KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI D-IV KEBIDANAN KEDIRI
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website : http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email : direktorat@poltekkes-malang.ac.id Kediri 64114

FORMAT ASUHAN KEBIDANAN KB

PENGKAJIAN

Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Alamat : Alamat :
Cara Masuk :
Datang sendiri Rujukan dari :
Diagnosa :

A. DATA SUBJEKTIF
1. Keluhan utama : …………………………………………….
2. Riwayat menstruasi
Usia manarche : ............. tahun - Lama haid :............ hari
Jumlah darah haid : .............. softex/hari - Fluor albus : ...........
HPHT : - TP :
Keluhan saat haid :
Dismenorhoe Spoting Menorrhagia Premenstrual syndrome
Dll..........
3. Riwayat kehamilan, persalinan, dan nifas yang lalu.
G ................. P ................ A ............. Hidup ..................

Keadaan
Tgl,th Tempat Umur Jenis Penolong Anak
No Penyulit anak
partus partus kehamilan persalinan persalinan JK/BB
sekarang

4. Riwayat KB dan rencana KB

Metode yang pernah dipakai : ..................., Lama : .................bulan/tahun
Komplikasi dari KB : ..................., Rencana KB selanjutnya : .................
5. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS Endometriosis
Polip serviks Kanker kandungan Opersai kandungan Perkosaan
DUB dll
B. DATA OBJEKTIF

1. PEMERIKSAAN FISIK
Pemeriksaan umum
- Keadaan umum : .................. - kesadaran : ...............
- BB/TB : .......kg/......cm - Tekanan darah : .........mmHg
- Nadi : ............x/menit - Suhu : .........o C
- Pernafasan : ............x/menit
2. Pemeriksaan fisik
- Mata : Konjungtiva : anemis/tidak Sklera : ikterik/tidak
Pandangan kabur adanya pemandangan dua
- Leher : adanya pembesaran vena jugularis/tidak, adanya pembesaran kelenjar
tyroid/tidak.
- Dada : tumor
- Sistem cardio : nyeri dada murmur palpitasi
3. Pemeriksaan khusus
a. Ginekologi
Inspekulo : vagina (cairan/darah dan luka), porsio : (licin/berdungkul,cairan/darah,
luka/lesi
C. ANALISA/INTERPRETASI DATA
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D. PENATALAKSANAAN
Tanggal : ........................

Jam : ......................................................................................................................................
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Kediri,............................
Pembimbing Praktik Mahasiswa

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NIP. NIM.

Dosen Pembimbing

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NIP.