UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
BAGIAN/SMF. PSIKIATRI
Sekretariat : RSUP Sanglah Denpasar – Bali 80114
Telp/Fax (0361) 228824 . E-mail : psychiatry_denpasar@yahoo.com
RM.5.14.1/ASS.RI/2015
Pemeriksa : dr .................................................................... Tanggal :........................................
Co-Ass : ..................................................................... BPJS/JKBM/KIS/IKS/Umum
I. IDENTITAS
Nama Lengkap : ................................................... Jenis Kelamin :L / P
Alamat Domisili : ................................................... Suku/Etnis :. ....................................
Tempat/Tgl Lahir : ................................................... Bangsa :. ....................................
Status Perkawinan : ................................................... Agama :. ....................................
Pendidikan : ................................................... No. CM :. ....................................
Pekerjaan : ...................................................
Cara Datang : Rujukan dari :............................................................................
Prakarsa sendiri :............................................................................
Pro. MPK/Visum dari :...........................................................................
D. RIWAYAT PENGOBATAN
F. RIWAYAT KELUARGA
G. RIWAYAT KEHIDUPAN PRIBADI.
1. Prenatal dan Perinatal
5. Masa Dewasa
a. Riwayat Pekerjaan
b. Riwayat Perkawinan
c. Agama
d. Aktivitas Sosial
e. Riwayat Psikoseksual
f. Riwayat Hukum
III. PEMERIKSAAN STATUS PSIKIATRI
A. Deskripsi Umum
1. Penampilan
B. Pembicaraan
2. Afek/ekspresi afek.
D. Proses Berfikir :
1. Bentuk Pikir
2. Arus Pikir
3. Isi Pikir
E. Gangguan Persepsi
1. Halusinasi dan Ilusi :
Halusinasi : ada / tidak,.....................................................................................
Ilusi : ada / tidak,.....................................................................................
2. Depersonalisasi dan derealisasi
Dipersonalisasi : ada/tidak
Derealisasi : ada/tidak
2. Orientasi :
Waktu : baik / terganggu
Tempat : baik / terganggu
Orang : baik / terganggu
5. Perhatian
Baik / terganggu
6. Kemampuan visuospasial
Baik / terganggu
7. Pikiran abstrak
Baik / terganggu
9. Kapasitas intelegensia
Baik / terganggu
H. Pengendalian impuls :
B. Status Neurologis :
GCS : E V M
Nervus Kranialis :
Pupil : Reflek cahaya / ; Bulat/Tidak Bulat ; Isokor/ Anisokor
Motorik :
Tenaga = Tonus = Trofik =
Refleks Fisiologis :
Refleks Patologis :
Refleks Primitif :
C. Pemeriksaan Penunjang :
D. Pemeriksaan Laboratorium :
V. RINGKASAN.
Aksis II : .................................................................................................................................
Aksis IV : .................................................................................................................................
Aksis V : .................................................................................................................................
D. PENATALAKSANAAN
A. Farmakoterapi :
1. .....................................................................................................................................
2. .....................................................................................................................................
3. .....................................................................................................................................
4. .....................................................................................................................................
B. Non Farmakoterapi :
1. .....................................................................................................................................
2. .....................................................................................................................................
3. .....................................................................................................................................
4. .....................................................................................................................................
5. .....................................................................................................................................
Pemeriksa
Co-Ass_______________________ Dr. .
Mengetahui,
DPJP
Dr. Sp.KJ