Format Asuhan Kebidanan pada Ibu Hamil

ASUHAN KEBIDANAN PADA IBU HAMIL

PADA NY. ...... USIA ...... TAHUN G.. P.. A.. USIA HAMIL .... MGG
DI ...............................................................

PENGKAJIAN:
Tanggal :...................................................... Jam :....................................
IDENTITAS PASIEN:
Identitas Pasien Penanggung Jawab
Status : Suami/.....................
1. Nama : ....................... 1. Nama : .........................
2. Umur : ....................... 2. Umur : .........................
3. Agama : ....................... 3. Agama : .........................
4. Pendidikan : ....................... 4. Pendidikan : .........................
5. Pekerjaan : ....................... 5. Pekerjaan : .........................
6. Suku bangsa: ....................... 6. Suku Bangsa: .........................
7. Alamat : ......................... 7. Alamat : .........................

I. DATA SUBYEKTIF
1. ALASAN DATANG:
…………………................................................................................................................
............................................
…………………................................................................................KELUHAN UTAMA:
……………...............................................................................................................................
...............................................................................................................................
Uraian keluhan
utama ........................................................................................................................................
.............
…………………........................................................................................................................
....................................………………….....................................................
RIWAYAT KESEHATAN:
Penyakit/kondisi yang pernah atau sedang
diderita : ..................................................................................................
…………………........................................................................................................................
.............................. Riwayat penyakit dalam Keluarga (menular maupun keturunan)
: ...............................................................................
…………………........................................................................................................................
......................................……\

RIWAYAT OBSTETRI
a. Riwayat Haid:
Menarche : …………......................... Nyeri Haid : ......................
Siklus : ………….........................Lama : ………….....
Warna darah : ………….........................Leukhorea : …................
Banyaknya : …………………….....................................................................
b. Riwayat Kehamilan sekarang :
1) G......... P...........A..........Ah.........
2) Usia kehamilan :
3) HPHT :............……..............................…….....................
4) HPL :. ...................……..............................…….............
5) Gerak janin
 Pertama kali : .......................................……..................
 Frekuensi dalam 12 jam :..........................................................……
6) Tanda bahaya :
a. TM I :
b. TM II :
c. TM III :
7) Keluhan
a) Trimester I :
b) Trimester II :
c) Trimester III :.
8) Riwayat terapi
a. Trimester I :
b. Trimester II :
c. Trimester III :.
rr
9) Riwayat Alergi:
10)Kekhawatiran khusus : …...................….......……..............................……............................
……………………………………………………………………………………………..........
..............
11)Imunisasi / TT :
…………………………………………………………………………………..........................
..............................................................................................……......................
 12)ANC : ……… x
Suplement &
ANC
Tanggal Tempat Fe MASALAH TINDAKAN/PENDKES
Ke
(Jenis & Jml)

Catatan : Bisa ditambah sesuai kebutuhan

c. Riwayat Kehamilan persalinan dan nifas yang lalu:

Kehamilan Persalinan Nifas
Kead
Frek Tempat
Tahun KELUHAN U JK/ IM Asi anak
AN Jenis persalianan Penolong Penyulit Penyulit
/PENYULIT K BB D eksklusif sekarang
C

2. RIWAYAT KB :Pernah/ tidak pernah*)

a. Jika pernah :
Lama
Jenis Kontrasepsi Keluhan Alasan dilepas
Pemakaian

b. RencanaSetelah
Melahirkan :................................................................................................................................
3. POLA PEMENUHAN KEBUTUHAN SEHARI-HARI:
Sebelum hamil :
Sebelum hamil Selama Hamil
A. Nutrisi
1) Makan
Frekuensi makan pokok ............X/hari ..............X/hari
Komposisi
Nasi ……. x @ ……. piring ……. x @ ……. piring (sedang /
(sedang / penuh) penuh)
Lauk …….. x @ ……. potong …….. x @ ……. potong
(sedang / besar), jenisnya (sedang / besar), jenisnya
Sayuran …….. x @ ……… mangkuk …….. x @ ……… mangkuk
 sayur ; jenis sayuran sayur ; jenis sayuran
Buah …….. x sehari / seminggu; …….. x sehari / seminggu; jenis
jenis
Camilan ……… x sehari; jenis ……… x sehari; jenis
Pantangan: …………Alasan …………Alasan
Keluhan: …………………………… ……………………………
Perubahan selama Hamil …………………………… ……………………………
2) Minum
Jumlah total gelas perhari; jenis gelas perhari; jenis
Susu ….gelas perhari; jenis susu …gelas perhari; jenis susu
Jamu .......x/hari, jenis .......x/hari, jenis
Keluhan: …………………………… ……………………………
Perubahan selama Hamil …………………………… ……………………………
b. Eliminasi
1) BAK
Frekuensi perhari ..............x ..............x
Warna ............................................. .............................................
Keluhan ............................................. .............................................
Konsistensi Keras/lembek Keras/lembek
2) BAB
Frekuensi perhari ..............x ..............x
Warna ............................................. .............................................
Konsistensi Keras/lembek Keras/lembek
Keluhan …………………………… ……………………………
C. Personal Hygine
Mandi ……… x sehari ……… x sehari
Keramas ……. x seminggu ……. x seminggu
Gosok Gigi …….. x sehari …….. x sehari
Ganti Pakaian ……….. x sehari ……….. x sehari
celana dalam ……….. x sehari ……….. x sehari
Kebiasaan memakai alas ............................................. .............................................
kaki
Keluhan …………………………… ……………………………
d. Hubungan sexsual
Frekuensi ………….x seminggu ………….x seminggu
Contact bleeding ............................................. .............................................
Keluhan lain ............................................. .............................................
Perubahan selama hamil ............................................. .............................................
ini
e. Istirahat/Tidur
Tidur malam …..jam …..jam
Tidur siang ……………. jam ……………. Jam
Keluhan/masalah ............................................. .............................................
Perubahan selama hamil ............................................. .............................................
ini
f. Aktivitas fisik dan
olah raga
Aktivitas fisik (beban ............................................. .............................................
pekerjaan)
Olah raga jenisnya Jenisnya
Frekuensi ……….. x seminggu ……….. x seminggu
Perubahan selama hamil ............................................. .............................................
ini
g. Kebiasaan yang
merugikan kesehatan
Merokok aktif ............................................. .............................................
 Lingkungan perokok ............................................. .............................................
Minuman beralkohol ............................................. .............................................
Obat-obatan ............................................. .............................................
Napza ............................................. .............................................
Aktifitas yang ............................................. .............................................
merugikan

4. Riwayat Psikososial-spiritual
a. Riwayat perkawinan :
1) Status perkawinan : menikah / tidak menikah*), umur waktu menikah : .................th.
2) Pernikahan ini yang ke ………… sah/ tidak*) lamanya ……….
3) Hubungan dengan suami : baik/ ada masalah
b. Kehamilan ini diharapkan / tidak*) oleh ibu, suami, keluarga;
Respon & dukungan keluarga terhadap kehamilan ini : .....................................
c. Mekanisme koping (cara pemecahan masalah) :
……………………................................................................................................
d. Ibu tinggal serumah dengan : ..
………………………………………...................................................................
e. Pengambil keputusan utama dalam keluarga : ......……………..
…...................................................................................................
Dalam kondisi emergensi, ibu dapat / tidak * mengambil keputusan sendiri.
f. Orang terdekat ibu :............................……………….............................................
Yang menemani ibu untuk kunjungan ANC : .........………....................................
g. Adat istiadat yang dilakukan ibu berkaitan dengan kehamilan :
…………………......................................................................................................
h. Rencana tempat dan penolong persalinan yang diinginkan : ...
…………...............................................................................................................
i. Penghasilan perbulan: Rp.............................................………….......…….........Cukup/Tidak
Cukup*)
j. Praktek agama yang berhubungan dengan kehamilan :
1) Kebiasaan puasa /apakah ibu berpuasa selama hamil ini?................................
Jika ‘ya’ frekuensi puasa : ...............................................................................
Keluhan selama
puasa : ...........................................................................................................................
2) Keyakinan ibu tentang pelayanan kesehatan :
 ibu dapat menerima segala bentuk pelayanan kesehatan yang diberikan oleh nakes
wanita maupun pria;
 tidak boleh menerima transfusi darah;
 tidak boleh diperiksa daerah genitalia,
 lainnya : ..................................................................................
 
k. Tingkat pengetahuan ibu :
Hal-hal yang sudah diketahui
ibu : ...................................................................................................................................
...................................................................................................................................
Hal-hal yang ingin diketahui
ibu : ..................................................................................................................................
...................................................................................................................................
l. Lingkungan:
Kebiasaan kontak dengan binatang :........................................................................
m. Paparann dengan polutan : ........................................................................

DATA OBYEKTIF:
1. PEMERIKSAAN FISIK:
a. Pemeriksaan Umum:
1) Keadaan umum : ........... Tensi : ...........
2) Kesadaran : ........... Nadi : ...........
3) BB Sebelum/ Sekarang: .........../ .......... Suhu /T : ...........
4) TB : ........... RR : ...........
5) LILA : ........... IMT : ...........
b. Status present
Kepala :.......................................................................................................
Mata :.......................................................................................................
Hidung :.......................................................................................................
Mulut :.......................................................................................................
Telinga :.......................................................................................................
Leher :.......................................................................................................
Ketiak :.......................................................................................................
Dada :.......................................................................................................
Perut :.......................................................................................................
Lipat paha :.......................................................................................................
Vulva :.......................................................................................................
Ekstremitas :.......................................................................................................
Refleks patella : ............./...............
Punggung :......................................................................................................
Anus :......................................................................................................
c. Status Obstetrik
1. Inspeksi:
 Muka : .....................................................................................................
  Mamae : .....................................................................................................
 Abdomen : ..............................................................................
 Vulva : ................................................................................
2. Palpasi
 Leoplod I : ....................................................................................
 Leoplod II : ....................................................................................
 Leoplod III : ....................................................................................
 Leoplod IV : .......................................................................................
3. Test osborn
3.TFU : ...............cm
4.TBJ : ................gram
5. Auskultasi :
DJJ : ..................x/menit Frekuensi : ...............-.....................-
5. Lain lain : ................................................................................
6. Perkus i: .......................................................................
7. Pemeriksaan panggul :..........................................................
8. KSPR dan kartu sudarto : .........................................................................
d. Pemeriksaan penunjang :....................................................................................

III. Analisis
Diagnosa Kebidanan:.................................................................................................................
Masalah :………………………………………………………………………..............
IV. PELAKSANAAN Tanggal ............................................. Jam ..................

1. ....................................................................................................................................
Rasionalisasi: ………………………………………………………………………
Hasil:.........................................................................................................................

2. ....................................................................................................................................
Rasionalisasi: ………………………………………………………………………
Hasil:.........................................................................................................................

3. ....................................................................................................................................
Rasionalisasi: ………………………………………………………………………
Hasil:.........................................................................................................................

........................, .......................2020
Pembimbing Klinik Praktikan

------------------------------ -------------------------------------
Mengetahui
Pembimbing Prodi
 --------------------------------------

CATATAN PERKEMBANGAN

Nama Pasien: No. RM Ruang:

Umur: Tanggal:

Tanggal/Jam: Catatan Perkembangan Nama dan Paraf

(SOAP)

S=

O=

A=

P=
Format Asuhan Kebidanan pada Ibu Bersalin

ASUHAN KEBIDANAN PADA IBU BERSALIN

PADA NY. ...... USIA ...... TAHUN G.. P.. A.. USIA HAMIL .... MGG
DI ...............................................................
PENGKAJIAN:
Tanggal :...................................................... Jam :....................................
IDENTITAS PASIEN:
Identitas Pasien Penanggung Jawab
Status : Suami/.....................
8. Nama : ....................... 8. Nama : .........................
9. Umur : ....................... 9. Umur : .........................
10.Agama : ....................... 10. Agama : .........................
11.Pendidikan : ....................... 11. Pendidikan : .........................
12.Pekerjaan : ....................... 12. Pekerjaan : .........................
13.Suku bangsa: ....................... 13. Suku Bangsa: .........................
14.Alamat : ......................... 14. Alamat : ........... ..........
....
KALA I(tanggal, jam)

I. DATA SUBJEKTIF
1. Alasan masuk kamar bersalin …
2. Keluhan Utama …
3. Tanda-tanda persalinan
a. Konraksi sejak … lamanya …, intensitas…, lokasi ketidaknyamanan di
…
b. Pengeluaran pervaginam (pengeluaran lendir darah, air ketuban, darah)
4. Pergerakan janin dalam 24 jam terakhir … kali
5. Riwayat sebelum masuk kamar bersalin …
6. Riwayat Perkawinan
 7. Kawin … kali, penikahan ke-… , umur saat menikah … tahun, lamanya
pernikahan… tahun.
8. Riwayat Menstruasi
9. Menarche usia…Siklus…Teratur/Tidak.Lama … hari.Sifat darah:
encer/beku. Bau… Flour albous ya/ tidak. Disminorhee: ya/tidak. Banyaknya
… cc.
a. HPMT:
b. HPL:
c. UK:
10. Riwayat Kehamilan ini:
a. Riwayat ANC
ANC tertur/tidak, frekuensi selama hamil … kali, oleh … di …
b. Obat-obatan/jamu yang dikonsumsi selama hamil …
c. Imunisasi TT
TT 1: tanggal … , TT 2: tanggal …
d. Keluhan/masalah/keadaan yang dirasakan ibu selama hamil:
No. Keluhan Tindakan Oleh Ket. (Tempat)

11. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu

G … P … Ab … Ah …

Ha Persalinan Nifas
mil
ke- Tgl U Jenis Penolo Kompli J BB Perdara Lakt Kompli
Lahi K Persalin ng kasi K Lah han asi kasi
r an ir
Ib Ba
u yi

12. Riwayat Kontrasepsi yang Digunakan

No Jenis Mulai Memakai Berhenti / Ganti Cara
 . Kontrasepsi Tg Ole Tempat Keluha Tg Ole Tempat Alasan
l h n l h

13. Riwayat Kesehatan

a. Penyakit sistemik, menurun, menular yang pernah/sedang diderita …
(jantung, asma, TBC, ginjal, DM, malaria, HIV/AIDS )
b. Penyakit yang pernah/ sedang diderita keluarga …
c. Riwayat operasi …
d. Riwayat kembar, cacat …
14. Kebutuhan Fisik
a. Nutrisi :
(Makan terakhir (tanggal, jam), minum terakhir (tanggal, jam), porsi,
jenis makanan/minuman yang dikonsumsi)
b. Eliminasi :
1) BAK terakhir (tanggal, jam)
(sifat … jumlah … warna … bau … keluhan)
2) BAB terakhir (tanggal, jam)
(sifat … jumlah … warna … bau … keluhan)
c. Istirahat (tidur)
(dalam satu hari terakhir)
d. Personal hygiene
(mandi, keramas terakhir)
15. Keadaan Psiko, Sosio dan Spiritual (kesiapan menghadapi proses
persalinan)
a. Pendamping persalinan …
b. Tanggapan ibu dan keluarga terhadap proses persalinan yang
dihadapi …
c. Persiapan persalinan yang telah dilakukan …
d. Pengetahuan tentang proses persalinan …

II. DATA OBJEKTIF

1. Pemeriksaan Umum
 a. Keadaanumum: … Kesadaran: …
b. Tanda – Tanda Vital
Tekanan Darah… Suhu… Respirasi… Nadi…

c. Berat Badan:
Sebelum hamil … kg, kunjungan lalu … kg, kunjungan ini… kg.
Tingg badan …
d. IMT …
e. LILA …

2. Pemeriksaan Fisik
a. Kepala :
(rambut, muka (odema, cloasma), mata (sklera, konjungtiva), hidung,
mulut, gigi, lidah, gusi, telinga)

b. Leher :
(kelenjar tiroid, kelenjar getah bening, vena jugularis eksterna)

c. Dada (payudara):
(Bentuk, areola, putting susu, pengeluaran colostrum, massa/ benjolan)

d. Abdomen
1) Inspeksi
Bentuk … bekas luka … striae gravidarum/ striae albican … linea
nigra … gerakan janin …

2) Palpasi
a) Leopold 1: (menentukan TFU … jari, teraba …)
b) Leopold 2: (menentukan letak janin)
c) Leopold 3: (menentukan presentasi)
d) Leopold 4: (menentukan bagian terendah janin sudah/belum
masuk PAP)
e) Osborn Test …
f) TFU Mc.Donald … cm.
Taksiran Berat Janin:
 3) Auskultasi:
Punctum maksimum di … DJJ: frekuensi …kali/menit, teratur/tidak,
intensitas …
4) His: frekuensi … kali/10 menit, durasi … detik, intensitas … (kuat,
sedang, lemah)
5) Palpasi supra pubik …
e. Ekstrimitas
(odema, kelainan, varices, warna kuku, reflex Patella)
f. Genetalia Eksterna dan Anus
Vagina: (kebersihan, tanda Chadwick, kelainan, fluor albus, oedem,
varises, bekas luka, infeksi, kelenjar Bartholini, kelenjar Skene). Anus:
(hemoroid)
3. Pemeriksaan Dalam
a. Indikasi …
b. Tujuan …
c. Hasil …
(vagina, uretra, cerviks (pendataran dan pembukaan), selaput ketuban,
presentasi, petunjuk presentasi, penurunan bagian terendah, pengeluaran
(air ketuban, lendir darah, darah)).
d. Kesimpulan …
4. Pemeriksaan laboratorium (atas indikasi)
a. Darah (Hb, golongan darah, HbSAg, WR/VDRL)
b. Urine (Protein urin, glukosa urin, lakmus test)
c. dll
III. ANALISIS DATA
Diagnosa :
Dasar Diagnosa :
Masalah :
Dasar masalah :
Kebutuhan : Jika terdapat masalah
Diagnosa Potensial : (Jika ada kondisi risiko patologi/ Gawat Darurat)
Tindakan Segera : Dilakukan jika terdapat diagnosa potensial
 (Diagnosa kebidanan, masalah, kebutuhan)
IV. PENATALAKSANAAN
(Asuhan yang telah dilakukan , Rasionalisasi setiap tindakan dan evaluasinya)
Data Perkembangan Kala II, III dan IV diuraikan SOAP
Dapat ditulis dalam bentuk Matriks
CATATAN PERKEMBANGAN

Nama Pasien: No. RM Ruang:

Umur: Tanggal:

Tanggal/Jam: Catatan Perkembangan Nama dan

Paraf
(SOAP)

S=

O=

A=

P=

Disertakan data bayi segera setelah lahir, dengan

asuhan IMD

....................... , ................................

Praktikan

--------------------------------------

Mengetahui,

Pembimbing Institusi Pembimbing Klinik

------------------------------ -------------------------------------
Format Asuhan Kebidanan pada Ibu Nifas

ASUHAN KEBIDANAN PADA IBU NIFAS

PADA NY. ...... UMUR ...... TAHUN P.. A..
DI ...............................................................

I. DATA SUBYEKTIF
A. IDENTITAS / BIODATA
Nama Pasien :………………… Nama suami :………………
Umur :………………………Umur :………………
Pendidikan :………………………Pendidikan :………………
Pekerjaan :………………………Pekerjaan :………………
Alamat :………………………Alamat :………............

B. Keluhan Utama
……………………………………………………………………………
…………………………………………………………………………...
C. Riwayat Persalinan
Waktu melahirkan : .....................
Pukul ..........................
Jenis Kelamin bayi:....................
Berat Badan :........... gram,
Panjang badan :........... cm,
Apgar Score: ....................
Jenis Persalinan: ..........................
Tempat persalinan : ............................................
Plasenta : ......................
Lama Persalinan : .....................
Jumlah Perdarahan : .............................
Kala I : ............................................Kala I : ......
Kala II : ............................................Kala II : .......
Kala III :............................................ Kala III : ......
Kala IV : ........................................... Kala IV : .......

D. Riwayat Kehamilan
Trimester I : ...........................................................................................................................
Keluhan : ...........................................................................................................................
...........................................................................................................................
Terapi : ...........................................................................................................................
............................................................................................................................
Trimester II: ...........................................................................................................................
Keluhan : ..........................................................................................................................
............................................................................................................................
Terapi : ...........................................................................................................................
: ..........................................................................................................................
Trimester III.........................................................................................................................:
Keluhan : ...........................................................................................................................
............................................................................................................................
Terapi : ...........................................................................................................................
............................................................................................................................

E. Riwayat Kesehatan Sekarang

Mobilisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
F. Keadaan Psikososial
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

G. Riwayat Kesehatan Keluarga

................................................................................................................................................
................................................................................................................................................

H. Pola Kebutuhan Dasar Nifas

Eliminasi : BAB : ........................................
BAK : .......................................................
Nutrisi : ...........................................................................................................................
Istirahat : ...........................................................................................................................
Aktivitas : Melakukan / tidak melakukan senam nifas ......................................................
............................................................................................................................
Personel Hygiene : ................................................................................................................
................................................................................................................................................

II. DATA OBYEKTIF

Keadaan Umum : .............................................
Kesadaran : .............................................
Status Emosional : ..........................................................................
Tanda Vital
Tekanan : ............................................. mmHg
Nadi : .............................................
Pernapasan : ............................................. x/menit
Suhu : .............................................
Muka
Kelopak Mata : .................................................................................................................
Konjungtiva : ............................................. Sklera :..............................................
Cloasma Gravidarum :..........................................................................
Mulut & Gigi :
Lidah & Geraham
: ......................Gigi: .....................
Carries:...........................
Kelenjar tyroid : .............................................pembesaran
tyroid :........................... Kelenjar getah bening :
Pembesaran ....................................................
Dada
Jantung : ...................................... Paru-paru: .............. Pernapasan
:
 Payudara : Pemesaran ................... Puting Susu :..........................................................
Pengeluaran Asi: ................................... Simetris.....................Benjolan :

Nyeri : ............................................. Kemerahan : ..................................................

Punggung & Pinggang
Punggung......................................................... Nyeri Sudut
Costoverbratre .....................................................
Ekstremitas atas :
Oedema ..................................... Ketegangan ....................... Kemerahan

Varises ......................................
Abdomen
Bekas Operasi .................................... Pembesaran : ...........................................................
Konsistensi : .............................. Benjolan .......................... Kontraksi ...............................
Pembesaran liver ...................................TFU .......................................................................
Strie : .....................................................
Pemeriksaan Diastasis Recti : Normal/ Tidak Normal : .......................................................
Ano Genital
Perineum : Luka Parut : ..................................Vulva Vagina : warna ..................................
Luka ........................................ Fistula ................................ Varises ...................................
Pengeluaran Pervaginam ................................warna : ..........................................................
Lokhea ............................................................ Anus : hemoroid ..........................................
Kaki
Oedema : ........................................................ Vagina .........................................................
Tanda Hofman ................................................ Kemerahan ..................................................
Serviks (Jika ada indikasi)
Warna .............................. Posisi : ................................. Konsistensi .................................
Nyeri ................................Pengeluaran .......................... Lochea ........................................
Dinding Vagina
Warna .............................. varises .................................. Oedema .......................................
Luka ..............................Penonjolan/Fistula/Varises ................... Nyeri .............................
Luka Perineum : ............................... (Basah/kering) Lasrasi derajat : ................................

III. ASSASSMENT
DIAGNOSA
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 DASAR
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MASALAH
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KEBUTUHAN

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IV. PERENCANAAN
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CATATAN PERKEMBANGAN

TANGGAL/JAM
DATA SUBJEKTIF
ANAMNESA
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DATA OBJEKTIF
1 Pemeriksaan Umum :
Tekanan Darah :
Nadi :
Lila :
BB :
RR :
S :

1. pemeriksaan fisik

2. Pemeriksaan Penunjang

ASSESMENT

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PERENCANAAN

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Praktikan

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Mengetahui,
Pembimbing Akademik Pembimbing Klinik

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Format Asuhan Dokumentasi Kebidanan pada BBL

ASUHAN KEBIDANAN PADA BAYI NY “____”

DENGAN BBL _______ UMUR _________
DI ________________________________

Tanggal masuk : ______________________________

Pukul : ______________________________
Tempat : ______________________________

PENGKAJIAN Tgl/jam : _______________________________

I. DATA SUBYEKTIF
A. Identitas
1. Identitas Bayi
Nama : ...........................................................................
Umur : ...........................................................................
Tanggal lahir : ...........................................................................
2. Identitas Orang Tua/Wali
Nama :............................................................................
Umur :............................................................................
Agama :............................................................................
Pendidikan :............................................................................
Pekerjaan :............................................................................
Suku/bangsa :............................................................................
Alamat :............................................................................
 B. Anamnesa
1. Riwayat Kehamilan
Hamil :.................................................................
Frekuensi ANC :.................................................................
Imunisasi TT :.................................................................
Kenaikan BB Hamil :.................................................................
Kejadian waktu Hamil :.................................................................

Riwayat penyakit/kehamilan
a. Perdarahan : ada/tidak
b. Eklamsia : ada/tidak
c. Pre eklamsi : ada/tidak
d. Penyakit Kelamin : ada/tidak
e. Penyakit Lain
: ................................................................

Kebiasaan waktu hamil

a. Makanan : ......................................................................
b. Obat-obatan/jamu : ......................................................................
c. Merokok : ......................................................................
d. Lain-lain : .....................................................................

Komplikasi Persalinan
Ibu : ada/tidak

2. Riwayat persalinan
a. Lama kala I
: ......................................................................
b. Lama Kala II
: ......................................................................
c. Warna air ketuban : ......................................................................
d. Jenis persalinan
: ......................................................................
e. Penolong : ...................................................................
...
f. Jam/tgl/lahir
: ......................................................................
g. Jenis kelamin
: ......................................................................
h. BB/PB
: ......................................................................

II. DATA OBYEKTIF

1. Pemeriksaan Umum
KU : ........................................................................................
Kesadaran : ........................................................................................
BB : ........................................................................................
 Tanda – tanda vital :
Nadi : ...........x/menit
Respirasi : ..........x/menit
Suhu : ..........C

2. Pemeriksaan Fisik
Muka : ..............................................................................................
Ubun-ubun : ..............................................................................................
Hidung: ..............................................................................................
Bibir : ..............................................................................................
Telinga : ..............................................................................................
Leher : ..............................................................................................
Dada : ..............................................................................................
Tali pusat : ..............................................................................................
Punggung : ..............................................................................................
Genetalia : ..............................................................................................
Anus : ..............................................................................................
Ekstremitas : ..............................................................................................
3. Reflek.
Reflek Moro : ada/tidak
Reflek Rooting : ada/tidak
Reflek Walking : ada/tidak
Reflek Grasping : ada/tidak
Reflek Sucking : ada/tidak
Reflek Tonik neck : ada/tidak
4. Antropometri
Lingkar kepala : ..................................................................................
Lingkar dada : ..................................................................................
Lingkar lengan : ..................................................................................
5. Eliminasi
Miksi :..................................................................................
Defekasi/ Pengeluaran mekonium :...............................................................

6. Pemeriksaan penunjang (jika dilakukan)

a. Urine : tgl...................................
PP test : .........................
Protein : .........................
Glukosa : .......................

b. Darah : tgl..................................
Hb : ...............................
Al : ................................
HMT : ............................
Golongan darah : .......

III. ANALISIS DATA

Diagnosa :
 Dasar Diagnosa :
Masalah :
Dasar masalah :
Kebutuhan : Jika terdapat masalah
Diagnosa Potensial : (Jika ada kondisi risiko patologi/ Gawat Darurat)
Tindakan Segera : Dilakukan jika terdapat diagnosa potensial
(Diagnosa kebidanan, masalah, kebutuhan)
IV. PENATALAKSANAAN
(Asuhan yang telah dilakukan , Rasionalisasi setiap tindakan dan evaluasinya)
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Praktikan

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Mengetahui,
Pembimbing Institusi Pembimbing Klinik

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