Nama : Achmad Tasrif Dwi Kurniawan

NIM : P3.73.20.2.18.001
‘Puspa Kencana’ Hospital Admission Form
(Video Pertama)
Surname: Beamer First name: Tracy
Age: 51 sex: Female Marital status: Married
ID: ID Number:
Religion: ER religion Methodist Ethnicity:
Address:

Phone number:
Occupation: Warehous manager of paul reed smith guitar
Legal next of kin: Dr. Paula
Present Condition : physical forward
Past medical history : astma, liver disease, add plastic surgery over lip
Medication : she consume ventolin and clarion
Other

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OBSERVATION CHART
Admission Observation
Full Name : Tracy Beamer
Date : 23/7/2020
Preferred Name : Tracy
BP T
DOB : Augst 25th 1969
P Wt
GP : Dr. Paulip
RR O2 SATS
Nurse : Ns. Sarah
Hosp. No : 002
‘Puspa Kencana’ Hospital Admission Form
(Video Dua)
Surname: Mayhid First name: Susi
Age: 26 sex: Female Marital status: Maried
ID: ID Number:
Religion: Ethnicity:
Address:

Phone number:
Occupation:
Legal next of kin:
Present Condition : For a Chest X-Ray
Past medical history : had a pneumonia two year ago, operation history (appendix) when 14

years old,
Medication : take aspirint everday for her arthritis, she had allergic to nuts
Other

_____________________________________________________________________

OBSERVATION CHART
Admission Observation
Full Name : Susi Mayhid
Date : 23/7/2020
Preferred Name : Susi
BP 110/80 mmHg T 370C
DOB : July, 18 1994
P 80x/mnt Wt 65 Kg
GP :
RR 22x/mnt O2 SATS 95%
Nurse : Ns. Achmad
Hosp. No : 003