VII.

STATUS OBSTETRIK/GYNEKOLOGI

STATUS OBSTETRI / GINEKOLOGI

TFU :........cm His: ........x/10 menit Kontraksi : Ada DJJ:
TBJ :........Gram : Tidak ada .....Dpm
Leopold Janin Tunggal / Gemeli,.......................................*)
Letak O / /................................................................*)
Bagian bawah 1/5 2/5 3/5 4/5 5/5 *)
Masuk panggul
INSPEKSI

INSPEKULO

VT

RT

VIII. PEMERIKSAAN PENUNJANG

USG :................................................................................................

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NST :................................................................................................

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Laboratorium:..............................................................................................

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IX. DIAGNOSA KERJA

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*)lingkari yang sesuai

 X. DIAGNOSIS BANDING.............................................................................
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XI. PERENCANAAN PELAYANAN......................................................................

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XII. PROGNOSIS
Ad sanationam ........................................................................................
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Ad vitam ........................................................................................
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Ad functionam ........................................................................................
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XIII. MASALAH KEBIDANAN/KEPERAWATAN..................................................

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XIV. INTERVENSI KEBIDANAN/KEPERAWATAN..............................................

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XV. OBSERVASI

Jam Suhu Kesadaran Nadi TTD FP Jam Suhu Kesadaran Nadi TTD FP

JAM NAMA OBAT DOSIS CARA PEMBERIAN PARAF

JAM NAMA CAIRAN TETESAN CAIRAN CAIRAN MASUK PARAF

ADA/SISA

XVI. HASAIL PENANGANAN DI UGD

Pulang untuk berobat
Observasi
Dirawat di RSUD Bangil untuk penanganan ke:SKD/LRS/SBD/MHD/TTD *)
Meninggal di UGD (penyebab kematian..............................................................)
Pulang atas permintaan pasien
Dirujuk ke.................................................................................................

Atas dasar: Diantar oleh:

Tempat penuh Ambulans RSUD Bangil
Perlu fasilitas lebih baik Ambulans lain
Permintaan pasien

Dokter pemeriksa Bidan pemeriksa

(dr.........................................) (.......................................)
Nama jelas Nama jelas