Catatan Kesehatan Anak

Anda

No : .......................................
Nama : ..................................

Dr. Edwin Tohaga. SpA

Praktek :
RSUD RA Kartini Jepara
RS Graha Husada Jepara

Catatan Kelahiran Buah Hatiku

Nama .............................................................................
.......................
Jenis
kelamin ..........................................................................
..............
Tanggal Lahir
.......................................jam ..........................................
Nama Orang Tua
Ayah ...............................................................................
......................
Pekerjaan .......................................................................
......................
Ibu .................................................................................
.......................
Pekerjaan .......................................................................
......................
Alamat
rumah ............................................................................
..........
.................................................................
.....................
Telp ................................................................................
......................

Riwayat Persalinan
Dokter
Kebidanan ......................................................................
..........

Dokter
anak ...............................................................................
..........
Jenis persalinan ................................Nilai
apgar..................................
Berat/ panjang
badan ..........................................................................
Lingkar kepala /
dada ..........................................................................
Golongan
darah .............................................................................
......
Skiring laboratorium.
Hb............HT...........T4.......................................

Riwayat Masa Neonatal

Ya

Tidak

ASI/Breast Fed
Kuning / Jaundice
Kejang
Defisiensi enzim G6PD
Inkompatabilitas ABO
Terapi sinar / Phototerapi
Transfusi tukar
Hipoglikemia
Sindroma gangguan pernapasan
Cacat bawaan
Lainlain..................................................................................
.............
.......................................................................................
.......................
Kadar bilirubin tertinggi....................................mg/dl
waktu pulang .............................mg/dl
Pulang dari RS/RB
tanggal ..........................................................................
...................................
Berat saat pulang..................gr
ASI .................................................................................
.......................
Susu
Formula ..........................................................................
.............
Tanggal kontrol
.............................................................................
.......

Skrining penyakit jantung bawaan kritikal

Dilakukan pada 24 jam usia persalinan dengan
melakukan pemeriksaan saturasi oksigenasi pada
keempat ektrimitas bayi.
Hasil pemeriksaan

SaO2 tangan kanan

..........

SaO2 tangan Kiri

..........

SaO2 kaki kanan

..........

SaO2 kaki kiri

..........

Kesimpulan ....................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.
Pemeriksa

( .........................)

Jadwal Imunisasi anak anda

Jenis
BCG
HEPATITIS B

DPT

POLIO

CAMPAK
HIB

PNEUMOKOKU
S (PCV)
INFLUENSA
(SETAHUN
SEKALI)
MMR
TIFOID

Rencana
Pemberian

Tanggal
Pemberian

Paraf

(DIULANG
TIAP 3
TAHUN)
HEPATITIS A
(2X INTERVAL
6 BULAN)
VARICELA
HPV
MANTOUX

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan konsultasi
Tgl

BB/PB/LK

Keluhan

Terapi

Catatan Perawatan Rumah Sakit

Tgl perawatan

Diagnosis

Dokter yang
merawat