FORMAT

KALA.......

I.                    PENGKAJIAN DATA                   Tanggal/Pukul:...........................          WIB Oleh:............

A.     DATA SUBYEKTIF

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B.     DATA OBYEKTIF

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II.                 INTERPRETASI DATA

A.     Diagnosa Kebidanan

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Data Dasar

DS       : ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

DO       : .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B.     Diagnosa Masalah

Data Dasar

DS       : ...........................................................................................................................................................................................................................................................................................................................................................................................................................

DO       :

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III.               IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV.              TINDAKAN SEGERA

a.       Mandiri

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b.      Kolaborasi

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c.       Merujuk

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V.                 PERENCANAAN              Tanggal :....................................                      Pukul:..........WIB

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VI.              PELAKSANAAN              Tanggal:....................................                       Pukul:............WIB

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VII.            EVALUASI                       Tanggal            :.................................  Pukul:..............WIB

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LEMBAR DDST PADA BAYI USIA 16 BULAN

LEMBAR DDST PADA BAYI USIA 16 BULAN

NO	ITEM	DDST
		KIRI GARIS	TEPAT GARIS	KANAN GARIS
1	PERSONAL SOSIAL	Menirukan kegiatan	Menyuapi boneka	Cuci dan meringakan tangan
		Main bola dengan pemeriksa	Membuka pakian	Gosok gigi dengan bantuan
		Daag-daag dengan tangan	Menggunakan sendok/garpu	Memaki baju
			Membantu di rumah
			Minum dengan cangkir
2	MOTORIK HALUS	Menaruh kubus di cangkir	Menara dari 2 kubus	Meniru garis vertikal
		Membenturkan 2 kubus	Ambil manik-manik ditunjukkan	Menara dari 6 kubus
		Memegang dengan ibu jari dan jari	Mencoret-coret	Menara dari 4 kubus
3	BAHASA	1 kata	6 kata	Menyebut 1 gambar
		Papa/mama spesifik	3 kata	Kombinasi kata
		Mengoceh	2 kata	Menunjuk 2 gambar
4	MOTORIK KASAR	Berjalan dengan baik	Menendang bola kedepan	Loncat jauh
		Membungkuk kemudian berdiri	Berjalan naik tangga	Melempar bola tangan ke atas
		Berdiri sendiri	Lari	melompat
			Berjalan mundur