nr. 110e_amu
DESCRIPTION
formulare MS RMTRANSCRIPT
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Ministerul Sntii al Republicii Moldova
denumirea staiei AMU
Data
Nr. fiei
Nr. echipei
Nr. substaiei
Ora primirii solicitrii
Ora transmiterii solicitrii echipei
Ora sosirii la locul solicitrii
Ora sosirii la spital
Ora transmiterii pacientului
Ora ncheierii solicitrii
Ora sosirii la substaie
GRADUL URGENEI, STABILIT PREALABIL DE DISPECERATUL 903:
, 903:
Urgen major
Urgen gradul II II-
Urgen gradul III III-
Transport specializat asistat
ADRESA PACIENTULUI: raionul (municipiul) __________________ oraul (satul) ___________________ strada ___________________ Nr. _____ : () () bl. ____ scara ____ etaj ____ apartament ________ Telefon _______________ Numele, prenumele ______________________________ Vrsta ____ , DISPECER ________________________________________ PUNCTE DE REPER ____________________________________________________ Solicitant __________________________ Motivul solicitrii (simptomatologie relatat de ctre solicitant(): _________________________________ (, ():
Numele, prenumele bolnavului__ ____________________________________________________________ Vrsta ______ ani _______ luni_____ zile ,
Adresa ________________________________________________________ Locul de munc ____________________________________________
SOLICITARE: :
PRIMIT: :
REZULTATUL SOLICITRII: :
SEX: :
1. Masculin
2. Feminin
LOCALITATEA: :
1. Urban
2. Rural
3. Strintate
. 1. Primar
2. Repetat
3. Concomitent
4. Adresare de sine stttor
5. Activ
6. De echipa 903 903
7. De instituia de medicin primar
8. De spital
. 1. ntemeiat
2. Nentemeiat
1. Personal
2. Prin telefon
3. Prin telefon mobil
LOCUL SOLICITRII: : 1. Apartament
2. Strad
3. Locul de munc
4. Instituie medical
5. Substaie
6. Loc public
7. coal
8. Instituie precolar
9. Poliia 10. Altele
1. Bolnavul e deservit
2. Lipsa bolnavului
3. Refuz de ajutor
4. Solicitare fals
5. Deces pn la sosirea AMU
6. Practic sntos
7. Nu se poate ajunge la locul solicitrii
STARE DE EBRIETATE: :
1. Da
2. Nu
CATEGORII SOLICITRI URGENE MAJORE
. Catastrofe (urgene n mas) ( )
. Colective
. Individuale
STAREA GENERAL BOLNAVULUI: :
1. Satisfctoare
2. Gravitate medie
3. Grav
4. Foarte grav
5. Depit
SOLICITAREA E TRANSMIS LA: CMF ________________________ POLIIE __________________________ CSP ___________________ :
DIAGNOSTICUL _________________________________________________________________________________________________________
__________________________________________________________________________________________________ Cifrul Clasificaiei internaionale maladiilor (revizia X)
(10- )
DOCUMENTAIE MEDICAL
Formular
nr. 110/e
Aprobat de MS RM PM
nr. 828 din 31.10. 2011
FI DE SOLICITARE ASISTENEI MEDICALE DE URGEN
Editura de Imprimate Statistica, 2a4 (1091). 06.05. t. 160.000
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GRADUL DE URGEN A TRAUMEI l INTOXICAIEI ___________________________________________________________________________
GRADUL URGENEI, STABILIT DE ECHIPA DE ASISTEN MEDICAL DE URGEN C,
URGEN MAJOR
URGEN GRADUL II II-
URGEN GRADUL III III-
TRANSPORT MEDICAL
AS1STAT
-
C OD
1.Asigurat Polia de asigurare medical nr.__________________seria__________codul personal____________________________________ 2. Neasigurat
COMPLICAII: :
1. Fibrilaie ventricular
2. Asistolie ventricular
3. Disociaie electromecanic
4. Com
5. Status astmaticus
6. Edem pulmonar
7. Embolie
8. oc
9. Asfixie
10. Aspiraie (sindromul Mendelson)
( ) 11. Hemoragie acut
12. Colaps
13. Anurie
14. Aritmii cardiace
15. Convulsii
16. Pneumotorax
EFICACITATEA MSURILOR N CAZ DE COMPLICAII: :
1. Complicaiile sunt nlturate
2. Ameliorare
3. Fr dinamic pozitiv
ANAMNEZA (ACUZE) ()
Tensiunea arterial
Pulsul
Frecvena respiraiei
Temperatura
CONTIINA: :
PUPILELE:
: TEGUMENTELE:
: RESPIRAIA: :
1. Clar
2. Obnubilare superficial
3. Obnubilare profund
4. Sopor
5. Com
1. Simetrice
2. Anizocorie
3. Reacia fotomotorie a) da b) nu
4. Reflexele
a) pstrate
b) lipsesc
) diminuate
1. Normale
2. Palide
3. Cianotice
4. Hiperemie
5. Uscate
6. Umede
7. Transpiraie abundent
1. Vezicular
2. Murmur vezicular diminuat
3. Respiraie aspr
4. Suflu bronic
5. Lipsete
RALURI:
: PULSUL:
: DISPNEE:
: ZGOMOTELE CARDIACE:
:
1. Uscate (sibilante)
() 2. Umede:
: ) buloase mici
b) buloase mijlocii
) buloase mari
d) ronflante
3. Crepitaie
1. Normal
2. Accelerat
3. Slab
4. Filiform
5. Lipsete
1. Expiratorie
2. Inspiratorie
3. Mixt
l. Clare
2. Atenuate
3. Asurzite
4. Ritmice
5. Aritmice
6. Forma de aritmie
TULBURRI MENTALE: :
1. Maniacale
2. Depresive
3. Catatonice
4. Psihomotorii
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SCARA GLAZGOV
DESCHIDEREA OCHILOR
RSPUNSUL VERBAL
1. Spontan
4 baluri
1. Bolnavul este orientat
5 baluri
2. La comand verbal
3 baluri
2. Bolnavul este dezorientat
4 baluri
3. La stimul dureros
2 baluri
3. Rspunsul este complet dezorientat
3 baluri
4. Lipsete
1 bal
4. Rspuns nearticulat (nedesluit) ()
2 baluri
5. Lipsa contactului verbal
1 bal
REACII MOTORICE
1. Executarea micrilor la comand
6 baluri
4. Flexiune patologic ca rspuns la excitare dureroas
3 baluri
2. Micri adecvate ca rspuns la excitare dureroas
5 baluri
5. Extensie patologic ca rspuns la excitare dureroas
2 baluri
3. Tragerea extremitii ca rspuns la excitare dureroas
4 baluri
6. Lipsa micrilor
1 bal
LIMBA: :
ABDOMENUL: :
FICATUL __________________________________________________________________
SPLINA ___________________________________________________________________
SCAUNUL _________________________________________________________________
MICIUNEA _______________________________________________________________
1. Umed
2. Curat
3. Sabural
1. Suplu
2. Balonat
3. Asimetric
4. Dureros
5. ncordat
6. Obinuit
n actul de respiraie: a) particip b) nu particip :
Date obiective suplimentare ________________________________
________________________________________________________
Starea general a nou-nscutului scara Apgar ________________
________________________________________________________
AJUTORUL MEDICAL ACORDAT
01 Subcutanate
17 Ventilaia pulmonar
02
IN
JEC
II
Intramusculare
18 Intubaie traheal
19 oc electric extern (defibrilare) ()
20 Puncie pericardic (pericardiocentez) ()
03 Intravenoase
21 Imobilizare cervical
22 Imobilizare
04 Intratraheale
23 Drenaj pleural
05 Sublinguale
24 Lavaj gastric
06 Perfuzii
25 Sonda Blakemore Blakemore
26 Manevra Heimlich Heimlich
07 Cateterizarea venei subclavia
27 Hemostaz
08 Cateterizarea vezicii urinare
28 Toracocentez
09 Aspiraia coninutului traheobronic
29 Pansament aseptic
10 Electrocardiograma
30 Pansament compresiv
11 Fonocardiograma
31 Pantaloni antioc
12 Oxigenoterapia
32 Alte msuri
13 Cricotireotomia
33 Anunat Departamentul de Urgen
14 Cricotireostomia
34 Anunat medicul coordonator 903 903
15 Neuroleptanalgezia
35
Solicitat echipa specializat
16 Masaj extern al cordului
36 Semntura pacientului
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RITMUL ________________________________________________________________________________________________________________
F.C.C. ___________________________________________________ A.E.C. _________________________________________________________ ... ...
MODIFICRI ____________________________________________________________________________________________________________
RCR (algoritm) ____________________________________________________________________________________________________________ ()
STAREA DUP ACORDAREA AJUTORULUI MEDICAL
Tensiunea arterial _________________________________________________________________________________________________________
Pulsul ___________________________________________________________________________________________________________________
Respiraia ________________________________________________________________________________________________________________
Starea general ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
ACIUNILE BRIGZII LA FINAL
1. Transportat la spital _________________________________________________________________Medic _________________________________
2. Transportat la punctul traumatologic nr. ______________________________________________________________________________________
3. Lsat l _____________________________________________________________________________________________________________
4. Transportat acas ________________________________________________________________________________________________________
5. Transportat n instituia de medicin primar ___________________________________________________________________________________
6. Transportat la poliie ______________________________________________________________________________________________________
7. Transportat la expertiza medico-legal ________________________________________________________________________________________ -
8. Deservit i lsat n instituia medical _________________________________________________________________________________________
9. Deces n prezena echipei __________________________________________________________________________________________________
10. Refuz categoric de spitalizare ______________________________________________________________________________________________
MEDICUL _________________________________________________________________ COD _________________________________________
FELCERUL ________________________________________________________________ COD _________________________________________
INFIRMIERUL ___________________________________________________________________________________________________________
OFERUL _________________________________________________________________ Nr. AUTO ____________________________________
KILOMETRAJ ____________________________________________________________________________________________________________
eful staiei AMU .