Format

Panduan Praktik Klinik Kebidanan Prodi S.
Tr Kebidanan tahun 2022
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL TENAGA KESEHATAN
POLITEKNIK KESEHATAN PALU
JURUSAN KEBIDANAN PRODI SARJANA TERAPAN KEBIDANAN
Jl.Thalua Konchi No.19 Mamboro Palu Utara
Telp. (0451) 492518 Fax. (0451)491451 e-mail: poltekkeskemenkespalu@yahoo.com
website : www.poltekkespalu.ac.id
DAFTAR HADIR
BIMBINGAN PRAKTIK KLINIK KEBIDANAN
MAHASISWA TINGKAT II SEMESTER IV PRODI S.TR KEBIDANAN
JURUSAN KEBIDANAN POLTEKKES KEMENKES PALU T.A 2021/2022
HARI/ TANGGAL
NO NAMA PEMBIMBING TTD KET
TEMPAT PRAKTIK
1.
2.
3.
4.
5.
6.
7.
Panduan Praktik Klinik Kebidanan Prodi S.Tr Kebidanan tahun 2022
.................................................2022
CI/ PEMBIMBING LAHAN PRAKTIK
(...............................................)
NIP.

JADWAL PRAKTIK KLINIK KEBIDANAN KOMPREHENSIF

MAHASISWA PRODI S.TR KEBIDANAN POLTEKKES KEMENKES PALU
Hari/ Tanggal : ................................................................... Kelompok : ..............................................................
Tempat Praktik : ...................................................................
TANDA-TANGAN KEHADIRAN DINAS
NO NAMA NIM
Hari/tggl Hari/tggl Hari/tggl Hari/tggl Hari/tggl Hari/tggl
1.
2.
3.
4.
5
6
Palu, ...................................................2022
Mengetahui
Ketua Prodi S.Tr Kebidanan Kepala Ruangan/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIP ....................................................... NIP .......................................................

ABSENSI PRAKTIK KLINIK KEBIDANAN KOMPREHENSIF
MAHASISWA PRODI S.TR KEBIDANAN POLTEKKES KEMENKES PALU
Hari/ Tanggal : ................................................................... Kelompok : ..............................................................
Tempat Praktik : ...................................................................
TANDA-TANGAN KEHADIRAN DINAS
NO NAMA NIM Hari/tggl Hari/tggl Hari/tggl Hari/tggl Hari/tggl Hari/tggl
DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG
1.
2.
3.
4.
5
6
Palu, ...................................................2022
Mengetahui
Ketua Prodi S.Tr Kebidanan Kepala Ruangan/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIP ....................................................... NIP .......................................................
Catatan :Tanda-tangan CI Lahan Praktik disertai Cap Basah
FORMAT LAPORAN KEGIATAN HARIAN (ACTIVITY DAILY LIFE)

Nama / NIM : ................................................................... Tempat Praktik : ..............................................................
Tingkat / Smestr : ................................................................... Waktu Praktik : ..............................................................
KEGIATAN SELAMA PRAKTIK (ACTIVITY DAILY LIFE) TANDA -TANGAN
NO
DIAGNOSA TINDAKAN YANG PEMBIMBING LAHAN
NAMA PASIEN UMUR MAHASISWA
PENYAKIT/MASALAH DILAKUKAN PRAKTIK
1.
2.
3.
dst
Palu, ...................................................2022
Mengetahui
Pembimbing Akademik Kepala Ruangan/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIP ....................................................... NIP .......................................................
Catatan :Tanda-tangan CI Lahan Praktik disertai Cap Basah

FORMAT PENCAPAIAN KOMPETENSI

Nama / NIM : ................................................................... Jenis Ketrampilan : ..............................................................
Tingkat / : ................................................................... Pencapaian Kompetensi : ..............................................................
Semester
Tempat Praktik : ...................................................................
Waktu Praktik : ...................................................................
A. LANDASAN TEORI
1. PENGERTIAN
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
2. ETIOLOGI
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
3. GEJALA/TANDA
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
4. PROSEDUR PELAKSANAAN/TAHAPAN KERJA
a. Persiapan alat dan bahan
..............................................................................................................................................................................................................
...............................................................................................................................................................................................................
b. Persiapan pasien dan penolong
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
c. Langkah kerja
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
CATATAN ;UNTUK ISI DARI LANDASAN TEORI DISESUAIKAN DENGAN JENIS KETRAMPILAN YANG AKAN DILAKUKAN
B. TINJAUAN KASUS
1. Pengkajian
Data Subyektif :
......................................................................................................................................................................................................................
Data Objektif :
......................................................................................................................................................................................................................
Data Pendukung / laboratorium :
......................................................................................................................................................................................................................
2. Analisa Data
Diagnosa Kebidanan (aktual) :...................................................................................................................................................................
Masalah (aktual...........................................................................................................................................................................................
Diagnosa Potensial :……...........................................................................................................................................................................
Masalah potensial :……............................................................................................................................................................................
3. Penatalaksanaan
Hari/tanggal/jam pelaksanaan :...................................................................................................................................................................
Pelaksanaan dan hasil evaluasi
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
C. CATATAN PERKEMBANGAN
Pendokumentasian SOAP
............................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Palu, ...................................................2022
Mengetahui
Mahasiswa Pembimbing/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIM ....................................................... NIP .......................................................
Pembimbing Akademik
(.............................................................)
NIP .......................................................
Catatan :
Tanda-tangan CI Lahan Praktik disertai Cap Basah

FORMAT BUKU PENCAPAIAN KETERAMPILAN

(LOG BOOK)
Kompetensi : ...................................................................
Tempat / Lokasi Praktik : ...................................................................
Waktu Praktik : ...................................................................
Kelompok : ...................................................................
Nama Pembimbing : ...................................................................
1. CI Institusi : ...................................................................
2. CI Lahan Praktik : ...................................................................
Proses Pencapaian
Kompetensi/ Keterampilan Tanda-tangan
Hari/tgl Komentar
Nama / NIM Learning Keterampilan Dengan Pembimbing
Pelaksanaan Mandiri Pembimbing
Outcomes Bimbingan dan Cap
(M)
(B)
Palu, ...................................................2022
Mengetahui
Pembimbing Akademik Kepala Ruangan/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIP ....................................................... NIP .......................................................

FORMAT LAPORAN PENDAHULUAN

Nama / NIM : ................................................................... Tempat Praktik : ..............................................................
Tingkat / : ................................................................... Waktu Praktik : ..............................................................
Semester
A. KONSEP TEORI
1. PENGERTIAN
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
2. ETIOLOGI
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
3. GEJALA/TANDA
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
......................................................................................................................................................................................................................
4. PROSEDUR PELAKSANAAN/TAHAPAN KERJA
a. Persiapan alat dan bahan

...............................................................................................................................................................................................................
..............................................................................................................................................................................................................
b. Persiapan pasien dan penolong
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
a. Langkah kerja
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
B.
DAFTAR PUSTAKA
C. TINJAUAN KASUS
1. Pengkajian
Data Subyektif :
......................................................................................................................................................................................................................
Data Objektif :
......................................................................................................................................................................................................................
Data Pendukung / laboratorium :
......................................................................................................................................................................................................................
2. Analisa Data
Diagnosa Kebidanan (aktual) :...................................................................................................................................................................
Masalah (aktual...........................................................................................................................................................................................
Diagnosa Potensial :……...........................................................................................................................................................................
Masalah potensial :……............................................................................................................................................................................
3. Penatalaksanaan
Hari/tanggal/jam pelaksanaan :...................................................................................................................................................................
Pelaksanaan dan hasil evaluasi
......................................................................................................................................................................................................................
D. CATATAN PERKEMBANGAN
Pendokumentasian SOAP
............................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Palu, ...................................................2022
Mengetahui
Mahasiswa Pembimbing/ CI Lahan Praktik
(.............................................................) (.............................................................)
NIM ....................................................... NIP .......................................................
Pembimbing Akademik
(.............................................................)
NIP .......................................................
Catatan :
Tanda-tangan CI Lahan Praktik disertai Cap Basah
FORMAT PENILAIAN PRAKTIK KLINIK KEBIDANAN KOMPREHENSIF

MAHASISWA PRODI S.TR KEBIDANAN
POLTEKKES KEMENKES PALU T.A 2021/2022
Nama Mahasiswa : ............................................

NIM : ............................................
Tempat Praktik : ............................................
No ASPEK YANG DINILAI ANGKA HURUF KET
A SIKAP
1. Kejujuran
1.1 Prakarsa
1.2 Tanggung Jawab 40 %
1.3 Disiplin (Kehadiran)
1.4 Hubungan dengan orang lain
T O T A L NILAI SIKAP
B PENGETAHUAN (Hasil Responsi CI)
1. Kemampuan memahami konsep teori
 Mampu menyebutkan konsep teori
30 %
 Mampu menjelaskan konsep teori
 Mampu menguraikan konsep teori
T O T A L NILAI PENGETAHUAN
C KETRAMPILAN
1. Kompeten dalam melaksanakan ketrampilan

(Askeb / Bimbingan Preseptor mentor)
 Kelengkapan alat / media praktik
 Prosedur kerja /Sistematis
 Ketelitian / ketepatan
 Prinsip pencegahan infeksi / teknik dan 30 %
metode bimbingan
2. Laporan Kegiatan
 ADL
 Laporan Pendahuluan (Ruangan Umum)
 Askeb (Dokumentasi SOAP)
T O T A L NILAI KETRAMPILAN
Jumlah Rata-rata
Absen Praktek: Petunjuk Penilaian: .....................,......................2022

Alpa : PRESEPTOR/CI LAHAN PRAKTIK
> 80 :A : Baik Sekali
Izin :
70 – 79 :B : Baik
Sakit :
(.................................................................................)
NIP.

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Panduan Praktik Klinik Kebidanan Prodi S.

Tr Kebidanan tahun 2022

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

JADWAL PRAKTIK KLINIK KEBIDANAN KOMPREHENSIF

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

FORMAT LAPORAN KEGIATAN HARIAN (ACTIVITY DAILY LIFE)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

FORMAT PENCAPAIAN KOMPETENSI

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

FORMAT BUKU PENCAPAIAN KETERAMPILAN

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

FORMAT LAPORAN PENDAHULUAN

a. Persiapan alat dan bahan

FORMAT PENILAIAN PRAKTIK KLINIK KEBIDANAN KOMPREHENSIF

Nama Mahasiswa : ............................................

No ASPEK YANG DINILAI ANGKA HURUF KET

1. Kompeten dalam melaksanakan ketrampilan

Absen Praktek: Petunjuk Penilaian: .....................,......................2022

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