Contoh Format Pendokumentasian Manajemen Kebidanan pada Keluarga Berencana

ASUHAN KEBIDANA PADA AKSEPTOR KBSUNTIK PROGESTIN

No. Register: .Masuk RS tanggal / jam: .Dirawat diruang: .

I.PENGKAJIANTanggal : ...................., Jam : ...............WIB, Oleh : .................................A.DATA SUBYEKTIF1.IdentitasIbuSuamiNama: ......................................................................................................Umur: ......................................................................................................Agama: ......................................................................................................Suku/Bangsa: ......................................................................................................Pendidikan: ......................................................................................................Pekerjaan: ......................................................................................................Alamat: ......................................................................................................No. Telp: ......................................................................................................2. Alasan datang............................................................................................................................................................................................................................................................................................................

3. Keluhan utama.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Riwayat menstruasiMenarche: .. tahunSiklus: .. hariLama: .. hariTeratur:..Sifat darah: ....Keluhan:..

5. Riwayat perkawinanStatus pernikahan : ......................Menikah ke: .....................Lama: tahunUsia menikah pertama kali :. tahun6. Riwayat kehamilan, persalinan, dan nifas yang laluP.........Ab.........Ah.....

Hamil ke-PersalinanNifas

TanggalUmur khamilnJns prsalinanPenolongkomplikasiJKBB LahirLaktasiKomplikasi

7. Riwayat kontrasepsi yang digunakanNo.Jenis KontrasepsiPasangLepas

TglOlehTempatKeluhanTgl.OlehTempatAlasan

8.Riwayat kesehatana.Penyakit yang pernah /sedang diderita (menular, menurun dan menahun)...............................b.Penyakit yang pernah /sedang diderita keluarga (menular, menurun dan menahun)...............................c.Riwayat penyakit ginekologi.

9.Pola Pemenuhan kebutuhan sehari-haria.Pola nutrisiMakanFrekuensi: .......x/hari,Porsi:..............................................Jenis: ..........................................Pantangan:..............................................Keluhan: ..........................................MinumFrekuensi: .......x/hari,Porsi:..............................................Jenis: ..........................................Pantangan:..............................................Keluhan: ..........................................b.Pola eliminasiBABFrekuensi: ..........................................Konsistesi:..............................................Warna: ..........................................Keluhan:..........................................

BAKFrekuensi: ..........................................Konsistesi:..............................................Warna: ..........................................Keluhan:..........................................c.Pola istirahatTidursiangLama: ..... jam/hari,Keluhan:..............................................Tidur malamLama: ..... jam/hari,Keluhan:..............................................d.Personal hygieneMandi: ..... x/hariGanti pakaian: ...... x/hariGosok gigi: ...... x/hariMencuci rambut: ...... x/minggue.Pola seksualitasFrekuensi: ..... x/mingguKeluhan:..............................................f.Pola aktivitas (terkait kegiatan fisik, olah raga)................................................................................................................................................................................................................................................................................................

10.Keadaan psiko sosial spiritual

a.Pengetahuan ibu tentang alat kontrasepsi................................................................................................................................................................................................................................................................................................................................................................................................................................................b.Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang................................................................................................................................................................................................................................................................................................................................................................................................................................................c.Dukungan suami/keluarga................................................................................................................................................................................................................................................................................................................................................................................................................................................

B.DATA OBYEKTIF1.Pemeriksaan umumKeadaan umum: ....................................Kesadaran: ....................................Status emosional: ....................................Tanda vital sign :Tekanan darah: ................. mmHgNadi: ................ x/menitPernapasan: ................. x/menitSuhu: ................ x/menitBerat badan: ................. kg

2.Pemeriksaan fisikKepala:......................................................................................................................Rambut:......................................................................................................................Muka:......................................................................................................................Mata: ................., sklera ..............................., konjungtiva....................................Hidung:......................................................................................................................Mulut:......................................................................................................................Telinga:......................................................................................................................Leher:......................................................................................................................Dada:...................................................................................................................... Payudara:............................................................................................................................................................................................................................................Abdomen:............................................................................................................................................................................................................................................Ekstremitas atas:......................................................................................................................Ekstremitasbawah:......................................................................................................................Genetalia luar:......................................................................................................................Anus:......................................................................................................................Pemeriksaandalam/ginekologis :..........................................................................................................................................................................................................................................................................................................

3.Pemeriksaan Penunjang........................................................................................................................................................................................................................................................................................................................

II.INTERPRETASI DATAA.Diagnosa Kebidanan.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................B.Masalah.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C.Kebutuhan.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III.IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL...............................................................................................................................................................................................................................................................................................................................................................................................................................................................

IV.ANTISIPASI TINDAKAN SEGERA...............................................................................................................................................................................................................................................................................................................................................................................................................................................................V.PERENCANAAN..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VI.PELAKSANAANTanggal : ....................., Jam : ...............WIB, Oleh :...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VII.EVALUASITanggal : ....................., Jam : ...............WIB............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda Tangan(....................)