PEMERINTAH KABUPATEN SRAGEN No. RM : ................................................

RSUD dr. SOEHADI PRIJONEGORO SRAGEN Nama Pasien : ................................................

Jln. Raya Sukowati No. 534 Telp. (0271) 891068 Fax. 890158 Sragen 57215
SR
AGEN

Website http://www.rsspsragen.com
Tanggal Lahir : ................................................
E-mail : rsudsragen1958@gmail.com Jenis Kelamin : Laki-laki Perempuan
ASESMEN MEDIS RAWAT INAP Alamat : ................................................
GIGI DAN MULUT ................................................
Pekerjaan :
DAFTAR ALERGI OBAT DAN REAKSI EFEK SAMPING OBAT
Nama Obat Reaksi Tanggal/Tahun
1. ................................................ ................................................................. ....................................................
2. ................................................ ................................................................. ....................................................
3. ................................................ ................................................................. ....................................................
Anamnesa/Alloanamnesis* dengan : .............................. Hubungan dengan pasien : ............................
KELUHAN UTAMA :
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PERJALANAN PENYAKIT SEKARANG :
(Lokasi, Onset dan Kronologis, Kualitas, Faktor Memperberat, Faktor Memperingan, Gejala Penyerta)
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RIWAYAT PENYAKIT LAIN
Penyakit jantung : Tidak ada / Ada : .......................................................................................
Diabetes : Tidak ada / Ada : .......................................................................................
Haemophilia : Tidak ada / Ada : .......................................................................................
Hepatitis : Tidak ada / Ada : .......................................................................................
Penyakit lain : Tidak ada / Ada : .......................................................................................
Operasi : 1. ............................................... Tanggal/Tahun : ............................ Di .....................
2. ............................................... Tanggal/Tahun : ............................ Di .....................

RIWAYAT SOSIAL EKONOMI

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Obat-obatan yang dikonsumsi pasien saat ini :
1. ...............................................................................................................................................................................
2. ...............................................................................................................................................................................
3. ...............................................................................................................................................................................
4. ...............................................................................................................................................................................

PEMERIKSAAN FISIK PASIEN TANDA VITAL

Tekanan darah : ...........mmHg Denyut jantung : ............x/menit Saturasi O2 : .................%
Pernafasan : ...........x/menit Reguler/Irregular : ......................... Tipe : ....................
Suhu : ...........°C
Keadaan Umum : Baik Tampak baik
Sesak Pucat Lemah Kejang Lainnya ................................
Gambar umum lainnya : Nutrisi : ..................................... Oedema : .....................................
Clubing finger : ..................................... Dehidrasi : .....................................
Pucat : ..................................... Jaundice : .....................................

RM : 1r/Rev.1/2019 Asesmen Medis Rawat Inap Gigi dan Mulut I Hal.1

 PEMERIKSAAN FISIK (STATUS INTRA ORAL)
Oklusi : Normal bite / Cross bite / Steep bite
Torus palatines : Tidak ada / kecil / sedang / besar / multiple
Torus : Tidak ada / sisi kiri / sisi kanan / kedua sisi
Mandibularis : Dalam / sedang / rendah
Palatum : Tidak ada/ada ..................................................................................................
Supernumerary : Tidak ada/ada ..................................................................................................
Teeth : Tidak ada/ada ..................................................................................................
Diasterna : ..........................................................................................................................
Gigi anomaly : ..........................................................................................................................
Lain-lain : ..........................................................................................................................

GAMBAR KEADAAN GIGI

PEMERIKSAAN PENUNJANG

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DIAGNOSIS KERJA

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RM : 1r/Rev.1/2019 Asesmen Medis Rawat Inap Gigi dan Mulut I Hal.2

 DIAGNOSIS BINDING (Bila Ada)

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TERAPI

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RENCANA TINDAK LANJUT
Rawat Inap Ruang : ................................................... Indikasi : ..............................
DPJP Rawat Inap : ...................................
Pengantar Pasien : Ada / Tidak* (Bila tidak, rujuk ke Dinas Sosial)
Rujuk ke : RS .................................................. Puskesmas
Dokter keluarga ............................. Dokter .............................................
Homecare
Kontrol Klinik / Homecare di : ..........................................................
Tanggal : ..........................................................

EDUKASI PASIEN
Edukasi Awal, disampaikan tentang diagnosis, Rencana dan Tujuan Terapi kepada :
Pasien
Keluarga pasien, nama : ........................................................................................................................................
Tidak dapat memberi edukasi kepada pasien atau keluarga, Karena ...................................................................

Sragen, .......................................... Jam .............. WIB

DPJP

( ................................. )
Tanda tangan dan nama terang

RM : 1r/Rev.1/2019 Asesmen Medis Rawat Inap Gigi dan Mulut I Hal.3