KLINIK DOKTER KELUARGA

FAKULTAS KEDOKTERAN
UNIV. MUHAMMADIYAH PALEMBANG

KARTU BEROBAT
CATATAN MEDIS BAYI DAN BALITA

No. ..... / ..... / ..... / 20...

Nama Pasien : ......................................................................................................................... (L/P)

TTL : ......................................................................
Umur : ............................. bulan
Anak ke : ................... dari ........................ bersaudara

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

Alamat : ......................................................................................................................
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Kunjungan I : Umum Gigi KIA/KB Tindakan Lab

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 ..................................................
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 : .....................................................................................................................
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Data faktor risiko dalam keluarga (alergi / perilaku)

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DATA IMUNISASI

JADWAL YANG DILAKSANAKAN

JENIS
DIANJURKAN TANGGAL
BCG Umur 2-3 bulan
1. Lahir 1.
Hepatitis B 2. Umur 1 bulan 2.
3. Umur 6 bulan 3.
1. Lahir 1.
2. Umur 2 bulan 2.
Polio 3. Umur 4 bulan 3.
4. Umur 3 tahun 4.
5. Umur 6 tahun 5.
1. Umur 2 bulan 1.
DPT
2. Umur 4 bulan 2.
(Difteri, Pertusis, Tetanus)
3. Umur 6 bulan 3.
1. Umur 9 bulan 1.
Campak
2. Umur 6 tahun 2.
1. Umur 2 bulan 1.
2. Umur 4 bulan 2.
Haemophilus influenzae Type B) 3. Umur 6 bulan 3.
4. Umur 15-18 bulan 4.
1. Umur 2 bulan 1.
PCV 2. Umur 4 bulan 2.
Pneumococcal Conjugate Vaccine) 3. Umur 6 bulan 3.
4. Umur 12-15 bulan 4.
1. Umur 2 bulan 1.
Rotavirus 2. Umur 4 bulan 2.
3. Umur 6 bulan 3.
Influenza Setiap tahun 1 kali sejak umur
 6 bulan 18 tahun
Varisela Umur 6 bulan 18 tahun
MMR 1. Umur 15 bulan 1.
(Measles, Mumps, Rubela) 2. Umur 5-6 tahun 2.
Ulangan tiap 3 tahun sejak
Tifoid
umur 1 18 tahun
2 kali, interval 6-12 bulan sejak 1.
Hepatitis A
umur 1 18 tahun 2.
1.
HPV
3 kali sejak umur 10 -18 tahun 2.
Human Papiloma Virus)
3.

Pemeriks
No Diagnosis
Tanggal SOAP Terapi a
. (ICD)
(TTD)