Download - Lb3 Kia 2013 Baru Pkm Nglumber
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LAPORAN TRIBULAN KIA (LTB3)BULAN : JANUARI. TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : NGLUMBER
Pustu yg ada / yg lapor : 2 2
Polindes yg ada / yg lapor : 10 10
BPS / DPS yg ada / yg lapor : 0
RS pemerintah / RS Swasta yg ada / yg lapor : 0
RB yg ada / yg lapor : 0
NO
TEMPAT PELAYANAN
TOTALPosyandu Polindes Pustu PKM RB
1 2 3 4 5 6 7 8 9 10 11 12
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses). 0 0 22 9 4 0 0 0 0 35
2 Jumlah ibu hamil baru < 12 minggu 0 0 22 9 4 0 0 0 0 35
(K1 murni) 0
3 Jumlah ibu hamil dengan K4 0 0 21 4 3 0 0 0 0 28
4 Jumlah Ibu Hamil dengan Hb < 11 gr % 9 5 0 0 0 0 0 14
5 Kasus Maternal ditemukan 0 0 4 2 0 2 0 0 14 22
a. Hyperemesis (kasus baru) 0 0 1 0 0 0 0 0 0 1
b. Keguguran (kasus baru) 0 0 2 0 0 0 0 1 3
c. Eklamsi / Pre eklamsi 0 0 0 0 0 0 0 0 1 1
d. Perdarahan pada kehamilan (kasus baru) 0 0 0 0 0 0 0 0 0 0
e. Perdarahan pada persalinan (kasus baru) 0 0 0 0 0 0 0 1 1
f. Perdarahan pada nifas (kasus baru) 0 0 0 0 0 0 0 0 1 1
g. Partus lama (kasus baru) 0 0 0 0 0 0 0 2 2
h. Infeksi 0 0 0 0 0 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll ) 0 0 0 0 0 0 0 0 0 0
- Sepsis 0 0 0 0 0 0 0 0 0 0
i.Penyakit Penyerta 0 0 0 0 0 0 0 0 0 0
- Demam Berdarah 0 0 0 0 0 0 0 0 0 0
- Typus 0 0 0 0 0 0 0 0 0 0
- Malaria 0 0 0 0 0 0 0 0 0 0
- TBC 0 0 0 0 0 0 0 0 0 0
i. KPD 0 0 0 0 0 1 0 0 1 2
j. Hamil lewat waktu / serotinus 0 0 0 0 0 1 0 0 5 6
k. Kelainan letak / presentasi 0 0 3 0 0 0 0 0 0 3
l. Persalinan Macet 0 0 0 0 0 0 0 0 1 1
m. Persalinan tak maju 0 0 0 0 0 0 0 0 0 0
n. Kontraksi dini 0 0 0 0 0 0 0 0 0 0
o. Kehamilan ganda / gemelli 0 0 0 0 0 0 0 0 0 0
p. IMS ( Infeksi Menular Seksual ) 0 0 0 0 0 0 0 0 0 0
Rumah Pasien
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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NO
TEMPAT PELAYANAN
TOTALPosyandu Polindes Pustu PKM RB
1 2 3 4 5 6 7 8 9 10 11 12
Rumah Pasien
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
q. HIV / AIDS 0 0 0 0 0 0 0 0 0 0
s. Lain Lain………………………………… 0 0 0 0 0 0 0 0 1 1
6 Jumlah Persalinan oleh Tenaga Kesehatan 0 17 5 5 4 0 0 10 41
7 Jumlah Persalinan oleh dukun 0 0
8 Ibu Nifas Paripurna 33 0 1 0 0 0 0 0 0 34
9 Jumlah Ibu Meneteki Baru 0 0 17 5 5 4 0 0 10 41
10 Jumlah kematian Maternal 0 0 0 0 0 0 0 0 0
11 Penyebab Kematian Maternal. 0 0 0 0 0 0 0 0 0
a. Perdarahan 0 0 0 0 0 0 0 0 0
b. Infeksi Jalan Lahir 0 0 0 0 0 0 0 0 0
c. Pre / eklamsi 0 0 0 0 0 0 0 0 0
d...................................................(sebutkan) 0 0 0 0 0 0 0 0 0
12 Tempat Kematian Maternal 0 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0 0 0 0 0 0 0 0
b. Puskesmas Pustu 0 0 0 0 0 0 0 0 0
c. Polindes 0 0 0 0 0 0 0 0 0
d. Rumah Bidan 0 0 0 0 0 0 0 0 0
e. Rumah Ibu 0 0 0 0 0 0 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0 0 0 0 0 0
g. Lain-lain (………………………………..) 0 0 0 0 0 0 0 0 0
13 Penolong Persalinan Terakhir 0 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0 0 0 0 0 0 0 0
b. Bidan 0 0 0 0 0 0 0 0 0
c. Dukun 0 0 0 0 0 0 0 0 0
d. Belum ditolong 0 0 0 0 0 0 0 0 0
14 Persalinan normal 0 17 5 5 4 0 0 5 36
15 Persalinan dengan operasi 0 0 2 2
16 Persalinan dengan tindakan 0 0 13 14
a. Drip 0 0 9 9
b. Vakum 0 0 3 3
c. Curetage 0 0 1 1
d. Placenta Manual 0 0 1 1
17 Kematian Maternal yang di audit 0
17 Kematian Maternal yang di audit 0
NO KEGIATANRumah Pasien Posyandu Polindes Pustu PKM
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NO
TEMPAT PELAYANAN
TOTALPosyandu Polindes Pustu PKM RB
1 2 3 4 5 6 7 8 9 10 11 12
Rumah Pasien
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
NO KEGIATAN
L P L P L P L P L P
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 11 19 5 3 5 2
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 11 19 5 3 5 2
3 Jumlah Lahir Mati 0 0 0 0 0 0 0 0 0 0
4 Penyebab Lahir Mati 0 0 0 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0 0 0 0
b. Kelainan Kongenital 0 0 0 0 0 0 0 0
c. BBLR < 1000 gr. 0 0 0 0 0 0 0 0
d. Penyebab Ibu 0 0 0 0 0 0 0 0
e. Kelainan placenta/tali pusat 0 0 0 0 0 0 0 0
f. Tak diketahui 0 0 0 0 0 0 0 0
5 Jumlah Lahir Prematur 0 0 0 0 0 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 11 19 5 3 5 2
7 KN2 40 33 0 0 1 2 6 6 0 0
8 Kasus Neonatal yg ditemukan 0 0 0 0 0 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0 0 0 0 0 0
b. asfiksia 0 0 0 0 0 0 0 0 0 0
c. BBLR < 2.500 gr. 0 0 0 0 0 0 0 0 0 0
d. infeksi 0 0 0 0 0 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0 0 0 0 0 0
g. Ikterus 0 0 0 0 0 0 0 0 0 0
h. Hypothermi 0 0 0 0 0 0 0 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0 0 0 0 0 0
j. …………………........................(sebutkan) 0 0 0 0 0 0 0 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0 0 0 0 0 0
b. Asfiksia 0 0 0 0 0 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0 0 0 0 0 0
d. Infeksi 0 0 0 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0 0 0 0
g. ………………………................(sebutkan). 0 0 0 0 0 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0 0 0 0 0 0
b. Asfiksia 0 0 0 0 0 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0 0 0 0 0 0
d. Infeksi 0 0 0 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0 0 0 0
g. ……………………….................(sebutkan). 0 0 0 0 0 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0 0 0 0 0 0 0
b. Bidan 0 0 0 0 0 0 0 0
c. Dukun 0 0 0 0 0 0 0 0
d. Belum ditolong 0 0 0 0 0 0 0 0
12 Tempat Kematian Neonatal 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0 0 0 0 0 0 0
b. Puskesmas Pustu 0 0 0 0 0 0 0 0
c. Polindes 0 0 0 0 0 0 0 0
d. Rumah Bidan 0 0 0 0 0 0 0 0
e. Rumah Ibu 0 0 0 0 0 0 0 0
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NO
TEMPAT PELAYANAN
TOTALPosyandu Polindes Pustu PKM RB
1 2 3 4 5 6 7 8 9 10 11 12
Rumah Pasien
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0 0 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0 0 0 0 0 0
13 Jumlah Bayi Baru 18 20 0 0 11 19 5 3 5 2
14 Bayi Paripurna 2 2 16 21 10 11 3 2 0 0
15 0 0 0 0 0 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0 0 0 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0 0 0 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0 0 0 0 0 0
b. Diare 0 0 0 0 0 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0 0 0 0 0 0
d. Infeksi (......................... ..................) 0 0 0 0 0 0 0 0
e. Kejang Demam 0 0 0 0 0 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0 0 0 0 0 0
g. ……………………….............(sebutkan). 0 0 0 0 0 0 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0 0 0 0 0 0 0
b. Bidan 0 0 0 0 0 0 0 0
c. Dukun 0 0 0 0 0 0 0 0
d. Belum ditolong 0 0 0 0 0 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0 0 0 0 0 0 0
b. Puskesmas Pustu 0 0 0 0 0 0 0 0
c. Polindes 0 0 0 0 0 0 0 0
d. Rumah Bidan 0 0 0 0 0 0 0 0
e. Rumah Ibu 0 0 0 0 0 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0 0 0 0 0 0
9. Lain Lain…………………….. 0 0 0 0 0 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0 0 0 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 87 82 0 0 0 0 0 0
2 Jumlah AnakPrasekolah Baru 0 0 54 56 0 0 0 0 0 0
3 Jumlah TK 0 0 0 50 0 0 0 0 0 0
4 Jumlah TK dikunjungi 0 0 0 30 0 0 0 0 0 0
5 0 0 0 0 0 0 0 0 0 0
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 2 2 16 21 10 11 3 2 0 0
2 Jumlah anak balita dideteksi tumbuh kembang 5 5 63 61 17 23 31 29 0 0
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 14 14 22 23 8 11 0 0
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0 0 0 0 0 0 0 0
d. KPSP penyimpangan 0 0 0 0 0 0 0 0 0 0
f. TDL gannguan 0 0 0 0 0 0 0 0 0 0
h. TDD gannguan 0 0 0 0 0 0 0 0 0 0
i. MME mungkin ada gangguan 0 0 0 0 0 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0 0 0 0 0 0 0 0 0
b. Dirujuk ke RS 0 0 0 0 0 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangan #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
Jumlah Kematian Bayi ( bukan lahir mati )
Jumlah Kematian Anak Balita (1-5 tahun)
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NO
TEMPAT PELAYANAN
TOTALPosyandu Polindes Pustu PKM RB
1 2 3 4 5 6 7 8 9 10 11 12
Rumah Pasien
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat LahirHidup /
PenyebabL P
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin lahir lahir
Tgl LahirL P hidup mati
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
………………………….NIP
BOJONEGORO,................................Mengetahui,
Pengelola KIA Kepala Puskesmas.............................
( )NIP
NIP.
umur(mnt,jam,hr,bln)
LahirMati ( isi )
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Linakes + Lindukun 41
LinNormal,SC&tind 52
LH + LM 166
Gemelli 125
Jumlh kematian Ibu 0
Penyebab 0
penolong 0
Tempat 0
Jumlah 0-7 hr mati 0
Jumlah 8-28 mati 0
di jumlahkan 0
Kematian Neo 0
Penolong 0
Tempat 0
Kematian post neo 0
penyebab 0
penolong 0
tempat 0
Kontraksi dini 0
persalinan prematur 0
BBLR 1
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Kematian AKBAL 0
PKM PONED BPS RB TOTAL TOTALRS Pemerintah/Rs
Swasta
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L P L P L P L P L P L + P
2 5 0 0 0 0 16 15 39 44 83
2 5 0 0 0 0 16 15 39 44 83
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
2 5 0 0 0 0 16 15 39 44 83
0 0 0 0 0 0 0 0 47 41 88
0 0 0 0 0 0 1 4 1 4 5
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 0 3 3
0 0 0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 39 44 83
0 0 0 0 0 0 0 0 31 36 67
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 87 82 169
0 0 0 0 0 0 0 0 54 56 110
0 0 0 0 0 0 0 0 0 50 50
0 0 0 0 0 0 0 0 0 30 30
0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 31 36 67
0 0 0 0 0 0 0 0 116 118 234
0 0 0 0 0 0 0 0 44 48 92
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
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DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Penyebab Alur Rujukan Penolong Tanggal kematian
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
…………………………. NIP.
( )
Faktor Resiko Ibu / faktor resiko balita
Tempat kematian & lama di rawat di tempat kematian
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,.
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NO KEGIATANRumah Pasien Posyandu Polindes Pustu PKM PKM PONED BPS RB TOTAL TOTAL
L P L P L P L P L P L P L P L P L P L P L + P
B PERINATAL
1 Jumlah Lahir Hidup 6 10 4 1 5 0 1 3 0 0 0 0 4 7 20 21 41
2 Bayi dengan Vit K1 Injeksi 6 10 4 1 5 0 1 3 0 0 0 0 4 7 20 21 41
3 Jumlah Lahir Mati 0 0 0
4 Penyebab Lahir Mati 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma Lahir 0 0 0
b. Kelainan Kongenital 0 0 0
c. BBLR < 1000 gr. 0 0 0
d. Penyebab Ibu 0 0 0
e. Kelainan placenta/tali pusat 0 0 0
f. Tak diketahui 0 0 0
5 Jumlah Lahir Prematur 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 6 10 4 1 5 0 1 3 0 0 0 0 4 7 20 21 41
7 KN2 19 13 0 0 1 2 2 1 0 0 0 0 0 0 0 0 0 0 22 16 38
8 Kasus Neonatal yg ditemukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1
a. Trauma Lahir 0 0 0
b. asfiksia 1 0 1 1
c. BBLR < 2.500 gr. 0 0 0
d. infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. Ikterus 0 0 0
h. Hypothermi 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0
j. …………………........................(sebutkan) 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
RS Pemerintah/Rs Swasta
![Page 31: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/31.jpg)
g. ………………………................(sebutkan). 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ……………………….................(sebutkan). 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
12 Tempat Kematian Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0
13 Jumlah Bayi Baru 5 10 0 0 6 10 4 1 5 0 0 0 0 0 0 0 0 0 20 21 41
14 Bayi Paripurna 1 0 6 11 8 10 3 2 0 0 0 0 0 0 0 0 0 0 18 23 41
15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0 0
b. Diare 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi (......................... ..................) 0 0 0
e. Kejang Demam 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0
g. ……………………….............(sebutkan). 0 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
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17 Penolong Terakhir Kematian Post Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0
9. Lain Lain…………………….. 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 35 42 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35 42 77
2 Jumlah AnakPrasekolah Baru 31 29 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31 29 60
3 Jumlah TK 25 0 25 25
4 Jumlah TK dikunjungi 11 0 11 11
5 0 0 0
6 Penyebab Kematian Anak Balita 0 0 0
...............................................(sebutkan) 0 0 0
7 Tempat Kematian Anak Balita 0 0 0
...............................................(sebutkan) 0 0 0
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 1 0 6 11 8 10 3 2 0 0 0 0 0 0 0 0 0 0 18 23 41
2 Jumlah anak balita dideteksi tumbuh kembang 2 0 26 26 9 11 10 13 0 0 0 0 0 0 0 0 0 0 47 50 97
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 4 8 8 13 4 5 0 0 0 0 0 0 0 0 0 0 16 26 42
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0
d. KPSP penyimpangan 0 0 0
f. TDL gannguan 0 0 0
h. TDD gannguan 0 0 0
i. MME mungkin ada gangguan 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
Jumlah Kematian Anak Balita (1-5 tahun)
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a. Puskesmas 0 0 0
b. Dirujuk ke RS 0 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat LahirHidup /
Penyebab Alur Rujukan Penolong Tanggal kematianL P
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin lahir lahir
Tgl LahirL P hidup mati
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Bojonegoro, 2-2-2013Pengelola KIA Mengetahui,
Kepala Puskesmas Nglumber
YOHANA WAHYUNI, Amd. Keb.NIP. 19631110 198501 2 003 dr. YOGI SETYA WARDANA
NIP. 19751208 201001 1 003
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balita
Tempat kematian & lama di rawat di tempat kematian
LahirMati ( isi )
![Page 34: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/34.jpg)
NO KEGIATANRumah Pasien Posyandu Polindes Pustu PKM PKM PONED BPS RB TOTAL
L P L P L P L P L P L P L P L P L P L P
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 5 9 1 2 0 2 1 2 0 0 0 0 12 8 19 23
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 5 9 1 2 0 2 1 2 0 0 0 0 12 8 19 23
3 Jumlah Lahir Mati 0 0
4 Penyebab Lahir Mati 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma Lahir 0 0
b. Kelainan Kongenital 0 0
c. BBLR < 1000 gr. 0 0
d. Penyebab Ibu 0 0
e. Kelainan placenta/tali pusat 0 0
f. Tak diketahui 0 0
5 Jumlah Lahir Prematur 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 5 9 1 2 0 2 1 2 0 0 0 0 12 8 19 23
7 KN2 21 20 0 0 0 0 4 5 0 0 0 0 0 0 0 0 0 0 25 25
8 Kasus Neonatal yg ditemukan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 3
a. Trauma Lahir 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. asfiksia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2
c. BBLR < 2.500 gr. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
d. infeksi 0 0
e. Tetanus Neonatorum 0 0
f. Kelainan Bawaan 0 0
g. Ikterus 0 0
h. Hypothermi 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1
j. …………………........................(sebutkan) 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0
b. Asfiksia 0 0
c. BBLR < 2.500 gr + komplikasi 0 0
d. Infeksi 0 0
e. Tetanus Neonatorum 0 0
RS Pemerintah/Rs Swasta
![Page 35: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/35.jpg)
f. Kelainan Bawaan 0 0
g. ………………………................(sebutkan). 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0
b. Asfiksia 0 0
c. BBLR < 2.500 gr + komplikasi 0 0
d. Infeksi 0 0
e. Tetanus Neonatorum 0 0
f. Kelainan Bawaan 0 0
g. ……………………….................(sebutkan). 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0
b. Bidan 0 0
c. Dukun 0 0
d. Belum ditolong 0 0
12 Tempat Kematian Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0
b. Puskesmas Pustu 0 0
c. Polindes 0 0
d. Rumah Bidan 0 0
e. Rumah Ibu 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0
g.Lain Lain………………………( sebutkan) 0 0
13 Jumlah Bayi Baru 13 10 0 0 5 9 1 2 0 2 0 0 0 0 0 0 0 0 19 23
14 Bayi Paripurna 1 2 10 10 2 1 0 0 0 0 0 0 0 0 0 0 0 0 13 13
15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Trauma lahir 0 0
b. Diare 0 0
c. BBLR < 2.500 gr + komplikasi 0 0
d. Infeksi (......................... ..................) 0 0
e. Kejang Demam 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
![Page 36: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/36.jpg)
f. Kelainan Bawaan (.............................) 0 0
g. ……………………….............(sebutkan). 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Dokter / DSOG 0 0
b. Bidan 0 0
c. Dukun 0 0
d. Belum ditolong 0 0
18 Tempat Kematian Post Neonatal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
a. Rumah Sakit 0 0
b. Puskesmas Pustu 0 0
c. Polindes 0 0
d. Rumah Bidan 0 0
e. Rumah Ibu 0 0
f. Perjalanan ke .......................(sebutkan) 0 0
9. Lain Lain…………………….. 0 0
19 Kematian Perinatal yang di Audit 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 52 40 52 40
2 Jumlah AnakPrasekolah Baru 23 27 23 27
3 Jumlah TK 25 0 25
4 Jumlah TK dikunjungi 19 0 19
5 0 0
6 Penyebab Kematian Anak Balita 0 0
...............................................(sebutkan) 0 0
7 Tempat Kematian Anak Balita 0 0
...............................................(sebutkan) 0 0
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 1 2 10 10 2 1 0 0 0 0 0 0 0 0 0 0 0 0 13 13
2 Jumlah anak balita dideteksi tumbuh kembang 3 5 37 35 8 12 21 16 0 0 0 0 0 0 0 0 0 0 69 68
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 10 6 14 10 4 6 0 0 0 0 0 0 0 0 0 0 28 22
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0
d. KPSP penyimpangan 0 0
f. TDL gannguan 0 0
Jumlah Kematian Anak Balita (1-5 tahun)
![Page 37: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/37.jpg)
h. TDD gannguan 0 0
i. MME mungkin ada gangguan 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0
b. Dirujuk ke RS 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat LahirHidup /
Penyebab Alur Rujukan Penolong Tanggal kematianL P
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin lahir lahir
Tgl LahirL P hidup mati
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Bojonegoro, 2-3-2013Pengelola KIA Mengetahui,
Kepala Puskesmas Nglumber
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balita
Tempat kematian & lama di rawat di tempat kematian
LahirMati ( isi )
![Page 38: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/38.jpg)
YOHANA WAHYUNI, Amd. Keb.NIP. 19631110 198501 2 003 dr. YOGI SETYA WARDANA
NIP. 19751208 201001 1 003
![Page 39: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/39.jpg)
TOTAL
L + P
42
42
0
0
0
0
0
0
0
0
0
42
50
4
0
2
1
0
0
0
0
0
1
0
0
0
0
0
0
0
![Page 40: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/40.jpg)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
42
26
0
0
0
0
0
0
0
0
0
![Page 41: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/41.jpg)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
92
50
25
19
0
0
0
0
0
26
137
50
0
0
0
![Page 42: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/42.jpg)
0
0
0
0
Tanggal kematian
![Page 43: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/43.jpg)
LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
![Page 44: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/44.jpg)
f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
![Page 45: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/45.jpg)
7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
![Page 46: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/46.jpg)
d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
![Page 47: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/47.jpg)
5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
![Page 49: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/49.jpg)
d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses). 0 0 40 18 6
2 Jumlah ibu hamil baru < 12 minggu 0 0 40 18 6
(K1 murni)
3 Jumlah ibu hamil dengan K4 0 0 49 10 3
4 Jumlah Ibu Hamil dengan Hb < 11 gr % 9 11 0
5 Kasus Maternal ditemukan 0 0 4 2 0
a. Hyperemesis (kasus baru) 0 0 1 0 0
b. Keguguran (kasus baru) 0 0 2 0
c. Eklamsi / Pre eklamsi 0 0 0 0 0
d. Perdarahan pada kehamilan (kasus baru) 0 0 0 0 0
e. Perdarahan pada persalinan (kasus baru) 0 0 0 0
f. Perdarahan pada nifas (kasus baru) 0 0 0 0 0
Rumah Pasien
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g. Partus lama (kasus baru) 0 0 0 0
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll ) 0 0 0 0 0
- Sepsis 0 0 0 0 0
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah 0 0 0 0 0
- Typus 0 0 0 0 0
- Malaria 0 0 0 0 0
- TBC 0 0 0 0 0
i. KPD 0 0 0 0 0
j. Hamil lewat waktu / serotinus 0 0 0 0 0
k. Kelainan letak / presentasi 0 0 3 0 0
l. Persalinan Macet 0 0 0 0 0
m. Persalinan tak maju 0 0 0 0 0
n. Kontraksi dini 0 0 0 0 0
o. Kehamilan ganda / gemelli 0 0 0 0 0
p. IMS ( Infeksi Menular Seksual ) 0 0 0 0 0
q. HIV / AIDS 0 0 0 0 0
s. Lain Lain………………………………… 0 0 0 0 0
6 Jumlah Persalinan oleh Tenaga Kesehatan 0 31 8 7
7 Jumlah Persalinan oleh dukun 0
8 Ibu Nifas Paripurna 74 0 1 0 0
9 Jumlah Ibu Meneteki Baru 0 0 31 8 7
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10 Jumlah kematian Maternal 0 0 0 0
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan 0 0 0 0
b. Infeksi Jalan Lahir 0 0 0 0
c. Pre / eklamsi 0 0 0 0
d...................................................(sebutkan) 0 0 0 0
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit 0 0 0 0
b. Puskesmas Pustu 0 0 0 0
c. Polindes 0 0 0 0
d. Rumah Bidan 0 0 0 0
e. Rumah Ibu 0 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0
g. Lain-lain (………………………………..) 0 0 0 0
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG 0 0 0 0
b. Bidan 0 0 0 0
c. Dukun 0 0 0 0
d. Belum ditolong 0 0 0 0
14 Persalinan normal 0 31 8 7
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
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b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 11
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 11
3 Jumlah Lahir Mati 0 0 0 0 0
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir 0 0 0
b. Kelainan Kongenital 0 0 0
c. BBLR < 1000 gr. 0 0 0
d. Penyebab Ibu 0 0 0
e. Kelainan placenta/tali pusat 0 0 0
f. Tak diketahui 0 0 0
5 Jumlah Lahir Prematur 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 11
7 KN2 40 33 0 0 1
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0
b. asfiksia 0 0 0 0 0
c. BBLR < 2.500 gr. 0 0 0 0 0
d. infeksi 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0
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g. Ikterus 0 0 0 0 0
h. Hypothermi 0 0 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0
j. …………………........................(sebutkan) 0 0 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ………………………................(sebutkan). 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ……………………….................(sebutkan). 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0
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13 Jumlah Bayi Baru 18 20 0 0 11
14 Bayi Paripurna 2 2 16 21 10
15 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir 0 0 0
b. Diare 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi (......................... ..................) 0 0 0
e. Kejang Demam 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0
g. ……………………….............(sebutkan). 0 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0
9. Lain Lain…………………….. 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 87 82 0
2 Jumlah AnakPrasekolah Baru 0 0 54 56 0
3 Jumlah TK 0 0 0 50 0
4 Jumlah TK dikunjungi 0 0 0 30 0
5 0 0 0 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
Jumlah Kematian Anak Balita (1-5 tahun)
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6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 2 2 16 21 10
2 Jumlah anak balita dideteksi tumbuh kembang 5 5 63 61 17
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 14 14 22
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0 0 0
d. KPSP penyimpangan 0 0 0 0 0
f. TDL gannguan 0 0 0 0 0
h. TDD gannguan 0 0 0 0 0
i. MME mungkin ada gangguan 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0 0 0 0
b. Dirujuk ke RS 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
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NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0 0 0 0 64
0 0 0 0 64 Linakes + Lindukun 83
0 LinNormal,SC&tind 83
0 0 0 0 62 LH + LM 166
0 0 0 0 20 Gemelli 83
1 0 0 19 26
0 0 0 0 1 Jumlh kematian Ibu 0
0 0 0 1 3 Penyebab 0
0 0 0 1 1 penolong 0
0 0 0 0 0 Tempat 0
0 0 0 1 1
0 0 0 1 1 Jumlah 0-7 hr mati 0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 0 0 3 3 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 0 0 0 0 Kematian Neo 0
0 0 0 0 0 Penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian post neo 0
0 0 0 0 0 penyebab 0
0 0 0 5 5 penolong 0
1 0 0 5 6 tempat 0
0 0 0 0 3
0 0 0 1 1
0 0 0 0 0 Kontraksi dini 0
0 0 0 0 0 persalinan prematur 0
0 0 0 0 0 BBLR 1
0 0 0 0 0
0 0 0 0 0
0 0 0 1 1 Kematian AKBAL 0
7 0 0 30 83
0
0 0 0 0 75
7 0 0 30 83
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0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
7 0 0 11 64
0 0 6 6
0 0 13 13
0 0 9 9
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0 0 2 2
0 0 1 1
0 0 1 1
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
19 5 3 5 2 2 5 0 0
19 5 3 5 2 2 5 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
19 5 3 5 2 2 5 0 0
2 6 6 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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19 5 3 5 2 0 0 0 0
11 3 2 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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11 3 2 0 0 0 0 0 0
23 31 29 0 0 0 0 0 0
23 8 11 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 16 15 39 44 83
0 0 16 15 39 44 83
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 16 15 39 44 83
0 0 0 0 47 41 88
0 0 1 4 1 4 5
0 0 0 0 0 0 0
0 0 0 3 0 3 3
0 0 1 0 1 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
RS Pemerintah/Rs Swasta
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0 0 39 44 83
0 0 0 0 31 36 67
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 87 82 169
0 0 0 0 54 56 110
0 0 0 0 0 50 50
0 0 0 0 0 30 30
0 0 0 0 0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 31 36 67
0 0 0 0 116 118 234
0 0 0 0 44 48 92
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
![Page 154: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/154.jpg)
………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
![Page 156: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/156.jpg)
0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
![Page 159: Lb3 Kia 2013 Baru Pkm Nglumber](https://reader035.vdocuments.pub/reader035/viewer/2022062217/55cf9c00550346d033a833cc/html5/thumbnails/159.jpg)
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses). 0 0 0 0 0
2 Jumlah ibu hamil baru < 12 minggu 0 0 0 0 0
(K1 murni)
3 Jumlah ibu hamil dengan K4 0 0 0 0 0
4 Jumlah Ibu Hamil dengan Hb < 11 gr % 0 0 0
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru) 0 0 0 0 0
b. Keguguran (kasus baru) 0 0 0 0
c. Eklamsi / Pre eklamsi 0 0 0 0 0
d. Perdarahan pada kehamilan (kasus baru) 0 0 0 0 0
e. Perdarahan pada persalinan (kasus baru) 0 0 0 0
f. Perdarahan pada nifas (kasus baru) 0 0 0 0 0
Rumah Pasien
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g. Partus lama (kasus baru) 0 0 0 0
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll ) 0 0 0 0 0
- Sepsis 0 0 0 0 0
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah 0 0 0 0 0
- Typus 0 0 0 0 0
- Malaria 0 0 0 0 0
- TBC 0 0 0 0 0
i. KPD 0 0 0 0 0
j. Hamil lewat waktu / serotinus 0 0 0 0 0
k. Kelainan letak / presentasi 0 0 0 0 0
l. Persalinan Macet 0 0 0 0 0
m. Persalinan tak maju 0 0 0 0 0
n. Kontraksi dini 0 0 0 0 0
o. Kehamilan ganda / gemelli 0 0 0 0 0
p. IMS ( Infeksi Menular Seksual ) 0 0 0 0 0
q. HIV / AIDS 0 0 0 0 0
s. Lain Lain………………………………… 0 0 0 0 0
6 Jumlah Persalinan oleh Tenaga Kesehatan 0 0 0 0
7 Jumlah Persalinan oleh dukun 0
8 Ibu Nifas Paripurna 0 0 0 0 0
9 Jumlah Ibu Meneteki Baru 0 0 0 0 0
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10 Jumlah kematian Maternal 0 0 0 0
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan 0 0 0 0
b. Infeksi Jalan Lahir 0 0 0 0
c. Pre / eklamsi 0 0 0 0
d...................................................(sebutkan) 0 0 0 0
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit 0 0 0 0
b. Puskesmas Pustu 0 0 0 0
c. Polindes 0 0 0 0
d. Rumah Bidan 0 0 0 0
e. Rumah Ibu 0 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0
g. Lain-lain (………………………………..) 0 0 0 0
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG 0 0 0 0
b. Bidan 0 0 0 0
c. Dukun 0 0 0 0
d. Belum ditolong 0 0 0 0
14 Persalinan normal 0 0 0 0
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
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b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 0
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 0
3 Jumlah Lahir Mati 0 0 0 0 0
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir 0 0 0
b. Kelainan Kongenital 0 0 0
c. BBLR < 1000 gr. 0 0 0
d. Penyebab Ibu 0 0 0
e. Kelainan placenta/tali pusat 0 0 0
f. Tak diketahui 0 0 0
5 Jumlah Lahir Prematur 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 0
7 KN2 0 0 0 0 0
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0
b. asfiksia 0 0 0 0 0
c. BBLR < 2.500 gr. 0 0 0 0 0
d. infeksi 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0
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g. Ikterus 0 0 0 0 0
h. Hypothermi 0 0 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0
j. …………………........................(sebutkan) 0 0 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ………………………................(sebutkan). 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ……………………….................(sebutkan). 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0
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13 Jumlah Bayi Baru 0 0 0 0 0
14 Bayi Paripurna 0 0 0 0 0
15 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir 0 0 0
b. Diare 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi (......................... ..................) 0 0 0
e. Kejang Demam 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0
g. ……………………….............(sebutkan). 0 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0
9. Lain Lain…………………….. 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 0 0 0
2 Jumlah AnakPrasekolah Baru 0 0 0 0 0
3 Jumlah TK 0 0 0 0 0
4 Jumlah TK dikunjungi 0 0 0 0 0
5 0 0 0 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
Jumlah Kematian Anak Balita (1-5 tahun)
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6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 0 0 0 0 0
2 Jumlah anak balita dideteksi tumbuh kembang 0 0 0 0 0
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 0 0 0
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0 0 0
d. KPSP penyimpangan 0 0 0 0 0
f. TDL gannguan 0 0 0 0 0
h. TDD gannguan 0 0 0 0 0
i. MME mungkin ada gangguan 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0 0 0 0
b. Dirujuk ke RS 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
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NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0 0 0 0 0
0 0 0 0 0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 0 0 0 0 LH + LM 0
0 0 0 0 0 Gemelli 0
0 0 0 0 0
0 0 0 0 0 Jumlh kematian Ibu 0
0 0 0 0 0 Penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0 Jumlah 0-7 hr mati 0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 0 0 0 0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 0 0 0 0 Kematian Neo 0
0 0 0 0 0 Penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian post neo 0
0 0 0 0 0 penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kontraksi dini 0
0 0 0 0 0 persalinan prematur 0
0 0 0 0 0 BBLR 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian AKBAL 0
0 0 0 0 0
0
0 0 0 0 0
0 0 0 0 0
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0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
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0 0 0 0
0 0 0 0
0 0 0 0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
RS Pemerintah/Rs Swasta
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun #REF!
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli #REF!
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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#REF!
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses). 0 0 0 0 0
2 Jumlah ibu hamil baru < 12 minggu 0 0 0 0 0
(K1 murni)
3 Jumlah ibu hamil dengan K4 0 0 0 0 0
4 Jumlah Ibu Hamil dengan Hb < 11 gr % 0 0 0
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru) 0 0 0 0 0
b. Keguguran (kasus baru) 0 0 0 0
c. Eklamsi / Pre eklamsi 0 0 0 0 0
d. Perdarahan pada kehamilan (kasus baru) 0 0 0 0 0
e. Perdarahan pada persalinan (kasus baru) 0 0 0 0
f. Perdarahan pada nifas (kasus baru) 0 0 0 0 0
Rumah Pasien
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g. Partus lama (kasus baru) 0 0 0 0
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll ) 0 0 0 0 0
- Sepsis 0 0 0 0 0
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah 0 0 0 0 0
- Typus 0 0 0 0 0
- Malaria 0 0 0 0 0
- TBC 0 0 0 0 0
i. KPD 0 0 0 0 0
j. Hamil lewat waktu / serotinus 0 0 0 0 0
k. Kelainan letak / presentasi 0 0 0 0 0
l. Persalinan Macet 0 0 0 0 0
m. Persalinan tak maju 0 0 0 0 0
n. Kontraksi dini 0 0 0 0 0
o. Kehamilan ganda / gemelli 0 0 0 0 0
p. IMS ( Infeksi Menular Seksual ) 0 0 0 0 0
q. HIV / AIDS 0 0 0 0 0
s. Lain Lain………………………………… 0 0 0 0 0
6 Jumlah Persalinan oleh Tenaga Kesehatan 0 0 0 0
7 Jumlah Persalinan oleh dukun 0
8 Ibu Nifas Paripurna 0 0 0 0 0
9 Jumlah Ibu Meneteki Baru 0 0 0 0 0
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10 Jumlah kematian Maternal 0 0 0 0
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan 0 0 0 0
b. Infeksi Jalan Lahir 0 0 0 0
c. Pre / eklamsi 0 0 0 0
d...................................................(sebutkan) 0 0 0 0
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit 0 0 0 0
b. Puskesmas Pustu 0 0 0 0
c. Polindes 0 0 0 0
d. Rumah Bidan 0 0 0 0
e. Rumah Ibu 0 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0
g. Lain-lain (………………………………..) 0 0 0 0
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG 0 0 0 0
b. Bidan 0 0 0 0
c. Dukun 0 0 0 0
d. Belum ditolong 0 0 0 0
14 Persalinan normal 0 0 0 0
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
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b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 0
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 0
3 Jumlah Lahir Mati 0 0 0 0 0
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir 0 0 0
b. Kelainan Kongenital 0 0 0
c. BBLR < 1000 gr. 0 0 0
d. Penyebab Ibu 0 0 0
e. Kelainan placenta/tali pusat 0 0 0
f. Tak diketahui 0 0 0
5 Jumlah Lahir Prematur 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 0
7 KN2 0 0 0 0 0
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0
b. asfiksia 0 0 0 0 0
c. BBLR < 2.500 gr. 0 0 0 0 0
d. infeksi 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0
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g. Ikterus 0 0 0 0 0
h. Hypothermi 0 0 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0
j. …………………........................(sebutkan) 0 0 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ………………………................(sebutkan). 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ……………………….................(sebutkan). 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0
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13 Jumlah Bayi Baru 0 0 0 0 0
14 Bayi Paripurna 0 0 0 0 0
15 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir 0 0 0
b. Diare 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi (......................... ..................) 0 0 0
e. Kejang Demam 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0
g. ……………………….............(sebutkan). 0 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0
9. Lain Lain…………………….. 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 0 0 0
2 Jumlah AnakPrasekolah Baru 0 0 0 0 0
3 Jumlah TK 0 0 0 0 0
4 Jumlah TK dikunjungi 0 0 0 0 0
5 0 0 0 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
Jumlah Kematian Anak Balita (1-5 tahun)
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6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 0 0 0 0 0
2 Jumlah anak balita dideteksi tumbuh kembang 0 0 0 0 0
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 0 0 0
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0 0 0
d. KPSP penyimpangan 0 0 0 0 0
f. TDL gannguan 0 0 0 0 0
h. TDD gannguan 0 0 0 0 0
i. MME mungkin ada gangguan 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0 0 0 0
b. Dirujuk ke RS 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
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NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0 0 0 0 0
0 0 0 0 0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 0 0 0 0 LH + LM 0
0 0 0 0 0 Gemelli 0
0 0 0 0 0
0 0 0 0 0 Jumlh kematian Ibu 0
0 0 0 0 0 Penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0 Jumlah 0-7 hr mati 0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 0 0 0 0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 0 0 0 0 Kematian Neo 0
0 0 0 0 0 Penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian post neo 0
0 0 0 0 0 penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kontraksi dini 0
0 0 0 0 0 persalinan prematur 0
0 0 0 0 0 BBLR 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian AKBAL 0
0 0 0 0 0
0
0 0 0 0 0
0 0 0 0 0
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0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
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0 0 0 0
0 0 0 0
0 0 0 0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
RS Pemerintah/Rs Swasta
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun #REF!
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli #REF!
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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#REF!
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses).
2 Jumlah ibu hamil baru < 12 minggu
(K1 murni)
3 Jumlah ibu hamil dengan K4
4 Jumlah Ibu Hamil dengan Hb < 11 gr %
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru)
b. Keguguran (kasus baru)
c. Eklamsi / Pre eklamsi
d. Perdarahan pada kehamilan (kasus baru)
e. Perdarahan pada persalinan (kasus baru)
Rumah Pasien
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f. Perdarahan pada nifas (kasus baru)
g. Partus lama (kasus baru)
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll )
- Sepsis
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah
- Typus
- Malaria
- TBC
i. KPD
j. Hamil lewat waktu / serotinus
k. Kelainan letak / presentasi
l. Persalinan Macet
m. Persalinan tak maju
n. Kontraksi dini
o. Kehamilan ganda / gemelli
p. IMS ( Infeksi Menular Seksual )
q. HIV / AIDS
s. Lain Lain…………………………………
6 Jumlah Persalinan oleh Tenaga Kesehatan
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7 Jumlah Persalinan oleh dukun
8 Ibu Nifas Paripurna
9 Jumlah Ibu Meneteki Baru
10 Jumlah kematian Maternal
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan
b. Infeksi Jalan Lahir
c. Pre / eklamsi
d...................................................(sebutkan)
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g. Lain-lain (………………………………..)
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
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d. Belum ditolong
14 Persalinan normal
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup
2 Bayi dengan Vit K1 Injeksi
3 Jumlah Lahir Mati
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir
b. Kelainan Kongenital
c. BBLR < 1000 gr.
d. Penyebab Ibu
e. Kelainan placenta/tali pusat
f. Tak diketahui
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5 Jumlah Lahir Prematur
6 KN1 (kunjungan pertama nakes ke bayi baru lahir)
7 KN2
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir
b. asfiksia
c. BBLR < 2.500 gr.
d. infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. Ikterus
h. Hypothermi
i. Syndroma Gangguan Pernapasan
j. …………………........................(sebutkan)
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ………………………................(sebutkan).
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir
b. Asfiksia
c. BBLR < 2.500 gr + komplikasi
d. Infeksi
e. Tetanus Neonatorum
f. Kelainan Bawaan
g. ……………………….................(sebutkan).
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11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
d. Belum ditolong
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke ..........................(sebutkan)
g.Lain Lain………………………( sebutkan)
13 Jumlah Bayi Baru
14 Bayi Paripurna
15 0 0 0
a. Neonatal ( 0 - 28 hari )
b. Post Neonatal ( 29 hari - 12 bulan )
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir
b. Diare
c. BBLR < 2.500 gr + komplikasi
d. Infeksi (......................... ..................)
e. Kejang Demam
f. Kelainan Bawaan (.............................)
g. ……………………….............(sebutkan).
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG
b. Bidan
c. Dukun
Jumlah Kematian Bayi ( bukan lahir mati )
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d. Belum ditolong
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit
b. Puskesmas Pustu
c. Polindes
d. Rumah Bidan
e. Rumah Ibu
f. Perjalanan ke .......................(sebutkan)
9. Lain Lain……………………..
19 Kematian Perinatal yang di Audit
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru
2 Jumlah AnakPrasekolah Baru
3 Jumlah TK
4 Jumlah TK dikunjungi
5
6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang
2 Jumlah anak balita dideteksi tumbuh kembang
3 Jumlah APRAS dideteksi tumbuh kembang
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal
d. KPSP penyimpangan
f. TDL gannguan
h. TDD gannguan
i. MME mungkin ada gangguan
Jumlah Kematian Anak Balita (1-5 tahun)
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5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas
b. Dirujuk ke RS
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
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………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0
0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 LH + LM 0
0 Gemelli 0
0 0 0 0 0
0 Jumlh kematian Ibu 0
0 Penyebab 0
0 penolong 0
0 Tempat 0
0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 Jumlah 0-7 hr mati 0
0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 Kematian Neo 0
0 Penolong 0
0 0 0 0 0 Tempat 0
0
0
0 Kematian post neo 0
0 penyebab 0
0 penolong 0
0 tempat 0
0
0
0 Kontraksi dini 0
0 persalinan prematur 0
0 BBLR 0
0
0
0 Kematian AKBAL 0
0
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0
0
0
0
0 0 0 0 0
0
0
0
0
0 0 0 0 0
0
0
0
0
0
0
0
0 0 0 0 0
0
0
0
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0
0
0
0 0 0 0
0
0
0
0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
RS Pemerintah/Rs Swasta
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0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 ( Juml neo mati )
0 0 0 ( juml > 28 hr mati )
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
( Juml kmtian bayi )
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0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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0 0 0
0 0 0
Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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( Juml neo mati )
( juml > 28 hr mati )
( Juml kmtian bayi )
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,.
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
KABUPATEN : BOJONEGORO
PROPINSI : JAWA TIMUR
PUSKESMAS : Pustu yg ada / yg lapor : Polindes yg ada / yg laporBPS / DPS yg ada / yg laporRS pemerintah / RS Swasta yg ada / yg lapor :RB yg ada / yg lapor :
NO KEGIATAN
TEMPAT PELAYANAN
Posyandu Polindes Pustu PKM
1 2 3 4 5 6 7
A MATERNAL
1 Jumlah Ibu hamil baru (K1 akses). 0 0 0 0 0
2 Jumlah ibu hamil baru < 12 minggu 0 0 0 0 0
(K1 murni)
3 Jumlah ibu hamil dengan K4 0 0 0 0 0
4 Jumlah Ibu Hamil dengan Hb < 11 gr % 0 0 0
5 Kasus Maternal ditemukan 0 0 0 0 0
a. Hyperemesis (kasus baru) 0 0 0 0 0
b. Keguguran (kasus baru) 0 0 0 0
c. Eklamsi / Pre eklamsi 0 0 0 0 0
d. Perdarahan pada kehamilan (kasus baru) 0 0 0 0 0
e. Perdarahan pada persalinan (kasus baru) 0 0 0 0
f. Perdarahan pada nifas (kasus baru) 0 0 0 0 0
Rumah Pasien
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g. Partus lama (kasus baru) 0 0 0 0
h. Infeksi 0 0 0 0 0
- Nifas (metritis,peritonitis,inf payudara, dll ) 0 0 0 0 0
- Sepsis 0 0 0 0 0
i.Penyakit Penyerta 0 0 0 0 0
- Demam Berdarah 0 0 0 0 0
- Typus 0 0 0 0 0
- Malaria 0 0 0 0 0
- TBC 0 0 0 0 0
i. KPD 0 0 0 0 0
j. Hamil lewat waktu / serotinus 0 0 0 0 0
k. Kelainan letak / presentasi 0 0 0 0 0
l. Persalinan Macet 0 0 0 0 0
m. Persalinan tak maju 0 0 0 0 0
n. Kontraksi dini 0 0 0 0 0
o. Kehamilan ganda / gemelli 0 0 0 0 0
p. IMS ( Infeksi Menular Seksual ) 0 0 0 0 0
q. HIV / AIDS 0 0 0 0 0
s. Lain Lain………………………………… 0 0 0 0 0
6 Jumlah Persalinan oleh Tenaga Kesehatan 0 0 0 0
7 Jumlah Persalinan oleh dukun 0
8 Ibu Nifas Paripurna 0 0 0 0 0
9 Jumlah Ibu Meneteki Baru 0 0 0 0 0
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10 Jumlah kematian Maternal 0 0 0 0
11 Penyebab Kematian Maternal. 0 0 0 0
a. Perdarahan 0 0 0 0
b. Infeksi Jalan Lahir 0 0 0 0
c. Pre / eklamsi 0 0 0 0
d...................................................(sebutkan) 0 0 0 0
12 Tempat Kematian Maternal 0 0 0 0
a. Rumah Sakit 0 0 0 0
b. Puskesmas Pustu 0 0 0 0
c. Polindes 0 0 0 0
d. Rumah Bidan 0 0 0 0
e. Rumah Ibu 0 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0 0
g. Lain-lain (………………………………..) 0 0 0 0
13 Penolong Persalinan Terakhir 0 0 0 0
a. Dokter / DSOG 0 0 0 0
b. Bidan 0 0 0 0
c. Dukun 0 0 0 0
d. Belum ditolong 0 0 0 0
14 Persalinan normal 0 0 0 0
15 Persalinan dengan operasi
16 Persalinan dengan tindakan
a. Drip
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b. Vakum
c. Curetage
d. Placenta Manual
17 Kematian Maternal yang di audit
17 Kematian Maternal yang di audit
NO KEGIATANRumah Pasien Posyandu Polindes
L P L P L
B PERINATAL
1 Jumlah Lahir Hidup 0 0 0 0 0
2 Bayi dengan Vit K1 Injeksi 0 0 0 0 0
3 Jumlah Lahir Mati 0 0 0 0 0
4 Penyebab Lahir Mati 0 0 0
a. Trauma Lahir 0 0 0
b. Kelainan Kongenital 0 0 0
c. BBLR < 1000 gr. 0 0 0
d. Penyebab Ibu 0 0 0
e. Kelainan placenta/tali pusat 0 0 0
f. Tak diketahui 0 0 0
5 Jumlah Lahir Prematur 0 0 0
6 KN1 (kunjungan pertama nakes ke bayi baru lahir) 0 0 0
7 KN2 0 0 0 0 0
8 Kasus Neonatal yg ditemukan 0 0 0 0 0
a. Trauma Lahir 0 0 0 0 0
b. asfiksia 0 0 0 0 0
c. BBLR < 2.500 gr. 0 0 0 0 0
d. infeksi 0 0 0 0 0
e. Tetanus Neonatorum 0 0 0 0 0
f. Kelainan Bawaan 0 0 0 0 0
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g. Ikterus 0 0 0 0 0
h. Hypothermi 0 0 0 0 0
i. Syndroma Gangguan Pernapasan 0 0 0 0 0
j. …………………........................(sebutkan) 0 0 0 0 0
9 Jumlah Kematian Neonatal 0-7 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ………………………................(sebutkan). 0 0 0
10 Jumlah Kematian neonatal 8-28 hari 0 0 0
a. Trauma lahir 0 0 0
b. Asfiksia 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi 0 0 0
e. Tetanus Neonatorum 0 0 0
f. Kelainan Bawaan 0 0 0
g. ……………………….................(sebutkan). 0 0 0
11 Penolong Terakhir Kematian Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
12 Tempat Kematian Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke ..........................(sebutkan) 0 0 0
g.Lain Lain………………………( sebutkan) 0 0 0
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13 Jumlah Bayi Baru 0 0 0 0 0
14 Bayi Paripurna 0 0 0 0 0
15 0 0 0
a. Neonatal ( 0 - 28 hari ) 0 0 0
b. Post Neonatal ( 29 hari - 12 bulan ) 0 0 0
16 Penyebab Kematian Post Neonatal . 0 0 0
a. Trauma lahir 0 0 0
b. Diare 0 0 0
c. BBLR < 2.500 gr + komplikasi 0 0 0
d. Infeksi (......................... ..................) 0 0 0
e. Kejang Demam 0 0 0
f. Kelainan Bawaan (.............................) 0 0 0
g. ……………………….............(sebutkan). 0 0 0
17 Penolong Terakhir Kematian Post Neonatal 0 0 0
a. Dokter / DSOG 0 0 0
b. Bidan 0 0 0
c. Dukun 0 0 0
d. Belum ditolong 0 0 0
18 Tempat Kematian Post Neonatal 0 0 0
a. Rumah Sakit 0 0 0
b. Puskesmas Pustu 0 0 0
c. Polindes 0 0 0
d. Rumah Bidan 0 0 0
e. Rumah Ibu 0 0 0
f. Perjalanan ke .......................(sebutkan) 0 0 0
9. Lain Lain…………………….. 0 0 0
19 Kematian Perinatal yang di Audit 0 0 0
C ANAK BALITA & APRAS
1 Jumlah Anak balita Baru 0 0 0 0 0
2 Jumlah AnakPrasekolah Baru 0 0 0 0 0
3 Jumlah TK 0 0 0 0 0
4 Jumlah TK dikunjungi 0 0 0 0 0
5 0 0 0 0 0
Jumlah Kematian Bayi ( bukan lahir mati )
Jumlah Kematian Anak Balita (1-5 tahun)
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6 Penyebab Kematian Anak Balita
...............................................(sebutkan)
7 Tempat Kematian Anak Balita
...............................................(sebutkan)
D DETEKSI DINI TUMBUH KEMBANG
1 Jumlah bayi dideteksi tumbuh kembang 0 0 0 0 0
2 Jumlah anak balita dideteksi tumbuh kembang 0 0 0 0 0
3 Jumlah APRAS dideteksi tumbuh kembang 0 0 0 0 0
4 Penyimpangan tumbuh kembang yang ditemukan
c. LKA Tak Normal 0 0 0 0 0
d. KPSP penyimpangan 0 0 0 0 0
f. TDL gannguan 0 0 0 0 0
h. TDD gannguan 0 0 0 0 0
i. MME mungkin ada gangguan 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditangani
a. Puskesmas 0 0 0 0 0
b. Dirujuk ke RS 0 0 0 0 0
5 Penyimpangan tumbuh kembang yang ditanga #REF! #REF! #REF! #REF! #REF!
LAMPIRAN /DATA DUKUNG LAPORAN KEMATIAN DI LB3 KIA
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
Nama Bayi , anak balita Nama Ibu / BapakAlamat
DATA GEMELLI
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NAMA BAYI NAMA ORTU AlamatJenis Kelamin
L
Keterangan* Setiap Kematian Neonatal ( 0 - 28 hari ) dan Kematian Maternal di buatkan Laporan Otopsi Verbal Kematian Terbaru beserta Kronologisnya
Pengelola KIA
………………………….NIP
Pengelola KIA
NIP
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LAPORAN TRIBULAN KIA (LTB3)BULAN : TAHUN : 2013
BOJONEGORO
TEMPAT PELAYANAN
TOTALRB
8 9 10 11 12
0 0 0 0 0
0 0 0 0 0 Linakes + Lindukun 0
0 LinNormal,SC&tind 0
0 0 0 0 0 LH + LM 0
0 0 0 0 0 Gemelli 0
0 0 0 0 0
0 0 0 0 0 Jumlh kematian Ibu 0
0 0 0 0 0 Penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0 Jumlah 0-7 hr mati 0
PKM PONED
BPS/DPS
RS pemerintah / RS Swasta
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0 0 0 0 0 Jumlah 8-28 mati 0
0 0 0 0 0 di jumlahkan 0
0 0 0 0 0 Kematian Neo 0
0 0 0 0 0 Penolong 0
0 0 0 0 0 Tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian post neo 0
0 0 0 0 0 penyebab 0
0 0 0 0 0 penolong 0
0 0 0 0 0 tempat 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kontraksi dini 0
0 0 0 0 0 persalinan prematur 0
0 0 0 0 0 BBLR 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 Kematian AKBAL 0
0 0 0 0 0
0
0 0 0 0 0
0 0 0 0 0
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0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
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0 0 0 0
0 0 0 0
0 0 0 0
0
0
Polindes Pustu PKM PKM PONED BPS
P L P L P L P L P
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
#REF! #REF! #REF! #REF! #REF!
DATA KEMATIAN PERINATAL MULAI USIA 22 MGG ( termasuk Lahir Mati ), NEONATAL I ( 0 - 28 HARI ) BAYI ( 0 - 12 bln ) dan KEMATIAN ANAK BALITA ( 1- 5 THN )
LahirHidup /
Penyebab Alur RujukanL P
umur(mnt,jam,hr,bln) Faktor Resiko Ibu / faktor resiko balitaLahirMati
( isi )
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Jenis Kelamin lahir lahirTgl Lahir
P hidup mati
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
…………………………. NIP.
( )
BOJONEGORO,................................Mengetahui,Kepala Puskesmas.............................
( )
NIP.
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RB TOTAL TOTAL
L P L P L P L + P
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
RS Pemerintah/Rs Swasta
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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0 0 0
0 0 0
0 0 0
0 0 0
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Alur Rujukan Penolong Tanggal kematianTempat kematian & lama di rawat di tempat kematian
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,.
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Compatibility Report for LB3 KIA TRIB II 2010 bojonegoro New.xlsRun on 04/07/2010 16:16
Minor loss of fidelity # of occurrences
5
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