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Judeul ..................

Nr. nregistrare SC
CNP pacient

Localitatea .....................................................
Spitalul ............................................................

ntocmit de: ...............................................................

Secia ................................................................

parafa medicului

FOAIE DE OBSERVAIE CLINIC GENERAL


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

Data naterii: zi

Domiciliul legal: judeul

Sect.

Mediul U/R

an

Grup sangvin: A/B/AB/0; Rh + / -

Localitatea .......................................................... Alergic la: ..............................................................


Str. ....................................................................... Nr. ...... Data internrii:

ora

lun

an

Reedina: judeul

Localitatea .........................................................................

zi

Sect.

Str. ....................................................................... Nr. ......

Data externrii:

Mediul U/R

Romn

Cetenie:

Strin

ora

....

Greutatea la natere (nou nscui)

grame

lun

zi

Ocupaia: fr ocupaie (1); salariat (2); lucrtor pe cont propriu (3);


patron (4); agricultor (5); elev/ student (6); omer (7); pensionar (8)

an

Nr. zile spitalizare .........................................

Nr. zile c.m. la externare .........................


Locul de munc ..............................................................................
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
Statut asigurat:

Certificat natere (copil) seria

Nr.
Asigurat CNAS

Asig. oblig. CAS

Nr.

Asigurare voluntar

Asig. facultativ CAS

Eurocard

Neasigurat
Acorduri internaionale

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 internare: .................................................................................................................................

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


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

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


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

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


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

Diagnostice secundare la externare (complicaii / comorbiditi):


1. ................................ ................................ ........................................ ................................ ................................ ...........................................
2. ................................ ................................ ........................................ ................................ ................................ ...........................................
3. ................................ ................................ ........................................ ................................ ................................ ...........................................
4. ................................ ................................ ........................................ ................................ ................................ ...........................................
5. ................................ ................................ ........................................ ................................ ................................ ...........................................
6. ................................ ................................ ........................................ ................................ ................................ ...........................................
Semntura i parafa medicului ef
...............................................

Semntura i parafa medicului curant


.......................................................
23.3 A4 t2

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


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

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


medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

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

medic ATI

medic operator III


Data interveniei chirurgicale: zi

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

asistent/

luna

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

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

an

Intervenii chirurgicale concomitente (cu cea principal):


1........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

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

medic ATI

medic operator III

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

asistent/

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

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

2........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

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

medic ATI

medic operator III

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

asistent/

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

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

Alte intervenii chirurgicale:


1........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

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

medic ATI

medic operator III

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

asistent/

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

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

Data interveniei chirurgicale: zi


luna
an
2........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie:

medic operator II

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

medic ATI

medic operator III


Data interveniei chirurgicale: zi

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

asistent/

luna

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

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

an

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


Examen extemporaneu ..................................................................................................... ...................................................................................................
Examen histopatologic (biopsie pies operatorie) .....................................................................................................
...................................

Transfer ntre seciile spitalului:


Secia

Data intrrii (ora) Data ieirii (ora)

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
2

Nr. zile
spitalizare

Diagnostic n caz de deces:


a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................
b. Cauza antecedent .............................................................. .............................................................. .........................................................
I
Stri morbide iniiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................
II

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


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

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


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

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


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

Codul morfologic (n caz de cancer)

Explorri funcionale:
Denumirea

Codul

Nr.

Codul

Nr.

Codul

Nr.

1. .............................................................. ....................................................................................................
2. .............................................................. ....................................................................................................
3. .............................................................. ....................................................................................................
4. .............................................................. ....................................................................................................
5. .............................................................. ....................................................................................................
6. .............................................................. ....................................................................................................

Investigaii radiologice:
Denumirea
7. .............................................................. ....................................................................................................
8. ............................................................. ....................................................................................................
9. ............................................................. ....................................................................................................
10. ............................................................. ....................................................................................................
11. ............................................................. ....................................................................................................
12. ............................................................. ....................................................................................................

Alte proceduri terapeutice:


Denumirea
13. ............................................................. ....................................................................................................
14. ............................................................. ....................................................................................................
15. ............................................................. ....................................................................................................
16. ............................................................. ....................................................................................................
17. ............................................................. ....................................................................................................
18. ............................................................. ....................................................................................................

ALTE OBSERVAII:
1

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

MOTIVELE INTERNRII: .............................................................................................................................................................................................


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

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


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

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

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

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 EXAMENE DE SPECIALITATE ..................................................................................................................................................................


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EXAMENE DE LABORATOR ......................................................................................................................................................................................


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EXAMENE RADIOLOGICE (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,


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

FOAIE DE TEMPERATUR ADULI


CNP

Numele . Prenumele ....


Anul luna Nr. foii de observaie Nr. salon .. Nr. pat ..

Resp.

T.A.

Puls

Temp

Ziua
Zile de boal

35

30

160

41O

30

25

140

40O

25

20

120

39O

20

15

100

38O

15

10

80

37O

10

60

36O

D S

D S

D S

D S

D S D S

D S

D S

D S D S D S D S

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

FOAIE DE EVOLUIE I TRATAMENT


DATA

EVOLUIE

10

TRATAMENT