Upload
indah-mardiyanthi
View
220
Download
0
Embed Size (px)
Citation preview
8/18/2019 RM OBG 1 Pengkajian Data Partus
1/2
RM.RI. 27.2
DATA PARTUS
Nama :
L
P
No. Register :
No. Rekam Medik :
PARTUS
NORMAL ( )
G______________ P _____________ /______________ /______________ /______________
NP ( ) NP Post Sectio ( ) NP dengan Exprsi ( ) NP dengan Extrx ( )
EPISOTOMI Ya ( ) Tidak ( ) Midline ( ) Median laternal ( )
PRESENTASI Vertex ( ) Puncak ( ) Sungsang ( ) ***************Replacement Cairan ( ) Darah ( ) Antibiotik ( )
PARTUS
DENGAN
INDIKASI ( )
INDIKASI IBU ANAK WAKTU
* Pre Eksklampsia IUFD
Premi > 2 jamINDUKSI Eksklampsia Prolap Fun
*
PRM Fetal Dest
Dystocia Kel Letak Multi > 1 jam
FORCEPS CPD Gemelli Lain-lain
*
Prev Sect Sungsang
Plac Prev Hydrocephalus
SECTIO Sol Plac Post DatePeny sbl Anak Mahal
Hypotonia Hydramnios
TINDAKAN LAIN P 1 Man ( ) Lain-lain:_________________________________
* * * PENOLONG PARTUS Dokter ( ) Bidan ( ) Paramedis ( ) Anesthesi ( )
* ***
KOMPLIKASI
Pendarahan ( ) Dehidrasi ( ) Infeksi ( ) Wound Dehist ( ) Episiotomi Total ( )
Episiotomi Subtotal ( ) UTI ( ) Retentio Urine ( ) Lain-lain:*
* TAMBAH DARAH * JUMLAH:__________________cc
*** DATA ANAK *** Tgl. Lahir :____/_________/________
Lk ( ) Pr ( ) BB:____________________ Aterm ( ) Premature ( ) Dysmature ( )
ANAK HIDUP AS 1 ( ) 5 ( ) Ket Lain:__________________________________________
ANAK MATI
I U F D
Anomali Cong ( ) Sol P1 ( ) Prek 1 ( ) Ekl ( ) DM ( )
Hipertensi ( ) P1 Previa ( ) Lain-lain:________________________________
* IMUNISASI * Tetanus Toxoid I ( ) II ( ) III ( ) IV ( ) ***********
Partus Resiko Tinggi ( )KESAN – KESAN :
Partus Resiko Rendah ( )
NAMA:__________________________________________ KLINIK
1/1
8/18/2019 RM OBG 1 Pengkajian Data Partus
2/2
RM.RI. 27.2
RUMAH SAKIT BAPTIS BATUJl. Raya Tlekung No. 1 Tlekung – Junrejo – Batu
Telp. (0341) 594161 Fax. (0341) 598911
DATA PARTUS
Nama :
L
P
No. Register :
Umur : Ruang : Lantai : No. Rekam Medik :
RSBB 2013