Documentos de Académico
Documentos de Profesional
Documentos de Cultura
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Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :
A. DATA SUBYEKTIF
1. IDENTITAS
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Penghasilan : Penghasilan :
Alamat : Alamat :
No Reg :
2. KELUHAN
a. Saat MRS
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3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
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3.2 Penyakit sekarang
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3.3 Penyakit Keluarga
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7. RIWAYAT KB
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8. RIWAYAT PERNIKAHAN
Usia....................berapa kali.................................
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2. Eliminasi
4. Personal hygiene
5. Aktivitas
6. Pola Sexualitas
B. DATA OBJEKTIF
1. KEADAAN UMUM :
- Kesadaran :............................................................................................................................................
- TTV :............................................................................................................................................
- TB :...........................................................................................................................................
- Lila :...........................................................................................................................................
2. PEMERIKSAAN FISIK
- Rambut :............................................................................................................................................................
- Wajah :...........................................................................................................................................................
- Mata :...........................................................................................................................................................
- Hidung :..........................................................................................................................................................
- Mulut :............................................................................................................................................................
- Telinga :............................................................................................................................................................
- Payudara
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- Jantung
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- Paru
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Inspeksi :............................................................................................................................................................................
Palpasi
- Leopold I :...........................................................................................................................................................................
TFU :........................cm
TBJ :.........................gr
- Leopold II :...........................................................................................................................................................................
DJJ :..........................................................................................................................................................................
- Leopold IV :...........................................................................................................................................................................
b. Pemeriksaan Ekstremitas
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c. Pemeriksaan Genetalia
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Hasil :...........................................................................................................................................................................
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e. Pemeriksaan Integumen
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1. PEMERIKSAAN PENUNJANG
- Laboratorium/USG
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- Radiologi
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2. TERAPI
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3. KESIMPULAN
G….............P…................Ab……................Usia Kehamilan......................minggu
Inpartu............................................................................................................................................................................................
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Keterangan:
4. ANALISA DATA
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6. INTERVENSI
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NO TANGGAL/JAM IMPLEMENTASI
NO TANGGAL/JAM IMPLEMENTASI
8. EVALUASI
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NO TANGGAL/JAM EVALUASI
NO TANGGAL/JAM EVALUASI