Nama Mahasiswa : …………………………………………
Semester :
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Tanggal Ujian : …………………………………………
Penguji : 1. ………………………………………
2. ………………………………………
I. PENGKAJIAN
A. Data Histori Pasien/ Riwayat
1.
Identitas Pasien
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2.
Keluhan Utama
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3.
Riwayat Keluhan Utama (PQRST)
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4.
Riwayat penyakit sekarang
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5.
Riwayat penyakit yang lalu
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6.
Riwayat penyakit keluarga
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7.
Riwayat kehamilan, persalinan, nifas, yang lalu
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8.
Riwayat kehamilan, persalinan sekarang
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9.
Kebutuhan dasar sehari-hari
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10. Data
psikososial
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11. Pengetahuan
dan kemampuan ibu tentang
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B. Pemeriksaan Fisik
1.
Pemeriksaan keadaan umum
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2.
Kulit
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3.
Muka dan kepala
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4.
Mata
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5.
Hidung
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6.
Mulut dan tenggorokan
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7.
Leher
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8.
Buah dada/ Payudara
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9.
Abdomen (GIT)
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10.
Abdomen (Obstetri)
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11.
Genetalia Eksterna
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12.
Ekstrimitas atas
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13.
Ekstrimitas bawah
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C. Pemeriksaan Penunjang
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D. Pengobatan / tindakan yang sudah
didapat :
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II.
DIAGNOSA
KEBIDANAN
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III.
PERENCANAAN/
INTERVENSI
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IV.
IMPLEMENTASI
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V.
EVALUASI
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Sidoarjo,……………………………………………….
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Penguji I
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Nama Penguji & Tanda Tangan
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Pemberi Asuhan
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Nama Mahasiswa
& Tanda Tangan
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