DATA IBU HAMIL

TEMPAT/LOKASI IMUNISASI :
DESA / KELURAHAN : Sindangkasih
PUSKESMAS : Purwakarta
TANGGAL PELAKSANAAN :
TAHUN : 2023

Hasil Pemeriksaan
Nama Triple Eliminasi Gizi Bumil
no rekam TANGGAL Satus
No ALAMAT KTP Hamil Ke HPHT TP No BPJS No Telp No NIK
medik LAHIR Imunisasi
Ibu Hamil Suami PPIA Sipilis HBSAG HB Lila

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Cucu Komalasari asep irawan

1 12/4/1994 rt 30/03 G2P1A0 8/3/2022 5/10/2023 T3 NR NR NR 26 3214016412970001

Hana samsul 25 TH
2 rt 45/03 G2P1A0 8/25/2022 6/2/2023

3 353.22 Mia Megawati M ramdan 27 mei 1990 rt 15/03 G3P2A0 5/11/2022 2/16/2023 TT0 087879707524

4 141.23 Sri Mulyani Ali 20 juni 1996 rt 18/13 G1P0A0 9/6/2023 6/13/2023 TT2 NR NR NR 10.2 22 0895406286050 1602206006990002

5 118.23 Patimah nurul haniah Indra 5/17/1996 rt 11/03 G2P1A0 2/7/2023 11/15/2023 TT2 082122176508 3214015705960006

6 A.155.23 Mira Septi Iqbal 8/27/1992 rt 45/03 G3P2A0 11/8/2022 8/13/2023 TT3 NR NR NR 11.8 26 081779866111 3273126708920011

7 A.110.23 Dela Adinisa M.diki 3/23/1999 rt 38/03 G1P0A0 7/15/2022 4/22/2023 TT2 NR NR NR 11.3 25 081911422832 3203116303990007

8 A.108.23 Yanti Kusyanti Odik 8/5/1985 rt 45/03 G2P1A0 12/13/2022 9/20/2023 TT2 NR NR NR 13.1 23.3 0003043218611 3214014508850006

9 A.94.23 Ida Dariah guntur 8/18/1987 rt 11/03 G2P1A0 11/30/2022 9/7/2023 TT1 0003275973729 085222201068 3214015808870009
 Hasil Pemeriksaan
Nama Triple Eliminasi Gizi Bumil
no rekam TANGGAL Satus
No medik LAHIR ALAMAT KTP Hamil Ke HPHT TP Imunisasi No BPJS No Telp No NIK
Ibu Hamil Suami PPIA Sipilis HBSAG HB Lila

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

10 A.44.23 Kokom Komalasari Rizki 1/10/2001 rt 42/08 G2P0A1 9/21/2022 6/28/2023 TT2 NR NR NR 12.8 22 0002894038042 083126330061 321416501010002

11 A.026.23 Indri Nuryanti Rian Hariansyah 11/13/1989 rt 11/03 G3P2A0 9/15/2022 6/21/2023 TT4 NR NR NR 11.1 26 082123629179 3214015311890010

12 A.292.23 Nanik Nulyanik Asep 30 th rt 30/03 G3P2A0 2/27/2023 12/4/2023 T3 NR NR NR 12.6 31.3 085782499935

13 IRMA HADIYANTI 15-061986` RT 38/3 G3P2A0 9/28/2022 6/1/2023 TT5 087824612457

RIZKA CAHYA INDRI KURNIASIH Fahmi 9.6

14 A.236.23 10/27/1994 RT 16/03 G3P1A1 9/4/2023 6/11/2024 TT1 NR NR NR 25.5 085718285718 3671096710940007

15 A.61.23 NUNUNG NURJANAH ENGKUS 4/24/1988 RT 38/03 G3P2A0 12/20/2022 9/27/2023 TT3 0000063101733 085974189771 3214016404880004

16 A.150.23 DIANA BINTI SUMARYO DIAN 4/13/1989 RT 38/03 G3P2A0 11/15/2022 8/22/2023 TT5 NR NR NR 10.2 23.5 0002705181074 3214115304890005

17 A.189.23 SHINTYA NURANI MASTUR 6/6/1994 RT 30/03 G3P2A0 2/20/2023 11/27/2023 TT2 NR NR NR 10.7 28 085870566666 3203104606940017

18 Yanti Kusyanti Odik Gunawansyah 8/5/1985 rt 45/03 G2P1A0 12/20/2022 9/27/2023 TT3

19 Vicka Sundari Andika 1/17/1991 rt 15/03 G2P1A0 1/28/2023 11/5/2023 NR NR NR 12

20 Rini Oktriani Apud 36 TH rt 11/03 G5P3A1 2/19/2023 11/26/2023 T5 NR NR NR 11.7

 Hasil Pemeriksaan
Nama Triple Eliminasi Gizi Bumil
no rekam TANGGAL Satus
No medik LAHIR ALAMAT KTP Hamil Ke HPHT TP Imunisasi No BPJS No Telp No NIK
Ibu Hamil Suami PPIA Sipilis HBSAG HB Lila

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

21 A.313.23 Nadia maulidina Erpan Permadi 25 th rt 11/03 G1P0A0 1/8/2023 10/15/2023 T1 NR NR NR 12.3 083803071518 3214016706980001

22 3 Dede 33 th rt 38/03 G2P1A0 3/15/2022 12/22/2023 T2 NR NR NR 12.7 000270511822 08779683567 3214014702890001

23 A.373.23 Dina Aprilianti Panggah 29 th rt 16/03 G4P2A1 11/20/2022 8/27/2023 T4 NR NR NR 11.1 000244189919 085219462526 3312186404940003

0000020045036
24 A.273.23 Rika Novianti Endi 38 th rt 45/03 G3P2A0 4/10/2023 4/17/2024 T4 NR NR NR 14.6 2 083821243649 3214016811840003

21
25 A.272.23 Zulfa Apin 20 th rt 45/03 G1P0A0 10/27/2022 8/4/2023 T0 NR NR NR 12 083874363053 3214015202030002

26

27

29
 Tanggal Jenis Resiko/Komplikasi Rencana Kontak Indikator KIA
KET
Partus

Bumil Bulin Bufas K 1 Murni Skrining drUSG TM 1 K2 K3 K4 K5 Skrining Dr TMUSG

3 TM 3 K6
19

6/11/2023 SC
Tanggal Jenis Resiko/Komplikasi Rencana Kontak Indikator KIA
Partus KET

Bumil Bulin Bufas K 1 Murni Skrining drUSG TM 1 K2 K3 K4 K5 Skrining Dr TMUSG

3 TM 3 K6
19
Tanggal Jenis Resiko/Komplikasi Rencana Kontak Indikator KIA
Partus KET

Bumil Bulin Bufas K 1 Murni Skrining drUSG TM 1 K2 K3 K4 K5 Skrining Dr TMUSG

3 TM 3 K6
19
 Nama
no rekam TANGGAL ALAMAT
No Hamil Ke
medik Ibu Hamil Suami LAHIR KTP

1 2 3 4 5 6 7

10/22/2000 rt 17/08 G2P1A0

1 123.23 Tuti binti wahid dudi

9/9/1998 rt 52/08 G2P1A0

2 A.113.23 Yeti Rosmayanti Iqbal

6/30/2004 rt 17/08 G1P0A0

3 A.111.23 Silvia Nurfauziah M.Wahyudin

12/5/1990 rt 61/08 G3P2A0

4 A.88.23 Titing binti mumud Wawan

Imas Solihat ujang 37 TH rt 42/08 G3P2A0

5

Ice Nadiyah Aryanto ramadan 23 rt 42/08 G1P0A0

6

12/7/2022 RT 26/08 G3P0A2

7 A.228.23 IMAS SRI HARTINI DEDEN

Nunung Nurhayati Santosa supriadi 27 rt 17/08 G2P1A0

8

6/8/1996 rt 42/08 G1P0A0

9 Putri Fahri

9/9/1998 rt 17/08 G2P1A0

10 Rosmiyanti Iqbal

27 th rt 42/08 G1P0A0
11 A.266.23 Nunung nadiyah Santosa

21 th rt 42/08 G1P0A0
12 Kokom Rizki
 21 th rt 42/08 G1P0A0
13 A.382.23 Nurpalah Nurdin

26 th rt 42/08 G3P1A1
14 Siti Nurmilah Yono

37 th rt 17/08 G3P2A0
15 A.304.23 Dewi Sri utami Ahmad

37 th rt 42/08 G3P1A1
16 A.372.23 Praptiningsih Rusmano

24 th rt 18/13 G2P0A1
17 A.305.23 Chandra Kartika Defan

18

19

20

21

22
 Hasil Pemeriksaan Triple
Gizi Bumil
Eliminasi
Satus
HPHT TP No BPJS
Imunisasi PPIA Sipilis HBSAG HB Lila

8 9 10 11 12 13 14 15 16

12/28/2022 10/5/2023 TT2 NR NR NR 11 24

11/4/2022 8/11/2023 TT3 NR NR NR 14.7 32

TT1 11.3 23

11/9/2022 8/16/2023 TT4 NR NR NR 11.1 29

6/15/2022 3/22/2023 NR NR NR

9/7/2022 6/14/2022 T2 NR NR NR 12.6 23.3

12/7/2022 9/14/2023 TT2 NR NR NR 11.3 32

11/16/2022 8/23/2023

NR NR NR

11/4/2022 8/11/2023 NR NR NR

00016637313
9/7/2022 6/14/2023 T3 NR NR NR 13.1 26.5 25

9/21/2022 6/28/2023 NR NR NR 22.7

 00017761244
12/10/2022 9/17/2023 T1 NR NR NR 12.1 22.8
27

2/13/2023 11/20/2023

3/6/2023 12/17/2023 T3

6/15/2023 3/22/2024 T2 NR NR NR 13.3 25

3/25/2023 1/1/2024 T1 NR NR NR 12.6 24

 Jenis Resiko/Komplikasi
No Telp No NIK Tanggal Partus
Bumil Bulin Bufas K 1 Murni

17 18 19

083172700011 321415681200001

081909885862 3214114909980005

083822640216 3214017006040010

083196927502 3205094512900002

3214135808850001 5/8/2023

3214016506000005 6/16/2023

083131898324 3214014609930004

083841182440

081329578144 3/28/2023

081909085062 3214114909980005

083841182440 3214016402950006
 32140196908020003

085724907841 3214015808850010

087718180389

083807093084 3214015005990001
 Rencana Kontak Indikator KIA

Skrining dr TM 1 USG TM 1 K2 K3 K4 K5 Skrining Dr TM 3

 KET
USG TM 3 K6

NORMAL
 Nama
no rekam
No TANGGAL LAHIR ALAMAT KTP
medik Ibu Hamil Suami

1 2 3 4 5 6

1 A.16.23 Lisna Septiani Dariawan 9/30/2002 rt 19/10

Susi Kusmiawati Edi 35 rt 32/10

2

Dinda Deri 20 rt 32/10

3

4 A.232.23 SRI MULYANI D NANANG 5/12/1995 RT 32/10

5 A.235.232 NOVITA RANI ABDUL BASIT 11/15/2000 RT32/10

6 A.2321.23 YONA YOLANDA AGUS 10/4/1995 RT 32/10

7 A.214.23 KARSIH ANGGRAENI ASEP C 7/7/2002 RT 50/10

Lisna Septiani Daniawan 20 rt 19/10

8

Sulastri Tama Tahrudin 37 rt 49/10

9

Hasna Fatimah Zahra Abdul Muhamad H 26 rt 49/10

10

11 Fitriani Suryadi 33 th RT 50/10

12 Martono Tarsono 3/3/1990 rt 32/10

13 A.329.23 Eni Nuraeni Roli Susanto 41 th rt 49/10

14 A.303.23 Sri Irma Sansori 25 th rt 49/10

15 Karsih ASEP 21 th RT 50/10

16 A.231.23 Yona Agus 28 th rt 32/10

17 Sri mulyani Dori 28 th rt 32/10

18 Neng Resa Agus 20 th rt 50/10

19 Neng Nurhasanah Setia 32 th RT 50/10

20 A.289.23 Irmalasari Deni 26 th rt 49/10

21 A.214.23 Karsih Anggraeni Asep 20 th rt 50/10

22
 Hasil Pemeriksaan Triple
Gizi Bumil
Eliminasi
Hamil Ke HPHT TP Satus Imunisasi
PPIA Sipilis HBSAG HB

7 8 9 10 11 12 13 14

G1P0A0 8/28/2022 6/5/2023 TT2 NR NR NR 8.9

G3P2A0 7/12/2022 4/19/2023

G2P1A0 8/11/2022 5/18/2023

NR NR NR

G2P1A0 12/10/2022 10/17/2023 TT3 NR NR NR

G2P1A0 9/1/2022 6/8/2023 TT3 NR NR NR

G4P2A1

G1P0A0 1/6/2023 9/13/2023 TT0 NR NR NR 12

G1P0A0 8/28/2022 6/3/2023 8.9

NR NR NR

G3P1A1 5/1/2023

G4P0A3 9/15/2022 6/22/2023

NR NR NR 13.1

G3P2A0 11/7/2022 8/14/2023

G3P2A0 12/18/2022 9/25/2023

G4P2A1 ? ? T4 NR NR NR 11.9

10.3
G1P0A0 1/20/2023 10/27/2023 T2 NR NR NR

G1P0A0 1/6/2023 9/13/2023

G3P2A0 8/11/2023 T2 NR NR NR 15.1

G2P1A0 12/15/2022 9/22/2023

G1P0A0 9/11/2022 6/18/2024

G3P1A1 11/30/2022 8/26/2023 T3 NR NR NR 12.6

10.6
G4P23A0 3/22/2023 12/29/2023 T5 NR NR NR

G1P0A0 1/6/2023 9/13/2023 T1 NR NR NR 12

Gizi Bumil
Jenis Resiko/Komplikasi
No BPJS No Telp No NIK Tanggal Partus
Lila
Bumil Bulin
15 16 17 18 19

24 002797062276 083126163788 3214017009020001

087866786656 3213305009860001

083129660478 3214016701020002

26 085425055800 3214015205950003

32 085559433804 3215305511000003

24 088290670560

23.5 083126163788 3214017009020001

089648276901

3214015904960005

085871498128 321401540990004

081909462539 321401430390007
 26 000323693696 087879747343 3214016002820016

21.3
083107061413 3214014707980001

088290670560 3201174107020025

24.6
3214104410950003

0895425055800 3214015205950003

0001010099035 08993147194 3214016603020005

081398944347 3214016410880002

23.5
083112510961 3205386812960002

24 088290670560
Resiko/Komplikasi Rencana Kontak Indikator KIA

Bufas K 1 Murni Skrining dr USG TM 1 K2 K3 K4 K5 Skrining Dr TMUSG

3 TM 3
 KET
K6
 Nama
no rekam TANGGAL
No ALAMAT KTP Hamil Ke
medik Ibu Hamil Suami LAHIR

1 2 3 4 5 6 7

5/9/1995 rt 43/13 G2P1A0

1 140.23 Sri Hajar Rahmawati Rian

6/20/1999 rt 18/13 G1P0A0

2 141.23 Sri Mulyani Ali

1/7/2003 rt 18/13 G1P0A0

3 A.100.23 Naina ratul afifah Entis

5/23/1985 rt 43/13 G4P3A0

4 A.32.23 Wati Susilawati Ujang

Puspita Apriani wahyudin 4/3/2001 rt 18/13 G3P2A0

5

Nurfitria Agus priadi rt 37/13 G1P0A0

6

Naina Ratul a Entis Sutisna rt 18/13 G1P0A0

7

Nisrinan Agung rt 37/13 G1P0A0

8

rt 53/13 G2P1A0
9 Dima Erika Dendis

Meri Rieki Hamdani rt 53/13 G1P0A0

10

2/4/1992 RT 53/13 G1P0A0

11 A.166.23 RIZKA FEBRIANTI RIZKI

Arsi Maeta Hanafi rt 18/13 G2P1A0

12
 Zihan soleh bajri abdul azis rt 43/13 G2P1A0
13

5/9/1995 rt 43/13 G2P1A0

14 Sri Hajar Ryan

31 th rt 53/13 G2P1A0
15 Awang Dadi

33 th rt 53/13 G3P2A0
16 Siti Hasanah Saepul

29 th rt 43/13 G2P1A0
17 Jumiati Mulyono

34 th rt 53/13 G3P2A0
18 A.294.23 Yuni Yulianti Rojak

19

20

21

22
 Hasil Pemeriksaan Triple
Gizi Bumil
Satus Eliminasi
HPHT TP
Imunisasi PPIA Sipilis HBSAG HB Lila

8 9 10 11 12 13 14 15

6/5/2022 3/12/2023 TT2 NR NR NR 12.3 33

9/6/2022 6/13/2023 TT2 NR NR NR 10.2 24.8

11/10/2022 8/17/2023 TT1 NR NR NR 13.6 36

10/23/2022 8/2/2023 TT4

6/6/2022 3/13/2023 |NR NR NR

5/15/2022 2/22/2023

11/10/2022 9/17/2023 TT2 NR NR NR

7/25/2022 5/2/2023 TT2 NR NR R

7/11/2023 4/17/2023 TT3 NR NR NR

12/1/2022 9/8/2023

2/22/2023 11/29/2023 TT1 NR NR NR 12 25

7/26/2022 5/3/2023 NR NR NR
8/28/2022 6/5/2023

6/5/2022 3/12/2023 TT3 NR NR NR

1/21/2023 10/28/2023

2/7/2023 11/14/2023

5/10/2022 2/17/2024

3/10/2023 12/17/2023 28
 Jenis Resiko/Komplikasi
No BPJS No Telp No NIK Tanggal Partus
Bumil
16 17 18 19

082130696007 3214014905950001

0895406286050 1602206006990002

083816374443 3214044701030004

0002234517434 08509874526 3214016304010007 3/10/2023

083811798126 2/22/2023

000239540201 083816374443 3214044701030004

087805333993 3214014901990001 5/4/2023

087848770312

3214014503050004

000481128603 0895424150408 3214014402990003

089693534293 05-052023
 089604029264

000063471791 082130696007 3214014905950001

081389732781 320515105930001

083844024773

085280558121
Jenis Resiko/Komplikasi Rencana Kontak Indikator KIA

Bulin Bufas K 1 Murni Skrining dr USG TM 1 K2 K3 K4 K5 Skrining Dr TM 3

 KET
USG TM 3 K6
 Nama
no rekam TANGGAL
No ALAMAT KTP
medik Ibu Hamil Suami LAHIR

1 2 3 4 5 6

Ratna Ace Karim

1 A.122.23 11/25/1995 RT 55/14

2 A.69.23 Elis Susanti Ahmad 7/20/1987 rt 29/14

3 A.58.23 Siti halimah Hada 7/11/1993 RT 55/14

Rina Haryani Candra

4 A.33.23 9/18/1981 RT 48/14

Dea Pitriani Asep 27 rt 29/14

5

Neng Tria Ahmad 28 rt 55/14

6

APRILIA BINTI
7 A.218.23 UJANG HENDRA 4/2/1999 RT 48/14

Ade Yanti Jajat 37 rt 29/14

8

Ika Purnamasari Rusdan 28 rt 44/14

9

10 A.254.23 Intan Abdul 25 th RT 55/14

11 A/363.23 Mirna Yanto 23 th RT 55/14

19 th
12 A.354.23 Hildad Agustina Riko RT 48/14
 44 th
13 A.338.23 Aan Hasanah Asep rt 29/14

14

15

16

17

18

19

20

21

22
 Hasil Pemeriksaan Triple
Gizi Bumil
Eliminasi
Hamil Ke HPHT TP Satus Imunisasi
PPIA Sipilis HBSAG HB

7 8 9 10 11 12 13 14

G3P1A1 10/2/2022 7/9/2023 TT4 NR NR NR 10.3

G5P2A2 9/28/2022 7/3/2023 TT4 NR NR NR 12.3

G2P1A0 TT1 NR NR NR

G7P6A0 10/30/2022 8/7/2023 TT5 NR NR NR 13.1

G3P2A0 10/15/2022 7/22/2023

NR NR NR

G3P2A0 7/15/2022 4/22/2023

G2P1A0 3/23/2023 12/30/2023 TT2

G5P4A0 5/29/2022 3/6/2023

NR NR NR

G3P2A0 10/7/2022 7/14/2023

NR NR NR

G2P1A0 2/25/2023 12/2/2023 TT3 NR NR NR 12.3

G1P0A0 12/28/2022 10/4/2023 T2 NR NR NR 11.4

G1P0A0 2/15/2023 11/22/2023 T1 NR NR NR 12.1

G3P2A0
Gizi Bumil
No BPJS No Telp No NIK Tanggal Partus
Lila

15 16 17 18 19

0000481852888 3214016511950004
24 085794332862

6/26/2023

3214015809810001
29.5

3214106010950001

085721597292
4/1/2023

0000481017317 083124351756 3214014204990004

31

083140681198

087708986274 3214014903980003
35

34 0855224874055 3214016305000004

23.5 083816157113 ;3214010308030005

000480921963 083852225344 321401670780006
 Jenis Resiko/Komplikasi Rencana Kontak Indikator KIA

Bumil Bulin Bufas K 1 Murni Skrining dr TM 1 USG TM 1 K2 K3 K4

HT
HT
ak Indikator KIA
KET
K5 Skrining Dr TM 3 USG TM 3 K6