BIDAN PRAKTEK MANDIRI

IDI ISTIYANA, AM.KEB

Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

SURAT KETERANGAN KELAHIRAN

Dengan ini saya menerangkan bahwa :

Nama : .......................................................................................................
Umur : .......................................................................................................
Pekerjaan : .......................................................................................................
Nama suami : .......................................................................................................
Umur : .......................................................................................................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................

Telah melahirkan seorang bayi pada:

Hari : .......................................................................................................
Tanggal : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Berat Badan : .......................................................................................................
Panjang : .......................................................................................................
Anak Ke : .......................................................................................................
Diberi Nama : .......................................................................................................

Demikian surat keterangan ini untuk dipergunakan sebagaimana mestinya.

Banjarbaru,

Bidan Idi Istiyana, Am.Keb

Cap telapak kaki bayi
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

SURAT KETERANGAN KEMATIAN

Dengan ini saya menerangkan bahwa :

Nama : .............................................................................................................................
Tanggal Lahir : .............................................................................................................................
Alamat : .............................................................................................................................

Telah meninggal dunia pada :

Hari : . ...........................................................................................................................
Tanggal : .............................................................................................................................
Jam : . ...........................................................................................................................
Penyebab : .............................................................................................................................

Demikian Surat Keterangan ini dibuat agar dapat dipergunakan sebagaimana mestinya.

Banjarbaru, .............................20.......

Bidan Idi Istiyana, Am.Keb

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

SURAT KETERANGAN CUTI BERSALIN

Yang bertanda tangan di bawah ini, menerangkan bahwa :

Nama : .............................................................................................................................
Umur : .............................................................................................................................
Pekerjaan : .............................................................................................................................
Alamat : .............................................................................................................................
.............................................................................................................................

Dalam keadaan hamil..........bulan, perlu mendapatkan cuti bersalin selama..........bulan, terhitung mulai
tanggal .............................................. s/d ............................................. Harap Surat Keterangan ini dapat
dipergunakan seperlunya.

Banjarbaru, ..............................20......

Bidan Idi Istiyana, Am.Keb

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

Kepada Yth :
.........................................................
.........................................................
di
Tempat

SURAT RUJUKAN
Bersama ini kami kirimkan pasien :
Nama : ..........................................................................................................................................
Umur : ..........................................................................................................................................
Alamat : ..........................................................................................................................................
Anamnesa : ..........................................................................................................................................
................................................................................................................. .........................
Hasil Pemeriksaan : KU : , TD : mmHg , N : x/m , R : x/m , T : ºC
Leopold I : ...............................................................................................
Leopold II : ...............................................................................................
Leopold III : ...............................................................................................
Leopold IV : ...............................................................................................
HIS : ...............................................................................................
DJJ : . .............................................................................................
Pemeriksaan Dalam : ...............................................................................................
...............................................................................................
Belum/Telah kami berikan : .........................................................................................................................................
Atas bantuannya kami ucapkan terima kasih.

Banjarbaru, ............................20....
Hormat Kami,

Bidan Idi Istiyana, Am.Keb

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

SURAT PERNYATAAN PENOLAKAN RUJUKAN

Yang bertanda tangan dibawah ini :

Nama :
Umur :
Alamat :

Selaku SUAMI/ISTERI/KELUARGA/KLIEN telah mendapatkan penjelasan tentang keadaan

pasien oleh BIDAN, menyatakan :
“MENOLAK DIRUJUK”
Persetujuan ini diberikan dengan penuh kesadaran dengan kemungkinan terjadinya akibat
sampingan dari tindakan tersebut diatas.
Demikian surat persetujuan ini dibuat dengan penuh rasa tanggung jawab.

Banjarbaru, ........................................20.......

Mengetahui Bidan, Yang Membuat Pernyataan,

(.............................................) (.................................................)
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

LEMBAR PERSETUJUAN MEDIK (INFORMED CONSENT)

“PERTOLONGAN PERSALINAN”

Saya yang bertanda tangan di bawah ini :

Nama :
Umur :
Alamat :

Selaku SUAMI/ISTERI/KELUARGA/KLIEN telah mendapat penjelasan, memahami dan ikut

menyetujui terhadap tindakan dan atau pertolongan persalinan yang akan diberikan.
Meliputi : Pemeriksaan dalam
Amniotomi
Episiotomi
Penjahitan Perineum
Manual Plasenta

Pernyataan ini kami buat dengan KESADARAN PENUH ATAS SEGALA RESIKO
TINDAKAN MEDIK yang akan diberikan.

Banjarbaru,......................................20.......

Yang Memberi Pelayanan, Klien, Suami/Istri Klien,

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

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

STATUS IBU BERSALIN

Hari / Tanggal :
Jam :
No. Register :

A. IDENTITAS
Nama Ibu : ............................................. Nama Suami : ..............................................
Umur : ............................................. Umur : ..............................................
No. Telp : .............................................
Alamat : ..........................................................................................................................................

B. ANAMNESA
1. HPHT :
2. TP :
3. Mules : Keluar lendir darah :
4. Keluar air-air :
5. Riwayat Obstetri
Hamil ke- Tahun UK Cara Persalinan BB JK Komplikasi Keadaan

6. Riwayat penyakit : Tidak ada Ada, ...............................................................

C. PEMERIKSAAN
Keadaan Umum :
TD : mmHg , N : x/m , R : x/m , T : ºC
Leopold I : .............................................................................................................................
Leopold II : .............................................................................................................................
Leopold III : .............................................................................................................................
Leopold IV : .............................................................................................................................
TBJ : .............................................................................................................................
His : .............................................................................................................................
DJJ : .............................................................................................................................
Tungkai oedem : ........./ .........
Reflek patella : ......../ ..........
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

Pada Pukul ................. WITA , dilakukan VT .....................................................................................

...........................................................................................................
...........................................................................................................
...........................................................................................................

D. ASSESMENT
...............................................................................................................................................................
...............................................................................................................................................................

E. PLANNING
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................

Diisi oleh,

Bidan Idi Istiyana, Am.Keb

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

STATUS IBU BERSALIN

Nama : ........................................................................... No. Register :
Umur : ...........................................................................
Alamat : ............................................................................

HARI/TANGGAL/JAM CATATAN PERKEMBANGAN

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

STATUS IBU BERSALIN

Nama : ........................................................................... No. Register :
Umur : ...........................................................................
Alamat : ............................................................................

LEMBAR OBSERVASI KALA 1 FASE LATEN

TGL/JAM TD N T HIS DJJ Ø KET MOLASE HODGE KET

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

STATUS BAYI BARU LAHIR

No. Register :

1. Nama Bayi : ................................................................................................................

2. Nama Ibu : ................................................................................................................

3. Nama Ayah : ................................................................................................................

4. Tanggal lahir : ................................................................................................................

5. Jam : ................................................................................................................

6. Cara lahir : ................................................................................................................

7. Jenis kelamin : Laki-laki Perempuan

8. Keadaan : Hidup Mati

9. Segera menangis/ tidak : Segera menangis Tidak segera menangis

10. APGAR SCORE

Kriteria 1` 5` 10`
Appearence (warna kulit)
Pulse (nadi)
Grimace (reaksi terhadap rangsangan)
Activity (tonus otot)
Respiration (usaha nafas)
APGAR SCORE

11. Kelainan konginetal : Tidak ada kelainan Ada kelainan, ............................

12. BB / PB : ..............gr / .......... cm

13. LK / LD : ..............cm /..........cm

14. Anus : Positif Negatif

15. Salep mata antibiotika : Sudah diberikan Belum diberikan

16. Injeksi Vit. K : Sudah diberikan Belum diberikan

17. Imunisasi Hbo : Sudah diberikan Belum diberikan

18. Assesment : ................................................................................................................

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482

19. Terapi : ................................................................................................................

................................................................................................................

CAP KAKI KIRI CAP KAKI KANAN

Banjarbaru, ............................... 20

Diisi oleh,

Bidan Idi Istiyana, Am.Keb

 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482
 BIDAN PRAKTEK MANDIRI
IDI ISTIYANA, AM.KEB
Jl. Golf komp. Sinar Lestari 2 No. 44
SIPB : 401/2015 Telp. 082135070482