PEMERINTAH KABUPATEN BELITUNG

DINAS KESEHATAN
UPT. RSUD dr. H. MARSIDI JUDONO
JALAN JEND. SUDIRMAN KM 5,5 AIK RAYAK TANJUNGPANDAN Telp (0719) 21071,
Fax (0719) 22190
KODE RS.1902010 E-Mail: rsudbelitung@yahoo.com

ASESMEN RAWAT JALAN (POLI) PSIKIATRI

RIWAYAT PASIEN
1. Keluhan Utama :…………………………………………………………………………
2. Riwayat Penyakit Sekarang :…………………………………………………………………………
…………………………………………………………………………………………………………..
…………………………………………………………………………………………………………..

3. Riwayat Penyakit Dahulu :…………………………………………………………………………

………………………………………………………………………………………………………….
………………………………………………………………………………………………………….

4. Riwayat Penyakit Keluarga :………………………………………………………………………..

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………

5. Genogram :

6. Riwayat Alergi : Obat/ makanan…………………………………………………….

7. Riwayat Kejang :……………………………………………………………………….
Kejang terakhir…………………………………………………….
Frekuensi………kali
Jenis ………………………………………………………………..
8. Riwayat Penyakit Fisik :………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
9. Riwayat Extrapiramidal Syndrome (EPS) :………………………………………………………
10. Riwayat Penggunaan NAPZA : Amphetamin/ Benzodiazepin/ Canabis/ Opiate
Alkohol/ lainnya………………………………….
11. Riwayat Pengobatan Psikiatri :……………………………………………………...
……………………………………………………………………………………………………..

PEMERIKSAAN FISIK :

1. Keadaan Umum :………………………………………………………………

2. Kesadaran Kuantitatif (GCS) : E…….V……..M…….
3. Tanda Vital : TD :…………….. Suhu :……………….
Nadi :…………….. RR :……………….
 PEMERINTAH KABUPATEN BELITUNG
DINAS KESEHATAN
UPT. RSUD dr. H. MARSIDI JUDONO
JALAN JEND. SUDIRMAN KM 5,5 AIK RAYAK TANJUNGPANDAN Telp (0719) 21071,
Fax (0719) 22190
KODE RS.1902010 E-Mail: rsudbelitung@yahoo.com

4. Kepala :………………………………………………………………………………….
5. Leher :………………………………………………………………………………….
6. Thorax :………………………………………………………………………………….
7. Abdomen :………………………………………………………………………………….
8. Ekstremitas :………………………………………………………………………………….

PEMERIKSAAN PSIKIATRI (STATUS MENTALIS)

1. Kesadaran Kualitatif :…………………………………………………………………………
2. Perilaku/Psikomotor :…………………………………………………………………………
3. Pembicaraan :…………………………………………………………………………
4. Alam Perasaan
a. Mood :…………………………………………………………………………
b. Afek :…………………………………………………………………………
5. Proses Pikir
a. Bentuk Pikir :…………………………………………………………………………
b. Isi Pikir :…………………………………………………………………………
c. Arus Pikir :………………………………………………………………………...
6. Gangguan Persepsi
a. Halusinasi :………………………………………………………………………..
b. Ilusi :………………………………………………………………………..
c. Derealisasi :……………………………………………………………………….
d. Depersonalisasi :……………………………………………………………………….
7. Kognisi Sensorium
a. Konsentrasi :……………………………………………………………………….
b. Orientasi : Waktu……………………………………………………………….
Tempat……………………………………………………………..
Orang………………………………………………………………
c. Memori : Panjang…………………………………………………………….
Menengah………………………………………………………….
Pendek ……………………………………………………………..
Sewaktu…………………………………………………………….
d. Insight / Tilikan :1/2/3/4
8. Riwayat Percobaan Bunuh Diri / Melukai diri :………………………………………………..

DIAGNOSIS MULTIAKSIAL
Aksis I (ICD-10) :……………………………………………………………………………………...

Aksis II (ICD-10) :……………………………………………………………………………………..

Aksis III :……………………………………………………………………………………..

Aksis IV :…………………………………………………………………………………….

Aksis V :…………………………………………………………………………………….

DIAGNOSIS BANDING :………………………………………………………………………

 PEMERINTAH KABUPATEN BELITUNG
DINAS KESEHATAN
UPT. RSUD dr. H. MARSIDI JUDONO
JALAN JEND. SUDIRMAN KM 5,5 AIK RAYAK TANJUNGPANDAN Telp (0719) 21071,
Fax (0719) 22190
KODE RS.1902010 E-Mail: rsudbelitung@yahoo.com

RENCANA TERAPI

1. Psikofarmaka :…………………………………………………………………………..
…………………………………………………………………………..
……………………………………………………………………………
……………………………………………………………………………
2. Non-Psikofarmaka
(ICD-9) :…………………………………………………………………………
…………………………………………………………………………..
…………………………………………………………………………...
TINDAK LANJUT : Rawat Jalan / Rawat Inap / Konsul Bagian Lain

DPJP PSIKIATRI,………………………

(……………………………)