Formulir 1

Pelaporan dan Pencatatan Kelahiran Bayi

Puskesmas : Purabaya
Bulan / Tahun : Agustus 2018

Uraian

No Nomor Kartu NIK Anak Nama Jenis Usia Tempat

Nama Orang Tua Keluarga (KK) Alamat Jelas (jika ada) Bayi Kelamin Gestasi Lahir
(minggu)

1 Ny. tintin/ ruslan
2 Ny. neng sinta/ sandi
3 Ny. cucum/deden
4 Ny. elis/saep
5 Ny. herlin/ la Ode
6 Ny. lilis/ rustam
7 Ny. juju/eman
8 Ny. epah/ suparman
9 Ny. siti jubaedah/ jenal
10 Ny. Amah/ mudin
11 Ny. rina/ dalil
12 Ny. genita/ endang
13 Ny. siti zenab/ abdul hamid 3202382902160003
14 Ny. cicah/ suherlan
15 Ny. deri/ tohaerun
16 Ny. meri/ sandi
17 Ny. euis/ risman
18 Ny. imas/ sopyan
19 Ny. darsih/ engkos
20 Ny. mega/ feri
21 Ny. st. aisyah/ yamin
22 Ny. evi/ agun
23 Ny. arisma/ deden
24 Ny. yati/ misbah
25 Ny. nia/ nenja
26 Ny. nenda/ adam
27 Ny. lia/ heri
28 Ny. dewi/ lili
29 Ny. wati/ uus
30 Ny. mayawati/ endang
31 Ny. siti nurhini/rudi
32 Ny. st nuraeni/ idrus
33 Ny. esih/saepul
34 Ny. ambar sulastri/ didin
35 Ny. rini/ uso
36 Ny. st. maesaroh/ samsudin 3202380801180007
37 Ny. pariah/ abdulloh
3202380808072059 Kp. cipari ds. Neglasari L 40 mgg poned
3202381807180008 Kp. cirangkong ds. Purabaya L 36 mgg poned
3202381204110012 Kp. ancol ds. Citamiang P 40 mgg poned
3202384606840006 Kp. cibolang ds. Cicukang 37 mgg rsud
Kp. rawa tapo ds. Cipicung L 39 mgg poned
3202380908070530 Kp. cipari ds. Neglasari P 39 mgg poned
3202381701110004 Kp. rawa udin ds. Purabaya L 38 mgg rsud
3202382710090019 Kp. cigembong ds. Purabaya L 38 mgg poned
Kp. cigawir ds. Citamiang P 38 mgg poned
3202380707110007 Kp. pasir astana ds. Purabaya L 38 mgg poned
3202381503180009 Kp. pasir huni ds. Purabaya L 40 mgg poned
3202270301180010 Kp. mangkalaya kec. Gn guruh L 39 mgg poned
Kp. cipeutey ds. Neglasari L 39 mgg poned
3202381308130003 Kp. cimanggu ds. Pagelaran P 38 mgg poned
3202382906180008 Kp. cimerang hilir ds. Cimerang L 38 mgg poned
3202380610170011 Kp. rawa udin ds. Purabaya P 38 mgg poned
3202386205920001 Kp. cikupa ds. Pagelaran L 36 mgg poned
3202381205110004 Kp. karikil ds. Neglasari L 38 mgg poned
3202385009730001 Kp. cigembong ds. Purabaya P 41 mgg poned
3202380903170001 Kp. ciakar ds. Citamiang L 41 mgg poned
3202382305180003 Kp. citamiang L 39 mgg poned
3202380507180006 Kp. padaringan ds. Cimerang 39 mgg rsud
3202382511130005 Kp. ciseureh ds. Pagelaran L 39 mgg poned
3202382908120025 Kp. nangewer ds. Neglasari 39 mgg rsud
3202384912950006 Kp. padaringan ds. Cimerang L 40 mgg poned
3202381205120016 Kp. citamiang P 39 mgg poned
3202384601880001 Kp. cibengang ds. Purabaya L 41 mgg poned
3202382701170008 Kp. cirangkong ds. Purabaya P 39 mgg poned
3202381808140016 Kp. ciroyom ds. Pagelaran P 39 mgg rumah
3202385607930005 Kp. selakopi ds. Cimerang L 38 mgg poned
3202382007180006 Kp. ciseureh ds. Pagelaran P 39 mgg poned
3202380608120016 Kp. citeureup ds. Neglasari L 38 mgg poned
3202382104110007 Kp. sindang hayu ds. Citamiang L 38 mgg poned
3202380602180001 Kp. selakopi ds. Cimerang L 42 mgg poned
3202380402100005 Kp. kuta ds. Purabaya L 37 mgg poned
Kp. nangewer ds.margaluyu L 43 mgg poned
Kp. cibening ds. Margaluyu L 39 mgg poned
38 Ny. rustini/ jenal 3202380811170001 Kp. lembur pasir ds. Cimerang L 40 mgg poned
39 Ny. siska/ sutoyo 3202383009150002 Kp. ciakar ds. Neglasari L 39 mgg poned
40 Ny. ai martini/ susanto 3202386206840001 Kp. cipari ds. Neglasari L 40 mgg poned
41 Ny. siti/ deni 3202381407110000 Kp. sindang hayu ds. Citamiang P 37 mgg poned
42 Ny. munarsih/dudu 3202382711100005 Kp. tipar ds. Cimerang P 39 mgg poned
43 Ny. winda/m. ofik Kp. cisepat ds. Sagaranten L 38 mgg poned
44 Ny. susi/asad Kp. cipingpa ds. Sindangraja 39 mgg rsud
45 Ny. santi/agus 3202329120917002 Kp. caringin ds. Cijati P 38 mgg poned
46 Ny. titoh Kp. udug L 38 mgg poned
47 Ny. solehat Kp. kp. Ciipari ds. Cimerang P 28 mgg rumah
48 Ny. eha Kp. narogong ds. Margaluyu L 38 mgg rumah
49 Ny. wati Kp. ciroyom ds.pagelaran P 38 mgg rumah
50 Ny. siti aisyah 3202382010170001 Kp. cicurug ds. Citamiang L 40 mgg rumah
51 Ny. lilis / dami Kp. sikluk ds. Cicukang P 40 mgg rumah
52 Ny. riyanti/ wawan 3202382701140005 Kp. cigagak ds. Cimerang L 42 mgg poned
53 Ny. nurlela/m. rendi 3202381805180004 Kp. babakan bungur ds. Cicukang L 38 mgg poned

Mengetahui,
Kepala Puskesmas Purabaya

Cepi Hermansyah, AM.Kep.,SKM

NIP. 19690114.199503.1.002
Berat Jenis Panjang Tempat
Badan Kelahiran Tanggal Lahir Bayi Persalinan Keterangan
(gram)

2300 normal 8/2/2018 47 poned

2900 normal 8/2/2018 50 poned
2700 normal 8/3/2018 49 poned
8/3/2018 rsud PEB
3800 normal 8/4/2018 51 poned
2500 normal 8/7/2018 46 poned
3000 sc 8/7/2018 40 rsud PER
3200 normal 8/8/2018 50 poned
2500 normal 8/8/2018 47 poned replas
3000 normal 8/9/2018 49 poned
2700 normal 8/9/2018 46 poned
3700 normal 8/9/2018 50 poned
2700 normal 8/10/2018 50 poned
3300 normal 8/11/2018 52 poned
2900 normal 8/12/2018 50 poned
2500 normal 8/12/2018 49 poned
2500 normal 8/12/2018 49 poned
3000 normal 8/13/2018 52 poned
2800 normal 8/13/2018 48 poned
2500 normal 8/14/2018 49 poned
2700 normal 8/15/2018 50 poned
8/15/2018 rsud kala I fase aktf memanjang
3200 normal 8/16/2018 49 poned
8/16/2018 rsud kala I fase aktf memanjang
3200 normal 8/17/2018 50 poned
2100 normal 8/18/2018 50 poned
3500 normal 8/19/2018 50 poned
3400 normal 8/19/2018 52 poned
3000 normal 8/21/2018 48 rumah
2900 normal 8/22/2018 49 poned
3300 normal 8/22/2018 52 poned
3400 normal 8/22/2018 50 poned
2100 normal 8/24/2018 41 poned
3300 normal 8/27/2018 52 poned
3200 normal 8/27/2018 52 poned
3500 normal 8/27/2018 52 poned
3000 normal 8/26/2018 49 poned
3000 normal 8/28/2018 50 poned
4000 normal 8/29/2018 52 poned
3300 normal 8/29/2018 50 poned
3000 normal 8/29/2018 50 poned
4000 normal 8/29/2018 50 poned
3100 normal 8/1/2018 50 poned
sc 8/8/2018 rsud plasenta previa
2900 normal 8/12/2018 49 poned
2900 normal 8/21/2018 50 poned
1500 normal 8/2/2018 42 rumah
3500 normal 8/20/2018 50 rumah
3000 normal 8/21/2018 52 rumah
3200 normal 8/24/2018 48 rumah
2700 normal 8/26/2018 50 rumah
3200 normal 8/30/2018 52 poned
3700 normal 8/30/2018 51 poned

Purabaya, 31 Agustus 2018

Bidan Koordinator,

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

Uraian

No Nomor Kartu Cara Tempat

Nama Ibu / Suami Keluarga (KK) Alamat Jelas Persalinan Persalinan GPA

1 Ny. tintin/ ruslan 3202380808072059 Kp. cipari ds. Neglasari normal poned G1 P0 A0
2 Ny. neng sinta/ sandi 3202381807180008 Kp. cirangkong ds. Purabaya normal poned G1 P0 A0
3 Ny. cucum/deden 3202381204110012 Kp. ancol ds. Citamiang normal rsud G2 P1 A0
4 Ny. elis/saep 3202384606840006 Kp. cibolang ds. Cicukang normal poned G2 P1 A0
5 Ny. herlin/ la Ode Kp. rawa tapo ds. Cipicung normal poned G3 P2 A0
6 Ny. lilis/ rustam 3202380908070530 Kp. cipari ds. Neglasari normal rsud G2 P1 A0
7 Ny. juju/eman 3202381701110004 Kp. rawa udin ds. Purabaya sc poned G5 P3 A1
8 Ny. epah/ suparman 3202382710090019 Kp. cigembong ds. Purabaya normal poned G3 P2 A0
9 Ny. siti jubaedah/ jenal Kp. cigawir ds. Citamiang normal poned G4 P3 A0
10 Ny. Amah/ mudin 3202380707110007 Kp. pasir astana ds. Purabaya normal poned G3 P2 A0
11 Ny. rina/ dalil 3202381503180009 Kp. pasir huni ds. Purabaya normal poned G8 P7 A0
12 Ny. genita/ endang 3202270301180010 Kp. mangkalaya kec. Gn guruh normal poned G1 P0 A0
13 Ny. siti zenab/ abdul hamid 3202382902160003 Kp. cipeutey ds. Neglasari normal poned G1 P0 A0
14 Ny. cicah/ suherlan 3202381308130003 Kp. cimanggu ds. Pagelaran normal poned G3 P2 A0
15 Ny. deri/ tohaerun 3202382906180008 Kp. cimerang hilir ds. Cimerang normal poned G1 P0 A0
16 Ny. meri/ sandi 3202380610170011 Kp. rawa udin ds. Purabaya normal poned G1 P0 A0
17 Ny. euis/ risman 3202386205920001 Kp. cikupa ds. Pagelaran normal poned G2 P1 A0
18 Ny. imas/ sopyan 3202381205110004 Kp. karikil ds. Neglasari normal poned G3 P2 A1
19 Ny. darsih/ engkos 3202385009730001 Kp. cigembong ds. Purabaya normal poned G4 P3 A0
20 Ny. mega/ feri 3202380903170001 Kp. ciakar ds. Citamiang normal poned G1 P0 A0
21 Ny. st. aisyah/ yamin 3202382305180003 Kp. citamiang normal rsud G1 P0 A0
22 Ny. evi/ agun 3202380507180006 Kp. padaringan ds. Cimerang normal poned G1 P0 A0
23 Ny. arisma/ deden 3202382511130005 Kp. ciseureh ds. Pagelaran normal rsud G2 P1 A0
24 Ny. yati/ misbah 3202382908120025 Kp. nangewer ds. Neglasari normal poned G3 P1 A1
25 Ny. nia/ nenja 3202384912950006 Kp. padaringan ds. Cimerang normal poned G2 P1 A0
26 Ny. nenda/ adam 3202381205120016 Kp. citamiang normal poned G2 P1 A0
27 Ny. lia/ heri 3202384601880001 Kp. cibengang ds. Purabaya normal poned G2 P1 A0
28 Ny. dewi/ lili 3202382701170008 Kp. cirangkong ds. Purabaya normal rumah G3 P2 A0
29 Ny. wati/ uus 3202381808140016 Kp. ciroyom ds. Pagelaran normal poned G2 P1 A0
30 Ny. mayawati/ endang 3202385607930005 Kp. selakopi ds. Cimerang normal poned G1 P0 A0
31 Ny. siti nurhini/rudi 3202382007180006 Kp. ciseureh ds. Pagelaran normal poned G1 P0 A0
32 Ny. st nuraeni/ idrus 3202380608120016 Kp. citeureup ds. Neglasari normal poned G2 P1 A0
33 Ny. esih/saepul 3202382104110007 Kp. sindang hayu ds. Citamiang normal poned G1 P0 A0
34 Ny. ambar sulastri/ didin 3202380602180001 Kp. selakopi ds. Cimerang normal poned G2 P1 A0
35 Ny. rini/ uso 3202380402100005 Kp. kuta ds. Purabaya normal poned G1 P0 A0
36 Ny. st. maesaroh/ samsudin 3202380801180007 Kp. nangewer ds.margaluyu normal poned G1 P0 A0
37 Ny. pariah/ abdulloh Kp. cibening ds. Margaluyu normal poned G2 P1 A0
38 Ny. rustini/ jenal 3202380811170001 Kp. lembur pasir ds. Cimerang normal poned G2 P1 A0
39 Ny. siska/ sutoyo 3202383009150002 Kp. ciakar ds. Neglasari normal poned G1 P0 A0
40 Ny. ai martini/ susanto 3202386206840001 Kp. cipari ds. Neglasari normal poned G2 P1 A0
41 Ny. siti/ deni 3202381407110000 Kp. sindang hayu ds. Citamiang normal poned G1 P0 A0
42 Ny. munarsih/dudu 3202382711100005 Kp. tipar ds. Cimerang normal poned G5 P2 A2
43 Ny. winda/m. ofik Kp. cisepat ds. Sagaranten normal rsud G1 P0 A0
44 Ny. susi/asad Kp. cipingpa ds. Sindangraja sc poned G2 P1 A0
45 Ny. santi/agus 3202329120917002 Kp. caringin ds. Cijati normal poned G1 P0 A0
46 Ny. titoh Kp. udug normal rumah G7 P6 A0
47 Ny. solehat Kp. kp. Ciipari ds. Cimerang normal rumah G2 P1 A0
48 Ny. eha Kp. narogong ds. Margaluyu normal rumah G2 P1 A0
49 Ny. wati Kp. ciroyom ds.pagelaran normal rumah G2 P1 A0
50 Ny. siti aisyah 3202382010170001 Kp. cicurug ds. Citamiang normal rumah G1 P0 A0
51 Ny. lilis / dami Kp. sikluk ds. Cicukang normal rumah G3 P2 A0
52 Ny. riyanti/ wawan 3202382701140005 Kp. cigagak ds. Cimerang normal poned G2 P1 A0
53 Ny. nurlela/m. rendi 3202381805180004 Kp. babakan bungur ds. Cicukang normal poned G1 P0 A0

P
Mengetahui,
Kepala Puskesmas Purabaya

Cepi Hermansyah, AM.Kep.,SKM

NIP. 19690114.199503.1.002
Penolong Komplikasi Frekuensi Berat Badan Komplikasi
Kelahiran Kehamilan ANC Saat Persalinan
Melahirkan

bidan
bidan
bidan
bidan PEB
bidan
bidan
bidan PER
bidan
bidan replas
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan kala I fase aktf memanjang
bidan
bidan kala I fase aktf memanjang
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan plasenta previa
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan
bidan

Purabaya, 31 Agustus 2018

Bidan Koordinator,

ERNA YULIAWATI,S.ST
NIP. 19660901 198901 2 003
Formulir 3
Pencatatan dan Pelaporan Kematian Ibu
Puskesmas : Purabaya
Bulan / Tahun : Agustus 2018

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

IL
NI H

Mengetahui,
Kepala Puskesmas Purabaya

Cepi Hermansyah, AM.Kep.,SKM

NIP. 19690114.199503.1.002
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 : Agustus 2018

Uraian

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

I L
N IH

Mengetahui,
Kepala Puskesmas Purabaya Bidan Koordinator,

Cepi Hermansyah, AM.Kep.,SKM ERNA YULIAWATI, S.ST

NIP. 19690114.199503.1.002 NIP. 19660901 198901 2 003
 Sebab Tempat Panjang Ket
Meninggal Meninggal Bayi (cm)

I L