Documente Academic
Documente Profesional
Documente Cultură
Judeul BUCURETI
Localitatea BUCURETI S.I
Spitalul Clin. Nefrologie Carol
Davila
9 0 9 8
Nr. nregistrare SC
CNPpacient
2 7 1 0 3 2 6 2 5 3 2 1 7
0 0 3 8 4 5
ntocmit de: Dr. Topor Liliana
1 1 9 1
Secia NEFROLOGIE 1
parafamedicului
COTIRI
Data naterii: zi
2 6 lun 0 3 an 1 9 7 1
Sect.
PRENUMELE
ELENA
Str. ALEEA
Mediul U/R U MRGRITARULUI
Nr. 3
Str. ALEEA
MRGRITARULUI
Mediul U/R
Cetenie:
Romn X
Strin
Sexul M/F
Data internrii:
zi 2 7
Nr. 3
ora 0 9 0 6
lun 1 1 an 2 0 1 5
Data externrii:
ora 0 8 1 0
....
zi 0 2
grame
lun 1 2 an 2 0 1 5
MH Nr. 2 9 6 0 9 9
Statut asigurat:
Asigurat CNAS X
X
Nr.
Asigurare voluntar
Eurocard
Neasigurat
Acorduri internaionale
Categ. asig. CNAS: salariat (1); coasig. (2); pensionar (3); copil<18 ani (4); elev/ucenic/student 18-26 ani (5);
gravid (6) veteran (7); revoluionar (8); handicap (9); PNS (10); ajutor social (11); omaj (12); alte (13)
Tipul internrii: urgen (1); trimit. MF (2); trimit. ambulatoriu (3); transfer interspit. (4); la cerere (5); alte (9)
Criteriu internare: urgen (1); diagnostic (2); tratament (3); nedeplasabil (4) epidemiologic (5); medic ef (6)
3
Diagnosticul de trimitere: .................................................................................................................................
................................ .......................................... ................................ ................................ ...........................
Diagnosticul la internare: SPONDILOZA CERVICAL
................................ ................................ ....................... ........ ..............................................
Semntura i parafa medicului
................................................
...............................................
.......................................................
23.3 A4 t2
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
luna
..........................................................
..............................................................
an
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
2........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie:
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
..........................................................
..............................................................
medic operator II
...........................................................
medic ATI
..........................................................
asistent/
luna
..........................................................
..............................................................
an
Diagnostic
Starea la externare: vindecat (1); ameliorat (2); staionar (3); agravat (4); decedat (5)
2
Nr. zile
spitalizare
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
Explorri funcionale:
Denumirea
Codul
Nr.
Codul
Nr.
Codul
Nr.
1. .............................................................. ....................................................................................................
2. .............................................................. ....................................................................................................
3. .............................................................. ....................................................................................................
4. .............................................................. ....................................................................................................
5. .............................................................. ....................................................................................................
6. .............................................................. ....................................................................................................
Investigaii radiologice:
Denumirea
7. .............................................................. ....................................................................................................
8. ............................................................. ....................................................................................................
9. ............................................................. ....................................................................................................
10. ............................................................. ....................................................................................................
11. ............................................................. ....................................................................................................
12. ............................................................. ....................................................................................................
ALTE OBSERVAII:
1
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
ANAMNEZA: ...........................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Mucoase ......................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Fanere ............................................................................................................................................................................................................................................
esut conjunctiv-adipos ..................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
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
D S
D S
D S
D S
D S D S D S D S
D S D S D S D S
Lichide ingerate
Diurez
Scaune
Diet
10
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
EVOLUIE
11
TRATAMENT