FORMATO REPORTE INDIVIDUAL DE FUGAS

ENF-11-V1

PAGINA 1 DE 1

NOMBRE DEL ASISTIDO: ________________________________________________________

FECHA: _____________ HORA: ____________ SERVICIO: ____________________________
CC: __________________________ EPS: ___________________________________________
SITIO DE LA FUGA: _____________________________________________________________
DESCRIPCIN DE LA SITUACIN:_________________________________________________
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SE INFORMAA
JEFE DE TURNO: _______________________________________________________________
PSIQUIATRA DE TURNO O TRATANTE: ____________________________________________
SUBDIRECCION CIENTIFICA: ____________________________________________________
AUDITORIA INTERNA: __________________________________________________________
AUTORIDADES: ________________________________________________________________
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TRABAJO SOCIAL EN CASO DE NO LOCALIZAR EL ASISTIDO: _______________________
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NOMBRE DEL FAMILIAR: ________________________________________________________
PARENTESCO: _________________________ TELFONO: ____________________________
MEDIDAS PREVENTIVAS TOMADAS: ______________________________________________
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MEDIDAS CORRECTIVAS: _______________________________________________________
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SEGUIMIENTO DEL CASO
24 HORAS: ____________________________________________________________________
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48 HORAS: ____________________________________________________________________
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72 HORAS: ____________________________________________________________________
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OTROS:_______________________________________________________________________
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INFORMA: ________________________________
FIRMA: ______________________
CARGO: __________________________________