EMERGENCY MEDICAL TEAM MEDICAL RECORD (MDS+)

MDS - Check all that apply Date 10 / April / 2021 (dd/mm/yyyy)

_____1____□ Month √ Year ID 00010
Age
□<1, √1-4, □5-17, □18-64, □65- An.10 (nickname)
1 □ Male Name
Sex 2 √ Female non-preg.
3 □ Female pregnant Tirtoyudo Kepatihan Malang Selatan
latan
Present
Address

2/3TypeEMTatcareRequi
4 □ Major head / spine injury

re
Measles □Y □N □ Unknown

5 □ Major torso injury Breast-feed □Y √N □ Unknown Arm circumference(<5yo) cm

Trauma

6 □ Major Extremely Injury

Vaccination
7 □ Moderate injury EMT Type 1 capable Tetanus □Y □N √Unknown
8 □ Minor injury EMT Type 1 mobile capable Allergy □ Y（Drug / Food / Other ） □ N √Unknown

9 □ Acute respiratory infection Past History □ Y（HT / DM / BA / Other ） □ N √Unknown

10 □ Acute watery diarrhea Medication □ Y（HT / DM / BA / Other ） □ N √ Unknown
11 □ Acute bloody diarrhea Sesak nafas karena memiliki penyakit ISPA
Infectious disease

12 □ Acute jaundice syndrome Chief complaints

13 □ Suspected measles
14 □ Suspected meningitis BT ℃ BP / mmHg

15 □ Suspected tetanus Vital signs PR / min RR / min

Health events

16 □ Acute flaccid paralysis Wt. Kg Ht. cm

17 □ Acute haemorrhagic fever History of

18 □ Fever of unknown origin Present illness
typhoid fever
Additiona

19 √
20 □ Demam, lemas, kelelahan,
pasien kurang nafsu makan
□
l

21
22 □
Em

□ Surgical emergency (Non-trauma)

rg.

23
24 □ Medical emergency (Non-infectious)
25 □ Skin disease
26 □ Acute mental health problem
Other key
diseases

27 □ Obstetric complications
28 □ Severe Acute Malnutrition (SAM) *
29 □ Other diagnosis, not specified above

30 □ Major procedure (excluding MDS31)

31 □ Limb amputation excluding digits *
32 □ Minor surgical procedure
□ Normal Vaginal Delivery (NVD)
Procedure

33
34 □ Caesarean section
Outcome

35 □ Obstetrics others
36 □ Discharge without medical follow-up Diagnosis
Demam tifus
37 □ Discharge with medical follow-up
Outcome
Procedure &

38 □ Discharge against medical advice

39 □ Referral
40 □ Admission Drug Name / Dose
41 □ Dead on arrival
42 □ Death within facility *
43 □ Requiring long term rehabilitation *

44 □ Directly related to event

Relati

45 □ Indirectly related to event Staff Signature Reception Doctor MDS Nurse

on

46 □ Not related to event (Dr.)

47 □ Vulnerable child *
Protection

48 □ Vulnerable adult * Drug Examination Data Input

context

49 □ Sexual Gender Based Violence (SGBV) *

50 □ Violence (non-SGBV) *

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