PEMERINTAH KABUPATEN KAYONG UTARA

DINAS KESEHATAN DAN KELUARGA BERENCANA

PUSKESMAS TELUK MELANO
Alamat : Jalan Merdeka no. 01 Desa Teluk Melano Kec. Simpang Hilir, Kode Pos: 78853

STATUS KEBIDANAN

A. DATA DASAR PASIEN

 Nama : .....................................................................
 Jenis Kelamin : Perempuan
 Umur : .....................................................................
 Alamat/No.Hp : .....................................................................
 Pekerjaan : .....................................................................
 Jenis Pelayanan : UMUM / JKN (KIS,ASKES,PBI,MANDIRI)
 Tanggal Masuk Puskesmas / Dirawat : ....................................................................
 Anamnesis : .....................................................................
..........................................................................................................................................
 Keluhan Utama : .....................................................................
 Riwayat Perjalanan Penyakit : .....................................................................
 Riwayat Perkawinan : .....................................................................
 Riwayat Obstetrik : G...P...A...M...

TEMPAT USIA JENIS JENIS KEADAAN

NO TAHUN BERAT
BERSALIN KEHAMILAN PERSALINAN KELAMIN ANAK

 Riwayat Penyakit /Operasi yang pernah diderita :

Anemia Diabetes Tuberkulosis Lain-lain
Penyakit Kelamin Alergi Sakit Ginjal
Asthma Jantung Hepatitis
Operasi : 1. ........................................
2. ........................................
 Riwayat Kehamilan Sekarang :
HPHT :.....................................TP :...................................Total Periksa Hamil :......kali
USG :..............kali, Taksiran Persalinan Oleh Dokter Tanggal :....................................
 Riwayat Persalinan Sekarang :
His mulai Tgl : ...................................................Jam : ............WIB
Darah Lendir Sejak Tgl : ...................................................Jam : ............WIB
Ketuban: a. Utuh
b. Pecah Tgl : ...................................................Jam : ............WIB
c. Sudah Pecah Tgl : ...................................................Jam : ............WIB
B. PEMERIKSAAN FISIK PASIEN KEBIDANAN
 Keadaan Umum : ...........................................- Urine : - HCG test : + / -
 Kesadaran : ...........................................- Protein Urine :
 Berat Badan : .........kg Hb : .............g/dl
 Tinggi badan : .........cm Lakmus : + / -
 Tekanan Darah : .........mmhg
 Nadi : .........x/mt
 Pernapasan : .........x/mt
 Suhu : .........°C
 Leopold I : TFU : ...........cm
 Leopold II : DJJ : ............ x/mt
 Leopold III : ................................................................................
 Leopold IV : ................................................................................
 TBBJ : ............gr
 HIS : ...................mt/kali, lamanya : .....detik,
 Pemeriksaan Dalam / VT : Pembukaan : .............................................
Portio : .............................................
Bag Terbawah : .............................................
Hodge : .............................................
Ketuban : .............................................
Lain-lain : .............................................
 Hasil Pemeriksaan Panggul: Baik / Sempit
 Diagnosa Sementara : .................................................................................
 Tindakan / Terapi : .................................................................................
- IVFD ....................................................................Gtt........./ Menit ( Makro/Mikro )
................................................................................................................................................
................................................................................................................................................
..............................................................................................................................
Bidan Jaga : ....................................................................................................

Teluk Melano, 2018

Penanggung Jawab Kebidanan Dokter Jaga

NORHASIAH, A.Md.Keb dr. Hamdirullah S Harahap

NIP. 19880522 201101 2 003

Mengetahui
Kepala Puskesmas Teluk Melano

EVI NORSITA, A. Md.Kep

NIP : 19841106 200902 2 006