Nama
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:
Keluhan Utama:
2.
Hetero Anamnesa:
-
Faktor Pencetus/Penyebab:..........................................................................................................................................
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
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