Formulir 1

Pelaporan dan Pencatatan Kelahiran Bayi

UPTD Puskesmas Lengkong
Bulan/Tahun Mar-19
Uraian
No
Nomor Kartu Alamat Jelas NIK Bayi Nama Bayi Jenis
Keluarga (KK) (jika ada) Kelamin

1 3202073003170002 Kp sindanggalih, desa By Ny Nursiti/salih L

lengkong
2 3202071101190001 kp bojong genteng By Ny Sintia P
Dewi/Rizky
3 3202071604110003 kp padahurip By Ny Fitri/Kusnadi L
4 3202071407110010 kp padahurip By Ny Erna/hamdan P

5 3202072410180001 kp ciwangi atas 20/10 By Ny Meli/Hanan L

6 3202072408180004 kp wates 27/08 By Ny Rina/Indra P
7 3202071501190001 kp babakan pada hurip 30/7 By Ny Sri M/Majid P
8 Kp Tegal Datar Desa Neglasari By Ny Nanay/Dede P
9 Kp babakan By wita/Rustam L
10 3202071004130004 Kp sirna Hurip 25/06 By Ny Sumi/Asep L
11 3202072610180001 Kp Nyalindung 10/02 By Ny Siti Salma/Ajum P
12 3202070108180002 Kp Cikadu 13/03 By Ny L
Novitasari/Maulana
13 3202072608100143 Kp Bojong Sawah 17/04 By Ny siti latipah/Ujang P
Hendar
14 3202073105180003 Kp Cadas ngampar BY NY Dewi/Ujang L
rohman
15 3202070809170002 Kp Cipareang By Ny Rini/Dede L
16 3202071810130001 Kp Tegal Datar By Ny Aisyah/Misbah L
17 Kp Cimanggu, Desa Langkap By Ny Dede/Madin
Jaya
18 Kp Cibuluh BY NY Alwis/Abdul P
19 3202072106100014 Kp Cisuren BY Ny Rini/Oman P
20 3202071001190002 Kp cibuluh By NY Aisah/M.dede L
21 3202072410180001 Kp Sampalan 17/05 By Rani/Prana P
22 Kp Cijulang
23 3202071108071556 Kp Cimanggu Girang By Ny Lisnawati/ P
24 3202070807120005 Kp Cimanggu Girang By NY L
Nurhasanah/Korib
25 By Ny Sinta/Suryana L
26 Kp Joglo By Devitasari/Nudiono P
27 3202071107120007 KP Cicau BY NY Latipah/Andi L
28 3202071607180004 Kp Cijulang BY NY Dea P
febrilia/Farid
29 KP Cikupa BY Ny desi/Yanto P
30 Kp Sampalan 17/05 BY NY yusi/Amirullah P
31 3202070719180002 Kp Cijambe 17/06 Desa By Ny Silvia/Aldin L
Cilangkap
32 3202071802110016 Kp Sarongge 6/2 BY Ny Sri maryati/TugionP
33 3202072211180002 KP Nangoh 33/11 BY NY Rika/Firman P
34 KP Cingenca BY Ny Rini/Aep L
35 3202070103180002 Kp Simpenan 31/11 By Ny Neng desi/Denis L
36 KP Nungku BY Ny Lia/Hasan L
37 KP Cipanengah By Ny Dea/Ujang L
38 Kp Sarongge 6/2 By Ny lusi/Iwan L
39 Kp Cigandok BY Ny Yanti/Juned P
40 3202071705120001 Kp Simpenan 31/11 BY Ny Nina/Deri P
41 KP Cicadas By NY Aisyah/Paridudin P
42 KP Cigandok BY NY yayan/Encep P
43 Kp cikaso By NY Siti Nurhayati/BurP
44 Kp Cikasap By Ny Fitri/Cecep L
45 Kp Lengsar BY Ny Sri/Agus L
46 Kp Lengsar BY Ny Sri/Agus L
47 Kp Situmekar By Ny Nida/Agus P
48 3202072700150006 Kp Cibogo, Desa Tegallega By Ny Yuyun/Heri L
49 3202213101130001 Kp Malingping By Ny arum/Jepri L
50 Kp tegallega By Ny Nurohmah/Tatang L
51 3202071008071117 Kp Tipar By Ny Susi/Uyok P
52 Kp cibandung By NY Yuni/Yadi L
53 3202070808110005 Kp Cikaso BY Ny Ai/Nasrane L
54 3202071512110002 Kp Cikupa By Ny aminah/Pendi P
55 3202072504120023 Kp Cidite BY NY Iin/Dian P
56 3202071306120012 KP Cikaso BY NY Ristawati/Dodi P
57 KP Jantra By NY Maslilah/Nurmaw L
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
Kepala UPTD Puskesmas Lengkong

Dr.Leaderman
NIP. 19670523200212001
Uraian

Usia Tempat Berat Jenis Tanggal Panjang Tempat

Gestasi Lahir Badan Kelahiran Lahir Bayi (cm) Persalinan KET
(minggu) (gram)
38 SMI 3000 SPONTAN 26-Feb-19 49 PONED

38 SMI 3000 SPONTAN 1-Mar-19 51 PONED

39 SMI 2600 SPONTAN 17-Mar-19 48 RUMAH

38 SMI 4000 SPONTAN 5-Mar-19 50 RUMAH

40 SMI 3600 SPONTAN 23-Mar-19 51 PONED

37 SMI 3000 SPONTAN 12-Mar-19 48 PONED
37 SMI 3000 SPONTAN 20-Mar-19 49 BPM
40 SMI 3300 SPONTAN 28-Feb-19 51 PONED
40 SMI 3500 SPONTAN 2-Mar-19 50 BPM
39 SMI 3200 SPONTAN 3-Mar-19 50 BPM
39 SMI 2900 SPONTAN 12-Mar-19 49 PONED
39 SMI 3200 SPONTAN 17-Mar-19 51 PONED

39 SMI 2700 SPONTAN 20-Mar-19 49 BPM

40 SMI 3500 SPONTAN 21-Mar-19 51 BPM

39 SMI 2500 SPONTAN 23-Mar-19 48 BPM

40 SMI 2800 SPONTAN 26-Mar-19 49 PONED
39 SMI SC 6-Mar-19 RS

39 SMI 3000 SPONTAN 12-Mar-19 49 RUMAH

40 SMI 2900 SPONTAN 14-Mar-19 48 PONED
39 SMI 2400 SPONTAN 16-Mar-19 48 PONED
40 SMI 3000 SPONTAN 22-Jan-19 42 PONED
40 SMI SPONTAN 22-Mar-19 RUMAH
38 SMI SPONTAN 27-Feb-19 RUMAH
39 SMI SPONTAN RUMAH

42 SMI 3400 SPONTAN 25-Mar-19 51 PONED

38 SMI 3500 SPONTAN 8-Mar-19 50 PONED
39 SMI 2700 SPONTAN 18-Mar-19 51 PONED
38 SMI 3200 SPONTAN 48 BPM

38 SMI 3500 SPONTAN 17-Mar-19 50 BPM

38 SMI 2800 SPONTAN 3/27/2019 48 BPM
37 SMI 3100 SPONTAN 3/1/2019 49 PONED

38 SMI 3100 SPONTAN 1-Mar-19 49 BPM

39 SMI 2800 SPONTAN 5-Mar-19 49 PONED
38 SMI 2800 SPONTAN 6-Mar-19 49 PONED
39 SMI 2800 SPONTAN 7-Mar-19 51 PONED
38 SMI 3200 SC 13-Mar-19 51 RS
42 SMI 3300 SC 13-Mar-19 50 RS
36 SMI 3200 SPONTAN 11-Mar-19 50 RS
35 SMI 3200 SPONTAN 28-Feb-19 50 BPM
39 SMI 3100 SPONTAN 18-Mar-19 50 PONED
41 SMI 3200 SPONTAN 26-Mar-19 52 RUMAH
38 SMI 3300 SPONTAN 26-Mar-19 50 BPM
42 SMI 3100 SPONTAN 26-Mar-19 51 PONED
39 SMI 3400 SPONTAN 21-Mar-19 50 PONED
40 SMI 2200 SC 2/27/2019 49 RS
40 SMI 2500 SC 2/27/2019 49 RS
41 SMI 3200 SPONTAN 2/27/2019 50 RS
37 SMI 3000 SPONTAN 3/2/2019 49 BPM
39 SMI 2500 SPONTAN 3/3/2019 49 PONED
40 SMI 3500 SPONTAN 3/3/2019 50 PONED
42 SMI 3000 SPONTAN 3/3/2019 50 RS
40 SMI 3000 SPONTAN 3/6/2019 48 BPM
38 SMI 2800 SPONTAN 3/7/2019 48 PONED
39 SMI 2500 SPONTAN 3/14/2019 49 PONED
40 SMI 3000 SPONTAN 3/14/2019 50 PONED
41 SMI 3200 SPONTAN 3/16/2019 49 PONED
39 SMI 3000 SPONTAN 3/23/2019 50 RUMAH
Sukabumi,
Bidan Koordinator Puskesmas Lengkong

N.IDA SRINURWENDA
NIP. 196512141986032007
Formulir 2
Pelaporan dan Pencatatan Ibu Melahirkan
UPTD Puskesmas Lengkong
Bulan/Tahun Jan-19

Uraian

No Nomor Kartu Tempat

Nama Ibu/Suami Alamat Jelas
Keluarga (KK) Persalinan

3202073003170002 Ny Nursiti/salih Kp sindanggalih, desa PONED

1 lengkong
2 3202071101190001 Ny Sintia Dewi/Rizky kp bojong genteng PONED
3 3202071604110003 Ny Fitri/Kusnadi kp padahurip RUMAH
4 3202071407110010 Ny Erna/hamdan kp padahurip RUMAH
5 3202072410180001 Ny Meli/Hanan kp ciwangi atas 20/10 PONED
6 3202072408180004 Ny Rina/Indra kp wates 27/08 PONED
7 3202071501190001 Ny Sri M/Majid kp babakan pada hurip 30/7 BPM
Ny Nanay/Dede Kp Tegal Datar Desa PONED
8 Neglasari
9 Ny wita/Rustam Kp babakan BPM
3202071004130004 Ny Sumi/Asep Kp sirna Hurip 25/06 BPM
10

11 3202072610180001 Ny Siti Salma/Ajum Kp Nyalindung 10/02 PONED

12 3202070108180002 Ny Novitasari/Maulana Kp Cikadu 13/03 PONED
13 3202072608100143 Ny siti latipah/Ujang Hendar Kp Bojong Sawah 17/04 BPM
3202073105180003 NY Dewi/Ujang rohman Kp Cadas ngampar BPM
14

15 3202070809170002 Ny Rini/Dede Kp Cipareang BPM

16 3202071810130001 Ny Aisyah/Misbah Kp Tegal Datar PONED
Ny Dede/Madin Kp Cimanggu, Desa RS
17 Langkap Jaya
18 NY Alwis/Abdul Kp Cibuluh RUMAH
19 3202072106100014 Ny Rini/Oman Kp Cisuren PONED
20 3202071001190002 NY Aisah/M.dede Kp cibuluh PONED
21 3202072410180001 Rani/Prana Kp Sampalan 17/05 PONED
22 Kp Cijulang RUMAH
23 3202071108071556 Ny Lisnawati/ Kp Cimanggu Girang RUMAH
24 3202070807120005 NY Nurhasanah/Korib Kp Cimanggu Girang RUMAH
25 Ny Sinta/Suryana PONED
26 Ny Devitasari/Nudiono Kp Joglo PONED
27 3202071107120007 NY Latipah/Andi KP Cicau PONED
28 3202071607180004 NY Dea febrilia/Farid Kp Cijulang BPM
29 Ny desi/Yanto KP Cikupa BPM
30 NY yusi/Amirullah Kp Sampalan 17/05 BPM
3202070719180002 Ny Silvia/Aldin Kp Cijambe 17/06 Desa PONED
31 Cilangkap
32 3202071802110016 Ny Sri maryati/Tugiono Kp Sarongge 6/2 BPM
33 3202072211180002 NY Rika/Firman KP Nangoh 33/11 PONED
34 Ny Rini/Aep KP Cingenca PONED
35 3202070103180002 Ny Neng desi/Denis Kp Simpenan 31/11 PONED
Ny Lia/Hasan KP Nungku RS
36
Ny Dea/Ujang KP Cipanengah RS
37
38 Ny lusi/Iwan Kp Sarongge 6/2 RS
39 Ny Yanti/Juned Kp Cigandok BPM
40 3202071705120001 Ny Nina/Deri Kp Simpenan 31/11 PONED
41 NY Aisyah/Paridudin KP Cicadas RUMAH
42 NY yayan/Encep KP Cigandok BPM
43 NY Siti Nurhayati/Burhan Kp cikaso PONED
44 Ny Fitri/Cecep KP Cikasap PONED
45 Ny Sri/Agus Kp Lengsar RS
46 Ny Nida/Agus Kp Situmekar RS
47 3202072700150006 Ny Yuyun/Heri Kp Cibogo, Desa Tegallega BPM
48 3202213101130001 Ny arum/Jepri Kp Malingping PONED
49 Ny Nurohmah/Tatang Kp tegallega PONED
50 3202071008071117 Ny Susi/Uyok Kp Tipar RS
51 NY Yuni/Yadi Kp cibandung BPM
52 3202070808110005 Ny Ai/Nasrane Kp Cikaso PONED
53 3202071512110002 Ny aminah/Pendi Kp Cikupa PONED
54 3202072504120023 NY Iin/Dian Kp Cidite PONED
55 3202071306120012 NY Ristawati/Dodi KP Cikaso PONED
56 NY Maslilah/Nurmawan KP Jantra RUMAH
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
Kepala UPTD Puskesmas Lengkong

Dr.Leaderman
NIP. 19670523200212001
Uraian

Berat keterangan
Penolong Komplikasi Frekuensi
GPA Badan Saat Komplikasi Persalinan
Kelahiran Kehamilan ANC
Melahirkan

G1P0A0 BIDAN - 13 60 -
G1P0A0 BIDAN - 9 54 -
G3P2A0 PARAJI - 5 58 -
G3P2A0 PARAJI - 4 63 -
G1P0A0 BIDAN - 10 66 -
G1P0A0 BIDAN - 9 60 -
G1P0A0 BIDAN - 10 80 -

G3P2A0 BIDAN - 8 59 -

G3P2A0 BIDAN - 8 58 -

G3P2A0 BIDAN - 7 60 -

G1P0A0 BIDAN - 7 60 -
G1P0A0 BIDAN - 7 59 -
G3P2A0 BIDAN - 5 58 -
G3P2A0 BIDAN - 8 62 -

G1P0A0 BIDAN - 6 59 -
G5P4A0 BIDAN - 5 58 -

DOKTER PEB 7 - -

G1P0A0 PARAJI - 1 - -
G2P1A0 BIDAN - 7 - -
G1P0A0 BIDAN - 6 - -
G3P2A0 BIDAN - 5 - -
G1P0A0 BIDAN - 6 - -
G2P1A0 PARAJI - - - -
G1P0A0 PARAJI - 6 - -
G2P1A0 BIDAN - 5 - -
G3P2A0 BIDAN - 5 - -
G3P2A0 BIDAN - 7 - -
G1P0A0 BIDAN - - - -
G2P1A0 BIDAN - - - -
G1P0A0 BIDAN - - - -

G1P0A0 BIDAN - 6 - -
 G2P1A0 BIDAN - 7 - -
G1P0A0 BIDAN - 7 - -
G3P2A0 BIDAN - 7 - -
G1P0A0 BIDAN - 8 - -
plasenta
G2P1A0 DOKTER 3 - -
previa
G1P0A0 DOKTER serotinus 6 - -
G2P1A0 BIDAN sungsang 7 - -
G3P2A0 BIDAN - 6 - -
G2P1A0 BIDAN - 9 - -
G2P1A0 PARAJI - 6 - -
G1P0A0 BIDAN - 6 - -
G1P0A0 BIDAN - 9 - -
G2P1A0 BIDAN - 9 - -
G1P0A0 DOKTER - 4 - -
G1P0A0 BIDAN - 6 - kala 2 lama
G1P0A0 BIDAN - 7 60 -
G1P0A0 BIDAN - 10 58 -
G5P2A2 BIDAN - 8 55 -
G4P3A0 BIDAN - 14 60 -
G2P1A0 BIDAN - 11 61 -
G2P1A0 BIDAN - 12 58 -
G2P1A0 BIDAN - 7 59 -
G3P2A0 BIDAN - 11 64 -
G2P1A0 BIDAN - 10 65 -
G4P3A0 PARAJI - 11 67 -
- -
- -
- -
- -
- -
-
-
-
-
-
-
-
-
-
-
-
- Sukabumi,
- Bidan Koordinator Puskesmas Lengkong
N.IDA SRINURWENDA
NIP. 196512141986032007
Formulir 3
Pencatatan dan Pelaporan Kematian Ibu
UPTD Puskesmas : Lengkong
Bulan/Tahun Mar-19

Uraian
Nomor
No Kartu Tanggal Sebab
Alamat Jelas Nama Ibu
Keluarga Kematian Meninggal
(KK)

Mengetahui
Kepala UPTD Puskesmas Lengkong Bidan Koordinator Puskesmas Lengkon

dr. L E A D E R M A N N.IDA SRINURWENDA

NIP. 196705232002121001 NIP. 196512141986032007
 Periode Tempat KET
Meninggal Meninggal

Sukabumi,
Bidan Koordinator Puskesmas Lengkong

N.IDA SRINURWENDA
NIP. 196512141986032007
Formulir 4
Pencatatan dan Pelaporan Kematian Neonatal, Bayi dan Balita
UPTD Puskesmas : Lengkong
Bulan/Tahun Friday, March 01, 2019

Uraian

No Nomor Kartu Keluarga Jenis

Alamat Jelas NIK Anak Nama Anak
(KK) Kelamin

1
2
3
4

Mengetahui,
Kepala UPTD Puskesmas Lengkong

dr. L E A D E R M A N
NIP. 196705232002121001
Uraian
Berat Tempat Panjang
Tanggal Badan Sebab Meninggal Meningga Bayi KET
Meninggal Bayi/Anak (cm)
l
(gram)

Sukabumi,
Bidan Koordinator Puskesmas Lengkong

N.IDA SRINURWENDA
NIP. 196512141986032007