PAPER

EXPRESSION OF ANAMNESIS

Disusun Oleh :

Kelompok 6

1. Dewi Yuni Anggraini (S16012)

2. Dian Fatmawati (S16013)

3. Husadaning Panggalih (

4. Iin Sekarsari (

5. Marditya Ahmad Nugroho (

6. Maya Puji Astuti (S16039)

7. Rara Suci Ramadhan (

8. Rika Nilamsari (S16051)

9. Vika Septia Nur Annisa (S16062)

PROGRAM STUDI SARJANA KEPERAWATAN

STIKES KUSUMA HUSADA SURAKARTA

2019
 PART I

BACKGROUND

History is one important part in determining the diagnosis and patient therapy.
Success in extracting patient information has a role to play 75% to determine
accuracy in diagnosis, anamnesa is performed for know the patient's identity,
patient complaints, current disease history, disease history first, family history,
and treatment history. In the doctor-patient interaction, the initial meeting is the
foundation success of the next stage of the relationship. How to say hello to
patients and others in the examination room will affect comfort patient. After the
doctor-patient relationship starts, a doctor will be easier get information from
patients. Some characteristics of a successful doctor-patient relationship, the
patient feels comfortable expressing the complaint he is experiencing, the patient
will articulate the history of the disease openly and begin to build feelings trust
between doctor-patient. Sometimes patients do not express complaints or specific
problem, they just want to check their blood pressure or do routine inspection.
Some patients say that they just want to physical examination, but actually, they
feel less comfortable to convey the real problem.

General Purpose

Know and understand about the contents of medical records

►Know and understand the contents of informed consent

►Know and understand the purpose of the medic record

► Know and understand the purpose of informed consent

►Know and understand the medical medico aspects of medical records

►Know and understand the contents of the history

► identity column Know and understand the procedures for history taking
Special Purpose

Know and understand good and correct communication

►Know and understand the principles of medical ethics

►Know and understand the types, elements and sanctions of the medical records
►Know and understand history taking (sequence, benefits, history of illness

►past,presenthistory,familyhistory)
 PART II

A. Definition

Anamnesis is usually done in the fiend of health and psychology. It can be

done by a doctor to the patient, a nurse to the patient, and a psychologist to
their clients.

Anamnesis is recollection, a medical or psychiatric patient case history,

partycularly using the patient’s recollections. Anamnesis is the act of
remembering, the medical or developmental history of a patient.

Anamnesis is signs/ symptoms of the patient, allergies, medications, past

medical history, last oral intake, events leading to this injury of illnes,
immunization, travelling into the category chief complaints, history of present
illnes, or past health history.

B. Purpose

The objectives of anamnesis are :

1. Establish relationship between a doctor and the patient

2. Explore medical information

C. Expression of anamnesis

1. Chief complaints

Sign/ symptoms of the patient

a. “How are you feeling?”

 b. “Describe what it feels like.”

c. “How long have you been feeling this way”

2. History of present illnes

Past medical history

a. “what kinds of things were going on before this happened”

b. “how did it start”

3. Past health history

Immunization

a. “have you ever got immunizations?”

b. “what kind of immunizations have you taken” “.....Are you they

complete?”

c. “have you got complete immunizations?”

4. Allergies

a. “Are you allergic to a certain food or medication?”

b. “what are you allergic to?”

c. “Do you have any allergies?”

Medications

a. “what medications do you take?”

b. “what other medications are you taking?”

c. “What medications are you supposed to be taking, but aren’t?”

d. “What medications are you taking only if they are needed?”

Events leading to the injury or illnes

a. “have you ever had medical problems or physical injuries?”

b. “what medical problems or physical have you had, and when did you
have them? ”

Last oral intake

a. “What was the last thing you drank or ate?” “...and when did you drink
or eat it?”

Travelling

a. “where did you have a foreign/ local travel within 6 months?”

 PART III

Conclusion Anamnesis

At the end of the history a doctor must be able to draw conclusions from the
history which is conducted. The conclusion is in the form of an estimated
diagnosis that can be single diagnosis or differential diagnosis of several diseases.
That conclusion must be made logical and in accordance with the main complaint
of the patient. When you see a case which is difficult with many complaints that
cannot be concluded, then try to make a list of problems or patient complaints.
The list can then be used to guide a physical examination or examination support
that will be implemented, so that eventually one can be made more targeted work
diagnosis.
 REFERENCES

Hand out by mrs tika

http://prasko17.blogspot.com/2015/02/definition-and-purpose-of-
anamnesis.html?m=1

https://dokumen.tips/documents/133109716-makalah-
anamnesa.html