1ST ASSIGNMENT ENGLISH

MEDICAL RECORD

ARRANGED BY :

TANIA HARTATI RAHMAN

093STYC17

YAYASAN RUMAH SAKIT ISLAM NUSA TENGGARA BARAT

SEKOLAH TINGGI ILMU KESEHATAN YARSI MATARAM
PROGRAM STUDI KEPERAWATAN JENJANG S1
MATARAM
2020
 Medical Record
1. No. RM : show no. patient identity that is personal                           
2. Name : contains the patient's full name                           
3. Date of birth : contains the complete date of birth of the patient ( date / month / year)
4. Age : contains the age of the patient                           
5. Address : contains the full address of the patient along with the telephone number
that is easiest to contact             
6. Type Gender : contains the type of sex that is appropriate to the patient              
7. Complaints main (CC) : contains the reason patients request treatment that involves
aspects of motivation of patients coming              
Example : patients come to RSGM of their own volition with complaints of feeling
their teeth are dirty and disturbing comfort when eating
8. The state of pain now (PI) : contains the condition of the patient at the time of
coming              
Example : the patient did not complain of a sense of pain and ready to do
maintenance cleaning of coral teeth
9. History of health family : contains a history of the health of families of patients
which consists of a history of health public and the health of teeth              
Example :
Teeth : Father using dental mock most jaw up from 1.5 in the past ; Mother never
done odontektomi tooth molars three right down approximately 3 years of the past .
General : Father has a history of gout ; Hypotensive mother
10. History of health common : contains a history of the health of the general who never
experienced by patients              
Example : patient ever treated in hospital for typhoid approximately 6 months of the
last
11. History of health of teeth : contains a history of the health of the teeth that never
experienced by patients              
Example : the patient never sews tooth molars first right down approximately 2
years the last
12. Prevention of diseases of teeth : contains the effort - an effort that has been done the
patient to prevent the occurrence of diseases of teeth , such as for example the
frequency of brushing teeth , application of topical fluoride , consume tablets
fluorine or mouthwash - gargle solution of fluorine.
13. Examination objective : contains columns inspection is an objective in the system of
the body, extraoral, and intraoral. The body system consists of endokrine ,
gastrointestinal, hematopoietic , cardiovascular , musculoskeletal , neurological ,
respiratory , urogenital. Examination ektraoral consists of a head / face , neck , skin ,
nose , eyes , lips , ears , musculoskeletal system of mastication , glands kudah , and
lymphatics . Intraoral consists of network software , mucosa , tongue , gums , sky -
sky , network hardware , occlusion , and odontogram              
 
ACTION SHEET
1. No. RM
2. The identity of the patient ( name , date of birth , age , address , and type of sex )
3. Column examination that contains the date and time of the examination , the
element gear that will do the action , history taking, examination of the
objective, diagnosis, plan of care and treatment are carried out , as well as the
initials and name bright examiner
4. Sheet action must be filled in full accordance with the actions and care that is
given to patients as evidence of care and accountability of operators who provide
care . The action sheet is filled out by the operator / doctor who performed the
examination .
 
CARE CONTROL SHEET
1. No. RM
2. The identity of the patient ( name , date of birth , age , address , type of sex )
3. Column examination which consists of the date and time of inspection , the
problem / diagnosis, ICD, action / maintenance , code procedures dental, initials
and name bright examiner
Sheet control of care required by the assistant operator / nurse
SUPPORTING INVESTIGATION
1. No. RM
2. The identity of the patient ( name , date of birth , age , address , type of sex )
3. Examination of supporting diagnostic / laboratory : containing the results of the
examination lab that has been done by the patient
4. Examination radiography : provides an overview radiographs were visible on
radiographs of patients
5. Summary of examination results : contains a summary of examination results
complete with work diagnosis
6. Plans treatments : contains a plan of care , action , rehabilitation , education ,
assessment and action further
 
SHEET CONSULTATION
In the form of a letter to a colleague to consult a case with a patient who was
sent without including attachments to other medical records . The consultation sheet
contains no. RM, the identity of the patient ( name , date of birth , age , address , type of
sex ), place , date , and time of writing , the name bright friends colleagues were
intended , an overview of the clinical and laboratory brief , consultations were requested
, a sign of the hand and the name of bright writers and supervisor.
 
SHEET INFORMED CONSENT
Contains statements approval of the patient to do the treatment . The informed
consent form can be filled in by the patient himself or can be filled in by the
accompanying family . Sheets informed consent is accompanied by signs hands and
name the light of which makes the statement , the witness of families , physicians who
perform an act , as well as witnesses of home sickness related . The informed consent
sheet also contains no. RM and identity complete patient Sertan who made the
statement.
 
PERIODONTAL CHART
Contains no. RM, the identity of the patient ( name , date of birth , age , address , type
of sex ), complaint major , history of illness general , history of disease gear , and a
history of the disease periodontal experienced by the patient .
 
PHYSICAL EXAMINATION
1. Extraoral examination                            
a. Head : symmetrical / not , there is a lump / no , there is a wound / not             
b. Neck : starting from the part below the ear . There is a lump / no , there is a
wound / not             
c. Face : symmetrical / not                                         
d. TMJ : symmetrical / no , no clicking / no                                                       
2. Intraoral examination                           
a. The mucosa of the tongue : shape , color , and papilla normal / not , there are
lesions / no              
b. The mucosa of the palate : tone Palatines normal / no                            
c. Mucosa of the cheek : color normal / no , there sprue / no                                          
d. Lip mucosa : normal / not frenulum                            
e. Dental teeth : 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8                                          
8 7654321 12345678
3. Gingiva                                                       
a. Color : normal / not (coral pink)                                         
b. Texture : there is stipling / not                                         
c. Shape : correspond with less contour gear / no                                         
d. Consistency : chewy / hard                                         
e. BOP : yes / no to the use of probe                                                       
f. Gingival pocket : present / not                            
g. Recession : there / no                                         
4. Periodontal tissue                           
a. Periodontal Poket : present / not                           
5. Examination of hygiene mouth : consists of the examination of debris and
inspection calculus              
6. Temporary diagnosis :                           
7. Final diagnosis :                                         
8. Prognosis :                                                       
9. Plans treatments : contains a plan of care , action , rehabilitation , education ,
assessment and action further