85 Permetrin krim 5% Tube @ 10 g Tube

86 Pirantel pamoat 125 mg Dus,100 Tablet tablet

87 Piridoksin (Vitamin B6) tablet 10 mg (HCl) KF dus, 10 strip @ 10 tablet Tablet
88 Povidon Iodida larutan 10% 300 ml botol @ 300 ml Botol
89 Prednison tablet 5 mg Dus, 10 strip @ 10 tablet Tablet
90 Ranitidin injeksi 25 mg/ml Dus, 10 Ampul @ 2 ml Ampul
91 Ranitidin tablet 150 mg Dus, 10 Strip @ 10 tablet salut Tablet
selaput
92 Ringer Laktat larutan infus botol 500 ml Botol
93 Salbutamol cairan ih 0,1%
Dus, 4x5 Botol Plastik@2.5 ml Ampul
94 Salbutamol tablet 2 mg (sebagai Sulfat) strip @ 10 tablet Tablet
95 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang
endap 4% Pot @ 30 gram Pot
96 Sefadroksil kapsul/kaplet 500 mg Dus, 10 strip @ 10 kapsul Kapsul
97 Sefiksim kapsul/kaplet 100 mg Dus, 10 blister @ 10 kapsul Kapsul
98 Sefotaksim injeksi 1 g Dus, 10 Vial @ 1 g Vial
99 Setirizin sirup 5 mg/5 ml Botol @ 60 ml Botol
100 Setirizin tablet 10 mg Box, 10 strips @ 10 capsules Tablet
101 Sianokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml Ampul
102 Simvastatin 20 mg Dus,100 Tablet tablet
103 Simvastatin scored tablet 10 mg Dus, 3 Strip @ 10 Kaplet salut Tablet
selaput
104 Siprofloksasin infus 2% Vial 200 ml Botol
105 Siprofloksasin tablet 500 mg (sebagai HCl) Dus, 10 blister @ 10 tab ss Tablet
106 Spinorolakton 25 mg Dus,100 Tablet tablet
107 Sukralfat susp 500 mg/5 mL Botol, 100 ml Botol
108 Terbutalin tablet 2,5 mg Box 50's Tablet
109 Tetrasiklin kapsul 500 mg DUS,10 STRIP @ 10 KAPSUL Kapsul
110 Thiamin tab 50 mg DUS, 100 TABLET Tablet
111 Triheksifenidil 2 mg Dus,100 Tablet tablet
112 Tramadol injeksi 50 mg/ml Dus, 10 Ampul @ 2 ml Ampul
113 Vitamin B Kompleks tablet Dus 10 strip x 10 tab Tablet
114 Zinc 20 mg Dus,100 Tablet tablet
115 Zinc sir 10 mg/mL Dus, botol @ 100 ml Botol

ALAT PERBEKALAN KESEHATAN

116 Alat suntik sekali pakai 1 ml Dus, 100 biji biji

117 Alat suntik sekali pakai 3 ml Dus, 100 biji biji
118 Alat suntik sekali pakai 5 ml Dus, 100 biji biji
119 Alkacide 1l High Level Disinfectant Botol botol
120 Alkazyme Sachet 25 mg Sachet Sachet
121 Alkohol Swab Dus, 100 biji Dus
122 Catgut Benang Bedah Plain 3/0HR 20 /37 Dus, 24 sachet Dus
123 Cuticell classic 10 cm x 10 cm Dus,100biji pcs
124 Dermafix s Blister Blister
125 ETAKRIDIN ( RIVANOL ) 300 ML Botol Botol
126 Etanol 70% cairan botol 1 liter Botol
127 FolLey Chateter No. 14 Dus, 10 pcs pcs
128 FolLey Chateter No. 16 Dus, 10 pcs pcs
129 FolLey Chateter No.18 Dus, 10 pcs pcs
130 Handscoon Non Steril Dus, 50 pasang pcs
131 Handscoon Steril Dus, 50 pasang Pasang
132 Infusion Set dewasa Dus, 50 pcs pcs
133 Kapas Pemb. /Absorben 250 g Rol Rol
134 Kasa Pembalut Hidrofil 2 m x 80 cm Rol Rol
135 Kasa Pembalut Hidrofil 4 m x 5 cm Rol Rol
136 Kasa Pembalut Hidrofil 4m x 10 cm Rol Rol
137 Kasa PembalutHidrofil 4 m x 15 cm Rol Rol
138 Kasa Steril 16 x1 6 Dus,16 Pads Dus
 30
1100
5000
50
30000
1000
5000

2900
60

2000
30

3000
1000
300

50
2000

3000
2200
10000

20
3000
1100
100
1000
2500
4500
500
300
30000
1100
100

0
5600
3000
1
1
5
72
100
500
13
60
20
20
20
20
10
1000
70
150
100
100
100
100
PERENCANAAN OBAT PELAYANAN KESEHATAN DASAR TAHUN ANGGARAN 2017
KEGIATAN PENGADAAN OBAT DAN PERBEKALAN KESEHATAN
DANA DAK 2017 PLAVON
SELISIH
JUMLAH
NO NAMA OBAT KEMASAN SATUAN PERENCANAAN
1 2 3 4 5
OBAT
1 Air untuk Injeksi 25 ml Dus, 120 ampul PE @ Ampul 500
25ML
2 Albendazol 400 mg Dus,30 Tablet tablet 1110
3 Aminofilin injeksi 24 mg/ml dus 30 ampul @10 ml Ampul 90
4 Aminofilin tab 200 mg botol 100 tab Tablet 2200
5 Amlodipin tablet 5 mg Box, 3 strips @ 10 Tablet 4500
tablets
6 Amoksisilin sirup kering 125 mg/ 5 ml btl @ 60 ml Botol 200
7 Amoksisilin tablet 500 mg KOTAK @ 10 x 10 TAB Tablet 70000
8 Antasida DOEN II suspensi, kombinasi : Aluminium
Hidroksida 200 mg/5 ml Magnesium Hidroksida 200 Botol @ 60 ml Botol 1000
mg/5 ml

9 Asam Mefenamat kaplet 500 mg Dus, 10 blister @ 10 Tablet 70000

kaptab ss
10 Asiklovir tablet 400 mg
Dus, 5 strip @ 10 tablet Tablet 1000
11 Atropin injeksi i.v./i.m./s.k. 0,25 mg/ml 100 AMPUL @ 1 ML ampul 400
12 Bedak salisil serbuk 2% Dus @ 50 gram Dus 100
13 Betametason krim 0,1% (sebagai Valerat) Tube 5 gr Tube 288
14 Diazepam larutan rektal 5 mg/2,5 Ml ( STESOLID Dus, 5 alubag @ 1 tube Rectal
SUPP ) 20
@ 2,5ml
15 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Dus @ 30 Ampul Ampul 1980
16 Domperidon tablet 10 mg dus 10 X 10'S Tablet 3000
17 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml
Dus @ 30 Ampul Ampul 150
18 Eugenol cairan Botol 10 ml Botol 10
19 Fenobarbital injeksi i.m./i.v. 50 mg/ml Dus @ 30 Ampul Ampul 150
20 Fenoksimetil penisilin (penisilin V)tablet 500 mg
Dus @ 10 X 10 's Tablet
21 Fitomenadion (Vit.K1) tablet salut gula 10 mg Dus @ 10 X 10 's Tablet 2000
22 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml
dus @ 30 ampul Ampul 600
23 Gentamisin salep mata 0,3% Tube @ 3,5 gr Tube 240
24 Gentamisin tetes mata 0,3%
Dus, botol plastik 5 ml Botol 1000
25 Glukosa larutan infus 10 % steril botol @ 500 ml Botol 300
26 Glukosa larutan infus 5 % steril botol @ 500 ml Botol 2000
27 Griseofulvin tablet 125 mg Dus @ 10 X 10 's Tablet 3000
28 Haloperidol tablet 1,5 mg Dus, 10 blister @ 10 Tablet 1000
tablet
29 Hidroclorotiazid 25 mg Dus,100 Tablet tablet 1100
30 Hidrokortison krim 2,5 % Tube 5 gr Tube 240
31 Human tetanus imunoglobulinn injeksi i.m. 250 UI
Prefilled syringe Vial 10
32 Ibuprofen tablet 400 mg dus 10 X 10'S Tablet 80000
33 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 mg Dus,10 Strip @ 10 Tablet 5000
tablet
34 Kaptopril tablet scored 25 mg
Dus, 10 strip @10 tablet Tablet 5000
35 Ketokonazol krim 2% KF tube 5 gr Tube 240
36 Ketokonazol tablet 200 mg
Dus, 5 Strip @ 10 tablet Tablet 2000
37 Ketroprofen supp 100 mg Dus, 10 Supp supp 100
38 Kloramfenikol salep kulit ( BUFACETIN ) Tube Tube 54
39 Kloramfenikol salep mata 1 % Tube 5 gr Tube 240
40 Kloramphenikol 500 mg ( cloramex ) dos 100 tablet tablet 6000
41 Klorfeniramina Maleat (CTM) tablet 4 mg
kotak,10strip@10 tablet Tablet 50000
42 klorpromazin tab/kap 100 mg HCL Dos @ 10 x 10's Tablet 200
43 Kodein tablet 10 mg ktk 10x10 tablet Tablet 2000
44 Kombinasi Ferro Fumarat 60 mg + as.folat 0.4 mg tab
salut gula ( tablet tambah darah ) dus 3 strip @ 10tsg Tablet 5400
45 Kombinasi tetes mata 2,5 mg/mL: Natrium klorida
8,664 mg; Kalium klorida 1,32 mg (CENDO LYTERS ) botol 15 ml Botol 300

46 Kotrimoksazol DOEN I (dewasa) kombinasi :

Sulfametoksazol 400 mg Trimetoprim 80 mg Dus, 10 Strip@10 Tablet Tablet 10000
47 Kotrimoksazol Suspensi komb: Sulfametoksazol 200
mg + Trimetoprim 40 mg / 5 ml Botol, 60 ml Botol 500

48 Larutan mengandung Asam Amino (Asam Amino 30

g, Glukosa 7,3 % dan elektrolit) 500 ml (AMINOFLUID Double Chamber Botol 10
) Softbag 500 ML

49 Larutan mengandung Elektrolit (Na 130 mEq, Cl 109

mEq, Ca 3 mEq, Asetat 28 mEq) ( ASERING ) Plastic Bottle 500 ML Botol 800
50 Larutan mengandung Karbohidrat + Elektrolit (Nacl
1.75 gr, KCl 1.5 gr, Na Lactat 2.24 gr, Dekstrosa 27 gr) Plastic Bottle 500 ML Botol 200
( KAEN 3B )

51 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml

Dus, 30 ampul @ 2 ml Ampul 5000
52 Metformin HCl tablet 500 mg Dus, 10 blister @ 10 Tablet 5000
tablet
53 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 1 ml Ampul 500
54 Metilprednisolon tablet 4 mg Dus, 10 Blister @ 10 Tablet 6000
Tablet
55 Metoclopramid Inj Dus, 10 Ampul ampul 680
56 Metronidazol infus 500 mg/100 ml Dus, 1 Botol @ 100 ml Botol 200
57 Metronidazol tablet 500 mg 10 strip @ 10 tab Tablet 10000
58 Nacl 0,9% Botol 500 ml Botol 2400
59 Natrium Diklofenak tablet 50 mg Dus @ 5 X 10 's Tablet 10000
60 Nifedipin tab 30 mg, oros blister Tablet 300
61 Ofloksasin tets telinga 3% Btl @ 5 ml Botol 200
62 Oksitosin injeksi 10 IU/ml ampul @ 1 ml Ampul 500
63 Omeprazol inj 40 mg/10 ml Ds, 10 Ampul ampul 130
64 Ondansetron 4 mg Dus, 12 Tab tablet 1128
65 ondansetron inj 4 mg/ 2 mL Dus, 5 Ampul @ 2ml Ampul 1000
66 Parasetamol sirup 120 mg / 5 ml botol 60 ml Botol 500
67 Parasetamol tablet 500 mg Dus, 10 Strip@10 Tablet 70000
Kaplet Salut Selaput
68 Perak sulfadiazin krim 1% tube @ 35 gram Tube 50
69 Permetrin krim 5% Tube @ 10 g Tube 100
70 Pirantel pamoat 125 mg Dus,100 Tablet tablet 1100
71 Povidon Iodida larutan 10% 300 ml botol @ 300 ml Botol 200
72 Prednison tablet 5 mg Dus, 10 strip @ 10 Tablet 10000
tablet
73 Ranitidin injeksi 25 mg/ml
Dus, 10 Ampul @ 2 ml Ampul 4100
74 Ranitidin tablet 150 mg Dus, 10 Strip @ 10 Tablet 5000
tablet salut selaput
75 Ringer Laktat larutan infus botol 500 ml Botol 5900
76 Salbutamol cairan ih 0,1% Dus, 4x5 Botol Ampul 500
Plastik@2.5 ml
77 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang
endap 4% Pot @ 30 gram Pot 100
78 Sefadroksil kapsul/kaplet 500 mg Dus, 10 strip @ 10 Kapsul 10000
kapsul
79 Sefadroksil sirup kering 125 mg/5ml Dus, Botol 60 ml Botol 100
80 Sefiksim kapsul/kaplet 100 mg Dus, 10 blister @ 10 Kapsul 2600
kapsul
81 Sefotaksim injeksi 1 g Dus, 10 Vial @ 1 g Vial 3000
82 Setirizin tablet 10 mg Box, 10 strips @ 10 Tablet 1000
capsules
83 Sianokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml Ampul 3000
84 Simvastatin 20 mg Dus,100 Tablet tablet 2200
85 Simvastatin scored tablet 10 mg Dus, 3 Strip @ 10 Kaplet Tablet 20000
salut selaput
86 Siprofloksasin infus 2% Vial 200 ml Botol 200
87 Siprofloksasin tablet 500 mg (sebagai HCl) Dus, 10 blister @ 10 tab Tablet 10000
ss
88 Spinorolakton 25 mg Dus,100 Tablet tablet 1100
89 Sukralfat susp 500 mg/5 mL Botol, 100 ml Botol 200
90 Thiamin tab 50 mg DUS, 100 TABLET Tablet 4500
91 Triheksifenidil 2 mg Dus,100 Tablet tablet 500
92 Tramadol injeksi 50 mg/ml Dus, 10 Ampul @ 2 ml Ampul 100
93 Vitamin B Kompleks tablet Dus 10 strip x 10 tab Tablet 50000
94 Zinc 20 mg Dus,100 Tablet tablet 1100
95 Zinc sir 10 mg/mL Dus, botol @ 100 ml Botol 200
ALAT PERBEKALAN KESEHATAN

96 Alat suntik sekali pakai 1 ml Dus, 100 biji biji 2000

97 Alat suntik sekali pakai 3 ml Dus, 100 biji biji 11600
98 Alat suntik sekali pakai 5 ml Dus, 100 biji biji 1000
99 Alkacide 1l High Level Disinfectant Botol botol 1
100 Alkazyme Sachet 25 mg Sachet Sachet 1
101 Catgut Benang Bedah Plain 3/0HR 20 /37 Dus, 24 sachet Dus 48
102 Cuticell classic 10 cm x 10 cm Dus,100biji pcs 200
103 Dermafix s Blister Blister 500
104 ETAKRIDIN ( RIVANOL ) 300 ML Botol Botol 13
105 Etanol 70% cairan botol 1 liter Botol 20
106 FolLey Chateter No. 16 Dus, 10 pcs pcs 200
107 Handscoon Non Steril Dus, 50 pasang pcs 100
108 Kasa Pembalut Hidrofil 2 m x 80 cm Rol Rol 125
109 LISOL 1 LITER Botol Botol 2
110 Masker Dus,50 pcs Dus 1000
111 Masker Nebulizer Anak Dus,50 pcs pcs 65
112 Masker Nebulizer Dewasa Dus,50 pcs pcs 65
113 Medicut No. 20 Dus,50 pcs biji 800
114 Medicut No. 24 Dus,50 pcs biji 900
115 One sept Solution Botol Botol 13
116 Oxigen Masker Anak Dus,50 pcs pcs 65
117 Oxigen Masker Dewasa Dus,50 pcs pcs 70
118 Silk (Benang Bedah Sutera)@ 36 3-0 Dus, 12 pcs Dus 50
119 Underpad Dus,10 pcs pcs 40
120 Urine Bag Dus, 10 pcs pcs 50

Bangkalan, Januari 2017

MENGETAHUI, PENGELOLA OBAT
KEPALA UPT DINAS KESEHATAN UPT DINAS KESEHATAN
PUSKESMAS AROSBAYA PUSKESMAS AROSBAYA

Hj. MASTURAH, Amd.Kep SITI CHOIYATUN, S.Sos

NIP. 19680503 199303 2 006 NIP. 196710151996032001
 PERENCANAAN OBAT PELAYANAN KESEHATAN DASAR TAHUN
KEGIATAN PENGADAAN OBAT DAN PERBEKALAN KES
DANA DAK 2017

NO NAMA OBAT KEMASAN SATUAN

1 2 3 4
OBAT
1 Air untuk Injeksi 25 ml Dus, 120 ampul PE @ Ampul
25ML
2 Albendazol 400 mg Dus,30 Tablet tablet
3 Alopurinol tablet 100 mg Box, 10 strips @ 10 Tablet
tablets
4 Aminofilin injeksi 24 mg/ml dus 30 ampul @10 ml Ampul
5 Aminofilin tab 200 mg botol 100 tab Tablet
6 Amitriptilin tablet salut 25 mg (HCl) Dus, 10 strip @ 10 tss Tablet
7 Amlodipin tablet 5 mg Noza tab Box, 3 strips @ 10 Tablet
tablets
8 Amoksisilin kapsul 250 mg Lexavit tab dus 10 X 10'S Kapsul
9 Amoksisilin sirup kering 125 mg/ 5 ml Metaneuron tab btl @ 60 ml Botol
10 Amoksisilin tablet 500 mg Alpara Syrup KOTAK @ 10 x 10 TAB Tablet
11 Antasida DOEN I tablet kunyah, kombinasi : Hepagard Capsul Dus, 10 Strip @ 10
Aluminium Hidroksida 200 mg Magnesium Tablet Tablet
Hidroksida 200 mg
12 Antasida DOEN II suspensi, kombinasi :
Aluminium Hidroksida 200 mg/5 ml Magnesium Cendo Lyters Botol @ 60 ml Botol
Hidroksida 200 mg/5 ml
13 Asam Askorbat (Vitamin C) tablet 50 mg Hemafort tab Dus 10 strip x 10 tab Tablet
14 Asam Mefenamat kaplet 500 mg Procurma Plus Dus, 10 blister @ 10 Tablet
Syrup kaptab ss
15 Asam traneksamat injeksi 50 mg/ml OBH syrup Dus, 10 ampul @ 5 ml Ampul
16 Asiklovir tablet 400 mg Cystone tab Dus, 5 strip @ 10 tablet Tablet
17 Atapulgit tablet 600 mg Norages Inj Dus 5 strip @ 10 tablet Tablet
18 Atropin injeksi i.v./i.m./s.k. 0,25 mg/ml Antalgidon Inj 100 AMPUL @ 1 ML ampul
19 Bedak salisil serbuk 2% Dus @ 50 gram Dus
20 Betametason krim 0,1% (sebagai Valerat) Tube 5 gr Tube
21 Bisakodil suppositoria 5 mg ( DULCOLAX SUPP ) 1 Box @ 6's Supp
22 Deksametason injeksi i.v./i.m. 5 mg/ml Dus, 100 ampul @ 1 ml Ampul
23 Deksametason tablet 0,5 mg Dus, 10 Strip@10 Tablet Tablet
24 Diazepam larutan rektal 5 mg/2,5 Ml ( STESOLID SUPP ) Dus, 5 alubag @ 1 tube Rectal
@ 2,5ml
25 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Dus @ 30 Ampul Ampul
26 Digoksin tablet 0,25 mg Box 10 X 10 Tab Tablet
27 Domperidon suspensi/sirup 5 mg/5 ml btl @ 60 ml Botol
28 Domperidon tablet 10 mg dus 10 X 10'S Tablet
29 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Dus @ 30 Ampul Ampul
30 Eritromisin kapsul 250 mg ktk 10 x 10 kapsul Kapsul
31 Eritromisin kapsul 500 mg Dus, 10 blister @ 10 kss Kapsul
32 Eritromisin sirup kering 200 mg/ 5 ml Botol @60 ml Botol
33 Fenobarbital injeksi i.m./i.v. 50 mg/ml Dus @ 30 Ampul Ampul
 Fenobarbital tablet 30mg Dus, 10 strip @ 10 Tablet
tablet
34 Fitomenadion (Vit.K1) tablet salut gula 10 mg Dus @ 10 X 10 's Tablet
35 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml dus @ 30 ampul Ampul
36 Furosemid tablet 40 mg Dus, 10 strip @ 10 Tablet
tablet
37 Garam Oralit I serbuk, kombinasi : Natrium klorida 0,52 g kalium Dus @ 100 Sachet Sachet
klorida 0,30 g Trinatrium sitrat dihidrat 0,58 g Glukosa Anhidrat
38 Gentamisin
2,70 g salep mata 0,3% Tube @ 3,5 gr Tube
39 Gentamisin tetes mata 0,3% Dus, botol plastik 5 ml Botol
40 Gliklazid tab 80 mg ( GLUCODEK ) DUS, 100 TABLET Tablet
41 Glukosa larutan infus 5 % steril botol @ 500 ml Botol
42 Griseofulvin tablet 125 mg Dus @ 10 X 10 's Tablet
43 Haloperidol tablet 0,5 mg Dus, 10 blister @ 10 Tablet
tablet
44 Haloperidol tablet 1,5 mg Dus, 10 blister @ 10 Tablet
tablet
45 Hidroclorotiazid 25 mg Dus,100 Tablet tablet
46 Hidrokortison krim 2,5 % Tube 5 gr Tube
47 Human tetanus imunoglobulinn injeksi i.m. 250 UI Prefilled syringe Vial
48 Ibuprofen suspensi 200 mg/5 ml Dus, botol 60 ml Botol
49 Ibuprofen tablet 400 mg dus 10 X 10'S Tablet
50 Isosorbid Dinitrat tablet sublingual 5 mg Dus, 10 strip @ 10 Tablet
tablet
51 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 mg Dus,10 Strip @ 10 Tablet
tablet
52 Kaptopril tablet scored 25 mg Dus, 10 strip @10 tablet Tablet
53 Kaptopril tablet scored12,5 mg Dus, 10 strip @ 10 Tablet
tablet
54 Ketokonazol krim 2% KF tube 5 gr Tube
55 Ketokonazol tablet 200 mg Dus, 5 Strip @ 10 tablet Tablet
56 Ketroprofen supp 100 mg Dus, 10 Supp supp
57 Kloramfenikol salep kulit ( BUFACETIN ) Tube Tube
58 Kloramfenikol salep mata 1 % Tube 5 gr Tube
59 Kloramphenikol 250 mg ( cloramex ) dos 100 tablet tablet
60 Klorfeniramina Maleat (CTM) tablet 4 mg kotak,10strip@10 tablet Tablet
61 klorpromazin tab/kap 100 mg HCL Dos @ 10 x 10's Tablet
62 Kodein tablet 10 mg ktk 10x10 tablet Tablet
63 Kombinasi : Ipratropium bromida inhalasi 0,5 mg Salbutamol 2,5 1 dus @ 20 vial
mg ( COMBIVENT ) Vial
64 Kombinasi Ferro Fumarat 60 mg + as.folat 0.4 mg tab salut gula
( tablet tambah darah ) dus 3 strip @ 10tsg Tablet

65 Kotrimoksazol DOEN I (dewasa) kombinasi : Sulfametoksazol 400 Dus, 10 Strip@10 Tablet

mg Trimetoprim 80 mg Tablet

66 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg +

Trimetoprim 40 mg / 5 ml Botol, 60 ml Botol

67 Larutan mengandung Elektrolit (Na 130 mEq, Cl 109 mEq, Ca 3 Plastic Bottle 500 ML
mEq, Asetat 28 mEq) ( ASERING ) Botol

68 Larutan mengandung Karbohidrat + Elektrolit (Nacl 1.75 gr, KCl 1.5 Plastic Bottle 500 ML
gr, Na Lactat 2.24 gr, Dekstrosa 27 gr) ( KAEN 3B ) Botol

69 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Dus, 30 ampul @ 2 ml Ampul

70 Loperamid tablet 2 mg Dus, 10 Strip @ 10 Tablet
Tablet
71 Magnesium sulfat injeksi 20% Dus, 120 ampul plastik Ampul
@ 25 ml
72 Magnesium sulfat injeksi 40% Dus, 120 ampul plastik Ampul
@ 25 ml
73 Mebendazol tablet 500 mg Dus,24 Catch @ 1 tablet Tablet
74 Metformin HCl tablet 500 mg Dus, 10 blister @ 10 Tablet
tablet
75 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 1 ml Ampul
76 Metilprednisolon tablet 4 mg Dus, 10 Blister @ 10 Tablet
Tablet
77 Metoclopramid Inj Dus, 10 Ampul ampul
78 Metoklopramide sirup 5 mg/ 5 ml 9LEXAPRAM SYR ) BOTOL 60 ML Botol
79 Metoklopramide tablet 5 mg ktk 10 x 10 tablet Tablet
80 Metronidazol infus 500 mg/100 ml Dus, 1 Botol @ 100 ml Botol
81 Metronidazol tablet 500 mg 10 strip @ 10 tab Tablet
82 Mikonazol krim/salep 2 % (Nitrat) Tube 10 gram Tube
83 Nacl 0,9% Botol 500 ml Botol
84 Natrium Diklofenak tablet 50 mg Dus @ 5 X 10 's Tablet
Natrium Diklofenak tablet 25 mg Dus @ 5 X 10 's Tablet
85 Nifedipin tablet 10 mg Dus, 10 Strip @ 10 Tablet
tablet salut selaput
86 Oksitosin injeksi 10 IU/ml ampul @ 1 ml Ampul
87 Omeprazol inj 40 mg/10 ml Ds, 10 Ampul ampul
88 Omeprazol kapsul 20 mg dus 10 X 3'S kapsul
89 Ondansetron 4 mg Dus, 12 Tab tablet
90 ondansetron inj 4 mg/ 2 mL Dus, 5 Ampul @ 2ml Ampul
91 Parasetamol sirup 120 mg / 5 ml botol 60 ml Botol
92 Parasetamol tablet 500 mg Dus, 10 Strip@10 Tablet
Kaplet Salut Selaput
Parasetamol tetes 60mg/0,6ml
93 Perak sulfadiazin krim 1% tube @ 35 gram Tube
94 Permetrin krim 5% Tube @ 10 g Tube
95 Pirantel pamoat 125 mg Dus,100 Tablet tablet
96 Piridoksin (Vitamin B6) tablet 10 mg (HCl) KF dus, 10 strip @ 10 Tablet
tablet
97 Povidon Iodida larutan 10% 300 ml botol @ 300 ml Botol
Povidon Iodida larutan 10% 60 ml botol @ 60 ml Botol
98 Prednison tablet 5 mg Dus, 10 strip @ 10 Tablet
tablet
99 Ranitidin injeksi 25 mg/ml Dus, 10 Ampul @ 2 ml Ampul
100 Ranitidin tablet 150 mg Dus, 10 Strip @ 10 Tablet
tablet salut selaput
101 Rifampisin kaplet 450 mg Dus, 10 strip @ 10 Kaplet
kapsul
102 Rifampisin kapsul 300 mg Dus, 10 Strip @ 10 kapsul
Kapsul
103 Ringer Laktat larutan infus botol 500 ml Botol
104 Salbutamol tablet 2 mg (sebagai Sulfat) strip @ 10 tablet Tablet
105 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang endap 4% Pot @ 30 gram Pot
106 Sefadroksil kapsul/kaplet 500 mg Dus, 10 strip @ 10 Kapsul
kapsul
107 Sefadroksil sirup kering 125 mg/5ml Dus, Botol 60 ml Botol
108 Sefiksim kapsul/kaplet 100 mg Dus, 10 blister @ 10 Kapsul
kapsul
109 Sefiksim sirup kering 100 mg/ 5 ml Dus, Botol 30 ml Botol
 110 Sefotaksim injeksi 1 g Dus, 10 Vial @ 1 g Vial
Setirisin sirup 5mg/5ml Botol
Setirisin tablet 10mg tablet
111 Sianokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml Ampul
112 Simvastatin 20 mg Dus,100 Tablet tablet
113 Simvastatin scored tablet 10 mg Dus, 3 Strip @ 10 Kaplet Tablet
salut selaput
114 Siprofloksasin tablet 500 mg (sebagai HCl) Dus, 10 blister @ 10 tab Tablet
ss
115 Spinorolakton 25 mg Dus,100 Tablet tablet
Sukralfat susp 500mg/5ml Botol
Terbutalin tablet 2,5mg
Tetrasiklin kapsul 250 mg
116 Tetrasiklin kapsul 500 mg DUS,10 STRIP @ 10 Kapsul
KAPSUL
117 Thiamin tab 50 mg DUS, 100 TABLET Tablet
118 Triheksifenidil 2 mg Dus,100 Tablet tablet
119 Vitamin B Kompleks tablet Dus 10 strip x 10 tab Tablet
120 Zinc 20 mg Dus,100 Tablet tablet
121 Zinc sir 10 mg/mL Dus, botol @ 100 ml Botol

ALAT PERBEKALAN KESEHATAN

122 Alat suntik sekali pakai 1 ml Dus, 100 biji Dus, 100 biji biji
123 Alat suntik sekali pakai 3 ml Dus, 100 biji Dus, 100 biji biji
124 Alat suntik sekali pakai 5 ml Dus, 100 biji Dus, 100 biji biji
125 Alkacide 1l High Level Disinfectant Botol Botol botol
126 Alkazyme Sachet 25 mg Sachet Sachet Sachet
127 Alkohol Swab Dus, 100 biji Dus, 100 biji Dus
128 Catgut Benang Bedah Plain 3/0HR 20 /37 Dus, 24 sachet Dus, 24 sachet Dus
129 Cuticell classic 10 cm x 10 cm Dus,100biji Dus,100biji pcs
130 Dermafix s Blister Blister Blister
131 ETAKRIDIN ( RIVANOL ) 300 ML Botol Botol Botol
132 Etanol 70% cairan botol 1 liter botol 1 liter Botol
Etanol 70% cairan 100ml botol 100ml botol 100ml Botol
133 FolLey Chateter No. 16 Dus, 10 pcs Dus, 10 pcs pcs
134 FolLey Chateter No.18 Dus, 10 pcs Dus, 10 pcs pcs
135 Handscoon Non Steril Dus, 50 pasang Dus, 50 pasang pcs
136 Handscoon Steril Dus, 50 pasang Dus, 50 pasang Pasang
137 Infusion Set anak Dus, 50 pcs Dus, 50 pcs pcs
138 Infusion Set dewasa Dus, 50 pcs Dus, 50 pcs pcs
139 Kasa Pembalut Hidrofil 2 m x 80 cm Rol Rol Rol
140 Kasa Pembalut Hidrofil 4 m x 5 cm Rol Rol Rol
141 Kasa Pembalut Hidrofil 4m x 10 cm Rol Rol Rol
142 Kasa PembalutHidrofil 4 m x 15 cm Rol Rol Rol
143 Kasa Steril 16 x1 6 Dus,16 Pads Dus,16 Pads Dus
144 LISOL 1 LITER Botol Botol Botol
145 Masker Dus,50 pcs Dus,50 pcs Dus
146 Masker Nebulizer Anak Dus,50 pcs Dus,50 pcs pcs
147 Masker Nebulizer Dewasa Dus,50 pcs Dus,50 pcs pcs
148 Medicut No. 18 Dus,50 pcs Dus,50 pcs biji
149 Medicut No. 20 Dus,50 pcs Dus,50 pcs biji
150 Medicut No. 22 Dus,50 pcs Dus,50 pcs biji
151 Medicut No. 24 Dus,50 pcs Dus,50 pcs biji
152 Nasal Oksigen anak Dus,50 pcs Dus,50 pcs pcs
153 Nasal Oksigen bayi Dus,50 pcs Dus,50 pcs pcs
154 Nasal Oksigen dewasa Dus,50 pcs Dus,50 pcs pcs
155 One sept Solution Botol Botol Botol
156 Oxigen Masker Anak Dus,50 pcs Dus,50 pcs pcs
157 Oxigen Masker Dewasa Dus,50 pcs Dus,50 pcs pcs
158 Plester 5 yards x 2 inch ( Pharmafix) Dus,6 Rol Dus,6 Rol Rol
159 Silk (Benang Bedah Sutera)@ 36 3-0 Dus, 12 pcs Dus, 12 pcs Dus
160 Underpad Dus,10 pcs Dus,10 pcs pcs

MENGETAHUI,
KEPALA UPT DINAS KESEHATAN
PUSKESMAS KEDUNGDUNG

dr. RATNA ERIANTI NUGROHO RINI

NIP. 19730322 200801 2 016
 LAYANAN KESEHATAN DASAR TAHUN ANGGARAN 2017
GADAAN OBAT DAN PERBEKALAN KESEHATAN
DANA DAK 2017
SELISIH
JUMLAH REALISAI OBAT JUMLAH
PERENCANAAN MARET MEI JULI OKT NOV TOTAL
5 6 7 8 9 10

100 120 120 120 360

1110 0
20,000 4000 2000 3000 9000
90 30 30 60
2,200 0
500 0
10,000 1800 600 2400
8,000 2000 1000 2000 2000 7000
600 240 100 340
30,000 5000 5000 5000 3000 18000

25,000
5000 4000 9000

500
200 100 300
10,000 2000 1000 3000
40,000 7000 9600 16600
100 20 20
5,000 500 500
5,000 0
200 100 100
100 100 100 100 300
500 100 100 200
120 0
3,000 500 500 500 500 2000
30,000 5000 2000 500 7500
100 10 10
3,000 600 600 1200
2,000 1000 1000
300 50 50 50 50 200
10,000 1000 1500 1500 4000
60 30 30
1,000 500 500 1000 2000
1,000 120 120 240
60 0
90 0
5,000 1000 1000 2000
10,000 3000 1500 4500
300 150 150 300
3,000 1000 1000 2000
1,500 1200 500 1700
200 50 48 48 146
200 48 48
5,000 0
400 80 80
2,000 700 700
500 0
500 0
1100 0
480 72 72
30 10 10 20
240 50 50
25,000 5000 5000 2500 12500
500 100 500 600
10,000 10000 10000
15,000 2500 2500 2500 7500
15,000 2500 2500 5000
200 0
3,000 1000 900 1900
100 0
54 0
500 48 48
5,000 500 1000 1500
15,000 10000 10000 20000
200 0
3,000 200 200
100
0

5,400
0

15,000
2500 2500 5000

300
50 50

400
0

200
0
500 90 90 90 90 360
5,000 1000 1000
60 0
60 0
1,000 0
2,000 800 500 1300
300 100 100 100 100 400
3,000 1000 1000 1500 3500
680 0
600 120 60 180
5,000 500 500
100 50 50
5,000 1000 1000
124 24 48 48 120
600 40 40
5,000 1000 500 1000 2500
1000 1000
5,000 1000 1000 500 2500
500 100 100 100 100 400
130 0
3,000 600 600 600 600 2400
1128 0
500 100 180 100 100 480
500 100 100 200
25,000 5000 5000 2500 12500
150 56 56
20 0
100 0
1100 0
15,000 2500 2500 5000
50 48 48
50 48 48 96
15,000 5000 5000 10000
10,000 500 1000 1500
15,000 2000 2000
1,000 200 200 400
300 100 200 500 800
2,900 200 2000 2200
5,000 1000 2000 1000 4000
120 24 24 48 96
15,000 5000 2000 1000 8000
540 120 60 180
5,000 1000 1000
300 48 48 48 144
1,000 100 100 200
100 100
1000 1000 2000
2,500 500 500 500 1500
2200 0
10,000 900 900
5,000 1500 1000 2000 2000 6500
1100 0
100 100
100 100
2000 2000
10,000 2000 1500 1500 1500 6500
4,500 1500 1500 3000
500 0
10,000 1000 1000 1000 3000
1100 0
50 48 48
0
0
0
1,000 200 200 200 600
13,600 2400 2400 2400 2400 9600
5,000 1000 800 800 2600
1 0
1 0
1 20 20 40
36 48 48
100 2 2 4
500 0
13 24 24
50 20 20 40
500 100 100
25 10 10 20
25 10 10 20
32 10 10 10 30
100 0
50 200 200
500 100 100 300 500
100 20 20 40 80
100 600 100 700
100 20 100 120
100 20 100 100 220
100 100 100
 2 5 2 7
500 20 20 40
65 20 20
65 20 20
50 50 50
100 50 50 100
100 50 100 150
100 100 100 200
20 0
10 0
20 50 50 100
13 0
65 20 20
70 20 20
50 30 30
36 24 36 60
40 50 50

Bangkalan, Januari 2017

PENGELOLA OBAT
UPT DINAS KESEHATAN
PUSKESMAS KEDUNGDUNG

ACH. HOEZAINI
PERENCANAAN OBAT PELAYANAN KESEHATAN DASAR TAHUN ANGGARAN 2017
KEGIATAN PENGADAAN OBAT DAN PERBEKALAN KESEHATAN
DANA DAK 2017

NO NAMA OBAT KEMASAN SATUAN

1 2 3 4
OBAT
1 Air untuk Injeksi 25 ml Dus, 120 ampul PE @ Ampul
25ML
2 Albendazol 400 mg Dus,30 Tablet tablet
3 Alopurinol tablet 100 mg Box, 10 strips @ 10 Tablet
tablets
4 Aminofilin tab 200 mg botol 100 tab Tablet
5 Amoksisilin kapsul 250 mg dus 10 X 10'S Kapsul
6 Amoksisilin sirup kering 125 mg/ 5 ml btl @ 60 ml Botol
7 Amoksisilin tablet 500 mg KOTAK @ 10 x 10 TAB Tablet
8 Antasida DOEN I tablet kunyah, kombinasi : Aluminium Dus, 10 Strip @ 10 Tablet Tablet
Hidroksida 200 mg Magnesium Hidroksida 200 mg

9 Antasida DOEN II suspensi, kombinasi : Aluminium Botol @ 60 ml Botol

Hidroksida 200 mg/5 ml Magnesium Hidroksida 200
mg/5 ml

10 Asam Askorbat (Vitamin C) tablet 50 mg Dus 10 strip x 10 tab Tablet

11 Asam Mefenamat kaplet 500 mg Dus, 10 blister @ 10 Tablet
kaptab ss
12 Asiklovir tablet 400 mg Dus, 5 strip @ 10 tablet Tablet

13 Atapulgit tablet 600 mg Dus 5 strip @ 10 tablet Tablet

14 Atropin injeksi i.v./i.m./s.k. 0,25 mg/ml 100 AMPUL @ 1 ML ampul

15 Bedak salisil serbuk 2% Dus @ 50 gram Dus

16 Betametason krim 0,1% (sebagai Valerat) Tube 5 gr Tube
17 Deksametason tablet 0,5 mg Dus, 10 Strip@10 Tablet Tablet

18 Diazepam larutan rektal 5 mg/2,5 Ml ( STESOLID SUPP ) Dus, 5 alubag @ 1 tube Rectal
19 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) @
Dus2,5ml
@ 30 Ampul Ampul
20 Digoksin tablet 0,25 mg Box 10 X 10 Tab Tablet
21 Domperidon suspensi/sirup 5 mg/5 ml btl @ 60 ml Botol
22 Domperidon tablet 10 mg dus 10 X 10'S Tablet
23 Eritromisin kapsul 500 mg Dus, 10 blister @ 10 kss Kapsul

24 Fitomenadion (Vit.K1) tablet salut gula 10 mg Dus @ 10 X 10 's Tablet

25 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml dus @ 30 ampul Ampul
26 Furosemid tablet 40 mg Dus, 10 strip @ 10 tablet Tablet

27 Gentamisin salep mata 0,3% Tube @ 3,5 gr Tube

28 Gentamisin tetes mata 0,3% Dus, botol plastik 5 ml Botol
29 Glukosa larutan infus 5 % steril botol @ 500 ml Botol
30 Griseofulvin tablet 125 mg Dus @ 10 X 10 's Tablet
31 Hidroclorotiazid 25 mg Dus,100 Tablet tablet
32 Hidrokortison krim 2,5 % Tube 5 gr Tube
33 Human tetanus imunoglobulinn injeksi i.m. 250 UI Prefilled syringe Vial
34 Ibuprofen tablet 400 mg dus 10 X 10'S Tablet
35 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 mg Dus,10 Strip @ 10 tablet Tablet

36 Kaptopril tablet scored 25 mg Dus, 10 strip @10 tablet Tablet

37 Kaptopril tablet scored12,5 mg Dus, 10 strip @ 10 tablet Tablet

38 Ketokonazol krim 2% KF tube 5 gr Tube

39 Ketokonazol tablet 200 mg Dus, 5 Strip @ 10 tablet Tablet

40 Ketroprofen supp 100 mg Dus, 10 Supp supp

41 Kloramfenikol salep kulit ( BUFACETIN ) Tube Tube
42 Kloramfenikol salep mata 1 % Tube 5 gr Tube
43 Kloramphenikol 500 mg ( cloramex ) dos 100 tablet tablet
44 Klorfeniramina Maleat (CTM) tablet 4 mg kotak,10strip@10 tablet Tablet

45 klorpromazin tab/kap 100 mg HCL Dos @ 10 x 10's Tablet

46 Kombinasi Ferro Fumarat 60 mg + as.folat 0.4 mg tab dus 3 strip @ 10tsg Tablet
salut gula ( tablet tambah darah )
47 Kombinasi tetes mata 2,5 mg/mL: Natrium klorida 8,664 botol 15 ml Botol
mg; Kalium klorida 1,32 mg (CENDO LYTERS )
48 Kotrimoksazol DOEN I (dewasa) kombinasi : Dus, 10 Strip@10 Tablet Tablet
Sulfametoksazol 400 mg Trimetoprim 80 mg
49 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 mg + Botol, 60 ml Botol
Trimetoprim 40 mg / 5 ml
50 Larutan mengandung Elektrolit (Na 130 mEq, Cl 109 Plastic Bottle 500 ML Botol
mEq, Ca 3 mEq, Asetat 28 mEq) ( ASERING )
51 Larutan mengandung Karbohidrat + Elektrolit (Nacl 1.75 Plastic Bottle 500 ML Botol
gr, KCl 1.5 gr, Na Lactat 2.24 gr, Dekstrosa 27 gr) ( KAEN
3B )

52 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Dus, 30 ampul @ 2 ml Ampul

53 Loperamid tablet 2 mg Dus, 10 Strip @ 10 Tablet Tablet

54 Metformin HCl tablet 500 mg Dus, 10 blister @ 10 Tablet

tablet
55 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 1 ml Ampul
56 Metilprednisolon tablet 4 mg Dus, 10 Blister @ 10 Tablet
Tablet
57 Metoclopramid Inj Dus, 10 Ampul ampul
58 Metoklopramide sirup 5 mg/ 5 ml 9LEXAPRAM SYR ) BOTOL 60 ML Botol

59 Metoklopramide tablet 5 mg ktk 10 x 10 tablet Tablet

60 Metronidazol tablet 500 mg 10 strip @ 10 tab Tablet
61 Mikonazol krim/salep 2 % (Nitrat) Tube 10 gram Tube
62 Nacl 0,9% Botol 500 ml Botol
63 Natrium Diklofenak tablet 50 mg Dus @ 5 X 10 's Tablet
64 Nifedipin tab 30 mg, oros blister Tablet
65 Nifedipin tablet 10 mg Dus, 10 Strip @ 10 tablet Tablet
salut selaput
66 Oksitosin injeksi 10 IU/ml ampul @ 1 ml Ampul
67 Omeprazol inj 40 mg/10 ml Ds, 10 Ampul ampul
68 Omeprazol kapsul 20 mg dus 10 X 3'S kapsul
69 Ondansetron 4 mg Dus, 12 Tab tablet
70 ondansetron inj 4 mg/ 2 mL Dus, 5 Ampul @ 2ml Ampul
71 Parasetamol sirup 120 mg / 5 ml botol 60 ml Botol
72 Parasetamol tablet 500 mg Dus, 10 Strip@10 Kaplet Tablet
Salut Selaput
73 Perak sulfadiazin krim 1% tube @ 35 gram Tube
74 Permetrin krim 5% Tube @ 10 g Tube
75 Pirantel pamoat 125 mg Dus,100 Tablet tablet
76 Piridoksin (Vitamin B6) tablet 10 mg (HCl) KF dus, 10 strip @ 10 tablet Tablet

77 Povidon Iodida larutan 10% 300 ml botol @ 300 ml Botol

 78 Prednison tablet 5 mg Dus, 10 strip @ 10 tablet Tablet

79 Ranitidin injeksi 25 mg/ml Dus, 10 Ampul @ 2 ml Ampul

80 Ranitidin tablet 150 mg Dus, 10 Strip @ 10 tablet Tablet
salut selaput
81 Ringer Laktat larutan infus botol 500 ml Botol
82 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang Pot @ 30 gram Pot
endap 4%
83 Sefadroksil kapsul/kaplet 500 mg Dus, 10 strip @ 10 kapsul Kapsul

84 Sefadroksil sirup kering 125 mg/5ml Dus, Botol 60 ml Botol

85 Sefiksim kapsul/kaplet 100 mg Dus, 10 blister @ 10 Kapsul
kapsul
86 Sefotaksim injeksi 1 g Dus, 10 Vial @ 1 g Vial
87 Setirizin sirup 5 mg/5 ml Botol @ 60 ml Botol
88 Setirizin tablet 10 mg Box, 10 strips @ 10 Tablet
capsules
89 Sianokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml Ampul
90 Simvastatin 20 mg Dus,100 Tablet tablet
91 Simvastatin scored tablet 10 mg Dus, 3 Strip @ 10 Kaplet Tablet
salut selaput
92 Siprofloksasin tablet 500 mg (sebagai HCl) Dus, 10 blister @ 10 tab Tablet
ss
93 Spinorolakton 25 mg Dus,100 Tablet tablet
94 Thiamin tab 50 mg DUS, 100 TABLET Tablet
95 Triheksifenidil 2 mg Dus,100 Tablet tablet
96 Vitamin B Kompleks tablet Dus 10 strip x 10 tab Tablet
97 Zinc 20 mg Dus,100 Tablet tablet
98 Zinc sir 10 mg/mL Dus, botol @ 100 ml Botol

ALAT PERBEKALAN KESEHATAN

99 Alat suntik sekali pakai 3 ml Dus, 100 biji biji

100 Alkacide 1l High Level Disinfectant Botol botol
159 Alkazyme Sachet 25 mg Sachet Sachet
162 Cuticell classic 10 cm x 10 cm Dus,100biji pcs
163 Dermafix s Blister Blister
164 ETAKRIDIN ( RIVANOL ) 300 ML Botol Botol
165 Etanol 70% cairan botol 1 liter Botol
169 Handscoon Non Steril Dus, 50 pasang pcs
176 Kasa Pembalut Hidrofil 4m x 10 cm Rol Rol
177 Kasa PembalutHidrofil 4 m x 15 cm Rol Rol
179 LISOL 1 LITER Botol Botol
181 Masker Nebulizer Anak Dus,50 pcs pcs
182 Masker Nebulizer Dewasa Dus,50 pcs pcs
186 Medicut No. 24 Dus,50 pcs biji
190 One sept Solution Botol Botol
191 Oxigen Masker Anak Dus,50 pcs pcs
192 Oxigen Masker Dewasa Dus,50 pcs pcs
193 Plester 5 yards x 2 inch ( Pharmafix) Dus,6 Rol Rol
194 Silk (Benang Bedah Sutera)@ 36 3-0 Dus, 12 pcs Dus
195 Underpad Dus,10 pcs pcs
196 Urine Bag Dus, 10 pcs pcs

Bangkalan, Januari 2017

MENGETAHUI, PENGELOLA OBAT
KEPALA UPT DINAS KESEHATAN UPT DINAS KESEHATAN
PUSKESMAS BURNEH PUSKESMASBURNEH
 drg. HANDAYANINGSIH ANISAH
NIP.19640306 199203 2 003 NIP.19761026 200701 2 010
 PLAVON
SELISIH
JUMLAH
PERENCANAAN
5

200

1110
30000

2200
2000
1000
50000
50000

300

5000
80000

1000

3000

100

150
300
30000

20
900
1000
150
2000
3000

5000
300
1000

300
300
300
20000
1100
300
30
20000
30000

30000
20000

100
10000

100
54
300

30000

200
5400

20

30000

300

300

200

300

20000

10000

200
20000

680
300

10000
30000
50
700
30000
1000
5000

1000
130
10000
1128
500
500
80000

10
20
1100
10000

200
 30000

1000
10000

1900
300

5000

50
2000

200
20
30000

2000
2200
50000

30000

1100
4500
500
50000
1100
200

1600
1
1
50
500
13
60
20
200
200
2
65
65
300
13
65
70
100
10
40
50

Bangkalan, Januari 2017

PENGELOLA OBAT
UPT DINAS KESEHATAN
PUSKESMASBURNEH
 ANISAH
NIP.19761026 200701 2 010
PERENCANAAN OBAT PELAYANAN KESEHATAN DASAR TAHUN ANGGARAN 2017
KEGIATAN PENGADAAN OBAT DAN PERBEKALAN KESEHATAN
DANA DAK 2017 PLAVON
SELISIH
JUMLAH
NO NAMA OBAT KEMASAN SATUAN PERENCANAAN
1 2 3 4 5
OBAT
1 Air untuk Injeksi 25 ml Dus, 120 ampul PE @ 25ML Ampul 1000
2 Albendazol 400 mg Dus,30 Tablet tablet 1110
3 Alopurinol tablet 100 mg Box, 10 strips @ 10 tablets Tablet 4000
4 Alopurinol tablet 300 mg Dus, 10 blister @ 10 tablet Tablet 5000
6 Aminofilin injeksi 24 mg/ml dus 30 ampul @10 ml Ampul 60
7 Aminofilin tab 200 mg botol 100 tab Tablet 2200
8 Amitriptilin tablet salut 25 mg (HCl) Dus, 10 strip @ 10 tss Tablet 1000
9 Amlodipin tablet 5 mg Box, 3 strips @ 10 tablets Tablet 3000
10 Amoksisilin kapsul 250 mg dus 10 X 10'S Kapsul 3000
11 Amoksisilin sirup kering 125 mg/ 5 ml btl @ 60 ml Botol 200
12 Amoksisilin sirup kering forte 250 mg/5 ml Dus, Botol 60 ml Botol 300
13 Amoksisilin tablet 500 mg KOTAK @ 10 x 10 TAB Tablet 60000
14 Antasida DOEN I tablet kunyah, kombinasi : Dus, 10 Strip @ 10 Tablet Tablet
Aluminium Hidroksida 200 mg Magnesium 5000
Hidroksida 200 mg

15 Antasida DOEN II suspensi, kombinasi : Aluminium Botol @ 60 ml Botol

Hidroksida 200 mg/5 ml Magnesium Hidroksida 200 300
mg/5 ml

17 Asam Askorbat (Vitamin C) tablet 250 mg ktk 10x10 tablet Tablet

3000
18 Asam Askorbat (Vitamin C) tablet 50 mg Dus 10 strip x 10 tab Tablet 3000
19 Asam Mefenamat kaplet 500 mg Dus, 10 blister @ 10 kaptab Tablet
ss 20000
20 Asam traneksamat injeksi 50 mg/ml Dus, 10 ampul @ 5 ml Ampul
400
21 Asiklovir tablet 400 mg Dus, 5 strip @ 10 tablet Tablet 500
22 Atapulgit tablet 600 mg Dus 5 strip @ 10 tablet Tablet 5000
23 Atropin injeksi i.v./i.m./s.k. 0,25 mg/ml 100 AMPUL @ 1 ML ampul
200
25 Bedak salisil serbuk 2% Dus @ 50 gram Dus 100
26 Betametason krim 0,1% (sebagai Valerat) Tube 5 gr Tube 1000
29 Deksametason injeksi i.v./i.m. 5 mg/ml Dus, 100 ampul @ 1 ml Ampul 5000
30 Deksametason tablet 0,5 mg Dus, 10 Strip@10 Tablet Tablet 10000
31 Diazepam larutan rektal 5 mg/2,5 Ml ( STESOLID Dus, 5 alubag @ 1 tube @ Rectal
SUPP ) 2,5ml 50
32 Difenhidramin injeksi i.v./i.m. 10 mg/ml (HCl) Dus @ 30 Ampul Ampul 5000
33 Digoksin tablet 0,25 mg Box 10 X 10 Tab Tablet 1000
34 Domperidon suspensi/sirup 5 mg/5 ml btl @ 60 ml Botol 200
35 Domperidon tablet 10 mg dus 10 X 10'S Tablet 4000
36 Epinefrin (Adrenalin) injeksi i.v/s.k./i.m 1 mg/ml Dus @ 30 Ampul Ampul
100
37 Eritromisin kapsul 250 mg ktk 10 x 10 kapsul Kapsul 500
38 Eritromisin kapsul 500 mg Dus, 10 blister @ 10 kss Kapsul 500
39 Eritromisin sirup kering 200 mg/ 5 ml Botol @60 ml Botol 100
42 Fenobarbital injeksi i.m./i.v. 50 mg/ml Dus @ 30 Ampul Ampul 60
44 Fitomenadion (Vit.K1) tablet salut gula 10 mg Dus @ 10 X 10 's Tablet 3000
45 Fitomenadion (Vitamin K1) injeksi i.m. 2 mg/ml dus @ 30 ampul Ampul
500
47 Furosemid tablet 40 mg Dus, 10 strip @ 10 tablet Tablet 500
49 Gentamisin injeksi 40 mg/ ml Dus, 5 ampul @ 2 ml Ampul 50
50 Gentamisin salep mata 0,3% Tube @ 3,5 gr Tube 300
51 Gentamisin tetes mata 0,3% Dus, botol plastik 5 ml Botol 300
53 Glukosa larutan infus 10 % steril botol @ 500 ml Botol 100
54 Glukosa larutan infus 5 % steril botol @ 500 ml Botol 300
55 Griseofulvin tablet 125 mg Dus @ 10 X 10 's Tablet 4000
58 Hidroclorotiazid 25 mg Dus,100 Tablet tablet 1100
59 Hidrokortison krim 2,5 % Tube 5 gr Tube 400
61 Ibuprofen suspensi 200 mg/5 ml Dus, botol 60 ml Botol 300
62 Ibuprofen tablet 400 mg dus 10 X 10'S Tablet 10000
63 Isosorbid Dinitrat tablet sublingual 5 mg Dus, 10 strip @ 10 tablet Tablet 3000
64 Kalsium Laktat (Kalk) tablet/kapsul/kaplet 500 mg Dus,10 Strip @ 10 tablet Tablet
6000
65 Kaptopril tablet scored 25 mg Dus, 10 strip @10 tablet Tablet 6000
67 Karbamazepin tablet 200 mg Dus, 10 blister @ 10 tablet Tablet 200
68 Ketokonazol krim 2% KF tube 5 gr Tube 3000
69 Ketokonazol tablet 200 mg Dus, 5 Strip @ 10 tablet Tablet 5000
70 Ketroprofen supp 100 mg Dus, 10 Supp supp 100
71 Kloramfenikol salep kulit ( BUFACETIN ) Tube Tube 54
72 Kloramfenikol salep mata 1 % Tube 5 gr Tube 5000
73 Kloramphenikol 500 mg ( cloramex ) dos 100 tablet tablet 2000
75 klorpromazin tab/kap 100 mg HCL Dos @ 10 x 10's Tablet 200
76 Kodein tablet 10 mg ktk 10x10 tablet Tablet
78 Kombinasi Ferro Fumarat 60 mg + as.folat 0.4 mg dus 3 strip @ 10tsg Tablet
tab salut gula ( tablet tambah darah ) 5400
81 Kotrimoksazol DOEN I (dewasa) kombinasi : Dus, 10 Strip@10 Tablet Tablet
Sulfametoksazol 400 mg Trimetoprim 80 mg 5000
82 Kotrimoksazol Suspensi komb: Sulfametoksazol 200 Botol, 60 ml Botol
mg + Trimetoprim 40 mg / 5 ml 300

84 Larutan mengandung Elektrolit (Na 130 mEq, Cl 109 Plastic Bottle 500 ML Botol
mEq, Ca 3 mEq, Asetat 28 mEq) ( ASERING ) 300

87 Larutan mengandung Karbohidrat + Elektrolit (Nacl Plastic Bottle 500 ML Botol

1.75 gr, KCl 1.5 gr, Na Lactat 2.24 gr, Dekstrosa 27 200
gr) ( KAEN 3B )

89 Lidokain injeksi 2% (HCl) + Epinefrin 1 : 80.000 - 2ml Dus, 30 ampul @ 2 ml Ampul

1000
90 Loperamid tablet 2 mg Dus, 10 Strip @ 10 Tablet Tablet 3000
94 Metformin HCl tablet 500 mg Dus, 10 blister @ 10 tablet Tablet 3000
95 Metilergometrin Maleat injeksi 0,200 mg-1 ml ampul @ 1 ml Ampul 200
96 Metilprednisolon tablet 4 mg Dus, 10 Blister @ 10 Tablet Tablet 5000
97 Metoclopramid Inj Dus, 10 Ampul ampul 680
98 Metoklopramide sirup 5 mg/ 5 ml 9LEXAPRAM SYR ) BOTOL 60 ML Botol
100
99 Metoklopramide tablet 5 mg ktk 10 x 10 tablet Tablet 3000
101 Metronidazol tablet 500 mg 10 strip @ 10 tab Tablet 5000
103 Nacl 0,9% Botol 500 ml Botol 600
104 Natrium Diklofenak tablet 25 mg Dus @ 5 X 10 's Tablet 500
105 Natrium Diklofenak tablet 50 mg Dus @ 5 X 10 's Tablet 500
108 Ofloksasin tets telinga 3% Btl @ 5 ml Botol 10
109 Oksitosin injeksi 10 IU/ml ampul @ 1 ml Ampul 300
110 Omeprazol inj 40 mg/10 ml Ds, 10 Ampul ampul 130
111 Omeprazol kapsul 20 mg dus 10 X 3'S kapsul 1000
112 Ondansetron 4 mg Dus, 12 Tab tablet 1128
113 ondansetron inj 4 mg/ 2 mL Dus, 5 Ampul @ 2ml Ampul 500
114 Parasetamol sirup 120 mg / 5 ml botol 60 ml Botol 500
115 Parasetamol tablet 500 mg Dus, 10 Strip@10 Kaplet Tablet
Salut Selaput 30000
118 Pirantel pamoat 125 mg Dus,100 Tablet tablet 1100
119 Piridoksin (Vitamin B6) tablet 10 mg (HCl) KF dus, 10 strip @ 10 tablet Tablet 5000
120 Povidon Iodida larutan 10% 300 ml botol @ 300 ml Botol 50
121 Prednison tablet 5 mg Dus, 10 strip @ 10 tablet Tablet 15000
 124 Ranitidin injeksi 25 mg/ml Dus, 10 Ampul @ 2 ml Ampul 1000
125 Ranitidin tablet 150 mg Dus, 10 Strip @ 10 tablet Tablet
salut selaput 3000
126 Rifampisin kaplet 450 mg Dus, 10 strip @ 10 kapsul Kaplet 500
127 Rifampisin kapsul 300 mg Dus, 10 Strip @ 10 Kapsul kapsul 200
128 Ringer Laktat larutan infus botol 500 ml Botol 1400
130 Salbutamol tablet 2 mg (sebagai Sulfat) strip @ 10 tablet Tablet 3000
131 Salep 2-4 , Kombinasi : Asam Salisilat 2% + Belerang Pot @ 30 gram Pot
endap 4% 50
132 Sefadroksil kapsul/kaplet 500 mg Dus, 10 strip @ 10 kapsul Kapsul 25000
133 Sefadroksil sirup kering 125 mg/5ml Dus, Botol 60 ml Botol 300
136 Sefotaksim injeksi 1 g Dus, 10 Vial @ 1 g Vial 1000
137 Setirizin sirup 5 mg/5 ml Botol @ 60 ml Botol 100
138 Setirizin tablet 10 mg Box, 10 strips @ 10 capsules Tablet
1000
139 Sianokobalamin (vitamin B12) injeksi 500 mcg 100 ampul @ 1 ml Ampul 5000
140 Simvastatin 20 mg Dus,100 Tablet tablet 2200
141 Simvastatin scored tablet 10 mg Dus, 3 Strip @ 10 Kaplet salut Tablet
selaput 5000
143 Siprofloksasin tablet 500 mg (sebagai HCl) Dus, 10 blister @ 10 tab ss Tablet 10000
144 Spinorolakton 25 mg Dus,100 Tablet tablet 1100
147 Tetrasiklin kapsul 500 mg DUS,10 STRIP @ 10 KAPSUL Kapsul
5000
149 Thiamin tab 50 mg DUS, 100 TABLET Tablet 4500
150 Triheksifenidil 2 mg Dus,100 Tablet tablet 500
152 Vitamin B Kompleks tablet Dus 10 strip x 10 tab Tablet 5000
153 Zinc 20 mg Dus,100 Tablet tablet 1100
154 Zinc sir 10 mg/mL Dus, botol @ 100 ml Botol 50

ALAT PERBEKALAN KESEHATAN

155 Alat suntik sekali pakai 1 ml Dus, 100 biji biji 500
156 Alat suntik sekali pakai 3 ml Dus, 100 biji biji 6600
157 Alat suntik sekali pakai 5 ml Dus, 100 biji biji 5000
158 Alkacide 1l High Level Disinfectant Botol botol 1
159 Alkazyme Sachet 25 mg Sachet Sachet 1
160 Alkohol Swab Dus, 100 biji Dus 200
161 Catgut Benang Bedah Plain 3/0HR 20 /37 Dus, 24 sachet Dus 50
163 Dermafix s Blister Blister 500
164 ETAKRIDIN ( RIVANOL ) 300 ML Botol Botol 13
165 Etanol 70% cairan botol 1 liter Botol 30
171 Infusion Set anak Dus, 50 pcs pcs 100
172 Infusion Set dewasa Dus, 50 pcs pcs 150
173 Kapas Pemb. /Absorben 250 g Rol Rol 30
174 Kasa Pembalut Hidrofil 2 m x 80 cm Rol Rol 30
175 Kasa Pembalut Hidrofil 4 m x 5 cm Rol Rol 100
176 Kasa Pembalut Hidrofil 4m x 10 cm Rol Rol 50
177 Kasa PembalutHidrofil 4 m x 15 cm Rol Rol 50
178 Kasa Steril 16 x1 6 Dus,16 Pads Dus 100
179 LISOL 1 LITER Botol Botol 2
180 Masker Dus,50 pcs Dus 500
181 Masker Nebulizer Anak Dus,50 pcs pcs 65
182 Masker Nebulizer Dewasa Dus,50 pcs pcs 65
183 Medicut No. 18 Dus,50 pcs biji 50
184 Medicut No. 20 Dus,50 pcs biji 50
185 Medicut No. 22 Dus,50 pcs biji 50
186 Medicut No. 24 Dus,50 pcs biji 50
187 Nasal Oksigen anak Dus,50 pcs pcs 30
188 Nasal Oksigen bayi Dus,50 pcs pcs 30
189 Nasal Oksigen dewasa Dus,50 pcs pcs 30
190 One sept Solution Botol Botol 13
191 Oxigen Masker Anak Dus,50 pcs pcs 65
192 Oxigen Masker Dewasa Dus,50 pcs pcs 70
193 Plester 5 yards x 2 inch ( Pharmafix) Dus,6 Rol Rol 20
194 Silk (Benang Bedah Sutera)@ 36 3-0 Dus, 12 pcs Dus 20
195 Underpad Dus,10 pcs pcs 40
196 Urine Bag Dus, 10 pcs pcs 50

Bangkalan, Januari 2017

MENGETAHUI, PENGELOLA OBAT
KEPALA UPT DINAS KESEHATAN UPT DINAS KESEHATAN
PUSKESMAS GALIS PUSKESMAS GALIS

AGUS ANSORI SRI KURNIATI

NIP. 19660307 198703 1 010 NIP. 19630702 198703 2 005