KLINIK PRATAMA RH MEDICA

Jl. Trunojoyo No. 43 Penjalinan Gondanglegi Kulon – Malang No Tlp. (0341) 8571808 / 08113501867

RM.01 c1
ODONTOGRAM

NAMA PASIEN : ……………………………………………………………… NO. RM :

NIK : PEKERJAAN : ………………………….

KEPALA KELUARGA : …………………………………… IBU : …………………………………… ALERGI :

TANGGAL LAHIR :

JENIS KELAMIN : LAKI – LAKI PEREMPUAN

TRIAGE :
AGAMA : ISLAM KRISTEN KATOLIK HINDU BUDHA ……….. P1
P2
STATUS PASIEN : UMUM ASKES BPJS NON PBI BPJS PBI
P3
NO. BPJS/ASKES : P0

ALAMAT : ………………………………………………………………. NO TELPON : ……………………………...................

TMJ :......................................................

Tonsil :......................................................

Bibir :......................................................

Lidah :......................................................

Palatum :......................................................

Gingiva :......................................................

Mokusa Mulut :......................................................

Orofaring :......................................................

: Tambalan Amalgam = amf : Tambalan Amalgam pada gigi non : Full metal bridge 3 units. (meb)
vital = Root Canal Filling ( amf - (masing-masing gigi dijelaskan,
: Tambalan Composite (di arsir) (cof) rct) Pontic =PON)
: Di arsir
: Tambalan Composite pada gigi : Porcelain bridge 4 units (pob)
: pit dan fissure sealant = (fis) non-vital = Root Canal Filling
(cof - rct)
: gigi non-vital (nvt)

: Perawatan Saluran Akar (rct)
: gigi tidak ada, tidak diketahui ada
atau tidak ada. (non)
: Un-Erupted (une)
: Partial Erupt (pre)
: Normal/ baik (sou)
: Full metal crown pada gigi vital : full metal cantilever bridge (meb)
(fmc)
: Partial Denture/ Full Denture
: Full metal crown pada gigi non- (frm =Frame;acr = Acrylic)
vital (fmc-rct)
: Migrasi/ Version/Rotasi dibuat
: Porcelain crown pada gigi vital panah sesuai arah
(poc)
: Porcelain crown pada gigi non
vital (poc-rct)

: Anomali (ano)
: Sisa Akar (rrx)
Pegshaped, micro, fusi, etc

: Caries Tambalan sementara (car)

(garis batas caries dibuat sesuai : Gigi hilang (mis)
posisi caries, dan di posisi caries
ditulis di tabel, misal O-car)

: fracture (cfr) : Implant + Porcelain crown

(ipx - poc)
NAMA PASIEN : ………………………………………………………………
: Tambalan Amalgam = amf
: Tambalan Composite (di arsir) (cof)
: Di arsir
: pit dan fissure sealant = (fis)
: gigi non-vital (nvt)
: Perawatan Saluran Akar (rct)
: gigi tidak ada, tidak diketahui ada
atau tidak ada. (non)
: Un-Erupted (une)
: Partial Erupt (pre)
: Normal/ baik (sou)
: Anomali (ano)
Pegshaped, micro, fusi, etc
: Caries Tambalan sementara (car)
(garis batas caries dibuat sesuai
posisi caries, dan di posisi caries
ditulis di tabel, misal O-car)
: fracture (cfr)
NO. RM :
TMJ :......................................................
Tonsil :......................................................
Bibir :......................................................
Lidah :......................................................
Palatum :......................................................
Gingiva :......................................................
Mokusa Mulut :......................................................
Orofaring :......................................................
: Tambalan Amalgam pada gigi non : Full metal bridge 3 units. (meb)
vital = Root Canal Filling ( amf - (masing-masing gigi dijelaskan,
rct) Pontic =PON)
: Tambalan Composite pada gigi : Porcelain bridge 4 units (pob)
non-vital = Root Canal Filling
(cof - rct)
: Full metal crown pada gigi vital : full metal cantilever bridge (meb)
(fmc)
: Partial Denture/ Full Denture
: Full metal crown pada gigi non- (frm =Frame;acr = Acrylic)
vital (fmc-rct)
: Migrasi/ Version/Rotasi dibuat
: Porcelain crown pada gigi vital panah sesuai arah
(poc)
: Porcelain crown pada gigi non
vital (poc-rct)
: Sisa Akar (rrx)
: Gigi hilang (mis)
: Implant + Porcelain crown
(ipx - poc)