UNIT 5

MEDICAL RECORD

In this unit student is expected to be

able to ask and describe someone
personal information for a medical
record

Presentation

Have you been here before? Or have you got a medical card? These are probably the
first questions that a hospital staff will ask. The question is important for the
administration staff whether or not he/she should ask and record again personal data
and the illness of the patients. This record is called a medical record. It is certainly
important for the administration staff. Do you think it is important for a doctor, too?

Here is the sample of a medical record. Read and learn the form below!

MEDICAL RECORD
UJUNGBERUNG GENERAL HOSPITAL

Personal Information

1. Name of the patient : Syamsudin Bahri

2. Sex : Male/Female
3. Place & Date of birth : Padang, 23 March 1978
4. Home Address : Jl. Kiaracondong 412 Bandung
5. Telephone : 022 736815
6. Profession : Businessman
7. Office Address : Jl. Surapati No. 432 Bandung
8. Telephone : 022 413776
9. Marital Status : Married
10. Name of Spouse : Shinta Dewi
11. Blood Group : O
12. Height : 160 m
13. Weight : 49 kg

Patients Condition Past IIlness

Ailment : Backache TB : Yes/No
Blood Pressure: 140/90 Typhoid : Yes/No
Heart Rate : 70/minute Hepatitis : Yes/No
Body Temperature: 39 C Diabetes : Yes/No
Sign : red-eyes, reddish urine Malaria : Yes/No
Symptoms : pain on the back, headache, fever Dengue Fever : Yes/No

Important points to note in Medical Record:

 Pre-existing conditions: If you have a medical condition that would affect the way you
are treated in a medical emergency, you should make sure to include this information in a
prominent place on the form. Examples of these types of conditions include diabetes,
heart conditions or other chronic ailments that need to be known by any medical
professional treating you in an emergency.
 Allergies: There are some medications that might be used in an emergency that can be
very dangerous for a person with an allergy to the medication. For your own protection, it
is a good idea to list any medications that you have an allergy to or that you have
experienced an adverse reaction from. This information will be invaluable to medical
professionals treating you.
 Contact information for your primary physician: Emergency medical personnel will
want to consult with your primary physician when the opportunity arises. Be sure that the
contact phone number you list on the form is current. You should also include contact
information for an emergency contact, and if the form is for a minor you should include
parent or guardian contact information.
 Medications: Include a complete list of any medications you routinely take, including
any over-the-counter medications and herbal supplements. You want to make sure that
any emergency medications that are administered to you do not have contraindications
with the medicines already in your system

Useful expressions

 Asking Personal Information

What is your name?

When were you born? / How old are you, sir/mam?
Where do you live? / Do you live with your parent?
What is your phone number?
What do you do, sir/mam?
Are you married? What is your wife/husband’s name?

 Finding the medical history

To have a better diagnosis, a nurse or a doctor commonly asks several questions

about the patients’ illness. The questions are as follows:

What‘s the problem?

What is the matter with you? How long have you had this?
What do you feel? Have you ever had this before?
What happened? Have you had any allergy on food or particular
drug?
Have you had a routine check up?

Practice

1. Filling out the Medical Record

Interview your partner who plays a role as a patient and fill out the form below!

MEDICAL RECORD
UJUNGBERUNG GENERAL HOSPITAL
Personal Information
1. Name of the patient :
2. Sex : Male/Female
3. Place & Date of birth :
4. Home Address :
5. Telephone :
6. Profession :
7. Office Address :
8. Telephone :
9. Marital Status : Married/Single
10. Name of Spouse :
11. Blood Group :
12. Height :
13. Weight :
 Patients Condition Past Illness
Ailment : TB : Yes/No
Blood Pressure: Typhoid : Yes/No
Heart Rate : Hepatitis : Yes/No
Body Temperature: Diabetes : Yes/No
Sign : Malaria : Yes/No
Symptoms : Dengue Fever : Yes/No

2. Reporting the medical record.

Read again the patient’s medical record and tell only the important thing of it to
your partner who plays a role as a doctor!

You can start like this:

Excuse me, Doc! I want to tell you about a new patient in …. room.
His/her name is …