copyright© Yuflihul Khair (R_R)

Ns. YUFLIHUL KHAIR, S.Kep

PENGKAJIAN AWAL KEBIDANAN

GYNAECOLOGI

Ruang Rawat : ______________________________ Dokter yang mengirim : _______________________________________

Kelas/No TT : ______________________________ Dokter yang merawat : _______________________________________
A. IDENTITAS
Data Umum Identitas Suami
Agama : __________________________________ Nama Lengkap : ________________________________________
Suku Bangsa : __________________________________ Umur : ________________________________________
Pekerjaan : __________________________________ Agama : ________________________________________
Pendidikan : __________________________________ Suku Bangsa : ________________________________________
Alamat : __________________________________ Pendidikan : ________________________________________
__________________________________ Pekerjaan : ________________________________________
No. Telp : __________________________________ Alamat : ________________________________________
No Telp : __________________________________ _____
B. RIWAYAT PENYAKIT SEKARANG
a. Keadaan Umum : ____________________________________________________________________________________________
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b. Keluhan Utama : ____________________________________________________________________________________________
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c. Keluhan yang Menyertai :
Amenorrhoe : _______________________________________________________________________________________
Pengeluaran : _______________________________________________________________________________________
d. Riwayat penyakit Sekarang : _______________________________________________________________________________
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e. Hasil Palpasi : _____________________________________________________________________________________
f. Keterangan lain-lain : _______________________________________________________________________________________
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C. TANDA-TANDA VITAL :
Tensi : _________ mmHg Suhu : _______ °C Pernafasan : ___________ x/mnt
Nadi : _________ x/mnt Teratur Tidak Teratur
D. RIWAYAT KEHAMILAN.
Gravida : _______________ Partus : _________________ Abortus : ________________ Meninggal : ____________________
Keturunan kembar : Ya Tidak
E. TINDAKAN DI KAMAR BERSALIN
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Kota Bima, ___________________________

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