PENGUMPULAN DATA
Identitas pasien :
1. Nama : ....................................................................................
2. Tempat/Tgl. Lahir : ....................................................................................
3. Suku/ Bangsa : ....................................................................................
Foto
Pasien 4. Agama : ....................................................................................
3x4 5. Jenis Kelamin : L/P
6. Gol. Darah : ....................................................................................
7. Asal sekolah : ....................................................................................
8. Alamat : ....................................................................................
Status Kesehatan :
A. Pemeriksaan Subyektif
1. Keluhan Utama : .......................................................................................................................
2. Anamnese : .......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
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3. Kesehatan Umum :
3.1. Penyakit yang pernah dialami
3.1.1. Kanak-kanak : .......................................................................
3.1.2. Pernah dirawat (penyakitnya) : .......................................................................
3.1.3. Pernah operasi (waktunya/apa) : .......................................................................
3.2. Alergi : .......................................................................
3.3. Imunisasi : .......................................................................
3.4. Kebiasaan : merokok/ kopi/ alcohol/obat-obatan
B. Pemeriksaan Obyektif
1. Ekstra Oral :
- Muka : Simetris/ Asimetris
- Kelenjar Limpa : Kanan Kiri
Teraba / tidak teraba Teraba / tidak teraba
Keras / lunak Keras / lunak
Sakit / tidak sakit Sakit / tidak sakit
- Bibir : Simetris / asimetris, basah / kering / lesi....................,Warna......................
2. Intra Oral
- Lidah : warna..............................................Lesi : ada / tidak
Pergerakan : kaku / tidak, Sensasi rasa panas / dingin : ada / tidak
- Reflek menelan/ mengunyah : dapat / tidak dapat
- Pembesaran tonsil : ada / tidak
- Bau mulut : amoniak / aceton / busuk / alcohol
- Sekret saliva : kental / kering
- Oklusi : Normal/ Progeni / Protrusi
- Anomali gigi geligi : Bentuk : .....................................................................
Jumlah : .....................................................................
Enamel : .....................................................................
- Palatum : ada kelainan / tidak
- Gingival : ada kelainan / tidak, warna : ..............................................
- Posisi gigi : ............................................................................................
3. Status Kesehatan Gigi
Debris Calculus
Gigi/ Diagnosa
Kelainan Sondasi Perkusi Tekanan Thermis Palpasi Mobility Paraf
Geligi keperawatan
C. RENCANA PERAWATAN
Konsul ke :
a. Bagian pencegahan : ........................................................................................................
b. Bagian pencabutan : ........................................................................................................
c. Bagian pengawetan : ........................................................................................................
d. Bagian rehabilitatif : ........................................................................................................
D. TINDAKAN/ PERAWATAN
Paraf
NO TGL UNSUR/REGIO DIAGNOSA TINDAKAN OPERATOR
pembimbing