FORMAT PENDOKUMENTASIAN ASUHAN KEBIDANAN KESEHATAN REPRODUKSI

FORMAT PENDOKUMENTASIAN

ASUHAN KEBIDANAN KESEHATAN REPRODUKSI

RS/PKM/RB/BPS/KLINIK : NOMOR RM :		Pj. Ruangan : Tangal/Pukul pengkajian :
Nama mahasiswa : NIM                     : Pembimbing         :		Sumber Informasi tempat pelayanan ¨ Teman                       ¨ Orang tua/keluarga ¨ Nakes                        ¨ Sendiri
A	BIODATA Nama                     : ................................................................................................................. Umur                      : ................................................................................................................. Suku/bangsa           : ................................................................................................................. Agama                    : ................................................................................................................. Pendidikan             : ................................................................................................................. Pekerjaan               : ................................................................................................................. Alamat                   : .................................................................................................................                                : .................................................................................................................
B 1	DATA SUBJEKTIF Keluhan Utama ..................................................................................................................................................
2	Riwayat Kesehatan/penyakit sekarang ..................................................................................................................................................
3	Riwayat kesehatan yang lalu ..................................................................................................................................................
4	Riwayat kesehatan keluarga ..................................................................................................................................................
5	Riwayat fungsi reproduksi a. Riwayat menstruasi Menarche       : ................................... Siklus             : ................................... Lamanya        : ................................... Banyaknya    : ................................... Warna/bau     : ................................... Disminorhea  : ................................... HPHT            : ...................................		b. Kebiasaan Seksual   : .......................................... c. Riwayat kehamilan, persalinan dan nifas yang lalu : ................................................................................ d. Tumor                      : .......................................... e.  Infeksi                    : .......................................... f.  Gangguan KB          : .......................................... g.  Riwayat perkawinan                                 : ..........................................
6	Riwayat Kebiasaan Sehari hari a.    Makan/Minum Frekuensi      : ................................... Macam          : ................................... Pantangan     : ................................... Minum          : ................................... b.   Eliminasi BAK             Frekuensi      : ................................... Konsistensi   : ................................... Warna           : ................................... Bau               : ................................... BAB              Frekuensi      : ................................... Konsistensi   : ................................... Warna           : ................................... Bau               : ...................................		c.    Personal Hygiene Mandi                             : ................................... Sikat gigi                        : ................................... Ganti pakaian                 : ................................... d.   Ketergantungan Alergi                             : ................................... Merokok                        : ................................... Obat-obatan/alkohol       : ................................... Jamu                              : ................................... e.    Keadaan psikologis, sosial dan spiritual Status emosional            : ................................... Status sosial                    : ................................... Komunikasi dg keluarga : ................................... Status ekonomi               : ...................................
B 1	DATA OBJEKTIF Pemeriksaan Umum Keadaan umum           : ........................................ Kesadaran                   : ........................................ Keadaan emosional     : ........................................ BB                              : ........................................ TB                               : ........................................			Tanda-tanda Vital - TD                  : ............................ - Nadi               : ............................ - Pernafasan     : ............................ - Suhu               : ............................
2	Pemeriksaan Fisik a.       Kepala Rambut                 : ¨ Bersih                        ¨ Rontok                             ¨ Ketombe     Konjungtiva          : ........................................ Sclera                    : ........................................ b.      Mulut dan gigi       : ........................................ c.       Leher Pembengkakan      : ¨ Kelenjar tyroid           ¨ Kelenjar getah bening       ¨ Vena jugularis d.      Dada Jantung                 : ........................................ Paru-paru              : ........................................ e.       Payudara ¨ Pembesaran                  ¨ Puting menonjol        ¨ Benjolan                 ¨ Simetris ¨ Nyeri                            ¨ Pengeluaran               f.       Punggung dan pinggang ¨ Posisi punggung normal                                     ¨ Nyeri ketuk g.       Ekstremitas ¨ Oedema                        ¨ Kekakuan otot           ¨ Kemerahan             ¨ Varises h.      Abdomen ¨ Bekas luka operasi       ¨ Acites                        ¨ Konsistensi             ¨ Tumor i.        Anogenitalia Vulva dan vagina              : ...................................................... Oedema                            : ...................................................... Pengeluaran                      : ...................................................... Banyaknya                       : ...................................................... Anus                                 : ...................................................... Inspekulo                          : ...................................................... Pemeriksaan dalam           : ......................................................
2	Pemeriksaan penunjang a.       Laboratorium Hb                                    : ...................................................... Protein urine                     : ...................................................... Glukosa urine                   : ...................................................... b.      USG                                  : ...................................................... c.       Papsmear                          : ...................................................... d.      Dll                                    : ......................................................
C	ASESSMENT .................................................................................................................................................. ..................................................................................................................................................
D	PENATALAKSANAAN .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..................................................................................................................................................

Pembimbing Lahan, (............................................)

Pembimbing akademik, (............................................)

.................., ................................ Mahasiswa, (............................................)