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    Materi 2 & 3 (Filling in Medical Report)

    Uploaded by

    Anggie Rambu
    After completing learning activity 2, students are able to ask questions and properly fill out a medical report for a patient. Specifically, students can: a) Ask several types of questions to obtain initial patient data b) Fill out a medical report for a patient by asking them questions The material covered asking questions and filling out a medical report for a patient. Common questions asked by midwives to new patients for obstetric cases were discussed. Students will now practice filling out a medical report as an exercise by finding a case from their practice site.

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    © All Rights Reserved
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    Materi 2 & 3 (Filling in Medical Report)

    Uploaded by

    Anggie Rambu
    1K views8 pages
    After completing learning activity 2, students are able to ask questions and properly fill out a medical report for a patient. Specifically, students can: a) Ask several types of questions to obtain initial patient data b) Fill out a medical report for a patient by asking them questions The material covered asking questions and filling out a medical report for a patient. Common questions asked by midwives to new patients for obstetric cases were discussed. Students will now practice filling out a medical report as an exercise by finding a case from their practice site.

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    © © All Rights Reserved

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    After completing learning activity 2, students are able to ask questions and properly fill out a medical report for a patient. Specifically, students can: a) Ask several types of questions to obtain initial patient data b) Fill out a medical report for a patient by asking them questions The material covered asking questions and filling out a medical report for a patient. Common questions asked by midwives to new patients for obstetric cases were discussed. Students will now practice filling out a medical report as an exercise by finding a case from their practice site.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views8 pages

    Materi 2 & 3 (Filling in Medical Report)

    Uploaded by

    Anggie Rambu
    After completing learning activity 2, students are able to ask questions and properly fill out a medical report for a patient. Specifically, students can: a) Ask several types of questions to obtain initial patient data b) Fill out a medical report for a patient by asking them questions The material covered asking questions and filling out a medical report for a patient. Common questions asked by midwives to new patients for obstetric cases were discussed. Students will now practice filling out a medical report as an exercise by finding a case from their practice site.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 8

    Kegiatan Belajar

    Asking –Filling in Medical Report

    2x 100 Menit

    I. Tujuan Pembelajaran Umum : Setelah menyelesaikan kegiatan belajar 2,


    mahasiswa mampu membuat pertanyaan dan mengisi medical report pasien dengan
    benar

    II. Tujuan pembelajarank khusus: Setelah mempelajari kegiatan belajar 2 mahasiswa


    mampu:
    a. Mengajukan beberapa jenis pertanyaan untuk mendapatkan data awal pasien
    b. Mengisi medical report pasien dengan bertanya pada pasien

    III. Pokok pokok materi

    A. Asking question/bertanya

    B. Filling in medical report/mengisi medical report pasien


    Bahan ajarmata kuliah

    URAIANMATERI

    A.Asking question

    Midwife : Good Morning Mrs Maria. I need


    to fill a medical report about
    your health status
    Patient : Sure
    Midwife : Your complete name ?
    Patient : Devi Maria
    Midwife : What is your complete address?
    Patient : I live in Surabaya / at Ir Sukarno
    street, No.38 .Surabaya
    Midwife : What makes you come to hospital?
    Patient :I have a backache.
    Midwife : Where is the pain, could you point
    at the pain ?
    Patient :It’s around here (pointing at the

    lower back)

    Midwife : Did you take any medicine for your pain ?


    Patient : No, I didn’t
    Midwife : Do you know the cause of pain ?
    Patient :I don’t know
    Midwife : What’s the pain like?

    Patient :It’s sharp

    Midwife : How often do you feel the pain ?


    Patient ;It’s occasional.
    Midwife : Well, thank you Mrs Maria for your information. I will report this to your
    obstetrician .
    Bahan ajarmata kuliah

    Beberapa pertanyaan yang sering digunakan dalam keseharian bidan

    a). Pertanyaan untuk mengetahui kondisi pasien misalnya sebagai berikut !

    1. What’s your problem ?

    2. How are you feeling today?

    3. What makes you call me?

    4. What’s your chief complaint?

    5. What’s troubling you ?

    6. What’s the matter with you?

    7. What’s wrong with you ?

    8. What seems to be bothering you ?

    9. Doctor “what are the symptoms?/ what is

    she complaining about ?

    b). Ekspresi pasien atau cara pasien menjawab tentang masalah kesehatan yang dihadapi:

    1. I have+( a part oft he body+ache) 4. I experience+kinds of symptoms


    ( a toothache) and physical problems
    (a headache) ( low backpain)

    ( a backache) ( difficult breathing )

    2. I have(a sore+parts oft he body) 5. Isuffer from +kinds of certain


    ( a sore arm) illness
    ( a sore knee) ( cancer )

    3. Ihave/ get +kind of physical problems ( constipation

    ( themeasles)
    ( the flu )
    ( af ever )

    ( a bad cough)
    c). Beberapa pertanyaan yang berhubungan dengan nyeri yang di alami pasien

    a. Current pain medication( pengobatan yang diambil saat ini )

    Question : Did you take( any medicine / anything ) for your pain

    How many do you take?

    b. Where is the pain ?(lokasi nyeri )


    Instruction; show me where the pain is?
    Point at the pain you feel

    c. Describe because of pain, if known (penyebab nyeri jika


    diketahui ) Question; Do you know the cause of your pain ?
    Why do you feel that ?

    d. How does a pain feel to thepatient?(seperti apa nyeri yang dialami oleh
    pasien ?
    Question : what is the pain like ?

    Is it sharp, dull, stabbing, aching ?

    e. Frequency of pain ( berapa sering nyeri itu muncul )


    Question: How often doyou feel the pain ?
    B. Fillingin Medical report/ Mengisi medical report pasien

    Ketika pasien baru datang bidan perlu mengambil personal data untuk mengisi medical
    report tentang status kesehatan pasien
    Beberapa data yang diperlukan khususnya pada pasien dengan kasus kebidanan

    Adalahsebagai berikut;

    Data Cara
    Bertanya
    1. Name What is your name?
    2. Age When were you born?/ Your date of birth please.
    What is your nationality? What is your race?
    3. Nationality&Race

    4. Address&telephone
    What is your address and telephone number?
    5. Religion What is your religion?

    6. Marital status Are you married?

    7. Occupation What is your occupational?

    Chief complaint/ keluhan utama What’s your problem? / what’s your chief
    complaint?

    History of present illnes relates to the


    chief complain or problem
    1. Date and time onset When did the complaint start?
    Where is the location? Or show me where the
    2. Specific location
    location is?
    3. Type of pain or discomfort
    How does the pain feel or what is the pain like?

    Menstrual history

    1. Age at menarche When did you get the first time period?
    How many days usually it happened ?
    2. Duration

    3. Last menstrual period, When did you have your last menstrual period?
    duration and amount
    4. Dysmenorrhoea Is there any problem during period like
    Dysmenorrhoea or premenstrual syndrome?

    Obstetric history

    1. Gravida/ Para
    How many children do you have?
    2. Each pregnancy How many times do you experience of pregnancy?

    a. Date oftermination:
    When was your previous baby born?
    b. Weeks gestation:
    How many weeks was your previous pregnancy?
    c. Placeof delivery Where were you delivery our previous baby?

    d. Any problem during


    pregnancy, labour and Did you have any problem for your previous

    postpartum period? pregnancy, labour and postpartum period?

    e. Weightof babybirth;
    How many kilos was your previous baby born?
    f. Sexof baby:
    Is it a boy or a girl?
    g.Any complication Status of Were there any complications for your previous
    infant at birth: baby born?
    i. Present status of infant: How is your child now?
    Contraceptive history
    Present contraceptive method

    a. Type
    What type of contraceptive did you use before?
    b. Side effect Are there any side effects?

    c. Length of time using this How long did you use this method of contraceptive?
    method
    TUGA
    S

    Carilah1kasusditempatandapraktek,lakukaninterviewpadapasienandatersebut

    dan isikandalammedical reportpasien

    Tuliskanhasil interviewandadalambahasaInggris.

    RANGKUMAN
    Setelahmempelajari kegiatanbelajar2maka dapatdiambil kesimpulanbahwabidanharus
    mampuberkomunikasidenganpasienkhususnyaketikabidan mempunyai pasienbaru.
    Beberapapertanyaanyangberhubungandenganpasienbaru khususnyauntuk kasus
    kebidanantelahdipelajari dancarapengisianmedicalreportakan kita praktekkansebagai
    latihan.Sekarang marilah kita lanjutkanpada kegiatanbelajarselanjutnyayaitugiving
    instruction.

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