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  • Hoja de Ingreso Hospital A Rio

    Încărcat de

    Rodrigo Solis Reyes
    4K vizualizări1 pagină

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    Hoja de Ingreso Hospital a Rio

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    Attribution Non-Commercial (BY-NC)
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    4K vizualizări1 pagină

    Hoja de Ingreso Hospital A Rio

    Încărcat de

    Rodrigo Solis Reyes

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    din 1

    Código: GMH022008

    HOJA DE EVALUACIÓN MÉDICA EN INGRESO HOSPITALARIO


    Alameda Roosevelt No. 3104, San Salvador.
    Call Center: 2261-8333 Fax: 2261-0581 Emergencia hospitalaria: 2261-8333

    Este formulario debe anexarse a la documentación de la solicitud de reembolso hospitalario debidamente completada.

    SECCIÓN PARA SER COMPLETADA POR EL MÉDICO TRATANTE

    Contratante: ______________________________________________________________________________________________________________________

    Nº de póliza: ______________________________________________________ Nº de certificado: _______________________________________________

    Nombre del paciente: _______________________________________________________________________________________________________________

    Nombre del hospital: ______________________________________________________________Fecha de ingreso: Día __________ Mes ________ Año__________

    Nombre del médico o médicos tratantes: (indicar especialidades): ____________________________________________________________________________

    _________________________________________________________________________________________________________________________________

    Diagnóstico principal: _______________________________________________________________________________________________________________

    _________________________________________________________________________________________________________________________________

    Diagnóstico secundario: _____________________________________________________________________________________________________________

    _________________________________________________________________________________________________________________________________

    PLAN DE TRATAMIENTO

    Días previstos de internamiento: ________________________________________________________________________________________________________

    Exámenes especiales: _________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    Cirugía: ____________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    Otros: _____________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    SECCIÓN PARA SER COMPLETADA POR EL MÉDICO AUDITOR DE ACSA (indispensable para trámites de pago)

    Observaciones: ______________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________

    _____________________________
    Firma y sello del médico auditor Fecha de auditoria: Día ____________ Mes __________ Año___________

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