form_lplpo_13LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT (LPLPO)PUSKESMAS/BALAI KESEHATANMohon dibuat rangkap tiga (3) setPUSKESMAS :PELAPORAN BULAN/PERIODE : DOKUMENNOMOR/KODETANGGALKECAMATAN :PERMINTAAN BULAN/PERIODE: UPKF/UPKF/TU.4/ /..................................KAB/KODYA : BanyumasPUSKESMAS ............................. ..................................DAFTAR DISUSUN BERDASARKAN KELAS TERAPINONAMA OBATSATUANSTOKPENERIPERSEPEMASISASTOKPERMINTAANPEMBERIANNOMOR BATCHKETERANGAN (Diisi Waktu Kosong, bila ada)AWALMAANDIAANKAIANSTOKOPTMLDAN ED123456789=(7+25%)10=(9-8)111213 (Waktu kosong)01ANTI INFEKTIVES1AMOKSILIN SYR KERBOTOL2AMOKSILLIN KAP 500 MGTABLET3AMOXICLAV TABTABLET4AMPISILIN INJ IM/IV 1000MG/MLVIAL5BENZATIN BENZIL PENISILIN 2,4 JUTA IU/VIALVIAL6CIPROFLOXACIN 500 MGTABLET7DOXICICLIN 100 MGCAPSUL8ERYTROMISIN SYRUP 200 MG/5MLBOTOL9ERYTROMISIN 500 MGTABLET10GENTAMISIN INJEKSI 80 MG/2MLAMPUL11KLINDAMYCIN 300 MGCAPSUL12KLORAMFENIKOL SUSPENSIBOTOL13KLORAMFENIKOL KAPS 250 MGCAPSUL14KOTRIMOKSAZOL SUSPENSI 60 MLBOTOL15KOTRIMOKSAZOL 480 MGTABLET16LEVOFLOKSASIN 500 MGTABLET17LINKOMISIN 500 MGCAPSUL18OFLOXACIN 400 MGTABLET19OKSITETRASIKLIN INJVIAL20SEFADROKSIL 500 MGCAPSUL21SEFADROXIL SIR 125 MG/5MLBOTOL22SEFIKSIM 100 MGCAPSUL23SEFOTAKSIM INJEKSI 1GR/VIALVIAL24SEFTRIAKSON SERB INJ 1G/VIALVIAL25SULFADIMIDIN 500 MGTABLET26TETRASIKLIN HCL 500 MGCAPSUL27THYAMPHENICOL 500 MGTABLET02ANTI FUNGI28ANTIFUNGI DOENPOT29FLUKONAZOL 150 MGTABLET30GRISEOVULFIN 125 MGTABLET31KETOKONAZOL 200 MGTABLET32KETOKONAZOL CREAM 2%TUBE33METRONIDASOL 500 MGTABLET34MICONASOL CREAMTUBE35NISTATIN 100.000 IUTABLET36NISTATIN 500.000 IUTABLET03ANTIVIRAL37ACICLOVIR 200 MGTABLET38ACICLOVIR 400 MGTABLET39ACICLOVIR CREAMTUBE04ANTIMALARIA40ARTESUNATE INJEKSIAMPUL41ARTESUNATE+AMODIAQUIN TABTABLET42ARTHEMETER INJEKSIAMPUL43KOMB PIRIMETAMIN 25 MG+SULFADOTABLET44KUININE Hydrochlorida injAMPUL45KUININE 222 MGTABLET46PRIMAKINA 15 MGTABLET05DERMATOLOGICAL-ANTIINFECTIVES47ANTIBAKTERI DOEN (BACITHRACIN)TUBE48GENTAMISIN SALEP KULITTUBE49OKSITETRASIKLIN HCL SKTUBE06DERMATOLOGICAL- CORTICOSTEROID50BETAMETASON CREAMTUBE51HIDROKORTISON KRIM 1%TUBE52HIDROKORTISON KRIM 2,5%TUBE07TBC PREPARATION53ETAMBUTOL HCL 250 MGTABLET54ISONIAZIDA 100 MGTABLET55ISONIAZIDA 300 MGTABLET56OAT/FDC KATEGORI ANAKPAKET57OAT/FDC KATEGORI IPAKET58OAT/FDC KATEGORI IIPAKET59OAT/FDC SISIPANPAKET60OAT KATEGORI I DEWASAPAKET61PIRAZINAMIDA TAB 500 MGTABLET62RIFAMPICIN 450 MGTABLET63RIFAMPISIN 300 MGCAPSUL64RIFAMPISIN 600 MGTABLET08ANALGETIC-ANTIPIRETIC65ACETOSAL 100 MGTABLET66ANTALGIN 500 MGTABLET67ANTALGIN INJAMPUL68PARACETAMOL 500 MGTABLET69PARACETAMOL SYRBOTOL70PARASETAMOL DROPBOTOL71TRAMADOL 50 MGCAPSUL72TRAMADOL INJAMPUL09ANTACIDA73ANTASIDA DOEN 500 MGTABLET74ANTASIDA DOEN SUPENSIBOTOL75NATRIUM BIKARBONAT 500 MGTABLET10ANTHELMINTIC76ALBENDAZOL TAB 400 MGTABLET77ALBENDAZOL SUSPENSI 200 MG/5 MLBOTOL78DIETILKARBAMAZEPIN SITRATTABLET79MEBENDAZOL 100 MGTABLET80MEBENDAZOL SYRBOTOL81PYRANTEL PAMOAT 125 MGTABLET11ANTI ANEMIA82BESI II SULFAT 300 MGTABLET12ANTI ASMATHIC83AMBROXOL 30 MGTABLET84AMBROXOL SYRUP 15 MG/MLBOTOL85AMINOPHYLLIN 200 MGTABLET86AMINOPHYLLIN INJEKSIAMPUL87EPHEDRIN 25 MGTABLET88SALBUTAMOL 2 MGTABLET89SALBUTAMOL 4 MGTABLET90SALBUTAMOL SYRUP 2 mg/5 mlBOTOL13ANTI DIABETIC91GLIBENKLAMID 5 MGTABLET92METFORMIN 500 MGTABLET14ANTI KHOLESTEROL93SIMVASTATIN 10 MGTABLET15ANTI DIARREHEAL94LOPERAMID HCl 2 MGTABLET95ZINC 20 MGTABLET16ANTI PARKINSONISM96ANTI PARKINSON DOENTABLET97TRIHEXYPENIDRIL 2 MGTABLET17ANTIHIPERTENSI98AMLODIPIN 5 MGTABLET99CAPTOPRIL 12,5 mgTABLET100CAPTOPRIL 25 mgTABLET101CAPTOPRIL 50 MGTABLET102CLONIDIN 0,15 MGTABLET103FUROSEMID 40 MGTABLET104FUROSEMID INJAMPUL105HIDROKLOROTIASIDA (HCT)TABLET18CARDIOVARCULAR PREP106DIGOKSINTABLET107DILTIAZEM HCL 30 MGTABLET108ISOSORBID DINITRATTABLET109NIFEDIPIN 10 MGTABLET110RESERPIN TAB 0,25 MGTABLET19CORTICOSTEROID111DEXAMETHASON 0,5 MGTABLET112DEXAMETHASON 5 MG/ML INJAMPUL113METHYLPREDNISOLON 4 MGTABLET114PREDNISON 5 MGTABLET20ANTI HISTAMINES115CETIRIZINE SYRUP 5 MG/5MLBOTOL116CETIRIZINE 10 MGCAPSUL117DIFENHIDRAMIN INJEKSIAMPUL118KLORFENIRAMINE MALEAT (CTM 4 MG)TABLET119LORATADINE 10 MGTABLET21EXPECTORANT & ANTITUSIVE120DEKSTROMETHORPHAN HBr 15 MGTABLET121DEKSTROMETHORPHAN HBr SYRBOTOL122GLYSERIL GUAIAKOLAT 100 MGTABLET123OBAT BATUK HITAM 100 MLBOTOL22GIT-ANTIEMETIC124DIMENHYDRINAT 50 MGTABLET125DOMPERIDONE SUSPENSI 5MG/5MLBOTOL126DOMPERIDONE TABLETTABLET127IPEKA SYRUPBOTOL128METOCLOPRAMIDE 10 MGTABLET23GIT-ULCER129CIMETIDIN 200 MGTABLET130LANZOPRAZOL 30 MGCAPSUL131OMEPRAZOL 20 MGCAPSUL132RANITIDIN INJEKSI 25 MGAMPUL133RANITIDIN TAB 150 MGTABLET24GIT-DISORDERS134ATROPIN SULFAT INJEKSIAMPUL135ATROPIN SULFAT 0,5 MG TABLETTABLET25GOUT PREPARATION136ALLOPURINOL 100 MGTABLET26LOCAL ANAESTHETIC137LIDOCAIN COMP INJEKSI KOMB.AMPUL138LIDOKAIN INJ 2%AMPUL27NSAID139ASAM MEFENAMAT 500 MGTABLET140IBUPROFEN 100 MG/5 ML SUSPENSIBOTOL141IBUPROFEN 200 MGTABLET142IBUPROFEN 200 MG/5 ML SUSPENSIBOTOL143IBUPROFEN 400 MGTABLET144KETOPROFEN INJ 100 MG/2 MLAMPUL145MELOKSIKAM 15 MGTABLET146NATRIUM DIKLOFENAK 50 MGTABLET147PIROKSIKAM 10 MGTABLET148PIROKSIKAM 20 MGTABLET28PSICOTROPICS149AMITRIPTILINA 25 MGTABLET150CLORPROMASIN 25 MGTABLET151DIAZEPAM 5 mgTABLET152DIAZEPAM 2 MGTABLET153DIAZEPAM INJ 5 MG/MLAMPUL154HALLOPERIDOL 0,5 MGTABLET155KLORPROMAZIN INJ 5MG/ML-2MLAMPUL29TRASSQUILIZER156FENOBARBITAL 30 MGTABLET157FENOBARBITAL INJAMPUL158PIRACETAM 1200 MGTABLET159PIRACETAM INJ 1 GRAMPUL160PIRACETAM INJEKSI 3 GRAMPUL30VITAMIN161ASAM ASCORBAT 50 MGTABLET162ASAM ASKORBAT 250 MGTABLET163ASAM FOLAT 1 MGTABLET164PIRIDOKSIN (VIT B6)TABLET165THIAMIN HCL INJ 100 MG/MLAMPUL166VITAMIN B 12 INJ 500 MCG/MLAMPUL167VITAMIN A 100.000 IUCAPSUL168VITAMIN A 200.000 IUCAPSUL169VITAMIN B KOMPLEKSTABLET170VITAMIN B1 TAB 50 MGTABLET171VITAMIN B12 TABTABLET172VITAMIN K 10 MGTABLET173VITAMIN K INJAMPUL31OFTAMOLOGIKUM174ATROPIN SULFAT TM 0,5%BOTOL175GENTAMISIN SULFAT TM 0,3%BOTOL176KLORAMFENIKOL 1% SALEP MATATUBE177KLORAMFENIKOL 0,5% TETES MATABOTOL178NATRIUM FLOURESEIN TM 2%BOTOL179OKSITETRASIKLIN 1% SALEP MATATUBE180PILOKARPIN HCL NITRAT T.MBOTOL181SULFACETAMID TETES MATABOTOL32OTOLOGIKUM182FENOL GLYSEROL TETES TELINGA 10%BOTOL183KLORAMFENIKOL 3% TETES TELINGABOTOL33ANTI VERTIGO184BETAHISTIN MESILAT 6 MGTABLET34ANTI HEMOROID185ANTI HEMOROID SUPPOSITORIASUPPO35ANTI MIGREN186ERGOTAMIN CAFFEINTABLET36LARUTAN INFUS187DEXTRAN 70 LARBOTOL188GLUKOSA LAR INFUS 10%BOTOL189GLUKOSE 5 %BOTOL190NATRIUM KLORIDA 0,9% INFUSBOTOL191RINGER LAKTATBOTOL37OBAT KULIT LAIN1922-4 SALEPPOT193KALIUM PERMANGANAT SERBUKPOT194LEVERSTAN SALEPPOT195SALISIL TALKBOTOL38OBAT BISUL196ICHTIYOL SALEPPOT39OKSITOSIKUM197METILERGOMETRIN 0,2 MG/ML INJEKSIAMPUL198METILERGOMETRIN 0,125 MGTABLET199OKSITOSIN 10 IU/ML INJEKSIAMPUL40LARUTAN UNTUK LUKA200ETANOL 70%BOTOL201RIVANOL / ETAKRIDINBOTOL202YODIUM POVIDON 300 MLBOTOL41ANTI EPILEPTIKUM/ANTIKONVULSI203NATRIUM FENITOIN 30 MGTABLET42SERUM204ATS 1500 IUAMPUL205SERUM ABU INJ 5 MLVIAL43OBAT SARIAWAN206GENTIAN VIOLETPOT44ORALIT207GARAM ORALIT 200 ML AIRSACHET45LAIN-LAIN208AQUA PRO INJVIAL209EPINEPRIN INJAMPUL210EXTRAC BELLADONTABLET211FLOUR TAB 0,5 MGTABLET212GLISEROL /GLISERILBOTOL213IODIOL KAPSUL LUNAKCAPSUL214KALIUM KLORIDATABLET215KALSIUM LAKTAT 500 MGTABLET216LISOLBOTOL217MgSO 40%BOTOL218MINERAL MIXSACHET219NATRIUM THIOSULFAT INJ 25% 10MLVIAL220PAPAVERIN TABLETTABLET221PARAFORMALDEHIDTABLET222PROPILTHIOURACIL 100 MGTABLET223TABURIASACHET46ALAT KESEHATAN224BISTURI NO.22BUAH225CAT GUT NO 2/0SACHET226CAT GUT NO. 3/0SACHET227DISPOSIBLE 3 CCPCS228DISPOSIBLE SPUIT 1CCPCS229DISPOSIBLE SPUIT 2,5 CCPCS230DISPOSIBLE SPUIT 5 CCPCS231FILM X-RAY 24X30 CMBOX232FILM X-RAY 30X40 CMBOX233FILM X-RAY 35X35 CMBOX234FIXER DEVELOPER FILMSET235FOLEY CATH TWO WAY 16PCS236FOLEY CATH TWO WAY 18PCS237FOLEY CATH TWO WAY 20PCS238HANDSCOEN NO. 7,5PASANG239HANNSCOEN NO. 6,5PASANG240HANSCOEN NO.7PASANG241HYPAFIKROL242INFUSET ANAKSET243INFUSET DEWASASET244IV CATHETER NO. 18SET245IV CATHETER NO. 20SET246IV CATHETER NO. 22SET247IV CATHETER NO. 24SET248JARUM JAHIT NO. 22 DAN 23SAK/12249JARUM SUNTIK 23 GBIJI250KASA 2 M X 80 CMROL251KAPAS 250 GRAMBKS252KAPAS BERLEMAK 500 GRBKS253KASA 5 CMROL254KASA 10 CM X 4 MROL255KASA 3 X 4ROL256KASA 40 X 40BIJI257KASA HID STERIL UK 18 X 22 CMKOTAK258KASA HIDR STERIL 16 X 16KOTAK259KASA HIDROFIL UK 36M X 80CMROL260KASA HYDROFIL 4 X 15ROL261LANCETBOX262MASKERPCS263OBYEK GLASSBOX264PEMBALUT GIBSROL265PLESTER 5 YARD X 1 INCHIROL266PLESTER 5 YARDX 2 INCHROL267SAVETY BOXBUAH268SILK 2/0SACHET269SILK 3/0SACHET270SPUIT IMUNISASI 0,5ML 23GPCS271SPUIT IMUNISASI BCG 0,05 26GPCS272SPUTUM POTBUAH273URINE BAGPCS274VACCINE CARRIERBUAH275WING NEEDLE NO 25GSET276WING NEEDLE NO. 23SET47OBAT GIGI277AIR RAKSA DENTAL USEBOTOL278ALBOTHYL CONCENTRATEBOTOL279BETADINE KUMURBOTOL280CAVITON / SEMENSET281CHKMBOTOL282CRESOPHEN / ENDOSEPTONSET283DEVITALISASI PASTABOTOL284ETHYLKLORIT SEMPROTBOTOL285EUGENOL CAIRAN 10 MLBOTOL286GLASS ISOMER CEMENT (GC 1 X)SET287KALSIUM HIDROKSIDA PASTATUBE288MUMFYING PASTABOTOL289SEMEN SENG POSPAT SER+CASET290SILVER AMALGAMBOTOL291SPON GELATINBUAH292T K FSET293TEMPORARY STOPING (Fletcher)SET48LARUTAN LABORATORIUM294AQUABIDESTBOTOL295ASAM KLORIDA 0,1 NBOTOL296ASAM SULFOSALISILATBOTOL297GIMSA STAINBOTOL298KAPORIT 1 KGBOTOL299LARUTAN BENEDICTBOTOL300LARUTAN EOSIN 2 %BOTOL301LARUTAN GABBETBOTOL302LARUTAN KARBON FUSCHINBOTOL303LARUTAN KINYOUNBOTOL304LARUTAN METILEN BIRUBOTOL305LARUTAN TURKBOTOL306METANOLBOTOL307OIL IMERSIBOTOL308PERHYDROLBOTOL309REAGEN ZIEHL NEELSENSET310SPIRTUSBOTOL49OBAT PATEN NON GENERIK311RECOVIT SIRUPBOTOL312MOLAGITTABLET313NEO KAOMINALBOTOL314MOLEX FLUTABLET315NEOCENTA GELTUBE316ZINKID SIRUPBOTOL317NOPROSTOLTABLET318DUMIN REKTALTUBE319SCABICID CREAMTUBE320LAXANATABLETU M U MJUMLAHJUMLAH KUNJUNGAN RESEPBAYARTDK BAYARASKESMengetahuiYang menyerahkan,Yang meminta/memesanPetugas/Pengelola Obat PuskesmasKepala Unit Perbekalan Alkes dan FarmasiPetugas Gudang UPKFKepala Puskesmas Drs. Soni Arsono, Apt M.KesLeny Andayani, Amd FarNIP. 19660509 199303 1 006NIP. 19770821 200112 2 002NIP. NIP. .

&L&8&F&CPage-&P

blangko_pkoPERMINTAAN KEKURANGAN OBAT (PKO)PUSKESMAS : KEBASENDOKUMENNOMOR/KODETANGGALKECAMATAN : KEBASENUPKF/UPKF/TU.4/ /KAB/KODYA : BanyumasPUSKESMAS...NONAMA OBATSATSTOK AWALPENERI MAANPERSE DIAANPEMAKAIANSISAWAKTU KOSONGKEKURANGANPERMINTAAN KEKURANGANKETERANGANBULAN/MINGGUMINGGUOBAT123456=(4+5)789=(6-8)101112131Ethylklorit Semprot (276)Botol00012001222Kapas 250 Gram (243)Bks00012001223Disposible 3 cc (219)Buah500.05012500121004Disposible 5 cc (222)Buah1600.0160121600121005Infus set anak (234)Set0.0100100121000121006Infus set dewasa (235)Set0.0300300123000121007IV Catheter No 22 (238)Set0.00.00120.00121008IV Catheter No 24 (239)Set0.00.00120.0012100Purwokerto,30 Nopember 2013Petugas Pengelola Obat PuskesmasYang meminta/memesanKepala PuskesmasNani NurrohmahDr.Tri Lesrari KNIP.19691215 199003 2 006NIIP.19700909 200212 2 004PERMINTAAN KEKURANGAN OBAT (PKO)PUSKESMAS : KEBASENDOKUMENNOMOR/KODETANGGALKECAMATAN : KEBASENUPKF/UPKF/TU.4/ /KAB/KODYA : BanyumasPUSKESMAS440/03/20141/7/14NONAMA OBATSATSTOK AWALPENERI MAANPERSE DIAANPEMAKAIANSISAWAKTU KOSONGKEKURANGANPERMINTAAN KEKURANGANKETERANGANBULAN/MINGGUMINGGUOBAT123456=(4+5)789=(6-8)101112131FILM X-RAY 24X30 CM (223)BOX0000001212FILM X-RAY 30X40 CM (224)BOX0000001213FILM X-RAY 35X35 CM (225)BOX0.00.000.00.001214FIXER DEVELOPER FILM (226)SET0.00.000.00.001215006007008000000000000000000000000000Purwokerto,07 Januari 2014Petugas Pengelola Obat PuskesmasYang meminta/memesanKepala PuskesmasNani NurrohmahDr.Tri Lesrari KNIP.19691215 199003 2 006NIIP.19700909 200212 2 004