Professional Documents
Culture Documents
Localitatea
Spitalul
Secia
Nr. nregistrare SC
..................
CNP pacient
.....................................................
............................................................
................................................................
lun
an
Localitatea
.............................................................. Sect.
internrii:
PRENUMELE ........................................................
Sexul M/F
Mediul U/R
Alergic la:
Data
ora
Reedina: judeul
Localitatea
Sect.
Mediul U/R
Cetenie:
Romn
.........................................................................
Strin
zi
lun
an
Data externrii:
ora
zi
an
....
grame
lun
.........................................
.........................
Nivel de instruire: fr studii (1); ciclu primar (2); ciclu gimnazial (3); coal profesional (4); liceu (5)
coal postliceal (6); studii superioare de scurt durat (7); studii superioare (8); nespecificat (9)
C.I / B.I. seria
Nr.
Statut asigurat:
Nr.
Asigurare voluntar
Neasigurat
Categ. asig. CNAS: salariat (1); coasig. (2); pensionar (3); copil<18 ani (4); elev/ucenic/student 18-26 ani (5);
gravid (6) veteran (7); revoluionar (8); handicap (9); PNS (10); ajutor social (11); omaj (12); alte (13)
Tipul internrii: urgen (1); trimit. MF (2); trimit. ambulatoriu (3); transfer interspit. (4); la cerere (5); alte (9)
Criteriu internare: urgen (1); diagnostic (2); tratament (3); nedeplasabil (4) epidemiologic (5); medic ef (6)
Diagnosticul de trimitere: .................................................................................................................................
Diagnosticul la 72 de ore:
.................................................................................................................................................................................................................................................................
23.3 A4 t2
Asigurat CNAS
Asig. oblig. CAS
Eurocard
Acorduri internaionale
.....................................................................................................................................................................
..................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
luna
..........................................................
..............................................................
an
............................................................................................................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
2........................................................................................................................................
medic operator principal
Echipa operatorie:
............................................................................................................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
............................................................................................................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
............................................................................................................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
Examen citologic
luna
..........................................................
..............................................................
an
..................................................................................................... ................................................................................................................
Examen extemporaneu
..................................................................................................... ...................................................................................................
.....................................................................................................
...................................
Diagnostic
Starea la externare: vindecat (1); ameliorat (2); staionar (3); agravat (4); decedat (5)
Tipul externrii: externat (1); externat la cerere (2); transfer interspitalicesc (3); decedat (4)
Deces: intraoperator (1); postoperator: 0 23 ore (2); 24 47 ore (3); > 48 ore (4)
Data i ora decesului:
zi
luna
an
ora
Nr. zile
spitalizare
Diagnostic
a.
b.
I
c.
d.
II
n caz de deces:
Cauza direct (imediat) .............................................................. .............................................................. ..........................................
Cauza antecedent .............................................................. .............................................................. .........................................................
Stri morbide iniiale:
.............................................................. .............................................................. .......................................................................................................
.............................................................. .............................................................. .......................................................................................................
...........................................................................................................................
Microscopic:
Explorri funcionale:
Denumirea
1.
.............................................................. ....................................................................................................
2.
.............................................................. ....................................................................................................
3.
.............................................................. ....................................................................................................
4.
.............................................................. ....................................................................................................
5.
.............................................................. ....................................................................................................
6.
.............................................................. ....................................................................................................
Codul
Nr.
Codul
Nr.
Codul
Nr.
Investigaii radiologice:
Denumirea
7.
.............................................................. ....................................................................................................
8.
............................................................. ....................................................................................................
9.
............................................................. ....................................................................................................
10.
............................................................. ....................................................................................................
11.
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12.
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14.
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15.
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16.
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17.
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18.
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ALTE OBSERVAII:
1
MOTIVELE INTERNRII:
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
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ANAMNEZA:
...........................................................................................................................................................................................................................
a) Antecedente heredo-colaterale
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ISTORICUL BOLII:
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............................................................................................................................................................................................................................................................
.
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.
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Mucoase
....................................................................................................................................................................................................................................
..
.............................................................................................................................................................................................................................................................
Fanere ..........................................................................................................................................................................................................................................
..
esut
conjunctiv-adipos
..................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
..
Sistem
ganglionar
................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................
.
............................................................................................................................................................................................................................................................
.
Sistem
muscular
....................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Sistem
osteo-articular
.......................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................
..
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..
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............................................................................................................................................................................................................................................................
.
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.
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EXAMENE DE LABORATOR
......................................................................................................................................................................................
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EXAMENE ANATOMO-PATOLOGICE:
.............................................................................................................................................................
EPICRIZA:
Temp
Puls
T.A.
Resp.
Ziua
Zile de boal
D S
D S
D S
D S
D S D S
D S
D S
D S D S
D S
35
30
160
41
30
25
140
40
25
20
120
39
20
15
100
38
15
10
80
37
10
60
36
Lichide ingerate
Diurez
Scaune
Diet
D S
D S
D S D S
D S
D S
D S D S D S
D S
D S
D S
D S
D S D S D S
EVOLUIE
10
TRATAMENT