Status RSU UKI/Obstetri/Obgyn RSU UKI/04.

10

No. MR
RUMAH SAKIT UMUM UKI
SMF OBSTETRI GINEKOLOGI
Jl. Mayjen Sutoyo No. 2, Cawang, Jakarta 13630
Tel. ( 021 ) 8092317 ext. 205 / 108

STATUS OBSTETRI

IDENTITAS
PASIEN
Nama
Umur
Pendidikan
Pekerjaan
Agama
Suku Bangsa
Alamat

: ...........................................
: ...........................................
: ...........................................
: ...........................................
: ...........................................
: ...........................................
: ...........................................
...........................................
...........................................
...........................................

SUAMI / ORANG TUA / KELUARGA

Nama
: ................................................
Umur
: ................................................
Pendidikan
: ................................................
Pekerjaan
: ................................................
Agama
: ................................................
Suku Bangsa
: ................................................
Alamat
: ................................................
................................................
................................................
................................................

Tanggal masuk RS

: ........................................................

Jam

: .....................

Asal Pasien

: datang sendiri / poli umum / poli spesialis / konsul bagian lain / rujukan
Oleh : .........................................................................................................

I.

SUBJEKTIF ( Primer Sekunder )

1.

Keluhan utama :
....................................................................................................................................................

2. Keluhan tambahan :
1.
2.
3.
4.
5.

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

3. Kronologi keluhan / penyakit sekarang

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

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4. Riwayat Haid
Haid pertama umur
Siklus : teratur / tidak teratur
Lamanya
Banyaknya
Haid pertama haid terakhir
Lamanya
Banyaknya
Taksiran persalinan
Sakit saat haid ( dismenorea )
5

6.

Riwayat perkawinan
a. Status pernikahan
jika menikah
b. Lama perkawinan yang terakhir

: ............................................................................tahun
: ..................................................................hari / bulan
: ..............................................................................hari
: .................................................................................cc
: ....................................................................................
: ..............................................................................hari
: ................................................................................cc
: ....................................................................................
: ....................................................................................

: menikah / tidak menikah / janda

: 1 / 2 / 3 / 4 / 5 kali
: ................................................................bulan / tahun

Riwayat kehamilan persalinan, nifas yang lalu

No.

Usia Kehamilan

Jenis Persalinan

BBL

Jenis

Usia

Kelamin

Sekarang

1
2
3
4
5
6
7
8

7.

Riwayat penyakit dahulu

No.

Kelainan Berdasarkan Sistem

SSP

Kardiovaskuler

Traktus Respiratorius

Traktus Gastrointestinal

Traktus Urogenital

Hematologi

Imunologi / Metabolik

dll ........................................

Status RSU UKI /Obstetri/Ginekologi RSU UKI / 04.10

Keterangan ( jika ada )

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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

8.

Riwayat penyakit dalam keluarga

No.
1
2
3
4
5
6
7
8

9.

Kelainan Berdasarkan Sistem

SSP
Kardiovaskuler
Traktus Respiratorius
Traktus Gastrointestinal
Traktus Urogenital
Hematologi
Imunologi / Metabolik
dll ........................................

Keterangan ( jika ada )

Riwayat Operasi
No.
1
2
3
4

Jenis Operasi

Tahun

Keterangan

10. Metode Keluarga Berencana

Jenis

Tahun

Tidak KB
Hormonal ( pil, suntik, susuk )
IUD ( lipes, loops, cooper T, ... )
Kondom
Alamiah ( kalender , interuptus )
Kontap
Lain - lain
11. Riwayat antenatal
Waktu hamil periksa di : Oleh : .......................
Keluhan, kelainan, dan masalah :

Waktu
ANC

12.

Usia
Kehamilan

Tempat

Masalah

Penatalaksanaan

Hal hal lain ( data sekunder lain / Informasi lain yang berhubungan dengan obstetri dan
ginekologi )

...
...
...
...
...
...
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...

II. OBJEKTIF
A.

PEMERIKSAAN UMUM / STATUS GENERALIS

Tinggi badan

: .................................................................................................cm

Berat badan

: ..................................................................................................kg

Keadaan umum

: ..

Kesadaran

: ..

.
1. Tanda vital
Tekanan darah

: ...mmHg

Nadi

: ...........................................................................kali / menit

Suhu

: ................................................................................................. C

Pernafasan

: ..........................................................................kali / menit

2. Kepala
Mata

i. Konjungtiva

: .....

ii. Sklera

: .....

Gigi

: ..........

THT

: ......
......
......

3. Leher

: ..........
..

4. Thorax
a.

Payudara : ..
..
..

b.

Jantung

: ..
..
..

c.

Paru

: ..
..
..

5. Abdomen :
a.

Inspeksi

: ..
..

b.

Palpasi

: ..
..

c.

Perkusi

: ..
..

d.

Auskultasi : ..

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..
8. Ekstremitas :
a.

Superior

: ..
..
..

b.

Inferior

: ..
..
..

B. PEMERIKSAAN OBSTETRIK
1. Pemeriksaan Luar
a.

Inspeksi
...
...
...
...
...

b.

Palpasi
TFU

: ......cm

Lingkar perut

: ......cm

1. LeopoId I :
.........
.........
.........
.........
Leopoid II :
.........
.........
.........
.........
Leopoid III :
.........
.........
.........
.........
Leopoid IV :
.........
.........
.........
.........
2. Perabaan kepala ( perlimaan ) : 5/5. 4/5, 3/5, 2/5, 1/5
3. HIS
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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

Frekuensi
Lamanya
Kekuatan
Relaksasi

c.

: .....x / 10 menit
: ....detik
: kuat / kurang kuat
: - ada / tidak ada
- lamanya :

Auskultasi
Detak Jantung Janin ( DJJ )
i. Frekuensi
: ....
ii. Irama
: teratur / tidak teratur

2. Pemeriksaan dalam
a. Inspekulo (atas indikasi : .........)
i. Fluor
:+/jika positif :
Warna : putih bening / putih encer /
Putih bergumpal-gumpal / kekuning-kuningan
ii. Fluksus

: + / - ( mengalir aktif : + / - )
....
....

iii. Vulva / urethra / vagina : ....

....

iv. Portio

: ukuran
Warna

: ..
..
: ..
..

b. Perabaan melalui vagina / Vaginal Toucher ( atas indikasi : ......)

i.

Vulva / vagina

: ....
....

ii. Portio
:
Axis
Konsistensi
Penipisan ( effacement )
Pembukaan

: ...
: ...
: ...
: ...

iii. Ketuban

: utuh / tidak utuh

jika tidak utuh, jenis cairan : jernih / mekonium / keruh
iv. Bagian terendah janin : kepala / bokong / bokong kaki / kaki / lintang
turunnya bagian terendah : Hodge I / II / III / IV
denominatior : .

Status RSU UKI /Obstetri/Ginekologi RSU UKI / 04.10

caput

: .

moulage

: .

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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

v. Taksiran Berat Janin ( TBJ )

: .......................................................................gr

3. Pemeriksaan tambahan / khusus

a. Pemeriksaan panggul / pelvimetri klinik ( dilakukan / tidak dilakukan ) :
i.

Pintu atas panggul ( inlet )

Promontorium

: teraba / tidak teraba

Conjugata Diagonal

: .........................cm,

Linea Terminalis

: ...............................................................................

CV : ............................cm

Kesan : sempit / tidak sempit

ii.

Bidang tengah panggul ( midpelvik )

Sakrum

: ..............................................................................

Dinding panggul

: ..............................................................................

Spina ischiadica

: ..............................................................................

Kesan : sempit / tidak sempit

iii.

Pintu bawah panggul ( outlet )

Os. Coccygeus

: ..............................................................................

Arkus Pubis

: ..............................................................................

Kesan : sempit / tidak sempit

Kesan panggul

Panggul tidak sempit

Panggul sempit relatif
Panggul sempit absolut

b.

Pemeriksaan panggul dengan kepala bayi

Pemeriksaan Osborn

: + / - , teraba kepala ..........................................cm

Pemeriksaan Muller Monro Kerr : + / Imbang Feto Pelvik

Proporsional
CPD ringan / suspek CPD
CPD

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c. Pemeriksaan Pelvic Score / Bishop Score

Pembukaan serviks ( cm )
Penipisan ( effacement )
Penurunan kepala
Konsistensi serviks
Posisi serviks

4.

0
0
0 30 %
-3
keras
posterior

1
1-2
40 50 %
-2
sedang
medial

2
3-4
60 70 %
-1
lunak
anterior

3
56
80 %
+1- +2
Total

Nilai

Pemeriksaan laboratorium dan pemeriksaan penunjang

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

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Catatan :
0 3 = resiko rendah
3 5 = borderline
> 5 = resiko tinggi

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III. ASSESMENT

A. DIAGNOSIS KERJA
Ibu

: ...................................................................................................................................
....................................................................................................................................

Janin

: ...................................................................................................................................
....................................................................................................................................

B. PROGNOSIS
Kehamilan : ..............................................................................................................................
Persalinan : ..............................................................................................................................
C. DAFTAR MASALAH
1.

..............................................................................................................................................

2.

..............................................................................................................................................

3.

..............................................................................................................................................

4.

..............................................................................................................................................

5.

.............................................................................................................................................

6.

.............................................................................................................................................

IV. PLANNING
1.

Rencana pemeriksaan untuk konfirmasi diagnosis

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

2.

Rencana pengobatan / penatalaksanaan khusus

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

3.

Rencana pendidikan / inform consent

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

Nama dokter muda : .....................................................

Dokter Jaga / Dokter Konsulen Obgin
Jakarta, ........................................................

(...................................................................)

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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

PEMANTAUAN PERSALINAN
( kala I,II,III,IV)

Tanggal

Waktu

Status RSU UKI /Obstetri/Ginekologi RSU UKI / 04.10

Follow up

Nama dan
tanda tangan

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Status RSU UKI/Obstetri/Obgyn RSU UKI/04.10

Keadaan ibu post partum :

Keadaan umum

: ............................................................................................................................

Kesadaran

: ............................................................................................................................

Tekanan darah

: ................................................................................................................ mmHg

Nadi

: ............................................................................................................. x / menit

Pernafasan

: ............................................................................................................. x / menit

Suhu

: ...................................................................................................................... C

Perdarahan :
Kala I

: .............................................................................................................................. cc

Kala II

: .............................................................................................................................. cc

Kala III : .............................................................................................................................. cc

Kala IV : .............................................................................................................................. cc
Total

: .............................................................................................................................. cc

Bayi :
Jenis kelamin

: laki laki / perempuan, hidup / mati

Nilai Apgar

: ...............................................................................................................

Panjang

: ......................................................................................................... cm

Berat badan

: ........................................................................................................... gr

Anus

:+/-

Kelainan kongenital mayor

:+/-

Hal hal lain

: ...............................................................................................................

Plasenta :
Ukuran

: ............................. x ....................................... x ............................. cm

Panjang tali pusat

: ......................................................................................................... cm

Insertio

: sentralis / marginalis / parasentralis

Berat

: ........................................................................................................... gr

Kelainan kelainan

: ...............................................................................................................

Nama dokter muda : .....................................................

Dokter Jaga / Dokter Konsulen Obgin :
Jakarta, ............................................................

(.......................................................................)

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