ANEXA 8 A

- model - Furnizor de servicii medicale ....................................

Medic ............................................................

Specialitatea ....................................................

Contract ncheiat cu Casa de Asigurri de Sntate ...............

Nr. contract .....................................................

FIA DE MONITORIZARE

n cazul bolnavilor cronici n ambulatoriul de specialitate pentru specialitile clinice i reabilitare medical Nume: ..................... Prenume: .............................

Data naterii:

..................................................................

_ _ _ _ _ _ _ _ _ _ _ _ _

Cod numeric personal: |_|_|_|_|_|_|_|_|_|_|_|_|_|

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Cod unic de asigurare: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|

Sex: M/F

Adresa: .....................................................

Diagnostic: .................................................

Data lurii n eviden: ....................................

Comorbiditi: ..............................................

Factori de risc: ............................................

______________________________________________________________________

| Data | Data | Concluzii/Recomandri/Tratament | Semntura,|

| programrii| realizrii| | parafa i |

| Examinri | | | tampila |

| clinice | | | |

|____________|___________|_________________________________|___________|

| | | | |

|____________|___________|_________________________________|___________|

| | | | |

|____________|___________|_________________________________|___________|

| | | | |

|____________|___________|_________________________________|___________|

| | | | |

|____________|___________|_________________________________|___________|

Investigaii paraclinice

______________________________________________________________________

| Tip | Data | Rezultat/Data | Semntura,|

| investigaie| programrii | efecturii/Concluzii | parafa i |

| | | | tampila |

|_____________|_____________|______________________________|___________|

| | | | |

|_____________|_____________|______________________________|___________|

| | | | |

|_____________|_____________|______________________________|___________|

| | | | |

|_____________|_____________|______________________________|___________|

| | | | |

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