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KARTU DETEKSI DINI KARTU DETEKSI DINI KARTU DETEKSI DINI

KANKER LEHER RAHIM & PAYUDARA KANKER LEHER RAHIM & PAYUDARA KANKER LEHER RAHIM & PAYUDARA

Puskesmas/Pustu/BPM...................... Puskesmas/Pustu/BPM...................... Puskesmas/Pustu/BPM......................

NIK : ................................ NIK : ................................ NIK : ................................


No Register : ................................ No Register : ................................ No Register : ................................
Nama : ................................. Nama : ................................. Nama : .................................
Umur : ................................ Umur : ................................ Umur : ................................
Alamat : ................................ Alamat : ................................ Alamat : ................................
Tanggal Pemeriksaan : ................................. Tanggal Pemeriksaan : ................................. Tanggal Pemeriksaan : .................................

Hasil penapisan Payudara Hasil penapisan Payudara Hasil penapisan Payudara


Normal Normal Normal
Benjolan Benjolan Benjolan
Kelainan Payudara lain ................................ Kelainan Payudara lain ................................ Kelainan Payudara lain ................................

Hasil Penapisan Leher Rahim Hasil Penapisan Leher Rahim Hasil Penapisan Leher Rahim
Normal Normal Normal
IVA (+) IVA (+) IVA (+)
Curiga Kanker Leher rahim Curiga Kanker Leher rahim Curiga Kanker Leher rahim
Kelainan ginekologi Lain.............................. Kelainan ginekologi Lain.............................. Kelainan ginekologi Lain..............................

Tindak lanjut Tindak lanjut Tindak lanjut


Kontrol ulang : Kontrol ulang : Kontrol ulang :

Terapi: ............................................. Terapi: ............................................. Terapi: .............................................

Dirujuk ke:.............................................. Dirujuk ke:.............................................. Dirujuk ke:..............................................

Nama petugas: ............................ Nama petugas: ............................ Nama petugas: ............................


No.Kontak person petugas : ............................. No.Kontak person petugas : ............................. No.Kontak person petugas : .............................
Hasil penapisan Payudara Hasil penapisan Payudara Hasil penapisan Payudara
Normal Normal Normal
Benjolan Benjolan Benjolan
Kelainan Payudara lain ................................ Kelainan Payudara lain ................................ Kelainan Payudara lain ................................

Hasil Penapisan Leher Rahim Hasil Penapisan Leher Rahim Hasil Penapisan Leher Rahim
Normal Normal Normal
IVA (+) IVA (+) IVA (+)
Curiga Kanker Leher rahim Curiga Kanker Leher rahim Curiga Kanker Leher rahim
Kelainan ginekologi Lain.............................. Kelainan ginekologi Lain.............................. Kelainan ginekologi Lain..............................

Tindak lanjut Tindak lanjut Tindak lanjut


Kontrol ulang : Kontrol ulang : Kontrol ulang :

Terapi: ............................................. Terapi: ............................................. Terapi: .............................................

Dirujuk ke:.............................................. Dirujuk ke:.............................................. Dirujuk ke:..............................................

Nama petugas: ............................ Nama petugas: ............................ Nama petugas: ............................


No.Kontak person petugas : ............................. No.Kontak person petugas : ............................. No.Kontak person petugas : .............................

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