NAMA_________________ MELEWATI GAS : Y/T KELUAR_____________

WAKTU PENGIRIMAN _______________ DIET ____________

V______C________EPISIOTOMI: Y / T BAYI

KOMPLIKASI____________________________________ PEDIATRIKIA_________________________________
______________________________________________
MALE_____ WANITA_________
_
WT:_______LBS________OZ________GRAM
G______ P_______
APGARS:______1MIN________5MIN
ALERGI ____________________
KEHAMILAN:_______WKS________HARI
DARAH : AOB AB + -
PAYUDARA / BOTOL / KEDUA
BUTUH RHOGAM : Y/T
MAKANAN? Y /
RUBELLA: IMM / TIDAK N_________________________________

HEP B: POS / NEGARA KONSULTASI LAKTASI : Y/N

HIV: POS / NEGARA Kencing: Y / T POOP: Y / T

VS 0800 1200 1600 HEP B: Y / T

T TES PENDENGARAN: Y/ T

♥ DARAH : AOB AB+-

BP COOMBS: NEG/POS
RR PKU: Y/T

O2 VS 0800 1200 1600

T
NYERI ♥
RR
B AS B B L e H e
0800 LAB
1200
1600 ______________________________________________
CATATAN______________________________________ ______________________________________________
______________________________________________
_ MED

MEDS:_________________________________________ ______________________________________________
______________________________________________ ______________________________________________
______________________________________________
___

MEMBUKTIKAN: Y / T DI
DALAM________________