STATUS PSIKIATRIKUS

Nama :
NIM :
Semester :
Tanggal :
Pengampu :
Kegiatan :

BAGIAN ILMU KEDOKTERAN JIWA

FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
BAGIAN ILMU KEDOKTERAN JIWA
FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA Tanggal Masuk :
PALEMBANG Tanggal Periksa :

STATUS PASIEN JIWA

Inisial Nama.........................................................Laki-laki/Perempuan
Umur : .................................... Tempat Lahir : ....................................
Status Perkawinan : .................................... Warga Negara : ....................................
Agama : .................................... Suku Bangsa : ....................................
Tingkat Pendidikan : .................................... Pekerjaan : ....................................
Lokasi Tempat Tinggal: ........................................................................................................

Nama Mahasiswa : .................................................................................

NIM : .................................................................................
Dokter Supervisor / yang mengobati : .................................................................................
Rumah Sakit/Bangsal : .................................................................................

MENGETAHUI
SUPERVISOR

( ...................................... )

1
STATUS PRESENS TANGGAL : ....................................................................................
STATUS INTERNUS

Status Vital
Sensorium : ........................ Suhu : ............... Berat Badan : ..................
Nadi : ........................ Pernafasan: ............... Tinggi Badan : ..................
Tekanan Darah : ........................ Turgor : ............... Status Gizi : ..................

Sistem Kardiovaskular : ......................................................................................................

Sistem Respiratorik : ......................................................................................................

Sistem Gastrointestinal : ......................................................................................................

Sistem Urogenital : ......................................................................................................

Kelainan Khusus : ......................................................................................................

STATUS NEUROLOGIKUS

Urat Syaraf Kepala (Panca Indera) : ........................................................................

................................................................................................................................
................................................................................................................................
Gejala Rangsang Meningeal : ........................................................................
................................................................................................................................
Gejala Peningkatan Tekanan Intrakranial : ........................................................................
................................................................................................................................
Mata : - Gerakan : ..............................................................................
- Persepsi Mata : ..............................................................................
- Pupil : Bentuk ........................ Ukuran.............................
Refleks Cahaya ........................... Refleks Konvergensi ............................
- Refleks Kornea : ..............................................................................
- Pemeriksaan Oftalmoskopi : ..............................................................................
Motorik : - Tonus : ...................................................................................................
- Koordinasi : ...................................................................................................
- Turgor : ...................................................................................................
- Refleks : ...................................................................................................
- Kekuatan : ...................................................................................................
Sensibilitas : ................................................................................................
Susunan Syaraf Vegetatif : ................................................................................................
Fungsi Luhur : ................................................................................................
Kelainan Khusus : ................................................................................................
................................................................................................................................

2
 STATUS PSIKIATRIKUS

ALLOANAMNESIS (daftarkan semua narasumber)

Inisial Narasumber : .......................................................................................
Umur : .......................................................................................
Status Tinggal : .......................................................................................
Pendidikan : .......................................................................................
Hubungan dengan pasien : .......................................................................................

3
AUTOANAMNESIS DAN OBSERVASI
Deskripsi keadaan, kegiatan, dan penampilan pasien sebelum mulai diwawancara:
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
PEMERIKSA PASIEN INTERPRETASI
(PSIKOPATOLOGI)

4
 LAPORAN HASIL PEMERIKSAAN STATUS MENTAL

Keadaan umum
Kesadaran : ....................................................................................................
Penampilan & Dekorum : ....................................................................................................
Keterhubungan : ....................................................................................................
.....................................................................................................................................................
Psikomotor & postur tubuh : ....................................................................................................
.....................................................................................................................................................
Pembicaraan : ....................................................................................................
.....................................................................................................................................................

Alam Perasaan
Mood : ......................................................................................................................................
.....................................................................................................................................................
Afek : ......................................................................................................................................
.....................................................................................................................................................

Alam Pikiran
Kognisi : ...................................................................................................................
.....................................................................................................................................................
Sensasi & Persepsi : ...................................................................................................................
.....................................................................................................................................................
Proses Pikiran : ...................................................................................................................
.....................................................................................................................................................
Isi Pikiran : ...................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Bentuk Pikiran : ...................................................................................................................
.....................................................................................................................................................

Alam Perbuatan
Perilaku : ...............................................................................................................................
.....................................................................................................................................................
Katatonia : ...............................................................................................................................
.....................................................................................................................................................
Seksualitas : ...............................................................................................................................
.....................................................................................................................................................

5
 HASIL PEMERIKSAAN LABORATORIUM

HASIL PEMERIKSAAN ELEKTROENSEFALOGRAM (EEG)

HASIL PEMERIKSAAN RADIOLOGI

PEMERIKSAAN LAIN-LAIN

1. Evaluasi psikologik (oleh Psikolog) tanggal : ......................................................

2. Evaluasi sosial (oleh Ahli Pekerja Sosial) tanggal : ......................................................
3. Karangan/Tulisan/Gambaran tanggal : ......................................................
4. Evaluasi lain-lain tanggal : ......................................................
(Bila ada, hasilnya dilampirkan)

6
FOLLOW UP

7
RESUME (Dibuat dalam bentuk timeline)
FORMULASI DIAGNOSTIK
 DIAGNOSIS MULTIAKSIAL

AKSIS I : ...........................................................................................................................
AKSIS II : ...........................................................................................................................
AKSIS III : ...........................................................................................................................
AKSIS IV : ...........................................................................................................................
AKSIS V : ...........................................................................................................................

DIAGNOSIS BANDING

TERAPI

PROGNOSIS
Quo ad vitam:
Quo ad
functionam:
Quo ad
sanationam:

10