TGL. STATUS : ………………………………….

BAGIAN / SMF OBSTETRI & GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS ABDURRAB
RSUD DUMAI

STATUS OBSTETRI
(ANC / VK / NIFAS) *)coret yg tidak
I. INDENTITAS PENDERITA
Nama :…………………………….. Nama Suami :……………………………..
Umur :……………………………..Umur :…………………………….
Pendidikan :…………………………….. Pendidikan : ……………………………
Pekerjaan :…………………………….. Pekerjaan :…………………………….
Agama :…………………………….. Agama :…………………………….
Suku :……………………………. Suku :…………………………….
Alamat :……………………………..Alamat :…………………………….
No. MR :……………………………………………………………………………..

II.ANAMNESA
Seorang Pasien masuk Kamar Bersalin RSUD Pekanbaru pada tanggal ……………………
Jam ……… Wib Kiriman ………………………… dengan ………………………………

II.1. Keluhan Utama : ________________________________________________

II.2. Riwayat Penyakit Sekarang :______________________________________
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TGL. STATUS : ………………………………….

II.3. R H M :______________________________________
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II.4. R H T :______________________________________
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II.5. P N C :______________________________________
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II.6. R. Makan Obat :______________________________________

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II.7. Riwayat Penyakit Dahulu :______________________________________
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II.8. Riwayat Penyakit Keluarga :______________________________________
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II.9. Riwayat Haid :______________________________________
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II.10. R. Perkawinan : ______________________________________
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II.11. R. Kehamilan/R.Abortus/R.Persalinan :______________________________
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II.12. R. K B : ______________________________________
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III.PEMERIKSAAN FISIK

Keadaan Umum : Kesadaran : TD : ND : Sh: Nfs :

Gizi : dema: Sianosis : Anemis : Kepala : TB: BB:
Kepala : ______________________________________________________
Leher : ______________________________________________________
THT : ______________________________________________________
Dada : Paru : Jantung :
Abdomen : Status Obstetrikus
Genetalia : Status Obstetrikus
Ekstremitas : ______________________________________________________
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TGL. STATUS : ………………………………….

IV.STATUS OBSTETRIKUS
Muka : _____________________________________________________
Mammae : _____________________________________________________
Abdomen : _____________________________________________________
Inspeksi : ________________________________________________
Palpasi : ________________________________________________
L1 : ________________________________________________
L2 : ________________________________________________
L3 : ________________________________________________
L4 : ________________________________________________
TFU : Cm, TBA : Gram HIS :
Auskultasi : BJA : Frekuensi ........ /Menit Teratur / tdk teratur .
Genetalia Eksterna :
Inspeksi / Palpasi : .................................................................................
Genitalia Interna / Pemeriksaan dalam
Inspekulo : - Vagina :...........................................................................
- Porsio :...........................................................................
VT / Bimanual Palpasi
- Panggul Dalam : Promontorium : ......................................
Linea innominata : ......................................
Sakrum : ......................................
Spina Iskiadika : ......................................
Arkus pubis : ......................................
Os.Koksigis : .......................................
- Janin : Presentasi : ......................................
Situs : ......................................
Station : ......................................
Posisi : ......................................
Ketuban : ......................................
- Porsio : Pembukaan : ......................................
Penipisan : ......................................
Konsistensi : ......................................
Arah Sumbu : ......................................

V. PEMERIKSAAN LABORATORIUM RUTIN BILA SUDAH ADA

V.1. Darah Lengkap : Hb : ________________________________
Leukosit : ________________________________
LED : ________________________________
Hitung Jenis : ________________________________
TGL. STATUS : ………………………………….

V.2. Faal Hemostatik : ___________________________________________

V.3. Kimia Darah : ___________________________________________
V.4. Urine : ___________________________________________

VI. RESUME PEMERIKSAAN : ………………………………………………………..

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VII. DIAGNOSIS
- DIAGNOSIS KERJA : ………….............................................................

- DIAGNOSIS BANDING 1………………………………

2………………………………

VIII. PEMERIKSAAN PENUNJANG DIAGNOSTIK YANG DIUSULKAN :

1. ....................................................................................................................
2. ....................................................................................................................
3. ....................................................................................................................

IX. TERAPI
Simtomatik : ....................................................................................................................
Supportive : ....................................................................................................................
Kausal : ...................................................................................................................
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X. PEMERIKSAAN PENUNJANG (Jika ada)

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XI. DIAGNOSA PASTI

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TGL. STATUS : ………………………………….

XII. RENCANA TINDAKAN

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XIII. LAPORAN TINDAKAN
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XIV. FOLOWUP :__________________________________________________

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XV. PROGNOSA__________________________________________________
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Mengetahi : Mahasiswa yang memeriksa

Dokter Konsulen ruangan

(dr. .……………………………Sp.OG.) (………………………………..)

NIP : NIM :
TGL. STATUS : ………………………………….

STATUS FOLOW UP

TANGGAL PERJALANAN PENYAKIT TERAPI PARAF

JAM