LEMBAR OBSERVASI CATATAN PERKEMBANGAN KALA I

BPM TRI WAYATI Amd Keb – MANGUN REJO

HIS DALAM
TGL JAM DJJ TENSI SUHU NADI VT KET
10 ‘’
 LEMBAR PENAPISAN IBU BERSALIN
NAMA : .............................................. ALAMAT :............................................

NO KETERANGAN YA TIDAK
1 Riwayat bedah Saecar
2 Perdarahan per vaginam
3 Kehamilan kurang bulan
4 Ketuban pecah dengan mekonial
5 Ketuban pecah ( 24 jam )
6 Ketuban pecah pada kehamilan kurang bulan
7 ikteru
8 Anemia
9 Tinggi fundus uteri > 40 cm ( Makrosomi ) & Hamil
Kembar
10 Pre eklamsia berat
11 Demam Tinggi ( > 38 ®C )
12 Gawat Janin
13 Presentasi bukang Belakang kepala
14 Tali Pusat Menumbung
15 Primi Para pada fase aktif Persalinan dg kepala Masih
tinggi ( 5/5 )
16 Presentasi Ganda
17 Gemelli
18 Syok
19 HIV / AIDS

HASIL PEMERIKAAN FISIK :

TTV : BB / PB : ...../...... TENSI :.......... PERNAFASAN : .......... SUHU BADAN :............ NADI :............

PALPASI : ........................................................................................................................................................

........................................................................................................................................................

AUSCULTASI :..................................................................................................................................................

PEMERIKSAAN PENUNJANG :..........................................................................................................................

.........................................................................................................................

KEPANJEN :..................................................

BIDAN PEMERIKSA

(................................................)
 KARTU PEMERIKSAAN PERSALINAN
BIDAN PRAKTEK MANDIRI

TRI WAYATI Amd Keb - MANGUN REJO

NAMA IBU : ...................................... NAMA SUAMI :...............................................

TEMPAT TGL LAHIR : ...................................... UMUR : ...............................................

PEKERJAAN IBU : ...................................... PEKERJAAN SUAMI : ......................................

ALAMAT / NO TELEPONE : ...............................................................................................................

.........................................................................................................................

KEHAMILAN KE :............................................ HPHT : .................... HPL : ........................

RIWAYAT KEHAMILAN : ....................................................................................................................

RIWAYAT PERSALINAN : ...................................................................................................................

...................................................................................................................

...................................................................................................................

RIWAYAT PENYAKIT : ....................................................................................................................

KETERANGAN LAIN : ....................................................................................................................

....................................................................................................................

RIWAYAT PERSALINAN :

TANGGAL PERSALINAN : ......................................... JAM : ................. HARI : ................

KONDISI IBU : ..................................................................................................................................

...................................................................................................................................

KONDISI BAYI : .................................................................................................................................

..................................................................................................................................
 .0

STATUS PEMERIKSAAN PASIEN

BPM MANGUN REJO STATUS PEMERIKSAAN PASIEN
BPM MANGUN REJO
Nama :
Umur : Nama :
Alamat : Umur :
Alamat :
Keluhan yg dirasakan :
................................................................................. Keluhan yg dirasakan :
................................................................................. .................................................................................
.................................................................................
Hasil Pemeriksaan :
.................................................................................. Hasil Pemeriksaan :
.................................................................................. ..................................................................................
..................................................................................
Diagnosa :
.................................................................................. Diagnosa :
..................................................................................
Terapy :
1. Terapy :
2. 1.
3. 2.
4. 3.
4.
Pemeriksa
Pemeriksa
(.....................................)
(.....................................)

STATUS PEMERIKSAAN PASIEN STATUS PEMERIKSAAN PASIEN

BPM MANGUN REJO BPM MANGUN REJO

Nama : Nama :
Umur : Umur :
Alamat : Alamat :

Keluhan yg dirasakan : Keluhan yg dirasakan :

................................................................................. .................................................................................
................................................................................. .................................................................................

Hasil Pemeriksaan : Hasil Pemeriksaan :

.................................................................................. ..................................................................................
.................................................................................. ..................................................................................

Diagnosa : Diagnosa :
.................................................................................. ..................................................................................

Terapy : Terapy :
1. 1.
2. 2.
3. 3.
4. 4.

Pemeriksa Pemeriksa

(.....................................) (.....................................)
 STATUS PEMERIKSAAN PASIEN STATUS PEMERIKSAAN PASIEN
BPM MANGUN REJO BPM MANGUN REJO

Nama : Nama :
Umur : Umur :
Alamat : Alamat :

Keluhan yg dirasakan : Keluhan yg dirasakan :

................................................................................. .................................................................................
................................................................................. .................................................................................

Hasil Pemeriksaan : Hasil Pemeriksaan :

.................................................................................. ..................................................................................
.................................................................................. ..................................................................................

Diagnosa : Diagnosa :
.................................................................................. ..................................................................................

Terapy : Terapy :
1. 1.
2. 2.
3. 3.
4. 4.

Tgl :............................. Tgl : ............................

(Dr. Gladiar Ayu Pawintri) (Dr. Gladiar Ayu Pawintri)

STATUS PEMERIKSAAN PASIEN STATUS PEMERIKSAAN PASIEN

BPM MANGUN REJO BPM MANGUN REJO

Nama : Nama :
Umur : Umur :
Alamat : Alamat :

Keluhan yg dirasakan : Keluhan yg dirasakan :

................................................................................. .................................................................................
................................................................................. .................................................................................

Hasil Pemeriksaan : Hasil Pemeriksaan :

.................................................................................. ..................................................................................
.................................................................................. ..................................................................................

Diagnosa : Diagnosa :
.................................................................................. ..................................................................................

Terapy : Terapy :
1. 1.
2. 2.
3. 3.
4. 4.

Tgl :............................. Tgl :..............................

(Dr. Gladiar Ayu Pawintri) (Dr. Gladiar Ayu Pawintri)