ASUHAN KEBIDANAN PADA IBU KELUARGA BERENCAANA

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NO.REGISTER

MASUK BPM TANGGAL,JAM

Biodata : Ibu Suami

Nama :

Umur :

Agama :

Suku/Bangsa :

Pendidikan :

Pekerjaan :

Alamat :

No.telp/HP :

DATA SUBJEKTIF

1. Alasan datng ke klink

KB : ........................................................................................
Yang mengantar
: ..................................................................................
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2. Riwayat menstruasi
Menarche ............tahun,siklus ................. hari,
lamanya ............. hari, banyaknya ......
Sifat darah ................warna ........................
HPHT ............................
3. Riwayat perkawinan
Status perkawinan : ...............................................
Kawin ke : ...............................................
Lamanya perkawinan : .............................................. tahun
4. Riwayat obstetric yang lalu
o Riwayat seluruh kehamilan
Gravida : ................... kali
Partus : .................... kali
Abortus : ...........................
Lahir hidup : ...................... orang
Lahir mati : ...................... orang

o R iwayat persalinan terakir / aborsi terakhir

Tanggal persalinan terakhir
: .......................................
Jenis persalinan : .......................................
 Apakah sedang menyusui :
5. Riwayat KB sebelumnya
Dalam 2 tahun trakhir apakah ada memakai kontrasepsi

Ya Tidak

Bila Ya, jelaskan masing-masing

No Metode Lama Pemakaian Alasan Penghentian

Metode Komtrasepsi
1 PIL
2 IUD
3 Injeksi / suntikan
4 Kondom
5 Dll
6. Riwayat medis sebelumnya
o Sedang mendapat pengobatan jangka panjang
o Saat ini sedang menderita penyakit kronis
7. Riwayat social
o Merokok : .....................................
o Minuman keras : ...............................
8. Riwayat ginekologi
o Tumor ginekologi : .........................................
o Operasi ginekologi yang pernah dialami : ........................
o Penyakit kelamin : ..................................
GO : ........................................
Siphilis : ........................................
Herpes : ........................................
Keputihan : ........................................
9. Riwayat kesehatan yang lalu
- DM ( Diabetes Melitus ) : ........................................
- Jantung : ........................................
- Hepatitis : ........................................
- Hipertensi : ........................................
- TBC : ........................................

DATA OBJEKTIF

1. Pemeriksaan fisik
a. Status generalis :
b. Tanda vital :
TD :
HR :
RR :
Suhu :
1. Pemeriksaan Khusus Obstetri
a. Abdomen : pembesaran : .....................................
b. Pemeriksaan vagina
VT : Tumor : ....................................
Posisi rahim :.................................
Inspekulo : Tanda-tanda peradangan : ..................................

CATATAN PERKEMBANGAN

Tanggal .......................... jam ................................

DATA SUBJEKTIF

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DATA OBJEKTIF

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ANALISA

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PENATALAKSANAAN

Tanggal ................................ jam ...............................

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Tanda Tangan