MEDICAL REPORT
B. Filling in Medical report / Mengisi medical report pasien
Ketika pasien baru datang bidan perlu mengambil personal data untuk mengisi
medical report tentang status kesehatan pasien.
Beberapa data yang diperlukan khususnya pada pasien dengan kasus kebidanan
adalah sebagai berikut:
Data Cara Bertanya
1. Name 1. What is your name?
2. Age 2. When were you born?/ Your date of birth please
3. Race 3. What is your race ?
4. Address & telephone 4. What is your address and telephone number ?
5. Religion 5. What is your religion?
6. Occupation 6. What is your occupational? Housewife (IRT)
Chief complaint / keluhan utama 1. What’s your problem?
2. What’s your chief complaint?
History of present illnes relates to the chief
complain or problem
1. Date and time onset 1. When did the complaint start?
it was started at 2 weeks ago
2. Specific location 2. Where is the location?
Or ( show me where the location is)?
3. Type of pain or discomfort 3. what is the pain like?
Menstrual history
1. Age at menarche 1. When did you get the first time period?
2. Duration 2. How many days usually it happened ?
3. Last menstrual period, duration and 3. When did you have your last menstrual period?
amount
4. Is there any problem during period like
4. Dysmenorrhoea dysmenorrhoea or premenstrual syndrome?
Obstetric history
1. How many weeks was your first pregnancy ?
1. Gravida ?
2. Each pregnancy ? 2. When was your first baby born?
a. Date of termination : a. How many weeks was your first pregnancy ?
b. Weeks gestation: b. Where were you deliver your first baby ?
c. Place of delivery: c. Did you have any problem for your?
d. Any problem during pregnancy, d. first pregnancy, labour and postpartum
labour and postpartum period? period?
e. Weight of baby birth; e. How many kilos was your first baby born?
f. Sex of baby: f. Is it a boy or a girl?
g. Any complication : g. Were there any complications for your
first baby born?
h. Present status of infant: h. How is your child now?
Contraceptive history Present
contraceptive method
a. What type of contraceptive did you use before?
a. Type
b. Are There any side effects?
b. Side effect
c. Length of time using this method
c. How long did you use this method of
contraceptiv
1. Gravida/ Para
2. Each pregnancy
a. Date of termination:
b. Weeks gestation:
c. Place of delivery
d. Any problem during pregnancy, labour and postpartum period?
e. Weight of baby birth;
f. Sex of baby:
g. Any complication :
h. Present status of infant:
MEDICAL REPORT
HOW TO ASK HOW TO ANSWER
1. What is your name? 1. My name is miss, NOVITA SAFITRI
2. Your date of birth please ? 2. My birth date ,kolaka 09 Novenber 1986
( kolaka, nine November one thousand nine
hundred eighty-six)
3. What is your race ? 3. My tribe is tolaki
4. What is your address and telephone number ? 4. My address konawe south and my phone
namber
082325492240( empty,eigth,two,three,two,fiv
e,four,nine,
5. What is your religion? Twenty-two forty)
6. What is your occupational? Housewife (IRT) 5. My religion is islam
6. My job is civil servant
Chief complaint / keluhan utama
1. What’s your chief complaint?
1. My. Main complaint is pain in the stomach
History of present illnes relates to the chief
complain or problem
1. When did the complaint start?it was started at 2
weeks ago 1. My complaint Appeared since two weeks ago
2. Where is the location? Or ( show me where
the location is)? 2. At the waist
3. what is the pain like?
3. The pain is like aches and cramps
Menstrual history
1. When did you get the first time period? 1. First menstrual period date 20 september
2021( twenty September two thousand twenty-
one)
2. How many days usually it happened ?
2. Usually there are many menstrual period and
regular
3. When did you have your last menstrual period?
3. I have had may period since I was 18 tahun
4. Is there any problem during ( eighteen years)
period like dysmenorrhoea or
premenstrual syndrome? 4. There is not any
Obstetric history
1. How many children do you have? 1. I have two children
2. When was your first baby born? 2. My first child was bron date eighteen
April two thousand eleven ( 18 April
2011)
3. How many weeks was your first 3. Thirty-nine weeks
pregnancy ?
4. Where were you deliver your 4. At the health center Amondo
first baby ?
5. Did you have any problem for 5. There is not any
your first pregnancy, labour and
postpartum period?
6. How many kilos was your first baby 6. Two hundred fifty furious
born?
7. Is it a boy or a girl? 7. Woman
8. Were there any complications for 8. There is not any
your first baby born?
9. How is your child now? 9. Praise be to Allah I’m healthy
Contraceptive history Present
contraceptive method
1. What type of contraceptive did you use 1. IUD
before?
2. Are There any side effects? 2. Yes, pain in the waist
3. How long did you use this method of 3. Five Years
contraceptiv
MEDICAL REPORT
HOW TO ASK
1. What is your name?
2. Your date of birth please ?
3. What is your race ?
4. What is your address and telephone number ?
5. What is your religion?
6. What is your occupational? Housewife (IRT)
Chief complaint / keluhan utama
1. What’s your chief complaint?
History of present illnes relates to the chief complain or problem
1. When did the complaint start?
2. Where is the location? Or ( show me where the location is)?
3. what is the pain like?
Menstrual history
1. When did you get the first time period?
2. How many days usually it happened ?
3. When did you have your last menstrual period?
4. Is there any problem during period like dysmenorrhoea or premenstrual syndrome?
Obstetric history
1. How many children do you have?
2. When was your first baby born?
3. How many weeks was your first pregnancy ?
4. Where were you deliver your first baby ?
5. Did you have any problem for your first pregnancy, labour and
postpartum period?
6. How many kilos was your first baby born?
7. Is it a boy or a girl?
8. Were there any complications for your first baby born?
9. How is your child now?
Contraceptive history Present contraceptive method
1. What type of contraceptive did you use before?
2. Are There any side effects?
3. How long did you use this method of contraceptive?
MEDICAL REPORT
HOW TO ANSWER
1. My name is miss, NOVITA SAFITRI
2. My birth date ,kolaka 09 Novenber 1986
( kolaka, nine November one thousand nine hundred eighty-six)
3. My tribe is tolaki
4. My address konawe south and my phone namber
082325492240( empty,eigth,two,three,two,five,four,nine, Twenty-two forty)
5. My religion is islam
6. My job is civil servant
Chief complaint / keluhan utama
1. My. Main complaint is pain in the stomach
History of present illnes relates to the chief complain or problem
1. My complaint Appeared since two weeks ago
2. At the waist
3. The pain is like aches and cramps
Menstrual history
1. First menstrual period date 20 september 2021( twenty September two thousand
twenty-one)
2. Usually there are many menstrual period and regular
3. I have had may period since I was 18 tahun ( eighteen years)
4. There is not any
Obstetric history
1. I have two children
2. My first child was bron date eighteen April two thousand eleven ( 18 April 2011)
3. Thirty-nine weeks
4. At the health center Amondo
5. There is not any
6. Two hundred fifty furious
7. Woman
8. There is not any
9. Praise be to Allah I’m healthy
Contraceptive history Present contraceptive method
1. IUD
2. Yes, pain in the waist
3. Five Years
MEDICAL REPORT
B. Filling in Medical report / Mengisi medical report pasien
Ketika pasien baru datang bidan perlu mengambil personal data untuk mengisi
medical report tentang status kesehatan pasien.
Beberapa data yang diperlukan khususnya pada pasien dengan kasus kebidanan
adalah sebagai berikut:
Data Cara
Bertanya
1. Name : Novita safitri What is your name?
2. Age : 33 years old When were you born?/ Your date of birth
3. Race : Tolaki tribe please
4. Address & telephone : Konawe south and my phone What is your race ?
namber 082325492240
What is your address and telephone number ?
5. Religion : Muslim
What is your religion?
6. Occupation : Civil servant
What is your occupational? Housewife (IRT)
Chief complaint : Pain in the stomach What’s your chief complaint?
History of present illnes relates to the chief complain or
problem
a. Date and time onset : date 18 and 2 weeks ago When did the complaint start?
b. Specific location : in the center Where is the location? Or ( show me where
the location is)?
c. Type of pain or discomfort : Pain and cramps what is the pain like?
Menstrual history
a. Age at menarche : 18 years When did you get the first timeperiod?
b. Duration : 1 weeks How many days usually it happened ?
c. Last menstrual period, duration and amount : date 20 When did you have your last menstrual period?
September 2021 , 1 weeks and many
Is there any problem during period
d. Dysmenorrhoea : not any like dysmenorrhoea or premenstrual syndrome?
Obstetric history
How many weeks was your first pregnancy ?
1. Gravida : G2 P1 A0
2. Each pregnancy ? When was your first baby born?
i. Date of termination : 11 juli 2020 i. How many weeks was your first pregnancy ?
j. Weeks gestation : 39 weeks j. Where were you deliver your first baby ?
k. Place of delivery : not any k. Did you have any problem for your?
l. Any problem during pregnancy, labour and l. first pregnancy, labour and postpartum
postpartum period : not any period?
m. Weight of baby birth : 2500 gram m. How many kilos was your first baby born?
n. Sex of baby : Woman n. Is it a boy or a girl?
o. Any complication : Not any o. Were there any complications for your
first baby born?
p. Present status of infant : healthy p. How is your child now?
Contraceptive history Present
contraceptive method
d. What type of contraceptive did you use before?
a. Type : IUD
e. Are There any side effects?
b. Side effect : Pain in the waist
c. Length of time using this method : 5 years
f. How long did you use this method of
contraceptiv
