KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI KEBIDANAN KEDIRI
Jl. KH Wachid Hasyim 64 B Kediri

FORMULIR ASUHAN KEBIDANAN UNTUK BAYI BARU LAHIR

Tanggal / Jam MRS : …………………………………………………………………
Tanggal / Jam pengkajian : ..………………………………………………………………..
No. Registrasi : …………………………………………………………………
Ruang Perawatan : …………………………………………………………………

A. DATA SUBYEKTIF
BIODATA
Identitas Bayi Baru Lahir
Nama : …………………………………………………………………
Tanggal lahir : …………………………………jam……………………….…
Jenis Kelamin …………………………………………………………………
Anak ke : …………………………………………………………………

Identitas Orang Tua

Nama Ibu : …………………………………………………………………
Umur : …………………………………………………………………
Suku Bangsa : …………………………………………………………………
Agama : ………………………………………...……………………….
Pendidikan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Penghasilan : …………………………………………………………………
Alamat Rumah : …………………………………………………………………

Nama Ayah : ....………………………………………………………………

Umur : …………………………………………………………………
Suku Bangsa : …………………………………………………………………
Agama : ………………………………………...……………………….
Pendidikan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Penghasilan : …………………………………………………………………
Alamat Rumah : …………………………………………………………………

A. ANAMNESIS
Sumber informasi :

1. Keluhan utama
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………
2. Riwayat Kesehatan Ibu
a. HPHT : ………………… Usia Kehamilan : …………. minggu

b. Riwayat penyakit selama kehamilan:

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c. Riwayat Antenatal :
d. Persalinan :
e. Kebiasaan merokok :
f. Kebiasaan minum jamu :
B. DATA OBYEKTIF
1. Ketuban :
Jam: .......... Warna : ……… Jumlah : …… Bau : ………….

2. Plasenta : ……………………………………………………………………...….

3. Keadaan Umum :
a. Suhu Tubuh : ………………………………..……………………………….
b. Berat lahir: …………………………gram
c. Panjang badan: …………………….cm
d. BAB : …………………….BAK : ………………………………………………..

4. Pemeriksaan Head to Toe

a. Kepala :
Lingkar kepala: …………………………… cm

b. Mata :

c. Wajah :

d. Telinga :

e. Mulut :

f. Dada :

g. Abdomen :
Bentuk :
Tali pusar :

h. Genetalia :
Labia :
Scrotum :

i. Anus :

j. Ekstremitas :
Atas :
Bawah :

C. ANALISIS:
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D. PENATALAKSANAAN :
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Kediri, ……………………..
Pembimbing Klinik, Mahasiswa,

….………………………….
………………………………. NIM.
NIP.

Dosen Pembimbing

….……………………………..
NIP.
 CATATAN PERKEMBANGAN

Nama : ……………………………………………………………………………………
Umur : ……………………………………………………………………………………
No. Reg. : ……………………………………………………………………………………

Tgl SUBYEKTIF OBYEKTIF ANALISIS PENATALAKSANAAN TTD