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CATATAN KESEHATAN IBU BERSALIN DAN BAYI BARU LAHIR

 
IBU BERSALIN

Tanggal Persalinan              :……………………Pukul : …........................................................
Umur Kehamilan                                :……………………Minggu                             
Penolong Persalinan            : Dokter / Bidan / Lain-Lain……………………………………….           
Cara Persalinan                   : Normal / Tindakan……………………….(sebutkan)
Keadaan Ibu                        : Sehat / Sakit / (Pendarahan/ Demam/ Kejang
                                                  Lokhia Berbau/ Lain – Lain………………meninggal
Keterangan Tambahan     :……………………………………………………………………


BAYI SAAT LAHIR

Anak Ke                                                :……………………………….                         
Berat Lahir                           :……………………………….Gram
Panjang Badan                    :……………………………….Cm
Lingkar Kepala                    :……………………………….Cm
Jenis Kelamin                       : Laki – Laki / Perempuan

Keadaan Bayi Saat Lahir
(          ) Segera Menangis                                                    (        ) Anggota Gerak Kebiruan
(          ) Menangis Beberapa Saat                                     (        ) Seluruh Tubuh Biru
(          ) Tidak Menangis                                                     (        ) Meninggal
(          ) Seluruh Tubuh Kemerahan

Asuhan Bayi Baru Lahir
(          ) Inisiasi Menyusu Dini (Imd) Dalam 1 Jam Pertama Kelahiran Bayi
(          ) Suntikan Vitamin K1
(          ) Salep Mata Antibiotika Profilaksis
(          ) Imunisasi Hbo

Keterangan Tambahan :………………………………………..................................
                                          ……………………………………………………………..
                                       ……………………………………………………………..









RUJUKAN

Tanggal / Bulan / Tahun    : ………/………/……….Jam : …………………………..
Dirujuk Ke                            :………………………………............................................
Sebab Dirujuk                      :………………………………………................................
Diagnosis Sementara          :…………………………………………………………….
Tindakan Sementara          :……………………………………………………………                                                                                                                            
                                                                                         Yang Merujuk
                                                                               

                                                                                          (                                        )
               
UMPAN BALIK RUJUKAN
Diagnosis                               :…………………………………………………………….
Tindakan                              :………………………….....................................................
Anjuran                                 :……………………………………………………………..
Tanggal                                 :……………………………………………………………..                                                                                        
                                                                                              Penerima Rujukan


                                                                                         (                                          )
RUJUKAN          
Tanggal/ Bulan / Tahun     :………/………/………..Jam :…….....................................
Dirujuk Ke                            :……………………………….............................................
Sebab Dirujuk                      :…………………………………………………………….
Diagnosis Sementara          :…………………………………………………………….
Tindakan Sementara          :…………………………………………………………….
                                                                                               Yang Merujuk


                                                                                        (                                            )

Umpan Balik Rujukan
Diagnosis                               :…………………………………………………………….                         
Tindakan                              :…………………………………………………………….
Anjuran                                 :……………………………………………….....................
Tanggal                                 :……………………………………………..........................
                                                                                             Penerima Rujukan


                                                                                 (                                      )
                                                                                                                                                                                                               
                                                                                        

                                                               

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