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Foaie de Observatie Clinica
Foaie de Observatie Clinica
Nr. nregistrare SC
CNPpacient
Localitatea .....................................................
Spitalul ............................................................
Secia ................................................................
parafamedicului
lun
Sect.
Mediul U/R
an
Localitatea ..........................................................
Data internrii:
Reedina: judeul
Localitatea .........................................................................
zi
Sect.
Data externrii:
Mediul U/R
Cetenie:
Romn
Strin
ora
lun
an
ora
....
grame
zi
lun
an
Nr.
Asigurat CNAS
Nr.
Asigurare voluntar
Neasigurat
Eurocard
Acorduri internaionale
Categ. asig. CNAS: salariat (1); coasig. (2); pensionar (3); copil<18 ani (4); elev/ucenic/student 18-26 ani (5);
gravid (6) veteran (7); revoluionar (8); handicap (9); PNS (10); ajutor social (11); omaj (12); alte (13)
Tipul internrii: urgen (1); trimit. MF (2); trimit. ambulatoriu (3); transfer interspit. (4); la cerere (5); alte (9)
Criteriu internare: urgen (1); diagnostic (2); tratament (3); nedeplasabil (4) epidemiologic (5); medic ef (6)
Diagnosticul de trimitere: .................................................................................................................................
...............................................
.......................................................
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
Data ieirii
(ora)
Starea la externare: vindecat (1); ameliorat (2); staionar (3); agravat (4); decedat (5)
Tipul externrii: externat (1); externat la cerere (2); transfer interspitalicesc (3); decedat (4)
Deces: intraoperator (1); postoperator: 0 23 ore (2); 24 47 ore (3); > 48 ore (4)
Data i ora decesului:
zi
luna
an
ora
2
Nr. zile
spitalizare
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
3
5
3
0
160
41O
3
0
2
5
140
40O
2
5
2
0
120
39O
2
0
1
5
100
38O
1
5
1
0
80
37O
1
0
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 D S
EVOLUIE
TRATAMENT