Edit Laporan

Nama Pasien Lengkap

Tanggal Lahir Pasien

Jenis Kelamin

No Rekam Medis

Nama Ibu

Nama Ayah

No RM Bayi

Nama Bayi

Berat Badan Bayi

Lingkar Kepala

Tanggal Lahir

Jam Bayi Lahir

Jenis Kelamin Bayi

Panjang Badan Bayi

Dokter / Bidan penolong

Cap sidik jari

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 <tbody><tr>
 <td width="213" valign="top" style="width:159.6pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Cap
 Ibu Jari Tangan Kanan Ibu<o:p></o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-left:none;mso-border-left-alt:solid black .5pt;
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 Cap
 Telapak Kaki Kiri Bayi<o:p></o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-left:none;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt">
 Cap
 Telapak Kaki Kanan Bayi<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:268.6pt">
 <td width="213" valign="top" style="width:159.6pt;border:solid black 1.0pt;
 mso-border-themecolor:text1;border-top:none;mso-border-top-alt:solid black .5pt;
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 text1;padding:0in 5.4pt 0in 5.4pt;height:268.6pt">
 <o:p> </o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:268.6pt">
 <o:p> </o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-left-alt:solid black .5pt;
 mso-border-left-themecolor:text1;mso-border-alt:solid black .5pt;mso-border-themecolor:
 text1;padding:0in 5.4pt 0in 5.4pt;height:268.6pt">
 <o:p> </o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;mso-yfti-lastrow:yes;height:108.4pt">
 <td width="213" valign="top" style="width:159.6pt;border-top:none;border-left:
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 mso-border-bottom-themecolor:text1;border-right:none;mso-border-top-alt:solid black .5pt;
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 Tanda Tangan Orang Yang Menentukan
 Jenis Kelamin Bayi<o:p></o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 (dr.…………………………………………..)<o:p></o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border:none;border-bottom:solid black 1.0pt;
 mso-border-bottom-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-top-alt:solid black .5pt;
 mso-border-top-themecolor:text1;mso-border-bottom-alt:solid black .5pt;
 mso-border-bottom-themecolor:text1;padding:0in 5.4pt 0in 5.4pt;height:108.4pt">
 <o:p> </o:p>
 </td>
 <td width="213" valign="top" style="width:159.6pt;border-top:none;border-left:
 none;border-bottom:solid black 1.0pt;mso-border-bottom-themecolor:text1;
 border-right:solid black 1.0pt;mso-border-right-themecolor:text1;mso-border-top-alt:
 solid black .5pt;mso-border-top-themecolor:text1;mso-border-top-alt:solid black .5pt;
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 Bidan / Perawat<o:p></o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 (dr.…………………………………………..)<o:p></o:p>
 </td>
 </tr>
</tbody></table>

Sewaktu Pulang, Tanggal :

Pernyataan :

IDENTIFIKASI BAYI