AKADEMI KEBIDANAN HELVETIA MEDAN

FORMAT PENDOKUMENTASIAN MANAJEMEN KEBIDANAN

PADA IBU HAMIL

NO. REGISTER : 00000566................................................................................

MASUK RS TANGGAL/JAM : 20-06-2012 jam 01.00 WIB....................................................
DIRAWAT DIRUANG : Ruang Mawar..........................................................................

Biodata Ibu Ayah

Nama : Ny. M......................................... Tn. R...............................................
Umur : 23 tahun...................................... 25 tahun...........................................
Agama : Islam........................................... Islam................................................
Suku/Bangsa : Jawa/ Indonesia.......................... Jawa/ Indonesia...............................
Pendidikan : SMA........................................... SMA................................................
Pekerjaan : IRT............................................. Wiraswasta......................................
Alamat : Jln. Merdeka............................... Jln.Merdeka.....................................
No. Telepon/HP : ................................................... .........................................................

I. DATA SUBJEKTIF
1. Kunjungan saat ini : Kunjungan Pertama Kunjungan Ulang
Keluhan Utama
Ibu mengatakan ingin memeriksa kehamilannya dan sakit kepala dan mengeluh kepala
terasa pusing .
2. Riwayat Perkawinan
Kawin 1 kali. Kawin pertama umur 22 tahun. Dengan suami sekarang 1 tahun

3. Riwayat Menstruasi
Menarche umur 13 tahun. Siklus 28 hari. Teratur/Tidak.
Lama 7 Hari. Sifat darah : encer/beku. Bau khas Fluor albus : ya/tidak
Dismenorroe : ya/tidak. Banyaknya tidak terkaji cc
HPHT 13-12-2011 TTP 20-09-2012

4. Riwayat Kehamilan ini

a. Riwayat ANC
ANC sejak umur kehamilan .5 Minggu. ANC di klinik.
Frekuensi : Trimester I 1 kali
Trimester II ...2.. kali
Trimester III ..1. kali
b. Pergerakan janin yang pertama pada umur kehamilan 20. minggu, pergerakan
janin dalam 24 jam terakhir 13. Kali
c. Keluhan yang dirasakan
Ibu mengatakan pusing di kepala dan terasa sakit di kepala.....................................
....................................................................................................................................
d. Pola nutrisi Makan Minum
Frekuensi 3x................................... 6-7 x sehari.................
Macam nasi+lauk+pauk............. air putih+teh manis....
Jumlah 1 porsi habis.................. 7-8 gelas.....................
Keluhan tidak ada........................ tidak ada.....................
Pola Eliminasi BAB BAK
Frekuensi 1x sehari........................ 5-6x sehari..................
Warna kuning........................... kuning jernih..............
Bau khas............................... khas............................
Konsistensi lunak.............................. cair..............................
Jumlah ....................................... ....................................
Pola aktivitas
Kegiatan sehari-hari : melakukan pekerjaan rumah...............................................
Istirahat/tidur : siang kurang lebih 2 jam, malam 6 jam..............................
Seksualitas : Frekuensi 1x seminggu......................................................
Keluhan tidak ada...............................................................
e. Personal Hygiene
Kebiasaan mandi 2 kali/hari
Kebiasaan membersihkan alat kelamin setiap habis BAB dan BAK........................
Kebiasaan mengganti pakaian dalam setiap kkali lembab.........................................
Jenis pakaian dalam yang digunakan kain katun.......................................................
f. Imunisasi
TT 1 tanggal 12-01-2012............................
TT 2 tanggal 05-03-2012............................
TT 3 tanggal ...............................................
TT 4 tanggal ...............................................
TT 5 tanggal ...............................................
5. Riwayat kehamilan, persalinan dan nifas yang lalu
G1 ... P1 ... Ab0 .. Ah0 .
Penulisan Nifas
Hami Tgl Umur Jenis Komplikas Jenis BB
Penolon Laktas Komplikas
l ke Lahi Kehamila Persalina i Kelami Lahi
g Ibu Bayi i i
r n n n r
H A M I L I N I

6. Riwayat kontrasepsi
Mulai Memakai Berhenti/Ganti Cara
Jenis
No Keluha
kontrasepsi Tanggal Oleh Tempat Tanggal Oleh Tempat Keluhan
n
T I D A K A D A

7. Riwayat Kesehatan
a. Penyakit sistematik yang pernah/sedang diderita
Tidak ada....................................................................................................................
....................................................................................................................................
b. Penyakit yang pernah/sedang diderita
Tidak ada....................................................................................................................
....................................................................................................................................
c. Riwayat keturunan kembar
Tidak ada....................................................................................................................
....................................................................................................................................
d. Kebiasaan-kebiasaan
Merokok tidak ada.....................................................................................................
Minum jamu-jamuan tidak ada..................................................................................
Minum-minuman keras tidak ada..............................................................................
Makan/minum pantang tidak ada...............................................................................
Perubahan pola makan (termasuk ngidam, nafsu makan turun, dan lain).................
Tidak ada....................................................................................................................
 8. Keadaan Psiko Sosial Spiritual
a. Kelahiran ini : Diinginkan Tidak Diinginkan
b. Pengetahuan ibu tentang kehamilan dan keadaan sekarang :
Ibu sudah mengerti tentang kehamilannya................................................................
....................................................................................................................................
c. Penerimaan ibu terhadap kehamilan saat ini
Ibu sangat senang terhadap kehamilannya.................................................................
....................................................................................................................................
d. Tanggapan keluarga terhadap kehamilan
Suami dan keluarga sangat senang terhadap kehamilannya......................................
....................................................................................................................................
e. Ketaatan ibu dalam beribadah
Ibu taat beribadah.......................................................................................................
....................................................................................................................................
II. DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umumbaik. Kesadaran compos mentis.......................
b. Tanda vital :
Tekanan darah : 140/90..................mmHg
Nadi : 84x/ i....................kali per menit
Pernafasan : 20x/i.....................kali per menit
Suhu : 36..........................oC
c. TB : 156........................ cm
BB : sebelum hamil 55 kg, BB sekarang 60. kg
d. Kepala dan leher :
Edema wajah : tidak ada.................................................................................
Cloasma gravidarum +/ -
Mata : sklera tidak icterus, conjungtiva merah jambu......................
Mulut : bersih, gigi utuh dan tidak ada carises pada gigi...................
Leher : tidak ada pembengkakan kelenjar typoid dan limpa..............
Payudara
Bentuk : simetris...................................................................................
Aerola Mammae : hiperpigmentasi......................................................................
Putting susu : menonjol................................................................................
Colostrum : belum keluar...........................................................................
e. Abdomen
Bentuk : asimetris.................................................................................
Bekas luka : tidak ada.................................................................................
 Striae gravidarum : ada..........................................................................................
Palpasi Leopold
Leopold I : TFU=25 cm, pertengahan pusat.............................................

Leopold II : bagian kanan teraba panjang memapan dan kiri teraba bagian
terbawah janin........................................................................
Leopold III : teraba bagian bulat, keras melenting dan bergerak................
Leopold IV : kedua tangan konvergen, bagian terendah janin belum masuk
PAP.........................................................................................
Osborn test : (-)............................................................................................
TBJ :
Aukultasi DJJ : Punctum maksimum Kuadran kanan bawah pusat................
Frekuensi : 140 kali per menit (12/11/11)
f. Ekstremitas :
Edema : tidak ada.................................................................................
Varices : tidak ada.................................................................................
Refleks patella : +/= KA-KI..............................................................................
Kuku : Pendek , bersih.......................................................................
g. Genetalia luar
Tanda chadwich : ada..........................................................................................
Varices : tidak ada.................................................................................
Bekas luka : tidak ada.................................................................................
Kelenjar bartholini : tidak tampak pera

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III. ASSESSMENT
1. Diagnosis Kebidanan
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2. Masalah
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3. Kebutuhan
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4. Diagnosis Potensial
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5. Masalah Potensial
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6. Kebutuhan Tindakan Segera Berdasarkan Kondisi Klien
a. Mandiri
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b. Kolaborasi
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c. Merujuk
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IV. PLANNING (Termasuk Pendokumentasian Implentasi dan Evaluasi)

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CATATAN PERKEMBANGAN
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DATA SUBJEKTIF
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ASSESSMENT
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PLANNING
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TT. CI Klinik/RB/RS Tanda Tangan Mahasiswa

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