Nama operator :

NIM :

PROGRAM STUDI KEDOKTERAN GIGI

FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA

REKAM MEDIK UMUM

NAMA PASIEN : ________________________________________________________

NOMOR REKAM MEDIK : ________________________________________________________

 MILIK PSKG FK UNSRI

 TIDAK BOLEH DIBAWA PULANG
 TIDAK UNTUK DIBAWA PASIEN/OPERATOR, HANYA PETUGAS
 RAHASIA, HANYA UNTUK KEPENTINGAN PASIEN DAN ILMIAH
DATA PRIBADI
Diisi oleh pasien
Nama pasien : …………………………………………………………….
Nama keluarga : …………………………………………………………….
Tempat lahir/tgl lahir : …………………………/………………………………….
Suku : ……………………………………………………………..
Jenis kelamin : pria wanita
Status perkawinan : kawin belum kawin janda/duda
Agama : Islam Kristen Katolik Hindu Budha
Alamat tetap : ……………………………………………………………...
……………………………………………………………….
Alamat termudah dihubungi : ………………………………………………………………
……………………………………………………………….
Telepon rumah/Hp : ………………………………………………………………
Pendidikan terakhir : SD SLTP SLTA Diploma S1 S2/S3
Pekerjaan : ………………………………………………………………
Peserta Asuransi Kesehatan : ………………………………………………………………

Riwayat Penyakit/Kelainan Sistemik

Penyakit/kelainan sistemik Ada Disangkal Penyakit/kelainan sistemik Ada Disangkal

Alergi: debu, Dingin HIV/AIDS
Penyakit Jantung Penyakit pernapasan/paru
Penyakit Tekanan Darah
Kelainan pencernaan
Tinggi
Penyakit Kencing
Penyakit ginjal
Manis/Diabetes Melitus
Penyakit/kelainan kelenjar
Penyakit kelainan Darah
ludah
Penyakit Hepatitis
Epilepsy
A/B/C/D/E/F/G
Kelainan Hati Lainnya

Palembang,
Petugas Pendaftaran Yang Menerangkan

(…………………...….) (………………………….)
STATUS UMUM PASIEN
Rujukan : ……………………………………………………………………………….……..……..
Keadaan Umum : ………………………………………………….………………………….….…………..
Berat Badan : …………….kg Tekanan Darah : ………………………...…..….…..mmHg
Tinggi Badan : …………….cm Nadi : ……………………………….……./menit
Pernapasan : ……………………………….……./menit
Pupil Mata : ……………………………………………
ANAMNESIS
Keluhan Utama
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Keluhan Tambahan
………………………………………………………………………………………………………………………
Riwayat perawatan gigi
Belum pernah dirawat
Pernah dirawat : jelaskan …………………………………………………………………...
Kebiasaan Buruk : …………………………………………………………………………….
Riwayat Sosial : …………………………………………………………………………….

PEMERIKSAAN EKSTRA ORAL

Wajah : Simetri Asimetri ……………………………………………………………
Bibir : Sehat ada kelainan ………………………………………………………..
KGB Submandibula :
Kanan : tidak teraba teraba (Lunak/Kenyal/Keras) sakit tidak sakit
Kiri : tidak teraba teraba (Lunak/Kenyal/Keras) sakit tidak sakit
Kelenjar lainnya : …………………………………………………………………………………………...

KEADAAN UMUM INTRA ORAL

Debris : tidak ada ada, regio : ………………………………………….
Plak : tidak ada ada, regio : ………………………………………….
Kalkulus : tidak ada ada, regio : ………………………………………….
Perdarahan Papilla Interdental : tidak ada ada, regio : ………………………………………….
Identifikasi Resiko Karies : pH Plak : ………….. pH Saliva : …………...
Hubungan rahang : ortognati retrognati prognati
Kelainan lain : ……………………………………………….……………………………….
OHI-S
DI CI OHI-S = DI + CI Ket : baik
= ..........+…….. sedang
= ……... buruk
PEMERIKSAAN JARINGAN LUNAK

Kanan Kiri

Ket:
Mukosa
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Palatum
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Fauces
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Uvula
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Lidah
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Dasar Mulut
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Gingiva
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PEMERIKSAN GIGI GELIGI DAN JARINGAN PENYANGGA

Bukal
palatal

lingual
Bukal

PEMERIKSAAN LANJUTAN
Radiologi : Panoramik
Sefalometrik
TMJ
Dental : Regio ……………...………………………….
Lain-lain ………………..….…………………………..
Laboratorium : ………………………………………………………….
TEMUAN MASALAH
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URUTAN PRIORITAS PERAWATAN

1. ………………………………………………………………………………………………………………
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PERSETUJUAN INSTRUKTUR KLINIK Instruktur Klinik

Tanggal : ……………………………………..

Nama Operator : ……………………………………..

NIM : ……………………………………... (………………………………….)

NO. Tanggal Gigi Diagnosa Tindakan Paraf Ket.