fornas2.xls

7/23/2019 fornas2.xls

1/18

PERESEPAN OBAT DI LUAR FORMULARIUM NASIONAL

Tanggal No R/ RM Nama Pasien Obat Jumlah Harga

02/01/15 20 003739 Ny. Murtini Darto Ambroxol sirup 1 Rp 5,400.00

rama!ol 10 Rp 5,000.00

29 005512 Ny. "u!in#m Mat$il!a Antal%in 10 Rp 4,000.00

3& 042474 Ny. 'ai(#m N#uro!#x 10 Rp 5,500.00

41 0217&1 Ny. "iy#m )!i$ar(o Antal%in 10 Rp 4,000.00

N#uro!#x 7 Rp 3,*50.00

05/01/15 30 042&53 Ny. Romiyatun Ambroxol sirup 1 Rp 5,400.00

3& 0425&4 Ny. "u%iyanti +axa!in sirup 1 Rp 3*,300.00

40 00003& Ny. 'ar(iati Antal%in 10 Rp 4,000.00

42 023971 Ny. ati "utarti -alium !ilo#na 25 m% 14 Rp 7,000.00

Ambroxol sirup 1 Rp 5,400.00

43 0042*5 p. "ari "osro As. ran#xamat * Rp 24,*00.00

4& 041925 p."a$ari "unoto n!an#tron 10 Rp 31,000.00

&2 042&54 p. #ri -urniaan uruma 14 Rp 12,&00.00

0&/01/15 34 001425 Ny. ar%iyanti Ambroxol sirup 1 Rp 5,400.00

3& 007175 Ny. 6stinin%si$ N#uro!#x 7 Rp 3,*50.00

37 03*113 p. Mar(ui 6smaryanto uruma 10 Rp 9,000.00

0*/01/15 24 03&992 Ny. An#s #lla Ambroxol sirup 1 Rp 5,400.00

N#uro!#x 7 Rp 3,*50.00

09/01/15 12 042*04 Ny. "u(ini lunari8in 10 Rp 2&,500.00

1* 01*&09 Ny.'aira$ 'i!i sirup 1 Rp *,*00.00

22 0219&4 Ny. Rubila$ Antal%in 10 Rp 4,000.00

24 042777 Ny. Mariy#m N#uro!#x 7 Rp 3,*50.00

2& 042*** Ny. "umaryati #rna!#ta Ambroxol sirup 1 Rp 5,400.00

34 0427*2 p. "ami!i 'i!i Ambroxol sirup 1 Rp 5,400.00

N#uro!#x 5 Rp 2,750.00

10/01/15 29 042913 Ny. "ri '#las -alium !ilo#na 25 m% 10 Rp 5,000.00

12/01/15 29 042174 Ny. umin#m Antal%in 10 Rp 4,000.00

45 019&90 Ny. umira$ Antal%in 10 Rp 4,000.0049 024577 p. uarno "im:astatin 15 Rp 9,750.00

50 017221 Ny. "ri 'a$yuni "im:astatin 15 Rp 9,750.00

13/01/15 2* 02&5*7 p. "aiyo oro Ambroxol sirup 1 Rp 5,400.00

35 03*9&5 p. "upar(o #ixim 200 m% & Rp 29,100.00

45 042*31 Ny. "uini sirup 1 Rp *,*00.00

Antal%in 10 Rp 4,000.00

14/01/15 30 037355 p. "aroso A%ustinus N#uro!#x 7 Rp 3,*50.00

39 032725 6bu Muryatin sirup 1 Rp *,*00.00

Antal%in 15 Rp &,000.00

42 033&54 Ny. "upiatin Ambroxol sirup 1 Rp 5,400.00

50 003&&9 p. "u!arta N#uro!#x 5 Rp 2,750.00


2/18


15/01/15 24 040472 Ny. 'ain#m loni!in 5 Rp 2,000.00

2& 01&0&5 Ny. rinin%si$ N#uro!#x 7 Rp 3,*50.00

1&/01/15 24 02720* p. "u!(ono N#uro!#x 7 Rp 3,*50.00

27 042**5 Ny. "lam#t 'a$yuti Antal%in 10 Rp 4,000.00

2* 042*4* p. 6n!ri ;anto N#uro!#x 5 Rp 2,750.00

30 003739 Ny. Murtini Darto rama!ol 10 Rp 5,000.00

N#uro!#x 7 Rp 3,*50.00

37 042*04 Ny. "u(ini lunari8in 10 Rp 2&,500.00

41 042*** Ny. "umaryati #rna!#ta sirup 1 Rp *,*00.00

45 003&&9 p."u!arta N#uro!#x 7 Rp 3,*50.00

17/01/15 25 042*4& p. "ubari "umar!i Ambroxol sirup 1 Rp 5,400.00

uruma 10 Rp 9,000.00

19/01/15 30 0042*5 p. "ari "osro As. ran#xamat 15 Rp 25,&00.00

49 01*1*7 Ny. ;unarti -alium !ilo#na 25 m% 15 Rp 7,500.00

20/01/15 31 015710 p. Ra!iman Ambroxol sirup 1 Rp 5,400.00

"im:astatin 7 Rp 4,550.00

33 007&37 Ny. Rum!iyati N#uro!#x 7 Rp 3,*50.00

21/01/15 1& 043100 Ny. "u!iya$ sirup 1 Rp *,*00.00

22/01/15 22 041925 p. "a$ari "unoto sirup 1 Rp *,*00.00

25 01*532 p. umi(o As. ran#xamat * Rp 25,&00.002& 032920 Ny. +#s an!ayani Antal%in 5 Rp 2,000.00

N#uro!#x 7 Rp 3,*50.00

2* 03&992 Ny. An#s #lla N#uro!#x 5 Rp 2,750.00

39 02&1*7 p. "ui%nyo #ru -alium !ilo#na 14 Rp 7,000.00

23/01/15 20 041237 Nn. D#si Nur N#uro!#x 5 Rp 2,750.00

2& 0430&* p. N%a!iyono "uyitno N#uro!#x 5 Rp 2,750.00

27 021530 Ny. "ar(iy#m Antal%in 10 Rp 4,000.00

35 0429*& p. "arnyoto uruma 15 Rp 13,500.00

3& 0334*2 p. 'a%imin N#uro!#x 7 Rp 3,*50.00

24/01/15 39 014355 p. "u$arlan "im:astatin 15 Rp 9,750.00

Antal%in 10 Rp 4,000.00

40 0009*4 Ny. "uatmi N%abi!in -alium !ilo#na 25 m% 20 Rp 10,000.00

27/01/15 19 0157&0 Ny. oniy#m Alpra8olam 2 Rp 1,&00.00

29 043100 Ny. "u!iya$ sirup 1 Rp *,*00.00

35 0079&3 Ny. . "umina$ Antal%in 10 Rp 4,000.00

37 01&0&5 Ny. rinin%si$ N#uro!#x 7 Rp 3,*50.00

3* 032920 Ny. +#s an!ayani Antal%in 7 Rp 2,*00.00

N#uro!#x 7 Rp 3,*50.00

2*/01/15 33 042913 Ny. "ri '#las -alium !ilo#na 25 m% 15 Rp 7,500.00

35 01*532 p. umi(o As. ran#xamat 15 Rp 4*,000.00


3/18


41 04294* Ny. Dola$ a!i lunari8in 15 Rp 39,750.00

"im:astatin 7 Rp 4,550.00

45 03&733 Ny. "a!in#m airo N#uro!#x 5 Rp 2,750.00

4& 043101 Ny. )ntari an!ayani sirup 1 Rp *,*00.00

47 043077 Ny. Rismiyatun Antal%in 10 Rp 4,000.00

4* 02&5*7 p. "aiyo oro Ambroxol sirup 1 Rp 5,400.00


N#uro!#x 5 Rp 2,750.00

sirup 1 Rp *,*00.00

54 043029 p. uiman "u!i N#uro!#x 5 Rp 2,750.00

57 032725 6bu Muryatin Antal%in 15 Rp &,000.00

sirup 1 Rp *,*00.00

59 019&90 Ny. umira$ Antal%in 10 Rp 4,000.00

&2 023971 Ny. ati "utarti sirup 1 Rp *,*00.00

&3 04324& Ny. #ta "uasi$ Antal%in 10 Rp 4,000.00

&5 043245 p. "urati!(a Antal%in 10 Rp 4,000.00

N#uro!#x 5 Rp 2,750.00

29/01/15 2& 043044 p. "u(iman u!i N#uro!#x 7 Rp 3,*50.00

30 042504 p. "u!irin loni!in 15 Rp &,000.00

31 0051&5 p. "u%ito sirup 1 Rp *,*00.00

3* 011179 p. . "u$arto Antal%in 10 Rp 4,000.00

30/01/15 19 043254 Ny. "umarni #ixim 200 m% & Rp 29,100.00

27 040232 p. Diyono "ubiyato Ambroxol sirup 1 Rp 7,950.00

40 043159 "!r. "ar(ono n!an#tron 10 Rp 31,000.00

43 024231 p. Mu(iran Antal%in 10 Rp 4,000.00

31/01/15 44 043329 p. Mu(ilan Antal%in 12 Rp 4,*00.00

N#ro!#x 5 Rp 2,750.00

TOTAL HARGA Rp 887,750.00


4/18

Keterangan

r#strisi p(s

r#strisi p(s

r#strisi p(s

r#strisi p(s


5/18

Keterangan

r#strisi p(s

r#strisi p(s

r#strisi p(s


6/18

Keterangan

r#strisi p(s

r#strisi p(s

r#strisi p(s


7/18

PERESEPAN OBAT DI LUAR FORMULARIUM NASION

Tanggal No R/ RM Nama Pasien Obat Jumlah

02/02/15 21 043050 p. "ar(ono uruma 10

23 01*329 Ny. a!ria$ As. ran#xamat 10

24 042174 Ny. umin#m Antal%in 10

32 0431&3 Nn. ri 6stanti N#uro!#x 5

3* 00021* p. Musiran N#uro!#x 5

43 02&11* Ny. "u!arti #ixim 200 m% 10

Antal%in 10

44 029053 p. "ar(iman N#uro!#x 5

03/02/15 31 040232 p. Diyono Ambroxol sirup 1

3* 043244 p. oyo "uparto N#uro!#x 5

40 0079&3 Ny. "umina$ -alium !ilo#na 25 m% 10

43 040472 Ny. 'ain#m loni!in 22

Ambroxol sirup 1

04/02/15 32 03&733 Ny. "a!in#m Alpra8olam 1

41 024577 p. uarno "im:astatin 30

43 017221 Ny. "ri 'a$yuni "im:astatin 30

44 0042*5 p. "ari "osro Ambroxol sirup 1

47 042*** Ny. "umaryati #rna!#ta sirup 1

51 033&54 Ny. "upiatin Ambroxol sirup 1

57 013291 Ny.


8/18


12/02/15 23 00003& Ny. 'ar(iati lunari8in 10

Antal%in 10

n!an#tron tab &

24 032725 6bu Muryatin Antal%in 10

sirup 1

27 0203*5 Ny. Mu(in#m N#uro!#x 7

29 02444* p. Noto "uarno Antal%in 14

N#uro!#x 7

13/02/15 23 0434&5 "!r. A!itya ani n!an#tron &

N#uro!#x 3

24 01*&09 Ny.'aira$ 'i!i Antal%in 10

27 02&5*7 p. "aiyo oro Ambroxol sirup 1

14/02/01 2& 0042*5 p. "ari "osro As.ran#xamat 5

Antal%in 10

1&/02/15 1* 003739 Ny. Murtini Darto rama!ol 4

sirup 1

20 043050 p. "ar(ono "#tyo uruma 15

41 02*552 p. Ra!iya Mar!i Antal%in 10

17/02/15 2& 01&0&5 Ny. rinin%si$ N#uro!#x 7

1*/02/15 30 043504 p. u!i "antoso N#uro!#x 5

32 03*594 Ny. 'a%ina$ n!an#tron &

35 02&1*7 p. "ui%nyo #ru N#uro!#x 5

-alium !il#na 25 m% 14

37 027317 p. -amiyo -alium !il#na 25 m% 10

43 032909 p. Rupi Antal%in 10

20/02/15 2& 043532 p. umari N#uro!#x 5

Antal%in &

29 043545 p. "urobo Alpra8olam &

21/02/15 25 043577 Ny. "ri )tami Antal%in 10

N#uro!#x 5

40 01404& p. -asimin = Antal%in 10

23/02/15 2* 027317 p. -amiyo risno -alium !ilo#na 25 m% 10

44 043&34 p. "#tyo "u%iyono #ixim 200 m% 10

24/02/15 25 0435&* p. "#nin Atmo Antal%in 10

33 043745 Ny. ratiinin%si$ -alium !ilo#na 25 m% 10

25/02/15 15 02&1*7 p. "ui%nyo #ru -alium !ilo#na 25 m% 10

23 043771 Ny. Rusmini +axa!in sirup 1

Antal%in &


9/18


24 003739 Ny. Murtini Darto rama!ol 15

sirup 1

2& 005512 Ny. "u!in#m Mat$il!a sirup 1

27 01&&94 Ny. "uartina$ N#uro!#x 7

47 040472 Ny. 'ain#m loni!in 30

Ambroxol sirup 1

50 0137&& Ny. Rini "u#n%si sirup 1

27/02/15 22 021530 Ny. "ar(iy#m Antal%in 10

TOTAL HARGA


10/18

L

Harga Keterangan

Rp 9,000.00

Rp 32,000.00 r#strisi p(s

Rp 4,000.00

Rp 2,750.00

Rp 2,750.00

Rp 4*,500.00

Rp 4,000.00

Rp 2,750.00

Rp 7,950.00

Rp 2,750.00

Rp 5,000.00

Rp *,*00.00 r#strisi p(s

Rp 7,950.00

Rp *00.00



Rp 7,950.00

Rp *,*00.00

Rp 7,950.00

Rp *,*00.00

Rp 5,000.00

Rp 2,000.00

Rp 4*,000.00

Rp 3,*50.00

Rp 7,500.00

Rp 7,950.00

Rp 7,950.00

Rp 2,750.00

Rp 4,000.00

Rp 2,750.00Rp 5,000.00

Rp 2,750.00

Rp 5,000.00


Rp 4,000.00

Rp *,*00.00

Rp 4,000.00

Rp 5,&00.00

Rp 3,*50.00

Rp 3,*50.00


11/18

Harga Keterangan

Rp 2&,500.00

Rp 4,000.00

Rp 39,&00.00 r#strisi p(s

Rp 4,000.00

Rp *,*00.00

Rp 3,*50.00

Rp 5,&00.00

Rp 3,*50.00

Rp 39,&00.00 r#strisi p(s

Rp 1,&50.00

Rp 4,000.00

Rp 7,950.00

Rp 4,750.00

Rp 4,000.00

Rp 2,000.00

Rp *,*00.00

Rp 13,500.00

Rp 4,000.00

Rp 3,*50.00

Rp 2,750.00

Rp 39,&00.00

Rp 2,750.00

Rp 7,000.00

Rp 5,000.00

Rp 4,000.00

Rp 2,750.00

Rp 2,400.00

Rp 4,*00.00

Rp 4,000.00

Rp 2,750.00

Rp 4,000.00

Rp 5,000.00

Rp 4*,500.00

Rp 4,000.00

Rp 5,000.00

Rp 5,000.00

Rp 3*,300.00

Rp 2,400.00


12/18

Harga Keterangan

Rp 7,500.00

Rp *,*00.00

Rp *,*00.00

Rp 3,*50.00


Rp 7,950.00

Rp *,*00.00

Rp 4,000.00

Rp 807,600.00


13/18

PERESEPAN OBAT DI LUAR FORMULARIUM NASIONAL


02/03/15 24 043771 Ny. Rusmini Antal%in 15 Rp &,000.00

30 0003& Ny. 'ar(iati lunari8in 14

Antal%in 10 Rp 4,000.00

n!an#tron tab & Rp 39,&00.00

33 02444* p. Noto "uarno Antal%in 10 Rp 4,000.00

35 043749 Nn. 6a "#tyanin%rum N#uro!#x 5 Rp 2,750.00

3* 02744* Ny. ai(#m Antal%in 10 Rp 4,000.00

47 017379 Ny. Rubin%a$ N#uro!#x 5 Rp 2,750.00

03/03/15 24 04379& p. -ami(an "an%obion 15 Rp 1&,500.00

As. ran#xamat & Rp 2,*50.00

27 019&90 Ny. umira$ lunari8in 10 Rp 2&,500.00

29 01&0&5 Ny. rinin%si$ N#uro!#x 7 Rp 3,*50.00

37 0014*5 Ny. 5 Rp 2,750.00

21 030400 p. ranyono Antal%in 10 Rp 4,000.00N#uro!#x 10 Rp 5,500.00

09/03/15 34 043*14 Ny. -asiy#m lunari8in 10 Rp 2&,500.00

35 042174 Ny. umin#m -alium !ilo#na 25 m% 15 Rp 7,500.00

39 041773 Ny. 'aliy#m Antal%in 10 Rp 4,000.00

50 03**17 Ny. umi!a$ Maria "im:astatin 15 Rp 9,750.00

51 037091 p. "u(iman ;o$an#s "im:astatin 15 Rp 9,750.00

11/03/15 17 043100 Ny. "u!iya$ sirup 1 Rp *,*00.00

1* 043*5& Ny. 'a%ila$ Antal%in 10 Rp 4,000.00

25 02&5*7 p. "aiyo oro Ambroxol sirup 1 Rp 7,950.00

27 035300 Ny. Masiy#m "im:astatin 30 Rp 19,500.00

N#uro!#x > 5 Rp 2,750.00


14/18


3& 019&90 Ny. umira$ Antal%in 10 Rp 4,000.00

N#uro!#x 5 Rp 2,750.00

12/03/15 22 005512 Ny. "u!in#m Mat$il!a sirup 1 Rp *,*00.00


3& 043*02 Ny. Mu(ina$ a!mo Antal%in & Rp 2,400.00

44 0435&9 Ny. . Muryantini Antal%in 10 Rp 4,000.00

13/03/15 22 033132 p. "a%iyo Ambroxol sirup 1 Rp 7,950.00

23 043772 p. "lam#t risno Ambroxol sirup 1 Rp 7,950.00

37 01*&09 Ny. 'aira$ 'i!i sirup 1 Rp *,*00.00

14/03/15 27 0042*5 p. "ari sosro As. ran#xamat 5 Rp *,500.00

Antal%in 10 Rp 4,000.00

31 030400 p. ranyono Alpra8olam 4 Rp 3,200.00

33 01&0&5 Ny. rinin%si$ Antal%in 10 Rp 4,000.00

42 030935 Ny. "u%iyanti Anastasia Alpra8olam 5 Rp 4,000.00

44 043953 Ny. uty 'ar!ani Antal%in 15 Rp &,000.00

17/03/15 22 043917 p. "alim A!i sirup 1 Rp *,*00.00

29 032909 p. Rupi Antal%in 10 Rp 4,000.00

3& 02&710 p. N%ati(o N#uro!#x 5 Rp 2,750.00

Antal%in 10 Rp 4,000.00

1*/03/15 21 00*107 p. Asri ;uanto uruma 7 Rp &,300.00

Antal%in 10 Rp 4,000.00

25 035*95 p. asui Ra$ar(o Antal%in 10 Rp 4,000.0030 04392& Ny. armila$ N#uro!#x 7 Rp 3,*50.00

32 043100 Ny. "u!iya$ Antal%in 10 Rp 4,000.00

34 032725 6bu Muryatin sirup 1 Rp *,*00.00

Antal%in 10 Rp 4,000.00

19/03/15 43 01&0&5 Ny. rinin%si$ N#uro!#x 5 Rp 2,750.00

20/03/15 15 044005 p. Dasui Antal%in 10 Rp 4,000.00

N#uro!#x 5 Rp 2,750.00

17 0439*0 Ny. "upar(ila$ Antal%in 10 Rp 4,000.00

20 019325 Ny. Marsina$ N#uro!#x & Rp 3,300.00

24 04397& Ny. "uratiy#m N#uro!#x & Rp 3,300.00

25 04339& p. ri 'a$ono As. ran#xamat 10 Rp 17,000.00

2& 03&*1* Ny. Marta Dotilan%i sirup 1 Rp 11,900.00

30 044013 Ny. -asin#m Ambroxol sirup 1 Rp 7,950.00

32 025*59 Ny. Nursiti asiro$ N#uro!#x 5 Rp 2,750.00

35 043*&* Ny. Martini N#uro!#x & Rp 3,300.00

41 03&100 Ny. 'a%in#m #ixim 200 m% 10 Rp 4*,500.00

Antal%in 10 Rp 4,000.00

20/03/15 32 04404* Nn.


15/18


24 02444* p. Noto "uarno Antal%in 10 Rp 4,000.00

25/03/15 2* 02*255 Ny. "u%iy#m #ixim 200 4 Rp 19,400.00

29 030935 Ny. "u%iyanti Anastasia sirup 1 Rp 11,900.00

34 04392& Ny. armila$ -alium !ilo#na 25 m% 10 Rp 5,000.00

N#uro!#x 5 Rp 2,750.00

39 04405* Ny. Mu%iy#m Antal%in 10 Rp 4,000.00

40 043953 Ny. uty 'ar!ani Antal%in 10 Rp 4,000.00

4& 013291 Ny.


16/18

Keterangan

r#tur

r#strisi p(s

r#strisi p(s

r#strisi p(s

r#stris p(s

r#strisi p(s


17/18

Keterangan

r#strisi p(s

r#strisi p(s

r#strisi p(s


18/18

Keterangan

r#strisi p(s

r#strisi p(s

Documents

fornas2.xls