Nama : Karina Chania dan Amalia Lenanda

Kelas/Prodi : 2B/D3 Keperawatan

TOPIC 4

GENERAL ASSESSMENT

Conversation

Nurse : Good Morning

Patient : Good Morning, Nurse

Nurse : How are you?

Patient : I’m Good

Nurse : Okay, I am Nurse Karina of Faletehan Serang. How can I call you?

Patient : You can call me Mrs. Amal

Nurse : Well, Mrs. Amal I need to collect your personal data. I’m going to ask you some questions.

Patient : Certainly, nurse.

Nurse : Could you tell me your complete name?

Patient : My name is Amalia Lenanda

Nurse : How old are you Mrs. Amal?

Patient : I’m 20 years old

Nurse : Are you married?

Patient : No, I’m single

Nurse : Where do you live?

Patient : I live in Serang at Kampung Baru

Nurse : Do you have any Mobile Phone number?

Patient : Yes, it’s 085282663799

Nurse : what’s your religion?

Patient : I’m moslem

Nurse : Do you have any health insurance?

Patient : Yes, I have health insurance.

Nurse : What is it?

Patient : My health insurance is BPJS, nurse.

Nurse : What is your occupation?

Patient : I’m a student

Nurse : Who is your next of kin?

Patient : My kin is Mrs. Siti Marina

Nurse : Do you have a doctor’s referral?

Patient : No, I don’t have.

Nurse : Okay, Why do you come to this hospital?

Patient : I want to check my condition.

(CURRENT HEALTH STATUS)

Nurse : Would you tell me about your condition?

Patient : I’m usually healthy, have usual cold, and have to take medicine for high blood pressure.

Nurse : Okay Mrs. Amal what do you feel now?

Patient : My throat is very painful, nurse.

Nurse : Okay, I want to check your throat now, please open your mouth Mrs. Amal?

Patient : How is it Nurse?

Nurse : Don’t be afraid Mrs. Amal. You will be fine.

Patient : Okay, Nurse.

(HEALTH HISTORY)

Nurse : Okay so might be for the next part of this interview is about you past issues just a few questions about
your past there is a great addition?

Patient : Yes

Nurse : Have you ever had measles or chicken pox?

Patient : No

Nurse : Have you ever been immunized against polio?

Patient : No

Nurse : Are you allergic to medicine or food? And are you taking any medications?

Patient : I’m not allergic to anything, I’m only taking some vitamins.

Nurse : Okay Mrs. Amal I have finish to asses your personal data. Now I will consultation with the doctor about
your condition

Patient : Thank you very much nurse

Nrse : Your welcome