Observatii UNITATE PRIMIRE URGENTE PACIENT STARE PACIENT
1 2 3 Radiologice CT EKG NR fisa: DATA: Nume 36-Coloana cervicala Resuscit. 01-Hct 46-Craniu 56-Ritm sinusal Z Z L L A A Prenume Critic 02-Hb 37-Coloana dorsala 47-Coloana cervicala 57-Frecventa Preluat de : La ora: 38-Coloana lombara M F Data nasterii: Urgent 03-H 48-Torace 58-ST-T normal ........................................... Varsta 39-Torace 49-Abdomen 59-FiA Non-urg. 04-L Ora prim consult medical: CNP S A A L L Z Z 40-Stern 50-Alte 60-FV/TV Consult 05-T Motivul prezentarii: Domiciliu: 06-Na 41-Bazin RMN 61-FIA Judet : Ora 07-K 42-Abdomen 51-Craniu 62-Asistolie Localitate G M 08-Cl 43-Membru superior 52-Coloana cervicala C V 44-Membru inferior 53-Torace Strada S 09-Ca O 10-Glicemie 45-Alte 54-Abdomen Nr. Bl.: Sc.: Et.: Ap.: GCS 11-Uree 55-Alte Fr res Radiologie Functii vitale la preluare: Adus de: Adus de la: 12-Creatinina Decedat Resuscitare la ora: AV 13-GOT/AST SAJ Domiciliu Puls Stop CR Reusit 14-GPT/ALT SMURD Unitate sanitara TA Cu manev. de Nereusit ora deces: 15-Amilaze Mijloace proprii Loc public resuscit. in curs SatO2 Alt: Loc munca de desfasurare Motivul neinceperii resuscitarii 16-pH Temp 17-HCO3 Fisa nr.: Alt: .......................................... Gli 15-Trauma 18-paO2 ANAMNEZA TRIAJ 19-paCO2 ANTECEDENTE PATOLOGICE Observatii General Ochi 20-BE CARDIACE 01-Talie(cm)............... 30-Pierdere ac. a ved. 21-Bilirubina T NEUROLOGICE 02-Greutate(kg)............. 31-Tulb. de vedere 22-Bilirubina D RENALE 03-Febra 32-Corp strain intraoc. Ecografie 04-Astenie 33-Alte manif. oculare 23-CK PULMONARE 24-CK-MB TBC 05-Ameteli 25-ProBNP HEPATICE Torace-respiratie 26-TroponinaI Arsuri 34-Durere toracica GASTRICE 06-Cai resp. s. afectate 27-Tn T DIABET ZAHARAT 35-Dispnee 07-Flacara 28-Mioglobina BOLI INF-CONTAGIOASE 36-Hemoptizie 08-Solid 29-D-dimer BOLI CU TRANSM SEXUALA 37-Tuse 09-Lichid 30- ALTELE 10-Vapori/ gaz 38-Expectoratie 31- 11-Chimic Gastrointestinal: 32- ANAMNEZA 39-Greata Psihiatric 33- 12-Depresie 40-Voma 34- 13-Tulb comportament 41-Tulb. tranzit Examen sumar de urina 35- 14-Suicid 42-Rectoragie EVALUARE -RECOMANDARI Cod DG DIAGNOSTIC PREZUMTIV 15-Halucinatii/ delir 43-Melena 44-Hematemeza Neurologic 45-Dureri abd. 16-Convulsii 17-Mioclonii Genito urinar 18-Cefalee 46-Tulb. mictionale 19-Paralizie 47-Disurie 48-Polakiurie Tegumente 49-Oligurie 11-Ameliorat 13-Agravat 20-Calde 50-Hematurie Stare pacient 14-Decedat 21-Reci 51-sang. vaginala 12-Stationar 22-Prurit 52-Sarcina Refuz ora: BI/ CI/ CNP 23-Umede 20-Examinare (bolnav/apartinator): 24-Paloare Ap locomotor 20-Tratament Asistent 1: 20-Internare Semnatura bolnav/ 25-Echimoze 53-Inflamatie Medic 1: apartinator 26-Icterice 54-Tumefactie Asistent 2: Alergic la: 55-Durere Medic 2: Predat la ora: 22-Internat sectia 27-Cianotice 28-eruptii 56-imp. funct. Asistent sef tura: 23-Transferat la: Medic sef garda: Tratament la domiciliu: 29-Arsuri 21-Pleaca cu recomandari/ RP