REPORTING AND DOCUMENTING

Dosen Pembimbing : Eka Wulandari, SPd, MPd

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEPERAWATAN

PRODI DIII KEPERAWATAN MALANG

TAHUN 2018
TASK 1

Ny. Sarah merasakan lenganya terasa sakit dan tidak bisa digerakkan. Akhirnya, Ny.
Sarah pergi ke Rumah Sakit Rasa Sayange.

Mrs. Sarah : good morning nurse, can you help me?

Nurse : of course, sit down please mom. Okey, for the first, can you mention your
name and your birth date?

Mrs. Sarah : my name Sarah Robet, my birth date is 2 January 1984 in new Orleans.

Nurse : apakah anda sudah menikah?

Mrs. Sarah : ya. Suami saya sedang bekerja dan tidak bisa menemani saya sekarang.

Nurse : oh okey mom. Apa keseharian anda sekarang mom?

Mrs. Sarah : saya mengajar di elementary school

Nurse : bolehkan saya meminta nomor wali anda? Untuk mengisi form consenst.

Mrs. Sarah : 01792793456

Nurse : okay thank you mom. what do you feel right now?

Mrs. Sarah : lengan sebelah kiri saya terasa sakit jika digerakkan sus.

Nurse : apakah di keluarga ibu memiliki riwayat penyakit?

Mrs. Sarah : yes, my father has heart disease.

Nurse : apakah ibu memiliki alergi. Like a seafood or any other nuts?

Mrs. Sarah : yes, saya alergi kacang sus. Jika saya memakan itu, tubuh saya terasa gata-
gatal.

Nurse : okay. Bisa ibu ceritakan kronologi kejadian sehingga lengan ibu menjadi
seperti ini?

Mrs. Sarah : kemarin saya jatuh di kamar mandi dan lengan saya terbentur lantai.

Nurse :
 TASK 2

A patient record form :

a. Surname : Nur Jannah

b. First name : Khofifah
c. Gender : Female
d. Date of Birth : 10/12/2000
e. Place of Birth : Pasuruan
f. Occupation : Student
g. Marital status : Single
h. Next of kin : Sister Tia
Contact no. : 081333444222
i. Smoking intake : n/a
j. Reason of admission : typhoid symptoms
k. Family history : hypertension (mother’s side)
l. Allergies : seafood

Role play

On a sunny day after school, miss Khofifah feel so sick, her head feel dizzy and her body
temperature is high. Then she go to the Rasa Sayange hospital. In the hospital…..

Miss Khofifah : Good afternoon, can you help me?

Nurse : of course, sit down please miss. Okay, for the first can you mention
your name and your date of birth?

Miss Khofifah : my name is Khofifah Nur Jannah. I was born in Pasuruan, 10

December 2000.

Nurse : are you married?

Miss Khofifah : not yet nurse, I’m single.

Nurse : oh okay miss. What your daily activities now ?

Miss Khofifah : I’m a student in Senior High School nurse.

Nurse : okey miss, can you tell me your next of kin and the telephone
number?

Miss Khofifah : yes nurse, her name is sister Tia and her telephone number is
081333444222.

Nurse : thank you miss. Can you tell your family history of disease?

Miss Khofifah : yes nurse, my mother has hypertension.

Nurse : do you have allergies miss?

Miss Khofifah : yes, I have allergic to seafood nurse.

Nurse : oh okay. What do you feel right now?

Miss Khofifah : I feel dizzy, my body temperature is high, and I vomit today.

Nurse : do you ever like that before?

Miss Khofifah : yes, I ever like this before when I’m in Junior High School. The
doctor said that I got thyphoid symptoms and can be cured after
taking medicine from the doctor.

Nurse : let me check your condision now.

Miss Khofifah : yes please

(check Khofifah’s vital sign)

Nurse : okay miss after I check your condition, possibility you get thyphoid
symptoms again. But I can’t confirm that before my examination data
can be submitted to the docter.

Miss Khofifah : yes nurse, then what should I do now?

Nurse : please wait a moment the doctor will check your condition too.

Miss Khofifah : yes nurse.

(fifteen minutes later…)

Nurse : this is the recipe, I hope you will be recovery soon.

Miss Khofifah : yes nurse, thank you

Nurse : you are welcome.