (10) - (10) 10 10
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,575 1,575 10 1,565 (1,532)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 23 150 173 - 173 (173)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 386 386 45 341 (190)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 46 46 - 46 (46)
68 Furosemid Tablet 40 mg Tablet 796 796 10 786 (753)
69 Garam Oralit I Serbuk Kombinasi Bks 467 467 38 429 (302)
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 68 500 568 268 300 598 800
72 Glimepirid 2 mg Tablet - 3,000 3,000 60 2,940 (2,739)
73 Griseofulvin Tablet 125 mg Tablet 40 500 540 - 540 (540)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500)
 77 Hidroklorotiazida Tablet 25 mg Tablet 685 200 885 285 600 355 500
78 Hidrokortison Krim 2,5 % Tube 270 270 44 226 (79)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 554 1,000 1,554 20 1,534 (1,467)
80 Ibuprofen Sirup 100 mg/5 ml Botol 59 59 15 44 6 100
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 - 2,960 (2,960)
82 Ibuprofen Tablet 400 mg Tablet 545 545 - 545 (545) 2,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,261 1,261 15 1,246 (1,196)
84 Kalsium glukonat inj 10% Botol 6 6 - 6 (6)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 1,103 1,103 615 488 1,572 2,000
87 Kaptopril Tablet 25 mg Tablet 865 865 520 345 1,397 2,000
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - -
90 Ketokonazol tab 200 mg Tablet 53 1,000 1,053 47 1,006 (849)
91 Klindamisin 300 mg Tablet 270 270 - 270 (270)
92 Klindamisin kap 150mg Tablet (14) (14) - (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 828 828 - 828 (828)
94 Kloramfenikol Salep Mata 1 % Tube 29 29 9 20 10
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - - 300
98 Kloramfenikol tetes telinga 1% Botol - - - - - 300
99 Klorfeniramin Tablet 4 mg Tablet 6,107 6,107 2,627 3,480 5,320 6,000
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 352 352 35 317 (200)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,368 1,368 40 1,328 (1,194)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 39 39 2 37 (30)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - - 500
108 Loratadin 10 mg tablet Tablet 2,159 1,000 3,159 225 2,934 (2,180)
109 Magnesium Sulfat Injeksi 20% Botol 12 12 - 12 (12)
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 16,925 20,000 36,925 220 36,705 (35,968)
115 Metformin 850 mg Kapsul - - - - - 1,000
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 2,386 (2,386)
118 Metilprednisolon tab 4 mg Tablet - 500 500 293 207 775 1,000
119 Metoklopramid Tablet 10 mg Tablet 221 221 170 51 519 1,000
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,025 1,025 22 1,003 (929)
124 Mikonazol Krim 2% (Nitrat) Tube 27 27 10 17 17 100
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - - 1,000
126 Natrium Diklofenak Tablet 25 mg Tablet 1,840 5,600 7,440 695 6,745 (4,417)
127 Natrium Diklofenak Tablet 50 mg Tablet - - - - - 1,000
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 316 316 150 166 337
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet (131) (131) 10 (141) 175
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) - (22) 22
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 63 200 263 263 (263)
134 Omeprazol tablet 20 mg Tablet - - - - -
135 Parasetamol Sirup 120 mg / 5 ml Botol 222 222 70 152 83 100
136 Parasetamol Tablet 500 mg Tablet 4,747 4,000 8,747 3,609 5,138 6,952
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube - - - - - 100
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 152 152 4 148 (135)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 6,413 6,413 340 6,073 (4,934)
142 Povidon Iodida 100 mg/ml 30 ml Botol 31 31 - 31 (31)
143 Povidon Iodida 100 mg/ml 300 ml Botol 27 27 1 26 (23)
144 Prednison Tablet 5 mg Tablet - 3,000 3,000 20 2,980 (2,913)
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,250 1,250 1,250 (1,250)
149 Propilitiourasil Tablet 100 mg Tablet 779 779 - 779 (779)
150 Ranitidin Tablet 150 mg Tablet - - - - - 2,000
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 1,875 1,875 181 1,694 (1,088)
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 310 310 - 310 (310) 2,000
154 Salep 2 - 4 Kombinasi Tube - - - - - 200
155 Sefadroksil Kapsul 500 mg Tablet 754 754 - 754 (754)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 (2)
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 17 17 5 12 5
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 224 224 94 130 185 300
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,443 1,443 365 1,078 145
160 Simvastatin Tablet 10 mg Tablet - 1,000 1,000 10 990 (957)
161 Simvastatin Tablet 20 mg Tablet - 1,000 1,000 30 970 (870)
162 Siprofloksasin Tablet scored 500 mg Tablet 936 5,700 6,636 573 6,063 (4,143)
163 Spironolakton 25 mg tablet Tablet 1,182 1,182 20 1,162 (1,095)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet 550 550 430 120 1,321
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 1,440 1,440 380 1,060 213
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 14,182 14,182 1,519 12,663 (7,574)
173 Zink sir 10 mg/ml Botol 73 73 - 73 (73) 100
174 Zink tablet dispersi 20 mg Tablet 406 406 - 406 (406) 2,000
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - -
1 Ambroxol Sirup 15 mg/ml Botol 64 - 64 21 43 27 100
2 Ambroxol Tablet 30 mg Tablet 1,630 1,630 592 1,038 945 1,000
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 21 21 14 7 40 100
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 54 100 154 20 134 (67)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 48 48 - 48 (48)
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 17 17 - 17 (17)
15 Fenol Gliserol Tetes Telinga 10 % Botol 70 70 - 70 (70)
16 Gentamisin Injeksi 40 mg/ml Amp 29 29 - 29 (29)
17 Gentamisin Salep Kulit 0,1 % Botol - - - - - 100
18 Gliseril Guaiakolat Tablet 100 mg Tablet 13,358 13,358 404 12,954 (11,601)
19 Glukosa Larutan Infus 10 % Steril Botol (5) (5) - (5) 5
20 Glukosa Larutan Infus 5 % Steril Botol - - - - -
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 6,801 6,801 805 5,996 (3,299)
23 Ketorolac inj 30mg/ml Amp - - - - - 500
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 140 140 36 104 17
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 43 43 20 23 44 100
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 140 140 29 111 (14)
39 Oksitetrasiklin Salep Kulit 3 % Tube 42 42 17 25 32 100
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 279 279 49 230 (66)
44 Propanolol tablet 40 mg Tablet - - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 390 390 109 281 84
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 700 700 188 512 118
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 181 181 13 168 (124)
51 Setirizin Tablet 10mg Tablet 830 830 115 715 (330)
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 50 50 - 50 (50)
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 77 77 58 19 175 100
III BAHAN MEDIS HABIS PAKAI (BMHP) - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 506 - 506 120 386 16 500
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,526 1,526 311 1,215 (173)
4 Alat Suntik Sekali Pakai 5 ml Pcs 820 820 171 649 (76)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 126 126 40 86 48
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 60 60 - 60 (60)
8 Foley Catheter No. 18 Pcs 33 33 3 30 (20)
9 Hanscoond no 6,5 Pcs - - - - -
10 Hanscoond no 7,5 Pcs 338 338 42 296 (155)
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 251 251 5 246 (229)
13 Infusion Set Dewasa Pcs 498 498 498 (498)
14 IV Catheter No. 18. G Pcs 263 263 263 (263)
15 IV Catheter No. 20 G Pcs 153 153 21 132 (62)
16 IV Catheter No. 22 G Pcs 79 79 8 71 (44)
17 IV Catheter No. 24 G Pcs 202 202 202 (202)
18 Jarum Jahit Kulit Pcs (24) (24) - (24) 24
19 Jarum Jahit Otot Pcs (24) (24) - (24) 24
20 Kapas Pembalut / Absorben 250 gr Pcs (9) (9) 2 (11) 18
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol - - - -
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 128 128 8 120 (93)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 26 26 3 23 (13)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol 6 6 6 - 20
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol 50 50 200 (150) 820 100
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 210 210 13 197 (153)
33 Urine Bag Pcs 40 40 - 40 (40)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - -
A. MALARIA - - -
1 Obat Anti Malaria (ACT) Tablet - - - - - -
2 Primaquin Tablet Tablet 18 - 18 10 8 26
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep 5 5 5 - 17
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - -
1 OAT FDC kategori 1 Paket - - - - - -
2 OAT FDC kategori 2 Paket - - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - -
2 Haloperidol tab 5 mg Tablet 4,670 4,670 90 4,580 (4,279)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - -
5 Risperidon Tablet Tablet 1,440 1,440 180 1,260 (657)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,660 3,660 90 3,570 (3,269)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,520 1,520 186 1,334 (711)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - -
1 BCG Amp 10 - 10 10 - 34
2 POLIO 10 DS Pcs 18 20 38 19 19 45
3 CAMPAK Amp - - - - -
4 IPV 10 10 - 10 (10)
5 HB UNIJEK 11 11 9 2 28
6 Td Amp 17 10 27 5 22 (5)
7 DPT HB-Hib Amp - 20 20 11 9 28
8 TT Amp - - - - -
9 Dt Amp - - - - -
10 POLIO 20 DS Pcs - - - - -
11 VAR (vaksin rabies ) Vial - - - - -
12 ADS 0,05 ml Pcs 130 130 10 120 (87)
13 ADS 0,5 ml Pcs 390 200 590 100 490 (155)
14 ADS 5 ml Pcs 32 32 15 17 33
15 VAKSIN MR Amp 22 20 42 12 30 10
E. KIA - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - -
1 Tablet tambah darah Tablet 8,600 - 8,600 8,100 500 26,635
2 Vit A Biru 100.000 IU Tablet 1,300 - 1,300 1,300 - 4,355
3 Vit A Merah 200.000 IU Tablet 28,750 28,750 11,950 16,800 23,233
4 Iodin test Pcs - - - - -
G. DIARE - - -
1 Garam Oralit 200 mg Bks 250 - 250 - 250 (250)
2 Zinc Tablet 20 mg Tablet - - - - - -
H. FILARIASIS - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - -
2 Parasetamol 500 mg Tablet - - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - -
1 Blood Lancet Pcs - - - - - -
2 Reagen TB Botol - - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs 700 700 500 200 1,475
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks 200 200 - 200 (200)
H. KUSTA - - -
1 MB Adult - - - - - -
2 MB (MDTDMB) child - - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - -
1 Rapid Test Merk :SD - - - - - -
2 Fokus (HIV ke 2) - - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - -
1 Gentamisin Tetes mata Botol - - - - - -
2 Gentian Violet Botol - - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 22 22 1 21 (18)
16 Guaifenisin Tablet (45) (45) - (45) 45
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs - 60 60 - 60 (60)
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 21 21 - 21 (21)
31 Surgical Blade no. 10-24 Pcs 10 10 - 10 (10)
32 Leucoplast Rol - - 2 (2) 9
33 Uniflex 7,5 x 4,5cm Rol 9 9 - 9 (9)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
45 Handscoon (M) Pcs 0 - 0 - - 500
46 Handscoon (L) Pcs 0 - 0 - - 500
47 Desinfektan Spray Pcs 0 144 144 30 114 (14)
48 Lansoprazole Tablet 232 360 592 592 - 1,983 1000
49 Betahistine HCL Tablet 900 900 155 745 (226)
50 Candesartan 8 mg Tablet 0 9000 9,000 90 8,910 (8,609)
51 Candesartan 16 mg Tablet 0 9000 9,000 80 8,920 (8,652)
52 Etanol cairan 70 % 1000ml Pcs 18 18 0 18 (18)
53 Handscoon size 7 100 100 0 100 (100)
54 - - -
55 - - -
56 - - -
57 - - -
 58 - - -
59 - - -
60 - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

0 9
2 0 2 1

N LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17

EXPIRED
KIR JUMLAH

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 61 - 61 6 55 (35)
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 2,304 2,304 11 2,293 (2,256)
5 Alupurinol Tab 300mg Tablet 390 390 - 390 (390)
6 Aminofilin injeksi 24 mg/ml Amp 58 58 - 58 (58) 50
7 Aminofilin tablet 200 mg Tablet (534) (534) - (534) 534 1,000
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,448 2,448 1 2,447 (2,444)
9 Amlodipin tablet 10 mg Tablet 21,544 21,544 956 20,588 (17,385)
10 Amlodipin tablet 5 mg Tablet 19,041 19,041 270 18,771 (17,867) 2,000
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 294 294 40 254 (120)
14 Amoksisilin Tablet 500 mg Tablet 9,834 9,834 989 8,845 (5,532)
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 6,221 6,221 1,935 4,286 2,196 3,000
17 Antasida DOEN II Suspensi Kombinasi Botol 102 200 302 31 271 (167)
18 Antifungi DOEN Kombinasi Tube 43 43 30 13 88 100
19 Antihemoroid Kombinasi sup Sup 404 404 - 404 (404)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 556 556 556 (556)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 1,240 1,240 233 1,007 (226)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 9,640 9,640 331 9,309 (8,200)
24 Asam Folat 1 mg Tablet 160 160 - 160 (160) 2,000
25 Asam Mefenamat tablet 500 mg Tablet 2,994 2,000 4,994 1,214 3,780 287
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 1,272 (1,272)
27 Asiklovir Tablet 400 mg Tablet 860 860 75 785 (534)
28 Atapulgit Tablet Tablet 1,209 1,209 - 1,209 (1,209) 3,000
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 17 17 17 (17)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 90 90 - 90 (90)
33 Betametason Krim 0,05 % Tube - - - - - 300
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet 168 168 168 - 563 1,000
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 213 213 33 180 (69)
37 Deksametason Tablet 0,5 mg Tablet 1,703 3,000 4,703 1,014 3,689 (292)
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 2 2 - 2 (2)
42 Diazepam Tablet 2 mg Tablet 973 973 46 927 (773)
43 Diazepam Tablet 5 mg Tablet 746 746 26 720 (633)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 154 154 33 121 (10)
46 Digoksin Tablet 0,25 mg tablet 721 721 - 721 (721) 1,000
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 1,938 1,938 - 1,938 (1,938)
49 Domperidon 10 mg Tablet Tablet 800 800 418 382 1,018 2,000
50 Domperidon 5mg/5ml Sirup Botol 59 59 - 59 (59) 200
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (10) (10) - (10) 10
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet - - - - -
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 - 50 (50) 50
56 Etanol cairan 70 % Botol (9) (9) 9 (18) 48
57 Etil Klorida Semprot 100 ml Botol (10) (10) - (10) 10
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,565 1,565 23 1,542 (1,465)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 173 173 8 165 (138)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 341 341 155 186 333 1,000
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 46 46 1 45 (42)
68 Furosemid Tablet 40 mg Tablet 786 786 100 686 (351)
69 Garam Oralit I Serbuk Kombinasi Bks 429 429 152 277 232
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 300 300 20 280 (213)
72 Glimepirid 2 mg Tablet 2,940 2,940 305 2,635 (1,613)
73 Griseofulvin Tablet 125 mg Tablet 540 540 40 500 (366)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 - 500 (500) 1,000
77 Hidroklorotiazida Tablet 25 mg Tablet 600 600 417 183 1,214 1,000
78 Hidrokortison Krim 2,5 % Tube 226 226 14 212 (165)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 1,534 1,534 100 1,434 (1,099)
 80 Ibuprofen Sirup 100 mg/5 ml Botol 44 100 144 11 133 (96)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,960 - 2,960 (2,960) 4,000
82 Ibuprofen Tablet 400 mg Tablet 545 545 - 545 (545) 2,000
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,246 1,246 64 1,182 (968)
84 Kalsium glukonat inj 10% Botol 6 6 - 6 (6)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 488 488 130 358 78 1,000
87 Kaptopril Tablet 25 mg Tablet 345 345 128 217 212 2,000
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - -
90 Ketokonazol tab 200 mg Tablet 1,006 1,006 1,006 (1,006)
91 Klindamisin 300 mg Tablet 270 270 - 270 (270) 1,000
92 Klindamisin kap 150mg Tablet (14) (14) - (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 828 828 87 741 (450)
94 Kloramfenikol Salep Mata 1 % Tube 20 20 11 9 28 144
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - -
99 Klorfeniramin Tablet 4 mg Tablet 3,480 1,728 5,208 1,247 3,961 216 1,805
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 317 317 40 277 (143)
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,328 1,328 174 1,154 (571)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 37 37 7 30 (7)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - -
108 Loratadin 10 mg tablet Tablet 2,934 2,934 10 2,924 (2,891)
109 Magnesium Sulfat Injeksi 20% Botol 12 12 12 (12)
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 36,705 36,705 408 36,297 (34,930)
115 Metformin 850 mg Kapsul - - - - -
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 - 2,386 (2,386)
118 Metilprednisolon tab 4 mg Tablet 207 207 207 - 693
119 Metoklopramid Tablet 10 mg Tablet 51 51 51 (51) 2,000
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 1,003 1,003 463 540 1,011 2,000
124 Mikonazol Krim 2% (Nitrat) Tube 17 240 257 30 227 (127)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 6,745 6,745 729 6,016 (3,574)
127 Natrium Diklofenak Tablet 50 mg Tablet - - - - - 2,000
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 166 166 12 154 (114)
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet (141) (141) 60 (201) 402
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) - (22) 22
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 263 263 263 (263)
134 Omeprazol tablet 20 mg Tablet - - - - - 2,000
135 Parasetamol Sirup 120 mg / 5 ml Botol 152 200 352 99 253 79
136 Parasetamol Tablet 500 mg Tablet 5,138 5,138 2,518 2,620 5,815 10,000
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube - 5 5 5 (5)
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 148 148 - 148 (148)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 6,073 6,073 356 5,717 (4,524)
142 Povidon Iodida 100 mg/ml 30 ml Botol 31 31 1 30 (27)
143 Povidon Iodida 100 mg/ml 300 ml Botol 26 26 - 26 (26)
144 Prednison Tablet 5 mg Tablet 2,980 2,980 178 2,802 (2,206)
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,250 1,250 - 1,250 (1,250)
149 Propilitiourasil Tablet 100 mg Tablet 779 779 20 759 (692)
150 Ranitidin Tablet 150 mg Tablet - - - - - 2,000
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 1,694 1,694 573 1,121 799 1,000
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 310 310 - 310 (310) 1,000
154 Salep 2 - 4 Kombinasi Tube - - - - - 168
155 Sefadroksil Kapsul 500 mg Tablet 754 754 - 754 (754) 4,000
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 (2)
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 12 12 12 (12)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 130 300 430 32 398 (291)
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,078 1,078 590 488 1,489 1,500
160 Simvastatin Tablet 10 mg Tablet 990 990 185 805 (185) 1,000
161 Simvastatin Tablet 20 mg Tablet 970 970 320 650 422 1,000
162 Siprofloksasin Tablet scored 500 mg Tablet 6,063 6,063 284 5,779 (4,828)
163 Spironolakton 25 mg tablet Tablet 1,162 1,162 17 1,145 (1,088)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet 120 120 120 - 402
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 1,060 1,060 321 739 336 1,500
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 12,663 12,663 1,435 11,228 (6,421)
173 Zink sir 10 mg/ml Botol 73 73 - 73 (73) 200
174 Zink tablet dispersi 20 mg Tablet 406 406 406 (406) 2,000
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - -
1 Ambroxol Sirup 15 mg/ml Botol 43 - 43 10 33 1 50
2 Ambroxol Tablet 30 mg Tablet 1,038 1,038 168 870 (307)
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 7 7 7 - 23 200
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 134 134 134 (134)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 48 48 - 48 (48)
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 17 17 - 17 (17)
15 Fenol Gliserol Tetes Telinga 10 % Botol 70 70 - 70 (70)
16 Gentamisin Injeksi 40 mg/ml Amp 29 29 - 29 (29)
17 Gentamisin Salep Kulit 0,1 % Botol - - - - -
18 Gliseril Guaiakolat Tablet 100 mg Tablet 12,954 12,954 3,571 9,383 2,580
19 Glukosa Larutan Infus 10 % Steril Botol (5) (5) - (5) 5 40
20 Glukosa Larutan Infus 5 % Steril Botol - - - - - 40
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 5,996 5,996 981 5,015 (1,729)
23 Ketorolac inj 30mg/ml Amp - - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 104 104 44 60 87 100
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 23 23 9 14 16 100
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 111 111 38 73 54 50
39 Oksitetrasiklin Salep Kulit 3 % Tube 25 25 25 - 84 50
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 230 230 10 220 (187)
44 Propanolol tablet 40 mg Tablet - - - - - 2,000
45 Ranitidin Injeksi 25 mg / 2 ml Amp 281 281 103 178 167 200
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 512 512 112 400 (25)
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 168 168 15 153 (103) 50
51 Setirizin Tablet 10mg Tablet 715 715 399 316 1,021 2,000
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 50 50 - 50 (50) 200
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 19 100 119 - 119 (119)
III BAHAN MEDIS HABIS PAKAI (BMHP) - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 386 500 886 5 881 (864)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,215 1,215 1,215 (1,215)
4 Alat Suntik Sekali Pakai 5 ml Pcs 649 649 30 619 (519)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 86 86 - 86 (86)
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 60 60 - 60 (60)
8 Foley Catheter No. 18 Pcs 30 30 5 25 (8)
9 Hanscoond no 6,5 Pcs - - - - - 500
10 Hanscoond no 7,5 Pcs 296 296 126 170 252
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 246 246 6 240 (220)
13 Infusion Set Dewasa Pcs 498 498 498 (498)
14 IV Catheter No. 18. G Pcs 263 263 263 (263)
15 IV Catheter No. 20 G Pcs 132 132 46 86 68
16 IV Catheter No. 22 G Pcs 71 71 - 71 (71)
17 IV Catheter No. 24 G Pcs 202 202 - 202 (202)
18 Jarum Jahit Kulit Pcs (24) (24) - (24) 24
19 Jarum Jahit Otot Pcs (24) (24) - (24) 24
20 Kapas Pembalut / Absorben 250 gr Pcs (11) (11) 3 (14) 24
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol - - 40 (40) 174
23 Kasa Hidrofil 4 m x 3 cm Rol - - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 120 120 32 88 19
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 23 23 1 22 (19)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol - - 29 (29) 126
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol (150) 500 350 800 (450) 3,130
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 197 197 23 174 (97)
33 Urine Bag Pcs 40 40 - 40 (40)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - -
A. MALARIA - - -
1 Obat Anti Malaria (ACT) Tablet - - - - - -
2 Primaquin Tablet Tablet 8 - 8 8 - 27
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep - - - - -
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - -
1 OAT FDC kategori 1 Paket - - - - - -
2 OAT FDC kategori 2 Paket - - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - -
2 Haloperidol tab 5 mg Tablet 4,580 4,580 40 4,540 (4,406)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - - -
5 Risperidon Tablet Tablet 1,260 1,260 60 1,200 (999)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,570 3,570 70 3,500 (3,266)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,334 1,334 80 1,254 (986)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - -
1 BCG Amp 3 - 3 3 - 10
2 POLIO 10 DS Pcs 27 20 47 17 30 27
3 CAMPAK Amp - - - - -
4 IPV 10 10 - 10 (10)
5 HB UNIJEK 6 10 16 6 10 10
6 Td Amp 22 22 22 - 74
7 DPT HB-Hib Amp 10 20 30 24 6 74
8 TT Amp 25 10 35 4 31 (18)
9 Dt Amp - - - - -
10 POLIO 20 DS Pcs - - - - -
11 VAR (vaksin rabies ) Vial - - - - -
12 ADS 0,05 ml Pcs 140 140 13 127 (83)
13 ADS 0,5 ml Pcs 490 200 690 454 236 1,285
14 ADS 5 ml Pcs 17 17 17 (17)
15 VAKSIN MR Amp 38 20 58 15 43 7
E. KIA - - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - -
1 Tablet tambah darah Tablet 500 - 500 500 (500)
2 Vit A Biru 100.000 IU Tablet - - - - -
3 Vit A Merah 200.000 IU Tablet 16,800 16,800 16,800 (16,800)
4 Iodin test Pcs - - - - -
G. DIARE - - -
1 Garam Oralit 200 mg Bks 250 200 450 - 450 (450)
2 Zinc Tablet 20 mg Tablet - 500 500 30 470 (370)
H. FILARIASIS - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - -
2 Parasetamol 500 mg Tablet - - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - -
1 Blood Lancet Pcs - - - - - -
2 Reagen TB Botol - - - - - -
 3 Slide Pcs - - - - -
4 Pot Sputum Pcs 200 200 200 (200)
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks 200 200 - 200 (200)
H. KUSTA - - -
1 MB Adult - - - - - -
2 MB (MDTDMB) child - - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - -
1 Rapid Test Merk :SD - - - - - -
2 Fokus (HIV ke 2) - - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - -
1 Gentamisin Tetes mata Botol - - - - - -
2 Gentian Violet Botol - - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 21 21 4 17 (4)
16 Guaifenisin Tablet (45) (45) - (45) 45
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs 60 20 80 - 80 (80)
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 21 21 5 16 1
31 Surgical Blade no. 10-24 Pcs 10 10 - 10 (10)
32 Leucoplast Rol (2) (2) 1 (3) 6
33 Uniflex 7,5 x 4,5cm Rol 9 9 - 9 (9)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
45 Handscoon (M) Pcs - - 0 - -
46 Handscoon (L) Pcs - - 0 - -
47 Desinfektan Spray Pcs 114 112 226 226 (226)
48 Lansoprazole Tablet - - - - 1000
49 Betahistine HCL Tablet 745 745 159 586 (53)
50 Candesartan 8 mg Tablet 8,910 8,910 0 8,910 (8,910)
51 Candesartan 16 mg Tablet 8,920 8,920 0 8,920 (8,920)
52 Etanol cairan 70 % 1000ml Pcs 18 18 1 17 (14)
53 Handscoon size 7 100 100 100 - 335 200
54 - - 0 - -
55 - - - -
56 - - - -
57 - - - -
58 - - - -
59 - - - -
60 - - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

 Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

1 0
2 0 2 1

EMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17
KIR JUMLAH

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : Rawat Inap Jangga Baru BULAN :
KECAMATAN : Batin XXIV TAHUN :

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PENERI- STOK PERMIN-

NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN

1 2 3 4 5 6 7 8 9 10
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 55 - 55 23 32 44
2 Albendazol 400mg Tablet - - - - -
3 Albendazol susp 200 mg/5ml Botol - - - - -
4 Alopurinol tablet 100 mg Tablet 2,293 2,293 34 2,259 (2,145)
5 Alupurinol Tab 300mg Tablet 390 390 - 390 (390)
6 Aminofilin injeksi 24 mg/ml Amp 58 60 118 - 118 (118)
7 Aminofilin tablet 200 mg Tablet (534) 200 (334) - (334) 334
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,447 2,447 - 2,447 (2,447)
9 Amlodipin tablet 10 mg Tablet 20,588 20,588 1,137 19,451 (15,642)
10 Amlodipin tablet 5 mg Tablet 18,771 6,000 24,771 100 24,671 (24,336)
11 Amoksisilin 250 mg Tablet - - - - -
12 Amoksisilin sir forte 250mg Botol - - - - -
13 Amoksisilin sir 125mg/5 ml Botol 254 254 76 178 77
14 Amoksisilin Tablet 500 mg Tablet 8,845 8,845 1,889 6,956 (628)
15 Ampisilin serb inj 1000 mg/vial Vial - - - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 4,286 3,000 7,286 1,090 6,196 (2,545)
17 Antasida DOEN II Suspensi Kombinasi Botol 271 271 28 243 (149)
18 Antifungi DOEN Kombinasi Tube 13 96 109 10 99 (66)
19 Antihemoroid Kombinasi sup Sup 404 404 48 356 (195)
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 556 556 - 556 (556)
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 1,007 1,007 147 860 (368)
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 9,309 9,309 2,045 7,264 (413)
24 Asam Folat 1 mg Tablet 160 2,000 2,160 1,000 1,160 2,190
25 Asam Mefenamat tablet 500 mg Tablet 3,780 3,780 1,687 2,093 3,558 4,000
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 - 1,272 (1,272)
27 Asiklovir Tablet 400 mg Tablet 785 785 785 (785)
28 Atapulgit Tablet Tablet 1,209 2,000 3,209 110 3,099 (2,731)
29 Atenolol 50 mg Tablet - - - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 17 17 3 14 (4)
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - - -
32 Bedak Salisil serbuk 2% Bks 90 90 18 72 (12)
33 Betametason Krim 0,05 % Tube - 240 240 11 229 (192)
34 Bisakodil sup 5 mg Botol - - - - -
35 Bisaprolol 5mg Tablet - 600 600 11 589 (552)
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 180 180 21 159 (89)
37 Deksametason Tablet 0,5 mg Tablet 3,689 3,689 394 3,295 (1,975)
38 Devitalisasi Pasta (Non Arsen) Botol - - - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50 (50)
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 - 18 (18)
41 Diazepam rektal 5mg/2 ml Amp 2 2 1 1 2
42 Diazepam Tablet 2 mg Tablet 927 927 23 904 (827)
43 Diazepam Tablet 5 mg Tablet 720 720 32 688 (581)
44 Dietilkarbamazin tab 100mg Tablet - - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 121 121 17 104 (47)
46 Digoksin Tablet 0,25 mg tablet 721 800 1,521 - 1,521 (1,521)
47 Diltiazem hcl tab 30mg Tablet - - - - -
48 Doksisiklin Kapsul 100 mg Tablet 1,938 1,938 - 1,938 (1,938)
49 Domperidon 10 mg Tablet Tablet 382 1,000 1,382 238 1,144 (347)
50 Domperidon 5mg/5ml Sirup Botol 59 100 159 - 159 (159)
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (10) (10) (10) 10
52 Ergotamin tab 1mg Tablet - - - - -
53 Eritromisin kapsul 250 mg Tablet - - - - -
54 Eritromisin Kapsul 500 mg Tablet - 500 500 - 500 (500)
55 Eritromisin Sirup 200 mg / 5 ml Botol 50 50 100 - 100 (100)
56 Etanol cairan 70 % Botol (18) (18) 1 (19) 22
57 Etil Klorida Semprot 100 ml Botol (10) (10) - (10) 10
58 Eugenol cairan Botol - - - - -
59 Fenitoin Na kaps Tablet - - - - -
60 Fenobarbital tablet 30 mg Tablet 1,542 1,542 13 1,529 (1,485)
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 165 165 165 (165)
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 186 300 486 486 (486)
65 Flufenazin inj 25 mg/ml (i.m) Amp - - - - -
66 Fluor kaps 1 mg Kapsul - - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 45 45 1 44 (41)
68 Furosemid Tablet 40 mg Tablet 686 686 186 500 123 1,000
69 Garam Oralit I Serbuk Kombinasi Bks 277 277 277 (277)
70 Glass Ionomer Cement Art Lar. Botol - - - - -
71 Glibenklamida Tablet 5 mg Tablet 280 280 187 93 533 1,000
72 Glimepirid 2 mg Tablet 2,635 2,635 38 2,597 (2,470)
73 Griseofulvin Tablet 125 mg Tablet 500 500 10 490 (457)
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - - -
76 Haloperidol Tablet 1,5 mg Tablet 500 500 1,000 - 1,000 (1,000)
 77 Hidroklorotiazida Tablet 25 mg Tablet 183 1,000 1,183 40 1,143 (1,009)
78 Hidrokortison Krim 2,5 % Tube 212 212 44 168 (21)
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 1,434 1,434 34 1,400 (1,286)
80 Ibuprofen Sirup 100 mg/5 ml Botol 133 133 20 113 (46)
81 Ibuprofen Tablet 200 mg Amp 2,960 2,000 4,960 1 4,959 (4,956)
82 Ibuprofen Tablet 400 mg Tablet 545 2,000 2,545 300 2,245 (1,240)
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,182 1,182 1,182 (1,182)
84 Kalsium glukonat inj 10% Botol 6 6 - 6 (6)
85 Kalsium Hidroksida bubuk,Pasta Botol - - - - -
86 Kaptopril Tablet 12,5 mg Tablet 358 2,000 2,358 90 2,268 (1,967)
87 Kaptopril Tablet 25 mg Tablet 217 2,000 2,217 406 1,811 (451)
88 Karbamazepin tab 100 mg Tablet - - - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - - -
90 Ketokonazol tab 200 mg Tablet 1,006 1,006 54 952 (771)
91 Klindamisin 300 mg Tablet 270 500 770 - 770 (770)
92 Klindamisin kap 150mg Tablet (14) (14) - (14) 14
93 Kloramfenikol kapsul 250 mg Tablet 741 741 21 720 (650)
94 Kloramfenikol Salep Mata 1 % Tube 9 100 109 (9) 118 (148)
95 Kloramfenikol susp 125mg/5ml Botol - - - - -
96 Kloramfenikol Tablet 500mg Tablet - - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - - -
99 Klorfeniramin Tablet 4 mg Tablet 3,961 3,961 2,433 1,528 6,623 7,000
100 Klorfenol Kamfer Menthol (CHKM) Botol - - - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - - -
103 Kodein tablet 10 mg Tablet 277 277 114 163 219 500
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,154 1,154 122 1,032 (623)
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 30 30 4 26 (13)
106 Kuinin Tab Tablet - - - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - - -
108 Loratadin 10 mg tablet Tablet 2,924 2,924 - 2,924 (2,924)
109 Magnesium Sulfat Injeksi 20% Botol 12 12 12 (12)
110 Magnesium Sulfat Injeksi 40% Botol 6 6 - 6 (6)
111 Mebendazol sir 50mg/ml Botol - - - - -
112 Mebendazol tab 100 mg Tablet - - - - -
113 Mebendazol tab 500 mg Tablet - - - - -
114 Metformin 500 mg Kapsul 36,297 36,297 398 35,899 (34,566)
115 Metformin 850 mg Kapsul - 2,000 2,000 10 1,990 (1,957)
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 - 2,386 (2,386)
118 Metilprednisolon tab 4 mg Tablet - - - - -
119 Metoklopramid Tablet 10 mg Tablet 51 1,500 1,551 56 1,495 (1,307)
120 Metrodinazol lar inf 5mg/ml Botol - - - - -
121 Metrodinazol sir 125mg/ml Botol - - - - -
122 Metronidazol Tablet 250 mg Tablet - - - - -
123 Metronidazol tablet 500 mg Tablet 540 1,500 2,040 205 1,835 (1,148)
124 Mikonazol Krim 2% (Nitrat) Tube 227 227 9 218 (188)
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 6,016 6,016 616 5,400 (3,336)
127 Natrium Diklofenak Tablet 50 mg Tablet - 2,000 2,000 322 1,678 (599)
128 Natrium tiosulfat inj 25% (i.v) Amp - - - - -
129 Nifedipin Tablet 10 mg Tablet 154 154 211 (57) 764
130 Nistatin Suspensi 100.000UI/ml Botol - - - - -
131 Nistatin Vagina 500.000 Tablet Tablet (201) (201) 24 (225) 305
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) - (22) 22
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 263 263 45 218 (67)
134 Omeprazol tablet 20 mg Tablet - 5,000 5,000 1,761 3,239 2,660
135 Parasetamol Sirup 120 mg / 5 ml Botol 253 253 60 193 8
136 Parasetamol Tablet 500 mg Tablet 2,620 10,400 13,020 5,147 7,873 9,369
137 Parasetamol drops 100 mg / 1 ml Botol - - - - -
138 Perak sulfadiazin krim1% Tube 5 5 5 (5)
139 Pirantel pamoat sus 125mg/5ml Botol - - - - -
140 Pirantel pamoat tab 125 mg Tablet 148 148 - 148 (148)
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 5,717 5,717 572 5,145 (3,229)
142 Povidon Iodida 100 mg/ml 30 ml Botol 30 30 6 24 (4)
143 Povidon Iodida 100 mg/ml 300 ml Botol 26 26 4 22 (9)
144 Prednison Tablet 5 mg Tablet 2,802 2,802 674 2,128 130
145 Primakuin Tablet 15 mg Tablet - - - - -
146 Probenesid tab 500mg Tablet - - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,250 1,250 28 1,222 (1,128)
149 Propilitiourasil Tablet 100 mg Tablet 759 759 - 759 (759)
150 Ranitidin Tablet 150 mg Tablet - 2,000 2,000 204 1,796 (1,113)
151 Risperidon 2 mg Tablet (185) (185) - (185) 185
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 1,121 1,121 321 800 275 2,000
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 310 310 - 310 (310) 2,000
154 Salep 2 - 4 Kombinasi Tube - 104 104 6 98 (78)
155 Sefadroksil Kapsul 500 mg Tablet 754 1,000 1,754 12 1,742 (1,702)
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 (2)
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 12 12 12 (12)
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 398 398 151 247 259
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 488 1,500 1,988 345 1,643 (487)
160 Simvastatin Tablet 10 mg Tablet 805 600 1,405 - 1,405 (1,405)
161 Simvastatin Tablet 20 mg Tablet 650 200 850 41 809 (672)
162 Siprofloksasin Tablet scored 500 mg Tablet 5,779 5,779 394 5,385 (4,065)
163 Spironolakton 25 mg tablet Tablet 1,145 1,145 5 1,140 (1,123)
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - - - -
166 Tetrasiksin 250 mg Tablet - - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 739 739 315 424 631 2,000
168 Valproat sir 250 mg/ml Botol - - - - -
169 Valproat tab sal 250mg Tablet - - - - -
170 Valproat tab sal 500 mg Tablet - - - - -
171 Verapamil 80mg Tablet - - - - -
172 Vitamin B Kompleks Tablet Tablet 11,228 11,228 3,600 7,628 4,432
173 Zink sir 10 mg/ml Botol 73 100 173 2 171 (164)
174 Zink tablet dispersi 20 mg Tablet 406 406 - 406 (406)
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS) - -
1 Ambroxol Sirup 15 mg/ml Botol 33 - 33 26 7 80 200
2 Ambroxol Tablet 30 mg Tablet 870 870 729 141 2,301 3,000
3 Antalgin Injeksi 250 mg Amp - - - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube - 150 150 44 106 41
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - - - -
6 Asetosal Tablet 100mg Tablet - - - - -
7 Asiklovir Krim 5% Tube 134 134 134 (134)
8 Counterpain 15 mg Tube - - - - -
9 Duvadilan Tablet - - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - - -
12 Etakridin Larutan 0,1 Botol 48 48 2 46 (39)
13 Famotidine Tablet 40 mg Tablet - - - - -
14 Fenobarbital inj Tablet 17 17 - 17 (17)
15 Fenol Gliserol Tetes Telinga 10 % Botol 70 70 - 70 (70)
16 Gentamisin Injeksi 40 mg/ml Amp 29 29 - 29 (29)
17 Gentamisin Salep Kulit 0,1 % Botol - - - - -
18 Gliseril Guaiakolat Tablet 100 mg Tablet 9,383 9,383 3,518 5,865 5,920
19 Glukosa Larutan Infus 10 % Steril Botol (5) (5) - (5) 5
20 Glukosa Larutan Infus 5 % Steril Botol - 40 40 - 40 (40)
21 Imersi Oil Botol - - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 5,015 5,015 400 4,615 (3,275)
23 Ketorolac inj 30mg/ml Amp - - - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - - -
25 Larutan Asam Asetat Botol - - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - - -
27 Larutan Benedict Botol - - - - -
28 Larutan Eosin 2% Botol - - - - -
29 Larutan Faucet Botol - - - - -
30 Larutan Giemsa Stalin Botol - - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - - -
32 Larutan Resserccer Botol - - - - -
33 Larutan Turk Botol - - - - -
34 Lisol Botol - - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 60 100 160 80 80 188
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 14 14 6 8 12 200
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 73 73 21 52 18
39 Oksitetrasiklin Salep Kulit 3 % Tube - - - - -
40 Parasetamol 100 mg Tablet - - - - -
41 Pehacain inj Amp - - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - - -
43 Piroxicam 20mg Tablet 220 2,000 2,220 250 1,970 (1,133)
44 Propanolol tablet 40 mg Tablet - - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 178 200 378 139 239 227
46 Reagen Golongan Darah Botol - - - - -
47 Reagen TB Botol - - - - -
48 Ringer Laktat Larutan Infus Steril Botol 400 400 120 280 122
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - - - -
50 Setirizin Sirup 5 mg/5ml Botol 153 50 203 16 187 (133)
51 Setirizin Tablet 10mg Tablet 316 1,500 1,816 659 1,157 1,051
52 Simetidin Tablet 200 mg Tablet - - - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - - -
54 Tablet Tambah Darah Tablet - - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 50 100 150 22 128 (54)
57 Trombophob Jeli 15 g Tube - - - - -
58 Ventolin Botol 119 119 37 82 42
III BAHAN MEDIS HABIS PAKAI (BMHP) - -
1 Alat Suntik Sekali Pakai 1 ml Pcs 881 - 881 5 876 (859)
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 1,215 1,000 2,215 2,215 (2,215)
4 Alat Suntik Sekali Pakai 5 ml Pcs 619 1,800 2,419 12 2,407 (2,367)
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 86 86 2 84 (77)
6 Elastis Verban 4 inci Pcs - - - - -
7 Foley Catheter No. 16 Pcs 60 60 - 60 (60)
8 Foley Catheter No. 18 Pcs 25 25 8 17 10
9 Hanscoond no 6,5 Pcs - - - - -
10 Hanscoond no 7,5 Pcs 170 170 170 (170)
11 HCG test Pcs - - - - -
12 Infusion Set Anak Pcs 240 240 102 138 204
13 Infusion Set Dewasa Pcs 498 498 498 (498)
14 IV Catheter No. 18. G Pcs 263 263 100 163 172
15 IV Catheter No. 20 G Pcs 86 86 38 48 79
16 IV Catheter No. 22 G Pcs 71 71 47 24 133
17 IV Catheter No. 24 G Pcs 202 202 44 158 (11)
18 Jarum Jahit Kulit Pcs (24) (24) - (24) 24
19 Jarum Jahit Otot Pcs (24) (24) - (24) 24
20 Kapas Pembalut / Absorben 250 gr Pcs (14) (14) 1 (15) 18
21 Kasa Pembalut 2 m x 80 cm Rol - - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol (40) (40) - (40) 40
23 Kasa Hidrofil 4 m x 3 cm Rol - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 88 88 5 83 (66)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 22 22 22 (22)
26 Kasa Kompres 40/40 Steril Rol - - - - -
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol (29) (29) - (29) 29
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - - -
29 Masker Rol (450) (450) - (450) 450
30 Pembalut Gips 4 Inci Rol - - - - -
31 Plester 5 Yards x 2 inci Rol - - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 174 174 20 154 (87)
33 Urine Bag Pcs 40 40 - 40 (40)
34 Wing Needle No.27 G Pcs - - - - -
35 Handscoond 8 Pcs - - - - -
36 Handscoond 7 Pcs - - - - -
37 Plesterin Non Woven Pcs - - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - - -
41 Plester 5cm x 5m Pcs - - - - -
IV OBAT PROGRAM - - -
A. MALARIA - - -
1 Obat Anti Malaria (ACT) Tablet - - - - - -
2 Primaquin Tablet Tablet - - - - - -
3 Kina tablet Tablet - - - - -
4 RDT Malaria (First Respon) Pcs - - - - -
5 Arterakina (DHP)=Dartep - - - - -
6 Artehemeter Injeksi Amp - - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - - -
B. TUBERCULOSIS (TB) - - -
1 OAT FDC kategori 1 Paket - - - - - -
2 OAT FDC kategori 2 Paket - - - - - -
3 OAT Kategori Anak Paket - - - - -
4 OAT Kombipak Paket - - - - -
5 Masker Pcs - - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - - - -
2 Haloperidol tab 5 mg Tablet 4,540 4,540 120 4,420 (4,018)
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25 (25)
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - -
5 Risperidon Tablet Tablet 1,200 1,200 30 1,170 (1,070)
6 Triheksifenidil HCLTablet 2 mg Tablet 3,500 3,500 200 3,300 (2,630)
7 Clobazam tablet 10 mg Tablet - - - - -
8 Clozapine 25 mg Tablet 1,254 1,254 94 1,160 (845)
9 Klorpromazine Tablet Tablet - - - - -
10 Diazepam 5 mg Tablet - - - - -
11 Asprazolam Tablet - - - - -
D. VAKSIN - - -
1 BCG Amp - 3 3 - 3 (3) 10
2 POLIO 10 DS Pcs 30 20 50 30 20 81 15
3 CAMPAK Amp - - - - -
4 IPV 10 10 - 10 (10) 20
5 HB UNIJEK 10 6 16 10 6 28 20
6 Td Amp - - - - -
7 DPT HB-Hib Amp 6 20 26 6 20 0 10
8 TT Amp 31 10 41 31 10 94
9 Dt Amp - - - - -
10 POLIO 20 DS Pcs - - - - -
11 VAR (vaksin rabies ) Vial - 1 1 - 1 (1)
12 ADS 0,05 ml Pcs 127 127 127 - 425
13 ADS 0,5 ml Pcs 236 454 690 236 454 337 200
14 ADS 5 ml Pcs 17 17 17 - 57
15 VAKSIN MR Amp 43 20 63 43 20 124 20
E. KIA - -
1 Glukanos kalsikus injeksi 10 % Amp - - - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - - -
5 Gentamicin inj 40mg/dl Amp - - - - -
6 Tes Kehamilan Pcs - - - - -
7 Tes Protein Urine Pcs - - - - - 100
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - - -
11 Reagen Golongan Darah Botol - - - - -
12 Hb Sahli Pcs - - - - -
13 Oto Klik Pcs - - - - -
14 Larutan Hcl Botol - - - - -
15 Blood lancet Pcs - - - - -
F. GIZI - - -
1 Tablet tambah darah Tablet 500 - 500 3,800 (3,300) 16,030
2 Vit A Biru 100.000 IU Tablet - - - - - - 5,000
3 Vit A Merah 200.000 IU Tablet 16,800 16,800 - 16,800 (16,800)
4 Iodin test Pcs - - - - - 10
G. DIARE - - -
1 Garam Oralit 200 mg Bks 450 - 450 25 425 (341)
2 Zinc Tablet 20 mg Tablet 470 - 470 38 432 (305)
H. FILARIASIS - - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - - - -
2 Parasetamol 500 mg Tablet - - - - - -
3 Albendazol 200 mg Tablet - - - - -
G.ALAT LABORATORIUM - - -
1 Blood Lancet Pcs - - - - - -
2 Reagen TB Botol - - - - - -
3 Slide Pcs - - - - -
4 Pot Sputum Pcs 200 200 200 - 670
5 Metanol 100 ml Botol - - - - -
6 Imersi Oil 60 ml Botol - - - - -
7 Buffer Phosphat 7,2 Botol - - - - -
8 Handscoon (M) Pcs - - - - -
9 Alkohol asam 100 ML Botol - - - - -
10 Masker Pcs - - - - -
11 Giemsa Solution 60 ml Botol - - - - -
12 Alkohol Swap Bks 200 200 - 200 (200)
H. KUSTA - - -
1 MB Adult - - - - - -
2 MB (MDTDMB) child - - - - - -
3 PB Adult - - - - -
4 PB (MTDPB) child - - - - -
I. HIV DAN SIFILIS - - -
1 Rapid Test Merk :SD - - - - - -
2 Fokus (HIV ke 2) - - - - - -
3 Rapid Test Merk : Vikia - - - - -
4 Human Hexogon Syphilis - - - - -
5 RPR Syphylis - - - - -
TAMBAHAN - - -
1 Gentamisin Tetes mata Botol - - - - - -
2 Gentian Violet Botol - - - - - -
3 OAM Tablet - - - - -
4 Glikonas Kalsikus inj 10% Botol - - - - -
5 Bromheksin Tablet - - - - -
6 sefadroxil Syr Botol - - - - -
7 Kasa Elastis 4 inc Rol - - - - -
8 Klindamisin Kap 150 mg Tablet - - - - -
9 Glukosa Lar.40% Botol - - - - -
10 Antiparkinson doen kombinasi Tablet - - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - - -
12 Aminofilin tab 150 mg Tablet - - - - -
13 Mumfying pasta Botol - - - - -
14 Safety box Pcs - - - - -
15 fixomul Rol 17 17 1 16 (13)
16 Guaifenisin Tablet (45) (45) - (45) 45
17 Metro 500mg/Injeksi Amp - - - - -
18 Ampisilin 100mg Tablet - - - - -
19 Euthirox 50mg Tablet - - - - -
20 Mineral mix Botol - - - - -
21 Urine 2 Parameter Pcs - - - - -
22 Urine 10 Parameter Pcs - - - - -
23 strip autochek Pcs - - - - -
24 strip glukose autochek Pcs - - - - -
25 Masker N 95 Pcs 80 80 40 40 94
26 objek glass Pcs - - - - -
27 Rapid HIV Pcs - - - - -
28 Kolesterol Auto chek Pcs - - - - -
29 Stip Cek Narkoba Pcs - - - - -
30 CutiCell 10cm x 10M Rol 16 16 - 16 (16)
31 Surgical Blade no. 10-24 Pcs 10 10 10 - 34
32 Leucoplast Rol (3) (3) - (3) 3
33 Uniflex 7,5 x 4,5cm Rol 9 9 - 9 (9)
34 HB ig Pcs - - - - -
35 RDT hepatitis B Pcs - - - - -
36 RDT Syphilis Pcs - - - - -
37 RDT HIV Pcs - - - - -
38 Blood Slide Pcs - - - - -
39 Oksitetra salp mata prog. KIA Tube - - - - -
40 Anti Hb SAG Pcs - - - - -
41 Metrodinazol 500mg/100ml Botol - - - - -
42 Betadine Salp Tube - - - - -
43 Gluko Protein Pcs - - - - -
44 Reagen Sphylis Botol - - - - -
45 Handscoon (M) Pcs - - - -
46 Handscoon (L) Pcs - - - -
47 Desinfektan Spray Pcs 226 226 226 (226)
48 Lansoprazole Tablet - - - - 1000
49 Betahistine HCL Tablet 586 586 586 (586) 700
50 Candesartan 8 mg Tablet 8,910 8,910 95 8,815 (8,497)
51 Candesartan 16 mg Tablet 8,920 8,920 67 8,853 (8,629)
52 Etanol cairan 70 % 1000ml Pcs 17 17 17 (17)
53 Handscoon size 7 Pcs - 200 200 200 (200) 200
54 Asam Askorbat (Vitamin C) Tablet 500 mg Tablet - 500 500 500 (500)
55 - -
56 - -
57 - -
 58 - -
59 - -
60 - -

UMUM
JAMKESDA JKN UKS
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
182 332

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor,

Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

1 1
2 0 2 1

T (LPLPO. LB.2)
PEMBERIAN TAHUN TAHUN
NO. BATCH KET
JKN APBD LAIN JUMLAH PENGADAAN Exp

11 12 13 14 15 16 17
KIR JUMLAH
514

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987
PUSKESMAS : RAWAT INAP JANGGA BARU BULAN : 1
KECAMATAN : BATIN XXIV TAHUN : 2

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO. LB.2)

PE
PENERI- STOK PERMIN-
NO NAMA OBAT SATUAN STOK AWAL MAAN PERSE-DIAAN PEMA-KAIAN SISA STOK OPTIMUM TAAN
JKN

1 2 3 4 5 6 7 8 9 10 11
I OBAT SESUAI FORMULARIUM NASIONAL (FORNAS)
1 Air untuk injeksi Botol 32 32 10 22
2 Albendazol 400mg Tablet - - -
3 Albendazol susp 200 mg/5ml Botol - - -
4 Alopurinol tablet 100 mg Tablet 2,259 2,259 20 2,239
5 Alupurinol Tab 300mg Tablet 390 390 390
6 Aminofilin injeksi 24 mg/ml Amp 118 118 - 118
7 Aminofilin tablet 200 mg Tablet (334) (334) - (334)
8 Amitriptilin Tablet Salut 25 mg (HCl) Tablet 2,447 2,447 - 2,447
9 Amlodipin tablet 10 mg Tablet 19,451 19,451 218 19,233
10 Amlodipin tablet 5 mg Tablet 24,671 24,671 900 23,771
11 Amoksisilin 250 mg Tablet - - -
12 Amoksisilin sir forte 250mg Botol - - - -
13 Amoksisilin sir 125mg/5 ml Botol 178 178 65 113
14 Amoksisilin Tablet 500 mg Tablet 6,956 6,956 1,300 5,656
15 Ampisilin serb inj 1000 mg/vial Vial - - -
16 Antasida DOEN I Tablet Kunyah Kombinasi Tablet 6,196 6,196 2,787 3,409
17 Antasida DOEN II Suspensi Kombinasi Botol 243 243 21 222
18 Antifungi DOEN Kombinasi Tube 99 99 10 89
19 Antihemoroid Kombinasi sup Sup 356 356 356
20 Antimalaria DOEN Kombinasi (Primetamin dan Sulfadoksin) Tablet - - -
21 Antimigren Komb ( Ergotamin 1mg + kafein 50 mg ) Tablet 556 556 - 556
22 Asam asetil salisilat (asetosal) tablet80 mg Tablet 860 860 - 860
23 Asam Askorbat (Vitamin C) Tablet 50 mg Tablet 7,264 7,264 900 6,364
24 Asam Folat 1 mg Tablet 1,160 1,160 540 620
25 Asam Mefenamat tablet 500 mg Tablet 2,093 5,000 7,093 1,400 5,693
26 Asiklovir Tablet 200 mg Tablet 1,272 1,272 279 993
27 Asiklovir Tablet 400 mg Tablet 785 785 - 785
28 Atapulgit Tablet Tablet 3,099 3,099 400 2,699
29 Atenolol 50 mg Tablet - - -
30 Atropin Injeksi . 0,25 mg/ml ( i.m./ i.v. / s.k) Amp 14 14 - 14
31 Atropin Sulfat Tablet 0,5 mg Tab Tablet - - - -
32 Bedak Salisil serbuk 2% Bks 72 72 - 72
33 Betametason Krim 0,05 % Tube 229 229 24 205
34 Bisakodil sup 5 mg Botol - - -
35 Bisaprolol 5mg Tablet 589 589 360 229
36 Deksametason Injeksi 5 mg/ml (i.v/i.m) Amp 159 159 50 109
37 Deksametason Tablet 0,5 mg Tablet 3,295 3,295 1,000 2,295
38 Devitalisasi Pasta (Non Arsen) Botol - - -
39 Diazepam Injeksi 5 mg/ml ( i.v/i.m) Amp 50 50 - 50
40 Diazepam rektal 10mg/2 ,5ml Amp 18 18 10 8
41 Diazepam rektal 5mg/2 ml Amp 1 1 - 1
42 Diazepam Tablet 2 mg Tablet 904 904 96 808
43 Diazepam Tablet 5 mg Tablet 688 688 166 522
44 Dietilkarbamazin tab 100mg Tablet - - - -
45 Difenhidramin Injeksi 10 mg / ml (i.v/i.m) Amp 104 104 38 66
46 Digoksin Tablet 0,25 mg tablet 1,521 1,521 200 1,321
47 Diltiazem hcl tab 30mg Tablet - - -
48 Doksisiklin Kapsul 100 mg Tablet 1,938 1,938 - 1,938
49 Domperidon 10 mg Tablet Tablet 1,144 1,144 500 644
50 Domperidon 5mg/5ml Sirup Botol 159 159 20 139
51 Epinefrin (Adrenalin) Injeksi 0,1 % (i.v/s.k/i.m) Amp (10) (10) 6 (16)
52 Ergotamin tab 1mg Tablet - - - -
53 Eritromisin kapsul 250 mg Tablet - - - -
54 Eritromisin Kapsul 500 mg Tablet 500 500 - 500
55 Eritromisin Sirup 200 mg / 5 ml Botol 100 100 5 95
56 Etanol cairan 70 % Botol (19) (19) (19)
57 Etil Klorida Semprot 100 ml Botol (10) (10) - (10)
58 Eugenol cairan Botol - - - -
59 Fenitoin Na kaps Tablet - - - -
60 Fenobarbital tablet 30 mg Tablet 1,529 1,529 34 1,495
61 Fenoksimetil penisilin ( Penisilin V ) 250mg Tablet - - - -
62 Fenoksimetil penisilin ( Penisilin V ) 500mg Tablet - - - -
63 Fitomenadion (Vitamin K1) Injeksi 2mg/ml (i.m) Amp 165 165 39 126
64 Fitomenadion (Vitamin K1) Tablet Salut 10 mg Tablet 486 486 153 333
65 Flufenazin inj 25 mg/ml (i.m) Amp - - -
66 Fluor kaps 1 mg Kapsul - - - -
67 Furosemid Injeksi 10 mg / ml ( i.v. / i.m) Amp 44 44 - 44
68 Furosemid Tablet 40 mg Tablet 500 300 800 94 706
69 Garam Oralit I Serbuk Kombinasi Bks 277 277 125 152
70 Glass Ionomer Cement Art Lar. Botol - - -
71 Glibenklamida Tablet 5 mg Tablet 93 1,000 1,093 300 793
72 Glimepirid 2 mg Tablet 2,597 2,597 162 2,435
73 Griseofulvin Tablet 125 mg Tablet 490 490 490
74 Griseril trinitrat tab sublingual 0,5 mg Tablet - - - -
75 Haloperidol Tablet 0,5 mg Tablet - - - -
76 Haloperidol Tablet 1,5 mg Tablet 1,000 1,000 - 1,000
77 Hidroklorotiazida Tablet 25 mg Tablet 1,143 1,143 200 943
78 Hidrokortison Krim 2,5 % Tube 168 168 168
79 Hyoscine -N-Butilbromide Tablet 10 mg Tablet 1,400 1,400 - 1,400
80 Ibuprofen Sirup 100 mg/5 ml Botol 113 113 53 60
81 Ibuprofen Tablet 200 mg Amp 4,959 4,959 600 4,359
82 Ibuprofen Tablet 400 mg Tablet 2,245 2,245 1,470 775
83 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 1,182 1,182 403 779
84 Kalsium glukonat inj 10% Botol 6 6 6
85 Kalsium Hidroksida bubuk,Pasta Botol - - - -
86 Kaptopril Tablet 12,5 mg Tablet 2,268 2,268 206 2,062
87 Kaptopril Tablet 25 mg Tablet 1,811 1,811 1,811
88 Karbamazepin tab 100 mg Tablet - - -
89 karbo Gliserin tetestelinga 10 % Botol - - - -
90 Ketokonazol tab 200 mg Tablet 952 952 63 889
91 Klindamisin 300 mg Tablet 770 770 400 370
92 Klindamisin kap 150mg Tablet (14) (14) (14)
93 Kloramfenikol kapsul 250 mg Tablet 720 720 29 691
94 Kloramfenikol Salep Mata 1 % Tube 118 118 56 62
95 Kloramfenikol susp 125mg/5ml Botol - - -
96 Kloramfenikol Tablet 500mg Tablet - - - -
97 Kloramfenikol Tetes Mata 1 % Botol - - - -
98 Kloramfenikol tetes telinga 1% Botol - - - -
99 Klorfeniramin Tablet 4 mg Tablet 1,528 1,528 1,528 -
100 Klorfenol Kamfer Menthol (CHKM) Botol - - -
101 Klorpromazin Tablet Salut 100 mg (HCl) Tablet - - - -
102 Klorpromazin Tablet Salut 25 mg (HCl) Tablet - - - -
103 Kodein tablet 10 mg Tablet 163 500 663 - 663
104 Kotrimoksazol (Dewasa ) Sulfa - Trimetoprim tablet 480 mg Tablet 1,032 1,032 200 832
105 Kotrimoksazol Sulfa - Trimetoprim suspensi 240 mg/5ml Botol 26 26 5 21
106 Kuinin Tab Tablet - - -
107 Lidokain 2% + Epineprin 1 : 80.000 injeksi 2 ml Amp - - - -
108 Loratadin 10 mg tablet Tablet 2,924 3,000 5,924 - 5,924
109 Magnesium Sulfat Injeksi 20% Botol 12 12 12
110 Magnesium Sulfat Injeksi 40% Botol 6 6 6
111 Mebendazol sir 50mg/ml Botol - - - -
112 Mebendazol tab 100 mg Tablet - - - -
113 Mebendazol tab 500 mg Tablet - - - -
114 Metformin 500 mg Kapsul 35,899 35,899 748 35,151
115 Metformin 850 mg Kapsul 1,990 1,990 300 1,690
116 Metilergometrin Maleat Injeksi 0.2 mg - 1ml Amp - - -
117 Metilergometrin Maleat Tablet Salut 0,125 mg Tab Tablet 2,386 2,386 - 2,386
118 Metilprednisolon tab 4 mg Tablet - - - -
119 Metoklopramid Tablet 10 mg Tablet 1,495 1,495 117 1,378
120 Metrodinazol lar inf 5mg/ml Botol - - -
121 Metrodinazol sir 125mg/ml Botol - - - -
122 Metronidazol Tablet 250 mg Tablet - - - -
123 Metronidazol tablet 500 mg Tablet 1,835 1,835 435 1,400
124 Mikonazol Krim 2% (Nitrat) Tube 218 218 24 194
125 Natrium Bikarbonat Tablet 500 mg ( Meylon ) Tablet - - -
126 Natrium Diklofenak Tablet 25 mg Tablet 5,400 5,400 600 4,800
127 Natrium Diklofenak Tablet 50 mg Tablet 1,678 1,678 398 1,280
128 Natrium tiosulfat inj 25% (i.v) Amp - - -
129 Nifedipin Tablet 10 mg Tablet (57) (57) 100 (157)
130 Nistatin Suspensi 100.000UI/ml Botol - - -
131 Nistatin Vagina 500.000 Tablet Tablet (225) (225) - (225)
132 Nistatin Vaginal Tablet 100.000 IU /g Tablet (22) (22) 142 (164)
133 Oksitosin Injeksi 10 iu/ml -1 ml Amp 218 218 - 218
134 Omeprazol tablet 20 mg Tablet 3,239 3,239 106 3,133
135 Parasetamol Sirup 120 mg / 5 ml Botol 193 193 130 63
136 Parasetamol Tablet 500 mg Tablet 7,873 7,873 2,655 5,218
137 Parasetamol drops 100 mg / 1 ml Botol - - -
138 Perak sulfadiazin krim1% Tube 5 5 - 5
139 Pirantel pamoat sus 125mg/5ml Botol - - - -
140 Pirantel pamoat tab 125 mg Tablet 148 2,000 2,148 2,148
141 Piridoksin (Vitamin B6) Tablet 10 mg (HCl) Tablet 5,145 5,145 1,300 3,845
142 Povidon Iodida 100 mg/ml 30 ml Botol 24 24 24
143 Povidon Iodida 100 mg/ml 300 ml Botol 22 22 22
144 Prednison Tablet 5 mg Tablet 2,128 2,128 500 1,628
145 Primakuin Tablet 15 mg Tablet - - -
146 Probenesid tab 500mg Tablet - - - -
147 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Vial - - - -
148 Propanolol Tablet 10 mg (HCl) Tablet 1,222 1,222 800 422
149 Propilitiourasil Tablet 100 mg Tablet 759 759 600 159
150 Ranitidin Tablet 150 mg Tablet 1,796 1,796 211 1,585
151 Risperidon 2 mg Tablet (185) (185) (185)
152 Salbutamol Tablet 2 mg (Sebagai Sulfat) Tablet 800 2,000 2,800 800 2,000
153 Salbutamol Tablet 4 mg (Sebagai Sulfat) Tablet 310 2,000 2,310 410 1,900
154 Salep 2 - 4 Kombinasi Tube 98 98 48 50
155 Sefadroksil Kapsul 500 mg Tablet 1,742 1,742 100 1,642
156 Serum Anti Bisa Ular Polivalen Injeksi 5 ml (ABU I) Vial 2 2 2 -
157 Serum Anti Tetanus Injeksi. 1.500 iu / 1 ml (ATS) Vial 12 12 12
158 Sianokobalamin (Vitamin B12) Injeksi 500 mcg Amp 247 247 115 132
159 Sianokobalamin (Vitamin B12) Tablet 50 mcg Tablet 1,643 1,643 775 868
160 Simvastatin Tablet 10 mg Tablet 1,405 1,405 120 1,285
161 Simvastatin Tablet 20 mg Tablet 809 809 450 359
162 Siprofloksasin Tablet scored 500 mg Tablet 5,385 5,385 1,800 3,585
163 Spironolakton 25 mg tablet Tablet 1,140 1,140 1,140
164 Tetrakain HCl Tetes Mata 0,5 % Botol - - -
165 Tetrasiklin Kapsul 500 mg Tablet - - - -
166 Tetrasiksin 250 mg Tablet - - - -
167 Tiamin (Vitamin B1) Tablet 50 mg (HCl / Nitrat) Tablet 424 2,000 2,424 100 2,324
168 Valproat sir 250 mg/ml Botol - - -
169 Valproat tab sal 250mg Tablet - - - -
170 Valproat tab sal 500 mg Tablet - - - -
171 Verapamil 80mg Tablet - - - -
172 Vitamin B Kompleks Tablet Tablet 7,628 7,628 3,903 3,725
173 Zink sir 10 mg/ml Botol 171 171 40 131
174 Zink tablet dispersi 20 mg Tablet 406 500 906 372 534
II OBAT SESUAI FORMULARIUM NON NASIONAL (FORNAS)
1 Ambroxol Sirup 15 mg/ml Botol 7 7 - 7
2 Ambroxol Tablet 30 mg Tablet 141 141 - 141
3 Antalgin Injeksi 250 mg Amp - - -
4 Antibakteri DOEN Salep Kombinasi (Bacytrasin Salep) Tube 106 106 60 46
5 Asam asetil salisilat (asetosal) tablet500 mg Tablet - - -
6 Asetosal Tablet 100mg Tablet - - - -
 7 Asiklovir Krim 5% Tube 134 134 14 120
8 Counterpain 15 mg Tube - - - -
9 Duvadilan Tablet - - - -
10 Efedrin Tablet 25mg ( HCL ) Tablet - - - -
11 Ekstraks Belladona Tablet 10 mg Tablet - - - -
12 Etakridin Larutan 0,1 Botol 46 46 - 46
13 Famotidine Tablet 40 mg Tablet - - - -
14 Fenobarbital inj Tablet 17 17 - 17
15 Fenol Gliserol Tetes Telinga 10 % Botol 70 70 48 22
16 Gentamisin Injeksi 40 mg/ml Amp 29 29 30 (1)
17 Gentamisin Salep Kulit 0,1 % Botol - 48 48 - 48
18 Gliseril Guaiakolat Tablet 100 mg Tablet 5,865 5,865 3,197 2,668
19 Glukosa Larutan Infus 10 % Steril Botol (5) (5) (5)
20 Glukosa Larutan Infus 5 % Steril Botol 40 40 11 29
21 Imersi Oil Botol - - - -
22 Kalsium Laktat (Kalk) Tablet 500 mg Tablet 4,615 4,615 118 4,497
23 Ketorolac inj 30mg/ml Amp - - -
24 Kotrimoksazol DOEN II (Pediatrik) Kombinasi Tablet - - - -
25 Larutan Asam Asetat Botol - - - -
26 Larutan Asam Klorida 0,1 N Botol - - - -
27 Larutan Benedict Botol - - - -
28 Larutan Eosin 2% Botol - - - -
29 Larutan Faucet Botol - - - -
30 Larutan Giemsa Stalin Botol - - - -
31 Larutan Natrium Sitrat 3,8% Botol - - - -
32 Larutan Resserccer Botol - - - -
33 Larutan Turk Botol - - - -
34 Lisol Botol - - - -
35 Natrium Klorida Larutan Infus 0,9% Botol 80 80 0 80
36 Obat Batuk Hitam (OBH) 100 ml Cairan Botol 8 8 - 8
37 Oksitetrasiklin HCl Injeksi. i.m. 50 mg/ml - 10 ml Amp - - - -
38 Oksitetrasiklin HCl Salep Mata 1 % Tube 52 52 24 28
39 Oksitetrasiklin Salep Kulit 3 % Tube - - - -
40 Parasetamol 100 mg Tablet - - - -
41 Pehacain inj Amp - - - -
42 Piracetam Injeksi 1 g / 5 mL Amp - - - -
43 Piroxicam 20mg Tablet 1,970 1,970 - 1,970
44 Propanolol tablet 40 mg Tablet - - - -
45 Ranitidin Injeksi 25 mg / 2 ml Amp 239 239 25 214
46 Reagen Golongan Darah Botol - - -
47 Reagen TB Botol - - - -
48 Ringer Laktat Larutan Infus Steril Botol 280 280 120 160
49 Semen Seng Fosfat Serbuk dan Cairan Botol - - -
50 Setirizin Sirup 5 mg/5ml Botol 187 187 - 187
51 Setirizin Tablet 10mg Tablet 1,157 1,157 679 478
52 Simetidin Tablet 200 mg Tablet - - -
53 Sulfasetamida Natrium Tetes Mata 15 % Botol - - - -
54 Tablet Tambah Darah Tablet - - - -
55 Temporary Stopping Fletcher Serbuk dan Cairan Botol - - - -
56 Tiamin (Vitamin B1) Injeksi 100 mg/ml Tablet 128 128 - 128
57 Trombophob Jeli 15 g Tube - - - -
58 Ventolin Botol 82 82 - 82
III BAHAN MEDIS HABIS PAKAI (BMHP) 22
1 Alat Suntik Sekali Pakai 1 ml Pcs 876 876 19 857
2 Alat Suntik Sekali Pakai 2,5 ml Pcs - - - -
3 Alat Suntik Sekali Pakai 3 ml Pcs 2,215 2,215 277 1,938
4 Alat Suntik Sekali Pakai 5 ml Pcs 2,407 2,407 700 1,707
5 Catgut / Benang bedah No. 3/0 Dengan Jarum Bedah Pcs 84 84 42 42
6 Elastis Verban 4 inci Pcs - - - -
7 Foley Catheter No. 16 Pcs 60 60 17 43
8 Foley Catheter No. 18 Pcs 17 17 7 10
9 Hanscoond no 6,5 Pcs - - - -
10 Hanscoond no 7,5 Pcs 170 170 170 -
11 HCG test Pcs - - -
12 Infusion Set Anak Pcs 138 138 66 72
13 Infusion Set Dewasa Pcs 498 498 11 487
14 IV Catheter No. 18. G Pcs 163 163 13 150
15 IV Catheter No. 20 G Pcs 48 48 55 (7)
16 IV Catheter No. 22 G Pcs 24 24 66 (42)
17 IV Catheter No. 24 G Pcs 158 158 29 129
18 Jarum Jahit Kulit Pcs (24) (24) - (24)
19 Jarum Jahit Otot Pcs (24) (24) - (24)
20 Kapas Pembalut / Absorben 250 gr Pcs (15) (15) - (15)
21 Kasa Pembalut 2 m x 80 cm Rol - - - -
22 Kasa Hidrofil 4 m x 15 cm Rol (40) (40) (40)
23 Kasa Hidrofil 4 m x 3 cm Rol - - - -
24 Kasa Hidrofil Steril Uk. 16 cm x 16 cm Rol 83 83 123 (40)
25 Kasa Hidrofil Uk. 36 m x 80 cm Rol 22 22 24 (2)
26 Kasa Kompres 40/40 Steril Rol - - 94 (94)
27 Kasa Pembalut Hidrofil 4 m x 10 cm Rol (29) (29) - (29)
28 Kasa Pembalut Hidrofil 4 m x 5 cm Rol - - - -
29 Masker Rol (450) (450) - (450)
30 Pembalut Gips 4 Inci Rol - - - -
31 Plester 5 Yards x 2 inci Rol - - - -
32 Silk (Benang Bedah Sutra) No. 3/0 Dengan Jarum Bedah Pcs 154 154 - 154
33 Urine Bag Pcs 40 40 8 32
34 Wing Needle No.27 G Pcs - - - -
35 Handscoond 8 Pcs - - - -
36 Handscoond 7 Pcs - - - -
37 Plesterin Non Woven Pcs - - - -
38 Kasa Hidrofil Uk. 40 m x 80 cm Pcs - - - -
39 Poligyp 10 cm x 2,7 m Pcs - - - -
40 Policrepe pembalut elastis 10 cm x 4,5 m Pcs - - - -
41 Plester 5cm x 5m Pcs - - - -
IV OBAT PROGRAM - -
A. MALARIA -
1 Obat Anti Malaria (ACT) Tablet - - - -
2 Primaquin Tablet Tablet - - - -
3 Kina tablet Tablet - - - -
4 RDT Malaria (First Respon) Pcs - - - -
5 Arterakina (DHP)=Dartep - - - -
6 Artehemeter Injeksi Amp - - - -
7 Kuinin Sulfat tablet 222 mg Tablet - - - -
B. TUBERCULOSIS (TB) - -
1 OAT FDC kategori 1 Paket - - - -
2 OAT FDC kategori 2 Paket - - -
3 OAT Kategori Anak Paket - - - -
4 OAT Kombipak Paket - - - -
5 Masker Pcs - - - -
C. PENYAKIT TIDAK MENULAR (PTM) - -
1 Flufenazin Deconat inj 25 mg/ml (im) Amp - - - -
2 Haloperidol tab 5 mg Tablet 4,420 4,420 - 4,420
3 Haloperidol injeksi 5 mg/ml (Iodomer) Amp 25 25 - 25
4 Haloperidol Dekanoat Injeksi 50 mg.ml Amp - - - -
5 Risperidon Tablet Tablet 1,170 1,170 - 1,170
6 Triheksifenidil HCLTablet 2 mg Tablet 3,300 3,300 - 3,300
7 Clobazam tablet 10 mg Tablet - - - -
8 Clozapine 25 mg Tablet 1,160 1,160 - 1,160
9 Klorpromazine Tablet Tablet - - - -
10 Diazepam 5 mg Tablet - - - -
11 Asprazolam Tablet - - - -
D. VAKSIN - -
1 BCG Amp 3 3 3 -
2 POLIO 10 DS Pcs 20 20 20 -
3 CAMPAK Amp - - - -
4 IPV 10 10 - 10
5 HB UNIJEK 6 6 6 -
6 Td Amp - - - -
7 DPT HB-Hib Amp 20 20 20 -
8 TT Amp 10 10 10 -
9 Dt Amp - - - -
10 POLIO 20 DS Pcs - - - -
11 VAR (vaksin rabies ) Vial 1 1 1 -
12 ADS 0,05 ml Pcs - - - -
13 ADS 0,5 ml Pcs 454 454 454 -
14 ADS 5 ml Pcs - - - -
15 VAKSIN MR Amp 20 20 20 -
E. KIA -
1 Glukanos kalsikus injeksi 10 % Amp - - - -
2 Magnesium sulfat injeksi 20%-25ml Botol - - - -
3 Metilgomertin meleat inj 0,200mg- 1ml Amp - - - -
4 Fenobarbital injeksi IM/IV 50mg/ml Amp - - - -
5 Gentamicin inj 40mg/dl Amp - - - -
6 Tes Kehamilan Pcs - - - -
7 Tes Protein Urine Pcs - - - -
8 Pytomenadion (vit K 1)inj IM ml/ml Amp - - - -
9 Oksitosin inj IV/ml-1ml Amp - - - -
10 Prokain Benzil Penisilin G. Injeksi 3 Juta iu/Vial Amp - - - -
11 Reagen Golongan Darah Botol - - - -
12 Hb Sahli Pcs - - - -
13 Oto Klik Pcs - - - -
14 Larutan Hcl Botol - - - -
15 Blood lancet Pcs - - - -
F. GIZI - -
1 Tablet tambah darah Tablet (3,300) (3,300) 500 (3,800)
2 Vit A Biru 100.000 IU Tablet - - - -
3 Vit A Merah 200.000 IU Tablet 16,800 16,800 - 16,800
4 Iodin test Pcs - - - -
G. DIARE - -
1 Garam Oralit 200 mg Bks 425 425 300 125
2 Zinc Tablet 20 mg Tablet 432 432 200 232
H. FILARIASIS - -
1 Dietilkarbamazin Sitrat (DEC) Tablet - - - -
2 Parasetamol 500 mg Tablet - - - -
3 Albendazol 200 mg Tablet - - - -
G.ALAT LABORATORIUM - -
1 Blood Lancet Pcs - - - -
2 Reagen TB Botol - - - -
3 Slide Pcs - - - -
4 Pot Sputum Pcs - - - -
5 Metanol 100 ml Botol - - - -
6 Imersi Oil 60 ml Botol - - - -
7 Buffer Phosphat 7,2 Botol - - - -
8 Handscoon (M) Pcs - - - -
9 Alkohol asam 100 ML Botol - - - -
10 Masker Pcs - - - -
11 Giemsa Solution 60 ml Botol - - - -
12 Alkohol Swap Bks 200 200 - 200
H. KUSTA - -
1 MB Adult - - - -
2 MB (MDTDMB) child - - - -
3 PB Adult - - - -
4 PB (MTDPB) child - - - -
I. HIV DAN SIFILIS - -
1 Rapid Test Merk :SD - - - -
2 Fokus (HIV ke 2) - - - -
3 Rapid Test Merk : Vikia - - - -
4 Human Hexogon Syphilis - - - -
5 RPR Syphylis - - - -
TAMBAHAN - -
1 Gentamisin Tetes mata Botol - - - -
2 Gentian Violet Botol - - - -
 3 OAM Tablet - - - -
4 Glikonas Kalsikus inj 10% Botol - - - -
5 Bromheksin Tablet - - - -
6 sefadroxil Syr Botol - - - -
7 Kasa Elastis 4 inc Rol - - - -
8 Klindamisin Kap 150 mg Tablet - - - -
9 Glukosa Lar.40% Botol - - - -
10 Antiparkinson doen kombinasi Tablet - - - -
11 benzatin Penisilin G I juta iu/Vial Vial - - - -
12 Aminofilin tab 150 mg Tablet - - - -
13 Mumfying pasta Botol - - - -
14 Safety box Pcs - - - -
15 fixomul Rol 16 16 - 16
16 Guaifenisin Tablet (45) (45) - (45)
17 Metro 500mg/Injeksi Amp - - - -
18 Ampisilin 100mg Tablet - - - -
19 Euthirox 50mg Tablet - - - -
20 Mineral mix Botol - - - -
21 Urine 2 Parameter Pcs - - - -
22 Urine 10 Parameter Pcs - - - -
23 strip autochek Pcs - - - -
24 strip glukose autochek Pcs - - - -
25 Masker N 95 Pcs 40 40 - 40
26 objek glass Pcs - - - -
27 Rapid HIV Pcs - - - -
28 Kolesterol Auto chek Pcs - - - -
29 Stip Cek Narkoba Pcs - - - -
30 CutiCell 10cm x 10M Rol 16 16 - 16
31 Surgical Blade no. 10-24 Pcs - - - -
32 Leucoplast Rol (3) (3) 10 (13)
33 Uniflex 7,5 x 4,5cm Rol 9 9 10 (1)
34 HB ig Pcs - - - -
35 RDT hepatitis B Pcs - - - -
36 RDT Syphilis Pcs - - - -
37 RDT HIV Pcs - - - -
38 Blood Slide Pcs - - - -
39 Oksitetra salp mata prog. KIA Tube - - - -
40 Anti Hb SAG Pcs - - - -
41 Metrodinazol 500mg/100ml Botol - - - -
42 Betadine Salp Tube - - - -
43 Gluko Protein Pcs - - - -
44 Reagen Sphylis Botol - - -
45 Handscoon (M) - - -
46 Handscoon (L) - - -
47 Desinfektan Spray 226 226 226
48 Lansoprazole - - -
49 Betahistine HCL 586 2144 2,730 86 2,644
50 Candesartan 8 mg 8,815 8,815 8,815
51 Candesartan 16 mg 8,853 8,853 8,853
52 Etanol cairan 70 % 1000ml 17 17 17
53 Handscoon size 7 200 200 200
54 Asam Askorbat (Vitamin C) Tablet 500 mg 500 500 500
55 - - -
56 - - -
57 - - -
58 - - -
59 - -
60 - -

UMUM
JAMKESDA JKN UKS KIR
JUMLAH KUNJUNGAN RESEP BAYAR TIDAK BAYAR
161 330

Kepala Dinas Kesehatan Ka. Instalasi Farmasi Yang Melapor, Yang Mene
Kabupaten Batang Hari Kab. Batang Hari Kepala Puskesmas Petugas Pusk
Sekretaris

dr. Hj. Elfi Yenni, MARS Yayat Hariman, S.Farm dr. Rinaldy Sinaga Masykur, S.
NIP. 196801302000022001 NIP. 198302082006041008 NIP.197504122005011010 NRPK.05.7.05

CATATAN :
1 Harap mengisi laporan sesuai Format
2 Jumlah kunjungan harap di isi
3 Jika ada permintaan rangkap 3, tidak ada permintaan rangkap 1
4 jika ada tambahan item obat. Harap di isi di kolom tambahan setelah no. 44
 LB.2

2
0 2 1

LB.2)
PEMBERIAN TAHUN TAHUN
NO. BATCH KET
APBD LAIN JUMLAH PENGADAAN Exp

12 13 14 15 16 17
 JUMLAH
491

Yang Menerima,
Petugas Puskesmas

Masykur, S. Farm
NRPK.05.7.0510987