ASESMEN

RUANG BERSALIN

Nama Pasien : Umur :

Nama Suami/Orang Tua : Alamat :
A. Data Umum
Tiba di VK : Tanggal : ........ / ........... / .............. Pukul : ....................
Cara Masuk : Jalan Kursi Roda Brankar
Dikirim Oleh : Dokter Klinik Bidan/BPS PKM
Rumah Sakit Datang Sendiri Lainnya
B. Data Subjektif :
1. Keluhan : ___________________________________________________________________
___________________________________________________________________

Keadaan Umum : ................................ Kesadaran : ........................................

G.........P........A.........H........................ HPHT......................... TP .............................

Riwayat PNC : Dokter Bidan Tidak Pernah

Gerakan Janin : Ada Tidak, sejak kapan ............................................

Berat Badan Sekarang : .......... Kg Tinggi Badan : ..........cm Golongan Darah :

Masalah selama kehailan : __________________________________________________

1. Riwayat Kehamilan dan Persalinan

Usia Tempat & Jenis BBL / PB Jenis ASI Umur

No Penyulit
Kehamilan Penolong Persalinan (Kg/Cm) Kelamin Ekslusif Sekarang

2. Riwayat Kesehatan
Merokok : Tidak Ya ......... batang / hari
Minuman beralkohol : Tidak Ya
Obat-obatan terlarang : Tidak Ya, Jenis ..............................
Mempunyai tatto : Tidak Ya
Senam hamil : Tidak Ya
Kesulitan berkemih : Tidak Ya
Nafsu makan : Meningkat Menurun Normal, Frekuensi: x/hr
Riwayat penyakit : Asma Jantung Hipertensi Diabetes Hepatitis
Alergi obat, jenis ............................. Lainnya...........................

RB/04/REV.01
 3. Riwayat Perkawinan :
PMS : Tidak Ya, Jenis .........................
Status Psikologi : Tenang Marah Sedih Menangis
Status Sosial : Tinggal bersama Suami Orang Tua Mertua ..........
Penerimaan terhadap kehamilan : Tidak Ya
4. Pemeriksaan Penunjang Sebelumnya : Tidak Ada : ..............
Lab: HB : .................. gr% Leukosit : ...........................HbsAg : ............................
Protein .......................... Gula Darah : ........................

CTG : Reaktive Non Reaktive EKG : ...........................................

Hasil USG : ................................................................................................................................

C. Data Objektif
Keadaan umum : BaikSedang Berat
Kesadaran : ComposmentisSomnolen Sopor Coma
TD : ................. mmHg HR : ..........x/mnt S : ......... oC RR : ........... x/mnt
Mata : Konjungtiva Anemis : YaTidak Sklera Ikterus : Ya Tidak
Payudara : Puting : Menonjol Datar Lainnya ............
Colostrum :Ada Tidak adaLainnya ............
Perut : Luka bekas operasi : Ada Tidak Lainnya ............
Massa : AdaTidak Lainnya ............
TFU : .............................. TBJ : ......................Gram
Leopold I : ................................
Leopold II Kanan : ................................
Kiri : ................................
Leopold III : ................................
Leopold IV : .................................
DJJ : ..................Reguler Ireguler His :.........................................
Periksa dalam : .....................................................................................................................
Eksremitas atas : Odema Sianosis Tidak ada keluhan
Eksremitas bawah : Odema Sianosis Tidak ada keluhan
D. Assesment :________________________________________________________________
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_________
E. Planning
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
SOAP Selesai Tanggal ......../........./.......... Pukul............
Nama dan Tanda Tangan Bidan

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RB/04/REV.01
 LAPORAN
PERSALINAN

A. KALA I Tanggal : ........ / ......... / ............. Pukul : ................

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B. KALA II Tanggal : ........ / ......... / ............. Pukul : ................

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C. KALA III Tanggal : ........ / ......... / ............. Pukul : ................

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D. KALA IV Tanggal : ........ / ......... / ............. Pukul : ................

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Selesai Tanggal ......../........./.......... Pukul............

Nama dan Tanda Tangan Bidan

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RB/04/REV.01