ENGLISH COURSE ASSIGNMENTS

Arranged By :
Name : Huswatun Hasanah
NIM : 036 STYC 17

YAYASAN RUMAH SAKIT ISLAM NUSA TENGGARA BARAT

SEKOLAH TINGGI ILMU KESEHATAN YARSI MATARAM

PROGRAM STUDI ILMU KEPERAWATAN JENJANG S1

MATARAM

2020
1. Search and explain the patients medical records in English.

. Based on REGULATION OF THE MINISTER OF HEALTH OF THE

REPUBLIC OF INDONESIA NUMBER 269 / MENKES / PER / III / 2008
CONCERNING MEDICAL RECORDS Article 3, namely:

1. The contents of the medical record for outpatients in health care facilities
at least contain :
a. Patient identity
b. Date and time
c. Anamnesis results, including at least complaints and history of the
disease
d. Results of physical examination and medical support
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Other services that have been provided to patients
i. For dental case patients equipped with a clinical odontogram
j. Approval of actions if needed
2. The contents of the medical record for inpatients and one-day care at least
contain :
a. Patient identity
b. Date and time
c. Anamnesis results, including at least complaints and history of the
disease
d. Results of physical examination and medical support
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Approval of actions if needed
i. Clinical observation records and treatment results.
j. Return summary (discharge summary)
k. Names and signatures of doctors, dentists or certain health
professionals who provide health services
 l. Other services provided by certain health workers
m. For dental case patients equipped with a clinical odontogram.
3. The contents of the medical record for emergency patients include at least:
a. Patient identity
b. Conditions when the patient arrives at a health care facility
c. The patient's introductory identity
d. Date and time
e. Anamnesis results, including at least complaints and history of the
disease
f. Results of physical examination and medical support
g. Diagnosis
h. Treatment and / or action
i. Summary of the patient's condition before leaving the emergency
services and follow-up plans
j. Names and signatures of doctors, dentists or certain health
professionals who provide health services
k. Means of transportation used for patients who will be transferred to
other health care facilities
l. Other services that have been provided to patients