LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD

PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : APRIL2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : MEI 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
1 Alopurinol tablet 100 mg tablet
2 Alopurinol tablet 300 mg tablet
3 Alpara Tablet
4 Alprazolam 0,5 mg tablet tablet
5 Ambroxol sirup 15 mg / ml botol @ 60 ml
6 Ambroxol tablet 30 mg tablet
Aminofilin tablet scored 150
7 tablet
mg
Aminofilin tablet scored 200
8 tablet
mg
9 Aminofilina injeksi 24 mg / ml ampul
Amitriptilin tablet salut 25 mg (
10 tablet
HCl )
11 Amlodipine tablet 10 mg tablet 540 540 540 -
12 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125
13 botol @ 60 ml
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet 410 410 360 50
16 Amoksisilin kapsul 250 mg tablet
Amoksisilin Serbuk injeksi
17 vial
1000 mg
Ampisilina sirup kering 125
18 botol
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet 220 220 190 30
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr

26 Antihemoroid DOEN supp
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet
28 Antiparkinson DOEN tablet tablet
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml
pirogen
botol @ 1000
30 Aquadest steril
ml
Asam Asetilsalisilat (Asetosal)
31 tablet
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet
tablet 50 mg
Asam Mefenamat kaplet 500 230
37 tablet
mg 230 230 -
Asam traneksamat injeksi 100
38 ampul
mg/ml
Asam traneksamat injeksi 50
39 ampul
mg/ml
Asam traneksamat tablet 500
40 tablet
mg
41 Asiklovir krim 5 % tube @ 5 gr
42 Asiklovir tablet 400 mg tablet 180 180 0 180
43 Atapulgit tablet 600 mg tablet
44 Atorvastatin 20 mg tablet tablet 50 50 0 50
Atropin Sulfat injeksi 0,25 mg
45 ampul
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet
Atropin Sulfat tetes mata
47 botol
0,5%
48 Azitromisiin tablet 250 mg tablet
49 Azitromisin tablet 500 mg tablet
50 Azithromicyn 500 mg inj vial
Batugin Elixir Sirup
51 botol
( Fitofarmaka )
52 Becefort tablet
53 Becom - C tablet tablet
54 Bedak salisil serbuk 2 % kotak
Betadin Gargle 190 ml /
55 botol
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet 60
60 20 40
Betametason krim 0.1%
57 tube 5 gr
( sebagai valerat )
58 Betason - N krim tube
59 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg (
60 supp
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet 140 140 30 110
62 Bisoprolol tablet 5 mg tablet
63 Boost D tablet ( Vitamin D3 ) tablet
64 Borak Gliserin 5% botol @ 15 ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml
67 Candesartan 16 mg Tablet Tablet
68 Candesartan 8 mg Tablet tablet
69 Cendo Lyters botol
minidose
70 Cendo Lyteers
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet
73 Curcuma tablet tablet
Deksametason injeksi 5 mg /
74 ampul @ 1 ml
ml
75 Deksametason tablet 0,5 mg tablet 340
340 250 90
Denomix Cream -
76 Desoksimetason 0,25 %, Tube
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr

78 Dextrofen Syrup botol @ 60 ml
Diazepam injeksi 5 mg / ml - 2
79 ampul
ml
Diazepam rectal tube
80 tube @ 2,5 ml
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet
82 Diazepam tablet 5 mg tablet
Difenhidramin HCl injeksi 10
83 ampul
mg / ml
84 Digoksin tablet 0,25 mg tablet
85 Dimenhidrinat tablet 50 mg tablet 60 60 30 30
86 Doksisiklin tablet 100 mg kapsul
87 Domperidone sirup 5 mg/5ml botol @ 60 ml
88 Domperidone tablet 10 mg tablet 30 30 10 20
89 Elkana Sirup botol
Epinefrina HCl ( Adrenalin )
90 ampul
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml
ml
92 Eritromisin kapsul 250 mg kapsul 50 50 30 20
93 Eritromisin kapsul 500 mg kapsul
Etynil estradiol (Lynoral tablet
94 tablet
0,05 mg)
95 Fenobarbital tablet 30 mg tablet
96 Fenofibrat kapsul 100 mg kapsul
97 Fenofibrat kapsul 300 mg kapsul
Fenol Gliserol tetes telinga
98 botol
10%
Fitbon tablet (Glucosamin)/
99 tablet
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet
Fluocinolone Acetonide tube @ 5
104
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet
botol @ 500
106 Gelofusin Infus
ml
107 Gemfibrosil kapsul 300 mg kapsul
108 Gemfibrosil kapsul 600 mg kapsul
109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
Gentamisin Salep Mata 0,3 %
110 tube
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol
112 Gentian Violet larutan 1 % botol @10 ml
113 Glibenklamid tablet 5 mg tablet 180 180 110 70
114 Glimepiride tablet 2 mg tablet
115 Glimepiride tablet 4 mg tablet
Gliseril Guaiakolat tablet 100
116 tablet
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet
botol @ 500
118 Glukosa 5% - 1/2 NS
ml
botol @ 500
119 Glukosa 5% - 1/4 NS
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml
steril
Glukosa larutan infus 40 % botol @ 500
122
steril ml
123 Griseofulvin tablet 125 mg tablet
124 Griseofulvin tablet 500 mg tablet
125 Hemorogard kapsul kapsul
126 Herba Cold tablet tablet
Hidroklorotiazid ( HCT ) tablet
127 tablet
25 mg
128 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20
129 ampul
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet
tablet
Hyaloph tetes mata ( Natrium
131 Botol
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml 3
3 0 3

133 Ibuprofen Sirup 200 mg / 5 ml Botol

134 Ibuprofen tablet 200 mg tablet
135 Ibuprofen tablet 400 mg tablet
136 Ichtiyol Zalf pot @ 15 gr
Ipratropium bromida
137 ampul
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet
mg
Kalsium Laktat ( Kalk ) tablet 30
141 tablet
500 mg 30 30 -

142 Kaptopril tablet scored 25 mg tablet

Kaptopril tablet scored 12,5
143 tablet
mg
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100
146 supp
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml

149 Kidmin SoftBag Fls
150 Klindamisin kapsul 150 mg kapsul
151 Klindamisin kapsul 300 mg kapsul
Kloramfenikol injeksi 1000 mg
152 Vial
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul

154 Kloramfenikol kapsul 500 mg kapsul

Kloramfenikol suspensi 125
155 botol @ 60 ml
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube
Kloramfenikol Tetes Mata 0.5
158 botol
%

minidose
159 Kloramfenikol 0,5% (cendo fen
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol
%
Klorfeniramin Maleat ( CTM )
161 tablet
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet
Kotrimoksazol 400 mg +
163 tablet
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml
165 Lactodia / Lacto B sachet
166 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) /
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet

Levofloxacin Tablet Salut
171 tablet
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml 2 2 0 2
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul
176 Loperamida tablet 2 mg tablet
177 Loratadin tablet 10 mg tablet
178 Matovit tablet
179 Meloksikam tablet 15 mg tablet
180 Metformin HCl tablet 500 mg tablet
Methyl Prednisolon 4 mg
181 tablet
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml
mg / ml
183 Metoklopropamid tablet 10 mg tablet
184 Metronidazol ovula ovula
185 Metronidazol tablet 250 mg tablet
186 Metronidazol tablet 500 mg tablet
187 Miconazol krim 2 % ( Nitrat ) tube
188 Molexflu tablet tablet
N-Acetyl systeine tablet 200
189 tablet
mg
Natrium Diklofenak tablet 50 10
190 tablet
mg 10 10 -
Natrium Klorida larutan infus
191 Botol
0,9% 100 cc
Natrium Klorida larutan infus
192 vial
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml
195 Neuralgin - RX tablet tablet
Neurosanbe 5000 mg tablet /
196 tablet
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet
E
199 Nifedipin tablet 10 mg tablet 280 280 230 50
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet
OROS)
Nistatin tablet salut 500.000
202 tablet
IU / g
Nistatin vaginal tablet 100.000
203 tablet
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet

205 No Pain Spray botol
Noretisteron tablet 5 mg
206 tablet
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209
100 ml ml
210 Obat Batuk Herbakof tablet tablet
211 Ofloxaxin tablet 200 mg tablet
Oksimetazolin tetes hidung
212 botol @ 10 ml
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
Oksitetrasiklin HCl salep mata
214 tube @ 3,5 gr
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml
ml
217 Omeprazole tablet 20 mg tablet
218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml
219 Ondansetron tablet 4 mg tablet
220 Ondansetron tablet 8 mg tablet
221 Oxyvit C + Kaplet tablet
222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
223 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml (
224 botol @ 15 ml
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol
ml
226 Parasetamol tablet 100 mg tablet
227 Parasetamol tablet 500 mg tablet 390 390 240 150
Pamol supp (paracetamol
228 supp
supp 125 mg)
229 Pehavral tablet tablet
230 Piracetam tablet 1200 mg tablet
231 Piracetam tablet 800 mg tablet
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet
tablet 10 mg
235 Piroxicam tablet 10 mg tablet
236 Piroxicam tablet 20 mg tablet
237 Prednison tablet 5 mg tablet 90 90 90 -

238 Propiltiourasil tablet 100 mg tablet

239 Propranolol HCl tablet 40 mg tablet

240 Proris suppositoria supp
241 Psidii Kapsul 500 mg kapsul
242 Psidii sirup 60 ml botol @ 60 ml
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet 40 40 40 -
245 Reserpin tablet 0,25 mg tablet
246 Salbutamol Inhaler (Salbulin) kapsul
Salbutamol tablet 2 mg 90
247 tablet
( sebagai sulfat ) 90 10 80
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr 4
endap 4 % 4 1 3
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube
%
250 Sefadroksil kapsul 250 mg kapsul
251 Sefadroksil kapsul 500 mg kapsul
Sefadroksil Sirup Kering 125
252 botol @ 60 ml
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul
254 Sefiksim kapsul 200 mg kapsul
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr
/ vial
258 Seretide Diskus 50/250 mcg Diskus
Serum Anti Bisa Ular
259 vial
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml
263 Setirizin tablet 10 mg tablet
Sianokobalamin ( Vitamin B12
264 ampul
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet
tablet 50 mcg
266 Silver Sulfadiazin Cream tube
267 Simetidin tablet 200 mg tablet
268 Simvastatin tablet 10 mg tablet 80 80 50 30
269 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
270 kapsul
( sebagai HCl )
271 Solafluz sirup Botol
272 Solvita Z Kapsul
Spasi Plus tablet / Scopma
273 tablet
Plus
274 Spasminal tablet tablet
275 Stimuno Forte Kapsul kapsul
276 Stimuno Sirup Berri 100 ml botol
Sucralfate suspensi 500 mg /
277 botol
5 ml
Sulfasetamida Natrium tetes
278 botol
mata 15 %
279 Tensigard kapsul kapsul
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul
283 Thiamfenikol kapsul 500 mg kapsul
Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul
100 mg/ml-1ml
Tiamin HCl / Mononitrat 110
286 tabletl
(Vitamin B1) tablet 50 mg 110 110 -
287 Ventolin Nebules 2,5 mg ampul
288 Vitamin B Kompleks tablet tablet
289 Xylocaine 10 % Spray botol
290 Xylocaine 2 % Jelly syringe

OBAT PROGRAM
PROGRAM JIWA :
1 Clobazam 10 Mg tab tablet
2 Clozapin 25 mg tablet tablet
Fenitoin Natrium kapsul 100
3 kapsul
mg
Fenitoin Natrium kapsul 30
4 kapsul
mg
5 Fluoxetine (Napres) tablet
Haloperidol 5 mg / ml
6 ampul
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet
9 Haloperidol tablet 1,5 mg tablet
10 Haloperidol tablet 5 mg tablet
11 Karbamazepin tablet 200 mg tablet
Klorpromazin HCl tablet salut
12 tablet
100 mg
Klorpromazin HCl tablet salut
13 tablet
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul
15 Risperidon tablet 1 mg tablet
16 Risperidon tablet 2 mg tablet
17 Sikzonoat Inj / Flupenaziin Inj ampul
18 Trifluoperasin tablet 5 mg tablet
Triheksifenidil Hidroklorida
19 tablet
tablet 2 mg
PROGRAM GIZI :
1 Asam Folat tablet 0,4 mg tablet
2 Asam Folat tablet 1 mg tablet
3 Besi Sirup botol
4 Iodiol kapsul lunak kapsul
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase
Retinol ( Vitamin A ) kapsul
7 kapsul
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul
200.000 IU kapsul lunak
9 Taburia sachet
10 Lytacur sirup 60 ml botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml
Kid Sirup )
PROGRAM KECACINGAN :
Albendazol suspensi 200 mg /
1 botol
5 ml
2 Albendazol tablet 400 mg tablet
Dietilkarbamazin Sitrat tablet
3 tablet
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml
ml
Pirantel tablet score ( base )
5 tablet
125 mg
PROGRAM KIA :
1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr
2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml
Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml
Kalsium Glukonat injeksi i.v
5 ampul
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml
ml
Procain Benzil Penisilin
11 vial
3.000.000 I.U
PROGRAM KUSTA :
1 MB Anak blister
2 MB Dewasa blister
3 PB Anak blister
4 PB Dewasa blister
5 Paket MB Anak Paket
6 Paket MB Dewasa Paket
7 Rifampisin 450 mg Kapsul
8 Rifampisin 600 mg Kapsul
PROGRAM TBC :
1 Bedaquiline 100 mg tablet
2 Clofazimine 100 mg tablet
3 Cycloserine 125 mg tablet
4 Cycloserine 250 mg tablet
5 Delamanid 50 mg tablet
6 Etionamid 250 mg tablet
7 Etambutol tablet 400 mg Tablet
8 Isoniazide tablet 100 mg tablet
9 Isoniazide tablet 300 mg tablet
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet
11 Levofloksasin 250 mg tablet
12 Levofloksasin 500 mg tablet
13 Linezolid 600 mg tablet
14 Moxifloxacin 400 mg tablet
OAT - FDC Kategori 1
15 paket
dewasa
OAT - FDC Kategori anak
16 paket
PAKET
OAT KDT kategori 1 Dosis
17 paket
Harian
OAT-Kombipak Kategori 1
18 paket
anak
OAT-Kombipak Kategori 1
19 paket
dewasa
20 Pirazinamid tablet 500 mg paket
21 Pretomanid 200mg tablet
22 Rifampisin kapsul 300 mg tablet
23 Rifapentin 150 mg kapsul
Rifapentin 300 mg + Isoniazid
24 Tablet
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet
tablet 50 mg
PROGRAM FLU BURUNG
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet
PROGRAM DIARE :
1 Garam Oralit untuk 200 ml air sase
2 Zink tablet disperible 20 mg tablet
PROGRAM DIPHTERI :
1 Serum ADS 20.000 vial
PROGRAM MALARIA :
1 Artesunate 60 mg Injeksi box
2 Chlorokuin tablet 150mg tablet
Dehidro Artemisin 40 mg +
3 tablet
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet
mg
5 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25%
6 ampul
( sebagai 2 HCl )
7 Primaquin 15 mg tablet
PROGRAM HIV :
1 Abacavir (ABC) 300 mg tablet
2 Amphotericin B vial
Azithromicyn 500 mg +
3 paket
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet
6 Efavirenz (EFV) 200 mg tablet
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet
8 Fluconazole tablet tablet
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet
tablet
10 Lamivudine (3TC) 150 mg tablet
11 Levotiroksin tab 100 µg tablet
Lopinavir 200 mg + Ritonavir
12 tablet
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial
Injeksi
14 Nevirapine (NVP) 200 mg tablet
15 Pyrimetamine tablet tablet
16 Ramdesivir inj 100 mg vial

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet

Tenofovir 300 mg (TDF) +
19 tablet
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet
Zidofudine (ZDV) 300 mg +
22 tablet
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet
Nevirapine 50 mg (Triple
FDC) Anak

BAHAN GIGI :
1 1470IK Z250XT Syr Intro Kit kotak
2 Air raksa dental use botol
3 Cavit - G botol
4 Caviton White kotak
5 Composit resin ( solare ) Kit
6 Cresotin Liquid II Technodent kotak
7 Cressophate botol
8 Cressophen botol
Devitalisasi Pasta ( Non
9 botol
Arsen )
10 Endoseal Kotak
Etil Klorida semprot ( Duta
11 botol
Kaisar )
12 Eugenol cairan botol
Glass Ionomer Cement ( GC
13 botol
IX )
14 Jarum Sitoject biji
Kalsium Hidroksida Pasta
15 botol
( hydcal )
Monoklorkamfer Mentol
16 botol
Cairan ( CHKM )
17 Mummifying Pasta botol
18 Pehacain Inj ampul @ 2 ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr
75 %
Spons Gelatin Cubicles 1 x 1
21 biji
x 1 cm
Temporary Stopping Fletcher
22 set
( Fletcher )
Trikresol Formalin (TKF)
23 botol
cairan
24 Tumpatan komposit kit set

BAHAN MEDIS HABIS

PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket
Alat suntik sekali pakai 1 ml
2 set
tuberculin
3 Alat suntik sekali pakai 10 ml set
4 Alat suntik sekali pakai 3 ml set
5 Alat suntik sekali pakai 5 ml set
6 Alkohol Peroxide Botol
7 Alkohol Swab pcs
8 Aseptik Gel Galon 5 Liter Galon
Aseptik Gel 500 cc +
9 botol
dispenser
10 Aseptic Gel 100 ml botol
11 Askina Calgitrol 15 gram tube
12 Askina Gel 15 gram tube
13 Bioplacenton Tulle lembar
14 Blood Lancet biji
15 Blood transfision set set
Catgut / Benang Bedah No.
16 biji
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji

18 Catgut Chromic 3-0 (TRITON) biji

19 Catgut Plain 2-0 (TRITON) biji
20 Catgut Plain 3-0 (TRITON) biji
21 Duk Lubang 25 cm x 30 cm biji
22 Duk Lubang 50 cm x 50 cm biji
Etakridin ( Rivanol ) larutan
23 botol
0,1%
24 Etanol 70 % 100 ml botol
25 Etanol 70% 1000 ml botol
Folleycatheter Silicon 2 way
26 biji
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol
Rub
Hans Coen Nitril Non steril /
28 biji
Sarung Tangan
Hans Coen Non steril /
29 biji
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang
Hans Coen steril / Sarung
31 pasang
Tangan
32 Hi - Oxygen Mask Dewasa Set
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol
5 cm x 5 m)
34 Infusion set anak set
35 Infusion set dewasa set
36 IV Dressing 6 x 7 S lembar
37 IV. Chateter No. 14 s/d 24 set
38 IV. Chateter No. 26 set
Jarum Jahit ( Bedah ) No. 9
39 biji
s/d 14
40 Jarum Suntik 22G s/d 25 G biji
41 Jarum Suntik 26G biji
Kapas Pembalut / Absorben 2
42 rol
250 gram 2 0 2

43 Kasa Kompres 40 / 40 steril rol 0

- 0 -

44 Kasa Pembalut 2 m x 80 cm rol 5

5 0 5
Kasa Pembalut Hidrofil 4 m x 1
45 rol
15 cm 1 1 -
Kasa Pembalut Hidrofil 4 m x 1
46 rol
3 cm 1 1 -
Kasa Steril 16 Cm X 16 Cm 20
47 Pads
(16 Pads) 20 20 -
Lisol, mengandung Kresol
48 botol
tersabun 50%
49 Lomatulle / Dermafix lembar
50 Masker Earloop/ Tie On biji
51 Masker KF94 biji
52 Masker KN 95 biji
53 Masker N 95 biji
54 Masker Nebulizer Set Anak Piece
55 Masker Nebulizer Set Dewasa Piece
Masker Oxygen Anak -
56 Piece
Oxyflow
Masker Oxygen Anak NR
57 biji
Mask
Masker Oxygen Dewasa -
58 Piece
Oxyflow
Masker Oxygen Dewasa NR
59 biji
Mask
60 Plester 1,25 cm x 4,5 m rol
Plesterin - plester bulat non box @ 200
61
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml
30 ml
Povidon Iodida Larutan 10% botol @ 300
63
300 ml ml
64 Prontosan Gel 30 gram botol
65 Prontosan Gel 50 gram botol
66 Prontosan Sol 350 ml botol
67 Safety Box 5 Liter Pcs
68 Scalp Vein no. 25 biji
Silk ( Benang Bedah Sutera ) 1
69 rol
No. 3 / 0 1 0 1
Solotio Perhydrol ( H2O2 ) 3 1
70 botol
% 1 0 1
71 Stabimed 1 L biji
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji

Umbilical cord klem nylon
73 biji
steril (Claim Umbilical)
74 Underpad biji
Urine Bag standard steril 2 Lt
75 biji
( T valve )
botol @ 250
76 USG Gel
ml

BAHAN MEDIS HABIS

PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes
2 Kondom biji
3 Kondom Sutra biji
4 Kondom Andalan Pcs
5 Lubricant biji
Masker Bedah TB KALTECH /
6 Piece
SUPERCARE
7 Masker Bedah TB Onemed Piece
8 Masker Bedah GF HIV AIDS Piece
9 Masker N95 WEGEN Piece
10 Paket BHP HIV Paket
11 Pot Dahak Steril Pot
12 Slide (Object Glass) Kotak
13 Tuberkulin vial
14 Wing Needle BHP Paket

REAGEN :
1 Cartridge Genexpert Test
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test
Load)
Deteksi HIV & Syphilis
3
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test
Line
6 HBV Viral Load Test
Indec HIV dan Sypilis Combo
7
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit
Test
10 Rapid 1 RDT HIV Virocheck Test
11 Rapid Test Anti HCV Test
12 Rapid Test HBeAg Test
13 Rapid Test Syphilis Test
Paket Malaria / Paket
14
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear
test
RDT DBD Dengue Combo
16 Test
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test
18 RDT Frambusia Test
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test
(colloidal gold) Test
20 RDT Leptopirosis Test
21 RDT Malaria Test
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit
23 Kit
24 100 C) 2 KHB
Reagen Test
Reagen 3 (Biomerieux / Vikia
25 Kit
HIV 1/2)
26 Reagen 3 Diagnostar Kit
27 Reagen CD 4 Control Kit
28 Reagen CD 4 Mobile Kit
29 Reagen HIV Right Sign kit
Reagen I (Intec One Step Anti
30 Test
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test
reagen pengukur Glukosa
33 kotak
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test
0/012)
38 TrepoCheck Syphilis Test
39 VTM COVID 19 Piece

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : MEI 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : JUNI 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN :
1 Alopurinol tablet 100 mg tablet 100

2 Alopurinol tablet 300 mg tablet 200 200 130 70 100

3 Alpara Tablet
4 Alprazolam 0,5 mg tablet tablet
5 Ambroxol sirup 15 mg / ml botol @ 60 ml
6 Ambroxol tablet 30 mg tablet
Aminofilin tablet scored 150
7 tablet
mg
Aminofilin tablet scored 200
8 tablet
mg
9 Aminofilina injeksi 24 mg / ml ampul
Amitriptilin tablet salut 25 mg (
10 tablet
HCl )
11 Amlodipine tablet 10 mg tablet - 300 300 300 - 500
12 Amlodipine tablet 5 mg tablet
Amoksisilin Sirup Kering 125
13 botol @ 60 ml
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet 50 300 350 300 50 500
16 Amoksisilin kapsul 250 mg tablet
Amoksisilin Serbuk injeksi
17 vial
1000 mg
Ampisilina sirup kering 125
18 botol
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet 200
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet 30 300 330 150 180 200
; Magnesium Hidroksida 200
mg
 Antasida DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr

26 Antihemoroid DOEN supp
27 Antimigren DOEN tablet tablet
28 Antiparkinson DOEN tablet tablet
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml
pirogen
botol @ 1000
30 Aquadest steril
ml
Asam Asetilsalisilat (Asetosal)
31 tablet
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet 200
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - 300 200 100 200
mg 300
Asam traneksamat injeksi 100
38 ampul
mg/ml
Asam traneksamat injeksi 50
39 ampul
mg/ml
Asam traneksamat tablet 500
40 tablet
mg
41 Asiklovir krim 5 % tube @ 5 gr
42 Asiklovir tablet 400 mg tablet 180 180 0 180
43 Atapulgit tablet 600 mg tablet
44 Atorvastatin 20 mg tablet tablet 50 50 0 50 100
Atropin Sulfat injeksi 0,25 mg
45 ampul
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet
Atropin Sulfat tetes mata
47 botol
0,5%
48 Azitromisiin tablet 250 mg tablet
49 Azitromisin tablet 500 mg tablet
50 Azithromicyn 500 mg inj vial
Batugin Elixir Sirup
51 botol
( Fitofarmaka )
52 Becefort tablet
53 Becom - C tablet tablet
54 Bedak salisil serbuk 2 % kotak
Betadin Gargle 190 ml /
55 botol
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet 40 40 0 40

Betametason krim 0.1%

57 tube 5 gr
( sebagai valerat )
58 Betason - N krim tube
59 Bisacodil ( Bicolak ) tablet tablet
Bisacodil suppositoria 10 mg (
60 supp
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet 110 110 0 110
62 Bisoprolol tablet 5 mg tablet
63 Boost D tablet ( Vitamin D3 ) tablet
64 Borak Gliserin 5% botol @ 15 ml
Bromhexin tablet ( Bronex
65 tablet
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml
67 Candesartan 16 mg Tablet Tablet
68 Candesartan 8 mg Tablet tablet
69 Cendo Lyters botol
minidose
70 Cendo Lyteers
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet
73 Curcuma tablet tablet
Deksametason injeksi 5 mg /
74 ampul @ 1 ml
ml
75 Deksametason tablet 0,5 mg tablet 90 90 90 - 200

Denomix Cream -
76 Desoksimetason 0,25 %, Tube
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr

78 Dextrofen Syrup botol @ 60 ml
Diazepam injeksi 5 mg / ml - 2
79 ampul
ml
Diazepam rectal tube
80 tube @ 2,5 ml
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet
82 Diazepam tablet 5 mg tablet
Difenhidramin HCl injeksi 10
83 ampul
mg / ml
84 Digoksin tablet 0,25 mg tablet
85 Dimenhidrinat tablet 50 mg tablet 30 30 0 30
86 Doksisiklin tablet 100 mg kapsul
87 Domperidone sirup 5 mg/5ml botol @ 60 ml
88 Domperidone tablet 10 mg tablet 20 20 10 10 100
89 Elkana Sirup botol
Epinefrina HCl ( Adrenalin )
90 ampul
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml
ml
92 Eritromisin kapsul 250 mg kapsul 20 20 0 20 200
93 Eritromisin kapsul 500 mg kapsul
Etynil estradiol (Lynoral tablet
94 tablet
0,05 mg)
95 Fenobarbital tablet 30 mg tablet
96 Fenofibrat kapsul 100 mg kapsul
97 Fenofibrat kapsul 300 mg kapsul
Fenol Gliserol tetes telinga
98 botol
10%
Fitbon tablet (Glucosamin)/
99 tablet
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml
103 Fludane Tablet tablet
Fluocinolone Acetonide tube @ 5
104
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet
botol @ 500
106 Gelofusin Infus
ml
107 Gemfibrosil kapsul 300 mg kapsul
108 Gemfibrosil kapsul 600 mg kapsul
109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr
Gentamisin Salep Mata 0,3 %
110 tube
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol
112 Gentian Violet larutan 1 % botol @10 ml
113 Glibenklamid tablet 5 mg tablet 70 300 370 90 280
114 Glimepiride tablet 2 mg tablet 300
115 Glimepiride tablet 4 mg tablet
Gliseril Guaiakolat tablet 100
116 tablet
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet
botol @ 500
118 Glukosa 5% - 1/2 NS
ml
 botol @ 500
119 Glukosa 5% - 1/4 NS
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml
steril
Glukosa larutan infus 40 % botol @ 500
122
steril ml
123 Griseofulvin tablet 125 mg tablet
124 Griseofulvin tablet 500 mg tablet
125 Hemorogard kapsul kapsul
126 Herba Cold tablet tablet
Hidroklorotiazid ( HCT ) tablet
127 tablet
25 mg
128 Hidrokortison krim 2,5 % tube
Hiosin Butil Bromid injeksi 20
129 ampul
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet
tablet
Hyaloph tetes mata ( Natrium
131 Botol
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml 3 13 4 9
10

133 Ibuprofen Sirup 200 mg / 5 ml Botol

134 Ibuprofen tablet 200 mg tablet
135 Ibuprofen tablet 400 mg tablet 100 100 70 30 200
136 Ichtiyol Zalf pot @ 15 gr
Ipratropium bromida
137 ampul
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus
ml
Kalium Diklofenak tablet 50
140 tablet
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet 200
500 mg
142 Kaptopril tablet scored 25 mg tablet
Kaptopril tablet scored 12,5
143 tablet 300 110 190 200
mg 300
144 Ketokonazol krim 2 % tube 10 gr
145 Ketokonazol tablet 200 mg tablet
Ketoprofen supositoria 100
146 supp
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml

149 Kidmin SoftBag Fls
150 Klindamisin kapsul 150 mg kapsul
151 Klindamisin kapsul 300 mg kapsul
Kloramfenikol injeksi 1000 mg
152 Vial
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul

154 Kloramfenikol kapsul 500 mg kapsul

Kloramfenikol suspensi 125
155 botol @ 60 ml
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube
Kloramfenikol Tetes Mata 0.5
158 botol
%

minidose
159 Kloramfenikol 0,5% (cendo fen
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol
%
Klorfeniramin Maleat ( CTM )
161 tablet 300 70 230
tablet 4 mg 300
162 Kodein HCl tablet 10 mg tablet
Kotrimoksazol 400 mg +
163 tablet 200
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml
165 Lactodia / Lacto B sachet
166 Lansoprazol tablet 30 mg tablet
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) /
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet
ml
170 Levofloksasin Tablet 750 mg tablet
Levofloxacin Tablet Salut
171 tablet
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml 2 2 0 2
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul
176 Loperamida tablet 2 mg tablet 200
177 Loratadin tablet 10 mg tablet
178 Matovit tablet
179 Meloksikam tablet 15 mg tablet
180 Metformin HCl tablet 500 mg tablet 300

Methyl Prednisolon 4 mg
181 tablet
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml
mg / ml
183 Metoklopropamid tablet 10 mg tablet
184 Metronidazol ovula ovula
185 Metronidazol tablet 250 mg tablet
186 Metronidazol tablet 500 mg tablet 100

187 Miconazol krim 2 % ( Nitrat ) tube

188 Molexflu tablet tablet
N-Acetyl systeine tablet 200
189 tablet
mg
Natrium Diklofenak tablet 50
190 tablet - 200 60 140 100
mg 200
Natrium Klorida larutan infus
191 Botol
0,9% 100 cc
Natrium Klorida larutan infus
192 vial
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml
195 Neuralgin - RX tablet tablet
Neurosanbe 5000 mg tablet /
196 tablet
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet
E
199 Nifedipin tablet 10 mg tablet 50 50 50 - 300
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet
OROS)
Nistatin tablet salut 500.000
202 tablet
IU / g
Nistatin vaginal tablet 100.000
203 tablet
IU / g
204 Nistatin suspensi 100.000 IU tablet
205 No Pain Spray botol
 Noretisteron tablet 5 mg
206 tablet
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209
100 ml ml
210 Obat Batuk Herbakof tablet tablet
211 Ofloxaxin tablet 200 mg tablet 200
Oksimetazolin tetes hidung
212 botol @ 10 ml
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr
Oksitetrasiklin HCl salep mata
214 tube @ 3,5 gr
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml
ml
217 Omeprazole tablet 20 mg tablet 200

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml

219 Ondansetron tablet 4 mg tablet
220 Ondansetron tablet 8 mg tablet
221 Oxyvit C + Kaplet tablet
222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml
223 Papaverin Tablet 40 mg tablet
Parasetamol drop 100 mg/ml (
224 botol @ 15 ml
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol
ml
226 Parasetamol tablet 100 mg tablet
227 Parasetamol tablet 500 mg tablet 150 300 450 100 350
Pamol supp (paracetamol
228 supp
supp 125 mg)
229 Pehavral tablet tablet
230 Piracetam tablet 1200 mg tablet
231 Piracetam tablet 800 mg tablet
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet 100
tablet 10 mg
235 Piroxicam tablet 10 mg tablet
236 Piroxicam tablet 20 mg tablet
237 Prednison tablet 5 mg tablet 200

238 Propiltiourasil tablet 100 mg tablet

239 Propranolol HCl tablet 40 mg tablet
240 Proris suppositoria supp
241 Psidii Kapsul 500 mg kapsul
242 Psidii sirup 60 ml botol @ 60 ml
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml
244 Ranitidin tablet 150 mg tablet - 200 200 50 150 100
245 Reserpin tablet 0,25 mg tablet
246 Salbutamol Inhaler (Salbulin) kapsul
Salbutamol tablet 2 mg
247 tablet 80 80 40 40 100
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr 3 3 2 1
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube
%
250 Sefadroksil kapsul 250 mg kapsul
251 Sefadroksil kapsul 500 mg kapsul 200
Sefadroksil Sirup Kering 125
252 botol @ 60 ml
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul
254 Sefiksim kapsul 200 mg kapsul
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr
/ vial
258 Seretide Diskus 50/250 mcg Diskus
Serum Anti Bisa Ular
259 vial
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml
263 Setirizin tablet 10 mg tablet 200 200 80 120 100
Sianokobalamin ( Vitamin B12
264 ampul
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet 200
tablet 50 mcg
266 Silver Sulfadiazin Cream tube
267 Simetidin tablet 200 mg tablet
268 Simvastatin tablet 10 mg tablet 30 200 230 40 190
269 Simvastatin tablet 20 mg tablet
Siprofloksasin kapsul 500 mg
270 kapsul 200
( sebagai HCl )
271 Solafluz sirup Botol
272 Solvita Z Kapsul
 Spasi Plus tablet / Scopma
273 tablet
Plus
274 Spasminal tablet tablet
275 Stimuno Forte Kapsul kapsul
276 Stimuno Sirup Berri 100 ml botol
Sucralfate suspensi 500 mg /
277 botol
5 ml
Sulfasetamida Natrium tetes
278 botol 5
mata 15 %
279 Tensigard kapsul kapsul
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit
UI
Tetrakain HCl tetes mata
281 botol
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul
283 Thiamfenikol kapsul 500 mg kapsul 200
Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl 200
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul
288 Vitamin B Kompleks tablet tablet 200
289 Xylocaine 10 % Spray botol
290 Xylocaine 2 % Jelly syringe

OBAT PROGRAM
PROGRAM JIWA :
1 Clobazam 10 Mg tab tablet
2 Clozapin 25 mg tablet tablet
Fenitoin Natrium kapsul 100
3 kapsul
mg
Fenitoin Natrium kapsul 30
4 kapsul
mg
5 Fluoxetine (Napres) tablet
Haloperidol 5 mg / ml
6 ampul
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet
9 Haloperidol tablet 1,5 mg tablet
10 Haloperidol tablet 5 mg tablet
11 Karbamazepin tablet 200 mg tablet
Klorpromazin HCl tablet salut
12 tablet
100 mg
Klorpromazin HCl tablet salut
13 tablet
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul
15 Risperidon tablet 1 mg tablet
16 Risperidon tablet 2 mg tablet
17 Sikzonoat Inj / Flupenaziin Inj ampul
18 Trifluoperasin tablet 5 mg tablet
Triheksifenidil Hidroklorida
19 tablet
tablet 2 mg
PROGRAM GIZI :
1 Asam Folat tablet 0,4 mg tablet
2 Asam Folat tablet 1 mg tablet
3 Besi Sirup botol
4 Iodiol kapsul lunak kapsul
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase
Retinol ( Vitamin A ) kapsul
7 kapsul
100.000 IU
Retinol ( Vitamin A ) kapsul
8 kapsul
200.000 IU kapsul lunak
9 Taburia sachet
10 Lytacur sirup 60 ml botol @ 60 ml
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml
Kid Sirup )
PROGRAM KECACINGAN :
Albendazol suspensi 200 mg /
1 botol
5 ml
2 Albendazol tablet 400 mg tablet
Dietilkarbamazin Sitrat tablet
3 tablet
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml
ml
Pirantel tablet score ( base )
5 tablet
125 mg
PROGRAM KIA :
1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr
2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml
Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml
Kalsium Glukonat injeksi i.v
5 ampul
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml
20 % - 25 ml
 Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml
ml
Procain Benzil Penisilin
11 vial
3.000.000 I.U
PROGRAM KUSTA :
1 MB Anak blister
2 MB Dewasa blister
3 PB Anak blister
4 PB Dewasa blister
5 Paket MB Anak Paket
6 Paket MB Dewasa Paket
7 Rifampisin 450 mg Kapsul
8 Rifampisin 600 mg Kapsul
PROGRAM TBC :
1 Bedaquiline 100 mg tablet
2 Clofazimine 100 mg tablet
3 Cycloserine 125 mg tablet
4 Cycloserine 250 mg tablet
5 Delamanid 50 mg tablet
6 Etionamid 250 mg tablet
7 Etambutol tablet 400 mg Tablet
8 Isoniazide tablet 100 mg tablet
9 Isoniazide tablet 300 mg tablet
10 Levofloksasin 100 mg tablet
11 Levofloksasin 250 mg tablet
12 Levofloksasin 500 mg tablet
13 Linezolid 600 mg tablet
14 Moxifloxacin 400 mg tablet
OAT - FDC Kategori 1
15 paket
dewasa
OAT - FDC Kategori anak
16 paket
PAKET
OAT KDT kategori 1 Dosis
17 paket
Harian
OAT-Kombipak Kategori 1
18 paket
anak
OAT-Kombipak Kategori 1
19 paket
dewasa
20 Pirazinamid tablet 500 mg paket
21 Pretomanid 200mg tablet
22 Rifampisin kapsul 300 mg tablet
23 Rifapentin 150 mg kapsul
Rifapentin 300 mg + Isoniazid
24 Tablet
300 mg
 Rifampisin 75 mg + Isoniazid
25 tablet
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet
tablet 50 mg
PROGRAM FLU BURUNG
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet
PROGRAM DIARE :
1 Garam Oralit untuk 200 ml air sase
2 Zink tablet disperible 20 mg tablet
PROGRAM DIPHTERI :
1 Serum ADS 20.000 vial
PROGRAM MALARIA :
1 Artesunate 60 mg Injeksi box
2 Chlorokuin tablet 150mg tablet
Dehidro Artemisin 40 mg +
3 tablet
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet
mg
5 Kuinin ( Kina ) tablet 200 mg tablet
Kuinin injeksi i.v 25%
6 ampul
( sebagai 2 HCl )
7 Primaquin 15 mg tablet
PROGRAM HIV :
1 Abacavir (ABC) 300 mg tablet
2 Amphotericin B vial
Azithromicyn 500 mg +
3 paket
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet
6 Efavirenz (EFV) 200 mg tablet
7 Efavirenz (EFV) 600 mg tablet
8 Fluconazole tablet tablet
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet
tablet
10 Lamivudine (3TC) 150 mg tablet
11 Levotiroksin tab 100 µg tablet
Lopinavir 200 mg + Ritonavir
12 tablet
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial
Injeksi
14 Nevirapine (NVP) 200 mg tablet
15 Pyrimetamine tablet tablet
16 Ramdesivir inj 100 mg vial

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet

Tenofovir 300 mg (TDF) +
19 tablet
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet
Zidofudine (ZDV) 300 mg +
22 tablet
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet
Nevirapine 50 mg (Triple
FDC) Anak

BAHAN GIGI :
1 1470IK Z250XT Syr Intro Kit kotak
2 Air raksa dental use botol
3 Cavit - G botol
4 Caviton White kotak
5 Composit resin ( solare ) Kit
6 Cresotin Liquid II Technodent kotak
7 Cressophate botol
8 Cressophen botol
Devitalisasi Pasta ( Non
9 botol
Arsen )
10 Endoseal Kotak
Etil Klorida semprot ( Duta
11 botol
Kaisar )
12 Eugenol cairan botol
Glass Ionomer Cement ( GC
13 botol
IX )
14 Jarum Sitoject biji
Kalsium Hidroksida Pasta
15 botol
( hydcal )
Monoklorkamfer Mentol
16 botol
Cairan ( CHKM )
17 Mummifying Pasta botol
18 Pehacain Inj ampul @ 2 ml
Semen Seng Fosfat serbuk
19 botol
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr
75 %
 Spons Gelatin Cubicles 1 x 1
21 biji
x 1 cm
Temporary Stopping Fletcher
22 set
( Fletcher )
Trikresol Formalin (TKF)
23 botol
cairan
24 Tumpatan komposit kit set

BAHAN MEDIS HABIS

PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket
Alat suntik sekali pakai 1 ml
2 set
tuberculin
3 Alat suntik sekali pakai 10 ml set
4 Alat suntik sekali pakai 3 ml set
5 Alat suntik sekali pakai 5 ml set
6 Alkohol Peroxide Botol
7 Alkohol Swab pcs
8 Aseptik Gel Galon 5 Liter Galon
Aseptik Gel 500 cc +
9 botol
dispenser
10 Aseptic Gel 100 ml botol
11 Askina Calgitrol 15 gram tube
12 Askina Gel 15 gram tube
13 Bioplacenton Tulle lembar
14 Blood Lancet biji
15 Blood transfision set set
Catgut / Benang Bedah No.
16 biji
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji

18 Catgut Chromic 3-0 (TRITON) biji

19 Catgut Plain 2-0 (TRITON) biji
20 Catgut Plain 3-0 (TRITON) biji
21 Duk Lubang 25 cm x 30 cm biji
22 Duk Lubang 50 cm x 50 cm biji
Etakridin ( Rivanol ) larutan
23 botol
0,1%
24 Etanol 70 % 100 ml botol
25 Etanol 70% 1000 ml botol
Folleycatheter Silicon 2 way
26 biji
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol
Rub
Hans Coen Nitril Non steril /
28 biji
Sarung Tangan
Hans Coen Non steril /
29 biji
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang
Hans Coen steril / Sarung
31 pasang
Tangan
32 Hi - Oxygen Mask Dewasa Set
Hypafix 5 x 5 (Fixomull stretch
33 rol
5 cm x 5 m)
34 Infusion set anak set
35 Infusion set dewasa set
36 IV Dressing 6 x 7 S lembar
37 IV. Chateter No. 14 s/d 24 set
38 IV. Chateter No. 26 set
Jarum Jahit ( Bedah ) No. 9
39 biji
s/d 14
40 Jarum Suntik 22G s/d 25 G biji
41 Jarum Suntik 26G biji
Kapas Pembalut / Absorben
42 rol 2 2 0 2
250 gram
43 Kasa Kompres 40 / 40 steril rol

44 Kasa Pembalut 2 m x 80 cm rol 5 5 0 5

Kasa Pembalut Hidrofil 4 m x

45 rol
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads
(16 Pads)
Lisol, mengandung Kresol
48 botol
tersabun 50%
49 Lomatulle / Dermafix lembar
50 Masker Earloop/ Tie On biji
51 Masker KF94 biji
52 Masker KN 95 biji
53 Masker N 95 biji
54 Masker Nebulizer Set Anak Piece
55 Masker Nebulizer Set Dewasa Piece
Masker Oxygen Anak -
56 Piece
Oxyflow
Masker Oxygen Anak NR
57 biji
Mask
Masker Oxygen Dewasa -
58 Piece
Oxyflow
Masker Oxygen Dewasa NR
59 biji
Mask
60 Plester 1,25 cm x 4,5 m rol
Plesterin - plester bulat non box @ 200
61
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml
30 ml
 Povidon Iodida Larutan 10% botol @ 300
63
300 ml ml
64 Prontosan Gel 30 gram botol
65 Prontosan Gel 50 gram botol
66 Prontosan Sol 350 ml botol
67 Safety Box 5 Liter Pcs
68 Scalp Vein no. 25 biji
Silk ( Benang Bedah Sutera )
69 rol 1 1 0 1
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol 1 1 0 1
%
71 Stabimed 1 L biji
72 Surgical Blade / Mess No. 11 biji
Umbilical cord klem nylon
73 biji
steril (Claim Umbilical)
74 Underpad biji
Urine Bag standard steril 2 Lt
75 biji
( T valve )
botol @ 250
76 USG Gel
ml

BAHAN MEDIS HABIS

PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes
2 Kondom biji
3 Kondom Sutra biji
4 Kondom Andalan Pcs
5 Lubricant biji
Masker Bedah TB KALTECH /
6 Piece
SUPERCARE
7 Masker Bedah TB Onemed Piece
8 Masker Bedah GF HIV AIDS Piece
9 Masker N95 WEGEN Piece
10 Paket BHP HIV Paket
11 Pot Dahak Steril Pot
12 Slide (Object Glass) Kotak
13 Tuberkulin vial
14 Wing Needle BHP Paket

REAGEN :
1 Cartridge Genexpert Test
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test
Load)
Deteksi HIV & Syphilis
3
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4
(CATIN) Test
 Fast Clear Q HIV 1/2 Ab 3 -
5 Test
Line
6 HBV Viral Load Test
Indec HIV dan Sypilis Combo
7
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit
Test
10 Rapid 1 RDT HIV Virocheck Test
11 Rapid Test Anti HCV Test
12 Rapid Test HBeAg Test
13 Rapid Test Syphilis Test
Paket Malaria / Paket
14
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear
test
RDT DBD Dengue Combo
16 Test
Verotec
17 RDT Chikunguya Test
18 RDT Frambusia Test
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test
(colloidal gold) Test
20 RDT Leptopirosis Test
21 RDT Malaria Test
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit
23 Kit
24 100 C) 2 KHB
Reagen Test
Reagen 3 (Biomerieux / Vikia
25 Kit
HIV 1/2)
26 Reagen 3 Diagnostar Kit
27 Reagen CD 4 Control Kit
28 Reagen CD 4 Mobile Kit
29 Reagen HIV Right Sign kit
Reagen I (Intec One Step Anti
30 Test
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test
reagen pengukur Glukosa
33 kotak
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test
0/012)
38 TrepoCheck Syphilis Test
39 VTM COVID 19 Piece
TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA PUSKESMAS SLEMPIT

dr. YUFIDAH
NIP. 19750607 200701 2 007
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : JUNI 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : JULI 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : JULI 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : AGUSTUS 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : AGUSTUS 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : SEPTEMBER 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : SEPTEMBER 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : OKTOBER 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : OKTOBER 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : NOVEMBER 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : NOVEMBER 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : DESEMBER 2025

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT
 LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT APBD
PUSTU / PONKESDES PUSKESMAS SLEMPIT

POSTU/PONKESDES : PUSTU CERMEN

KECAMATAN : KEDAMEAN
KABUPATEN : GRESIK PELAPORAN BULAN / PERIODE : DESEMBER 2025
PROVINSI : JAWA TIMUR PERMINTAAN BULAN / PERIODE : JANUARI 2026

SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI

NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
1 2 3 4 5 6 7 8 9 10
OBAT-OBATAN : - -
1 Alopurinol tablet 100 mg tablet - -

2 Alopurinol tablet 300 mg tablet - -

3 Alpara Tablet - -
4 Alprazolam 0,5 mg tablet tablet - -
5 Ambroxol sirup 15 mg / ml botol @ 60 ml - -
6 Ambroxol tablet 30 mg tablet - -
Aminofilin tablet scored 150
7 tablet - -
mg
Aminofilin tablet scored 200
8 tablet - -
mg
9 Aminofilina injeksi 24 mg / ml ampul - -

Amitriptilin tablet salut 25 mg (

10 tablet - -
HCl )
11 Amlodipine tablet 10 mg tablet - -
12 Amlodipine tablet 5 mg tablet - -
Amoksisilin Sirup Kering 125
13 botol @ 60 ml - -
mg / 5 ml
Amoksisilin Sirup Kering 250
14 botol @ 60 ml - -
mg / 5 ml
15 Amoksisilin kaplet 500 mg tablet - -
16 Amoksisilin kapsul 250 mg tablet - -
Amoksisilin Serbuk injeksi
17 vial - -
1000 mg
Ampisilina sirup kering 125
18 botol - -
mg/5ml
Antalgin ( Metamisol )injeksi
19 500 mg / ml - 2 ml ( Novalgin / ampul @ 2 ml - -
Antrain / Santagesik )

Antalgin ( Metampiron ) tablet

20 tablet - -
500 mg
Antalgin injeksi 250 mg / ml -
21 Antasida DOEN I tablet ampul @ 2 ml - -
2 ml
kunyah, kombinasi :
22 Aluminium Hidroksida 200 mg tablet - -
; Magnesium Hidroksida 200
Antasida
mg DOEN II suspensi,
kombinasi : Aluminium
23 Hidroksida 200 mg/ml ; botol @ 60 ml - -
Magnesium Hidroksida 200
mg/ml

Anti Bakteri Salep Kombinasi :

24 BASITRASIN 500 IU/G + pot @ 30 gr - -
POLIMIKSIN 10.000 IU/G

25 Antifungi DOEN pot @ 30 gr - -

26 Antihemoroid DOEN supp - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
27 Antimigren DOEN tablet tablet - -
28 Antiparkinson DOEN tablet tablet - -
Aqua pro Injeksi steril, bebas
29 botol @ 25 ml - -
pirogen
botol @ 1000
30 Aquadest steril - -
ml
Asam Asetilsalisilat (Asetosal)
31 tablet - -
tablet 100 mg
Asam Asetilsalisilat (Asetosal)
32 tablet - -
tablet 500 mg
Asam Asetilsalisilat (Asetosal)
33 tablet - -
tablet 80 mg
Asam askorbat (Vitamin C )
34 tablet - -
tablet 500 mg
Asam Askorbat ( Vitamin C )
35 tablet - -
tablet 250 mg
Asam Askorbat ( Vitamin C )
36 tablet - -
tablet 50 mg
Asam Mefenamat kaplet 500
37 tablet - -
mg
Asam traneksamat injeksi 100
38 ampul - -
mg/ml
Asam traneksamat injeksi 50
39 ampul - -
mg/ml
Asam traneksamat tablet 500
40 tablet - -
mg
41 Asiklovir krim 5 % tube @ 5 gr - -
42 Asiklovir tablet 400 mg tablet - -
43 Atapulgit tablet 600 mg tablet - -
44 Atorvastatin 20 mg tablet tablet - -
Atropin Sulfat injeksi 0,25 mg
45 ampul - -
/ ml - 1 ml
46 Atropin Sulfat tablet 0,5 mg tablet - -
Atropin Sulfat tetes mata
47 botol - -
0,5%
48 Azitromisiin tablet 250 mg tablet - -
49 Azitromisin tablet 500 mg tablet - -
50 Azithromicyn 500 mg inj vial - -
Batugin Elixir Sirup
51 botol - -
( Fitofarmaka )
52 Becefort tablet - -
53 Becom - C tablet tablet - -
54 Bedak salisil serbuk 2 % kotak - -
Betadin Gargle 190 ml /
55 botol - -
Molexdin obat kumur
56 Betahistin Mesilat tablet 6 mg tablet - -

Betametason krim 0.1%

57 tube 5 gr - -
( sebagai valerat )
58 Betason - N krim tube - -
59 Bisacodil ( Bicolak ) tablet tablet - -

Bisacodil suppositoria 10 mg (
60 supp - -
Stolax / Dulcolax supp )
61 Bisoprolol tablet 2,5 mg tablet - -
62 Bisoprolol tablet 5 mg tablet - -

63 Boost D tablet ( Vitamin D3 ) tablet - -

64 Borak Gliserin 5% botol @ 15 ml - -

 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Bromhexin tablet ( Bronex
65 tablet - -
tablet ; Novaheksin tablet)
66 Bronchitin Expektoran Sirup botol @ 50 ml - -

67 Candesartan 16 mg Tablet Tablet - -

68 Candesartan 8 mg Tablet tablet - -
69 Cendo Lyters botol - -

minidose
70 Cendo Lyteers - -
(botol 0,6 ml)

Centabio Jelly / Bioplacenton

71 tube @ 20 gr - -
Jelly
72 Clopidogrel Bisulfate 75 mg Tablet - -
73 Curcuma tablet tablet - -
Deksametason injeksi 5 mg /
74 ampul @ 1 ml - -
ml
75 Deksametason tablet 0,5 mg tablet - -

Denomix Cream -
76 Desoksimetason 0,25 %, Tube - -
neomycin sulfate 0.5%

77 Desoksimetason krim 0,25 % tube @ 15 gr - -

78 Dextrofen Syrup botol @ 60 ml - -

Diazepam injeksi 5 mg / ml - 2
79 ampul - -
ml
Diazepam rectal tube
80 tube @ 2,5 ml - -
(Stesolid rectal Tube)
81 Diazepam tablet 2 mg tablet - -
82 Diazepam tablet 5 mg tablet - -
Difenhidramin HCl injeksi 10
83 ampul - -
mg / ml
84 Digoksin tablet 0,25 mg tablet - -
85 Dimenhidrinat tablet 50 mg tablet - -
86 Doksisiklin tablet 100 mg kapsul - -

87 Domperidone sirup 5 mg/5ml botol @ 60 ml - -

88 Domperidone tablet 10 mg tablet - -

89 Elkana Sirup botol - -
Epinefrina HCl ( Adrenalin )
90 ampul - -
injeksi 1 mg/ml
Erithromisin sirup 200 mg / 5
91 botol @ 60 ml - -
ml
92 Eritromisin kapsul 250 mg kapsul - -
93 Eritromisin kapsul 500 mg kapsul - -
Etynil estradiol (Lynoral tablet
94 tablet - -
0,05 mg)
95 Fenobarbital tablet 30 mg tablet - -
96 Fenofibrat kapsul 100 mg kapsul - -
97 Fenofibrat kapsul 300 mg kapsul - -
Fenol Gliserol tetes telinga
98 botol - -
10%
Fitbon tablet (Glucosamin)/
99 tablet - -
Osteotin
Fitomenadion ( Vitamin K1 )
100 ampul - -
injeksi 10 mg /ml
Fitomenadion ( Vitamin K1 )
101 tablet - -
tablet salut gula 10 mg
102 Fludane Plus Sirup botol @ 60 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
103 Fludane Tablet tablet - -
Fluocinolone Acetonide tube @ 5
104 - -
(Dermasolon) gram
105 Furosemid tablet 40 mg tablet - -
botol @ 500
106 Gelofusin Infus - -
ml
107 Gemfibrosil kapsul 300 mg kapsul - -
108 Gemfibrosil kapsul 600 mg kapsul - -

109 Gentamisin Salep Kulit 0,1 % tube @ 5 gr - -

Gentamisin Salep Mata 0,3 %

110 tube - -
(Genoint salep mata)
111 Gentamisin Tetes Mata 0,3 % botol - -

112 Gentian Violet larutan 1 % botol @10 ml - -

113 Glibenklamid tablet 5 mg tablet - -
114 Glimepiride tablet 2 mg tablet - -
115 Glimepiride tablet 4 mg tablet - -
Gliseril Guaiakolat tablet 100
116 tablet - -
mg
117 Gliseril Trinitrat Tablet 0,5 mg Tablet - -

botol @ 500
118 Glukosa 5% - 1/2 NS - -
ml
botol @ 500
119 Glukosa 5% - 1/4 NS - -
ml
Glukosa larutan infus 5 %
120 botol @ 25 ml - -
steril
Glukosa larutan infus 10 %
121 botol @ 25 ml - -
steril
Glukosa larutan infus 40 % botol @ 500
122 - -
steril ml
123 Griseofulvin tablet 125 mg tablet - -
124 Griseofulvin tablet 500 mg tablet - -
125 Hemorogard kapsul kapsul - -
126 Herba Cold tablet tablet - -
Hidroklorotiazid ( HCT ) tablet
127 tablet - -
25 mg
128 Hidrokortison krim 2,5 % tube - -
Hiosin Butil Bromid injeksi 20
129 ampul - -
mg/ml (Spasi injeksi)
Hiosin Butil Bromid 10 mg
130 tablet - -
tablet
Hyaloph tetes mata ( Natrium
131 Botol - -
Hyaloronat 0,1 % )
132 Ibuprofen Sirup 100 mg / 5 mg botol @ 60 ml - -

133 Ibuprofen Sirup 200 mg / 5 ml Botol - -

134 Ibuprofen tablet 200 mg tablet - -

135 Ibuprofen tablet 400 mg tablet - -
136 Ichtiyol Zalf pot @ 15 gr - -
Ipratropium bromida
137 ampul - -
nebulazer 0,025
Isosorbid Dinitrat tablet
138 tablet - -
sublingual 5 mg
botol @ 500
139 KA-EN 3 B Otsu infus - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Kalium Diklofenak tablet 50
140 tablet - -
mg
Kalsium Laktat ( Kalk ) tablet
141 tablet - -
500 mg
142 Kaptopril tablet scored 25 mg tablet - -

Kaptopril tablet scored 12,5

143 tablet - -
mg
144 Ketokonazol krim 2 % tube 10 gr - -
145 Ketokonazol tablet 200 mg tablet - -
Ketoprofen supositoria 100
146 supp - -
mg ( Protofen supp )
147 Ketorolac injeksi 10 mg/ml ampul @ 1 ml - -

148 Ketorolac injeksi 30 mg/ml ampul @ 1 ml - -

149 Kidmin SoftBag Fls - -

150 Klindamisin kapsul 150 mg kapsul - -
151 Klindamisin kapsul 300 mg kapsul - -

Kloramfenikol injeksi 1000 mg

152 Vial - -
(Colsancetin injeksi 1000 mg )

153 Kloramfenikol kapsul 250 mg kapsul - -

154 Kloramfenikol kapsul 500 mg kapsul - -

Kloramfenikol suspensi 125

155 botol @ 60 ml - -
mg / 5 ml
Kloramfenikol Salep Kulit 2 %
156 tube - -
(BUFACETINE)
157 Kloramfenikol Salep Mata 1 % tube - -

Kloramfenikol Tetes Mata 0.5

158 botol - -
%

minidose
159 Kloramfenikol 0,5% (cendo fen - -
(botol 0,6 ml)

Kloramfenikol Tetes Telinga 1

160 botol - -
%
Klorfeniramin Maleat ( CTM )
161 tablet - -
tablet 4 mg
162 Kodein HCl tablet 10 mg tablet - -
Kotrimoksazol 400 mg +
163 tablet - -
Trimetropim 80 mg tablet
164 Kotrimoksazol Suspensi botol @ 60 ml - -
165 Lactodia / Lacto B sachet - -
166 Lansoprazol tablet 30 mg tablet - -
Larutan mengandung elektrolit
( Na 130 mEq, Cl 109 mEq ,
botol @ 500
167 Ca 3 mEq , Asetat 28 mEq ) / - -
ml
Asering 500 ml larutan infus
steril

Larutan mengandung elektrolit

botol @ 500
168 (Ringer Laktat larutan infus - -
ml
steril / Wida RL )

Levofloksasin Infus 750 / 150

169 Tablet - -
ml
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

170 Levofloksasin Tablet 750 mg tablet - -

Levofloxacin Tablet Salut

171 tablet - -
Selaput 500 mg
172 Levotiroksin tablet 50 mcg tablet - -
173 Lidokain injeksi 2% ( HCl) ampul @ 2 ml - -
Lidokain injeksi 2% ( HCl) +
174 ampul @ 2 ml - -
Epinefrin 1 : 80.000 - 2 ml
175 Linkomisina kapsul 500 mg kapsul - -
176 Loperamida tablet 2 mg tablet - -
177 Loratadin tablet 10 mg tablet - -
178 Matovit tablet - -
179 Meloksikam tablet 15 mg tablet - -

180 Metformin HCl tablet 500 mg tablet - -

Methyl Prednisolon 4 mg
181 tablet - -
tablet
Metoklopropamid injeksi 5
182 ampul @ 2 ml - -
mg / ml
183 Metoklopropamid tablet 10 mg tablet - -

184 Metronidazol ovula ovula - -

185 Metronidazol tablet 250 mg tablet - -
186 Metronidazol tablet 500 mg tablet - -

187 Miconazol krim 2 % ( Nitrat ) tube - -

188 Molexflu tablet tablet - -

N-Acetyl systeine tablet 200
189 tablet - -
mg
Natrium Diklofenak tablet 50
190 tablet - -
mg
Natrium Klorida larutan infus
191 Botol - -
0,9% 100 cc
Natrium Klorida larutan infus
192 vial - -
0,9% 25 cc
Natrium Klorida larutan infus botol @ 500
193 - -
0,9% steril ml
194 Neo Kauminal suspensi botol @ 60 ml - -
195 Neuralgin - RX tablet tablet - -

Neurosanbe 5000 mg tablet /

196 tablet - -
Ikaneuron 5000 / Sohobion

Neurosanbe injeksi /
197 Mersibion Injeksi 5000 / ampul - -
Sohobion 5000 Injeksi
Neurovit E tablet / Nervitone -
198 tablet - -
E
199 Nifedipin tablet 10 mg tablet - -
Nifedipin tablet 20 mg
200 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nifedipin tablet 30 mg
201 Sediaan lepas lambat (Adalat tablet - -
OROS)
Nistatin tablet salut 500.000
202 tablet - -
IU / g
Nistatin vaginal tablet 100.000
203 tablet - -
IU / g
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

204 Nistatin suspensi 100.000 IU tablet - -

205 No Pain Spray botol - -

Noretisteron tablet 5 mg
206 tablet - -
(Primolut N tablet)
Obat Batuk Hitam ( O.B.H. ) botol @ 100
207 - -
Generik ml
Obat Batuk Hitam ( O.B.H. ) botol @ 100
208 - -
Paten ml
Obat Batuk Herbakof Sirup botol @ 100
209 - -
100 ml ml
210 Obat Batuk Herbakof tablet tablet - -
211 Ofloxaxin tablet 200 mg tablet - -
Oksimetazolin tetes hidung
212 botol @ 10 ml - -
0,025 %
213 Oksitetrasiklin HCl salep 3 % tube @ 5 gr - -

Oksitetrasiklin HCl salep mata

214 tube @ 3,5 gr - -
1%
Oksitosin injeksi 10 IU / ml - 1
215 ampul @ 1 ml - -
ml
Omeprazole injeksi 40 mg / 10
216 vial @ 10 ml - -
ml
217 Omeprazole tablet 20 mg tablet - -

218 Ondansetron injeksi 4 mg/2ml ampul @ 2 ml - -

219 Ondansetron tablet 4 mg tablet - -

220 Ondansetron tablet 8 mg tablet - -
221 Oxyvit C + Kaplet tablet - -

222 Papaverin injeksi 40 mg / 1 ml ampul @ 1 ml - -

223 Papaverin Tablet 40 mg tablet - -

Parasetamol drop 100 mg/ml (
224 botol @ 15 ml - -
60 mg / 0,6 ml )
Parasetamol sirup 120 mg / 5
225 botol - -
ml
226 Parasetamol tablet 100 mg tablet - -
227 Parasetamol tablet 500 mg tablet - -
Pamol supp (paracetamol
228 supp - -
supp 125 mg)
229 Pehavral tablet tablet - -
230 Piracetam tablet 1200 mg tablet - -
231 Piracetam tablet 800 mg tablet - -
232 Piracetam injeksi 1 g / 5 ml ampul @ 5 ml - -
ampul @ 15
233 Piracetam injeksi 3 g / 15 ml - -
ml
Piridoksin HCl ( Vitamin B6 )
234 tablet - -
tablet 10 mg
235 Piroxicam tablet 10 mg tablet - -
236 Piroxicam tablet 20 mg tablet - -
237 Prednison tablet 5 mg tablet - -

238 Propiltiourasil tablet 100 mg tablet - -

239 Propranolol HCl tablet 40 mg tablet - -

240 Proris suppositoria supp - -

241 Psidii Kapsul 500 mg kapsul - -
242 Psidii sirup 60 ml botol @ 60 ml - -
243 Ranitidin injeksi 25 mg / ml ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
244 Ranitidin tablet 150 mg tablet - -
245 Reserpin tablet 0,25 mg tablet - -

246 Salbutamol Inhaler (Salbulin) kapsul - -

Salbutamol tablet 2 mg
247 tablet - -
( sebagai sulfat )
Salep 2-4 , kombinasi : Asam
248 Salisilat 2 % + Belerang pot @ 30 gr - -
endap 4 %
Scabicid krim / Scabimite
249 Cream 10 - Permetrin krim 5 tube - -
%
250 Sefadroksil kapsul 250 mg kapsul - -
251 Sefadroksil kapsul 500 mg kapsul - -
Sefadroksil Sirup Kering 125
252 botol @ 60 ml - -
mg / 5 ml
253 Sefiksim kapsul 100 mg kapsul - -
254 Sefiksim kapsul 200 mg kapsul - -
Sefiksim sirup kering 100 mg /
255 botol @ 60 ml - -
5 ml
256 Sefotaksim injeksi 1 gr vial @ 1 gr - -
Seftriakson serbuk injeksi 1 gr
257 vial @ 1 gr - -
/ vial
258 Seretide Diskus 50/250 mcg Diskus - -

Serum Anti Bisa Ular

259 vial - -
Polivalen injeksi I
Serum Anti Tetanus Injeksi
260 vial - -
1.500 IU / amp
Serum Anti Tetanus Injeksi
261 vial - -
20.000 IU / vial
262 Setirizin sirup 5 mg / 5 ml botol @ 60 ml - -
263 Setirizin tablet 10 mg tablet - -
Sianokobalamin ( Vitamin B12
264 ampul - -
) injeksi 500 mcg
Sianokobalamin (Vitamin B12)
265 tablet - -
tablet 50 mcg
266 Silver Sulfadiazin Cream tube - -
267 Simetidin tablet 200 mg tablet - -
268 Simvastatin tablet 10 mg tablet - -
269 Simvastatin tablet 20 mg tablet - -
Siprofloksasin kapsul 500 mg
270 kapsul - -
( sebagai HCl )
271 Solafluz sirup Botol - -
272 Solvita Z Kapsul - -
Spasi Plus tablet / Scopma
273 tablet - -
Plus
274 Spasminal tablet tablet - -
275 Stimuno Forte Kapsul kapsul - -
276 Stimuno Sirup Berri 100 ml botol - -
Sucralfate suspensi 500 mg /
277 botol - -
5 ml
Sulfasetamida Natrium tetes
278 botol - -
mata 15 %
279 Tensigard kapsul kapsul - -
TETAGAM - Human Tetanus
280 Imunoglobulin Injeksi I.M. 250 Unit - -
UI
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Tetrakain HCl tetes mata
281 botol - -
0,5%
282 Tetrasiklin HCl kapsul 500 mg kapsul - -

283 Thiamfenikol kapsul 500 mg kapsul - -

Thiamfenikol sirup 125 mg / 5
284 botol @ 60 ml - -
ml
Tiamin HCl (Vit.B1) injeksi
285 ampul - -
100 mg/ml-1ml
Tiamin HCl / Mononitrat
286 tabletl - -
(Vitamin B1) tablet 50 mg
287 Ventolin Nebules 2,5 mg ampul - -
288 Vitamin B Kompleks tablet tablet - -
289 Xylocaine 10 % Spray botol - -
290 Xylocaine 2 % Jelly syringe - -
- -
OBAT PROGRAM - -
PROGRAM JIWA : - -
1 Clobazam 10 Mg tab tablet - -
2 Clozapin 25 mg tablet tablet - -
Fenitoin Natrium kapsul 100
3 kapsul - -
mg
Fenitoin Natrium kapsul 30
4 kapsul - -
mg
5 Fluoxetine (Napres) tablet - -
Haloperidol 5 mg / ml
6 ampul - -
(Lodomer)
Haloperidol injeksi 50 mg/ml (
7 ampul - -
Haldol Decanoas )
8 Haloperidol tablet 0,5 mg tablet - -
9 Haloperidol tablet 1,5 mg tablet - -
10 Haloperidol tablet 5 mg tablet - -

11 Karbamazepin tablet 200 mg tablet - -

Klorpromazin HCl tablet salut

12 tablet - -
100 mg
Klorpromazin HCl tablet salut
13 tablet - -
25 mg
14 Klorpromazin injeksi 5 mg/ ml ampul - -

15 Risperidon tablet 1 mg tablet - -

16 Risperidon tablet 2 mg tablet - -

17 Sikzonoat Inj / Flupenaziin Inj ampul - -

18 Trifluoperasin tablet 5 mg tablet - -

Triheksifenidil Hidroklorida
19 tablet - -
tablet 2 mg
PROGRAM GIZI : - -
1 Asam Folat tablet 0,4 mg tablet - -
2 Asam Folat tablet 1 mg tablet - -
3 Besi Sirup botol - -
4 Iodiol kapsul lunak kapsul - -
Kombinasi tablet salut : Besi
(II) sulfat 7H2O 200 mg Asam
5 tablet - -
Folat 0,25 mg ( tablet tambah
darah )
6 Mineral Mix 8 gr sase - -
Retinol ( Vitamin A ) kapsul
7 kapsul - -
100.000 IU
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Retinol ( Vitamin A ) kapsul
8 kapsul - -
200.000 IU kapsul lunak
9 Taburia sachet - -
10 Lytacur sirup 60 ml botol @ 60 ml - -
Zink sirup 20 mg/5ml ( Zircum
11 botol @ 60 ml - -
Kid Sirup )
PROGRAM KECACINGAN : - -

Albendazol suspensi 200 mg /

1 botol - -
5 ml
2 Albendazol tablet 400 mg tablet - -
Dietilkarbamazin Sitrat tablet
3 tablet - -
100 mg
Pirantel suspensi 125 mg / 5
4 botol @ 60 ml - -
ml
Pirantel tablet score ( base )
5 tablet - -
125 mg
PROGRAM KIA : - -

1 Ampisilin Injeksi 1000 mg/ml vial @ 1 gr - -

2 Fenobarbital Inj 50 mg / ml ampul @ 1 ml - -

Fitomenadion ( Vitamin K1 )
3 ampul @ 1 ml - -
injeksi 2 mg / ml ( Neonatus )
4 Gentamisin Inj 40 mg / ml ampul @ 2 ml - -
Kalsium Glukonat injeksi i.v
5 ampul - -
10 % ( 100 mg/ml )
Magnesium Sulfat injeksi ( IV )
6 botol @ 25 ml - -
20 % - 25 ml
Magnesium Sulfat injeksi ( IV )
7 botol @ 25 ml - -
40 % - 25 ml
Metilergometrin Maleat
8 (Metilergometrin) tablet salut tablet - -
0,125 mg
Metilergometrin Maleat injeksi
9 ampul @ 1 ml - -
0,200 mg-1 ml
botol @ 100
10 Metronidazole Infus 100 ml - -
ml
Procain Benzil Penisilin
11 vial - -
3.000.000 I.U
PROGRAM KUSTA : - -
1 MB Anak blister - -
2 MB Dewasa blister - -
3 PB Anak blister - -
4 PB Dewasa blister - -
5 Paket MB Anak Paket - -
6 Paket MB Dewasa Paket - -
7 Rifampisin 450 mg Kapsul - -
8 Rifampisin 600 mg Kapsul - -
PROGRAM TBC : - -
1 Bedaquiline 100 mg tablet - -
2 Clofazimine 100 mg tablet - -
3 Cycloserine 125 mg tablet - -
4 Cycloserine 250 mg tablet - -
5 Delamanid 50 mg tablet - -
6 Etionamid 250 mg tablet - -
7 Etambutol tablet 400 mg Tablet - -
8 Isoniazide tablet 100 mg tablet - -
9 Isoniazide tablet 300 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
10 Levofloksasin 100 mg tablet - -
11 Levofloksasin 250 mg tablet - -
12 Levofloksasin 500 mg tablet - -
13 Linezolid 600 mg tablet - -
14 Moxifloxacin 400 mg tablet - -
OAT - FDC Kategori 1
15 paket - -
dewasa
OAT - FDC Kategori anak
16 paket - -
PAKET
OAT KDT kategori 1 Dosis
17 paket - -
Harian
OAT-Kombipak Kategori 1
18 paket - -
anak
OAT-Kombipak Kategori 1
19 paket - -
dewasa
20 Pirazinamid tablet 500 mg paket - -
21 Pretomanid 200mg tablet - -
22 Rifampisin kapsul 300 mg tablet - -
23 Rifapentin 150 mg kapsul - -
Rifapentin 300 mg + Isoniazid
24 Tablet - -
300 mg
Rifampisin 75 mg + Isoniazid
25 tablet - -
50 mg
Piridoksin HCl ( Vitamin B6 )
26 tablet - -
tablet 25 mg
Piridoksin HCl ( Vitamin B6 )
27 tablet - -
tablet 50 mg
PROGRAM FLU BURUNG
- -
DAN COVID :
Fapiravir 200 mg (Avigan)
1 Tablet - -
Tablet
2 Oseltamivir 75 mg (Tamiflu) tablet - -
PROGRAM DIARE : - -

1 Garam Oralit untuk 200 ml air sase - -

2 Zink tablet disperible 20 mg tablet - -

PROGRAM DIPHTERI : - -
1 Serum ADS 20.000 vial - -
PROGRAM MALARIA : - -
1 Artesunate 60 mg Injeksi box - -
2 Chlorokuin tablet 150mg tablet - -
Dehidro Artemisin 40 mg +
3 tablet - -
Piperakuin 320 mg ( DHP )
Klorokuin Fosfat tablet 250
4 tablet - -
mg
5 Kuinin ( Kina ) tablet 200 mg tablet - -

Kuinin injeksi i.v 25%

6 ampul - -
( sebagai 2 HCl )
7 Primaquin 15 mg tablet - -
PROGRAM HIV : - -
1 Abacavir (ABC) 300 mg tablet - -
2 Amphotericin B vial - -
Azithromicyn 500 mg +
3 paket - -
Cefixime 200mg
Benzatin Benzil Penisillin
4 vial - -
Injeksi 2.4 Jt IU/vial
5 Dolutegravir tablet - -
6 Efavirenz (EFV) 200 mg tablet - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
7 Efavirenz (EFV) 600 mg tablet - -
8 Fluconazole tablet tablet - -
Kotrimoksazol 800 mg +
9 Trimetropim 160 mg (Forte) tablet - -
tablet
10 Lamivudine (3TC) 150 mg tablet - -
11 Levotiroksin tab 100 µg tablet - -
Lopinavir 200 mg + Ritonavir
12 tablet - -
50 mg (Aluvia)
Mycafungin/ Mycamin 50mg
13 vial - -
Injeksi
14 Nevirapine (NVP) 200 mg tablet - -
15 Pyrimetamine tablet tablet - -
16 Ramdesivir inj 100 mg vial - -

Tenofovir 300 mg (TDF) +

17 Lamivudine (3TC) 300 mg + tablet - -
Dolutegravir (DTG) 50/TLD

18 Tenofovir 300 mg (TDF) tablet - -

Tenofovir 300 mg (TDF) +
19 tablet - -
Emcitritabine 200 mg (FTC)
Tenofovir 300 mg (TDF) +
Lamivudine (3TC) 300 mg +
20 tablet - -
Efavirenz (EFV) 600 mg
(Triple FDC) Dewasa
21 Zidofudine (ZDV) 100 mg tablet - -
Zidofudine (ZDV) 300 mg +
22 tablet - -
Lamivudine (3TC) 150 mg
Zidofudine 60 mg +
Lamivudine 300 mg +
23 Tablet - -
Nevirapine 50 mg (Triple
FDC) Anak
- -
BAHAN GIGI : - -

1 1470IK Z250XT Syr Intro Kit kotak - -

2 Air raksa dental use botol - -

3 Cavit - G botol - -
4 Caviton White kotak - -
5 Composit resin ( solare ) Kit - -

6 Cresotin Liquid II Technodent kotak - -

7 Cressophate botol - -
8 Cressophen botol - -
Devitalisasi Pasta ( Non
9 botol - -
Arsen )
10 Endoseal Kotak - -
Etil Klorida semprot ( Duta
11 botol - -
Kaisar )
12 Eugenol cairan botol - -
Glass Ionomer Cement ( GC
13 botol - -
IX )
14 Jarum Sitoject biji - -
Kalsium Hidroksida Pasta
15 botol - -
( hydcal )
Monoklorkamfer Mentol
16 botol - -
Cairan ( CHKM )
17 Mummifying Pasta botol - -
18 Pehacain Inj ampul @ 2 ml - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Semen Seng Fosfat serbuk
19 botol - -
dan cairan
Silver Amalgam serbuk 65 -
20 botol 30 gr - -
75 %
Spons Gelatin Cubicles 1 x 1
21 biji - -
x 1 cm
Temporary Stopping Fletcher
22 set - -
( Fletcher )
Trikresol Formalin (TKF)
23 botol - -
cairan
24 Tumpatan komposit kit set - -
- -
BAHAN MEDIS HABIS
- -
PAKAI ( BMHP )
1 Alat Laboratorium Malaria Paket - -
Alat suntik sekali pakai 1 ml
2 set - -
tuberculin
3 Alat suntik sekali pakai 10 ml set - -

4 Alat suntik sekali pakai 3 ml set - -

5 Alat suntik sekali pakai 5 ml set - -
6 Alkohol Peroxide Botol - -
7 Alkohol Swab pcs - -
8 Aseptik Gel Galon 5 Liter Galon - -
Aseptik Gel 500 cc +
9 botol - -
dispenser
10 Aseptic Gel 100 ml botol - -
11 Askina Calgitrol 15 gram tube - -
12 Askina Gel 15 gram tube - -
13 Bioplacenton Tulle lembar - -
14 Blood Lancet biji - -
15 Blood transfision set set - -
Catgut / Benang Bedah No.
16 biji - -
2/0 - 3/0
17 Catgut Chromic 2-0 (TRITON) biji - -

18 Catgut Chromic 3-0 (TRITON) biji - -

19 Catgut Plain 2-0 (TRITON) biji - -

20 Catgut Plain 3-0 (TRITON) biji - -
21 Duk Lubang 25 cm x 30 cm biji - -
22 Duk Lubang 50 cm x 50 cm biji - -
Etakridin ( Rivanol ) larutan
23 botol - -
0,1%
24 Etanol 70 % 100 ml botol - -
25 Etanol 70% 1000 ml botol - -
Folleycatheter Silicon 2 way
26 biji - -
14 - 18
Hand Sanitizer 500 ml/Hand
27 botol - -
Rub
Hans Coen Nitril Non steril /
28 biji - -
Sarung Tangan
Hans Coen Non steril /
29 biji - -
Sarung Tangan
30 Hans Coen Obgyn (Jayamas) pasang - -

Hans Coen steril / Sarung

31 pasang - -
Tangan
32 Hi - Oxygen Mask Dewasa Set - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
Hypafix 5 x 5 (Fixomull stretch
33 rol - -
5 cm x 5 m)
34 Infusion set anak set - -
35 Infusion set dewasa set - -
36 IV Dressing 6 x 7 S lembar - -
37 IV. Chateter No. 14 s/d 24 set - -
38 IV. Chateter No. 26 set - -
Jarum Jahit ( Bedah ) No. 9
39 biji - -
s/d 14
40 Jarum Suntik 22G s/d 25 G biji - -
41 Jarum Suntik 26G biji - -
Kapas Pembalut / Absorben
42 rol - -
250 gram
43 Kasa Kompres 40 / 40 steril rol - -

44 Kasa Pembalut 2 m x 80 cm rol - -

Kasa Pembalut Hidrofil 4 m x

45 rol - -
15 cm
Kasa Pembalut Hidrofil 4 m x
46 rol - -
3 cm
Kasa Steril 16 Cm X 16 Cm
47 Pads - -
(16 Pads)
Lisol, mengandung Kresol
48 botol - -
tersabun 50%
49 Lomatulle / Dermafix lembar - -
50 Masker Earloop/ Tie On biji - -
51 Masker KF94 biji - -
52 Masker KN 95 biji - -
53 Masker N 95 biji - -
54 Masker Nebulizer Set Anak Piece - -

55 Masker Nebulizer Set Dewasa Piece - -

Masker Oxygen Anak -

56 Piece - -
Oxyflow
Masker Oxygen Anak NR
57 biji - -
Mask
Masker Oxygen Dewasa -
58 Piece - -
Oxyflow
Masker Oxygen Dewasa NR
59 biji - -
Mask
60 Plester 1,25 cm x 4,5 m rol - -
Plesterin - plester bulat non box @ 200
61 - -
wofen pcs
Povidon Iodida Larutan 10%
62 botol @ 30 ml - -
30 ml
Povidon Iodida Larutan 10% botol @ 300
63 - -
300 ml ml
64 Prontosan Gel 30 gram botol - -
65 Prontosan Gel 50 gram botol - -
66 Prontosan Sol 350 ml botol - -
67 Safety Box 5 Liter Pcs - -
68 Scalp Vein no. 25 biji - -
Silk ( Benang Bedah Sutera )
69 rol - -
No. 3 / 0
Solotio Perhydrol ( H2O2 ) 3
70 botol - -
%
71 Stabimed 1 L biji - -
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN

72 Surgical Blade / Mess No. 11 biji - -

Umbilical cord klem nylon

73 biji - -
steril (Claim Umbilical)
74 Underpad biji - -
Urine Bag standard steril 2 Lt
75 biji - -
( T valve )
botol @ 250
76 USG Gel - -
ml
- -

BAHAN MEDIS HABIS

- -
PAKAI ( BMHP ) PROGRAM
1 DBS Collection Kit tes - -
2 Kondom biji - -
3 Kondom Sutra biji - -
4 Kondom Andalan Pcs - -
5 Lubricant biji - -
Masker Bedah TB KALTECH /
6 Piece - -
SUPERCARE
7 Masker Bedah TB Onemed Piece - -

8 Masker Bedah GF HIV AIDS Piece - -

9 Masker N95 WEGEN Piece - -

10 Paket BHP HIV Paket - -
11 Pot Dahak Steril Pot - -
12 Slide (Object Glass) Kotak - -
13 Tuberkulin vial - -
14 Wing Needle BHP Paket - -
- -
REAGEN : - -
1 Cartridge Genexpert Test - -
Cepheid Xpert HIV - 1 VL
2 Assay (Cartridge HIV Viral Test - -
Load)
Deteksi HIV & Syphilis
3 - -
Combo (CATIN) Test
Deteksi HBS Ag Rapid Test
4 - -
(CATIN) Test
Fast Clear Q HIV 1/2 Ab 3 -
5 Test - -
Line
6 HBV Viral Load Test - -
Indec HIV dan Sypilis Combo
7 - -
(HIV) Test
Indec HIV 1/2 dan Syphilis
8 test kit - -
Combo (deteksi)
Rapidan tester anti HIV 1/2
9 test kit - -
Test
10 Rapid 1 RDT HIV Virocheck Test - -

11 Rapid Test Anti HCV Test - -

12 Rapid Test HBeAg Test - -
13 Rapid Test Syphilis Test - -
Paket Malaria / Paket
14 - -
Bundling Indoreagen Kit
15 RDT DBD Dengue fast clear - -
test
RDT DBD Dengue Combo
16 Test - -
Verotec
 SISA PENERIM PERSEDI PEMAKAI STOK PERMIN PEMBERI
NO NAMA OBAT SAT.
AWAL AAN AAN AN AKHIR TAAN AN
17 RDT Chikunguya Test - -
18 RDT Frambusia Test - -
RDT HIV 2 Arkan Medical one
19 step anti hiv 1/2 rapid test - -
(colloidal gold) Test
20 RDT Leptopirosis Test - -
21 RDT Malaria Test - -
22 Reagen
Reagen 2 2 (Oncoprobe
(FOCUS) / IR - Kit - -
23 Kit - -
24 100 C) 2 KHB
Reagen Test - -
Reagen 3 (Biomerieux / Vikia
25 Kit - -
HIV 1/2)
26 Reagen 3 Diagnostar Kit - -
27 Reagen CD 4 Control Kit - -
28 Reagen CD 4 Mobile Kit - -
29 Reagen HIV Right Sign kit - -

Reagen I (Intec One Step Anti

30 Test - -
HIV (1&2) Tri Line Test (ard)

Reagen I (Standart Diagnostic

31 (SD) Bioline HIV 1/2) / Test - -
(deTeksi)
32 Reagen Rapid Tes Hbs Ag Test - -
reagen pengukur Glukosa
33 kotak - -
(proline GOD FS 10)
Reagen Kuantitatif Viral Load
36 Kit - -
Type 1
RPR Syphilis/Titer
37 (Plasmatec/RPR Tes Kit, RPR Test - -
0/012)
38 TrepoCheck Syphilis Test - -
39 VTM COVID 19 Piece - -

TAMBAHAN OBAT :

TAMBAHAN BMHP :

TAMBAHAN REAGEN :

NON BPJS BPJS JUMLAH

JUMLAH KUNJUNGAN RESEP PBI MANDIRI ASKES

Gresik, .........................................

YANG MENYERAHKAN YANG MELAPORKAN

PENGELOLA OBAT PUSKESMAS PENGELOLA OBAT PUSTU / PONKESDES

apt. NUR HUDA, S.Farm …………………………………………..

NIP. 19970208 202203 1 003

Mengetahui / Menyetujui
KEPALA UPT PUSKESMAS SLEMPIT