Dialog Pengkajian Perawat Dan Pasien
Dialog Pengkajian Perawat Dan Pasien
Dialog Pengkajian Perawat Dan Pasien
Oleh
Nony Chintia (P17210171005)
Maria Ulfah (P17210171006)
KEMENTERIAN KESEHATAN
POLITEKNIK KESEHATAN MALANG
JURUSAN KEPERAWATAN
D-III KEPERAWATAN MALANG
November 2018
Reporting and Documenting
SAMPLE
A patient record form
- Surname : Robert
- First Name : Sarah
- Gender : Female
- Date of Birth (DOB) : 2/1/84
- Place of Birth : New Orleans
- Occupation : teacher
- Marital status : married
- Next of kin : father Ian
- Contact no. : 01792793456
- Smoking intake : n/a
- Reason for admission : suspected fractured arm
- Familiy history : heart disease (father’s side)
- Allergies : nuts
Task 1:
Create a dialog between a nurse and a patient based on the sample form above!
Answer :
Nurse : Hi, good morning. Sit down please Mrs, Can I help you?
Client : Good morning. I want to inspect my fracture
Nurse : Ok. I will help you. First, I need information about you. So, what’s
your surname?
Client : My surname is Robbert
Nurse : What’s your name?
Client : My name is Sarah.
Nurse : May I know place and date of your birth?
Client : Sure. I’m born in New Orleans, 02 January 1984
Nurse : What is your occupation?
Client : I am a teacher
Nurse : Do you have married?
Client : Yes, I have
Nurse : Can I get information for your next of kin?
Client : Yes, you can. His name is father Ian and the phone number is
01792793456
Nurse : Are you smoking?
Client : No, I am not a smoker
Nurse : Are you have family history disease?
Client : Yes, I have. My father have heart disease
Nurse : Do you have any allergies
Client : Yes, I have. I am allergic to nuts
Task 2 :
a. Choose one of your friend to be your partner. Student A as a nurse,
Student B as a patient
b. Create a dialog with your partner to complete patient record form as the
sample above
c. Practice the dialog in class
Answer :
During the day after going home from school, a child named Nony and his mother
with condition of his child who feels itchy itching. There is a small lump on the
part of his arm. Finally she brought to the jasmine hospital.
Nurse : Good afternoon, sit down please Ms. Can I help you?
Nony : I want to inspect my skin, because I feel itchy itching on the part of
my arm.
Nurse : Well, first I want to fill in your Biodata. Please answer my question
Nony : Okay Sus.
Nurse : May I know your name?
Nony : Nony Chintia
Nurse : Well, May I know place and date of your birth?
Nony : Sure. I’m born in Malang “polehan”, 11 March 2004
Nurse : What is your occupation or school education?
Nony : I’m a junior high school student
Nurse : What is your phone number?
Nony : 085xxxxxxxxx
Nurse : Okay thank you, may i know what you feel?
Nony : I felt a itchy itching on the part of my arm.
Nurse : When did you feel that itchy itching?
Nony : Since this morning i ate shrimp and chicken.
Nurse : How many servants you ate shrimp and chicken?
Nony : Only one portion Sus.
Nurse : Do you have family history disease?
Nony : Yes nurse, my mother have disease Allergic.
Nurse : Well, Do you have allergic of food or medicine?
Nony : No, i don’t have. This is the first time for me Sus.
Nurse : Okay Ms, please wait in the waiting room first and we’ll call in again for
further examination, get well soon.
Nony : Okay Sus, thank you.