FORMAT ASUHAN KEBIDANAN KOMUNITAS PADA KELUARGA

Kecamatan : KK :
Kelurahan/Desa : Jenis Kelamin :
RT : Umur :
RW/Dusun : Pendidikan :
Alamat : Agama :
Pekerjaan :
Penghasilan :
Keadaan Kesehatan :
A. ANGGOTA KELUARGA :
NO NAMA HUB. L/P UMUR PENDIDIKAN PEKERJAAN AGAMA SUKU/ KEADAAN IMUNISASI KB
DG.K BANGSA KESH.
K KET
.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10

B. Tipe Keluarga : ............................................................................................................

C. Sifat Keluarga :
1. Pengambilan Keputusan
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......................................................................................................................................

2. Kebiasaan hidup sehari-hari

a. Kebiasaan Istirahat/tidur keluarga
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b. Kebiasaan makan keluarga dan contoh menu sehari-hari (cara makan, alat yang
dipakai, db)
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c. Kebiasaan dalam membersihkan diri dan anggota keluarga
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......................................................................................................................................
d. Sarana/hiburan keluarga
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e. Penggunaan waktu luang keluarga
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D. Faktor Sosial, Budaya dan Ekonomi

1. Adat istiadat dan kepercayaan
......................................................................................................................................
......................................................................................................................................
2. Interaksi dan komunikasi dalam keluarga
......................................................................................................................................
......................................................................................................................................
E. Faktor Lingkungan
1. Rumah :
 - Luas : ..............m2
- Tipe : ................
- Jenis rumah : susun/petak/kavling
- Letak : dekat/jauh dengan sarana kesehatan
- Dinding : tembok/papan/bambu
- Atap : genteng/seng/lain-lain
- Lantai : keramik/plester/tanah/basah/kering
- Cahaya : cukup/kurang
- Ventilasi : cukup/kurang
- Jumlah ruangan : ......................................................................................................

2. Air Minum :
- Asal : PAM/Sumber/Sungai
- Nilai Air : Bersih/kotor/berbau/berwarna
- Air untuk minum: dimasak/mentah
- Konsumsi : ......................................................................................................

3. Pembuangan sampah :
Dibakar/ditanam/dikompos/diambil petugas

4. Jamban dan Kamar mandi :

- Jenis jamban : cemplung/leher angsa/lain-lain
- Jarak dengan sumber air : ................m
- Kebersihan : bersih/kotor/berbau
- Kamar mandi : ada/tidak ada/bersih/kotor

5. Pekarangan dan selokan :

- Pengaturan : Teratur/berserakan
- Kebersihan : Bersih/teratur
- Air Limbah : Teratur/berserakan/dimanfaatkan
- Tanaman perdu : ada/tidak
- Pemanfaatan pekarangan : ada/tidak

6. Kandang ternak :
- Bangunan : permanen/darurat
- Letak : tersendiri/seatap
- Kebersihan : bersih/kotor

7. Denah rumah dan lingkungan :

8. Sarana komunikasi dan transportasi :

......................................................................................................................................
......................................................................................................................................
9. Fasilitas pelayanan kesehatan :
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F. Riwayat Kesehatan Keluarga

1. Riwayat Kesehatan Keluarga
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......................................................................................................................................
2. Keluarga Berencana
- Jenis : ....................................................................................
- Lama : ....................................................................................
- Komplikasi : ....................................................................................
- Pernah ganti cara/tidak : ....................................................................................
Bila pernah;jenisnya : ....................................................................................

G. Pengetahuan orang tua tentang tumbuh kembang anak

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H. Harapan Keluarga terhadap petugas kesehatan

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I. Data Khusus
1. Jenis penyakit yang sering diderita keluarga
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2. Riwayat Kebidanan
a. Kehamilan
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b. Persalinan
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c. Nifas
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d. Imunisasi
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e. Keluarga Berencana (KB)

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f. Nutrisi (ASI dan MPASI)

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3. Lain-lain
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J. Skala Prioritas
1. ........................................................................................................................................
........................................................................................................................................

KRITERIA BOBOT PERHITUNGAN SKORE PEMBENARAN

1. Sifat Masalah 1
2. Kemungkinan 2
masalah
dapat diubah
3. Potensi untuk 1
mengubah
masalah
4. Menonjol 1
masalah
JUMLAH

2. ........................................................................................................................................
........................................................................................................................................
 KRITERIA BOBOT PERHITUNGAN SKORE PEMBENARAN
1. Sifat Masalah 1
2. Kemungkinan 2
masalah
dapat diubah
3. Potensi untuk 1
mengubah
masalah
4. Menonjol 1
masalah
JUMLAH

3..........................................................................................................................................
.........................................................................................................................................

KRITERIA BOBOT PERHITUNGAN SKORE PEMBENARAN

1. Sifat Masalah 1
2. Kemungkinan 2
masalah
dapat diubah
3. Potensi untuk 1
mengubah
masalah
4. Menonjol 1
masalah
JUMLAH

4..........................................................................................................................................
.........................................................................................................................................

KRITERIA BOBOT PERHITUNGAN SKORE PEMBENARAN

1. Sifat Masalah 1
2. Kemungkinan 2
masalah
dapat diubah
3. Potensi untuk 1
mengubah
masalah
4. Menonjol 1
masalah
JUMLAH

5..........................................................................................................................................
.........................................................................................................................................

KRITERIA BOBOT PERHITUNGAN SKORE PEMBENARAN

1. Sifat Masalah 1
2. Kemungkinan 2
masalah
dapat diubah
3. Potensi untuk 1
mengubah
masalah
4. Menonjol 1
masalah
JUMLAH

MASALAH KESEHATAN SESUAI DENGAN PRIORITAS :

 1. ......................................................................................................................................
......................................................................................................................................

2. ......................................................................................................................................
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3. ......................................................................................................................................
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4. ......................................................................................................................................
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5. ......................................................................................................................................
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K. ANALISA DATA
 MASALAH
IDENTIFIKASI DATA DIAGNOSA
KESEHATAN/KEBIDANAN

L. INTERVENSI/RENCANA TINDAKAN
M. IMPLEMENTASI/PELAKSANAAN TINDAKAN

N. EVALUASI