KURSUS DIPLOMA PEMBANTU PERUBATAN

PSYCHIATRIC CASE CLERKING

Patients Biodata:
Name: I/C No.: .
Date of Birth: .. Sex: . Age: . Race:
Religion: .. Marital Status: ...
Occupation:
Present Address: ..
.....
Telephone: (H) (H/P) ..
Name of Next of Kin: .. I/C No.: ..
Relationship: . Occupation: .
Address: .
.
Telephone: (H) (H/P)
Admission Status: Voluntary
Temporary
Compulsory
Number of previous admission (If any):
Registration Number (If any):

ADMISSION:

DISCHARGE:

Date: .

Date:

Time:

Time:

REFERRAL SOURCE:
(Referral forms attached)

Language Spoken In History

Taking:
CHIEF COMPLAINTS:

HISTORY OF PRESENT
ILLNESS:

HISTORY FROM
RELATIVES:
(State relationship and name
of informant)
List Complaints, type of
onset, duration, precipitating
factors, relieving factors,
associate experience.

ABILITY FOR WORK:

SLEEP PATTERN:
APPETITE:
TOLET HABITS:
TREATMENT FROM
WHATEVER SOURCES:
Types of Treatment Given:

FAMILY HISTORY:
Father/Mother:
Siblings/Other Relatives:
Ages and Occupation:
Emotional Relationship:
Economic Status/Social
Standing:

Mental Illness or Other

Diseases In Family:

PERSONAL HISTORY:
Birth/Milestone:
Childhood:
Neurotic Problems and
Health In Childhood:
School:
Academic Record:
Activities/Social Ability:
Examination/Grades and
Dates:
Work Record:
List Jobs/Salaries:
Reasons for Changes:
Sexual Experience:
Menstrual History:
Marriage(s):
Age, Occupation and
Personality of Spouse:
Sexual Practice/Children:
List Ages and Occupation:
Miscarriages/Social-Cultural
Background:
Present Home:
Total Family Income:
Friends/Social-Cultural
Background:
Religious Affiliations:
Smoking/Drinking/Drugs:
PREMORBID
PERSONLITY: (Preferably
From Relatives Or Friends)
Previous Medical History:

Previous Psychiatry History:

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:

SUMMARY OF PHYSICAL FINDINGS:

List chief clinical features below:

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

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini:

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KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN PSYCHIATRIC CASE CLERKING
Nama Pelatih:

No. Matrik: ..

Tahun: Semester: Kawasan Penempatan: ...

Bil.
1
2

5
6

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

KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK PSYCHIATRIC CASE PRESENTATION
Nama Pelatih:

No. Matrik: ....

Tahun: Semester: Kawasan Penempatan: ...

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

PELAKSANAAN
Memuas
Baik
Lemah
kan

1
1

10

Skor: ......... x 100% = ..........................%

10

Tandatangan Pemeriksa

: .

Nama

: .

Tarikh

Skor

Catatan