RUMAH SAKIT

"AFDILA"
Jl.Soekarno-Hatta Telp. (0282) 542749 Menganti - Cilacap 53274
Email : rs.afdila@yahoo.co.id fax : 0282 542749

LAPORAN PERSALINAN
IDENTITAS PASIEN
(Diisi oleh Petugas Rekam Medis)
Nama Pasien : ….......................................................... Ruang : …..........................................................
Tgl Lahir : ….......................................................... Kelas : …..........................................................
No. RM : ….......................................................... Tanggal : …..........................................................
OBSERVASI PRA PERSALINAN
Masuk Kamar Bersalin Tanggal : …..................................................... Jam : ….....................................................
Tanggal / Jam Nadi Tensi Suhu HIS DJJ Keadaaan Umum dan Lain-lain

IKHTISAR PERSALINAN
KK Pecah : Tanggal …..................................................... Jam ….....................
Bayi Lahir : Tanggal …..................................................... Jam ….....................
Macam Persalinan : …...............................................................................................................
Indikasi : …...............................................................................................................
Lama Persalinan : …...............................................................................................................
KEADAAN IBU PASKA PERSALINAN
Keadaan Umum : …...............................................................................................................
Tanda-tanda Vital : Nadi : ….................................... X/menit Suhu : …........................................ °C
Tekanan Darah : …................................../ ….......................... mmHg Hb : ..................................
Uterus : …...............................................................................................................
Pendarahan Kala III : …....................................... cc Pendarahan Kala VI ...................................................... cc
Keadaan Placenta : Bentuk /Ukuran : ….........................................................
Tali Pusat : …...............................................................................................................
Kulit Ketuban : …...............................................................................................................
KEADAAN ANAK
Jenis Kelamin
Antropometri: Berat Badan : ...................... Gram Panjang Badan : ….................................. Cm
Lingkar Kepala
Kelainan Kongenital :
:….......................................................................
Untuk Bayi keadaan jelek, lahir hidup kemudian meninggal : ….................... Jam …...................menit
Penyebab Kematian : …..........................................
…..................................................................................
APGAR Skor : 1 menit.................................... 5 menit …..................................10 menit .........................
Catatan Lain-lain : ….....................................................................................................................................
….................................................................................................................................................................
….................................................................................................................................................................