Alamat : ......................................... No.

RM :

Tgl Masuk : ..........................Jam : ....... Nama Pasien : ………………. Jenis

Kelamin :L/P

Ruang/ Kelas : ......................./............... Tgl Lahir : ........................./........Thn / Bln

PENGKAJIAN AWAL PASIEN RAWAT INAP OBSTETRI
Jam Pengkajian : ............................................

Pekerjaan : Tani / PNS / Swasta / ABRI /………... Nama Suami/Ortu :

Pendidikan : TK/SD/SLTP/SLTA/Sarjana/ ……….. Umur :

Agama : Pekerjaan : Tani / PNS / Swasta / ABRI /…….......

Suku Bangsa : Pendidikan : TK/SD/SLTP/SLTA/Sarjana/ ……….

Cara Masuk :  Datang sendiri Agama :

 Rujukan : ………………………… Suku Bangsa :

Alergi Obat : ………………………………………..........................................................................................................

Status : G ............ P ............ A ............. ANC :  RSUD Nganjuk  …………..………..

………………………... kali
KB Terakhir :  Suntik  Pil
TT :1 2
 IUD  Implan
 Boster  Belum
 .....................................................
Menikah : ………..…kali, Lama : …………. Tahun

Pemeriksaan tanggal : ........................................... Jam :

.................. Bidan :
....................................................................... Dokter
Supervisor : ....................................................................... Tinggi
Badan : .............. cm
Berat Badan : .............. kg
HPHT : ..........................................
. HPL / TP :
...........................................
RIWAYAT PENYAKIT PENTING

 Jantung  Tuberculosis  Tumor Kandungan

 Diabetes  Asthma Bronchiale  Tumor Lain …………………………..………
 Hypertensi  Anemia  Penyakit Lain ………………………………...
 Ginjal  Penyakit Kelamin
RIWAYAT PERSALINAN SEKARANG
ANC dilakukan di Dukun / Bidan / Dokter :
............................................................................................................. ANC terakhir tanggal
: ....................................... Tempat : ..................................................... His mulai sejak tanggal
: ....................................... Jam : .............
Ketuban belum / sudah pecah sejak tanggal : ....................................... Jam :
............. Mengeluarkan darah / lendir sejak tanggal : ....................................... Jam
: ............. Rasa mengejan sejak tanggal : ....................................... Jam
: ............. Perawatan / pertolongan yang telah dilakukan oleh Dukun / Bidan / Dokter :
............................................................................................................................................... ...........................................
STATUS UMUM
Keadaan Umum : ………………………………... Conjungtiva :
………………………………………...
Tensi : ………….…...... mmHg Edema : ………………………………………...
Nadi : ………….…..… x/mnt Cor : ………………………………………...
Respirasi : …………….….. x/mnt Pulmo : ………………………………………...
o
Suhu Rectal : ………………... C
STATUS OBSTETRI
Tinggi Fundus Uteri : ………….…./.…………..…cm DJJ :
………....................................... Letak Janin : ………………………………... Taksiran Berat
Janin : ………...................................…
PEMERIKSAAN DALAM ( VAGINAL TOUCHER )
Pembukaan : …………………………................ Denominator : ………….........................
……… Effacemen : …………………………................ Hodge :
………….............................…… Presentasi : …………………………................ Ukuran Panggul Dalam
: ………............………………….
LABORATORIUM
Darah : ............................................................... Skala Nyeri :
........................................................... Urine : ............................................................... Resiko Jatuh
: ........................................................... Diagnosa :
.............................................................................................................................................
.............................................................................................................................................
Rencana Tindakan/ Terapi :
.............................................................................................................................................
............................................................................................................................... ..............
.............................................................................................................................................
Nganjuk, .......................................... Jam : ...........
Bidan

PEMERIKSAAN DOKTER Jam : ............

PEMERIKSAAN DALAM ( VAGINAL TOUCHER )

Diagnosa : ....................................................................................................................................... ........

.
................................................................................................................... ..........................
... Rencana Tindakan / Terapi :
................................................................................................................................................