FORMAT DOKUMENTASI

ASUHAN KEBIDANAN PADA IBU BERSALIN

No. Registrasi :
Tanggal Pengkajian :
Waktu Pengkajian :
Tempat Pengkajian :
Pengkaji :

A. DATA SUBYEKTIF
IDENTITAS
Nama : Nama Suami :
Umur : Umur :
Suku/kebangsaan : Suku/kebangsaan :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat rumah : Alamat rumah :
Telp : Telp :

1. Keluhan Utama:
……………………………………………………………………………………………….
......
2. Riwayat Menstruasi
 HPHT : ……………….
 TTP : ………………
 Lamanya : ………………
 Banyaknya : ………………
 Siklusnya : ………………
 Konsitensi : ………………

3. Riwayat kesehatan
 Riwayat penyakit menular dalam keluarga : ……………….
 Riwayat penyakit keturunan dalam keluarga : ……………….

4. Perilaku kesehatan :
 Penggunaan alkohol / obat sejenisnya : ………………
 Obat/jamu yang sering digunakan : ………………
 Rokok, makan sirih : ………………
 Irigasi vagina : ………………

Departemen Kebidanan STIKIM

 5. Riwayat kehamilan, persalinan, nifas, KB yang lalu
Penyulit
Tahun Tempat Jenis
No UK Penolong Kehamilan/ JK BB PB
lahir Bersalin persalinan
Persalinan

6. Riwayat hamil ini

 Pemeriksaan pertama kali pada kehamilan: ………………………..
 Tempat periksa hamil : ……………………….
 Frekwensi selama hamil : ……………………….
 Immunisasi TT 1 tgl : ………. TT2 tgl : …………….................
 Keluhan mual dan muntah : ………………………..
 Keluhan pusing : ………………………..
 Muntah : ………………………
 Oedem : ………………………
 Nyeri perut : ………………………
 Penglihatan kabur : ………………………
 Gerakan janin pertama kali : ………………………
 Rasa gatal vulva dan vagina : ………………………
 Gerakan Janin sekarang : ………………………

7. Aktivitas sehari-hari
a. Diet/makan
 Makan sehari-hari : ……………………….
 Ngidam : ……………………….
 Pantangan tehadap makanan : ……………………….

b. Pola eliminasi :

Departemen Kebidanan STIKIM

  Bak : …… x/ hari Warna : …………………
 BAB : …… x/ hari Konsistensi / warna: …………………
c. Pola istirahat dan tidur :
 Siang : ………………..
 Malam : ……………….
d. Pola seksulitas : ………………..
e. Aktifitas sehari-hari : ………………..

8. Riwayat Sosial
 Apakah kehamilan ini direncanakan : ………………
 Jenis kelamin yang diharapkan : ………………
 Status perkawinan : ………………
 Usia perkawinan : ……….. ……
 Kegiatan spiritual : ……………..

B. OBJEKTIF
1. Pemeriksaan umum
 Keadaan umum : ……………..
 kesadaran : ……………..
 Keadaan emosional : ……………..
 Vital sign :
 TD : ……….. mmHG Nadi : …………. x/i
 RR : ……….. x/I Suhu : ………….. 0C
 TB : …………. cm
 BB sebelum hamil : …… kg
BB sekarang : …... kg

2. Pemeriksaan fisik
a. Kepala
 Warna rambut : …………….
 Tekstur : …………….
 Luka : …………….
 Kebersihan : …………….
b. Muka
 Oedema : …………….
 Pucat : …………….
 Cloasma gravidarum : …………….
c. Mata
 Oedema : …………….
 Konjungtiva : …………….

Departemen Kebidanan STIKIM

  Sklera : …………….
d. Hidung
 Kebersihan : …………….
 Radang : …………….
e. Gigi/mulut :
 Lidah dan geraham : ……………
 Stomatits : ……………
 Tonsil : ……………
 Caries : ……………
 Karang gigi : ……………
f. Telinga
 Kebersihan : ……………
 Radang : ……………
 Pendengaran : ……………
g. Leher
 Kelenjer tiroid : ……………
 Kelenjar lymfa : ……………
 Vena jugularis : ……………
h. Dada
 Bunyi jantung : ……………
 Bunyi paru : ……………
i. Payudara
 Pembesaran : ……………
 Striae : ……………
 Putting : ……………
 Areola : ……………
 Benjolan : ……………
 Pengeluaran : ……………
 Kebersihan : ……………
j. Abdomen
 Bekas luka operasi : ……………
 Pembesaran perut : ……………
 Bentuk perut : ……………
 Striae : ……………
 Kandung kemih : ……………
 Oedema : ……………
 Linea : ……………
k. Pemeriksaan kebidanan
 Palpasi uterus
 Leopold I : …………………………………………………….

Departemen Kebidanan STIKIM

 ……………………………………………………………………...
 Leopold II : …………………………………………………….
……………………………………………………………………...
 Leopold III : …………………………………………………….
……………………………………………………………………...
 Leopold IV : …………………………………………………….
……………………………………………………………………...
 TFU : …………. cm
 TBJ : ………… gr
 Auskultasi
 Frekuensi : ………….x/i
 Tempat : …………..
 Irama : …………..
 Kontraksi
 Frekuensi : ……………
 Durasi : ……………..
l. Ekstremitas
 Oedema tangan dan jari : …………..
 Oedema kaki : …………..
 Betis merah/lembek/keras : …………..
 Varises : …………..
 Reflek patella ka/ki : …………..
m. Anogenital
 Inspeksi
 Vulva/vagina
- Varises : ………….
- Kemerahan : ………….
- Luka : ………….
- Oedema : ………….
- dll : ………….
 Perineum (luka parut) : …………
n. Periksa Dalam
 Atas indikasi : …………
 Pukul : …………
 Dinding vagina : …………
 Portio (Effecement) : …………
 Posisi portio : …………
 Pembukaan serviks : …………
 Konsistensi servik : …………
 Ketuban : …………

Departemen Kebidanan STIKIM

  Presentasi fetus : …………
 Penurunan bagian terendah : ………….
 Posisi janin : ………….
 Bagian lain yang teraba : ………….
o. Punggung / pinggang dan anus
 Posisi tulang belakang : ……………
 Hemoroid : ……………

3. Pemeriksaan Penunjang
 HB : …………… gr%
 Protein urin : ……………
 Glukosa urin : ……………
 Golongan darah : ……………
C. ANALISIS
DATA : ..................................................................................................................
..........................................................................................................................................
.....

D. PENATALAKSANAAN :

Jakarta, ___________________

Pengkaji,

(____________________________)

CATATAN PERKEMBANGAN (KALA I)

Departemen Kebidanan STIKIM

Tanggal Pengkajian : _________________________
Waktu Pengkajian : _________________________
Tempat Pengkajian : _________________________

S : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
O : Tanda-tanda Vital
TD : _______ mmHg, P : ______ x/menit, R : _______ x/menit, S : ________0C
His : ___________________, DJJ : ____________ x/menit (regular/ irregular)
Pemeriksaan Dalam (Vaginal Toucher) :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Volume urine : _________________________________________
Hasil pemeriksaan lainnya :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
A : __________________________________________________________________________
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P : __________________________________________________________________________
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____________, ________________
Pengkaji,

(____________________________)

CATATAN PERKEMBANGAN (KALA II)

Departemen Kebidanan STIKIM

Tanggal Pengkajian : _________________________
Waktu Pengkajian : _________________________
Tempat Pengkajian : _________________________

S : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
O : Tanda-tanda Vital
TD : _______ mmHg, P : ______ x/menit, R : _______ x/menit, S : ________0C
His : ___________________, DJJ : ____________ x/menit (regular/ irregular)
Pemeriksaan Dalam (Vaginal Toucher) :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Volume urine : _________________________________________
Hasil pemeriksaan lainnya :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
A : __________________________________________________________________________
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P : __________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

____________, ________________
Pengkaji,

(____________________________)

CATATAN PERKEMBANGAN (KALA III)

Departemen Kebidanan STIKIM

Tanggal Pengkajian : _________________________
Waktu Pengkajian : _________________________
Tempat Pengkajian : _________________________

S : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
O : TFU : ______________________________________
Kontraksi uterus : ______________________________________
Kandung kemih : ______________________________________
Hasil pemeriksaan lainnya :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
A : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
P : __________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

____________, ________________
Pengkaji,

(____________________________)

Departemen Kebidanan STIKIM

 CATATAN PERKEMBANGAN (KALA IV)

Tanggal Pengkajian : _________________________

Waktu Pengkajian : _________________________
Tempat Pengkajian : _________________________

S : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
O : Tanda-tanda Vital
TD : _______ mmHg, P : ______ x/menit, R : _______ x/menit, S : ________0C
TFU : ______________________________________
Kontraksi uterus : ______________________________________
Kandung kemih : ______________________________________
Hasil pemeriksaan lainnya :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
A : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
P : __________________________________________________________________________
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__________________________________________________________________________
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__________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

____________, ________________
Pengkaji,

(____________________________)

Departemen Kebidanan STIKIM