Unitatea sanitara________________

Localitatea____________________
Judet/sector___________________
Nr.conventie________cu CAS_________
REFERAT MEDICAL

Subsemnatul_________________________medic primar/specialist,specialitatea
_________________cod parafa__________,propun expertiza capacitatii de munca a
domnului/doamnei __________________________,CNP________________________
cu domiciliul in ___________,str._____________________nr._________,
judet/sector___________,de profesie _________________,angajat/angajata
la____________________________________.
Este in evidenta de la data _______________________.
Diagnosticul clinic la data luarii in evidenta _____________________________.
Diagnosticul clinic actual_____________________________________________
______________________________________________________________________.
Examen obiectiv____________________________________________________
_______________________________________________________________________.
A fost internat/internata in spital**)cu diagnosticul/diagnosticele______________
_______________________________________________________________________.
Investigatii clinice/paraclinice**)_______________________________________
_______________________________________________________________________ .
Tratamente urmate__________________________________________________
_______________________________________________________________________ .
Plan de recuperare___________________________________________________
_______________________________________________________________________ .

ORDIN_________________________________________________________________
Prognostic recuperator
__________________________________________________________________
se afla in incapacitate temporara de munca de la data de ____________________
si a totalizat un numar de _________zile de concediu medical la data de ____________.
Propunem:
a) prelungirea concediului medical,considerind ca bolnavul este recuperabil,
cu _______zile,de la _____________________pana la ____________________ .
b) reducerea temporara a timpului de munca cu o patrime din durata normala,
pentru ________zile,de la ____________________,pana la ____________________ .
c) bolnavul nu este recuperabil in limitele duratei concediului medical prevazut de lege
si propunem pensionarea de invaliditate temporara.
Nr.__________din data___________________.

Medic curant,
(parafa si stampila unitatii sanitare)
______________
*)Necompletarea tuturor rubricilor determina invalidarea referatului medical
**)Se vor anexa rezultatele,biletele de externare din spital