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RSIA UMMI BOGOR
Jl. Empang II no.2 bogor
Telp. : 0251-8341600
STATUS POLI KLINIK
RM. 01
Nama : …………………………………………
Umur : ………………………th/bl/hr ……..L/P
Alamat: ………………………………………….
No. RM :
Pekerjaan : ………………………
TAK TAHAN OBAT
TANGGAL ANAMNESA/ DIAGNOSA KODE
PENYAKIT
TERAPI PARAF/
NAMA JELAS
TANGGAL ANAMNESA/ DIAGNOSA KODE
PENYAKIT
TERAPI PARAF/
NAMA JELAS
RSIA UMMI BOGOR
Jl. Empang II no. 2 Bogor telp. : 0251- 8341600
POLI KLINIK GIGI RM. 14
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Nama L/ P Status Tanggal Lahir
Alamat
Telp Pekerjaan Nama Orang Tua (Pasien Anak)
Cacat Penyakit/ Kelainan dalam Keluarga
Hasil Pemeriksaan gigi & mulut __________________________________Tanggal__________________
Anamnesa ____________________________________________________________________________
TMJ __________________
Tonsil _________________
Bibir _________________
Lidah ________________
Palatum _______________
Gusi __________________
Mukosa Mulut __________
Oklusi _________________
Tekanan Darah __________
Nadi __________________
Ro foto
Gigi _______________________ Tgl. Foto ________________________
Gambaran Radiografis _________________________________________
____________________________________________________________
____________________________________________________________
________ _________________ __________________ ______________________
________ _________________ __________________ ______________________
________ _________________ __________________ ______________________
________ _________________ __________________ ______________________
Perio _________________ __________________ ______________________
Orto _________________ __________________ ______________________
Prosto _________________ __________________ ______________________
Bila dalam perawatan dokter :
dr. _________________ Spesialis_________
Alamat/ Telp _________________________
____________________________________
ALERGI OBAT PENYAKIT JANTUNG
__________________
__________________
__________________
__________________
Catatan
GIGI STATUS KLINIS DIAGNOSA RENCANA PERAWATAN
Tanggal Anamnesa / Diagnosa Kode
Penyakit
Terapi Paraf/
Nama Jelas

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Status rawat jalan poli

  • 1. RSIA UMMI BOGOR Jl. Empang II no.2 bogor Telp. : 0251-8341600 STATUS POLI KLINIK RM. 01 Nama : ………………………………………… Umur : ………………………th/bl/hr ……..L/P Alamat: …………………………………………. No. RM : Pekerjaan : ……………………… TAK TAHAN OBAT TANGGAL ANAMNESA/ DIAGNOSA KODE PENYAKIT TERAPI PARAF/ NAMA JELAS
  • 2. TANGGAL ANAMNESA/ DIAGNOSA KODE PENYAKIT TERAPI PARAF/ NAMA JELAS
  • 3. RSIA UMMI BOGOR Jl. Empang II no. 2 Bogor telp. : 0251- 8341600 POLI KLINIK GIGI RM. 14 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Nama L/ P Status Tanggal Lahir Alamat Telp Pekerjaan Nama Orang Tua (Pasien Anak) Cacat Penyakit/ Kelainan dalam Keluarga Hasil Pemeriksaan gigi & mulut __________________________________Tanggal__________________ Anamnesa ____________________________________________________________________________ TMJ __________________ Tonsil _________________ Bibir _________________ Lidah ________________ Palatum _______________ Gusi __________________ Mukosa Mulut __________ Oklusi _________________ Tekanan Darah __________ Nadi __________________ Ro foto Gigi _______________________ Tgl. Foto ________________________ Gambaran Radiografis _________________________________________ ____________________________________________________________ ____________________________________________________________ ________ _________________ __________________ ______________________ ________ _________________ __________________ ______________________ ________ _________________ __________________ ______________________ ________ _________________ __________________ ______________________ Perio _________________ __________________ ______________________ Orto _________________ __________________ ______________________ Prosto _________________ __________________ ______________________ Bila dalam perawatan dokter : dr. _________________ Spesialis_________ Alamat/ Telp _________________________ ____________________________________ ALERGI OBAT PENYAKIT JANTUNG __________________ __________________ __________________ __________________ Catatan GIGI STATUS KLINIS DIAGNOSA RENCANA PERAWATAN
  • 4. Tanggal Anamnesa / Diagnosa Kode Penyakit Terapi Paraf/ Nama Jelas