ANEXA 8 A
2
ANEXA 8 A - model - Furnizor de servicii medicale .................................... Medic ............................................................ Specialitatea .................................................... Contract încheiat cu Casa de Asigurări de Sănătate ............... Nr. contract ..................................................... FIŞA DE MONITORIZARE în cazul bolnavilor cronici în ambulatoriul de specialitate pentru specialităţile clinice şi reabilitare medicală Nume: ..................... Prenume: ............................. Data naşterii: .................................................................. _ _ _ _ _ _ _ _ _ _ _ _ _ Cod numeric personal: |_|_|_|_|_|_|_|_|_|_|_|_|_| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Cod unic de asigurare: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| Sex: M/F Adresa: ..................................................... Diagnostic: ................................................. Data luării în evidenţă: .................................... Comorbidităţi: .............................................. Factori de risc: ............................................ ______________________________________________________________________ | Data | Data | Concluzii/Recomandări/Tratament | Semnătura,| | programării| realizării| | parafa şi | | Examinări | | | ştampila | | clinice | | | | |____________|___________|_________________________________|___________| | | | | | |____________|___________|_________________________________|___________| | | | | | |____________|___________|_________________________________|___________| | | | | | |____________|___________|_________________________________|___________| | | | | | |____________|___________|_________________________________|___________| Investigaţii paraclinice ______________________________________________________________________ | Tip | Data | Rezultat/Data | Semnătura,| | investigaţie| programării | efectuării/Concluzii | parafa şi | | | | | ştampila | 99
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Anexa 8A la Norme 2015
Transcript of ANEXA 8 A
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 |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|
| | | | |
|_____________|_____________|______________________________|___________|PAGE 99
