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    Tugas Praktek 5

    Uploaded by

    Muthiaa
    The document provides instructions for a student assignment on writing a patient's medical record. Students are asked to conduct a medical interview roleplay with a classmate, with one student portraying a nurse and the other a patient. The roleplay should include questions about the patient's identifying data, medical history, family history, social history, and review of systems. Students should then write up the information from the interview in a medical record. They are provided a sample patient case of a 43-year-old businesswoman, Mrs. Natalia, experiencing weight loss, fatigue, and gastrointestinal issues to base the roleplay and medical record on.

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    Download as DOCX, PDF, TXT or read online from Scribd

    Tugas Praktek 5

    Uploaded by

    Muthiaa
    224 views2 pages
    The document provides instructions for a student assignment on writing a patient's medical record. Students are asked to conduct a medical interview roleplay with a classmate, with one student portraying a nurse and the other a patient. The roleplay should include questions about the patient's identifying data, medical history, family history, social history, and review of systems. Students should then write up the information from the interview in a medical record. They are provided a sample patient case of a 43-year-old businesswoman, Mrs. Natalia, experiencing weight loss, fatigue, and gastrointestinal issues to base the roleplay and medical record on.

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    2. TUGAS PRAKTEK 5

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    The document provides instructions for a student assignment on writing a patient's medical record. Students are asked to conduct a medical interview roleplay with a classmate, with one student portraying a nurse and the other a patient. The roleplay should include questions about the patient's identifying data, medical history, family history, social history, and review of systems. Students should then write up the information from the interview in a medical record. They are provided a sample patient case of a 43-year-old businesswoman, Mrs. Natalia, experiencing weight loss, fatigue, and gastrointestinal issues to base the roleplay and medical record on.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    224 views2 pages

    Tugas Praktek 5

    Uploaded by

    Muthiaa
    The document provides instructions for a student assignment on writing a patient's medical record. Students are asked to conduct a medical interview roleplay with a classmate, with one student portraying a nurse and the other a patient. The roleplay should include questions about the patient's identifying data, medical history, family history, social history, and review of systems. Students should then write up the information from the interview in a medical record. They are provided a sample patient case of a 43-year-old businesswoman, Mrs. Natalia, experiencing weight loss, fatigue, and gastrointestinal issues to base the roleplay and medical record on.

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    © All Rights Reserved
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    FIFTH PRACTICE ASSIGNMENT

    When you are going to write Patient’s Medical Record, you need to make medical interview
    to get the information about Subjective Data Patient. Start by making a dialog about asking Patient
    Medical History .Then write those informations you get in Medical Record.

    1. Make both a dialog and Written Medical Record.

    2. A dialog is about Medical interview between nurse and Patient. Then make it to Writtten
    Medical Record (hand writing). Write both Subjective and Objective Data of Patient in
    Medical Record.

    3. Make a dialog with your friend. So, it is a pair Work. Student as a nurse wears uniform.
    Student as a patient wears cloths freely.

    4. A dialog in the form of video. Make a video like your second practice video. (show
    yourselves in a video). Add also a text of your dialog in your video.

    4. The content of a dialog is about asking the following Questions below:


    ⚫ Identifying Data
    ⚫ Source/Reliability (Written in medical record)
    ⚫ Chief Complaint
    ⚫ History of Present Illness
    ⚫ Past Medical History
    ⚫ Family History
    ⚫ Patient Profile/Social History
    ⚫ Review of Systems

    5. One student up load a video, the other student upload Written Medical Record in google
    classroom.

    6. Make a dialog based on the case of Patient below:

    CASE OF PATIENT

    – The nurse interviews Ms. Theresia about her mother ‘s health. Her mother is Mrs.
    Natalia. She is a 43-years-old bussiness woman who lives with her only one daughter, She
    has a 10 year history of diabetes and hypertension, complains of anorexia for the past 3 to 4
    months, weight loss. She tires easily and take a nap each afternoon. She thinks this may
    well be related to her nerves since she has been depressed about her divorced. She feels
    nausea, vomiting, diarrhea, excess thirst, headache, dizziness, visual disturbance, and
    palpitations. Her Father has diabetes . Her Mother has hypertension. She has been living in
    Jakarta. Her childhood illnesses was chicken pox. Her adult illnesses was diabetes mellitus,
    type II, X 10 yearshypertension diagnosed 1991. she had allergies-sulfa (rash/hives). She
    wakes up at 5, makes breakfast and lunch, naps in the afternoon, makes dinner, and she and
    her daughter clean up together. She eats cereal and fruit for breakfast; sandwich or salad for
    lunch; rice, vegetable and meat or fish for dinner. She does not like snack.. She has never
    smoked. She drink one or two cocktails on weekends. She often takes anti-depressent
    medicine. She has never done exercise.She wears glasses and has a visual difficulty,
    inflammation or eye pain, double vision, or tearing. She has good hearing and no tinnitus or
    aural discharge. She has a cavity in her teeth. She gets a little hoarse sometimes.

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