KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

RUMAH SAKIT GIGI DAN MULUT

UNIVERSITAS JEMBER
Jl. Kalimantan 37 Kampus Tegal Boto Telp.(0331) 333536, Faks (0331) 331991
JEMBER 68121

KLINIK PENYAKIT MULUT

No. Reg :
Tanggal :
KARTU PERAWATAN
I. DATA PRIBADI
Nama :
Umur :
Jenis Kelamin :
Alamat :
Pekerjaan :
Status Perkawinan :
Kebangsaan/Suku Bangsa :

II. RIWAYAT KASUS

1. Keluhan Utama :....................................
2. Riwayat Penyakit

:.....................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
3. Keadaan Umum
Penyakit yang sedang/pernah diderita :........
(TB/BB:...........Cm/..............Kg., BP:............/.............P:...........T..............ͦC)
Keterangan:.................................................................................................................
4. Obat-obatan yang sedang dan telah dijalani dalam 6 bulan terakhir
5. Keadaan sosial : Baik/cukup/sedang/kurang
 Kebiasaan buruk: merokok/mandi di sungai/mengunyah sirih/alkohol/obat-obatan
6. Riwayat Keluarga:
Riwayat Penyakit:.........................................................................................................
Hubungan dengan penderita:......................................................................................
PEMERIKSAAN KLINIS

1. EKSTRA ORAL
a. Muka
a.1. Pipi Ka / ki : .............................................................................
a.2. Bibir Atas / Bawah : ..............................................................................
...................................................................................................................................
a.3. Sudut Mulut Ka / Ki : ..............................................................................
...................................................................................................................................
b. Kelenjar Saliva
b.1. Kelenjar Parotis Ka / Ki : .............................................................................
b.2. Kelenjar Submandibularis : .............................................................................
c. Kelenjar Limfe
c.1. Kelenjar Leher : ................................................................
c.2. Kelenjar Submandibularis : ................................................................
c.3. Kelenjar Pre dan Post Auricularis : ................................................................
c.4. Kelenjar Submentalis : ................................................................

2. INTRA ORAL

Riwayat Perawatan Gigi Geligi : ..........................................................................

..........................................................................
a. Mukosa Labial Atas (5) : ..........................................................................
Bawah (6) : ..........................................................................
b. Mukosa Pipi Kiri (41), (4), (3) : ..........................................................................
Kanan (40), (2), (1) : ..........................................................................
c. Bucal Fold Atas (9), (7) : ..........................................................................
Bawah (10), (12) : ..........................................................................
d. Gingiva Rahang
Atas (13), (14), (15), (19), (20), (21) : .....................................
: .........................................................................................................
Bawah (16), (17), (18), (22), (23), (24) : .....................................
e. Lidah (28), (29), (30), (31), (32), (33), (34), (35) : .....................................
f. Dasar Mulut dan Kelenjar sub Lingualis : .............................................................
..................................................................................................................................
g. Palatum (36), (37), (38), (39) : .........................................................................
h. Tonsil Ki / Ka : .........................................................................
i. Faring : .........................................................................
IV. DIAGNOSIS SEMENTARA

V. RENCANA PERAWATAN

1. KIE

2. Medikasi

2. Pemeriksaan Penunjang

 Lab. Rontgenologi Mulut / Radiologi

 Lab. Patologi Anatomi
 Sitologi
 Biopsi
 Lab. Mikrobiologi
 Bakteorologi
 Jamur

3. Rujukan
 Poli Penyakit Dalam
 Poli THT
 Poli Kulit Kelamin
 Poli Saraf

 Lab. Bedah Mulut

 Lab. Periodontia
 Lab. Pedodontia
 Lab. Konservasi Gigi Tumpatan
 Lab. Endodontia
 Lab. Gigi Tiruan Lepasan
 Lab. Gigi Tiruan Jembatan
 Lab. Ortodontia
 Lain – Lain (sebutkan)

VI. DIAGNOSIS AKHIR

 Nama Operator : ......................

Tanda tangan Instruktur : ......................

Daerah Jaringan Lunak yang mengalami kelainan harap diarsi

KLINIK PENYAKIT MULUT

 LEMBAR PERAWATAN
Tanggal Keterangan Paraf