RSUD TARAKAN JAKARTA Univ.

Kristen Krida Wacana (UKRIDA)

Jl. Kyai Caringin no 7, Jakarta Pusat Jl. Terusan Arjuna No. 6, Jakarta Barat

KEPANITERAAN KLINIK
STATUS ILMU KEBIDANAN DAN PENYAKIT KANDUNGAN

Nama : ……………………………………………………………… Tanda Tangan

Nim : ……………………………………………………………… …………………….

Dr. Pembimbing / Penguji : ……………………………………………..

………………………

Hari/Tanggal/Jam : …………………………………………

SUBYEKTIF
1. Identitas Pasien
Nama : ________________________________ Nama Suami /Keluarga: ____________________
Umur : ________________________________ Umur : __________________________
Pendidikan : __________________________ Pendidikan : __________________________
Pekerjaan : __________________________ Pekerjaan : __________________________
Agama : __________________________ Agama : __________________________
Suku / Bangsa : __________________________ Suku / Bangsa : __________________________
Alamat : ________________________________________________________________________
2. Keluhan Utama
____________________________________________________________________________
3. Keluhan Tambahan
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. Riwayat Penyakit Sekarang
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. Riwayat Penyakit Dahulu
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
6. Riwayat Penyakit Keluarga
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

7. Riwayat Haid
Haid pertama usia : …… thn
Siklus : teratur / tidak teratur Panjang Siklus : …. Hari
Lamanya : …… hari Jumlah darah : …. Softex per hari Nyeri Haid :
HTA / HPHT : TP :

8. Riwayat Perkawinan
Kawin : belum/sudah/cerai Kawin yang ke : ………. kali dengan suami sekarang sudah …… thn
Riwayat infertilitas : ada/tidak Lamanya : ……………… Thn : …………….
Riwayat berobat :

9. Riwayat Obstetrik : Gravida Para Abortus Hidup

Contoh :
1. G4 Pervaginam dengan EF, ditolong dokter, BBL 3200 g, hidup
2. Abortus spontan, UK 13 minggu, (2015)
3. SC a.i persalinan tidak maju, BBL 3500 g, † 1 tahun (2016)
4. Ini G4P2A1H1

1. 5.
2. 6.
3. 7.
4. 8.

10. Riwayat Kontrasepsi

Jenis …………………… Lama ………………………..

11. Hal-hal Lain / Kondisi Sosial Ekonomi / Psikologi

OBYEKTIF
A. Pemeriksaan Fisik Umum : Skala Nyeri

Keadaan Umum : ____________________ Keadaan Gizi : ____________________

Kesadaran : ____________________
TD : ___________ Nadi : _________ RR: __________ Suhu: ___________
TB : ___________cm BB : ____________Kg
Kepala :
 Dada :
Jantung :
Paru-paru :
Perut :
Ekstremitas:

B. Pemeriksaan Fisik Khusus / Status Ginekologi Umum

1. Status Genitalia Eksterna

a. Inspeksi Vulva / Uretra

b. Pertumbuhan rambut :
Kumis / Ketiak / Pubis
c. Payudara

d. Pemeriksaan Perut / Obstetri : (Leopold I – IV)

LI : L III :
L II : L IV :

Timbangan Berat Janin :

2. Status Genitalia Interna : Pemeriksaan Spekulum :
Portio :
Vagina :

Pemeriksaan bimanual / VT / RT :

C. Pemeriksaan Penunjang
1. Pemeriksaan non invasiv :
CTG / USG :
Radiologi :

2. Pemeriksaan Laboratorium / Invasiv :

3. Lain-lain : - Echo
- Patologi Anatomi
ANALISA Uraian Masalah :
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Daftar Masalah (termasuk diagnosis kerja dan diagnosis diferensial)

IBU :
1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ___________________________________________________________________________

4. ___________________________________________________________________________

BAYI :
1. ____________________________________________________________________________

2. ____________________________________________________________________________

PERENCANAAN
I. Rencana Diagnostik :
a. Observasi
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

b. Penegakkan diagnosis
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
c. Pemantauan terapi (frekuensi pemantauan dan target terapi)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

II. Rencana Terapi :

a. Terapi perilaku
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
b. Terapi nutrisi
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
c. Medikamentosa
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
d. Tindakan atau Operatif
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

RENCANA EDUKASI
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Prognosis
Ad vitam :

Ad functionam:

Ad sanactionam :

Edisi 15072018