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

Nr. nregistrare

Localitatea Bucuresti.

CNP

Spitalul Clinic Colentina.

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

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

parafa medicului

FOAIE DE OBSERVAIE CLINIC GENERAL

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

Data naterii: zi

lun

Domiciliul legal:
judeul
Sect.

Mediul U/R

an

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

Localitatea ...............................................
Str. ......................................................................

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

Nr. ......

Data internrii:

Reedina: judeul

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

zi

Sect.

Str. ......................................................................

Data externrii:

Mediul U/R

Nr. ......

ora

lun

an
ora

zi
lun
an
Ocupaia ............................................................................................................................................. Nr. zile spitalizare ..........................................
Locul de munc ........................................................................................................................
Nr. zile c. m. la externare .........................
C.I / B.I. seria

Nr.

Statut pacient: Asigurat CNAS

Casa de asigurare judeean

Certificat natere (copil) seria

Neasigurat CNAS
Transporturi

Nr.

Nr. carnet asigurat

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: ..................................................................................................................................................................................................
......................................................................................................................................................................................................................................

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

7. ................................ ................................ ........................................ ................................ ................................ ................................ .................

8. ................................ ................................ ........................................ ................................ ................................ ................................ .................
Semntura i parafa medicului ef
...............................................

Semntura i parafa medicului curant

.

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

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

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

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

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

medic operator II

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

medic ATI

medic operator III

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

asistent/

Data interveniei chirurgicale:

zi

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

Data interveniei chirurgicale: zi

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

asistent/

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 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)

Data i ora decesului: zi

luna
an
ora
Diagnostic n caz de deces:
a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................
b. Cauza antecedent .............................................................. .............................................................. .........................................................
I
Stri morbide iniiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................
Alte stri morbide importante .............................................................. .............................................................. ........................................

II

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

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

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

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

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

Codul morfologic (n caz de cancer)

Explorri funcionale:
Denumirea

Codul

Nr.

Codul

Nr.

1. .............................................................. ............................................................................................................
2. .............................................................. ............................................................................................................
3. .............................................................. ............................................................................................................
4. .............................................................. ............................................................................................................
5. .............................................................. ............................................................................................................
6. .............................................................. ............................................................................................................
7. .............................................................. ............................................................................................................
8. .............................................................. ............................................................................................................

Investigaii radiologice:
Denumirea
9. .............................................................. ............................................................................................................
10. .............................................................. ...........................................................................................................
11. .............................................................. ..........................................................................................................
12. .............................................................. ..........................................................................................................
13. .............................................................. ..........................................................................................................
14. .............................................................. ..........................................................................................................
15. .............................................................. ..........................................................................................................
16. .............................................................. ..........................................................................................................
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: .............................................................................................................................................................................................

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

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

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

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

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

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

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

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

d) Comportamente (fumat, alcool etc.)

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

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

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

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

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

EXAMENUL CLINIC GENERAL .............................................................................................................................................................................

EXAMEN OBIECTIV .........................................................................................................................................................................................................

Starea general ...................................................................................................... Talie ....................................... Greutate ...............................

Starea de nutriie .................................................................................. Starea de contien ............................................................................
Facies .............................................................................................................................................................................................................................................
Tegumente .................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EXAMENE RADIOLOGICE (rezultate) .................................................................................................................................................................

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

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

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

INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):

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

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

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

SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:

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

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

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

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

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

Semntura i parafa medicului,

FOAIE DE TEMPERATUR ADULI

CNP

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

Temp

Puls

T.A.

Resp.

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

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

D S D S D S D S

D S D S D S D S

D S D S D S

10
FOAIE DE EVOLUIE I TRATAMENT
DATA

EVOLUIE

TRATAMENT