PENDOKUMENTASIAN HASIL ASUHAN KEBIDANAN

GANGGUAN SISTEM REPRODUKSI PADA NY “......”

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

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

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

1. Identitas istri / suami

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

Data Subjektif (S)

1. .......................................................................................................................
2. .......................................................................................................................
3. .......................................................................................................................
4. .......................................................................................................................
5. .......................................................................................................................
Data Objektif (O)
1. Keadaan Umum : ...............................
2. Kesadaran : ...............................
3. Tanda-tanda vital.
 Tekanan Darah : ...............................
Nadi : ...............................
Pernafsan : ...............................
Suhu : ...............................
4. Pemeriksaan head to toe.
Kepala : ..............................................................................................
Wajah : ..............................................................................................
Mata : ..............................................................................................
Hidung : ..............................................................................................
Telinga : ..............................................................................................
Mulut : ..............................................................................................
Leher : ..............................................................................................
Payudara : ..............................................................................................
Abdomen : ..............................................................................................
Genitalia : ..............................................................................................
Anus : ..............................................................................................
Ekstremitas : ..............................................................................................
5. Pemeriksaan Penunjang.
Laboratorium : ..............................................................................................
USG : ..............................................................................................
Assessment (A)
Diangnosa Aktual : .............................................................................................
Masalah Aktual : .............................................................................................
Masalah Potensial : ............................................................................................
Planning (P)

Tanggal : .............................. Jam: ......................

1. .......................................................................................................................
Hasil : ..........................................................................................................
2. .......................................................................................................................
Hasil : ..........................................................................................................
3. .......................................................................................................................
 Hasil : ..........................................................................................................
4. .......................................................................................................................
Hasil : ..........................................................................................................
5. .......................................................................................................................
Hasil : ..........................................................................................................
6. .......................................................................................................................
Hasil : ..........................................................................................................
7. .......................................................................................................................
Hasil : ..........................................................................................................

Palopo, 2021
MENGETAHUI
Preseptor Lahan Preseptor Institusi

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