Kuesioner Otopsi Verbal Kematian Perinatal

KUESIONER KUESIONE R OTOPSI VERBAL KEMATIAN KEMATIAN PERINATAL, PERINATAL,  NEONAT  NEONATAL, BAY BAYII & BALITA A. IDENTI IDENTIT TAS ORANG ORANG TUA 1. Nama ibu / ayah !. A"ama# "$%'a( ). Umu* +*a% #ua . P$'$*-aa% +*a% #ua . S#a#u '$"ua*a

   ibu   ibu  

ayah  ayah 

B. RI0A RI0AYAT KEAMILAN DAN PERSALINAN 1. S#a#u '$hami"a%  !. Umu* '$hami"a% '$hami"a% ibu ibu aa# m$"ahi*'a% m$"ahi*'a% bayi bayi / ba"i#a ba"i#a i%i  ). Immu%iai ibu  TT 1  ya / #i2a'    TT !  ya / #i2a'    Ti2a' TT  ya / #i2a'   . B$*a(a 'a"i ($*i'a '$hami"a%  . Dima%a ($*i'a '$hami"a%  3. Ri4aya# ($*a"i%a%  Pa*#u "ama  ya / #i2a'    K$#uba% K$#uba% P$5ah P$5ah Di%i Di%i  ya / #i2a'  #i2a'   P$ P$*2a*aha%/ AP  ya ya / #i2a'  2a'   P$%+"+% P$%+"+% P$*a"i%a% P$*a"i%a%  '$"/DTT/DT '$"/DTT/DT/Bi2a /Bi2a%/D+'# %/D+'#$*  $*  D+'#$* ah"i/%a'$ ah"i/%a'$ "ai%  Ai* '$#uba%  6. IDENTITAS IDENTITAS NEONAT NEONATAL, BAYI BAYI DAN BALITA 1. Nama  !. Umu* / Ta%a" "ahi*  ). 7$%i '$"ami%  La'i8"a'i / ($*$m(ua%. . N+ u*u u*u## '$"a '$"ahi hi*a *a% % a%a' a%a' i%i i%i . B$*a# "ahi*  3. Ta%a" m$%i%a"  9. Umu* 4a'#u m$%i%a" 

D. RI0A RI0AYAT PENYAKIT PENYAKIT 1. K$a2aa K$a2aa% % (a2a 4a'# 4a'#u u "ahi* "ahi* Ku*u / L$bih L$bih '$5i" '$5i" / N+*m N+*ma" a"  $a*# *a#$  /m$%i#.  Kua# / L$mah, Ri#mi / A*i#mi  R$(i*ai  / m$%i#.  Ri#mi / A*i#mi. !. S$b$"um m$ m$%i%a", ($ ($*%ah 2i 2i#+"+%  a. Ti2a'.  ya / #i2a'    b. Du'u% bayi.  ya / #i2a'  5. Bi Bi2a% 4a#a.  ya / #i2a'   2. P$*a4a# 4a#a.  ya / #i2a'  

$. D+'#$* 4a#a :. D+'#$* ($ia"i. ). T$m(a# m$"ahi*'a%  a. Rumah.  b. Pu'$ma ($mba%#u. 5. Pu'$ma / *a4a# i%a( 2. Bi2a% P*a'#i' 4a#a $. Rumah a'i# M$2i'a Mu"ya :. Lai%8

 ya / #i2a'   ya / #i2a'    ya / #i2a'    ya / #i2a'   ya / #i2a'    ya / #i2a'    ya / #i2a'  

"ai%  ................................................................................................................... . A(a'ah a2a #a%2a8#a%2a bb  a. Pa%a  A2a / #i2a'    b. S$a' %a:a  A2a / #i2a'  5. T$*$2a' / a(i*ai  A2a / #i2a'   2. K$bi*ua%  A2a / Ti2a'   $. K$-a%8'$-a%  A2a / Ti2a'   :. Mu"u# m$5u5u $($*#i i'a%  A2a / Ti2a'   . Tiba8#iba #i2a' 2a(a# m$%hia(  A2a / Ti2a'   h. Lu'a / m$ma* / b$%'a'  A2a / Ti2a'   i. A%u  A2a / Ti2a'    -. 6a5a# ba4aa%  A2a / Ti2a'  Bi"a a2a

 .................................................................

'. Dia*$ ". S#a#u KEP

 

E. TANGGAL PENERIMAAN LAPORAN KEMATIAN a. Ta%a" m$%$*ima "a(+*a% '$ma#ia%   b. Ta%a" ($"a'a%aa% +#+(i ;$*ba"  5. T$m(a# m$%i%a"  <. KESIMPULAN S$bab '$ma#ia%  .........................................................................................  ......................................................................................... S$*+%a, M$%$#ahui  Bi2a%

KUESIONER OTOPSI VERBAL BAYI LAIR MATI A. IDENTITAS IBU 1. Nama ibu !. Nama ayah ). P$'$*-aa% Ibu / Ba(a' . P$%2i2i'a% Ibu / Ba(a' . A"ama# "$%'a( 3. S#a#u K$"ua*a

     

Umu*  Umu*  / /

B. RI0AYAT KEAMILAN IBU 1. S#a#u '$hami"a% G P A !. B$*a(a 'a"i $"ama maa '$hami"a% m$m$*i'a'a% 2i*i = >bu'u KIA? a.  b. 5. 2.

1 @ ) 'a"i  'a"i   'a"i B$"um ($*%ah

). Dima%a m$m$*i'a'a% '$hami"a%%ya a.  b. 5. 2. $.

D+'#$* ah"i D+'#$*  Bi2a% Du'u% Lai%8"ai%  .......................................................................

. A(a'ah (a2a 4a'#u m$m$*i'a'a% '$hami"a%%ya m$%2a(a# ($"aya%a%  T = a.  b. 5. 2. $. :.

T
. P$m$*i'aa% '$hami"a% a.

K$hami"a% '$mba* 

 b. 5. 2. $. :.

O2$ma 'a'i B$a* '$hami"a% $uai umu* '$hami"a% D77 #$*2$%a%, $-a' hami"  m, 'ua# / "$mah D77 #a' #$*2$%a*, hami"  .. mi%u/-am b"m ($*" L$#a' -a%i%  P*$'$(, (*$b+, "i%#a%

3. A(a'ah $"ama '$hami"a% ($*%ah m$%a"ami ha"8ha" $baai b$*i'u#  a. Sa'i# 'a*$%a ($%ya'ai#  b. 5. 2. $.

i%:$'i b$*a#  #hy(u, h$(a#i#i,

TB6, DM, 2"" ................................................................... M$%a"ami #*auma  -a#uh, 2""........................ .................... Mi%um +ba#/-amu 2i "ua* R/ 2+'#$* / bi2a% P$*2a*aha% mu"ai umu* '$hami"a% ......................... m M$*aa bayimya #i2a' b$*$*a', $-a' 'a(a% =

6. RI0AYAT PERSALINAN SEBELUMNYA a. Lahi* (+%#a%  b. Lahi* 2$%a% #i%2a'a%  S6, <+*5$(, Va5um E'#*a'i 5. Lahi* ma#i

D. RI0AYAT PERSALINAN SEKARANG a.  b. 5. 2. $. :.

Lahi* (+%#a% Lahi* 2$%a% #i%2a'a%  S6, <+*5$(, Va5um E'#*a'i Lahi* ma#i Umu* '$hami"a%  )C m ! ha*i K$#uba% P$5ah Di%i Pa*#u "ama

E. RI0AYAT BAYI 1. Ta%a" "ahi*  !. B$*a# "ahi*  ). K$a2aa% bayi 4a'#u "ahi*  a. T$*2a(a# #a%2a8#a%2a IUma#i $b$"um ($*a"i%a%, ma$*ai I @ II @ III, D77 & $*a'a% #i2a' a2a.  b. T$*2a(a# #a%2a8#a%2a #i""bi*#h >ma#i aa# ($*a"i%a%, "$bam maya#, ma$*ai #i2a' a2a, D77 & $*a'a% a%a' $b$"um%ya a2a. 5. Ku*u , "$bih '$5i" 2a*i %+*ma". 2. Ta%2a8#a%2a #*auma '$"ahi*a% >h$ma#+ma, "u'a, "$5$#, :*a'#u* ?.

. 0a'#u i ibu mu"ai #i2a' m$*aa'a% $*a'a% bayi a.  2a*i 1 m $b$"um ($*a"i%a%

 b.  2a*i 1 m $b$"um ($*a"i%a% 5. Maih m$*aa'a% am(ai aa# ($*a"i%a%

. T$m(a# '$"ahi*a% a.  b. 5. 2. $. :. .

Rumah $%2i*i Rumah 2u'u% Rumah bi2a% / BPS P+%2+' b$*a"i% Pu'$ma / Ra4a# i%a( Rumah a'i# Lai%8"ai%  ......................................................................

3. P$%+"+% ($*a"i%a% a.  b. 5. 2. $. :. .

Du'u% Ta' T$*"a#ih Du'u% T$*"a#ih Bi2a% D+'#$*   D+'#$* S($ia"i Na'$ "ai% Lai%8"ai%  ........................................................................

<. TANGGAL MENERIMA PELAPORAN KEMATIAN a. M$%$*ima "a(+*a% "ahi* ma#i   b. P$"a'a%aa% +#+(i ;$*ba"  5. T$m(a# m$%i%a"  G. KESIMPULAN ..............................................IU