Admission Form for Patients

Type of admission

x
Out-patient x
In-patient Out-patient day clinic (partial in-patient)
x x
x
Penyejuk Clinic x July 8, 2018
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x x ………………………………………
x x CLINIC
NOTIFICATION BY WHICH ADMISSION/TREATMENT DATE
n n
x x
s s
General Details
n n
c c
Personal Details
Maulana Yusuf Ucup
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SURNAME FIRST NAME MAIDEN NAME

March 9, 1989 Aceh/Takengon

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DATE OF BIRTH GENDER Female Male HOMETOWN/CANTON

Police Indonesia Indonesian

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OCCUPATION LANGUAGE NATIONALITY

RELIGION/RELIGIOUS DENOMINATION Moslem Catholic Other:…………

MARITAL STATUS Single Married Divorced

Domicile/residential address for tax purposes

Jl. Sepakat 3 25171/Tabing Pasir Putih

…………………………. ………………………… ………………………….
STREET/NUMBER POSTCODE/TOWN CANTON/STATE

(0751)482427 082354667898 rizkiperdana1@gmail.com

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TELEPHONE MOBILE E-MAIL
Contact person

Civil partner Spouse Parents/parent Sibling Other: …………..

Amara Riv 082367443567

…………………………. …………………………. ………………………….
SURNAME FIRST NAME TELEPHONE/MOBILE

Jl. Sepakat 3 25171/Tabing Pasir Putih

…………………………. …………………………. ………………………….
STREET/NUMBER POSTCODE/TOWN CANTON/STATE

Patient History

Past Medical History

2016: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids.
2017: Bunionectomy

Medical History
2017: Diagnosed with Hypertension and began on unknown medication. Stopped after 6 months
because of drowsiness.
2018: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. He
describes no history of cancer, lung disease or previous heart disease.

Family History
Mother : 55, alive and well.
Father : 54, deceased, heart attack. No brothers or sisters. There is a positive family history of
hypertension, but no diabetes, or cancer.

Habit
Alcohol use : 1 or 2 beers each weekend; 1 glass of wine once a week with dinner.
Cigarette use : 6 cigarette each day.
 Standard Operating Procedure: Measuring Respiratory

Definition Calculate the number of breathing in 1 minute

Goals
1. To know the frequency of rhythm and depth
of breathing
2. To assess the ability of respiratory function

Policy Improve the quality of nursing service

Procedures 1.) Preparation tool

1. Wristwatch
2. Books, stationery

2) How to calculate breathing

1. Washing hands
2. Explain to the patient the purpose and
procedure of the action to be performed
3. Set the patient's position ie the patient
according to his condition
4. Place the nurse's hand on the patient's
stomach
5. Calculate breathing time of inspiration and
expiration on chest or abdomen for 1 minute
- Observe the depth of breathing
- Observe the rhythm of breathing
- Observe the sound of breathing
6. Record the number, depth, rhythm and
 breathing sounds
7. Washing hands

RELATED UNIT 1. Space Treatment

2. Outpatient polyclinic
3. IGD