KLINIK DOKTER KELUARGA

FAKULTAS KEDOKTERAN
UNIV. MUHAMMADIYAH PALEMBANG

KARTU BEROBAT
CATATAN MEDIS BAYI DAN BALITA
No. ..... / ..... / ..... / 20...

Nama Pasien
TTL
Umur
Anak ke

:
:
:
:

......................................................................................................................... (L/P)
......................................................................
............................. bulan
................... dari ........................ bersaudara

Nama Kepala Keluarga : ......................................................................................................................

Alamat
: ......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................

Kunjungan I

: Umum Gigi KIA/KB

CATATAN KUNJUNGAN PERTAMA

Persalinan di :
Rumah
Rumah Bidan
Rumah Bersalin
Rumah Sakit
Lainnya ..................................................
Persalinan di tolong oleh :
Dukun Bayi
Bidan
Dokter Keluarga
Dokter Spesialis Obstetri dan Ginekologi
Lainnya ..................................................

Tindakan Lab

Proses persalinan :
Spontan normal
Pervaginam dengan alat
bantu ......................................................................................................................................................
..........
Sectio Caesaria
ec. ...........................................................................................................................................................
.....

Lainnya ..................................................................................................................................................
..............
Umur kandungan saat lahir : ............................... minggu
BB lahir : ........................ gram
PB lahir : ........................ cm
Nilai APGAR : ................................................................
CATATAN KHUSUS
Riwayat kesehatan masa neonatal :
ASI
Kejang
Ikterik
Terapi sinar
Inkompabilitas ABO
Sindroma gangguan napas
Hipoglikemia
Defisiensi enzim GBPD
Cacat kongenital
Transfusi tukar
Lainnya ...........................................................................
Riwayat penyakit sebelumnya :
Dirawat di RS
karena : ...................................................................................................................................................
.............
Pada
tanggal : .......................................................................................................
...............
Dioperasi
karena : ...................................................................................................................................................
.............
Pada
tanggal : ..............................................................................................................
...............
Masalah sosial yang
berat .......................................................................................................................................................
.........
Riwayat penyakit keluarga :
Masalah
keturunan : .............................................................................................................................................
...................

 Penyakit
tersering : ...............................................................................................................................................
.................
Masalah sosial yang berat dalam
keluarga : ...............................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.................
Data faktor risiko dalam keluarga (alergi / perilaku)
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
DATA IMUNISASI
JENIS
BCG
Hepatitis B

Polio

DPT
(Difteri, Pertusis, Tetanus)
Campak
HiB
(Haemophilus influenzae Type B)
PCV
(Pneumococcal Conjugate
Vaccine)
Rotavirus
Influenza

JADWAL YANG
DIANJURKAN
Umur 2-3 bulan
1. Lahir
2. Umur 1 bulan
3. Umur 6 bulan
1. Lahir
2. Umur 2 bulan
3. Umur 4 bulan
4. Umur 3 tahun
5. Umur 6 tahun
1. Umur 2 bulan
2. Umur 4 bulan
3. Umur 6 bulan
1. Umur 9 bulan
2. Umur 6 tahun
1. Umur 2 bulan
2. Umur 4 bulan
3. Umur 6 bulan
4. Umur 15-18 bulan
1. Umur 2 bulan
2. Umur 4 bulan
3. Umur 6 bulan
4. Umur 12-15 bulan
1. Umur 2 bulan
2. Umur 4 bulan
3. Umur 6 bulan
Setiap tahun 1 kali sejak umur

DILAKSANAKAN
TANGGAL
1.
2.
3.
1.
2.
3.
4.
5.
1.
2.
3.
1.
2.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.

6 bulan 18 tahun
Umur 6 bulan 18 tahun
1. Umur 15 bulan
2. Umur 5-6 tahun
Ulangan tiap 3 tahun sejak
umur 1 18 tahun
2 kali, interval 6-12 bulan sejak
umur 1 18 tahun

Varisela
MMR
(Measles, Mumps, Rubela)
Tifoid
Hepatitis A
HPV
(Human Papiloma Virus)

No.

Tanggal

3 kali sejak umur 10 -18 tahun

SOAP

Diagnosis
(ICD)

1.
2.
1.
2.
1.
2.
3.

Terapi

Pemeriksa
(TTD)