Nama Pemeriksa :

NIM :
STATUS PSIKIATRI

I. IDENTITAS PASIEN
Nama : .....................................................................
Jenis Kelamin : .....................................................................
Usia : .....................................................................
Agama : .....................................................................
Suku : .....................................................................
Pendidikan : .....................................................................
Pekerjaan : .....................................................................
Status Pernikahan : .....................................................................
Status Pasien : .....................................................................
Ruang : .....................................................................
Tanggal Masuk Rumah Sakit : .....................................................................
Tanggal Pertama Kali Masuk Rumah Sakit : .....................................................................

II. RIWAYAT PSIKIATRIK

A. Keluhan Utama
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B. Riwayat Gangguan Sekarang
Autoanamnesis pada tanggal .............................................................................................
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 Alloanamnesis pada tanggal ...............................................................................................
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C. Riwayat Gangguan Dahulu
1. Riwayat gangguan psikiatri
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2. Kondisi medis umum
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3. Riwayat penggunaan zat psikoaktif
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D. Riwayat Keluarga
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E. Riwayat Kehidupan Pribadi
1. Prenatal dan perinatal
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2. Masa kanak-kanak awal
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3. Masa kanak pertengahan
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4. Masa kanak akhir dan remaja
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F. Riwayat Masa Dewasa
1. Pendidikan
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2. Pekerjaan
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3. Perkawinan
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4. Agama
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5. Aktivitas sosial
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6. Riwayat militer
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7. Riwayat pelanggaran hukum
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8. Riwayat psikoseksual
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G. Situasi Kehidupan Sekarang
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H. Impian Fantasi dan Nilai-Nilai
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I. Persepsi Keluarga tentang Pasien
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III. STATUS MENTAL
Diperiksa pada tanggal ..............................................................................................................
A. Deskripsi Umum
1. Penampilan
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2. Perilaku dan aktivitas psikomotor
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3. Sikap terhadap pemeriksa
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B. Pembicaraan
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C. Mood, Afek dan Keserasian
1. Mood : .........................................................................................................
2. Afek : .........................................................................................................
3. Keserasian : .........................................................................................................
D. Pikiran/Proses Berpikir
1. Bentuk : .........................................................................................................
2. Arus : .........................................................................................................
3. Isi : .........................................................................................................
E. Persepsi
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F. Sensorium dan Kognisi
1. Taraf kesadaran
Kuantitas : .........................................................................................................
Kualitas : .........................................................................................................

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2. Orientasi
Waktu : .........................................................................................................
Tempat : .........................................................................................................
Orang : .........................................................................................................
3. Daya ingat
Jangka panjang : .........................................................................................................
Jangka sedang : .........................................................................................................
Jangka pendek : .........................................................................................................
Segera : .........................................................................................................
4. Pengetahuan umum
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5. Konsentrasi dan perhatian
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6. Kemampuan membaca dan menulis
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7. Kemampuan visuospasial
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8. Kemampuan berpikir abstrak
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9. Bakat kreatif
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10. Kemampuan menolong diri sendiri
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 G. Pengendalian Impuls
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H. Daya Nilai dan Tilikan
1. Kesan nilai sosial : .........................................................................................................
2. Daya nilai realita : .........................................................................................................
3. Tilikan : .........................................................................................................
I. Taraf Dapat Dipercaya
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IV. PEMERIKSAAN DIAGNOSTIK LEBIH LANJUT

A. Pemeriksaan Tanda-Tanda Vital
Keadaan umum : .........................................................................................................
Kesadaran : .........................................................................................................
Tekanan darah : .........................................................................................................
Frekuensi nadi : .........................................................................................................
Frekuensi napas : .........................................................................................................
Berat badan : .........................................................................................................
Tinggi badan : .........................................................................................................
Body mass index : .........................................................................................................
Kesan gizi : .........................................................................................................
B. Status Generalis
Kulit :..........................................................................................................
Kepala :..........................................................................................................
Rambut :..........................................................................................................
Mata :..........................................................................................................
THT :..........................................................................................................
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 Gigi dan mulut :..........................................................................................................
Leher :..........................................................................................................
Jantung :..........................................................................................................
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Paru :..........................................................................................................
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Abdomen :..........................................................................................................
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Punggung :..........................................................................................................
Alat kelamin :..........................................................................................................
Anus :..........................................................................................................
Ekstremitas :..........................................................................................................
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C. Status Neurologi
1. Glasgow Coma Scale
E...M...V...
2. Pupil
Bentuk : .........................................................................................................
Diameter : .........................................................................................................
Refleks cahaya : Langsung ...........................; tidak langsung ...................................
3. Tanda rangsang meningeal
Kaku kuduk : .........................................................................................................
Brudzinsky I : .........................................................................................................
Brudzinsky II : .........................................................................................................
Kernig : .........................................................................................................
Lasègue : .........................................................................................................
4. Pemeriksaan fungsi motorik

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 5. Pemeriksaan refleks fisiologis
Bicep : .........................................................................................................
Tricep : .........................................................................................................
Patella : .........................................................................................................
Achilles : .........................................................................................................
6. Pemeriksaan refleks patologis
Babinsky : .........................................................................................................
Oppenheim : .........................................................................................................
Chaddock : .........................................................................................................
Tromner : .........................................................................................................
Hoffman : .........................................................................................................
7. Pemeriksaan sensorik
Sensibilitas : .........................................................................................................
8. Pemeriksaan saraf otonom
Inkontinensia urin: ........................................................................................................
Inkontinensia alvi : .........................................................................................................

V. IKHTISAR TEMUAN BERMAKNA

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VI. USULAN PEMERIKSAAN PENUNJANG

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VII. DIAGNOSIS MULTIAKSIAL
Axis I : ..........................................................................................................
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Axis II : ..........................................................................................................
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Axis III : ..........................................................................................................
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Axis IV : ..........................................................................................................
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Axis V : ..........................................................................................................
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VIII. DAFTAR MASALAH

A. Organobiologis : .........................................................................................................
B. Psikologis : .........................................................................................................
C. Sosial : .........................................................................................................

IX. PENATALAKSANAAN
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X. PROGNOSIS
Quo ad vitam : .........................................................................................................
Quo ad functionam : .........................................................................................................
Quo ad sanationam : .........................................................................................................

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