Blangko Anc Dll.docx

BPS MELIA INDRAWATI,SST Jl. Raya Giri Tunggal ,Dusun Giri Sari RT 003/RW 008 Pekon Giri Tunggal , Kec. Pagelaran Utara Kab. Pringsewu

PEMERIKSAAN ANTENATAL

Nama Umur Alamat Dokter

: ..................................... : ..................................... : ..................................... ..................................... : .....................................

Tanggal : ........./ ........../ ........ Pukul : ............... Oleh : ............................ Riwayat Kehamilan ini Hari Pertama Haid Terakhir

: ..................................

Taksiran Persalinan

: ..................................

Gerakan Janin dirasakan tanggal

: ..................................

Gangguan selama kehamilan

: ..................................

Siklus : ...........................

Status Presents Keadaan Umum : Tensi : ............. mmHg

Suhu : .............. Nadi :............../ Menit

Pernafasan

: ............/ menit

Berat Badan

: ............ Kg Tinggi Badan : ................. Cm

Muka

: .............................................................................................................................................

Dada : Cor

: ..............................................................................................................................................

Pulmo

: ..............................................................................................................................................

Mammae

: ..............................................................................................................................................

Perut

: ...............................................................................................................................................

Ekstremitas : Oedema

: ......................................................................................................................

Refleks

: .......................................................................................................................

Status Obstetric Fundus Uteri

: ...................................

Letak Anak

: .............................................

Detak Jantung

: ...................................

HIS

: .............................................

Pemeriksaan Dalam : ...................................................................................................................................................................... ...................................................................................................................................................................... ......................................................................................................................................................................

BPS MELIA INDRAWATI,SST Jl. Raya Giri Tunggal ,Dusun Giri Sari RT 003/RW 008 Pekon Giri Tunggal , Kec. Pagelaran Utara Kab. Pringsewu

STATUS PASIEN RAWAT INAP Nama Pasien

: ........................................

Nama KK

: ..............................................

Umur

: .......................................

Penanggung Jawab

: ..............................................

Agama

: .......................................

Umur

: .............................................

Pekerjaan

: ......................................

Agama

: .............................................

Alamat

: .....................................

Pekerjaan

: ............................................

Alamat

: ..............................................

Anamnesa

:

................................................................................................................................................................................. ................................................................................................................................................................................ ................................................................................................................................................................................ Pemeriksaan Fisik : ................................................................................................................................................................................ ................................................................................................................................................................................ ............................................................................................................................................................................... Riwayat Penyakit Sekarang : .............................................................................................................................................................................. ............................................................................................................................................................................. Pemeriksaan Laboratorium : ............................................................................................................................................................................ ........................................................................................................................................................................... Diagnosa Penyakit : DD/Penyakit : Keluar Tanggal : Sembuh Pulang Paksa Dirujuk Meninggal

Dokter Yang Merawat :

Paraf :

BPS MELIA INDRAWATI,SST Jl. Raya Giri Tunggal ,Dusun Giri Sari RT 003/RW 008 Pekon Giri Tunggal , Kec. Pagelaran Utara Kab. Pringsewu

CATATAN MEDIK BAYI BARU LAHIR Nama Bayi :

Nomor Rekam Medik Bayi Cap Telapak Kaki Bayi(Kanan & Kiri)

I. Identitas Orang Tua Nama Ibu

:

Umur :

TH

Nama Bapak

:

Umur :

TH

Alamat

:

Riwayat Kehamilan : Hamil Ke

:

Umur Kehamilan :

Anak Hidup

:

Anak Mati

:

Aborsi :

Penyakit Ibu Selama Hamil II. Keadaan bayi waktu lahir Hari :

Tgl:

jam :

A/S:

Jenis kelamin BB:

Gr

PB:

Cm

LK:

Cm

LD:

Cm

Persalinan ditong oleh :

Cap ibu jai Tangan Kanan Ibu

Jenis partus

:

Induksi:

Letak bayi

:

Ketuban

: .......................................... Jam Sebelum Partus

Warna air ketuban : Anus

:

Kelainan bawaan : TGL

DIET

INSTRUKSI

TGL

DIET

INSTRUKSI DOKTER

Diagnosa Utama : Keadaan Keluar Sembuh Belum Sembuh Bila MENINGGAL, sebagai penyebab kematian:

Kode ICD/100PIM: Meninggal <48 jam

Meninggal >48 jam

Tgl Keluar:

DOKTER YANG MENYELAMATKAN

DOKTER YANG MEMULANGKAN

PASIEN PULANG PERMINTAAN SENDIRI:

Td. Tangan :

Td. Tangan :

Td. Tangan :

Nama Terang :

Nama Terang :

Nama Terang :

BPS MELIA INDRAWATI,SST Jl. Raya Giri Tunggal ,Dusun Giri Sari RT 003/RW 008 Pekon Giri Tunggal , Kec. Pagelaran Utara Kab. Pringsewu

LAPORAN PERSALINAN No Rekam Medik : Umur :

Ruang : Nama : Masuk kamar bersalin, Tanggal : Diagnosa Masuk

:

Diagnosa Keluar

:

Jam :

Pemeriksaan penting saat masuk :

Laboratorium / Rontgen / Hal penting :

Jenis Tindakan

:

Penolong

( Melia Indrawati, S.ST )