PEMERINTAH KABUPATEN BIMA

DINAS KESEHATAN
PUSKESMAS LAMBITU
JL. Lintas Lambitu, Desa Kuta, Kec. Lambitu, Kab. Bima, 84181

STATUS KEBIDANAN RM 014-PKM

A. DATA DASAR PASIEN
 Nama : .....................................................................
 Jenis Kelamin : Perempuan
 Umur : .....................................................................
 Alamat/No.Hp : .....................................................................
 Pekerjaan : .....................................................................
 Jenis Pelayanan : UMUM / JKN (KIS,ASKES,PBI,MANDIRI)
 Tanggal Masuk Puskesmas / Dirawat : ....................................................................
 Anamnesis : .....................................................................
..........................................................................................................................................
 Keluhan Utama : .....................................................................
 Riwayat Perjalanan Penyakit : .....................................................................
 Riwayat Perkawinan : .....................................................................
 Riwayat Obstetrik : G...P...A...M...

TEMPAT USIA JENIS JENIS KEADAAN

NO TAHUN BERAT ANAK
BERSALIN KEHAMILAN PERSALINAN KELAMIN

 Riwayat Penyakit /Operasi yang pernah diderita :

Anemia Diabetes Tuberkulosis Lain-lain
Penyakit Kelamin Alergi Sakit Ginjal
Asthma Jantung Hepatitis
Operasi : 1. ........................................
2. ........................................
 Riwayat Kehamilan Sekarang :
HPHT :.....................................TP :...................................Total Periksa Hamil :......kali
USG :..............kali, Taksiran Persalinan Oleh Dokter Tanggal :....................................
 Riwayat Persalinan Sekarang :
His mulai Tgl : ...................................................Jam : ............WIB
Darah Lendir Sejak Tgl : ...................................................Jam : ............WIB
Ketuban: a. Utuh
b. Pecah Tgl : ...................................................Jam : ............WIB
c. Sudah Pecah Tgl : ...................................................Jam : ............WIB
B. PEMERIKSAAN FISIK PASIEN KEBIDANAN
 Keadaan Umum : ...........................................- Urine : - HCG test : + / -
 Kesadaran : ...........................................- Protein Urine :
 Berat Badan : ...............kg Hb : .............g/dl
 Tinggi badan : ...............cm Lakmus : + / -
 Tekanan Darah : ...............mmhg
 Nadi : .........x/mt
 Pernapasan : .........x/mt
 Suhu : .........°C
 Leopold I : ………………………………..TFU :…. ...........cm
 Leopold II : ………………………………..DJJ : .............. x/m
 Leopold III : ................................................................................
 Leopold IV : ................................................................................
 TBBJ : ............gr
 HIS : ...................mt/kali, lamanya : .....detik,
 Pemeriksaan Dalam / VT : Pembukaan : .............................................
Portio : .............................................
Bag Terbawah : .............................................
Hodge : .............................................
Ketuban : .............................................
Lain-lain : .............................................
 Hasil Pemeriksaan Panggul: Baik / Sempit
 Diagnosa Sementara : .................................................................................
 Tindakan / Terapi : .................................................................................
- IVFD ....................................................................Gtt........./ Menit ( Makro/Mikro )
........................................................................................................................................................
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Bidan Jaga : ....................................................................................................

Lambitu, 2019

Penanggung Jawab Kebidanan Dokter Jaga

(…………………………….) dr. Moh. Arif Kurniawan Taufiq