PENDOKUMENTASIAN HASIL ASUHAN KEBIDANAN KEGAWAT

DARURATAN ANTENATAL CARE PADA NY “......”

DENGAN ........................................................................
DI PUSKESMAS MALILI, KAB LUWU TIMUR
TANGGAL ..................................... 2021

Nomor Register : ..........................................

Tanggal Masuk : ........................................... Jam : ........................
Tanggal Pegkajian : ........................................... Jam : ........................
Nama Pengkaji : MASRAH

Identitas Istri/ Suami

Nama : ........................... / ...........................
Umur : ........................... / ...........................
Nikah / Lamanya : ........................... / ...........................
Suku : ........................... / ...........................
Agama : ........................... / ...........................
Pendidikan : ........................... / ...........................
Pekerjaan : ........................... / ...........................
Alamat : ........................... / ...........................

A. Subjektif (S)
1. .......................................................................................................................
2. .......................................................................................................................
3. .......................................................................................................................
4. .......................................................................................................................
5. .......................................................................................................................
6. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu.
No. Tahun Jenis Partus JK BBL PBL Tempat partus Penolong Keadaan
 7. Riwayat Menstruasi.
Menarche : .................................
Siklus Haid : .................................
Durasi : .................................
Dismenorhea : .................................
B. Objektif (O)
1. Keadaan Umum : ...............................
2. Kesadaran : ...............................
3. Tinggi Badan : ...............................
Berat Badan : ...............................
LILA : ...............................
4. Pemeriksaan tanda-tanda vital.
Tekanan Darah : ...............................
Nadi : ...............................
Suhu : ...............................
Pernapasan : ...............................
5. Pemeriksaan USG : ..............................(hasil USG disi jika ada)
6. Pemeriksaan Laboratorium.
Protein Urin : ...............................
Glukosa : ...............................
HB : ...............................
Plano test : ...............................
7. Pemeriksaan Fisik Sistematis.
Kepala : ..............................................................................................
Wajah : ..............................................................................................
Mata : ..............................................................................................
Hidung : ..............................................................................................
Telinga : ..............................................................................................
Mulut : ..............................................................................................
 Leher : ..............................................................................................
Payudara : ..............................................................................................
Abdomen
Inspeksi : ..............................................................................................
Palpasi kebidanan : Leopold I : .............................................
Leopold II : .............................................
Leopold III : .............................................
Leopold IV : .............................................
Auskultasi : .........................................................................................
Genetalia : .........................................................................................
Ekstremitas : .........................................................................................
C. Assessment (A)
Diagnosa : ..........................................................................................................
D. Planning (P)
Tanggal : .............................. Jam: ......................
1. .......................................................................................................................
Hasil : ..........................................................................................................
2. .......................................................................................................................
Hasil : ..........................................................................................................
3. .......................................................................................................................
Hasil : ..........................................................................................................
4. .......................................................................................................................
Hasil : ..........................................................................................................
5. .......................................................................................................................
Hasil : ..........................................................................................................
Palopo, 2021
MENGETAHUI
Preseptor Lahan Preseptor Institusi

( ....................................... ) ( ......................................... )