KODE PUSKESMAS :

PUSKESMAS : KUNTO DARUSSALAM LAPORAN PEMAKAIAN DAN LEMB

KECAMATAN : KUNTO DARUSSALAM ( LPLPO ) JK
KABUPATEN : ROKAN HULU
PROVINSI : R I A U

KELAS PENERIMAAN
STOK PERSE-
KODE NAMA OBAT TERAP SATUAN
AWAL APBD JKN LAIN DIAAN
I
1 Alkohol Swab + 2 % Chlorhexidine Cosmo Med
2 Allopurinol
3 Ambroxol 15 mg Syrup

NIH
4 Ambroxol 30 mg tablet
5 Amlodipine Besylate 5 mg
6 Amoxicillin 500 mg kaplet
7 Antalgin 500mg kaplet
8 Asam Folat 1 mg
9 Asam Mefenamat
10 Becefort Syrup
11 Betahistin masilat
12 Bioplasenton gel
13 Burnazine cream
14 Catgut Chromic Gea 2/10 (150 cm)
15 Catgut Silk Gea 2/10 (500 cm)
16 Catgut Silk Gea 2/10 (75 cm) + Needle
17 Catgut Silk Gea 3/10 (500 cm)
18 Catgut Silk Gea 3/10 (75 cm) + Needle
19 Cefixime 100mg kapsul
20 Cefixime Dry Syrup
21 Ceftriaxon Sbk Inj. 1 mg
22 Ceftriaxone Sodium 1g Inj
23 Cendoxitrol tetes mata
24 Chili Plast 12,5mm x 1 m
25 Cimetidin 200 mg tablet
26 Ciprofloxacin 500 mg tablet
27 Clindamycin tablet
28 Cotrimoxazole 480 mg tablet
29 Dexamethason 0,5 mg tablet
30 Domperidon Syrup
31 Ear Drop
32 Ephineprin Inj 0,1%
33 Flutamol Syrup
34 Furosemide injeksi
35 Guanistrep Syrup
36 Handscoon Steeril Cosmo Med 7.0
37 Handscoon Steeril Cosmo Med 7.5
38 Hemorogard Caps
39 Hustab P Syrup 60 ml
40 I.V Catheter Pen Cosmo Med 20G
41 I.V Catheter Pen Cosmo Med 22G
42 I.V Catheter Pen Cosmo Med 24G
43 Infuset Cosmo Med Anak
44 Infuset Cosmo Med Dewasa
45 Kapas Ratu Brand 100 gram
46 Kapas Ratu Brand 250 gram
47 Kasa Gulung Salqi Husada 40y x 80 cm
48 Kassa Steril Salqi Husada 16 x 16
49 Ketorolac Injeksi
50 Leukoplast 1625 H (3X5) 7,5 cm x 4,5 cm
51 Livron B Plex
52 Lysol 50 % 1 liter Brataco
53 Mata Pisau Onemed No. 15
54 Mata Pisau Onemed No. 20
55 Metformin 500mg
56 Methanol 1 liter Brataco
57 Microlac suposikoria
58 Nasal Oxygen Canula Cosmo Med Adult
59 Nasal Oxygen Canula Cosmo Med Child
60 Nasal Oxygen Canula Cosmo Med Neonate
61 Neprolit tablet
62 Nystatin 500000 IU/10x10
63 Ondansetron Injeksi
64 Paracetamol 500mg tablet
65 Paracetamol Infus
66 Paracetamol Infus 100 mg
67 Pehacain Inj. 20 x 2 ml
68 Proris Suposikoria
69 Ranitidin 150mg
70 Ranitidin 25 mg Inj.
71 Salbutamol 2mg
72 Scopma Tablet
73 Semillas Non Woven Medical Tape 10x500cm
74 Semillas Non Woven Medical Tape 15x500cm
75 Semillas Non Woven Medical Tape 20x500cm
76 Semillas Non Woven Medical Tape 5x100cm
77 Semillas Non Woven Wound Dressing 10x20cm with pad (5x15cm)
78 Semillas Non Woven Wound Dressing 6x7cm with pad (3x4cm)
79 Semillas Non Woven Wound Dressing 9x10cm with pad (5x6cm)
80 Semillas Transparent IV Dressing 10 x 12 cm
81 Semillas Transparent IV Dressing 4,4 x 4,4 cm
82 Semillas Transparent IV Dressing 6 x 7 cm(common)
83 Semillas Transparent IV Dressing 6 x 7 cm(with notch)
84 Semillas Transparent IV Dressing 6 x 7 cm(with pad)
85 Spuit Cosmo Med 3cc
86 Strip Benecheck Cholesterol 10s
87 Strip Benecheck Gula 50s
88 Strip Benecheck Urid Acid 25s
89 Urine Bag + Hanger Cosmo Med
90 Ventolin nebulizer

Mengetahui / Menyetujui Yang Menyerahkan

Kepala Dinas Kesehatan Kepala GFK

(……………………………..) (………………………..)
 LB. 2
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT Halaman : 1
( LPLPO ) JKN
BULAN : Januari
TAHUN : 2019

SISA STOK PERMI PEMBERIAN

PEMAKA JUMLAH
STOK OPT. N- APBD JKN APBN LAIN
IAN
TAAN

NIHIL
 Yang Menerima / Melapor Yang Menerima
Kepala Puskesmas Petugas Puskesmas

Endang Suhada, SKM Dony Iswandi, S.Farm., Apt

NIP. 19700901 199101 1 001
KODE PUSKESMAS :
PUSKESMAS : KUNTO DARUSSALAM LAPORAN PEMAKAIAN DAN LEMB
KECAMATAN : KUNTO DARUSSALAM ( LPLPO ) JK
KABUPATEN : ROKAN HULU
PROVINSI : R I A U

KELAS PENERIMAAN
STOK PERSE-
KODE NAMA OBAT TERAP SATUAN
AWAL APBD JKN LAIN DIAAN
I
1 Alkohol Swab + 2 % Chlorhexidine Cosmo Med
2 Allopurinol
3 Ambroxol 15 mg Syrup
4 Ambroxol 30 mg tablet
5 Amlodipine Besylate 5 mg

NIH
6 Amoxicillin 500 mg kaplet
7 Antalgin 500mg kaplet
8 Asam Folat 1 mg
9 Asam Mefenamat
10 Becefort Syrup
11 Betahistin masilat
12 Bioplasenton gel
13 Burnazine cream
14 Catgut Chromic Gea 2/10 (150 cm)
15 Catgut Silk Gea 2/10 (500 cm)
16 Catgut Silk Gea 2/10 (75 cm) + Needle
17 Catgut Silk Gea 3/10 (500 cm)
18 Catgut Silk Gea 3/10 (75 cm) + Needle
19 Cefixime 100mg kapsul
20 Cefixime Dry Syrup
21 Ceftriaxon Sbk Inj. 1 mg
22 Ceftriaxone Sodium 1g Inj
23 Cendoxitrol tetes mata
24 Chili Plast 12,5mm x 1 m
25 Cimetidin 200 mg tablet
26 Ciprofloxacin 500 mg tablet
27 Clindamycin tablet
28 Cotrimoxazole 480 mg tablet
29 Dexamethason 0,5 mg tablet
30 Domperidon Syrup
31 Ear Drop
32 Ephineprin Inj 0,1%
33 Flutamol Syrup
34 Furosemide injeksi
35 Guanistrep Syrup
36 Handscoon Steeril Cosmo Med 7.0
37 Handscoon Steeril Cosmo Med 7.5
38 Hemorogard Caps
39 Hustab P Syrup 60 ml
40 I.V Catheter Pen Cosmo Med 20G
41 I.V Catheter Pen Cosmo Med 22G
42 I.V Catheter Pen Cosmo Med 24G
43 Infuset Cosmo Med Anak
44 Infuset Cosmo Med Dewasa
45 Kapas Ratu Brand 100 gram
46 Kapas Ratu Brand 250 gram
47 Kasa Gulung Salqi Husada 40y x 80 cm
48 Kassa Steril Salqi Husada 16 x 16
49 Ketorolac Injeksi
50 Leukoplast 1625 H (3X5) 7,5 cm x 4,5 cm
51 Livron B Plex
52 Lysol 50 % 1 liter Brataco
53 Mata Pisau Onemed No. 15
54 Mata Pisau Onemed No. 20
55 Metformin 500mg
56 Methanol 1 liter Brataco
57 Microlac suposikoria
58 Nasal Oxygen Canula Cosmo Med Adult
59 Nasal Oxygen Canula Cosmo Med Child
60 Nasal Oxygen Canula Cosmo Med Neonate
61 Neprolit tablet
62 Nystatin 500000 IU/10x10
63 Ondansetron Injeksi
64 Paracetamol 500mg tablet
65 Paracetamol Infus
66 Paracetamol Infus 100 mg
67 Pehacain Inj. 20 x 2 ml
68 Proris Suposikoria
69 Ranitidin 150mg
70 Ranitidin 25 mg Inj.
71 Salbutamol 2mg
72 Scopma Tablet
73 Semillas Non Woven Medical Tape 10x500cm
74 Semillas Non Woven Medical Tape 15x500cm
75 Semillas Non Woven Medical Tape 20x500cm
76 Semillas Non Woven Medical Tape 5x100cm
77 Semillas Non Woven Wound Dressing 10x20cm with pad (5x15cm)
78 Semillas Non Woven Wound Dressing 6x7cm with pad (3x4cm)
79 Semillas Non Woven Wound Dressing 9x10cm with pad (5x6cm)
80 Semillas Transparent IV Dressing 10 x 12 cm
81 Semillas Transparent IV Dressing 4,4 x 4,4 cm
82 Semillas Transparent IV Dressing 6 x 7 cm(common)
83 Semillas Transparent IV Dressing 6 x 7 cm(with notch)
84 Semillas Transparent IV Dressing 6 x 7 cm(with pad)
85 Spuit Cosmo Med 3cc
86 Strip Benecheck Cholesterol 10s
87 Strip Benecheck Gula 50s
88 Strip Benecheck Urid Acid 25s
89 Urine Bag + Hanger Cosmo Med
90 Ventolin nebulizer

Mengetahui / Menyetujui Yang Menyerahkan

Kepala Dinas Kesehatan Kepala GFK

(……………………………..) (………………………..)
 LB. 2
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT Halaman : 1
( LPLPO ) JKN
BULAN : februari
TAHUN : 2019

SISA STOK PERMI PEMBERIAN

PEMAKA JUMLAH
STOK OPT. N- APBD JKN APBN LAIN
IAN
TAAN

NIHIL
 Yang Menerima / Melapor Yang Menerima
Kepala Puskesmas Petugas Puskesmas

Endang Suhada, SKM Dony Iswandi, S.Farm., Apt

NIP. 19700901 199101 1 001
KODE PUSKESMAS :
PUSKESMAS : KUNTO DARUSSALAM LAPORAN PEMAKAIAN DAN LEMB
KECAMATAN : KUNTO DARUSSALAM ( LPLPO ) JK
KABUPATEN : ROKAN HULU
PROVINSI : R I A U

KELAS PENERIMAAN
STOK PERSE-
KODE NAMA OBAT TERAP SATUAN
AWAL APBD JKN LAIN DIAAN
I
1 Alkohol Swab + 2 % Chlorhexidine Cosmo Med
2 Allopurinol
3 Ambroxol 15 mg Syrup
4 Ambroxol 30 mg tablet
5 Amlodipine Besylate 5 mg
6 Amoxicillin 500 mg kaplet

NIHI
7 Antalgin 500mg kaplet
8 Asam Folat 1 mg
9 Asam Mefenamat
10 Becefort Syrup
11 Betahistin masilat
12 Bioplasenton gel
13 Burnazine cream
14 Catgut Chromic Gea 2/10 (150 cm)
15 Catgut Silk Gea 2/10 (500 cm)
16 Catgut Silk Gea 2/10 (75 cm) + Needle
17 Catgut Silk Gea 3/10 (500 cm)
18 Catgut Silk Gea 3/10 (75 cm) + Needle
19 Cefixime 100mg kapsul
20 Cefixime Dry Syrup
21 Ceftriaxon Sbk Inj. 1 mg
22 Ceftriaxone Sodium 1g Inj
23 Cendoxitrol tetes mata
24 Chili Plast 12,5mm x 1 m
25 Cimetidin 200 mg tablet
26 Ciprofloxacin 500 mg tablet
27 Clindamycin tablet
28 Cotrimoxazole 480 mg tablet
29 Dexamethason 0,5 mg tablet
30 Domperidon Syrup
31 Ear Drop
32 Ephineprin Inj 0,1%
33 Flutamol Syrup
34 Furosemide injeksi
35 Guanistrep Syrup
36 Handscoon Steeril Cosmo Med 7.0
37 Handscoon Steeril Cosmo Med 7.5
38 Hemorogard Caps
39 Hustab P Syrup 60 ml
40 I.V Catheter Pen Cosmo Med 20G
41 I.V Catheter Pen Cosmo Med 22G
42 I.V Catheter Pen Cosmo Med 24G
43 Infuset Cosmo Med Anak
44 Infuset Cosmo Med Dewasa
45 Kapas Ratu Brand 100 gram
46 Kapas Ratu Brand 250 gram
47 Kasa Gulung Salqi Husada 40y x 80 cm
48 Kassa Steril Salqi Husada 16 x 16
49 Ketorolac Injeksi
50 Leukoplast 1625 H (3X5) 7,5 cm x 4,5 cm
51 Livron B Plex
52 Lysol 50 % 1 liter Brataco
53 Mata Pisau Onemed No. 15
54 Mata Pisau Onemed No. 20
55 Metformin 500mg
56 Methanol 1 liter Brataco
57 Microlac suposikoria
58 Nasal Oxygen Canula Cosmo Med Adult
59 Nasal Oxygen Canula Cosmo Med Child
60 Nasal Oxygen Canula Cosmo Med Neonate
61 Neprolit tablet
62 Nystatin 500000 IU/10x10
63 Ondansetron Injeksi
64 Paracetamol 500mg tablet
65 Paracetamol Infus
66 Paracetamol Infus 100 mg
67 Pehacain Inj. 20 x 2 ml
68 Proris Suposikoria
69 Ranitidin 150mg
70 Ranitidin 25 mg Inj.
71 Salbutamol 2mg
72 Scopma Tablet
73 Semillas Non Woven Medical Tape 10x500cm
74 Semillas Non Woven Medical Tape 15x500cm
75 Semillas Non Woven Medical Tape 20x500cm
76 Semillas Non Woven Medical Tape 5x100cm
77 Semillas Non Woven Wound Dressing 10x20cm with pad (5x15cm)
78 Semillas Non Woven Wound Dressing 6x7cm with pad (3x4cm)
79 Semillas Non Woven Wound Dressing 9x10cm with pad (5x6cm)
80 Semillas Transparent IV Dressing 10 x 12 cm
81 Semillas Transparent IV Dressing 4,4 x 4,4 cm
82 Semillas Transparent IV Dressing 6 x 7 cm(common)
83 Semillas Transparent IV Dressing 6 x 7 cm(with notch)
84 Semillas Transparent IV Dressing 6 x 7 cm(with pad)
85 Spuit Cosmo Med 3cc
86 Strip Benecheck Cholesterol 10s
87 Strip Benecheck Gula 50s
88 Strip Benecheck Urid Acid 25s
89 Urine Bag + Hanger Cosmo Med
90 Ventolin nebulizer

Mengetahui / Menyetujui Yang Menyerahkan

Kepala Dinas Kesehatan Kepala GFK

(……………………………..) (………………………..)
 LB. 2
LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT Halaman : 1
( LPLPO ) JKN
BULAN : Maret
TAHUN : 2019

SISA STOK PERMI PEMBERIAN

PEMAKA JUMLAH
STOK OPT. N- APBD JKN APBN LAIN
IAN
TAAN

NIHIL
 Yang Menerima / Melapor Yang Menerima
Kepala Puskesmas Petugas Puskesmas

Endang Suhada, SKM Dony Iswandi, S.Farm., Apt

NIP. 19700901 199101 1 001