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SKPD : PUSKEMAS KRAMATWATU

KABUPATEN : SERANG
PROVINSI : BANTEN

LAMPIRAN I : BERITA ACARA PEMERIKSAAN PERHITUNGAN SISA PERSEDIAAN BARANG PAKAI HABIS
PER 31 DESEMBER 2016
-
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
Alat Suntik 1 ml Set 354 801 283,554 1,000 1,354 - 801
1
2 Alat suntik 20 ml Set 125 6,400 800,000 - 125 - 6,400

3 Alat Suntik 3 ml Set 195 957 186,615 4,000 3,525 670 957

4 Alat suntik 5 ml set 830 1,150 954,500 200 855 175 1,348

5 Albendazole Tablet 30 338 10,140 3,960 3,930 60 338

6 Allopurinol 100 mg Tablet 274 86 23,564 800 1,074 - 91

7 Ambroxol sirup 15 mg/ml Botol - - - 900 715 185 3,297

8 Ambroxol tablet 30 mg Tablet - 125 - 17,500 16,406 1,094 125

9 Aminophilin 200 mg Tablet 772 80 61,760 - 772 - 80

10 Aminophilin inj Ampul 5 3,822 19,110 - 2 3 3,345

11 Amitriptillin tab 25 mg 708 115 81,420 - 708 -


Tablet 115
12 Amlodipin - 187 - - - -
Tablet 187
13 Amlodipin 10 mg - 187 - 990 981 9
Tablet 148

1
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
14 Amoxicillin Inj Vial 2 7,500 15,000 19 16 5 7,500

15 Amoxicillin Syrup Forte 250 mg/ml Botol 140 4,045 566,300 2,150 2,283 7 4,045

16 Amoxisilin 125 mg syr Botol 4 2,445 9,780 288 290 2 2,090

17 Amoxisilin 250 mg Kapsul 535 211 112,885 6,000 2,794 3,741 195

18 Amoxisilin 500 mg Kapsul 5,340 261 1,393,740 78,300 75,992 7,648 232

19 Ampicillin 1 gr injeksi Ampul 5 5,100 25,500 20 12 13 5,100

20 Antalgin 500 mg Tablet 1,052 149 156,748 12,000 12,837 215 149

21 Antasida Doen Tablet 4,975 72 358,200 31,000 32,633 3,342 62

22 Antasida Doen Sirup Botol 226 2,140 483,640 800 938 88 2,025

23 Anti vertigo (Betahistin maleat) Tablet 134 660 88,440 1,380 1,449 65 149

24 Antibakteri Doen Salep Tube 25 2,516 62,900 100 125 - 2,516

25 Antihaemoroid Doen Komb. Supp Supp 32 2,450 78,400 151 159 24 3,045

26 Antimigrain Doen Komb. Tablet 143 135 19,305 - 143 - 135

27 Aqua Pro inj Steril 20 ml Ampul 53 2,200 116,600 140 142 51 2,200

28 Artesunate inj Ampul - 25,063 - - - - 25,063

29 Asam Aselilsalisilat 100mg Tablet 300 100 30,000 100 300 100 100

30 Asam Askorbat 250 mg Tablet 385 159 61,215 6,200 5,512 1,073 159

31 Asam Askorbat 50 mg 213 19 4,047 2,900 2,275 838


Tablet 104

2
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
32 Asam Mefenamat 500 mg Tablet - 112 - 21,400 20,065 1,335 106

33 Asam Traneksamat inj 250 mg / ml Ampul - 6,600 - - - - 6,600

34 Asering 500 cc Botol - 9,000 - - - - 9,000

35 Asiclovir 400 mg 522 336 175,392 1,400 1,306 616


Tablet 349
36 Asiclovir cream 57 2,998 170,858 350 377 30
Tube 2,998
37 Atrofin Sulfat inj 0,25 mg / ml 18 1,265 22,770 30 48 -
Ampul 1,265
38 Attapulgit 600 mg Tablet 532 190 101,080 3,900 4,432 - 190

39 Azythromycin 500 mg Tablet - 4,500 - - - - 4,500

40 Benzatin Benzilpenisillin 1,2 Juta IU/Vial - 9,800 - 2 2 -


Vial 9,800
41 Betamethason Krim 2 1,520 3,040 - 2 -
Tube 1,520
42 Bisacodyl - 764 - - - -
Tablet 764
43 Bisturi pcs 59 6,600 389,400 100 116 43 6,600

44 Ca glukonas Vial 82 10,425 854,850 24 95 11 9,955

45 Calsium Hidroksida Pasta (Dorident) Set - 231,000 - 2 2 - 231,000

46 Captopril 12,5 mg Tablet 1,736 62 107,632 5,100 6,662 174 62

47 Captopril 25 mg Tablet 907 84 76,188 8,100 8,836 171 68

48 Cat- Gut/Benang Bedah 66 5,583 368,498 408 452 22


Set 5,583
49 Cefadroxil 250 mg syr - - - -
Botol

3
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
50 Cefadroxyl sirup kering 125mg/ml Botol 35 4,746 166,110 150 147 38 4,746

51 Cefadroxyl 500 mg Kapsul 200 509 101,800 1,000 1,100 100 509

52 Cefixime 100 mg Kapsul - 859 - 60 60 -


Kapsul 859
53 Cendo Lyteers 8 15,750 126,000 30 29 9
Botol 15,750
54 Cetirizine 451 188 84,788 700 1,104 47
Tablet 188
55 Cetirizine 5 mg/5 ml Syrup 60 ml - - 100 20 80
Botol 2,850
56 Cimetidine 200 mg Tablet 96 108 10,368 - 96 - 108

57 Clobazam 10 mg Tablet - 760 - - - - 760

58 Clozapine Tablet - 2,475 - - - - 2,475

59 Composit (Diafil) Tube - 308,000 - 5 5 - 308,000

60 Cresophene Botol - 572,000 - 4 4 - 572,000

61 Deksametason 0,5 mg Tablet 3,087 62 191,394 49,500 47,783 4,804 62

62 Deksametason inj 5 mg Ampul 376 1,580 594,080 - 154 222 1,580

63 Devitalisasi pasta (non arsen) Botol 331,100 - - - - 331,100

64 Dextrose 40% inj Ampul 316 1,452 458,832 - 316 - 1,452

65 Diazepam inj 5 mg / ml Ampul 14 872 12,208 - 14 - 872

66 Diazepam rektal 5mg /2.5 ml (Stesolid) Tube - - 24 16 8 11,525

67 Dietylcarbamazin Sitrat 100 mg Tablet - 89 - 300 300 - 89

4
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
68 Difenhidramin HCL inj 10 mg/ml Ampul 30 960 28,800 30 43 17 1,176

69 Digoksin 0,25 mg Tablet 80 97 7,760 100 87 93 105

70 Diltiazem HCl 30 mg Tablet 120 134 16,080 100 20 200 127

71 Doksisiklin 100 mg Capsul - 230 - 200 - 200 269

72 Domperidon susp 5mg/ml Botol 111 3,624 402,264 450 378 183 3,000

73 Domperidone tab Tablet 501 167 83,667 8,400 7,986 915 118

74 Ekstraks Belladona tab 10 mg - 38 - - - -


Tablet 38
75 Epinefrin HCL inj 0,1%-1 ml Ampul 58 1,240 71,920 30 46 42 1,240

76 Erythromycin 500 mg Tablet Salut Tablet 232 930 215,760 - 232 - 730

77 Erytromisin syr Botol 27 7,500 202,500 242 226 43 7,700

78 Etakridin ( Rivanol ) 0.1% Botol 9 2,550 22,950 5 10 4 2,550

79 Etanol 70% - 1.000 ml - 21,500 - 24 15 9


Botol 21,500
80 Etanol 70% - 100 ml Botol 87 2,500 217,500 144 174 57 2,500

81 Etilklorida Semprot - 100 ml Botol 2 77,000 154,000 - 2 - 77,000

82 Eugenol cairan Botol 16,667 - 2 1 1 18,100

83 FDC KAT II 1 1,199,990 1,199,990 3 4 -


Paket 1,199,990
84 FDC Kat. I 26 359,990 9,359,740 96 116 6
Paket 359,990
85 Fenobarbital inj Ampul 1,560 - - - - 1,560

5
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
86 Fenol Glicerol TT Botol 111 2,042 226,662 24 87 48 2,042

87 Fitomenadion 10 mg Tablet 377 634 239,018 600 570 407 695

88 Fitomenadion inj 10 mg / ml Ampul - 978 - - - - 978

89 Fluconazole 150 mg Tablet - 22,000 - - - - 22,000

90 Fluoxetine 10 mg Tablet - 1,166 - - - - 1,166

91 Fluphenazine Decanoate Ampul - 55,000 - 10 5 5 55,000

92 Foley Catheter Pcs 22 16,500 363,000 - 22 - 16,500

93 Furalex Tablet - - - -

94 Furosemida 40 mg Tablet 300 75 22,500 100 242 158 75

95 Furosemida inj 10 mg/ml Ampul - 1,829 - 25 5 20 2,058

96 Garam Oralit 200 ml 2,331 288 671,328 9,900 9,426 2,805


Sachet 264
97 Gentamisin TT 2% tube - - - - -

98 Gentamycine inj Ampul - 3,696 - - - - 3,696

99 Gentamycine salep kulit 0,1 % 2 1,835 3,670 430 429 3


Tube 1,835
100 Gentamysin tetes mata 3 3,194 9,582 - 3 -
Botol 3,194
101 Glass Ionomer Semen Set - 385,000 - - - - 385,000

102 Glibenklamid 5 mg - 60 - 500 500 -


Tablet 87
103 Gliseril Guaiacolat 100 mg Tablet - 28 - 61,000 52,281 8,719 28

6
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
104 Glucosa 5% Botol 33 5,200 171,600 320 303 50 5,200

105 Glukosa 10 % Botol 30 5,700 171,000 - 2 28 7,500

106 Griseovulfin 125 mg Tablet 286 200 57,200 700 986 - 200

107 Haloperidol 5 mg Tablet - 96 - 300 - 300 96

108 Haloperidol decanoat Ampul - 128,460 - - - - 128,460

109 Haloperidol inj Ampul 24 12,155 291,720 - 24 - 12,155

110 Hand schoon non steril Kotak 3 32,500 97,500 77 80 - 32,500

111 Handscrub (Cutisoft) Botol - 85,800 - 17 16 1 85,800

112 Hidrocortison Cream 2,5% Tube 69 2,798 193,062 576 622 23 2,650

113 Hidroklortiazid (HCT) Tablet - - 500 214 286 36

114 Hyoscine-N-Butilbromide 20 mg/ml inj Ampul 17 7,700 130,900 20 37 - 7,700

115 Hyoscine-N-Butilbromide 10 mg Tablet 528 2,145 1,132,560 700 1,228 - 1,472

116 I.V catheter no : 18 Pcs - 7,480 - 405 345 60 8,355

117 I.V catheter no : 20 Pcs 39 8,750 341,250 310 287 62 8,355

118 I.V catheter no : 24 Set 80 7,780 622,400 200 224 56 8,355

119 I.V Catheter no 26 Set 33 4,100 135,300 100 117 16 21,065

120 I.V Catheter No.22 Tablet 35 8,750 306,250 430 359 106 8,355

121 Ibuprofen 200 mg 953 110 104,830 900 1,850 3


Tablet 110

7
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
122 Ibuprofen 400 mg Set 595 149 88,655 5,100 4,845 850 127

123 Infus Set Anak Set 41 17,670 724,470 285 252 74 10,406

124 Infus Set Dewasa Tablet 143 17,391 2,486,913 1,000 1,013 130 7,321

125 Isosorbit Dinitrat 5 mg Set 100 88 8,800 400 300 200 88

126 IV. Catheter no. 16 Pcs - - 70 23 47 8,750

127 Kalium Permanganat Serbuk Pot 165 312 51,480 280 424 21 312

128 Kalsium Laktas 500 mg Tablet 5,172 70 362,040 45,000 41,275 8,897 63

129 Kanamycin inj Vial - 5,390 - 1 1 - 5,390

130 Kapas Pembalut Adsorben Rol 6 12,500 75,000 34 37 3 12,500

131 Kasa 36 m x 80 cm Rol 2 93,500 187,000 31 33 - 105,000

132 Kasa Elastis 4 Inch Roll 55,000 - 27 2 25 55,000

133 Kasa Kompres 40/40 Steril Bungkus 119 1,600 190,400 100 217 2 1,600

134 Kasa Pemb.Hidropil 4mx10 cm - 35 35 - 1,500


Rol
135 Kasa Pemb.Hidropil 4mx15cm 3,800 - 70 70 -
Rol 3,800
136 Kassa 16 x 16 cm Steril Kotak 24 5,800 139,200 106 107 23 5,800

137 Ketokonazol cream 2 % Tube 37 2,569 95,053 75 112 - 2,545

138 Ketokonazol Tab Tablet 577 300 173,100 150 698 29 300

139 Ketorolac Ampul - 2,300 - - - - 2,300

8
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
140 Klindamisin kap 150 mg Kapsul 285 361 102,885 1,850 2,135 - 361

141 Klindamisin kap 300 mg Kapsul 208 553 115,024 200 408 - 603

142 Kloramfenikol 250 mg 693 266 184,477 1,700 1,893 500


Kapsul 266
143 Kloramfenikol SM 1% 1 1,600 1,600 336 336 1
Tube 1,798
144 Kloramfenikol suspensi Botol - - 100 33 67 3,680

145 Kloramfenikol TT Botol 62 1,601 99,231 264 306 20 1,601

146 Klorfeniramin Maleat ( CTM ) 4 mg Tablet 7,986 51 407,286 65,000 71,575 1,411 51

147 Klorpromazin tab 100 mg Tablet 149 - - - - 149

148 Kotrimoksazol 480 mg Tablet 1,145 138 158,010 3,900 4,955 90 138

149 Kotrimoksazol susp. Botol 215 2,145 461,175 600 752 63 2,140

150 Laxadin Emulsi 60 ml Botol - 24 - 24 12,450

151 Levofloxacin tab 500 mg Tablet 146 574 83,804 500 646 - 574

152 Lidocain Jelly 2 % Tube - 1 - 1 40,000

153 Lidocain kombinasi inj : lidokain HCl 2% + Ampul 97 1,363 132,201 1,610 1,409 298 1,845
Epinefrin 1:80.000
154 Lidokain inj Ampul 63 925 58,275 100 83 80 860

155 Loperamide 2 mg tab Tablet 89 - - - - 89

156 Loratadine 10 mg Tablet 342 154 52,668 100 233 209 154

157 Lysol 1 Ltr Botol - - - - 41,000

9
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
158 Magnesium Sulfat 20 % Ampul 10 1,540 15,398 - 10 - 1,540

159 Magnesium Sulfat 40 % Vial 33 - 90 78 45 3,650

160 Masker pcs 153 440 67,320 5,100 5,253 - 440

161 MDT MB Anak Blister 19,800 - 5 5 - 19,800

162 MDT MB Dewasa 25,742 - 31 31 -


Blister 30,595
163 MDT PB Anak 8,052 - - - -
blister 8,052
164 MDT PB Dewasa Blister 8,712 - 9 9 - 8,712

165 Meloxicam 15 Tablet 100 1,178 117,810 2,300 2,400 - 1,178

166 Metformin 500 mg Tablet 105 - - - - 100

167 Metildopa tab 250 mg Tablet 800 - 300 147 153 800

168 Metilergometrin Maleat 0,125 mg Tablet 154 - 700 319 381 154

169 Metilergometrin Maleat inj Ampul 44 1,292 56,848 - 44 - 1,292

170 Metilprednisolon 8 mg Tablet 375 - - - - 375

171 Metoclorpropamid injeksi Ampul 60 1,000 60,000 20 80 - 1,000

172 Metoclorpropamid 10 mg Tablet 370 76 28,120 1,400 1,100 670 90

173 Metronidazol 250mg Tablet 123 - - - - 123

174 Metronidazol 500 mg/ml infus Botol 6 9,950 59,700 - 3 3 9,950

175 Metronidazol 500mg Tablet 483 160 77,280 2,800 3,173 110 133

10
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
176 Miconazole cream Tube 94 3,000 282,000 168 173 89 3,250

177 Mumifying Pasta Botol 176,000 - - - - 176,000

178 Nalokson Hcl inj Vial 77,000 - - - - 77,000

179 Nasal Cannula Anak Set 8 7,700 61,600 35 17 26 6,600

180 Nasal Cannula Dewasa Set 7 12,650 88,550 40 18 29 6,600

181 Natrium Bicarbonat 500 mg Tablet 2,729 14 38,206 - 2,729 - 14

182 Natrium Bicarbonat lar 8,4 % Botol 23 11,000 253,000 10 3 30 11,000

183 Natrium dikloffenak tab 25 mg Tablet 133 - 300 250 50 145

184 Natrium dikloffenak tab 50 mg Tablet 951 176 167,376 400 1,331 20 176

185 Natrium Klorida 0,9% Botol 23 4,700 108,100 180 173 30 6,410

186 Neo K (fitomenadion 2 mg/ml) Ampul 117 3,417 399,789 540 563 94 3,550

187 Neokolina syr Botol - - - -

188 Nifedipin tab Tablet 110 - 1,100 355 745 108

189 Nistatin Vaginal tab 100.000 IU Tablet 587 480 281,760 300 665 222 480

190 Nistatin Vaginal tab 500.000 IU Tablet 640 - - - - 640

191 O.B.H.Sirup Botol 111 3,500 388,522 192 303 - 3,500

192 OAT Kat Anak Paket 2 214,990 429,980 10 10 2 214,990

193 Ofloxacin Tablet 413 - - - - 413

11
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
194 Oksitetrasiklin HCL inj Vial 3,100 - - - - 3,100

195 Oksitetrasiklin HCL SK 3% Tube 16 1,650 26,400 504 407 113 1,650

196 Oksitetrasiklin HCL SM 1% Tube 1,239 - - - - 1,239

197 Oksitosin Inj Vial - 900 582 318 1,900

198 Omeprazol kap 20 mg Kapsul 102 408 41,616 300 402 - 160

199 Papaverin 40 mg Tablet 63 - - - - 63

200 Parasetamol 100 mg Tablet 597 97 57,790 23,000 19,747 3,850 97

201 Parasetamol 160 mg supp supp 36 6,050 217,800 60 96 - 6,050

202 Parasetamol 240 mg supp supp 26 7,150 185,900 60 86 - 7,150

203 Parasetamol 500 mg Tablet 12,167 79 961,193 96,600 100,326 8,441 79

204 Parasetamol 80 mg supp 12 5,692 68,304 60 72 -


supp 5,692
205 Parasetamol Sirup Botol 194 1,438 278,972 1,292 1,486 - 1,074

206 Peahavral tab Tablet - - - -

207 Perak Sulfadiazin 1 % Tube 2 23,000 46,000 11 12 1 23,000

208 Pine oil 7,0%+benzyl clorophenol 0,6% Botol 15,400 - 51 51 - 15,400

209 Pirantel Pamoat 125 mg Tablet 80 194 15,520 - 80 - 291

210 Piridoksin HCL 10 mg Tablet 15 - 1,000 1,000 - 118

211 Piridoksin HCL 25 mg Tablet 4,345 46 200,739 9,000 9,907 3,438 46

12
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
212 Piroksikam 20 mg Tablet 40 105 4,180 3,900 3,890 50 105

213 Plester 10 yard x 1 inch Roll - - 142 130 12 18,086

214 Plester 5 yards x 1 inc Roll 3 11,660 34,980 13 16 - 12,075

215 Povidon Yodida 30 ml Botol 46 2,163 99,498 70 81 35 2,163

216 Povidon Yodida 300 ml Botol 6 14,203 85,218 28 29 5 18,000

217 Prednison 5 mg 1,072 40 42,880 2,600 3,408 264


Tablet 96
218 Primaquine Tablet 114 - - - - 114

219 Propanolol HCL 40 mg Tablet 300 106 31,800 - - 300 60

220 Ranitidine 1,517 120 182,040 16,100 15,251 2,366


Tablet 105
221 Ranitidine inj - 1,928 - - - -
Ampul 1,928
222 Retinol 100.000 IU Kapsul 242 - 2,650 2,650 - 260

223 Retinol 200.000 iu Kapsul 1,677 459 769,743 19,700 20,168 1,209 459

224 Ringer Laktat Botol 210 5,200 1,092,000 2,800 2,934 76 7,150

225 Risperidon tab 20 mg Tablet 210 2,375 498,750 300 425 85 495

226 Salbutamol 2 mg 489 59 28,851 2,100 2,359 230


Tablet 66
227 Salbutamol 4 mg 300 89 26,700 800 915 185
Tablet 89
228 Salep 2-4 Kombinasi 85 2,000 170,000 144 214 15
Pot 2,429
229 Salisil Bedak 2% - 50 gr 19 1,250 23,750 231 250 -
Kotak 1,025

13
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
230 Sanadril syr Botol - - - -

231 sanvita B syr Botol - - - -

232 Semen Seng Fosfat Set 80,659 - 1 - 1 80,659

233 Serum ABU I Vial 2 472,000 944,000 13 13 2 473,000

234 Serum ADS 660,000 - - - -


Ampul 660,000
235 Serum ATS 1.500 IU 6 123,500 741,002 170 135 41
Vial 170,000
236 Sianokobalamin inj. 195 1,037 202,215 - 67 128
Ampul 1,037
237 Sianokobalamin tab 1,970 57 112,290 - 1,970 -
Tablet 57
238 Silk Benang Bedah Sutra 70 2,778 194,445 432 468 34
Set 3,056
239 Simvastatin 10 mg 400 169 67,600 900 1,029 271
Kapsul 169
240 Siprofloksasin 250 mg - - - -
Tablet 237
241 Siprofloxacin 500 mg 334 255 85,237 1,900 2,194 40
Tablet 255
242 Spironolactone 200 315 63,000 100 200 100
Tablet 294
243 Tablet tambah darah 19,922 42 836,724 51,000 70,922 -
Tablet 42
244 Temporary Stopping Fletcher 34,000 - - - -
Set 34,000
245 Tetrakain 0,5 % T.M (PANTOCAIN) 12 11,500 138,000 - 3 9
Botol 11,500
246 Tetrasiklin 250 mg 462 148 68,376 4,200 3,972 690
Tablet 148
247 Tetrasiklin 500 mg 300 - 500 430 70
Tablet 300

14
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
248 Thiamin HCL 50 mg 4,422 39 170,247 20,400 24,822 -
Tablet 39
249 Thiamin HCL inj 700 - - - -
Ampul 700
250 Tiamfenikol kap 500 mg 6,340 616 3,905,440 100 6,440 -
Kapsul 616
251 Tramadol inj 6,402 - - - -
Ampul 6,402
252 Transfusi Bag 4 9,900 39,600 15 11 8
Set 9,900
253 Triamcinolone asetonide cream 47 15,000 704,981 96 143 -
Tube 15,000
254 Trifluoperazine 330 - - - -
Tablet 330
255 Trihexyphenidyl 2 mg - - - -
Tablet 41
256 Urine Bag 17 7,150 121,550 60 60 17
Set 5,500
257 Vaksin rabies verro 126,500 - 1 - 1
Vial 126,500
258 Ventolin Nebules 2,5 mg 6,600 - 120 83 37
Ampul 4,000
259 Vitamin B.Komplek 3,953 107 422,971 44,600 47,953 600
Tablet 107
260 Zinc Dispersible tab 324 474 153,576 5,400 4,989 735
Tablet 474
261 Zink Syrup (ZIRCUM KID SYRUP) 25 7,400 185,000 75 100 -
Botol 7,400
262 Permethrin Cream - 12,155 - 45 35 10
Botol 12,155
263 Alat Suntik 10 ml Set - 1,790 - 200 30 170
1,790
264 Handscoon Non Steril S Kotak - 46,200 - 25 25 -
46,200
265 Handscoon Non Steril M Kotak - 46,200 - 42 42 -
46,200

15
PERSEDIAAN AWAL PERSEDIAAN AKHIR
NO NAMA BARANG SATUAN PENAMBAHAN PENGURANGAN
Banyaknya Harga Satuan (Rp) Jumlah (Rp) Banyaknya Harga Satuan (Rp)
1 2 3 4 5 6 (4x5) 7 8 9 (4+7-8) 10
266 Handscoon Non Steril L Kotak - 46,200 - 18 18 -
46,200
267 Foley Catheter no.16 Set - 11,000 - 20 11 9
11,000
268 Foley Catheter no.18 Set - 11,000 - 30 22 8
11,000
269 Fenitoin 100mg Kapsul - 154 - - - -
154
270 Omeprazol injeksi Ampul - 16,997 - 20 5 15
16,997
271 Parasetamol Drops Botol 15 ml Botol - 5,200 - 60 60 -
5,200
JUMLAH 51,059,895.80 811,595 848,170 81,797

Serang, Januari 2017

Tim Pemeriksa :
Atasan Langsung Penyimpan/Pengurus Barang
Penyimpan/Pengurus Barang
1. Drs. H. M. Hikmatsyah
NIP. 19610726 198312 1 002 ………………………..

2. Abdul Fatah, SE
NIP. 19630320 198608 1 001
..................................................................... ....................................................................
NIP. ................................................ NIP. ....................................................... 3. Rukma Alfiana, SE. M.Si
NIP. 19700610 200312 1 004 ………………………..

4. Rayesh Tiwana, SE. MM


NIP. 19831212 200604 1 007

5. ELAN RUSLAN, SE
NIP. 19740707 201101 1001 ………………………..

16
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

641,190

235,900

20,280

609,945

136,750

10,035

1,332

17
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
37,499

28,315

4,180

729,495

1,774,336

66,301

32,035

207,204

178,200

9,685

73,080

112,200

10,000

170,607

87,152

18
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
141,510

214,984

89,925

283,800

109,505

10,788

11,628

122,833

19
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
180,348

50,900

141,750

8,836

228,000

297,848

350,760

92,200

20
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
19,992

9,765

25,400

53,800

549,000

107,970

52,080

331,100

10,200

193,500

142,500

18,100

2,159,940

21
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
98,016

282,865

275,000

11,850

41,160

740,520

5,504

239,773

22
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
260,000

210,000

28,800

85,800

60,950

10,296

501,300

518,010

467,880

337,040

885,630

330

23
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
107,950

770,044

951,730

17,600

411,250

6,552

560,511

37,500

1,375,000

3,200

133,400

8,700

24
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

133,100

1,798

246,560

32,010

71,961

12,420

134,820

298,800

40,000

549,810

68,800

32,186

25
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

164,250

122,400

58,674

60,300

29,850

14,630

26
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
289,250

171,600

191,400

330,000

7,250

3,520

192,300

333,700

80,460

106,560

429,980

27
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

186,450

604,200

372,680

666,839

23,000

158,836

28
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
5,225

217,032

75,705

90,000

25,344

18,000

248,430

554,931

543,400

42,075

15,180

16,465

36,435

29
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

80,659

946,000

6,970,000

132,736

103,904

45,799

10,208

29,400

103,500

102,120

21,000

30
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

79,200

93,500

126,500

148,000

64,200

348,390

121,550

304,300

31
ERSEDIAAN AKHIR

Jumlah (Rp)
11(9x10)
-

99,000

88,000

254,955

39,010,380

………………………..

………………………..

32
SKPD : PUSKEMAS KRAMATWATU
KABUPATEN : SERANG
PROVINSI : BANTEN

LAMPIRAN I : BERITA ACARA PEMERIKSAAN PERHITUNGAN SISA PERS


PER 31 APRIL 2017
-
PERSEDIAAN AWAL
NO NAMA BARANG SATUAN
Banyaknya Harga Satuan (Rp)
1 2 3 4 5
1 Blood Lancet Box -

2 Alkohol Sweb Box -

3 Handscoon -
Box
4 Spirtus 12
Liter
5 Pot Urin 20ml -
Buah
6 Aquadest -
Botol/500ml
7 Pipet kecil -
Pak
8 Spuit 3 cc
Pak
9 Yellow tip ( 1000 pcs ) -
Pack

10 Blue tip ( 1000 pcs ) -


Pack
11 Cybow Reagen Strip -
Tube
12 Tube EDTA -
Box
13 Sample Cup Buah -

14 Aquadest 500 ml Botol -

15 Reagen Hcl

16 Reagen Gol. Darah

17 Reagen Cleaner

18 Reagen Lyse

19 Reagen Diiluent

20 Reagen Kontrol fotometer


21 Reagen Kontrol Hematology

22 Reagen Glukosa

23 Reagen Asam urat

24 Reagen Kolesterol

25
Reagen HB
26
Reagen SGOT
27
Reagen SGPT
28
Reagen HDL
29
Reagen LDL
30 Reagen Trigliserida

31 Reagen Focus

32 Reagen Oncoprobe

33 Reagen Syphilis

34 Reagen IGG/IGM

JUMLAH

Atasan Langsung Penyimpan/Pengurus Barang

Penyimpan/Pengurus Barang
..................................................................... ....................................................................

NIP. ................................................ NIP. .......................................................


RIKSAAN PERHITUNGAN SISA PERSEDIAAN BARANG PAKAI HABIS
PER 31 APRIL 2017

EDIAAN AWAL PERSEDIAAN AKHIR


PENAMBAHAN PENGURANGAN
Jumlah (Rp) Banyaknya Harga Satuan (Rp) Jumlah (Rp)
6 (4x5) 7 8 9 (4+7-8) 10 11(9x10)
- - -

- - -

- - -

- 2 10 -

- - -

- - -

- - -

- - -

- - -

- -

- -

- - -

- -
- - 2 10 -

Serang, Januari 2017

Tim Pemeriksa :

1. Drs. H. M. Hikmatsyah

NIP. 19610726 198312 1 002 ………………………..

2. Abdul Fatah, SE

NIP. 19630320 198608 1 001 ………………………..


3. Rukma Alfiana, SE. M.Si

NIP. 19700610 200312 1 004 ………………………..

4. Rayesh Tiwana, SE. MM

NIP. 19831212 200604 1 007 ………………………..

5. ELAN RUSLAN, SE

NIP. 19740707 201101 1001 ………………………..


SKPD : PUSKESMAS KRAMATWATU
KABUPATEN : SERANG
PROVINSI : BANTEN

LAMPIRAN II : BERITA ACARA PEMERIKSAAN PERHITUNGAN SISA PERSEDIAAN BARANG PAKAI HABIS
PER 31 DESEMBER 2016
stok tgl.9
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Sisa 2016 Penambahan Didistribusikan Rusak/Usang JANUARI 2017 Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

1 Alat Suntik 1 ml Set 0 0 0 0 0 0 801


2 Alat suntik 20 ml Set 0 0 0 0 0 0 6,400
3 Alat Suntik 3 ml Set 670 0 236 0 434 670 957
4 Alat suntik 5 ml set 175 0 13 0 162 175 1,348
5 Albendazole Tablet 60 0 60 0 0 60 338
6 Allopurinol 100 mg Tablet 0 0 0 0 0 0 91
7 Ambroxol sirup 15 mg/ml Botol 185 0 87 0 98 185 3,297
8 Ambroxol tablet 30 mg Tablet 1094 0 394 0 700 1094 125
9 Aminophilin 200 mg Tablet 0 0 0 0 0 0 80
10 Aminophilin inj Ampul 3 0 0 0 3 3 3,345
11 Amitriptillin tab 25 mg 0 0 0 0 0 0
Tablet 115
12 Amlodipin 0 0 0 0 0 0
Tablet 187
13 Amlodipin 10 mg 9 0 9 0 0 9
Tablet 148
14 Amoxicillin Inj Vial 5 0 0 0 5 5 7,500
15 Amoxicillin Syrup Forte 250 mg/ml Botol 7 0 7 0 0 7 4,045
16 Amoxisilin 125 mg syr Botol 2 0 2 0 0 2 2,090

40
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

17 Amoxisilin 250 mg Kapsul 3741 0 341 0 3400 3741 195


18 Amoxisilin 500 mg Kapsul 7648 0 7148 0 500 7648 232
19 Ampicillin 1 gr injeksi Ampul 13 0 4 0 9 13 5,100
20 Antalgin 500 mg Tablet 215 0 215 0 0 215 149
21 Antasida Doen Tablet 3342 0 1943 0 1399 3342 62
22 Antasida Doen Sirup Botol 88 0 88 0 0 88 2,025
23 Anti vertigo (Betahistin maleat) Tablet 65 0 65 0 0 65 149
24 Antibakteri Doen Salep Tube 0 0 0 0 0 0 2,516
25 Antihaemoroid Doen Komb. Supp Supp 24 0 12 0 12 24 3,045
26 Antimigrain Doen Komb. Tablet 0 0 0 0 0 0 135
27 Aqua Pro inj Steril 20 ml Ampul 51 0 21 0 30 51 2,200
28 Artesunate inj Ampul 0 0 0 0 0 0 25,063
29 Asam Aselilsalisilat 100mg Tablet 100 0 0 0 100 100 100
30 Asam Askorbat 250 mg Tablet 1073 0 273 0 800 1073 159
31 Asam Askorbat 50 mg 838 0 738 0 100 838
Tablet 104
32 Asam Mefenamat 500 mg Tablet 1335 0 1335 0 0 1335 106
33 Asam Traneksamat inj 250 mg / ml Ampul 0 0 0 0 0 0 6,600
34 Asering 500 cc Botol 0 0 0 0 0 0 9,000
35 Asiclovir 400 mg 616 0 416 0 200 616
Tablet 349
36 Asiclovir cream 30 0 30 0 0 30
Tube 2,998
37 Atrofin Sulfat inj 0,25 mg / ml 0 0 0 0 0 0
Ampul 1,265

41
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

38 Attapulgit 600 mg Tablet 0 0 0 0 0 0 190


39 Azythromycin 500 mg Tablet 0 0 0 0 0 0 4,500
40 Benzatin Benzilpenisillin 1,2 Juta IU/Vial 0 0 0 0 0 0
Vial 9,800
41 Betamethason Krim 0 0 0 0 0 0
Tube 1,520
42 Bisacodyl 0 0 0 0 0 0
Tablet 764
43 Bisturi pcs 43 0 8 0 35 43 6,600
44 Ca glukonas Vial 11 0 11 0 0 11 9,955
45 Calsium Hidroksida Pasta (Dorident) Set 0 0 0 0 0 0 231,000
46 Captopril 12,5 mg Tablet 174 0 174 0 0 174 62
47 Captopril 25 mg Tablet 171 0 171 0 0 171 68
48 Cat- Gut/Benang Bedah 22 0 22 0 0 22
Set 5,583
49 Cefadroxil 250 mg syr 0 0 0 0 0 0
Botol
50 Cefadroxyl sirup kering 125mg/ml Botol 38 0 38 0 0 38 4,746
51 Cefadroxyl 500 mg Kapsul 100 0 100 0 0 100 509
52 Cefixime 100 mg Kapsul 0 0 0 0 0 0
Kapsul 859
53 Cendo Lyteers 9 0 9 0 0 9
Botol 15,750
54 Cetirizine 47 0 47 0 0 47
Tablet 188
55 Cetirizine 5 mg/5 ml Syrup 60 ml 80 0 30 0 50 80
Botol 2,850
56 Cimetidine 200 mg Tablet 0 0 0 0 0 0 108
57 Clobazam 10 mg Tablet 0 0 0 0 0 0 760
58 Clozapine Tablet 0 0 0 0 0 0 2,475

42
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

59 Composit (Diafil) Tube 0 0 0 0 0 0 308,000


60 Cresophene Botol 0 0 0 0 0 0 572,000
61 Deksametason 0,5 mg Tablet 4804 0 3304 0 1500 4804 62
62 Deksametason inj 5 mg Ampul 222 0 54 0 168 222 1,580
63 Devitalisasi pasta (non arsen) Botol 0 0 0 0 0 0 331,100
64 Dextrose 40% inj Ampul 0 0 0 0 0 0 1,452
65 Diazepam inj 5 mg / ml Ampul 0 0 0 0 0 0 872
66 Diazepam rektal 5mg /2.5 ml (Stesolid) Tube 8 0 2 0 6 8 11,525
67 Dietylcarbamazin Sitrat 100 mg Tablet 0 0 0 0 0 0 89
68 Difenhidramin HCL inj 10 mg/ml Ampul 17 0 9 0 8 17 1,176
69 Digoksin 0,25 mg Tablet 93 0 93 0 0 93 105
70 Diltiazem HCl 30 mg Tablet 200 0 0 0 200 200 127
71 Doksisiklin 100 mg Capsul 200 0 100 0 100 200 269
72 Domperidon susp 5mg/ml Botol 183 0 133 0 50 183 3,000
73 Domperidone tab Tablet 915 0 915 0 0 915 118
74 Ekstraks Belladona tab 10 mg 0 0 0 0 0 0
Tablet 38
75 Epinefrin HCL inj 0,1%-1 ml Ampul 42 0 18 0 24 42 1,240
76 Erythromycin 500 mg Tablet Salut Tablet 0 0 0 0 0 0 730
77 Erytromisin syr Botol 43 0 43 0 0 43 7,700
78 Etakridin ( Rivanol ) 0.1% Botol 4 0 0 0 4 4 2,550
79 Etanol 70% - 1.000 ml 9 0 8 0 1 9
Botol 21,500

43
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

80 Etanol 70% - 100 ml Botol 57 0 11 0 46 57 2,500


81 Etilklorida Semprot - 100 ml Botol 0 0 0 0 0 0 77,000
82 Eugenol cairan Botol 1 0 0 0 1 1 18,100
83 FDC KAT II 0 0 0 0 0 0
Paket 1,199,990
84 FDC Kat. I 6 0 2 0 4 6
Paket 359,990
85 Fenobarbital inj Ampul 0 0 0 0 0 0 1,560
86 Fenol Glicerol TT Botol 48 0 24 0 24 48 2,042
87 Fitomenadion 10 mg Tablet 407 0 207 0 200 407 695
88 Fitomenadion inj 10 mg / ml Ampul 0 0 0 0 0 0 978
89 Fluconazole 150 mg Tablet 0 0 0 0 0 0 22,000
90 Fluoxetine 10 mg Tablet 0 0 0 0 0 0 1,166
91 Fluphenazine Decanoate Ampul 5 0 0 0 5 5 55,000
92 Foley Catheter Pcs 0 0 0 0 0 0 16,500
93 Furalex Tablet 0 0 0 0 0 0
94 Furosemida 40 mg Tablet 158 0 158 0 0 158 75
95 Furosemida inj 10 mg/ml Ampul 20 0 5 0 15 20 2,058
96 Garam Oralit 200 ml 2805 0 1405 0 1400 2805
Sachet 264
97 Gentamisin TT 2% tube 0 0 0 0 0 0
98 Gentamycine inj Ampul 0 0 0 0 0 0 3,696
99 Gentamycine salep kulit 0,1 % 3 0 3 0 0 3
Tube 1,835
100 Gentamysin tetes mata 0 0 0 0 0 0
Botol 3,194

44
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

101 Glass Ionomer Semen Set 0 0 0 0 0 0 385,000


102 Glibenklamid 5 mg 0 0 0 0 0 0
Tablet 87
103 Gliseril Guaiacolat 100 mg Tablet 8719 0 3719 0 5000 8719 28
104 Glucosa 5% Botol 50 0 30 0 20 50 5,200
105 Glukosa 10 % Botol 28 0 9 0 19 28 7,500
106 Griseovulfin 125 mg Tablet 0 0 0 0 0 0 200
107 Haloperidol 5 mg Tablet 300 0 0 0 300 300 96
108 Haloperidol decanoat Ampul 0 0 0 0 0 0 128,460
109 Haloperidol inj Ampul 0 0 0 0 0 0 12,155
110 Hand schoon non steril Kotak 0 0 0 0 0 0 32,500
111 Handscrub (Cutisoft) Botol 1 0 0 0 1 1 85,800
112 Hidrocortison Cream 2,5% Tube 23 0 23 0 0 23 2,650
113 Hidroklortiazid (HCT) Tablet 286 0 136 0 150 286 36
114 Hyoscine-N-Butilbromide 20 mg/ml inj Ampul 0 0 0 0 0 0 7,700
115 Hyoscine-N-Butilbromide 10 mg Tablet 0 0 0 0 0 0 1,472
116 I.V catheter no : 18 Pcs 60 0 42 0 18 60 8,355
117 I.V catheter no : 20 Pcs 62 0 32 0 30 62 8,355
118 I.V catheter no : 24 Set 56 0 21 0 35 56 8,355
119 I.V Catheter no 26 Set 16 0 16 0 0 16 21,065
120 I.V Catheter No.22 Tablet 106 0 38 0 68 106 8,355
121 Ibuprofen 200 mg 3 0 3 0 0 3
Tablet 110

45
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

122 Ibuprofen 400 mg Set 850 0 850 0 0 850 127


123 Infus Set Anak Set 74 0 39 0 35 74 10,406
124 Infus Set Dewasa Tablet 130 0 69 0 61 130 7,321
125 Isosorbit Dinitrat 5 mg Set 200 0 0 0 200 200 88
126 IV. Catheter no. 16 Pcs 47 0 2 0 45 47 8,750
127 Kalium Permanganat Serbuk Pot 21 0 21 0 0 21 312
128 Kalsium Laktas 500 mg Tablet 8897 0 5897 0 3000 8897 63
129 Kanamycin inj Vial 0 0 0 0 0 0 5,390
130 Kapas Pembalut Adsorben Rol 3 0 3 0 0 3 12,500
131 Kasa 36 m x 80 cm Rol 0 0 0 0 0 0 105,000
132 Kasa Elastis 4 Inch Roll 25 0 0 0 25 25 55,000
133 Kasa Kompres 40/40 Steril Bungkus 2 0 2 0 0 2 1,600
134 Kasa Pemb.Hidropil 4mx10 cm 0 0 0 0 0 0 1,500
Rol
135 Kasa Pemb.Hidropil 4mx15cm 0 0 0 0 0 0
Rol 3,800
136 Kassa 16 x 16 cm Steril Kotak 23 0 15 0 8 23 5,800
137 Ketokonazol cream 2 % Tube 0 0 0 0 0 0 2,545
138 Ketokonazol Tab Tablet 29 0 29 0 0 29 300
139 Ketorolac Ampul 0 0 0 0 0 0 2,300
140 Klindamisin kap 150 mg Kapsul 0 0 0 0 0 0 361
141 Klindamisin kap 300 mg Kapsul 0 0 0 0 0 0 603
142 Kloramfenikol 250 mg 500 0 500 0 0 500
Kapsul 266

46
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

143 Kloramfenikol SM 1% 1 0 1 0 0 1
Tube 1,798
144 Kloramfenikol suspensi Botol 67 0 17 0 50 67 3,680
145 Kloramfenikol TT Botol 20 0 20 0 0 20 1,601
146 Klorfeniramin Maleat ( CTM ) 4 mg Tablet 1411 0 1411 0 0 1411 51
147 Klorpromazin tab 100 mg Tablet 0 0 0 0 0 0 149
148 Kotrimoksazol 480 mg Tablet 90 0 90 0 0 90 138
149 Kotrimoksazol susp. Botol 63 0 63 0 0 63 2,140
150 Laxadin Emulsi 60 ml Botol 24 0 0 0 24 24 12,450
151 Levofloxacin tab 500 mg Tablet 0 0 0 0 0 0 574
152 Lidocain Jelly 2 % Tube 1 0 0 0 1 1 40,000
153 Lidocain kombinasi inj : lidokain HCl 2% + 298 0 123 0
Ampul 175 298 1,845
Epinefrin 1:80.000
154 Lidokain inj Ampul 80 0 10 0 70 80 860
155 Loperamide 2 mg tab Tablet 0 0 0 0 0 0 89
156 Loratadine 10 mg Tablet 209 0 19 0 190 209 154
157 Lysol 1 Ltr Botol 0 0 0 0 0 0 41,000
158 Magnesium Sulfat 20 % Ampul 0 0 0 0 0 0 1,540
159 Magnesium Sulfat 40 % Vial 45 0 23 0 22 45 3,650
160 Masker pcs 0 0 0 0 0 0 440
161 MDT MB Anak Blister 0 0 0 0 0 0 19,800
162 MDT MB Dewasa 0 0 0 0 0 0
Blister 30,595
163 MDT PB Anak 0 0 0 0 0 0
blister 8,052

47
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

164 MDT PB Dewasa Blister 0 0 0 0 0 0 8,712


165 Meloxicam 15 Tablet 0 0 0 0 0 0 1,178
166 Metformin 500 mg Tablet 0 0 0 0 0 0 100
167 Metildopa tab 250 mg Tablet 153 0 153 0 0 153 800
168 Metilergometrin Maleat 0,125 mg Tablet 381 0 181 0 200 381 154
169 Metilergometrin Maleat inj Ampul 0 0 0 0 0 0 1,292
170 Metilprednisolon 8 mg Tablet 0 0 0 0 0 0 375
171 Metoclorpropamid injeksi Ampul 0 0 0 0 0 0 1,000
172 Metoclorpropamid 10 mg Tablet 670 0 470 0 200 670 90
173 Metronidazol 250mg Tablet 0 0 0 0 0 0 123
174 Metronidazol 500 mg/ml infus Botol 3 0 0 0 3 3 9,950
175 Metronidazol 500mg Tablet 110 0 110 0 0 110 133
176 Miconazole cream Tube 89 0 41 0 48 89 3,250
177 Mumifying Pasta Botol 0 0 0 0 0 0 176,000
178 Nalokson Hcl inj Vial 0 0 0 0 0 0 77,000
179 Nasal Cannula Anak Set 26 0 6 0 20 26 6,600
180 Nasal Cannula Dewasa Set 29 0 2 0 27 29 6,600
181 Natrium Bicarbonat 500 mg Tablet 0 0 0 0 0 0 14
182 Natrium Bicarbonat lar 8,4 % Botol 30 0 0 0 30 30 11,000
183 Natrium dikloffenak tab 25 mg Tablet 50 0 50 0 0 50 145
184 Natrium dikloffenak tab 50 mg Tablet 20 0 20 0 0 20 176

48
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

185 Natrium Klorida 0,9% Botol 30 0 30 0 0 30 6,410


186 Neo K (fitomenadion 2 mg/ml) Ampul 94 0 79 0 15 94 3,550
187 Neokolina syr Botol 0 0 0 0 0 0
188 Nifedipin tab Tablet 745 0 745 0 0 745 108
189 Nistatin Vaginal tab 100.000 IU Tablet 222 0 122 0 100 222 480
190 Nistatin Vaginal tab 500.000 IU Tablet 0 0 0 0 0 0 640
191 O.B.H.Sirup Botol 0 0 0 0 0 0 3,500
192 OAT Kat Anak Paket 2 0 1 0 1 2 214,990
193 Ofloxacin Tablet 0 0 0 0 0 0 413
194 Oksitetrasiklin HCL inj Vial 0 0 0 0 0 0 3,100
195 Oksitetrasiklin HCL SK 3% Tube 113 0 89 0 24 113 1,650
196 Oksitetrasiklin HCL SM 1% Tube 0 0 0 0 0 0 1,239
197 Oksitosin Inj Vial 318 0 123 0 195 318 1,900
198 Omeprazol kap 20 mg Kapsul 0 0 0 0 0 0 160
199 Papaverin 40 mg Tablet 0 0 0 0 0 0 63
200 Parasetamol 100 mg Tablet 3850 0 1850 0 2000 3850 97
201 Parasetamol 160 mg supp supp 0 0 0 0 0 0 6,050
202 Parasetamol 240 mg supp supp 0 0 0 0 0 0 7,150
203 Parasetamol 500 mg Tablet 8441 0 8441 0 0 8441 79
204 Parasetamol 80 mg supp 0 0 0 0 0 0
supp 5,692
205 Parasetamol Sirup Botol 0 0 0 0 0 0 1,074

49
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

206 Peahavral tab Tablet 0 0 0 0 0 0


207 Perak Sulfadiazin 1 % Tube 1 0 0 0 1 1 23,000
208 Pine oil 7,0%+benzyl clorophenol 0,6% Botol 0 0 0 0 0 0 15,400
209 Pirantel Pamoat 125 mg Tablet 0 0 0 0 0 0 291
210 Piridoksin HCL 10 mg Tablet 0 0 0 0 0 0 118
211 Piridoksin HCL 25 mg Tablet 3438 0 2438 0 1000 3438 46
212 Piroksikam 20 mg Tablet 50 0 50 0 0 50 105
213 Plester 10 yard x 1 inch Roll 12 0 3 0 9 12 18,086
214 Plester 5 yards x 1 inc Roll 0 0 0 0 0 0 12,075
215 Povidon Yodida 30 ml Botol 35 0 20 0 15 35 2,163
216 Povidon Yodida 300 ml Botol 5 0 3 0 2 5 18,000
217 Prednison 5 mg 264 0 264 0 0 264
Tablet 96
218 Primaquine Tablet 0 0 0 0 0 0 114
219 Propanolol HCL 40 mg Tablet 300 0 100 0 200 300 60
220 Ranitidine 2366 0 1766 0 600 2366
Tablet 105
221 Ranitidine inj 0 0 0 0 0 0
Ampul 1,928
222 Retinol 100.000 IU Kapsul 0 0 0 0 0 0 260
223 Retinol 200.000 iu Kapsul 1209 0 959 0 250 1209 459
224 Ringer Laktat Botol 76 0 76 0 0 76 7,150
225 Risperidon tab 20 mg Tablet 85 0 85 0 0 85 495
226 Salbutamol 2 mg 230 0 230 0 0 230
Tablet 66

50
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

227 Salbutamol 4 mg 185 0 185 0 0 185


Tablet 89
228 Salep 2-4 Kombinasi 15 0 15 0 0 15
Pot 2,429
229 Salisil Bedak 2% - 50 gr 0 0 0 0 0 0
Kotak 1,025
230 Sanadril syr Botol 0 0 0 0 0 0
231 sanvita B syr Botol 0 0 0 0 0 0
232 Semen Seng Fosfat Set 1 0 0 0 1 1 80,659
233 Serum ABU I Vial 2 0 1 0 1 2 473,000
234 Serum ADS 0 0 0 0 0 0
Ampul 660,000
235 Serum ATS 1.500 IU 41 0 5 0 36 41
Vial 170,000
236 Sianokobalamin inj. 128 0 48 0 80 128
Ampul 1,037
237 Sianokobalamin tab 0 0 0 0 0 0
Tablet 57
238 Silk Benang Bedah Sutra 34 0 34 0 0 34
Set 3,056
239 Simvastatin 10 mg 271 0 271 0 0 271
Kapsul 169
240 Siprofloksasin 250 mg 0 0 0 0 0 0
Tablet 237
241 Siprofloxacin 500 mg 40 0 40 0 0 40
Tablet 255
242 Spironolactone 100 0 0 0 100 100
Tablet 294
243 Tablet tambah darah 0 0 0 0 0 0
Tablet 42
244 Temporary Stopping Fletcher 0 0 0 0 0 0
Set 34,000
245 Tetrakain 0,5 % T.M (PANTOCAIN) 9 0 2 0 7 9
Botol 11,500
246 Tetrasiklin 250 mg 690 0 690 0 0 690
Tablet 148
247 Tetrasiklin 500 mg 70 0 70 0 0 70
Tablet 300

51
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

248 Thiamin HCL 50 mg 0 0 0 0 0 0


Tablet 39
249 Thiamin HCL inj 0 0 0 0 0 0
Ampul 700
250 Tiamfenikol kap 500 mg 0 0 0 0 0 0
Kapsul 616
251 Tramadol inj 0 0 0 0 0 0
Ampul 6,402
252 Transfusi Bag 8 0 0 0 8 8
Set 9,900
253 Triamcinolone asetonide cream 0 0 0 0 0 0
Tube 15,000
254 Trifluoperazine 0 0 0 0 0 0
Tablet 330
255 Trihexyphenidyl 2 mg 0 0 0 0 0 0
Tablet 41
256 Urine Bag 17 0 10 0 7 17
Set 5,500
257 Vaksin rabies verro 1 0 1 0 0 1
Vial 126,500
258 Ventolin Nebules 2,5 mg 37 0 7 0 30 37
Ampul 4,000
259 Vitamin B.Komplek 600 0 600 0 0 600
Tablet 107
260 Zinc Dispersible tab 735 0 335 0 400 735
Tablet 474
261 Zink Syrup (ZIRCUM KID SYRUP) 0 0 0 0 0 0
Botol 7,400
262 Permethrin Cream 10 0 10 0 0 10
Botol 12,155
263 Alat Suntik 10 ml Set 170 0 10 0 160 170 1,790
264 Handscoon Non Steril S Kotak 0 0 0 0 0 0 46,200
265 Handscoon Non Steril M Kotak 0 0 0 0 0 0 46,200
266 Handscoon Non Steril L Kotak 0 0 0 0 0 0 46,200
267 Foley Catheter no.16 Set 9 0 4 0 5 9 11,000
268 Foley Catheter no.18 Set 8 0 4 0 4 8 11,000

52
NO NAMA BARANG SATUAN HASIL PEMERIKSAAN TGL 9 JANUARI 2017 PERSDIAAN SISA PERSEDIAAN 31 DESEMBER 2016
BARANG / FISIK 9
Penambahan JANUARI 2017
Sisa 2016 Didistribusikan Rusak/Usang Banyaknya Harga Satuan (Rp)
2017
1 2 3 7 8 terpakai 10 11 (7+8-9-10) 4 5

269 Fenitoin 100mg Kapsul 0 0 0 0 0 0 154


270 Omeprazol injeksi Ampul 15 0 0 0 15 15 16,997
271 Parasetamol Drops Botol 15 ml Botol 0 0 0 0 0 0 5,200
JUMLAH 81,797 - 54,663 - 27,134 81,797

Serang, Januari 2017

Tim Pemeriksa :
Atasan Langsung Penyimpan/Pengurus Barang
Penyimpan/Pengurus Barang
1. H. Anas Dwi Satya P. S.Sos, M.Si
NIP. 19700706 198603 1 005 ………………………..

2. Drs. Monang Nababan


NIP. 19670810 199403 1 014
..................................................................... ....................................................................
NIP. ................................................ NIP. ....................................................... 3. HENI SUHAERI, SSTP,M.Si
NIP. 19830530 200112 1 004 ………………………..

4. Agus Manduri
NIP. 19760921 201001 1 002

53
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
641,190
235,900
20,280
-
609,945
136,750
-
10,035
-
-
1,332
37,499
28,315
4,180

54
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

729,495
1,774,336
66,301
32,035
207,204
178,200
9,685
-
73,080
-
112,200
-
10,000
170,607
87,152
141,510
-
-
214,984
89,925
-

55
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
-
-
-
283,800
109,505
-
10,788
11,628
122,833
-
180,348
50,900
-
141,750
8,836
228,000
-
-
-

56
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
297,848
350,760
-
-
-
92,200
-
19,992
9,765
25,400
53,800
549,000
107,970
-
52,080
-
331,100
10,200
193,500

57
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

142,500
-
18,100
-
2,159,940
-
98,016
282,865
-
-
-
275,000
-
-
11,850
41,160
740,520
-
-
5,504
-

58
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
239,773
260,000
210,000
-
28,800
-
-
-
85,800
60,950
10,296
-
-
501,300
518,010
467,880
337,040
885,630
330

59
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

107,950
770,044
951,730
17,600
411,250
6,552
560,511
-
37,500
-
1,375,000
3,200
-
-
133,400
-
8,700
-
-
-
133,100

60
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

1,798
246,560
32,010
71,961
-
12,420
134,820
298,800
-
40,000
549,810
68,800
-
32,186
-
-
164,250
-
-
-
-

61
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
-
122,400
58,674
-
-
-
60,300
-
29,850
14,630
289,250
-
-
171,600
191,400
-
330,000
7,250
3,520

62
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

192,300
333,700
-
80,460
106,560
-
-
429,980
-
-
186,450
-
604,200
-
-
372,680
-
-
666,839
-
-

63
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
23,000
-
-
-
158,836
5,225
217,032
-
75,705
90,000
25,344
-
18,000
248,430
-
-
554,931
543,400
42,075
15,180

64
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

16,465
36,435
-
-
-
80,659
946,000
-
6,970,000
132,736
-
103,904
45,799
-
10,208
29,400
-
-
103,500
102,120
21,000

65
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
-
-
-
79,200
-
-
-
93,500
126,500
148,000
64,200
348,390
-
121,550
304,300
-
-
-
99,000
88,000

66
IAAN 31 DESEMBER 2016

Jumlah (Rp)

6 (4x5)

-
254,955
-

39,010,380

………………………..

………………………..

67