FORMULIR PERMINTAAN BAHAN HABIS PAKAI

INSTALASI BEDAH SENTRAL

BHP BEDAH

NO. NAMA BARANG ITEM STOK PEMAKAIAN SISA STOK PERMINTAAN KET

1. Silk No 1 Tapper 1 10

2. Silk No 2/0 Tapper 1 10

3. Silk No 3/0 Usus Hr 26 1 10

4. Silk No 3/0 Gigi Hr 22 1 10

5. Surgion No 1 Tapper 1 10

6. Surgion No 2/0 Tapper 1 10

7. Surgion No 2/0 Cutting 1 10

8. Surgion No 3/0 Tapper 1 10

9. Surgion No 3/0 Cutting 1 10

10. Vicryl 4-0 Tapper 1 10

11. Green Polyster No 1 1 10

12. Monolon 2/0 Cutting 1 10

13. Monolon 3/0 Cutting 1 10

14. Monolon 4/0 Cutting 1 10

15. Monolon 5/0 Cutting 1 10

16. Monolon 3/0 Tapper 1 10

17. Chromic No 2 Tapper 1 10

18. Chromic No 1 Tapper 1 10

19. Chromic No 2/0 Tapper 1 10

21. Chromic No 4/0 Tapper 1 10

22. Chromic 5/0 Tapper 1 10

23. Ethibon 2/0 1 5

24. Ethibon 0 1 5

25. Prolene 2/0 1 5

26. Prolene 2/0 1 5

27. Prolene Mesh 15 X 7,5 1 10

28. Trokar 1 5

29. Asam Tranexamat 2 10

30. Sagestam 2 5

31. Dexametasone Inj 2 5

32. Oxitocyn 4 10

33. Metargin 2 5

34. Ph Cain 1 5

35. Nipedipine 1 5

36. Kaltropren Supp 2 5

37. Gentian Violet 1 5

38. Ceftriaxone Ini 1 5

39. Metronidazol Plash 1 5

40. Furosemide 2 5

41. Ngt No 14 1 5

42. Ngt No 16 1 5
43. Ngt No 18 1 5

44. Ngt No 5 100 Cm 1 5

45. Poley Cateter No 14 1 5

46. Poley Cateter No 16 1 5

47. Poley Cateter No 18 1 5

48. Poley Cateter No 18 3 Way 1 5

49. Poley Cateter No 20 3 Way 1 5

50. Poley Cateter No 22 3 Way 1 5

51. Poley Cateter No 24 3 Way 1 5

52. Nassal Canul Anak 1 5

53. Nassal Canul Dewasa 1 5

54. Urine Bag 1 10

55. Abb No 18 1 5

56. Abb No 20 1 10

57. Abb No 22 1 5

58. Abb No 24 1 5

59. Abb No 26 1 5

60. Blood Set 1 14

61. Dermafix 1 10

62. Alkohol Swab 2 20

63. Rl 500 Cc 3 30

64. Nacl 500 Cc 1 15

65. D5% 500 Cc 1 5

67. Spuit 5 Cc 1 5

68. Spuit 3 Cc 1 10

69. Spuit 1 Cc 1 5

70. Glove No 8 1 5

71. Glove No 7,5 1 10

72. Glove No 7 1 38

73. Glove No 6.5 1 21

74. Glove Obgyn 1 5

75. Handscoon On 5 PSG 100

76. Bisturi No 20 1 13

77. Bisturi No 15 1 5

78. Bisturi No 11 1 5

79. Betadine 1 5

80. Alkohol 1 6

81. Hbiscrub 1 5

82. Handscrub 1 5

83. Masker Bedah 7 100

84. Cap Operasi U/Tim 1 30

85. Cap Operasi U/Pasien 1 21

86. Hipafix 1 5

87. Plester Coklat 1 5

88. Micropore 1 5
89. Gell 1 5

90. Lomatulle 1 5

91. Underped 2 10

92. Spongostan 1 5

93. Spongostan Gigi 1 5

94. Transofix 1 5

95. Elektrocauter 1 1

96. Cauter Monopolar 1 1

97. Pen Cauter 1 10

98. Plat Cauter Mono 1 10

99. Suction No. 10 1 5

100. Suction No.14 1 5

101. Kassa Kecil 1 100

102. Kassa X Ray 1 50

103. Kassa Roll 1 50

104. Kassa Big Gauze 1 25

105. Lampu Operasi 1 1 1

106. Lampu Ronsen 1 1 1

107. Standar Infus 1 4

108. Meja Operasi 1 2

109. Meja Mayo 1 4

110. Troly Instrumen Operasi 1 4

111. Set Apendiktomi 1 1

113. Set SC 1 2

114. Set Laparatomi Bedah Dewasa 1 1

115. Set Laparatomi Bedah Anak 1 1

116. Set Laparatomi Bedah Obgine 1 1

117. Minor Set Dewasa 1 3

118. Minor Set Anak 1 1

119. Upper Abdominal Retractor (Ken 1 1

Retraktor)

120. Pinset Anatomis 1 2

121. Pinset Cerugis 1 2

122. Kleam Pean Kecil 1 10

123. Klem Pean Besar 1 1

124. Klem Elis 1 1

125. Klem Bengkok 1 1

126. Scapel Mess 1 1

127. Klem Koher Kecil 1 2

128. Klem Koher Besar 1 2

129. Langen Back 1 2

130. Nier Biaken 1 1

131. Nald Holder 1 2

132. Gunting Jaringan 1 2

133. Gunting Benang 1 1

135. Koher Lurus Besar 1 1

136. Pinser Kleam 1 1

137. Hak Abdomen 1 1

138. Pinset Anatomis 1 2

139. Pinset Cerugis 1 2

140. Kleam Pean Kecil 1 5

141. Klem Elis 1 1

142. Klem Bengkok 1 1

143. Scapel Mess No. 3 1 1

144. Klem Koher Kecil 1 4

145. Langen Back 1 2

146. Nier Biaken 1 1

147. Nald Holder 1 2

148. Gunting Jaringan 1 2

149. Gunting Benang 1 1

150. Duk Klem 1 5

151. Pinser Kleam 1 1

152. Linen 1 6

153. Spatu Boot No 40 1 4

154. Apron Disposible 1 100

155. Apron 1 6

156. Seragam / Baju Ok Ukuran M 1 3

158. Seragam / Baju Ok Ukuran Xl 1 1

BHP Anastesi

No. NAMA BARANG ITEM STOK PEMAKAIAN SISA STOK PERMINTAAN KET

1. Mesin Anastesi 1 2

2. USG 1 1

3. Mesin ventilator 1 2

4. Monitor Anastesi 1 2

5. Troly Obat Anastesi 1 4

6. Suction Pum Dewasa 1 2

7. Suction Pum Bayi 1 2

8. Laringoskop Dewasa 1 1

9. Laringoskop Pediatrik 1 1

10. Mayo 1 2

11. Stetoskop 1 2

12. Sungkup 1 2

13. LMA Dewasa 1 1

14. LMA Pediatrik 1 1

16. ETT Pediatrik 1 1

17. Set Jarum Spinal 1 10

18. Set Jarum Epidural 1 10

19. Infus set 1 10

20. Abb No 18 1 5

21. Abb No 20 1 5

22. Abb No 22 1 5

23. Abb No 24 1 5

24. Abb No 26 1 5

25. Blood Set 1 10

26. Dermafix 1 10

27. Alkohol Swab 1 100

28. RL 500 cc 1 10

29. Nacl 500 Cc 1 10

30. D5% 500 Cc 1 10

31. Spuit 10 Cc 1 10

32. Spuit 5 Cc 1 10

33. Spuit 3 Cc 1 10

34. Spuit 1 Cc 1 10

35. Glove No 8 1 5

36. Glove No 7,5 1 5

37. Glove No 7 1 5
38. Glove No 6.5 1 5

39. Urine bag 1 10

40. NGT dewasa 1 10

41. NGT pediatrik 1 5

42. Gas inhalasi sevofluran/ 1 5

ISO/desflurane (sesuaikan dengan

merk ventilator)

43. Soda lime (sesuaikan dengan merk 1 5 dirigen

ventilator)

44. Fentanyl 1 50 vial

45. Morfin 1 50 Vial

46. Propofol 1 50 Vial

47. Atracurium 1 50 Vial

48. Rocuronium 1 30 Vial

49. Neoastigmine 1 30 Vial

50. Naloxone 1 30 Vial

51. Bupivacain 1 30 Vial

52. Iso barik 1 30 Vial

53. Hiper barik 1 30 Vial

54. Pethidine 1 50 Vial

55. Asam tranixamat 500 mg 1 50 Vial

56. Vit K 1 30 Vial

57. Ketorolac 1 30 Vial

58. Ranitidin 1 50 Vial

60. Paracetamol 1 50 flas

61. Efedrin 1 50 Vial

62. Sulfas Atropine 1 50 Vial

63. Non Epineprin 1 30 Vial

64. Epineprin 1 30 Vial

65. Nikardipine 1 30 Vial

PEMOHON Kertasari, Mei 2023

Kepala Ruangan, Ka. Instalasi IBS,

(Tegar Maulana Wardiyan, S. Kep. Ners. M. Kep.) (dr. Andhika Rahmawan. Sp. BU.)

NIP. 198802112022031001