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KLINIK RAWAT INAP PRATAMA

BAITURRAHMAH
Jl. Raya Ambarawa Km. 02 Desa Waluyojati Kec. Pringsewu Kab. Pringsewu 35373
 0856 6972 2515

STATUS PASIEN
IDENTITAS
Nama Ibu : ……………………………. Nama Suami : …………………………….
Umur : ……………………………. Umur : …………………………….
Pekerjaan : ……………………………. Pekerjaan : …………………………….
Agama : ……………………………. Agama : …………………………….
Alamat : ……………………………. Alamat : …………………………….

STATUS OBSTETRI / GINEKOLOGI


G : ………… P : ………… A : ………….... Jumlah Anak Hidup : ……………
HPHT : ……………………............. Jumlah Anak Mati : ……………
TP : …………………………….. Jarak Persalinan Terakhir : ……………

Keluhan utama : …………………………….........................................................................


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Hasil Pemeriksaan : .....................................................................................................................


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CATATAN KEBIDANAN DAN INSTRUKSI DOKTER

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