Lampiran 1 dari SK DIREKSI No.

KEP/071/112011
FORMULARIUM OBAT KLINIK / IN HOUSE CLINIC NAYAKA 2012
Kelas Terapi
Antibiotik
Gol. Sefalosporin

Nama Obat

Kandungan

Sediaan

Pabrik

Kemasan

Cefadroxil
Lostacef

Cefadroxil 500 mg, 125 mg/5ml

Cefadroxil 500 mg, 125 mg/5ml

Tablet , Sirup
Tablet, Sirup

Indofarma
Ifars

box@100
box@100

botol@1
botol@1

Gol Penisilin

Amoxycillin
Hufanoxil
Novamox
Yusimox Forte
Ampicillin
Ampicillin

Amoxycillin 500 mg , 125 mg/5 ml

Amoxycillin 500 mg , 125 mg/5 ml
Amoxycillin 500 mg , 125 mg/5 ml
Amoxycillin 125 mg/5 ml
Ampicillin 500 mg
Ampicillin 125 mg/5 ml

Tablet, Sirup
Tablet, Sirup
Tablet, Sirup
Sirup
kapsul
Sirup

Indofarma
Hufa
Nova
Ifars
Indofarma
Errita

box@100
box@100
box@100
botol@1
box@100
botol@1

botol@1
botol@1
botol@1

Gol. Kloramfenikol

Kloramfenikol
Kloramfenikol
Novachlor
Tiamfenikol
Dionicol

Kloramfenikol 250 mg
Kloramfenikol 250 mg
Kloramfenikol 250 mg
Tiamfenikol 500 mg
Tiamfenikol 500 mg

Kapsul
Sirup
Sirup
tablet
Kapsul

Indofarma
Errita
Nova
Indofarma
Ifars

box@100
botol@1
botol@1
box@100
box@100

Gol. Kuinolon
Gol. Tetrasiklin

Ciprofloxacin
Doksisiklin
Tetrasiklin 500

Ciprofloxacin 500 mg
Doksisiklin 500 mg
Tetrasiklin 500 mg

Tablet
Tablet
Tablet

Indofarma
Indofarma
Errita

box@100
box@100
box@100

Antibiotik Kombinasi

Cotrimoxazol
Primadex
Primadex Forte

Sulfametoksazol, Trimetoprim
Sulfametoksazol, Trimetoprim
Sulfametoksazol, Trimetoprim

Tablet, Sirup
Tablet, Sirup
Tablet

Errita
Dexa Medika
Dexa Medika

box@100
box@100
box@100

Antibiotik Lain

Linkomisin
Clindamisin

Linkomisin 500 mg
Clindamisin 500 mg

Tablet
Tablet

Indofarma
Indofarma

box@60
box@100

Analgetik & Antipiretik

Asam Mefenamat
Novastan 500 mg
Antalgin
Paracetamol
Fasidol
Procet

Asam Mefenamat 500 mg

Asam Mefenamat 500 mg
Antalgin 500 mg
Paracetamol 500 mg
Paracetamol 500 mg
Paracetamol 500 mg

Tablet
Tablet, sirup
Tablet
Tablet, Sirup
Drops, Syrup
Tablet, Sirup

Indofarma
Nova
Indofarma
Indofarma
Ifars
Promed

box@100
box@100
box@100
box@100
botol@1
box@100

botol@1
botol@1

botol@1
botol@1
botol@1
botol@1

Kelas Terapi

Nama Obat
Novagesic
Neuralgin
Neuromec
Neurophyron V

Kandungan
Paracetamol 500 mg
Metampiron, Vit B1, Vit B6, Vit B12
Metampiron, Vit B1, Vit B6, Vit B12
Metampiron, Vit B1, Vit B6, Vit B12

Sediaan
Tablet, Sirup
Tablet
Tablet
Tablet

Pabrik
Nova
Kalbe Farma
Mecosin
Harsen

box@100
box@100
box@100
box@100

Alpara
Bronchifar
Dextral
Flucadex
Demacolin
Citocetin
Flutop C

Paracetamol. CTM. Dextromethorpan,

Paracetamol. CTM. Dextromethorpan,

PCT, Pseudoefedrin, CTM

PCT, Pseudoefedrin
PCT, DMP, GG, CTM

Tablet
Tablet
Tablet, Sirup
Sirup
Tablet
Sirup
Sirup

Molex Ayus
Ifars
Molex Ayus
Graha farma
Coronet
Ciubros Farma
Ifars

box@150
box@100
box@100
botol@1
box@100
botol@1
botol@1

Ambroxol
Roverton
Bromifar
Bronkris Elix
Zenirex
Dextromethorphan
Gliceryl guaikolat
OBH Itrasal
OBP Itrasal

Ambroxol
Ambroxol
Bromhexin
Bromhexin
Prometazin HCl, Ipeca, Guaifenisin
Dextromethorphan
Gliceryl guaikolat
Amm. Chloride
Amm. Chloride

Tablet, Sirup
Tablet, Sirup
Tablet
Sirup
Sirup
Tablet, Sirup
Tablet
Sirup
Sirup

Indofarma
Ifars
Ifars
Graha Farma
Zenith
Indofarma
Berlico
Itrasal
Itrasal

box@100
box@100
box@100
botol@1
botol@1
box@100
botol@1000
botol@1
botol@1

Anti Histamin

Loratadin
Cetirizin
CTM
Dehista
Dexteem Plus

Loratadin
Cetirizin
CTM
CTM
Dexametason, Dexchlorpheniramin maleat

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Indofarma
Kimia Farma
Berlico
Erlimplex

box@50
box@50
botol@1000
botol@1000
box@100

Antasida

Antasida
Hufamag Plus
Novamag
Ranitidin
Simetidin
Omeprazole

Al(OH)3, Mg(OH)3
Al(OH)3, Mg. Trisilikat, Simeticon
Al(OH)3, Mg. Trisilikat, Simeticon
Ranitidin
Simetidin
Omeprazole

Tablet, Sirup
Sirup
Tablet, Sirup
Tablet
Tablet
Tablet

Kimia Farma
Hufa
Nova
Indofarma
Promed
Indofarma

botol@1000
botol@1
box@100
box@100
box@100
box@30

Vosea
Domperidon

Metoclorpramide
Domperidon

Tablet, Sirup
Tablet

Graha Farma
Domperidon

box@100
box@100

Anti Piretik & Anti Tusif

Anti Tusif

Anti Emetic

Paracetamol. CTM. Dextromethorpan, GG

Paracetamol. CTM. Dextro, GG, PPA

Kemasan
botol@1

botol@1

botol@1
botol@1

botol@1

botol@1
botol@1

Kelas Terapi

Nama Obat
Vesperum

Domperidon

Sediaan
Sirup

Ifars

botol@1

Anti Spasmodik

Papaverin HCl
Spasminal
Scopma Plus

Papaverin HCl
Metamizol Na, Ext. belladon, Papaverin
Hyocine Bromid, Paracetamol

Tablet, Injeksi
Tablet
Tablet

Kimia Farma
Hexpharm
Ifars

botol@1000
box@100
box@100

Anti Diare

Neo Enterodin
Mecodiar
Oralit
Guanistrep
Diaform

Activated Attapulgit
Loperamid
Larutan elektrolit
Kaolin, Pectin
Adsorben

Tablet
Tablet
sacchet
Sirup
Tablet

Erela
Mecosin
Indofarma
Itrasal
unknown

box@100
box@100
box@100
botol@1
botol@500

Cardiovaskuler System

ISDN
Propanolol
Nifedipin

ISDN
Propanolol
Nefedipin

Tablet
Tablet
Tablet

Indofarma
Propanolol
Kimia Farma

box@100
box@100
box@100

Anti Hipertensi

Captopril
Dexacap

Captopril (12,5 mg , 25 mg )
Captopril 12,5

Tablet
Tablet

Indofarma
Dexa Medica

box@100
box@100

Dislipidemia

Simvastatin
Selvim
Gemfibrozil

Simvastatin 10 mg
Simvastatin 10 mg
Gemfibrozil 300

Tablet
Tablet
Tablet

Kimia Farma
Ifars
Indofarma

box@50
box@30
box@100

Anti Asma

Aminophyllin
Grafasma
Grafalin
Teosal
Teosal

Aminophyllin
Theofilin, Efedrin
Salbutamol Sulfat
salbutamol Sulfat 1 mg, Theofilin 150 mg
salbutamol Sulfat 0,5 mg, Theofilin 50 mg

Tablet
Tablet
Tablet
Tablet
Sirup

Coronet
Graha Farma
Graha Farma
Dexa Medica
Dexa Medica

botol@1000
box@100
box@100
box@100
botol@1

Anti Convulsan

Phenytoin Na
Amitriptilin

Phenytoin Na
Amyitriptilin

Tablet
Tablet

Ikapharmindo
Indofarma

box@100
box@100

Anti Vertigo

Histigo

Betahistin Mesilat

Tablet

Ifars

box@50

Meloxicam 7,5 mg, 15 mg

Ibuprofen 400 mg
Ibuprofen 200 mg
Na. Diklofenat 50 mg

Tablet
Tablet
Tablet
Tablet

Indofarma
Indofarma
Ifars
Indofarma

box@50
box@100
box@100
box@50

Non Steroid Anti Inflamasi Meloxicam

Ibuprofen
Farsifen
Na. Diklofenat

Kandungan

Pabrik

Kemasan

box@100

Kelas Terapi

Nama Obat
Grateos
Grazeo
Faxiden Gel
Kaditic

Kandungan
Na. Diklofenat 50 mg
Piroksikam
Piroksikam
Kalium Diklofenat 50 mg

Sediaan
Tablet
Tablet
Gel
Tablet

Pabrik
Graha Farma
Graha Farma
Ifars
Ifars

box@50
box@100
tube@1
box@50

Kemasan

DiuretiK

HCT
Furosemid

Hidroclortiazide 25 mg
Furosemid

Tablet
Tablet

Indofarma
Indofarma

botol@1000
box@100

Hyperuricemia

Allupurinol
Linogra

Allupurinol 100 mg
Allupurinol 100 mg

Tablet
Tablet

Indofarma
Ifars

box@100
box@100

Kortikosteroid

Methyl Prednison
Rhemafar 4 mg
Prednison
Inflason
Dexametason
Grathazon
Kalmetason

Methyl Prednisolon 4 mg
Methyl Prednisolon 4 mg
Prednison 5 mg
Prednison 5 mg
Dexametason 0,5 mg
Dexametason 0,5 mg
Dexametason 0,5 mg

Tablet
Tablet
Tablet
Tablet
Tablet, Ampul
Tablet
Tablet

Indofarma
Ifars
Kimia farma
Berlico
Indofarma
Graha Farma
Kalbe Farma

box@100
box@100
botol@1000
box@200
box@100
box@200
box@200

Haemostatik

Vitamin K
Danochrom

Vitamin K
Carbazochrom Na. Sulfonat

Tablet, Ampul
Tablet

Kimia Farma
Hexpharm

botol@500
box@100

Phlebitis Preparation

Nuwasir
Superhoid Supp

Graptophyllum pictum folia,

Tablet
Suppos

Medikon

box@6
box@6

Anti Viral

Acyclovir

Acyclovir 200 mg, 400 mg

Acyclovir Cream 5%

Tablet
Cream

Indofarma
Indofarma

box@100
box@25

Antelmintik

Pyrantel
Combantrin
Combicitrin

Pyrantel Pamoat 125

Pyrantel Pamoat 250
Piperazina

Tablet
Tablet
Sirup

Kimia Farma
Pfizer
Berlico

box@100
box@50
botol@1

Multivitamin

Neurodex
Caviplex Drops
Livron B-plex
Hufabion
Etabion Plus
Univit

Vitamin B1, B6, B12

Tablet
Multi Vitamin
Drops
Multi Vitamin
Tablet
Ferro Fumarat, Mn, Sulfat, Copper sulfat, Vit C, Folic acid
Tablet
Ferro Gluconat, Vit. C, asam Folat, Vit B12, Cu. Sulfat Tablet
Multi Vitamin
Sirup

Dexa Medica
Erela
Phapros
Hufa
Errita
Medifarma

box@200
botol@1
box@100
box@100
box@100
botol@1

box@100

box@100

box@100

Kelas Terapi

Nama Obat
Sulfas Ferrosus
Vitamin B1
Vitamin B6
Vitamin B12
Vitamin B komplek
Anelat

Sulfas Ferrosus
Vitamin B1
Vitamin B6
Vitamin B12
Vitamin B1, B6, B12
Asam Folat

Kandungan

Sediaan
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Pabrik
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Ifars

Kemasan
botol@1000
botol@1000
botol@1000
botol@1000
botol@1000
box@100

Vitamin C

Vitamin C

Vitamin C 50 mg

Tablet

Kimia Farma

botol@1000

Vitamin + Calcium

Lico Kalk
Calcicus Lactat

Calcii Laktat
Calcicus Lactat

Tablet
Tablet

Berlico
Erela

botol@100
botol@1000

Anti Fungi

Ketokonazol
Griseofulvin
Metronidazol
Grafazol

Ketokonazol 200 mg
Griseofulvin 125
Metronidazol 500
Metronidazol 500

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Indofarma
Indofarma
Graha Farma

box@100
box@100
box@100
box@100

Obat KB

Mikrodiol 30
Plano
Cyclogeston
Depogeston

Etinilestradiol
Medroxyprogesteron asetat, estradiol cypionat
Medroxyprogesteron asetat, estradiol cypionat

Tablet
Tablet
Ampul
Ampul

Kimia Farma
Triyasa
Triyasa
Triyasa

strip@20
strip@20
vial@1
vial@1

Anti TB

Rifampisin 600
Etambutol 500
INH 300
Pyrazinamid 500

Rifampisin
Etambutol
INH
Pyrazinamid

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Kimia Farma
Indofarma

box@100
box@100
box@100
box@100

Preparat Mata

Erlamycetin Salep mata

Erlamycetin Tetes mata

Kloramfenikol 1%
Kloramfenikol 0,5 %

Salep mata
Tetes mata

Erela
Erela

tube@1
botol@1

Preparat Telinga

Erlamycetin Tetes Telinga

Kloramfenikol

Tetes Telinga

Erela

botol@1

Preparat Mulut

Bufacomb in Orabase
GOM Cito

Tiamsinolon
Borax Gliserin

cream
Liquid

Bufa
Ciubros

tube@1

Preparat Kulit

Gentamisin Sulfat salep

Klorfeson Salep
Ketokonazol Salep

Gentamisin Sulfat 1%
Kloramfenikol, Prednisolon
Ketokonazol

Salep
Salep
Salep

Indofarma
Molex Ayus
Kimia Farma

box@25
tube@1
tube@1

Kelas Terapi

Nama Obat
Hydrocortison Cream
Miconazole salep
Salep Kulit 24
Oxytetrasiklin salep
Icthiol salep
Levertran salep
Salycil Talk
PK

Kandungan

ZnO, camphora, menthol

Kalium Permanganat

Sediaan
Cream
Salep
Salep
Salep
Salep
Salep
Talkum
Liquid

Pabrik
Indofarma
Indofarma
Ciubros
Indofarma
Ciubros
Ciubros
Afi Farma

box@25
tube@1
tube@1
box@25
tube@1
tube@1
pcs@1

Hidrocortison 2,5%
Miconazole
Salep Kulit 24
Oxytetrasiklin

Kemasan

Vaksin

Vaksin BCG
Vaksin Campak
Vaksin DPT
Vaksin TT
Vaksin Polio

Vaksin BCG
Vaksin Campak
Vaksin DPT
Vaksin TT
Vaksin Polio

Ampul
Ampul
Ampul
Ampul
Ampul

Biofarma
Biofarma
Biofarma
Biofarma
Biofarma

vial@1
vial@1
vial@1
vial@1
vial@1

Lain - lain
( Amprahan Ruangan )

Alkohol 70%
Rivanol 100ml
Betadine Solution
H2O2 3%
kasa steril husada
Kapas 250 husada
Verban
Spuit 3 cc
Spuit 5 cc
Needle 23
Needle 27
Cut Gut 3/0, 4/0
Silk 3/0 , 4/0 ( black, white)
Bisturi no.15
Handscoon S,M,L,XL
HCG test
Masker 3fly jeva

Alkohol 70%
Rivanol 100ml
Povidone Iodine
H2O2 3%
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes

Liquid
Liquid
Liquid
Liquid
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs

PIM
Molex
mahakam
prima plus
Askara
unknown
unknown
terumo
terumo
terumo
terumo
unknown
unknown
unknown
Sensi Gloves
care lamson
remedi

botol@1 liter
botol@100 ml
botol@1 liter
botol@100 ml
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1

Lampiran 2 dari SK DIREKSI No. KEP/071/112011

FORMULARIUM OBAT KLINIK GIGI NAYAKA 2012

No
I
a

Jenis Obat

Kemasan

1
2
3

KONSERVASI GIGI
Tambalan Sementara
Cavit
Eugenol
Znocide/ Fletcher

Tube
Fls
Tube

1
2
3
4
5
6
7

Tambalan Tetap
Amalgam Kapsul
Amalgam Likuid Mercury
Amalgam Powder
Fuji IX GP
Glass Ionomer II Fuji
Matrix Band
Stone

Pcs
Fls
Tube
Tube
Tube
Pack
Pcs

1
2
3
4

Tambalan Tetap / Light Curing ( LC )

Articulating Paper
Bonding
Stick untuk Bonding
Synergi A2, A3, dan A3,5

Pack@50 pcs
Tube
Pack @100 pcs
Tube

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

Perawatan Saluran Akar

Arsen
CHKM
Cresophene
Dycal
Endomethason
TKF Formocresol
Trimix + Powder
Larutan H2O2 3 %
Guttap Point
Paper Point
Jarum Reamer ( Alat )
Jarum Extirpasi ( Alat )
Endobox ( Alat )

Tube
Fls
Fls
Tube
Tube
Tube
Tube
Fls
Pack@100 pcs
Pack@100 pcs
Pack@5 pcs
Pack@5 pcs
Pack

2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11

BEDAH MULUT
Chloretyl
Curaspon/ Spongostan
Lidocaine
Pehacaine
Topical Anestesi gel
Xylestin
Xylocain Spray
Betadine Solution
Jarum ukuran 21 G
Blade
Jarum Citoject " Carpule "

Fls
Tube
Ampul
Ampul
Tube
Pcs
Fls
Fls
Pcs
pcs
pcs

II

III
3.1
3.2
3.3
3.4
3.5
3.6

PROSTO ( GIGI PALSU )

Cromophan Alginate
Moldano ( gips biru keras )
Self Curing Acrilic (stellon C )
Vaselin
Warna Gigi (Lumin vacum)
Waxlim

Pcs
Pcs
Tube
Tube
Pack@50 pcs
Pack@50 pcs

4.1

PERIODONSIA ( PENYANGGA GIGI / KARANG GIGI )

TSR / OCO

Fls

5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8

CONSUMABLE
Batu Arkansas
Bor Diamond
Celluloid Strip
Dental Flos
Handscoon
Handel Scalpel
Minosep Gargle
Spuit Terumo 3 cc

Pcs
Pcs
Pack@50 pcs
Tube
Box@100 pcs
Pcs
Fls
Pcs

IV

Lampiran 3 dari SK DIREKSI No. KEP/071/112011

FORMULARIUM OBAT IN HOUSE CLINIC PT HMS

Kelas Terapi
Antibiotik
Gol. Sefalosporin

Gol Penisilin

Gol. Kloramfenikol

Gol. Kuinolon

Gol. Tetrasiklin

Antibiotik Kombinasi

Gol. Makrolida

Nama Obat

Kandungan

Sediaan

Pabrik

Kemasan

Cefadroxil
Lostacef
Cefixime

Cefadroxil 500 mg, 125 mg/5ml

Cefadroxil 500 mg, 125 mg/5ml
Cefadroxil 500 mg

Tablet , Sirup
Tablet, Sirup
Tablet

Indofarma
Ifars
Indofarma

box@100

botol@1

box@100

botol@1

Hufanoxil
Novamox
Yusimox Forte
Dexymox
Lapimox
Ampicillin
Ampicillin

Amoxycillin 500 mg , 125 mg/5 ml

Amoxycillin 500 mg , 125 mg/5 ml
Amoxycillin 125 mg/5 ml
Amoxycillin 500 mg
Amoxycillin 500 mg
Ampicillin 500 mg
Ampicillin 125 mg/5 ml

Tablet, Sirup
Tablet, Sirup
Sirup
Tablet
Tablet
kapsul
Sirup

Hufa
Nova
Ifars
Dexa Medika
Lapi
Indofarma
Errita

box@100

botol@1

box@100

botol@1

Kloramfenikol
Kloramfenikol
Novachlor
Dionicol
Dexycol

Kloramfenikol 250 mg
Kloramfenikol 250 mg
Kloramfenikol 250 mg
Tiamfenikol 500 mg
Tiamfenikol 500 mg

Kapsul
Sirup
Sirup
Kapsul
Kapsul

Indofarma
Errita
Nova
Ifars
Dexa Medika

box@100

Ciprofloxacin
Hufaflox
Levofloxacin

Ciprofloxacin 500 mg
Ciprofloxacin 500 mg
Levofloxacin

Tablet
Tablet
Tablet

Indofarma
Hufa Farma
Indofarma

box@100

Doksisiklin
Tetrasiklin 500

Doksisiklin 500 mg
Tetrasiklin 500 mg

Tablet
Tablet

Indofarma
Errita

box@100

Cotrimoxazol
Primadex
Primadex Forte
San Prima F

Sulfametoksazol, Trimetoprim
Sulfametoksazol, Trimetoprim
Sulfametoksazol, Trimetoprim
Sulfametoksazol, Trimetoprim

Tablet, Sirup
Tablet, Sirup
Tablet
Tablet

Errita
Dexa Medika
Dexa Medika
Sanbe farma

box@100

botol@1

box@100

botol@1

Eritromisin
Eryra

Eritromisin 500 mg
Eritromisin 500 mg

Tablet
Tablet

Indofarma
Rama farma

box@100

box@30

botol@1
box@100
box@100
box@100
botol@1

botol@1
botol@1
box@100
box@100

box@100
box@100

box@100

box@100
box@100

box@100

Kelas Terapi
Antibiotik Lain

Analgetik & Antipiretik

Anti Piretik & Anti Tusif

Anti Tusif

Nama Obat

Kandungan

Sediaan

Pabrik

Tablet
Tablet

Indofarma
Indofarma

box@60

box@100

Tablet, sirup
Tablet, Sirup
Tablet, Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Sanbe Farma
Hexpharm
Nova
Promed
Nova
Sanbe Farma
Sanbe Farma
Kalbe Farma
Mecosin
Harsen
Indofarma
Indofarma
Molex Ayus
Ifars
Molex Ayus
Graha farma
Coronet
Ciubros Farma
Ifars

box@150

PCT, Pseudoefedrin, CTM

PCT, Pseudoefedrin
PCT, DMP, GG, CTM

Tablet
Tablet
Tablet, Sirup
Sirup
Tablet
Sirup
Sirup

Ambroxol
Ambroxol
Ambroxol
Pseudoefedrin 30 mg, Terfenadine
PCT, Phenyleprine HCl, Dexclorpheniramin
Bromhexin
Bromhexin
Prometazin HCl, Ipeca, Guaifenisin
Dextromethorphan
Dextromethorphan
Gliceryl guaikolat
PCT, DMP, Diphenhidramin

Tablet, Sirup
Tablet, Sirup
Tablet
Tablet
Tablet
Tablet
Sirup
Sirup
Tablet, Sirup
Tablet
Tablet
Sirup

Indofarma
Ifars
Tempo
Dexa Medika
Meprofarm
Ifars
Graha Farma
Zenith
Indofarma
Zenith
Berlico
Itrasal

box@100

botol@1

box@100

botol@1

Linkomisin
Clindamisin

Linkomisin 500 mg
Clindamisin 500 mg

Mefinal
Stanza
Novastan 500 mg
Procet
Novagesic
Sanmol
Analsik
Neuralgin
Neuromec
Neurophyron V
Antalgin
Tramadol

Asam mefenamat 500 mg

Asam mefenamat 500 mg
Asam Mefenamat 500 mg
Paracetamol 500 mg
Paracetamol 500 mg
Parasetamol 500 mg

Alpara
Bronchifar
Dextral
Flucadex
Demacolin
Citocetin
Flutop C

Paracetamol. CTM. Dextromethorpan,

Paracetamol. CTM. Dextromethorpan,

Ambroxol
Roverton
Mucoxol
Rhinofed
Intunal F
Bromifar
Bronkris Elix
Zenirex
Dextromethorphan
Dexitab
Gliceryl guaikolat
OBH Itrasal

Metampiron 500 mg, Diazepam 2 mg

Metampiron, Vit B1, Vit B6, Vit B12
Metampiron, Vit B1, Vit B6, Vit B12
Metampiron, Vit B1, Vit B6, Vit B12
Antalgin 500 mg
Tramadol

Paracetamol. CTM. Dextromethorpan, GG

Paracetamol. CTM. Dextro, GG, PPA

Tablet
Tablet

Kemasan

box@100

box@100
box@100

botol@1

box@100

botol@1

box@100

botol@1

box@100
box@100
box@100
box@100
box@100
box@100
box@30

box@100
box@100

botol@1

botol@1
box@100
botol@1
botol@1

box@100
box@50
box@100
box@100
botol@1
botol@1
box@100
box@100
botol@1000
botol@1

botol@1

Kelas Terapi

Anti Histamin

Antasida

Anti Emetic

Anti Spasmodik

Anti Diare

Nama Obat
OBP Itrasal
OBH Nellco Spesial
Sanadryl DMP

Kandungan
Amm. Chloride
PCT, DMP, Diphenhidramin
Diphenhidramin HCl, Amm. Chloride

Sediaan
Sirup
Sirup
Sirup

Pabrik
Itrasal
Nellco
Sanbe Farma

Loratadin
Cetirizin
CTM
Dehista
Dexteem Plus
Graperide
Decadryl Injeksi

Loratadin
Cetirizin
CTM
CTM
Dexametason, Dexchlorpheniramin maleat
Cryptoheptadine
Diphenhidramin 10 mg

Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Vial

Indofarma
Indofarma
Kimia Farma
Berlico
Erlimplex
Graha Farma
Harsen

Antasida
Hufamag Plus
Novamag
Ranitidin
Radin
Simetidin
Omeprazole
Sanmag
Sanmag sirup
Dexanta
Dexanta

Al(OH)3, Mg(OH)3
Al(OH)3, Mg. Trisilikat, Simeticon
Al(OH)3, Mg. Trisilikat, Simeticon
Ranitidin
Ranitidin
Simetidin
Omeprazole

Tablet, Sirup
Sirup
Tablet, Sirup
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Hufa
Nova
Indofarma
Dexa Medika
Promed
Indofarma
Mg Trisilkat 325 mg, Al(OH)4 325 mg, Papaverin HCL 30 mg, Chlordiazepoksid
Tablet HCL 5 mg,
Sanbe
vit Farma
Mg Trisilkat 325 mg, Al(OH)4 325 mg, Papaverin HCL 30 mg, Chlordiazepoksid
Sirup
HCL 5 mg,
Sanbe
vit Farma
Mg Trisilkat 325 mg, Al(OH)4 325 mg,
Tablet
dexa medica
Mg Trisilkat 325 mg, Al(OH)4 325 mg,
Sirup
dexa medica

botol@1000

Vosea
Domperidon
Vesperum
Primperan
Mediamer B6

Metoclorpramide
Domperidon
Domperidon
Metoclopramide HCl 10 mg
Pyrathiazine Theoclate 40 mg, Vit B6 37,5 mg

Tablet, Sirup
Tablet
Sirup
Tablet
Tablet

Graha Farma
Domperidon
Ifars
Soho
darya Varia

box@100

Papaverin HCl
Spasminal
Scopma Plus
Buscopan Injeksi

Papaverin HCl
Metamizol Na, Ext. belladon, Papaverin
Hyocine Bromid, Paracetamol

Kimia Farma
Hexpharm
Ifars
Boehringer

botol@1000

Hyocine Bromid

Tablet, Injeksi
Tablet
Tablet
Ampul

Neo Enterodin
Mecodiar

Activated Attapulgit
Loperamid

Tablet
Tablet

Erela
Mecosin

box@100

Kemasan
botol@1
botol@1
boto@1
box@50
box@50
botol@1000
botol@1000
box@100
box@100
box@25
botol@1

botol@1
box@100

botol@1

box@100
Box@100
box@100
box@30
box@100
Fls@1
box@100
Fls@1

box@100
botol@1
box@100
box@50

box@100
box@100
kotak@10ampul

box@100

box@100

Kelas Terapi

Nama Obat
Oralit
Guanistrep
Diaform
Loremid
New Diatabs

Larutan elektrolit
Kaolin, Pectin
Adsorben
Loperamid 2 mg
Attapulgite 600 mg

Sediaan
sacchet
Sirup
Tablet
Tablet
Tablet

Pabrik
Indofarma
Itrasal
unknown
Meprofarma
Medifarma

ISDN
Propanolol
Nifedipin

ISDN
Propanolol
Nefedipin

Tablet
Tablet
Tablet

Indofarma
Propanolol
Kimia Farma

box@100

Captopril
Dexacap

Captopril (12,5 mg , 25 mg )
Captopril 12,5

Tablet
Tablet

Indofarma
Dexa Medica

box@100

Ansiolitik
Antagonis Calsium

Diazepam
Amlodipine

Diazepam 2 mg
Amlodipine 10 mg

Tablet
Tablet

Indo Farma
Indo Farma

Botol@1000
box@30

Dislipidemia

Simvastatin
Selvim
Gemfibrozil

Simvastatin 10 mg
Simvastatin 10 mg
Gemfibrozil 300

Tablet
Tablet
Tablet

Kimia Farma
Ifars
Indofarma

box@50

Aminophyllin
Grafasma
Grafalin
Teosal
Teosal
Sedakter

Aminophyllin
Theofilin, Efedrin
Salbutamol Sulfat
salbutamol Sulfat 1 mg, Theofilin 150 mg
salbutamol Sulfat 0,5 mg, Theofilin 50 mg
terbutalin

Tablet
Tablet
Tablet
Tablet
Sirup
Tablet

Coronet
Graha Farma
Graha Farma
Dexa Medica
Dexa Medica
Corsa

botol@1000

Phenytoin Na
Amitriptilin

Phenytoin Na
Amitriptilin

Tablet
Tablet

Ikapharmindo
Indofarma

box@100

Histigo
Vastigo
Seremig

Betahistin Mesilat
Betahistin mesylate
Flunarizin

Tablet
Tablet
Tablet

Ifars
Dexa Medica
Ifars

box@50

Meloxicam
Ibuprofen
Farsifen

Meloxicam 7,5 mg, 15 mg

Ibuprofen 400 mg
Ibuprofen 200 mg

Tablet
Tablet
Tablet

Indofarma
Indofarma
Ifars

box@50

Cardiovaskuler System

Anti Hipertensi

Anti Asma

Anti Convulsan

Anti Vertigo

Non Steroid Anti Inflamasi

Kandungan

Kemasan
box@100
botol@1
botol@500
box@100
box@100

box@100
box@100

box@100

box@30
box@100

box@100
box@100
box@100
botol@1
box@100

box@100

box@30
box@50

box@100
box@100

Kelas Terapi

Nama Obat
Dofen
Na. Diklofenat
Grateos
Voltadex tab
Voltadex Gel
Grazeo
Faxiden Gel
Pirocam
Kaditic
Ketoprofen

Kandungan
Ibuprofen 200 mg
Na. Diklofenat 50 mg
Na. Diklofenat 50 mg
Natrium diklofenak 50 mg
Natrium diklofenak 10 mg/g
Piroksikam
Piroksikam
Piroxicam 10 mg
Kalium Diklofenat 50 mg
Ketoprofen

Sediaan
Tablet
Tablet
Tablet
Tablet
Gel
Tablet
Gel
Tablet
Tablet
Tablet

Pabrik
Dexa Medika
Indofarma
Graha Farma
Dexa Medika
Dexa Medika
Graha Farma
Ifars
Dexa Medika
Ifars
Indofarma

HCT
Furosemid
Classic
Gralixa 40

Hidroclortiazide 25 mg
Furosemid
Furosemida 40 mg
Furosemida 40 mg

Tablet
Tablet
Tablet
Tablet

Indofarma
Indofarma
Kimia Farma
Graha farma

botol@1000

Allupurinol
Linogra

Allupurinol 100 mg
Allupurinol 100 mg

Tablet
Tablet

Indofarma
Ifars

box@100

Vitazym
Dexazym

Pankreatin 50 mg, Papain 10 mg, oxbile 50 mg, curcuma rhixoma Tablet

35 mg liver extract 50Kalbe
mg, Farma

box@100

Pankreatin 170 mg, dimetilpolioksan aktif 80 mg. extracy Ox bile 50

Tablet
mg

Harsen

box@100

Antiseptik saluran kemih Urotractin

Asam pipemidik

Tablet

Sanbe Farma

box@60

Trombolitik

Ascardia 80

Asam asetilsalisilat 80 mg

Tablet

Pharos

box@100

Kortikosteroid

Methyl Prednison
Rhemafar 4 mg
Prednison
Inflason
Dexametason
Kalmetason
Lanadexon
Grafachlor

Methyl Prednisolon 4 mg
Methyl Prednisolon 4 mg
Prednison 5 mg
Prednison 5 mg
Dexametason 0,5 mg
Dexametason 0,5 mg
Dexametason 0,5 mg
Dexametason 0,5 mg, dexclorpheniramin maleat

Tablet
Tablet
Tablet
Tablet
Tablet, Ampul
Tablet
Tablet
Tablet

Indofarma
Ifars
Kimia farma
Berlico
Indofarma
Kalbe Farma
Dexa Medika
Graha Farma

box@100

Vitamin K
Danochrom

Vitamin K
Carbazochrom Na. Sulfonat

Tablet, Ampul
Tablet

Kimia Farma
Hexpharm

botol@500

DiuretiK

Hyperuricemia

kolagogum, kolelitolitik

Haemostatik

Kemasan
box@100
box@50
box@50
box@50
tube@1
box@100
tube@1
box@50
box@50
box@100

box@100
box@100
box@100

box@100

box@100
botol@1000
box@200
box@100

box@100

box@200
box@100
box@100

box@100

box@100

Kelas Terapi

Tranexamid Acid

Sediaan
Tablet

Pabrik

Nexitra
Nuwasir
Superhoid
Lanaven

Graptophyllum pictum folia,

Benzocain 1%, ZnO, alukol, ekstrak sitrus komplek
Lesitin murni 100 mg, ekstrak hipokasta 50 mg

Tablet
Suppos
Tablet

Medikon
Landson

box@6

Acyclovir
Acyclovir Cream

Acyclovir 200 mg, 400 mg

Acyclovir Cream 5%

Tablet
Cream

Indofarma
Indofarma

box@100

Pyrantel
Combantrin
Combicitrin

Pyrantel Pamoat 125

Pyrantel Pamoat 250
Piperazina

Tablet
Tablet
Sirup

Kimia Farma
Pfizer
Berlico

box@100

Neurodex
Livron B-plex
Hufabion
Etabion Plus
Sulfas Ferrosus
Anelat
Biosanbe

Vitamin B1, B6, B12

Tablet
Dexa Medica
Multi Vitamin
Tablet
Phapros
Ferro Fumarat, Mn, Sulfat, Copper sulfat, Vit C, Folic acid
Tablet
Hufa
Ferro Gluconat, Vit. C, asam Folat, Vit B12, Cu. Sulfat Tablet
Errita
Sulfas Ferrosus
Tablet
Kimia Farma
Asam Folat
Tablet
Ifars
Fe gluconat,manganese sulfat,copper sulfat,vit c,as folat,cyanokobalamin
Tablet
Sanbe Farma

box@200

Vitamin C
Selkom C

Vitamin C 50 mg
Vitamin C

Tablet
Tablet

Kimia Farma
Sapta Saritama

botol@1000

Lico Kalk
Ostine
Novakal
Trimakal

Calcii Laktat
Glucosamin, chondroitin sulfat,Mg, Zn, Mn
Ca. Laktat 500 mg,
Ca. Laktat 500 mg,

Tablet
Tablet
Tablet
Tablet

Berlico
graha farma
Nova

botol@100

Muscle Relaxant

Eperisone OGB

Eperisone HCl 50 mg

Tablet

Medixon

box@100

Anti Fungi

Ketokonazol
Griseofulvin
Grafazol
Fladex
Dexazol
Grisin

Ketokonazol 200 mg
Griseofulvin 125
Metronidazol 500
Metronidazole 500 mg
Ketokonazole 200 mg
Griseofulvin 125 mg

Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Indofarma
Graha Farma
Dexa Medika
Dexa Medika
Nova

box@100

Phlebitis Preparation

Anti Viral

Antelmintik

Multivitamin

Vitamin C

Vitamin + Calcium

Nama Obat

Kandungan

Kemasan
box@100

kotak@6supp
box@100

box@25

box@50
botol@1

box@100
box@100
box@100
botol@1000
box@100
box@100

box@100

box@60
box@200

box@100
box@100
box@100
box@50
box@100

box@100

Kelas Terapi
Obat KB

Nama Obat

Kandungan

Sediaan

Pabrik

Kemasan

Microgynon
Exluton
Cyclofem
Triclofem injeksi
Planotab
Cyclogeston

Levonorgestrel 150 mcg,ethynil estradiol 30 mcg plus Tablet

7 tab placebo
Lynestrenol
Tablet
Medroxyprogesterone asetat 50 mg, estradiol cypionate
Injeksi
10 mg
Medroxyprogesterone asetat
Injeksi
Levonorgestrel 150 mcg,ethynil estradiol 30 mcg plus tablet
7 tab placebo
Medroxyprogesterone asetat
Injeksi

Bayer
Schering
Tunggal Idaman
Tunggal Idaman
Triyasa
Triyasa

Rifampisin 600
Etambutol 500
INH 300
Pyrazinamid 500

Rifampisin
Etambutol
INH
Pyrazinamid

Kimia Farma
Kimia Farma
Kimia Farma
Indofarma

Erlamycetin Salep mata

Erlamycetin Tetes mata
Reco Tetes mata
Alletrol Compositum

Kloramfenikol 1%
Salep mata
Erela
Kloramfenikol 0,5 %
Tetes mata
Erela
Kloramfenikol 0,5%
Tetes mata
Global Multi
Deksametason 0,1%, Neomisin Sulfat 3,5 mg, Polimiksin
Tetes
B sulfat
mata6000 uiErela

tube@1

Preparat Telinga

Erlamycetin Tetes Telinga

Kloramfenikol

Tetes Telinga

Erela

botol@1

Preparat Mulut

Bufacomb in Orabase
GOM Cito

Tiamsinolon
Borax Gliserin

cream
Liquid

Bufa
Ciubros

tube@1

Topical Antibiotik

Gentamisin Sulfat salep

Klorfeson Salep
Ketokonazol Salep
Solinfec cream
Hydrocortison Cream
Miconazole salep
Salep Kulit 2-4
Oxytetrasiklin salep
Mycoral krim
Scabicid Cream
Sagestam krim
Bufacort

Gentamisin Sulfat 1%
Kloramfenikol, Prednisolon
Ketokonazol
Ketokonazol
Hidrocortison 2,5%
Miconazole
Salep Kulit 24
Oxytetrasiklin
Ketokonazole 2% cream
Gameksan, usnic acid
Gentamisin Sulfat 0,1%
Neomisin Sulfat, hidrocortison acetat

Salep
Salep
Salep
Cream
Cream
Salep
Salep
Salep
Cream
Cream
Cream
Salep

Indofarma
Molex Ayus
Kimia Farma
Ifars
Indofarma
Indofarma
Ciubros
Indofarma
Kalbe Farma
Kimia Farma
Sanbe Farma
Bufa

box@25

Icthiol salep

Icthiol salep

Salep

Ciubros

tube@1

Anti TB

Preparat Mata

Preparat Kulit

Tablet
Tablet
Tablet
Tablet

box@280
box@84
ampul@2
ampul@1
strip@28tablet
[email protected]
box@100
box@100
box@100
box@100

botol@1
Fls@1
Fls@1

tube@1
tube@1
Tube@1
box@25
tube@1
tube@1
box@25
Tube@1
Tube@1
tube@1
tube@1

Kelas Terapi

Lain - lain
( Amprahan Ruangan )

Nama Obat
Levertran salep
Salycil Talk
PK
Molacream
Lafalos Cream

Kandungan
Levertran salep
ZnO, camphora, menthol
Kalium Permanganat
Menthol, eugenol, methyl salisilat
Menthol, eugenol, methyl salisilat

Sediaan
Salep
Talkum
Liquid
Cream
Cream

Pabrik
Ciubros
Afi Farma
Ciubros
Molex Ayus
Sanbe Farma

Alkohol 70%
Rivanol 100ml
Betadine Solution
Bioplacenton
H2O2 3%
kasa steril husada
Kapas 250 husada
Verban
Spuit 3 cc
Spuit 5 cc
Needle 23
Needle 27
Cut Gut 3/0, 4/0
Silk 3/0 , 4/0 ( black, white)
Bisturi no.15
Handscoon S,M,L,XL
HCG test
Masker 3fly jeva

Alkohol 70%
Rivanol 100ml
Povidone Iodine
Placenta Extract, neomisin sulfat
H2O2 3%
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes
Alkes

Liquid
Liquid
Liquid
tube
Liquid
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs

PIM
Molex
mahakam
Kalbe Farma
prima plus
Askara
unknown
unknown
terumo
terumo
terumo
terumo
unknown
unknown
unknown
Sensi Gloves
care lamson
remedi

Kemasan
tube@1
pcs@1
tube@1
tube@1
botol@1 liter
botol@100 ml
botol@1 liter
Tube@1
botol@100 ml
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1
pcs@1

Lampiran 6 dari SK DIREKSI No. KEP/071/112011

LAPORAN STOK OPNAME OBAT / ALAT KESEHATAN

Klinik
Cabang

: Nayaka Era Husada

: Cirebon

Periode

: Agustus 2014
Nama Obat

1
1

Form 1
Sediaan

Pabrik

Gol. Sefalosporin
Cefadroxil 500 mg
Cefadroxil 125 mg/ 5 ml
Lostacef 500 mg
Lostacef 125 mg / 5 ml

Tablet
Sirup
Tablet
Sirup

Indofarma
Indofarma
Ifars
Ifars

Gol Penisilin
Amoxycillin 500 mg
Amoxycillin 125 mg / 5 ml
Hufanoxil 500 mg
Hufanoxil 125 mg/5 ml
Novamox 500 mg
Novamox 125 mg/5 ml
Yusimox Forte
Ampicillin
Ampicillin

Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
kapsul
Sirup

Indofarma
Indofarma
Hufa
Hufa
Nova
Nova
Ifars
Indofarma
Errita

Gol. Kloramfenikol
Kloramfenikol
Kloramfenikol
Novachlor
Tiamfenikol
Dionicol

Kapsul
Sirup
Sirup
tablet
Kapsul

Indofarma
Errita
Nova
Indofarma
Ifars

Gol. Kuinolon
Ciprofloxacin

Tablet

Indofarma

Gol. Tetrasiklin
Doksisiklin
Tetrasiklin 500

Tablet
Tablet

Indofarma
Errita

Antibiotik Kombinasi
Kotrimoxazol
Kotrimoxazol

Tablet
Syrup

Errita
Errita

Sisa

Penambahan

Jumlah

Pemakaian

Sisa

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

Bulan Ini

Harga Satuan
HNA + PPN

Stok Obat

Pemakaian

8= 6+7

10 = 8-9

11

12 = 8 x 11

13 = 9 x 11

130
15

200

15
263

1600

34

330
15
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
15
0
263
0
0
0
1600
0
0
0
0
0
0
0
34

130
9

9
93

900

200
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
0
170
0
0
0
700
0
0
0
0
0
0
0
29

Total Harga

836
8800

424
3960

4730
649
4180

374

4950

275,880
132,000
70,950
170,687
598,400
168,300

108,680
79,200
42,570
60,357
336,600
24,750

Sisa Obat EX
14=10 x 11

167,200
52,800
28,380
110,330
261,800
143,550

Jan-16
Oct-16

Nov-16
Oct-16

Sep-16
Sep-15

Mar-16

Jun-16

Nama Obat

Sediaan

Pabrik

10

Primadex
Primadex
Primadex Forte

Tablet
Syrup
Tablet

Dexa Medika
Dexa Medika
Dexa Medika

Antibiotik Lain
Linkomisin
Clindamisin

Tablet
Tablet

Indofarma
Indofarma

Analgetik & Antipiretik

Asam Mefenamat
Novastan 500 mg
Novastan
Antalgin
Paracetamol 500 mg
Paracetamol
Fasidol Drops
Fasidol Syrup
Procet tablet
Procet Syrup
Novagesic tablet
Novagesic Syrup
Neuralgin
Neuromec
Neurophyron V

Tablet
Tablet
Sirup
Tablet
Tablet
Sirup
Drops
Sirup
Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Tablet

Indofarma
Nova
Nova
Indofarma
Indofarma
Indofarma
Ifars
Ifars
Promed
Promed
Nova
Nova
Kalbe Farma
Mecosin
Harsen

Anti Piretik & Anti Tusif

Alpara
Bronchifar
Dextral Tablet
Dextral Syrup
Flutamol
Flucadex
Demacolin
Citocetin
Milsen
Etaflusin
Hufagrif Forte
Flutop C

Tablet
Tablet
Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
Tablet
Tablet
Sirup

Molex Ayus
Ifars
Molex Ayus
Molex Ayus
Molex Ayus
Graha farma
Coronet
Ciubros Farma
Ifars

Anti Tusif

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

125
105

1060

900

100
2100
65

500
40

680

228

150

456

150
1300

285
230
35
10
747

50
20
1600

Ifars

Jumlah

125
0
105
0
0
0
0
0
0
1960
0
0
100
2600
105
0
0
0
0
0
0
0
680
0
0
0
378
0
606
0
1300
285
230
85
30
747
1600
0
0
0

Pemakaian

Sisa

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
10 = 8-9

46
6

1,062

2,492
62

278

88
315
1,000
285
60
85
30
533
1477

79
0
99
0
0
0
0
0
0
898
0
0
100
108
43
0
0
0
0
0
0
0
402
0
0
0
290
0
291
0
300
0
170
0
0
214
123
0
0
0

11

165
429

825

198
2310
209
195
4950

330

503
367
292
385
638
4400
4400
297
192.5

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

20,625
45,045
388,080
20,900
507,000
519,750
224,400
190,134
222,402
379,600
109,725
146,740
374,000
132,000
221,859
308,000
-

7,590
2,574
210,276
485,940
306,900
91,740
44,264
115,605
292,000
109,725
38,280
374,000
132,000
158,301
284,323
-

Sisa Obat EX
14=10 x 11

13,035
42,471
177,804
20,900
21,060
212,850
132,660
145,870
106,797
87,600
108,460
63,558
23,678
-

Dec-17
Jun-18

May-16

Apr-18

Mar-17
May-17
Jan-16

May-17

Jan-18
Oct-18
Apr-18
Jan-17
Mar-18
Oct-16
Jun-16
Jul-16
Jun-18

Nama Obat

Sediaan

Pabrik

11

12

13

Ambroxol tablet
Ambroxol Syrup
Roverton Tablet
Roverton Syrup
Ephedrine
Bromifar
Bronkris Elix
Zenirex
Dextromethorphan Tablet
Dextromethorphan Syrup
Gliceryl guaikolat Tablet
OBH Itrasal Syrup
OBP Itrasal Syrup

Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Sirup
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup

Indofarma
Indofarma
Ifars
Ifars
Kimia Farma
Ifars
Graha Farma
Zenith
Indofarma
Indofarma
Berlico
Itrasal
Itrasal

Anti Histamin
Loratadin
Gabiten
CTM
Dehista
Dexteem Plus

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Ifars
Kimia Farma
Berlico
Erlimplex

Antasida
Antasida Tablet
Antasida Syrup
Hufamag Plus
Hufamag Plus
Novamag Tablet
Novamag Syrup
Ranitidin
Simetidin
Omeprazole
Vitazym
Dulcolax

Tablet
Sirup
Sirup
Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Hufa
Hufa
Nova
Nova
Indofarma
Promed
Indofarma
Kalbe Farma
Boehringer Ingeheim

Anti Emetic
Vosea Tablet
Vosea Syrup
Domperidon
Vesperum

Tablet
Sirup
Tablet
Sirup

Graha Farma
Graha Farma
Domperidon
Ifars

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

500
16

60

3000
42
6

270
1715
170
1150

20

300

5000
8
106
72

30
20

226

400

40
89

125
7

300
35

Jumlah

500
76
0
0
0
0
0
0
0
0
3000
42
26
0
0
0
570
1715
170
1150
0
0
5000
0
38
126
72
626
0
0
40
89
0
0
425
42
0
0
0

Pemakaian

Sisa

10 = 8-9

328
40

725
14
11

118
751
10
1,150

1480
35
306

405

65
19

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
172
36
0
0
0
0
0
0
0
0
2275
28
15
0
0
0
452
964
160
0
0
0
3520
0
3
-180
72
0
221
0
0
40
89
0
0
360
23
0
0
0

11

187
4070

660

46.2
3520
30.8
4950
4400

330
14.3
143
253

38.5
3300
4400
198
165
280

424
1020

275
3850

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

93,500
309,320
92,400
207,900
114,400
188,100
24,525
24,310
290,950
192,500
167,200
24,948
11,880
175,280
16,960
90,780
116,875
161,700
-

61,336
162,800
22,330
69,300
48,400
38,940
10,739
1,430
290,950
56,980
154,000
60,588
113,400
17,875
73,150
-

Sisa Obat EX
14=10 x 11

32,164
146,520
70,070
138,600
66,000
149,160
13,785
22,880
135,520
13,200
(35,640)
11,880
61,880
16,960
90,780
99,000
88,550
-

Nov-18
May-18

May-16
Nov-17
Feb-16
Aug-17
Aug-17

Apr-16
Jan-16
Jun-16
Oct-17

Jun-18
May-17
May-18
Mar-17
Oct-16

Apr-15
Nov-13

Jul-18
May-17

Nama Obat

Sediaan

Pabrik

1
14

15

16

17

18

19

20

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

Anti Spasmodik
Papaverin HCl Tablet
Papaverin HCl Injeksi
Spasminal
Scopma Plus

Tablet
Injeksi
Tablet
Tablet

Kimia Farma
Kimia Farma
Hexpharm
Ifars

Anti Diare
Zinc 20 mg
Mecodiar / Inamid
Oralit
Guanistrep
Diaform

Tablet
Tablet
sacchet
Sirup
Tablet

Indofarma
Mecosin
Indofarma
Itrasal
unknown

Cardiovaskuler System
ISDN
Propanolol
Nifedipin
Aspilet
Digoxin 0,25 mg

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Propanolol
Kimia Farma
Medifarma Laboratoris
Indofarma

Anti Hipertensi
Captopril 25 mg
Captopril 12,5 mg
Dexacap

Tablet
Tablet
Tablet

Indofarma
Indofarma
Dexa Medica

130
187

100

Dislipidemia
Simvastatin
Selvim
Gemfibrozil
Glibenclamide

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Ifars
Indofarma
Indofarma

100

Anti Asma
Aminophyllin
Bisolvon Nebu
Grafalin
Prosmalin 25 mg
Teosal
Ventolin Nebules 2,5 mg

Tablet
Tablet
Tablet
Tablet
Sirup
pcs

Coronet
Graha Farma
Graha Farma
Dexa Medica
Dexa Medica
GlaxoSmithKline

Anti Convulsan

847
167
154

63
136
12
544

100
110
35
500

42
100

70

50
1
73
68
7

100

Jumlah

0
0
847
167
154
0
0
163
136
110
47
1044
0
0
0
0
0
42
100
0
0
230
187
0
0
0
108
0
0
70
0
0
50
1
73
168
0
7
0
0

Pemakaian

Sisa

10 = 8-9

22
33
10

163
136
32
16
814

230
100

68
88

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
0
0
825
134
144
0
0
0
0
78
31
230
0
0
0
0
0
42
100
0
0
0
87
0
0
0
100
0
0
70
0
0
50
1
5
80
0
7
0
0

11

115

594
550

550
165
880
4950
89.1

534
127

165
104.5

953

116

62700
181.5
192.5
10120

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

99,198
84,700
89,650
22,440
96,800
232,650
93,020
22,428
12,700
37,950
19,542
102,924
8,120
62,700
13,250
32,340
70,840
-

19,602
5,500
89,650
22,440
28,160
79,200
72,527
37,950
10,450
7,624
12,342
16,940
-

Sisa Obat EX
14=10 x 11

79,596
79,200
68,640
153,450
20,493
22,428
12,700
9,092
95,300
8,120
62,700
908
15,400
70,840
-

Nov-16
Jun-18
Sep-16

Mar-14
Aug-17
Feb-18
Aug-15
Nov-17

Jun-14
Mar-15

Aug-16
Dec-16

Jun-16

Aug-17

May-15
Jan-16
Apr-18
Sep-18
Sep-14

Nama Obat

Sediaan

Pabrik

21

22

23

24

25

26

Phenytoin Na
Amitriptilin
Luminal

Tablet
Tablet
Tablet

Ikapharmindo
Indofarma

Anti Vertigo
Histigo
Dimendyhidinate

Tablet
Tablet

Ifars
Indo Farma

Non Steroid Anti Inflamasi

Meloxicam 7,5 mg
Meloxicam 20 mg
Ibuprofen
Ibuprofen
Farsifen
Na. Diklofenat
Grateos
Grazeo
Faxiden Gel
Kaditic

Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Gel
Tablet

Indofarma
Indofarma
Indofarma
Indofarma
Ifars
Indofarma
Graha Farma
Graha Farma
Ifars
Ifars

DiuretiK
HCT
Furosemid
Bicorbinat

Tablet
Tablet
Tablet

Indofarma
Indofarma

Hyperuricemia
Allupurinol
Linogra

Tablet
Tablet

Indofarma
Ifars

Kortikosteroid
Methyl Prednison
Rhemafar 4 mg
Prednison
Inflason
Dexametason tablet
Dexametason ampul
Grathazon
Kalmetason

Tablet
Tablet
Tablet
Tablet
Tablet
Ampul
Tablet
Tablet

Indofarma
Ifars
Kimia farma
Berlico
Indofarma
Indofarma
Graha Farma
Kalbe Farma

Haemostatik

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

69
177

293
30
2500
650

772
41

139

80

5000
77

Jumlah

0
0
0
0
0
69
177
0
0
0
293
30
2500
0
650
0
0
0
0
0
0
772
41
0
0
0
139
0
0
0
80
0
0
0
5000
0
77
0
0
0

Pemakaian

Sisa

10 = 8-9

14
41

140
30
1,500
326

36

20

1,710
77

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
0
0
0
0
0
55
136
0
0
0
153
0
1000
0
324
0
0
0
0
0
0
736
41
0
0
0
119
0
0
0
80
0
0
0
3290
0
0
0
0
0

11

220

3500
143

514
5500
330
264

100
100

187

473
28
33
110

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

241,500
25,311
150,602
165,000
825,000
171,600
77,200
25,993
37,840
165,000
8,470
-

49,000
5,863
71,960
165,000
495,000
86,064
3,600
3,740
56,430
8,470
-

Sisa Obat EX
14=10 x 11

192,500
19,448
78,642
330,000
85,536
73,600
22,253
37,840
108,570
-

Oct-14

Oct-16
May-18

Jan-16
Feb-17
Dec-17
Aug-15

Jul-17
Feb-18

Dec-18

Apr-16

Aug-17
Jul-18

Nama Obat

Sediaan

Pabrik

Vitamin K tablet
Vitamin K Injeksi
Danochrom

Tablet
Ampul
Tablet

Kimia Farma
Kimia Farma
Hexpharm

Phlebitis Preparation
Nuwasir
Superhoid Supp

Tablet
Suppos

Medikon

Anti Viral
Acyclovir
Acyclovir

Tablet
Cream

Indofarma
Indofarma

Antelmintik
Pyrantel
Combantrin 250 mg
Combicitrin 125 mg

Tablet
Tablet
Tablet

Kimia Farma
Pfizer
Pfizer

Vitamin
Neurodex
Caviplex Drops
Livron B-plex
Hufabion
Etabion Plus
Univit / Vitamin
Sulfas Ferrosus
Vitamin B1
Vitamin B6
Vitamin B12
Vitamin B komplek
Enervit
Vitamin C
Lico Kalk
Calcicus Lactat

Tablet
Drops
Tablet
Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Dexa Medica
Erela
Phapros
Hufa
Errita
Medifarma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Balatif
Kimia Farma
Berlico
Erela

Anti Fungi
Ketokonazol
Griseofulvin
Metronidazol
Grafazol

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Indofarma
Indofarma
Graha Farma

27

28

29

30

31

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

304

150
36

5
19

478

500

202
5

500

2169
1597
1309
1060
228

400
114
517

167
15
25

200

Jumlah

304
0
0
0
0
0
0
0
0
150
36
0
0
0
5
19
0
0
978
0
0
0
702
5
0
2169
1597
1309
1060
628
0
114
517
0
0
167
15
225
0
0

Pemakaian

Sisa

10 = 8-9

10
7

1
1

238

238

562
1400
899
1060
428
40
218

111

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
295
0
0
0
0
0
0
0
0
140
29
0
0
0
4
18
0
0
740
0
0
0
464
5
0
1607
197
410
0
200
0
74
299
0
0
167
15
114
0
0

11

39.6

660
3850

5500
2750

330

193
3410
100
38.5
26
22
27.5
616
37.4
159.5
38.5

484
341
209

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

12,038
99,000
138,600
27,500
52,250
322,740
135,486
17,050
83,507
41,522
28,798
29,150
386,848
18,183
19,905
80,828
5,115
47,025
-

356
6,600
26,950
5,500
2,750
78,540
45,934
21,637
36,400
19,778
29,150
263,648
6,380
8,393
23,199
-

Sisa Obat EX
14=10 x 11

11,682
92,400
111,650
22,000
49,500
244,200
89,552
17,050
61,870
5,122
9,020
123,200
11,803
11,512
80,828
5,115
23,826
-

Feb-16

Jul-16
May-17

Oct-14
Sep-15

Aug-18

May-15
May-15
Mar-16
Jun-16
Oct-15
May-17
Jun-15
Jun-17
Aug-17
Mar-18
Feb-18

May-17
Oct-16
Jun-18

Nama Obat

Sediaan

Pabrik

1
32

33

34

35

36

37

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

Obat KB
Mikrodiol 30 / Andalan
Plano
Cyclogeston
Depogeston
Kondom Sutra

Tablet
Tablet
Ampul
Ampul
pcs

Kimia Farma
Triyasa
Triyasa
Triyasa
unknown

38
19

30

16
16

60

Anti TB
Rifampisin 600
Rifampisin 450
Etambutol 500
INH 300
Pyrazinamid 500

Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Indofarma

76

Preparat Mata
Erlamycetin Salep mata
Erlamycetin Tetes mata

Salep mata Erela

Tetes mata Erela

13

Preparat Telinga
Erlamycetin Tetes Telinga

Tetes TelingaErela

Preparat Mulut
Bufacomb in Orabase
GOM Cito
Dentasol

cream
Liquid
Liquid

Bufa
Ciubros
Erela

Preparat Kulit
Gentamisin Sulfat salep
Klorfeson Salep
Ketokonazol Salep
Betametason
Hydrocortison Cream
Miconazole salep
Salep Kulit 24
Oxytetrasiklin salep
Icthiol salep
Levertran salep
Salycil Talk
PK

Salep
Salep
Salep
Salep
Cream
Salep
Salep
Salep
Salep
Salep
Talkum
Liquid

Indofarma
Molex Ayus
Kimia Farma
Molex Ayus
Indofarma
Indofarma
Ciubros
Indofarma
Ciubros
Ciubros
Afi Farma

68
968
60

100
100
300

80

10
9

25

23

35

14

30
65
31

5
2
2

70
3

28

30

Jumlah

0
68
19
0
76
16
0
0
76
100
168
968
360
0
0
13
80
0
0
7
0
0
0
35
9
0
0
58
0
0
44
65
36
2
70
5
0
58
0
0

Pemakaian

Sisa

10 = 8-9

52
9
26
1

32
43
113
141
103

8
16

18
2

47

16
21
18
8

22

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
0
16
10
0
50
15
0
0
44
57
55
827
257
0
0
5
64
0
0
1
0
0
0
17
7
0
0
11
0
0
28
44
18
2
62
5
0
36
0
0

11

4125
3850
5390
1210

891
616
660
116
275

3630
7370

6050

2750
4950

4400

3850
3300
3960
3300
2200
4620
3520
3300

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

280,500
73,150
409,640
19,360
67,716
61,600
110,880
112,288
99,000
47,190
589,600
42,350
96,250
44,550
255,200
169,400
214,500
142,560
6,600
154,000
23,100
191,400
-

214,500
34,650
140,140
1,210
28,512
26,488
74,580
16,356
28,325
29,040
117,920
36,300
49,500
9,900
206,800
61,600
69,300
71,280
17,600
72,600
-

Sisa Obat EX
14=10 x 11

66,000
38,500
269,500
18,150
39,204
35,112
36,300
95,932
70,675
18,150
471,680
6,050
46,750
34,650
48,400
107,800
145,200
71,280
6,600
136,400
23,100
118,800
-

Sep-18
Sep-17
Aug-16
Feb-17

Jan-14
Aug-17
Apr-16
May-16
Jun-16

Jan-17
Sep-15

Nov-14

Oct-17
Jul-17

Sep-16

May-15
Dec-15
Sep-17
Dec-15
Mar-15
Apr-18
Sep-18
Aug-17

Nama Obat

Sediaan

Pabrik

1
38

39

Vaksin
Vaksin BCG
Vaksin Campak
Vaksin DPT
Vaksin TT
Vaksin Polio

Ampul
Ampul
Ampul
Ampul
Ampul

Biofarma
Biofarma
Biofarma
Biofarma
Biofarma

Lain - Lain
Aguabidsit
Alkohol 70% 1 liter
Rivanol 100ml
Betadine 1 liter
H2O2 3%
kasa steril husada
Kapas 250 husada
Verban
Spuit 3 cc
Spuit 1 cc
Needle 23
Benang Jahit + Jarum Jahit
Nacl
Plester
Cut Gut 3/0, 4/0
Silk 3/0 , 4/0 ( black, white)
Bisturi no.15
Handscoon S,M,L,XL
Plester Anti Air
Saccharin
Masker 3fly

liquid
liquid
liquid
liquid
liquid
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
Tablet
pcs

unknown
PIM
Molex
mahakam
prima plus
Askara
unknown
unknown
terumo/BD
terumo
terumo
Qomic
unknown
unknown
unknown
unknown
unknown
Sensi Gloves
care lamson
Trifa Laboratories
remedi

Sisa

Penambahan

Bln Lalu

Bulan Ini

Bulan Ini

Bulan Ini

8= 6+7

1
1

260

106
42
2
2
3

100

100

20

50

Jumlah

0
0
0
0
0
0
0
0
1
1
0
0
0
260
0
0
106
0
42
2
2
3
0
0
0
200
0
0
70

Pemakaian

Sisa

10 = 8-9

150

46
28
2
1

100

40

Total Harga

Harga Satuan
Bulan Ini HNA + PPN
0
0
0
0
0
0
0
0
1
0
0
0
0
110
0
0
60
0
14
2
0
2
0
0
0
100
0
0
30

11

4400
23.1
57.75
440
52.8
1100
880
302.5
2100
8250
16500

440
16500
11
770

Stok Obat

Pemakaian

12 = 8 x 11

13 = 9 x 11

4,400
23
114,400
116,600
12,705
4,200
16,500
49,500
88,000
53,900

23
66,000
50,600
8,470
16,500
16,500
44,000
30,800

15,741,378

7,950,115

Cirebon, 30 Agustus
Yang Menyetujui

(dr. Penanggung jawab Klinik )

Yang Membuat

( Jamala)

2014

Sisa Obat EX
14=10 x 11

4,400
48,400
66,000
4,235
4,200
33,000
44,000
23,100
7,791,264

Oct-15
Sep-14
Sep-14
Sep-14
Sep-16
Mar-16
Apr-18
Jun-16
Jun-16

Jun-16
Jun-16
Oct-13
Oct-15

Lampiran 7 dari SK DIREKSI No. KEP/071/112011

LAPORAN PERMINTAAN OBAT / ALAT KESEHATAN

Klinik
: NAYAKA ERA HUSADA
KaCab
: CIREBON
Periode : AGUSTUS 2014
,

Nama Obat

Sediaan

1
2
1 Gol. Sefalosporin
Cefadroxil 500 mg
Cefadroxil 125 mg/ 5 ml
Lostacef 500 mg
Lostacef 125 mg / 5 ml

Form 2

Pabrik
4

Tablet
Sirup
Tablet
Sirup

Indofarma
Indofarma
Ifars
Ifars

Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
kapsul
Sirup

Indofarma
Indofarma
Hufa
Hufa
Nova
Nova
Ifars
Indofarma
Errita

Kapsul
Sirup
Sirup
tablet
Kapsul

Indofarma
Errita
Nova
Indofarma
Ifars

Tablet

Indofarma

Tablet
Tablet

Indofarma
Errita

Tablet
Syrup
Tablet
Syrup
Tablet

Errita
Errita
Dexa Medika
Dexa Medika
Dexa Medika

Tablet
Tablet

Indofarma
Indofarma

Tablet
Tablet
Sirup
Tablet
Tablet
Sirup
Drops
Sirup
Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Tablet

Indofarma
Nova
Nova
Indofarma
Indofarma

2 Gol Penisilin
Amoxycillin 500 mg
Amoxycillin 125 mg / 5 ml
Hufanoxil 500 mg
Hufanoxil 125 mg/5 ml
Novamox 500 mg
Novamox 125 mg/5 ml
Yusimox Forte
Ampicillin
Ampicillin

3 Gol. Kloramfenikol
Kloramfenikol
Kloramfenikol
Novachlor
Tiamfenikol
Dionicol

4 Gol. Kuinolon
Ciprofloxacin

5 Gol. Tetrasiklin
Doksisiklin
Tetrasiklin 500

6 Antibiotik Kombinasi
Kotrimoxazol
Kotrimoxazol
Primadex
Primadex
Primadex Forte

7 Antibiotik Lain
Linkomisin
Clindamisin

8 Analgetik & Antipiretik

Asam Mefenamat
Novastan 500 mg
Novastan
Antalgin
Paracetamol 500 mg
Paracetamol
Fasidol Drops
Fasidol Syrup
Procet tablet
Procet Syrup
Novagesic tablet
Novagesic Syrup
Neuralgin
Neuromec
Neurophyron V

Ifars
Ifars
Promed
Promed
Nova
Nova
Kalbe Farma
Mecosin
Harsen

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

200
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
0
170
0
0
0
700
0
0
0
0
0
0
0
29
79
0
99
0
0
0
0
0
0
898
0
0
100
108
43
0
0
0
0
0
0
0
402
0
0

Harga Satuan
HNA + PPN
9

Total Harga
Penambahan Obat
10 = 7 x 9

200
20

400
26
0
0

836
7700

167,200
154,000
-

1500
100

1500
100
0
0
0
0
0
0
0

374
3850

561,000
385,000
83,600
105,600
238,700
68,200
54,450
248,490
198,000
166,980
-

200

0
26
0
370

700

1400

20

4180
528

341

0
0

200

300

1800
60

600

0
29
79
0
299

3520
165
341

0
0

825

1198
0
0
100
1908
103
0
0
0
0
0
0
0
1002
0

181.5
2310
77
138.05
3300

278.3

Nama Obat

Sediaan

Pabrik

9 Anti Piretik & Anti Tusif

Alpara
Bronchifar
Dextral Tablet
Dextral Syrup
Flutamol
Flucadex
Demacolin/ Molexflu
Citocetin
Milsen
Etaflusin
Hufagrif Forte
Flutop C

Tablet
Tablet
Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
Tablet
Tablet
Sirop

Molex Ayus
Ifars
Molex Ayus
Molex Ayus
Molex Ayus
Graha farma
Coronet
Ciubros Farma
Ifars

Ifars

10 Anti Tusif
Ambroxol tablet
Ambroxol Syrup
Roverton Tablet
Roverton Syrup
Ephedrine
Bromifar
Bronkris Elix
Zenirex
Dextromethorphan Tablet
Dextromethorphan Syrup
Gliceryl guaikolat Tablet
OBH Itrasal Syrup
OBP Itrasal Syrup

Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Sirup
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup

Indofarma
Indofarma
Ifars
Ifars
Kimia Farma
Ifars
Graha Farma
Zenith
Indofarma
Indofarma
Berlico
Itrasal
Itrasal

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Ifars
Kimia Farma
Berlico
Erlimplex

Tablet
Sirup
Sirup
Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Hufa
Hufa
Nova
Nova
Indofarma
Promed
Indofarma
Kalbe Farma
Boehringer Ingeheim

Tablet
Sirup
Sirup
Tablet
Sirup

Graha Farma
Graha Farma
Domperidon
Domperidon
Ifars

Tablet
Injeksi
Tablet
Tablet

Kimia Farma
Kimia Farma
Hexpharm
Ifars

Tablet
Tablet
sacchet
Sirup
Tablet

Indofarma
Mecosin
Indofarma
Itrasal
unknown

11 Anti Histamin
Loratadin
Gabiten
CTM
Dehista
Dexteem Plus

12 Antasida
Antasida Tablet
Antasida Syrup
Hufamag Plus
Hufamag Plus
Novamag Tablet
Novamag Syrup
Ranitidin
Simetidin
Omeprazole
Vitazym
Dulcolax

13 Anti Emetic
Vosea Tablet
Vosea Syrup
Domperidon
Domperidon
Vesperum

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

0
290
0
291
0
300
0
170
0
0
214
123
0
0
0
172
36
0
0
0
0
0
0
0
0
2275
28
15
0
0
0
452
964
160
0
0
0
3520
0
3
-180
72
0
221
0
0
40
89
0
0
360
23
0
0
0
0

290
0
591
0
700
0
370
20
15
1014
723

300
400
200
20
15
800
600

100
50

10
1000
20
15

200
1000
600

1000
40

500

500
20

Harga Satuan
HNA + PPN

15 Anti Diare
Zinc 20 mg
Mecodiar / Inamid
Oralit
Guanistrep
Diaform

0
825
134
144
0
0
0
0
78
31
230
0

368
278.4
231
385
352
4400
4070
247.5
192.5

272
86
0
0
0
0
0
0
0
10
3275
48
30
0
0
0
652
1964
160
600

154
3447

4520
0
43
-180
72
0
721
0
0
40
89

48.4
3300
4070
182
165

860
43
0
0
0

165
3300

660

52.8
3300
30
3630
3630

319
13.2
165
253

231

424
1020

105

0
825

482
264

134

200

200
100
40

344

0
200
178
71
230

Penambahan Obat
10 = 7 x 9

14 Anti Spasmodik
Papaverin HCl Tablet
Papaverin HCl Injeksi
Spasminal
Scopma Plus

Total Harga

550
165
462
3300
89.1

83,520
92,400
70,400
88,000
61,050
198,000
115,500
15,400
172,350
33,000
30,000
72,600
54,450
63,800
13,200
151,800
48,400
162,800
115,500
82,500
66,000
52,800
33,000
46,200
132,000
-

Nama Obat

Sediaan

Pabrik

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

16 Cardiovaskuler System
ISDN
Propanolol
Nifedipin
Aspilet
Digoxin 0,25 mg

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Propanolol
Kimia Farma
Medifarma Laboratoris
Indofarma

Tablet
Tablet
Tablet

Indofarma
Indofarma
Dexa Medica

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Ifars
Indofarma
Indofarma

Tablet
Tablet
Tablet
Tablet
Sirup
pcs

Coronet
Graha Farma
Graha Farma
Dexa Medica
Dexa Medica
GlaxoSmithKline

Tablet
Tablet
Tablet

Ikapharmindo
Indofarma

Tablet
Tablet

Ifars
Indo Farma

17 Anti Hipertensi
Captopril 25 mg
Captopril 12,5 mg
Dexacap

18 Dislipidemia
Simvastatin
Selvim
Gemfibrozil
Glibenclamide

19 Anti Asma
Aminophyllin
Grafasma
Grafalin
Prosmalin
Teosal
Ventolin Nebules 2,5 mg

20 Anti Convulsan
Phenytoin Na
Amitriptilin
Luminal

21 Anti Vertigo
Histigo
Dimendyhidinate

22 Non Steroid Anti Inflamasi

Meloxicam 7,5 mg
Meloxicam 20 mg
Ibuprofen
Ibuprofen
Farsifen
Na. Diklofenat
Grateos
Grazeo
Faxiden Gel
Kaditic

Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Gel
Tablet

Indofarma
Indofarma
Indofarma
Indofarma
Ifars
Indofarma
Graha Farma
Graha Farma
Ifars
Ifars

Tablet
Tablet
Tablet

Indofarma
Indofarma

Tablet
Tablet

Indofarma
Ifars

23 DiuretiK
HCT
Furosemid
Bicorbinat

24 Hyperuricemia
Allupurinol
Linogra

0
0
0
0
42
100
0
0
0
87
0
0
0
100
0
0
70
0
0
50
1
5
80
0
7
0
0
0
0
0
0
0
55
136
0
0
0
153
0
1000
0
324
0
0
0
0
0
0
736
41
0
0
0
119
0
0

100

100

Harga Satuan
HNA + PPN
9

0
0
0
42
100

534
127

0
187

162
105

100
0
0
70

550

116

50
1
5
80
0
7

10120

0
0
0

220

99
170

506
143

0
253
10
1000
0
624
0
0
0
0

300

736
41
0

231
4400
319
288.2

100
100

119
0

Penambahan Obat
10 = 7 x 9

155

100
10

Total Harga

170.5

10,500
50,600
23,100
44,000
86,460
-

Nama Obat

Sediaan

Pabrik

25 Kortikosteroid
Methyl Prednison
Rhemafar 4 mg
Prednison
Inflason
Dexametason tablet
Dexametason ampul
Grathazon
Kalmetason

Tablet
Tablet
Tablet
Tablet
Tablet
Ampul
Tablet
Tablet

Indofarma
Ifars
Kimia farma
Berlico
Indofarma
Indofarma
Graha Farma
Kalbe Farma

Tablet
Ampul
Tablet

Kimia Farma
Kimia Farma
Hexpharm

Tablet
Suppos

Medikon

Tablet
Salep

Indofarma
Indofarma

Tablet
Tablet
Tablet

Kimia Farma
Pfizer
Pfizer

Tablet
Drops
Tablet
Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Dexa Medica
Erela
Phapros
Hufa
Errita
Medifarma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Ifars
Kimia Farma
Berlico
Erela

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Indofarma
Indofarma
Graha Farma

Tablet
Tablet
Ampul
Ampul
pcs

Kimia Farma
Triyasa
Triyasa
Triyasa
unknown

Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Indofarma

Salep mata
Tetes mata

Erela
Erela

26 Haemostatik
Vitamin K tablet
Vitamin K Injeksi
Danochrom

27 Phlebitis Preparation
Nuwasir
Superhoid Supp

28 Anti Viral
Acyclovir 400 mg
Acyclovir Cream

29 Antelmintik
Pyrantel
Combantrin 250 mg
Combantrin 125 mg

30 Vitamin
Neurodex
Caviplex Drops
Livron B-plex
Hufabion
Etabion Plus
Univit
Sulfas Ferrosus
Vitamin B1
Vitamin B6
Vitamin B12
Vitamin B komplek
Enervit / Arkavit
Vitamin C
Lico Kalk
Calcicus Lactat

31 Anti Fungi
Ketokonazol
Griseofulvin
Metronidazol
Grafazol

32 Obat KB
Mikrodiol 30 / Andalan
Plano
Cyclogeston
Depogeston
Kondom Sutra

33 Anti TB
Rifampisin 600
Rifampisin 450
Etambutol 500
INH 300
Pyrazinamid 500

34 Preparat Mata
Erlamycetin Salep mata
Erlamycetin Tetes mata

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

0
80
0
0
0
3290
0
0
0
0
0
295
0
0
0
0
0
0
0
0
140
29
0
0
0
4
18
0
0
740
0
0
0
464
5
0
1607
197
410
0
200
0
74
299
0
0
167
15
114
0
0
0
16
10
0
50
15
0
0
44
57
55
827
257
0
0
5
64
0

2000

Harga Satuan
HNA + PPN
9

80
0
0
0
5290
0
0
0

28
28
28.6
110

45

0
0

600

1000
1000

140
29

660
3850

0
4
18

4950
2475

940
0
0
0
1064
5
0
1607
197
410
1000
1200
0
74
299

167
15
314

200

30

25
15

Penambahan Obat
10 = 7 x 9

295
0
0

200

Total Harga

357.5

181.5
3410
100
33
25.3
50
26.4
110
39.6
121
38.5

484
1122
231

46
10
0
50
15

4107
3575

44
57
55
827
257

891
616
748
90
275

30
79

3520
4950

5390
770

57,200
71,500
108,900
26,400
110,000
46,200
123,210
88,000
74,250
-

Nama Obat

Sediaan

Pabrik

35 Preparat Telinga
Erlamycetin Tetes Telinga

Tetes Telinga

Erela

cream
Liquid
Liquid

Bufa
Ciubros
Erela

Salep
Salep
Salep
Salep
Cream
Salep
Salep
Salep
Salep
Salep
Talkum
Liquid

Indofarma
Molex Ayus
Kimia Farma
Molex Ayus
Indofarma
Indofarma
Ciubros
Indofarma
Ciubros
Ciubros
Afi Farma

Ampul
Ampul
Ampul
Ampul
Ampul

Biofarma
Biofarma
Biofarma
Biofarma
Biofarma

Liquid
Liquid
Liquid
Liquid
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
Tablet
pcs

PIM
Molex
mahakam
prima plus
Askara
unknown
unknown
terumo
terumo
terumo
terumo
unknown
unknown
unknown
unknown
unknown
Sensi Gloves
care lamson
Trifa Laboratories
remedi

36 Preparat Mulut
Bufacomb in Orabase
GOM Cito
Dentasol

37 Preparat Kulit
Gentamisin Sulfat salep
Klorfeson Salep
Ketokonazol Salep
Betametason
Hydrocortison Cream
Miconazole salep
Salep Kulit 24
Oxytetrasiklin salep
Icthiol salep
Levertran salep
Salycil Talk
PK

38 Vaksin
Vaksin BCG
Vaksin Campak
Vaksin DPT
Vaksin TT
Vaksin Polio

39 Lain - Lain
Alkohol 70% 1 liter
Rivanol 100 ml
Betadine 1 liter
H2O2 3%
kasa steril husada
Kapas 250 husada
Verban
Spuit 3 cc
Spuit 1 cc
Needle 23
Needle 27
Nacl
Plester
Cut Gut 3/0, 4/0
Silk 3/0 , 4/0 ( black, white)
Bisturi no.15
Handscoon S,M,L,XL
HCG test
Saccharin
Masker 3fly

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

0
1
0
0
0
17
7
0
0
11
0
0
28
44
18
2
62
5
0
36
0
0
0
0
0
0
0
0
0
0
0
0
0
0
110
0
0
60
0
14
2
0
2
0
0
0
100
0
0
30

10 = 7 x 9

11

3520

20

0
37
7

2750
4950

30
30
15

1000

1000

100

Penambahan Obat

10

40

Total Harga

Harga Satuan
HNA + PPN

51
0
0
58
74
33
2
62
5
0
36

3300

1000
0
0
0
110
1000
0
60
0
14
2
0
3
0
0
0
100
0
0
130

23.1

35,200
55,000
132,000
79,200
99,000
70,950
23,100
198,000
11,550
77,000

2640
3300
4730
3300
2200
4620
3300
2750

24
385
198
920
880
303
8250
11550

440
11
770

TOTAL

6,187,210

Cirebon, 30 April 2014

Yang Menyetujui

(dr. Penanggung jawab Klinik )

Yang Membuat

Jamala

Lampiran 8 dari SK DIREKSI No. KEP/071/112011

LAPORAN REKAPITULASI PERMINTAAN OBAT / ALAT KESEHATAN
KaCab : CIREBON
Periode : Februari 2014

Form 3
Sisa

No

Nama Obat

Sediaan

Pabrik

1
1

Gol. Sefalosporin
Cefadroxil 500 mg
Cefadroxil 125 mg/ 5 ml
Lostacef 500 mg
Lostacef 125 mg / 5 ml

Tablet
Sirup
Tablet
Sirup

Indofarma
Indofarma
Ifars
Ifars

Gol Penisilin
Amoxycillin 500 mg
Amoxycillin 125 mg / 5 ml
Hufanoxil 500 mg
Hufanoxil 125 mg/5 ml
Novamox 500 mg
Novamox 125 mg/5 ml
Yusimox Forte
Ampicillin
Ampicillin

Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
kapsul
Sirup

Indofarma
Indofarma
Hufa
Hufa
Nova
Nova
Ifars
Indofarma
Errita

Gol. Kloramfenikol
Kloramfenikol
Kloramfenikol
Novachlor
Tiamfenikol
Dionicol

Kapsul
Sirup
Sirup
tablet
Kapsul

Indofarma
Errita
Nova
Indofarma
Ifars

Gol. Kuinolon
Ciprofloxacin

Tablet

Indofarma

Gol. Tetrasiklin
Doksisiklin
Tetrasiklin 500

Tablet
Tablet

Indofarma
Errita

Antibiotik Kombinasi
Kotrimoxazol
Kotrimoxazol
Primadex
Primadex
Primadex Forte

Tablet
Syrup
Tablet
Syrup
Tablet

Errita
Errita
Dexa Medika
Dexa Medika
Dexa Medika

Antibiotik Lain
Linkomisin
Clindamisin

Tablet
Tablet

Indofarma
Indofarma

Analgetik & Antipiretik

Asam Mefenamat
Novastan 500 mg
Novastan
Antalgin
Paracetamol 500 mg
Paracetamol
Fasidol Drops
Fasidol Syrup
Procet tablet
Procet Syrup
Novagesic tablet
Novagesic Syrup
Neuralgin
Neuromec
Neurophyron V

Tablet
Tablet
Sirup
Tablet
Tablet
Sirup
Drops
Sirup
Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Tablet

Indofarma
Nova
Nova
Indofarma
Indofarma

Anti Piretik & Anti Tusif

Alpara
Bronchifar
Dextral Tablet
Dextral Syrup
Flutamol
Flucadex
Demacolin
Citocetin
Milsen
Etaflusin
Hufagrif Forte
Flutop C

Tablet
Tablet
Tablet
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup
Tablet
Tablet
Sirup

Molex Ayus
Ifars
Molex Ayus
Molex Ayus
Molex Ayus
Graha farma
Coronet
Ciubros Farma

Tablet
Sirup
Tablet
Sirup
Tablet
Tablet
Sirup
Sirup
Tablet
Sirup
Tablet
Sirup
Sirup

Indofarma
Indofarma
Ifars
Ifars
Kimia Farma
Ifars
Graha Farma
Zenith
Indofarma
Indofarma
Berlico
Itrasal
Itrasal

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Ifars
Kimia Farma
Berlico
Erlimplex

Tablet
Sirup
Sirup
Tablet
Tablet
Sirup
Tablet

Kimia Farma
Kimia Farma
Hufa
Hufa
Nova
Nova
Indofarma

Ifars
Ifars
Promed
Promed
Nova
Nova
Kalbe Farma
Mecosin
Harsen

Ifars

Bln Lalu
6

200
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
0
170
0
0
0
700
0
0
0
0
0
0
0
29
79
0
99

0
0
0
0
898
0
0
100
108
43
0
0
0
0
0
0
0
402
0
0
0
290
0
291
0
300
0
170
0
0
214
123
0

10 Anti Tusif
Ambroxol tablet
Ambroxol Syrup
Roverton Tablet
Roverton Syrup
Ephedrine
Bromifar
Bronkris Elix
Zenirex
Dextromethorphan Tablet
Dextromethorphan Syrup
Gliceryl guaikolat Tablet
OBH Itrasal Syrup
OBP Itrasal Syrup

11 Anti Histamin
Loratadin
Gabiten
CTM
Dehista
Dexteem Plus

12 Antasida
Antasida Tablet
Antasida Syrup
Hufamag Plus
Hufamag Plus
Novamag Tablet
Novamag Syrup
Ranitidin

172
36
0
0
0
0
0
0
0
0
2275
28
15
0
0
0
452
964
160
0
0
0
3520
0
3
-180
72
0
221

Penambahan

Jumlah

Total Harga
Harga Satuan HNA + PPN

Bulan Ini

Bulan Ini

8= 6+7

Penambahan Obat
9

200
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
0
170
0
0
0
700
0
0
0
0
0
0
0
29
79
0
99
0
0
0
0
0
0
898
0
0
100
108
43
0
0
0
0
0
0
0
402
0
0
0
290
0
291
0
300
0
170
0
0
214
123
0
0
0
172
36
0
0
0
0
0
0
0
0
2275
28
15
0
0
0
452
964
160
0
0
0
3520
0
3
-180
72
0
221

10 = 7 x 9

836
8800
0
0
0
0
424
3960
0
0
0
0
0
0
0
0
0
0
4730
0
649
4180
0
0
374
0
0
0
0
0
0
0
4950
165
0
429
0
0
825
0
0
0
198
2310
0
209
195
4950
0
0
0
0
0
0
0
330
0
0
0
503
0
367
0
292
385
638
4400
4400
297
192.5
0
0
0
187
4070
0
0
660
0
0
0
46.2
3520
30.8
4950
4400
0
0
0
330
14.3
143
253
0
0
38.5
3300
4400
198
165
0
280

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

No

Nama Obat

2
Simetidin
Omeprazole
Vitazym
Dulcolax

Sediaan
3
Tablet
Tablet
Tablet
Tablet

Pabrik

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

4
Promed
Indofarma
Kalbe Farma
Boehringer Ingeheim

0
0
40
89

Total Harga
Harga Satuan HNA + PPN
Penambahan Obat
9

0
0
40
89

10 = 7 x 9

0
0
424
1020

0
0
0
0

No

Nama Obat

Sediaan
3

Pabrik

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

13 Anti Emetic
Vosea Tablet
Vosea Syrup
Domperidon
Vesperum

Tablet
Sirup
Tablet
Sirup

Graha Farma
Graha Farma
Domperidon
Ifars

360
23
0
0

Tablet
Injeksi
Tablet
Tablet

Kimia Farma
Kimia Farma
Hexpharm
Ifars

152
2

Tablet
Tablet
sacchet
Sirup
Tablet

Indofarma
Mecosin
Indofarma
Itrasal
unknown

0
0
78
31
230

Tablet
Tablet
Tablet
Tablet
Tablet

Indofarma
Propanolol
Kimia Farma
Medifarma Laboratoris
Indofarma

0
0
0
42
100

Tablet
Tablet
Tablet

Indofarma
Indofarma
Dexa Medica

0
0
87
0

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Ifars
Indofarma
Indofarma

100
0
0
70

Tablet
Tablet
Tablet
Tablet
Sirup
pcs

Coronet
Graha Farma
Graha Farma
Dexa Medica
Dexa Medica
GlaxoSmithKline

Tablet
Tablet
Tablet

Ikapharmindo
Indofarma

14 Anti Spasmodik
Papaverin HCl Tablet
Papaverin HCl Injeksi
Spasminal
Scopma Plus

87

15 Anti Diare
Zinc 20 mg
Mecodiar/ inamid
Oralit
Guanistrep
Diaform

16 Cardiovaskuler System
ISDN
Propanolol
Nifedipin
Aspilet
Digoxin

17 Anti Hipertensi
Captopril 25 mg
Captopril 12,5 mg
Dexacap

18 Dislipidemia
Simvastatin
Selvim
Gemfibrozil
Glibenclamide

19 Anti Asma
Aminophyllin
Grafasma
Grafalin
Prosmalin
Teosal
Ventolin Nebules 2,5 mg

0
0
50
5
80
0
7

20 Anti Convulsan
Phenytoin Na
Amitriptilin
Luminal

21 Anti Vertigo
Histigo
Dimendyhidinate

0
32
200

Tablet
Tablet

Ifars
Indo Farma

Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Gel
Tablet

Indofarma
Indofarma
Indofarma
Indofarma
Ifars
Indofarma
Graha Farma
Graha Farma
Ifars
Ifars

Tablet
Tablet
Tablet

Indofarma
Indofarma

Tablet
Tablet

Indofarma
Ifars

Tablet
Tablet
Tablet
Tablet
Tablet
Ampul
Tablet
Tablet

Indofarma
Ifars
Kimia farma
Berlico
Indofarma
Indofarma
Graha Farma
Kalbe Farma

80
0
0
0
3290
0
0
0

Tablet
Ampul
Tablet

Kimia Farma
Kimia Farma
Hexpharm

295
0
0

Tablet
Suppos

Medikon

Tablet
Cream

Indofarma
Indofarma

22 Non Steroid Anti Inflamasi

Meloxicam 7,5 mg
Meloxicam 20 mg
Ibuprofen
Ibuprofen
Farsifen
Na. Diklofenat
Grateos
Grazeo
Faxiden Gel
Kaditic

0
0
41

0
0
153
0
1000
0
324
0
0
0
0

23 DiuretiK
HCT
Furosemid
Bicorbinat

24 Hyperuricemia
Allupurinol
Linogra

736
41
0
0
119
0

25 Kortikosteroid
Methyl Prednison
Rhemafar 4 mg
Prednison
Inflason
Dexametason tablet
Dexametason ampul
Grathazon
Kalmetason

26 Haemostatik
Vitamin K tablet
Vitamin K Injeksi
Danochrom

27 Phlebitis Preparation
Nuwasir
Superhoid Supp

28 Anti Viral
Acyclovir 400 mg
Acyclovir

140
29

Total Harga
Harga Satuan HNA + PPN
Penambahan Obat
9

0
0
360
23
0
0
0
0
87
0
152
2
0
0
0
0
78
31
230
0
0
0
0
0
42
100
0
0
0
87
0
0
0
100
0
0
70
0
0
0
50
5
80
0
7
0
0
0
0
41
0
0
32
200
0
0
0
153
0
1000
0
324
0
0
0
0
0
0
736
41
0
0
0
119
0
0
0
80
0
0
0
3290
0
0
0
0
0
295
0
0
0
0
0
0
0
0
140
29
0

10 = 7 x 9

0
0
275
3850
0
0
0
0
115
0
594
550
0
0
550
165
880
4950
89.1
0
0
0

534
127
0
165
104.5
0

953
0
0
116

181.5
192.5
0
10120

220

3500
143

514
5500
330
0
264
0
0
0
0

100
0
100

170.5

473
0
28
0
33
0
110
0

39.6
0
0

660
3850

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

No

Nama Obat

Sediaan

Pabrik

Sisa

Penambahan

Jumlah

Bln Lalu

Bulan Ini

Bulan Ini

8= 6+7

29 Antelmintik
Pyrantel
Combantrin 250
Combicitrin 125

Tablet
Tablet
Tablet

Kimia Farma
Pfizer
Pfizer

4
18

Tablet
Drops
Tablet
Tablet
Tablet
Sirup
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet
Tablet

Dexa Medica
Erela
Phapros
Hufa
Errita
Medifarma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Ifars
Kimia Farma
Berlico
Erela

740
0
0
0
464
5
0
1607
197
410
0
200
0
74
299

Tablet
Tablet
Tablet
Tablet

Kimia Farma
Indofarma
Indofarma
Graha Farma

167
15
114
0

Tablet
Tablet
Ampul
Ampul
pcs

Kimia Farma
Triyasa
Triyasa
Triyasa
unknown

16
10
0
50
15

Tablet
Tablet
Tablet
Tablet
Tablet

Kimia Farma
Kimia Farma
Kimia Farma
Kimia Farma
Indofarma

44
57
55
827
257

30 Vitamin
Neurodex
Caviplex Drops
Livron B-plex
Hufabion
Etabion Plus
Univit
Sulfas Ferrosus
Vitamin B1
Vitamin B6
Vitamin B12
Vitamin B komplek
Anelat
Vitamin C
Lico Kalk
Calcicus Lactat

31 Anti Fungi
Ketokonazol
Griseofulvin
Metronidazol
Grafazol

32 Obat KB
Mikrodiol 30 / Andalan
Plano
Cyclogeston
Depogeston
Kondom Sutra

33 Anti TB
Rifampisin 600
Rifampisin 450
Etambutol 500
INH 300
Pyrazinamid 500

34 Preparat Mata
Erlamycetin Salep mata
Erlamycetin Tetes mata

Salep mata Erela

Tetes mata Erela

5
64

Tetes TelingaErela

35 Preparat Telinga
Erlamycetin Tetes Telinga

36 Preparat Mulut
Bufacomb in Orabase
GOM Cito
Dentasol

Total Harga
Harga Satuan HNA + PPN

cream
Liquid
Liquid

Bufa
Ciubros
Erela

0
17
7

Salep
Salep
Salep
Salep
Cream
Salep
Salep
Salep
Salep
Salep
Talkum
Liquid

Indofarma
Molex Ayus
Kimia Farma
Molex Ayus
Indofarma
Indofarma
Ciubros
Indofarma
Ciubros
Ciubros
Afi Farma

11
0
0
28
44
18
2
62
5
0
36
0

Ampul
Ampul
Ampul
Ampul
Ampul

Biofarma
Biofarma
Biofarma
Biofarma
Biofarma

Liquid
Liquid
Liquid
Liquid
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
Tablet
pcs

PIM
Molex
mahakam
prima plus
Askara
unknown
unknown
terumo
terumo
terumo
terumo
unknown
unknown
unknown
unknown
unknown
Sensi Gloves
care lamson
Trifa Laboratories
remedi

Penambahan Obat
9

0
0
4
18
0
0
740
0
0
0
464
5
0
1607
197
410
0
200
0
74
299
0
0
167
15
114
0
0
0
16
10
0
50
15
0
0
44
57
55
827
257
0
0
5
64
0
0
1
0
0
0
17
7

10 = 7 x 9

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

5500
2750

330
0
0
0
193
3410
100
38.5
26
22
27.5
616
37.4
159.5
38.5

484
341
209
0
0
0
4125
3850
0
5390
1210

891
616
660
116
275

3630
7370

6050

2750
4950

37 Preparat Kulit
Gentamisin Sulfat salep
Klorfeson Salep
Ketokonazol Salep
Betametason
Hydrocortison Cream
Miconazole salep
Salep Kulit 24
Oxytetrasiklin salep
Icthiol salep
Levertran salep
Salycil Talk
PK

38 Vaksin
Vaksin BCG
Vaksin Campak
Vaksin DPT
Vaksin TT
Vaksin Polio

39 Lain - Lain
Alkohol 70% 1 liter
Rivanol 100ml
Betadine 1 liter
H2O2 3%
kasa steril husada
Kapas 250 husada
Verban
Spuit 3 cc
Spuit 1 cc
Needle 23
Needle 27
Nacl
Plester
Cut Gut 3/0, 4/0
Silk 3/0 , 4/0 ( black, white)
Bisturi no.15
Handscoon S,M,L,XL
HCG test
Saccharin
Masker 3fly

0
0
0
0
110
0
0
60
0
14
2
0
2
0
0
0
100
0
0
30

11
0
0
28
44
18
2
62
5
0
36
0
0
0
0
0
0
0
0
0
0
0
0
0
0
110
0
0
60
0
14
2
0
2
0
0
0
100
0
0
30

4400
0
0
3850
3300
3960
3300
2200
4620
3520
3300

23.1
0
57.75
0
440
52.8
0
1100
880
302.5
2100
8250
16500
0
0
0
440
16500
11
770

Cirebon, 02 Januari 2014

Yang Menyetujui

Yang Membuat

([Link] )

( Manager Hub. PPK )

LAPORAN MONITORING PEMAKAIAN OBA

No

Jenis Obat

Kemasan

KONSERVASI GIGI

a
1
2
3

Tambalan Sementara
Cavit
Eugenol
Znocide/ Fletcher

Tube
Fls
Tube

1
2
3
4
5
6
7

Tambalan Tetap
Amalgam Kapsul
Amalgam Likuid Mercury
Amalgam Powder
Fuji IX GP
Glass Ionomer II Fuji
Matrix Band
Stone

Pcs
Fls
Tube
Tube
Tube
Pack
Pcs

1
2
3
4

Tambalan Tetap / Light Curing ( LC )

Articulating Paper
Bonding
Stick untuk Bonding
Synergi A2, A3, dan A3,5

Pack@50 pcs
Tube
Pack @100 pcs
Tube

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

Perawatan Saluran Akar

Arsen
CHKM
Cresophene
Dycal
Endomethason
TKF Formocresol
Trimix + Powder
Larutan H2O2 3 %
Guttap Point
Paper Point
Jarum Reamer ( Alat )
Jarum Extirpasi ( Alat )
Endobox ( Alat )

Tube
Fls
Fls
Tube
Tube
Tube
Tube
Fls
Pack@100 pcs
Pack@100 pcs
Pack@5 pcs
Pack@5 pcs
Pack

2.1
2.2
2.3
2.4

BEDAH MULUT
Chloretyl
Curaspon/ Spongostan
Lidocaine
Pehacaine

Fls
Tube
Ampul
Ampul

II

Tgl
Pembelian

Jumlah

100

1/17/2012

30

1/17/2012

Tgl Mulai
digunakan

2.5
2.6
2.7
2.8
2.9
2.10
2.11

Topical Anestesi gel

Xylestin
Xylocain Spray
Betadine Solution
Jarum ukuran 21 G
Blade
Jarum Citoject " Carpule "

Tube
Pcs
Fls
Fls
Pcs
pcs
pcs

3.1
3.2
3.3
3.4
3.5
3.6

PROSTO ( GIGI PALSU )

Cromophan Alginate
Moldano ( gips biru keras )
Self Curing Acrilic (stellon C )
Vaselin
Warna Gigi (Lumin vacum)
Waxlim

Pcs
Pcs
Tube
Tube
Pack@50 pcs
Pack@50 pcs

III

IV

PERIODONSIA ( PENYANGGA GIGI / KARANG GIGI )

4.1

TSR / OCO

Fls

5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8

CONSUMABLE
Batu Arkansas
Bor Diamond
Celluloid Strip
Dental Flos
Handscoon
Handel Scalpel
Minosep Gargle
Spuit Terumo 3 cc

Pcs
Pcs
Pack@50 pcs
Tube
Box@100 pcs
Pcs
Fls
Pcs

Yang Menyetujui

(dr. Penanggung jawab Klinik )

Lampiran 9 dari SK DIREKSI No. KEP/071/112011

ORING PEMAKAIAN OBAT GIGI

Tanggal Pemakaian Berdasarkan Diagnosa
1

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

.., 20..
Yang Membuat

( Tenaga Administrasi Klinik )