home visite form kosong

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HALAMAN PERSETUJUAN Laporan kunjungan rumah Nama Penderita : Nomor Register : Alamat : Pelaksana kunjungan rumah 1. .............................. (..............................) Dokter Muda Fakultas Kedokteran UWKS 2. .............................. (..............................) Dokter Muda Fakultas Kedokteran UWKS Hari dan tanggal kunjungan : Diterima dan disetujui Oleh Dokter Ruang ............... ................................................................

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Page 1: Home Visite Form Kosong

HALAMAN PERSETUJUAN

Laporan kunjungan rumah

Nama Penderita :

Nomor Register :

Alamat :

Pelaksana kunjungan rumah

1. .............................. (..............................) Dokter Muda Fakultas Kedokteran UWKS

2. .............................. (..............................) Dokter Muda Fakultas Kedokteran UWKS

Hari dan tanggal kunjungan :

Diterima dan disetujui

Oleh Dokter Ruang ...............

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Page 2: Home Visite Form Kosong

LAPORAN KUNJUNGAN RUMAH

I. IDENTITAS PENDERITA

Nama :

Nomor register :

Umur :

Jenis kelamin :

Pendidikan :

Status perkawinan :

Alamat :

Diagnosa :

II. SUSUNAN KELUARGA

Ayah : (..... tahun)

Ibu : (..... tahun)

Penderita anak ke-..... dari ..... bersaudara

No NamaJenis

Kelamin Umur Pendidikan Status Pekerjaan Keterangan1 L /

P / ...............

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ...............

.........

2 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

3 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

4 L / P / ............

..... th Tidak Sekolah /

Menikah /

................. / Tidak

Sehat / Sakit / ...............

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Page 3: Home Visite Form Kosong

... SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Belum Menikah / .......

......

Bekerja .........

5 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

6 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

7 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

8 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

9 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

10 L / P / ............

...

..... th Tidak Sekolah /

SD / SLTP / SMU / S-1 /

S-2 / S-3 / .................

..

Menikah /

Belum Menikah / .......

......

................. / Tidak

Bekerja

Sehat / Sakit / ........................

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Page 4: Home Visite Form Kosong

..........

..........

..........

..........

..........

III. KESAN PENERIMAAN

Sikap keluarga terhadap dokter muda ..............................

Kunjungan rumah diterima dengan ..........

oleh .............................. , .............................. , .............................. , .............................. , ........

...................... .

.............................. dan .............................. penderita menceritakan semua perihal kehidupan

penderita dan riwayat sakitnya dengan baik dan terbuka.

.............................. dan ..............................penderita menanyakan bagaimana keadaan dan

perkembangan kejiwaan penderita selama dirawat di RS Jiwa Menur Surabaya.

IV. RIWAYAT HIDUP PENDERITA

A. Masa Prenatal

Sewaktu hamil ibu penderita sedang / tidak sedang mengalami kelainan maupun

penyakit fisik.

B. Masa Natal

Penderita lahir .............................. di .............................., cukup bulan, berat lahir

.............................. gram. Setelah lahir ..............................

C. Masa Post-natal

Tumbuh kembang penderita seperti berdiri, berjalan, dan berbicara dalam batas normal

dan tidak ada kelainan / ada kelainan, yaitu ..............................

Saat bayi, balita, dan anak-anak penderita pernah / tidak pernah mengalami kejang,

panas, maupun penyakit serius.

Penderita pernah / tidak pernah mengalami cedera dan trauma kepala.

D. Riwayat Pendidikan

Penderita pernah mengenyam pendidikan

di .............................., .............................. ..........................................................................

.............................................................................................................................................

...................................................................

E. Riwayat Sakit

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Sebelum tampak mengalami gangguan,

penderita ...................................................... ......................................................................

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V. FAKTOR HEREDITER

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VI. FAKTOR PREMORBID

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VII. HUBUNGAN DALAM KELUARGA

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VIII. SOSIAL EKONOMI

Keluarga penderita termasuk keluarga

yang............................................................................ .......................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

...........................................................................................................................................................

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Page 7: Home Visite Form Kosong

Untuk biaya pengobatan dan perawatan penderita di RS Jiwa Menur Surabaya, didapat

dari ....................................................................................................................................................

.......

IX. KEADAAN RUMAH DAN LINGKUNGAN

A. Ukuran rumah : ..... meter x ..... meter (.....m2)

B. Status rumah : Milik ....................................................................................................

C. Bangunan rumah :

Dinding rumah terbuat dari ...................................................................................,

rumah berlantai ..............................................................................................................

Kamar mandi terbuat dari ..............................................................................................

D. Keterangan rumah :

Rumah mempunyai ..... kamar tidur, ..... kamar dibagian ..... rumah dan ..... kamar

dibagian ..... rumah; hanya ..... kamar mandi; ..... dapur; dengan ruang makan di

bagian .................... rumah..

Kamar penderita

dilengkapi ................................................................................... ..................................

........................................................................................................................................

......................................................................................................

Ruang tamu dilengkapi dengan ...................., ...................., dan ....................

Rumah tampak .................... dan tertata dengan ....................

Ventilasi dan pencahayaan rumah ....................

E. Keadaan lingkungan :

Rumah penderita terletak di .................... jalan raya

Lingkungan ....................................................................................................................

Rumah yang satu dengan yang lain ...............................................................................

X. PENYULUHAN YANG DIBERIKAN KEPADA KELUARGA

Jangan memusuhi dan mengucilkan penderita sepulang dari RS Jiwa Menur Surabaya,

Perhatikan semua kebutuhan penderita termasuk berkomunikasi, makan, minum, dan mandi,

Perhatikan hal-hal yang menimbulkan rasa sedih atau marah penderita, dan sebisa mungkin

hindarkan penderita dari hal-hal tersebut,

Motivasi dan latih penderita untuk memenuhi kebutuhannya secara mandiri,

Motivasi, latih, dan ajak penderita untuk mampu mengerjakan hal-hal yang berguna

(misalnya bersih-bersih rumah ataupun berbelanja kebutuhan toko pracangan) dengan

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Page 8: Home Visite Form Kosong

perlahan-lahan, dimulai dengan lebih sering memujinya jika penderita melakukan hal

berguna dengan baik,

Ajak penderita berbincang-bincang tentang hal-hal yang bersifat ringan dan menarik bagi

penderita seperti acara TV, sepak bola, dan lain-lain,

Jangan terlalu sering memarahi dan menasehati penderita, karena hal itu akan menjadikan

penderita merasa tertekan dan memperlambat proses rehabilitasinya,

Berikan obat sesuai dengan dosis dan petunjuk dokter, awasi penderita dalam meminumnya,

dan taati jangka waktu pemakaian obat,

Perhatikan efek samping obat yang terlihat pada penderita,

Kontrol rutin ke dokter bila obat habis atau tampak efek samping obat yang tidak biasa pada

penderita, ataupun jika tidak tampak perkembangan yang bermakna dalam kejiwaan

penderita.

XI. DENAH RUMAH (Skala 1:100)

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