FORMAT RUJUKAN NEONATUS

A. Identitas Bayi

Nama : .............................................................................................
.....
Jenis Kelamin : ..................................................................................................
Tanggal Lahir/Jam : ..................................................................................................
Alamat : ..................................................................................................
Anak Ke : ..................................................................................................
Tempat Lahir : ..................................................................................................
Pengirim : ..................................................................................................
Alamat Pengirim : .................................................................................................
No.Hp Pengirim : .................................................................................................

B. Identitas Orang Tua (Suami sesuai KTP)

Ayah
Nama : .............................................................................................
.........
Umur : ......................................................................................................
Pekerjaan : ......................................................................................................
Gol Darah : .......................................................................................................

Ibu
Nama : .............................................................................................
..........
Umur : .......................................................................................................
Pekerjaan : .......................................................................................................
Gol Darah : .......................................................................................................

C. Keluhan Utama:........................................................................................................
D. Data Persalinan : ........................................................................................................
....................................................................................................
....

Persalinan Ke : ........................................................................................................
Cara Persalinan :
Tempat Persalinan: ........................................................................................................
Penolong : ........................................................................................................
Indikasi Persalinan : .......................................................................................................
Ketuban : Pecah Tanggal : Jam :
Jumlah : Normal/Digahidramnion/Polihidramnion
Warna : jernih/Hijau/Kuning/Mekonium/Bau busuk
Umur Kehamilan : minggu
Ballard Score :
 Plasenta : Berat :
Kelainan :
Jika bayi gemelli : ½ plasenta
Durante Persalinan :
Riwayat ANC : .....................................................................................................
.....................................................................................................
Perawatan Antenatal : kali
Dimana :

Jumlah Anak seluruhnya

Hidup Anak ke 1......... Anak ke 2................ Anak ke 3..............
Usia saat ini .......................... .......................... ..........................
Riwayat .......................... .......................... ..........................
Persalinan ........................... ........................... ...........................
Riwayat Penyakit ......................... ......................... .........................
Meninggal ......................... ......................... .........................
Sebab Meninggal

Keadaan Ibu pada waktu Hamil Ini : sehat / sakit

: ......................................................
Jenis Penyakit
: ......................................................
Faktor Resiko
: .....................................................
Obat yag di konsumsi Ibu
: .....................................................

E. Pemeriksaan Fisik

Keadaan Umum
: .....................................................................................................
HR : .............................................................................................
.......
RR : .............................................................................................
.......
Suhu Axilla
: ......................................................................................................
Posisi Bayi
: .....................................................................................................
Aktifitas : .............................................................................................
.......
 Tonus : .............................................................................................
.......
Kepala : .............................................................................................
......
Thorax : .............................................................................................
.......
Abdomen : .............................................................................................
.......
Umbilikus : .............................................................................................
......
Alat Kelamin
: ...................................................................................................
Anus : .............................................................................................
......
Ektermitas : .............................................................................................
.......
Kulit : .............................................................................................
......
Warna Kulit
: ...................................................................................................

F. Pemeriksaan Reflek :
....................................................................................................
G. Pemeriksaan Penunjang :
 Darah Lengkap
: ....................................................................................................
 Golongan Darah
: ....................................................................................................
 GDA : .............................................................................................
........
 Albumin : .............................................................................................
.......
Terapi yang diberikan
: ........................................................................................
Tindakan yang sudah dilakukan
: .........................................................................................
..................................................................................
.......
..................................................................................
.......
Edukasi : Setiap bayi baru lahir mempunyai resiko tunggi memerlukan masa
adaptasi dini usia 0 7 hari setelah lahir, masa adaptasi lanjut 8 28 hari.
Makin muda usia kehamilannya makin lama dan komplek masa
adaptasinya, sehingga dapat terjadi gangguan fungsi multiorgan yang
dapat mengancam jiwa / meninggal dunia.

“SEBELUM MERUJUK”

 Tentukan Kasus yang akan di rujuk

 Komunikasikan dengan tempat rujukan
 Stabilkan kondisi Pasien
 Cegah Hypotermi,Hypoglikemi,gangguan nafas
 Persiapan alat selama rujukan
 Pastikan O2 cukup sampai di tempat rujukan
 Lakukan rujukan dengan BAKSOKU :
- Bidan
- Alat
- Keluarga
- Surat
- O2
- Kendaraan
- Uang termasuk Kartu JKN, Jankesmas/Jamkesda dan Asuransi lainnya.
 FORMAT RUJUKAN NEONATUS

A. Identitas IBU

Nama : .............................................................................................
.....
Umur : ..................................................................................................
Pendidikan : ..................................................................................................
Pekerjaan : .................................................................................................
Alamat : ..................................................................................................
Hamil Ke : ..................................................................................................
KSPR : ..................................................................................................
Golongan Darah : .................................................................................................
Pembiayaan : .............................................................................................
....
Nama Pengirim : ..................................................................................................
Alamat Pengirim : .................................................................................................
No.Hp Pengirim : .................................................................................................

B. Identitas Orang Tua (Suami sesuai KTP)

SUAMI

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

C. Keluhan Utama:........................................................................................................
D. Data Kehamilan
Kehamilan Ke : ........................................................................................................
Riwayat Kehamilan :
ANC (Frekuensi) : ........................................................................................................
Tempat ANC
: ........................................................................................................
Umur Kehamilan : ........................................................................................................
Ketuban : Pecah Tanggal : Jam :
Jumlah : Normal/Digahidramnion/Polihidramnion
Warna : jernih/Hijau/Kuning/Mekonium/Bau busuk
Umur Kehamilan : minggu
Ballard Score :
 Plasenta : Berat :
Kelainan :
Jika bayi gemelli : ½ plasenta
Durante Persalinan :
Riwayat ANC : .....................................................................................................
.....................................................................................................
Perawatan Antenatal : kali
Dimana :

Jumlah Anak seluruhnya

Hidup Anak ke 1......... Anak ke 2................ Anak ke 3..............
Usia saat ini .......................... .......................... ..........................
Riwayat .......................... .......................... ..........................
Persalinan ........................... ........................... ...........................
Riwayat Penyakit ......................... ......................... .........................
Meninggal ......................... ......................... .........................
Sebab Meninggal

Keadaan Ibu pada waktu Hamil Ini : sehat / sakit

: ......................................................
Jenis Penyakit
: ......................................................
Faktor Resiko
: .....................................................
Obat yag di konsumsi Ibu
: .....................................................

E. Pemeriksaan Fisik

Keadaan Umum
: .....................................................................................................
HR : .............................................................................................
.......
RR : .............................................................................................
.......
Suhu Axilla
: ......................................................................................................
Posisi Bayi
: .....................................................................................................
 Aktifitas
: ....................................................................................................
Tonus : .............................................................................................
.......
Kepala : .............................................................................................
......
Thorax : .............................................................................................
.......
Abdomen : .............................................................................................
.......
Umbilikus : .............................................................................................
......
Alat Kelamin
: ...................................................................................................
Anus : .............................................................................................
......
Ektermitas
: ....................................................................................................
Kulit : .............................................................................................
......
Warna Kulit
: ...................................................................................................

F. Pemeriksaan Reflek :
....................................................................................................
G. Pemeriksaan Penunjang :
 Darah Lengkap
: ....................................................................................................
 Golongan Darah
: ....................................................................................................
 GDA : .............................................................................................
........
 Albumin : .............................................................................................
.......
Terapi yang diberikan
: ........................................................................................
Tindakan yang sudah dilakukan
: .........................................................................................
..................................................................................
.......
..................................................................................
.......
Edukasi : Setiap bayi baru lahir mempunyai resiko tunggi memerlukan masa
adaptasi dini usia 0 7 hari setelah lahir, masa adaptasi lanjut 8 28 hari.
Makin muda usia kehamilannya makin lama dan komplek masa
adaptasinya, sehingga dapat terjadi gangguan fungsi multiorgan yang
dapat mengancam jiwa / meninggal dunia.

“SEBELUM MERUJUK”

 Tentukan Kasus yang akan di rujuk

 Komunikasikan dengan tempat rujukan
 Stabilkan kondisi Pasien :
o Gula Darah (min 50 mg/dl
o Temperatur (36,5◦C – 37,5◦C)
o Airway : O2 sesuai indikasi
o Pastikan pengisian darah perifer (CRT <3 detik)
o Laboratorium : skrining infeksi
o KIE keluarga tertulis (infont Concent)
 Cegah Hypotermi,Hypoglikemi,gangguan nafas
 Persiapan alat selama rujukan
 Pastikan O2 cukup sampai di tempat rujukan
 Lakukan rujukan dengan BAKSOKU :
- Bidan
- Alat