Ministerul Sntii al Republicii Moldova

DOCUMENTAIE MEDICAL
Formular
nr. 097/e

Aprobat de MS al RM
nr. 828 din 31.10. 2011

_________________________________________________________________
denumirea instituiei

FOAIE DE OBSERVAIE A NOU-NSCUTULUI nr. ___________

Mama

Tata

Copilul

Grupa de snge

Factor Rhesus
-
Numele, prenumele mamei _________________________________________________________________________________________
, ,
Numr de identificare _______________________________________ Numrul poliei de asigurare _______________________________


Vrsta mamei _________________________________ Naionalitatea (etnia) _________________________________________________

()
Adresa la domiciliu _______________________________________________________________________________________________

Studii:
primare,
medii incomplete,
medii
: , , ,
Starea familial:
cstorie nregistrat,
: ,

medii speciale,
superioare incomplete,
superioare
, ,

cstorie nenregistrat,
,

necstorit (a specifica)
()

Serviciul n afara casei pe parcursul sarcinii_____________________________________________________________________________

Locul de munc __________________________________________________________________________________________________

Profesia sau funcia _______________________________________________________________________________________________

Condiiile de munc:
:

favorabile
sau nocive.
A indica factorii nocivi ________________________________________
.
Date despre sntatea tatlui

Vrsta tatlui __________________ Relaii de rudenie ntre soi ____________________________________________________________

Date antecedente despre familie ______________________________________________________________________________________

Ziua

Luna

Anul

Ora

Min.
.

Registru de internare nr. __________________________________

Salonul copilului nr. _____________________________________

S-a nscut

Patul copilului nr. _______________________________________

Internat

Salonul mamei nr. _______________________________________

Externat

Decedat

Transferat

Unde

Patul mamei nr. _________________________________________

Copilul transferat n salonul nr. _____________________________ ,

patul nr. _______________________________

Data transferrii _________________________________________

Anamneza ginecologic i obstetrical

A cta graviditate______________________________________ , a cta natere________________________________________________


Natere la termen da, nu (a specifica), dac nu, la ______________________________________________________ sptmni de gestaie
, (), ,

Natere: monofetal,
multipl
(a specifica),
la natere multipl s-a nscut al ctelea la numr________________________
: , (),
Ruptura membranelor amniotice a avut loc la ___________________________________________________________________________
ora

Durata travaliului:
<12 ore,
12 - 18 ore,
>18 ore
(a specifica)
:
<12 .,
12 - 18 .,
>18 .
()
Prezentaia ______________________________________________________________________________________________________

Complicaii n natere din partea mamei i copilului ______________________________________________________________________

Administrarea:
analgezicelor ____________________ , anesteticelor ___________________ , oxitocinelor______________________ ,
:

eficacitatea lor ___________________________________________________________________________________________________

Intervenii chirurgicale _____________________________________________________________________________________________

Afeciuni, complicaii n perioada sarcinii ______________________________________________________________________________
,
_______________________________________________________________________________________________________________
Durata naterii pe perioade:
I perioad______________________________ , II perioad____________________________ ,
:

particularitile evoluiei, interveniile _________________________________________________________________________________

,
Perioada alichidian ______________________________________________________________________________________________ ,

Caracteristica apelor fetale __________________________________________________________________________________________

Sex

viu

S-a nscut

mort
(a indica pn la sau
n timpul travaliului)

(

)

Nscut
la termen,
prematur
,

Greutatea
(masa)
n g

()

Perimetrul

Talia, cm
,

cranian

cutiei
toracice

Asfixie

durata

msuri de reanimare

Etapele eseniale de reanimare a nou-nscutului

Msuri iniiale:
plasarea sub o surs de lumin radiant _________________ , tergerea copilului _________________
:

Permeabilizarea cilor respiratorii:
:
poziionarea nou-nscutului ______________________ , dezobstruarea gurii _____________________ ,


nasului_________________________ , traheei_________________, introducerea sondei endotraheale _____________________________

Meninerea respiraiei: stimularea tactil________________________________________ , ventilare cu presiune pozitiv
:

prin inspiraie: a) balon cu masc _______________________________ , b) balon cu sond endotraheal ___________________________
:


Meninerea circulaiei:
masaj cardiac extern _________ , medicamente: Adrenalin (doza, numrul de administrri) ________
:
: (, )
Volumul expanderii (doza, numrul de administrri) ______________ Bicarbonat de sodiu (doza, numrul de administrri) ____________
(, )
(, )
Naloxon (doza, numrul de administrri) ______________________________________________________________________________
(, )
Respiraie autonom dup_______________________________ minute. Oprirea reanimrii la______________________________ minute

.

Aprecierea strii nou-nscutului dup scara Apgar

Timpul dup
natere

Btile inimii

Respiraia

Culoarea epidermei Tonusul muscular

Reflexe

Aprecierea n
puncte

Aplicarea pe burta mamei n contact "piele-la-piele" imediat dup natere _____________________________________________________

Aplicat la sn:
n primele 30 minute_________________ , n primele 2 ore ____________________ , dup 2 ore _______________
: 30
2
2
Malformaii congenitale ____________________________________________________________________________________________

Traume puerperale ________________________________________________________________________________________________

Profilaxia gonoblenoreei (denumirea medicamentului, ora) _________________________________________________________________
( , )
_______________________________________________________________________________________________________________
Naterea asistat de (numele, prenumele i calificarea specialistului i moaei) _________________________________________________
( )
Copilul transferat n secia nou-nscuilor _______ _____________________20 _____ , ora _______________ _____________ min.

.
Starea copilului la transferare din sala de natere ________________________________________________________________________
.
_________________________________________________ , culoarea tegumentelor, caracterul strigtului ________________________
,
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
A predat copilul moaa ____________________________________________________________________________________________

A preluat i a prelucrat asistenta medical ______________________________________________________________________________

Diagnosticul preliminar ____________________________________________________________________________________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Diagnosticul definitiv _____________________________________________________________________________________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
3

Primul examen al copilului n salonul (secia ) nou-nscuilor

______ __________________________20____
data examenului

()
Date generale:
:
Starea general (poziia copilului, caracterul strigtului) ___________________________________________________________________
( , )
_______________________________________________________________________________________________________________
Tegumentele _____________________________________________________________________________________________________

Mucoasele vizibile ________________________________________________________________________________________________

Bontul ombilical _________________________________________________________________________________________________

Examinarea neurologic:
:
Activitatea motorie spontan:
sczut____________________________________, intens __________________________ .
:

Tremor: ndelungat ____________________ , de amplitudine mic __________________ , de amplitudine nalt_____________________

:


Tonus muscular:
distonie muscular _____________, hipertonie muscular __________________ , hipertonie extensorie __________ ,
:


hipotonie muscular:
generalizat _________ , local________ , poziie extensorie a picioarelor _______, retroflexia capului _________
:

Examenul capului:
:
Forma: brahicefalie,
dolicocefalie,
asimetrie,
oxicefalie (a specifica).
Configuraia________ Suturile (cm) _______
: , , , ().
()
Palparea capului:
oase integre,
bosa serosangvin, cefalohematom, hemoragie subaponeurotic,
: ,
, , ,
hernie cerebral, infiltrate,
abcese (a specifica) __________________________________________________________________
a indica lipsete

, , ()
Starea fontanelelor (dimensiuni, proeminena, a specifica i indica):
fontanela mare ____ , fontanela mic ___ , fontanele laterale ___
(, , ):

Reflexe necondiionate: labial,
de cercetare, Babkin,
de prehensiune,
Moro, de aprare,
Galant,
: ,
, , ,
, ,
,
Peres, Bauer, de sugere
(a specifica)
, , ()
Simptomatologia ocular patologic: ptoz, nistagmus vertical,
rotator,
orizontal,
lagoftalm, strabism convergent,
: , , , , , ,
strabism divergent,
simptom Graefe, simptom "apus de soare",
pareza privirii, simptom "ochi de ppu", mioz,
, , , , , ,
midriaz, anizocorie (a specifica, ce lipsete a indica) _______________________________________________________________
, (, )
Convulsii: tonice,
clonice,
mioclonale,
fragmentare (a specifica, ce lipsete a indica)_______________________ .
: , , , (, )
Statutul somatic:
:
Forma cutiei toracice ______________________________________________________________________________________________

Respiraia, starea plmnilor, aprecierea dup scara Silverman n caz de insuficien pulmonar ____________________________________
, ,
_________________________________________________________________________________ FR/minut _____________________
/
Cordul (limita, prezena suflurilor, caracterul ritmului) ____________________________________________________________________
(, , )
_______________________________________________________________________________________________________________
_______________________________________________________________ , pulsul _________________________________________

Organele cavitii abdominale: ficatul, splina ___________________________________________________________________________

: ,
_______________________________________________________________________________________________________________
Eliminarea meconiului _____________________________________________________________________________________________

4

Miciunea _______________________________________________________________________________________________________

Organele genitale externe __________________________________________________________________________________________

Prezena anusului _________________________________________________________________________________________________

Starea articulaiilor coxofemurale ____________________________________________________________________________________

Concluzia i diagnosticul preliminar __________________________________________________________________________________

_______________________________________________________________________________________________________________
Prescripii i argumentarea lor _______________________________________________________________________________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

2
3
4
5
6
7

Semntura

Starea plgii ombilicale

Timpul cderii bontului

ombilical

Miciunea

Caracterul scaunului

Activitatea reflexului de
sugere

tegumentelor

cavitii bucale

ochilor

Schimbarea strii

mucoasa

prezena crizelor
de asfixie

Greutatea (masa)
()

Temperatura

Data

Ziua de via

Datele privind supravegherea nou-nscutului de ctre asistenta medical

d
s
d
s
d
s
d
s
d
s
d
s
d
s

Not:
La nou-nscuii prematuri cu greutatea sub 1500 g se va msura temperatura axial i rectal.
: 1500
Vaccinarea contra tuberculozei

Data

Ziua vieii

Doza

Nr. seriei
vaccinului

Termenul
valabilitii

Reacia la vaccin

Semntura

Vaccinarea nu s-a efectuat (a indica cauza) _____________________________________________________________________________

( )
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
ALIMENTAIA NOU-NSCUTULUI (eviden n grame)
( )

Ziua vieii

Ziua vieii

alptare

alptare

alptare

alptare

alptare

10

alptare

alptare

alptare

alptare

alptare

Zilnicul medicului-pediatru
-
Data

Ziua vieii

Datele examenului, examinrii

,

Prescripii

Zilnicul medicului-pediatru
-
Data

Ziua vieii

Datele examenului, examinrii

,

Prescripii

Zilnicul medicului-pediatru
-
Data

Ziua vieii

Datele examenului, examinrii

,

Prescripii

Zilnicul medicului-pediatru
-
Data

Ziua vieii

Datele examenului, examinrii

,

10

Prescripii

Zilnicul medicului-pediatru
-
Data

Ziua vieii

Datele examenului, examinrii

,

11

Prescripii

Epicriza ________________________________________________________________________________________________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Starea copilului la externare (transferare) ______________________________________________________________________________
()
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Recomandri medicului de familie ___________________________________________________________________________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Data

_____________________

A predat copilul________________________________________________________
semntura asistentei medicale

_____________________

A preluat copilul _______________________________________________________

semntura asistentei medicale

Certificatul medical constatator al naterii copilului a primit ________________________________________________________________

semntura mamei


Instituia de asisten medical primar la locul de trai
_______________________________ despre externarea copilului este ntiinat
denumirea


_______ ________________________________ 20 _______
Telefonograma a transmis___________________________________________ , a recepionat ___________________________________

12