…………………………………………………………………………………………………..

…………………………………………………………………………………………………...
…………………………………………………………………………………………………...

No. Register : .................................... Tanggal Pengkajian : …………………

Tanggal masuk : .................................... Waktu Pengkajian : …………………
Waktu masuk : .................................... Tempat Pengkajian : …………………

A. DATA SUBJEKTIF
1. Alasan kedatangan
………………………………………………………………………………………..
………………………………………………………………………………………..

2. Identitas Penanggung Jawab

Nama Ibu : Ny. “…..” Nama Suami : Tn. “ ….. “
Umur : ...... th Umur : ..... th
Pekerjaan : .................................... Pekerjaan : .....................................
Agama : .................................... Agama : .....................................
Pendidikan : .................................... Pendidikan : .....................................
Suku/bangsa : ................................... Suku/bangsa : .....................................
Alamat : .................................... Alamat : .....................................
.................................... .....................................
No. HP : .................................... No. HP : .....................................

3. Riwayat Antenatal G.....P.....A.....

Usia Kehamilan : ................................. minggu
Frekuensi ANC : ……….. kali
Imunisasi TT : ………………………………………………………………..
Kenaikan BB hamil: ……….. kg
Keluhan saat hamil: .................................................................................................

4. Riwayat Penyakit dalam Kehamilan………………………………………………….

Menurun : .....................................................................................................................
………………………………………………………………………………………...
Menular : ......................................................................................................................
………………………………………………………………………………………...
Menahun :......................................................................................................................
………………………………………………………………………………………...

5. Riwayat Intranatal
Tanggal lahir : …………………………… Jam :………………………………
Jenis persalinan : Spontan / SC
Penolong : ………………………... Tempat:………………………………
Warna air ketuban : ....................................................................................................
Komplikasi : …………………………………………………………………
Metode menyusui : …………………………………………………………………..
 6. Keadaan Bayi Baru Lahir
Jenis kelamin : Perempuan / Laki Laki
BB/ PB : …….. g / ……….cm
Nilai APGAR : ...................................................................................................
Caput Succedaneum : ada / tidak ada
Cepal Haematom : ada / tidak ada
Cacat Bawaan : ada / tidak ada

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum :…………………………………………………………………...
TTV : Suhu : .......... oC
Nadi : ........... x/menit Pernapasan : .......... x/menit
BB : ............. g PB : .............. cm

2. Pemeriksaan Fisik
a. Kepala
………………………………………………………………………………….
………………………………………………………………………………….
b. Ubun-ubun
………………………………………………………………………………….
………………………………………………………………………………….
c. Muka
………………………………………………………………………………….
………………………………………………………………………………….
d. Mata
………………………………………………………………………………….
………………………………………………………………………………….
e. Hidung
………………………………………………………………………………….
………………………………………………………………………………….
f. Telinga
………………………………………………………………………………….
………………………………………………………………………………….
g. Mulut
………………………………………………………………………………….
………………………………………………………………………………….
h. Leher
………………………………………………………………………………….
………………………………………………………………………………….
i. Dada
………………………………………………………………………………….
………………………………………………………………………………….
j. Tali Pusat
………………………………………………………………………………….
………………………………………………………………………………….
 k. Abdomen
………………………………………………………………………………….
………………………………………………………………………………….

l. Genetalia
………………………………………………………………………………….
………………………………………………………………………………….
m. Punggung
………………………………………………………………………………….
………………………………………………………………………………….
n. Anus
………………………………………………………………………………….
………………………………………………………………………………….
o. Kulit
………………………………………………………………………………….
………………………………………………………………………………….
p. Ekstremitas
1) Atas :……………………………………………………………………
……………………………………………………………………………..
2) Bawah : ........................................................................................................
……………………………………………………………………………..
q. Reflek
Reflek moro : Ada / Tidak Reflek tonikneck : Ada / Tidak
Refelek rooting : Ada / Tidak Reflek gaps : Ada / Tidak
Reflek sucking : Ada / Tidak Reflek walking : Ada / Tidak
Reflek swallowing: Ada / Tidak Reflek babinski : Ada / Tidak

r. Antropometri
Lingkar kepala : …… cm
Lingkar dada : …… cm
s. Eliminasi
Miksi :……………………………………………………………………….
Defekasi :………………………………………………………………………

3. Pemeriksaan Penunjang
Tgl : ................................... Tempat : ..............................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Terapi :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
…………………………………………………………………………………………
C. ANALISA DATA
Tanggal : ............................................. Jam : ………………………

1. Diagnosa Kebidanan
…………………………………………………………………………………………
………………………………………………………………………………………….
………………………………………………………………………………………….
2. Masalah
.........................................................................................................................................
.........................................................................................................................................
3. Kebutuhan
.........................................................................................................................................
.........................................................................................................................................

D. PENATALAKSANAAN
Tanggal : ............................................. Jam : ………………………

…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………..
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………...
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………………….