Responder Bag Checklist Page 1 of 4

RESPONDER BAG CHECK LISTSITE NAME : INDO MURO KENCANA

PERIOD OF : 1-Dec-12

CONTENT FORM WEEKLY CHECKLIST SCHEDULED

CODE FORM

D7M6034 MASK CPR CLEAR ADULT POCKETMAS # 820011 W/O O2 1 PcsD4G6022 GOEDEL BLACK 60MM/1156 1 PcsD4G6023 GOEDEL WHITE 70MM/1157 1 PcsE4L2028 LARYNGOSCOPE ADULT RIESTER 1 UnitE4L2021 LARYNGOSCOPE PAEDIATRIC RIESTER SET / MACHINTOS 1 UnitD4E6011 E.T.T.DISP.NON CUFF SIZE 3 1 PcsD4E6030 E.T.T.DISP.NON CUFF SIZE 3,5 1 PcsD4E6126 E.T.T.DISP. NON CUFF SIZE 4 1 PcsD4E6128 E.T.T DISP. W/CUFF SIZE 4,5 1 PcsD4E6014 E.T.T.DISP.W/CUFF SIZE 5 1 PcsD4E6015 E.T.T.DISP.W/CUFF SIZE 5,5 1 PcsD4E6090 E.T.T.DISP.W/CUFF SIZE 6 1 PcsD4E6017 E.T.T.DISP.W/CUFF 6,5 1 PcsD4E6027 E.T.T.DISP.W/CUFF SIZE 7 1 PcsD4E6087 E.T.T.DISP.W/CUFF SIZE 7,5 1 PcsD4E6089 E.T.T.DISP.W/CUFF SIZE 8 1 PcsD4E6021 E.T.T.DISP.W/CUFF SIZE 8,5 1 PcsD4E6022 E.T.T.DISP.W/CUFF SIZE 9 1 PcsD4R6045 REBREATHING MASK ADULT 2 PcsD4N6011 NASAL OXYGEN CANULA ADULT 1820 / 1103 2 PcsD4O6051 OXYGEN TUBING 1 PcsD4S6214 STYLET PORTEX S / 100-120-100 ( FOR ETT SIZE 2.5 2 PcsD4S6215 STYLET PORTEX M / 100-120-200 ( FOR ETT SIZE 5.0 2 PcsD4S6013 STERIL SCALPEL W/HANDLE NO.15 1 PcsD4S6259 STERIL SCALPEL W/HANDLE 21 1 PcsI4M2033 MOSQUITO CLAMP STRAIGHT 2 PcsI4A2023 ARTERY CLAMP 14CM 2 PcsI5M2021 MAGIL FORCEP ADULT 1 PcsI5M2022 MAGIL FORCEP CHILD 1 PcsD4L6082 LARYNGEAL MASK SIZE 3 1 PcsD4C6087 COMBITUBE ADULT (SIZE 41) BOX/4 PCS TYCO 1 PcsE4R2024 RESUSITATOR ADULT MANUAL 1 SetD4M6022 MINI TRACH II PORTEX#100-461-000 1 Set

CODE FORM

D4B7025 BURNSHIELD DRESSING 10 X 10 1 PcsD4B7026 BURNSHIELD DRESSING 20 X 20 1 PcsD4B7027 BURNSHIELD DRESSING 60 X 40 1 Pcs

CODE FORM

D4P6065 PEN LIGHT ONEMED 1 PcsE4O2077 GLUCOTEST 1 Unit

E4B2143 BLOOD PRESSURE ANEROID ABN 1 TubeD4G6029 GLOVES STERIL 7 ANSELL BX/40 10 PairE4T6013 THERMOMETER DIGITAL YPN 1 Unit

D4S6121 STERI TEMP BOX/1000 IMP 5 PcsE4S2183 STETOSCOPE LITTMANN ADULT ( CLASSIC II ) 1 UnitE4P2088 PULSE OXIMETRY TUFFSAT 1 UnitI4S2015 SCISSOR 14CM SH/BLT 1 Unit

CODE FORM

D4S6412 SYRINGE 1ML TB BOX/100 TERUMO 5 PcsD4S6414 SYRINGE 5ML BOX/100 TERUMO 5 PcsD4S6416 SYRINGE 20ML BOX/50 TERUMO 5 PcsD4S6415 SYRINGE 10ML BOX/100 TERUMO 5 PcsD4S6413 SYRINGE 2,5/3ML BOX/100 TERUMO 5 PcsD4S6417 SYRINGE 50ML BOX/20 TERUMO 2 Pcs

D4N6021 NEEDLE STERILE 18 G BOX/100 6 PcsD4N6025 NEEDLE STERILE 23 G BOX/100 6 Pcs

CODE FORM

D4S7096 STIFFNECK SELECT ADJUSTABLE 1 Pcs

D4S6251 SAM SPLINT 1 Pcs

CODE FORM

D4M7022 MICROPORE 1 INCH BOX/12 2 Roll

D4H6032 BANDAGES 4 PcsD4C7041 COMBINE DRESSING 10X20CM PACK/5 5 PcsD4O7013 OVAL EYE PAD-OPTICLUDE 3M NEXCARE TM 1539 BOX/20 5 PcsD4G7022 GAUZE PAD 6,5X7CM PACK/100 100 PcsD4W7034 WOUND DRESSING NO.15 LOCAL 4 RollM4B0082 BETADINE SOL ML60 1 BtlD4M7032 MITELA(TRIANGULAR BANDAGE) - L 2 Pcs

CODE FORM

M4A5021 ADRENALIN/EPINEPHRINE 0.1% AMP BOX/100 10 AmpM4A0111 ASPIRIN TAB MG500 BOX/120 8 TabM4N0091 NORIT TAB MG125 TUBE/40TAB 1 Bottle

M4A5165 ADENOCOR(ADENOSIN) 6MG/2ML IMP BOX/6 3 AmpM4C5111 CORDARONE AMP BOX/6 3 AmpM4A5091 ATROPINE SULFAS AMP ML1 BOX100 12 AmpM4C5015 CALCIUM CHLORIDE10% MINJET(IMP 1 Amp

M4S5026 SOLUMEDROL 125MG VIAL 2 AmpM4P0510 PLAVIX TABLET MG75 BOX/28 28 TabM4D5141 DEXTROSE 40% SOL CC25 2 Kolf

M4L5011 LASIX AMP CC2 BOX/5 3 AmpM4X5016 XYLOCAIN 2% 2ML AMP BOX/50 3 AmpM4X5011 XYLOCAIN 2% 20ML BOX/5 1 AmpM4X0015 XYLOCAIN 10% SPR ML50 1 BtlM4P5091 PRIMPERAN AMP CC2 BOX/6 2 AmpM4N5053 NOKOBA AMP BOX/5 2 AmpM4G0116 GLYTRIN SPRAY 400 MCG/200 IMP 1 TubeM4M5032 MEYLON INJ ML25 1 Vial

M4N5031 NEUROBION 5000 AMP BOX/20 1 Amp

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AIRWAY MANAGEMENT & BREATHING(AIRWAY BAG)

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BURN KIT(MIDDLE FLAP)

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DIAGNOSIS(SIDE POUCH)

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DISPOSABLE FOR INJECTIONS / IVs(INNER BAG)

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IMMOBILIZATION SETS(INSIDE)

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DRESSINGS(INNER BAG)

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ACLS MEDICINES(DRUG BAG)

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Responder Bag Checklist Page 2 of 4

M4V0071 VENTOLIN INHALER MCG100 3 Btl

CODE NARCOTIC FORM

M4D5011 DOPAMINE AMP MG200 CC10 BOX/5 1 AmpM4S5076 STESOLID 10MG/2ML BOX/5 4 AmpM4M5025 MORPHINE HCL 10MG AMPUL BOX/10*CD 2 Amp

M4D5062 DORMICUM 5MG/5ML BOX/10 1 AmpM4P5101 PHENERGAN AMPCC2/PROMETHAZINIM IMP BOX/5 2 Amp

CODE FORM

M4G8011 GELOFUSIN CC500 1 KolfM4D8011 DEXTROSE/GLUCOSE 5% SOL CC500 1 KolfM4S8011 SODIUM CHLORIDE 0,9% SOL CC500 1 KolfM4S5011 SODIUM CHLORIDE SOL CC25 5 Kolf

M4A5073 AQUA DEST PRO INJ ML25 BOX/120 5 KolfM4R8011 RINGER LACTATE SOL CC500 1 KolfD4S7051 STERI SWAB BOX/100" 6 PcsD4S6023 SOL ADMIN SET TSPA BOX/20 2 PcsD4S6021 SOL ADMIN SET ADULT TSA BOX/50 2 PcsD4B6011 BLOOD ADMIN SET#TB*A200L002 2 PcsD4S6311 SURFLO FLASH 14 SR*FS1451 2 Pcs

D4S6312 SURFLO FLASH 16 SR*FR1651 2 PcsD4S6313 SURFLO FLASH 18 SR*FR1832 2 PcsD4S6316 SURFLO FLASH 20 SR*FS2032 2 PcsD4O6024 OP SITE POST-OP 6.5 X 5CM BOX/100 6 Pcs

D9B9057 BD DISPOSAL CONTAINER 1 LITER 1 PcsD4T7043 TOURNIQUET IDEAL 1 Pcs

CODE FORM

D4S6044 SUCTION CATHETER CH 14 2 PcsI4Y2013 YANKAUER SUCTION TUBE IMP 2 PcsD4F6024 FOLLEY BALON CATH. CH 14 1 PcsD4F6025 FOLLEY BALON CATH CH 16 1 PcsD4F6026 FOLLEY BALON CATH. 18 1 PcsD4S6153 STOMACH TUBE FR 12 TERUMO 2 PcsD4S6154 STOMACH TUBE FR 14 TERUMO 2 PcsD4U6013 URINE BAG STERIL ADULT ONEMED 2 Pcs

CODE FORM

D4S7011 SANITARY NAPKINS 24 PCS/PACK 2 PCSD4U6071 UMBILICAL CORD CLAMP DISPOS 4 PCS

D4M6011 MUCOUS EXTRACTOR 1 PCSD4D6073 DRAPE SPUNGUARD WRAP 61X61 1 PCSD4S6259 STERIL SCALPEL W/HANDLE 21 2 PCsD4U6079 UNDERPAD DISPOS. 60X60 HARTMAN 2 Pcs

N0240033 PLASTIC FEEDING BOTTLE 120 ML 1 PcsN0240284 BAG, RESPONDER BAG ( GMS ) 1 Pcs

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FLUIDS(IV BAG)

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CATHETERS(SIDE)

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OBSGYN & PEDIATRIC(OBSGYN)

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