Form Baru Akbid

ASUHAN KEBIDANAN PADA IBU BERSALIN
NO. REGISTER : ......................

MASUK TANGGAL, JAM : ............................................, JAM ............. WIB
DI RAWAT DI RUANG : ......................
Biodata :
Ibu Ayah
Nama : Ny.S Nama : Tn. S
Umur : 25 tahun Umur : 28 tahun
Agama : Islam Agama : Islam
Suku / bangsa : Aceh / indonesia Suku / agama : Aceh / indonesia
Pendidikan : SMA Pendidikan : S1
Pekerjaan : IRT Pekerjaan : Guru
Alamat : sigli Alamat : sigli
No telepon : 085260313933 No telepon : 01919673331
DATA SUBJEKTIF
1. Alasan masuk kamar bersalin
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2. Keluhan utama
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3. Tanda-tanda persalinan
a. Kontraksi uterus sejak tanggal.............................................., jam ..................
Frekwensi ............................ kali dalam 10 menit.
Durasi ................... detik
Kekuatan : kuat/ sedang / lemah.
Lokasi ketidaknyamanan di .................................................................................
b. Pengeluaran per vagina
Lendir darah : ya / tidak.
Air ketuban : ya / tidak, banyaknya ..........cc, warna ..................
Darah : ya / tidak, banyaknya ..........cc, warna ..................
4. Riwayat sebelum masuk ruang bersalin

5. Riwayat kehamilan sekarang
HPM............................ HPL .....................................
Menarche umur ...........tahun, siklus ....... hari, lama ....... hari, banyaknya ........ cc
ACN teratur / tidak, frekwensi ......... kali, di ........................................
Keluhan / komplikasi selama kehamilan
....................................................................................................................................
....................................................................................................................................
Riwayat merokok/minum-minuman keras/minum jamu.........................
Imunisasi TT.1 : ya / tidak, tanggal, ...................................................
Imunisasi TT.2 : ya / tidak, tanggal, ...................................................
6. Pergerakan janin dalam 24 jam terakhir ............. kali

7. Riwayat kehamilan, persalinan dan nifas yang lalu.
Persalinan Nifas
Hamil Tgl. Umur Jenis Komplikasi Jenis BB
Penolong Laktasi Komplikasi
Lahir Kehamilan Persalinan Ibu Bayi Kehamilan Lahir
8. Riwayat Kontrasepsi yang digunakan

Jenis Mulai memakai Berhenti / Ganti Cara
No
Kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan
9. Riwayat Kesehatan
a. Penyakit yang pernah / sedang diderita
............................................................................................................................
............................................................................................................................
b. Penyakit yang pernah / sedang diderita keluarga
............................................................................................................................
............................................................................................................................
c. Riwayat keturunan kembar
............................................................................................................................
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10. Makan terakhir tanggal, ............................, jam ..............., jenis ........................
Minum terakhir tanggal, ............................, jam ..............., jenis ........................
11. Buang air besar terakhir tanggal, ............................... jam .....................
12. Buang air kecil terakhir tanggal, ............................... jam .....................
13. Istirahat / tidur dalam 1 hari terakhir ........................, jam .....................
14. Keadaan psiko sosio spiritual/kesiapan menghadapi dan proses persalinan
a. Pengetahuan tentang tanda – tanda persalinan dan proses persalinan
..............................................................................................................................
..............................................................................................................................
b. Persiapan persalinan yang telah dilakukan (Pendamping ibu, biaya, dll)
..............................................................................................................................
..............................................................................................................................
c. Tanggapan Ibu dan Keluarga terhadap proses persalinan yang dihadapi
..............................................................................................................................
.............................................................................................................................
DATA OBJEKTIF
1. Pemeriksaan fisik
a. Keadaan umum : ...................... kesadaran : ............................
b. Status Umum : ....................................
c. Tanda Vital :
Tekanan darah : ............ mmHg
Nadi : ............ kali per menit
Pernafasan : ............ kali per menit
Suhu : ........... 0
C
d. TB : ........... cm
BB : sebelum hamil ...... kg, BB Sekarang .... kg
LLA : ............ cm
e. Kepala dan leher
Edema wajah : ...................................................................................................
Cloasma gravidarium : + / -
Mata : ...................................................................................................
Mulut : ...................................................................................................
Leher : ...................................................................................................
f. Payudara
Bentuk : simetris
Puting susu : ..........................
Colostrum : ..........................
g. Abdomen
Pembesaran : ...................................................................................................
Benjolan : ...................................................................................................
Bekas luka : ...................................................................................................
Strie gravidarum : ...................................................................................................
Palpasi leopold
Leopold I : ...................................................................................................
Leopold II : ...................................................................................................
Leopold III : ...................................................................................................
Leopold IV : ...................................................................................................
Osborn test : ...................................................................................................
TBJ : ...................................................................................................
Auskultasi DJJ : Pusctum maksimum .............................................................

Frekwensi : ........ kali per menit ( ....... / ......../ ..... )
His : kemajuan dalam persalinan
Kala I
Frekwensi : ........ kali dalam 25 menit
Durasi : ........ detik
Kekuatan : kuat /sedang/lemah.
Kala II
h. Punggung : ...................................................................................................
i. Pinggang : nyeri / tidak
j. Ekstremitas
Kekakuan otot dan sendi : ........................................................................................
Edema : ........................................................................................
Varises : ........................................................................................
Refleks patela : ........................................................................................
Kuku : ........................................................................................
k. Genetalia
Tanda chadwich : ........................................................................................
Varises : ........................................................................................
Bekas luka : ........................................................................................
Kelenjar bartholini : ........................................................................................
Pengeluaran : ........................................................................................
l. Anus
Hemoroid : ........................................................................................
2. Pemeriksaan Dalam, tanggal ................................., oleh .............................................

...............................................................................................................................................
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3. Pemeriksaan penunjang
...............................................................................................................................................
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ASESSMENT
1. Diagnosis Kebidanan
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2. Masalah
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3. Kebutuhan
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4. Diagnosis Potensial
...............................................................................................................................................
...............................................................................................................................................
5. Masalah Potensial
...............................................................................................................................................
...............................................................................................................................................
6. Kebutuhan Tindakan Segera Berdasarkan Kondisi Klien
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................
PLANNING ( Termasuk Pendokumentasian Implementasi dan Evaluasi)

Tanggal ..........................................., jam .....................
Tanda Tangan
( ......................................... )
CACATAN PERKEMBANGAN
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
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DATA OBJEKTIF
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ASSESSMENT
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PLANNING
Tanggal ................................................................, jam ..............................................................
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ASUHAN KEBIDANAN PADA ASEPTOR KB
NO. REGISTER : ......................

DI RAWAT DI RUANG : ......................
Biodata :
Ibu Ayah
DATA SUBJEKTIF
1. Kunjungan saat ini Kunjungan Pertama Kunjungan Ulang
Keluhan Utama
...............................................................................................................................................
...............................................................................................................................................
2.
Kawin ........... kali. Kawin pertama umur ............ tahun
Dengan suami sekarang ........................ tahun.
3. Riwayat Menstruasi
Menarche umur ........... tahun. Siklus .......... hari. Teratur / tidak.
Lama .............. hari. Sifat darah : encer / beku. Bau ......... Flour
Albus ya / tidak. Dismenorroe ya / tidak.
Banyaknya ..................................... cc HPM .....................................................
P ....................... Ab .......................... Ah .................................
Persalinan Nifas
Hamil
Tgl. Umur Jenis Penolong Komplikasi Jenis BB Laktasi Komplikasi

No
a. Penyakit sistemik yang pernah/sedang diderita
.........................................................................................................................................
.........................................................................................................................................
b. Penyakit yang pernah/ sedang diderita keluarga
.........................................................................................................................................
.........................................................................................................................................
c. Riwayat penyakit ginekologi
.........................................................................................................................................
.........................................................................................................................................
7. Pola pemenuhan kebutuhan sehari – hari
a. Pola nutrisi Makan Minum
Frekwensi ................................. .....................................
Macam ................................. .....................................
Jumlah ................................. .....................................
Keluhan ................................. .....................................
b. Pola eliminasi BAB BAK
Frekwensi ................................. .....................................
Warna ................................. .....................................
Bau ................................. .....................................

Konsistensi ................................. .....................................
Jumlah ................................. .....................................
c. Pola aktivitas
Kegiatan sehari – hari : ................................................................................................
Istirahat / tidur : ................................................................................................
d. Seksualitas : Frekuensi ................................................................................
Keluhan .................................................................................
e. Personal Hygiene
Kebiasaan mandi ...................... kali/hari
Kebiasaan membersihkan alat kelamin ...........................................................................
Kebiasaan menggantikan pakaian dalam ........................................................................
Jenis pakaian dalam yang digunakan .............................................................................
8. Keadaan Psiko Sosial Spiritual
a. Pengetahuan ibu tentang alat kontrasepsi
..........................................................................................................................................
..........................................................................................................................................
b. Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang
..........................................................................................................................................
..........................................................................................................................................
c. Dukungan suami / keluarga
..........................................................................................................................................
..........................................................................................................................................
DATA OBJEKTIF
a. Keadaan umum ........................................ kesadaran ..................................
Tanda Vital
Tekanan darah : .................. mmHg
Nadi : .................. kali per menit
Pernafasan : .................. kali per menit
Suhu : .................. 0C
BB : .................. Kg
b. Kepala
Hiperpigmentasi : .............................................................................................
Mata : .............................................................................................
Mulut : .............................................................................................
c. Leher : .............................................................................................
d. Payudara
Bentuk : .............................................................................................
Puting susu : .............................................................................................
Massa / tumor : .............................................................................................
e. Abdomen
Bentuk : .............................................................................................
Bekas luka : .............................................................................................
Massa / tumor : .............................................................................................
f. Ekstremitas
Edema : .............................................................................................
Varises : .............................................................................................
Refleks patela : .............................................................................................
g. Genetalia luar
Tanda chadwich : .............................................................................................
Varises : .............................................................................................
Bekas luka : .............................................................................................
Kelenjar bartholini : .............................................................................................
Pengeluaran : .............................................................................................
h. Anus Hemoroid : .............................................................................................
2. Pemeriksaan Dalam / ginekologis

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ASESSMENT
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2. Masalah
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3. Kebutuhan
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...............................................................................................................................................
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................

Tanggal ..........................................., jam .....................
Tanda Tangan
( ......................................... )
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
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DATA OBJEKTIF
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ASSESSMENT
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PLANNING
Tanggal ................................................................, jam ..............................................................
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Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA IBU HAMIL

MASUK TANGGAL, JAM : 05 Desember 2017, JAM 09:00 WIB
Si Tempat Pemeriksaan : BPS….
Biodata :
Ibu Ayah
Umur : 23 Tahun25 tahun Umur : 28 tahun
DATA SUBJEKTIF
1. Kunjungan saat ini Kunjungan Pertama Kunjungan Ulang
Keluhan Utama
Ibu mengeluh sakit pinggang dan pegal-pegal
2. Riwayat Perkawinan
Kawin ........... kali. Kawin pertama umur 23 tahun
Dengan suami sekarang ........................ tahun.
3. Riwayat Menstruasi
Menarche umur 12 tahun. Siklus 28 hari. Teratur / tidak.
Lama 7 hari. Sifat darah : encer. Bau khas Flour Albus tidak
Dismenorroe ya. Banyaknya 50 cc
HPM 10 Maret 2017 HPL 17 Desember 2017
4. Riwayat kehamilan ini .
a. Riwayat ANC
ANC sejak umur kehamilan 8 Minggu. ANC di BPS…….
Frekuensi : Trimester I 3 kali.
Tanggal 09 April, 10 Mei, 10 Juni 2017
Tempat BPS, Posyandu, Puskesmas
Keluhan Mual Muntah
Trimester II 2 kali
Tanggal
Tempat
keluhan
Trimester III .............. kali
b. Pergerakan janin yang pertama pada umur kehamilan 16 Minggu, pergerakan janin dalam
24 jam terakhir 12 kali.
c. Pola nutrisi Makan Minum
Frekwensi ................................. .....................................
Macam ................................. .....................................
Jumlah ................................. .....................................
Keluhan ................................. .....................................
Pola eliminasi BAB BAK
Frekwensi ................................. .....................................
Warna ................................. .....................................
Bau ................................. .....................................
Konsistensi ................................. .....................................
Jumlah ................................. .....................................
Pola aktivitas
Kegiatan sehari – hari : Ibu hanya melakukan pekerjaan dirumah
(mencuci,memasak,menyapu)
Istirahat / tidur : Siang 2 jam, Malam 8 jam
Seksualitas : Frekuensi 3 x dalam seminggu
Keluhan nyeri pinggang
d. Personal Hygiene
Kebiasaan mandi 2 kali/hari
Kebiasaan membersihkan alat kelamin setiap BAK dan BAB
Kebiasaan menggantikan pakaian dalam setiap mandi
Jenis pakaian dalam yang digunakan kain katun
e. Imunisasi
TT 1 tanggal 10 Juni 2017
TT 2 tanggal 10 juli 2017
5. Riwayat kehamilan, persalinan dan nifas yang lalu

G 1 P 0 Ab 0 Ah 0
Ibu belum pernah melahirkan sebelumnya
Ibu belum pernah menggunakan alat kontasepsi sebelumnya
Ibu tidak pernah / sedang menderita penyakit sistemik
b. Penyakit yang pernah/ sedang diderita keluarga
.........................................................................................................................................
.........................................................................................................................................
c. Riwayat keturunan kembar
.........................................................................................................................................
.........................................................................................................................................
d. Kebiasaan – kebiasaan
Merokok Tidak ada
Minum jamu – jamuan ....................................................................................................
Minum – minuman keras ................................................................................................
Makanan / minuman pantang ..........................................................................................
Perubahan Pola Makan (termasuk nyidam, nafsu makan turun dll) ...............................
a. Kelahiran ini : Diinginkan Tidak diinginkan
b. Pengetahuan ibu tentang kehamilan dan keadaan sekarang
Ibu belum mengetahui tentang kehamilan dikarenakan ibu dengan hamil pertama dan
belu mengetahui keadaaan kehamilan sekarang
c. Penerimaan ibu terhadap kehamilan saat ini.
.........................................................................................................................................
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d. Tanggapan keluarga terhadap kehamilan
.........................................................................................................................................
.........................................................................................................................................
e. Ketaatan ibu dalam beribadah
......................................................................................................................................... .....
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DATA OBJEKTIF
a. Keadaan umum baik kesadaran CM
b. Tanda Vital
Tekanan darah : 120/80 mmHg
Nadi : 78 kali per menit
Pernafasan : 22 kali per menit
Suhu : 36 0C
c. TB : 155 cm
BB : sebelum hamil 48 Kg, BB sekarang 60 Kg.
LLA : 30 cm
d. Kepala dan leher
Edema wajah : Tidak Ada
Cloasma gravidarum + / -
Mata : .............................................................................................
Mulut : .............................................................................................
Leher : .............................................................................................
Payudara
Bentuk : .............................................................................................
Areola mammae : .............................................................................................
Puting susu : .............................................................................................
Colostrum : .............................................................................................
e. Abdomen
Bentuk : .............................................................................................
Bekas luka : .............................................................................................
Strie gravidarum : .............................................................................................
Palpasi Leopoid
Leopold I : TFU 34 cm (TFU teraba pada pertengahan pusat dengan PX
Leopold II : Bagian kanan teraba panjang memapar (PUKA)
Leopold III : Bagian terbawah janin teraba bulat keras melenting (Kepala)
Leopold IV : Bagian terbawah janin sudah masuk PAP( Disvergen)
TBJ : (34-11) 155 = 3565 gram
Auskultasi DJJ : Pusctum maksimum kanan

Frekwensi : 145 kali per menit
f. Ekstremitas
Edema : .............................................................................................
Varises : .............................................................................................
Refleks patela : .............................................................................................
Kuku : .............................................................................................
g. Genetalia luar
Tanda chadwich : .............................................................................................
Varises : .............................................................................................
Bekas luka : .............................................................................................
Kelenjar bartholini : .............................................................................................
Pengeluaran : .............................................................................................
h. Anus
Hemoroid : .............................................................................................
Tidak ada
ASESSMENT
Ibu dengan G1 P0 Ab0 dengan usia kehamilan 34 minggu keadaan ibu dan janin baik, bagian
terbawah janin sudah masuk PAP.
2. Masalah
Ibu mengalami nyeri pinggang dan pegal-pegal
3. Kebutuhan
Ibu istirahat dan tidak bekerja terlalu berat

1. Bertahu ibu hasil pemeriksaan
2.
Evaluasi
Ibu terlihat sehat dan hany mengalami nyeri pinggang
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
Ibu ingin melakukan pemeriksaan HB dan Gol darah
DATA OBJEKTIF
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ASSESSMENT
Ibu g1 p0 ab0 dengan uk 34 minggu janin sudah pap, gol 0 hb 12
PLANNING
Tanggal ................................................................, jam ..............................................................
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Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA BAYI BARU LAHIR

DI RAWAT DI RUANG : ......................
Biodata : Ibu Ayah

DATA SUBJEKTIF
1. Keluhan Utama :
2. Riwayat Antenatal
G ............ P .............. A ................ Ah . Umur Kehamilan ..... Minggu Riwayat ANC
: teratur / tidak, ... kali, di ... Oleh ....
Imunisasi TT : ........ kali
TT 1 tanggal ..........., TT 2 ........... tanggal .............
TT 3 tanggal ..........., TT 4 ........... tanggal .............
TT 5 tanggal ...........,
Kenaikan BB : ......... kali
Keluhan saat hamil : .............................................................................................................
Penyakit selama hamil : jantung, Diabetes Mellitus, Gagal Ginjal, Hepatitis B, Tuberkulosis,
HIV Positif, Trauma/Penganiayaan.
Kebiasaan Makan : ..............................................................................................................
Obat/jam : ............................................................................................................................
Merokok : .............................................................................................................................
Komplikasi ibu : Hiperemesis, Abortus, pendarahan, Pre-eklampsi, Diabetes Gestasional.
Infeksi,
Janin : IUGR, Polihidramnion, Gemelli
3. Riwayat Intranatal
Lahir tanggal ................................................... jam .....................
Jenis persalinan : spontan / tindakan ....................................................Atas indikasi :……..
Penolong : ............................. di ..................................................

Lama Persalinan : Kala I ...................... jam .................... menit
Kala II .................... jam .................... menit
Komplikasi
a. Ibu : Hipertensi/hipontensi, partus lama, penggunaan obat,infeksi/suhu badan naik, KPD,
pendarahan.
b. Janin : Prematur/postmatur, malposisi/malpresentasi, gawat janin, ketuban campur,
mekonium, prolaps tali pusat.
4. Riwayat Bayi Baru Lahir
BB/BP Lahir : .....................................................................................
Nilai APGAR : 1 menit / 5 menit / 10 menit : ...... / ...... / .....
No Kriteria 1 Menit 5 Menit 10 Menit
Denyut Jantung
Usaha Nafas
Tonus Otot
Reflek
Warna Kulit
TOTAL
Caput succedaneum : ......................................................................
Cepal haematoma : ......................................................................
Cacat Bawaan : ......................................................................
Resusitasi : Ransangan : ya / tidak.
Penghisapan lendir : ya / tidak
Ambu bag : ya / tidak ..... liter/menit
Massese jantung : ya / tidak ..... liter/menit
Intubasi Endotrakheal : ya / tidak
O2 : ya / tidak ..... liter/menit
DATA OBJEKTIF
1. Pemeriksaan Umum
a. Pernafasan : ...................................................................................................
b. Warna kulit : ...................................................................................................
c. Denyut jantung : ...................................................................................................
d. Suhu Aksiler : ...................................................................................................
e. Postur dan Gerakan : ...................................................................................................
f. Tonus otot / tingkat : ...................................................................................................
g. Kesadaran : ...................................................................................................
h. Ekstremitas : ...................................................................................................
i. Kulit : ...................................................................................................
j. Tali pusat : ...................................................................................................
k. BB sekarang : ...................................................................................................
2. Pemeriksaan Fisik
a. Kepala : ...................................................................................................
b. Muka : .............................................................................................
......
c. Mata
: ...................................................................................................
d. Telinga : ...................................................................................................
e. Hidung : ...................................................................................................
f. Mulut
: ...................................................................................................
g. Leher : .............................................................................................
......
h. Klavikula : ...................................................................................................
i. Lengan tangan : ...................................................................................................
j. Dada
: ...................................................................................................
k. Abdomen : ...................................................................................................
l. Genetalia : ...................................................................................................
m. Tungkai dan kaki : ...................................................................................................
n. Anus
: ...................................................................................................
o. Panggung : ...................................................................................................
3. Refleks : Moro
: ...................................................................................................
Rooting : ...................................................................................................
Walking : ...................................................................................................
Graphs : ...................................................................................................
Sucking : ...................................................................................................
Tonicneck : ...................................................................................................
4. Antropometrik : PB : ............... cm
LK : ............... cm
LD : ............... cm
LLA : ............... cm
5. Eliminasi Miksi : .......................................................................................................
Mekonium : .......................................................................................................
6. Pemeriksaan Penunjang
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ASESSMENT
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2. Masalah
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3. Kebutuhan
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a. Mandiri
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b. Kolaborasi
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c. Merujuk
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Tanggal ..........................................., jam .....................
Tanda Tangan
( ......................................... )
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
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ASSESSMENT
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PLANNING
Tanggal ................................................................, jam ..............................................................
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Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA TUMBUH KEMBANG BALITA
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NO. REGISTER : ..........................................

MASUK RS TANGGAL, JAM : ...........................................
DI RAWAT DI RUANG : ..........................................
Biodata :
Nama Bayi : .............................................................................................................
Tanggal Lahir : ............................................, jam .........................
Jenis Kelamin : ............................................
Nama Ibu : ............................................ Nama Ayah : .....................................S
Umur : ............................................ Umur : .....................................
Agama : ............................................ Agama : .....................................
DATA SUBJEKTIF
1. Keluhan Utama (anak/orang tua)
....................................................................................................................................
....................................................................................................................................
2. Riwayat penyakit sekarang.
....................................................................................................................................
....................................................................................................................................
3. Respon Keluarga.
....................................................................................................................................
....................................................................................................................................
4. Riwayat kesehatan yang lalu.
a. Riwayat prenatal dan perinatal.
Masa kehamilan : ............................. minggu.
Lahir tanggal ...................................., jam ......................
Jenis persalinan : spontan / tindakan ..............................
Atas indikasi ........................................
Penolong : ...................................... di ...................................................
Lama persalinan : Kala I ........................ jam ..................................... menit
Kala II ........................ jam ..................................... menit
Komplikasi
1) Ibu : Hipertensi /hipotensi, partus lama, penggunaan obat, infeksi/suhu badan naik,
KPD, pendarahan.
2) Janin : Prematur/postmatur, malposisi/malpresentasi, gawat janin, ketuban campur
mekonium, prolaps tali pusat.
Keadaan Bayi Baru Lahir
BB / PB Lahir : ................................................................
Nilai APGAR : 1 menit/ 5 menit / 10 menit /.........../ ..............
b. Riwayat Paemberian Nutrisi
ASI Eksklusif ya / tidak. Lama pemberian ASI ............ bulan / tahun
PASI sejak umur ............... bulan / tahun, jenis .............................
Makanan tambahan sejak umur ...................... bulan / tahun, jenis ..............
Keluhan ..........................................................................................................
5. Status Kesehatan terakhir.
a. Riwayat alergi
Jenis makanan : ....................................................................................
Debu : ....................................................................................
Obat : ....................................................................................
b. Imunisasi Dasar :
Jenis Pemberian ke / Tanggal pemberian
Keterangan
Imunisasi I II III IV
BCG
HEPATITIS B
ANTI POLIO
DPT
CAMPAK
Imunisasi Ulang : ..................................... tanggal ...............................................

: ..................................... tanggal ...............................................
` : ...................................... tanggal ..............................................
c. Uji skrining : ..................................................................................................
d. Riwayat penyakit yang lalu ...........................................................................................
..........................................................................................................................................
DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : .............................................................................................
b. Kesadaran : ..............................................................................................
c. Tanda vital :
Tekanan darah : ............
Nadi : ............
Pernafasan : ............
Suhu : ...........
d. Status Gizi : TB ............. cm, BB ........................ Kg.
LK ............ cm, LLA ....................... cm
e. Kulit : ..................................................................................................
f. Kuku : .................................................................................................
g. Kelenjar getah bening/limfe ( palpasi leher atau inguinal )
a. Kepala
Rambut : .........................................................................................................
Ubun – ubun : .........................................................................................................
Wajah : .........................................................................................................
Mata : .........................................................................................................
Telinga : .........................................................................................................
Hidung : .........................................................................................................
Mulut : .........................................................................................................
Faring dan laring : .........................................................................................................
b. Leher : .........................................................................................................
c. Dada
Bentuk dan besar : .........................................................................................................
Gerakan : .........................................................................................................
Payudara : .........................................................................................................
Paru : .........................................................................................................
Jantung : .........................................................................................................
d. Abdomen
Ukuran dan bentuk : ............................................................................................
Gerakan : ............................................................................................
Dinding perut : ............................................................................................
Auskultasi : ............................................................................................
Perkusi : bunyi timpani, obstruksi dan redup.
Palpasi : hepar, limpa, ginjal.
e. Anus dan Rektum : ............................................................................................
f. Genetalia
Laki – laki : (ukuran, bentuk penis, testis, kelainan/peradangan)
: ............................................................................................
Perempuan : (epispadia, tanda seks sekunder, cairan)
: ............................................................................................
g. Tulang belakang : ............................................................................................
h. Ekstremitas : ............................................................................................
i. Neurologis : (kejang, tanda meningeal, kekuatan dan tonus otot)
............................................................................................
3. Pemeriksaan Penunjang ...............................................................................................
.....................................................................................................................................................
...........................................................................................................................................
ASESSMENT
...............................................................................................................................................
...............................................................................................................................................
2. Masalah
...............................................................................................................................................
...............................................................................................................................................
3. Kebutuhan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................

Tanggal ..........................................., jam .....................
Tanda Tangan
( ......................................... )
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
DATA OBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
ASSESSMENT
.....................................................................................................................................................
.....................................................................................................................................................
PLANNING
Tanggal ................................................................, jam ..............................................................
.....................................................................................................................................................
......................................................................................................................................................
Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA IBU NIFAS
NO. REGISTER : ......................

MASUK RS TANGGAL, JAM : ............................................, JAM ............. WIB
DI RAWAT DI RUANG : ......................
Biodata :
Ibu Ayah
DATA SUBJEKTIF
1. Alasan masuk rumah sakit.
...............................................................................................................................................
...............................................................................................................................................
2. Riwayat Perkawinan .
Kawin ........... kali. Kawin pertama umur ............ tahun
Dengan suami sekarang ........................ tahun
3. Riwayat Menstruasi.
Menarche umur ........... tahun. Siklus .......... hari. Teratur / tidak.
Lama .............. hari. Sifat darah : encer / beku. Bau ......... Flour Albus ya / tidak
Dismenorroe ya / tidak. Banyaknya .............. cc
HPM ......................................... HPL ....................................................................
G ........ P ............ Ab ............... Ah ...............
Persalinan Nifas
No
.........................................................................................................................................
...............................................................................................................................
b. Penyakit yang pernah/ sedang diderita keluarga.
.........................................................................................................................................
...............................................................................................................................
7. Keadaan Psiko Sosial Spiritual..
Masa kehamilan : ..................................... minggu
Tempat persalinan : .................................... Penolong ............................................
Jenis persalinan : spontan / tindakan ....................................................................
Atas indikasi : ..........................................................................
Komplikasi : ..................................................................................................
a. Partus lama : ................................. jam
b. KPD : ................................. jam
Plasenta : lengkap / tidak
a. Lahir : spontan / manual
b. Ukuran / berat : ..........................................
c. Tali pusat : panjang ........... cm, intersio : .........................................
d. Kelainan : .................................................................................................
Perineum : Utuh
Ruptur (derajat 1/2/3/totalis)
Episiotomi (medialis/lateralis/mediolateralis)
Jahitan dalam ..................... benang .....................................
Jahitan luar ........................ benang .....................................
Jahitan jelujur .......................................................................
Pendarahan : Kala I ........................ cc.
Kala II ....................... cc
Kala III ..................... cc
Kala IV ..................... cc
Selama operasi ................................. cc
Tindakan lain : Infus ..............................................................................

Transfusi darah ..............................................................
Lama persalinan : Kala I ................................ jam .............................. menit
Kala II .............................. jam .............................. menit
Kala III ............................ jam ............................... menit
Kala IV ............................ jam ............................... menit
Operasi ............................ jam ............................... menit
8. Keadaan bayi baru lahir

Lahir tanggal .......................................... jam ..............................
Masa gestasi : .................................. minggu
BB/PB Lahir : ......................... gram/ .............. cm
Nilai APGAR : 1 menit/5 menit/10 menit/2 jam : ........./ ........../ ........ / ........
Cacat bawaan : ................................................................................................
Rawat gabung : ya / tidak
9. Riwayat post partum
Ambulasi : ...............................................................................................................
Pola makan : ...............................................................................................................
Pola tidur : ...............................................................................................................
Pola eliminasi
a. BAB : ...............................................................................................................
b. BAK : ...............................................................................................................
Pengalaman menyusui ..........................................................................................................
Pengalaman waktu melahirkan .............................................................................................
Pendapat ibu tentang bayinya ...............................................................................................
Lokasi ketidaknyamanan : payudara/perut/perineum
a. Kelahiran ini : diinginkan tidak diinginkan
b. Penerimaan Ibu terhadap kelahiran bayinya
.........................................................................................................................................
.........................................................................................................................................
c. Tinggal serumah dengan .................................................................................................
d. Orang terdekat ibu ..........................................................................................................
e. Tanggapan keluarga terhadap kelahiran bayinya
.........................................................................................................................................
.........................................................................................................................................
f. Pengetahuan ibu tentang masa nifas dan perawatan bayi ...............................................
.........................................................................................................................................
.........................................................................................................................................
g. Rencana perawatan bayi .................................................................................................
.........................................................................................................................................
.........................................................................................................................................
11. Keluhan sekarang ..................................................................................................................
................................................................................................................................................
12. Pertanyaan yang diajukan ....................................................................................................
................................................................................................................................................
DATA OBJEKTIF
a. Keadaan umum ........................................ kesadaran ..................................
b. Status emasional .............................................................................................................
c. Tanda Vital
Tekanan darah : ...................................................................................................
Nadi : ...................................................................................................
Pernafasan : ...................................................................................................
Suhu : ...................................................................................................
d. BB/TB : ..................................................................................................
e. Kepala dan leher
Edema wajah : .............................................................................................
Mata : .............................................................................................
Mulut : .............................................................................................
Leher : .............................................................................................
f. Payudara : .............................................................................................
Bentuk : .............................................................................................
Benjolan : .............................................................................................
Puting susu : .............................................................................................
Pengeluaran : .............................................................................................
Keluhan : .............................................................................................
g. Abdomen
Dinding perut : .............................................................................................
Bekas luka : .............................................................................................
Kontraksi uterus : .............................................................................................
Kandungan kemih : .............................................................................................
h. Ekstremitas
Edema : .............................................................................................
Varises : .............................................................................................
Refleks patela : .............................................................................................
Kuku : .............................................................................................
i. Genetalia luar
Udem : .............................................................................................
Varises : .............................................................................................
Perineum : .............................................................................................
Jahitan : .............................................................................................
Pengeluaran lokhea : ( jenis, warna, jumlah, konsistensi, bau ). .................................
.........................................................................................................................................
j. Anus : Hemoroid / tidak.
Hemoroid : .............................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................ ....
............................................................................................................................................
................................................................................................................................................ ....
............................................................................................................................................
................................................................................................................................................
ASESSMENT
...............................................................................................................................................
...............................................................................................................................................
2. Masalah
...............................................................................................................................................
...............................................................................................................................................
3. Kebutuhan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................

Tanggal ..........................................., jam .....................
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
DATA OBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
ASSESSMENT
.....................................................................................................................................................
.....................................................................................................................................................
PLANNING
Tanggal ................................................................, jam ..............................................................
.....................................................................................................................................................
......................................................................................................................................................
Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA TUMBUH KEMBANG

BALITA
NO. REGISTER : ......................

MASUK RS TANGGAL, JAM : ............................................, JAM ............. WIB
DI RAWAT DI RUANG : ......................
Biodata
Nama Bayi : .....................................................................................
Tanggal Lahir : ................................................., Jam ...........................
Jenis Kelamin : ......................................................................................
Nama Ibu : .................................. Ayah ..............................
Umur : .................................. ........................................
Agama : .................................. ........................................
Suku / bangsa : .................................. ........................................Aesia
Pendidikan : .................................. ........................................
Pekerjaan : .................................. ........................................Guru
Alamat : .................................. ........................................igli
No telepon/Hp: .................................. ........................................ : 01919673331
DATA SUBJEKTIF
1. Keluhan Utama (anak / orang tua).
...............................................................................................................................................
...............................................................................................................................................
2. Riwayat penyakit sekarang .
...............................................................................................................................................
...............................................................................................................................................
3. Respon Keluarga.
...............................................................................................................................................
...............................................................................................................................................
4. Riwayat kesehatan yang lalu.
a. Riwayat prenatal dan perinatal.
Masa kehamilan : ................. minggu.
Lahir Tanggal.......................................... jam ....................................
Jenis persalinan : spontan/tindakan ....................................................
Atas indikasi ........................................................
Penolong : ...................................... di .................................
Lama persalinan : Kala I ............................. Jam .................... menit
Kala II ............................ Jam .................... menit
Kombinasi
1)
b.
G ........ P ............ Ab ............... Ah ...............
Persalinan Nifas

No
.........................................................................................................................................
...............................................................................................................................
b. Penyakit yang pernah/ sedang diderita keluarga.
.........................................................................................................................................
...............................................................................................................................
7. Keadaan Psiko Sosial Spiritual..
Masa kehamilan : ..................................... minggu
Tempat persalinan : .................................... Penolong ............................................
Jenis persalinan : spontan / tindakan ....................................................................
Atas indikasi : ..........................................................................
Komplikasi : ..................................................................................................
c. Partus lama : ................................. jam
d. KPD : ................................. jam
Plasenta : lengkap / tidak
e. Lahir : spontan / manual
f. Ukuran / berat : ..........................................
g. Tali pusat : panjang ........... cm, intersio : .........................................
h. Kelainan : .................................................................................................
Perineum : Utuh
Ruptur (derajat 1/2/3/totalis)
Episiotomi (medialis/lateralis/mediolateralis)
Jahitan dalam ..................... benang .....................................
Jahitan luar ........................ benang .....................................
Jahitan jelujur .......................................................................
Pendarahan : Kala I ........................ cc.
Kala II ....................... cc
Kala III ..................... cc
Kala IV ..................... cc
Selama operasi ................................. cc
Tindakan lain : Infus ..............................................................................

Transfusi darah ..............................................................
Lama persalinan : Kala I ................................ jam .............................. menit
Kala II .............................. jam .............................. menit
Kala III ............................ jam ............................... menit
Kala IV ............................ jam ............................... menit
Operasi ............................ jam ............................... menit
8. Keadaan bayi baru lahir

Lahir tanggal .......................................... jam ..............................
Masa gestasi : .................................. minggu
BB/PB Lahir : ......................... gram/ .............. cm
Nilai APGAR : 1 menit/5 menit/10 menit/2 jam : ........./ ........../ ........ / ........
Cacat bawaan : ................................................................................................
Rawat gabung : ya / tidak
9. Riwayat post partum
Ambulasi : ...............................................................................................................
Pola makan : ...............................................................................................................
Pola tidur : ...............................................................................................................
Pola eliminasi
c. BAB : ...............................................................................................................
d. BAK : ...............................................................................................................
Pengalaman menyusui ..........................................................................................................
Pengalaman waktu melahirkan .............................................................................................
Pendapat ibu tentang bayinya ...............................................................................................
Lokasi ketidaknyamanan : payudara/perut/perineum
a. Kelahiran ini : diinginkan tidak diinginkan
b. Penerimaan Ibu terhadap kelahiran bayinya
.........................................................................................................................................
.........................................................................................................................................
c. Tinggal serumah
dengan .................................................................................................
d. Orang terdekat
ibu ..........................................................................................................
e. Tanggapan keluarga terhadap kelahiran bayinya
.........................................................................................................................................
.........................................................................................................................................
f. Pengetahuan ibu tentang masa nifas dan perawatan
bayi ...............................................
.........................................................................................................................................
.........................................................................................................................................
g. Rencana perawatan
bayi .................................................................................................
.........................................................................................................................................
.........................................................................................................................................
11. Keluhan
sekarang ..................................................................................................................
................................................................................................................................................
12. Pertanyaan yang diajukan ....................................................................................................
................................................................................................................................................
DATA OBJEKTIF
k. Keadaan umum ........................................ kesadaran ..................................
l. Status emasional .............................................................................................................
m. Tanda Vital
Tekanan darah : ...................................................................................................
Nadi : ...................................................................................................
Pernafasan : ...................................................................................................
Suhu : ...................................................................................................
n. BB/TB : ..................................................................................................
o. Kepala dan leher
Edema wajah : .............................................................................................
Mata : .............................................................................................
Mulut : .............................................................................................
Leher : .............................................................................................
p. Payudara : .............................................................................................
Bentuk : .............................................................................................
Benjolan : .............................................................................................
Puting susu : .............................................................................................
Pengeluaran : .............................................................................................
Keluhan : .............................................................................................
q. Abdomen
Dinding perut : .............................................................................................
Bekas luka : .............................................................................................
Kontraksi uterus : .............................................................................................
Kandungan kemih : .............................................................................................
r. Ekstremitas
Edema : .............................................................................................
Varises : .............................................................................................
Refleks patela : .............................................................................................
Kuku : .............................................................................................
s. Genetalia luar
Udem : .............................................................................................
Varises : .............................................................................................
Perineum : .............................................................................................
Jahitan : .............................................................................................
Pengeluaran lokhea : ( jenis, warna, jumlah, konsistensi, bau ). .................................
.........................................................................................................................................
t. Anus : Hemoroid / tidak.
Hemoroid : .............................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................ ....
............................................................................................................................................
................................................................................................................................................ ....
............................................................................................................................................
................................................................................................................................................
ASESSMENT
...............................................................................................................................................
...............................................................................................................................................
8. Masalah
...............................................................................................................................................
...............................................................................................................................................
9. Kebutuhan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................

Tanggal ..........................................., jam .....................
Tanggal ..................................., jam .............................
DATA SUBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
DATA OBJEKTIF
.....................................................................................................................................................
.....................................................................................................................................................
ASSESSMENT
.....................................................................................................................................................
.....................................................................................................................................................
PLANNING
Tanggal ................................................................, jam ..............................................................
.....................................................................................................................................................
......................................................................................................................................................
Tanda Tangan
( ......................................... )
ASUHAN KEBIDANAN PADA BAYI BARU LAHIR
MASUK TANGGAL, JAM : 15 Oktober 2018 JAM 09.00 WIB

TEMPAT : PKM
Biodata :
Ibu Ayah
Nama : Ny.A .S Nama : Tn.ITn. S
Umur : 25 tahun 25 tahun Umur : 3028 tahun
Agama : Islam Islam Agama : Islam Islam
Suku / bangsa : Aceh/IndonesiaAceh / indo Suku / agama : Aceh/Indonesia Aceh / indo
Pendidikan : SMASMA Pendidikan : S1S1
Pekerjaan : IRTIRT Pekerjaan : WiraswastaGuru
Alamat : Blang Pasehsigli Alamat : Blang Pasehsigli
No telepon : - 085260313933 No telepon : -01919673331
DATA SUBJEKTIF
1. Riwayat Antenatal
G1 P1 A0 Ah1 Umur kehamilan - minggu.
Riwayat ANC : teratur / tidak,2 kali, di PKM oleh Bidan
Imunisasi TT : 2 kali.
TT 1 : ada TT 2 : ada
TT 3 : - TT 4 : -
TT 5 : -
Kenaikan BB : 3 Kg.
Penyakit selama hamil : Tidak ada
Kebiasaan Makan : 2x sehari
Obat/jamu : Tidak ada
Merokok : Tidak ada
Komplikasi Ibu : Tidak ada
2. Riwayat Intranatal.
Lahir tanggal 12 Oktober jam 10.30 wib
Jenis persalinan : Spontan / tindakan : Dibantu
Penolong : Bidan di Puskesmas
Lama persalinan : Kala I : Normal
Kala II : Normal
Komplikasi.
a. Ibu : Tidak ada
b. Janin : Prematur
c. BB / PB lahir : 1.500 gram
Nilai APGAR : 1 menit / 5 menit / 10 menit : ........../ ........ / ..........
No. Kriteria 1 Menit 5 Menit 10 Menit

1 Denyut jantung
2 Usaha Nafas
3 Tunos Otot
4 Reflek
5 Warna Kulit
Total
Capu succedaneum : .............................................................................
Cepal haematoma : .............................................................................
Cacat bawaan : .............................................................................
Resusitasi : Rangsangan : Ya / tidak
Penghisapan lendir : Ya / tidak
Ambu bag : ya / tidak ....Liter / Menit
Massase jantung : ya / tidak ....Liter / Menit
Intubasi Endotrakheal : ya / tidak
O2 : ya/ tidak ....Liter / menit
DATA OBJEKTIF
1. Pemeriksaan Umum
a.Pernafasan : ..................................................................
b. Warna Kulit : ...................................................................
c.Denyut Jantung : ...................................................................
d. Suhu aksiler : ....................................................................
e.Postur dan Gerakan : ....................................................................
f. Tonus otot / Tingkat : ...................................................................
g. Kesadaran : ....................................................................
h. Ekstremitas : ...................................................................
i. Kulit : ...................................................................
j. Tali Pusat : ....................................................................
k. BB Sekarang : ..................................................................
a.Kepala : .................................................................
b. Muka : ...................................................................
c.Mata : .................................................................
d. Telinga : .................................................................
e. Hidung : .................................................................
f. Mulut : ...................................................................
g. Leher : ...................................................................
h. Klavikula : ...................................................................
i. Lengan Tangan : ....................................................................
j. Dada : ...................................................................
k. Abdomen : ...................................................................
l. Genetalia : .....................................................................
m. Tungkai dan Kaki : ...................................................................
n. Anus : ....................................................................
o. Punggung : .................................................................
3.Reflek : Moro
Rooting : .....................................................................
Walking : .....................................................................
Grapsh : ...................................................................
Sucking : ....................................................................
Tonicneck : .................................................................
4. Antrometrik : PB : ...................................................................
LK : ....................................................................
LD : ....................................................................
LLA : ............................................................
5.Eliminasi Miksi : .............................................................
Mekonium : ..............................................................
6. Pemeriksaan Penunjang
.............................................................................................................
..............................................................................................................
ASSESMENT
1. Diagonasi Kebidana
................................................................................................................
...................................................................................................................
2. Masalah
...................................................................................................................
...................................................................................................................
3. Kebutuhan
....................................................................................................................
....................................................................................................................
4. Diagonasis potensial
......................................................................................................................
.......................................................................................................................
..................................................................................................................
...................................................................................................................
6. Kebutuhan Tindakan Segara berdasarkan kondisi klien
a. Mandiri
..........................................................................................................
...........................................................................................................
b. Kolaborasi
............................................................................................................
............................................................................................................
c. Merujuk
............................................................................................................
.............................................................................................................
PLANNING ( Termasuk Pendokumentasi Implementasi dan Evcaluasi )

Tanggal ......................................jam ....................................
Tanda Tangan
( ........................)
ASUHAN KEBIDANAN PADA GANGGUAN SISTEM

REPRODUKSI
NO. REGISTER : ......................

DI RAWAT DI RUANG : ......................
Biodata :
Ibu Ayah
DATA SUBJEKTIF
1. Kunjungan saat ini Kunjungan pertama Kunjungan ulang
Keluahan Utama
....................................................................................................................................
.................................................................................................................................
2. Riwayat perkawinan
Kawin .......... kali. Kawin pertama umur ............. tahun
Dengan suami sekarang ............. tahun.
3. Riwayat Mestruasi
Menarche umur .... tahun. Siklus ..... hari. Teratur / tidak.
Lama ....... hari. Sifat darah : encer / beku. Bau ........... Fluor albus ya / tidak. Dismenorroe ya
/ tidak.
Banyaknya ........... cc. HPM .......................................
P .......... Ab ............. Ah ....................
Persalinan Nifas
Hamil
Tgl. Umur Jenis Komplikasi Jenis BB
Ke Penolong Laktasi Komplikasi
Lahir Kehamilan Persalinan Ibu Bayi Kelamin Lahir
Jenis Mulai Memakai Berhenti / Ganti Cara

No
a. Penyakit sistemik yang pernah / sedang diderita

No
d. Penyakit yang pernah / sedang diderita
............................................................................................................................
............................................................................................................................
e. Penyakit yang pernah / sedang diderita keluarga
............................................................................................................................
............................................................................................................................
f. Riwayat keturunan kembar
............................................................................................................................
............................................................................................................................
10. Makan terakhir tanggal, ............................, jam ..............., jenis ........................

Minum terakhir tanggal, ............................, jam ..............., jenis ........................
11. Buang air besar terakhir tanggal, ............................... jam .....................
12. Buang air kecil terakhir tanggal, ............................... jam .....................
13. Istirahat / tidur dalam 1 hari terakhir ........................, jam .....................
14. Keadaan psiko sosio spiritual/kesiapan menghadapi dan proses persalinan
d. Pengetahuan tentang tanda – tanda persalinan dan proses persalinan
..............................................................................................................................
..............................................................................................................................
e. Persiapan persalinan yang telah dilakukan (Pendamping ibu, biaya, dll)
..............................................................................................................................
..............................................................................................................................
f. Tanggapan Ibu dan Keluarga terhadap proses persalinan yang dihadapi
..............................................................................................................................
.............................................................................................................................
DATA OBJEKTIF
a. Keadaan umum : ...................... kesadaran : ............................
b. Status Umum : ....................................
c. Tanda Vital :
Tekanan darah : ............ mmHg
Nadi : ............ kali per menit
Pernafasan : ............ kali per menit
Suhu : ........... 0
C
d. TB : ........... cm
BB : sebelum hamil ...... kg, BB Sekarang .... kg
LLA : ............ cm
e. Kepala dan leher
Edema wajah : ...................................................................................................
Cloasma gravidarium : + / -
Mata : ...................................................................................................
Mulut : ...................................................................................................
Leher : ...................................................................................................
f. Payudara
Bentuk : simetris
Puting susu : ..........................
Colostrum : ..........................
g. Abdomen
Pembesaran : ...................................................................................................
Benjolan : ...................................................................................................
Bekas luka : ...................................................................................................
Strie gravidarum : ...................................................................................................
Palpasi leopold
Leopold I : ...................................................................................................
Leopold II : ...................................................................................................
Leopold III : ...................................................................................................
Leopold IV : ...................................................................................................
Osborn test : ...................................................................................................
TBJ : ...................................................................................................
Auskultasi DJJ : Pusctum maksimum .............................................................

Frekwensi : ........ kali per menit ( ....... / ......../ ..... )
His : Frekwensi : ........ kali dalam 10 menit
Durasi : ........ detik
Kekuatan : kuat /sedang/lemah.
Palpasi supra publik : ...................................................................................................

h. Punggung : ...................................................................................................
i. Pinggang : nyeri / tidak
j. Ekstremitas
Kekakuan otot dan sendi : ........................................................................................
Edema : ........................................................................................
Varises : ........................................................................................
Refleks patela : ........................................................................................
Kuku : ........................................................................................
k. Genetalia
Tanda chadwich : ........................................................................................
Varises : ........................................................................................
Bekas luka : ........................................................................................
Kelenjar bartholini : ........................................................................................
Pengeluaran : ........................................................................................
l. Anus
Hemoroid : ........................................................................................
5. Pemeriksaan Dalam, tanggal ................................., oleh .............................................

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
ASESSMENT
...............................................................................................................................................
...............................................................................................................................................
8. Masalah
...............................................................................................................................................
...............................................................................................................................................
9. Kebutuhan
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
a. Mandiri
..........................................................................................................................................
..........................................................................................................................................
b. Kolaborasi
..........................................................................................................................................
..........................................................................................................................................
c. Merujuk
..........................................................................................................................................
..........................................................................................................................................

Tanggal ..........................................., jam .....................
Tanda Tangan
( ......................................... )

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NO. REGISTER : ......................

4. Riwayat sebelum masuk ruang bersalin

6. Pergerakan janin dalam 24 jam terakhir ............. kali

8. Riwayat Kontrasepsi yang digunakan

Auskultasi DJJ : Pusctum maksimum .............................................................

2. Pemeriksaan Dalam, tanggal ................................., oleh .............................................

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5. Riwayat Kontrasepsi yang digunakan

Bau ................................. .....................................

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5. Riwayat kehamilan, persalinan dan nifas yang lalu

Auskultasi DJJ : Pusctum maksimum kanan

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Biodata : Ibu Ayah

Penolong : ............................. di ..................................................

No Kriteria 1 Menit 5 Menit 10 Menit

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Imunisasi Ulang : ..................................... tanggal ...............................................

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Tindakan lain : Infus ..............................................................................

8. Keadaan bayi baru lahir

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8. Keadaan bayi baru lahir

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NO. REGISTER : ......................

5. Riwayat Kontrasepsi yang digunakan

Jenis Mulai Memakai Berhenti / Ganti Cara

8. Riwayat Kontrasepsi yang digunakan

10. Makan terakhir tanggal, ............................, jam ..............., jenis ........................

Auskultasi DJJ : Pusctum maksimum .............................................................

Palpasi supra publik : ...................................................................................................

5. Pemeriksaan Dalam, tanggal ................................., oleh .............................................

PLANNING ( Termasuk Pendokumentasian Implementasi dan Evaluasi)

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