Escolar Documentos
Profissional Documentos
Cultura Documentos
Religion: ISLAM
Occupation: SECURITY
Voluntary
Temporary
Compulsory
DISCHARGE:
Date: .
Date:
Time:
Time:
REFERRAL SOURCE:
1.P57
2.Borang 5
Bahasa Melayu
Taking:
CHIEF COMPLAINTS:
HISTORY OF PRESENT
ILLNESS:
FAMILY HISTORY:
Father/Mother:
Siblings/Other Relatives:
Ages and Occupation:
Emotional Relationship:
Economic Status/Social
Standing:
GENERAL APPEARANCE
AND BEHAVIOUR:
General Impression:
State of Consciousness:
Physical Appearance:
Manner of
Dressing/Cleanliness:
Facial Expression and
Posture:
Reactivity to Surrounding:
Mannerisms:
Ability to Co-operate:
TALK:
Languages/Dialect Spoken:
Amount of Talk:
Rational/Relevance/Coheren
ce:
Flights of Ideas:
Looseness or Clang
Association:
Thought Block:
Circumstantiality:
Neologies (Quote Speech
Samples):
Pressure of Speech:
Word Salad:
MOODS:
Mood State:
Affective Response:
Consistency of Mood:
Withdrawal:
THOUGHT CONTENTS:
Delusion &
Misinterpretations:
Feelings of Influence:
Feelings of Passivity:
Depersonalizations:
Hypochondrias:
Hallucinations:
Preoccupation:
Obsessions/Phobias:
Over Determined Ideas:
Suicidal Thoughts:
Repetitive Dreams:
(Described these in details)
ORIENTATION:
Place:
Time:
Person:
MEMORY:
Remote Memory:
Recent Memory:
Immediate Memory:
Confabulation:
Five Minutes Memory Test:
INFORMATION &
VOCABULARY:
Estimate Intelligence Level:
ABSTRACTION:
Proverbs Test:
ATTENTION &
CONCENTRATION:
Distractibility:
Serial Seven Test:
Digit Span:
JUDGEMENT:
INSIGHT:
PHYSICAL EXAMINATION:
GENERAL:
Temp:
Pulse Rate:
Resp. Rate:
B/P:
CARDIO-VASCULAR
SYSTEM:
RESPIRATORY SYSTEM:
ABDOMEN:
CENTRAL NERVOUS
SYSTEM:
DIAGNOSIS:
DIFFERENTIAL
DIAGNOSIS:
TREATMENT PLAN:
LAPORAN REFLEKTIF:
(Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang
telah diperolehi daripada pengkajian kes ini)
Pengurusan kes:
Baik
Memuaskan
Lemah
......................................................................................................................................
.......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
5
6
7
No. Matrik: ..
Perkara
Biodata pesakit
Riwayat Pesakit:
2.1 Aduan Utama
2.2 Sejarah Penyakit Kini
2.3 Sejarah Dari Ahli Keluarga
2.4 Sejarah Keluarga
2.5 Sejarah Personal
(Lain2 yang berkenaan)
Penilaian Staus Mental:
3.1 Keadaan Am & Tingkah Laku
3.2 Percakapan
3.3 Mood
3.4 Pemikiran
3.5 Orientasi
3.6 Memori
3.7 Information,Vocabulary & Abstraction
3.8 Attention & Concentration
3.9 Judgement & Insight
Pemeriksaan Fizikal:
4.1 Pemeriksaan Am
4.2 Tanda-tanda Vital
4.3 Kepala & E/ENT
4.4 Dada (Jantung)
4.5 Dada (Paru-paru)
4.6 Abdomen
4.7 Sistem Saraf
4.8 Anggota Atas & Bawah
4.9 Lain-lain (seperti genitalia & rektum, dll)
Ringkasan Penemuan Klinikal
Diagnosis:
6.1 Diagnosis Sementara
6.2 Diagnosis Perbezaan
Pengurusan:
7.1 Pengendalian awal
7.2 Ubat-ubatan
7.3 Penjagaan kejururawatan
Laporan reflektif
JUMLAH
Wajaran
5
25
25
10
5
5
20
5
100
Tandatangan Pemeriksa
: .
Nama
: .
Tarikh
Skor
Catatan
Tahun:
Bil.
Perkara
Wajaran
Pembentangan biodata
pesakit yang tepat dan
lengkap
Pembentangan riwayat
pesakit yang lengkap
Melakukan penilaian
status mental yang
lengkap dan relevan
dengan tepat
Melakukan pemeriksaan
fizikal yang lengkap dan
relevan dengan betul
Cadangan diagnosis &
diagnosis perbezaan
yang tepat
Pembentangan
pengurusan pesakit yang
tepat dan lengkap
JUMLAH
Skor:
PELAKSANAAN
Memuas
Baik
Lemah
kan
1
2
1
1
2
10
Tandatangan Pemeriksa
: .
Nama
: .
Tarikh
Skor
Catatan