KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN KEMENKES MALANG
- Kampus Utama : Jl. Besar Ijen No. 77 C Malang, 65112, Telp. (0341) 566075,571888
Fax (041556746)
- Kampus I : Jl. Srikoyo No. 106 Jember Telp. (0331) 486613
- Kampus II : Jl. A. Yani Sumber Porong Lawang Telp. (0341) 427847
- Kampus III : Jl. Dr. Soetomo No. 46 Blitar Telp. (0342) 801043
- Kampus IV : Jl. KH. Wachid Hasyim No. 64 B. Kediri Telp. (0354) 773095
- Kampus V : Jl. Dr. Sutomo No. 5 Trenggalek Telp. 0355-791293
- Kampus VI : Jl. Dr. Cipto Mangunkusumo No. 82A Ponorogo Telp. 0352-461792
Website :http://www.poltekkes-malang.ac.id Email : direktorat@Poltekkes-malang.ac.id

FORMAT ASUHAN KEBIDANAN PADA 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 kelahiran :.....................................................................................................
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:

……………………………………...........................................................................
...................................................................................................................................
...................................................................................................................................
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,

………………………………. ….………………………….
NIP. NIM.

Dosen Pembimbing

….……………………………..
NIP.