foaie de observatie

of 21/21
Judeţul …………………….......... …….......…. Nr. înregistrare Localitatea Bucuresti. CNP Spitalul Clinic Colentina. Întocmit de: ............................................... ................ parafa medicului Secţia ....................... ................................. ........ FOAIE DE OBSERVAŢIE CLINICĂ GENERALĂ NUMELE .................................... ............................................. .... PRENUMELE ............................... ........................................... Sexul M/F Data naşterii: zi lun ă an Grup sangvin: A/B/AB/0; Rh + / - Domiciliul legal: judeţul Localitatea ................... ............................ Alergic la: ..................................... ......................... Sec t. Mediul U/R Str. .......................... .................................. .......... Nr. . ..... Data internării : ora Reşedinţa: judeţul Localitatea ......................... ........................................... ..... z i lun ă a n Sec t. Mediul U/R Str. .......................... .................................. .......... Nr. . ..... Data externării: ora z i lun ă a n Ocupaţia ....................................................... .................................................................... .................. Nr. zile spitalizare ..................................... ..... Locul de muncă ................................................................... ..................................................... Nr. zile c. m. la externare ...................... ... C.I / B.I. seria Nr . Certificat naştere (copil) seria Nr. Statut pacient: Asigurat CNAS Neasigurat CNAS Nr. carnet asigurat Casa de asigurare judeţeană Transpor turi CASAOPSNAJ Talon pensie Tipul internării: urgenţă (1); trimitere medic de familie (2); trimitere medic specialist ambulatoriu (3); transfer interspitalicesc (4); la cerere (5); alte (9) Diagnosticul de trimitere: ........................................................................................................... ....................................................................................... ...............................................................................................

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Foaie de observatie

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Foaie de Observatie Clinica Generala

Judeul ..................Nr. nregistrare

Localitatea Bucuresti.CNP

Spitalul Clinic Colentina.ntocmit de: ............................................................... parafa medicului

Secia ................................................................

FOAIE DE OBSERVAIE CLINIC GENERALNUMELE .....................................................................................PRENUMELE ..........................................................................Sexul M/F

Data naterii: zilunanGrup sangvin: A/B/AB/0; Rh + / -

Domiciliul legal: judeul Localitatea ...............................................Alergic la: ..............................................................

Sect.Mediul U/RStr. ......................................................................Nr. ...... Data internrii:ora

Reedina: judeulLocalitatea .........................................................................zilunan

Sect.Mediul U/RStr. ......................................................................Nr. ......Data externrii:ora

zilunan

Ocupaia ............................................................................................................................................. Nr. zile spitalizare ..........................................

Locul de munc ........................................................................................................................ Nr. zile c. m. la externare .........................

C.I / B.I. seria Nr.Certificat natere (copil) seriaNr.

Statut pacient: Asigurat CNAS Neasigurat CNASNr. carnet asigurat

Casa de asigurare judeeanTransporturiCASAOPSNAJTalon pensie

Tipul internrii: urgen (1); trimitere medic de familie (2); trimitere medic specialist ambulatoriu (3);

transfer interspitalicesc (4); la cerere (5); alte (9)

Diagnosticul de trimitere: ..................................................................................................................................................................................................

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Diagnosticul la internare: ...................................................................................................................................................................................................

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

Semntura i parafa medicului

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

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Diagnosticul principal la externare:................................ ................................ ............................. ...............................................

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Diagnostice secundare la externare (complicaii / comorbiditi):

1. ................................ ................................ ........................................ ................................ ................................ ................................ .................

2. ................................ ................................ ........................................ ................................ ................................ ................................ .................

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

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

Semntura i parafa medicului efSemntura i parafa medicului curant

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

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Consimmntul pentru intervenie: ...........................................................................................................................................................................

Echipa operatorie: medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................

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

Data interveniei chirurgicale: ziluna an

Intervenii chirurgicale concomitente (cu cea principal):

1. ..................................................................................................................................................................................................................

Echipa operatorie: medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................

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

2. ..................................................................................................................................................................................................................

Echipa operatorie: medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................

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

Alte intervenii chirurgicale:

1. ..................................................................................................................................................................................................................

Echipa operatorie: medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................

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

Data interveniei chirurgicale: ziluna an

2. ..................................................................................................................................................................................................................

Echipa operatorie: medic operator principal ............................................................................................................................................

medic operator II ........................................................... medic ATI ..........................................................

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

Data interveniei chirurgicale: ziluna an

Examen citologic ..................................................................................................... ................................................................................................................

Examen extemporaneu ..................................................................................................... ...................................................................................................

Examen histopatologic (biopsie pies peratorie) ..................................................................................................... ...................................

Transfer ntre seciile spitalului:

SeciaData intrrii (cu ora)Data ieirii (cu ora)Nr. zile spit.

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)

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Data i ora decesului:ziluna anora

Diagnostic n caz de deces:

Ia.Cauza direct (imediat) .............................................................. .............................................................. ..........................................

b.Cauza antecedent .............................................................. .............................................................. .........................................................

Stri morbide iniiale:

c............................................................... .............................................................. .......................................................................................................

d............................................................... .............................................................. .......................................................................................................

IIAlte stri morbide importante .............................................................. .............................................................. ........................................

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

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Codul morfologic (n caz de cancer) M

Explorri funcionale:

DenumireaCodul Nr.

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Investigaii radiologice:

DenumireaCodul Nr.

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ALTE OBSERVAII:

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

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

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

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

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

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

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

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

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

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

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

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

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INTERVENII CHIRURGICALE (numrul interveniei chirurgicale, protocol operator):

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

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SUSINEREA DIAGNOSTICULUI I TRATAMENTULUI:

CLINIC: ..................................................................................... ............................................................................... ..................................................

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

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

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Semntura i parafa medicului,

9FOAIE DE TEMPERATUR ADULI

CNP

Numele.Prenumele....

AnullunaNr. foii de observaieNr. salon..Nr. pat..

Ziua

Zile de boal

Resp.T.A.PulsTempDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDSDS

353016041O

302514040O

252012039O

201510038O

15108037O

1056036O

Lichide ingerate

Diurez

Scaune

Diet

10

FOAIE DE EVOLUIE I TRATAMENT

DATAEVOLUIETRATAMENT

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