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Formulare Medicale Foaie Observatie Clinica Generala PDF
Formulare Medicale Foaie Observatie Clinica Generala PDF
nregistrare SC
Localitatea ..................................................... CNP pacient
Spitalul ............................................................
ntocmit de: ...............................................................
Secia ................................................................ parafa medicului
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Consimmntul pentru intervenie: ...........................................................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................
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medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................
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
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Diagnostic n caz de deces:
a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................
b. Cauza antecedent .............................................................. .............................................................. .........................................................
I Stri morbide iniiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................
Investigaii radiologice:
Denumirea Codul Nr.
7. .............................................................. ....................................................................................................
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
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ANAMNEZA: ...........................................................................................................................................................................................................................
a) Antecedente heredo-colaterale ..........................................................................................................................................................
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b) Antecedente personale, fiziologice i patologice ................................................................................................................
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c) Condiii de via i munc .....................................................................................................................................................................
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d) Comportamente (fumat, alcool etc.)
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e) Medicaie de fond administrat naintea internrii (inclusiv preparate hormonale i imunosupresoare
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EXAMENUL CLINIC GENERAL .............................................................................................................................................................................
EXAMEN OBIECTIV .........................................................................................................................................................................................................
Starea general ...................................................................................................... Talie ....................................... Greutate ...............................
Starea de nutriie .................................................................................. Starea de contien ............................................................................
Facies .............................................................................................................................................................................................................................................
Tegumente .................................................................................................................................................................................................................................
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Mucoase ......................................................................................................................................................................................................................................
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Fanere ............................................................................................................................................................................................................................................
esut conjunctiv-adipos ..................................................................................................................................................................................................
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Sistem ganglionar ................................................................................................................................................................................................................
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Sistem muscular ....................................................................................................................................................................................................................
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Sistem osteo-articular .......................................................................................................................................................................................................
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EXAMEN ONCOLOGIC: .................................................................................................................................................................................................
1. Cavitatea bucal ............................................................................... ............................................................................... ...............................................
2. Tegumente ............................................................................... ............................................................................................ ..............................................
3. Grupe ganglioni palpabile ............................................................................... ............................................................................... ........................
4. Sn ............................................................................... ............................................................................................................. ...............................................
5. Organe genitale feminine ............................................................................... ............................................................................... .........................
6. Citologia secreiei vaginale ............................................................................... ............................................................................... .........................
7. Prostat i Rect ....................................................................................................... ............................................................................... .........................
8. Alte ............................................................................... .................................................................................................................................. .........................
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SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:
CLINIC: ..................................................................................... ............................................................................... ..................................................
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FOAIE DE TEMPERATUR ADULI
CNP
Ziua
Zile de boal
Temp
Resp.
T.A.
Puls
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 D S
35 30 160 41O
30 25 140 40O
25 20 120 39O
20 15 100 38O
15 10 80 37O
10 5 60 36O
Lichide ingerate
Diurez
Scaune
Diet
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FOAIE DE EVOLUIE I TRATAMENT
DATA EVOLUIE TRATAMENT
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