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Foaie de Observatie Clinica Generala

Foaie de Observatie Clinica Generala

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Judeţul ……………………..........…….......…. Nr.

înregistrare SC
Localitatea ..................................................... CNP pacient
Spitalul ............................................................
Întocmit de: ...............................................................
parafa medicului Secţia ................................................................
FOAIE DE OBSERVAŢIE CLINICĂ GENERALĂ
Statut asigurat: Asigurat CNAS Asigurare voluntară Neasigurat
Asig. oblig. CAS Asig. acultativă CAS !urocard Acorduri internaţionale
Categ. asig. CNAS: salariat "#$% coasig. "&$% pensionar "'$% copil(#) ani "*$% elev+ucenic+student #),&- ani ".$%
gravidă "-$ veteran "/$% revoluţionar ")$% 0andicap "1$% 2NS "#3$% a4utor social "##$% 5oma4 "#&$% alte "#'$
Tipul internării: urgenţă "#$% trimit. 67 "&$% trimit. ambulatoriu "'$% transer interspit. "*$% la cerere ".$% alte "1$
Criteriu internare: urgenţă "#$% diagnostic "&$% tratament "'$% nedeplasabil "*$ epidemiologic ".$% medic 5e "-$
Diagnsti!ul "e tri#itere: .................................................................................................................................
................................ .......................................... ................................ ................................ ...........................
Diagnsti!ul la internare: .................................................................................................................................
................................ ................................ ....................... ........ ..............................................
Semnătura 5i paraa medicului
................................................
Diagnsti!ul la $% "e re: .............................. ................................ ................................ ................................ ................................ ..............................
.................................................................................................................................................................................................................................................................
Diagnsti!ul prin!ipal la e&ternare:................................ ................................ ..................... ...............................................
................................ ................................ ........................................ ................................ ................................ ...........................................
Diagnsti!e se!un"are la e&ternare '!#pli!a(ii ) !#r*i"ită(i+:
#. ................................ ................................ ........................................ ................................ ................................ ...........................................
&. ................................ ................................ ........................................ ................................ ................................ ...........................................
'. ................................ ................................ ........................................ ................................ ................................ ...........................................
*. ................................ ................................ ........................................ ................................ ................................ ...........................................
.. ................................ ................................ ........................................ ................................ ................................ ...........................................
-. ................................ ................................ ........................................ ................................ ................................ ...........................................
N86!L! ......................................... 29!N86!L! ........................................................ Se:ul 6+7
Data na,terii: ;i lună an <rup sangvin: A+=+A=+3% 90 > + ,
D#i!iliul legal: 4udeţul Localitatea .......................................................... Alergic la: ..............................................................
Sect. 6ediul 8+9 Str. ....................................................................... Nr. ...... ?ata internării: ora
Re,e"in(a: 4udeţul Localitatea ......................................................................... ;i lună an
Sect. 6ediul 8+9 Str. ....................................................................... Nr. ...... ?ata e:ternării: ora
Cetă(enie: 9om@n Străin ……………..…..
Greutatea la na,tere 'nu năs!u(i+ grame ;i lună an
O!upa(ia: ără ocupaţie "#$% salariat "&$% lucrător pe cont propriu "'$% Nr. ;ile spitali;are .........................................
patron "*$% agricultor ".$% elev+ student "-$% 5omer "/$% pensionar ")$
L!ul "e #un!ă ..............................................................................
Nr. ;ile c.m. la e:ternare .........................
Ni-el "e instruire: ără studii "#$% ciclu primar "&$% ciclu gimna;ial "'$% 5coală proesională "*$% liceu ".$
5coală postliceală "-$% studii superioare de scurtă durată "/$% studii superioare ")$% nespeciicat "1$
C.I ) B.I. seria Nr. Certiicat na5tere "copil$ seria Nr.
Semnătura 5i paraa medicului 5e Semnătura 5i paraa medicului curant
............................................... .......................................................
&'.'5 A*5 t&
Inter-en(ia !.irurgi!ală prin!ipală/ .....................................................................................................................................................................
..................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................
Consimţăm@ntul pentru intervenţie: ...........................................................................................................................................................................
!c0ipa operatorie:
medic operator principal ............................................................................................................................................
medic operator AA ........................................................... medic ABA ..........................................................
medic operator AAA .......................................................... asistent+ă ..............................................................
?ata intervenţiei c0irurgicale: ;i luna an
Inter-en(ii !.irurgi!ale !n!#itente "cu cea principală$:
#........................................................................................................................................
!c0ipa operatorie:
medic operator principal ............................................................................................................................................
medic operator AA ........................................................... medic ABA ..........................................................
medic operator AAA .......................................................... asistent+ă ..............................................................
&........................................................................................................................................
!c0ipa operatorie:
medic operator principal ............................................................................................................................................
medic operator AA ........................................................... medic ABA ..........................................................
medic operator AAA .......................................................... asistent+ă ..............................................................
Alte inter-en(ii !.irurgi!ale/
#........................................................................................................................................
!c0ipa operatorie:
medic operator principal ............................................................................................................................................
medic operator AA ........................................................... medic ABA ..........................................................
medic operator AAA .......................................................... asistent+ă ..............................................................
?ata intervenţiei c0irurgicale: ;i luna an
&........................................................................................................................................
!c0ipa operatorie:
medic operator principal ............................................................................................................................................
medic operator AA ........................................................... medic ABA ..........................................................
medic operator AAA .......................................................... asistent+ă ..............................................................
?ata intervenţiei c0irurgicale: ;i luna an
!:amen citologic ..................................................................................................... ................................................................................................................
!:amen e:temporaneu ..................................................................................................... ...................................................................................................
!:amen 0istopatologic "biopsie C piesă operatorie$
..................................................................................................... ...................................
Branser între secţiile spitalului:
Secţia ?iagnostic ?ata intrării "ora$ ?ata ie5irii "ora$ Nr. ;ile
spitali;are
Starea la e:ternare: vindecat "#$% ameliorat "&$% staţionar "'$% agravat "*$% decedat ".$
Bipul e:ternării: e:ternat "#$% e:ternat la cerere "&$% transer interspitalicesc "'$% decedat "*$
?eces: intraoperator "#$% postoperator: 3 C &' ore "&$% &* C */ ore "'$% D *) ore "*$
&
?ata 5i ora decesului: ;i luna an ora
?iagnostic în ca; de deces:
A
a. Cau;a directă "imediată$ .............................................................. .............................................................. ..........................................
b. Cau;a antecedentă .............................................................. .............................................................. .........................................................
Stări morbide iniţiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................
AA
Alte stări morbide importante .............................................................. .............................................................. ........................................
.............................................................. ..................................................................................................................... .........................................................
?iagnostic anatomo,patologic "autopsie$E macroscopic: ...........................................................................................................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
6icroscopic: .............................................................. ..................................................................................................................... ...........................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
Codul morologic "în ca; de cancer$ 6
!:plorări uncţionale:
?enumirea Codul Nr.
#. .............................................................. ....................................................................................................
&. .............................................................. ....................................................................................................
'. .............................................................. ....................................................................................................
*. .............................................................. ....................................................................................................
.. .............................................................. ....................................................................................................
-. .............................................................. ....................................................................................................
Anvestigaţii radiologice:
?enumirea Codul Nr.
/. .............................................................. ....................................................................................................
). ............................................................. ....................................................................................................
1. ............................................................. ....................................................................................................
#3. ............................................................. ....................................................................................................
##. ............................................................. ....................................................................................................
#&. ............................................................. ....................................................................................................
Alte proceduri terapeutice:
?enumirea Codul Nr.
#'. ............................................................. ....................................................................................................
#*. ............................................................. ....................................................................................................
#.. ............................................................. ....................................................................................................
#-. ............................................................. ....................................................................................................
'
#/. ............................................................. ....................................................................................................
#). ............................................................. ....................................................................................................
ALB! F=S!9GAHAA:
# & ' * . - / ) 1 #3 ## #& #' #* #. #- #/ #) #1 &3 &# && &' &* &. &- &/ &) &1 '3
6FBAG!L! ANB!9NI9AA: .............................................................................................................................................................................................
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ANA6N!JA: ...........................................................................................................................................................................................................................
a$ Antecedente 0eredo,colaterale ..........................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
b$ Antecedente personaleE i;iologice 5i patologice ................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
c$ Condiţii de viaţă 5i muncă .....................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
d$ Comportamente "umatE alcool etc.$
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
e$ 6edicaţie de ond administrată înaintea internării "inclusiv preparate 0ormonale 5i imunosupresoare
.............................................................................................................................................................................................................................................................
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ASBF9AC8L =FLAA: ..............................................................................................................................................................................................................
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*
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!KA6!N8L CLANAC <!N!9AL .............................................................................................................................................................................
!KA6!N F=A!CBAG .........................................................................................................................................................................................................
Starea generală ...................................................................................................... Balie ....................................... <reutate ...............................
Starea de nutriţie .................................................................................. Starea de con5tienţă ............................................................................
7acies .............................................................................................................................................................................................................................................
Begumente .................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
6ucoase ......................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
7anere ............................................................................................................................................................................................................................................
Hesut con4unctiv,adipos ..................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Sistem ganglionar ................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Sistem muscular ....................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Sistem osteo,articular .......................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
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A2A9AB 9!S2A9ABF9 ...................................................................................................................................................................................................
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A2A9AB CA9?AFGASC8LA9 ..................................................................................................................................................................................
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A2A9AB ?A<!SBAG ...................................................................................................................................................................................................
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7ACABE CIA =ALAA9!E S2LANA ...................................................................................................................................................................................
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A2A9AB 89F,<!NABAL ...............................................................................................................................................................................................
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SASB!6 N!9GFSE !N?FC9ANE F9<AN! ?! SA6H .................................................................................................................................
.
.............................................................................................................................................................................................................................................................
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.............................................................................................................................................................................................................................................................
!KA6!N FNCFLF<AC: .................................................................................................................................................................................................
#. Cavitatea bucală ............................................................................... ............................................................................... ...............................................
&. Begumente ............................................................................... ............................................................................................ ..............................................
'. <rupe ganglioni palpabile ............................................................................... ............................................................................... ........................
*. S@n ............................................................................... ............................................................................................................. ...............................................
.. Frgane genitale eminine ............................................................................... ............................................................................... .........................
-. Citologia secreţiei vaginale ............................................................................... ............................................................................... .........................
/. 2rostată 5i 9ect ....................................................................................................... ............................................................................... .........................
). Alte ............................................................................... .................................................................................................................................. .........................
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ALB! !KA6!N! ?! S2!CAALABAB! ..................................................................................................................................................................
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!KA6!N! ?! LA=F9ABF9 ......................................................................................................................................................................................
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!KA6!N! 9A?AFLF<AC! "re;ultate$ .................................................................................................................................................................
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!KA6!N! !CF<9A7AC! "re;ultate$ ...................................................................................................................................................................
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ANB!9G!NHAA CLA989<ACAL! "numărul intervenţiei c0irurgicaleE protocol operator$:
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!KA6!N! ANABF6F,2ABFLF<AC!: .............................................................................................................................................................
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S8SHAN!9!A ?AA<NFSBAC8L8A MA B9ABA6!NB8L8A:
CLANAC: ..................................................................................... ............................................................................... ..................................................
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2A9ACLANAC: ....................................................................... ............................................................................... ...................................................
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!2AC9AJA: ...................................................................................... ............................................................................... ...........................................................
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Semnătura 5i paraa mediculuiE
......................................................
1
F O A I E D E T E 01 E R A T 2 R Ă A D 2 L Ţ I
CNP
Numele ……………………………………. 2renumele …………….….………………………..
Anul ………… luna ………… Nr. oii de observaţie ………… Nr. salon ……….. Nr. pat …………..
Jiua
Jile de boală
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Scaune
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#3
7FAA! ?! !GFL8HA! MA B9ABA6!NB
?ABA !GFL8HA! B9ABA6!NB

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