PEMERINTAH KABUPATEN SRAGEN

RUMAH SAKIT UMUM DAERAH SUKOWATI

Dk.Brakbunder Desa Katelan, Kecamatan Tangen, Kabupaten Sragen
SRAGEN

POLI GIGI DAN MULUT

No. Rekam Medis : - -

Nama Pasien :......................................................................................................
Tanggal Lahir : .........../........./.............. Umur :.......................Tahun/ Bulan/ Hari
Jenis Kelamin : Laki- laki / Perempuan

Skala Nyeri:

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

TidakNyeri NyeriRingan NyeriSedang NyeriBerat

DATA MEDIS
1 Gol darah : ……………..
.
2 Penyakit jantung : ……………..
.
3 DM : ……………..
.
4 Haemopili : ……………..
.
5 Hepatitis : ……………..
.
6 Gastritis : ……………..
.
7 Penyakit lain : ……………..
.
8 Alergi : Obat : …… Makanan :…..
.
 TERAPI
Tgl / Jam
Anamnesa, Riwayat penyakit,Skala nyeri, Rujuk Ke/
Pemeriksaanfisik, Diagnosa(Kode ICD 10) Rujuk Balik
Rujukan danHasilkonsultasi
Tanda Tangan
dari
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