FORMAT DOKUMENTASI ASUHAN KEBIDANAN POST PARTUM

Judul : Asuhan Kebidanan

Pada Ny : P............
Tanggal pengkajian : Jam Rekam Medis : ...........................

A. DATA SUBJEKTIF (PENGKAJIAN)

1. Identitas
Nama pasien : ................................ Nama Suami : .....................................
Umur : ................................ Umur : .....................................
Agama : ................................ Agama : .....................................
Suku/Bangsa : ................................ Suku/Bangsa : .....................................
Pendidikan : ................................ Pendidikan : .....................................
Pekerjaan : ...........Pekerjaan :
Alamat : ................................ Alamat : .....................................
2. Keluhan Utama / Alasan Kunjungan
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3. Riwayat Kebidanan
1. Riwayat Perkawinan
Status perkawinan : Kawin : Ya Tidak
Jika Kawin : Berapa kali ............... Lamanya............
Usia pertama kawin ........... th
2. Riwayat Kehamilan, Persalinan, Nifas yang lalu

Riwayat KB
Riwayat kehamilan Riwayat persalianan Anak Riwayat nifas
Perkawinan ke-
Kehamila ke-

sekarang Umur
Jenis kelamin

Komplikasi
Menyusui
Penolong
prematur

tindakan
spontan
abortus

BB/TB
imatur

Aterm

3. Riwayat Kehamilan
Usia kehamilan : ........................................................................... bulan
Gerakan janin : ................................. sejak kehamilan .............. bulan
ANC : ......................................:............... kali, di ...................
Pemberian : Fe : .............................................. Yodium: ................
Keluhan selama hamil : .....................................................................................
Perawatan payudara : .....................................................................................
Senam hamil : .....................................................................................
4. Riwayat Persalinan
Tanggal Persalinan : .............................................................................................
Jenis Persalinan : .............................................................................................
Lama Persalinan : .............................................................................................
Kala I : ................................... Kelaianan : ............................
Kala II : ................................... Kelainan : .............................
 Kala III : ................................... Kelainan : .............................
Keadaan Ketuban
Pecah jam : .............................................................................................
Warna : .............................................................................................
Banyaknya : .............................................................................................
Bau : .............................................................................................
Keadaan Plasenta
Lahir jam : ................................... Berat : .............................
Keadaan maternal : .............................................................................................
Keadaan fetal : .............................................................................................
Jumlah perdarahan : cc
Tali pusat
Panjang : ................................... cm, Kelainan .............................
Keadaan Perineum
Episiotomi : .............................................................................................
Ruptur: derajat : .............................................................................................
Heacting : ..................., .........jika Ya, berapa jumlah jahitannya ..........
Kontraksi Uterus : .............................................................................................
TFU : .............................................................................................
Keadaan Bayinya
KU : ...................................
BB : ................................... TB : .....................................
Jenis Kelamin : ................................... A-S : .....................................
Kelaianan : ...................................
5. Riwayat Kesehatan Keluarga
Keturunan kembar : Ada Tidak
Penyakit menular dan keturunan :
Diabetes Hipertensi Jantung
Hepatitis Tifoid TB
Lain-lain : ..............................................................................................
6. Riwayat Kesehatan Ibu
Penyakit menular dan keturunan :
Diabetes Hipertensi Jantung
Hepatitis Tifoid TB
Lain-lain : ..............................................................................................
7. Riwayat KB
Pernah menggunakan : Ya Tidak
Keluhan : Ada Tidak
Jika ada, jelaskan : ...............................................................................................
Jenis kontrasepsi : ...............................................................................................
Lamanya : ...............................................................................................
8. Riwayat Psikososial Dan Spiritual
Komunikasi : Lancar Gugup
Keadaan emosi : Kooperatif Depresi
Agresif Cemas Marah
Hubungan dengan keluarga : Akrap
Biasa Terganggu
Hubungan dengan orang lain : Akrap
Biasa Terganggu
4. Pola Kebiasaan Sehari-Hari
1. Nutrisi
Sebelum hamil :
Makan : ..................................................................................................
 Minum : ..................................................................................................
Saat hamil :
Makan : ..................................................................................................
Minum : ..................................................................................................
2. Obat-obatan, jamu, alkohol dan minuman keras
Sebelum hamil : ..................................................................................................
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Saat hamil : .................................................................................................
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3. Aktivitas
Sebelum hamil : ..................................................................................................
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Saat hamil : .................................................................................................
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4. Pola istirahat
Sebelum hamil : ..................................................................................................
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Saat hamil : .................................................................................................
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5. Personal hygine
Sebelum hamil : ..................................................................................................
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Saat hamil : .................................................................................................
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6. Eliminasi
Sebelum hamil :
BAB : ...................................................................................................................
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BAK : ...................................................................................................................
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Saat hamil :
BAB : ...................................................................................................................
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BAK : ...................................................................................................................
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B. DATA OBJEKTIF (PEMERIKSAAN)

7. Keadaan umum : Lemah Baik
Cukup
8. Kesadaran : Composmentis
Apatis
Somnolen Sopor Koma
Delirium Semi Koma
9. Tanda-tanda vital
TD : ............... mmHg Nadi : .................... kali/menit
RR : kali/menit Suhu : oc
10. Antropometri
BB : sebelum hamil ............ kg Saat hamil : ............ kg
TB : ........... cm
11. Kepala
Rambut :
Bersih : Ya Tidak
Rontok : Ya Tidak
Wajah : Pucat Sianosis
Cloasma Gravidarum : Ya Tidak
Mata :
Konjungtiva : Pucat Merah Muda
Sklera : Putih Ikterus
Mulut
Bibir : Stomatitis Trismus Perdarahan Gusi
Gigi : Karies
Lidah : Bersih Kotor
Telinga : Serumen Perdarahan Lain-Lain
Jelaskan : ............................................................................................................
12. Leher :
Pembesaran kelenjar tiroid
Pembesaran vena jugularir
Pembesaran kelenjar limfe
Lain-lain, jelaskan......................
13. Dada
Tarikan : Ya Tidak
Bentuk : Simetris Asimetris
Mamae : Radang Ada Benjolan
Tidak Ada Benjolan
Puting susu : Menonjol Datar
Masuk Masuk
Bersih Kotor
Colostrum : Bersih Kotor
Pembesaran mamae : Bersih Kotor
14. Abdomen
Adakah bekas SC : ...............................................................................................
TFU : ...............................................................................................
Kontraksi uterus : ...............................................................................................
Kelainan : ...............................................................................................
15. Genetalia :
Lochea : ...............................................................................................
Warna : ................................ jumlah: ......................, bau:...................
Luka perineum : ...............................................................................................
Keadaan lain-lain, jelaskan :........................................................................................
16. Ekstremitas atas dan bawah:
Atas : Edema Varises
Bawah : Edema Varises
Reflek patela : ...............................................................................................
 17. Pemeriksaan penunjang:
Laboratorium : Hb ................................ Glukosa ..................................
Protein ......................... Urine ......................................
Radiologi : .....................................
18.................................................................Lain-lain, jelaskan jika ada : ...................

C. Assesment
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D. Perencanaan (rencana asuhan, implementasi dan evaluasi)

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