DOKUMENTASI ASUHAN KEBIDANAN PADA IBU HAMIL (ANC)

UPT PUSKESMAS BENDA KOTA TANGERANG

Hari/TGL : .................................................. Nama Petugas : ............................................................

Tempat Pelayanan : POLI KIA / POSYANDU / RUMAH

I. DATA SUBYEKTIF
Nama Ibu : ................................................... Nama suami : ..........................................................
Umur : ................................................... Umur : ..........................................................
Pekerjaan : ................................................... Pekerjaan : ..........................................................
Agama : ................................................... Pendidikan Terakhir Ibu : .............................................
Alamat : ........................................... Kel. ............................. Kec. ....................... Kota Tangerang
Keluhan : ....................................................................................................................................................

RIWAYAT OBSTETRIK :
HPHT : ................................................... TP : ..........................................................
Hamil ke .............. Jumlah Persalinan .............. Jumlah Keguguran .............. G ........ P ........ A ........
Jumlah anak hidup ............... Jumlah lahir mati ............... Jumlah anak lahir kurang bulan .......................... anak
Jarak kehamilan ini dengan persalinan terakhir ................ Penolong persalinan terakhir ......................................
Cara persalinan terakhir : Spontan / Normal Tindakan ........................................................................
Status Imunisasi TT / Td ................. Golongan darah.............................................................
Penggunaan Kontrasepsi sblm kehamilan ini .................... Riwayat Alergi ...............................................................
Riwayat penyakit yang diderita ibu .............................................................................................................................

II. DATA OBYEKTIF

Keadaan Umum : ........................ Kesadaran : ................................. Keadaan Emosional : ......................
TB : ................... cm BB Sebelum Hamil : ................ kg. BB sekarang : ................. kg
TD : ............. mmHg LILA : ............................ cm Oedema : ......................

Pemeriksaan Palpasi abdomen :

Leopold 1 : TFU : ............................................................., teraba .............................................................................
Leopold 2 : teraba ............................... di sebelah kiri ibu, teraba ............................................disebelah kanan ibu
Leopold 3 : teraba ........................................................................................................................................................
Leopold 4 : .................................................................., DJJ : ................. X/mnt, Teratur / Tidak Teratur

Pemeriksaan Laboratorium :
Urine : Protein Urine : ................................... , Reduksi Urine : .......................................................................
Darah : HB : ........................ g/dl, Gol. Darah : ............................., Tes HIV/AIDS : ......................................

Pemeriksaan Lain : ...........................................................................................................................

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III. ANALISA / DIAGNOSA

G ..... P ..... A ..... Hamil .......... minggu
Janin ............................................................................................................................................................................
Masalah : .................................................................................................................................................................

IV. PENATALAKSANAAN
1. Melaksanakan informed consent
2. Memberitahukan hasil pemeriksaan bahwa ........................................................................................................
..............................................................................................................................................................................
3. Memberikan penyuluhan tentang : .....................................................................................................................
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4. Memberikan : ......................................................................................................................................................
..............................................................................................................................................................................
5. Melakukan kolaborasi dengan BP Umum, BP Gigi, Gizi, dan Laboratorium
6. Menyepakati kunjungan ulang pada tanggal : .....................................................................................................

PETUGAS PELAKSANA TANDA TANGAN PERSETUJUAN TINDAKAN

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