No.

HC
= s ig n ific a A L E R T A

= r e q u ie r e s e g u im ie n to c o n tin u o

A p e llid o s y N o m b r e s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E s t a b le c im ie n to :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E s t a b l . O r ig e n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D N I (L .E ) N

N o A p li c a

AUTOGENERADO:
< 15

D ir e c c i n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ O c u p a c i n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E d a d : _ _ _ _ _ _ _ _ _ > 3 5
L o c a lid a d :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Aos
E s t u d io s :
_
A n a lfa b e ta P r im a r ia S e c u n d a r ia S u p e r io r S u p e r io r N o U n iv . a p r o b a d o s
D e p a r t a m e n to : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P r o v in c ia :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E s ta d o C iv il:
D is t r i t o : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P a d re R N : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C a s a d a C o n v iv ie n te S o lte r a
O tro
T e l fo n o :_ _ _ _ _ _ _ _ _

A n te c e d e n te s O b s te tr ic o s
G e s ta s

V a g in a le s

A b o rto s

V iv e n

N a c id o s
v iv o s

0 + 3
M u e rto - 1 ra
sem ana

< 2500 g
G e m e la r

P a rto s

< 37 sem .

C e s re a s

N a c id o s
m u e rto s

D e s p u s - 1 ra
sem ana

F in G e s ta c i n A n te r io r

T e r m in a c i n :
P a rto

A b o rto

F e c h a _ _ _ /_ _ _ /_ _ _
E c t p ic o

M o la r

O tro

N o A p lic a

S i fu e a b o r t o : T ip o d e A b o r to
In c o m p le to

C o m p le to

F ru s tro

R N de m ayor peso:

S p tic o

N o A p lic a

O tro

C a p ta d a : S i

R e m itid a x
A g .C o m u n i.

No

: Si

No

A n te c e d e n te s F a m ilia r e s
N in g u n a
A
A
E
D
E
G

le r g ia s
n o m a lia s G o n g n it.
p ile p s ia
ia b e t e s
n fe r m .C o n g n ita s
e m e la r e s

H ip e r t e n s i n A r te r ia l
N e o p l s ia
T B C P u lm o n a r
O tro s _ _ _ _ _ _ _ _ _ _ _

A n te c e d e n te s P e r s o n a le s
N
A
A
A
A
A
B
C
C

in g u n a
b o r to h a b itu a l
b o rto re c u rre n te
lc o h o lis m o
le r g ia a m e d ic a m e n t o s
s m a B r o n q u ia l
a jo P e s o a l n a c e r
a r d io p a ta
ir u g a P lv .- u te r in a

D ia b e te s
E n fe r m .C o n g n ita s
E n fe r m .In fe c c io s a s
E p ile p s ia
H e m o rra .P o s tp a rto
H ip e r te n s i n A r te r ia l
H o ja d e C o c a
In fe r tilid a d
N e o p la s ia s

O tra s D ro g a s
P a r to p r o lo n g .
P r e /E c la m p s ia
P r e m a tu r id a d
R e te n . p la c e n ta
Tabaco
T B C P u lm o n a r
V IH /S ID A
O tro s _ _ _ _ _ _ _ _ _

P e s o y T a lla
P e s o H a b itu a l :

kg

T a lla :

cm

A n tite t n ic a
N D o s is
P r e v ia 1 ra

S in
d o s is

D o s is

No
A p lic a

2da
m e s d e g e s ta c i n

T ip o d e S a n g r e
G ru p o :
R h:

R h
(+ )

B
R h (-) S e n
D esc

A B
R h (-) N o
S en

O
R h (-) S e n

F u m a
N C ig a r r o s
p o r d a

F .U .M .
C o n o c id a ? :

Duda :
Si

N o

Si

F e c h a U ltim a M e n s tr u a c i n :
E G .(E c o g ra fa )

Sem .

N o

_ _ /_ _ /_ _

F e c h a :_ _ /_ _ _ /_ _ _

N o A p lic a

L o n g itu d C e f lo C a u d a l
:
D i m e tr o B ip a r ie ta l

m m .
:

m m .

F e c h a P r o b a b le d e P a r to : _ _ _ _ /_ _ _ _ /_ _ _

H o s p ita liz a c i n
H o s p ita liz a c i n :
N o

S i

F e c h a :_ _ _ /_ _ _ /_ _ _
D ia g
____
____
____
____

n
_
_
_
_

s tic o :
_______
_______
_______
_______

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

_
_
_
_

N o A p lic a

E m e r g e n c ia
E m e r g e n c ia 1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D ia g n s tic o :
N o A p lic a

_
_________________________
_

F e c h a : _ _ /_ _ _ /_ _ _
E m e r g e n c ia 2 :
D ia g n s tic o :
N o A p lic a

_________________________
_
_________________________
_

F e c h a : _ _ /_ _ _ /_ _ _

S e r o lo g a L u tic a
V D R L /R P R
1

F e c h a :_ _ _ /_ _ _ /_ _ _
N e g a tiv o

P o s it iv o

N o s e h iz o

N e g a tiv o

P o s it iv o

N o s e h iz o

F e c h a :_ _ _ /_ _ _ /_ _ _

H e m o g lo b in a
H b (g % )
1

F e c h a :_ _ _ /_ _ _ /_ _ _

.
N o s e h iz o

F e c h a :_ _ _ /_ _ _ /_ _ _

.
N o s e h iz o

P s ic o p r o fila x is

N ro .

s e s io n e s

Exm enes
C ln ic o :
S in E x a m e n

N o rm a l

P a to l g ic o

N o rm a l

P a to l g ic o

P e lv is :

S in E x a m e n

N o rm a l

A n o rm a l

S in E x a m e n

N e g a tiv o

P o s itiv o

H IV :

O d o n t.:
S in E x a m e n

C e r v ix :

BK en :
e s p u to
O rin a :

N o rm a l

A n o rm a l

M am as:

S in E x a m e n

N o rm a l

A n o rm a l

S in E x a m e n

N o rm a l

A n o rm a l

N o rm a l

A n o rm a l

P o s itiv o

S in E x a m e n

N o rm a l

A n o rm a l

S in E x a m e n

N o rm a l

A n o rm a l

S in E x a m e n

N e g a tiv o

P o s itiv o

TO RCH :

C o lp o s .:
S in E x a m e n

N e g a tiv o

N o A p lic a

G lu c o s a :

PAP :
S in E x a m e n

S in E x a m e n

N o A p lic a

N o A p lic a

CONTROLES PRENATALES

CONTROL 1

CONTROL 2

CONTRO L 3

CONTROL 4

CONTRO L 5

CONTROL 6

CONTRO L 7

CO NTROL 8

CONTROL 9

F e c h a d e C P N (a /m /d )
E d a d G e s t. (s e m a n a s )
P e s o m a d re (k g )
T e m p e ra tu ra ( C )
T e n s i n a r te r . ( m m . H g )
S is t lic a /D i s t lic a

C = C e f lic a

N A = N o A p lic a

A ltu r a U te r in a (c m )
P r e s e n ta c i n (C /P /T /N A )

F .C .F . (p o r m in ./N A )
M o v .f e ta l( + /+ + /+ + + /S M /N A )

E d e m a (+ /+ + /+ + + /S E )
P u ls o m a te r n o (p o r m in .)
C o n s e je r a P F (S i/N o /N A )
P e rfil B io fs ic o
(4 , 6 , 8 , 1 0 d e 1 0 /N S H /N A )

C ita (a /m /d )
V is ita d o m ic il. ( S i/N o /N A )

E s ta b le c . d e la a te n c i n
R e s p o n s a b le d e l C o n tr o l
N S H = N o s e H iz o

P = P lv ic a

S E = S in E d e m a

S M = S in M o v im ie n to

T = T ra n s v e rs a

P a to lo g a s M a te r n a s (C IE 1 0 )

Fecha:

S in p a to lo g a s

1 . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ /_ _ _ /_ _ _
2 . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ /_ _ _ /_ _ _
3 . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ /_ _ _ /_ _ _

E s ta d o
HCMP :

C o n tr o l P re n a ta l

In g r e s o
T e m p e ra tu ra

A b o r to

P a r to

H i jo U n i c o

P R E S E N T A C IO N :

TAM AO FETAL
ACORDE:
No

P e lv ia n a
T ra n s v e rs a

Si

1:
2:

E m b a ra z o
M u lt ip le

A b o rto
O rd e n

F e c h a y H o r a : _ _ _ /_ _ _ /_ _ _ _ _ _ :_ _ _
C e f lic a

E d a d G e s ta c .

P ro d u c to d e
la c o n c e p c i n

O tr o s (C IE 1 0 ):

IN IC IO :

M E M B R . A L IN G R E S O :

E s p o n t n e a

R o ta s

C la r o

In te g ra s

V e r d e c la r o

In d u c id o
C e s re a e le c tiv a

FECHA Y HORA DE RUPTURA:

_ _ _ /_ _ _ /_ _ _ _ _ _ :_ _ _

L IQ . A M N I T IC O :

V e rd e o s c u ro

M e d ic a c i n e n P a r to

(V e r a n e x o )
S in m e d ic a c i n

M E D IC A C IO N :

M E D IC A M E N T O S :

1. _________________________________________________
2. _________________________________________________

1. ______________________________________________
2. ______________________________________________

3. _________________________________________________

3. ______________________________________________

T e r m in a c i n
E s p o n t n e a

F e c h a : _ _ _ /_ _ _ /_ _ _ _ _ _ :_ _ _
M MU UEE RR TT EE I N T R A U T :
D U R A C IO N :
I N N To Rh uA b Uo T . :
N o rm a l

F o rc e p s

P r o lo n g a d o

D u ra n te e m b a ra z o

P r e c ip ita d o

D u ra n te p a rto

N o a p lic a

M o m e n to
d e s c o n o c id o

T E R M IN A C IO N :

C e s re a
Vacum m

IN D IC . P R IN C . P A R T O O P E R . O IN D U C C .

(V e r a n e x o )

______________________________
E P IS IO T O M IA
:
DESG ARRO S :

N o hubo

No
a p lic a

Si

N o

II

III/IV

ALUM BRAM . :

M anual

E x p o n ta n e o

PLACENTA

In c o m p le ta

C o m p le ta

N o a p lic a

No
hubo

A te n c i n
N IV E L :
P r im a r io
S e c u n d a rio
T e r c ia r io

PARTO
LEGRADO
M e d ic o
O b s te triz
In te rn o
E n fe rm e r a

D o m ic ilia r io

A u x . d e E n fe r m e r ia

O tro

E s tu d ia n te
E m p ric a o p a rte r a
F a m ilia r
O tro

NEONATO

P a rto o L e g ra d o
u te r in o a te n d id o p o r :
____________________
____________________
____________________
N e o n a to a te n d id o p o r :
____________________
____________________

N o. H C R N : ________________________________________________
N O M B RE RN : ______________________________________________

R e c i n N a c id o
Sexo :

Fem .

T a lla :

M as.
m m

Edad por
:
E x .F s ic o

P .C e f. :

sem

< 37

m m

APGAR:
1'

P e s o x E d a d G e s ta c io n a l :
Adecuado

< 2500 g

Peso :

Pequeo

G ra n d e

5'

< 1500 g

Tem p

4 - 7

0 - 3

E x m e n V IH :

R e a n im a c i n
R e s p ir a to r ia :

No

S .L u tic a R N :
V D R L /R P R
E x a m . F s ic o :

B o ls a y
M s c a ra

O x ig e n o

C o n ta c to p ie l
a p ie l

Si

No

Si

Si

No

No

N o A p lic a

S in
d a to

No

Si

T ip o d e S a n g r e
G ru p o : A
Rh :

Rh +

In t u b a c .
e n d o tra .

N o s e h iz o
A n o rm a l

N o rm a l

A lo ja m ie n to :
C o n ju n to
H o s p ita liz a c . :
N e c r o p s ia

N o s e h iz o

AB
Rh -

N o s e h iz o
N o s e h iz o

Vacunas RN
V ita m in a K :

Si

No

BCG :

Si

No

P r o fila x is O c u la r : S i

No

P o lio :

Si

No

P a to lo g a s R e c i n N a c id o

S in p a to lo g a s

Fecha:

1. _________________________________

_ _ _ /_ _ _ /_ _ _

2. _________________________________

_ _ _ /_ _ _ /_ _ _

3. _________________________________

_ _ _ /_ _ _ /_ _ _

O tr a s (C IE 1 0 )
1:
2:

H o r a s /d a s p o s t p a r to o a b o r to
T e m p e ra tu ra
P u ls o ( la tid o s /m in u t o )
T e n s . A r t e r ia l m a x /m in .(m m .H g )
In v o lu c i n u t e r in a
C a r a c te r s t ic a s d e L o q u io s
H e r id a o p e r . ( a b d o m in a l/p e r in )
O b s e r v a c io n e s

E g re s o R N
E g re s o :

F e c h a : _ _ /_ _ /_ _ _ _ :_ _
Con
P a t o lo g ia

Sano

T ra s la d o

F a lle c e
N o A p lic a

D x . F a lle c im .

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

D x . T r a s la d o

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E s ta b l.T r a s l.

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A lim e n to :
Peso :

Pecho
S o lo

P e c h o y A r tific ia l

A r t if ic ia l
s o lo

No
A p lic a

R e in g re s o R N

F e c h a : _ _ /_ _ /_ _ _ _ :_ _

R e in g r e s o :

Si

No

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

D ia g n s t.

F e c h a e g re s o : _ _ _ /_ _ _ /_ _ _ _ _ _ :_ _ _
E g re s o :

Con
P a to lo g ia

S ano

T ra s la d o

F a lle c e

D x . F a lle c im .

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

D x . T r a s la d o

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E s ta b l.T r a s l.

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C o n tro l d e l R N :

Si

No

F e c h a : _ _ _ /_ _ _ / _ _ _

E g re s o M a te rn o
_ _ :_ _
Sano
E g re s o :

F e c h a : _ _ /_ _ /_ _
Con
P a to lo g ia

T ra s la d o

F a lle c e
N o A p lic a

D x . F a lle c im .

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

D x . T r a s la d o

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E s ta b l.T r a s l.

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A n tic o n c e p tiv o s
A b s tin e n c ia P e r i d ic a
Condn
D IU
L ig a d u r a T u b a ria
M ELA

:
:

P r o g e s t g . In y e c ta b le s :
P ro g e s t g . O r a le s
:
S lo C o n s e je r a
:
N in g u n o
:
O tro
:

:
:
:

R e in g r e s o M a te r n o F e c h a : _ _ /_ _ /_ _
_ _ :_ _
R e in g r e s o :
No
D ia g n s t.

Si

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

F e c h a e g re s o : _ _ _ /_ _ _ /_ _ _ _ _ _ :_ _ _
E g re s o :

Sano

Con
P a to lo g ia

T ra s la d o

F a lle c e

D x . F a lle c im .

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

D x . T r a s la d o

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E s ta b l.T r a s l.

:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C o n tr o l P u e r p e r a l :

Si

No

F e c h a : _ _ /_ _ /_ _

N o A p lic a
N o A p lic a