No/ Tanggal

Nama

Nomor RM
Alamat

umur

sex
1.1 L

kunjungan
B
L

diagnosa
U

tumpatan
tetap gigi
permanen
IH AP AS U

tumpatan
teap gigi
sulung
IH AP AS U

cabut gigi
tetap
IH AP AS U

cabut gigi
sulung
IH AP AS U

tambalan
sementara
IH AP AS U

pengobat an
pulpa
IH AP AS U
IH
scalling
 r
u

pengunjung
perawatan
j
scalling u
lain-lain

k obat ket
a
n
AP AS U IH AP B L dari ke
 tgl/no

20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Nama
Alamat

umur

sex
B L

kunjungan
B L

diagnosa

tumpatan
tetap gigi
permanen

tumpatan
teap gigi
sulung

cabut gigi
tetap

cabut gigi
sulung

tambalan
sementara

pengobat
an pulpa
U IH AP AS U IH AP AS U IH AP AS U IH AP AS U IH AP AS U IH AP
 perawatan
an pulpa

lain-lain
scalling rujukan
obat ket

AS U IH AP AS U IH AP AS dari ke
 kelengkapan RM
PERAWATAN LAIN
kunjungan

SCALLING
Biaya
umur
TGL/ Tumpatan

Sex
NO Nama Alamat Tumpatan Sementar
Tetap a EXO
B L S P S P S P
Informed Consent

RUJUKAN
obat ket

dari ke