Formulir 1

Pelaporan dan Pencatatan Kelahiran Bayi

Puskesmas : Purabaya
Bulan / Tahun : Februari 2018

Uraian
No Usia Berat
Nomor Kartu NIK Anak Nama Jenis Tempat Jenis
Nama Orang Tua Keluarga (KK) Alamat Jelas (jika ada) Bayi Kelamin Gestasi Lahir Badan Kelahiran Tanggal Lahir
(minggu) (gram)
1 Ny. eli ratnasari/ ali 3202382310170004 baru 01/01 ds. Citamiang L 40 mgg poned 3000 normal 02/02/2018
2 Ny. st. nurjanah/ bajari 3202381512090013 Kp. ancol 04/03 ds. Citamiang P 36 mgg poned 3200 normal 01/02/2018
3 Ny. ai aisyah/delan 3202382106120009 Kp. cibungbulang 22/03 ds. Ngl L 38 mgg poned 3300 normal 01/02/2018
4 Ny. epa/ fajar 3202382312130002 Kp. mirmon 15/02 ds. Ngl L 37 mgg poned 3000 normal 02/02/2018
5 Ny. cucu/ h. acep Kp. ciroyom 2/1 ds. Pgl L 40 mgg rsud 3000 SC 02/02/2018
6 Ny. siti aidah/ jajang 3202382701160009 Kp. psr manyar 19/6 ds. Prb L 36 mgg poned 3000 normal 02/02/2018
7 Ny. anisa/ panji 3202381210170006 Kp. cimerang hilir 1/1 ds. Cmr P 36 mgg poned 2700 normal 02/02/2018
8 Ny. masikah/ jujun 3202382201100008 Kp. cikaret 15/8 ds. Purabaya P 37 mgg poned 3000 normal 07/02/2018
9 Ny. dewi/ nurman 3202380403120001 Kp. cibulubadag ds. Ngl L 38 mgg poned 3000 normal 04/02/2018
10 Ny. sukaesih/ marna 3202081612120001 Kp. cicupak ds. Cijulang (luar wilayah) P 41 mgg poned 3100 normal 04/02/2018
11 Ny. reni/ ali 3202385607830007 Kp. cimanggu ds. Pgl L 38 mgg poned 3000 normal 04/02/2018
12 Ny. rita/ robi 3202381603170003 Kp. cimanggu ds. Pgl P 39 mgg poned 2600 normal 2/5/2018
13 Ny. elah/nurmah 3202380903150001 Kp. cikaret 15/8 ds. Purabaya P 40 mgg poned 3100 normal 2/5/2018
14 Ny. citra/ deki 3202382003150002 Kp. mirmon 15/02 ds. Ngl L 39 mgg poned 2800 normal 2/5/2018
15 Ny. dati/ engkus 3202381109170004 Kp. malingping ds. Margaluyu P 40 mgg rumah 2900 normal 2/5/2018
16 Ny. ani/ayi 3202345010830007 Kp. citamiang P 40 mgg poned 2700 normal 2/6/2018
17 Ny. rika/uce 3202381103110009 Kp. cipari ds. Neglasari P 36 mgg rsud 3000 normal 2/6/2018
18 Ny. st.mariah/asep 3202382104110011 Kp. sindang hayu ds. Citamiang P 38 mgg poned 2800 normal 2/6/2018
19 Ny. yuningsih/herli 3202381805170008 Kp. cikadu ds. Neglasari P 38 mgg poned 3200 normal 2/6/2018
20 Ny. risma/mardi 3202384204850004 Kp. cigembong ds. Purabaya L 38 mgg poned 2600 normal 2/7/2018
21 Ny. siti aidah/ abdurohim 3202382012170004 Kp. cikembang ds. Neglasari L 37 mgg poned 3700 normal 2/7/2018
22 Ny. ai yeti/ nurul wisnu 3202382710090006 Kp. pasir bitung ds. Purabaya L 36 mgg poned 3600 normal 2/7/2018
23 Ny. sri mulyani/ gunawan 3202380211150006 Kp. batu gede ds. Cimerang P 41 mgg poned 3200 normal 09/02/2018
24 Ny. ida/ a. sirojudin 3202382905120010 Kp. cibungbulang 22/03 ds. Ngl P 39 mgg poned 2800 normal 2/10/2018
25 Ny. merawati/solehudin 3202382604110011 Kp. lembur pasir ds. Cimerang P 38 mgg poned 3100 normal 2/11/2018
26 Ny. heni/nanang 3202380809090004 Kp. rawa udin ds. Purabaya L 39 mgg poned 3600 normal 2/11/2018
27 Ny. ai/aas 3202382605100016 Kp. ciroyom 2/1 ds. Pgl P 39 mgg poned 2500 normal 2/10/2018
28 Ny. ika/ nurdin 3202382408150005 Kp. cipeuteuy ds. Ngl L 41 mgg poned 2700 normal 2/10/2018
29 Ny. st. fatimah/ suherman 3202381906170003 Kp. ciguha ds. Cmr P 38 mgg poned 3200 normal 13/02/2018
30 Ny. milasari/ saepuloh 3202381102160002 Kp. cikupa ds. Pgl P 39 mgg poned 3500 normal 14/02/2018
31 Ny. st. mudrikah/ anwar 3202381705100003 Kp. pasir manyar ds. Purabaya P 38 mgg poned 2500 normal 15/02/2018
32 Ny. respi/ mulyadi 3202381602110017 Kp. legok ds. Citamiang L 41 mgg poned 3200 normal 14/02/2018
33 Ny. meri/ jaelani 3202381002110021 Kp. pasirkuda ds. Purabaya P 37 mgg rsud 3800 normal 14/02/2018
34 Ny. st. nurjanah/ kiki 3202380305170005 Kp. lebaksiuh ds. Citamiang L 39 mgg rsud 3000 normal 15/02/2018
35 Ny. masliah/ hendi 3202380812110001 Kp. hanyawar ds. Margluyu L 38 mgg poned 3100 normal 16/02/2018
36 Ny. ny. Atikah/damin 1 3202383006090012 Kp. Cikupa ds. Pgl p 39 mgg rsud 2300 normal 17/02/2018
37 Ny. atikah/damin 2 3202383006090012 Kp. cikupa ds. Pgl P 41 mgg poned 2000 normal 17/02/2018
38 Ny. purnama/ lukmanul hakim 3202386606860005 Kp. pasir astana ds. Purabaya P 38 mgg poned 3000 normal 18/02/2018
39 Ny. iin sumarni/ saepudin 3202382407120007 Kp. citeurep ds. Neglasari P 36 mgg poned 3700 normal 18/02/2018
40 Ny. totoh/ jiri 3202382604110010 Kp. cinangka ds. Neglasari L 40 mgg poned 2600 normal 21/02/2018
41 Ny. heni/ suherlan 3202382402110007 cigembong ds. Purabaya L 36 mgg poned 3500 normal 20/02/2018
42 Ny. st. nurhasanah/ parman 3202383008100018 cigembong ds. Purabaya L 38 mgg poned 2700 normal 21/02/2018
43 Ny. nia/ jenal 3202382704150001 jabir ds. Neglasari P 37 mgg poned 3300 normal 22/02/2018
44 Ny. antika/ saepudin 3202380711170001 ciwangsana ds. Neglasari P 38 mgg poned 2800 normal 23/02/2018
45 Ny. tita sari/ deni 3202381512160001 Kp. legok ds. Citamiang L 38 mgg poned 2000 normal 23/02/2018
46 Ny. maria/gesa Kp. pasirhuni ds. Prb P 39 mgg poned 3300 normal 24/02/2018
47 Ny. Santi/ dera 3202382909160002 Kp. legok nangka ds. Neglasari L 39 mgg poned 3000 normal 24/08/2018
48 Ny. enah/ adriansyah 3202382812170008 Kp. nangerang ds. Cicukang L 37 mgg poned 2800 normal 24/02/2018
49 Ny. diah/ adi 3202380509140003 Kp. cimerang hilir 1/1 ds. Cmr P 38 mgg poned 3000 normal 25/02/2018
50 Ny. elah/ nurman 3202380903150001 Kp. cikaret 15/8 ds. Purabaya L 38 mgg poned 3200 normal 25/02/2018
51 Ny. neli/ rahmat 3202382209160004 Kp. cikupa ds. Pgl P 38 mgg poned 3100 normal 25/02/2018
52 Ny. martini/ kani 3202382107100001 Kp. narogong ds. Margaluyu L 38 mgg poned 3000 normal 27/02/2018
53 Ny. st. fatimah/ andri 32023808081180011 Kp. cipeuteuy ds. Ngl P 38 mgg poned 2700 normal 27/02/2018
54 Ny. liniawati/ usep 3202382408090002 Kp. cikontrang ds. Citamiang P 39 mgg poned 3000 normal 28/02/2018
55 Ny. ida/ yudiarto 3202382012170009 Kp. cibening ds. Margaluyu L 37 mgg poned 3200 normal 28/02/2018
56 Ny. desi Kp. cikupa ds. Pgl L 40 mgg RSUD 2500 normal 01/02/2018
57 Ny. linda/utep 3202380601180003 Kp. cigawir ds. Citamiang P 36 mgg poned 3000 normal 11/02/2018
58 Ny. N. weulis/ abd. Fatah Kp. ciseupan ds. Cicukang L 37 mgg poned 3200 normal 15/02/2018
59 Ny. samsidah/ abd. Rohman Kp. legok picung ds. Cicukang L 38 mgg poned 2900 normal 14/02/2018
60 Ny. riska/ almizan Kp. sindang raja ds. Cicukang L 39 mgg poned 2700 normal 14/02/2018
61 Ny. risnawati/ sopian Kp. cipingpa ds. Cicukang P 40 mgg poned 3000 normal 15/02/2018
62 Ny. maspupah/ arisman Kp. cipingpa ds. Cicukang P 41 mgg poned 3200 normal 15/02/2018
63 Ny. ny. Repa Kp. babakan bogor ds. Purabaya P 42 mgg poned 3200 normal 18/02/2018
64 Ny. enah/ adedin 3202385506900008 Kp. ranca keuyep ds. Cijulang (lw) L 40 mgg poned 2600 normal 19/02/2018
65 Ny. neng siti/ dayu 3202385210970003 Kp. cicadas ds. Jaya mekar (lw) P 38 mgg poned 2700 normal 25/02/2018

Purabaya, 1
Mengetahui,
Kepala Puskesmas Purabaya Bidan Ko

H. Ujang Ruhiyat, SKM,. MM.Kes., ERNA YUL

NIP. 196901141995031002 NIP. 19660901
Panjang Tempat
Bayi Persalinan Keterangan

50 poned
52 poned
50 poned
52 poned
50 rsud PEB
50 poned
48 poned
50 poned
50 poned
50 poned
52 poned
48 poned
50 poned
49 poned
45 rumah
48 poned
50 rsud PLR
48 poned
50 poned
48 poned
52 poned
52 poned
50 poned
50 poned
50 poned
52 poned
48 poned
47 poned
 50 poned
50 poned
48 poned
52 poned
52 rsud kpd
52 rsud kala I memanjang
50 poned
45 rsud gemeli
42 poned gemeli
50 poned
50 poned
48 poned
50 poned
48 poned
50 poned
50 poned
45 poned
52 poned
50 poned
52 poned
50 poned
50 poned
52 poned
52 poned
50 poned
52 poned
50 poned
50 RSUD SUNGSANG
52 poned
52 poned
50 poned
48 poned
50 poned
50 poned
50 poned
50 poned
48 poned

Purabaya, 1 Maret 2018

Bidan Koordinator,

ERNA YULIAWATI,S.ST
NIP. 19660901 198901 2 003
Formulir 2
Pelaporan dan Pencatatan Ibu Melahirkan
Puskesmas : Purabaya
Bulan / Tahun : Februari 2018

Uraian

No Berat Badan
Nomor Kartu Cara Tempat Penolong Komplikasi Frekuensi
Nama Ibu / Suami Keluarga (KK) Alamat Jelas Persalinan Persalinan GPA Kelahiran Kehamilan ANC Saat
Melahirkan

1 Ny. eli ratnasari/ ali 3202382310170004 baru 01/01 ds. Citamiang normal poned G1 P0 A0 bidan
2 Ny. st. nurjanah/ bajari 3202381512090013 Kp. ancol 04/03 ds. Citamiang normal poned G4 P3 A0 bidan
3 Ny. ai aisyah/delan 3202382106120009 Kp. cibungbulang 22/03 ds. Ngl normal poned G2 P1 A0 bidan
4 Ny. epa/ fajar 3202382312130002 Kp. mirmon 15/02 ds. Ngl normal poned G2 P1 A0 bidan
5 Ny. cucu/ h. acep Kp. ciroyom 2/1 ds. Pgl sc rsud G4 P3 A0 dr.spog
6 Ny. siti aidah/ jajang 3202382701160009 Kp. psr manyar 19/6 ds. Prb normal poned G1 P0 A0 bidan
7 Ny. anisa/ panji 3202381210170006 Kp. cimerang hilir 1/1 ds. Cmr normal poned G1 P0 A0 bidan
8 Ny. masikah/ jujun 3202382201100008 Kp. cikaret 15/8 ds. Purabaya normal poned G3 P2 A0 bidan
9 Ny. dewi/ nurman 3202380403120001 Kp. cibulubadag ds. Ngl normal poned G5 P3 A1 bidan
10 Ny. sukaesih/ marna 3202081612120001 Kp. cicupak ds. Cijulang (luar wilayah) normal poned G5 P4 A0 bidan
11 Ny. reni/ ali 3202385607830007 Kp. cimanggu ds. Pgl normal poned G2 P1 A0 bidan
12 Ny. rita/ robi 3202381603170003 Kp. cimanggu ds. Pgl normal poned G1 P0 A0 bidan
13 Ny. elah/nurmah 3202380903150001 Kp. cikaret 15/8 ds. Purabaya normal poned G1 P0 A0 bidan
14 Ny. citra/ deki 3202382003150002 Kp. mirmon 15/02 ds. Ngl normal poned G2 P1 A0 bidan
15 Ny. dati/ engkus 3202381109170004 Kp. malingping ds. Margaluyu normal rumah G3 P0 A2 bidan
16 Ny. ani/ayi 3202345010830007 Kp. citamiang normal poned G2 P1 A0 bidan
17 Ny. rika/uce 3202381103110009 Kp. cipari ds. Neglasari normal rsud G4 P1 A2 dr.spog
18 Ny. st.mariah/asep 3202382104110011 Kp. sindang hayu ds. Citamiang normal poned G2 P1 A0 bidan
19 Ny. yuningsih/herli 3202381805170008 Kp. cikadu ds. Neglasari normal poned G3 P1 A1 bidan
20 Ny. risma/mardi 3202384204850004 Kp. cigembong ds. Purabaya normal poned G4 P3 A0 bidan
21 Ny. siti aidah/ abdurohim 3202382012170004 Kp. cikembang ds. Neglasari normal poned G1 P0 A0 bidan
22 Ny. ai yeti/ nurul wisnu 3202382710090006 Kp. pasir bitung ds. Purabaya normal poned G3 P2 A0 bidan
23 Ny. sri mulyani/ gunawan 3202380211150006 Kp. batu gede ds. Cimerang normal poned G2 P1 A0 bidan
24 Ny. ida/ a. sirojudin 3202382905120010 Kp. cibungbulang 22/03 ds. Ngl normal poned G5 P4 A0 bidan
25 Ny. merawati/solehudin 3202382604110011 Kp. lembur pasir ds. Cimerang normal poned G3 P2 A0 bidan
26 Ny. heni/nanang 3202380809090004 Kp. rawa udin ds. Purabaya normal poned G3 P2 A0 bidan
27 Ny. ai/aas 3202382605100016 Kp. ciroyom 2/1 ds. Pgl normal poned G2 P1 A0 bidan
28 Ny. ika/ nurdin 3202382408150005 Kp. cipeuteuy ds. Ngl normal poned G5 P3 A1 bidan
29 Ny. st. fatimah/ suherman 3202381906170003 Kp. ciguha ds. Cmr normal poned G2 P1 A0 bidan
30 Ny. milasari/ saepuloh 3202381102160002 Kp. cikupa ds. Pgl normal poned G1 P0 A0 bidan
31 Ny. st. mudrikah/ anwar 3202381705100003 Kp. pasir manyar ds. Purabaya normal poned G1 P0 A0 bidan
32 Ny. respi/ mulyadi 3202381602110017 Kp. legok ds. Citamiang normal poned G2 P1 A0 bidan
33 Ny. meri/ jaelani 3202381002110021 Kp. pasirkuda ds. Purabaya normal rsud G4 P3 A0 dr.spog
34 Ny. st. nurjanah/ kiki 3202380305170005 Kp. lebaksiuh ds. Citamiang normal rsud G1 P0 A0 dr.spog
35 Ny. masliah/ hendi 3202380812110001 Kp. hanyawar ds. Margluyu normal poned G2 P1 A0 bidan
36 Ny. atikah/damin 3202383006090012 Kp. cikupa ds. Pgl normal rsud G3 P2 A0 dr.spog
37 Ny. purnama/ lukmanul hakim 3202386606860005 Kp. pasir astana ds. Purabaya normal poned G3 P2 A0 bidan
38 Ny. iin sumarni/ saepudin 3202382407120007 Kp. citeurep ds. Neglasari normal poned G7 P5 A1 bidan
39 Ny. totoh/ jiri 3202382604110010 Kp. cinangka ds. Neglasari normal poned G6 P3 A2 bidan
40 Ny. heni/ suherlan 3202382402110007 cigembong ds. Purabaya normal poned G2 P1 A0 bidan
41 Ny. st. nurhasanah/ parman 3202383008100018 cigembong ds. Purabaya normal poned G1 P0 A0 bidan
42 Ny. nia/ jenal 3202382704150001 jabir ds. Neglasari normal poned G1 P0 A0 bidan
43 Ny. antika/ saepudin 3202380711170001 ciwangsana ds. Neglasari normal poned G1 P0 A0 bidan
44 Ny. tita sari/ deni 3202381512160001 Kp. legok ds. Citamiang normal poned G1 P0 A0 bidan
45 Ny. maria/gesa Kp. pasirhuni ds. Prb normal poned bidan
46 Ny. Santi/ dera 3202382909160002 Kp. legok nangka ds. Neglasari normal poned G1 P0 A0 bidan
47 Ny. enah/ adriansyah 3202382812170008 Kp. nangerang ds. Cicukang normal poned G1 P0 A0 bidan
48 Ny. diah/ adi 3202380509140003 Kp. cimerang hilir 1/1 ds. Cmr normal poned G3 P2 A0 bidan
49 Ny. elah/ nurman 3202380903150001 Kp. cikaret 15/8 ds. Purabaya normal poned G1 P0 A0 bidan
50 Ny. neli/ rahmat 3202382209160004 Kp. cikupa ds. Pgl normal poned G1 P0 A0 bidan
51 Ny. martini/ kani 3202382107100001 Kp. narogong ds. Margaluyu normal poned G4 P3 A0 bidan
52 Ny. st. fatimah/ andri 32023808081180011 Kp. cipeuteuy ds. Ngl normal poned G1 P0 A0 bidan
53 Ny. liniawati/ usep 3202382408090002 Kp. cikontrang ds. Citamiang normal poned G5 P3 A1 bidan
54 Ny. ida/ yudiarto 3202382012170009 Kp. cibening ds. Margaluyu normal poned G1 P0 A0 bidan
55 Ny. desi Kp. cikupa ds. Pgl normal RSUD G2 P1 A1 dr.spog
56 Ny. linda/utep 3202380601180003 Kp. cigawir ds. Citamiang normal poned G2 P1 A0 bidan
57 Ny. N. weulis/ abd. Fatah Kp. ciseupan ds. Cicukang normal poned G2 P1 A0 bidan
58 Ny. samsidah/ abd. Rohman Kp. legok picung ds. Cicukang normal poned G2 P1 A0 bidan
59 Ny. riska/ almizan Kp. sindang raja ds. Cicukang normal poned G2 P1 A0 bidan
60 Ny. risnawati/ sopian Kp. cipingpa ds. Cicukang normal poned G1 P0 A0 bidan
61 Ny. maspupah/ arisman Kp. cipingpa ds. Cicukang normal poned G1 P0 A0 bidan
62 Ny. Ny. Repa Kp. babakan bogor ds. Purabaya normal poned G1 P0 A0 bidan
63 Ny. enah/ adedin 3202385506900008 Kp. ranca keuyep ds. Cijulang (lw) normal poned G2 P1 A0 bidan
64 Ny. neng siti/ dayu 3202385210970003 Kp. cicadas ds. Jaya mekar (lw) normal poned G1 P0 A0 bidan

Purabaya, 1 Maret 2018

Mengetahui,
Kepala Puskesmas Purabaya Bidan Koordinator,

H. Ujang Ruhiyat, SKM,. MM.Kes., ERNA YULIAWATI,S.ST

NIP. 196901141995031002 NIP. 19660901 198901 2 003
 Komplikasi
Persalinan

PEB

PLR
kpd
kala I memanjang

gemeli

sungsang
Formulir 3
Pencatatan dan Pelaporan Kematian Ibu
Puskesmas : Purabaya
Bulan / Tahun : Februari 2018

Uraian
No Nama Ibu No. kartu keluarga Alamat jelas tanggal meninggal sebab meninggal

IL
NIH

Mengetahui,
Kepala Puskesmas Purabaya

H. Ujang Ruhiyat, SKM,. MM.Kes.,

NIP. 196901141995031002
periode meninggal tempat meninggal

Bidan Koordinator,

ERNA YULIAWATI, S.ST

NIP. 19660901 198901 2 003
Formulir 4
Pencatatan dan Pelaporan Kematian Neonatal, Bayi dan Balita
Puskesmas : Purabaya
Bulan / Tahun : Februari 2018

Uraian
Nomor Berat
No Nama
Orang Kartu Alamat Jelas NIK Anak Nama Jenis Tanggal Badan Sebab
Keluarga Anak Kelamin Meninggal Bayi/Anak Meninggal
Tua
(KK) (gram)

I L
N IH
Mengetahui,
Kepala Puskesmas Purabaya Bidan Koordinator,

H. Ujang Ruhiyat, SKM,. MM.Kes., ERNA YULIAWATI, S.ST

NIP. 196901141995031002 NIP. 19660901 198901 2 003
 Tempat Panjang Ket
Meninggal Bayi (cm)