Yth :
………………………
………..
………………………
Di
Subang
Diagnosa:........................................................................................................................
Tindakan / therapi yang sudah diberikan .......................................................................
Tanggal :..............................................
Pukul ..................................................
Perujuk
SURAT RUJUKAN KOMPLIKASI KEBIDANAN
Dari Bidan :
Kepada :
Bersama ini kami kirimkan pasien :
Nama :................................................................................
Umur :................................................................................
GPA :...............................................................................
Nama Suami :...............................................................................
Pekerjaan :...............................................................................
Alamat :...............................................................................
Pukul :
a. Anamnesa......................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
........................................................
b. Pemeriksaan
Keadaan umum ..............................Kesadaran ......................................
Tensi Darah....................................Nadi...............................................
Pernafasan .....................................Suhu .............................................
TB..................................................BB...............................................
Pemeriksaan Luar :
o TFU.................................
o Presentasi .......................
o Puka/Puki........................
o BJJ..................................
o His .................................
Pemeriksaan Dalam
o Vulva /vagina.....................
o Portio ...............................
o Pembukaan ........................
o Ketuban .............................
o Denominator ..............................
o Penurunan bag.terendah.......................................
c. Riwayat kehamilan dan persalinan lalu
.......................................................................................................................................................
.......................................................................................................................................................
.............................................................................................
d. Diagnosa .......................................................................................................................................
.........................................................................................................................
e. Tindakan /terapi yang
diberikan. ......................................................................................................................................
..................................................................................................................................
Mohon penatalaksanaan selanjutnya , atas bantuan dan kerjasamanya kami ucapkan terima kasih .
Subang.............................
Pukul...............................
........................................