Judeul .................. Nr.

nregistrare SC
Localitatea ..................................................... CNPpacient
Spitalul ............................................................
ntocmit de: ...............................................................
Secia ................................................................ parafamedicului

FOAIE DE OBSERVAIE CLINIC GENERAL

NUMELE ......................................... PRENUMELE ........................................................ Sexul M/F
Data naterii: zi lun an Grup sangvin: A/B/AB/0; Rh + / -
Domiciliul legal: judeul Localitatea .......................................................... Alergic la: ..............................................................
Sect. Mediul U/R Str. ....................................................................... Nr. ...... Data internrii: ora
Reedina: judeul Localitatea ......................................................................... zi lun an
Sect. Mediul U/R Str. ....................................................................... Nr. ...... Data externrii: ora
Cetenie: Romn Strin ....
Greutatea la natere (nou nscui) grame zi lun an
Ocupaia: fr ocupaie (1); salariat (2); lucrtor pe cont propriu (3); Nr. zile spitalizare .........................................
patron (4); agricultor (5); elev/ student (6); omer (7); pensionar (8)
Locul de munc .............................................................................. Nr. zile c.m. la externare .........................
Nivel de instruire: fr studii (1); ciclu primar (2); ciclu gimnazial (3); coal profesional (4); liceu (5)
coal postliceal (6); studii superioare de scurt durat (7); studii superioare (8); nespecificat (9)
C.I / B.I. seria Nr. Certificat natere (copil) seria Nr.
Statut asigurat: Asigurat CNAS Asigurare voluntar Neasigurat
Asig. oblig. CAS Asig. facultativ CAS 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: .................................................................................................................................
................................ .......................................... ................................ ................................ ...........................
Diagnosticul la internare: .................................................................................................................................
................................ ................................ ....................... ........ ..............................................
Semntura i parafa medicului
................................................

Diagnosticul la 72 de ore: .............................. ................................ ................................ ................................ ................................ ..............................

.................................................................................................................................................................................................................................................................
Diagnosticul principal la externare:................................ ................................ ..................... ...............................................
................................ ................................ ........................................ ................................ ................................ ...........................................
Diagnostice secundare la externare (complicaii / comorbiditi) :
1. ................................ ................................ ........................................ ................................ ................................ ...........................................
2. ................................ ................................ ........................................ ................................ ................................ ...........................................
3. ................................ ................................ ........................................ ................................ ................................ ...........................................
4. ................................ ................................ ........................................ ................................ ................................ ...........................................
5. ................................ ................................ ........................................ ................................ ................................ ...........................................
6. ................................ ................................ ........................................ ................................ ................................ ...........................................
Semntura i parafa medicului ef Semntura i parafa medicului curant
 ............................................... .......................................................
23.3 A4 t2

Intervenia chirurgical principal: .....................................................................................................................................................................

..................................................................................................................................................................................................................................................................

...............................................................................................................................................................................................................
Consimmntul pentru intervenie: ...........................................................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

Data interveniei chirurgicale: zi luna an

Intervenii chirurgicale concomitente (cu cea principal):
1........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

2........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

Alte intervenii chirurgicale:

1........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

Data interveniei chirurgicale: zi luna an

2........................................................................................................................................
medic operator principal ............................................................................................................................................
Echipa operatorie: medic operator II ........................................................... medic ATI ..........................................................

medic operator III .......................................................... asistent/ ..............................................................

Data interveniei chirurgicale: zi luna an

Examen citologic ..................................................................................................... ................................................................................................................
Examen extemporaneu ..................................................................................................... ...................................................................................................
Examen histopatologic (biopsie pies operatorie)
..................................................................................................... ...................................

Transfer ntre seciile spitalului:

Secia Diagnostic Data intrrii (ora) Data ieirii (ora) Nr. zile
spitalizare

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
Diagnostic n caz de deces:
a. Cauza direct (imediat) .............................................................. .............................................................. ..........................................
b. Cauza antecedent .............................................................. .............................................................. .........................................................
I Stri morbide iniiale:
c. .............................................................. .............................................................. .......................................................................................................
d. .............................................................. .............................................................. .......................................................................................................

II Alte stri morbide importante .............................................................. .............................................................. ........................................

.............................................................. ..................................................................................................................... .........................................................

Diagnostic anatomo-patologic (autopsie), macroscopic: ...........................................................................................................................

.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................

Microscopic: .............................................................. ..................................................................................................................... ...........................................

.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
.............................................................. ..................................................................................................................... .............................................................................
Codul morfologic (n caz de cancer) M
Explorri funcionale:
Denumirea Codul Nr.
1. .............................................................. ....................................................................................................
2. .............................................................. ....................................................................................................
3. .............................................................. ....................................................................................................
4. .............................................................. ....................................................................................................
5. .............................................................. ....................................................................................................
6. .............................................................. ....................................................................................................

Investigaii radiologice:
Denumirea Codul Nr.
7. .............................................................. ....................................................................................................
8. ............................................................. ....................................................................................................
9. ............................................................. ....................................................................................................
10. ............................................................. ....................................................................................................
11. ............................................................. ....................................................................................................
12. ............................................................. ....................................................................................................

Alte proceduri terapeutice:

Denumirea Codul Nr.
13. ............................................................. ....................................................................................................
14. ............................................................. ....................................................................................................
15. ............................................................. ....................................................................................................
16. ............................................................. ....................................................................................................
17. ............................................................. ....................................................................................................
3
 18. ............................................................. ....................................................................................................
ALTE OBSERVAII:

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

MOTIVELE INTERNRII: .............................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

ANAMNEZA: ...........................................................................................................................................................................................................................
a) Antecedente heredo-colaterale ..........................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
b) Antecedente personale, fiziologice i patologice ................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
c) Condiii de via i munc .....................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
d) Comportamente (fumat, alcool etc.)
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
e) Medicaie de fond administrat naintea internrii (inclusiv preparate hormonale i imunosupresoare
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

ISTORICUL BOLII: ..............................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

4
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
EXAMENUL CLINIC GENERAL .............................................................................................................................................................................
EXAMEN OBIECTIV .........................................................................................................................................................................................................
Starea general ...................................................................................................... Talie ....................................... Greutate ...............................
Starea de nutriie .................................................................................. Starea de contien ............................................................................
Facies .............................................................................................................................................................................................................................................
Tegumente .................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Mucoase ......................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Fanere ............................................................................................................................................................................................................................................
esut conjunctiv-adipos ..................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
Sistem ganglionar ................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
Sistem muscular ....................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
Sistem osteo-articular .......................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

APARAT RESPIRATOR ...................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

APARAT CARDIOVASCULAR ..................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

APARAT DIGESTIV ...................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

FICAT, CI BILIARE, SPLINA ...................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

APARAT URO-GENITAL ...............................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................

SISTEM NERVOS, ENDOCRIN, ORGANE DE SIM .................................................................................................................................

.............................................................................................................................................................................................................................................................

5
.............................................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................................
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 ............................................................................... .................................................................................................................................. .........................
................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

ALTE EXAMENE DE SPECIALITATE ..................................................................................................................................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE DE LABORATOR ......................................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE RADIOLOGICE (rezultate) .................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE ECOGRAFICE (rezultate) ...................................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

6
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EXAMENE ANATOMO-PATOLOGICE: .............................................................................................................................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

7
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:
CLINIC: ..................................................................................... ............................................................................... ..................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

PARACLINIC: ....................................................................... ............................................................................... ...................................................
.................................................. ............................................................................. ............................................................................... ............................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

EPICRIZA: ...................................................................................... ............................................................................... ...........................................................
................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

................................................................................................................. ............................................................................... ...........................................................

Semntura i parafa medicului,

8
 ......................................................

9
 F O A I E D E T E M P E R AT U R A D U L I

CNP

Numele . Prenumele ....

Anul luna Nr. foii de observaie Nr. salon .. Nr. pat ..

Ziua
Zile de boal
Resp.

Temp
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

10
 FOAIE DE EVOLUIE I TRATAMENT

DATA EVOLUIE TRATAMENT

11