Kohort Ibu Mekarsari

D.
Kohort Ibu
Puskesmas :JAMBE
Alamat : MEKARSARI
Telepon :
No NAMA IBU NIK IBU ALAMAT SUMBER USIA IBU

Urut DESA/KELURAHAN PEMBIYAYAAN
0 1 2 3 4 5
1
esih/hamdan FLAMBOYAN 1 KIS 38

2
susilawati/heru FLAMBOYAN 1 KIS 24

3
yusrona/fadli FLAMBOYAN 2 KIS 24

4
nurwiyah/aminudin FLAMBOYAN 2 KIS 27

5
st romaniah/aminudin FLAMBOYAN 3 JAMPERSAL 30

6
nurjanah/heris FLAMBOYAN 3 KIS 28

7
dewi/artoyo FLABOYAN 4 JAMPERSAL 30

8
asih/heru FLAMBOYAN 1 KIS 28

9
kartini/wawi FLAMBOYAN 1 KIS 17

10
siti saidah/nurrohman FLAMBOYAN 2 KIS 25

11
sukanah/parman FLAMBOYAN 3 KIS 18

12
nurastuti/a.fauzi FLAMBOYAN 3 KIS 20

13
ridia/suhendra FLAMBOYAN 3 KIS 24

14
esih salsabilah/heru FLAMBOYAN 1 KIS 20

15
widianingsih/h sanudin FLAMBOYAN 1 KIS 36

16
irma/tajudin FLAMBOYAN 2 KIS 24

17
esih/tatang FLAMBOYAN 2 JAMPERSAL 34

18
della/pepeng FLAMBOYAN 3 KIS 24

19
eneng/abdul rohim FLAMBOYAN 3 JAMPERSAL 18

20
bedah/basir FLAMBOYAN 3 KIS 34

21
marlinah/suhendra FLAMBOYAN 4 KIS 20

22
erin karlina/samsul
hidayat FLAMBOYAN 1 KIS 26
23
nuri/nurmudin FLAMBOYAN 1 KIS 20

24
liah/karna FLAMBOYAN 2 KIS 27

25
nurhayati/M.nazmudin FLAMBOYAN 2 KIS 20

26
asmiati/uji FLAMBOYAN 3 JAMPERSAL 34

27
ifah/hendrik FLAMBOYAN 3 JAMPERSAL 21

28
annisa/agus FLAMBOYAN 3 KIS 19

29
naris/madrosid FLAMBOYAN 1 KIS 35

30
sari lestari/rustam FLAMBOYAN 1 UMUM 23

31
tia/adit FLAMBOYAN 2 KIS 26

32
elis lisnawati/ajat
sudrajat FLAMBOYAN 2 KIS 32
33
ismawati/hendra FLAMBOYAN 3 KIS 32

34
mia awalia/rian FLAMBOYAN 3 KIS 21

35
nurhayati/M.najmudin FLAMBOYAN 3 KIS 34

36
st.sulistiawati/aditya FLAMBOYAN 1 UMUM 26

37
rohani/iwan FLAMBOYAN 1 JAMPERSAL 20

38
tuti/jumi FLAMBOYAN 2 UMUM 23

39
nuraisyah/haidir ali FLAMBOYAN 2 KIS 27

40
titin/hendi FLAMBOYAN 3 KIS 41

41
st.hotimah/ahmad FLAMBOYAN 3 UMUM 25

42
sarimanah/abdullah FLAMBOYAN 4 KIS 35

43
kartini/umar sidik FLAMBOYAN 1 KIS 32

44
St.nurjanah/anto FLAMBOYAN 1 KIS 33

45
rena S/sutisna FLAMBOYAN 2 UMUM 32

46
tiah/eni FLAMBOYAN 2 UMUM 35

47
dian/maulana FLAMBOYAN 3 KIS 20

48
nanih/sumadi FLAMBOYAN 3 KIS 30

49
rusminah/bandi FLAMBOYAN 4 KIS 25

50
nurhalimah/A.jalaludin FLAMBOYAN 1 KIS 28

51
sumyati/sapturi FLAMBOYAN 1 KIS 34

52
sainah/amir FLAMBOYAN 2 UMUM 29

53
St.nurul
amalia/M.abdul aziz FLAMBOYAN 2 UMUM 24
54
Devilas/cecep FLAMBOYAN 3 KIS 18

55
neneng/rozak FLAMBOYAN 3 UMUM 25

56
sainah/amir FLAMBOYAN 4 UMUM 2831

57
nurhasanh/sumarni FLAMBOYAN 1 KIS 25

58
mardiana/nasrullah FLAMBOYAN 1 UMUM 33

59
neneng/egi sterian FLAMBOYAN 2 KIS 22

60
St.hodijah/agus sopiah FLAMBOYAN 2 KIS 24

61
st.salbiah/sahrudin FLAMBOYAN 3 KIS 28

62
kasuma/ahmad eli FLAMBOYAN 2 KIS 20

63
samsiah/asjaya FLAMBOYAN 2 KIS 20

64
selawati/yuhaedi FLAMBOYAN 2 KIS 25

65
salmah/ato sunarto FLAMBOYAN 2 KIS 27

66
nunung/A.aziz FLAMBOYAN 2 UMUM 32

67
astrifah/irwan FLAMBOYAN 3 KIS 18

68
serina/endang FLAMBOYAN 3 KIS 26

69
St.aminah/anggi FLAMBOYAN 1 KIS 22

70
suheni/cecep FLAMBOYAN 1 KIS 35

71
rasiah/atok parha FLAMBOYAN 2 KIS 48

72
erah/selamet FLAMBOYAN 2 UMUM 31

73
nurlaelah/yayat FLAMBOYAN 1 KIS 24

74
nurhayati/rudi FLAMBOYAN 1 KIS 36

75
milah/samsudin FLAMBOYAN 3 KIS 17

76
junah/saripudin FLAMBOYAN 3 KIS 33

77
radesi/cecep FLAMBOYAN 1 KIS 20

78
linah/aris FLAMBOYAN 1 KIS 24

79
gita/wawan FLAMBOYAN 2 KIS 20

80
anita/hendri FLAMBOYAN 2 KIS 24

81
melia ulfa/ade heryadi FLAMBOYAN 3 KIS 20

82
eka/sandi FLAMBOYAN 3 UMUM 21

83
winda/arya FLAMBOYAN 3 UMUM 30

84
aqila/mistar FLAMBOYAN 4 UMUM 20

Provinsi : Banten
Kab/Kota : Tangerang
Kecamatan : MEKARSARI
STATUS GPA JARAK TAFSIRAN TB (CM) LILA (CM) Skrining Imunisasi Td SCRINING
KEHAMILAN PERSALINAN TBC
Status Injeksi Td Hb (gr/dl)
Imunisasi Td
6 7 8 9 10 11 12 13 14
3 5 TAHUN 150 24 TT2 6/2/2019 x 11.2
2 4 TAHUN 154 25 TT2 6/2/2019 x 12.5
2 1 TAHUN 160 24 TT2 7/2/2019 x 12.3
2 6 TAHUN 154 25 TT2 7/2/2019 x 11
2 4 TAHUN 155 26 TT2 8/2/2019 x 10.9
3 9 TAHUN 150 26 TT2 8/2/2019 x 11.4

2 5 TAHUN 155 25 TT2 9/2/2019 x 12.7
5 6 TAHUN 160 26 TT2 5/4/2019 x 13
3 5 TAHUN 165 26 TT2 6/4/2019 x 11.5
1 - 155 27 TT2 6/4/2019 x 10.9
2 5 TAHUN 150 26 TT2 8/4/2019 x 11.2
1 - 160 27 TT2 8/4/2019 x 12.5
1 - 149 25 TT2 8/4/2019 x 12.3

2 4 TAHUN 145 24 TT2 9/4/2019 x 11
1 - 160 25 TT2 6/5/2019 x 10.9
5 4 TAHUN 150 25 TT2 6/5/2019 x 11.4
1 - 148 25 TT2 7/5/2019 x 12.7
1 - 150 26 TT2 7/5/2019 x 13
2 5 TAHUN 155 27 TT2 8/5/2019 x 11.5
1 - 157 24 TT2 8/5/2019 x 10.9

6 5 TAHUN 160 25 TT2 8/5/2019 x 11.4
1 - 150 24 TT2 7/6/2019 x 12.7
1 - 153 25 TT2 7/6/2019 x 13
1 - 144 26 TT2 8/6/2019 x 11.5
2 5 TAHUN 153 26 TT2 8/6/2019 x 10.9
1 - 160 25 TT2 10/6/2019 x 11.2
3 5 TAHUN 150 26 TT2 10/6/2019 x 12.5

1 - 155 20 TT2 10/6/2019 x 12.3
1 - 157 27 TT2 5/7/2019 x 11
3 5 TAHUN 150 26 TT2 5/7/2019 x 10.9
1 - 150 27 TT2 6/7/2019 x 11.4
2 5 TAHUN 160 25 TT2 6/7/2019 x 12.7
2 6 TAHUN 156 24 TT2 8/7/2019 x 10.9
4 6 TAHUN 158 25 TT2 8/7/2019 x 11.4

1 - 149 25 TT2 9/7/2019 x 12.7
1 - 150 25 TT2 5/8/2019 x 13
1 - 150 26 TT2 5/8/2019 x 11.5
1 - 153 27 TT2 6/8/2019 x 10.9
1 - 158 24 TT2 6/8/2019 x 11.2
3 5 TAHUN 159 25 TT2 7/8/2019 x 12.5

2 6 TAHUN 157 21.5 TT2 7/8/2019 x 12.3
1 - 150 25 TT2 8/8/2019 x 11
2 7 TAHUN 150 26 TT2 5/9/2019 x 10.9
6 3 TAHUN 150 26 TT2 5/9/2019 x 11.4
1 - 150 25 TT2 6/9/2019 x 12.7
4 3 TAHUN 158 26 TT2 6/9/2019 x 10.9

1 - 160 26 TT2 7/9/2019 x 11.4
3 5 TAHUN 160 27 TT2 7/9/2019 x 12.7
4 6 TAHUN 158 26 TT2 8/9/2019 x 13
3 6 TAHUN 155 27 TT2 5/10/2019 x 11.5
2 7 TAHUN 150 25 TT2 5/10/2019 x 10.9
5 5 TAHUN 155 24 TT2 6/10/2019 x 11.2
3 5 TAHUN 150 25 TT2 6/10/2019 x 12.5
1 - 154 25 TT2 7/9/2019 x 10.9

1 - 160 25 TT2 7/9/2019 x 11.4
2 5 TAHUN 154 26 TT2 5/11/2019 x 12.7
3 5 TAHUN 155 27 TT2 5/11/2019 x 10.9
2 5 TAHUN 150 24 TT2 7/11/2019 x 11.4
3 6 TAHUN 155 25 TT2 7/11/2019 x 12.7
1 - 160 24 TT2 8/11/2019 x 13
2 6 TAHUN 165 25 TT2 8/11/2019 x 11.5
3 5 TAHUN 155 26 TT2 7/12/2019 x 10.9
2 3 TAHUN 150 26 TT2 7/12/2019 x 11.2
2 5 TAHUN 160 25 TT2 8/12/2019 x 12.5
3 5 TAHUN 149 26 TT2 8/12/2019 x 10.9

3 5 TAHUN 145 26 TT2 10/12/2019 x 11.4
1 - 160 20 TT2 8/11/2019 x 12.7
1 - 150 26 TT2 8/11/2019 x 10.9
1 - 148 27 TT2 6/11/2019 x 11.4
4 6 TAHUN 150 21 TT2 6/11/2019 x 12.7
6 2 TAHUN 155 24 TT2 7/12/2019 x 13
3 6 TAHUN 157 25 TT2 7/12/2019 x 11.5
2 5 TAHUN 160 25 TT2 8/12/2019 x 10.9
3 7 TAHUN 150 25 TT2 8/12/2019 x 11.2
1 - 153 26 TT2 10/12/2019 x 12.5
3 5 TAHUN 144 27 TT2 10/12/2019 x 12.7
1 - 153 24 TT2 6/1/2020 x 13

2 7 TAHUN 160 25 TT2 6/1/2020 x 11.5
1 - 150 24 TT2 8/1/2020 x 10.9
1 - 155 25 TT2 8/1/2020 x 11.2
3 4 TAHUN 157 26 TT2 9/1/2020 x 12.5
1 - 150 26 TT2 9/1/2020 x 10.9
1 - 150 25 TT2 9/1/2020 x 11.4
1 - 160 26 TT2 11/1/2020 x 12.7

18. Diisi hasil pemeriksaan HIV +/-
19. Diisi hasil pemeriksaan sifilis +/-
20. Diisi hasil pemeriksaan hepatitis B +/-
21. Diisi hasil pemeriksaan TBC +/-
22. Diisi bila ada pemeriksaan laboratorium yang lain
23. Diisi jenis konseling yang sudah diberikan
24. Diisi tata laksana kasus untuk ibu hamil dengan risiko dan penyulit, termasuk didalamnya rujukan
25-48. Diisi tanggal kunjungan dan hasil pemeriksaan (misal : BB, TFU, DJJ, Presentasi, dll)
49. Diisi hasil kelahiran, hidup atau mati (maserasi atau fresh)
50-51. Diisi berat bayi lahir dalam gram
52. Diisi cara persalinan : normal, SC, Vakum, Forcep
53. Diisi tempat persalinan : Rumah, Poskesdes, Polindes, Puskesmas, BPK, Klinik, Rumah sakit
54. Diisi penolong persalinan bidan, dokter umum, SpOG, perawat, dukun
55-58. Diisi hasil pelayanan dan klasifikasi sesuai bagan
59. Diisi metode KBPP yang dipilih: pil suntik implant, IUD, Kondom, MOW, MOP, cara lain
60. Diisi tata laksana kasus untuk ibu nifas dengan penyulit termasuk didalamnya rujukan
61. Diisi hal-hal lain yang penting untuk dituliskan
Laboratorium KONSELING
*
GOLDAR PROTEIN GLUKOSA HIV (-/+) SIFILIS (-/+) HBSAG MALARIA(- TBC (-/+) LAIN LAIN
URIN (-/+) UR (-/+) (-/+) /+)
15 16 17 18 19 20 21 22 23
AB NEGATIF NEGATIF NEGATIF NEGATIF NEGATIF X X √
O NEGATIF NEGATIF NEGATIF NEGATIF NEGATIF X X √
A NEGATIF NEGATIF NEGATIF NEGATIF NEGATIF X X √

B NEGATIF NEGATIF NEGATIF NEGATIF NEGATIF X X √


0 NEGATIF NEGATIF NEGATIF NEGATIF NEGATIF X X √





O NEGATIF NEGATIF NEGATIF NEGATIF POSITIF X X √



1).Presentasi : KP : Kepala
BS : Bokong / Sungsang
LLO : Letak Lintang / Oblique
2). Status imunisasi : T0, T1, T2, T3, T4, T5
(stillbirth) Maserasi
Fresh
* : √ jika Ya/Dilakukan X jika tidak
** : Tulis √ pada salah satu kolom
*** : Tata laksana yang diberikan (terapi/rujuk), pencatatan terapi
tuliskan jenis pengobatan mis. ARV, OAT, dll
18.
Diisi
hasil
pem
eriks
aan
HIV
+/-
19.
Diisi
hasil
pem
eriks
aan
sifili
s +/-
20.
Diisi
hasil
pem
eriks
aan
Hep
atitis
B +/-
21.
Diisi
hasil
pem
eriks
aan
TBC
+/-
22.
Diisi
bila
ada
hasil
pem
eriks
aan
labo
rator
ium
yan
g
Iain
23.
Diisi
jenis
kons
eling
yan
g
sud
ah
dibe
rika
n
24.
Diisi
tata
laks
ana
kasu
s
untu
k ibu
ham
il
den
M
E
K
A
Desa : R
S
Bidan : A
R
I
Bulan :
TATALAKSANA Tahun:2019
KASUS ***
Jan Feb Mar Apr Mei Jun Jul Ags
24 25 26 27 28 29 30 31 32
6-1-
19,16mgg,BB: 5-4- 6-5- 7-6- 7-7-
5/1/2019/12 57 kg,tfu:2jr d 5-3-19,20 19,24mgg,BB: 19,28mgg,BB 19,32mgg,BB: 19,36mgg,BB:
mgg,BB: 54 bwah pstdjj: mgg,BB:59tfu 61tfu:23cm,djj 65,tfu:26cm,d 65,30cm,djj:1 6933cm,djj:1
√ kg,djj:- 143 :18 cm djj:132 :14x jj:135 34 43
6-1-29,16
mgg,BB: 57 5-4- 6-5- 7-6-
5/1/2019/12 kg,tfu:2jr d 5-3-19,20 19,24mgg,BB: 19,28mgg,BB: 19,32mgg,BB:
mgg,BB: 54 bwah pstdjj: mgg,BB:60tfu 64,tfu:23cm,dj 68,tfu:26cm,d 69,30cm,djj:1
√ kg,djj:- 143 :18 cm djj:132 j:14x jj:135 34
7-2/19, 6-3-19, 6-4-19, 7-5-19, 8-6-19, 6-7-19,

7-01-19, 16mgg,tfu:18 20mgg,BB:59, 24mgg,tfu:26c 28mgg,tfu:29 32mgg,BB67, 36mgg,BB:69
12mgg,BB:50,dj cm,BB54,djj:1 tfu: m,BB:62,Djj:14 cm,BB:65,djj: Tfu:29cm,djj: cm,tfu:32cm,
√ j:- 43 23cm,djj:143 3 140 132 djj:136
7-2-19, 6-3-19, 7-5-19, 8-6-19, 6-7-19,

7-1-19, 16mgg,BB:50 20:mgg,BB:50 6-4-19, 28mgg,tfu:28 32mgg,tfu:30 36mgg,BB:72
12mgg,BB:45,tf kg,tfu kg,tfu:23cm,d 24mgg,BB:54k cm,BB:65,djj: cm,BB:69,djj: cm,tfu:31cm,
√ u:balt,djj:- balt,Djj:142 jj:143 g,djj:135 140 145 djj:136
8-3-19, 8-4-19,24 8-5-19, 10-6-19, 8-7-19,

8-1-19, 8-2-19, 20mgg,bb:59 mgg,BB: 57 28mgg,bb:60 32mgg,BB:63 36mgg,BB:66
12mgg,BB:50kg, bb:54kg,tfu k,ftu:18cm,djj kg,tfu: kg,tfu:27cm,d kg,tfu:30cm,d kg,tfu:32cm,d
√ tfu:balt,djj:- balt,djj:142 :145 23djj:134 jj:145 jj:134 jj:134
8-2-19, 8-3- 8-4-19, 8-5-19, 10-6-19, 8-7-19,

8-1-19, 16mgg,BB:52 19,20mgg,bb: 24mgg,bb:59k 28mgg,bb:61 32mgg,BB:66 36mgg,BB:66
12mgg,BB:50kg, kg,tfu:balt,djj: 56kg,tfu:23c g,tfu:27cm,djj: kg,tfu:29cm,d kg,tfu:32cm,d kg,tfu:32cm,d
√ tfu:balt,djj:- 134 m,djj:145 142 jj:145 jj:145 jj:134
9-2-19, 9-3- 9-5- 11-6-19, 9-7-19,
9-1-19, 16mgg,bb:59 19,20mgg,bb: 9-4-19,24mgg 19,28mgg,bb: 32mgg,bb:73 36mgg,bb:76
12mgg,bb:54kg, kg,tfu:spst,djj: 61kg,tfu:23c bb:67kg,tfu:26 70kg,tfu:29c kg,tfu:32cm,d kg,tfu:32cm,d
√ tfu:balt,djj:134 145 m,djj:145 cm,djj:145 m,djj:145 jj:142 jj:134
6-2-19, 5-3-19, 5-4-19, 6-5-19, 7-6-19, 5-7-19,

12mgg,bb:49 16mgg,bb:52 20mgg,bb:58k 24mgg,bb:53 28mgg,bb:63 32mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: g,tfu:23cm,djj: kg,tfu:26cm,d kg,tfu:29cm,d kg,tfu:32cm,d
√ - 145 142 jj:134 jj:145 jj:150
6-2-19 , 5-3-19, 5-4-19, 7-5-19, 7-6-19, 5-7-19, 5-8-19,

12mgg,bb:49 16mgg,bb:52 20mgg,bb:58k 24mgg,bb:62 28mgg,bb:63 32mgg,bb:65 36mgg,bb:59cm
kg,tfu:balt,djj: kg,tfu:spst,djj: g,tfu:23cm,djj: kg,tfu:27cm,d kg,tfu:29cm,d kg,tfu:32cm,d ,tfu:33cm,djj:12
√ - 145 142 jj:143 jj:145 jj:150 4
7-2- 6-3-19, 6-4-19, 7-5-19, 8-6-19, 6-7-19, 6-8-19,

19,12mgg,bb: 16mgg,bb:56 20mgg,bb:60k 24mgg,bb: 28mgg,bb:67 32mgg,bb:80 36mgg,bb:83cm
50,tfu:balt,djj: kg,tfu:spst,djj: g,tfu:23cm,djj: 63kg,tfu:27c kg,tfu:29cm,d kg,tfu: ,tfu:33cm,djj:14
√ - 134 145 m,djj:143 jj:134 32cm,djj:134 5
7-2-19, 6-3-19, 6-4-19, 8-5-19, 8-6-19, 6-7-19, 6-8-19,

12mgg,bb:48 16mgg,bb:51 20mgg,bb:54k 24mgg,bb:57 28mgg,bb:60, 32mgg,bb:64 36mgg,bb:68cm
kg,tfu:balt,djj: kg,tfu:spst,djj: g,tfu:23cm,djj: cm,tfu:27cm, tfu:29cm,djj:1 kg,tfu: ,tfu:32cm,djj:14
√ - 134 134 djj:145 34 30cm,djj:134 5
8-2-19, 8-3-19, 8-4-19, 8-5-19, 10-6-19, 8-7-19,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:56k 24mgg,bb:59 28mgg,bb:63 32mgg,bb:68 7-8-19,
kg,tfu:balt,djj: kg,tfu:balt,djj: g,tfu:20cm,djj: kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d 36mgg,bb:70,tf
√ - 140 140 jj:145 jj:134 jj:134 u:32cm,djj:134
8-2-19, 8-3-19, 8-4-19, 8-5-19, 10-6-19, 8-7-19,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:56k 24mgg,bb:59 28mgg,bb:63 32mgg,bb:68 7-8-19,
kg,tfu:balt,djj: kg,tfu:balt,djj: g,tfu:20cm,djj: cm,tfu:24cm, kg,tfu:28cm,d kg,tfu:30cm,d 36mgg,bb:70,tf
√ - 140 140 djj:134 jj:134 jj:134 u:32cm,djj:134
5-3-19, 5-4-19, 6-5-19, 7-6-19, 7-7-19, 5-8-19,
12mgg,bb:54 16mgg,bb:58k 20mgg,bb:60 24mgg,bb:63 28mgg,bb:65 32mgg,bb:69kg,
kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:19cm,d kg,tfu:26cm,d kg,tfu:29cm,d tfu:31cm,djj:14
√ - 43 jj:145 jj:134 jj:140 5
5-3-19, 5-4-19, 6-5-19, 7-6-19, 7-7-19, 5-8-19,

kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:19cm,d kg,tfu:26cm,d kg,tfu:29cm,d tfu:31cm,djj:14
√ - 43 jj:145 jj:134 jj:140 5
6-3-19, 6-4-19, 6-5-19, 8-6-19, 6-7-19, 6-8-19,

kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:21cm,d kg,tfu:23cm,tf cm,tfu:26cm, tfu:29cm,djj:13
√ - 30 jj:145 u:143 djj:145 4
6-3-19, 6-4-19, 6-5-19, 8-6-19, 6-7-19, 6-8-19,

kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:23cm,d kg,tfu:23cm,tf cm,tfu:26cm, tfu:29cm,djj:13
√ - 30 jj:145 u:143 djj:145 4
8-3-19, 8-4-19, 7-5-19, 10-6-19, 8-7-19,

12mgg,bb:59 16mgg,bb:64k 20mgg,bb:69 24mgg,bb:71 28mgg,bb:74 7-8-19,
kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:21cm,d kg,tfu:24cm,d kg,tfu:29cm,d 32mgg,bb:76kg,
√ - 45 jj:145 jj:132 jj:140 tfu:32,djj:134
8-3-19, 8-4-19, 7-5-19, 10-6-19, 8-7-19,

12mgg,bb:59 16mgg,bb:64k 20mgg,bb:69 24mgg,bb:71 28mgg,bb:74 7-8-19,
kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:21cm,d kg,tfu:24cm,d kg,tfu:29cm,d 32mgg,bb:76kg,
√ - 45 jj:145 jj:132 jj:140 tfu:32,djj:134
9-3-19, 9-4-19, 9-5-19, 11-6-19, 9-7-19, 8-8-19,

kg,tfu:balt,djj: g,tfu:spst,djj:1 kg,tfu:20cm,d kg,tfu:24cm,d kg,tfu:26,djj:1 tfu:29cm,djj:13
√ - 34 jj:134 jj:143 45 4
6-5-19, 7-6-19, 5-7-19,
5-4-19, 16mgg,bb:53 20mgg,bb:56 24mgg,bb:58 5-8-19,
12mgg,bb:50k kg,tfu:spst,djj: kg,tfu:22cm,d kg,tfu:26cm,d 28mgg,bb:60kg,
√ g,tfu:balt,djj:- 134 jj:134 jj:143 tfu:28kg,djj:143
6-5-19, 7-6-19, 5-7-19,

5-4-19, 16mgg,bb:59 20mgg,bb:63 24mgg,bb:67 5-8-19,
12mgg,bb:56k kg,tfu:spst,djj: kg,tfu:22cm,d kg,tfu:26cm,d 28mgg,bb:69kg,
√ g,tfu:balt,djj:- 134 jj:134 jj:143 tfu:28kg,djj:143
7-5-19, 8-6-19, 6-7-19, 6-8-19,

6-4-19, 16mgg,bb:49 20mgg,20mg 24mgg,24mg 28mgg,bb:60kg,
12mgg,bb:46k kg,tfu:spst,djj: g,bb:52kg,tfu: g,bb:57kg,tfu: tfu:28cm,djj:13
√ g,tfu:balt,djj:- 145 23cm,djj:143 26cm,djj:145 4
7-5-19, 8-6-19, 6-7-19, 6-8-19,

6-4-19, 16mgg,bb:49 20mgg,20mg 24mgg,24mg 28mgg,bb:60kg,
12mgg,bb:46k kg,tfu:spst,djj: g,bb:52kg,tfu: g,bb:57kg,tfu: tfu:28cm,djj:13
√ g,tfu:balt,djj:- 145 23cm,djj:143 26cm,djj:145 4
8-5-19, 10-6-19, 8-7-19, 7-8-19,

8-4-19, 16mgg,bb:53 20mgg,bb:58 24mgg,bb:59 28mgg,bb:61kg,
12mgg,bb:50k kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:26cm, tfu:29cm,djj:14
√ g,tfu:balt,djj:- 145 jj:145 djj:145 5
8-5-19, 10-6-19, 8-7-19, 7-8-19,

8-5-19, 10-6-19, 8-7-19, 7-8-19,

5-5-19, 7-6-19, 5-7-19, 5-8-19,
12mgg,bb:50 16mgg,bb:54 20mgg,bb:59 24mgg,bb:63kg,
kg,tfu:balt,djj: kg,tfu:spst,sjj: kg,tfu:23cm,d tfu:26cm,djj:14
√ 134 143 jj:136 3
5-5-19, 7-6-19, 5-7-19, 5-8-19,

kg,tfu:balt,djj: kg,tfu:spst,sjj: kg,tfu:23cm,d tfu:26cm,djj:14
√ 134 143 jj:136 3
7-5-19, 8-6-19, 6-7-19, 6-8-19,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d tfu:
√ - 134 jj:134 26cm,djj:134
7-5-19, 8-6-19, 6-7-19, 6-8-19,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d tfu:
√ - 134 jj:134 26cm,djj:134
8-5-19, 10-6-19, 8-7-19, 7-8-19,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d tfu:26cm,djj:14
√ - 134 jj:134 0
8-5-19, 10-6-19, 8-7-19, 7-8-19,

√ - 134 jj:134 0
8-5-19, 10-6-19, 8-7-19, 7-8-19,

√ - 134 jj:134 0
7-6-19, 5-7-19, 5-8-19,
12mgg,bb:50 16mgg,bb:53 20mgg,bb:57kg,
kg,tfu:balt,djj: kg,tfu:spst,djj: tfu:23cm,djj:13
√ - 134 4
7-6-19, 5-7-19, 5-8-19,

√ - 134 4
8-6-19, 6-7-19, 6-8-19,

√ - 134 0
8-6-19, 6-7-19, 6-8-19,

√ - 134 0
10-6-19, 8-7-19, 7-8-19,

√ - 135x,preskeb 4x,preskeb
10-6-19, 8-7-19, 7-8-19,

√ - 135x,preskeb 4x,preskeb
11-6-19, 9-7-19, 8-8-19,
kg,tfu:balt/djj kg,tfu:spst,djj: tfu:23cm,djj:13
√ :- 134x,preskeb 9x,preskeb
5-8-19,
5-7-19, 16mgg,bb:57kg,
12mgg,bb:53 tfu:balt,djj:134,
√ kg,tfu:-,djj:- prekeb
5-8-19,
5-7-19, 16mgg,bb:57kg,
12mgg,bb:53 tfu:balt,djj:134,
√ kg,tfu:-,djj:- prekeb
6-7-19,
12mgg,bb:50 6-8-19,
kg,tfu:balt,djj: 16mgg,bb:54kg,
√ - tfu:spst,djj:130
6-7-19,
12mgg,bb:50 6-8-19,
√ - tfu:spst,djj:130
8-7-19,
12mgg,bb:53 7-8-19,
√ - tfu:balt,djj:134
8-7-19,
12mgg,bb:53 7-8-19,
√ - tfu:balt,djj:134
9-7-19, 9-8-19,
12mgg,bb:54 16mgg,bb:58kg,
kg,tfu:balt,djj: tfu:balt,djj:123,
√ - prekeb
5-8-19,
12mgg,bb:50kg,
√ tfu:balt,djj:-
5-8-19,
12mgg,bb:50kg,
√ tfu:balt,djj:-
6-8-19,
12mgg,bb:54kg,
√ tfu:balt,djj:-
6-8-19,
12mgg,bb:54kg,
√ tfu:balt,djj:-
7-8-19,
12mgg,bb:59kg,
√ tfu:balt,djj:-
7-8-19,
12mgg,bb:59kg,
√ tfu:balt,djj:-
8-8-19,
12mgg,bb:50kg,
√ tfu:balt,djj:-
√
√
√
√
√
tatan terapi
Tahun:
Sep Okt Nop Des Jan Feb Mar Apr Mei Jun
33 34 35 36 37 38 39 40 41 42
6-9-19,
36mgg,bb:73
kg,tfu:30cm,d
jj:134
6-9-19,
36mgg,bb:76
kg,tfu:33cm,d
jj:134
7-9-19,
36mgg,bb:79
cm,tfu:33cm,
djj:134
7-9-19,
36mgg,bb:79
cm,tfu:33cm,
djj:134
5-9-
19,32mgg,bb:
65kg,tfu:30c
m,djj:143
5-9-
19,32mgg,bb:
672kg,tfu:30c
m,djj:143
6-9-19,
32mgg,bb:64
kg,tfu:30cm,d
jj:134
6-9-19, 6-10-
32mgg,bb:64 19,36mgg,bb:
kg,tfu:30cm,d 66kg,tfu:32c
jj:134 m,djj:143 PINDAH
9-7-19,
32mgg,bb:64
kg,tfu:32cm,d
jj:145
9-7-19, 7-
32mgg,bb:64 36mgg,bb:68
kg,tfu:32cm,d kg,tfu:33cm,d
jj:145 jj:143 PINDAH
9-7-19,
32mgg,bb:64
kg,tfu:32cm,d
jj:145
5-9-19, 5-10-
kg,tfu:28kg,dj 67kg,tfu:30c
j:134 m,djj:134
5-9-19, 5-10-
j:134 m,djj:134
6-9-19, 6-10-19,
jj:134 jj:143
6-9-19, 6-10-19,
jj:134 jj:143 PINDAH
7-9- 7-10-19, 7-11-19,

19,28mgg,bb: 32mgg,bb:65 36cm,bb:68kg
63kg,tfu:29c kg,tfu:31cm,d ,tfu:33cm,djj:
m,djj:134 jj:145 134
7-9- 7-10-19, 7-11-19,

m,djj:134 jj:145 134
7-9- 7-10-19, 7-11-19,

m,djj:134 jj:145 134
5-9-19, 5-10-19, 5-11-19, 6-12-19,
24mgg,bb:59 28mgg,bb:63 32mgg,bb:65 36mgg,bb:68
cm,tfu:25,djj: kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d
135 jj:138 jj:142 jj:134
5-9-19, 5-10-19, 5-11-19,

24mgg,bb:59 28mgg,bb:63 32mgg,bb:65
cm,tfu:25,djj: kg,tfu:26cm,d kg,tfu:28cm,d
135 jj:138 jj:142
7-10-19, 7-11-19,
6-9-19, 28mgg,bb:60 32mgg,bb:64
24mgg,bb:57 kg,tfu:27cm,d kg,tfu:30cm,d
kg,tfu:25cm,d jj:134x,preske jj:134x,preske
jj:135 b b
7-10-19, 7-11-19,
6-9-19, 28mgg,bb:60 32mgg,bb:64
24mgg,bb:57 kg,tfu:27cm,d kg,tfu:30cm,d
kg,tfu:25cm,d jj:134x,preske jj:134x,preske
jj:135 b b
7-9-19, 8-10-19,
24mgg,bb:59 28mgg,bb:62 8-11-19,
kg,tfu:26cm,d kg,tfu:29cm,d 32mgg,bb:65
jj:132x,preske jj:140x,preske kg,tfu:32x,djj:
b b 130,preskeb
7-9-19, 8-10-19, 8-12-19,

24mgg,bb:59 28mgg,bb:62 8-11-19, 36mgg,bb:70
kg,tfu:26cm,d kg,tfu:29cm,d 32mgg,bb:65 kg,tfu:34cm,d
jj:132x,preske jj:140x,preske kg,tfu:32x,djj: jj:124x/m,pre
b b 130,preskeb skeb
10-11-19,
8-9-19, 10-10-29, 32mgg,bb:65
24mgg,bb:59 28mgg,bb:62 kg,tfu:30cm,d
kg,tfu:26,djj:1 kg,tfu:28cm,d jj:130x,preke
34x,preskeb jj:132,prekeb b
5-9-19, 5-11-19, 6-12-19,

20mgg,bb:60 5-10-19, 28mgg,bb:68 32mgg,bb:70
kg,tfu:23cm,d 24mgg,bb:63 kg,tfu:28cm,d kg,tfu:30cm,d
jj:130x,preske kg,tfu:24cm,d jj:135x,preke jj:134x/preke
b jj:124,prekeb b b
5-9-19, 5-11-19, 6-12-19,

20mgg,bb:60 5-10-19, 28mgg,bb:68 32mgg,bb:70
kg,tfu:23cm,d 24mgg,bb:63 kg,tfu:28cm,d kg,tfu:30cm,d
jj:130x,preske kg,tfu:24cm,d jj:135x,preke jj:134x/preke
b jj:124,prekeb b b
7-11-19,
6-9-19, 6-10-19, 28mgg,bb:62 7-12-19,
20mgg,bb:57 24mgg,bb:59 kg,tfu:29cm,d 32mgg,bb:65
kg,tfu:23cm,d kg,tfu:26cm,d jj:139x,preke kg,tfu:30x,djj:
jj:130,prekeb jj:130,prekeb b 126x,prekeb
7-11-19,
6-9-19, 6-10-19, 28mgg,bb:62 7-12-19,
20mgg,bb:57 24mgg,bb:59 kg,tfu:29cm,d 32mgg,bb:65
kg,tfu:23cm,d kg,tfu:26cm,d jj:139x,preke kg,tfu:30x,djj:
jj:130,prekeb jj:130,prekeb b 126x,prekeb
7-10-19, 8-11-19,
7-9-19, 24mgg,24mg 28mgg,bb:62 8-12-19,
20mgg,bb:58 g,60kg,tfu:25 kg,tfu:27cm,d 32mgg,bb:65
kg,tfu:23x,djj: cm,djj:140,pr jj:134x,preke kg,tfu:30cm,d
134,prekeb ekeb b jj:134x/pekeb
7-10-19, 8-11-19,
7-9-19, 24mgg,24mg 28mgg,bb:62
20mgg,bb:58 g,60kg,tfu:25 kg,tfu:27cm,d
kg,tfu:23x,djj: cm,djj:140,pr jj:134x,preke
134,prekeb ekeb b PINDAH
8-10-19,
8-9-19, 24mgg,bb:63 9-11-19,
20mgg,bb:60 kg,tfu:25cm,d 28mgg,bb:65
kg,tfu:23cm,d jj:140x/m,pre kg,tfu:29cm,d
jj:140,prekeb skeb jj:130,prekeb PINDAH
5-11-19, 6-12-19, 6-01-20,

5-9-19, 5-10-19, 24mgg,bb:58 28mgg,bb:60 32mgg,bb:63
16mgg,bb:53 20mgg,bb:56 kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d
kg,tfu:balt,djj: kg,tfu:23cm,d jj:142x/m,pre jj:142x/m,pre jj:123x/m,pre
134,preskeb jj:140,prekeb keb skeb keb
5-11-19, 6-12-19, 6-01-20,

5-9-19, 5-10-19, 24mgg,bb:58 28mgg,bb:60 32mgg,bb:63
16mgg,bb:53 20mgg,bb:56 kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d
kg,tfu:balt,djj: kg,tfu:23cm,d jj:142x/m,pre jj:142x/m,pre jj:123x/m,pre
134,preskeb jj:140,prekeb keb skeb keb
6-10-19, 7-11-19, 7-12- 8-1-20,

6-9-19, 20mgg,62kg, 24mgg,bb:67 19,28mgg, 32mgg,bb:76
16mgg,bb:59 tfu24cm,djj:1 kg,tfu:26cm,d 72kg,tfu:27c kg,tfu:30cm,d
kg,tfu:spst,djj: 23x/m,preske jj:140/m,prek m,djj:140x/m, jj:143x/m,pre
134x/m b eb preskeb skeb
6-10-19, 7-11-19, 7-12- 8-1-20,

6-9-19, 20mgg,62kg, 24mgg,bb:67 19,28mgg, 32mgg,bb:76
16mgg,bb:59 tfu24cm,djj:1 kg,tfu:26cm,d 72kg,tfu:27c kg,tfu:30cm,d
kg,tfu:spst,djj: 23x/m,preske jj:140/m,prek m,djj:140x/m, jj:143x/m,pre
134x/m b eb preskeb skeb
8-12-
7-9-19, 7-10- 8-11- 19,28mgg, 9-1-
16mgg,bb:62 19,20mgg,bb: 19,24mgg,bb: bb:72kg,tfu:2 20,32mgg,bb:
kg,tfu:spst,djj: 65kg,tfu:23c 69kg,tfu:26c 8cm,djj:138x/ 76kg,tfu:30c
134x/m m,djj:134x/m m,djj:140x/m m m,djj:135x/m
7-9-19, 7-10- 8-11- 8-12- 9-1-

16mgg, 19,20mgg, 19,24mgg, 19,28mgg, 20,32mgg,
bb:62kg,tfu:s bb:65kg,tfu:2 bb:69kg,tfu:2 bb:72kg,tfu:2 bb:76kg,tfu:3
pst,djj:134x/ 3cm,djj:134x/ 6cm,djj:140x/ 8cm,djj:138x/ 0cm,djj:135x/
m m m m m
8-9- 8-10-19, 10-11- 10-12-
19,16mgg, 20mgg, 19,24mgg, 19,28mgg, 11-1-20,
bb:62kg,tfu:s bb:65kg,tfu:2 bb:69kg,tfu:2 bb:72kg,tfu:2 32mgg,bb:76
pst,djj:134x/ 3cm,djj:134x/ 6cm,djj:140x/ 8cm,djj:138x/ kg,tfu:30cm,d
m m m m jj:135x/m
6-12-19, 6-01-19,
5-9-19, 5-10-19, 5-11-19, 24mgg, 28mgg,
12mgg,bb:48 16mgg,bb:50 20mgg,bb:54 bb:59kg,tfu:2 bb:64kg,tfu:2
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d 6cm,djj:134x/ 8cm,djj:140x/
- 140x/m jj:140x/m m m
6-12-19, 6-01-19,
5-9-19, 5-10-19, 5-11-19, 24mgg, 28mgg,
12mgg,bb:48 16mgg,bb:50 20mgg,bb:54 bb:59kg,tfu:2 bb:64kg,tfu:2
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d 6cm,djj:134x/ 8cm,djj:140x/
- 140x/m jj:140x/m m m
6-9-19, 6-10-19, 7-11-19, 7-12-19, 8-1-19,

12mgg,bb:56 16mgg,bb:68 20mgg,bb:71 24mgg,bb:75 28mgg,bb:78
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:26cm,d kg,tfu:28cm,d
- 145x/m jj:134 d:140x/m jj:145
6-9-19, 6-10-19, 7-11-19, 7-12-19, 8-1-19,

- 145x/m jj:134 d:140x/m jj:145
7-9-19, 7-10-19, 8-11-19, 8-12-19, 9-1-19,

- 145x/m jj:134 d:140x/m jj:145
7-9-19, 7-10-19, 8-11-19, 8-12-19, 9-1-19,

- 145x/m jj:134 d:140x/m jj:145
5-10-19, 5-11-19, 6-12-19, 6-1-20,

12mgg,bb:45 16mgg,bb:47 20mgg,bb:52 24mgg,tfu:25
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d cm,djj:134x/
- 145 jj:123x/m m,preskeb
5-10-19, 5-11-19, 6-12-19, 6-1-20,

6-10-19, 7-11-19, 7-12-19, 8-1-20,

6-10-19, 7-11-19, 7-12-19, 8-1-20,

8-12- 9-1-20,
7-10-19, 8-11-19, 19, :20mgg,b 24mgg,bb:65
12mgg,bb:50 16mgg,bb:53 b:62kg,tfu:23 kg,tfu:25cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: cm,djj:140x/ jj:134x/m,pre
- 134x/m m.preskeb skeb
8-12- 9-1-20,
7-10-19, 8-11-19, 19, :20mgg,b 24mgg,bb:65
12mgg,bb:50 16mgg,bb:53 b:62kg,tfu:23 kg,tfu:25cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: cm,djj:140x/ jj:134x/m,pre
- 134x/m m.preskeb skeb
5-11-19, 6-12-19, 6-1-20,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d
- 140x/m jj:134x/m
5-11-19, 6-12-19, 6-1-20,

- 140x/m jj:134x/m
6-11-19, 7-12-19, 8-1-20,

12mgg,bb:46 16mgg,bb:49 bb:52kg,tfu:2
kg,tfu:balt,djj: kg,tfu:spst,djj: 3cm,djj:143x/
- 124x/m m,preskeb
6-11-19, 7-12-19, 8-1-20,

- 124x/m m,preskeb
7-11-19, 8-12-19, 8-1-20,

- 124x/m m,preskeb
7-11-19, 8-12-19, 8-1-20,

- 124x/m m,preskeb
8-11-19, 10-12-19, 8-1-20,

- 124x/m m,preskeb
8-11-19, 10-12-19, 8-1-20,

- 124x/m m,preskeb
6-12-19, 6-1-20,
kg,tfu:balt,djj: kg,tfu:spst,djj:
- -
6-12-19, 6-1-20,
- -
7-12-19, 8-1-20,
- -
7-12-19, 8-1-20,
- -
8-12-19, 9-1-20,
- -
8-12-19, 9-1-20,
- -
8-12-19, 9-1-20,
- -
10-12-19, 11-1-20,
- -
6/◦/F1
Tahun: Lahir Berat Bayi Lahir Cara
Hidup/Mati Persalinan
Jul Ags Sep Okt Nop Des <2500gr >2500gr
43 44 45 46 47 48 49 50 51 52
HIDUP 2560 NORMAL
HIDUP 2800 NORMAL
HIDUP 2900 NORMAL
HIDUP 3500 NORMAL
HIDUP 2900 NORMAL
HIDUP 2700 SC
HIDUP 2600 NORMAL
HIDUP 2600 NORMAL
HIDUP 2600 NORMAL
HIDUP 3200 NORMAL
HIDUP 3000 NORMAL
HIDUP 2900 NORMAL
HIDUP 3200 NORMAL

HIDUP 3300 SC
HIDUP 3400 NORMAL
HIDUP 3000 NORMAL
HIDUP 3000 NORMAL
HIDUP 2300 2600 SC
HIDUP 3000 NORMAL
HIDUP 3300 NORMAL

HIDUP 2500 NORMAL
HIDUP 3700 NORMAL
HIDUP 3200 NORMAL
PINDAH
HIDUP 2900 NORMAL
PINDAH
HIDUP 2900 NORMAL

HIDUP 2900 NORMAL
HIDUP 3000 NORMAL
HIDUP 3680 SC
pindah
HIDUP 3200 NORAML
HIDUP 2900 NORMAL
PINDAH
PINDAH
HIDUP 2900 NORMAL
HIDUP 3200 NORMAL
HIDUP 3100 NORMAL
HIDUP 3000 NORMAL
HIDUP 2800 NORMAL

HIDUP 3100 NORMAL
HIDUP 3200 NORMAL
HIDUP 2900 NORMAL
HIDUP 3100 NORMAL
HIDUP 2500 NORMAL
PINDAH
PINDAH
Lampiran KIA-4
KF*
Pelayanan Tata
Tempat Penolong Keterangan
KF1 KF2 KF3 KBPP Laksana
53 54 55 56 57 59 60 61
PONED BIDAN 20/08/2019 28/8/19 28/9/19 SUNTIK
RS HARMUL DOKTER 27/7/2019 5/8/2019 27/8/19 SUNTIK

RSU
BALARAJA DOKTER 10/8/2019 18/8/19 18/9/19 SUNTIK
RS
HARMUL DOKTER 1/9/2019 9/9/2019 1/10/2019 SUNTIK
PONED BIDAN 4/9/2019 13/9/19 9/10/2019 PIL
PONED BIDAN 6/9/2019 14/9/19 "10/10/2019 SUNTIK
PONED BIDAN 10/9/2019 18/9/19 "10/10/2019 PIL

BPM BIDAN 6/9/2019 15/9/19 10/10/2019 SUNTIK
BPM BIDAN 4/10/2019 22/10/19 12/11/2019 SUNTIK

BPM BIDAN 20/9/19 28/9/19 20/10/19 SUNTIK
BPM BIDAN 8/10/2019 16/10/9 16/11/19 SUNTIK

PONED BIDAN 19/12/19 7/1/2020 27/1/19 MOW

PONED BIDAN 10/12/2019 18/12/19 10/1/2020 MOW


* : V; jika ya/dilakukan X ; jlka tidak ”° : Tulls V pada
salah satu kolom
’”’ : Tata laksana yang diberikan (Terapi/Rujuk), Pencatatan
terapi tuliskan jenis pengobatan mis. ARV, OAT,dII
D. Kohort Ibu
Puskesmas Alamat Telp/Fax
NAMA IBU NIK IBU ALAMAT SUMBER USIA IBU STATUS GPA
DESA/KELURAHAN PEMBIYAYAAN
NENENG/RIDWAN
NENTI/MUKRI
Petunjuk Pengisian
1. Diisi Nama lengkap ibu
hamil
2. Diisi Nomor Induk
Kependudukan di KTP , bila
ibu tidak punya KTP diberi
tanda (-)
3. Diisi alamat lengkap ibu
hamil
4. Disi sumber pembiayaan :
JKN, Jamkesda, Jampersal,
Pribadi,dll
5. Diisi usia ibu dalam tahun
6. Diisi status Gravida, Partus
dan Abortus
7. Diisi jarak kehamilan saat ini
dengan kehamilan terakhir
(tahun)
8. Diisi tanggal taksiran
persalinan (ddmmyyyy)
9. Diisi tinggi badan ibu hamil
dalam cm
10. Diisi ukuran Lingkar lengan
atas dalam cm, saat diukur
pertama kali Untuk bumil KEK
hasil pemantauan LILA diisi di
bulan kunjungan
11. Diisi status Td ibu hamil
saat skrining
12. Diisi Tanggal pemberian
lnjeksi Td bila diberikan
13. Diisi hasil skrining
anamnesa TBC ( suspek atau
non suspek )
14. Diisi hasil pemeriksaan
hemoglobin
15. Diisi golongan darah ibu
hamil
proteinuri +/-
glukosauri +/-
Provinsi Kab/Kota Kecamatan :
JARAK TAFSIRAN TB (CM) LILA (CM) IMUNISASI TD SCRINING HI R/D GOLDAR

KEHAMILAN PERSALINAN TBC
STATUS INJEKSI
IMUNISAS
I
Desa Bidan Bulan
PROTEIN GLUKOSA HIV (-/+) SIFILIS HBSAG MALARIA( TBC (-/+) LAIN LAIN KONSELIN TATALAKS
URIN (-/+) UR (-/+) (-/+) (-/+) -/+) G ANA
KASUS
18.
Diisi
hasil
pem
eriks
aan
HIV
+/-
19.
Diisi
hasil
pem
eriks
aan
sifili
s +/-
20.
Diisi
hasil
pem
eriks
aan
Hep
atitis
B +/-
21.
Diisi
hasil
pem
eriks
aan
TBC
+/-
22.
Diisi
bila
ada
hasil
pem
eriks
aan
labo
rator
ium
yan
g
Iain
23.
Diisi
jenis
kons
eling
yan
Desa Bidan Bulan
t8
JAN FEB MAR

katB§i kfii ?eeIiI¥ir
Lampiran KIA-4
TeNyat 9efoblg Itft Pt P3 04

1).Presentasi: KP : Kepala
BS : Bokong/Sungsang
LLO : Letak Lintang/Oblique 2). Status Imunisasi : TO, T1, T2, T3, T4, TS
(stillbinh): Maserasl Fresh
* : V; jika ya/dilakukan X ; jlka tidak ”° : Tulls V pada

salah satu kolom
’”’ : Tata laksana yang diberikan (Terapi/Rujuk), Pencatatan
terapi tuliskan jenis pengobatan mis. ARV, OAT,dII
Lampiran KIA-4
D. Kohort Ibu
Puskesmas :JAMBE
Alamat : MEKARSARI
Telepon :
No NAMA IBU NIK IBU ALAMAT SUMBER USIA IBU STATUS JARAK
Urut DESA/KELURAHAN PEMBIYAY GPA KEHAMILA
AAN N
0 1 2 3 4 5 6 7
1
anita/ali FLAMBOYAN 1 KIS 17 1 -

2
nuraida/viki FLAMBOYAN 1 KIS 27 2 4 TAHUN

3
mia/david FLAMBOYAN 2 KIS 24 2 4 TAHUN

4
dede/rian FLAMBOYAN 2 KIS 21 2 6 TAHUN

5
JAMPERSA
esih/hamdan FLAMBOYAN 3 L 25 2 4 TAHUN
6
st.saliah/ria FLAMBOYAN 3 KIS 27 2 9 TAHUN

7
JAMPERSA
dwi/noko FLABOYAN 3 L 22 2 5 TAHUN
8
rini/mansyur FLAMBOYAN 4 KIS 24 2 6 TAHUN

9
fitri/suhendri FLAMBOYAN 1 KIS 28 2 5 TAHUN

10
susi/isan FLAMBOYAN 1 KIS 20 1 -

11
wawat/toni FLAMBOYAN 2 KIS 37 9 5 TAHUN

12
karsih/hodes FLAMBOYAN 2 KIS 33 4 3 TAHUN

13
sutinah/kosim FLAMBOYAN 3 KIS 33 5 4 TAHUN

14
maya/ahmad FLAMBOYAN 3 KIS 38 4 4 TAHUN

15
rica
elyawati/nuralams
yah FLAMBOYAN 4 KIS 34 2 6 TAHUN
16
munaroh/muamar FLAMBOYAN 4 KIS 27 2 4 TAHUN

17
JAMPERSA
sinta/wawan FLAMBOYAN 1 L 24 2 7 TAHUN
18
st/hindun/daeropin FLAMBOYAN 2 KIS 24 2 5 TAHUN

19
may JAMPERSA
julianti/artoyo FLAMBOYAN 3 L 28 1 -
20
sunarti/mulyadi FLAMBOYAN 3 KIS 33 7 7 TAHUN

21
yamah/cecep FLAMBOYAN 3 KIS 36 2 5 TAHUN

22
asnawati/bambang FLAMBOYAN 4 KIS 26 2 7 TAHUN

23
eva/ A gozali FLAMBOYAN 1 KIS 27 1 -

24
rinata/sartoyo FLAMBOYAN 1 KIS 21 1 -

25
nursih/marhedin FLAMBOYAN 2 KIS 30 2 5 TAHUN

26
ratih/maman FLAMBOYAN 2 KIS 37 5 6 TAHUN

27
JAMPERSA
wiwin/fitra FLAMBOYAN 3 L 29 2 5 TAHUN
28
lulu/ilham FLAMBOYAN 3 KIS 28 1 -

29
maya/sopa FLAMBOYAN 3 KIS 26 2 5 TAHUN

30
indah/rohim FLAMBOYAN 4 UMUM 26 2 5 TAHUN

31
sopiah/
nurdiansyah FLAMBOYAN 1 KIS 20 1 -
32
senah/h/ilun FLAMBOYAN 1 KIS 43 5 5 TAHUN

33
enjah/wawan FLAMBOYAN 2 KIS 20 1 -

34
narti
dinata/maman FLAMBOYAN 2 KIS 25 1 -
35
st/.rohimah/sutisna FLAMBOYAN 3 KIS 20 1 -

36
mia/aziz FLAMBOYAN 3 UMUM 19 1 -

37
JAMPERSA
enih/A.rozak FLAMBOYAN 4 L 32 3 5 TAHUN
Provinsi : Banten
TAFSIRAN TB (CM) LILA (CM) Skrining Imunisasi Td SCRINING Laborator

PERSALINAN TBC
Status Injeksi Td Hb (gr/dl) GOLDAR PROTEIN GLUKOSA
Imunisasi URIN (-/+) UR (-/+)
Td
8 9 10 11 12 13 14 15 16 17
150 24 TT2 √ x 11.2 AB NEGATIF NEGATIF
154 25 TT2 √ x 12.5 O NEGATIF NEGATIF
154 25 TT2 √ x 11 AB NEGATIF NEGATIF
155 26 TT2 √ x 10.9 A NEGATIF NEGATIF

160 26 TT2 √ x 13 O NEGATIF NEGATIF
150 26 TT2 √ x 11.2 B NEGATIF NEGATIF

150 20 TT2 √ x 13 A NEGATIF NEGATIF

153 25 TT2 √ x 13 0 NEGATIF NEGATIF

157 27 TT2 √ x 11 AB NEGATIF NEGATIF


M
E
K
Desa : A
R
S
Bidan : A
R
Bulan : I
Laboratorium KONSELIN TATALAKS

G* ANA
HIV (-/+) SIFILIS (-/+) HBSAG MALARIA(- TBC (-/+) LAIN LAIN KASUS *** Jan Feb
(-/+) /+)
18 19 20 21 22 23 24 25 26
NEGATIF NEGATIF NEGATIF X X √ √




NEGATIF NEGATIF POSITIF X X √ √


Tahun:2019
Mar Apr Mei Jun Jul Ags Sep Okt Nop Des
27 28 29 30 31 32 33 34 35 36
5/9/18 ,16mg x/
g,BB: 57 5/11/18,24m m,preskeb6/1
5/1/2018 12 kg,tfu:2jr d 6/10/18, 20 gg,BB:61tfu:2 2/18,28mgg,B
mgg,BB: 54 bwah pstdjj: mgg,BB:59tfu 3cm,djj:142x/ B65,tfu:26cm,
kg,djj:- 143 :18 cm djj:132 m,preskeb djj:135
5/9/18,16
mgg,BB: 57 5/11/18,24m 6/12/18,28m
5/1/2018 12 kg,tfu:2jr d 6/10/18,20 gg,BB:64,tfu:2 gg,BB:68,tfu:2
mgg,BB: 54 bwah pstdjj: mgg,BB:60tfu 3cm,djj:142x/ 6cm,djj:135x/
kg,djj:- 143 :18 cm djj:132 m,preskeb m,preskeb
6/9/18, 6/10/18 , 6/11/18 , 6/12/18 ,

9/8/18, 16mgg,tfu:18 20mgg,BB:59, 24mgg,tfu:26 28mgg,tfu:29
12mgg,BB:50, cm,BB54,djj:1 tfu: cm,BB:62,Djj: cm,BB:65,djj:
djj:- 43 23cm,djj:143 143 140
7/12/18,
8/9/18 , 8/10/18, 28mgg,tfu:28
10/8/18, 16mgg,BB:50 20:mgg,BB:50 7/11/18 , cm,BB:65,djj:
12mgg,BB:45, kg,tfu kg,tfu:23cm,d 24mgg,BB:54 140x/m,presk
tfu:balt,djj:- balt,Djj:142 jj:143 kg,djj:135 eb
7/12/18,
8/9/18 , 8/10/18, 28mgg,tfu:28
10/8/18, 16mgg,BB:50 20:mgg,BB:50 7/11/18 , cm,BB:65,djj:
12mgg,BB:45, kg,tfu kg,tfu:23cm,d 24mgg,BB:54 140x/m,presk
tfu:balt,djj:- balt,Djj:142 jj:143 kg,djj:135 eb
7/12/18,
11/8/18 , 8/9/18 , 8/10/18,20m 7/11/18, 28mgg,bb:61
12mgg,BB:50 16mgg,BB:52 gg,bb:56kg,tf 24mgg,bb:59 kg,tfu:29cm,d
kg,tfu:balt,djj: kg,tfu:balt,djj: u:23cm,djj:14 kg,tfu:27cm,d jj:145x/m,pre
- 134 5 jj:142 skeb
7/12/18,
11/8/18 , 8/9/18 , 8/10/18,20m 7/11/18, 28mgg,bb:61
12mgg,BB:50 16mgg,BB:52 gg,bb:56kg,tf 24mgg,bb:59 kg,tfu:29cm,d
kg,tfu:balt,djj: kg,tfu:balt,djj: u:23cm,djj:14 kg,tfu:27cm,d jj:145x/m,pre
- 134 5 jj:142 skeb
5/11/18, 5/12/18,
5/9/18, 5/10/18, 20mgg,bb:58 24mgg,bb:53
12mgg,bb:49 16mgg,bb:52 kg,tfu:23cm,d kg,tfu:26cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:142x/m,pre jj:134x/m,pre
- 145 skeb skeb
5/11/18, 5/12/18,
5/9/18, 5/10/18, 20mgg,bb:58 24mgg,bb:53
- 145 skeb skeb
6/12/18,
6/10/18 , 6-11/18, 24mgg,bb:
6/9/19 ,12mg 16mgg,bb:56 20mgg,bb:60 63kg,tfu:27c
g,bb:50,tfu:ba kg,tfu:spst,djj: kg,tfu:23cm,d m,djj:143x/m
lt,djj:- 134 jj:145 mpreskeb
6/12/18,
6/10/18 , 6-11/18, 24mgg,bb:
6/9/19 ,12mg 16mgg,bb:56 20mgg,bb:60 63kg,tfu:27c
g,bb:50,tfu:ba kg,tfu:spst,djj: kg,tfu:23cm,d m,djj:143x/m
lt,djj:- 134 jj:145 mpreskeb
8-9-18, 8-10-18, 7-11-18, 7-12-18,

kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d kg,tfu:26cm,d
- 140 jj:140 jj:145
8-9-18, 8-10-18, 7-11-18, 7-12-18,
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d kg,tfu:26cm,d
- 140 jj:140 jj:145
8-11-18, 8-12-18,
10-9-18, 9-10-18, 20mgg,bb:60 24mgg,bb:63
- 143 skeb skeb
5-10-18, 5-11-18, 5-12-18,

- 143 jj:145
5-10-18, 5-11-18, 5-12-18,

- 143 jj:145
6-12-18,
6-10-18, 6-11-18, 20mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:145x/m,pre
- 130 skeb
6-12-18,
6-10-18, 6-11-18, 20mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:145x/m,pre
- 130 skeb
8-10-18, 7-11-18, 7-12-18,

- 145 jj:145
8-10-18, 7-11-18, 7-12-18,
- 145 jj:145
5-11-18,
12mgg,bb:50
kg,tfu:balt,djj:
- ABORTUS
5-11-18, 5-12-18,
- 134
6-11-18, 6-12-18,
- 134
6-11-18, 6-12-18,
- 134
7-11-18, 7-12-18,
- 145x/m
7-11-18, 7-12-18,
- 145x/m
7-11-18, 7-12-18,
- 145x/m
6-11-18, 8-12-18,
kg,tfu:balt,djj: kg,tfu:spst,sjj:
- 143
5-12-18,
12mgg,bb:55
kg,tfu:balt,djj:
=
5-12-18,
12mgg,bb:55
kg,tfu:balt,djj:
=
6-12-18,
12mgg,bb:50
kg,tfu:balt,djj:
-
6-12-18,
12mgg,bb:50
kg,tfu:balt,djj:
-
7-12-18,
12mgg,bb:54
kg,tfu:balt,djj:
-
7-12-18,
12mgg,bb:54
kg,tfu:balt,djj:
-
7-12-18,
12mgg,bb:54
kg,tfu:balt,djj:
-
7-12-18,
12mgg,bb:54
kg,tfu:balt,djj:
-
7-12-18,
12mgg,bb:54
kg,tfu:balt,djj:
-
Tahun:
Jan Feb Mar Apr Mei Jun Jul Ags Sep
37 38 39 40 41 42 43 44 45
05/1/19,32mgg,BB:
65,30cm,djj:134x/
m,preskeb
7/2/19,
05/1/19,32mgg,BB: 36mgg,bb:72kg,
69,30cm,djj:134x/ tfu:32cm,djj:138
m,preskeb x/m,preskeb
6-1-19,
32mgg,BB67,Tfu:29 8-2-19,
cm,djj:132x/m,pres 36mgg,BB:69cm,
keb tfu:32cm,djj:136
7/1/20 , 9/2/10 ,
32mgg,tfu:30cm,BB 36mgg,BB:72cm,
:69,djj:145x/m,pres tfu:31cm,djj:136
keb x/m,preskeb
7/1/20 , 9/2/19 ,
32mgg,tfu:30cm,BB 36mgg,BB:72cm,
:69,djj:145x/m,pres tfu:31cm,djj:136
keb x/m,preskeb
9/2/19,
7-1-19, 36mgg,BB:72cm,
32mgg,BB:66kg,tfu: tfu:31cm,djj:136
32cm,djj:145 x/m,preskeb
9/2/19,
7-1-19, 36mgg,BB:72cm,
32mgg,BB:66kg,tfu: tfu:31cm,djj:136
32cm,djj:145 x/m,preskeb
6/1/19, 5-2-19,
28mgg,bb:63kg,tfu: 32mgg,bb:65kg,
29cm,djj:145x/m,pr tfu:32cm,djj:150
eskeb x/m,preskeb
6/1/19,
28mgg,bb:63kg,tfu:
29cm,djj:145x/m,pr
eskeb
7-2-19, 8-3-19,
6/1/19, 32mgg,bb:80kg, 36mgg,bb:83
28mgg,bb:67kg,tfu: tfu: cm,tfu:33cm,
29cm,djj:134x/m,pr 32cm,djj:134x/ djj:145x/m,pr
eskeb m,preskeb eskeb
7-2-19, 8-3-19,
6/1/19, 32mgg,bb:80kg, 36mgg,bb:83
28mgg,bb:67kg,tfu: tfu: cm,tfu:33cm,
29cm,djj:134x/m,pr 32cm,djj:134x/ djj:145x/m,pr
eskeb m,preskeb eskeb
7-1-20, 8-3-20,
28mgg,bb:63kg,tfu: 8-2-20, 36mgg,bb:70,
28cm,djj:134x/m,pr 32mgg,bb:68kg, tfu:32cm,djj:1
eskeb tfu:30cm,djj:134 34
7-1-20, 8-3-20,
28mgg,bb:63kg,tfu: 8-2-20, 36mgg,bb:70,
28cm,djj:134x/m,pr 32mgg,bb:68kg, tfu:32cm,djj:1
eskeb tfu:30cm,djj:134 34
9-3-20,
8-1-20, 9-2-20, 36mgg,bb:70, 9-4-20,
28mgg,bb:65kg,tfu: 32mgg,bb:69kg, tfu:32cm,djj:1 40mgg,bb:70,tfu:
29cm,djj:140x.m,pr tfu:31cm,djj:145 34x/m,preske 34cm,djj:134x/m
eskeb x/m,preskeb b ,preskeb
5-3-19,
6-1-19, 5-2-19, 31mgg,bb:69 9-2-20,
24mgg,bb:63kg,tfu: 28mgg,bb:65kg, kg,tfu:31cm,d 32mgg,bb:69kg,
26cm,djj:134x/m,pr tfu:29cm,djj:140 jj:145x/m,pre tfu:31cm,djj:145
eskeb x/m,preskeb skeb x/m,preskeb
5-3-19,
6-1-19, 5-2-19, 31mgg,bb:69
24mgg,bb:63kg,tfu: 28mgg,bb:65kg, kg,tfu:31cm,d
26cm,djj:134x/m,pr tfu:29cm,djj:140 jj:145x/m,pre
eskeb x/m,preskeb skeb
7-1-19, 6-2-19, 6-3-19,

24mgg,bb:64kg,tfu: 28mgg,bb:67cm, 32mgg,bb:70
23cm,tfu:143x/m,p tfu:26cm,djj:145 kg,tfu:29cm,d
rreskeb x/m,preskeb jj:134
7-1-19, 6-2-19, 6-3-19,

24mgg,bb:64kg,tfu: 28mgg,bb:67cm, 32mgg,bb:70
23cm,tfu:143x/m,p tfu:26cm,djj:145 kg,tfu:29cm,d
rreskeb x/m,preskeb jj:134
8-3-19,
9-2-19, 32mgg,bb:76 8-4-19,
7-1-19, 28mgg,bb:74kg, kg,tfu:32,djj:1 36mgg,bb:79cm,
24mgg,bb:71kg,tfu: tfu:29cm,djj:140 34x/m,preske tfu:33cm,djj:134
24cm,djj:132 x/m,preskeb b x/m,preskeb
8-3-19,
9-2-19, 32mgg,bb:76 8-4-19,
7-1-19, 28mgg,bb:74kg, kg,tfu:32,djj:1 36mgg,bb:79cm,
24mgg,bb:71kg,tfu: tfu:29cm,djj:140 34x/m,preske tfu:33cm,djj:134
24cm,djj:132 x/m,preskeb b x/m,preskeb
6-3-19, 6-5-19,
5-1-19, 5-2-19, 28mgg,bb:69 5-4- 36mgg,bb:79
20mgg,bb:63kg,tfu: 24mgg,bb:67kg, kg,tfu:28kg,dj 19 ,32mgg,bb:67 cm,tfu:33cm,
22cm,djj:134x/m,pr tfu:26cm,djj:143 j:143x/m,pres 2kg,tfu:30cm,djj: djj:134x/m,pr
eskeb x/m,preskeb keb 143 eskeb
6-3-19, 7-5-19,
6-1-19, 7-2-19, 28mgg,bb:69 6-4- 36mgg,bb:79
6-3-19, 7-5-19,
6-1-19, 7-2-19, 28mgg,bb:69 6-4- 36mgg,bb:79
8-5-19, 8-6-19,
7-1-19, 8-2-19, 8-3-19, 8-4-19, 36mgg,bb:79 40mgg,bb:79
20mgg,bb:58kg,tfu: 24mgg,bb:59cm, 28mgg,bb:61 32mgg,bb:64kg, cm,tfu:33cm, cm,tfu:34cm,
23cm,djj:145x/m,pr tfu:26cm,djj:145 kg,tfu:29cm,d tfu:32cm,djj:145 djj:134x/m,pr djj:134x/m,pr
eskeb x/m,preskeb jj:145 x/m,preskeb eskeb eskeb
8-5-19,
7-1-19, 8-2-19, 8-3-19, 8-4-19, 36mgg,bb:79
20mgg,bb:58kg,tfu: 24mgg,bb:59cm, 28mgg,bb:61 32mgg,bb:64kg, cm,tfu:33cm,
23cm,djj:145x/m,pr tfu:26cm,djj:145 kg,tfu:29cm,d tfu:32cm,djj:145 djj:134x/m,pr
eskeb x/m,preskeb jj:145 x/m,preskeb eskeb
7-1-19, 8-2-19, 8-3-19, 8-4-19,
20mgg,bb:58kg,tfu: 24mgg,bb:59cm, 28mgg,bb:61 32mgg,bb:64kg,
23cm,djj:145x/m,pr tfu:26cm,djj:145 kg,tfu:29cm,d tfu:32cm,djj:145
eskeb x/m,preskeb jj:145 x/m,preskeb
9-3-19,
9-2-19, 28mgg,bb:65 9-4-
8-1-19, 24mgg,bb:63kg, kg,tfu:28kg,dj 19,32mgg,bb:67k
20mgg,bb:59kg,tfu: tfu:26cm,djj:143 j:134x/m,pres g,tfu:30cm,djj:13
23cm,djj:136 x/m,preskeb keb 4x/m,preskeb
5-3-19, 6-5-
6-2-19, 24mgg,bb:65 5-4-19, 19 ,32mgg,bb
5-1-19, 20mgg,bb:62kg, kg,tfu:26cm,d 28mgg,bb:68kg, :69kg,tfu:30c
16mgg,bb:57kg,tfu: tfu:23cm,djj:136 jj:143x/m,pre tfu:28kg,djj:134x m,djj:134x/m,
spst,sjj:143 x/m,preskeb skeb /m,preskeb preskeb
5-3-19, 6-5-
6-2-19, 24mgg,bb:65 5-4-19, 19 ,32mgg,bb
5-1-19, 20mgg,bb:62kg, kg,tfu:26cm,d 28mgg,bb:68kg, :69kg,tfu:30c
16mgg,bb:57kg,tfu: tfu:23cm,djj:136 jj:143x/m,pre tfu:28kg,djj:134x m,djj:134x/m,
spst,sjj:143 x/m,preskeb skeb /m,preskeb preskeb
6-3-19, 6-5-19, 7-6-19,

6-1-19, 7-2-19, 24mgg,bb:62 6-4-19, 32mgg,bb:69 36mgg,bb:79
16mgg,bb:54kg,tfu: 20mgg,bb:56kg, kg,tfu: 28mgg,bb:65kg, kg,tfu:30cm,d cm,tfu:33cm,
spst,djj:134x/m,pre tfu:23cm,djj:134 26cm,djj:134x tfu:28cm,djj:134 jj:143x/m,pre djj:134x/m,pr
skeb x/m,preskeb /m,preskeb x/m,presken skeb eskeb
6-3-19, 6-5-19, 7-6-19,

6-1-19, 7-2-19, 24mgg,bb:62 6-4-19, 32mgg,bb:69 36mgg,bb:79
16mgg,bb:54kg,tfu: 20mgg,bb:56kg, kg,tfu: 28mgg,bb:65kg, kg,tfu:30cm,d cm,tfu:33cm,
spst,djj:134x/m,pre tfu:23cm,djj:134 26cm,djj:134x tfu:28cm,djj:134 jj:143x/m,pre djj:134x/m,pr
skeb x/m,preskeb /m,preskeb x/m,presken skeb eskeb
8-3-19, 8-5-19, 8-6-19,

7-1-19, 8-2-19, 24mgg,bb:60 8-4- 32mgg,bb:65 36mgg,bb:79
16mgg,bb:57kg,tfu: 20mgg,bb:58kg, kg,tfu:26cm,d 19 ,28mgg,bb:63 kg,tfu:31cm,d cm,tfu:33cm,
spst,djj:134x/m,pre tfu:23cm,djj:134 jj:140x/m,pre kg,tfu:29cm,djj:1 jj:145x/m,pre djj:134x/m,pr
skeb x/m,preskeb skeb 34x/m,preskeb skeb eskeb
8-3-19, 8-5-19, 8-6-19,
8-3-19, 8-5-19, 8-6-19,

8-3-19, 8-5-19, 8-6-19,

9-2-19, 8-4-19, 8-5-19,

7-1-19, 24mgg,bb:57 9-3-19, 32mgg,bb:64 36mgg,bb:79
712-18, 20mgg,bb:53kg, kg,tfu:25cm,d 28mgg,bb:60kg, kg,tfu:30cm,d cm,tfu:33cm,
16mgg,bb:50kg,tfu: tfu:23cm,djj:140 jj:135x/m,pre tfu:27cm,djj:134 jj:134x,preske djj:134x/m,pr
spst,djj:134 x/m,preskeb skeb x,preskeb b eskeb
Lahir Berat Bayi Lahir Cara KF*
Hidup/Ma Persalinan
Okt Nop Des ti <2500gr >2500gr
Tempat Penolong
KF1
46 47 48 49 50 51 52 53 54 55
HIDUP 2900 NORMAL PONED BPM 6/2/2019
HIDUP 3200 NORMAL PONED BIDAN 19/3/2019

HIDUP 2700 SC RS HARMUL DOKTER 9/2/109
RSU
HIDUP 2600 NORMAL BALARAJA DOKTER 19/3/2019
RS
HIDUP 2600 NORMAL HARMUL DOKTER 9/4/2019

HIDUP 3300 SC RS HARMUL DOKTER 4/5/2019
HIDUP 3400 NORMAL BPM BIDAN 3/5/2019
HIDUP 2300 2600 SC RS HARMUL DOKTER 15/4/19

ABORTUS

HIDUP 3200 NORAML PONED BIDAN 15/7/2019


Lampiran KIA-4
KF*
Pelayanan Tata Keteranga
KF2 KF3 KBPP Laksana n
56 57 59 60 61
12/2/2019 28/9/19 SUNTIK
28/3/2019 18/9/19 SUNTIK
24/3/2019 21/9/19 SUNTIK
3/3/2019 18/9/19 SUNTIK
22/03/109 24/9/19 SUNTIK

18/2/109 27/8/19 SUNTIK
22/3/109 18/9/19 SUNTIK
28/3/2019 18/9/19 SUNTIK
17/4/2019 1/10/2019 SUNTIK
28/3/2019 9/10/2019 PIL
"10/10/20
25/4/2019 19 SUNTIK
"10/10/20
10/4/2019 19 PIL
"12/10/20
9/4/2019 19 SUNTIK
22/5/2019 ### SUNTIK
11/5/2019 ### SUNTIK
18/5/2019 ### SUNTIK
10/4/2019 20/11/19 SUNTIK
23/4/2019 1/11/2019 SUNTIK
30/4/2019 23/11/19 SUNTIK

19/5/2019 ### SUNTIK
28/6/2019 1/11/2019 SUNTIK
11/6/2019 20/10/19 SUNTIK
13/6/2019 PIL
15/7/2019 16/11/19 SUNTIK
24/6/2019
24/5/2019 24/11/19 SUNTIK
23/6/2019 18/12/19 SUNTIK
19/11/19 ### SUNTIK
23/6/2019 27/12/19 SUNTIK
27/7/2019
23/7/2019 27/1/19 SUNTIK
7/1/2020 27/1/19
23/7/2019
23/7/1019
18/7/2019 20/1/20 SUNTIK
19/7/19 19/1/20 SUNTIK

Alamat : MEKARSARI
Telepon :
No Urut NAMA IBU NIK IBU ALAMAT SUMBER USIA IBU STATUS JARAK TAFSIRAN TB (CM)
DESA/KELU PEMBIYAY GPA KEHAMILA PERSALINA
RAHAN AAN N N
0 1 2 3 4 5 6 7 8 9
1
FLAMBOYA
anita/ali N1 KIS 17 1 - 150
2
nuraida/ FLAMBOYA
viki N1 KIS 27 2 4 TAHUN 154
3
mia/ FLAMBOYA
david N2 KIS 24 2 4 TAHUN 160
4
FLAMBOYA
dede/rian N2 KIS 21 2 6 TAHUN 154
5
esih/ FLAMBOYA JAMPERSA

hamdan N3 L 25 2 4 TAHUN 155
6
st.saliah/ FLAMBOYA
ria N3 KIS 27 2 9 TAHUN 150
7
FLABOYAN JAMPERSA
dwi/noko 3 L 22 2 5 TAHUN 155
8
rini/ FLAMBOYA
mansyur N4 KIS 24 2 6 TAHUN 160
9
fitri/ FLAMBOYA
suhendri N1 KIS 28 2 5 TAHUN 165
10
FLAMBOYA
susi/isan N1 KIS 20 1 - 155
11
wawat/ FLAMBOYA
toni N2 KIS 37 9 5 TAHUN 150
12
karsih/ FLAMBOYA
hodes N2 KIS 33 4 3 TAHUN 160
13
sutinah/ FLAMBOYA
kosim N3 KIS 33 5 4 TAHUN 149
14
maya/ FLAMBOYA
ahmad N3 KIS 38 4 4 TAHUN 145
15
rica
elyawati/
nuralams FLAMBOYA
yah N4 KIS 34 2 6 TAHUN 160
16
munaroh/ FLAMBOYA
muamar N4 KIS 27 2 4 TAHUN 150
17
sinta/ FLAMBOYA JAMPERSA

wawan N1 L 24 2 7 TAHUN 148
18
st/
hindun/ FLAMBOYA
daeropin N2 KIS 24 2 5 TAHUN 150
19
may
julianti/a FLAMBOYA JAMPERSA
rtoyo N3 L 28 1 - 155
20
sunarti/ FLAMBOYA
mulyadi N3 KIS 33 7 7 TAHUN 157
21
yamah/ FLAMBOYA
cecep N3 KIS 36 2 5 TAHUN 160
22
asnawati/ FLAMBOYA
bambang N4 KIS 26 2 7 TAHUN 150
23
eva/ A FLAMBOYA
gozali N1 KIS 27 1 - 153
24
rinata/ FLAMBOYA
sartoyo N1 KIS 21 1 - 144
25
nursih/ FLAMBOYA
marhedin N2 KIS 30 2 5 TAHUN 153
26
ratih/ FLAMBOYA
maman N2 KIS 37 5 6 TAHUN 160
27
wiwin/ FLAMBOYA JAMPERSA

fitra N3 L 29 2 5 TAHUN 150
28
lulu/ FLAMBOYA
ilham N3 KIS 28 1 - 155
29
maya/ FLAMBOYA
sopa N3 KIS 26 2 5 TAHUN 157
30
indah/ FLAMBOYA
rohim N4 UMUM 26 2 5 TAHUN 150
31
sopiah/
nurdians FLAMBOYA
yah N1 KIS 20 1 - 150
32
senah/h/ FLAMBOYA
ilun N1 KIS 43 5 5 TAHUN 160
33
enjah/ FLAMBOYA
wawan N2 KIS 20 1 - 156
34
narti
dinata/m FLAMBOYA
aman N2 KIS 25 1 - 158
35
st/.rohim
ah/ FLAMBOYA
sutisna N3 KIS 20 1 - 149
36
FLAMBOYA
mia/aziz N3 UMUM 19 1 - 150
37
enih/ FLAMBOYA JAMPERSA

A.rozak N4 L 32 3 5 TAHUN 150
37
esih/ FLAMBOYA
hamdan N1 KIS 38 3 5 TAHUN 150
38
susilawat FLAMBOYA
i/heru N1 KIS 24 2 4 TAHUN 154
39
yusrona/ FLAMBOYA
fadli N2 KIS 24 2 1 TAHUN 160
40
nurwiyah
/ FLAMBOYA
aminudin N2 KIS 27 2 6 TAHUN 154
41
st
romaniah
/aminudi FLAMBOYA JAMPERSA
n N3 L 30 2 4 TAHUN 155
42
nurjanah/ FLAMBOYA
heris N3 KIS 28 3 9 TAHUN 150
43
dewi/ FLABOYAN JAMPERSA

artoyo 4 L 30 2 5 TAHUN 155
44
FLAMBOYA
asih/heru N1 KIS 28 5 6 TAHUN 160
45
kartini/ FLAMBOYA
wawi N1 KIS 17 3 5 TAHUN 165
46
siti
saidah/nu FLAMBOYA
rrohman N2 KIS 25 1 - 155
47
sukanah/ FLAMBOYA
parman N3 KIS 18 2 5 TAHUN 150
48
nurastuti/ FLAMBOYA
a.fauzi N3 KIS 20 1 - 160
49
ridia/ FLAMBOYA
suhendra N3 KIS 24 1 - 149
50
esih
salsabila FLAMBOYA
h/heru N1 KIS 20 2 4 TAHUN 145
51
widianin
gsih/h FLAMBOYA
sanudin N1 KIS 36 1 - 160
52
irma/ FLAMBOYA
tajudin N2 KIS 24 5 4 TAHUN 150
53
esih/ FLAMBOYA JAMPERSA

tatang N2 L 34 1 - 148
54
della/ FLAMBOYA
pepeng N3 KIS 24 1 - 150
55
eneng/
abdul FLAMBOYA JAMPERSA
rohim N3 L 18 2 5 TAHUN 155
56
bedah/ FLAMBOYA
basir N3 KIS 34 1 - 157
57
marlinah/ FLAMBOYA
suhendra N4 KIS 20 6 5 TAHUN 160
58
erin
karlina/s
amsul FLAMBOYA
hidayat N1 KIS 26 1 - 150
59
nuri/
nurmudi FLAMBOYA
n N1 KIS 20 1 - 153
60
liah/ FLAMBOYA
karna N2 KIS 27 1 - 144
61
nurhayati/
M.nazmudi FLAMBOYA
n N2 KIS 20 2 5 TAHUN 153
62
asmiati/ FLAMBOYA JAMPERSA

uji N3 L 34 1 - 160
63
ifah/ FLAMBOYA JAMPERSA

hendrik N3 L 21 3 5 TAHUN 150
64
annisa/ FLAMBOYA
agus N3 KIS 19 1 - 155
65
naris/ FLAMBOYA
madrosid N1 KIS 35 1 - 157
66
sari
lestari/ru FLAMBOYA
stam N1 UMUM 23 3 5 TAHUN 150
67
FLAMBOYA
tia/adit N2 KIS 26 1 - 150
68
elis
lisnawati
/ajat FLAMBOYA
sudrajat N2 KIS 32 2 5 TAHUN 160
69
ismawati FLAMBOYA
/hendra N3 KIS 32 2 6 TAHUN 156
70
mia
awalia/ri FLAMBOYA
an N3 KIS 21 4 6 TAHUN 158
71
nurhayati
/
M.najmu FLAMBOYA
din N3 KIS 34 1 - 149
72
st.sulistia
wati/ FLAMBOYA
aditya N1 UMUM 26 1 - 150
73
rohani/ FLAMBOYA JAMPERSA

iwan N1 L 20 1 - 150
74
FLAMBOYA
tuti/jumi N2 UMUM 23 1 - 153
75
nuraisya
h/haidir FLAMBOYA
ali N2 KIS 27 1 - 158
76
titin/ FLAMBOYA
hendi N3 KIS 41 3 5 TAHUN 159
77
st.hotima FLAMBOYA
h/ahmad N3 UMUM 25 2 6 TAHUN 157
78
sarimana
h/ FLAMBOYA
abdullah N4 KIS 35 1 - 150
79
kartini/
umar FLAMBOYA
sidik N1 KIS 32 2 7 TAHUN 150
80
St.nurjan FLAMBOYA
ah/anto N1 KIS 33 6 3 TAHUN 150
81
rena FLAMBOYA
S/sutisna N2 UMUM 32 1 - 150
82
FLAMBOYA
tiah/eni N2 UMUM 35 4 3 TAHUN 158
83
dian/ FLAMBOYA
maulana N3 KIS 20 1 - 160
84
nanih/sumadi
FLAMBOYA
N3 KIS 30 3 5 TAHUN 160
85
rusminah FLAMBOYA
/bandi N4 KIS 25 4 6 TAHUN 158
86
nurhalimah/ FLAMBOYA
A.jalaludin N1 KIS 28 3 6 TAHUN 155
87
sumyati/ FLAMBOYA
sapturi N1 KIS 34 2 7 TAHUN 150
88
sainah/ FLAMBOYA
amir N2 UMUM 29 5 5 TAHUN 155
89
St.nurul
amalia/M
.abdul FLAMBOYA
aziz N2 UMUM 24 3 5 TAHUN 150
90
Devilas/ FLAMBOYA
cecep N3 KIS 18 1 - 154
91
neneng/ FLAMBOYA
rozak N3 UMUM 25 1 - 160
92
sainah/ FLAMBOYA
amir N4 UMUM 2831 2 5 TAHUN 154
93
nurhasan
h/ FLAMBOYA
sumarni N1 KIS 25 3 5 TAHUN 155
94
mardiana
/ FLAMBOYA
nasrullah N1 UMUM 33 2 5 TAHUN 150
95
neneng/
egi FLAMBOYA
sterian N2 KIS 22 3 6 TAHUN 155
96
St.hodija
h/agus FLAMBOYA
sopiah N2 KIS 24 1 - 160
97
st.salbiah FLAMBOYA
/sahrudin N3 KIS 28 2 6 TAHUN 165
98
kasuma/
ahmad FLAMBOYA
eli N2 KIS 20 3 5 TAHUN 155
99
samsiah/ FLAMBOYA
asjaya N2 KIS 20 2 3 TAHUN 150
100
selawati/ FLAMBOYA
yuhaedi N2 KIS 25 2 5 TAHUN 160
101
salmah/
ato FLAMBOYA
sunarto N2 KIS 27 3 5 TAHUN 149
102
nunung/ FLAMBOYA
A.aziz N2 UMUM 32 3 5 TAHUN 145
103
astrifah/ FLAMBOYA
irwan N3 KIS 18 1 - 160
104
serina/ FLAMBOYA
endang N3 KIS 26 1 - 150
105
St.amina FLAMBOYA
h/anggi N1 KIS 22 1 - 148
106
suheni/ FLAMBOYA
cecep N1 KIS 35 4 6 TAHUN 150
107
rasiah/
atok FLAMBOYA
parha N2 KIS 48 6 2 TAHUN 155
108
erah/ FLAMBOYA
selamet N2 UMUM 31 3 6 TAHUN 157
109
nurlaelah FLAMBOYA
/yayat N1 KIS 24 2 5 TAHUN 160
110
nurhayati FLAMBOYA
/rudi N1 KIS 36 3 7 TAHUN 150
111
milah/ FLAMBOYA
samsudin N3 KIS 17 1 - 153
112
junah/ FLAMBOYA
saripudin N3 KIS 33 3 5 TAHUN 144
113
radesi/ FLAMBOYA
cecep N1 KIS 20 1 - 153
114
FLAMBOYA
linah/aris N1 KIS 24 2 7 TAHUN 160
115
gita/ FLAMBOYA
wawan N2 KIS 20 1 - 150
116
anita/ FLAMBOYA
hendri N2 KIS 24 1 - 155
117
melia
ulfa/ade FLAMBOYA
heryadi N3 KIS 20 3 4 TAHUN 157
118
FLAMBOYA
eka/sandi N3 UMUM 21 1 - 150
119
winda/ FLAMBOYA
arya N3 UMUM 30 1 - 150
120
aqila/ FLAMBOYA
mistar N4 UMUM 20 1 - 160
LILA (CM) Skrining Imunisasi Td SCRINING Laboratorium

Status Injeksi Td TBC Hb (gr/dl) GOLDAR PROTEIN GLUKOSA HIV (-/+) SIFILIS (-/+)
Imunisasi URIN (-/+) UR (-/+)
Td
10 11 12 13 14 15 16 17 18 19
24 TT2 √ x 11.2 AB NEGATIF NEGATIF NEGATIF NEGATIF
25 TT2 √ x 12.5 O NEGATIF NEGATIF NEGATIF NEGATIF
25 TT2 √ x 11 AB NEGATIF NEGATIF NEGATIF NEGATIF
26 TT2 √ x 10.9 A NEGATIF NEGATIF NEGATIF NEGATIF

26 TT2 √ x 13 O NEGATIF NEGATIF NEGATIF NEGATIF
26 TT2 √ x 11.2 B NEGATIF NEGATIF NEGATIF NEGATIF

20 TT2 √ x 13 A NEGATIF NEGATIF NEGATIF NEGATIF

25 TT2 √ x 13 0 NEGATIF NEGATIF NEGATIF NEGATIF

27 TT2 √ x 11 AB NEGATIF NEGATIF NEGATIF NEGATIF

24 TT2 6/2/2019 x 11.2 AB NEGATIF NEGATIF NEGATIF NEGATIF
25 TT2 6/2/2019 x 12.5 O NEGATIF NEGATIF NEGATIF NEGATIF
25 TT2 7/2/2019 x 11 AB NEGATIF NEGATIF NEGATIF NEGATIF
26 TT2 8/2/2019 x 10.9 A NEGATIF NEGATIF NEGATIF NEGATIF

26 TT2 5/4/2019 x 13 O NEGATIF NEGATIF NEGATIF NEGATIF
26 TT2 8/4/2019 x 11.2 B NEGATIF NEGATIF NEGATIF NEGATIF

26 TT2 7/5/2019 x 13 A NEGATIF NEGATIF NEGATIF NEGATIF

25 TT2 7/6/2019 x 13 0 NEGATIF NEGATIF NEGATIF NEGATIF


21.5 TT2 7/8/2019 x 12.3 A NEGATIF NEGATIF NEGATIF NEGATIF



26 TT2 ### x 11.4 O NEGATIF NEGATIF NEGATIF NEGATIF
24 TT2 7/12/2019 x 13 A NEGATIF NEGATIF NEGATIF NEGATIF

26 TT2 ### x 12.5 B NEGATIF NEGATIF NEGATIF NEGATIF
27 TT2 ### x 12.7 B NEGATIF NEGATIF NEGATIF NEGATIF
24 TT2 6/1/2020 x 13 B NEGATIF NEGATIF NEGATIF NEGATIF

Bidan :
Bulan :
atorium KONSELIN TATALAKS Ta

HBSAG MALARIA(- TBC (-/+) LAIN LAIN G* ANA Jan Feb Mar Apr
(-/+) /+) KASUS ***
20 21 22 23 24 25 26 27 28
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
POSITIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
6-1-
19,16mgg,BB: 5-4-
5/1/2019/12 57 kg,tfu:2jr d 5-3-19,20 19,24mgg,BB:
mgg,BB: 54 bwah pstdjj: mgg,BB:59tfu 61tfu:23cm,dj
NEGATIF X X √ √ kg,djj:- 143 :18 cm djj:132 j:14x
6-1-29,16
mgg,BB: 57 5-4-
5/1/2019/12 kg,tfu:2jr d 5-3-19,20 19,24mgg,BB:
mgg,BB: 54 bwah pstdjj: mgg,BB:60tfu 64,tfu:23cm,d
NEGATIF X X √ √ kg,djj:- 143 :18 cm djj:132 jj:14x
7-2/19, 6-3-19, 6-4-19,

7-01-19, 16mgg,tfu:18 20mgg,BB:59, 24mgg,tfu:26
12mgg,BB:50, cm,BB54,djj:1 tfu: cm,BB:62,Djj:
NEGATIF X X √ √ djj:- 43 23cm,djj:143 143
7-2-19, 6-3-19,
7-1-19, 16mgg,BB:50 20:mgg,BB:50 6-4-19,
12mgg,BB:45, kg,tfu kg,tfu:23cm,d 24mgg,BB:54
NEGATIF X X √ √ tfu:balt,djj:- balt,Djj:142 jj:143 kg,djj:135
8-1-19, 8-3-19, 8-4-19,24

12mgg,BB:50 8-2-19, 20mgg,bb:59 mgg,BB: 57
kg,tfu:balt,djj: bb:54kg,tfu k,ftu:18cm,djj kg,tfu:
NEGATIF X X √ √ - balt,djj:142 :145 23djj:134
8-1-19, 8-2-19, 8-3- 8-4-19,

12mgg,BB:50 16mgg,BB:52 19,20mgg,bb: 24mgg,bb:59
kg,tfu:balt,djj: kg,tfu:balt,djj: 56kg,tfu:23c kg,tfu:27cm,d
NEGATIF X X √ √ - 134 m,djj:145 jj:142
9-1-19, 9-2-19, 9-3-
12mgg,bb:54 16mgg,bb:59 19,20mgg,bb: 9-4-19,24mgg
kg,tfu:balt,djj: kg,tfu:spst,djj: 61kg,tfu:23c bb:67kg,tfu:2
NEGATIF X X √ √ 134 145 m,djj:145 6cm,djj:145
6-2-19, 5-3-19, 5-4-19,

NEGATIF X X √ √ - 145 jj:142
6-2-19 , 5-3-19, 5-4-19,

NEGATIF X X √ √ - 145 jj:142
7-2- 6-3-19, 6-4-19,

19,12mgg,bb: 16mgg,bb:56 20mgg,bb:60
50,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d
NEGATIF X X √ √ - 134 jj:145
7-2-19, 6-3-19, 6-4-19,

NEGATIF X X √ √ - 134 jj:134
8-2-19, 8-3-19, 8-4-19,

kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d
NEGATIF X X √ √ - 140 jj:140
8-2-19, 8-3-19, 8-4-19,

kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d
NEGATIF X X √ √ - 140 jj:140
5-3-19, 5-4-19,
NEGATIF X X √ √ - 143
5-3-19, 5-4-19,
6-3-19, 6-4-19,
6-3-19, 6-4-19,
8-3-19, 8-4-19,
8-3-19, 8-4-19,
9-3-19, 9-4-19,
5-4-19,
12mgg,bb:50
kg,tfu:balt,djj:
NEGATIF X X √ √ -
5-4-19,
12mgg,bb:56
kg,tfu:balt,djj:
6-4-19,
12mgg,bb:46
kg,tfu:balt,djj:
6-4-19,
12mgg,bb:46
kg,tfu:balt,djj:
8-4-19,
12mgg,bb:50
kg,tfu:balt,djj:
8-4-19,
12mgg,bb:50
kg,tfu:balt,djj:
8-4-19,
12mgg,bb:50
kg,tfu:balt,djj:
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
POSITIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
NEGATIF X X √ √
Tahun:2019
Mei Jun Jul Ags Sep Okt Nop Des Jan Feb
29 30 31 32 33 34 35 36 37 38
5/9/18 ,16mg x/
g,BB: 57 5/11/18,24m m,preskeb6/1 05/1/19,32mgg,
5/1/2018 12 kg,tfu:2jr d 6/10/18, 20 gg,BB:61tfu:2 2/18,28mgg,B BB:65,30cm,djj:
mgg,BB: 54 bwah pstdjj: mgg,BB:59tfu 3cm,djj:142x/ B65,tfu:26cm,
kg,djj:- 143 :18 cm djj:132 m,preskeb djj:135 134x/m,preskeb
5/9/18,16
mgg,BB: 57 5/11/18,24m 6/12/18,28m 7/2/19,
5/1/2018 12 kg,tfu:2jr d 6/10/18,20 gg,BB:64,tfu:2 gg,BB:68,tfu:2 05/1/19,32mgg, 36mgg,bb:72kg,tf
mgg,BB: 54 bwah pstdjj: mgg,BB:60tfu 3cm,djj:142x/ 6cm,djj:135x/ BB:69,30cm,djj: u:32cm,djj:138x/
kg,djj:- 143 :18 cm djj:132 m,preskeb m,preskeb 134x/m,preskeb m,preskeb
6/9/18, 6/10/18 , 6/11/18 , 6/12/18 , 6-1-19,

9/8/18, 16mgg,tfu:18 20mgg,BB:59, 24mgg,tfu:26 28mgg,tfu:29 32mgg,BB67,Tfu 8-2-19,
12mgg,BB:50, cm,BB54,djj:1 tfu: cm,BB:62,Djj: cm,BB:65,djj: :29cm,djj:132x/ 36mgg,BB:69cm,
djj:- 43 23cm,djj:143 143 140 m,preskeb tfu:32cm,djj:136
7/12/18,
8/9/18 , 8/10/18, 28mgg,tfu:28 7/1/20 , 9/2/10 ,
10/8/18, 16mgg,BB:50 20:mgg,BB:50 7/11/18 , cm,BB:65,djj: 32mgg,tfu:30cm 36mgg,BB:72cm,
12mgg,BB:45, kg,tfu kg,tfu:23cm,d 24mgg,BB:54 140x/m,presk ,BB:69,djj:145x/ tfu:31cm,djj:136x
tfu:balt,djj:- balt,Djj:142 jj:143 kg,djj:135 eb m,preskeb /m,preskeb
7/12/18,
8/9/18 , 8/10/18, 28mgg,tfu:28 7/1/20 , 9/2/19 ,
10/8/18, 16mgg,BB:50 20:mgg,BB:50 7/11/18 , cm,BB:65,djj: 32mgg,tfu:30cm 36mgg,BB:72cm,
12mgg,BB:45, kg,tfu kg,tfu:23cm,d 24mgg,BB:54 140x/m,presk ,BB:69,djj:145x/ tfu:31cm,djj:136x
tfu:balt,djj:- balt,Djj:142 jj:143 kg,djj:135 eb m,preskeb /m,preskeb
7/12/18,
11/8/18 , 8/9/18 , 8/10/18,20m 7/11/18, 28mgg,bb:61 9/2/19,
12mgg,BB:50 16mgg,BB:52 gg,bb:56kg,tf 24mgg,bb:59 kg,tfu:29cm,d 7-1-19, 36mgg,BB:72cm,
kg,tfu:balt,djj: kg,tfu:balt,djj: u:23cm,djj:14 kg,tfu:27cm,d jj:145x/m,pre 32mgg,BB:66kg, tfu:31cm,djj:136x
- 134 5 jj:142 skeb tfu:32cm,djj:145 /m,preskeb
7/12/18,
11/8/18 , 8/9/18 , 8/10/18,20m 7/11/18, 28mgg,bb:61 9/2/19,
12mgg,BB:50 16mgg,BB:52 gg,bb:56kg,tf 24mgg,bb:59 kg,tfu:29cm,d 7-1-19, 36mgg,BB:72cm,
kg,tfu:balt,djj: kg,tfu:balt,djj: u:23cm,djj:14 kg,tfu:27cm,d jj:145x/m,pre 32mgg,BB:66kg, tfu:31cm,djj:136x
- 134 5 jj:142 skeb tfu:32cm,djj:145 /m,preskeb
5/11/18, 5/12/18,
5/9/18, 5/10/18, 20mgg,bb:58 24mgg,bb:53 6/1/19, 5-2-19,
12mgg,bb:49 16mgg,bb:52 kg,tfu:23cm,d kg,tfu:26cm,d 28mgg,bb:63kg, 32mgg,bb:65kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:142x/m,pre jj:134x/m,pre tfu:29cm,djj:145 u:32cm,djj:150x/
- 145 skeb skeb x/m,preskeb m,preskeb
5/11/18, 5/12/18,
5/9/18, 5/10/18, 20mgg,bb:58 24mgg,bb:53 6/1/19,
12mgg,bb:49 16mgg,bb:52 kg,tfu:23cm,d kg,tfu:26cm,d 28mgg,bb:63kg,
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:142x/m,pre jj:134x/m,pre tfu:29cm,djj:145
- 145 skeb skeb x/m,preskeb
6/12/18, 7-2-19,
6/10/18 , 6-11/18, 24mgg,bb: 6/1/19, 32mgg,bb:80kg,tf
6/9/19 ,12mg 16mgg,bb:56 20mgg,bb:60 63kg,tfu:27c 28mgg,bb:67kg, u:
g,bb:50,tfu:ba kg,tfu:spst,djj: kg,tfu:23cm,d m,djj:143x/m tfu:29cm,djj:134 32cm,djj:134x/m,
lt,djj:- 134 jj:145 mpreskeb x/m,preskeb preskeb
6/12/18, 7-2-19,
6/10/18 , 6-11/18, 24mgg,bb: 6/1/19, 32mgg,bb:80kg,tf
6/9/19 ,12mg 16mgg,bb:56 20mgg,bb:60 63kg,tfu:27c 28mgg,bb:67kg, u:
g,bb:50,tfu:ba kg,tfu:spst,djj: kg,tfu:23cm,d m,djj:143x/m tfu:29cm,djj:134 32cm,djj:134x/m,
lt,djj:- 134 jj:145 mpreskeb x/m,preskeb preskeb
8-9-18, 8-10-18, 7-11-18, 7-12-18, 7-1-20,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:56 24mgg,bb:59 28mgg,bb:63kg, 8-2-20,
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d kg,tfu:26cm,d tfu:28cm,djj:134 32mgg,bb:68kg,tf
- 140 jj:140 jj:145 x/m,preskeb u:30cm,djj:134
8-9-18, 8-10-18, 7-11-18, 7-12-18, 7-1-20,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:56 24mgg,bb:59 28mgg,bb:63kg, 8-2-20,
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:20cm,d kg,tfu:26cm,d tfu:28cm,djj:134 32mgg,bb:68kg,tf
- 140 jj:140 jj:145 x/m,preskeb u:30cm,djj:134
8-11-18, 8-12-18,
10-9-18, 9-10-18, 20mgg,bb:60 24mgg,bb:63 8-1-20, 9-2-20,
12mgg,bb:54 16mgg,bb:58 kg,tfu:19cm,d kg,tfu:26cm,d 28mgg,bb:65kg, 32mgg,bb:69kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:145x/m,pre jj:134x/m,pre tfu:29cm,djj:140 u:31cm,djj:145x/
- 143 skeb skeb x.m,preskeb m,preskeb
5-10-18, 5-11-18, 5-12-18, 6-1-19, 5-2-19,

12mgg,bb:54 16mgg,bb:58 20mgg,bb:60 24mgg,bb:63kg, 28mgg,bb:65kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:19cm,d tfu:26cm,djj:134 u:29cm,djj:140x/
- 143 jj:145 x/m,preskeb m,preskeb
5-10-18, 5-11-18, 5-12-18, 6-1-19, 5-2-19,

12mgg,bb:54 16mgg,bb:58 20mgg,bb:60 24mgg,bb:63kg, 28mgg,bb:65kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:19cm,d tfu:26cm,djj:134 u:29cm,djj:140x/
- 143 jj:145 x/m,preskeb m,preskeb
6-12-18,
6-10-18, 6-11-18, 20mgg,bb:65 7-1-19, 6-2-19,
12mgg,bb:57 16mgg,bb:63 kg,tfu:23cm,d 24mgg,bb:64kg, 28mgg,bb:67cm,
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:145x/m,pre tfu:23cm,tfu:143 tfu:26cm,djj:145x
- 130 skeb x/m,prreskeb /m,preskeb
6-12-18,
6-10-18, 6-11-18, 20mgg,bb:65 7-1-19, 6-2-19,
12mgg,bb:57 16mgg,bb:63 kg,tfu:23cm,d 24mgg,bb:64kg, 28mgg,bb:67cm,
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:145x/m,pre tfu:23cm,tfu:143 tfu:26cm,djj:145x
- 130 skeb x/m,prreskeb /m,preskeb
8-10-18, 7-11-18, 7-12-18, 9-2-19,

12mgg,bb:59 16mgg,bb:64 20mgg,bb:69 7-1-19, 28mgg,bb:74kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:21cm,d 24mgg,bb:71kg, u:29cm,djj:140x/
- 145 jj:145 tfu:24cm,djj:132 m,preskeb
8-10-18, 7-11-18, 7-12-18, 9-2-19,

12mgg,bb:59 16mgg,bb:64 20mgg,bb:69 7-1-19, 28mgg,bb:74kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:21cm,d 24mgg,bb:71kg, u:29cm,djj:140x/
- 145 jj:145 tfu:24cm,djj:132 m,preskeb
5-11-18,
12mgg,bb:50
kg,tfu:balt,djj:
- ABORTUS
5-11-18, 5-12-18, 5-1-19, 5-2-19,
12mgg,bb:56 16mgg,bb:59 20mgg,bb:63kg, 24mgg,bb:67kg,tf
kg,tfu:balt,djj: kg,tfu:spst,djj: tfu:22cm,djj:134 u:26cm,djj:143x/
- 134 x/m,preskeb m,preskeb
6-11-18, 6-12-18, 6-1-19, 7-2-19,

6-11-18, 6-12-18, 6-1-19, 7-2-19,

7-11-18, 7-12-18, 7-1-19, 8-2-19,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:58kg, 24mgg,bb:59cm,
kg,tfu:balt,djj: kg,tfu:spst,djj: tfu:23cm,djj:145 tfu:26cm,djj:145x
- 145x/m x/m,preskeb /m,preskeb
7-11-18, 7-12-18, 7-1-19, 8-2-19,

7-11-18, 7-12-18, 7-1-19, 8-2-19,

6-11-18, 8-12-18, 9-2-19,

12mgg,bb:50 16mgg,bb:54 8-1-19, 24mgg,bb:63kg,tf
kg,tfu:balt,djj: kg,tfu:spst,sjj: 20mgg,bb:59kg, u:26cm,djj:143x/
- 143 tfu:23cm,djj:136 m,preskeb
5-12-18, 6-2-19,
12mgg,bb:55 5-1-19, 20mgg,bb:62kg,tf
kg,tfu:balt,djj: 16mgg,bb:57kg, u:23cm,djj:136x/
= tfu:spst,sjj:143 m,preskeb
5-12-18, 6-2-19,
12mgg,bb:55 5-1-19, 20mgg,bb:62kg,tf
= tfu:spst,sjj:143 m,preskeb
6-12-18, 6-1-19, 7-2-19,

12mgg,bb:50 16mgg,bb:54kg, 20mgg,bb:56kg,tf
kg,tfu:balt,djj: tfu:spst,djj:134x u:23cm,djj:134x/
- /m,preskeb m,preskeb
6-12-18, 6-1-19, 7-2-19,

7-12-18, 7-1-19, 8-2-19,

7-12-18, 7-1-19, 8-2-19,

7-12-18, 7-1-19, 8-2-19,

7-12-18, 7-1-19, 8-2-19,
7-12-18, 7-1-19,
12mgg,bb:54 712-18, 20mgg,bb:53kg,tf
- tfu:spst,djj:134 m,preskeb
6-5- 7-6- 7-7-

19,28mgg,BB 19,32mgg,BB: 19,36mgg,BB:
65,tfu:26cm,d 65,30cm,djj:1 6933cm,djj:1
jj:135 34 43
6-5- 7-6-
19,28mgg,BB: 19,32mgg,BB:
68,tfu:26cm,d 69,30cm,djj:1
jj:135 34
7-5-19, 8-6-19, 6-7-19,

28mgg,tfu:29 32mgg,BB67, 36mgg,BB:69
cm,BB:65,djj: Tfu:29cm,djj: cm,tfu:32cm,
140 132 djj:136
7-5-19, 8-6-19, 6-7-19,

28mgg,tfu:28 32mgg,tfu:30 36mgg,BB:72
cm,BB:65,djj: cm,BB:69,djj: cm,tfu:31cm,
140 145 djj:136
8-5-19, 10-6-19, 8-7-19,

28mgg,bb:60 32mgg,BB:63 36mgg,BB:66
kg,tfu:27cm,d kg,tfu:30cm,d kg,tfu:32cm,d
jj:145 jj:134 jj:134
8-5-19, 10-6-19, 8-7-19,

28mgg,bb:61 32mgg,BB:66 36mgg,BB:66
jj:145 jj:145 jj:134
9-5- 11-6-19, 9-7-19,
19,28mgg,bb: 32mgg,bb:73 36mgg,bb:76
70kg,tfu:29c kg,tfu:32cm,d kg,tfu:32cm,d
m,djj:145 jj:142 jj:134
6-5-19, 7-6-19, 5-7-19,

jj:134 jj:145 jj:150
7-5-19, 7-6-19, 5-7-19, 5-8-19,

kg,tfu:27cm,d kg,tfu:29cm,d kg,tfu:32cm,d cm,tfu:33cm,
jj:143 jj:145 jj:150 djj:124
7-5-19, 8-6-19, 6-7-19, 6-8-19,

24mgg,bb: 28mgg,bb:67 32mgg,bb:80 36mgg,bb:83
63kg,tfu:27c kg,tfu:29cm,d kg,tfu: cm,tfu:33cm,
m,djj:143 jj:134 32cm,djj:134 djj:145
8-5-19, 8-6-19, 6-7-19, 6-8-19,

24mgg,bb:57 28mgg,bb:60, 32mgg,bb:64 36mgg,bb:68
cm,tfu:27cm, tfu:29cm,djj:1 kg,tfu: cm,tfu:32cm,
djj:145 34 30cm,djj:134 djj:145
8-5-19, 10-6-19, 8-7-19, 7-8-19,

24mgg,bb:59 28mgg,bb:63 32mgg,bb:68 36mgg,bb:70,
kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d tfu:32cm,djj:1
jj:145 jj:134 jj:134 34
8-5-19, 10-6-19, 8-7-19, 7-8-19,

24mgg,bb:59 28mgg,bb:63 32mgg,bb:68 36mgg,bb:70,
cm,tfu:24cm, kg,tfu:28cm,d kg,tfu:30cm,d tfu:32cm,djj:1
djj:134 jj:134 jj:134 34
6-5-19, 7-6-19, 7-7-19, 5-8-19,
kg,tfu:19cm,d kg,tfu:26cm,d kg,tfu:29cm,d kg,tfu:31cm,d
jj:145 jj:134 jj:140 jj:145
6-5-19, 7-6-19, 7-7-19, 5-8-19,

kg,tfu:19cm,d kg,tfu:26cm,d kg,tfu:29cm,d kg,tfu:31cm,d
jj:145 jj:134 jj:140 jj:145
6-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19,

kg,tfu:21cm,d kg,tfu:23cm,tf cm,tfu:26cm, kg,tfu:29cm,d kg,tfu:30cm,d
jj:145 u:143 djj:145 jj:134 jj:134
6-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19,

kg,tfu:23cm,d kg,tfu:23cm,tf cm,tfu:26cm, kg,tfu:29cm,d kg,tfu:33cm,d
jj:145 u:143 djj:145 jj:134 jj:134
7-5-19, 10-6-19, 8-7-19, 7-8-19, 7-9-19,

kg,tfu:21cm,d kg,tfu:24cm,d kg,tfu:29cm,d kg,tfu:32,djj:1 cm,tfu:33cm,
jj:145 jj:132 jj:140 34 djj:134
7-5-19, 10-6-19, 8-7-19, 7-8-19, 7-9-19,

kg,tfu:21cm,d kg,tfu:24cm,d kg,tfu:29cm,d kg,tfu:32,djj:1 cm,tfu:33cm,
jj:145 jj:132 jj:140 34 djj:134
9-5-19, 11-6-19, 9-7-19, 8-8-19,

kg,tfu:20cm,d kg,tfu:24cm,d kg,tfu:26,djj:1 kg,tfu:29cm,d
jj:134 jj:143 45 jj:134
6-5-19, 7-6-19, 5-7-19, 5-8-19, 5-9-
16mgg,bb:53 20mgg,bb:56 24mgg,bb:58 28mgg,bb:60 19,32mgg,bb:
kg,tfu:spst,djj: kg,tfu:22cm,d kg,tfu:26cm,d kg,tfu:28kg,dj 65kg,tfu:30c
134 jj:134 jj:143 j:143 m,djj:143
6-5-19, 7-6-19, 5-7-19, 5-8-19, 5-9-

16mgg,bb:59 20mgg,bb:63 24mgg,bb:67 28mgg,bb:69 19,32mgg,bb:
kg,tfu:spst,djj: kg,tfu:22cm,d kg,tfu:26cm,d kg,tfu:28kg,dj 672kg,tfu:30c
134 jj:134 jj:143 j:143 m,djj:143
7-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19,

16mgg,bb:49 20mgg,20mg 24mgg,24mg 28mgg,bb:60 32mgg,bb:64
kg,tfu:spst,djj: g,bb:52kg,tfu: g,bb:57kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d
145 23cm,djj:143 26cm,djj:145 jj:134 jj:134
7-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19, 6-10-

16mgg,bb:49 20mgg,20mg 24mgg,24mg 28mgg,bb:60 32mgg,bb:64 19,36mgg,bb:
kg,tfu:spst,djj: g,bb:52kg,tfu: g,bb:57kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d 66kg,tfu:32c
145 23cm,djj:143 26cm,djj:145 jj:134 jj:134 m,djj:143 PINDAH
8-5-19, 10-6-19, 8-7-19, 7-8-19, 9-7-19,

kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:26cm, kg,tfu:29cm,d kg,tfu:32cm,d
145 jj:145 djj:145 jj:145 jj:145
8-5-19, 10-6-19, 8-7-19, 7-8-19, 9-7-19, 7-

16mgg,bb:53 20mgg,bb:58 24mgg,bb:59 28mgg,bb:61 32mgg,bb:64 36mgg,bb:68
kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:26cm, kg,tfu:29cm,d kg,tfu:32cm,d kg,tfu:33cm,d
145 jj:145 djj:145 jj:145 jj:145 jj:143 PINDAH
8-5-19, 10-6-19, 8-7-19, 7-8-19, 9-7-19,

kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:26cm, kg,tfu:29cm,d kg,tfu:32cm,d
145 jj:145 djj:145 jj:145 jj:145
5-5-19, 7-6-19, 5-7-19, 5-8-19, 5-9-19, 5-10-

12mgg,bb:50 16mgg,bb:54 20mgg,bb:59 24mgg,bb:63 28mgg,bb:65 19,32mgg,bb:
kg,tfu:balt,djj: kg,tfu:spst,sjj: kg,tfu:23cm,d kg,tfu:26cm,d kg,tfu:28kg,dj 67kg,tfu:30c
134 143 jj:136 jj:143 j:134 m,djj:134
5-5-19, 7-6-19, 5-7-19, 5-8-19, 5-9-19, 5-10-
12mgg,bb:55 16mgg,bb:57 20mgg,bb:62 24mgg,bb:65 28mgg,bb:68 19,32mgg,bb:
kg,tfu:balt,djj: kg,tfu:spst,sjj: kg,tfu:23cm,d kg,tfu:26cm,d kg,tfu:28kg,dj 69kg,tfu:30c
134 143 jj:136 jj:143 j:134 m,djj:134
7-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19, 6-10-19,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d
- 134 jj:134 26cm,djj:134 jj:134 jj:143
7-5-19, 8-6-19, 6-7-19, 6-8-19, 6-9-19, 6-10-19,

kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d
- 134 jj:134 26cm,djj:134 jj:134 jj:143 PINDAH
8-5-19, 10-6-19, 8-7-19, 7-8-19, 7-9- 7-10-19, 7-11-19,

12mgg,bb:54 16mgg,bb:57 20mgg,bb:58 24mgg,bb:60 19,28mgg,bb: 32mgg,bb:65 36cm,bb:68kg
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:26cm,d 63kg,tfu:29c kg,tfu:31cm,d ,tfu:33cm,djj:
- 134 jj:134 jj:140 m,djj:134 jj:145 134
8-5-19, 10-6-19, 8-7-19, 7-8-19, 7-9- 7-10-19, 7-11-19,

- 134 jj:134 jj:140 m,djj:134 jj:145 134
8-5-19, 10-6-19, 8-7-19, 7-8-19, 7-9- 7-10-19, 7-11-19,

- 134 jj:134 jj:140 m,djj:134 jj:145 134
7-6-19, 5-7-19, 5-8-19, 5-9-19, 5-10-19, 5-11-19, 6-12-19,

12mgg,bb:50 16mgg,bb:53 20mgg,bb:57 24mgg,bb:59 28mgg,bb:63 32mgg,bb:65 36mgg,bb:68
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:25,djj: kg,tfu:26cm,d kg,tfu:28cm,d kg,tfu:30cm,d
- 134 jj:134 135 jj:138 jj:142 jj:134
7-6-19, 5-7-19, 5-8-19, 5-9-19, 5-10-19, 5-11-19,
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d cm,tfu:25,djj: kg,tfu:26cm,d kg,tfu:28cm,d
- 134 jj:134 135 jj:138 jj:142
7-10-19, 7-11-19,
8-6-19, 6-7-19, 6-8-19, 6-9-19, 28mgg,bb:60 32mgg,bb:64
12mgg,bb:47 16mgg,bb:50 20mgg,bb:53 24mgg,bb:57 kg,tfu:27cm,d kg,tfu:30cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:25cm,d jj:134x,preske jj:134x,preske
- 134 jj:140 jj:135 b b
7-10-19, 7-11-19,
8-6-19, 6-7-19, 6-8-19, 6-9-19, 28mgg,bb:60 32mgg,bb:64
12mgg,bb:50 16mgg,bb:50 20mgg,bb:53 24mgg,bb:57 kg,tfu:27cm,d kg,tfu:30cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:25cm,d jj:134x,preske jj:134x,preske
- 134 jj:140 jj:135 b b
7-8-19, 7-9-19, 8-10-19,

10-6-19, 8-7-19, 20mgg,bb:57 24mgg,bb:59 28mgg,bb:62 8-11-19,
12mgg,bb:52 16mgg,bb:54 kg,tfu:23cm,d kg,tfu:26cm,d kg,tfu:29cm,d 32mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:134x,preske jj:132x,preske jj:140x,preske kg,tfu:32x,djj:
- 135x,preskeb b b b 130,preskeb
7-8-19, 7-9-19, 8-10-19, 8-12-19,

10-6-19, 8-7-19, 20mgg,bb:57 24mgg,bb:59 28mgg,bb:62 8-11-19, 36mgg,bb:68
12mgg,bb:52 16mgg,bb:54 kg,tfu:23cm,d kg,tfu:26cm,d kg,tfu:29cm,d 32mgg,bb:65 kg,tfu:34cm,d
kg,tfu:balt,djj: kg,tfu:spst,djj: jj:134x,preske jj:132x,preske jj:140x,preske kg,tfu:32x,djj: d:134x/m,pre
- 135x,preskeb b b b 130,preskeb skeb
8-8-19, 10-11-19,
11-6-19, 9-7-19, 20mgg,bb:57 8-9-19, 10-10-29, 32mgg,bb:65
12mgg,bb:50 16mgg,bb:54 kg,tfu:23cm,d 24mgg,bb:59 28mgg,bb:62 kg,tfu:30cm,d
kg,tfu:balt/djj kg,tfu:spst,djj: jj:139x,preske kg,tfu:26,djj:1 kg,tfu:28cm,d jj:130x,preke
:- 134x,preskeb b 34x,preskeb jj:132,prekeb b
5-9-19, 5-11-19, 6-12-19,
5-7-19, 16mgg,bb:57 kg,tfu:23cm,d 24mgg,bb:63 kg,tfu:28cm,d kg,tfu:30cm,d
12mgg,bb:53 kg,tfu:balt,djj: jj:130x,preske kg,tfu:24cm,d jj:135x,preke jj:134x/preke
kg,tfu:-,djj:- 134,prekeb b jj:124,prekeb b b
5-9-19, 5-11-19, 6-12-19,

5-7-19, 16mgg,bb:57 kg,tfu:23cm,d 24mgg,bb:63 kg,tfu:28cm,d kg,tfu:30cm,d
12mgg,bb:53 kg,tfu:balt,djj: jj:130x,preske kg,tfu:24cm,d jj:135x,preke jj:134x/preke
kg,tfu:-,djj:- 134,prekeb b jj:124,prekeb b b
7-11-19,
6-7-19, 6-8-19, 6-9-19, 6-10-19, 28mgg,bb:62 7-12-19,
12mgg,bb:50 16mgg,bb:54 20mgg,bb:57 24mgg,bb:59 kg,tfu:29cm,d 32mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:26cm,d jj:139x,preke kg,tfu:30x,djj:
- 130 jj:130,prekeb jj:130,prekeb b 126x,prekeb
7-11-19,
6-7-19, 6-8-19, 6-9-19, 6-10-19, 28mgg,bb:62 7-12-19,
12mgg,bb:50 16mgg,bb:54 20mgg,bb:57 24mgg,bb:59 kg,tfu:29cm,d 32mgg,bb:65
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:26cm,d jj:139x,preke kg,tfu:30x,djj:
- 130 jj:130,prekeb jj:130,prekeb b 126x,prekeb
7-10-19, 8-11-19,
8-7-19, 7-8-19, 7-9-19, 24mgg,24mg 28mgg,bb:62 8-12-19,
12mgg,bb:53 16mgg,bb:56 20mgg,bb:58 g,60kg,tfu:25 kg,tfu:27cm,d 32mgg,bb:65
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:23x,djj: cm,djj:140,pr jj:134x,preke kg,tfu:30cm,d
- 134 134,prekeb ekeb b jj:134x/pekeb
7-10-19, 8-11-19,
8-7-19, 7-8-19, 7-9-19, 24mgg,24mg 28mgg,bb:62
12mgg,bb:53 16mgg,bb:56 20mgg,bb:58 g,60kg,tfu:25 kg,tfu:27cm,d
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:23x,djj: cm,djj:140,pr jj:134x,preke
- 134 134,prekeb ekeb b PINDAH
8-10-19,
9-7-19, 9-8-19, 8-9-19, 24mgg,bb:63 9-11-19,
12mgg,bb:54 16mgg,bb:58 20mgg,bb:60 kg,tfu:25cm,d 28mgg,bb:65
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:23cm,d jj:140x/m,pre kg,tfu:29cm,d
- 123,prekeb jj:140,prekeb skeb jj:130,prekeb PINDAH
5-11-19, 6-12-19,
5-8-19, 5-9-19, 5-10-19, 24mgg,bb:58 28mgg,bb:60 6-01-20,
12mgg,bb:50 16mgg,bb:53 20mgg,bb:56 kg,tfu:26cm,d kg,tfu:28cm,d 32mgg,bb:63kg,
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:23cm,d jj:142x/m,pre jj:142x/m,pre tfu:30cm,djj:123
- 134,preskeb jj:140,prekeb keb skeb x/m,prekeb
5-11-19, 6-12-19,
5-8-19, 5-9-19, 5-10-19, 24mgg,bb:58 28mgg,bb:60 6-01-20,
12mgg,bb:50 16mgg,bb:53 20mgg,bb:56 kg,tfu:26cm,d kg,tfu:28cm,d 32mgg,bb:63kg,
kg,tfu:balt,djj: kg,tfu:balt,djj: kg,tfu:23cm,d jj:142x/m,pre jj:142x/m,pre tfu:30cm,djj:123
- 134,preskeb jj:140,prekeb keb skeb x/m,prekeb
6-10-19, 7-11-19,
6-8-19, 6-9-19, 20mgg,62kg, 24mgg,bb:67 7-12-19, 8-1-20,
12mgg,bb:54 16mgg,bb:59 tfu24cm,djj:1 kg,tfu:26cm,d 72kg,tfu:27c bb:76kg,tfu:30c
kg,tfu:balt,djj: kg,tfu:spst,djj: 23x/m,preske jj:140/m,prek m,djj:140x/m, m,djj:143x/m,pr
- 134x/m b eb preskeb eskeb
6-10-19, 7-11-19,
6-8-19, 6-9-19, 20mgg,62kg, 24mgg,bb:67 7-12-19, 8-1-20,
12mgg,bb:54 16mgg,bb:59 tfu24cm,djj:1 kg,tfu:26cm,d 72kg,tfu:27c bb:76kg,tfu:30c
kg,tfu:balt,djj: kg,tfu:spst,djj: 23x/m,preske jj:140/m,prek m,djj:140x/m, m,djj:143x/m,pr
- 134x/m b eb preskeb eskeb
7-8-19, 7-9-19, 7-10-19, 8-11-19, 8-12-19,

12mgg,bb:59 bb:62kg,tfu:s bb:65kg,tfu:2 bb:69kg,tfu:2 bb:72kg,tfu:2 9-1-20,
kg,tfu:balt,djj: pst,djj:134x/ 3cm,djj:134x/ 6cm,djj:140x/ 8cm,djj:138x/ bb:76kg,tfu:30c
- m m m m m,djj:135x/m
7-8-19, 7-9-19, 7-10-19, 8-11-19, 8-12-19,

8-8-19, 8-9-19, 8-10-19, 10-11-19, 10-12-19,

6-12-19,
5-9-19, 5-10-19, 5-11-19, 24mgg,
12mgg,bb:48 16mgg,bb:50 20mgg,bb:54 bb:59kg,tfu:2 6-01-19, 28mgg,
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d 6cm,djj:134x/ bb:64kg,tfu:28c
- 140x/m jj:140x/m m m,djj:140x/m
6-12-19,
5-9-19, 5-10-19, 5-11-19, 24mgg,
12mgg,bb:48 16mgg,bb:50 20mgg,bb:54 bb:59kg,tfu:2 6-01-19, 28mgg,
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d 6cm,djj:134x/ bb:64kg,tfu:28c
- 140x/m jj:140x/m m m,djj:140x/m
6-9-19, 6-10-19, 7-11-19, 7-12-19,

12mgg,bb:56 16mgg,bb:68 20mgg,bb:71 24mgg,bb:75 8-1-19,
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d kg,tfu:26cm,d 28mgg,bb:78kg,
- 145x/m jj:134 d:140x/m tfu:28cm,djj:145
6-9-19, 6-10-19, 7-11-19, 7-12-19,

7-9-19, 7-10-19, 8-11-19, 8-12-19,

7-9-19, 7-10-19, 8-11-19, 8-12-19,

5-10-19, 5-11-19, 6-12-19, 6-1-20,
12mgg,bb:45 16mgg,bb:47 20mgg,bb:52 24mgg,tfu:25cm
kg,tfu:balt,djj: kg,tfu:spst,djj: kg,tfu:23cm,d ,djj:134x/m,pres
- 145 jj:123x/m keb
5-10-19, 5-11-19, 6-12-19, 6-1-20,

- 145 jj:123x/m keb
6-10-19, 7-11-19, 7-12-19, 8-1-20,

- 145 jj:123x/m keb
6-10-19, 7-11-19, 7-12-19, 8-1-20,

- 145 jj:123x/m keb
8-12-
7-10-19, 8-11-19, 19, :20mgg,b 9-1-20,
12mgg,bb:50 16mgg,bb:53 b:62kg,tfu:23 24mgg,bb:65kg,
kg,tfu:balt,djj: kg,tfu:spst,djj: cm,djj:140x/ tfu:25cm,djj:134
- 134x/m m.preskeb x/m,preskeb
8-12-
7-10-19, 8-11-19, 19, :20mgg,b 9-1-20,
12mgg,bb:50 16mgg,bb:53 b:62kg,tfu:23 24mgg,bb:65kg,
kg,tfu:balt,djj: kg,tfu:spst,djj: cm,djj:140x/ tfu:25cm,djj:134
- 134x/m m.preskeb x/m,preskeb
5-11-19, 6-12-19, 6-1-20,

- 140x/m x/m
5-11-19, 6-12-19, 6-1-20,

- 140x/m x/m
6-11-19, 7-12-19, 8-1-20,

12mgg,bb:46 16mgg,bb:49 bb:52kg,tfu:23c
kg,tfu:balt,djj: kg,tfu:spst,djj: m,djj:143x/m,pr
- 124x/m eskeb
6-11-19, 7-12-19, 8-1-20,

- 124x/m eskeb
7-11-19, 8-12-19, 8-1-20,

- 124x/m eskeb
7-11-19, 8-12-19, 8-1-20,

- 124x/m eskeb
8-11-19, 10-12-19, 8-1-20,

- 124x/m eskeb
8-11-19, 10-12-19, 8-1-20,
- 124x/m eskeb
6-12-19,
12mgg,bb:46 6-1-20,
- tfu:spst,djj:-
6-12-19,
12mgg,bb:46 6-1-20,
- tfu:spst,djj:-
7-12-19,
12mgg,bb:46 8-1-20,
- tfu:spst,djj:-
7-12-19,
12mgg,bb:46 8-1-20,
- tfu:spst,djj:-
8-12-19,
12mgg,bb:46 9-1-20,
- tfu:spst,djj:-
8-12-19,
12mgg,bb:46 9-1-20,
- tfu:spst,djj:-
8-12-19,
12mgg,bb:46 9-1-20,
- tfu:spst,djj:-
10-12-19,
12mgg,bb:46 11-1-20,
- tfu:spst,djj:-
10-12-19,
12mgg,bb:46 11-1-20,
- tfu:spst,djj:-
Tahun:
Mar Apr Mei Jun Jul Ags Sep Okt Nop Des
39 40 41 42 43 44 45 46 47 48
8-3-19,
36mgg,bb:83
cm,tfu:33cm,
djj:145x/m,pr
eskeb
8-3-19,
36mgg,bb:83
cm,tfu:33cm,
djj:145x/m,pr
eskeb
8-3-20,
36mgg,bb:70,
tfu:32cm,djj:1
34
8-3-20,
36mgg,bb:70,
tfu:32cm,djj:1
34
9-3-20, 9-4-20,
36mgg,bb:70, 40mgg,bb:70,
tfu:32cm,djj:1 tfu:34cm,djj:1
34x/m,preske 34x/m,preske
b b
5-3-19, 9-2-20,
jj:145x/m,pre jj:145x/m,pre
skeb skeb
5-3-19,
31mgg,bb:69
kg,tfu:31cm,d
jj:145x/m,pre
skeb
6-3-19,
32mgg,bb:70
kg,tfu:29cm,d
jj:134
6-3-19,
32mgg,bb:70
kg,tfu:29cm,d
jj:134
8-3-19, 8-4-19,
kg,tfu:32,djj:1 cm,tfu:33cm,
34x/m,preske djj:134x/m,pr
b eskeb
8-3-19, 8-4-19,
kg,tfu:32,djj:1 cm,tfu:33cm,
34x/m,preske djj:134x/m,pr
b eskeb
6-3-19, 6-5-19,
28mgg,bb:69 5-4- 36mgg,bb:79
kg,tfu:28kg,dj 19 ,32mgg,bb cm,tfu:33cm,
j:143x/m,pres :672kg,tfu:30 djj:134x/m,pr
keb cm,djj:143 eskeb
6-3-19, 7-5-19,
28mgg,bb:69 6-4- 36mgg,bb:79
6-3-19, 7-5-19,
28mgg,bb:69 6-4- 36mgg,bb:79
8-4-19, 8-5-19, 8-6-19,

8-3-19, 32mgg,bb:64 36mgg,bb:79 40mgg,bb:79
28mgg,bb:61 kg,tfu:32cm,d cm,tfu:33cm, cm,tfu:34cm,
kg,tfu:29cm,d jj:145x/m,pre djj:134x/m,pr djj:134x/m,pr
jj:145 skeb eskeb eskeb
8-4-19, 8-5-19,
8-3-19, 32mgg,bb:64 36mgg,bb:79
28mgg,bb:61 kg,tfu:32cm,d cm,tfu:33cm,
kg,tfu:29cm,d jj:145x/m,pre djj:134x/m,pr
jj:145 skeb eskeb
8-4-19,
8-3-19, 32mgg,bb:64
28mgg,bb:61 kg,tfu:32cm,d
kg,tfu:29cm,d jj:145x/m,pre
jj:145 skeb
9-3-19, 9-4-
j:134x/m,pres m,djj:134x/
keb m,preskeb
5-3-19, 5-4-19, 6-5-
24mgg,bb:65 28mgg,bb:68 19 ,32mgg,bb
kg,tfu:26cm,d kg,tfu:28kg,dj :69kg,tfu:30c
jj:143x/m,pre j:134x/m,pres m,djj:134x/m,
skeb keb preskeb
5-3-19, 5-4-19, 6-5-

24mgg,bb:65 28mgg,bb:68 19 ,32mgg,bb
kg,tfu:26cm,d kg,tfu:28kg,dj :69kg,tfu:30c
jj:143x/m,pre j:134x/m,pres m,djj:134x/m,
skeb keb preskeb
6-3-19, 6-4-19, 6-5-19, 7-6-19,

kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d cm,tfu:33cm,
26cm,djj:134x jj:134x/m,pre jj:143x/m,pre djj:134x/m,pr
/m,preskeb sken skeb eskeb
6-3-19, 6-4-19, 6-5-19, 7-6-19,

kg,tfu: kg,tfu:28cm,d kg,tfu:30cm,d cm,tfu:33cm,
26cm,djj:134x jj:134x/m,pre jj:143x/m,pre djj:134x/m,pr
/m,preskeb sken skeb eskeb
8-3-19, 8-4- 8-5-19, 8-6-19,

24mgg,bb:60 19 ,28mgg,bb 32mgg,bb:65 36mgg,bb:79
kg,tfu:26cm,d :63kg,tfu:29c kg,tfu:31cm,d cm,tfu:33cm,
jj:140x/m,pre m,djj:134x/m, jj:145x/m,pre djj:134x/m,pr
skeb preskeb skeb eskeb
8-3-19, 8-4- 8-5-19, 8-6-19,

8-3-19, 8-4- 8-5-19, 8-6-19,

8-3-19, 8-4- 8-5-19, 8-6-19,
9-2-19, 9-3-19, 8-4-19, 8-5-19,

kg,tfu:25cm,d kg,tfu:27cm,d kg,tfu:30cm,d cm,tfu:33cm,
jj:135x/m,pre jj:134x,preske jj:134x,preske djj:134x/m,pr
skeb b b eskeb
Lahir Berat Bayi Lahir Cara KF*
Hidup/Ma <2500gr >2500gr Persalinan
ti Tempat Penolong Pelayanan
KF1 KF2 KF3 KBPP
49 50 51 52 53 54 55 56 57 59
HIDUP 2900 NORMAL PONED BPM 6/2/2019 12/2/2019 24/3/2019 SUNTIK
HIDUP 3200 NORMAL PONED BIDAN 19/3/2019 28/3/2019 30/4/19 SUNTIK
HIDUP 2700 SC RS HARMUL DOKTER 9/2/2019 18/2/109 21/3/19 SUNTIK

RSU
HIDUP 2600 NORMAL BALARAJA DOKTER 19/3/2019 28/3/2019 29/4/19 SUNTIK
RS
HIDUP 2600 NORMAL HARMUL DOKTER 9/4/2019 17/4/2019 19/05/2019 SUNTIK
HIDUP 3200 NORMAL PONED BIDAN 20/3/2019 28/3/2019 25/04/2019 PIL
HIDUP 3000 NORMAL PONED BIDAN 17/4/19 25/4/19 "27/05/19 SUNTIK
HIDUP 2900 NORMAL PONED BIDAN 2/4/2019 10/4/2019 "10/05/2019 PIL

HIDUP 3400 NORMAL BPM BIDAN 3/5/2019 11/5/2019 12/6/2019 SUNTIK
HIDUP 2300 2600 SC RS HARMUL DOKTER 15/4/19 23/4/2019 1/11/2019 SUNTIK
ABORTUS

HIDUP 3200 NORAML PONED BIDAN 15/7/2019 23/7/2019 27/1/19 SUNTIK

20/08/201
HIDUP 2560 NORMAL PONED BIDAN 9 28/8/19 28/9/19 SUNTIK
13/08/201

RSU
HIDUP 2600 NORMAL BALARAJA DOKTER 10/8/2019 18/8/19 18/9/19 SUNTIK
RS
HIDUP 2600 NORMAL HARMUL DOKTER 1/9/2019 9/9/2019 1/10/2019 SUNTIK
HIDUP 2900 NORMAL PONED BIDAN 10/9/2019 18/9/19 "10/10/2019 PIL

"11/11/20
HIDUP 3300 SC RS HARMUL DOKTER 19 19/11/19 11/12/2019 SUNTIK
HIDUP 2300 2600 SC RS HARMUL DOKTER 30/9/19 8/10/2019 1/11/2019 SUNTIK

PINDAH
PINDAH

HIDUP 3000 NORMAL PONED BIDAN ### 19/11/19 10/12/2019 SUNTIK
pindah
HIDUP 3200 NORAML PONED BIDAN 19/12/19 7/1/2020 27/1/19 SUNTIK
HIDUP 2900 NORMAL PONED BIDAN 19/12/19 7/1/2020 27/1/19 MOW
PINDAH
PINDAH
"10/12/20
HIDUP 2800 NORMAL PONED BIDAN 19 18/12/19 10/1/2020 MOW

"12/12/20
PINDAH
PINDAH
Lampiran KIA-4
Tata Keteranga
Laksana n
60 61

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ifah/hendrik FLAMBOYAN 3 JAMPERSAL 21

annisa/agus FLAMBOYAN 3 KIS 19

naris/madrosid FLAMBOYAN 1 KIS 35

sari lestari/rustam FLAMBOYAN 1 UMUM 23

tia/adit FLAMBOYAN 2 KIS 26

ismawati/hendra FLAMBOYAN 3 KIS 32

mia awalia/rian FLAMBOYAN 3 KIS 21

nurhayati/M.najmudin FLAMBOYAN 3 KIS 34

st.sulistiawati/aditya FLAMBOYAN 1 UMUM 26

rohani/iwan FLAMBOYAN 1 JAMPERSAL 20

tuti/jumi FLAMBOYAN 2 UMUM 23

nuraisyah/haidir ali FLAMBOYAN 2 KIS 27

titin/hendi FLAMBOYAN 3 KIS 41

st.hotimah/ahmad FLAMBOYAN 3 UMUM 25

sarimanah/abdullah FLAMBOYAN 4 KIS 35

kartini/umar sidik FLAMBOYAN 1 KIS 32

St.nurjanah/anto FLAMBOYAN 1 KIS 33

rena S/sutisna FLAMBOYAN 2 UMUM 32

tiah/eni FLAMBOYAN 2 UMUM 35

dian/maulana FLAMBOYAN 3 KIS 20

nanih/sumadi FLAMBOYAN 3 KIS 30

rusminah/bandi FLAMBOYAN 4 KIS 25

nurhalimah/A.jalaludin FLAMBOYAN 1 KIS 28

sumyati/sapturi FLAMBOYAN 1 KIS 34

sainah/amir FLAMBOYAN 2 UMUM 29

Devilas/cecep FLAMBOYAN 3 KIS 18

neneng/rozak FLAMBOYAN 3 UMUM 25

sainah/amir FLAMBOYAN 4 UMUM 2831

nurhasanh/sumarni FLAMBOYAN 1 KIS 25

mardiana/nasrullah FLAMBOYAN 1 UMUM 33

neneng/egi sterian FLAMBOYAN 2 KIS 22

St.hodijah/agus sopiah FLAMBOYAN 2 KIS 24

st.salbiah/sahrudin FLAMBOYAN 3 KIS 28

kasuma/ahmad eli FLAMBOYAN 2 KIS 20

samsiah/asjaya FLAMBOYAN 2 KIS 20

selawati/yuhaedi FLAMBOYAN 2 KIS 25

salmah/ato sunarto FLAMBOYAN 2 KIS 27