Tgl Masuk : ..........................Jam : ....... Nama Pasien : ………………. Jenis
Kelamin :L/P
Ruang/ Kelas : ......................./............... Tgl Lahir : ........................./........Thn / Bln
PARTOGRA F Status : G .......... P............. A Waktu saat masuk : .............................................. .............. HPHT : Waktu mulai mulas : ..................................................... HPL / TP ............................................... Waktu saat ketuban pecah : ..................................................... : …………..............................