Essential Medicines & Medical Supplies Standard Order and Report Form (RHFs) 2012/13 (Ver 1) Health Facility Name:
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1 MFL No: Essential Medicines & Medical Supplies Standard and Report Form (RHFs) 2012/13 (Ver 1) Health Facility Name: OPD Visits & Revisits: Level: Dispensary Health Centre County: District: A) Essential Medicines: Tablets and Capsules In-patient Bed Days : PM03ART004 Artemether/lumefantrine tab 120/20mg Blister (6) 0.01 PM03ART005 Artemether/lumefantrine tab 120/20mg Blister (12) 0.01 PM03ART006 Artemether/lumefantrine tab 120/20mg Blister (18) 0.01 PM03ART007 Artemether/lumefantrine tab 120/20mg Blister (24) 0.01 PM03ALB001 Albendazole tab 400mg 1, PM01AMX004 Amoxicillin cap 250mg 1,000 1, PM05ASA001 Aspirin tab 300mg 1, PM01CEF003 Cefixime tab 400mg PM13CHL004 Chlorpheniramine tab 4mg 1, PM01CPR001 Ciprofloxacin tab 250mg PM01CTX004 Cotirmozaxole tab 480mg 1, PM07DAZ002 Diazepam tab 5mg PM03TND003 Diloxanide furoate tab 500mg 500 1, PM01DXY001 Doxycycline cap 100mg 1,000 1, PM01ERY002 Erythromycin tab 250mg 1,000 3, PM14FER001 Ferrous sulphate tab 200mg 1, PM14FER003 Ferrous sulph./folic acid tab 200mg/400mcg 1, PM01FLU001 Flucloxacillin cap 250mg 1,000 1, PM14FLC001 Folic acid tab 5mg PM02GRF001 Griseofulvin tab 125mg 1,000 1, PM11HBB002 Hyoscine butylbromide tab 10mg (f/c) 1,000 1, PM05BRU002 Ibuprofen tab f/c 200mg (scored) 1, PM11CMT001 Magnesium trisilicate co tab 370mg 1, PM05PAR005 Paracetamol tab 500mg 1, Date: no. Start Date: End Date: Out of 1/7 SORF-RHFs 2012/13 (Ver 1 July 2012)
2 PM03QUN001 Quinine sulphate tab 300mg (f/c, scored) 1,000 4, Out of PM11HBB002 Retinol (vitamin A) palmitate cap 50,000 IU PM13SAL006 Salbutamol tab 4mg (scored) 1, PM03TND001 Tinidazole tab 500mg (f/c) PM09ZNC001 Zinc sulphate tab 20mg B) Essential Medicines: Oral Liquids PM01AMX005 Amoxicillin oral susp 125mg/5mL 100mL PM13CHL003 Chlorpheniramine syrup 2mg/5mL 5L PM01CTX001 Cotrimoxazole susp 240mg/5mL 50mL PM01ERY001 Erythromycin ethyl succ. susp 125mg/5mL (pfr) 100mL PM03MET002 Metronidazole susp 200mg/5mL 100mL PM02NYS001 Nystatin oral susp 100,000 IU/mL 30mL PM09REH001 ORS sachet (for 500mL) low osmolality PM05PAR002 Paracetamol syrup 120mg/5mL 5L PM13SAL004 Salbutamol syrup 2mg/5mL 100mL C) Essential Medicines: Parenterals PM07ADR001 Adrenaline (epinephrine) inj 1mg/1mL amp PM13AMN001 Aminophylline inj 25mg/mL, 10mL amp PM03ART008 Artesunate inj 60mg vial PM01PEN001 Benzathine penicillin inj 2.4 MU vial pfr PM01PEN002 Benzylpenicillin inj 600mg (1 MU) vial pfr PM01CAF002 Chlorampenicol sod. succ. inj 1g vial (pfr) PM13CHL001 Chlorpheniramine inj 10mg/1mL amp PM07DAZ001 Diazepam inj 5mg/ml, 2mL amp PM01GEN001 Gentamicin sulphate inj 10mg/ml, 2ml amp PM01GEN002 Gentamicin sulphate inj 40mg/ml, 2ml amp PM09DEX004 Glucose (dextrose) IV infusion 5%, 500mL PM09DEX004 Glucose (dextrose) IV infusion, 10% (hypertonic) 500mL PM09DEX003 Glucose (dextrose) IV infusion 50%, 100mL /7 SORF-RHFs 2012/13 (Ver 1 July 2012)
3 PM10HYD001 Hydrocortisone inj 100mg vial Out of PM11HBB001 Hyoscine butylbromide inj 20mg/mL amp PM07LGN001 Lidocaine (lignocaine) inj 1%, 1mg/1mL 30mL vial PM06MAG001 Magnesium sulphate inj 50%, 10mL amp PM10XYT001 Oxytocin injection 10 IU/1mL ampoule PM14PHY002 Phytomenad.(Vit K) inj 2mg/mL, 0.2mL amp PM03QUN003 Quinine dihyd. inj 300mg/mL, 2mL amp 100 1, PM09SDU001 Sodium bicarbonate 8.4%, 10mL amp PM09SDU002 Sodium chloride IV infusion 0.9%, 500mL (Normal saline) PM09SDU003 Sodium lactate co IV infusion, 500mL (Hartmann's/Ringer-Lactate) PM09WAT001 Water for injection, 10mL vial D) Essential Medicines: External use PM12BBE001 Benzyl benz.emulsion 25% w/v application 10 x 50mL PM12CAL001 Calamine lotion 15% 10 x 50mL PD01CHL001 Chlorhexidine gluconate soln 5% 4 x 5L 3, PM12CLT001 Clotrimazole cream 1% 100 x 20g 1, PM12CLT002 Clotrimazole pessary 200mg PD01ETH002 Ethanol denatured solution 70% 5L PM12GEN002 Gentamicin sulphate solution 0.3% w/v (eye/ear drops) 10 x 5mL PM12HYD001 Hydrocortisone ointment 1% 100 x 15g 3, PM12SLV001 Silver sulphadiazine cream 1% 250g PD01SHS001 Sodium hypochlorite solution 4-6% 4 x 5L PM12TET001 Tetracycline eye ointment 1% 25 x 5g E) Essential Medicines: Psychotropics PM07CHL001 Chlorpromazine inj 25mg/mL, 2mL amp PM07PHB001 Phenobarbitone inj 200mg/mL, 1mL amp /7 SORF-RHFs 2012/13 (Ver 1 July 2012)
4 F) Essential Medicines: For Specific Zones Out of PM03PRA001 Praziquantel tab 600mg PM03SPY001 Sulfadoxine/pyrimethamine tab 500mg/25mg 1, G) Essential Medicines: s with Limited s PM07AMT001 Amitriptyline tab 25mg 1, PM01CEF001 Ceftriaxone inj 250mg vial (pfr) PM02KET001 Ketoconazole tab 200mg PM07MET002 Metoclopramide inj 5mg/mL, 2mL amp PM07MET001 Metoclopramide tab 10mg PM03MET003 Metronidazole tab 200mg 1, PM14MUL001 Multivitamin syrup 4 x 5L 2, PM07PHB002 Phenobarbitone tab 30mg PD01PDS001 Povidone iodine solution 10% 12 x 1L 2, H) Reproductive Health Supplies For Health Center and Dispensary Levels NM21CND001 Condom, male 7, PM10DMP001 Medroxyprogest. acetate 150mg depot inj 100 vials 0.01 PM10LEV004 Levonorgestrel/ethinylestradiol tab 150/30 micrograms (COC) 3 x PM10LEV003 Levonorgestrel tab 30 micrograms (POP) 3 x PM10LEV002 Levonorgestrel tab 750 micrograms (e/c) I) Additional RH Supplies for HC Level only NM21CDM002 Condom, female 1, PM10ETN001 Etonogestrel implant 68mg (1 rod + trocar) 10 sets 0.01 PM10UDC001 IUCDs (Intra-Uterine Contraceptive Devices) 50 sets 0.01 PM10LEV007 Levonorgestrel implant 75mg (2 rods + trocar) 10 sets 0.01 J) Essential Medical Supplies (EMS) for Health Center and Dispensary NM12ADH003 Alcoholic disinfectant detergent 500mL NM12ADH004 Alcoholic disinfectant hand rub 75mL NM12ADH006 Alcoholic pre injection swabs Pack (200) NM18TAP001 Autoclave tape 19mm x 50m 10 2, /7 SORF-RHFs 2012/13 (Ver 1 July 2012)
5 NM02CAT012 Catheter, Foley's, 30ml 10FG Piece NM19MAT001 Cord clamp Piece 3.15 NM01BAN002 Cotton bandage, 7.5cm x 4.5m NM01BAN005 Cotton crepe bandage, 7.5cm x 5m NM01GAU002 Cotton gauze plain, 36" x 100yds, 1,500g Roll 1, NM01CTW001 Cotton wool, absorbent, 400g Roll NM01BAN007 Crepe bandage, 15cm x 4.5m Roll NM05TUB022 Nasogastric/feeding tube, 8FG (for term) Piece NM05TUB019 Nasogastric/feeding tube, 18FG Piece NM07GLV003 Gloves, latex examination, large 50 pairs NM07GLV001 Gloves, latex examination, medium 50 pairs NM07GLV005 Gloves, surgical, size 7 (sterile) 50 pairs 1, NM07GLV006 Gloves, surgical, size 7.5 (sterile) 50 pairs 1, NM07GLV010 Gloves, gynaecological, size pairs 3, NM19MAT002 Identification band, baby Piece 4.50 NM08CAN002 IV cannula 18G Piece NM08CAN003 IV cannula 20G Piece NM08CAN004 IV cannula 22G Piece NM08CAN005 IV cannula 24G Piece NM09SET001 IV infusion giving set with air inlet NM19MAT005 Maternity towels EM10XYM004 Oxygen mask, adult with strap Piece NM20RES012 Oxygen mask, child with strap Piece NM20RES013 Oxygen mask, neonate with strap Piece NM01GAU001 Paraffin gauze dressing, 10cm x 10cm Pack (10) NM05TUB028 Rectal tube, CH20 Piece NM11BXS001 Sharps safe disposal box Piece NM03SCA007 Suction catheter, size 4FG NM03SCA008 Suction catheter, size 6FG Out of 5/7 SORF-RHFs 2012/13 (Ver 1 July 2012)
6 NM03SCA001 Suction catheter, size 10FG Out of NM03SCA002 Suction catheter, size 12FG NM03SCA004 Suction catheter, size 16FG NM06BLA001 Surgical blade, size NM06BLA002 Surgical blade, size NM03SUT015 Suture, polyglycolic acid No 2/0 75cm on 40mm ½C RBN 12 1, NM03SUT036 Suture, nylon, No. 1, 90cm on 60mm ½C RCN NM03SUT035 Suture, nylon, No. 2/0, 75cm on 40mm ½C RCN NM10SYR004 Syringe 2mL + needle 23G x 1" NM10SYR006 Syringe 5mL + needle 21G x 1.5" NM10SYR002 Syringe 10mL + needle 21G x 1.5" NM10SYR008 Syringe, insulin, 1mL, 29G x 3/8" (12.7mm) 100 1, NG02SPA006 Tongue depressor wooden HG05CMB001 Torniquet Piece 9.84 NM19MAT001 Umbilical cord clamp NM01BAG014 Urine bag grad. with inlet/outlet 2000mL Piece NM13KYJ001 Water-based lubricant gel 250g NM01ZNS002 Zinc oxide strapping, 5cm x 4.5m Roll NM01ZNS003 Zinc oxide strapping, 7.5cm x 4.5m Roll K) Additional EMS for HC Level Only NM02CAT006 Catheter, Foley's, 16FG 30mL 2-way Piece NM02CAT007 Catheter, Foley's, 18FG 30mL 2-way Piece NM05TUB023 Nasogastric/feeding tube, 6FG (pre-term) Piece NM05TUB016 Nasogastric/feeding tube, 12FG Piece NM05TUB018 Nasogastric/feeding tube, 16FG Piece /7 SORF-RHFs 2012/13 (Ver 1 July 2012)
7 L) Supplies & Miscellaneous s Out of NP02BTT001 bottle, plastic, 60mL NP02ENV002 envelope, plastic, resealable 1, NP02LBL001 label, self-adhesive NP02MSD001 Measuring spoon, double-sided 5mL/2.5mL 200 1, PD01ETH001 Methylated spirit 96% 4 x 5L 1, NG04TTC001 Tablet counter, triangular M) Transactional Documents NS01CLL003 Control Card NS01CLL001 Prescription Pad NS01CLL031 Medicine Register Piece 0.01 NS01CLL032 Medical Supplies Register Piece 0.01 N) Diagnostics Malaria Rapid Diagnostic Test Kit Each 0.01 Value: Kshs Drawing Rights Available : Kshs FACILITY TEL NO: FACILITY Prepared by (Name/Designation) Tel Date Signature Checked by (Name/DPF/DPHN) Tel Date Signature Authorised by (Name/DMoH) Tel Date Signature 7/7 SORF-RHFs 2012/13 (Ver 1 July 2012)
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