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  • RM. 50 Kuisoner Otopsi Verbal

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    Anda Anggara
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    This document is a questionnaire for a verbal autopsy of a perinatal death from the Lahat Regional Hospital in South Sumatra, Indonesia. The questionnaire collects identifying information about the deceased baby and mother, medical history of the pregnancy and birth, symptoms the baby had before death, and date of death report and verbal autopsy. The conclusion section is for documenting the determined cause of the perinatal death.

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    This document is a questionnaire for a verbal autopsy of a perinatal death from the Lahat Regional Hospital in South Sumatra, Indonesia. The questionnaire collects identifying information about the deceased baby and mother, medical history of the pregnancy and birth, symptoms the baby had before death, and date of death report and verbal autopsy. The conclusion section is for documenting the determined cause of the perinatal death.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    27 views2 pages

    RM. 50 Kuisoner Otopsi Verbal

    Uploaded by

    Anda Anggara
    This document is a questionnaire for a verbal autopsy of a perinatal death from the Lahat Regional Hospital in South Sumatra, Indonesia. The questionnaire collects identifying information about the deceased baby and mother, medical history of the pregnancy and birth, symptoms the baby had before death, and date of death report and verbal autopsy. The conclusion section is for documenting the determined cause of the perinatal death.

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    PEMERINTAH KABUPATEN LAHAT

    RUMAH SAKIT UMUM DAERAH LAHAT


    Jl Letjen Harun Sohar I No 28 Lahat, Kode Pos 31414, Provinsi Sumatera Selatan
    Telp/ Fax.(0731) 321785/323080, Email : rsud_lahat@yahoo.co.id

    RM. 50
    KUESIONER OTOPSI VERBAL KEMATIAN PERINATAL

    I. IDENTITAS BAYI
    1. Nama Bayi : Umur bayi : ........................ hari / jam
    2. Nama Ibu :
    3. Nama Bapak :
    4. Alamat : Desa / Kelurahan .......................................
    Kecamatan : .........................................
    Kab/Kota : .........................................
    5. Jenis kelamin bayi : a. Laki-laki ( ) b. Perempuan ( )
    6. Nomor urut kelahiran anak ini
    7. Umur bayi pada waktu meninggal
    a. Lahir mati
    b. Umur 0-7 hari
    8. a. Ibu belum mendapat TT ( ) c. Ibu sudah mendapat TT 2 ( )
    b. Ibu sudah mendapat TT 1 ( ) d. TT seumur hidup ( )

    II. RIWAYAT PENYAKIT


    1. Berat lahir : a. ............. kg b. Tidak ditimbang ( )
    2. Umur kehamilan ibu saat melahirkan bayi ini : ........................ ( minggu )
    3. Keadsaan bayi pada waktu lahir : kurus, lebih kecil dari normal ya ( ) Tidak ( )
    4. Sebelum meninggal, bayi pernah ditolong :
    a. Tidak ( ) e. Pustu ( )
    b. Dukun bayi ( ) f. Puskesmas ( )
    c. Bidan / perawat swasta ( ) g. RSUD ( )
    d. Dokter swasta ( ) h. lain-lain, sebutkan ................................
    5. Apakah ada tanda-tanda berikut :
    a. Apnoe Ada ( ) Tidak ( )
    b. Sesak nafas Ada ( ) Tidak ( )
    c. Kebiruan Ada ( ) Tidak ( )
    d. Kejang - kejang Ada ( ) Tidak ( )
    e. Mulut mencucu seperti ikan Ada ( ) Tidak ( )
    f. Tiba-tiba tidak dapatr menghisap Ada ( ) Tidak ( )
    g. Luka / memar / bengkak Ada ( ) Tidak ( )
    h. Cacat bawaan Ada ( ) Tidak ( )

    Bila ada sebutkan : ............................................................................................................


    III. TANGGAL MENERIMA LAPORAN KEMATIAN ....................................................................
    Tanggal pelaksanaan otopsi verbal ....................................................................................
    IV. KESIMPULAN
    Sebab kematian perinatal : .............................................................................................

    Mengetahui Tanggal ..........................


    Dokter Puskesmas / RSUD Bidan / Perawat Pencatat

    (............................................) (............................................)

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