NAME : HESTINING YUNIAR PRATIWI

NIM : P07125119014
PRODI : D3 Kesehetan Gigi

POLYTECHNIC HEALTH MINISTRY OF YOGYAKARTA

DENTAL NURSING DEPARTEMENT

KYAI MOJO STREET NO.56 PINGIT YOGYAKARTA

OPERATOR NAME :............................... CARD NUMBER :.............................

NIM :............................... DATE :.............................

DENTAL AND ORAL RECORDING CARD AT THE CLINIC

A. ASSESSMENT
1. Pasien Identity

Complete Name : …………………………………… ….... Gender :M/F

Place, date of Birth : ……………………………………....... Religion : ………….............................

Profession : …………………………………… ….... Nationality : ………….............................

Address : ……………………………………........ Phone Number :.........................................

Vital Sign
Blood pressure : ...................... height : ......................
pulse : ...................... weight : ......................
temperature : ......................

2. Patient Complaint
1). Main complaint :

2). Additional complaint :

2. General Medical History :

ANALYSIS Yes No

The patient feels well

During the last 5 years, has the patient been diagnosed with a serious illness, underwent surgery and or
was hospitalized?
If YES ... state the name of the disease:.....
The patient has a blood clotting abnormality
The patient has an allergic reaction to the following:
- Food .............................................................
- Medicine .....................................................
- anesthesia .................................
- weather , and others .................................................................
The patient is currently under treatment/ taking the prescribed medication/ not prescribed by the Doctor/
Dentist
4. History of Dental Health:
YES NO

1. The patient had previous dental work

2. If you have been treated before, has the treatment experience been unsatisfactory or made you anxious /
afraid to be re-examined?
3. Patients know how to maintain good and correct oral health
4. Patients brush their teeth at least 2 times a day after breakfast and before going to bed at night
5. The patient brushes his teeth in a correct, precise and accurate manner
6. The patient reduces sweet and sticky foods
7. Patients eat more fibrous fruits and vegetables
 8. The patient has the following habits:
- Drink tea / coffee
- Drinking alcohol
- soft drink
- Smoke
- Chew one side
- Chewing betel / tobacco
- Chewing on hard objects
- Bruxism

5. Extra Oral Examination :

Face : Symmetrical / asymmetrical
Limpe Gland: Right Left
Palpable / not palpable Palpable / not palpable
Hard / Soft Hard / Soft
It hurts / doesn't hurt
It hurts / doesn't hurt
6. Intra Oral Examination :
1) Dental Checkup
a) Caries Experience Index
def-t : DMF-T :
D = D = c) Community Periodontal Index of
Treatment Needs (CPITN)
E = M =
F = F =
def-t= DMF-T =

b) Oral Hygiene Index

Debris Index Calculus Index

OHI-S Score : OHI-S Criteria :

c) Dental Hard Tissues Examination ( Including Calculus )

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

55 54 53 52 51 61 62 63 64 65

85 84 83 82 81 71 72 73 74 75

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Tooth Inspeksi Thermis Sondasi Perkusi Druk Mobiliti Diagnosis

d) Oral Mucosa Examination :
1. Tongue :

2. Cheek :

3. Lips :

4. Palate :

5. Gum :
Abnormalities that are found:

Location Consistency Papilled Form Margin Form

Tooth buccal palatal labial lingual Chewy Tender Pointed Rounded normal abnormal Color Diagnosis

e) Tooth abnormalities / anomalies

1. Shape :

2. Amount :

3. Size :

4. Position :
5. Color :
f) Informed Consent :

The undersigned below :

I am, the patient:

Name : ................................................ ...............
Age : ................................................ ................
Address : ................................................ ................

Patient's Parents / Guardians:

Name : ................................................ ................
Age : ................................................ ................
Address : ................................................ ................

Declare that they have received information regarding the examination and treatment that will be carried out on me
/ my child, with possible side effects, the number of visits that must be carried out and the costs to be paid for the
examination and treatment in question.
Furthermore, I gave approval to the dental nurse who was appointed to carry out the action of dental nursing care
for me / my child according to what had been explained to me previously.
This consent is given with full awareness of the possible side effects of the actions mentioned above.

Thus, this statement letter is made with a true and full of responsibility

Bukittinggi .........................

That states Parents / Guardians of Patients Witness

Patient

( ............................. ) ( ............................. ) ( ............................. )

Dentist statement:
I declare that I have explained the nature and purpose as well as the possible consequences that will arise from
this dental treatment to the patient himself / his / her parents / guardian / wife / husband / other family except
for the unconscious patient / mental disorder.
Bukittinggi ..................................
That states
Operators (Dental Nurses / Students)

( ................................................ )
B. DIAGNOSIS
(DENTAL NURSING DIAGNOSIS)

DATA PROBLEM POSSIBLE CAUSE

3.6 = The tooth hole Pain - Poor oral hygiene
reaches the dentin on - The wrong way to brush your teeth
the occlusal surface - Cariogenic dietary habit
(Sondasi; - termis; - - Never did routine dental check
etc. - Untreated caries reaches the enamel

The patient does not feel - Untreated caries reaches the pulp
4.7 = the hole reaches pain - Poor oral hygiene
the root - Never had a routine dental check
(percussion; - mobility;
-)

- Untreated caries reaches the dentin

3.5 The tooth hole The patient feels intense - Poor oral hygiene
reaches the pulp pain and pain - Cariogenic dietary habit

2.5 The tooth cavity No complaints - Poor oral hygiene

reaches the enamel on - Cariogenic dietary habit
the buccal surface - Never do routine dental check

- Poor oral hygiene

Teeth 4.4, 4.5, 4.6, 4.7 Calculus - Never do routine dental checks
contained tartar - Improper toothbrush

C. NURSING INTERVENTION PLANNING

1. INTERVENTION PLANNING
COUNSELING (According to
CLINICAL ACTION
the cause of the problem)
Tooth of 3.6 will do Counseling about:
- Patching using Fuji - The importance of
IX / GI maintaining healthy
teeth and mouth
HOME DENTAL CARE
INSTRUCTION
- Given instructions on how to brush
teeth correctly
- Leaflets were given
- Check your teeth at least every 6
months
- After eating at least gargle your
mouth
- Reducing cariogenic foods
- Brushing your teeth properly and
correctly

Tooth 4.7 is The result of a - Immediately make a referral

referrenced to the gangrenous tooth that
Exodonti section was not pulled out

Tooth 3.5 is
referrenced to the Due to dental caries - Brushing teeth right / right
conservation section that were not filled
Tooth 2.5 will do The result of un-patched
patching with GI caries -Good and correct toothbrush
-Reducing cariogenic foods

Teeth 4.4, 4.5, 4.6, Causes of calculus and Effects Brushing the right and proper teeth
4.7 are scaled of calculus that is not cleared At least gargle after eating
Check your teeth every 6 months

2. MAINTENANCE OBJECTIVES AND TREATMENT TIME

PURPOSE HOW TO EVALUATE TREATMENT TIME

Implementation of the Recheck with articulating
tooth 3.6 is filling with paper
purpose :
- Stops the Assessed how to brush his 1st visit (date? ....)
demineralization teeth
process
- Reduce pain interviewed
- Restores the
anatomical shape
and function of
teeth
- Change patient
behavior

D. IMPLEMENTATION OF TREATMENT AND EVALUATE

COUNSELING/INTRU
VISIT TO : CLINICAL CARE EVALUATE RESULT
CTION
Filling teeth 3.6 It is already done The patch is good (the
1 with GI - The importance of patient feels comfortable)
treating teeth with cavities
Patients already know how
to brush their teeth
 ………………………………20……

SUPERVISIOR DENTAL NURSE: IMPLEMENTING DENTAL NURSE

(…………………………...........) (…………………………...........)

NURSING IMPLEMENTATION RECORDING

THE
NO DAY/DATE DIAGNOSIS ACTION
LEADERSHIP