RSUD TARAKAN JAKARTA Univ.

Kristen Krida Wacana (UKRIDA)

Jl. Kyai Caringin no 7, Jakarta Pusat Jl. Terusan Arjuna No. 6, Jakarta Barat

KEPANITERAAN KLINIK
STATUS ILMU KEBIDANAN DAN PENYAKIT KANDUNGAN

Nama : ……………………………………………………………… Tanda Tangan

Nim : ……………………………………………………………… …………………….

Dr. Pembimbing / Penguji : ……………………………………………..

………………………

Hari/Tanggal/Jam : …………………………………………
SUBYEKTIF
1. Identitas Pasien
Nama : ________________________________ Nama Suami /Keluarga: ____________________
Umur : ________________________________ Umur : __________________________
Pendidikan : __________________________ Pendidikan : __________________________
Pekerjaan : __________________________ Pekerjaan : __________________________
Agama : __________________________ Agama : __________________________
Suku / Bangsa : __________________________ Suku / Bangsa : __________________________
Alamat : ________________________________________________________________________
2. Keluhan Utama auto / aaloanamnesa
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3. Keluhan Tambahan
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4. Riwayat Penyakit Sekarang
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5. Riwayat Penyakit Dahulu
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6. Riwayat Penyakit Keluarga

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7. Riwayat Haid Menars
Ginekologi :
Haid pertama/menars: …… thn
Siklus : teratur / tidak teratur Panjang Siklus Siklus : …. Hari
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Obstetri :
Lama haid : …… hari Jumlah darah : …. Softex per hari Nyeri Haid :
HTA / HPHT : TP :
(Haid terakhir/Hari Pertama Haid Teratur) (Taksiran Persalinan)

8. Riwayat Perkawinan
Kawin : belum/sudah/cerai Kawin yang ke : ………. kali dengan suami sekarang sudah …… thn
Riwayat infertilitas : ada/tidak Lamanya : ……………… Thn : …………….
Riwayat berobat infertilitas.

9. Riwayat Obstetrik : Gravida Para Abortus Hidup

Contoh : G4 P2 A1 H1
1.
2.
3.
4.

1. 5.
2. 6.
3. 7.
4. 8.

10. Riwayat Kontrasepsi

Jenis …………………… Lama ……………………….. lepas
Status saat ini

11. Hal-hal Lain / Kondisi Status Sosial Ekonomi / Psikologi / napi

OBYEKTIF
A. Pemeriksaan Fisik Umum : Skala Nyeri
Jam :
Keadaan Umum : ____________________ Keadaan Gizi : ____________________
Kesadaran : ____________________
TD : ___________ Nadi : ___________ RR : ____________ Suhu : ____________
TB : ____________ cm BB : ____________ Kg
 Kepala : Paru-paru :
Dada : Perut :
Jantung : Ekstemitas :

B. Pemeriksaan Fisik Khusus / Status Ginekologi Umum

1. Status Genitalia Eksterna

a. Inspeksi Vulva / Uretra
Himen
b. Pertumbuhan rambut :
Kumis / Ketiak / Pubis
c. Payudara, Btk, Simetris, Puting

d. Pemeriksaan Perut / Obstetri : (Leopold I – IV)

LI : TFU : ……. cm L III :
L II : L IV :

Taksiran Berat Janin :

2. Status Genitalia Interna : Pemeriksaan Spekulum/Inspeculo :
Vagina :
Portio :

Pemeriksaan bimanual / VT / RT :

C. Pemeriksaan Penunjang
1. Pemeriksaan non invasiv :
CTG / USG :
Radiologi :

2. Pemeriksaan Laboratorium / Invasiv :

3. Lain-lain : - Echo
- Patologi Anatomi

ANALISA Uraian Masalah :

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Daftar Masalah (termasuk diagnosis kerja dan diagnosis diferensial) pada jam tersebut

IBU :
1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

BAYI :
1. ____________________________________________________________________________

2. ____________________________________________________________________________

PERENCANAAN
I. Rencana Diagnostik :
a. Observasi / satuan waktu
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b. Penegakkan diagnosis
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c. Pemantauan terapi (frekuensi pemantauan dan target terapi)
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II. Rencana Terapi :

a. Terapi perilaku
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b. Terapi nutrisi
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c. Medikamentosa
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d. Tindakan atau Operatif
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RENCANA EDUKASI
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Prognosis
Ad vitam :

Ad functionam:

Ad sanactionam :

Edisi 14032019