Rekam Medik Kedokteran GigiPERSATUAN SENAT MAHASISWA KEDOKTERAN GIGI INDONESIA(Indonesian Dental Students Assosiation)

Komisi C PSMKGI Salam Pengabdian

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Data Pasien:Nama Lengkap(jenis kelamin):_____________________________________________(L/P)Tempat, Tanggal Lahir:_________________________________________________Agama:_________________________________________________Pekerjaan:_________________________________________________Status:_________________________________________________Alamat Rumah:_________________________________________________No kontak:_________________________________________________Golongan Darah:_________________________________________________

Catatan perawatan :TanggalGigiKeluhan / DiagnosaPerawatanParaf

PEMERIKSAAN VitalKesadaran: __________________Nadi: ______/menitTekanan darah: __________________Pernafasan: ______/menitRiwayat Penyakit : penyakit jantung/hipertensi/hepatitis/Diabetes/alergi/hepar/lambung*Keterangan riwayat penyakit......................................................................................................

Anamnesis_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ EkstraoralTonus bibir : [ ] hipotonus [ ] Normal [ ] HipertonusTMJ : [ ] Normal [ ] ada kelainan .................................Kelenjar Limfe : [ ] teraba (sakit/tidak) [ ] tidak teraba

IntraoralKebersihan mulut : [ ] Normal [ ] sedang [ ] burukMukosa Bukal: [ ] Normal [ ] ada kelainan ..............Mukosa labial: [ ] Normal [ ] ada kelainan ..............Frenulum labii: [ ] Normal [ ] RendahLidah: [ ] Normal [ ] ada kelainan ..............Palatum: [ ] Normal [ ] DangkalTonsil: [ ] Normal [ ] ada kelainan ..............

Odontogram

Diagnosa_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Rencana Perawatan_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Operator pemeriksa:Tanggal pemeriksaan:Rekam Medik Kedokteran Gigi PSMKGI | komisi-c@psmkgi.org | SALAM PENGABDIAN