(All) Manual FT1 - 3.64 (ENG)

Intramuscular injection procedures training data recording form

Case Study No. 3

Patient No. ..........................

Age........years..........month Gender.......................... Vital Signs.......................................................................

Weight..................kg. Height...................cm. BMI = ...........................Date of birth........................................

Chief Complaint....................................................................................................................................................

..................................................................................................................................................................................

Present Illness …………………………………………………………………………………………………………………….....................

…………....................……………………………………………………………………………………………………………………………………..

Name of injecting drug.........................................................................................................................................

Injection type ampule VIAL

Method of injection intramuscular injection subcutaneous injection

intradermal injection intravenous injection

Position of injection……………………………………………………………………………………………………………………..........

Method of preparation of the drug…………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Caution

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Advice

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Next appointment Date ……………/……………/……………

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 97 | p a g e

Intramuscular injection procedures training data recording form

Case Study No. 4

Patient No. ..........................

Age........years..........month Gender.......................... Vital Signs.......................................................................

Weight..................kg. Height...................cm. BMI = ...........................Date of birth........................................

Chief Complaint....................................................................................................................................................

..................................................................................................................................................................................

Present Illness …………………………………………………………………………………………………………………….....................

…………....................……………………………………………………………………………………………………………………………………..

Name of injecting drug.........................................................................................................................................

Injection type ampule VIAL

Method of injection intramuscular injection subcutaneous injection

intradermal injection intravenous injection

Position of injection……………………………………………………………………………………………………………………..........

Method of preparation of the drug…………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Caution

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Advice

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Next appointment Date ……………/……………/……………

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 98 | p a g e

Intramuscular injection procedures training data recording form

Case Study No. 5

Patient No. ..........................

Age........years..........month Gender.......................... Vital Signs.......................................................................

Weight..................kg. Height...................cm. BMI = ...........................Date of birth........................................

Chief Complaint....................................................................................................................................................

..................................................................................................................................................................................

Present Illness …………………………………………………………………………………………………………………….....................

…………....................……………………………………………………………………………………………………………………………………..

Name of injecting drug.........................................................................................................................................

Injection type ampule VIAL

Method of injection intramuscular injection subcutaneous injection

intradermal injection intravenous injection

Position of injection……………………………………………………………………………………………………………………..........

Method of preparation of the drug…………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Caution

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Advice

………………………………………………………………………………………………………………………………………………………....……

………………………………………………………………………………………………………………………………………………………....……

Next appointment Date ……………/……………/……………

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 99 | p a g e

4.5 History taking, disease screening (2 cases)

Practice Recording Form History taking and screening at the emergency room
Case Study No. 1

Patient No......................
Age...........years................month Gender..........................Vital sign...................................................................
Body Weight................Kg. Height ...............Cm. BMI………………… Date of birth........................................
Chief Complaint.....................................................................................................................................................
Present Illness........................................…………………………………………………………………………………………………....
History Illness...........................................................................................................................................................
Personal History and behaviors..........................................................................................................................
Family History Illness.............................................................................................................................................
Menstrual history in female patients................................................................................................................
History in children under 6 years old

• Parturition  Normal  Abnormal (specify) ……………………...........………

Accoucheur................................................................................................................

• Growth  Normal
 Abnormal (specify) …………………................................................…...........………

• Feeding  Breast feeding
 Powdered milk
 Condensed milk (brand).........................
 supplement (brand).................

• Immunization

 BCG when (Date)................................................................

 Hepatitis B virus when (Date)................................................................

 DTP when (Date)................................................................

 OPV when (Date)................................................................

 MMR when (Date)................................................................

 LAJE when (Date)................................................................

 dT when (Date)................................................................

 Others when (Date)................................................................

Other information

....................................................................................................................................................................................

....................................................................................................................................................................................

....................................................................................................................................................................................

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 100 | p a g e

Practice Recording Form History taking and screening at the emergency room

Case Study No. 2

Patient No......................

Age...........years................month Gender..........................Vital sign...................................................................

Body Weight................Kg. Height ...............Cm. BMI………………… Date of birth........................................

Chief Complaint.....................................................................................................................................................

Present Illness........................................…………………………………………………………………………………………………....

History Illness...........................................................................................................................................................

Personal History and behaviors..........................................................................................................................

Family History Illness.............................................................................................................................................

Menstrual history in female patients................................................................................................................

History in children under 6 years old

• Parturition  Normal  Abnormal (specify) ……………………...........………

Accoucheur................................................................................................................

• Growth  Normal

 Abnormal (specify) …………………................................................…...........………

• Feeding  Breast feeding

 Powdered milk

 Condensed milk (brand).........................

 supplement (brand).................

• Immunization

 BCG when (Date)................................................................

 Hepatitis B virus when (Date)................................................................

 DTP when (Date)................................................................

 OPV when (Date)................................................................

 MMR when (Date)................................................................

 LAJE when (Date)................................................................

 dT when (Date)................................................................

 Others when (Date)................................................................

Other information

....................................................................................................................................................................................

....................................................................................................................................................................................

....................................................................................................................................................................................

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 101 | p a g e

4.6 Physical examination (2 cases)

Practice Recording Form History taking and screening at the emergency room
Case Study No. 1

Patient No......................
Age...........years................month Gender..........................Vital sign...................................................................
Body Weight................Kg. Height ...............Cm. BMI………………… Date of birth........................................
Chief Complaint.....................................................................................................................................................
Present Illness........................................…………………………………………………………………………………………………....
History Illness...........................................................................................................................................................
Personal History and behaviors..........................................................................................................................
Family History Illness.............................................................................................................................................
Menstrual history in female patients................................................................................................................
History in children under 6 years old

• Parturition  Normal  Abnormal (specify) ……………………...........………

Accoucheur................................................................................................................

• Growth  Normal
 Abnormal (specify) …………………................................................…...........………

• Feeding  Breast feeding
 Powdered milk
 Condensed milk (brand).........................
 supplement (brand).................

• Immunization

 BCG when (Date)................................................................

 Hepatitis B virus when (Date)................................................................

 DTP when (Date)................................................................

 OPV when (Date)................................................................

 MMR when (Date)................................................................

 LAJE when (Date)................................................................

 dT when (Date)................................................................

 Others when (Date)................................................................

Physical examination

....................................................................................................................................................................................

....................................................................................................................................................................................

....................................................................................................................................................................................

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 102 | p a g e

Practice Recording Form History taking and screening at the emergency room

Case Study No. 1

Patient No......................

Age...........years................month Gender..........................Vital sign...................................................................

Body Weight................Kg. Height ...............Cm. BMI………………… Date of birth........................................

Chief Complaint.....................................................................................................................................................

Present Illness........................................…………………………………………………………………………………………………....

History Illness...........................................................................................................................................................

Personal History and behaviors..........................................................................................................................

Family History Illness.............................................................................................................................................

Menstrual history in female patients................................................................................................................

History in children under 6 years old

• Parturition  Normal  Abnormal (specify) ……………………...........………

Accoucheur................................................................................................................

• Growth  Normal

 Abnormal (specify) …………………................................................…...........………

• Feeding  Breast feeding

 Powdered milk

 Condensed milk (brand).........................

 supplement (brand).................

• Immunization

 BCG when (Date)................................................................

 Hepatitis B virus when (Date)................................................................

 DTP when (Date)................................................................

 OPV when (Date)................................................................

 MMR when (Date)................................................................

 LAJE when (Date)................................................................

 dT when (Date)................................................................

 Others when (Date)................................................................

Physical examination

....................................................................................................................................................................................

....................................................................................................................................................................................

....................................................................................................................................................................................

Signature ________________________________ Signature________________________________
(_______________________________) (_______________________________)
Student Supervisor

Date ________________________________ Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 103 | p a g e

Learning Process 5: Summary of Activities
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____________________________________________________________________ _______________________
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___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Signature ________________________________
(_______________________________)
Student

Date ________________________________

Signature ________________________________
(_______________________________)
Supervisor

Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 104 | p a g e

PH 20.1

Part 12 Activities of Pharmacy

Learning Activity 12.1 Report on Pharmacy Study (Pharmaceutical Room)

Objective
To enable students to learn the process and have basic skills about drug use and drug behavior

Learning Process 1: Recording in Records and Reports
___________________________________________________________________________________________
Learning Process 2: The Acceptance Process
___________________________________________________________________________________________
Learning Process 3: Recording Process of taking the patient's medicine
___________________________________________________________________________________________
Learning Process 4: Dispensing Medicines to Patients
___________________________________________________________________________________________
Learning Process 5: Appointment of a patient group for the next dose.
___________________________________________________________________________________________
Learning Process 6: Summary of Activities
___________________________________________________________________________________________

Signature ________________________________
(_______________________________)
Student

Date ________________________________

Signature ________________________________
(_______________________________)
Supervisor

Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 105 | p a g e

PH 20.2

Part 12 Activities of Pharmacy

Learning Activity 12.2 Report on Pharmacy Education (Drug Inventory)

Objective
To enable students to learn the process and have skills in managing inventory

Learning Process 1: Registering Drug Records and Inventory Reports
___________________________________________________________________________________________
Learning Process 2: Process of receiving and dispensing drugs from the drug warehouse (proper
management of the drug inventory)
___________________________________________________________________________________________
Learning Process 3: Record system, record of drug receipts and inventory.
_________________________________________________________________________________________ __
Learning Process 4: Distributing Medicines to Other Parts of hospitals/health promotion hospitals.
___________________________________________________________________________________________
Learning Process 5: Drug Inventory Check and purchasing.
___________________________________________________________________________________________
Learning Process 6: Summary of Activities
___________________________________________________________________________________________

Signature ________________________________
(_______________________________)
Student

Date ________________________________

Signature ________________________________
(_______________________________)
Supervisor

Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 106 | p a g e

PH 20.3

Part 12 Activities of Pharmacy

Learning Activity 12.3 Consumer Protection Performance Report

Objective
To enable students to learn the process and have basic skills related to consumer protection in

public health, consisting of
1. Knowledge of medicine psychotropic substances Drugs, cosmetics, hazardous

substances, volatile substances, medical devices, and food
2. Knowledge about
2.1 General law principles Procedural law and the law specific to each product
2.2 Quality analysis
2.3 The production site standard consists of reading plans, schematics
2.4 Communication and Public Relations

Learning Process 1: Systematic records and reports on the operation of surveillance and inspection of
various establishments.
___________________________________________________________________________________________
Learning Process 2: Product Randomization Process
___________________________________________________________________________________________
Learning Process 3: Product Screening Test Submission Process
___________________________________________________________________________________________
Learning Process 4: Label and Advertising Review
___________________________________________________________________________________________
Learning Process 5: Summary of Activities and Knowledge Based Activities
___________________________________________________________________________________________

Signature ________________________________
(_______________________________)
Student

Date ________________________________

Signature ________________________________
(_______________________________)
Supervisor

Date ________________________________

Manual of Public Health Internship (Filed training 1) 3.2021 107 | p a g e