Name : Lala

NIM : P174102210190
Class : 1A

Instruction!

1. Find 1 template of medical records form (it can be In English or Indonesian)

2. Describe the content in that medical records form into a paragraph (In English)

Answer!
 A medical record form is a piece of paper contains medical information. Includes
patient identity, physical examination, diagnosis, laboratory all actions and medical services
provided to patiens. Both inpatients, outpatients, and emergency patients.

On the medical record form sheet, the top part contains the medical record number
which serves to assign numbers to patients where one medical record number (admitting
number) is used for each outpatient, inpatient and emergency department which will be used
onward for each visit to a general hospital. In addition, there is also a summary of entry and
exit which serves as an explanation of how the patient was treated and recovered

The form also records whether the patient is a participant in health insurance or not.
There is also how to receive, whether IRJ, IRD, or TP2RI. As well as how to enter whether
sent by doctors, heatlh centers, other hospitals, other agencies, coming alone, police, etc.

The main thing in the medical record form includes the patient’s identity which
contains the full name, date of birth, gender, religion, complete address, mobile phone
number, and marital status. In addition, there is the name and address of the next of kin as
well as the name of the person in charge of payment.

In addition, this form also contains a medical summary containing the date of
admission, date of discharge, admission diagnosis, primary or final diagnosis, and secondary
diagnosis (complications). If the patient is being treated, there is the name of the ward, class,
section, period of treathment, and the diagnostic code number.

If you have a history of allergies, blood transfusions, blood type, all will be recorded on
the form. In addition, if the patient has had surgery, type of anesthesia, date of execution and
code number will be recorded in the form. Not only that, if the patient has an infection, the
type of infection and the cause of the infection will also be noted.

Also recorded in the medical record form, the number of immunizations obtained
during treatment at the hospital. And if his condition has improved, the patient is allowed to
go home. However, it will also be noted how the condition of the situation when discharged
form the hospital, whether recovered, have not recovered, died less than 48 hours or more
than 48 hours.

In addition, the method of leaving the hospital will also be recorded, whether it is
allowed to go home, run away from the hospital, change hospitals, be forced to leave or be
referred to another agency. At the end of the medical record form, there is the date of filling
out the form, the name of the treating doctor and also the signature of the treating doctor.