Judetul

Localitatea

C~Wpacient

o=JTITI
.
ITLLIJ

Situatii speciale * 1)

SpitaluI

,'Sectia

Nr. inregistrareSC

L-'--J'---J-,,----l--L---l-,,-L---L-,-L-L-L-L-l

Intocmit de:

"

parafa medicului

Internat prin * 3) ,

FOAIE DE OBSERVATIE CLINICA GENERALA

'NUMELE
Data nasterii: ziCD

lunaCD

anCITIJ

Grup sangvin: NB/AB/O;'

Domiciliul lega~: judetul CD Local~tatea

Sect.D Medi~lV!RD Str.. :..:
Resedinta: judetul CD

Localit~tea

:
:
Nr.. ............

Cetatenle:

Nr.

Roman

Strain' D

Nivel

anLCITl
oraITIIJ

. IT].,.. ,Iuna IT] an,~

ITi-:rl
Nr. zile spitalizare'
~
.
Nr-zile c.m. la externare
.

. .,'

Locul de munca

Rh +1_

ZI

Greutatea la nastere (nou nascuti) [L[IJ grame

Greutatcala internare (copii 0-1 an)LU:IJ
gr,ame
CNPmam'a
. Ocupatia: fara ocupatiet lj.salariat/z); lucrator pecont propriu (~ FO main=

lunarn

Data externarii:
.

patron (4); agricultor (S); elev/student (6); seiner 0); pensionar (8)

Alergic la:
,
:
Data internarii:
oraITIIJ

:.. .zi IT]

Mediul VIR D Str

Sect. D

Sexul Mzl-

PRENlJMELE

- ,.'~

.
fara studii (1);"C1clu primar

de instruire:

(2); ciclu

gimnazial

(3); scoala

profesionala

scoala postliceala (6); studii superioare de scurta durata (7); studii superioare (8); nespecificat (9)

DIrIIJ

C.I./B"lseria CD

Nr.

StatuI asigurat:

Asigurat CNASD

(4); liceu

(5);
.---.
.U

Certificat nastere (copil)'seriarnNr.o=rI:II]

Asigurare vol~nta~a

CD

Neasigurat D

CD

[I]

Tip asig. CNAS: 1. Obligatorie CAS

2.Facultativa CAS
3.Acord international
4. Card european D
Nr. card european f-1""""'1--'--'--'-1-'-1-'-"'1--'-1---'-,--'-1
-'-1~Ir--rl--'I---rl-'-I -,-, -'1"-1
Nr. pasaport
I'
1
1 .,
1 1 '1 , 1 1 1 . 1 I' ,1 I' i .,
5. Fonnulare europene 1 I 1 I' I
Nr. card international] . 1~ I"
1 ,I 1 1 1 I I I I

fara bilet internare P); bilet intemare MF (2); bilet intemare Med. Spec. (3); transfer interspit. (4); la cerere (5);
alte (9)
Serie BII I I 1 I I Nr. BII 1 I 1 1 I 1 I I' I 1
.
Criteriu internare *2) CCI ,
. _ .
Tipul internarii:

Diagnostic de trimitere:

"

'

,"

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Semnatura si parafa medicului .

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

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..

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la externare:

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la externare (compiicatiilcomorbiditati):

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6

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Diagnosticulla 72 de ore:

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Semnatura si parafa'medicului sef~

':;-Semnatura si parafa medicului curant

./ J

Numar ore de ventilatie mecanica.] I

'1nrerven
terventi a. chirurgtcata
. -. prmcrpa
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a

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Echipa operatorie:

medic operator II

:~

medic ATI

-: 'fu~dic operator III (:.L

, ;:.... >:: 'asistentl~ .:

-'-

.1

Data si ora inceperii interventiei:

Data si ora sfarsit interventie: ... f .!..

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operator II

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Data siora inceperii interventiei:
.1 .1............
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.1................
2

.
---1

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.~~:medic operator principal

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medicoperator

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III~~, ~:

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J'!
. . .,.
. [mediC operator principal
r

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2

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./

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.1

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asistent/a

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..~.............
:.., :

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Echipa operatorie: . medic operator II

'.. ,..: medic AlJ

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i' '.

.:'

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.

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Examen citologic ..:,.;,

;.:.r: ........................
:......................................................................
Examen extemporaneu
,
,.'1' , '. :~., ,~~~.,:
Examen histopatologic (biopsie - piesa operatorie)
: ~......: ~~~:~~'
.. "
Transfer.intre sectiile spitaluiui:
:;";<'.',.:,
":.,', ;"/
.;:'.::':"
Nr. zile
,Sectia
Data si ora iesirii .
Data si ora intrarii
Diagnostic
spitalizare

.Starea la extemare: vind~cat (l); ameliorat (2); stationar (3); agravat (4); decedat (5)

.~Tlpu{e~tema.rii: externat (l); extemat la cer~re (2); transfer interspitalicesc (3); decedat (4)

Deces: intraoperator (1); postoperator 0-23 ore (2); 24-47 ore (3); >48 ore (4)
Data si ora decesului:

zi [[]

luna

[IJ

an
2.

[II:IJ

ora

[II:IJ

INTERVENTII CHIRURGICA.L~;(numa:r;u!interventiei chirurgicale,

protocol operator):

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

.~
...............................................................................................................................................
...............................................................................................................................................

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

................................................................................................................................................
...............................................................................................................................................
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SUSTINEREA DIAGN08'i]~ICu'tUISlTRATAl'V1ENTULUI:
CLINIC:

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.;

8.

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Diagnostic in caz de deces:

a. Cauza directa (imediata) ...........................................................
I

"

b. Cauza antecedenta
. Stari morbide initiale:

II

~;;;

;..;

Alte stari rnorbide h-nportante ...............................................................................................

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

Diagnostic anatomo-patologic (autopsie), macroscoPi~:....................

:
'::

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

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0: ':
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,.,~..t'o:.;.

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Mi~~~~~~~i~~:::::::::::~::::::::::::::::::-::::::::~:::::::::::~::.::::::::~:~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

;. .....

~ ..

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Explorari functionale;

=
=
=
=.
Codul

Denumirea
1.................................................................................................

:: :

:...:..:.::

::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::'::::::
Investigatii radiologice:

Denumirea

7
8

"

~ ,

9
10

;..~-;.;,

"

~~~

:;;
:.:.i...':

:,

>

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; ........

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, ............

: :

16

;..:

17

18

::.:

ALTE OBSERVATII:

.:

:
;

=
=
=
ortIrn
Codul

14

.Codul

=
=
=
=

"lli::DIIJ"

:..,

Alte proceduri terapeutice: .

Denumirea
13

'.,

~-."
..~,

11......................................................................
12.

,.....;~.;.;

.' . .

.~.

:.=
rn=oITI

Nr.

OJ
OJ
OJ
OJ
OJ
_OJ
Nr.

OJ
OJ
OJ
OJ
OJ
OJ
Nr.

OJ
OJ
OJ
OJ
OJ
OJ

[[ill
I ITIIJJ I' I I 0 I [[IIIIIIDJ I I
1 2 3 4 5 6 7 8 9 10 11 12 }3 14 15 16 17 18 1920 21 222324252627282930

MOTIVELE INTERNARII:

\.,.,", ,'-'...:

..

. ..

ANAIvn~EzA: .................................................................. ,

,~

~.~

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-.

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

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Antecedente heredo-colaterale

a)
. . ..

. .

; : ::

. . . . . . . . . . . . . ,. ...........................

.
e,,,, ~ eo ~ .

;. ~ .......

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

.'

b) Antecedente personale-fiziologicesi

patologice

_.
................................................................................................................................................................
.

...................................................
........................ ~.,.::

. -

--

,.

.,

.. dee viata
vi
c ) C. on di.itn
Si. munca

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

..

io

,;

O'

d) Comportamente (fumat, alcool etc.)

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

~.
~ '. ..~

"'

~.:-

..

e) Medicatie 'de fond administrata inaintea internarii .

(inclusivpreparate honnonale si imunosupresoare)
-,

~
-...
..
............................................................................................................................................................
~.
.
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..............................................................................................................................................................
-

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ISTORICUL BOLlI: .r....

:................. .'

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

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EXAMENUL CLINIC GENERAL

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

Starea generala

Talie

Starea de nutritie

Greutate

Starea de constienta

Facies

Tegumente

.
",,-.,

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

,.

..............................................................................................................................................................
Fanere

Iesut conjunctiv-a, d'IpOS

'T'

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

~..............................

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

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.....................................................................................................................................................
-'

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....

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.

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

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

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.

.
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APARAT RESPIRATOR

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

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APARAT CARDIOVASCULAR

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APARAT DIGESTIV,

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-

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FICAT, CAI BILIARE, SPILNA,

....
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SISTEM NERVOS, -ENDOCRIN, ORGANE DE,SIMT

APARAT URO-GENITAL

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

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EXAJ\1EN 01~COLOGIC:
1. Cavitatea bucala

.,

..

H'

;;

,'..; ;; ;

; - :.~

2..Tegumente ........................................... ;;
3. Grupe ganglioni palpabile
>(1.
4 ...San

,\f:

:. _.

:..........

:,:; ...................................

~:

,:.~.::'

'..

.
f.
..
5. 0 rgane genitaie ~emlnln.e
1

:..

6. Citologia secretiei vaginale

'

: ":" ~

7. Prostata si Reet

:.:..:
:.1;~

....

y.

8. Altele

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ALTEEXAMENE

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DE.SPECIALITATE

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EXAMENE DE, LABORATOR

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EXAMENERADIOLOGICE

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

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EXAMENE ECOGRAFICE (rezultate)

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Numele
Anul

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FOAIE DE TEMPERATURA ADUL TI

,
CNP DTIIlT~T_-rrJ
_prenumele
Nr. foii de observatie

Luna

_
Nr. salon

----_._-Nr. pat

, ...

~~~----------T-~~r_-~-+_-~-~-4--+_--~-~-~_+--+_-~-~-r--+-~-~-+--+-~-~-r--T--'-Zile de boala
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Resp. TA

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Puis !Emlp.D S 0 S 0 S 0 S 0 S D S 0 S D S D!S D S 0 S 0 S 0 S 0 S 0 S 0 S D S 0 S 0 S D S D S 0 S D S D S 0 S D S D S D S D S

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41u

35

30

160

30

25

1140 40"

25

20

140

39"
.

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20

'100

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10

10

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...
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