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BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT

PROGRAM STUDI KEDOKTERAN GIGI


FAKULTAS KEDOKTERAN
UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

No. RM : __________

FORMULIR REKAM MEDIK


KEDOKTERAN GIGI
(DENTAL RECORD)

MANADO
NOVEMBER 2013

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

REKAM MEDIK
Operator

: _______________

No. RM : _______________
Tanggal : _______________

STATUS UMUM PASIEN


Identitas Pasien
Nama
Jenis Kelamin
Umur
Pekerjaan
Alamat
No Telepon
Tempat / tanggal Lahir
Status Perkawinan
Pendidikan Terakhir

: ___________________________________________________________

:
Laki-laki
Perempuan
: __________ Tahun
: ___________________________________________________________
: ___________________________________________________________
___________________________________________________________
: ____________________
No. HP : ____________________
: ____________________ / ____________________
:
Belum Kawin
Kawin
Janda / Duda
:
SD
SMP
SMA
S1
S2
S3
Lainnya

ANAMNESA
Keluhan Utama
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Riwayat Perjalanan Penyakit
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Riwayat Kesehatan Gigi dan Mulut
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Riwayat Kesehatan Umum
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Catatan:
Beri tanda centang ( ) pada kotak yang dipilih.
Tulis / gambar sesuai pada tempat yang tersedia.

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

Riwayat Kesehatan Keluarga


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Riwayat Keadaan Sosial Ekonomi
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

KONDISI SISTEMIK
Golongan Darah

: __________

Nama Penyakit

Keluhan / Gejala
Ya
Tidak

Keterangan

Gangguan Jantung
Hipertensi / Hipotensi
Kelainan Darah
Hemofilia
Diabetes Mellitus
Gangguan Ginjal
Hepatitis
Gangguan Saluran Pernafasan
Gangguan Saluran Pencernaan
Epilepsi
HIV / AIDS
Alergi Obat
Alergi Makanan
Hamil / Menyusui
Lainnya

Keadaan Umum
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

PEMERIKSAAN OBJEKTIF
Pemeriksaan Tanda Vital
Tekanan Darah
: __________ / __________ mmHg
Nadi
: __________ x / menit
Pernafasan
: __________ x / menit
Pemeriksaan Fisik
Berat Badan
Tinggi Badan

Normal

Hipertensi

Hipotensi

: __________ kg
: __________ cm

Pemeriksaan Ekstra Oral

Deformalitas

Nyeri

Tumor

Gangguan Fungsi

Bentuk Kepala
Fasial
Neuromuskular
Kelenjar Ludah
Kelenjar Limfe
Tulang Rahang
TMJ
Lainnya

: ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Pemeriksaan Intra Oral


Jaringan Lunak Mulut
Bibir
: Normal Kelainan; ________________________________________
Lidah
: Normal Kelainan; ________________________________________
Mukosa Bukal
: Normal Kelainan; ________________________________________
Mukosa Palatinal
: Normal Kelainan; ________________________________________
Gingiva
: Normal Kelainan; ________________________________________
Frenulum Labialis
: Normal Kelainan; ________________________________________
Frenulum Lingualis
: Normal Kelainan; ________________________________________
Frenulum Bukalis
: Normal Kelainan; ________________________________________
Lainnya
: ___________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

Peta Mukosa dan Jaringan Lunak

Deskripsi Kelainan yang ditemukan


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

KETERANGAN :

1. Labial Commisure Right

23. Alveolar Ridge Lingually Anterior

2. Buccal Mucose Right

24. Alveolar Ridge Lingually Left

3. Labial Commisure Left

25. Floor of Mouth Lateral Right

4. Buccal Mucose Left

26. Floor of Mouth Triangular Area

5. Labial Mucose Upper

27. Floor of Mouth Lateral Left

6. Labial Mucose Lower

28. Ventral Surface of the Tongue Right

7. Buccal Sulcus Right Maxillary

29. Ventral Surface of the Tongue Left

8. Labial Sulcus Maxillary

30. Margin of the Tongue Right

9. Buccal Sulcus Left Maxillary

31. Margin of the Tongue Left

10. Buccal Sulcus Right Mandibular

32. Tip of the Tongue

11. Labial Sulcus Mandibular

33. Dorsum of the Tongue Right

12. Buccal Sulcus Left Mandibular

34. Dorsum of the Tongue Left

13. Alveolar Ridge Buccally Right Maxillary

35. Base of the Tongue

14. Alveolar Ridge Labially Maxillary

36. Hard Palate Right

15. Alveolar Ridge Buccally Left Maxillary

37. Hard Palate Left

16. Alveolar Ridge Buccally Right Mandibula

38. Soft Palate Right

17. Alveolar Ridge Labially Mandibular

39. Soft Palate Left

18. Alveolar Ridge Buccally Left Mandibular

40. Anterior Tonsillar Pillar Right

19. Alveolar Ridge Palatally Right

41. Anterior Tonsillar Pillar Left

20. Alveolar Ridge Palatally Anterior

42. Vermillion Border Upper

21. Alveolar Ridge Palatally Left

43. Vermillion Border Lower

22. Alveolar Ridge Lingually Right

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

Jaringan Keras
Oklusi
Maloklusi
Torus Palatinus
Torus Mandibula
Palatum
Supernumerary Teeth

Diastema
Gigi Anomali
Gigi Tiruan
OHI-S

Index
DIS
CIS

Lainnya

: Normal Bite Cross Bite Deep Bite Lainnya : __________


: Tidak Ada : Klasifikasi Angle Klas : I II III Divisi : _____
: Tidak Ada : Kecil Sedang Besar Multiple
: Tidak Ada : Sisi Kiri Sisi Kanan Kedua Sisi
: Dalam Sedang Rendah
: Tidak Ada : _____________________________
: Tidak Ada : _____________________________
: Tidak Ada : _____________________________
: Tidak Ada : _____________________________
: __________
Kategori : Baik Sedang Buruk

Regio
RA
RB
RA
RB

Molar Kanan

Anterior

Molar Kiri

Total

: ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

ODONTOGRAM
18

48

17

47

16

46

15

14

13

12

11

21

22

23

24

25

55

54

53

52

51

61

62

63

64

65

85

84

83

82

81

71

72

73

74

75

45

44

43

42

41

31

32

33

34

35

26

27

28

36

37

38

18 : ____________________

28 : ____________________

17 : ____________________

27 : ____________________

16 : ____________________

26 : ____________________

(55) 15 : ____________________

(65) 25 : ____________________

(54) 14 : ____________________

(64) 24 : ____________________

(53) 13 : ____________________

(63) 23 : ____________________

(52) 12 : ____________________

(62) 22 : ____________________

(51) 11 : ____________________

(61) 21 : ____________________

(81) 41 : ____________________

(71) 31 : ____________________

(82) 42 : ____________________

(72) 32 : ____________________

(83) 43 : ____________________

(73) 33 : ____________________

(84) 44 : ____________________

(74) 34 : ____________________

(85) 45 : ____________________

(75) 35 : ____________________

46 : ____________________

36 : ____________________

47 : ____________________

37 : ____________________

48 : ____________________

38 : ____________________

Indeks Karies Gigi


DMF - T

def - t

: __________

: __________

: __________

: __________

: __________

: __________

DMF - T : __________

def - t : __________

Tanggal Pencatatan Data : ____________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

Keterangan ODONTOGRAM:
UE
= Un-erupted [0]

= composite filling [2]

= Partial erupt [0]

= inlay (metal/composite)

PE

= Normal [1]

= non-vital teeth [3]

A
=

Anomali [1]
pegshaped, micro, fusi

= amalgam filling on non-vital = AF [3]

= Composite filling on non-vital teeth [3]

= caries = temp filling [2]

= Amalgam filling = AF [2]

= Radix dentis [4]

= Full metal bridge 3 units.

= full metal crown on vital


[ 2 ]

[5]

[2]

= Porcelain bridge.

= full metal crown on non-vital


[3]

[5 ]

[ 5]

= full metal cantilever

= porcelain crown on vital


[ 1]

[2]

[5]

= porcelain crown on non-vital [3]

= missing teeth

= venster crown on vital [2]

= removable partial denture

= venster crown on non-vital [3]

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

PEMERIKSAAN PENUNJANG
Pemeriksaan Laboratorium
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Pemeriksaan Roentgen
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

RENCANA PERAWATAN
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

BALAI PENGOBATAN - RUMAH SAKIT GIGI DAN MULUT


PROGRAM STUDI KEDOKTERAN GIGI
FAKULTAS KEDOKTERAN - UNIVERSITAS SAM RATULANGI
Jl. Dr. Soetomo No. 3, Pinaesaan Manado Telp. (0431) 855116
Jl. Kampus Unsrat, Kleak Manado - 95115 Telp. (0431) 827009 Fax. (0431) 827007

RIWAYAT PERAWATAN
Tanggal

Mengetahui

Gigi

Masalah

Rencana Terapi

Paraf

Keterangan

Manado,

20

Instruktur

Operator

________________

__________________

10