KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
HIMPUNAN MAHASISWA PRODI
PROGRAM STUDI D-III KEBIDANAN KEDIRI
TAHUN 2014/2015
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website :http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email :direktorat@poltekkes-malang.ac.id Kediri 64114

FORMAT ASUHAN KEBIDANAN KB

PENGKAJIAN

Tanggal : Jam :

No. RM :

Nama : Nama Suami :

Umur : Umur :

Agama : Agama :

Pendidikan : Pendidikan :

Alamat : Alamat :

Cara Masuk :

Datang sendiri Rujukan dari :

Diagnosa :

A. DATA SUBJEKTIF
1. Keluhan utama : ......................................................

2. Riwayat menstruasi

- Usia manarche : ............. tahun - Lama haid :............ hari

- Jumlah darah haid : .............. softex/hari - Fluor albus : ...........
- HPHT : - TP :
- Keluhan saat haid :
Dismenorhoe Spoting Menorrhagia Premenstrual syndrome
Dll..........

3. Riwayat kehamilan, persalinan, dan nifas yang lalu.

G ................. P ................ A ............. Hidup ..................
 Umur Jenis Penolong Keadaan
N Tgl,th Tempat Anak
kehamila persalina persalina Penyulit anak
o partus partus JK/BB
n n n sekarang

4. Riwayat KB dan rencana KB

Metode yang pernah dipakai : ..................., Lama : .................bulan/tahun
Komplikasi dari KB : ..................., Rencana KB selanjutnya : .................
5. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS Endometriosis
Polip serviks Kanker kandungan Opersai kandungan Perkosaan
DUB dll

B. DATA OBJEKTIF
1. PEMERIKSAAN FISIK
Pemeriksaan umum
- Keadaan umum : .................. - kesadaran : ...............
- BB/TB : .......kg/......cm - Tekanan darah : .........mmHg
- Nadi : ............x/menit - Suhu : .........o C
- Pernafasan : ............x/menit
2. Pemeriksaan fisik
- Mata : Konjungtiva : anemis/tidak Sklera : ikterik/tidak
Pandangan kabur adanya pemandangan dua
- Leher : adanya pembesaran vena jugularis/tidak, adanya pembesaran kelenjar
tyroid/tidak.
- Dada : tumor
- Axilla :
- Sistem cardio : nyeri dada murmur palpitasi
3. Pemeriksaan khusus
a. Ginekologi
Inspekulo : vagina (cairan/darah dan luka), porsio : (licin/berdungkul, cairan/darah,
luka/lesi.

C. ANALISIS/INTERPRETASI DATA
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 PENATALAKSANAAN
Tanggal : ........................ Jam : .................................
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Kediri,............................
Pembimbing Praktik Mahasiswa

.................................................... ......................................................
NIP. NIM.
NIP. NI
Dosen Pembimbing

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NIP.