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RS ISLAM MALAHAYATI MEDAN RM

ILMU PENYAKIT JIWA

Nama :

Tgl.Lahir : L/P

No RM :Ruangan : Tgl : Jam :

Rujukan : Ya dari RS ...............................................

.Puskesmas ...................................................

Dr. ............................................... Lainnya ........................................................

Dx Rujukan ..............................................................................................................................

Tidak Datang Sendiri Diantar...........................................................

Nama Keluarga yang bisa dihubungi:..................................................No.P!Tel":.........................................................................

#lamat :................................................................................................................................................

Trans"ortasi $aktu datang : #mbulans RS %slam &alahayati #mbulans Lain................. .Kend.

Lainnya................

ALERGI TERHADAP:

Penilaian Nyeri

Nyeri : ' ( tidak) ' ( ya: lokasi: ************** %ntensitas '+,-+(:*****

enis : akut ' () kronis ' (

Tanda Tangan DokterDokter Yang &emeriksa :................................................................

Su"er/isor aga :................................................................

#N#&N0S#1a$an2ara:...............................................................

-. Keluhan 3tama:

4. Ri$ayat Penyakit Sekarang:

#uto #namnesa:

etero #namnesa:

, 5aktor Pen2etus!Penyebab:..........................................................................................................................................

, 5aktor Keluarga ...........................................................................................................................................................

, 5ungsi Kerja!Sosial .....................................................................................................................................................

, Ri$ayat N#P6#: #da: Lama Pemakaian.................................................................................. Tidak

enis 6at................................................................................................

7ara Pemakaian....................................................................................

Latar 8elakang Pemakaian...................................................................

, 5aktor Premorbid:........................................................................................................................................................

, 5aktor 9rganik:............................................................................................................................................................

ST#T3S PS%K%#TR%

Kesan 3mum:....................................................................................................................................................................................

Kesadaran:.........................................................................................................................................................................................

&ood!#ek:........................................................................................................................................................................................

Proses Pikir:.......................................................................................................................................................................................

Pen2era"an:........................................................................................................................................................................................

%ntelegensi:.........................................................................................................................................................................................

Dorongan %nsting:..............................................................................................................................................................................

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7/26/2019 5.14 smf jiwa RSIM

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