FORMAT PENGKAJIAN

ASUHAN KEBIDANAN PADA NEONATUS

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I. DATA SUBYEKTIF (TANGGAL................................PUKUL……………WITA)

1) Identitas
a) Bayi
Nama :
Umur/Tanggal/Jam Lahir :
Jenis Kelamin :
b) Orang Tua
Ibu Suami
Nama : .................................................................................
Umur : .................................................................................
Agama : .................................................................................
Suku Bangsa : .................................................................................
Pendidikan : .................................................................................
Pekerjaan : .................................................................................
Alamat Rumah : .................................................................................
Telepon/Hp : .................................................................................
Golongan Darah : .................................................................................
2) Alasan Berkunjung dan Keluhan Utama
…………………………………………………………………………………………
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3) Riwayat Pranatal
1) G…. P….. A……
2) Masa Gestasi ……………………….
3) Riwayat ANC
ANC …… kali, di Bidan …… kali, Dokter …... kali, Puskesmas ………….. kali
TM I : ANC Bidan …… kali, keluhan………………………………….,
suplemen ……………………………………. dan ………………,
ANC Dokter ……. kali, hasil USG: ………………………………
 ……………………………………………………………………..,
ANC di Puskesmas ………………………… kali, hasil pemeriksaan
darah: ……………………………………………………………
TM II : ANC Bidan …… kali, keluhan………………………………….,
suplemen …………………………………………. dan ………………,
ANC Dokter ……. kali, hasil USG: ……………………………………
…………………………………………………………………………..,
ANC di Puskesmas ………………………… kali, hasil pemeriksaan
darah: ……………………………………………………………………
TM III : ANC Bidan …… kali, keluhan………………………………….,
suplemen …………………………………………. dan ………………,
ANC Dokter ……. kali, hasil USG: ……………………………………
…………………………………………………………………………..,
ANC di Puskesmas ………………………… kali, hasil pemeriksaan
darah: ……………………………………………………………………
4) Riwayat Intranatal
…………………………………………………………………………………………
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a) Kala I : ……………………………………………………………………….
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b) Kala II : ……………………………………………………………………….
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c) Kala III : ……………………………………………………………………….
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d) Kala IV : ……………………………………………………………………….
……………………………………………………………………….
5) Faktor Infeksi
□ TBC □ Demam Saat Bersalin □ KPD > 6 jam □ Hepatitis B/C □ Sifilis
□ HIV/AIDS □ Obat Terlarang □ Tidak Ada
II. DATA OBYEKTIF (TANGGAL...................……………PUKUL……………WITA)
Tanggal/Jam Lahir :
Jenis Kelamin :
Tangis :
Gerak :

III. ANALISA
1) Diagnosa ……………………………………………………………………………….
……………………………………………………………………………….
2) Masalah ...........................................................................................................................
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IV. PENATALAKSANAAN
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I. CATATAN PERKEMBANGAN
Hari/Tanggal Catatan Perkembangan Paraf/
Waktu Nama

Tempat
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