FORMAT PENDOKUMENTASIAN
ASUHAN KEBIDANAN KESEHATAN REPRODUKSI
RS/PKM/RB/BPS/KLINIK :
NOMOR RM :
|
Pj. Ruangan :
Tangal/Pukul pengkajian :
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Nama mahasiswa :
NIM :
Pembimbing :
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Sumber Informasi tempat pelayanan
¨ Teman ¨ Orang tua/keluarga
¨ Nakes ¨ Sendiri
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A
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BIODATA
Nama : .................................................................................................................
Umur : .................................................................................................................
Suku/bangsa : .................................................................................................................
Agama : .................................................................................................................
Pendidikan : .................................................................................................................
Pekerjaan : .................................................................................................................
Alamat : .................................................................................................................
:
.................................................................................................................
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B
1
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DATA SUBJEKTIF
Keluhan Utama
..................................................................................................................................................
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2
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Riwayat
Kesehatan/penyakit sekarang
..................................................................................................................................................
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3
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Riwayat kesehatan
yang lalu
..................................................................................................................................................
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4
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Riwayat kesehatan
keluarga
..................................................................................................................................................
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5
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Riwayat fungsi
reproduksi
a. Riwayat menstruasi
Menarche : ...................................
Siklus : ...................................
Lamanya : ...................................
Banyaknya : ...................................
Warna/bau : ...................................
Disminorhea : ...................................
HPHT : ...................................
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b. Kebiasaan Seksual :
..........................................
c. Riwayat kehamilan, persalinan dan nifas yang lalu
:
................................................................................
d. Tumor :
..........................................
e. Infeksi : ..........................................
f. Gangguan
KB : ..........................................
g. Riwayat
perkawinan :
..........................................
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6
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Riwayat Kebiasaan
Sehari hari
a. Makan/Minum
Frekuensi : ...................................
Macam
: ...................................
Pantangan
: ...................................
Minum : ...................................
b. Eliminasi
BAK
Frekuensi : ...................................
Konsistensi : ...................................
Warna : ...................................
Bau : ...................................
BAB
Frekuensi : ...................................
Konsistensi : ...................................
Warna : ...................................
Bau : ...................................
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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 : ...................................
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B
1
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DATA OBJEKTIF
Pemeriksaan Umum
Keadaan umum : ........................................
Kesadaran : ........................................
Keadaan emosional : ........................................
BB :
........................................
TB :
........................................
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Tanda-tanda Vital
- TD : ............................
- Nadi : ............................
- Pernafasan : ............................
- Suhu : ............................
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2
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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 : ......................................................
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2
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Pemeriksaan penunjang
a. Laboratorium
Hb :
......................................................
Protein urine : ......................................................
Glukosa urine : ......................................................
b.
USG :
......................................................
c.
Papsmear :
......................................................
d.
Dll :
......................................................
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C
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ASESSMENT
..................................................................................................................................................
..................................................................................................................................................
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D
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PENATALAKSANAAN
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Pembimbing Lahan,
(............................................)
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Pembimbing akademik,
(............................................)
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..................,
................................
Mahasiswa,
(............................................)
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