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Rekam Medik Kedokteran Gigi

PERSATUAN SENAT MAHASISWA KEDOKTERAN GIGI INDONESIA

(Indonesian Dental Students Assosiation)


Komisi C PSMKGI Salam Pengabdian

No. File : ...............

Data Pasien:
Nama Lengkap
(jenis kelamin)
:_____________________________________________(L/P)
Tempat, Tanggal Lahir
:_________________________________________________
Agama
:_________________________________________________
Pekerjaan
:_________________________________________________
Status
:_________________________________________________
Alamat Rumah
:_________________________________________________
No kontak
:_________________________________________________
Golongan Darah
:_________________________________________________
Catatan perawatan :
Tanggal
Gigi
Keluhan / Diagnosa

Perawatan

Paraf

PEMERIKSAAN
Vital
Kesadaran
: __________________
Nadi
: ______/menit
Tekanan darah
: __________________
Pernafasan :
______/menit
Riwayat Penyakit : penyakit
jantung/hipertensi/hepatitis/Diabetes/alergi/hepar/lambung*
Keterangan riwayat penyakit
......................................................................................................
Rekam Medik Kedokteran Gigi PSMKGI | komisi-c@psmkgi.org | SALAM
PENGABDIAN

Rekam Medik Kedokteran Gigi


PERSATUAN SENAT MAHASISWA KEDOKTERAN GIGI INDONESIA

(Indonesian Dental Students Assosiation)


Komisi C PSMKGI Salam Pengabdian

Anamnesis
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Ekstraoral

Tonus bibir
: [ ] hipotonus [ ] Normal [ ]
Hipertonus
TMJ : [ ] Normal [ ] ada kelainan
.................................

Odontogram

Intraoral
Kebersihan mulut
sedang [ ] buruk
Mukosa Bukal : [
kelainan ..............
Mukosa labial : [
kelainan ..............
Frenulum labii : [
Lidah
:[

: [ ] Normal [ ]
] Normal [ ] ada
] Normal [ ] ada
] Normal [ ] Rendah
] Normal [ ] ada

Diagnosa
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Rencana Perawatan
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Operator pemeriksa:
Tanggal pemeriksaan:
Rekam Medik Kedokteran Gigi PSMKGI | komisi-c@psmkgi.org | SALAM
PENGABDIAN