Kb 2 asking –filling in

Introduction to Midwifery Practice

Pusat Pendidikan dan Pelatihan Tenaga KesehatanBadan Pengembangan dan Pemberdayaan Sumber Daya Manusia

Jakarta 2015

Kh Endah Widhi Astuti

Australia Indonesia Partnership for Health System Strengthening(AIPHSS)

BAHASA INGGRISMODUL I

Semester 2

KEGIATAN BELAJAR 2ASKING – FILLING IN MEDICAL REPORT

Modul Pendidikan Jarak Jauh Pendidikan Tinggi Kesehatan

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KegiatanBelajar 2 Asking – Filling in Medical Report

Tujuan Pembelajaran Umum

Tujuan Pembelajaran Khusus

Setelah menyelesaikan kegiatan belajar 2, mahasiswa mampu membuat pertanyaan dan mengisi medical report pasien dengan benar

Setelah mempelajari kegiatan belajar 2 mahasiswa mampu:a. Mengajukan beberapa jenis pertanyaan untuk mendapatkan data awal pasienb. Mengisi medical report pasien dengan bertanya pada pasien

A. Asking question / bertanyaB. Filling in medical report / mengisi medical report pasien

Gambar: Filling Medical Report

Pokok-Pokok Materi

Modul Pendidikan Jarak Jauh Jenjang Diploma 3 Program Studi Kebidanan

3UraianMateri

A. Asking question

Midwife :GoodMorningMrsMaria.Ineedtofillamedicalreportaboutyour health status

Patient : SureMidwife : Your complete name ?Patient : Devi MariaMidwife : What is your complete address?Patient : Ir Sukarno , 38 .SurabayaMidwife : 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’tMidwife : Do you know the cause of pain ?Patient : I don’t knowMidwife : What’s the pain like ?Patient : It’s sharpMidwife : 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 .

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 ?

Carilah kata kata sulit dan temukan artinya dalam kamus.

Beberapa pertanyaan yang sering digunakan dalam keseharian bidana). Pertanyaan untuk mengetahui kondisi pasien misalnya sebagai berikut !


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b). Ekspresi pasien atau cara pasien menjawab tentang masalah kesehatan yang dihadapi:1. I have + ( a part of the body + ache )

(a toothache )(a headache)( a backache)

4. I experience + kinds of symptoms and physical problems( low back pain )(difficultbreathing)

2. I have ( a sore + parts of the body )( a sore arm)( a sore knee)

5.Isufferfrom+kindsofcertainillness( cancer )( constipation )

3. I have/ get + kind of physical problems( the measles)(theflu)( a fever )( a bad cough )

Carilah arti kata dari• Toothache :....................................• Backache :....................................• Headache :....................................• Soar arm :.....................................• Soar knee :.....................................

c). Beberapa pertanyaan yang berhubungan dengan nyeri yang dialami 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 feelc. Describe cause 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 the patient? ( 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 do you feel the pain ? Is it occasional, frequent or constant ?


5B. Filling in 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 adalah sebagai berikut;Data Cara Bertanya1. Name 2. Age 3. Nationality & Race4. Address & telephone 5. Religion 6. Marital status7. Occupation

Chief complaint / keluhan utama

History of present illnes relates to the chief complain or problem1. Date and time onset2. Specificlocation

3. Type of pain or discomfort

Menstrual history1. Age at menarche 2. Duration3. Last menstrual period, duration and

amount4. Dysmenorrhoea

Obstetric history1. Gravida/ Para 2. Each pregnancya. Date of termination:

b. Weeks gestation:c. Place of delivery d. Any problem during pregnancy,

labour and postpartum period? e. Weight of baby birth; f. Sex of baby:g. Any complication h. Status of infant

at birth: i. Present status of infant:

Contraceptive historyPresent contraceptive method

a. Type b. Sideeffectc. Length of time using this method

What is your name?When were you born? / Your date of birth please.What is your nationality? What is your race ?What is your address and telephone number ?What is your religion?Are you married?What is your occupational?

What’s your problem? / what’s your chief complaint?

When did the complaint start?Where is the location? Or show me where the location is?How does the pain feel or what is the pain like?

Whendidyougetthefirsttimeperiod?How many days usually it happened?When did you have your last menstrual period?

Is there any problem during period like dysmenorrhoea or premenstrual syndrome?How many children do you have? How many times do you experience of pregnancy? When was your previous baby born?How many weeks was your previous pregnancy?Where were you deliver your previous baby ?Did you have any problem for your previous pregnancy, labour and postpartum period?How many kilos was your previous baby born?Is it a boy or a girl?Were there any complications for your previous baby born?How is your child now?What type of contraceptive did you use before?Arethereanysideeffects?How long did you use this method of contraceptive?


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Rangkuman

EvaluasiFormatif

Carilah 1 kasus ditempat anda praktek, lakukan interview pada pasien anda tersebut dan isikan dalam medical report pasienTuliskan hasil interview anda dalam bahasa Inggris.

Setelah mempelajari kegiatan belajar 2 maka dapat diambil kesimpulan bahwa bidan harus mampu berkomunikasi dengan pasien khususnya ketika bidan mempunyai pasien baru. Beberapa pertanyaan yang berhubungan dengan pasien baru khususnya untuk kasus kebidanan telah di pelajari dan cara pengisian medical report akan kita praktekkan sebagai latihan. Sekarang marilah kita lanjutkan pada kegiatan belajar selanjutnya yaitu giving instruction.

CASEThe admission interview was conducted by Midwife Eka on july 10th 2013. The patient was Mrs Fatima, 35 years old, muslim, married, a teacher, Javanes. The address is nakulo st 26, Medan, her problem is contraction in uterus after working since 3 days ago. She has 1 son 3 years old, he was born on March, 5th, , He was healthy, at independent midwife, normal, term. His weight was 3000 gram. Now, Mrs Fatima is pregnant, her last menstrual period was on march 13th 2013. She had never used any contraceptive method. Menarche when she was 13 years old, never had problem, regular every month, normal.

Bacalah kasus diatas, pahami dan isikan data diatas dalam medical report pasien.

TugasMandiri


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Umpan Balik& Tindak Lanjut

Terdapat 28 point yang harus anda isikan dalam medical report form. Arti tingkatan penguasaan yang anda capai jika anda mampu mengisikan a. Antara 25-28 point benar atau 90% - 100% = baik sekalib. Antara 22 sd 24 point benar atau 80% - 89% = baikc. Antara 18 sd 21 point benar atau 70% - 79% = sedangd. Kurang 17 point yang benar atau < 69% = kurang

Kalau Anda mencapai tingkat penguasaan 80% ke atas, maka Anda dinyatakan telah menguasai Kegiatan Belajar 1, dan dapat meneruskan ke kegiatan belajar berikutnya. Tetapi kalau nilai Anda masih di bawah 75%, maka Anda harus mengulang kegiatan belajar 1 ini terutama bagian yang belum dikuasai atau belajar memahami kasus dalam bahasa Inggris.

Hak Cipta Kementrian Republik Indonesia Bekerjasama DenganAustralia Indonesia for Health System Strengthening (AIPHSS)

2015

Health & Medicine

Kb 2 asking –filling in