Contoh Rekam Medik

NOMOR REKAM MEDIK

Universitas Jenderal Soedirman Purwokerto
Jl. Dr. Soeparno, Kampus Karangwangkal, Purwokerto
Telp. (0281) 641234 Fax. (0281) 641233 - -
REKAM MEDIK KHUSUS
PROSTODONTIA
JENIS PERAWATAN: GIGI TIRUAN LENGKAP

NAMA PASIEN
: .................................................................................................
..................................

JENIS KELAMIN : L / P USIA : .....................

PEKERJAAN : ................................................................................
.........TELP. : ...........................

ALAMAT :

OPERATOR : ................................................. /
NIM : ........................

A. PERAWATAN PRA PROSTODONTIK :

1. Perawatan periodontal : tidak ada ada, yaitu :
2. Perawatan bedah : tidak ada ada, yaitu :
....
................................
....
................................
....
................................
....
................................
3. Macam cetakan :
R.A. : mukostatis / mukokompresi / mukofungsional / selective
pressure*
R.B. : mukostatis / mukokompresi / mukofungsional / selective
pressure*

4. Warna gigi : ...

.......................
.....

B. DESAIN GIGI TIRUAN PENUH

RAHANG ATAS
1. Frenulum labialis
2. Frenulum bukalis
3. Tuberositas maksilaris
4. Hamular notch
5. Postdam/posterior palatal seal

REKAM MEDIK KHUSUS PROSTODONTIA / GTP Page 1

 Contoh Rekam Medik
NOMOR REKAM MEDIK
Universitas Jenderal Soedirman Purwokerto
Jl. Dr. Soeparno, Kampus Karangwangkal, Purwokerto
Telp. (0281) 641234 Fax. (0281) 641233
6. Palatum keras
7. Fovea palatini
8. Rugae area
9. Papilla incicivum
RAHANG BAWAH
1. Retromolar pad
2. Frenulum lingualis
3. Ruang retromylohyoid
4. Area bucal shelf

- -

Desain gigi tiruan:

C. PROGNOSIS : Baik / Sedang / Buruk*

Alasan: ..................................................................................................
........................................................
..............................................................................................................
............................................................. ................................................
..............................................................................................................
.............
..............................................................................................................
............................................................. ................................................
..............................................................................................................
.............

D. PERAWATAN ULANG :
1. Relining : Regio : ...................... Tanggal :
...
2. Reparasi : Regio : ................ Tanggal :
...

REKAM MEDIK KHUSUS PROSTODONTIA / GTP Page 2

 Contoh Rekam Medik
NOMOR REKAM MEDIK
Universitas Jenderal Soedirman Purwokerto
Jl. Dr. Soeparno, Kampus Karangwangkal, Purwokerto
Telp. (0281) 641234 Fax. (0281) 641233 - -
Sebab : .
...........................
3. Lain lain : ................... Tanggal :
..............
Keterangan :
..............................................................................................................
............................................................. ................................................
..............................................................................................................
.............

Telah melalui diskusi dan

disetujui oleh Dosen
Pembimbing
TANGGAL :

(drg...................................
PERAWATAN .........................)

PARAF KETERANGA
TANGGAL PERAWATAN PARAF MHS
DOSEN N

REKAM MEDIK KHUSUS PROSTODONTIA / GTP Page 3

 Contoh Rekam Medik
NOMOR REKAM MEDIK
Universitas Jenderal Soedirman Purwokerto
Jl. Dr. Soeparno, Kampus Karangwangkal, Purwokerto
Telp. (0281) 641234 Fax. (0281) 641233

REKAM MEDIK KHUSUS PROSTODONTIA / GTP Page 4