AKADEMI KEBIDANAN HELVETIA MEDAN

FORMAT PENDOKUMENTASIAN MANAJEMEN KEBIDANAN

PADA IBU HAMIL

No. Register : …………………………....................................

Masuk RS/PKM/BPM Tanggal/Pukul : ………………………………….......………......
Dirawat di ruang : .............................................................................

I. PENGKAJIAN DATA, Tanggal/Pukul : ...............................

Oleh : ...................................
A. Biodata Ibu Suami
1. Nama : .................................................... ......................................................
2. Umur : .................................................... ......................................................
3. Agama : .................................................... ......................................................
4. Suku/bangsa : .................................................... ......................................................
5. Pendidikan : .................................................... ......................................................
6. Pekerjaan : .................................................... ......................................................
7. Alamat : .................................................... ......................................................

B. Data Subjektif
1. Alasan datang/dirawat
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2. Keluhan utama
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3. Riwayat menstruasi
Menarche : ................................. Siklus : ........................................
Lama : ................................. Teratur : ........................................
Sifat darah : ................................. Keluhan : ........................................

4. Riwayat perkawinan
Status perkawinan : ..................... Menikah ke : ..................................
Lama : ..................... Usia menikah pertama kali : ..........

5. Riwayat obstetrik : G...... P....A....Ah....

Hamil ke Persalinan Nifas
Tanggal Umur Jenis Penolong Komplikas JK BB Laktasi Komplikas
kehamila persalina i lahir i
n n

6. Riwayat kontrasepsi yang digunakan

No Jenis Pasang Lepas
kontraseps tangga oleh tempat keluha tanggal oleh Tempa Alasan
i l n t
7. Riwayat Kehamilan Sekarang
a. HPM : .......................... HPL:.......................................

b. ANC pertama umur kehamilan : .......... minggu

c. Kunjungan ANC
Trimester I
Frekuensi : ..........kali Tempat :........................... Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi : .................................................................................................................
Trimester II
Frekuensi : ..........kali Tempat :........................... Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi : .................................................................................................................
Trimester III
Frekuensi: ..........kali Tempat :........................... Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi : .................................................................................................................
d. Imunisasi TT : ............kali
TT 1 : tanggal...............................
TT 2 : tanggal...............................
TT 3 : tanggal...............................
TT 4 : tanggal...............................
TT 5 : tanggal...............................
e. Pergerakan janin selama 24 jam(dalam sehari)
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8. Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)
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b. Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan
menahun)
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c. Riwayat keturunan kembar
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d. Riwayat operasi
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 e. Riwayat alergi obat
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9. Pola pemenuhan kebutuhan

Sebelum hamil Saat hamil
a. Nutrisi
Makan
Frekuensi : ........ x/hari ........... x/hari
Jenis : .............................. ................................
Porsi : .............................. ................................
Pantangan : .............................. ................................
Keluhan : .............................. ................................
Minum
Frekuensi : ........ x/hari ........... x/hari
Jenis : .............................. ................................
Porsi : .............................. ................................
Pantangan : .............................. ................................
Keluhan : .............................. ................................

b. Eliminasi
BAB
Frekuensi : ........ x/hari ........... x/hari
Warna : .............................. ...............................
Konsistensi : .............................. ...............................
Keluhan : .............................. ...............................
BAK
Frekuensi : ........ x/hari ........... x/hari
Warna : .............................. ...............................
Konsistensi : .............................. ...............................
Keluhan : .............................. ...............................

c. Istirahat
Tidur siang
Lama : ........ Jam/hari .................. Jam/hari
Keluhan : ................................ ................................
Tidur malam
Lama : ................ Jam/hari ……............ Jam/hari
Keluhan : ................................ ................................

d. Personal Hygiene
Mandi : ...... x/hari ...... x/hari
Ganti pakaian : ...... x/hari ...... x/hari
Gosok gigi : ...... x/hari ...... x/hari
Keramas : ...... x/minggu ...... x/minggu

e. Pola seksualitas
Frekuensi : ...... x/minggu ...... x/minggu
Keluhan : ................................ ................................

f. Pola aktivitas (terkait kegiatan fisik, olah raga)

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10. Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman

beralkohol)
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11. Data psikososial, spiritual dan ekonomi (penerimaan ibu/suami/keluarga

terhadap kelahiran, dukungan keluarga, hubungan dengan suami/keluarga/tetangga,
perawatan bayi, kegiatan ibadah, kegiatan sosial, keadaan ekonomi keluarga
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12. Pengetahuan ibu (tentang kehamilan, persalinan, nifas)

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13. Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)

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C. Data Objektif
1. Pemeriksaan umum
Keadaan umum : .......................................................................
Kesadaran : .......................................................................
Status emosional : .......................................................................
Tanda vital :
Tekanan darah : .............mmHg Nadi : ...........x/menit
Pernafasan : ............x/menit Suhu : ...........x/menit
BB : ............kg TB : ...........cm

2. Pemeriksaan Fisik
Kepala : .................................................................................................................
Wajah : .................................................................................................................
Mata : .................................................................................................................
Hidung : .................................................................................................................
Mulut : .................................................................................................................
Telinga : .................................................................................................................
Leher : .................................................................................................................
Dada : .................................................................................................................
Payudara : .................................................................................................................
Abdomen : .................................................................................................................

Palpasi
Leopold I : .................................................................................................................
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Leopold II : .................................................................................................................
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Leopold III : .................................................................................................................
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Leopold IV : .................................................................................................................
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Osborn test : .................................................................................................................

Pemeriksaan Mc. Donald
TFU : ...........cm TBJ :..................................................................
Auskultasi
Djj : ...........x/menit

Ekstremitas Atas : .....................................................................................................

Ekstremitas Bawah : .....................................................................................................
Genetalia luar : .....................................................................................................
Pemeriksaan panggul: ....................................................................................................
(bila perlu) .....................................................................................................
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3. Pemeriksaan penunjang Tgl : ....................... Pukul : .........WIB

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4. Data penunjang
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II. INTERPRETASI DATA

A. Diagnosa kebidanan
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Data Dasar:
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B. Masalah
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Data Dasar:
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III. IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV. TINDAKAN SEGERA

A. Mandiri
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 B. Kolaborasi
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C. Merujuk
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V. PERENCANAAN Tanggal : …………………. ……. Pukul :

……….....WIB
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VI. PELAKSANAAN Tanggal: ..........................................
Pukul : ................WIB
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VII. EVALUASI Tanggal : ........................................... Pukul : ..........

.....WIB
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Dosen Penguji Mahasiswa

Winda Agustina, S.Tr.Keb, M.K.M HERLIANA