LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

(LPLPO)
KODE PUSKESMAS :
NAMA PUSKESMAS :
KECAMATAN : BULAN :
KABUPATEN : TAHUN :
PROVINSI :

NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
OBAT - OBATAN :
1 ACYCLOVIR SALEP 5 % SALEP 0 0
2 ACYCLOVIR TABLET 200 MG TABLET 0 0
3 ACYCLOVIR TABLET 400 MG TABLET 0 0
4 ALLOPURINOL TABLET 100 MG TABLET 0 0
5 AMBROXOL SIRUP 30 MG/5 ML BOTOL 0 0
6 AMBROXOL TABLET 30 MG BOTOL 0 0
7 AMINOPHYLLINE INJEKSI 24 MG/ML AMPUL 0 0
8 AMINOPHYLLINE TABLET 200 MG TABLET 0 0
9 AMITRIPTYLINE TABLET 25 MG TABLET 0 0
10 AMLODIPINE TABLET 10 MG TABLET 0 0
11 AMLODIPINE TABLET 5 MG TABLET 0 0
12 AMOXYCILLIN SIRUP 125 MG/5 ML BOTOL 0 0
13 AMOXYCILLIN SIRUP 250 MG/5 ML BOTOL 0 0
14 AMOXYCILLIN SIRUP/DROPS 100 MG/ML BOTOL 0 0
15 AMOXYCILLIN TABLET 500 MG TABLET 0 0
16 ANTACIDA SUSPENSI 60 ML+B111 BOTOL 0 0
17 ANTACIDA TABLET TABLET 0 0

18 ANTI-FUNGI DOEN Kombinasi : ASAM BENZOAT SALEP 0 0

6% + ASAM SALISILAT 3%
19 ANTIHEMOROID DOEN SUPPOSITORIA 2 gr SUPPOSITORIA 0 0
20 AQUA PRO INJEKSI 25 ML BOTOL 0 0
21 ASAM ASKORBAT (VITAMIN C) 50 MG TABLET TABLET 0 0
22 ASAM FOLAT 1 MG TABLET 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
23 ASAM FOLAT 400 MG TABLET 0 0
24 ASAM MEFENAMAT TABLET 500 MG TABLET 0 0
25 ATORVASTATIN TABLET 10 MG TABLET 0 0
26 ATTAPULGITE TABLET 600 MG TABLET 0 0
27 BEDAK SALISIL SERBUK 2 % BOTOL 0 0
28 BETAHISTINE TABLET 6 MG TABLET 0 0
29 BETAMETHASONE SALEP 0.1% SALEP 0 0
30 BETAMETHASONE|GENTAMYCIN SALEP SALEP 0 0
31 BETAMETHASONE|MICONAZOLE SALEP SALEP 0 0
32 BISACODYL SUPPOSITORIA 10 MG SUPPOSITORIA 0 0
33 BISACODYL TABLET 5 MG TABLET 0 0
34 CALCIUM LACTAT TABLET 500 MG TABLET 0 0
35 CAPTOPRIL TABLET 12.5 MG TABLET 0 0
36 CAPTOPRIL TABLET 25 MG TABLET 0 0
37 CAPTOPRIL TABLET 50 MG TABLET 0 0
38 CARBAMAZEPINE TABLET 200 MG TABLET 0 0
39 CEFADROXIL SIRUP 125 MG/5 ML BOTOL 0 0
40 CEFADROXIL TABLET 500 MG TABLET 0 0
41 CEFIXIME TABLET 200 MG TABLET 0 0
42 CETIRIZINE SIRUP 1 MG/ML BOTOL 0 0
43 CETIRIZINE TABLET 10 MG TABLET 0 0
44 CHLORAMPHENICOL KAPSUL 250 MG KAPSUL 0 0
45 CHLORAMPHENICOL SALEP MATA 1% SALEP 0 0
46 CHLORAMPHENICOL TETES MATA 0.5% BOTOL 0 0
47 CHLORAMPHENICOL TETES TELINGA 3% BOTOL 0 0
48 CHLORPHENIRAMINE TABLET 4 MG TABLET 0 0
49 CHLORPROMAZINE HCL TABLET 100 MG TABLET 0 0
50 CIPROFLOXACIN HCl TABLET 500 MG TABLET 0 0
51 CLINDAMYCIN TABLET 150 MG TABLET 0 0
52 CLINDAMYCIN TABLET 300 MG TABLET 0 0
53 CLOBAZAM TABLET 10 MG TABLET 0 0
54 CLOZAPINE TABLET 100 MG TABLET 0 0
55 COTRIMOXAZOLE SIRUP 240 MG/5 ML BOTOL 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
56 COTRIMOXAZOLE TABLET 480 MG TABLET 0 0
57 DEXAMETHASONE 0.5 MG TABLET TABLET 0 0
58 DEXAMETHASONE INJEKSI 5 MG/ML AMPUL 0 0
59 DIAZEPAM ENEMA 5 MG/2.5 ML RECTAL TUBE TUBE 0 0
60 DIAZEPAM INJEKSI 5 MG/ML AMPUL 0 0
61 DIAZEPAM TABLET 2 MG TABLET 0 0
62 DIAZEPAM TABLET 5 MG TABLET 0 0
63 DIGOXIN TABLET 0.25 MG TABLET 0 0
64 DILTIAZEM TABLET 30 MG TABLET 0 0
65 DIPHENHYDRAMINE INJEKSI 10 MG/ML AMPUL 0 0
66 DOMPERIDONE SIRUP 5 MG/5 ML BOTOL 0 0
67 DOMPERIDONE TABLET 10 MG TABLET 0 0
68 DOXYCYCLINE TABLET 100 MG TABLET 0 0
69 EKSTRAK GINKGO BILOBA (TEBOKAN SPECIAL) TABLET 0 0
70 EPINEPHRINE INJEKSI 1 MG/ML AMPUL 0 0
71 ERYTHROMYCIN SIRUP 200 MG/5 ML BOTOL 0 0
72 ERYTHROMYCIN TABLET 250 MG TABLET 0 0
73 ERYTHROMYCIN TABLET 500 MG TABLET 0 0
74 ETIL KLORIDA SPRAY SPRAY 0 0
75 FUROSEMIDE TABLET 40 MG TABLET 0 0
76 GARAM ORALIT SERBUK SERBUK 0 0
77 GENTAMYCIN DROPS 0.3 % TETES MATA BOTOL 0 0
78 GENTAMYCIN SALEP 0.1 % TUBE 0 0
79 GENTIAN VIOLET LIQUID 1 % BOTOL 0 0
80 GLIBENCLAMIDE TABLET 5 MG TABLET 0 0
81 GLISERIL GUAIAKOLAT TABLET TABLET 0 0
82 GLUCOSE INFUS 5 % INFUS 0 0
83 GRISEOFULVIN TABLET 125 MG TABLET 0 0
84 HALOPERIDOL TABLET 1.5 MG TABLET 0 0
85 HALOPERIDOL TABLET 5 MG TABLET 0 0
86 HYDROCHLOROTHIAZIDE TABLET 25 MG TABLET 0 0
87 HYDROCORTISONE SALEP 2.5 % TUBE 0 0
88 HYOSCINE | PARACETAMOL TABLET TABLET 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
89 HYOSCINE TABLET 10 MG TABLET 0 0
90 IBUPROFEN SIRUP 100 MG/5 ML BOTOL 0 0
91 IBUPROFEN SIRUP 200 MG/5 ML BOTOL 0 0
92 IBUPROFEN TABLET 200 MG TABLET 0 0
93 IBUPROFEN TABLET 400 MG TABLET 0 0
94 ISOSORBIDE DINITRATE SUBLINGUAL 5 MG TABLET 0 0
95 KAOLIN|PECTIN TABLET TABLET 0 0
96 KETOCONAZOLE SALEP 2% TUBE 0 0
97 KETOCONAZOLE TABLET 200 MG TABLET 0 0
98 KETOROLAC INJEKSI 30 MG/ML AMPUL 0 0
99 LANSOPRAZOLE TABLET TABLET 0 0
100 LIDOCAINE INJEKSI 2% AMPUL 0 0
101 LIDOCAINE|EPINEPHRINE INJEKSI AMPUL 0 0
102 LOPERAMIDE TABLET 2 MG TABLET 0 0
103 LORATADINE TABLET 10 MG TABLET 0 0
104 MAGNESIUM SULFAT 20% (MgSO4 20%) BOTOL 0 0
105 MAGNESIUM SULFAT 40% (MgSO4 40%) BOTOL 0 0
106 MELOXICAM TABLET 7.5 MG TABLET 0 0
107 METAMIZOLE SODIUM INJEKSI 500 MG/ML AMPUL 0 0
108 METAMIZOLE SODIUM TABLET 500 MG TABLET 0 0
109 METFORMIN HCL TABLET 500 MG TABLET 0 0
110 METHYLERGOMETRINE INJEKSI 0.2 MG/ML AMPUL 0 0
111 METHYLERGOMETRINE TABLET 0.125 MG TABLET 0 0
112 METHYLPREDNISOLONE TABLET 4 MG TABLET 0 0
113 METHYLPREDNISOLONE TABLET 8 MG TABLET 0 0
114 METOCLOPRAMIDE TABLET 10 MG TABLET 0 0
115 METRONIDAZOLE 500MG|NYSTATIN 100.000UI OVULA 0 0
116 METRONIDAZOLE INFUS 5 MG/ML BOTOL 0 0
117 METRONIDAZOLE TABLET 250 MG TABLET 0 0
118 METRONIDAZOLE TABLET 500 MG TABLET 0 0
119 MICONAZOLE SALEP 2% TUBE 0 0
120 MINERAL MIX SERBUK 8 G SACHET 0 0
121 MULTIVITAMIN SIRUP 60 ML (IMBOOS) BOTOL 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
122 MULTIVITAMIN SIRUP 60 ML (PROCURMA) BOTOL 0 0
123 MULTIVITAMIN TABLET MG (BENOVIT) TABLET 0 0
124 MULTIVITAMIN TABLET MG (BEXCE) TABLET 0 0
125 NATRIUM DIKLOFENAK TABLET 25 MG TABLET 0 0
126 NATRIUM DIKLOFENAK TABLET 50 MG TABLET 0 0
127 NIFEDIPINE TABLET 10 MG TABLET 0 0
128 NYSTATIN TABLET OVULA 10000 IU TABLET 0 0
129 OBH SIRUP 100 ML BOTOL 0 0
130 OFLOXACIN TABLET 400 MG TABLET 0 0
131 OMEPRAZOLE KAPSUL 20 MG KAPSUL 0 0
132 ONDANSETRON INJEKSI 2 MG/ML AMPUL 0 0
133 OXYTETRACYCLINE 3 % SALEP KULIT TUBE 0 0
134 OXYTETRACYCLINE SALEP MATA 1 % (HCL) TUBE 0 0
135 OXYTOCIN INJEKSI 10 IU/ML AMPUL 0 0
136 PAPAVERINE TABLET 40 MG TABLET 0 0
137 PARACETAMOL DROPS 100 MG/ML BOTOL 0 0
138 PARACETAMOL ENEMA 125 MG/2.5 ML TUBE 0 0
139 PARACETAMOL SIRUP 120 MG/5 ML BOTOL 0 0
140 PARACETAMOL TABLET 500 MG TABLET 0 0
141 PERMETHRIN SALEP 5 % TUBE 0 0
142 PHENOBARBITAL TABLET 30 MG TABLET 0 0
143 PHYTOMENADIONE (VITAMIN K) INJEKSI AMPUL 0 0
144 PHYTOMENADIONE (VITAMIN K) TABLET 10 MG TABLET 0 0
145 PIRACETAM TABLET 400 MG TABLET 0 0
146 PIRIDOKSIN HCL ( VIT. B6 ) 10 MG TABLET 0 0
147 PIROXICAM TABLET 10 MG TABLET 0 0
PLACENTA EXTRACT|NEOMYCIN SULPHATE
148 TUBE 0 0
SALEP (BIOPLACENTON)
149 PREDNISONE TABLET 5 MG TABLET 0 0
150 PROPYLTHIOURACIL TABLET 100 MG TABLET 0 0
151 PSEUDOEPHEDRINE|CTM SIRUP 15 MG/1ML BOTOL 0 0
152 PSEUDOEPHEDRINE|TRIPROLIDINE |PARACETAMOL TA TABLET 0 0
153 PSEUDOEPHEDRINE|TRIPROLIDINE TABLET TABLET 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
154 PYRANTEL TABLET 125 MG TABLET 0 0
155 RANITIDINE INJEKSI 25 MG/ML AMPUL 0 0
156 RANITIDINE TABLET 150 MG TABLET 0 0
157 RETINOL (VITAMIN A) 100.000 UI KAPSUL 0 0
158 RETINOL (VITAMIN A) 200.000 UI KAPSUL 0 0
159 RINGER LAKTAT 500 ML BOTOL 0 0
160 RISPERIDONE TABLET 2 MG TABLET 0 0
161 RIVANOL / ETAKRIDIN 100 ML BOTOL 0 0
162 RIVANOL / ETAKRIDIN 300 ML BOTOL 0 0

163 SACCHARIN SODIUM|SODIUM CYCLAMATE TABLET 0 0

TABLET (PEMANIS)
164 SALBUTAMOL TABLET 2 MG (SEBAGAI SULFAT) TABLET 0 0
165 SALBUTAMOL TABLET 4 MG (SEBAGAI SULFAT) TABLET 0 0
SALEP 2-4 KOMBINASI: ASAM SALISILAT 2% +
166 POT 0 0
BELERANG ENDAP 4%
167 SIANOKOBALAMIN INJEKSI AMPUL 0 0
168 SIANOKOBALAMIN TABLET 50 MCG TABLET 0 0
169 SIMVASTATIN TABLET 10 MG TABLET 0 0
170 SIMVASTATIN TABLET 20 MG TABLET 0 0
171 SODIUM CHLORIDE INFUS 0.9 % BOTOL 0 0
172 THIAMINE (VITAMIN B1) 50 MG TABLET 0 0
173 THIAMPHENICOL TABLET 500 MG TABLET 0 0
174 TRAMADOL TABLET 50 MG TABLET 0 0
175 TRANEXAMIC ACID INJEKSI 50 MG/ML AMPUL 0 0
176 TRANEXAMIC ACID TABLET 500 MG TABLET 0 0
177 TRIHEXYPHENIDYL TABLET 2 MG TABLET 0 0
178 VAKSIN TETANUS TOXOID INJEKSI AMPUL 0 0
179 VITAMIN B COMPLEX TABLET 25 MG TABLET 0 0
180 ZINC SULFATE SIRUP 20 MG BOTOL 0 0
181 ZINC SULPHATE TABLET 20 MG TABLET 0 0
BAHAN MEDIS HABIS PAKAI : 0 0
182 ALAT SUNTIK 1 ML PIECES 0 0
183 ALAT SUNTIK 10 ML PIECES 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
184 ALAT SUNTIK 20 ML PIECES 0 0
185 ALAT SUNTIK 3 ML PIECES 0 0
186 ALAT SUNTIK 5 ML PIECES 0 0
187 ALKOHOL 70% 1 LITER BOTOL 0 0
188 ALKOHOL 70% 100 ML BOTOL 0 0
189 ALKOHOL SWAB PIECES 0 0
190 APRON ONE DISPOSABLE PIECES 0 0
191 BLOOD LANCET PIECES 0 0
192 CANULA NASAL OKSIGEN ADULT (L) PIECES 0 0
193 CANULA NASAL OKSIGEN INFANT (S) PIECES 0 0
194 CANULA NASAL OKSIGEN NEONATES (XS) PIECES 0 0
195 CANULA NASAL OKSIGEN PEDIATRIC (M) PIECES 0 0
196 CAT GUT CHROMIC NO.2/0 PIECES 0 0
197 CAT GUT CHROMIC NO.3/0 PIECES 0 0
198 FACE SHIELD PIECES 0 0
199 FOLLEY CATHETER NO. 18 PIECES 0 0
200 FOLLEY CATHETER NO. 20 PIECES 0 0
201 General Purpose DISINFECTANTS GALON 0 0
202 HIDROGEN PEROKSIDA (H2O2) 800 ML BOTOL 0 0
203 INFUSION SET DEWASA PIECES 0 0
204 INFUSION SET PEDIATRIC PIECES 0 0
205 IV CATHETER NO.18 PIECES 0 0
206 IV CATHETER NO.20 PIECES 0 0
207 IV CATHETER NO.22 PIECES 0 0
208 IV CATHETER NO.24 PIECES 0 0
209 KAPAS PEMBALUT 250 gr PIECES 0 0
210 KASA KOMPRES DRC 40cm x 40cm PIECES 0 0
211 KASA PEMBALUT HIDROFIL 3,6 M X 15 CM ROLL 0 0
212 KASA PEMBALUT HIDROFIL 4m x 3 cm ROLL 0 0
213 KASA STERIL 16 X 16 CM KOTAK 0 0
214 LYSOL CONCENTRATE 1 LITER BOTOL 0 0
215 MASKER (SURGICAL MASK) 3 PLY PIECES 0 0
216 MASKER HIJAB 3 PLY PIECES 0 0
NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13
217 MASKER N95 PIECES 0 0
218 PAPER TAPE 7,5 CM ROLL 0 0
219 PLESTER 2.5 CM X 4.5 M ROLL ROLL 0 0
220 POVIDONE IODINE 10% 300ML BOTOL 0 0
221 POVIDONE IODINE 10% 30ML BOTOL 0 0
222 RAPID TEST SARS COV ANTIGEN (COVID-19) TEST 0 0
223 RIVANOL / ETAKRIDIN 100 ML BOTOL 0 0
224 RIVANOL / ETAKRIDIN 300 ML BOTOL 0 0
225 SARUNG TANGAN NON STERIL NO.7 PASANG 0 0
226 SARUNG TANGAN NON STERIL NO.7,5 PASANG 0 0
227 SARUNG TANGAN NON STERIL UK. L PASANG 0 0
228 SARUNG TANGAN NON STERIL UK. M PASANG 0 0
229 SARUNG TANGAN STERIL NO. 7 PASANG 0 0
230 SARUNG TANGAN STERIL NO. 7.5 PASANG 0 0
231 SILK 3/0 HR 26 MM PIECES 0 0
232 STRIP ASAM URAT PIECES 0 0
233 STRIP GLUCOSA PIECES 0 0
234 STRIP TOTAL KOLESTEROL PIECES 0 0
235 UMBILICAL CORD KLEM STERILE NYLON PIECES 0 0
236 URINE BAG 2 LITER PIECES 0 0
0 0
0 0
0 0
0 0
0 0

ASKES JAMKESMAS JUMLAH

JUMLAH KUNJUNGAN RESEP TIDAK BAYAR

Mengetahui, .............................., ........ ......................... 20...

Kepala Puskesmas ................................... Yang Membuat Laporan
 NO NAMA OBAT SEDIAAN STOK AWAL PENERIMAAN PERSEDIAAN PEMAKAIAN RUSAK/ED SISA STOK STOK OPT PERMINTAAN PEMBERIAN KET

1 2 3 4 5 6=(4+5) 7 8 9=(6-7-8) 10 11 12 13

__________________________ _____________________________

*Kalo ada yang tidak masuk dalam daftar obat di atas, tambahkan di dalam kolom kosong di bawah