Anda di halaman 1dari 2

RM

RS ISLAM MALAHAYATI MEDAN

Nama

ILMU PENYAKIT JIWA


Ruangan :

Tgl.Lahir :
No RM

Tgl

L/P
Jam :

: Ya dari
RS ...............................................
.Puskesmas ...................................................
Dr. ...............................................

Lainnya ........................................................
Dx Rujukan ..............................................................................................................................
Tidak Datang Sendiri
Diantar...........................................................
Nama Keluarga yang bisa dihubungi:..................................................No.HP/Telp:.........................................................................
Alamat
:................................................................................................................................................
Transportasi waktu datang
: Ambulans RS Islam Malahayati
Ambulans Lain................. . Kend.
Lainnya................
ALERGI TERHADAP:
Rujukan

Penilaian Nyeri
Nyeri : ( ) tidak, ( ) ya:

lokasi: ______________ Intensitas (0-10):_____

Jenis : akut ( ), kronis ( )

Tanda Tangan Dokter


Dokter Yang Memeriksa
:................................................................
Supervisor Jaga
:................................................................
ANAMNESA
Wawancara:...............................................................
1.

Keluhan Utama:

2.

Riwayat Penyakit Sekarang:


Auto Anamnesa:

Hetero Anamnesa:
-

Faktor Pencetus/Penyebab:..........................................................................................................................................

Faktor Keluarga ...........................................................................................................................................................

Fungsi Kerja/Sosial .....................................................................................................................................................

Riwayat NAPZA: Ada: Lama Pemakaian..................................................................................


Jenis Zat................................................................................................
Cara Pemakaian....................................................................................
Latar Belakang Pemakaian...................................................................

Faktor Premorbid:........................................................................................................................................................

Faktor Organik:............................................................................................................................................................

Tidak

STATUS PSIKIATRI
Kesan Umum:....................................................................................................................................................................................
Kesadaran:.........................................................................................................................................................................................
Mood/Afek:........................................................................................................................................................................................
Proses Pikir:.......................................................................................................................................................................................
Pencerapan:........................................................................................................................................................................................
Intelegensi:.........................................................................................................................................................................................
Dorongan Insting:..............................................................................................................................................................................

Psikomotor:........................................................................................................................................................................................
STATUS INTERNE
Keadaan Umum: ........................... Gizi:...................................
Tensi:..................mmHg,
Suhu:............................oC
Nadi:....................x/mnt
Respirasi:.............x/mnt
Berat Badan:............Kg

STATUS NEUROLOGI

DIAGNOSA KERJA / DIAGNOSA BANDING

TERAPI / TINDAKAN

RENCANA KERJA

DISPOSISI
Boleh pulang Jam Keluar:........WIB Tanggal:...
Kontrol Poliklinik Ya................ Tanggal:........
Tidak
Dirawat di ruang: Intensif Rawat Inap
Ruang lain:.......................
Tanda Tangan dan Nama Dokter

DiReview oleh dokter yang merawat di Rawat Inap


Medan, Tgl

Anda mungkin juga menyukai