SEKRETARIAT JENDERAL KEMHAN

ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : OKTOBER
Unit/ Poli yang membutuhkan : Polban Pusdiklat Te Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 300
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 0 0
4. Ampicillin 500 mg Tablet Obat bln Oktober
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.0-10-2018
7. Acyclovir 200 mg Tablet 0 0
8. Bactrim Adult Tablet 0 0
9. Bactrim Forte Tablet 300
10. Bactrim Syrup Botol 0 0
11. Cephadroxil 500 MG Tablet 300
12. Cephadroxil syrup Botol 0 0
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 0
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 0
29. Lincomycin 500 mg Tablet 0 0 0
30. Thiampenicol 500 mg Tablet 0 0
31. Thiampenicol Syrup Botol 0 0
32 Cefixime 100 mg Tablet 0
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 0 0 0
35 Ketokonazole Tablet 0
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 1 0
2. Ambroxol 30 mg Tablet
3. Ambroxol syrup Botol
4. OBH Syrup Botol 19
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 0
13. Alphara Tablet 300
14. Zenirex Syrup Botol 0
15. Molexflu / Paraflu Tablet 300
16 Gryceryl guaiacolate 100mg Tablet 1000
3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 0
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 0
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 0 0 0
8. Lambucid Tablet 200
9. Lambucid Syrup Botol 21 1 20
10. Loperamid Tablet
11. Librozym / Vitazym Tablet
12. Molagit / New Diatab Tablet 0
13. Neo kaominal Syrup Botol
14. Omeperazole Tablet 0 0
15. Oralit Sach 0
16. Papaverin Tablet
17. Primperan/Ondansentron/Lexaparm Tablet 0
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 200
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 0 0 0
22. Estalex 50 mg Tablet .
23. Superhoid Supp Supp 0
24. Plantacid Syrup Botol 6 0
25 Hufadon Syrup Botol 0
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 120 120
2. Amlodipine 10 mg Tablet 150 10 140
3. Aptor Tablet 0

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 0 0
5. Captopril 25 mg Tablet 300 300 300
6. Captopril 12,5 mg Tablet 300 20 280
7. Bisoprolol 5 mg Tablet
8. Diltiazem 30 mg Tablet 100 100
9. Furosemide 40 mg Tablet 0
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 0
12. Nifedipin 10 mg Tablet
13. Valsartan 80 mg Tablet 0 0
14. Valsartan 160 mg Tablet 0
15. Salbutamol 2 mg Tablet
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 0 0 0
2. Allopurinol 300 mg Tablet
3. Antalgin Tablet
4. Asam Mefenamat Tablet 200
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 0 0
7. Natrium diklofenac 50 mg Tablet 0
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet
12. Parasetamol 500 mg Tablet
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 0 0 0

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 0 0

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 0 0
3. Dexametasone Tablet 0
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 0 0
3. Dexteem Plus Tablet 0
4. Methylprednisolon 4 mg Tablet

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 0
2. Metfromin 500 mg Tablet 200
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 200 10 190
5. Simvastatin 20 mg Tablet 0 0 0
6. Gemfibrozil 300 mg Tablet 0
7. Myonal Tablet

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 0
2. Erlamycetin Tetes Telinga Flesh 0 0
3. Cendophenicol eye Tube
4. Cendo Minidose Eye Fresh Strip 0

C. OBAT MULUT
1. Molexdine Gargle Botol 0
2. GOM Botol

D. OBAT KULIT
1. Acyclovir Tube 0
2. Betasone Cream 15 gr Tube
3. Chloramfecort Tube
4. Gentamicin Tube
5. Hydrocortison 25 mg Tube
6. Kemicetin Tube 0 0 0
7. Miconazole Tube
8. PK Pot
9. Salicyl Talk Botol
10. Salep 24 Pot 0

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 200
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex/ Hufaneuron Tablet 200
7. Siobion Tablet

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 0

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol
4. Rivanol Sol Botol 0
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 0
8. Ringer Lactat Infus Kolf 0
9. Dextrose Infus Kolf 0
10. Hansaplast Pak 0 0
11. Kapas gulung Gulung
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 0
16. Kassa Steril Pak
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 0
24. Hand schoon 'M Box 0
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 0
28. Microphore Pcs 0
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs
34. Infus Set Pcs 0

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Kacih
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : SEPTEMBER
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 1034 1034 384 650
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 3 3 0 3
4. Ampicillin 500 mg Tablet Obat bln September
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.06-09-2018
7. Acyclovir 200 mg Tablet 190 190 60 130
8. Bactrim Adult Tablet 90 90 30 60
9. Bactrim Forte Tablet 92 92 82 10
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 162 162 22 140
12. Cephadroxil syrup Botol 5 5 2 3
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 70 70 0 70
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 100 100 0 100

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 100 100 0 100
29. Lincomycin 500 mg Tablet 80 80 80 0
30. Thiampenicol 500 mg Tablet 60 60 10 50
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 0 150 150 30 120
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 1 1 1 0
35 Ketokonazole Tablet 20 150 170 80 90
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 280 280 100 180
3. Ambroxol syrup Botol 5 5 1 4
4. OBH Syrup Botol 3 3 3 0
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 260 260 140 120
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 68 68 0 68
13. Alphara Tablet 250 150 400 130 270
14. Zenirex Syrup Botol 12 12 2 10
15. Molexflu / Paraflu Tablet 200 150 350 110 240

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 100 100 0 100
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 5 35
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 0 0 0
8. Lambucid Tablet 474 474 114 360
9. Lambucid Syrup Botol 1 8 9 3 6
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 79 79 54 25
12. Molagit / New Diatab Tablet 130 130 100 30
13. Neo kaominal Syrup Botol 1 8 9 3 6
14. Omeperazole Tablet 194 194 104 90
15. Oralit Sach 12 12 3 9
16. Papaverin Tablet
17. Primperan/Ondansentron/Lexaparm Tablet 104 104 0 104
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 516 516 371 145
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 5 5 5 0
22. Estalex 50 mg Tablet 180 150 330 80 250 .
23. Superhoid Supp Supp 12 12 3 9
24. Plantacid Syrup Botol 0 8 8 3 5
25 Hufadon Syrup Botol 3 3 0 3
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 205 205 115 90
2. Amlodipine 10 mg Tablet 160 180 340 140 200
3. Aptor Tablet 130 130 10 120

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 80 80 0 80
5. Captopril 25 mg Tablet 50 50 50 0
6. Captopril 12,5 mg Tablet 110 110 0 110
7. Bisoprolol 5 mg Tablet 360 360 60 300
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 140 140 0 140
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 110 110 0 110
12. Nifedipin 10 mg Tablet
13. Valsartan 80 mg Tablet 120 120 0 120
14. Valsartan 160 mg Tablet 120 120 0 120
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 80 80 80 0
2. Allopurinol 300 mg Tablet 150 150 30 120
3. Antalgin Tablet
4. Asam Mefenamat Tablet 570 300 870 316 554
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 270 270 20 250
7. Natrium diklofenac 50 mg Tablet 50 50 10 40
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 416 416 136 280
12. Parasetamol 500 mg Tablet 420 420 166 254
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 60 60 60 0

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 38 38 18 20

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 270 270 150 120
3. Dexametasone Tablet 244 244 44 200
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 0 0
3. Dexteem Plus Tablet 220 220 50 170
4. Methylprednisolon 4 mg Tablet 580 580 140 440

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 420 420 140 280
2. Metfromin 500 mg Tablet 700 400 1100 420 680
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 200 200 150 50
5. Simvastatin 20 mg Tablet 10 10 10 0
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 20 20 10 10

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 4 4 0 4
2. Erlamycetin Tetes Telinga Flesh 2 2 0 2
3. Cendophenicol eye Tube 1 1 0 1
4. Cendo Minidose Eye Fresh Strip 2 2 0 2

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 1 1
2. GOM Botol 5 5 1 4

D. OBAT KULIT
1. Acyclovir Tube 9 9 1 8
2. Betasone Cream 15 gr Tube 30 30 7 23
3. Chloramfecort Tube 42 42 1 41
4. Gentamicin Tube 8 8 5 3
5. Hydrocortison 25 mg Tube 6 6 0 6
6. Kemicetin Tube 2 2 2 0
7. Miconazole Tube 13 36 49 17 32
8. PK Pot
9. Salicyl Talk Botol 5 5 0 5
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 830 830 395 435
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 350 350 160 190
7. Siobion Tablet 230 230 110 120

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 1 1 0 1

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 3 2
4. Rivanol Sol Botol 2 2 0 2
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 11 11 0 11
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 15 15 8 7
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 1 2
34. Infus Set Pcs 3 3 1 2

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : AGUSTUS
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 844 400 1244 210 1034
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 3 3 0 3
4. Ampicillin 500 mg Tablet Obat bln Agustus
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.06-08-2018
7. Acyclovir 200 mg Tablet 200 200 10 190
8. Bactrim Adult Tablet 90 90 90
9. Bactrim Forte Tablet 92 92 92
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 182 182 20 162
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 30 70
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 100 100 0 100

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 110 110 10 100
29. Lincomycin 500 mg Tablet 80 80 80 0
30. Thiampenicol 500 mg Tablet 60 60 30 30
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 50 50 50 0
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 1 1 0 1
35 Ketokonazole Tablet 30 30 10 20
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 190 200 390 110 280
3. Ambroxol syrup Botol 5 5 0 5
4. OBH Syrup Botol 5 5 2 3
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 370 370 110 260
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 68 68 0 68
13. Alphara Tablet 380 380 130 250
14. Zenirex Syrup Botol 12 12 0 12
15. Molexflu / Paraflu Tablet 260 260 60 200

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 10 100 110 10 100
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 0 0 0
8. Lambucid Tablet 524 524 50 474
9. Lambucid Syrup Botol 3 3 2 1
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 134 134 55 79
12. Molagit / New Diatab Tablet 264 264 134 130
13. Neo kaominal Syrup Botol 3 3 2 1
14. Omeperazole Tablet 214 214 20 194
15. Oralit Sach 19 19 7 12
16. Papaverin Tablet
17. Primperan/Ondansentron/Lexaparm Tablet 120 120 16 104
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 656 656 140 516
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 5 5 5
22. Estalex 50 mg Tablet 60 150 210 30 180
23. Superhoid Supp Supp 19 19 7 12
24. Plantacid Syrup Botol 0 0 0
25 Hufadon Syrup Botol 3 3 3
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 310 310 105 205
2. Amlodipine 10 mg Tablet 260 260 100 160
3. Aptor Tablet 140 140 10 130

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 80 80 80
5. Captopril 25 mg Tablet 60 60 10 50
6. Captopril 12,5 mg Tablet 110 110 110
7. Bisoprolol 5 mg Tablet 10 400 410 50 360
8. Diltiazem 30 mg Tablet 100 100 100
9. Furosemide 40 mg Tablet 140 140 140
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 110 110 110
12. Nifedipin 10 mg Tablet
13. Valsartan 80 mg Tablet
14. Valsartan 160 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 100 100 20 80
2. Allopurinol 300 mg Tablet 100 100 200 50 150
3. Antalgin Tablet
4. Asam Mefenamat Tablet 284 400 684 114 570
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 270 270 270
7. Natrium diklofenac 50 mg Tablet 80 80 30 50
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 496 496 80 416
12. Parasetamol 500 mg Tablet 540 540 130 410
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 70 70 10 60

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 68 68 30 38

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 90 250 340 70 270
3. Dexametasone Tablet 34 300 334 90 244
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 0 0
3. Dexteem Plus Tablet 220 220 220
4. Methylprednisolon 4 mg Tablet 420 300 720 140 580

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 190 300 490 70 420
2. Metfromin 500 mg Tablet 590 300 890 190 700
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 10 200 210 10 200
5. Simvastatin 20 mg Tablet 50 50 50 0
6. Gemfibrozil 300 mg Tablet 70 70 70
7. Myonal Tablet 30 30 10 20

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 4 4 0 4
2. Erlamycetin Tetes Telinga Flesh 2 2 0 2
3. Cendophenicol eye Tube 1 1 0 1
4. Cendo Minidose Eye Fresh Strip 4 4 2 2

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 1 1
2. GOM Botol 5 5 1 4

D. OBAT KULIT
1. Acyclovir Tube 9 9 0 9
2. Betasone Cream 15 gr Tube 4 36 40 10 30
3. Chloramfecort Tube 43 43 1 42
4. Gentamicin Tube 9 9 1 8
5. Hydrocortison 25 mg Tube 6 6 0 6
6. Kemicetin Tube 6 6 4 2
7. Miconazole Tube 21 21 8 13
8. PK Pot
9. Salicyl Talk Botol 5 5 0 5
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 645 300 945 115 830
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 500 500 150 350
7. Siobion Tablet 240 240 10 230

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 1 1 1

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 5
4. Rivanol Sol Botol 2 2 2
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 3
8. Ringer Lactat Infus Kolf 3 3 3
9. Dextrose Infus Kolf 2 2 2
10. Hansaplast Pak 1 1 1
11. Kapas gulung Gulung 16 16 5 11
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 8 10 18 3 15
16. Kassa Steril Pak 2 2 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 1
24. Hand schoon 'M Box 1 1 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 1
28. Microphore Pcs 1 1 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 3
34. Infus Set Pcs 3 3 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : JULI
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 610 400 1010 166 844
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 4 4 1 3
4. Ampicillin 500 mg Tablet Obat bln Juli
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.03-07-2018
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 90
9. Bactrim Forte Tablet 92 92 92
10. Bactrim Syrup Botol 3 3 3
11. Cephadroxil 500 MG Tablet 212 212 30 182
12. Cephadroxil syrup Botol 5 5 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 100
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 100 100 100

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 110 110 110
29. Lincomycin 500 mg Tablet 80 80 80
30. Thiampenicol 500 mg Tablet 60 60 60
31. Thiampenicol Syrup Botol 1 1 1
32 Cefixime 100 mg Tablet 120 120 70 50
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 2 2 1 1
35 Ketokonazole Tablet 50 50 20 30
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 320 320 130 190
3. Ambroxol syrup Botol 5 5 5
4. OBH Syrup Botol 14 14 10 4
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 470 470 100 370
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 68 68 68
13. Alphara Tablet 520 520 140 380
14. Zenirex Syrup Botol 14 14 2 12
15. Molexflu Tablet 390 390 130 260

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 30 30 20 10
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 10 10 10 0
8. Lambucid Tablet 564 564 40 524
9. Lambucid Syrup Botol 3 3 3
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 174 174 40 134
12. Molagit / New Diatab Tablet 224 150 374 110 264
13. Neo kaominal Syrup Botol 3 3 3
14. Omeperazole Tablet 64 150 214 214
15. Oralit Sach 19 19 19
16. Papaverin Tablet
17. Primperan/Ondansentron/Lexaparm Tablet 140 140 20 120
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 420 300 720 64 656
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 26 26 21 5
22. Estalex 50 mg Tablet 70 70 20 50
23. Superhoid Supp Supp 19 19 19
24. Plantacid Syrup Botol 0 0 0
25 Hufadon Syrup Botol 3 3 3
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 440 440 130 310
2. Amlodipine 10 mg Tablet 330 330 70 260
3. Aptor Tablet 140 140 140

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 20 80
5. Captopril 25 mg Tablet 70 70 10 60
6. Captopril 12,5 mg Tablet 110 110 110
7. Bisoprolol 5 mg Tablet 40 40 30 10
8. Diltiazem 30 mg Tablet 100 100 100
9. Furosemide 40 mg Tablet 240 240 100 140
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 210 210 100 110
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 110 110 10 100
2. Allopurinol 300 mg Tablet 120 120 20 100
3. Antalgin Tablet
4. Asam Mefenamat Tablet 440 440 156 284
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 270 270 270
7. Natrium diklofenac 50 mg Tablet 100 100 20 80
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 550 550 54 496
12. Parasetamol 500 mg Tablet 620 620 80 540
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 90 90 20 70

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 88 88 30 58

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 130 130 40 90
3. Dexametasone Tablet 104 104 70 34
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 0 0
3. Dexteem Plus Tablet 240 240 24 216
4. Methylprednisolon 4 mg Tablet 420 100 520 100 420

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 170 100 270 80 190
2. Metfromin 500 mg Tablet 250 500 750 160 590
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 10 10 10
5. Simvastatin 20 mg Tablet 100 100 50 50
6. Gemfibrozil 300 mg Tablet 70 70 70
7. Myonal Tablet 30 30 30

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 4 4 4
2. Erlamycetin Tetes Telinga Flesh 2 2 2
3. Cendophenicol eye Tube 1 1 1
4. Cendo Minidose Eye Fresh Strip 4 4 4

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 2
2. GOM Botol 6 6 1 5

D. OBAT KULIT
1. Acyclovir Tube 11 11 2 9
2. Betasone Cream 15 gr Tube 4 4 4
3. Chloramfecort Tube 8 36 44 1 43
4. Gentamicin Tube 10 10 1 9
5. Hydrocortison 25 mg Tube 6 6 6
6. Kemicetin Tube 6 6 6
7. Miconazole Tube 24 24 3 21
8. PK Pot
9. Salicyl Talk Botol 5 5 5
10. Salep 24 Pot 3 3 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 430 300 730 85 645
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 380 200 580 90 490
7. Siobion Tablet 250 250 10 240

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 2 2 1 1

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 5
4. Rivanol Sol Botol 2 2 2
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 3
8. Ringer Lactat Infus Kolf 3 3 3
9. Dextrose Infus Kolf 2 2 2
10. Hansaplast Pak 1 1 1
11. Kapas gulung Gulung 16 16 16
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 5 5 10 2 8
16. Kassa Steril Pak 2 2 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : JUNI
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 420 300 720 110 610
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 5 5 1 4
4. Ampicillin 500 mg Tablet Obat bln Juni
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.05-06-2018
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 92 92 0 92
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 222 222 10 212
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 0 100
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 100 100 0 100

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 110 110 0 110
29. Lincomycin 500 mg Tablet 80 80 0 80
30. Thiampenicol 500 mg Tablet 60 60 0 60
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 160 160 40 120
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 2 2 0 2
35 Ketokonazole Tablet 50 50 0 50
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 390 390 70 320
3. Ambroxol syrup Botol 0 5 5 0 5
4. OBH Syrup Botol 11 10 21 7 14
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 240 300 540 80 460
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 68 68 0 68
13. Alphara Tablet 440 150 590 70 520
14. Zenirex Syrup Botol 14 14 0 14
15. Molexflu Tablet 325 150 475 85 390

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 50 50 20 30
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 10 10 0 10
8. Lambucid Tablet 400 200 600 36 564
9. Lambucid Syrup Botol 5 5 2 3
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 94 94 25 69
12. Molagit / New Diatab Tablet 100 150 250 26 224
13. Neo kaominal Syrup Botol 4 4 1 3
14. Omeperazole Tablet 74 74 10 64
15. Oralit Sach 19 19 0 19
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 140 140 0 140
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 270 270 60 210
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 26 26 0 26
22. Estalex 50 mg Tablet 70 70 0 70
23. Superhoid Supp Supp 19 19 0 19
24. Plantacid Syrup Botol 0 0 0 0
25 Hufadon Syrup Botol 3 3 0 3
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 470 470 30 440
2. Amlodipine 10 mg Tablet 270 150 420 90 330
3. Aptor Tablet 140 140 0 140

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 90 90 20 70
6. Captopril 12,5 mg Tablet 110 110 0 110
7. Bisoprolol 5 mg Tablet 60 60 20 40
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 80 200 280 40 240
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 10 200 210 0 210
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 110 110 0 110
2. Allopurinol 300 mg Tablet 150 150 30 120
3. Antalgin Tablet
4. Asam Mefenamat Tablet 534 534 94 440
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 280 280 10 270
7. Natrium diklofenac 50 mg Tablet 230 230 130 100
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 400 200 600 50 550
12. Parasetamol 500 mg Tablet 500 200 700 80 620
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 90 90 0 90

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 88 88 0 88

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 140 140 10 130
3. Dexametasone Tablet 154 154 50 104
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 200 200 0 200
3. Dexteem Plus Tablet 150 100 250 10 240
4. Methylprednisolon 4 mg Tablet 200 300 500 80 420

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 240 240 70 170
2. Metfromin 500 mg Tablet 360 360 110 250
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 10 10 0 10
5. Simvastatin 20 mg Tablet 110 110 10 100
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 10 30

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 4 4 0 4
2. Erlamycetin Tetes Telinga Flesh 2 2 0 2
3. Cendophenicol eye Tube 1 1 0 1
4. Cendo Minidose Eye Fresh Strip 4 4 1 3

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 3 5 8 2 6

D. OBAT KULIT
1. Acyclovir Tube 13 13 2 11
2. Betasone Cream 15 gr Tube 4 4 0 4
3. Chloramfecort Tube 8 8 0 8
4. Gentamicin Tube 12 12 2 10
5. Hydrocortison 25 mg Tube 6 6 2 4
6. Kemicetin Tube 6 6 1 5
7. Miconazole Tube 0 24 24 0 24
8. PK Pot
9. Salicyl Talk Botol 5 5 0 5
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 190 300 490 60 430
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 220 200 420 40 380
7. Siobion Tablet 260 260 10 250

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 3 3 1 2

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 0 5
4. Rivanol Sol Botol 3 3 1 2
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 16 16 0 16
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 7 7 2 5
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : MEI
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 440 200 640 220 420
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 5 5 0 5
4. Ampicillin 500 mg Tablet Obat bln Mei
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.04-05-2018
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 92 92 0 92
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 254 254 32 222
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 0 100
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 200 200 100 100

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 120 120 10 110
29. Lincomycin 500 mg Tablet 100 100 20 80
30. Thiampenicol 500 mg Tablet 60 60 0 60
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 250 250 90 160
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 3 3 1 2
35 Ketokonazole Tablet 60 60 10 50
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 246 200 446 56 390
3. Ambroxol syrup Botol 5 5 5 0
4. OBH Syrup Botol 10 10 20 9 11
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 300 100 400 160 240
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 68 68 0 68
13. Alphara Tablet 470 470 40 430
14. Zenirex Syrup Botol 22 22 8 14
15. Molexflu Tablet 480 480 155 325

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 60 60 10 50
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 64 64 54 10
8. Lambucid Tablet 270 200 470 70 400
9. Lambucid Syrup Botol 5 5 0 5
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 170 170 76 94
12. Molagit / New Diatab Tablet 170 170 70 100
13. Neo kaominal Syrup Botol 4 4 0 4
14. Omeperazole Tablet 104 104 30 74
15. Oralit Sach 23 23 4 19
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 150 150 10 140
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 205 200 405 135 270
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 26 26 0 26
22. Estalex 50 mg Tablet 70 70 0 70
23. Superhoid Supp Supp 19 19 0 19
24. Plantacid Syrup Botol 0 0 0
25 Hufadon Syrup Botol 4 4 1 3
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 290 210 500 30 470
2. Amlodipine 10 mg Tablet 200 210 410 140 270
3. Aptor Tablet 140 140 0 140

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 100 100 10 90
6. Captopril 12,5 mg Tablet 140 140 30 110
7. Bisoprolol 5 mg Tablet 100 100 40 60
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 80 80 0 80
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 10 10 0 10
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 110 110 0 110
2. Allopurinol 300 mg Tablet 170 170 20 150
3. Antalgin Tablet
4. Asam Mefenamat Tablet 434 200 634 100 534
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 290 290 10 280
7. Natrium diklofenac 50 mg Tablet 150 100 250 20 230
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 526 526 126 400
12. Parasetamol 500 mg Tablet 472 200 672 172 500
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 120 120 30 90

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 128 128 40 88

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 190 190 50 140
3. Dexametasone Tablet 154 154 0 154
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 0 0 0 0
3. Dexteem Plus Tablet 90 100 190 40 150
4. Methylprednisolon 4 mg Tablet 40 200 240 40 200

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 240 240 0 240
2. Metfromin 500 mg Tablet 400 400 40 360
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 20 20 10 10
5. Simvastatin 20 mg Tablet 120 120 10 110
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 0 40

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 5 5 1 4
2. Erlamycetin Tetes Telinga Flesh 2 2 0 2
3. Cendophenicol eye Tube 1 1 0 1
4. Cendo Minidose Eye Fresh Strip 5 5 1 4

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 5 5 2 3

D. OBAT KULIT
1. Acyclovir Tube 15 15 2 13
2. Betasone Cream 15 gr Tube 8 8 4 4
3. Chloramfecort Tube 9 9 1 8
4. Gentamicin Tube 13 13 1 12
5. Hydrocortison 25 mg Tube 7 7 1 6
6. Kemicetin Tube 9 9 3 6
7. Miconazole Tube 0 0 0
8. PK Pot
9. Salicyl Talk Botol 5 5 0 5
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 360 100 460 270 190
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 426 426 216 210
7. Siobion Tablet 120 250 370 110 260

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 3 3 0 3

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 0 5
4. Rivanol Sol Botol 4 4 1 3
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 17 17 1 16
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 12 12 5 7
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : APRIL
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 300 300 600 160 440
2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 5 5 0 5
4. Ampicillin 500 mg Tablet Obat bln April
5. Ampicillin syrup Tablet tahun 2018
6. Acyclovir 400 mg Tablet terima tgl.9 -04 -2018
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 100 100 8 92
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 100 200 300 46 254
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 0 100
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 200 200 0 200

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 120 120 10 110
29. Lincomycin 500 mg Tablet 100 100 0 100
30. Thiampenicol 500 mg Tablet 80 80 20 60
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 0 250 250 0 250
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 3 3 0 3
35 Ketokonazole Tablet 60 60 0 60
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 0 0 0
2. Ambroxol 30 mg Tablet 366 366 120 246
3. Ambroxol syrup Botol 2 5 7 2 5
4. OBH Syrup Botol 0 25 25 15 10
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 5 300 305 5 300
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 80 80 12 68
13. Alphara Tablet 300 300 600 130 470
14. Zenirex Syrup Botol 3 24 27 5 22
15. Molexflu Tablet 300 300 600 120 480

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 60 60 0 60
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 64 64 64
8. Lambucid Tablet 0 400 400 130 270
9. Lambucid Syrup Botol 5 5 0 5
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 190 190 20 170
12. Molagit / New Diatab Tablet 90 150 240 70 170
13. Neo kaominal Syrup Botol 5 5 1 4
14. Omeperazole Tablet 0 120 120 16 104
15. Oralit Sach 26 26 3 23
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 150 150 0 150
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 245 245 40 205
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 44 44 18 26
22. Estalex 50 mg Tablet 80 80 10 70
23. Superhoid Supp Supp 19 19 0 19
24. Plantacid Syrup Botol 1 1 1 0
25 Hufadon Syrup Botol 4 4 0 4
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 330 330 40 290
2. Amlodipine 10 mg Tablet 270 270 90 180
3. Aptor Tablet 140 140 0 140

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 150 150 50 100
6. Captopril 12,5 mg Tablet 40 100 140 0 140
7. Bisoprolol 5 mg Tablet 100 100 0 100
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 80 80 0 80
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 10 10 0 10
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 140 140 30 110
2. Allopurinol 300 mg Tablet 190 190 20 170
3. Antalgin Tablet
4. Asam Mefenamat Tablet 484 484 50 434
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 320 320 30 290
7. Natrium diklofenac 50 mg Tablet 200 200 50 150
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 336 300 636 120 516
12. Parasetamol 500 mg Tablet 412 200 612 170 442
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 120 120 0 120

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 128 128 0 128

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 220 220 40 180
3. Dexametasone Tablet 254 254 100 154
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 30 30 30 0
3. Dexteem Plus Tablet 130 130 40 90
4. Methylprednisolon 4 mg Tablet 170 170 170 0

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 350 350 110 240
2. Metfromin 500 mg Tablet 510 510 110 400
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 70 70 50 20
5. Simvastatin 20 mg Tablet 40 100 140 20 120
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 0 40

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 0 5 5 1 4
2. Erlamycetin Tetes Telinga Flesh 2 2 0 2
3. Cendophenicol eye Tube 3 3 2 1
4. Cendo Minidose Eye Fresh Strip 1 5 6 1 5

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 5 5 0 5

D. OBAT KULIT
1. Acyclovir Tube 15 15 0 15
2. Betasone Cream 15 gr Tube 8 8 0 8
3. Chloramfecort Tube 9 9 0 9
4. Gentamicin Tube 4 10 14 1 13
5. Hydrocortison 25 mg Tube 7 7 1 6
6. Kemicetin Tube 9 9 0 9
7. Miconazole Tube 0 0 0 0
8. PK Pot
9. Salicyl Talk Botol 5 5 1 4
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 292 200 492 152 340
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 424 200 624 198 426
7. Siobion Tablet 145 145 25 120

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 3 3 0 3

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 0 5
4. Rivanol Sol Botol 4 4 0 4
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 17 17 0 17
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 12 12 2 10
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : MARET
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 490 100 590 290 300 Obat bln Maret
2. Amoxillin 250 mg Tablet tahun 2018
3. Amoxillin syrup Botol 5 5 0 5 terima tgl.07-03 -2018
4. Ampicillin 500 mg Tablet
5. Ampicillin syrup Tablet
6. Acyclovir 400 mg Tablet
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 100 100 0 100
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 190 190 90 100
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 100 100 0 100
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 200 200 0 200

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 130 130 10 120
29. Lincomycin 500 mg Tablet 0 100 100 0 100
30. Thiampenicol 500 mg Tablet 80 80 0 80
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 22 22 22 0
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 4 4 1 3
35 Ketokonazole Tablet 80 80 20 60
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 1 1 1 0
2. Ambroxol 30 mg Tablet 136 300 436 70 366
3. Ambroxol syrup Botol 3 3 1 2
4. OBH Syrup Botol 1 1 1 0
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 190 190 185 5
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 80 80 0 80
13. Alphara Tablet 300 150 450 150 300
14. Zenirex Syrup Botol 13 13 10 3
15. Molexflu Tablet 300 150 450 150 300

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 60 60 0 60
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 70 70 6 64
8. Lambucid Tablet 0 0
9. Lambucid Syrup Botol 6 6 1 5
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 190 190 190
12. Molagit / New Diatab Tablet 180 180 90 90
13. Neo kaominal Syrup Botol 5 5 0 5
14. Omeperazole Tablet 0 0 0
15. Oralit Sach 4 25 29 3 26
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 150 150 0 150
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 103 200 303 58 245
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 44 44 0 44
22. Estalex 50 mg Tablet 80 80 0 80
23. Superhoid Supp Supp 19 19 0 19
24. Plantacid Syrup Botol 5 5 4 1
25 Hufadon Syrup Botol 4 4 0 4
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 350 150 500 170 330
2. Amlodipine 10 mg Tablet 250 150 400 130 270
3. Aptor Tablet 240 240 100 140

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 90 100 190 40 150
6. Captopril 12,5 mg Tablet 40 40 40
7. Bisoprolol 5 mg Tablet 100 100 200 100 100
8. Diltiazem 30 mg Tablet 100 100 100
9. Furosemide 40 mg Tablet 180 180 100 80
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 110 110 100 10
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 140 140 0 140
2. Allopurinol 300 mg Tablet 210 210 20 190
3. Antalgin Tablet
4. Asam Mefenamat Tablet 600 600 116 484
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 340 340 20 320
7. Natrium diklofenac 50 mg Tablet 50 150 200 0 200
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 436 436 100 336
12. Parasetamol 500 mg Tablet 502 502 90 412
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 170 170 50 120

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 148 148 20 128

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 70 200 270 50 220
3. Dexametasone Tablet 314 314 60 254
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 30 30 0 30
3. Dexteem Plus Tablet 140 140 10 130
4. Methylprednisolon 4 mg Tablet 29 200 229 59 170

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 470 470 120 350
2. Metfromin 500 mg Tablet 690 690 180 510
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 130 130 60 70
5. Simvastatin 20 mg Tablet 70 70 30 40
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 0 40

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 0 0 0
2. Erlamycetin Tetes Telinga Flesh 4 4 2 2
3. Cendophenicol eye Tube 3 3 0 3
4. Cendo Minidose Eye Fresh Strip 4 4 3 1

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 5 5 0 5

D. OBAT KULIT
1. Acyclovir Tube 15 15 0 15
2. Betasone Cream 15 gr Tube 8 8 0 8
3. Chloramfecort Tube 10 10 1 9
4. Gentamicin Tube 6 6 2 4
5. Hydrocortison 25 mg Tube 7 7 0 7
6. Kemicetin Tube 13 13 4 9
7. Miconazole Tube 5 5 5 0
8. PK Pot
9. Salicyl Talk Botol 6 6 1 5
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 401 401 109 292
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 600 600 176 424
7. Siobion Tablet 165 165 20 145

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 3 5 8 0 8

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 5 5 0 5
4. Rivanol Sol Botol 4 4 0 4
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 19 19 2 17
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 5 10 15 3 12
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : PEBRUARII
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 370 300 670 180 490 Obat bln Pebruari
2. Amoxillin 250 mg Tablet tahun 2018
3. Amoxillin syrup Botol 1 5 6 1 5 terima tgl.08-02 -2018
4. Ampicillin 500 mg Tablet
5. Ampicillin syrup Tablet
6. Acyclovir 400 mg Tablet
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 100 100 0 100
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 180 100 280 90 190
12. Cephadroxil syrup Botol 5 5 0 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 200 200 0 200

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 150 150 20 130
29. Lincomycin 500 mg Tablet 80 80 80 0
30. Thiampenicol 500 mg Tablet 90 90 10 80
31. Thiampenicol Syrup Botol 1 1 0 1
32 Cefixime 100 mg Tablet 64 64 42 22
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 5 5 1 4
35 Ketokonazole Tablet 90 90 10 80
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 4 4 3 1
2. Ambroxol 30 mg Tablet 206 206 70 136
3. Ambroxol syrup Botol 5 5 2 3
4. OBH Syrup Botol 12 12 11 1
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 240 100 340 150 190
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 80 80 0 80
13. Alphara Tablet 150 300 450 150 300
14. Zenirex Syrup Botol 16 16 3 13
15. Molexflu Tablet 90 300 390 90 300

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 60 60 0 60
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 100 100 30 70
8. Lambucid Tablet
9. Lambucid Syrup Botol 6 6 0 6
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 164 100 264 74 190
12. Molagit / New Diatab Tablet 100 150 250 70 180
13. Neo kaominal Syrup Botol
14. Omeperazole Tablet 0 0 0
15. Oralit Sach 7 7 3 4
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 150 150 0 150
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 180 180 77 103
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 50 50 6 44
22. Estalex 50 mg Tablet 90 90 10 80
23. Superhoid Supp Supp 7 12 19 0 19
24. Plantacid Syrup Botol 2 6 8 3 5
25 Hufadon Syrup Botol 4 4 0 4
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 180 210 390 40 350
2. Amlodipine 10 mg Tablet 110 210 320 70 250
3. Aptor Tablet 40 200 240 0 240

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 140 140 50 90
6. Captopril 12,5 mg Tablet 40 40 0 40
7. Bisoprolol 5 mg Tablet 100 100 0 100
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 0 200 200 20 180
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 10 100 110 0 110
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet 100 100 0 100
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 150 150 10 140
2. Allopurinol 300 mg Tablet 230 230 20 210
3. Antalgin Tablet
4. Asam Mefenamat Tablet 270 400 670 70 600
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 390 390 50 340
7. Natrium diklofenac 50 mg Tablet 110 110 60 50
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 336 200 536 100 436
12. Parasetamol 500 mg Tablet 644 644 142 502
13. Parasetamol Syrup / Itramol Botol 0
14. Piroxicam 10 mg Tablet 170 170 0 170

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 190 190 42 148

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 100 100 30 70
3. Dexametasone Tablet 374 374 60 314
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 60 60 30 30
3. Dexteem Plus Tablet 60 100 160 20 140
4. Methylprednisolon 4 mg Tablet 139 139 110 29

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 300 200 500 30 470
2. Metfromin 500 mg Tablet 310 400 710 20 690
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 130 130 0 130
5. Simvastatin 20 mg Tablet 90 90 20 70
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 0 40

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 1 1 1 0
2. Erlamycetin Tetes Telinga Flesh 6 6 2 4
3. Cendophenicol eye Drop Tube 4 4 1 3
4. Cendo Minidose Eye Fresh Strip 5 5 1 4

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 5 5 0 5

D. OBAT KULIT
1. Acyclovir Tube 18 18 3 15
2. Betasone Cream 15 gr Tube 9 9 1 8
3. Chloramfecort Tube 13 13 3 10
4. Gentamicin Tube 11 11 5 6
5. Hydrocortison 25 mg Tube 8 8 1 7
6. Kemicetin Tube 14 14 1 13
7. Miconazole Tube 15 15 10 5
8. PK Pot
9. Salicyl Talk Botol 6 6 0 6
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 276 200 476 75 401
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 400 400 800 200 600
7. Siobion Tablet 175 175 10 165

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 6 6 3 3

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 6 6 1 5
4. Rivanol Sol Botol 5 5 1 4
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 0 1
11. Kapas gulung Gulung 19 19 0 19
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 8 8 3 5
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

BULAN : JANUARI
Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :
Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

SISA YG JUMLAH SISA YG Kwantitas

NO NAMA OBAT SATUAN PENERIMAAN PEMAKAIAN KET
LALU PERSEDIAAN ADA Diminta Diberi
1 2 3 4 5 6 7 8 9 10 11
I. ANTIBIOTIKA
1. Amoxillin 500 mg Tablet 590 590 220 370 Obat bln Januari
2. Amoxillin 250 mg Tablet tahun 2018
3. Amoxillin syrup Botol 1 1 0 1 terima tgl. 1 -01 -2018
4. Ampicillin 500 mg Tablet
5. Ampicillin syrup Tablet
6. Acyclovir 400 mg Tablet
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet 90 90 0 90
9. Bactrim Forte Tablet 100 100 0 100
10. Bactrim Syrup Botol 3 3 0 3
11. Cephadroxil 500 MG Tablet 200 200 20 180
12. Cephadroxil syrup Botol 6 6 1 5
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet 200 200 0 200

2
1 2 3 4 5 6 7 8 9 10 11
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Camiciclyne 500 /Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet 150 150 0 150
29. Lincomycin 500 mg Tablet 100 100 20 80
30. Thiampenicol 500 mg Tablet 90 90 0 90
31. Thiampenicol Syrup Botol 6 6 5 1
32 Cefixime 100 mg Tablet 70 50 120 56 64
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 5 5 0 5
35 Ketokonazole Tablet 90 90 0 90
II. SALURAN PERNAFASAN
1. Anti Flu Syrup Botol 7 7 3 4
2. Ambroxol 30 mg Tablet 226 226 20 206
3. Ambroxol syrup Botol 5 5 0 5
4. OBH Syrup Botol 7 10 17 5 12
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 370 370 130 240
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet 80 80 0 80
13. Alphara Tablet 90 150 240 90 150
14. Zenirex Syrup Botol 18 18 2 16
15. Molexflu Tablet 240 240 150 90

3
1 2 3 4 5 6 7 8 9 10 11
III. SALURAN PENCERNAAN
1. Adrome Tablet 60 60 0 60
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet 40 40 0 40
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 100 100 0 100
8. Lambucid Tablet
9. Lambucid Syrup Botol 0 6 6 6
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 230 230 66 164
12. Molagit / New Diatab Tablet 198 198 98 100
13. Neo kaominal Syrup Botol
14. Omeperazole Tablet 0 0 0
15. Oralit Sach 7 7 0 7
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet 150 150 0 150
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 190 190 10 180
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 70 70 20 50
22. Estalex 50 mg Tablet 90 90 0 90
23. Superhoid Supp Supp 12 12 5 7
24. Plantacid Syrup Botol 6 6 4 2
25 Hufadon Syrup Botol 4 4 0 4
IV. CARDIOVASCULER/DIURETIK
1. Amlodipine 5 mg Tablet 200 90 290 110 180
2. Amlodipine 10 mg Tablet 280 90 370 260 110
3. Aptor Tablet 240 240 200 40

4
1 2 3 4 5 6 7 8 9 10 11
4. Aspilet Tablet 100 100 0 100
5. Captopril 25 mg Tablet 140 140 0 140
6. Captopril 12,5 mg Tablet 40 40 0 40
7. Bisoprolol 5 mg Tablet 190 190 90 100
8. Diltiazem 30 mg Tablet 100 100 0 100
9. Furosemide 40 mg Tablet 160 160 160 0
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 210 210 200 10
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet
16 Salbutamol 4 mg Tablet

V.ANALGETIKA/ANTIPIRETIK/
NEUROMUSKULER/ANTIREUMATIK
1. Allopurinol 100 mg Tablet 170 170 20 150
2. Allopurinol 300 mg Tablet 30 200 230 0 230
3. Antalgin Tablet
4. Asam Mefenamat Tablet 439 439 169 270
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 390 390 0 390
7. Natrium diklofenac 50 mg Tablet 210 210 100 110
8. Hexamin Tablet 0 0
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 376 376 40 336
12. Parasetamol 500 mg Tablet 781 781 137 644
13. Parasetamol Syrup / Itramol Botol 0 0
14. Piroxicam 10 mg Tablet 180 180 10 170

5
1 2 3 4 5 6 7 8 9 10 11
15. Piroxicam 20 mg Tablet 190 190 0 190

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 150 150 50 100
3. Dexametasone Tablet 394 394 20 374
4. Prednison Botol

VII. ANTI ALERGI

1. Chlorpheramin / CTM 4 mg Tablet
2. Gabiten/Interhistin Tablet 60 60 0 60
3. Dexteem Plus Tablet 60 60 0 60
4. Methylprednisolon 4 mg Tablet 229 229 90 139

VII. METABOLISME
1. Glibenclamida 5 mg Tablet 400 400 100 300
2. Metfromin 500 mg Tablet 380 200 580 270 310
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 190 190 60 130
5. Simvastatin 20 mg Tablet 90 90 0 90
6. Gemfibrozil 300 mg Tablet 70 70 0 70
7. Myonal Tablet 40 40 0 40

VIII.CHEMOTERAPI/ANTIHELMENTES
1. Ethambutol 500 mg Tablet
2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11
B.OBAT MATA/THT
1. Erlamycetin Tetes Mata Flesh 1 1 0 1
2. Erlamycetin Tetes Telinga Flesh 8 8 2 6
3. Cendophenicol eye Drop Flesh 4 4 0 4
4. Cendo Minidose Eye Fresh Strip 5 5 0 5

C. OBAT MULUT
1. Molexdine Gargle Botol 2 2 0 2
2. GOM Botol 6 6 1 5

D. OBAT KULIT
1. Acyclovir Tube 18 18 0 18
2. Betasone Cream 15 gr Tube 9 9 0 9
3. Chloramfecort Tube 13 13 0 13
4. Gentamicin Tube 12 12 1 11
5. Hydrocortison 25 mg Tube 9 9 1 8
6. Kemicetin Tube 16 16 2 14
7. Miconazole Tube 26 26 11 15
8. PK Pot
9. Salicyl Talk Botol 6 6 0 6
10. Salep 24 Pot 3 3 0 3

E.VITAMIN & MINERAL

1. Betaminoplex Tablet
2. Caviplex Tablet 315 100 415 139 276
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 120 400 520 120 400
7. Siobion Tablet 195 195 20 175

7
1 2 3 4 5 6 7 8 9 10 11
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 7 7 1 6

F. OBAT-OBAT LAIN
1. Alkohol 70 % 1 Liter Botol
2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol 1 5 6 0 6
4. Rivanol Sol Botol 5 5 0 5
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf 3 3 0 3
8. Ringer Lactat Infus Kolf 3 3 0 3
9. Dextrose Infus Kolf 2 2 0 2
10. Hansaplast Pak 1 1 1
11. Kapas gulung Gulung 20 20 1 19
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak 10 10 2 8
16. Kassa Steril Pak 2 2 0 2
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
1 2 3 4 5 6 7 8 9 10 11
21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box 1 1 0 1
24. Hand schoon 'M Box 1 1 0 1
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box 1 1 0 1
28. Microphore Pcs 1 1 0 1
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs 3 3 0 3
34. Infus Set Pcs 3 3 0 3

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib
 SEKRETARIAT JENDERAL KEMHAN
ROUM BAG RUMGA POLIKLINIK SUBBAGYANKES

DAFTAR PEMAKAIAN BARANG FARMASI

Unit/ Poli yang membutuhkan : Polban Pusdiklat Tekfunghan Nomor :

Nama Barang : OBAT-OBAT BPJS Tanggal : 2018

BULAN
NO NAMA OBAT SATUAN
JAN PEB MAR APR MEI JUN JUL AGU SEP OCT NOV DEC
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1. Amoxillin 500 mg Tablet 90 140

2. Amoxillin 250 mg Tablet
3. Amoxillin syrup Botol 1
4. Ampicillin 500 mg Tablet
5. Ampicillin syrup Tablet
6. Acyclovir 400 mg Tablet
7. Acyclovir 200 mg Tablet
8. Bactrim Adult Tablet
9. Bactrim Forte Tablet 6
10. Bactrim Syrup Botol
11. Cephadroxil 500 MG Tablet 10 40 10
12. Cephadroxil syrup Botol
13. Chlorampenicol 250 mg Tablet
14. Chlorampenicol 500 mg Tablet
15. Chlorampenicol Syrup Tablet
16. Clindamycin 150 mg Tablet
17. Clindamycin 300 mg Tablet
18. Doxicyclin 100 mg Tablet
19. Erythromicin 500 mg / Eryra Tablet 20
20. Erythromicin 250 mg Tablet
21. Griseopulvin 500 mg Tablet

2
1 2 3 4 5 6 7 8 9 10 11 12 12 12 12
22. Griseopulvin 125 mg Tablet
23. Metronidazole 250 mg Tablet
24. Metronidazole 500 mg Tablet
25. Rifampicin 450 mg Tablet
26. Rifampicin 600 mg Tablet
27. Tetracyclin 500 mg Tablet
28. Ciprofloxacin 500 mg Tablet
29. Lincomycin 500 mg Tablet
30. Thiampenicol 500 mg Tablet 10
31. Thiampenicol Syrup Botol
32 Cefixime 100 mg Tablet 10 42
33 Cefixime 200 mg Tablet
34 Cefixime Syrup Botol 1
35 Ketokonazole Tablet 10

1. Anti Flu Syrup Botol 3

2. Ambroxol 30 mg Tablet 30 50
3. Ambroxol syrup Botol 2
4. OBH Syrup Botol 3 7
5. OBP Syrup Botol
6. Dextrosin / Dextral syrup Botol
7. Fluzep Tablet
8. Aminophillin 200 Mg Tablet
9. Grantusif Tablet 60 60 10
10. Ephedrin Tablet
11. Luminal Tablet
12. Nalgestan Tablet
13. Alphara Tablet 70 70
14. Zenirex Syrup Botol 2 3
15. Molexflu Tablet 70 100

3
1 2 3 4 5 6 7 8 9 10 11 12 12 12 12

1. Adrome Tablet
2. Ambeven Tablet
3. Antasida Doen Tablet
4. Buscopan / Scopma Tablet
5. Buscopan Injeksi Ampul
6. Cimetidine Tablet
7. Dramamine/Mantino Tablet 30
8. Lambucid Tablet 20 10
9. Lambucid Syrup Botol
10. Loperamid Tablet
11. Librozym / Vitazym Tablet 26 50
12. Molagit Tablet 66 60
13. Neo kaominal Syrup Botol
14. Omeperazole Tablet 5
15. Oralit Sach 3
16. Papaverin Tablet
17. Primperan/Ondansentron Tablet
18. Primperan Injeksi Ampul
19. Ranitidine Tablet 18 87
20. Ranitidine Injeksi Ampul
21. Spasminal Tablet 26 6
22. Estalex 50 mg Tablet 10
23. Superhoid Supp Supp 5
24. Plantacid Syrup Botol 4 2
25 Hufadon Syrup Botol
1. Amlodipine 5 mg Tablet 80 40
2. Amlodipine 10 mg Tablet 190 60
3. Aptor Tablet 100

4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
4. Aspilet Tablet
5. Captopril 25 mg Tablet 20 50
6. Captopril 12,5 mg Tablet
7. Bisoprolol 5 mg Tablet 50
8. Diltiazem 30 mg Tablet
9. Furosemide 40 mg Tablet 100 20
10. HCT 25 mg Tablet
11. Isosorbidinitrat Tablet 100
12. Nifedipin 10 mg Tablet
13. Propanolol 10 mg Tablet
14. Propanolol 40 mg Tablet
15. Salbutamol 2 mg Tablet
16 Salbutamol 4 mg Tablet

1. Allopurinol 100 mg Tablet 10 100

2. Allopurinol 300 mg Tablet 10 20
3. Antalgin Tablet
4. Asam Mefenamat Tablet 50 30
5. Diazepam 2mg Tablet
6. Natrium diklofenac 25 mg Tablet 40
7. Natrium diklofenac 50 mg Tablet 20 60
8. Hexamin Tablet
9. Meloxicam 7,5 mg Tablet
10. Molakrim Tablet
11. Neuropyron Tablet 50 90
12. Parasetamol 500 mg Tablet 60 112
13. Parasetamol Syrup / Itramol Botol
14. Piroxicam 10 mg Tablet 10

5
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15. Piroxicam 20 mg Tablet 42

VI.CORTICOSTEROID
1. Codein 10 mg Tablet
2. Cetirizine Tablet 30 30
3. Dexametasone Tablet 10 40
4. Prednison Botol

1. Chlorpheramin / CTM 4 mg Tablet

2. Gabiten/Interhistin Tablet 20
3. Dexteem Plus Tablet 10 20
4. Methylprednisolon 4 mg Tablet 60 90

1. Glibenclamida 5 mg Tablet 100 30

2. Metfromin 500 mg Tablet 180 20
3. Metformin 850 mg Tablet
4. Simvastatin 10 mg Tablet 60
5. Simvastatin 20 mg Tablet 10 20
6. Gemfibrozil 300 mg Tablet
7. Myonal Tablet

1. Ethambutol 500 mg Tablet

2. Pehadoxin Forte Tablet
3. Pyrazinamide 500 mg Tablet
4. I N H 100 MG Tablet
5. I N H 300 MG Tablet

6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1. Erlamycetin Tetes Mata Flesh 2 2

2. Erlamycetin Tetes Telinga Flesh 1 2
3. Cendophenicol eye Drop Flesh 1
4. Cendo Minidose Eye Fresh Tube 1 1

1. Molexdine Gargle Botol

2. GOM Botol

1. Acyclovir Tube 1 2
2. Betasone Cream 15 gr Tube 1 1
3. Chloramfecort Tube
4. Gentamicin Tube 3
5. Hydrocortison 25 mg Tube 2 1
6. Kemicetin Tube 1 1
7. Miconazole Tube 7 9
8. PK Pot 1
9. Salicyl Talk Botol
10. Salep 24 Pot

1. Betaminoplex Tablet
2. Caviplex Tablet 95 60
3. Dailyvita Tablet
4. Folic Acid Tablet
5. Lactas Calcicus Tablet
6. Sakaneuron/Neorodex Tablet 36 130 10
7. Siobion Tablet 20 10

7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
8. Vit. A Tablet
9. Vit. B1 Tablet
10. Vit. B12 Tablet
11. Vit. B6 Tablet
12. Vit. C Tablet
13. Vit. B Complex Tablet
14. Vit. B Injeksi Vial
15. Vit. K Tablet
16. Univit Tablet 3

1. Alkohol 70 % 1 Liter Botol

2. Alkohol 70 % 300 Ml Botol
3. Molexdine 10 % 60 cc Botol
4. Rivanol Sol Botol 1
5. Abbocath 14 G/ 24 G Pcs
8. Na Cl Infus Kolf
8. Ringer Lactat Infus Kolf
9. Dextrose Infus Kolf
10. Hansaplast Pak
11. Kapas gulung Gulung
12. Kantong Plastik 1 Kg Pak
13. Kantong Plastik Klip 10 x 15 Pak
14. Kantong Plastik Klip 7 x 10 Pak
15. Kantong Plastik Klip 13 x 8,5 Pak
16. Kassa Steril Pak
17. Kapsul Kosong 00 @ 1000 Bungkus
18. Kapsul Kosong 0 @ 1000 Bungkus
19. Kapsul Kosong 1 ( 1000/ bks ) Bungkus
20. Kapsul Kosong 2 ( 1000/ bks Bungkus

8
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21. Kapsul Kosong 3 ( 1000/ bks ) Bungkus
22. Hand schoon 'XS Box
23. Hand schoon 'S Box
24. Hand schoon 'M Box
25. Hand schoon 'L Box
26. Masker Two Ply panjang Box
27. Masker Two Ply karet Box
28. Microphore Pcs
29. Needle Terumo no. 23 Box
30. Silk 4"0 Pcs
31. Silk 4"0 Pcs
32. Wing Needle 27 G Pcs
33. Tensocraphe FL '4 Pcs
34. Infus Set Pcs

Jakarta: 2018
Diminta oleh, disetujui oleh, diserahkan oleh, diterima oleh,
dr. Oktianto Suryowasisto Muchotib