YAYASAN SINGAPERBANGSA KARAWANG

RUMAH SAKIT ISLAM KARAWANG

Jl. Pangkal Perjuangan KM 2 (By Pass) Karawang – Jawa Barat
Telp. (0267) 414520, Fax. (0267) 413277
Email: rsi_karawang@yahoo.com Website: www.rsislam-karawang.com
I. MCU STATUS MENTAL
A. Deskripsi Umum
1. Penampilan : .................................................................................................
2. Kesadaran   : .................................................................................................
3. Perilaku dan aktivitas prikomotor : ........................................................................
4. Pembicaraan : ..................................................................................................
5. Sikap terhadap pemeriksa : .....................................................................................

B. Keadaan Afektif
1. Mood         : ..................................................................................................
2. Afek             : ..................................................................................................
3. Keserasian   : ..................................................................................................

C. Fungsi Intelektual (Kognitif)

1. Taraf pendidikan, pengetahuan umum dan kecerdasan : .........................................
2. Daya konsentrasi : .....................................................................................
3. Orientasi (waktu, tempat, dan orang) : ....................................................................
4. Daya ingat : .....................................................................................
5. Pikiran abstrak : .....................................................................................

D. Gangguan Persepsi :
Halusinasi : ……………………………………………………………….
Ilusi                    : .................................................................................................
Depersonalisasi : .................................................................................................
Derealisasi          : .................................................................................................

E. Proses Berpikir :
1. Arus pikiran :
   a. Produktivitas : …………………………………………………………..
   b. Kontinuitas   : ..........................................................................................
   c. Hendaya berbahasa   : ..........................................................................................
 2. Isi pikiran
....................................................................................................................................
F. Daya Nilai
1. Norma sosial         : ..................................................................................................
2. Uji daya nilai         : ..................................................................................................
3. Penilaian realitas   : ……………………………………………………………….

G. Taraf dapat dipercaya

: ................................................................................................