Format Dokumentasi Persalinan
Format Dokumentasi Persalinan
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 :
7. Aktivitas sehari-hari
a. Diet/makan
Makan sehari-hari : ……………………….
Ngidam : ……………………….
Pantangan tehadap makanan : ……………………….
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
3. Pemeriksaan Penunjang
HB : …………… gr%
Protein urin : ……………
Glukosa urin : ……………
Golongan darah : ……………
C. ANALISIS
DATA : ..................................................................................................................
..........................................................................................................................................
.....
D. PENATALAKSANAAN :
Jakarta, ___________________
Pengkaji,
(____________________________)
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 : __________________________________________________________________________
__________________________________________________________________________
P : __________________________________________________________________________
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__________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________, ________________
Pengkaji,
(____________________________)
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 : __________________________________________________________________________
__________________________________________________________________________
P : __________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________, ________________
Pengkaji,
(____________________________)
S : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
O : TFU : ______________________________________
Kontraksi uterus : ______________________________________
Kandung kemih : ______________________________________
Hasil pemeriksaan lainnya :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
A : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
P : __________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________, ________________
Pengkaji,
(____________________________)
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 : __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________, ________________
Pengkaji,
(____________________________)