Foaie Obsv l Gen !!!!

8/22/2019 Foaie Obsv l Gen !!!!

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Judeul .................. Nr. nregistrare

Localitatea Bucuresti. CNP

Spitalul Clinic Colentina.ntocmit de: ...............................................................

parafa mediculuiSecia ................................................................

F O A I E D E O B S E R V A I E C L I N I C G E N E R A L

Statut pacient: Asigurat CNAS Neasigurat CNAS Nr. carnet asigurat

Casa de asigurare judeean Transporturi CASAOPSNAJ Talon pensie

Tipul internrii: urgen (1); trimitere medic de familie (2); trimitere medic specialist ambulatoriu (3);transfer interspitalicesc (4); la cerere (5); alte (9)

Diagnosticul de trimitere: ..................................................................................................................................................................................................

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Diagnosticul la internare: ...................................................................................................................................................................................................

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Semntura i parafa medicului................................................

Diagnosticul la 72 de ore: .............................. ................................ ................................ ................................ ................................ ...............................................................................................................................................................................................................................................................................................

Diagnosticul principal la externare:................................ ................................ ............................. ...............................................

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Diagnostice secundare la externare (complicaii / comorbiditi):

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8. ................................ ................................ ........................................ ................................ ................................ ................................ .................

Semntura i parafa medicului ef Semntura i parafa medicului curant............................................... . ................................................

NUMELE ..................................................................................... PRENUMELE .......................................................................... Sexul M/F

Data naterii: zi lun an Grup sangvin: A/B/AB/0; Rh + / -

Domiciliul legal:judeul Localitatea ............................................... Alergic la: ..............................................................

Sect. Mediul U/R Str. ...................................................................... Nr. ...... Data internrii: ora

Reedina: judeul Localitatea ......................................................................... zi lun an

Sect. Mediul U/R Str. ...................................................................... Nr. ...... Data externrii: ora

zi lun anOcupaia ............................................................................................................................................. Nr. zile spitalizare ..........................................

Locul de munc ........................................................................................................................ Nr. zile c. m. la externare .........................

C.I / B.I. seria Nr. Certificat natere (copil) seria Nr.


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Intervenia chirurgical principal:.......................................................................................................................................................................................................................................................................................................................................................................................................................................

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Consimmntul pentru intervenie: ...........................................................................................................................................................................

Echipa operatorie:

medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................medic operator III .......................................................... asistent/ ..............................................................

Data interveniei chirurgicale: zi luna an

Intervenii chirurgicale concomitente (cu cea principal):1. ..................................................................................................................................................................................................................

Echipa operatorie:


medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

2. ..................................................................................................................................................................................................................

Echipa operatorie:



medic operator III .......................................................... asistent/ ..............................................................

Alte intervenii chirurgicale:1. ..................................................................................................................................................................................................................

Echipa operatorie:


medic operator II ........................................................... medic ATI ..........................................................medic operator III .......................................................... asistent/ ..............................................................

Data interveniei chirurgicale: zi luna an

2. ..................................................................................................................................................................................................................

Echipa operatorie:



medic operator III .......................................................... asistent/ ..............................................................Data interveniei chirurgicale: zi luna an

Examen citologic ..................................................................................................... ................................................................................................................

Examen extemporaneu ..................................................................................................... ...................................................................................................

Examen histopatologic (biopsie pies peratorie) ..................................................................................................... ...................................

Transfer ntre seciile spitalului:Secia Data intrrii (cu ora) Data ieirii (cu ora) Nr. zile spit.

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)


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Data i ora decesului: zi luna an oraDiagnostic n caz de deces:

I

a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................b. Cauza antecedent .............................................................. .............................................................. .........................................................

Stri morbide iniiale:c. .............................................................. .............................................................. .......................................................................................................

d. .............................................................. .............................................................. .......................................................................................................

II Alte stri morbide importante .............................................................. .............................................................. ........................................

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Diagnostic anatomo-patologic (autopsie), macroscopic: ......................................................................................................................................................................................... ..................................................................................................................... .............................................................................

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Microscopic: .............................................................. ..................................................................................................................... ......................................................................................................... ..................................................................................................................... .............................................................................

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Codul morfologic (n caz de cancer) M

Explorri funcionale:Denumirea Codul Nr.

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Investigaii radiologice:Denumirea Codul Nr.

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ALTE OBSERVAII:

1 2 3 4 5 6 7 8 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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MOTIVELE INTERNRII: .............................................................................................................................................................................................

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ANAMNEZA: ...........................................................................................................................................................................................................................

a) Antecedente heredo-colaterale ..........................................................................................................................................................

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b) Antecedente personale, fiziologice i patologice ................................................................................................................

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c) Condiii de via i munc .....................................................................................................................................................................

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d) Comportamente (fumat, alcool etc.)

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e) Medicaie de fond administrat naintea internrii (inclusiv preparate hormonale i imunosupresoare

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ISTORICUL BOLII: ..............................................................................................................................................................................................................

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EXAMENUL CLINIC GENERAL.............................................................................................................................................................................EXAMEN OBIECTIV.........................................................................................................................................................................................................Starea general ...................................................................................................... Talie ....................................... Greutate ...............................Starea de nutriie .................................................................................. Starea de contien ............................................................................Facies .............................................................................................................................................................................................................................................Tegumente .................................................................................................................................................................................................................................

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Mucoase ......................................................................................................................................................................................................................................

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Fanere ............................................................................................................................................................................................................................................esut conjunctiv-adipos ..................................................................................................................................................................................................

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Sistem ganglionar................................................................................................................................................................................................................

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Sistem muscular.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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Sistem osteo-articular.......................................................................................................................................................................................................

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APARAT RESPIRATOR...................................................................................................................................................................................................

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APARAT CARDIOVASCULAR..................................................................................................................................................................................

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APARAT DIGESTIV ...................................................................................................................................................................................................

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FICAT, CI BILIARE, SPLINA...................................................................................................................................................................................

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APARAT URO-GENITAL ...............................................................................................................................................................................................

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SISTEM NERVOS, ENDOCRIN, ORGANE DE SIM .................................................................................................................................

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EXAMEN ONCOLOGIC: .................................................................................................................................................................................................

1. Cavitatea bucal............................................................................... ............................................................................... ...............................................2. Tegumente ............................................................................... ............................................................................................ ..............................................3. Grupe ganglioni palpabile ............................................................................... ............................................................................... ........................4. Sn ............................................................................... ............................................................................................................. ...............................................5. Organe genitale feminine ............................................................................... ............................................................................... .........................

6. Citologia secreiei vaginale............................................................................... ............................................................................... .........................7. Prostat i Rect ....................................................................................................... ............................................................................... .........................8. Alte ............................................................................... .................................................................................................................................. .........................

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ALTE EXAMENEDE SPECIALITATE ..................................................................................................................................................................

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EXAMENEDE LABORATOR......................................................................................................................................................................................

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EXAMENERADIOLOGICE (rezultate) .................................................................................................................................................................

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EXAMENE ECOGRAFICE (rezultate) ...................................................................................................................................................................

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INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):

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EXAMENE ANATOMO-PATOLOGICE: .............................................................................................................................................................

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SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:

CLINIC: ..................................................................................... ............................................................................... ..................................................

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PARACLINIC: ....................................................................... ............................................................................... ...................................................

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EPICRIZA: ...................................................................................... ............................................................................... ...........................................................

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Semntura i parafa medicului,


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F O A I E D E T E M P E R A T U R A D U L I

CNP

Numele.Prenumele....

AnullunaNr. foii de observaieNr. salon..Nr. pat..

ZiuaZile de boal

Resp.

T.A.

Puls

Temp

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 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

35 30 160 41O

30 25 140 40O

25 20 120 39O

20 15 100 38O

15 10 80 37O

10 5 60 36O

Lichide ingerateDiurezScauneDiet


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