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No. Register : .................................... Tanggal Pengkajian :..........................

Tanggal masuk : .................................... Waktu Pengkajian :.........................
Waktu masuk : .................................... Tempat Pengkajian :.........................

A. DATA SUBJEKTIF
1. Identitas Pasien
Nama : Ny. “….” Nama Suami : Tn. “….”
Umur : …. th Umur : …. th
Pekerjaan : .................................... Pekerjaan : .....................................
Agama : .................................... Agama : .....................................
Pendidikan : .................................... Pendidikan : .....................................
Suku / bangsa: ................................... Suku / bangsa : .....................................
Alamat : .................................... Alamat : .....................................
.................................... .....................................
No. HP : .................................... No. HP : .....................................

2. Alasan Kunjungan
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3. Keluhan Utama
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4. Riwayat Kesehatan
a. Riwayat Kesehatan Dahulu .....................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ...............................................................................................................
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b. Riwayat Kesehatan Sekarang .................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ..............................................................................................................
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c. Riwayat Kesehatan Keluarga .................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ..............................................................................................................
.................................................................................................................................
d. Riwayat Penyakit Ginekologi
.................................................................................................................................
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 5. Riwayat Perkawinan
Perkawinan ke ............................. Menikah sejak umur P :…. Th L :…. Th
Lama perkawinan......................... Status perkawinan sah / tidak

6. Riwayat Haid
Manarche : .......... Tahun Banyaknya darah: ........ Ganti pembalut/ Hari
Siklus haid : .......... Hari Konsistensi : .................................................
Lama : .......... Hari Disminorhoe : ..................................................
Flour Albus : ..................................................

7. Riwayat Obstetric ( …………………… )

Ha Persalinan Nifas Ket.

mil Tgl UK Jenis Penolong Komp. JK BB/ H/ Penyu Komp.
ke- Tempant TB M lit

8. Riwayat KB

No Mulai Memakai Berhenti / Ganti Cara

Metode Tanggal Petugas Tempat Tanggal Petugas Tempat Alasan

9. Pola Kebutuhan Sehari-hari

a. Nutrisi
Makan Teratur / Tidak teratur … kali/hari ………………………………………
Konsumsi air putih ± …… gelas/hari
Tidak ada/ ada masalah
b. Eliminasi
BAB … kali/hari, Teratur / Tidak teratur
BAK … kali/hari, Lancar / Tidak lancar
Tidak ada/ ada masalah
c. Istirahat
Tidur siang / Tidak tidur siang± … jam
Tidur malam ± ….. jam
Tidak ada/ ada masalah
 d. Aktivitas
Ibu dapat beraktivitas normal/ tidak normal
e. Personal Hygiene
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.................................................................................................................................
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f. Pola Seksual
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10. Data Psiko Sosial Spiritual

Tanggapan ibu tentang alat kontrasepsi : Ibu mengerti dan dapat menjelaskannya
ulang/ ibu bingung/
Pengetahuan ibu tetntang alat kontrasepsi yang dipakai sekarang : Setelah mendapat
informasi, ibu paham / tidak paham
Riwayat ketergantungan obat dan narkotika : Tidak / Iya
Pengambilan keputusan/dukungan suami dan keluarga………………………………..
………………………………………………………………………………………….
Ketaatan ibu beribadah, ibu menganut agama………………………………………….
Ibu tinggal bersama : Keluarga/ sendiri
Latar belakang sosial budaya, ibu mempercayai adat………………………………….
Ibu memiliki kebiasaan pijat perut. Tidak/ Iya

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum : Baik/ Cukup Baik/ Buruk
Kesadaran : Compomentis/ Apatis / Delirium / Somnolen / Soporou / Koma
Postur Tubuh : Tegak/ Bungkuk
Sikap tubuh : Lordosis/ Skoliosis / Kifosis
Cara berjalan : Normal/ Tidak
TTV : Tekanan Darah : ........... mmHg Suhu : .......... oC
Nadi : ........... x/menit Pernapasan : .......... x/menit
BB : ......Kg
TB : ........ cm
LILA : ........ cm
IMT : ........

2. Pemeriksaan Fisik
a. Kepala
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.................................................................................................................................
b. Muka
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c. Mata
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 d. Hidung
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e. Telinga
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f. Mulut
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g. Leher
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h. Dada
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i. Axila
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j. Payudara
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k. Abdomen
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l. Genetalia
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m. Anus
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n. Ekstremitas
1) Atas : ………………………………………………………………………
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2) Bawah : ……………………………………………………………………….
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3. Pemeriksaan Dalam/Ginekologi
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4. Pemeriksaan Panggul
Lingkar panggul : ......... cm

C. ANALISA DATA
Tanggal : ............................................. Jam : …………………
1. Diagnosa Kebidanan
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 2. Masalah
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3. Kebutuhan
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D. PENATALAKSANAAN
Tanggal : ............................................. Jam : …………………

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