LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)

PUSKESMAS PEMBANTU (PUSBAN)

PUSBAN : Sesulu PELAPORAN BULAN : …................................

KECAMATAN : Waru PERMINTAAN BULAN / PERIODE : …................................
KABUPATEN : Penajam Paser Utara

PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

OBAT-OBATAN :
1 DAK Acetylcystein 200 mg Cap. ktk 100 20 - 20 412 8,240
2 DAK Acyclovir 200 mg ktk 10 x 10 120 30 90 236 21,240
3 DAK Acyclovir 400 mg ktk 10 x 10 - - 454 0
4 DAK Allupurinol 100 mg ktk 100 80 - 80 89 7,120
5 DAK Ambroxol syr. Botol 15 2 13 3,639 47,307
6 DAK Amlodipin 5 mg ktk 30 - 74 0
7 DAK Amlodipin 10 mg ktk 30 - 520 0
8 DAK Amoksisilin 250 mg ktk 10x 10 140 - 140 188 26,320
9 DAK Amoksisilin 500 mg ktk 10x 11 200 - 200 231 46,200
10 DAK Amoksisilin syr Botol - 2,050 0
11 DAK Antasida syr. Botol - 1,756 0
12 DAK Antasida Tab. ktk 10 x 10 190 70 120 54 6,480
13 DAK Anti Hemoroid ktk 10 - 3,260 0
14 DAK Attapulgite ktk 100 - 175 0
15 DAK Aqua pro inj btl - 2,860 0
16 DAK Asam Askorbat Tab 50 mg ktk 10 x 10 140 90 50 46 2,300
17 DAK Asam Folat 400 mg (Profolat) ktk 10 x 10 - 45 0
18 DAK Asam Mefenamat 500 mg kotak 10 x 10 100 100 70 130 117 15,210
19 DAK Betahistine 6 mg ktk 30 - 119 0
20 DAK Betamethason Salep ktk 25 - 1,920 0
21 DAK Bioplacenton Tulle Tulle - 10,733 0
22 DAK Bisacodil 10 mg ktk 50 sup - 5,800 0
23 DAK Bisacodil 5 mg ktk 6 sup - 5,800 0
24 DAK Bufacetine salep kulit Tube - 3,760 0
25 DAK Captopril 50 mg ktk 10 x 10 tablet - 143 0
26 DAK Captopril 12,5 mg ktk 10 x 10 - 65 0
27 DAK Captopril 25 mg ktk 10 x 10 tablet 130 25 105 75 7,875
28 DAK Cetirizine 10 mg ktk 10 x 10 335 75 260 104 27,040
29 DAK Cetirizine sirup botol 7 10 7 10 3,061 30,610
30 DAK Ciprofloxacin 500 mg tab. ktk 10 x 10 - 50 50 260 13,000
31 DAK Cloramfenicol salep mata ktk 24 tube - 1,925 0
32 DAK Cyanocobalamin ( Vitamin B12 ) tab. Ktk 100 - 49 0
33 DAK Cyanokobalamin ( Vitamin B12 ) inj ktk 100 - 1,226 0
34 DAK Deksamethasone injeksi ktk 100 ampul x 1 ml - 2,336 0
35 DAK Deksamethasone Tablet btl 10 x 10 tablet - 75 0
36 DAK Difenhidramin HCL injeksi ktk 30 amp @1 ml - 1,156 0
37 DAK Dimenhidrinat 50 mg btl 100 - 121 0
38 DAK Domperidon 10 mg kotak 10 x 10 - 75 0
39 DAK Domperidon Sirup btl - 2,401 0
40 DAK Efinefrin 1 mg inj ktk 100 ampul x 1 ml - 1,740 0
41 DAK Ergotamine + Caffein Botol @ 100 - 199 0
42 DAK Eritromisin 250 mg ktk 12 x 10 tablet - 509 0
43 DAK Eritromisin 500 mg ktk 10 x 10 tablet - 913 0
44 DAK Furosemid 40 mg ktk 200 tab - 84 0
45 DAK Garam Oralit ktk 100 47 6 41 280 11,480
46 DAK Gentamisin TTS Mata ktk 24 btl - 4,600 0
47 DAK Glibenclamide 5 mg Tab. ktk 100 - 137 0
48 DAK Glukosa larutan infus 5 % btl 500 ml - 6,627 0
49 DAK Glyceryl guaiacolate ( GG ) Tab. ktk @ 100 - 157 0
50 DAK Griseofulvin 125 mg Tab. ktk 10 x 10 - 210 0
51 DAK Hidrokortisone Cream 2,5 % tube @ 5 g 19 - 19 2,325 44,175
52 DAK Herbakof btl 7 7 14,273 0
53 DAK Ibuprofen sirup btl 60 ml - 2,678 0
54 DAK Ibuprofen tablet 200 mg ktk 10 x 10 tablet - 111 0
55 DAK Ibuprofen tablet 400 mg ktk 10 x 10 tablet - 157 0
56 DAK Kalsium laktat ( Kalk ) tablet 500 mg 200 300 230 270 60 16,200
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

57 DAK Ketoconazole 200mg Tab. Box @ 50 - 260 0

 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

58 DAK Ketoconazole salep ktk 25 tube 10 - 10 2,577 25,770

59 DAK Klorfeniramin Maleat 4 mg ( CTM ) ktk 100 tablet 190 - 190 24 4,560
60 DAK Kotrimoksasol 480 mg ktk 100 40 - 40 133 5,320
61 DAK Kotrimoksasol Syr. Botol 6 - 6 2,052 12,312
62 DAK Lidocain 2 % inj ktk 100 - 891 0
63 DAK Lidokain komp injeksi, kombinasi ktk 30 amp 11 2 9 2,122 19,098
64 DAK Metformin 500 mg ktk 10x 10 100 - 100 77 7,700
65 DAK Methylprednisolon 4 mg Tab. ktk 10 x 10 tablet - 102 0
66 DAK Metilergometrin tab 0,125 mg ktk 10 x 10 tablet - 242 0
67 DAK Metronidazol 500 mg ktk 100 50 - 50 140 7,000
68 DAK Miconazole 2% krem tube 10 gram 14 - 14 1,900 26,600
69 DAK Natrium Chlorida 0,9 % btl 500 ml 2 2 2 2 6,900 13,800
70 DAK Natrium diklofenak 50 mg kotak 50 tablet 100 200 60 240 109 26,160
71 DAK Nifedipin tab ktk 10 x 10 tablet 100 - 100 123 12,300
72 DAK Nistatin vag tablet 100.000 IU / g ktk 10 x 10 tablet 10 - 10 688 6,880
73 DAK OBH syr. Botol - 3,500 0
74 DAK Omeprazol 20 mg ktk 3x 10 - 164 0
75 DAK Oxytetrasiklin salep mata ktk 25 - 2,600 0
76 DAK Pantocain 0,5 % tetes mata btl 5 mL - 11,500 0
77 DAK Paracetamol tab 500 mg ktk 100 tablet 215 45 170 225 38,250
78 DAK Parasetamol Sirup btl 11 10 11 10 1,160 11,600
79 DAK Phenol Glycerol TTS telinga btl - 2,500 0
80 DAK Phitomenadion Vit K ktk 10 x 10 tablet 90 - 90 781 70,290
81 DAK Phitomenadion Vit K inj ktk 30 - 1,452 0
82 DAK Povidon Iodida 10 % 300 ml btl 300 ml - 21,150 0
83 DAK Prednison 5 mg ktk 10 x 10 tablet - 73 0
84 DAK Pyridoxin ( Vit B6 ) tablet 10 mg ktk 100 195 - 195 150 29,250
85 DAK Ranitidin HCL 50 mg/ml kotak 10 ampul - 1,155 0
86 DAK Ranitidine Tablet 150 mg ktk 10 x 10 - 119 0
87 DAK Ringer Laktat Infus btl 3 2 1 7,703 7,703
88 DAK Risperidon 2 mg ktk 100 - 130 0
89 DAK Salbutamol tablet 2 mg ktk 10 x 10 tablet 50 - 50 51 2,550
90 DAK Simvastatin 10 mg ktk 30 160 5 155 73 11,315
91 DAK Tablet Tambah Darah ktk 30 - 409 0
92 DAK Thiamin ( vitamin B1 ) kotak 100 - 94 0
93 DAK Vit B Komplek Tablet btl 100 170 30 140 60 8,400
94 DAK Zink tablet ktk 10 x 10 65 5 60 253 15,180
95 DAK Zirkum kids sirup botol - 3,285 0
96
97
98
99
100

BMHP :
1 DAK Alat Suntik Sekali Pakai 1 ML 100 set / kotak 46 - 46 1,023 47,058
2 DAK Alat Suntik Sekali Pakai 3 ML 100 set / kotak 100 13 87 683 59,421
3 DAK Alat Suntik Sekali Pakai 5 ML 100 set / kotak - 1,045 0
4 DAK Alkohol 70 % 1 Liter btl 1 liter - 29,375 0
5 DAK Alkohol Swab 0,5 % pcs 100 - 100 129 12,855
6 DAK Bisturi ktk 100 - 2,873 0
7 DAK Catgut/benang bedah No.2/0 dgn jarum ktk 24 - 6,142 0
8 DAK Foley Catheter 16 pcs - 11,132 0
9 DAK Hand Scoon 7 (Steril) pcs 8 1 7 8,470 59,290
10 DAK Hand Scoon L ktk 100 - 1,435 0
11 DAK Hand Scoon M ktk 100 - 1,435 0
12 DAK Hand Scoon S ktk 100 100 - 100 8,470 847,000
13 DAK Infusion Dewasa ktk 50 - 7,250 0
14 DAK Infusion set anak set / kantong - 9,181 0
15 DAK IV Catheter No. 22 G 50 buah / kotak 5 - 5 4,818 24,090
16 DAK IV Catheter No. 18 G 50 buah / kotak - 4,818 0
17 DAK IV Catheter No. 24 G 50 buah / kotak - 4,818 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

18 DAK Kapas Pembalut 250 gr rol - 14,063 0

19 DAK Kasa Pembalut Hidrofil 10 cm x 360 cm rol/50 - 6,400 0
20 DAK Kasa Pembalut Hidrofil 6 cm x 360 cm rol/50 - 5,400 0
21 DAK Kasa steril 16 cmx16 cm ktk 5 5 - 15,000 0
22 DAK Leukoplast Plester kain 7,5x4,5 pcs - 35,532 0
23 DAK Lysol btl - 48,175 0
24 DAK Masker hijab / Karet ktk 50 pcs - 1,448 0
25 DAK Masker tali ikat Ties Aximed ktk 50 pcs - 567 0
26 DAK Mucus Extractor Pcs - 8,040 0
27 DAK Oxyflow Anak - 5,000 0
28 DAK Oxyflow Dewasa pcs - 5,000 0
29 DAK Pembalut Elastis roll - 35,592 0
30 DAK Polifix 5 cmx 5 m Roll - 39,217 0
31 DAK Silk 3/0 HR - 20 ktk 12 - 16,209 0
32 DAK Test Kehamilan ktk 50 - 2,185 0
33 DAK Umbilical cord klem ktk 50 pcs - 2,070 0
34 DAK Underpad Pcs - 8,602 0
35 DAK Urin Bag 10 pcs - 5,865 0

TOTAL OBAT + BMHP DAK 1,742,549

PROGRAM GIZI /KIA :

1 APBN Fe ktk 100 600 600 409 0
2 APBN Vitamin A Biru 100.000 IU Botol 50 kapsul - 305 0
3 APBN Vitamin A Merah 200.000 IU Botol 50 kapsul - 553 0

TOTAL OBAT + BMHP APBN 0

1 APBD

TOTAL OBAT + BMHP APBD

OBAT & BMHP :

1 JKN Acyclovir 200 mg Tab. Box @ 100 - 1,096 0
2 JKN Acyclovir 400 mg Tab Box @ 100 - 991 0
3 JKN Acyclovir cream Tube 1 20 1 20 4,000 80,000 20.00
4 JKN Acetylsystein 200 mg Cap. Box @ 100 300 100 200 1,008 201,600
5 JKN Allopurinol 100 mg Tab. Box @ 100 - 248 0
6 JKN Allopurinol 300 mg Tab. Box @ 100 - 567 0
7 JKN Ambroxol syr. Botol - 4,200 0
8 JKN Ambroxol Tab. Box @ 100 205 10 195 150 29,250
9 JKN Amlodipine 10 mg Tab. Box @ 30 200 - 200 450 90,000
10 JKN Amlodipine 5 mg Tab. Box @ 100 80 50 30 405 12,150
11 JKN Amoxycillin 500 mg Tab. Box @ 100 - 407 0
12 JKN Amoxycillin Syr. Botol 8 2 6 5,200 31,200
13 JKN Antasid Syr. Botol 21 1 20 3,900 78,000
14 JKN Antasida Tab. Box @ 100 - 165 0
15 JKN Asam Folat Box@100 - 110 0
16 JKN Asam Mefenamat 500 mg Tab. Box @ 100 - 275 0
17 JKN Aseptic Gell Botol 450 mL - 55,000 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

18 JKN Attapulgit Box @100 100 - 100 670 67,000

19 JKN Bedak Salicyl Pcs - 6,426 0
20 JKN Betahistine 6 mg Tab. Box @ 100 200 - 200 1,015 203,000
21 JKN Bethametasone salep Tube 14 3 11 3,200 35,200
22 JKN Calsium Laktat 500mg ( Kalk) Botol @ 100 - 145 0
23 JKN Captopril 12,5 mg Tab. Box @ 100 - 105 0
24 JKN Captopril 25 mg Tab. Box @ 100 - 132 0
25 JKN Cefadroxil 125 mg Syr. Botol - 7,700 0
26 JKN Cefadroxil 500 mg Cap. Box @ 100 90 - 90 852 76,680
27 JKN Cendo eyefresh mini dose Box@ 25 strip - 5,720 0
28 JKN Cetirizine Syr Botol 7 10 7 10 5,500 55,000
29 JKN Cetirizine Tab. Box @ 100 335 75 260 480 124,800
30 JKN Chloramfenicol Tetes mata (Reco) Botol - 12 12 9,000 108,000
31 JKN Chloramfenicol Tetes Telinga (Reco TT) Botol 8 - 8 9,000 72,000
32 JKN Chloramfenicol salep (Fasycol) Tube - 4,900 0
33 JKN Ciprofloxacin 500 mg tab. Box @ 100 - 720 0
34 JKN Cotrimoksazol 480 mg Box @ 100 - 290 0
35 JKN Cotrimoxazole syr. Botol - 4,290 0
36 JKN CTM Btl @ 100 - 56 0
37 JKN Daryantulle Box @ 10 - 26,300 0
38 JKN Dexamethasone 0,5 mg Tab. Box @ 100 - 100 100 120 12,000
39 JKN Dexamethasone Inj. Box @ 100 - 2,197 0
40 JKN Domperidone Syr. Botol 7 - 7 6,000 42,000
41 JKN Domperidone Tab. Box @ 100 45 - 45 272 12,240
42 JKN Dulcolax 10 mg Sup Ktk @ 5 - 31,240 0
43 JKN Dulcolax 5 mg Sup Ktk @ 6 - 21,833 0
44 JKN Dulcolax tab./ Laxana Box @ 10 - 1,980 0
45 JKN Dumin 125 mg Rectal Ktk @ 5 - 19,800 0
46 JKN Ephineprin Inj. Box @ 30 - 8,983 0
47 JKN Ergotamine + Caffein Box @ 100 - 306 0
48 JKN Etil Klorida 100 ml Botol - 223,850 0
49 JKN Garam Oralit Box @ 100 - 352 0
50 JKN Gentamicin SK Box @ 10 - 3,630 0
51 JKN Gentamicin Salep Mata (Genoint) Tube - 7,800 0
52 JKN Gentamisin Tetes Mata (Genoint TM) Botol 5 mL 5 1 4 10,100 40,400
53 JKN Gentian Violet Box @ 24 - 3,850 0
54 JKN Glibenclamide Tab. Box @ 100 - 159 0
55 JKN Gliceril Guaiakolat Tab. Box @ 100 270 - 270 130 35,100
56 JKN Guanistrep syr. Botol - 7,700 0
57 JKN Hyocine-N-Bromida (Scopma plus) Box @ 100 - 1,240 0
58 JKN Ibuprofen 200 mg Tab. Box @ 100 - 275 0
59 JKN Ibuprofen 400 mg Tab. Box @ 100 175 20 155 335 51,925
60 JKN Ibuprofen Syr Botol - 4,500 0
61 JKN Ketoconazole 200 mg Tab. Box @ 50 - 572 0
62 JKN Ketokonazole Salep Tube - 4,500 0
63 JKN Ketorolac inj 30mg/mL Box @ 6 - 5,000 0
64 JKN Lidocain + Adrenalin Inj. / Pehacain Inj Box @ 20 - 3,355 0
65 JKN Lidocain Inj. Box @ 100 - 1,420 0
66 JKN Metformin 500 mg Tab. Box @ 100 - 193 0
67 JKN Methylprednisolon 4 mg Tab. Box @ 50 - 440 0
68 JKN Metronidazole 500 mg Tab. Box @ 100 - 334 0
69 JKN Miconazole Salep Tube - 4,730 0
70 JKN NaCl infus Box @ 20 - 9,900 0
71 JKN Natrium diklofenak 25 mg Tab. Box @ 50 - 205 0
72 JKN Nifedipine 10 mg Tab Box @ 100 - 4 4 220 880
73 JKN Nystatin drop (Cazetin drop ) Botol 6 6 24,420 0
74 JKN Nystatin Vag ovula Box @ 100 - 828 0
75 JKN Omeprazole kap. Box @ 30 230 40 190 414 78,660
76 JKN Oxytetracycline salep mata Tube - 6,270 0
77 JKN Paracetamol 500 mg Tab. Botol @ 100 - 317 0
78 JKN Paracetamol Syr. Botol - 4,180 0
79 JKN Phenol Glycerol TT Botol - 5,498 0
80 JKN Povidone Iodine Botol - 33,000 0
81 JKN Prednison 5 mg Tab. Box @ 100 - 285 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

82 JKN Ranitidine Inj. Box @ 10 - 4,545 0

 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

83 JKN Ranitidine Tab. Box @ 100 40 100 5 135 293 39,555

84 JKN Ringer Laktat Infus Box @ 20 - 9,570 0
85 JKN Salbutamol 2mg Tab. Box @ 100 - 158 0
86 JKN Permetrin 5 % krim Tube - 48,000 0
87 JKN Simvastatin 20 mg Tab. Box @ 100 - 564 0
88 JKN Ultrasonic Gel 250 mL Botol - 24,200 0
89 JKN Vit B.1 Box @ 100 140 20 120 120 14,400
90 JKN Vit B6 Box @ 100 - 132 0
91 JKN Vit. B-Complex Btl @ 100 - 220 0
92 JKN Vit K inj. Box @ 5 - 7,150 0
93 JKN Vit K Tab. Box @ 100 - 1,320 0
94 JKN Water for Inj. 10 mL Botol - 5,940 0
95 JKN Water for Inj. 25 mL Botol - 8,200 0
96 JKN Zinc / Lecozinc Syr. Botol - 7,000 0
97 JKN Zinc Tab. Box @ 100 - 675 0

BMHP :
1 JKN Abbocat 18 G Box @ 50 - 5,500 0
2 JKN Abbocat 22 G Box @ 50 - 6,050 0
3 JKN Abbocat 24 G Box @ 50 - 13,000 0
4 JKN Alkohol 300 mL Botol - 30,000 0
5 JKN Alkohol Swab Bok - 150 0
6 JKN Bisturi no. 11 G Box @ 100 - 1,100 0
7 JKN Blood set Box @ 50 - 6,900 0
8 JKN Cat Gut Plain 3/0 Box @ 24 - 7,000 0
9 JKN Folley Catheter Fr. 16 Box @ 10 - 20,000 0
10 JKN Folley Catheter Fr. 18 Box @ 10 - 10,000 0
11 JKN Hand scoon steril No. 7 Box @ 50 - 11,000 0
12 JKN Hand scoon nonsteril No. L Box @100 - 1,701 0
13 JKN Hand scoon nonsteril No. M Box @100 - 1,701 0
14 JKN Hand scoon nonsteril No. S Box @100 - 1,701 0
15 JKN Kassa steril Box - 4,000 0
16 JKN Masker Bedah Box @ 50 - 806 0
17 JKN Nurse Cup Box @100 - 605 0
18 JKN Sendok obat Pcs - 600 0
19 JKN Silk 3/0 Box @ 36 - 5,000 0
20 JKN Umbilical cord Pcs 9 - 9 1,540 13,860
21 JKN Underpad Box @ 10 - 5,000 0
22 JKN Utrafix 5 x 5 Roll - 25,000 0
23 JKN Urine Bag Pcs - 7,700 0
24 JKN Verban 4 x 10 Roll - 3,500 0
25 JKN Verban 4 x 5 Roll - 1,100 0

TOTAL OBAT + BMHP JKN 1,604,900

UMUM
BPJS JUMLAH
JUMLAH KUNJUNGAN RESEP TIDAK BAYAR BAYAR

Mengetahui/ Menyetujui Yang Menyerahkan Yang Menerima

Ka. UPT Puskesmas Waru Petugas Gudang Farmasi Puskesmas Petugas Pusban

Rohani, A.Md.Kep (….......................................................) (….......................................................)

NIP. 1986061719911032010 Nip. Nip.
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)
PUSKESMAS PEMBANTU (PUSBAN)

PUSBAN : Sesulu PELAPORAN BULAN : …................................

KECAMATAN : Waru PERMINTAAN BULAN / PERIODE : …................................
KABUPATEN : Penajam Paser Utara

PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

OBAT-OBATAN :
1 DAK Acetylcystein 200 mg Cap. ktk 100 20 20 412 0
2 DAK Acyclovir 200 mg ktk 10 x 10 90 90 236 0
3 DAK Acyclovir 400 mg ktk 10 x 10 - 454 0
4 DAK Allupurinol 100 mg ktk 100 80 80 89 0
5 DAK Ambroxol syr. Botol 13 13 3,639 0
6 DAK Amlodipin 5 mg ktk 30 - 74 0
7 DAK Amlodipin 10 mg ktk 30 - 520 0
8 DAK Amoksisilin 250 mg ktk 10x 10 140 140 188 0
9 DAK Amoksisilin 500 mg ktk 10x 11 200 200 231 0
10 DAK Amoksisilin syr Botol - 2,050 0
11 DAK Antasida syr. Botol - 1,756 0
12 DAK Antasida Tab. ktk 10 x 10 120 120 54 0
13 DAK Anti Hemoroid ktk 10 - 3,260 0
14 DAK Attapulgite ktk 100 - 175 0
15 DAK Aqua pro inj btl - 2,860 0
16 DAK Asam Askorbat Tab 50 mg ktk 10 x 10 50 50 46 0
17 DAK Asam Folat 400 mg (Profolat) ktk 10 x 10 - 45 0
18 DAK Asam Mefenamat 500 mg kotak 10 x 10 130 100 230 117 0
19 DAK Betahistine 6 mg ktk 30 - 119 0
20 DAK Betamethason Salep ktk 25 - 1,920 0
21 DAK Bioplacenton Tulle Tulle - 10,733 0
22 DAK Bisacodil 10 mg ktk 50 sup - 5,800 0
23 DAK Bisacodil 5 mg ktk 6 sup - 5,800 0
24 DAK Bufacetine salep kulit Tube - 3,760 0
25 DAK Captopril 50 mg ktk 10 x 10 tablet - 143 0
26 DAK Captopril 12,5 mg ktk 10 x 10 - 65 0
27 DAK Captopril 25 mg ktk 10 x 10 tablet 105 105 75 0
28 DAK Cetirizine 10 mg ktk 10 x 10 260 260 104 0
29 DAK Cetirizine sirup botol 10 10 20 3,061 0
30 DAK Ciprofloxacin 500 mg tab. ktk 10 x 10 50 50 260 0
31 DAK Cloramfenicol salep mata ktk 24 tube - 1,925 0
32 DAK Cyanocobalamin ( Vitamin B12 ) tab. Ktk 100 - 49 0
33 DAK Cyanokobalamin ( Vitamin B12 ) inj ktk 100 - 1,226 0
34 DAK Deksamethasone injeksi ktk 100 ampul x 1 ml - 2,336 0
35 DAK Deksamethasone Tablet btl 10 x 10 tablet - 75 0
36 DAK Difenhidramin HCL injeksi ktk 30 amp @1 ml - 1,156 0
37 DAK Dimenhidrinat 50 mg btl 100 - 121 0
38 DAK Domperidon 10 mg kotak 10 x 10 - 75 0
39 DAK Domperidon Sirup btl - 2,401 0
40 DAK Efinefrin 1 mg inj ktk 100 ampul x 1 ml - 1,740 0
41 DAK Ergotamine + Caffein Botol @ 100 - 199 0
42 DAK Eritromisin 250 mg ktk 12 x 10 tablet - 509 0
43 DAK Eritromisin 500 mg ktk 10 x 10 tablet - 913 0
44 DAK Furosemid 40 mg ktk 200 tab - 84 0
45 DAK Garam Oralit ktk 100 41 41 280 0
46 DAK Gentamisin TTS Mata ktk 24 btl - 4,600 0
47 DAK Glibenclamide 5 mg Tab. ktk 100 - 137 0
48 DAK Glukosa larutan infus 5 % btl 500 ml - 6,627 0
49 DAK Glyceryl guaiacolate ( GG ) Tab. ktk @ 100 - 157 0
50 DAK Griseofulvin 125 mg Tab. ktk 10 x 10 - 210 0
51 DAK Hidrokortisone Cream 2,5 % tube @ 5 g 19 19 2,325 0
52 DAK Herbakof btl - 14,273 0
53 DAK Ibuprofen sirup btl 60 ml - 2,678 0
54 DAK Ibuprofen tablet 200 mg ktk 10 x 10 tablet - 111 0
55 DAK Ibuprofen tablet 400 mg ktk 10 x 10 tablet - 157 0
56 DAK Kalsium laktat ( Kalk ) tablet 500 mg 270 300 570 60 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

57 DAK Ketoconazole 200mg Tab. Box @ 50 - 260 0

 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

58 DAK Ketoconazole salep ktk 25 tube 10 10 2,577 0

59 DAK Klorfeniramin Maleat 4 mg ( CTM ) ktk 100 tablet 190 190 24 0
60 DAK Kotrimoksasol 480 mg ktk 100 40 40 133 0
61 DAK Kotrimoksasol Syr. Botol 6 6 2,052 0
62 DAK Lidocain 2 % inj ktk 100 - 891 0
63 DAK Lidokain komp injeksi, kombinasi ktk 30 amp 9 9 2,122 0
64 DAK Metformin 500 mg ktk 10x 10 100 100 77 0
65 DAK Methylprednisolon 4 mg Tab. ktk 10 x 10 tablet - 102 0
66 DAK Metilergometrin tab 0,125 mg ktk 10 x 10 tablet - 242 0
67 DAK Metronidazol 500 mg ktk 100 50 50 140 0
68 DAK Miconazole 2% krem tube 10 gram 14 14 1,900 0
69 DAK Natrium Chlorida 0,9 % btl 500 ml 2 2 4 6,900 0
70 DAK Natrium diklofenak 50 mg kotak 50 tablet 240 200 440 109 0
71 DAK Nifedipin tab ktk 10 x 10 tablet 100 100 123 0
72 DAK Nistatin vag tablet 100.000 IU / g ktk 10 x 10 tablet 10 10 688 0
73 DAK OBH syr. Botol - 3,500 0
74 DAK Omeprazol 20 mg ktk 3x 10 - 164 0
75 DAK Oxytetrasiklin salep mata ktk 25 - 2,600 0
76 DAK Pantocain 0,5 % tetes mata btl 5 mL - 11,500 0
77 DAK Paracetamol tab 500 mg ktk 100 tablet 170 170 225 0
78 DAK Parasetamol Sirup btl 10 10 20 1,160 0
79 DAK Phenol Glycerol TTS telinga btl - 2,500 0
80 DAK Phitomenadion Vit K ktk 10 x 10 tablet 90 90 781 0
81 DAK Phitomenadion Vit K inj ktk 30 - 1,452 0
82 DAK Povidon Iodida 10 % 300 ml btl 300 ml - 21,150 0
83 DAK Prednison 5 mg ktk 10 x 10 tablet - 73 0
84 DAK Pyridoxin ( Vit B6 ) tablet 10 mg ktk 100 195 195 150 0
85 DAK Ranitidin HCL 50 mg/ml kotak 10 ampul - 1,155 0
86 DAK Ranitidine Tablet 150 mg ktk 10 x 10 - 119 0
87 DAK Ringer Laktat Infus btl 1 1 7,703 0
88 DAK Risperidon 2 mg ktk 100 - 130 0
89 DAK Salbutamol tablet 2 mg ktk 10 x 10 tablet 50 50 51 0
90 DAK Simvastatin 10 mg ktk 30 155 155 73 0
91 DAK Tablet Tambah Darah ktk 30 - 409 0
92 DAK Thiamin ( vitamin B1 ) kotak 100 - 94 0
93 DAK Vit B Komplek Tablet btl 100 140 140 60 0
94 DAK Zink tablet ktk 10 x 10 60 60 253 0
95 DAK Zirkum kids sirup botol - 3,285 0
96
97
98
99
100

BMHP :
1 DAK Alat Suntik Sekali Pakai 1 ML 100 set / kotak 46 46 1,023 0
2 DAK Alat Suntik Sekali Pakai 3 ML 100 set / kotak 87 87 683 0
3 DAK Alat Suntik Sekali Pakai 5 ML 100 set / kotak - 1,045 0
4 DAK Alkohol 70 % 1 Liter btl 1 liter - 29,375 0
5 DAK Alkohol Swab 0,5 % pcs 100 100 200 129 0
6 DAK Bisturi ktk 100 - 2,873 0
7 DAK Catgut/benang bedah No.2/0 dgn jarum ktk 24 - 6,142 0
8 DAK Foley Catheter 16 pcs - 11,132 0
9 DAK Hand Scoon 7 (Steril) pcs 7 7 8,470 0
10 DAK Hand Scoon L ktk 100 - 1,435 0
11 DAK Hand Scoon M ktk 100 - 1,435 0
12 DAK Hand Scoon S ktk 100 100 100 8,470 0
13 DAK Infusion Dewasa ktk 50 - 7,250 0
14 DAK Infusion set anak set / kantong - 9,181 0
15 DAK IV Catheter No. 22 G 50 buah / kotak 5 5 4,818 0
16 DAK IV Catheter No. 18 G 50 buah / kotak - 4,818 0
17 DAK IV Catheter No. 24 G 50 buah / kotak - 4,818 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

18 DAK Kapas Pembalut 250 gr rol - 14,063 0

19 DAK Kasa Pembalut Hidrofil 10 cm x 360 cm rol/50 - 6,400 0
20 DAK Kasa Pembalut Hidrofil 6 cm x 360 cm rol/50 - 5,400 0
21 DAK Kasa steril 16 cmx16 cm ktk - - 15,000 0
22 DAK Leukoplast Plester kain 7,5x4,5 pcs - 35,532 0
23 DAK Lysol btl - 48,175 0
24 DAK Masker hijab / Karet ktk 50 pcs - 1,448 0
25 DAK Masker tali ikat Ties Aximed ktk 50 pcs - 567 0
26 DAK Mucus Extractor Pcs - 8,040 0
27 DAK Oxyflow Anak - 5,000 0
28 DAK Oxyflow Dewasa pcs - 5,000 0
29 DAK Pembalut Elastis roll - 35,592 0
30 DAK Polifix 5 cmx 5 m Roll - 39,217 0
31 DAK Silk 3/0 HR - 20 ktk 12 - 16,209 0
32 DAK Test Kehamilan ktk 50 - 2,185 0
33 DAK Umbilical cord klem ktk 50 pcs - 2,070 0
34 DAK Underpad Pcs - 8,602 0
35 DAK Urin Bag 10 pcs - 5,865 0

TOTAL OBAT + BMHP DAK 0

PROGRAM GIZI /KIA :

1 APBN Fe ktk 100 - 409 0
2 APBN Vitamin A Biru 100.000 IU Botol 50 kapsul - 305 0
3 APBN Vitamin A Merah 200.000 IU Botol 50 kapsul - 553 0

TOTAL OBAT + BMHP APBN 0

1 APBD

TOTAL OBAT + BMHP APBD

OBAT & BMHP :

1 JKN Acyclovir 200 mg Tab. Box @ 100 - 1,096 0
2 JKN Acyclovir 400 mg Tab Box @ 100 - 991 0
3 JKN Acyclovir cream Tube 20 20 20 20 4,000 80,000 20.00
4 JKN Acetylsystein 200 mg Cap. Box @ 100 200 200 1,008 0
5 JKN Allopurinol 100 mg Tab. Box @ 100 - 248 0
6 JKN Allopurinol 300 mg Tab. Box @ 100 - 567 0
7 JKN Ambroxol syr. Botol - 4,200 0
8 JKN Ambroxol Tab. Box @ 100 195 195 150 0
9 JKN Amlodipine 10 mg Tab. Box @ 30 200 200 400 450 0
10 JKN Amlodipine 5 mg Tab. Box @ 100 30 30 405 0
11 JKN Amoxycillin 500 mg Tab. Box @ 100 - 407 0
12 JKN Amoxycillin Syr. Botol 6 6 5,200 0
13 JKN Antasid Syr. Botol 20 20 3,900 0
14 JKN Antasida Tab. Box @ 100 - 165 0
15 JKN Asam Folat Box@100 - 110 0
16 JKN Asam Mefenamat 500 mg Tab. Box @ 100 - 275 0
17 JKN Aseptic Gell Botol 450 mL - 55,000 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

18 JKN Attapulgit Box @100 100 100 670 0

19 JKN Bedak Salicyl Pcs - 6,426 0
20 JKN Betahistine 6 mg Tab. Box @ 100 200 200 1,015 0
21 JKN Bethametasone salep Tube 11 11 3,200 0
22 JKN Calsium Laktat 500mg ( Kalk) Botol @ 100 - 145 0
23 JKN Captopril 12,5 mg Tab. Box @ 100 - 105 0
24 JKN Captopril 25 mg Tab. Box @ 100 - 132 0
25 JKN Cefadroxil 125 mg Syr. Botol - 7,700 0
26 JKN Cefadroxil 500 mg Cap. Box @ 100 90 90 852 0
27 JKN Cendo eyefresh mini dose Box@ 25 strip - 5,720 0
28 JKN Cetirizine Syr Botol 10 10 20 5,500 0
29 JKN Cetirizine Tab. Box @ 100 260 260 480 0
30 JKN Chloramfenicol Tetes mata (Reco) Botol 12 12 9,000 0
31 JKN Chloramfenicol Tetes Telinga (Reco TT) Botol 8 8 9,000 0
32 JKN Chloramfenicol salep (Fasycol) Tube - 4,900 0
33 JKN Ciprofloxacin 500 mg tab. Box @ 100 - 720 0
34 JKN Cotrimoksazol 480 mg Box @ 100 - 290 0
35 JKN Cotrimoxazole syr. Botol - 4,290 0
36 JKN CTM Btl @ 100 - 56 0
37 JKN Daryantulle Box @ 10 - 26,300 0
38 JKN Dexamethasone 0,5 mg Tab. Box @ 100 100 100 120 0
39 JKN Dexamethasone Inj. Box @ 100 - 2,197 0
40 JKN Domperidone Syr. Botol 7 7 6,000 0
41 JKN Domperidone Tab. Box @ 100 45 45 272 0
42 JKN Dulcolax 10 mg Sup Ktk @ 5 - 31,240 0
43 JKN Dulcolax 5 mg Sup Ktk @ 6 - 21,833 0
44 JKN Dulcolax tab./ Laxana Box @ 10 - 1,980 0
45 JKN Dumin 125 mg Rectal Ktk @ 5 - 19,800 0
46 JKN Ephineprin Inj. Box @ 30 - 8,983 0
47 JKN Ergotamine + Caffein Box @ 100 - 306 0
48 JKN Etil Klorida 100 ml Botol - 223,850 0
49 JKN Garam Oralit Box @ 100 - 352 0
50 JKN Gentamicin SK Box @ 10 - 3,630 0
51 JKN Gentamicin Salep Mata (Genoint) Tube - 7,800 0
52 JKN Gentamisin Tetes Mata (Genoint TM) Botol 5 mL 4 4 10,100 0
53 JKN Gentian Violet Box @ 24 - 3,850 0
54 JKN Glibenclamide Tab. Box @ 100 - 159 0
55 JKN Gliceril Guaiakolat Tab. Box @ 100 270 270 130 0
56 JKN Guanistrep syr. Botol - 7,700 0
57 JKN Hyocine-N-Bromida (Scopma plus) Box @ 100 - 1,240 0
58 JKN Ibuprofen 200 mg Tab. Box @ 100 - 275 0
59 JKN Ibuprofen 400 mg Tab. Box @ 100 155 155 335 0
60 JKN Ibuprofen Syr Botol - 4,500 0
61 JKN Ketoconazole 200 mg Tab. Box @ 50 - 572 0
62 JKN Ketokonazole Salep Tube - 4,500 0
63 JKN Ketorolac inj 30mg/mL Box @ 6 - 5,000 0
64 JKN Lidocain + Adrenalin Inj. / Pehacain Inj Box @ 20 - 3,355 0
65 JKN Lidocain Inj. Box @ 100 - 1,420 0
66 JKN Metformin 500 mg Tab. Box @ 100 - 193 0
67 JKN Methylprednisolon 4 mg Tab. Box @ 50 - 440 0
68 JKN Metronidazole 500 mg Tab. Box @ 100 - 334 0
69 JKN Miconazole Salep Tube - 4,730 0
70 JKN NaCl infus Box @ 20 - 9,900 0
71 JKN Natrium diklofenak 25 mg Tab. Box @ 50 - 205 0
72 JKN Nifedipine 10 mg Tab Box @ 100 4 4 220 0
73 JKN Nystatin drop (Cazetin drop ) Botol - 24,420 0
74 JKN Nystatin Vag ovula Box @ 100 - 828 0
75 JKN Omeprazole kap. Box @ 30 190 190 414 0
76 JKN Oxytetracycline salep mata Tube - 6,270 0
77 JKN Paracetamol 500 mg Tab. Botol @ 100 - 317 0
78 JKN Paracetamol Syr. Botol - 4,180 0
79 JKN Phenol Glycerol TT Botol - 5,498 0
80 JKN Povidone Iodine Botol - 33,000 0
81 JKN Prednison 5 mg Tab. Box @ 100 - 285 0
 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

82 JKN Ranitidine Inj. Box @ 10 - 4,545 0

 PUSBAN SESULU

SUMBER Stok akhir

No. DANA Nama Obat Satuan Permintaan Pemberian
Stok awal Penerimaan Pemakaian Harga Total
Sisa satuan

83 JKN Ranitidine Tab. Box @ 100 135 100 235 293 0

84 JKN Ringer Laktat Infus Box @ 20 - 9,570 0
85 JKN Salbutamol 2mg Tab. Box @ 100 - 158 0
86 JKN Permetrin 5 % krim Tube - 48,000 0
87 JKN Simvastatin 20 mg Tab. Box @ 100 - 564 0
88 JKN Ultrasonic Gel 250 mL Botol - 24,200 0
89 JKN Vit B.1 Box @ 100 120 120 120 0
90 JKN Vit B6 Box @ 100 - 132 0
91 JKN Vit. B-Complex Btl @ 100 - 220 0
92 JKN Vit K inj. Box @ 5 - 7,150 0
93 JKN Vit K Tab. Box @ 100 - 1,320 0
94 JKN Water for Inj. 10 mL Botol - 5,940 0
95 JKN Water for Inj. 25 mL Botol - 8,200 0
96 JKN Zinc / Lecozinc Syr. Botol - 7,000 0
97 JKN Zinc Tab. Box @ 100 - 675 0

BMHP :
1 JKN Abbocat 18 G Box @ 50 - 5,500 0
2 JKN Abbocat 22 G Box @ 50 - 6,050 0
3 JKN Abbocat 24 G Box @ 50 - 13,000 0
4 JKN Alkohol 300 mL Botol - 30,000 0
5 JKN Alkohol Swab Bok - 150 0
6 JKN Bisturi no. 11 G Box @ 100 - 1,100 0
7 JKN Blood set Box @ 50 - 6,900 0
8 JKN Cat Gut Plain 3/0 Box @ 24 - 7,000 0
9 JKN Folley Catheter Fr. 16 Box @ 10 - 20,000 0
10 JKN Folley Catheter Fr. 18 Box @ 10 - 10,000 0
11 JKN Hand scoon steril No. 7 Box @ 50 - 11,000 0
12 JKN Hand scoon nonsteril No. L Box @100 - 1,701 0
13 JKN Hand scoon nonsteril No. M Box @100 - 1,701 0
14 JKN Hand scoon nonsteril No. S Box @100 - 1,701 0
15 JKN Kassa steril Box - 4,000 0
16 JKN Masker Bedah Box @ 50 - 806 0
17 JKN Nurse Cup Box @100 - 605 0
18 JKN Sendok obat Pcs - 600 0
19 JKN Silk 3/0 Box @ 36 - 5,000 0
20 JKN Umbilical cord Pcs 9 9 1,540 0
21 JKN Underpad Box @ 10 - 5,000 0
22 JKN Utrafix 5 x 5 Roll - 25,000 0
23 JKN Urine Bag Pcs - 7,700 0
24 JKN Verban 4 x 10 Roll - 3,500 0
25 JKN Verban 4 x 5 Roll - 1,100 0

TOTAL OBAT + BMHP JKN 80,000

UMUM
BPJS JUMLAH
JUMLAH KUNJUNGAN RESEP TIDAK BAYAR BAYAR

Mengetahui/ Menyetujui Yang Menyerahkan Yang Menerima

Ka. UPT Puskesmas Waru Petugas Gudang Farmasi Puskesmas Petugas Pusban

Rohani, A.Md.Kep (….......................................................) (….......................................................)

NIP. 1986061719911032010 Nip. Nip.