MINISTERUL SĂNĂTĂŢII AL REPUBLICII MOLDOVA

МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ

РЕСПУБЛИКИ МОЛДОВА

O R D I N

П Р И К А З

„ 25 ” august 2009 Nr. 296 mun.Chişinău

Cu privire la testarea formularelor statistice de evidenţă medicală primară în cadrul proiectului moldo-elveţian: regionalizarea serviciilor pediatrice de urgenţă şi terapie intensivă

În scopul realizării prevederilor Memorandumului de Înţelegere între Direcţia Elveţiană pentru Dezvoltare şi Cooperare şi Ministerul Sănătăţii cu privire la proiectul moldo-elveţian: Regionalizarea Serviciilor Pediatrice de Urgenţă şi Terapie Intensivă în Republica Moldova, semnat la 21.10.2008, cît şi a punctului 1.2 al Planului de acţiuni pentru implementarea Strategiei de Dezvoltare a Sistemului de Sănătate în perioada 2008-2017, aprobat prin Hotărîrea Guvernului Republicii Moldova nr. 1471 din 24 decembrie 2007, cu privire la fortificarea capacităţilor autorităţilor medicale în domeniul monitorizării şi evaluării sistemului de sănătate,

ORDON 1. Organizarea şi realizarea testării în perioada 15.09.2009 – 30.11.2009 a formularelor statistice de evidenţă medicală primară „Fişa medicală a bolnavului de staţionar (formular nr. 003-4/e)”, conform anexei nr.1. şi „Fişa statistică a persoanei externate şi decedate din staţionar (formular nr. 066-2/e)" conform anexei nr.2. 2. Directorii IMSP Institutul de Cercetări Ştiinţifice în domeniul Ocrotirii Sănătăţii Mamei şi Copilului, IMSP Spitalul Regional Bălţi, IMSP Spitalul Clinic Municipal pentru Copii “V. Ignatenco” şi IMSP Spitalul Regional Cahul: 2.1. A efectua testarea Fişei medicale a bolnavului de staţionar (formular nr. 003-4/e) şi Fişei statistice a persoanei externate sau decedate din staţionar (formular nr. 066-2/e) pentru pacienţii pediatrici. 2.2. A efectua codificarea cu patru caractere a diagnosticelor de trimitere, la internare, diagnosticul principal şi diagnosticele secundare la externare, conform Clasificaţiei Internaţionale a Maladiilor (revizia a X) a Organizaţiei Mondiale a Sănătăţii. 2.3. A efectua codificarea procedurilor medicale si chirurgicale conform listei ce va fi distribuita de catre Centrul Naţional de Management în Sănătate (CNMS).

2.4. A colecta si transmite catre CNMS datele necesare, in formatul electronic pus la dispozitie de catre CNMS cu sprijinul proiectului REPEMOL si pe baza instructiunilor de raportare ale CNMS 2.5. A prezenta propunerile pentru modificarea şi perfecţionarea conţinutului formularelor testate către CNMS pînă pe data de 04.12.2009. 2.6. Pe perioada testării formularelor statistice de evidenţă medicală primară „Fişa medicală a bolnavului de staţionar (formular nr. 003-4/e)” şi „Fişa statistică a persoanei externate şi decedate din staţionar (formular nr. 066-2/e)" se suspendă utilizarea pentru pacienţii pediatrici a formularelor statistice de evidenţă medicală primară „Fişa medicală a bolnavului de staţionar (formular nr. 003/e)” şi „Fişa statistică a persoanei externate şi decedate din staţionar (formular nr. 066/e)" aprobate prin Ordinul Ministrului Sănătăţii nr. 139 din 28 mai 2002. 3. Directorul general al CNMS: 3.1. Va emite reglementari specifice privind regulile de codificare a diagnosticelor si procedurilor medicale in conformitate cu prevederile acestui Ordin. 3.2. Va pune la dispozitia spitalelor mentionate o aplicatie electronica de colectare si transmitere de date la nivel de pacient, precum si instructiunile de colectare si transmitere a acestor date. 3.4. Va generaliza propunerile parvenite şi va prezenta pînă pe data de 21.12.2009 spre aprobare şi implementare variantele definitivate a Fişei medicale a bolnavului de staţionar (formular nr. 003-4/e) şi a Fişei statistice a persoanei externate şi decedate din staţionar (formular nr. 066-2/e). Controlul executării prezentului ordin se atribuie viceministrului sănătăţii Mircea Buga.

Ministru Larisa CATRINICI

Ministerul Sănătăţii al Republicii Moldova DOCUMENTAŢIE MEDICALĂ Formular nr. 003-4/e Aprobat de MS al RM nr. 296 din 25-08.09

___________________________________________________ denumirea instituţiei

FOAIE DE OBSERVAŢIE CLINICĂ GENERALĂ A COPILULUI

NUMELE ...................................................... PRENUMELE ........................................Sexul M/F Data naşterii: zi lună an Domiciliul legal: Oraş/mun./raion ........................................... Localitatea ................................Str. ........................ Nr. ......... Reşedinţa: Oraş/mun./raion .................................................... Localitatea ................................Str. ........................ Nr. ......... Părinţii (persoana tutelă) ......................................................... ................................................................................................. ................................................................................................. Examinat la RW zi lună an Rezultatul ……………………………………….. B.I. seria nr. Certificat de naştere (copil) seria nr. Statut pacient: asigurat CNAM Neasigurat CNAM Nr. poliţă de asigurare Codul contingentului ..................................... Greutatea corpului .................... Înălţimea ...................... Spitalizat în anul curent în legătură cu boala dată: caz nou (1), repetat (2) Tipul internării: urgenţă (1); trimitere medic de familie (2); trimitere medic specialist ambulatoriu (3);

transfer spitalicesc (4); la cerere (5); altele (9) ........................................................ Рeste cîte ore după îmbolnăvire (traumă): 0-6 ore (1); 7 – 24 ore (2); peste 24 ore (3) Diagnosticul de trimitere .......................................................................................................................... .............................................................................................................................................. Diagnosticul la internare ........................................................................................................................... .............................................................................................................................................. Semnătura şi parafa medicului Diagnosticul la 72 ore .............................................................................................................................. .................................................................................................................................................................. Diagnosticul principal la externare .......................................................................................................... .............................................................................................................................................. Diagnostice secundare la externare (complicaţii / comorbidităţi): 1. ........................................................................................................................................ 2. ........................................................................................................................................ 3. ........................................................................................................................................ 4. ........................................................................................................................................ 5. ........................................................................................................................................ 6. ........................................................................................................................................

Departamentul ............................................................ Secţia .......................................................................... ..............................................................................................................................................................................................................................................................

nr. de înregistrare număr de identificare Întocmit de .........................................

parafa medicului

Grup sangvin: A/B/AB/0; Rh+/- Alergic la ......................................... Data internării: ora zi lună an Data externării: ora zi lună an Nr. zile spitalizare ........................... Nr. zile c.m. la externare .................

7. ........................................................................................................................................ 8. ........................................................................................................................................

Semnătura şi parafa medicului şef Semnătura şi parafa medicului curant - 1 -

Intervenţie chirurgicală principală: ..................................................................................................... ................................................................................................................................................................................................................................................................................................................. Consimţământul pentru intervenţie: .........................................................................................................

medic operator principal ....................................................................................... Echipă operatorie medic operator II .......................................... Medic ATI ..................................... medic operator III ........................................ asistent/ă ........................................ Data intervenţiei chirurgicale: zi lună an Alte intervenţii chirurgicale: 1. ........................................................................................................................................

medic operator principal ....................................................................................... Echipă operatorie medic operator II .......................................... Medic ATI ..................................... medic operator III ........................................ asistent/ă ........................................ Data intervenţiei chirurgicale: zi lună an 2. ........................................................................................................................................

medic operator principal ....................................................................................... Echipă operatorie medic operator II .......................................... Medic ATI ..................................... medic operator III ........................................ asistent/ă ........................................ Data intervenţiei chirurgicale: zi lună an Examen citologic ...................................................................................................................................... Examen extemporaneu ............................................................................................................................. Examen histo-patologic (biopsie piesă operatorie) .................................................................................. Transfer între secţiile spitalului:

Secţia Data intrării (cu oră) Data ieşirii (cu oră) Nr. zile spit

Starea la externare: vindecat (1); ameliorat (2); staţionar (3); agravat (4); decedat (5)

Tipul externării: 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 şi ora decesului: zi lună an ora

- 2 - Diagnosticul în caz de deces: a. cauza directă (imediată) ...................................................................................................................... b. cauza antecedentă ............................................................................................................................... I. Stări morbide iniţiale: c. ............................................................................................................................................................. d. ............................................................................................................................................................. II. Alte stări morbide importante ............................................................................................................. ...................................................................................................................................................................................................................................................................................................................................... Diagnosticul anatomo-patologic (autopsie), macroscopic ........................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Microscopic .............................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Codul morfologic (în caz de cancer) M Explorări funcţionale: Denumirea Nr. 1. ...................................................................................................................................... 2. ...................................................................................................................................... 3. ...................................................................................................................................... 4. ...................................................................................................................................... 5. ...................................................................................................................................... 6. ...................................................................................................................................... 7. ...................................................................................................................................... Investigatii radiologice: Denumirea Nr. 8. ...................................................................................................................................... 9. ...................................................................................................................................... 10. ...................................................................................................................................... 11. ...................................................................................................................................... 12. ......................................................................................................................................

13. ...................................................................................................................................... 14. ...................................................................................................................................... Alte proceduri terapeutice: Denumirea Nr. 15. ...................................................................................................................................... 16. ...................................................................................................................................... 17. ...................................................................................................................................... 18. ...................................................................................................................................... 19. ...................................................................................................................................... 20. ...................................................................................................................................... 21. ......................................................................................................................................

- 3 - MOTIVELE INTERNĂRII: ................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ANAMNEZA: ......................................................................................................................................... a) Antecedentele heredo-colaterale......................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ b) Antecedente personale, fiziologice şi patologice ............................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ c) Comportamente (fumat, alcool etc.) ...................................................................................................................................................................................................................................................................................................................................... d) Medicaţie de fond administrată înaintea internării (inclusiv preparate hormonale şi imunosupresoare)

............................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ISTORICUL BOLII ............................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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EXAMENUL CLINIC GENERAL .......................................................................................................... EXAMEN OBIECTIV ............................................................................................................................. Starea generală ........................................ Talia ...................................... Greutatea ................................ Starea de nutriţie ............................................................... Starea de conştienţă ...................................... Facies ........................................................................................................................................................ Tegumente ................................................................................................................................................ ................................................................................................................................................................... Mucoase .................................................................................................................................................... ................................................................................................................................................................... Fanere ....................................................................................................................................................... Ţesut conjunctiv adipos ............................................................................................................................ ................................................................................................................................................................... Sistem ganglionar ..................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................... Sistem muscular ..................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................... Sistem osteo-articular................................................................................................................................ ...................................................................................................................................................................................................................................................................................................................................... APARAT RESPIRATOR ......................................................................................................................... ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... APARAT CARDIO-VASCULAR ........................................................................................................

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................................................................................................................................................. APARAT DIGESTIV ............................................................................................................................... ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... FICAT, CĂI BILIARE, SPLINĂ ............................................................................................................. ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... APARAT URO-GENITAL ...................................................................................................................... ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... SISTEM NERVOS, ENDOCRIN, ORGANE DE SIMŢ ......................................................................... .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

- 5 - EXAMEN ONCOLOGIC ........................................................................................................................ 1. Cavitatea bucală .................................................................................................................................. 2. Tegumente .......................................................................................................................................... 3. Grupe ganglioni palpabile .................................................................................................................. 4. Sân ...................................................................................................................................................... 5. Organe genitale feminine ................................................................................................................... 6. Citologia secreţiei vaginale ................................................................................................................ 7. Prostată şi rect .................................................................................................................................... 8. Altele .................................................................................................................................................. ALTE EXAMENE DE SPECIALITATE ................................................................................................ ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ EXAMENE DE LABORATOR ............................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

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FOAIE ANEXĂ

LA F/O GENERALĂ Nr. .............................................

Nume şi prenume ............................................................................................................. Vârsta ............................................................................................................................... Secţia ................................................................................................................................

EXAMEN LOCAL ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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EXPLORĂRI FUNCŢIONALE

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PROTOCOL GHIPS

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ZILNIC .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 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ZILNIC .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. 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MEDICAŢIE ZILNICĂ

Data Medicaţia necesară

- 13 -

MEDICAŢIE ZILNICĂ Data Medicaţia necesară

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EPICRIZA

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SEMNĂTURA ŞI PARAFA MEDICULUI ...............................................................................

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Ministerul Sănătăţii al Republicii Moldova Министерство Здравоохранения Республики Молдова DOCUMENTAŢIE MEDICALĂ

Formular Форма nr. 066-2/e

___________________________________________________ denumirea instituţiei наименование учреждения Aprobat de MS al RM

Утверждена МЗ РМ nr.296 din 25-08.09

FIŞA STATISTICĂ A PERSOANEI EXTERNATE ŞI DECEDATE DIN STAŢIONAR

СТАТИСТИЧЕСКАЯ КАРТА ВЫБЫВШЕГО ИЗ СТАЦИОНАРА

1. Numele, prenumele ____________________________________________________________________________________ Фамилия, имя, отчество număr de identificare идентификационный номер

Sex M / F Data naşterii zi lună an Пол М / Ж Дата рождения число месяц год Asigurat CNAM: da – 1, nu – 2 Nr. poliţei de asigurare Застрахован: да нет № страхового полиса şi codul contingentului indicat în poliţa de asigurare __________________________________________________________ и код контингента, указанного в страховом полисе 2. Adresa la domiciliu permanent Oraş/mun./raion ........................... Localitatea ................................Str. ........................ Nr. ......... Адрес постоянного местожительства Город/мун./район Населенный пункт Ул. № Locuitor: urban – 1, rural – 2 Житель: городской сельский 3. Cine a trimis bolnavul__________________________________________________________________________________, Кем направлен больной secţia _________________________________________ , profilul de paturi_______________________________________ oтделение профиль коек 4.Tipul internării: urgenţă - 1; trimitere medic de familie - 2; trimitere medic specialist ambulatoriu- 3; Вид госпитализации: экстренная; направлен семейным врачем; направлен врачем специалистом transfer spitalicesc -4; la cerere- 5; altele- 9 ......................................................... больничный перевод; по прозьбе; другое 5. Рeste cîte ore după îmbolnăvire ( traumă): în primele 6 ore - 1, 7 – 24 ore - 2, Через сколько часов после заболевания (получения травмы): в первые 6 часов 7 - 24 часов peste 24 ore - 3 позднее 24 часов 6. Data şi timpul internării la staţionar zi lună an ora Дата и время поступления в стационаp день месяц год час 7. Tipul externării: externat - 1; externat la cerere - 2; transfer interspitalicesc - 3; decedat – 4 Тип выписки выписан; выписан по прозьбе; больничный перевод; умерший 7a. Data şi timpul externării, decesului zi lună an ora Дата и время выписки, смерти день месяц год час 7b. Zile-pat spitalizate __________________, din ele contra plată_________________________________________ Проведено койко-дней из них платныe 7c. Starea la externare: vindecat - 1, ameliorat - 2, staţionar – 3, agravat - 4, decedat - 5 Состояние при выписки: с выздоровлением с улучшением без перемен с ухудшением умерший

7d. Deces: intraoperator - 1; postoperator: 0-23 ore - 2; 24-47 ore - 3; > 48 ore – 4 Летальность во время операции; постоператорная: 0-23 часов; 24-47 часов; > 48 часов 8. Diagnosticul instituţiei, care a trimis bolnavul____________________________________________________________ Диагноз, направившего учреждения

___________________________________________________________________________________ 9. Spitalizat în anul curent în legătură cu boala dată: caz nou - 1, repetat - 2 Госпитализирован в данном году по поводу данного заболевания: впервые повторно 10. Diagnosticul principal la externare .......................................................................................................................... Основной диагноз при выписке Diagnostice secundare la externare (complicaţii / comorbidităţi): Сопутствующие диагнозы при выписке (осложнения/)

9. .................................................................................................................................................................................

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11. Diagnosticul patomorfologic……………………………………………………………………………...…………………… Патоморфологический диагноз

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12.Codul morfologic (în caz de cancer) M Морфологический код (в случае злокачественной опухоли)

13. În caz de deces (de indicat cauza): В случае смерти (указать причину):

I. Cauza nemijlocită a decesului (boala sau complicaţiile bolii de bază) a)________________________________________________________ Непосредственная причина смерти (заболевания или осложнение основного заболевания) boala, care a provocat sau a condiţionat cauza nemijlocită a decesului: b) ______________________________________________________ заболевание, вызвавшее или обусловившее непосредственную причину смерти:

boala de bază se indică ultima с)_______________________________________________________

основное заболевание указывается последним

II. Alte afecţiuni importante , care au favorizat decesul , dar care nu sînt legate de afecţiunea sau de complicaţia ei, care au constituit cauza nemijlocită a decesului Другие важные заболевания, способствовавшие смертельному исходу, но не связанные с заболеванием или его осложнением, послужившим непосредственной причиной смерти __________________________________________________________________________________________________________________

14. Intervenţii chirurgicale Хирургические операции

Data , ora Дата , час

Denumirea intervenţiei Название операции

Codul Код

Complicaţii Осложнения

15. Anestezie Обезболивание

Data , ora Дата , час

Metoda de anestezie Метод обезболивания

Complicaţii Осложнения

16. Examinat la RW zi lună an Rezultatul ______________________________________________________ Обследован на RW день месяц год Результат

17. Participant la al II Război Mondial: da - 1, nu - 2 dacă da, de indicat invalid : da - 1, nu - 2 Участник II Мировой Войны: да, нет если да, указать инвалид: да нет

18. Ostaş – internaţionalist: da - 1, nu - 2 dacă da, se indică invalid : da - 1, nu - 2 Воин интернационалист: да, нет если да, указать инвалид: да нет 19. Transfer între secţiile spitalului: Внутрибольничный перевод

Secţia Отделение

Data intrării (cu oră) Дата поступления(время)

Data ieşirii (cu oră) Дата выписки(время)

Nr. zile spit Количество койко -дней

Semnătura medicului____________________________ Подпись врача