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ASUHAN KEBIDANAN

PADA......................................................... DENGAN IMUNISASI.....................................


No. Register
Masuk RS / BPS tanggal, jam
Dirawat di ruang

Identitas
Nama
Umur
Jenis Kelamin
Agama
Suku/Bangsa
Pendidikan
Pekerjaan
Alamat

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: ..................................................................................................
: ..................................................................................................

Pasien
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Orang Tua Penanggungjawab


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Anamnesa
1. Alasan kunjungan:
.......................................................................................................................................................................
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2. Riwayat kesehatan
Ibu/........................................ mengatakan keluarga pernah/sedang/ tidak pernah menderita
Penyakit menular seperti
Hepatitis
HIV
TBC

Penyakit sistemik
Asma
Jantung
Hipertensi
Diabetes
Yang lain ..........................................................................................
Anak sudah/belum pernah menderita sakit parah hingga opname
3. Riwayat Obstetri
Ibu melahirkan pada tanggal:
secara:
BB lahir:
LK lahir:
TB Lahir:
LD lahir:
4. Riwayat Imunisasi
Waktu Diberikan
No
Macam
I
II
III
1.
BCG
2.
Hepatitis B
3.
DPT Combo
4.
Polio
5.
Campak
5. Pola Pemenuhan Kebutuhan Sehari-hari
a. Nutrisi
Makan :
Minum :
b. Eliminasi
BAB

BAK

c. Istirahat
d. Aktifitas

:
:

ditolong oleh:

IV

e. Personal Hygiene:

Pemeriksaan Umum
BB

TB

Status Gizi

Suhu

Pemeriksaan Khusus
Mata

Mulut

Dada

Perut

Genetalia

Ekstremitas

Motorik Kasar :
Motorik Halus :
Bahasa

Personal Sosial :
Pemeriksaan Penunjang

Tanggal:

Jam:

Tanggal:

Jam: