Kepada

Yth :
……………………………
…..………………………
Di
Subang

Dengan ini kami kirimkan :

Nama bayi :
Umur : hari/jam
Nama orang tua :
Alamat :
Anamnesa :.........................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.........................................................................................................................................
Pukul :........................................
Status Praesent :
K/U :.........................................kesadaran :..........................................
Nadi :...........x/menit, Suhu:...........oC Pernafasan ..........x/menit
BB :.............kg PB..........cm LK.......... cm LD............cm

Riwayat kehamilan ibu :. G......P.......A.......

Usia kehamilan.................

Riwayat Persalinan : lahir jam........................................................................

Jenis persalinan..............................................................
Apgar score................... ...... /....................................

Diagnosa:........................................................................................................................
Tindakan / therapi yang sudah diberikan .......................................................................
Mohon penatalaksanaan selanjutnya, atas bantuan dan kerjasama kami ucapkan
terima kasih.

Tanggal :..............................................
Pukul ..................................................
Perujuk

Bdn. Nicke Uriant D, S.Tr.Keb

 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
Tahun Jenis Tempat Penolong Keadaan BB/TB
persalinan persalinan persalinan anak

Diagnosa ...................................................................................................................
....................................................................................................................................
..... Tindakan /terapi yang
diberikan. ..................................................................................................................
....................................................................................................................................
......
Mohon penatalaksanaan selanjutnya , atas bantuan dan kerjasamanya kami ucapkan
terima kasih .

Subang.............................
Pukul...............................
Perujuk

Bdn. Nicke UD, S.Tr.Keb