Documente Academic
Documente Profesional
Documente Cultură
i
denumirea instituiei
2. Identificarea bolnavului:
Cetenia: RM(1)
Strin(2)
ara
seria
luna
, vrsta
anul
sectorul/localitatea
strada
nr.
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specificai denumirea
luna
anul
ora
......
pentru elevi locul de studii, pentru copii denumirea instituiei precolare, scolii
grame
luna
anul
ora
19. Internarea peste cte ore dup debutul bolii (traumei): 0-6 ore (1), 7-24 ore (2), peste 24 ore (3)
20. Diagnosticul de trimitere ...........................................................................................................................................
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cod diagnostic
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cod diagnostic
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cod diagnostic
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cod diagnostic
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cod diagnostic
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....
cod diagnostic
29. Starea la externare: vindecat (1), ameliorat (2), fr schimbri (3), agravat (4), decedat (5)
30. Capacitatea de munc: restabilit complet (1), sczut (2), temporar pierdut(3), pierdut total (4), pierdut
n legtur cu maladia dat (5), cu alte cauze (de nscris) (6)....................................................................................
31. Deces: gravid (1), la natere (2), n cursul spitalizrii (fr operaie) (3), intraoperator (4), postoperator: (0-23
ore) (5), peste 24-47 ore (6), peste 48 ore (7)
32. Nr. zile spitalizate:
de la.............................pna
luna
anul
ora
luna
anul
ora
ziua
Nr. zile
spitalizate
nr.
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denumirea
nr.
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4
Anexa nr. 1
la Fia medical a bolnavului de staionar
(formular nr. 003/e-2012)
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Anexa nr. 2
la Fia medical a bolnavului de
staionar
Formular nr. 003/e-2012
ZILNIC
Anexa nr. 3
la Fia medical a bolnavului de staionar
(formular nr. 003/e-2012)
Fia medical a bolnavului de staionar nr.
Executat
Data
Regimul
Dieta
Medicamente
SUB*)
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
sora
medicul
Semnturi
sora
*) Medicamentele prescrise snt:
S din spital,
B ale bolnavului
Anexa nr. 4
la Fia medical a bolnavului de staionar
(formular nr. 003/e-2012)
INDICAII OPERATORII
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Medicul curant________
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Denumirea operaiei____________________________________
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Medicul chirurg /principal____________________________
Medicul chirurg /doi_________________________________
Medicul chirurg /trei_________________________________
Anestezist ________________________
Asistent/ anestezie___________________
DESCRIEREA OPERAIEI
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Anexa nr. 5
la Fia medical a bolnavului de staionar
(formular nr. 003/e-2012)
Data
Denumirea investigaiei
Semntura
medicului
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Anexa nr. 6
la Fia medical a bolnavului de staionar
(formular nr. 003/e-2012)
, salon nr.
EPICRIZ
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10
Anexa nr. 7
la Fia medical a bolnavului de staionar
Formular Nr 003-1/e
Instruciuni
privind completarea Fiei medicale a bolnavului de staionar (F 003-1/e)
A. Completarea urmtoarelor rubrici din Fia medical a bolnavului de staionar (F 003-1/e)
(n continuare - Fi), se face cite i cu MAJUSCULE: denumirea spitalului, denumirea
seciei, numele, prenumele, patronimicul bolnavului i toate diagnosticele.
B. Completarea Fiei se face n baza urmtoarelor acte oficiale:
Pentru cetenii Republicii Moldova sau apatrizi:
- Buletin de identitate;
- Certificat de natere pentru copiii sub 15 ani;
- Formularul N9, pentru persoanele care dein acte de identitate provizorii n
conformitate cu HG RM nr. 42 din 17.01.1995.
Pentru cetenii altor state:
- Actul de identitate naional.
C. Rubricele se completeaz i se codific dup cum urmeaz:
- Denumirea instituiei medicale;
- Denumirea seciei;
- Numrul salonului n care a fost internat bolnavul;
- Numrul Fiei este un numr unic pe instituie;
1. Numele, prenumele, patronimicul bolnavului se trece numele, prenumele i
patronimicul bolnavului;
2. Identitatea bolnavului:
- Cetenia se bifeaz n csuele respective, n baza actului de identitate: 1 cnd
bolnavul este cetean al Republicii Moldova, 2 cnd bolnavul este cetean al altui
stat i se nscrie ara de origine;
- se trece codul IDNP al bolnavului, n cazul n care bolnavul deine numrul de
IDNP;
- se trece numrul actului de identitate al bolnavului, n cazul n care bolnavul este
cetean strin.
- pentru bolnavii, ceteni ai Republicii Moldova, care nu dein IDNP:
- copii se trece seria i numrul certificatului de natere;
- persoane care dein acte de identitate provizorii, formularul N9 se trece seria i
numrul Formularului N9;
3. Data naterii se codific n csuele respective cu: ziua (ex. 01-31), luna (ex.01-12),
anul (ex. 2010), vrsta se trece vrsta bolnavului n cifre i se specific prin marcarea unitii de
msur a vrstei - zile/luni/ani;
4. Locul de trai se trece locul de trai al bolnavului, n baza datelor din buletinul de
identitate sau alt act de identitate, i anume:
- municipiul/raionul se trece denumirea municipiului sau raionului;
- sectorul/localitatea se trece denumirea sectorului municipiului sau denumirea localitii
raionului;
- strada se trece denumirea strzii;
- nr. se trece numrul locuinei, blocului, apartamentului.
5. Bolnav asigurat se codific n casua respectiv cu 1 cnd bolnavul este asigurat i 2
cnd bolnavul nu este asigurat;
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21. Medicul de gard care a stablit diagnosticul la internare - semneaz, aplic parafa i
indic codul su IDNP n csuele respective;
22. Diagnosticul clinic (la 72 ore) diagnosticul clinic la 72 ore este nscris de medicul
curant i se codific conform CIM-10 cu 4 caractere*;
23. Diagnosticul principal la externare (clinic definitiv) este nscris de medicul
curant i se codific conform CIM-10 cu 4 caractere*;
24. Diagnostice secundare la externare (complicaii/maladii concomitente) este
nscris pentru maximum 6 complicaii i/sau maladii concomitente cu diagnosticul principal,
trecndu-se exclusiv compliciile/maladiile concomitente pentru care bolnavul a fost investigat
i tratat n timpul episodului respectiv de boal, se nscrie de medicul curant i se codific
conform CIM-10 cu 4 caractere*;
25. Medicul curant care a stablit diagnosticul principal la externare precum i
diagnosticele secundare la externare - semneaz, aplic parafa i indic codul su IDNP n csuele
respective;
26. Data externrii - se completeaz i se codific n csuele respective cu: ziua (ex.0131), luna (ex.01-12), anul (ex.2010) i ora externrii (ex. 0915, 2359, 0015);
27. Tipul externrii se completeaz i se codific cu 1 n cazul externrii bolnavului
ca i caz rezolvat, 2 n cazul externrii bolnavului la cererea lui sau a tutelelor, 3 n legtur cu
decesul bolnavului, 4 n cazul transferului bolnavului ca i caz nerezolvat n alt insituie, se
indic denumirea instituiei n care a fost transferat bolnavul;
28. Starea la externare se completeaz i se codific cu 1 n cazul cnd bolnavul a
fost vindecat, 2 n cazul cnd starea bolnavului doar s-a ameliorat, 3 n cazul cnd starea
bolnavului a rmas fr schimbri, 4 n cazul cnd starea bolnavului s-a agravat, 5 n cazul cnd
bolnavul a fost externat ca decedat;
29. Capacitatea de munc se completeaz i se codific cu 1 n cazul cnd
capacitatea de munc a bolnavului a fost restabilit complet, 2 n cazul cnd capacitatea de munc
a bolnavului este sczut, 3 - n cazul cnd capacitatea de munc a bolnavului a fost pierdut
temporar, 4 - n cazul cnd capacitatea de munc a bolnavului a fost pierdut total, 5 - n cazul cnd
capacitatea de munc a bolnavului a fost pierdut n legtur cu maladia dat, 6 - n cazul cnd
capacitatea de munc a bolnavului a fost pierdut din alt cauz, se indic cauza;
*n CIM-10 cu 4 caractere, se pot ntlni diagnostice cu 5 caractere.
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