LOGBOOK

ASUHAN KEBIDANAN PERSALINAN PROGRAM PENDIDIKAN

PROFESI BIDAN

PROGRAM STUDI SARJANA KEBIDANAN DAN PENDIDIKAN

PROFESI BIDAN
SEKOLAH TINGGI ILMU KESEHATAN STIKES
ABDI NUSANTARA JAKARTA
2020

TIM PENYUSUN

MARIYANI, M.Keb
FEVA TRIDIYAWATI, M.Kes, M.Keb
RAHAYU KHAIRIAH, M.Keb
ITA HERAWATI, M.Keb
 2

BIODATA MAHASISWA

Nama :.....................................................................
NIM :..................................................................... Tahun
Angkatan :.............../. .... ......REGULER/ALIH JENJANG
Alamat :.....................................................................
………………………………
Telp/Hp :.................................................

Jakarta,......................................

Mahasiswa,

....................................
NIM.

3
 KATA PENGANTAR

Puji syukur kehadirat Tuhan Yang Maha Esa atas limpahan rahmat dan hidayahNya, sehingga buku Log
Book Kegiatan Pelayanan Kebidanan Program sarjana Kebidanan dan Pendidikan Profesi Program Studi
Pendidikan Profesi Bidan STIKes Abdi Nusantara Jakarta selesai disusun.
Buku Log Book ini digunakan sebagai kelengkapan praktik profesi berupa catatan kegiatan pelayanan
kebidanan dan dokumentasi asuhan yang digunakan sebagai bahan refleksi saat proses bimbingan dengan
pembimbing. Buku ini menjelaskan tentangpendahuluan, pencapaian kompetensi minimal yang harus dipenuhi
dan dilaporkan dengan metode refleksi,petunjuk pengisian,kegiatan pelayanan kebidanan dan dokumentasi
asuhan kebidanan.
Terima kasih kami sampaikan kepada semua pihak yang telah berkontribusi dalam penyusunanan buku
panduan ini.Demi kesempurnaan buku Log Book ini di waktu yang akan datang, kami mengharapkan
masukan, kritik dan saran.

Jakarta, 14 Juli 2020

Tim Penyusun

DAFTAR ISI
Halaman Judul
Biodata Mahasiswa .............................................................................. 3
Kata Pengatar ....................................................................................... 4
Daftar Isi .............................................................................................. 5
I. Pendahuluan ............................................................................... 6
II. Pencapaian kompetensi .............................................................. 6
III. Petunjuk pengisian ..................................................................... 6
IV. Dokumentasi Asuhan Kebidanan ............................................... 8
 5

BAB I
PENDAHULUAN

Program pendidikan profesi adalah praktik yang dilaksanakan setelah menyelesaikan program
sarjana/akademik pada rangkaian Program pendidikan bidan di Program Studi Sarjana Kebidanan dan Pendidikan
Profesi Bidan STIKes Abdi Nusantara Jakarta.
Sebagian besar kegiatan selama Program Pendidikan Profesi adalah melakukan asuhan kebidanan.Asuhan
yang sudah dilaksanakan harus dibuktikan melalui Laporan Komprehensif, dokumentasi kebidanan (SOAP) dan
laporan refleksi yang di dokumentasikan pada tabel dokumentasi asuhan. Buku logbook ini merupakan salah satu
sarana penunjang yang harus dilengkapi oleh mahasiswa sebagai bahan refleksi kasus saat proses bimbingan
dengan pembimbing.

BAB II
Pencapaian Kompetensi Klinik dengan metode refleksi kasus
 Komponen No Daftar Keterampilan Level Jumlah Laporan Laporan Laporan
Kompetensi Kompet Penca Kasus Kasus Kasus
ensi paian dengan dengan Lengkap
Kasus Pathway Pathway &
SOAP
6. Persalinan
1. Perubahan Asuhan Persalinan 25 20 4 1
4
fisik dan psikologis normal
pada masa Asuhan Kasus 4 20 10 9 1
persalinan Kompleks dan
2. Pemantauan Kegawatdaruratan
dan asuhan kala I
3. Pemantauan
dan asuhan kala II
4. Pemantauan dan
asuhan kala III
5. Pemantauan
dan asuhan kala
IV 6. Deteksi dini,
komplikasi dan
penyulit
persalinan
7. Partograf 8.

Penanganan
kegawat daruratan
pada masa
persalinan

Keterangan :

Setiap Jenis keterampilan yang di capai wajib di dokumentasikan dalam bentuk foto dan Vidio dengan ketentuan
sebagai berikut
a. Jika jumlah target pada daftar keterampilan Lebih dari 10 maka bentuk dokumentasi :
1) Vidio Sebanyak 2 buah
2) Foto sebanyak 10 buah
b. Jika jumlah target pada daftar keterampilan antara 4 sampai dengan 10 maka dokumentasi hanya bentuk 2
vidio dan sisanya dalam bentuk foto.
c. Jika jumlah target kurang dari 3 maka seluruh dokumentasi dalam bentuk Vidio.

BAB III Petunjuk pengisian

a. Bagi Mahasiswa
1. Pelihara dan simpan buku ini secara baik
2. Setiap menjalankan praktik klinik buku ini harus dibawa
 3. Tentukan pasien yang akan dilakukan asuhan kebidanan bersama pembimbing
4. Tulisakan asuhan kebidanan yang telah dilaksanakan pada masing-masing kompetensi
5. Buku ini berisi dokumentasi asuhan yang telah dilaksanakan
6. Setiap asuhan kebidanan yang dilaksanakan harusdikonsultasikan dan mendapatkan tanda tanganpengesahan
oleh pembimbing klinik(maksimal sampai praktik selesai pada rotasi tersebut) dan dikonsultasikan ke
pembimbing pendididkan
7. Jika belum dikonsultasikan ke pembimbing klinik dan melebihi batas waktu praktik berakhir maka asuhan
dianggap gugur dan tidak dapat ditabulasi
8. Perhatikan jumlah minimal pencapaian kompetensi yang harus dilengkapi pada buku ini
9. Tabulasi pencapaian kompetensi asuhan dilaksanakan dua kali setelah blok II dan IV
10. Petunjuk Pengisian Tabel Dokumentasi Asuhan Kebidanan Keterangan Kolom
(1) : Nomor urut
(2) : Tanggal
(3) : Nama pasien (inisial) dan Nomor rekam medis
(4) : SOAP (data focus)
(5) : Refleksi
(6) : Tanda Tangan Pembimbing Klinik dan Pembimbing Akademik

b. Bagi Pembimbing
1. Pembimbing klinik dan akademik wajib melakukan response pada setiap kediatan dan kasus sehingga
mahasiswa mampu merefleksikan dan menganalisis setiap kegiatan pelayanan dan asuhan dengan baik
2. Pembimbing klinik dan pendidikan berhak untuk tidak menandatangani kasus jika :
(1) Mahasiswa tidak mampu merefleksikan kasusnya .
(2) Adanya ketidak benaran data pada kasus yang ditulis.
(3) Melebihi batas waktu praktik pada rotasi tersebut dengan tanpa kesepakatan sebelumnya.

BAB IV
DOKUMENTASI ASUHAN KEBIDANAN

1. Dokumentasi dalam bentuk Pathway Asuhan Kebidanan

Hari dan Tanggal : Tempat Praktik :

Nama :
Program Studi :
 Pathway Kasus Kebidanan
Kehamilan Trimester 1
Nama :
Usia :
GPA

Tanda / Gejala / keluhan secara Tanda / Gejala / keluhan yang

teori : dialami pasien
Patofisiologi (Sesuai Tanda /
Gejala / keluhan yang dialami
pasien)

Asuhan yangdiberikan : Rasionalisasi dari asuhan yang diberikan :

Evaluasi asuhan yang diberikan :

 II. DOKUMENTASI ASUHAN KEBIDANAN
2) Asuhan Kebidanan Persalinan (45 kasus)

Nama Ttd
Pasien dan Pembimbing
No Tanggal Rekam SOAP Refleksi Klinik dan
Medis Akademik

(1) (2) (3) (4) (5) (6)

 SEKOLAH TINGGI ILMU KESEHATAN ABDI NUSANTARA
PROGRAM PROGRAM SARJANA KEBIDANAN DAN PENDIDIKAN PROFESI BIDAN

ASUHAN KEBIDANAN PADA IBU BERSALIN

No Reg :……………………………………………………………
Nama Pengkaji :……………………………………………………………
Hari/tanggal :……………………………………………………………
Waktu :……………………………………………………………
Pengkajian
Tempat :……………………………………………………………
Pengkajian
DATA SUBJEKTIF
1. Identitas

Jenis Identitas Istri Suami

Nama

Umur

Suku/bangsa

Agama

Pendidikan

Pekerjaan

Alamat rumah

Alamat kantor
 2. Quick cek

No Jenis Quick cek Hasil Keterangan

Ya tidak

1 Sakit kepala hebat

2 Gangguan penglihatan

Pembengkakan pada wajah dan

3
tangan

4 Nyeri abdomen (epigastrium)

5 Mual dan muntah berlebihan

6 Pergerakan janin

7 Pengeluaran pervaginam

8 Demam

3. Keluhan saat ini

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

4. Riwayat kehamilan sekarang

• HPHT :
• Siklus haid :
• Taksiran waktu persalinan :
• Pemakaian obat dan jamu-jamuan :
• Kekhawatiran yang berkaitan dengan persalinan :

5. Riwayat obstetrik
 Tanggal Tempat Jenis Riwayat
No UK Penolong Penyulit JK BB PB Ket.
Partus Partus Partus Menyusui

6. Riwayat kesehatan

Hasil
No Jenis Keterangan
Ada Tidak ada

Jantung

Hipertensi

Asma

Hepatitis

AIDS/HIV

TBC

Ginjal kronis

Malaria

Epilepsi

Kejiwaan

Kelainan congenital

Alergi obat /makanan

Kecelakaan

Tranfusi darah

• Riwayat imunisasi TT :
TT I :

TT II :

TT III :
 TT IV :

TT V :
• Golongan darah :

7. Riwayat sosial ekonomi

• Usia pertama menikah:
• Status perkawinan:
• Respon ibu dan keluarga terhadap kehamilan dan kesiapan
persalinan:
................................................................................................................................................... ................
...................................................................................................................................
.............................................
• Dukungan keluarga :
• Pengambil keputusan dalam keluarga:
• Makan dan minum terakhir:
- Makan terakhir Pukul: Nafsu makan :
- Minumterakhir pukul : sebanyak ................cc
• BAB dan BAK terakhir :
- BAB Terakhir :
- BAK Terakhir :

• Kebiasaan merokok, obat-obatan dan alkohol:

• Kekerasan dalam rumah tangga :
• Tempat dan petugas kesehatan yang diinginkan untuk menolong persalinan :
• Keinginan ibu memberikan ASI eksklusif :
• Rencana ibu memberikan ASI :

DATA OBJEKTIF
1. Kesadaran :
2. Keadaan umum :
3. Keadaan emosional :
4. TB : ................cm BB : ...............kg
5. TTV

Tekanan darah : .............. mmHg Nadi: ..........x/menit

Respirasi : ...............x/menit Suhu : ..........°C

6. Head to toe
• Wajah:
• Mata: ................., konjungtiva ................, sklera ........................
• Hidung: .................................................................................
 • Mulut: ................................................................................... •
Telinga:.................................................................................
• Leher: ....................................................................................
• Payudara:
................................................................................................................................................... ............................
....................................................................................................................... ........................................................
...........................................................................................
.................
• Abdomen
Bekas luka operasi :

Strie :
Linea :

His :

TFU : ............ cm TBJ : .................gr

Leopold I :
...................................................................................................................................................
..........................................................................

Leopold II :
...................................................................................................................................................
...........................................................................

Leopold III :
...................................................................................................................................................
..........................................................................

Leopold IV :
...................................................................................................................................................
..........................................................................

DJJ :............................ x/menit, teratur/tidak teratur •

Ekstremitas: simetris, tidak ada edema, varises dan kekakuan sendi
• Anogenital:
- Tukak/luka :
- varises :
- kelenjar scene :
- kelenjar bartholin :
- PD :
• vulva vagina :
• portio :
• pembukaan :
• ketuban :
• presentasi :
• posisi : • penurunan :
• penyusupan :
 - haemoroid :
• CVAT: ...................................... : kanan ( ) kiri ( )
• Refleks patella : kanan (.............) kiri (...........)
7. Pemeriksaan penunjang

• HB :
• Golongan darah ABO dan Rhesus :
• HIV :
• Rapid test (K/P) :

ANALISIS .....................................................................................................................................................
............... ......................................................................................................................................................
.............. .......................................................................................................................................................
.............
...................

PENATALAKSANAAN
 SOAP KALA I
Tanggal :
Pkl :
Oleh :
Tempat :

SUBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

OBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

ANALISA
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.
PLANNING
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

SOAP KALA II Tanggal :

Pkl :
Oleh :
Tempat :

SUBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

OBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.
 ANALISA
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

PLANNING
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

SOAP KALA III

Tanggal :
Pkl :
Oleh :
Tempat :

SUBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.
OBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

ANALISA
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

PLANNING
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.
 SOAP KALA IV
Tanggal :
Pkl :
Oleh :
Tempat :

SUBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

OBJEKTIF
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

ANALISA
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.

PLANNING
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
.