SURAT BUKTI BARANG KELUAR (SBBK) OBAT

MINGGU 1 JUMLAH MINGGU 2 JUMLAH MINGGU 3 JUMLAH MINGGU 4 JUMLAH

NO NAMA OBAT SATUAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
1 Albendazol Tablet 400 mg Tablet 0 0 0 0
2 Allopurinol tablet 100 mg Tablet 100 100 0 100 100 0
3 Amlodipin Besilate 5 mg Tablet 0 300 300 0 0
4 Amoksisilin Tablet 500 mg Tablet 200 200 400 200 200 200 600 400 400 800 400 400 800
5 Retinol (Vitamin A) kapsul 200.000 IU capsul 0 0 0 0
6 Retinol (Vitamin A) kapsul 100.000 IU capsul 0 0 0 0
7 Amoksisillin Sirup Kering 125 mg/5 ml Botol 100 100 0 0 0
8 Ampisilin Injeksi 1 gr Vial 0 0 0 a
9 Tablet Penambah Darah ( FE ) Tablet 3780 3780 0 0 0
10 Antasida DOEN suspensi Botol 100 100 0 10 10 10 10
11 ANTASIDA DOEN Tablet Tablet 200 200 300 200 900 200 200 200 600 0 500 300 800
12 Aqua Pro Injeksi Vial 0 0 0 5 5
13 Asam Mefenamat 500 mg Tablet 200 200 200 200 400 200 200 400 0
14 Asering Botol 0 0 0 0
15 Betametason krim 0,1 % Tube 25 25 0 0 0
16 Captopril Tablet 25 mg Tablet 300 200 500 300 300 200 200 0
17 Cetirizine Capsul 50 mg Capsul 200 200 400 200 200 200 200 200 200
18 Deksametason tablet 0,5 mg Tablet 300 300 600 300 300 200 200 400 500 500
19 Diazepam tablet 5 mg Tablet 0 0 0 0
20 Difenhidramin HCL injeksi 10 mg/ml - 1ml Ampul 0 0 0 0
21 Domperidon 10mg Tablet Tablet 0 0 0 0
22 Fenobarbital injeksi 50 mg/ml - 2 ml Ampul 0 0 0 0
23 Fitomenadion (Vit.K1) Injeksi 10 mg/ml-1 ml Ampul 0 0 0 0
24 Garam Oralit Sachet 200 200 0 0 0
25 Gentamicin Injeksi Ampul 0 0 0 0
26 Gentamicin Tetes Mata Botol 24 24 0 0 0
27 Glibenclamid tablet 5 mg Tablet 0 0 0 0
28 Glimepiride 2 mg Tablet 0 0 0 0
29 Griseofulvin tablet 500 mg, Tablet 0 0 0 0
30 Hidrokortison krim 2,5% Tube 0 0 0 0
31 Isosorbid Dinitrat tablet sublingual 5 mg Tablet 0 0 0 0
32 Kalsium Laktat (Kalk) tablet 500 mg Tablet 200 200 400 500 500 0 0
33 Kotrimoksazol Dewasa Tablet 480 mg Tablet 0 200 200 0 0
34 Kotrimoksazol Sirup / Suspensi Botol 0 0 0 0
35 Lidocain 2%+efinefrin injeksi Ampul 0 0 0 0
36 Lidocain injeksi 2 ml Ampul 0 0 0 0
37 Loperamid 4 mg tablet Tablet 0 0 0 0
38 Metformin 500 mg Tablet Tablet 200 200 200 400 600 0 0
39 Methilprednisolon tablet 8 mg Tablet 0 0 0 300 300
40 Mikonazol kream Tube 0 0 0 24 24
41 Multivitamin Dewasa Antioksidan ( Becom c ) Tablet 0 0 0 0
42 Natrium Diklofenak 50 mg Tablet Tablet 300 200 500 300 300 200 200 300 300
43 Natrium Klorida Cairan Infus ( NaCL ) Botol 0 0 0 0
44 Nistatin tablet vaginal 100.000 IU/g Tube 0 0 0 0
45 Obat Batuk Flu ( Molexflu ) Tablet 150 150 300 150 150 0 150 150
46 Oksitetrasiklin HCL salep mata 1% Botol 0 0 0 0
47 Oksitosin injeksi 10 IU/ml - 1 ml Ampul 0 0 0 0
48 Omeprazol Kapsul 20 mg capsul 200 200 200 400 600 200 200 200 200
49 Paracetamol Drop 15 ml Botol 10 6 16 0 0 0
50 Prednison Tablet 5 mg Tablet 0 0 0 0
51 Ranitidin tablet Tablet 200 200 400 300 300 200 200 200 200
52 Salbutamol Tablet 2 mg Tablet 200 200 0 0 0
53 Salep 2-4 Tube 10 10 20 10 10 0 0
54 Serum Anti Bisa Ular Polivalen Inj 50 ml Vial 0 0 0 0
55 Serum Anti Tetanus inj 1500 IU ( Tetagam ) Vial 0 0 0 0
56 Simvastatin 10 mg tablet Tablet 0 300 300 0 0
57 Tiamin Tablet 50 mg ( B1 ) Tablet 0 0 0 0
58 Vitamin B komplek Tablet 300 300 400 1000 200 200 300 200 300 800 500 500
59 Zink sirup Botol 0 0 0 0
60 Zink tablet 20 mg Tablet 100 100 0 0 0
61 Diazepam Inj Ampul 0 0 0 0
0 0 0 0
1 Alat suntik 3 ml Pcs 100 100 0 0 0
23 Alat suntik 5 ml pcs 0 0 0 0
14 Cat Gut no 2/0 Sachet 0 0 0 0
15 Cat Gut no 3/0 Sachet 0 0 0 0
19 Demetech Silk 3/0 Set 0 0 0 0
20 E Care I.V Dresing Pcs 0 0 0 0
23 Folly No 16 Catether pcs 0 0 0 0
24 I.V Cathetter No. 20 Set 0 0 0 0
25 I.V Cathetter No. 22 Set 50 50 0 50 50 0
26 I.V Cathetter No. 24 Set 50 50 0 0 0
27 I.V Cathetter No. 26 Set 0 0 0 0
28 Infuset Anak Set 0 0 0 0
29 Infuset Dewasa Set 0 0 0 0
31 Kapas Berlemak 250 gr Bungkus 0 0 0 0
34 Kasa Hidrofil 36 x 80 cm Rol 0 0 0 0
36 Kasa Steril 16 x 16 cm Kotak 0 0 0 0
38 Masker karet Ear Loop Lembar 0 0 0 0
39 Masker tali Tube 0 0 0 0
40 Nasal Canula Oksigen Set 0 0 0 0
41 Plester 1" Rol 0 0 0 0
48 Sarung Tangan Gynecolog No 7 Pasang 0 0 0 0
49 Sarung tangan M (Non Steril) Pasang 0 0 0 0
51 Sarung tangan no 6,5 Steril Gloves Pasang 0 0 0 0
53 Selang Section ( Surgikal Conection Tube with yankaPcs 0 0 0 0
54 Underpad Lembar 0 0 0 0
55 Urine Bag Biji 0 0 0 0
57 Hazmat Pcs 0 0 0 0
58 Masker N-95 Pcs 0 0 0 0

1 Alkohol 70% 1 L 2021 Botol

2 Bisturi No 23 2021 Pcs
3 Blood Lancet Box
4 Blood set infus Pcs
5 Bur High Set
6 Catgut Chromic Pcs
7 Endo Forst Spray Botol
8 ETT No. 3,5 Pcs
9 Folley No.12 Pcs
10 Gelang bayi biru Pcs
11 Gelang bayi pink Pcs
12 Guedel Pcs
13 [Link] no.16 Pcs
14 Jarum Hecting Pcs
15 Kertas recording / EKG Pak
16 Lakmus Pink Box
17 Nasal Aspirator Pcs
18 Nasal Canul Dewasa Pcs
19 Nebu Mask Anak Pcs
20 Nebu Mask Dewasa Pcs
21 NGT No. 3,5 Pcs
22 NGT No. 5 Pcs
23 NGT No. 8 Pcs
24 Oxygen Mask Standard Neonatus Pcs
25 Oxygen Nasal Cannula Neonatus Pcs
26 Perban Elastis 7,5 Roll
27 Plastik Klip Kecil 10 X 7 Cm Pak
28 Plastik Klip Paling Kecil 8 X 5 Cm Pak
29 Plastik Klip Sedang 13 X 8,7 Cm Pak
30 Plastik Kresek No.15 Pak
31 Plester 1/2 Inch Pcs
32 Povidon Iodin 1L Botol
33 Rivanol 300 ml Botol
34 Silk 2/0 Box
35 Spuit 1 cc Pcs
36 Spuit 10 cc Pcs
37 Spuit 20 cc Pcs
38 Spuit 5 cc Pcs
39 Strip Asam Urat 2021 Box
40 Strip Kolestrol 2021 Box
41 Suction Catheter No. 10 Pcs
42 Suction Catheter No. 6 Pcs
43 Suction No.8 Pcs
44 Tes Celup Kehamilan (Tespek) Box
45 Urin Bag Pcs
46 USG Paper Sony Pcs
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT ( LPLPO )
PUSKESMAS
PUSTU/SUB UNIT :
PUSKESMAS : CADASARI DOKUMEN NOMOR TANGGAL
KECAMATAN : CADASARI PUSTU / SUB UNIT
KAB / KOTA : PANDEGLANG PELAPORAN BULAN / PERIODE :
PROVINSI : BANTEN PERMINTAAN BULAN / PERIODE :

Jumlah Jumlah
N0 NAMA OBAT SATUAN Stok Awal Penerimaan Pemakaian Stok Akhir PEMBERIAN
Persediaan Permintaan
1 2 3 4 5 6 7 8 9 10
A NAMA OBAT ( 4+5 ) (6-7)
1 Asam Traneksamat Tablet
2 Metil ergometrin Inj. Ampul
3 Oksitosin Inj. Ampul
4 Vit K Inj. Ampul
5 Asering Botol
6 Ringer Laktat Botol
7 NaCL 0,9 % Botol
8 Oksitetrasiklin Salep mata Tube
9 Lidokain Inj. Ampul
10 Aqua Pro Injek Botol
11 Diazepam Inj. Ampul
12 Misoprostol Tablet
13 MgSO4 Botol

B NAMA BMHP
1 Alat suntik 3 ml Pcs
2 Alat suntik 5 ml Pcs
3 Alat suntik 10 ml Pcs
4 Alat suntik 20 ml Pcs
5 Alkohol Swab Box
6 Cat Gut no 2/0 Sachet
7 Cat Gut no 3/0 Sachet
8 E Care I.V Dresing Pcs
9 Folly No 16 Catether pcs
10 I.V Cathetter No. 16 pcs
11 I.V Cathetter No. 18 pcs
12 I.V Cathetter No. 20 Set
13 I.V Cathetter No. 22 Set
14 I.V Cathetter No. 24 Set
15 Infuset Dewasa Set
16 Kapas Berlemak 250 gr Bungkus
17 Kasa Hidrofil 36 x 80 cm Rol
18 Kasa Steril 16 x 16 cm Kotak
19 Nasal Canula Oksigen Set
20 Plester Rol
21 Sarung Tangan Gynecolog No 7 Pasang
22 Sarung tangan Non Steril Pasang
23 Sarung tangan Steril Pasang
24 Underpad Lembar
25 Urine Bag Biji
26 Hazmat Pcs
27 Masker N-95 Pcs
 SURAT BUKTI BARA
MINGGU 1
NO NAMA OBAT SATUAN
1 2 3 4 5 6 7 8 9 10
1 Asam Tranexamat inj Ampul
2 Cefadroksil 500 mg Tablet
3 Ceftriaxone inj Vial
4 Ciprofloxacin 500 mg Tablet
5 D10% Botol
6 D40 Botol
7 Dexamethason inj Ampul
8 Erlamycetyn TT Botol
9 Furosemid inj Ampul
10 Gentamisin / Gentalex cream Tube
11 Gentamisin inj Ampul
12 Guaifenesin 100 mg Tablet
13 Histigo Tablet
14 Laxana Tablet
15 Methyl Ergomethrine inj Ampul
16 Metronidazol 500 mg Tablet
17 MgSO4 40% Botol
18 Misoprostol Tablet
19 Molagit Tablet
20 Natrium Bicarbonat Tablet
21 Nifedipin 10 mg Tablet
22 Oxytocyn inj Ampul
23 Paracetamol 500 mg Tablet
24 Propyretic 160 mg Supp
25 Ranitidine inj Ampul
26 Ventolin nebu 20 Ampul
27 Vit K Inj Ampul
RAT BUKTI BARANG KELUAR (SBBK) OBAT
JUMLAH MINGGU 2 JUMLAH MINGGU 3 JUMLAH
11 12 13 14 15 16 17 18 19 20 21 22 23 24
 MINGGU 4 JUMLAH
25 26 27 28 29 30