LAPORAN

KEGIATAN PRAKTIK KLINIK KEBIDANAN I PADA IBU HAMIL/SALIN/ANAK/DLL.............

DI PRAKTIK MANDIRI BIDAN / RB / PUSKESMAS…………..WILAYAH KOTA/KAB……………
TANGGAL : .............................. s/d ..............................

LOGO POLTEKKES

Disusun oleh :
1.
2.
3.
4.

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKESSURABAYA
JURUSAN KEBIDANAN
PROGRAM STUDI KEBIDANAN SUTOMO SURABAYA
TAHUN …

ASUHAN KEBIDANAN PADA ………..

1. Pengkajian

Tanggal pengkajian :.............................................................................................................

Pukul : ..............................................................................................................
Oleh : ..............................................................................................................

1.1. Data Subyektif

1.1.1. Biodata
Nama Pasien : ........................................................................................
Umur : ........................................................................................
Agama : ........................................................................................
Suku / bangsa : ........................................................................................
Pendidikan : ........................................................................................
Pekerjaan : ........................................................................................
Alamat : ........................................................................................
Nomor telepon : ........................................................................................

1.1.2. Keluhan
Utama : ........................................................................................
Tambahan : ........................................................................................

1.1.3. Riwayat penyakit sekarang

..............................................................................................................................
..............................................................................................................................

1.1.4. Riwayat penyakit dahulu

..............................................................................................................................
..............................................................................................................................
1.1.5. Data Lain yang mendukung

1.2. Data Obyektif

 1.2.1. Keadaan Umum
Kesadaran
Tanda-tanda vital : Tekanan darah :........................................................
Suhu : .........................................................
Nadi : .........................................................
Respirasi : .........................................................
1.2.2. Pemeriksaan Fisik
Kepala dan wajah : ........................................................................................
Leher : ........................................................................................
Dada : ........................................................................................
Abdomen : ........................................................................................
Punggung : ........................................................................................
Genetalia : ........................................................................................
Ekstrinitas : ........................................................................................
Atas : ........................................................................................
Bawah : ........................................................................................

1.2.3. Program therapi yang diperoleh

..............................................................................................................................
..............................................................................................................................

1.2.4. Data Penunjang

Hasil pemeriksaan laboratorium dan lainnya
..............................................................................................................................
..............................................................................................................................
2. Analisa
..................................................................................................................................................
..................................................................................................................................................
3. Penatalaksanaan
..................................................................................................................................................
..................................................................................................................................................