FORMAT LAPORAN PRENATAL CARE (PNC)

PADA BAYI Ny...................DI RUANG

PUSKESMAS............................

Tanggal :

Jam :

Data Subjektif

1. Biodata
Nama :
Umur :
Agama :
Pendidikan :
Pekerjaan :
Alamat :
Nama Suami :
Umur :
Agama :
Pendidikan :
Pekerjaan :
Penghasilan :

2. Keluhan Utama
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3. Riwayat kesehatan yang lalu

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4. Riwayat kesehatan sekarang
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5. Riwayat penyakit keluarga

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6. Riwayat haid
Menarche :
Lama :
Siklus :
Banyaknya :
Keluhan :
Keputihan :

7. Riwayat perkawinan
Menikah :
Lama Menikah :
Usia pertama kali menikah :

8. Riwayat kehamilan, persalinan dan nifas yang lalu

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9. Riwayat kehamilan, persalinan dan nifas sekarang
 Kehamilan

Trimester I :

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Trimester II :

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Trimester III :

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 Persalinan

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 Nifas

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10. Riwayat KB
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11. Pola kebiasaan sehari-hari

No Pola Saat Hamil Di BPS (Saat Nifas)
1. Nutrisi
 Makan

 Minum

2. Eliminasi
 BAB

 BAK
3. Istirahat

4. Aktivitas

5. Kebersihan

6. Kebiasaan
12. Data psikologi spiritual dan budaya
 Psikologis :

 Sosial :

 Spiritual :

 Budaya :

Data obyektif
Pemeriksaan umum :
Keadaan umum :
Kesadaran :
TTV
TD :
N :
RR :
S :
1. Pemeriksaan Fisik
1) Inspeksi
Kepala :

Wajah :

Mata :

Hidung :

Telinga :
 Mulut :

Leher :

Dada :

Payudara :

Abdomen :

Genetalia :

Ekstremitas :

2) Palpasi
Leher :

Payudara :

Abdomen :

3) Auskultasi
Dada :

4) Perkusi
Ekstremitas bawah:
IDENTIFIKASI DIAGNOSA DAN MASALAH
Dx :
Ds :

Do : - Keadaan Umum :
- Kesadaran :

- TTV TD :

N :

RR :

S :

- Leher :

- Payudara :

- Abdomen :

- Genetalia :

- Ekstremitas :

IDENTIFIKASI MASALAH POTENSIAL

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IDENTIFIKASI KEBUTUHAN SEGERA

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INTERVENSI

Dx :

Tujuan :

Kriteria Hasil:

Intervensi

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IMPLEMENTASI

Tanggal :

Jam :

Dx :

Implementasi

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EVALUASI

Tanggal :

Dx :

S :

O :

A :

P :