DOKUMEN

DINKES KABUPATEN

PUSKESMAS
PUSKESMAS : SIDAMULIH
KECAMATAN : SIDAMULIH .
KABUPATEN : PANGANDARAN PELAPORAN BULAN/PERIODE : OKTOBER
PROPINSI : JAWA BARAT PERMINTAAN BULAN / PERIODE : NOVEMBER

STOK STOK HARGA JUMLAH HARGA PEMBERIAN

NO NAMA OBAT SATUAN PENERIMAAN PERSEDIAAN PEMAKAIAN PERMINTAAN
AWAL AKHIR KEMASAN RP (8x9) DAK APBD BUFFER
1 2 3 4 5 6 7 8 9 10 11 12 13 14
A. APBD / DAK
1 Allopurinol tablet 100 mg Tablet 200 200 0 200 99 19,800
2 Albendazol suspensi 200mg/5 mL Botol 10 10 6 4 3,849 15,396
3 Albendazol suspensi 200mg/5 mL Botol 0 0 0 4,000 -
4 Ambroksol sirup 15 mg Botol 0 0 0 3,553 -
5 Ambroksol sirup 15 mg Botol 68 50 118 19 99 3,230 319,770.00
6 Ambroksol tablet 30 mg Tablet 0 0 0 161.7 -
7 Ambroksol tablet 30 mg Tablet 0 0 0 147 - 500
8 Aminofilin injeksi 24 mg/ml ampul 0 0 0 2,998 -
9 Aminofillin injeksi 25 mg/ml Ampul 30 30 0 30 3,822 114,660.00
10 Aminofilin tablet 200mg Tablet 0 0 0 89
11 Amlodipin tablet 5 mg Tablet 135 135 135 0 70 -
12 Amlodipin tablet 10 mg Tablet 1480 1480 177 1303 93 121,179.00
13 Amoksisilin kapsul 250 mg Kapsul 0 0 0 180 -
14 Amoksisilin kapsul 250 mg Kaplet 4440 4440 340 4100 195 799,500.00
15 Amoksisilin kaplet 500 mg Kaplet 9680 9680 660 9020 232 2,092,640.00
16 Amoksisilin kaplet 500 mg Kaplet 0 0 0 190 -
17 Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml 0 0 0 2000 -
18 Amoksisilin sirup kering 125 mg/ 5 mg Btl 60 ml 450 450 0 450 1881 846,450.00
19 Analgesik Krim (Molakrim) Tube 32 32 4 28 13860 388,080.00
 Antasida DOEN I tablet kunyah, kombinasi :
20 Aluminium Hidroksida 200 mg + Magnesium Tablet 54
Hidroksida 200 mg 0 0 0 -
Antasida DOEN I tablet kunyah, kombinasi :
21 Aluminium Hidroksida 200 mg + Magnesium Tablet 62
Hidroksida 200 mg 7314 7314 2756 4558 282,596.00
Antasida DOEN II suspensi, kombinasi : Aluminium
22 Btl 60 ml
Hidroksida 200 mg + Magnesium Hidroksida 200 mg
0 0 0 1,995 - 100
Anti Bakteri DOEN salep kombinasi : Basitrasin 500
23 Tube 3,035
IU/g + polimiksin 10.000 IU/g 0 0 0 -
Antifungi DOEN Kombinasi : Asam Benzoat 6% +
24 Pot 2,750.0
Asam Salisilat 3% 15 15 3 12 33,000.00
Antifungi DOEN Kombinasi : Asam Benzoat 6% +
25 Pot 4,158.0
Asam Salisilat 3% 0 0 0 -
Antihemoroid DOEN kombinasi : Bismut Subgalat
26 Supp 3,167
150 mg + Heksaklorofen 250 mg 0 0 0 -
27 Antimigren : Ergotamin tartrat 1mg + Kofein 50mg tablet 0 0 0 173 -
28 Asam Asetil Salisilat / Asetosal tablet 80mg Tablet 0 0 0 99 -
29 Asam Askorbat (vitamin C) tablet 50 mg Tablet 0 0 0 104.0 - 1000
30 Asam Folat Tablet 0,4mg tablet 0 0 0 52.0 - 300
31 Asam Mefenamat 500mg Tablet 6270 6270 1230 5040 103.0 519,120.00
32 Asam pipemidat 400 mg (Urotractin) kapsul 0 0 0 1,400 -
33 Asam Traneksamat 50 mg/ml inj Vial 0 0 0 1,748 -
34 Asam Traneksamat 500mg Tablet 0 0 0 2,915 - 50
35 Asering Infus bag 0 0 0 9,646 -
36 Asiklovir tablet 200 mg Kaplet 0 0 0 240.0 -
37 Asiklovir tablet 200 mg tablet 940 940 64 876 249.0 218,124.00
38 Asiklovir tablet 400 mg Tablet 480 480 90 390 365.0 142,350.00
39 Asiklovir krim 5% Tube 0 0 0 3,080 -
40 Atapulgit 600 mg (New Antides) Tablet 0 0 0 136 -
41 Atropin Inj 0,25 mg/ml Ampul 0 0 0 1,540 -
42 Betahistin Tablet Tablet 0 0 0 110.0 -
43 Betametason krim 0,1 % Tube 0 0 0 1,340 -
44 Betametason krim 0,1 % Tube 25 25 25 0 1,349 - 50
45 Bisakodil Suppositoria (Dulcolax) Supp 12 12 0 12 5,370 64,440.00
46 Deksametason tablet 0,5 mg Tablet 0 0 0 32 -
47 Deksametason tablet 0,5 mg Tablet 0 0 0 41 -
48 Deksametason tablet 0,5 mg Tablet 3226 3226 806 2420 44 106,480.00
49 Desoksimetason krim 0,25% tube 0 0 0 10,400 -
50 Diazepam enema 5 mg/2,5ml tube 0 0 0 12,573 -
51 Diazepam inj 5 mg/ml Ampul 0 0 0 1,735 - 5
52 Diazepam tablet 2 mg Tablet 0 0 0 86 - 100
53 Diazepam tablet 2 mg Tablet 0 0 0 110 -
54 Difenhidramin Injeksi I.M. 10 mg/ml (HCL) Ampul 0 0 0 1,095 - 50
55 Digoksin tablet 0,25 mg Tablet 100 100 0 100 104 10,400.00
56 Dimenhidrinat tablet 50 mg Tablet 1266 1266 29 1237 99 122,463.00
57 Doksisiklin kapsul 100 mg Kapsul 0 0 0 264 -
58 Domperidon Suspensi Btl 48 48 11 37 2,700 99,900.00
59 Domperidon Tablet 10 mg Tablet 0 0 0 85 -
60 Domperidon Tablet 10 mg Tablet 868 868 178 690 95 65,550.00
61 Epinefrin (adrenalin) injeksi 0,1% (sebagai HCl) Ampul 90 90 0 90 1,749 157,410.00
62 Epinefrin (adrenalin) injeksi 0,1% (sebagai HCl) ampul 0 0 0 1,408
63 Eugenol Btl 0 0 0 18,100
64 Fenol Gliserol tetes telinga 10% (Carbo Gliseril) Botol 0 0 0 2,590 - 48
65 Fitomenadion (Vit. K1) injeksi 10 mg/ml Ampul 0 0 0 6,490
66 Fitomenadion (Vit. K1) injeksi 10 mg/ml Ampul 27 27 2 25 3,550 88,750.00
67 Fitomenadion (Vit. K1) injeksi 2 mg/ml Ampul 0 0 0 5,900 -
68 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet 0 0 0 710 -
69 Furosemid tablet 40 mg Tablet 500 500 0 500 78 39,000.00
70 Furosemid tablet 40 mg Tablet 0 0 0 77 -
71 Garam Oralit Serbuk Kombinasi Sachet 0 0 0 257 - 300
72 Gemfinrozil 300mg Tablet 0 0 0 371 - 300
73 Gentamisin Injeksi Ampul 0 0 0 3,509 -
74 Gentamisin Sulfat Injeksi Ampul 0 0 0 3,386 -
75 Gentamisin Salep Kulit 0,1% tube 0 0 0 3,520 - 50
76 Gentamisin Salep Mata 0,3% tube 1 1 1 0 2,960 - 50
77 Glibenklamida tablet 5 mg Tablet 0 0 0 119 - 500
78 Glimepiride 2 mg Kotak 500 500 35 465 207 96,255.00
 79 Gliseril Gualakolat tablet 100 mg Tablet 0 0 0 176.00 - 1000
80 Glukosa Larutan Infus 10% btl 500 ml 0 0 0 7,500 -
81 Glukosa Larutan Infus 5% btl 500 ml 0 0 0 6,900 -
82 Griseofulvin tablet 125 mg, micronized Tablet 0 0 0 210.0 -
83 Haloperidol tablet 1,5 mg Tablet 0 0 0 61 -
84 Hidroklortiazid tab 25 mg tablet 0 0 0 155 -
85 Hidrokortison krim 2,5% Tube 0 0 0 2,475 -
86 Hidrokortison krim 2,5% Krim 48 48 96 24 72 2,639 190,008.00 24
87 Hiosin Butil bromida inj 20 mg/ml Ampul 0 0 0 9,790 -
88 Hiosin Butil bromida tab 20 mg Tablet 0 0 0 1,727 -
89 Ibuprofen suspensi 100 mg/5ml Btl 60ml 40 50 90 0 90 2,365 212,850.00
90 Ibuprofen tablet 400 mg Tablet 0 0 0 111 - 1000
91 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 0 0 0 89 -
92 KA EN 3B - Larutan Karbohidrat + elektrolit kantong 0 0 0 10,696 -
93 KA EN 3B - Larutan Karbohidrat + elektrolit Softbag 0 0 0 10,285 -
94 Kalium Klorida 600 mg / KSR tablet 0 0 0 1,755 -
95 Kalsium Glukonat Injeksi 100mg/ml (Ecosol Ca.Gluconas)Ampul 0 0 0 9,955 -
96 Kalsium Glukonat Injeksi 100mg/ml Ampul 24 24 0 24 7,800 187,200.00
97 Kalsium glukonat inj i.v 10% Ampul 0 0 0 10,351 -
98 Kanamisin Inj 1000 mg Ampul 0 0 0 12,100 -
99 Kaptopril 12,5 mg Tablet 5236 5236 481 4755 59 280,545.00
100 Kaptopril tablet 12,5 mg Tablet 0 0 0 62 -
101 Kaptopril tablet 25 mg Tablet 4868 4868 418 4450 80 356,000.00
102 Kaptopril tablet 25 mg Tablet 0 0 0 68 -
103 Ketokonazol Krim Tube 0 0 0 2,518 -
104 Ketokonazol Cream Tube 0 0 0 2,595 -
105 Ketokonazol Cream 2% tube 25 25 0 25 2,545 63,625.00 25
106 Ketorolak Inj 30 mg/ml Ampul 0 0 0 1,045 -
107 Klindamisin 300 mg Kapsul Kapsul 0 0 0 578 -
108 Kloramfenikol Salep Mata 1% tube 47 47 33 14 1,810 25,340.00 50
109 Kloramfenikol Salep Mata 1% tube 0 0 0 1,881 -
110 Kloramfenikol Salep Kulit 1% (Bufacetin SK) tube 0 0 0 3,091 - 48
111 Kloramfenikol suspensi 125 mg/5 ml Botol 60 ml 0 0 0 4,700 - 50
112 Kloramfenikol sirup 125 mg/5 ml Botol 60 ml 0 0 0 4,700 -
113 Kloramfenikol kapsul 250 mg (Chloramex) Kapsul 0 0 0 1,090 - 1000
114 Klorfeniraniramina Maleat (CTM) tablet 4 mg Tablet 0 0 0 22 -

Kotrimosakzol Suspensi Kombinasi :

115 botol 60 ml 2,120
Sulfametoksazol 200 mg + Trimetoprim 40 mg/ 5 ml
27 27 17 10 21,200.00

Kotrimosakzol Suspensi Kombinasi :

116 botol 60 ml 2,052
Sulfametoksazol 200 mg + Trimetoprim 40 mg/ 5 ml
100 100 0 100 205,200.00
Kotrimosakzol DOEN I (dewasa) Kombinasi :
117 Tablet 125
Sulfametoksazol 400 mg, Trimetoprim 80 mg 0 0 0 - 1000
118 Laktulosa sirup 3,335 g/5 mL botol 0 0 0 15,060 - 50
119 Lansoprazole capsul 30mg Kapsul 0 0 0 303 - 1500
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
120 Ampul 1,937
ml 0 0 0 -
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
121 Ampul 1,845
ml 268 268 36 232 428,040.00
Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2
122 Ampul 1,152
ml 0 0 0 -
123 Lidocain inj 2 % Ampul 0 0 0 1,144 -
124 Lidocain inj 2 % Ampul 0 0 0 1,111 -
125 Lidocain inj 2 % Ampul 0 0 0 860 -
126 Loperamide tablet Tablet 0 0 0 80 - 500
127 Loratadin tablet 10 mg Tablet 319 319 308 11 123 1,353.00 500
128 Magnesium Sulfat inj (IV) 20 %-25 ml vial 0 6 6 6 0 3,200 - 12
129 Metformin HCl tablet 500 mg tablet 0 0 0 96 - 500
130 Metildopa tab 250 mg tablet 0 0 0 946 - 200
131 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 0 0 0 2,959 -
132 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 164 164 0 164 2,684 440,176.00
133 Metilergometrin Maleat injeksi 0,200 mg -1 ml Ampul 0 0 0 2,849 -
134 Metilprednisolon tablet 4 mg Tablet 0 0 0 134 -
135 Metoklopramid tablet 10 mg tablet 0 0 0 80 -
136 Metoklopramid tablet 10 mg Tablet 0 0 0 87 -
137 Metronidazol infus 500 mg/100 ml Botol 0 0 0 8,110 -
138 Metronidazol infus 500 mg/100 ml Infus 0 0 0 9,200 -
139 Metronidazol Sirup Botol 0 0 0 3,950 -
140 Metronidazol Sirup 125mg Botol 65 65 1 64 3,800 243,200.00
141 Metronidazol Tablet 500 mg Tablet 0 0 0 124 -
142 Mikonazole krim / salep 2% (nitrat) tube 0 0 0 3,414 -
143 Mikonazole krim / salep 2% (nitrat) Tube 47 47 19 28 3,250 91,000.00
144 Misoprostol tablet 200mg Tablet 0 0 0 6,900 -
145 N-asetil sistein 200 mg tablet 0 0 0 358 -
146 N-asetil sistein 100 mg nebules inj (Fluimucil) ampul 0 0 0 12,535 -
147 Natrium Diklofenak 50 mg Tablet 0 0 0 115 - 1000
148 Natrium Klorida larutan infus 0,9 % Botol 0 0 0 6,410 -
149 Nifedifin 10 mg Tablet 50 50 0 50 104 5,200.00

150 Nifedifin 10 mg Tablet 99

0 0 0 -
151 Nistatin Tablet Tablet 0 0 0 790 - 100
152 Nistatin Vaginal tablet salut 100.000 IU/g Tablet 0 0 0 560 -
153 OAT Kategori 2 Paket 0 0 0 1,297,889 -
Obat Batuk Pilek Kombinasi Syrup (Tiap 5ml
154 mengandung: Difenhidramin 5mg, Dekstrometorfan Btl 7,350
10mg, Amonium Klorida 62,5mg ,Na.Sitrat
25mg/5ml ) (Samcodryl) 46 50 96 45 51 374,850.00 50
Obat Batuk Pilek Kombinasi Kaplet (Tiap Kaplet:
155 Parasetamol 250mg, Dextromethorphan HBr 15mg, Tablet 850
Penylephrine HCl 2mg, Glyseril Guaiakolat 50mg,
Klorfeniramin maleat 1mg) (Lodecon) 850 500 1350 430 920 782,000.00 500
156 Oksitosin injeksi 10 UI/ml-1 ml Ampul 6 100 106 16 90 1900 171,000.00
157 Oksitosin injeksi 10 UI/ml-1 ml Ampul 0 0 0 1,199.00 -
158 Omeprazole kapsul 10 mg Kapsul 0 0 0 130 - 1000
159 Ondansetron Inj 4 mg/2ml Ampul 30 30 1 29 1070 31,030.00
160 Parasetamol Drop Btl 0 0 0 6,649.00 - 50
161 Parasetamol syrup Btl 175 175 78 97 1,107.00 107,379.00 100
162 Parasetamol tablet 500 mg Tablet 990 990 990 0 53.00 -
163 Perak Sulfadiazin krim 1% Tube 0 0 0 20,700 -
164 Permetrin krim 5% tube 0 0 0 12,155 -
165 Piridoksin HCl (Vit B6) tablet 25 mg Tablet 0 0 0 118 -
166 Piridoksin HCl (Vit B6) tablet 10 mg Tablet 0 0 0 53 - 500
167 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet 0 0 0 123 -
168 Polikresulen cairan Btl 0 0 0 19,250 -
169 Povidon Iodida larutan 10 % Botol 30 ml 0 0 0 2,893 -
170 Prednison tablet 5 mg Tablet 500 500 156 344 68 23,392.00
171 Propanolol tablet 10 mg (HCL) Tablet 0 0 0 54.0 -
172 Ranitidin injeksi 25 mg/ 2ml Ampul 99 99 0 99 1,155.0 114,345.00
173 Ranitidin tablet 150 mg tablet 716 716 646 70 98 6,860.00
174 Ranitidin tablet 150 mg tablet 0 0 0 105 -
175 Ringer Laktat larutan infus Botol 500 ml 790 790 8 782 7,150 5,591,300.00
176 Salbutamol Cairan Inhalasi (Fartolin) Botol Inh 18 18 3 15 15,700 235,500.00
177 Salbutamol sirup botol 49 49 0 49 4,446 217,854.00
178 Salbutamol tablet (sebagai sulfat) 4 mg Tablet 290 290 60 230 70 16,100.00
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
179 Pot
endap 4% 0 0 0 2,527 -
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
180 Pot 2,621
endap 4% 0 0 0 -
181 Salisil bedak 2% Kotak 50 gram 0 0 0 5,610 - 20
182 Salisil bedak 2% Kotak 50 gram 0 0 0 1,020 -
183 Sefadroksil kapsul 500 mg kapsul 0 0 0 478 - 2000
184 Sefadroksil Sirup Botol 78 78 55 23 3,980 91,540.00 50
185 Sefadroksil Sirup Botol 0 0 0 3,922 -
186 Sefiksim Kapsul 100mg Kapsul 0 0 0 750 -
187 Sefiksim Sirup Botol 0 0 0 5,530 -
188 Sefotaksim injeksi 1 gram Vial 0 0 0 4,200 -
189 Seftriakson Inj Vial 0 0 0 4,483 -
190 Setirizin tablet Tablet 0 0 0 90 - 1000
191 Setirizin Sirup Btl 0 0 0 2,850 - 50
192 Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU I) Vial 0 0 0 479,996 -
193 Serum Anti Bisa Ular Polivalen injeksi 5 ml (ABU I) Vial 2 2 0 2 462,000 924,000.00
194 Serum Anti Tetanus Injeksi 1.500 IU/ampul (A.T.S.) Vial 10 10 0 10 176,800 1,768,000.00
195 Simvastatin 10mg tablet 0 0 0 110 - 1200
196 Siprofloksasin tablet 500 mg Tablet 500 500 0 500 240 120,000.00
197 Siprofloksasin 500mg Tablet 0 0 0 265 -
198 Sukralfat Suspensi Btl 78 100 178 71 107 8,338 892,166.00
199 Terbutalin Sulfat 1,5 mg/5 mL (Tebas Syr) botol 0 0 0 6,459 -
200 Tiamin (vitamin B1) tablet 50 mg (HCL/Nitrat) Tablet 1342 1342 282 1060 82 86,920.00
201 Tiamin (vitamin B1) tablet 50 mg (HCL/Nitrat) Tablet 0 0 0 85.0 -
202 Ursodeoksiholik 250 mg tablet 0 0 0 2,139 -
203 Vitamin B Kompleks tablet Tablet 0 0 0 156.2 - 2000
204 Zink Tablet Dispersible 20mg Tablet 0 0 0 524 -
205 Zink Tablet Dispersible 20mg Tablet 908 908 198 710 508 360,680.00
206 Zink Sirup 20 mg/ml Btl 60ml 98 98 11 87 4,789 416,643.00
207 Zink Sirup 20 mg/ml Btl 60ml 0 0 0 2,972 -
Alat Kesehatan -
208 Alat suntik sekali pakai 1 ml Ktk 100 0 1,614 -
209 Alat suntik sekali pakai 5 ml pcs 0 0 0 750 - 800
210 Alkohol Swab 100 pcs/box 8 8 4 4 10,000 40,000.00
211 Alkohol 70% 1 L Botol 35 20 55 0 55 21,500 1,182,500.00
212 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 0 0 0 2,295 -
213 Aquasonic 250 ml Gel Botol 3 3 0 3 186,867.75 560,603.25
214 Aquasonic Jelly Botol 4 4 0 4 156,640 626,560.00
215 Aseptik Gel Btl 7 7 1 6 22,000 132,000.00
216 Bisturi No 11 (Aesculap) box 0 0 0 300,000 -
217 Blood Lancet box 0 0 0 14,564 -
218 Catgut Cromic No. 2/0 Kotak 1 1 0 1 134,000 134,000.00
219 Catgut Cromic No. 3/0 Kotak 1 1 0 1 134,000 134,000.00
220 Catgut Plain No. 2/0 Kotak 2 2 1 1 134,000 134,000.00
221 Catgut Plain No. 3/0 Kotak 1 1 0 1 134,000 134,000.00
222 Cervical colar unit 0 0 0 121,000 -
223 Celemek Lengan Panjang (Apron non Steril waterproff) 0 0 0 25,256 -
224 Cuticell Classic 10cm x 10cm sachet 0 0 0 5,198 - 5
225 Folley Catheter 2 Way No. 16 Pcs 9 9 0 9 13,090 117,810.00
226 Folley Catheter 2 Way No. 18 Pcs 0 0 0 13,090 -
227 Gluco Protein (One Med) pcs 0 0 0 1,045 -
228 Guedel Airway 80mm steril Pcs 0 0 0 12,574 -
229 Guedel Airway 90mm steril Pcs 0 0 0 12,574 -
230 HCG Strip pcs 100 100 0 100 1,939 193,900.00
231 Infusion set anak (Aximed Pediatric Set) Set /kantong 0 0 0 5,100 -
232 Infusion set anak (Terumo) Set /kantong 0 0 0 5,100 -
233 Infusion set Y dws pcs 0 0 0 6,287 -
234 Infusion set dewasa / Aximed Infuset Set /kantong 100 100 0 100 4,800 480,000.00
235 IV Catheter No. 18 G (Aximed) 50 buah / kotak 0 0 0 7,000 -
236 IV Catheter No. 18 G 50 buah / kotak 0 0 0 7,700 - 50
237 IV Catheter No. 18 G 50 buah / kotak 0 0 0 8,700 -
238 IV Catheter No. 20 G 50 buah / kotak 0 0 0 7,700 -
239 IV Catheter No. 22 G 50 buah / kotak 50 50 0 50 7,700 385,000.00
240 IV Catheter No. 24 G 50 buah / kotak 0 0 0 7,700 -
241 IV Catheter No. 26 G (Jayamas Steracath) Pcs 0 0 0 4,100 -
242 Kapas Pembalut / Absorben 250 gram Bungkus 26 26 1 25 12,500 312,500.00
243 Kasa Hidrofil DRC 36m x 80 cm rol 1 1 0 1 130,000 130,000.00
244 Kasa Kompres 40/40 steril Bungkus 100 100 200 0 200 1,600 320,000.00
245 Kasa Pembalut 2 m x 80 cm Rol 34 34 9 25 7,700 192,500.00
246 Kasa Pembalut Hidrofil 4 m x 15 cm elastic Rol 0 0 0 2,100 -
247 Kasa Pembalut Hidrofil 4 m x 15 cm elastic roll 74 74 26 48 2,090 100,320.00 50
248 Kasa Steril 16x16 cm Bungkus 0 0 0 8,000 - 20
249 Leukomed IV Film 6cm x 8cm streil box 0 0 0 123,056 -
250 Leukomed IV Film 6cm x 8cm streil pcs 0 0 0 2,461.12 -
251 Masker kotak @50pcs 1 1 1 0 16,500 -
252 Masker ties on / tali dus 10 10 0 10 24,000 240,000.00
253 Masker Nebulizer Set Dewasa pcs 0 0 0 22,000 -
254 Masker Nebulizer Set Anak pcs 24 24 0 24 22,000 528,000.00
255 Mucus Extractor 25 mL pcs 0 0 0 7,040 -
256 Object Glass pax 0 0 0 144,605.50 -
257 Pro Crepe Pembalut Elastis Ukuran 10 cm X 4,55 M roll 0 0 0 33,272 -
258 Pro Crepe Pembalut Elastis Ukuran 10 cm X 4,55 M roll 0 0 0 33,000.00 -
259 Pro Crepe Pembalut Elastis Ukuran 15 cm X 4,55 M roll 0 0 0 41,910.00 -
260 Plester 7,5 x 4,5cm (Leukoplast) roll 23 23 2 21 35,532 746,172.00
261 Plester Bulat pcs 0 0 0 30,800 -
262 Plester 7,5 x 4,5cm (Hospital) roll 0 0 0 35,532 -
263 Sarung Tangan Examination S (Aximed) box/100 7 7 1 6 46,200 277,200.00
264 Sarung Tangan Examination M (Aximed) box/100 10 10 20 5 15 46,200 693,000.00 10
265 Sarung Tangan L (Sensi Gloves) kotak 12 12 6 6 46,200 277,200.00
266 Sarung Tangan Examination L (Aximed) box/100 0 0 0 46,200 -
267 Sarung Tangan Powder Free Steril No.7 pasang 0 0 0 12,925 -
268 Sarung Tangan Powder Free Steril No.7,5 pasang 0 0 0 12,925 -
269 Sarung Tangan Powder Free Steril (Mas DHD) pasang 0 0 0 13,101 -
270 Sarung Tangan Obgyn Steril pasang 0 0 0 19,360 -
271 Simple Oxygen Mask Dewasa / Masker O2 box/50 0 0 0 19,800 -
272 Selang Oksigen Anak (Canula Nasal O2 Anak) Pcs 0 0 0 5,500 -
273 Selang Oksigen Anak (Besmed Oxyflow Nasal O2) Pcs 0 0 0 5,500 -
274 Selang Oksigen Dewasa (Besmed Oxyflow Nasal O2) Pcs 0 0 0 5,500 -
275 Silk No. 2/0 Kotak 3 2 5 0 5 110,000 550,000.00 1
276 Silk No. 3/0 Kotak 3 2 5 0 5 110,000 550,000.00 1
277 Spalk kayu pcs 4 4 0 4 61,600 246,400.00
278 Tapping (Self Tapping Vertebral Screw) roll 0 0 0 151,800 -
279 Water Fuchsin / Water One 1 L btl 0 0 0 14,960 -
280 Underpad 60x90 cm pcs 190 190 5 185 7626.15 1,410,837.75
281 Urine Bag pcs 21 20 41 1 40 3,000 120,000.00 20
282 Umbilical Cord Klem Pcs 40 40 4 36 1,000 36,000.00
Reagensia 0 -
283 Reagen Gol. Darah Anti A (Lorne Lab) vial 0 70,575 -
284 Reagen Gol. Darah Anti AB (Lorne Lab) vial 0 94,885 -
285 Reagen Gol. Darah Anti B (Lorne Lab) vial 0 70,575 -
286 Reagen Gol. Darah Anti D (Lorne Lab) vial 0 116,445 -
287 Widal Test Salmonella Paratyphi AH (Lorne Lab) vial 0 69,035 -
288 Widal Test Salmonella Paratyphi AO (Lorne Lab) vial 0 69,035 -
289 Widal Test Salmonella Paratyphi BH (Lorne Lab) vial 0 69,035 -
290 Widal Test Salmonella Paratyphi BO (Lorne Lab) vial 0 69,035 -
291 Widal Test Salmonella Paratyphi CH (Lorne Lab) vial 0 69,035 -
292 Widal Test Salmonella Paratyphi CO (Lorne Lab) vial 0 69,035 -
293 Widal Test Salmonella Paratyphi H (Lorne Lab) vial 0 69,035 -
294 Widal Test Salmonella Paratyphi O (Lorne Lab) vial 0 69,035 -
 JUMLAH RP 32,830,312.00
B. PROGRAM 0
I. TB PARU (OAT FDC) 0
1 OAT kategori 1 Paket 0 - - 0 359,980 -
2 OAT kategori 2 Paket 0 3 3 - 3 1,199,985 3,599,955
3 OAT anak Paket 4 4 - 4 214,985 859,940
4 Pot Dahak (Pot Sputum) Pcs 600 600 - 600 5,800 3,480,000
5 Reagen ziehl nielsen (Indo reagen ZN) Kit 10 10 - 10 276,500 2,765,000
II. DIARE 0 -
1 Garam oralit / Oralit Granula Sachet 0 - 0 0 260 -
2 Zinc Tab 20 mg Tablet 0 - 0 0 508 -
III. KECACINGAN 0 -
1 Albendazol tablet 400 mg Tablet 200 200 0 200 1,356 271,200
2 Albendazol tablet kunyah 400 mg Tablet 1620 1,620 0 1620 403 652,860
IV. GIZI 0 -
1 Tablet Fe (Ferro Fumarat) 200mg Kotak 0 - 36,700 -
2 Vitamin A 100.000 IU Kapsul Botol 3 3 0 3 14,400 43,200
3 Vitamin A 200.000 IU Kapsul Botol 0 - 22,950 -
V. IMUNISASI 0 -
1 Vaksin BCG Vial 5 5 5 0 61,996 -
2 Vaksin boPv (Polio Oral) Vial 29 29 23 6 19,954 119,724
3 Vaksin Campak Bias Vial 13 13 0 13 28,204 366,652
4 Vaksin DPT-HB/Hib (Pentabio) Vial 39 39 22 17 76,285 1,296,845
5 Vaksin DPT-HB/Hib (Pentabio) Vial 0 - 0 78,991 -
6 Vaksin HB Uniject (Hepatitis B Rekombinan) Pouch 33 33 26 7 20,900 146,300
7 Vaksin Measles Rubella (MR) Vial 31 31 8 23 149,820 3,445,860
8 Vaksin Measles Rubella (MR) / MMR II Vial 0 - 0 155,813 -
9 Vaksin Polio IPV 5 ds (Poliomyelitis) Vial 2 2 2 0 158,994 -
10 Vaksin Td (Vaksin Jerap) Vial 0 - 0 16,995 -
11 Vaksin Td (Vaksin Jerap) Vial 59 59 11 48 16,500 792,000
12 Vaksin Td Bias (Vaksin Serap) Vial 0 - 0 16,500 -
VI. MALARIA 0 -
1 Artesunat Cairan injeksi 60mg Ampul 0 0 39,000 -
 2 Primakuin Tablet 15 mg Tablet 0 0 109 -
3 RDT Test Malaria combo Test 0 0 105,600 -
4 RDT Test Malaria Test 0 0 5,271 -
0 0 -
VII. HIV/AIDS 0 0 -
1 Efavirenz tablet 600mg tablet 0 0 191,250 -
2 Flukonazol tablet 150mg tablet 0 0 1,800 -
3 INH tablet 300mg tablet 0 0 173 -
4 Lamivudine Tablet salut Selaput 150mg tablet 0 0 90,000 -
5 Needle holder (Marwa Needle Holder) pcs 0 0 295 -
6 Nevirapine Kaplet 200mg Kaplet 0 0 168,000 -
7 Rapid HIV 2 / Fokus Test 0 0 14,470 -
8 Rapid Test HIV 1/2 Biometric/Vikia Test 0 0 22,475 -
9 Rapid Test Syphillis (Sensatest One-step Diagnostic) Test 148 148 2 146 26,527 3,872,942
10 Rapit Test HIV 1/2 Elisa Test 161 161 11 150 22,330 3,349,500
11 RPR Siphyllis / Fokus Test 0 0 0 4,150 -
12 Tabung Eppendrof pcs 0 0 0 750 -
13 Tenofovir tablet 300mg tablet 0 0 0 243,000 -
Tenofovir-Lamivudin-Efavirens (TDF-3TC-EFV) 0 0
14
tablet 300mg-300mg-600mg (FDC TDF-3TC-EFV) tablet 0 356,829 -
15 Zidovudine - Lamivudine Kaplet 0 0 0 222,000 -
0 0 0 -
VIII. KEJIWAAN 0 0 0 -
1 Haloperidol Injeksi Ampul 0 0 0 6,250 -
0 0 0 -
IX. RABIES 0 0 0 -
1 Vaksin Anti Rabies (Verorab) Kuur 2 5 7 3 4 165,000 660,000
0 0 -
X. KUSTA 0 0 -
1 MB Dewasa (MDT Combi MB Adult) Blister 0 0 31,570 -
2 MB Anak (MDT Combi MB Child) Blister 0 0 19,800 -
3 PB Anak (MDT Combi PB Child) Blister 0 0 8,712 -
0 0 -
XI. Vaksin Haji 0 0 -
1 Vaksin Meningitis (Remel Neisseria Meningitis) Paket 0 0 214,500 -
2 Vaksin Meningitis (Slidex) Paket 0 0 214,500 -
25,721,978
JUMLAH RP
C. OBAT TAMBAHAN Diluar JKN
1 Allopurinol tablet 100 mg Tablet 390 390 36 354 89.0 31,506.00
2 Allopurinol tablet 300 mg Tablet 100 100 0 100 220.00 22,000.00
3 Amlodipin tablet 5 mg Tablet 700 700 105 595 85 50,575.00
4 Amlodipin tablet 10 mg Tablet 0 0 0 104 -
5 Amitripiline 25 mg Tablet 0 0 0 143 -
Analgesik-Psikotropik (mengandung Diazepam
6 2mg+Metamizol 500mg) (Metaneuron)
Tablet 1,045
270 270 192 78 81,510.00
Anti Bakteri DOEN salep kombinasi : Basitrasin 500 IU/g
7 + polimiksin 10.000 IU/g
tube 0 2,516
15 15 15 37,740.00
Antihemoroid DOEN kombinasi : Bismut Subgalat 150 mg
8 + Heksaklorofen 250 mg
Supp 3 3,045
10 10 7 21,315.00
9 Antispasmodik-Analgetik tablet (Spasminal) Tablet 26 26 26 0 581.90 -
10 Antimigren : Ergotamin tartrat 1mg + Kofein 50mg Tablet 100 100 0 100 167 16,700.00
11 Asam Asetil Salisilat / Asetosal tablet 80mg Tablet 130 130 0 130 114 14,820.00
12 Asiklovir tablet 200 mg Tablet 0 0 0 237 -
13 Betametason krim 0,1 % tube 35 35 0 35 1,380 48,300.00
14 Bisakodil Suppositoria (Dulcolax) Supp 8 8 0 8 5,789.784 46,318.27
15 Diazepam tablet 2 mg Tablet 0 0 0 45.000 -
16 Fitomenadion (Vit. K1) tablet salut gula 10 mg Tablet 85 85 5 80 686.000 54,880.00
17 Furosemid injeksi Ampul 0 0 0 1,829.000 -
18 Flukonazol tablet 150mg Tablet 0 0 0 18,000.000 -
19 Garam Oralit Serbuk Kombinasi Tablet 542 542 41 501 260.000 130,260.00
20 Glukosa Larutan Infus 10% Botol 500 ml 50 50 0 50 5,700.000 285,000.00
21 Glukosa Larutan Infus 5% Botol 500 ml 19 19 0 19 5,200.000 98,800.00
22 Hidroklortiazid tab 25 mg Tablet 699 699 0 699 149.000 104,151.00
23 Hystolan 20 mg Tablet 50 50 0 50 4,900.500 245,025.00
24 Isosorbid Dinitrat Tablet Sublingual 5 mg Tablet 256 256 0 256 88.000 22,528.00
25 Kalsium Laktat (Kalk) tablet 500 mg Tablet 700 700 25 675 52.000 35,100.00
26 Kalsium Laktat (Kalk) tablet 500 mg Tablet 0 0 0 63.000 -
27 Kaporit Pail 1 1 0 1 418,000.000 418,000.00
28 Kloramfenikol sirup 125 mg/5 ml Botol 60 ml 13 13 8 5 3,955 19,775.00
29 Klorfeniraniramina Maleat (CTM) tablet 4 mg Tablet 5095 5095 955 4140 37 153,180.00
Kotrimosakzol DOEN I (dewasa) Kombinasi :
30 Sulfametoksazol 400 mg, Trimetoprim 80 mg
Tablet 149.000
480 480 40 440 65,560.00
31 Lansoprazole capsul 30mg Tablet 0 0 0 319.000 -
32 Lidokain injeksi 2% (HCL) + Epinefrin 1 : 80.000-2 ml Ampul 0 0 0 3,109.000 -
33 Lisol Botol 15 15 2 13 55,000.000 715,000.00
34 Magnesium Sulfat inj (IV) 20 %-25 ml Vial 36 36 36 0 3,650.000 -
35 Metformin HCl tablet 500 mg Tablet 249 249 169 80 94.000 7,520.00
36 Metilergometrin Maleat tablet salut 0,125 mg Tablet 68 68 10 58 154.000 8,932.00
37 Metilprednisolon tablet 4 mg Tablet 0 0 0 150.000 -
38 Metronidazol tablet 250 mg Tablet 85 85 7 78 94.000 7,332.00
39 Metronidazol Tablet 500 mg Tablet 3810 3810 255 3555 113.000 401,715.00
40 Mikonazole krim / salep 2% (nitrat) tube 0 0 0 3,000.000 -
41 Mikonazole serbuk (Mycorine) Botol 11 11 4 7 25,500.000 178,500.00
Multivitamin Sirup (Per 5 mL sir Vit A 2,000 iu, vit B1 1
mg, vit B2 0.5 mg, vit B6 1 mg, vit B12 1 mcg, vit C 10
42 mg, vit D 400 iu, Ca pantothenate 5 mg, Ca gluconate 50 Botol
mg, DHA 8 mg, lysine HCl 100 mg, colostrum bovine 250
mg.) (Truvit)
75 75 67 8 11,847.000 94,776.00 50
43 N-asetil sistein 100 mg nebules inj (Fluimucil) Ampul 15 15 0 15 13,175.000 197,625.00
44 Natrium Bikarbonat tablet 500 mg Tablet 0 0 0 44.000 - 1000
45 Natrium Diklofenak 50 mg Tablet 974 974 732 242 159.000 38,478.00 1000
46 Nistatin Vaginal tablet salut 100.000 IU/g Tablet 25 25 15 10 523.000 5,230.00
Obat Flu Kombinasi Syrup (Tiap 5ml mengandung:
Paracetamol 120mg, Glyseril Guaiakolat 25mg,
47 Klorfeniramin maleat 1mg, Phenylephrine HCL 5mg)
Botol 12,000.000
(Solaflu)
0 0 0 -
Obat Untuk Saluran Cerna (Tablet kombinasi: Pancreatin
48 170mg, simethicone 80mg) (Flazymec)
Tablet 0 1,002.100
160 160 160 160,336.00
49 Omeprazole kapsul 10 mg Kapsul 320 320 320 0 140.000 -
50 Omeprazole kapsul 10 mg Kapsul 0 0 0 160.000 -
51 Parasetamol tablet 500 mg Tablet 3700 3700 1970 1730 167.000 288,910.00
52 Piridoksin (Vitamin B6) tablet 10 mg (HCL) Tablet 290 290 215 75 45.000 3,375.00
53 Povidon Iodida larutan 10 % Botol 30 ml 33 33 7 26 2,163.000 56,238.00
54 Prednison tablet 5 mg Tablet 1200 1200 0 1200 76.000 91,200.00
55 Salbutamol cairan IH 0,5% (Ventolin Nebule) Ampul 0 0 0 4,000.000 -
56 Salbutamol sirup Botol 19 19 7 12 4,275.000 51,300.00
Salep 2-4, kombinasi: Asam Salisilat 2% + Belerang
57 endap 4%
Pot 12 2,000.000
24 24 12 24,000.00
58 Salisil bedak 2% Kotak 50 gram 0 0 0 1,025.000 -
59 Sefadroksil kapsul 500 mg Kapsul 2452 2452 1322 1130 450 508,500.00
60 Setirizin tablet Tablet 0 0 0 0 96 -
61 Simvastatin 10mg Tablet 890 890 360 530 111.000 58,830.00
62 Siprofloksasin 500mg Tablet 520 520 170 350 281.000 98,350.00
63 Tramadol injeksi 50 mg/ml Ampul 15 15 15 0 2,395 -
Alat Kesehatan 0
1 Alat suntik sekali pakai 2,5 ml Set /kantong 0 0 0 650 - 1600
2 Alkohol Swab 100 pcs/box 22 22 0 22 11,000 242,000.00
3 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 3 3 0 3 2,475 7,425.00
4 Aqua Pro Injeksi Steril, bebas pirogen vial @20ml 10 10 0 10 2,302 23,020.00
5 Bisturi No 11 (Aesculap) Buah 100 100 0 100 3,150 315,000.00
6 HCG Strip pcs 57 57 12 45 1,936 87,120.00
7 Infusion set anak Set /kantong 107 107 0 107 3,500 374,500.00
8 Infusion set dewasa Set /kantong 41 41 7 34 3,200 108,800.00
9 IV Catheter No. 18 G pcs 12 12 3 9 3,800 34,200.00
10 IV Catheter No. 20 (Adsyte 20) pcs 42 42 12 30 3,800 114,000.00
11 IV Catheter No. 22 G wings 50 buah / kotak 17 17 0 17 12,342 209,814.00
12 IV Catheter No. 24 G Pcs 5 5 5 0 3,800 -
13 IV Catheter No. 24 G wings 50 buah / kotak 98 98 0 98 7,000 686,000.00
14 Kasa Kompres 40/40 steril Bungkus 52 52 33 19 1,800 34,200.00
15 Object Glass Buah 100 100 0 100 290 29,000.00
16 Plester 7,5 x 4,5cm (Hansaplast) Rol 28 28 2 26 31,265 812,890.00
17 Pot Dahak (Pot Sputum) Buah 490 490 0 490 1,700 833,000.00
18 Tapping (Self Tapping Vertebral Screw) roll 0 7 7 1 6 138,000 828,000.00
 IMUNISASI
1 Vaksin Anti Rabies (Verorab) Kuur 0 0 0 78,500 -
2 Vaksin BCG Vial 31 31 7 24 59,950 1,438,800.00
3 Vaksin DT Vial 3 3 0 3 17,798 53,394.00
4 Vaksin Polio IPV 5 ds (Poliomyelitis) Vial 5 5 5 0 139,760 -
5 Ads 0,5 ml pcs 0 0 0 0 1,086.00 -
6 Ads 0,05 ml Oneject Buah 100 100 0 100 1,590.00 159,000.00
7 Ads 0,05 ml Oneject/2018 Buah 1600 1600 0 1600 1,195.00 1,912,000.00
8 Ads 5 ml Buah 200 200 0 200 1,640.00 328,000.00
9 Safety Box Pcs 25 25 0 25 24,122.00 603,050.00
10 Safety Box Pcs 25 25 0 25 22,433.00 560,825.00
11 Ads 0,5 oneject Buah 400 400 0 400 1,185.00 474,000.00
TB PARU (OAT FDC) 0
1 OAT kategori 1 Paket 10 10 1 9 359,900 3,239,100.00
2 Kaca Slide Kotak 5 5 0 5 19,700 98,500.00
GIZI 0
1 Iodine Test 4 4 0 4 5,806 23,224.00
2 Tablet Fe (Ferro Fumarat) 200mg Kotak @100 tab 2400 2400 551 1849 376 695,224.00
KEJIWAAN 0
1 Amitriptillin Tablet Salut 25mg Tablet 200 200 0 200 102.00 20,400.00
2 Amitriptillin Tablet Salut 25mg Tablet 0 100 100 0 100 167.00 16,700.00
3 Clozapine Tablet 25mg Tablet 100 100 0 100 1,550.00 155,000.00
4 Haloperidol Inj. 5 mg/ml Ampul 0 0 0 0 6,250.00 -
5 Haloperidol Tablet 5 mg Tablet 100 100 0 100 69.00 6,900.00
6 Haloperidol Tablet 5 mg Tablet 50 50 0 50 58.00 2,900.00
7 Haloperidol Tablet 5 mg Tablet 0 100 100 0 100 56.00 5,600.00
8 Klorpromazine Hcl Tablet Salut 100mg Tablet 0 0 0 0 162.00 -
9 Klorpromazine Hcl Tablet Salut 100mg Tablet 0 100 100 0 100 147.00 14,700.00
10 Risperidone Tablet 2mg Tablet 1450 1450 0 1450 1,008.00 1,461,600.00
11 Risperidone Tablet 2mg Tablet 0 100 100 0 100 273.00 27,300.00
12 Triheksifenidil Tablet Tablet 0 0 0 0 88.00 -
13 Triheksifenidil Tablet Tablet 0 100 100 0 100 85.00 8,500.00
KIA 0
 1 Ca Glukonas Injeksi 10 ml Ampul 44 44 0 44 7800.00 343,200.00
2 Gentamicin injeksi 40 mg Ampul 0 0 0 5900.00 -
3 Magnesium Sulfate Injeksi 20 % Botol 26 26 26 0 3650.00 -
4 Metil ergometrin maleat inj 0,3 mg Ampul 0 0 0 2175.00 -
5 Onemed Glucose + Protein Test Ampul 0 0 0 1045.00 -
6 U-PAD (U-PAD 60x90) Pcs 0 0 0 7626.15 -
DBD 0
1 Bactivec Botol 24 24 0 24 18,945 454,680.00
2 RDT DBD Combo ( IgG dan NS1 ) Test 30 30 0 30 110,089 3,302,670.00
HIV 0 -
1 Jarum Lanset Dus 1 1 0 1 52,800 52,800.00
2 Kasa Alkohol/HIV Box 1 1 0 1 40,700 40,700.00
3 Label Pack 1 1 0 1 4,400 4,400.00
4 Lampu Spirtus Buah 1 1 0 1 179,300 179,300.00
5 Mikro Pipet 5-50 ul Buah 1 1 0 1 1,749,000 1,749,000.00
6 Pen Lanset Buah 1 1 0 1 73,700 73,700.00
7 Rapid Test Syphilis Monotest Box 1 1 0 1 1,050,500 1,050,500.00
8 Tabung Vacutrimer/HIV Box 1 1 0 1 292,600 292,600.00

9 Tip Kuning/2018 Box@100pcs 0 224,400

1 1 1 224,400.00
10 Torniquett Buah 1 1 0 1 49,500 49,500.00
JUMLAH RP 28,860,326.27
D. JKN/BPJS
1 Donperidone Syr 60 ml Botol 0 0 0 0 3,333.00 0.00
2 Gentamicin injeksi Ampul 2 2 0 2 3,399.00 6,798.00
3 Ketorolac inj 30 mg Ampul 6 6 0 6 1,290.00 7,740.00
4 Amoksisilin 125 mg Botol 35 35 8 27 2,445.00 66,015.00
5 Erythromicyne Kaplet 500 mg Tablet 0 0 0 0 730.00 0.00
6 Furosemid 40 mg Tablet 2024 2,024 140 1884 78.00 146,952.00
7 Lidokain injeksi 2% Ampul 199 199 0 199 860.00 171,140.00
8 Ondansentron 4 mg Injeksi 2 ml Ampul 20 20 0 20 1,650.00 33,000.00
9 Accu check Performa Strip 400 400 100 300 4,200.00 1,260,000.00
10 Blood Lancet 26G Onemed Dus 0 0 0 0 14,564.00 0.00
11 One Scrub Botol 0 0 0 0 62,491.00 0.00
12 Oxyflow (Oxygen Nasal) Buah 23 23 0 23 5,500.00 126,500.00
13 Natrium Clorida Botol 112 112 19 93 6,410.00 596,130.00
14 Gentamisin Salep Kulit Tube 0 0 0 3,080.00 0.00
15 L-BIO Sachet 0 0 0 6,600.00 0.00
16 Thiampenicol 500 mg Tablet 0 0 0 921.10 0.00
17 Meloxicam 7,5 mg Tablet 0 0 0 629.00 0.00
18 Piroxicam 10 mg Tablet 0 0 0 115.00 0.00
19 Ambroxol Tablet 0 0 0 143.68 0.00

20 Hyosin n buthylbromide 10 mg, Paracetamol (SCOPMA) Tablet

8 8 8 0 1,795.20 0.00
21 Stesolid/Diazepam Tube 1 1 0 1 23,760.00 23,760.00
22 Metronidazole Syp 200mg Botol 25 25 0 25 20,240.00 506,000.00
23 Neo K inj Ampul 50 50 0 50 6,600.00 330,000.00
24 Lodecon Tablet 0 0 0 0 869.00 0.00
25 Paracetamol 500 mg Tablet 1600 1,600 0 1600 169.00 270,400.00
26 Antasida Tablet 1300 1,300 0 1300 113.00 146,900.00
27 Solaflus Botol 0 0 0 0 12,100.00 0.00
28 Salbutamol Tablet 1400 1,400 68 1332 89 118,548.00
29 Asiklovir krim 5% Tube 0 100 100 76 24 3025 72,600.00
30 Ambroxol Tablet 0 2000 2,000 1391 609 161.7 98,475.30
31 Biomega Tablet 0 2000 2,000 598 1402 739.2 1,036,358.40
32 Cendo Lyters Botol 0 50 50 50 0 24200 0.00
33 Dextral Forte Tablet 0 3000 3,000 688 2312 781 1,805,672.00
34 Gentalex Krim Tube 0 100 100 78 22 3410 75,020.00
35 Histigo Tablet 0 1000 1,000 442 558 1426.7 796,098.60
36 Human Cens Cholesterol Strip 0 320 320 120 200 27220 5,444,000.00
37 Lodecon Forte Tablet 0 600 600 600 0 1089 0.00
38 Meloxicam 7,5 mg Tablet 0 1000 1,000 1000 0 401.5 0.00
39 Metilprednisolon tablet 4 mg Tablet 0 8000 8,000 676 7324 134 981,416.00
40 Neucompli Tablet 0 2000 2,000 1888 112 1023 114,576.00
41 Reco Tetes Telinga Botol 0 50 50 7 43 6380 274,340.00
42 Rexavin 125 mg Tablet 0 2000 2,000 170 1830 1270.5 2,325,015.00
43 Sarung Tangan Obgyn Steril pcs 0 20 20 0 20 19360 387,200.00
44 One Scrub Botol 0 24 24 0 24 62500 1,500,000.00
45 Maxter Exam M Box 0 20 20 0 20 58300 1,166,000.00
46 Maxter Exam L Box 0 20 20 0 20 58300 1,166,000.00

JUMLAH RP 21,052,654.30
 JUMLAH TOTAL 108,465,270.572

UMUM
TIDAK BPJS JUMLAH
BAYAR
BAYAR
JUMLAH RESEP

Sidamulih , 31 Oktob
Mengetahui / Menyetujui : Yang Menyerahkan : Yang Melaporkan Dokter Puskesmas, Yang Menerima
An. Kepala Dinas Kesehatan Kab.Pangandaran Kepala UPT Farmasi Plt UPTD Kesehatan Puskesmas Sidamulih,
Bidang Sumber Daya Kesehatan,
Ub/Seksi Kefarmasian

Tuti Perwitasari, S.Si., Apt., MM. dr. Eka Suprijana, S.Ked. Tati Haryati, Am. Keb Indri Noviyanti, dr
NIP. 19800227 200901 2 004 NIP. 189641023 200212 1 002 NIP. 19680313 199003 2 007 NIP. 19851103 201503 2 001 NIP. 19690604 19930
 FORM : LPLPO
NOMOR TANGGAL

PEMBERIAN
KET
LAIN JML
15 16 17
ex.date
ex.date
ex.date
Ex.date
ex.date
108,465,270.572

Sidamulih , 31 Oktober 2018

Yang Menerima
Petugas
Pengelola Obat
Puskesmas

Hj. N Minarni
NIP. 19690604 199303 2 005
 FORM PEMANTAUAN KETERSEDIAAN OBAT DAN VAKSIN INDIKATOR
DI PUSKESMAS
Periode Pelaporan: Oktober 2018

Nama Puskesmas : Sidamulih Penanggung Jawab Farmasi: Hj. N. Minarni

Alamat : Jl. Karang Sari No. 139 No. HP:
Email : ciosmulih@gmail.com
Kabupaten: Pangandaran
Provinsi : Jawa barat

Ketersediaan Ada
No Nama Obat Satuan (1) / Tidak (0)
1 2 3 4
1 Albendazol tab tablet 1
2 Amoxicillin 500 mg tab tablet 1
3 Amoxicillin syrup botol 1
4 Deksametason tab tablet 1
5 Diazepam inj 5 mg/mL injeksi 0
6 Epinefrin (Adrenalin) Injeksi 0,1% (Sebagai HCl) injeksi 1
7 Fitomenadion (Vitamin K) injeksi injeksi 1
8 Furosemid tablet 40 mg/Hidroklortiazid (HCT) tablet 1
9 Garam Oralit serbuk 1
10 Glibenklamid/Metformin tablet 1
11 Kaptopril tab tablet 1
12 Magnesium Sulfat Injeksi injeksi 0
13 Metilergometrin Maleat 0,200 mg - 1 mL injeksi 1
14 OAT Dewasa tablet 1
15 Oksitosin injeksi 1
16 Parasetamol 500 mg tab tablet 1
17 Tablet tambah darah tablet 1
18 Vaksin BCG injeksi 1
19 Vaksin DPT - HB- Hib injeksi 1
20 Vaksin Td injeksi 1

Pangandaran, 31 Oktober 2018

Mengetahui Yang Melaporkan,
Plt UPTD Kesehatan Puskesmas Sidamulih Pengelola Obat

Tati Haryati, Am.Keb Hj. N Minarni

NIP. 19680313 199003 2 007 NIP. 19690604 199303 2 005

Nb. Isi Kolom keterangan dengan X bila puskesmas tidak membutuhkan obat tersebut
 Keterangan

daran, 31 Oktober 2018

ang Melaporkan,
Pengelola Obat

Hj. N Minarni
9690604 199303 2 005