PEMERINTAH KABUPATEN TUBAN

DINAS KESEHATAN, PENGENDALIAN PENDUDUK

DAN KELUARGA BERENCANA
UOBF PUSKESMAS KEBONHARJO
Jl.Raya Lasem No.4 Kebonharjo Telp.(0356) 531003

Kepada
Yth : .........................................................................................
RS : .........................................................................................
Di : .........................................................................................

KASUS MATERNAL
Mohon pemeriksaan, pengobatan, perawatan untuk :
Nama Ibu/Suami : ............................................................................................
Nama Suami : ............................................................................................
Umur : ............................................................................................
Alamat : ............................................................................................

1. ANEMSIS
Gravid [ ] Para [ ] Abortus [ ]
Anak hidup [ ] anak kecil [ ]
Persalinan yang lalu : normal [ ], ada kelainan [ ]
Bila ada kelainan sebutkan .............................................................................
.........................................................................................................................
Saat ini hamil ke : ...........................................................................................
2. PEMERIKSAAN FISIK :
a. K/U : ..................................................................................
b. Kesadaran : ..................................................................................
c. Tekanan darah : ..................................................................................
d. Tinggi fundus : ..................................................................................
e. His : Kuat [ ], lemah [ ]
Frekuensi : …………………….. ………. kali/ 10 menit
f. Denyut jantung janin : ………………………...................kali/menit
Teratur [ ], tidak [ ]
g. Pembukaan servis : …………………………………………..cm
h. Ketuban jam ………….. : Utuh [ ] pecah [ ]
Bila pecah, air ketuban : Jernih [ ], kerut [ ]
i. Faktor resiko yang ditemukan
..................................................................................................................
...................................................................................................................
...................................................................................................................
3. OBAT DAN TINDAKAN YANG DIBERIKAN
a. Obat : belum diberikan [ ], sudah diberikan [ ]
Bila sudah diberi, yaitu :............................................................................
b. Tindakan yang telah diberikan :
...................................................................................................................
...................................................................................................................
4. DIAGNOSIS SEMENTARA
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Tanggal merujuk ........................................................................................

Jam merujuk................................................................................................
Yang merujuk.............................................................................................