S Y t: .................................

Bnh vin: ................................

Khoa: .............................Ging........

S lu tr: ..............................
M YT ......../......../......../.......

BNH N SN KHOA

I. HNH CHNH:

Tui

1. H v tn(In hoa): ................................................................ 2. Sinh ngy:

3. Ngh nghip: ................................................
4. Dn tc: ................................................
5. Ngoi kiu: ..................................................
6. a ch: S nh ............ Thn, ph.............................................. X, phng...............................................................
Huyn (Q, Tx) .............................................................
Tnh, thnh ph ...............................................
7. Ni lm vic: ......................................................... 8. i tng : 1.BHYT
2.Thu ph
3.Min
4.Khc
9. BHYT gi tr n ngy .......thng...... nm ............ S th BHYT
10. H tn, a ch ngi nh khi cn bo tin: ................................................................................................................
................................................................................................. in thoi s................................................................

II. QUN L NGI BNH

11. Vo vin: ............ gi........ph ngy....../....../............

13.Ni gii thiu: 1.C quan y t

12. Trc tip vo: 1.Cp cu

Khoa

- Vo vin do bnh ny ln th
16. Chuyn vin: 1.Tuyn trn

14. Vo khoa

2.KKB
3.Khoa iu tr
ng / th / nm S ngy Tr

......Gi.....pht....../....../...........

2.T n

3.Khc

2.Tuyn di

3.CK

- Chuyn n ..........................................................................
.................................................................................................

15. Chuyn

......Gi.....pht....../....../...........

Khoa

17. Ra vin: .......... gi ....... ngy ........./........./................

......Gi.....pht....../....../...........

1. Ra vin

3. B v

4.a v

18. Tng s ngy iu tr.................................

......Gi.....pht....../....../...........

III. CHN ON

2. Xin v

19. Ni chuyn

25. Tnh hnh phu thut: 1. Cp cu

n: ........................................................................................

+ Chn on trc phu thut: ...........................................

20. KKB, Cp cu: .........................................................

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

21. Lc vo :..............................................................

+ Chn on sau phu thut: ..............................................

22. Ngy (m ):............................................................................

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

23. Ngi thai:........................................................................................

+ Phng php phu thut: ................................................

24. Cch thc :..................................................................................

26. Tr s sinh: 1. n thai

2.Ch ng

2. a thai

- Kim sot t cung: ...................................................................

3. Trai

- Tai bin

5. D tt: .........................................................................

- Bin chng:

1.Do phu thut

2.Do gy m

3.Do nhim khun

4.Khc

27. Tng s ngy iu tr sau phu thut:

4. Gi

a -Sng

b-Cht

6. Cn nng: .................................... gram

28. Tng s ln phu thut:

IV. TNH TRNG RA VIN

29. Kt qu iu tr
1. Khi

31. Tnh hnh t vong: ......... gi.......ph

4. Nng hn

ngy........ thng ...... nm ..........

1. Do bnh

2.Do tai bin iu tr

2.Ngoi 24 gi vo vin

3. Khc

2. , gim

5. Chuyn vin

1. Trong 24 gi vo vin

3. Khng thay i

6. T vong

32. Nguyn nhn chnh t vong: ............................................................................

30. Gii phu bnh (khi c sinh thit):

1. Lnh tnh

2.Nghi ng

3.c tnh

........................................................................................................
33. Khm nghim t thi:

34. Chn on gii phu t thi: . .

Ngy ....... thng ...... nm .............

Gim c bnh vin

H v tn .............................................

Trng khoa
H v tn .........................................

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BNH N

I. L do vo vin:................................................................................................... Vo ngy th ....................... ca bnh

II. Hi bnh:
1. Qu trnh k thai ny: kinh cui cng t ngy ......./......../....... n ngy ......./......./........ - Tui thai:
.............tun

- Khm thai ti: ..................................................................................................................................................................................

- Tim phng un vn

c tim .................... ln

- Bt u chuyn d t ........ gi ........ pht ngy ......../......../.................

- Du hiu lc u: ...........................................................................................................................................................................
- Bin chuyn: ....................................................................................................................................................................................
2. Tin s bnh:
+ Bn thn: (nhng bnh mc, d ng, thi quen n ung, sinh hot, khc ...)
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

+ Gia nh: ..........................................................................................................................................................................................

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

3. Tin s ph khoa:
- Bt u thy kinh nm: ...............................Tui: ...........................
- Tnh cht kinh nguyt:...........................

Chu k: .................... ngy

- Lng kinh: ...............................

- Ly chng nm:............................... tui ...................

- Nhng bnh ph khoa iu tr: .............................................................................................................................................
4. Tin s sn khoa
S ln
c
thai

Nm

thng

thiu
thng

Sy

Ht

No

Covac

Cha
ngoi
TC

Cha
trng

Thai
cht
lu

Con
hin
sng

Cn
nng

Phng
php

Tai bin

1
2
3
4
5
6

III-Khm bnh:

Mch ...................... ln/ph

1. Ton thn:
- Ton trng: ...............................................................................................................................
................................................................................................................................................
Ph
- Tun hon: ...............................................................................................................................

Nhit .........................0C
Huyt p ........./...... mmHg
Nhp th................. ln/ph
Chiu cao: .................. cm

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

Cn nng: ................... Kg
- H hp: ..............................................................................................................................................................................................
.................................................................................................................................................................................................................

- Tiu ho..............................................................................................................................................................................................
.................................................................................................................................................................................................................
- Tit niu: ...........................................................................................................................................................................................
- Cc b phn khc: ...........................................................................................................................................................................
29

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

2. Khm ngoi:
- Bng c so phu thut c

- Hnh dng TC: ........................... T th: .............................

- Chiu cao TC:................. cm, vng bng: . ........ cm

- Cn co TC: ...............................................................................

- Tim thai: .............. ln/ pht

- V: ...............................................................................................

3. Khm trong:
- Ch s Bishop

............ im

- m h: ............................. . - m o: ..........................

- Tng sinh mn: .....................................................................

- C t cung: ....................... .- Phn ph: .......................

- Tnh

- i v lc: . ....... gi ......... pht ngy ....../......./..........

- i v:

- Mu sc nc i:................................................................

- Nc

- Ngi: .................................... - Th: ..................................

- Kiu th: .................................................................................

- lt: 1.Cao

- ng knh nh h v: ......................................................

2.Chc

3. Cht

4.Lt

trng i: 1.i phng

1. T nhin

2.i dt

3.i qu l

2. Bm i

i nhiu hay t: ..........................................................

4. Cc xt nghim cn lm sng cn lm: .............................................................................................................................

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

5. Chn on:
- Khi vo khoa: ..................................................................................................................................................................................
- Phn bit: ..........................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

6. Tin lng: ...................................................................................................................................................................................

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

7. Hng iu tr: ...........................................................................................................................................................................

- Phng php chnh: .......................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................
.................................................................................................................................................................................................................

Ngy........thng....... .nm...............

Bc s lm bnh n

H v tn................................................

IV. Theo di ti bung :

30

- Vo bung lc: ................... gi ................. pht ngy ............/........../.............

- Tn ngi theo di: .............................................................. Chc danh: .................................................................................
1. c im tr s sinh:
- lc: ...... gi ....... ngy ......./......./....... - Apgar: 1 pht: ...... im 5 pht:....... im 10 pht: ....... im
- Cn nng: ...........gram

Cao: .........cm, Vng u: .........cm

- Con: - n thai 1.Trai

2.Gi

- a thai: 1. Trai

2. Gi

- Tt bm sinh:

- C hu mn

C th tt bm sinh: .......................................................................................................................................................................
- Tnh trng tr s sinh sau khi : ..............................................................................................................................................
- X l v kt qu: ............................................................................................................................................................................
2. c im s rau: Rau:
1. Bc
2. S
- Rau s lc: ....... gi ........ pht ngy ......./......./......... - Cch s rau: ...........................................................................
- Mt mng: .............................................................................. - Mt mi: ..................................................................................
- Bnh rau: ............................... - Cn nng: .............gram - Rau cun c:
- Cung rau di: ......... Cm

C chy mu sau s

Nu c, lng mu mt: ...................... ml

- Kim sot t cung:

- X l v kt qu: ............................................................................................................................................................................
3. Tnh trng sn ph sau : - Da, nim mc: ......................................................................... Mch ...................... ln/ph
- Phng php :1. thng

2.forceps

3.gic ht

4.PT

5. ch huy

6.khc

Nhit .........................0C

- L do can thip: ..................................................................................................................................... Huyt p ........./....... mmHg

- Tng sinh mn: 1. Khng rch

2. Rch

Nhp th................... ln/ph

3. Ct

Nu c, phng php khu v loi ch: ........................................................................................... S mi khu:

- C t cung:

1. Khng rch

2. Rch

4. Tnh hnh phu thut (nu c):

- Chn on trc phu thut: .......................................................................................................................................................
- Chn on sau phu thut: ........................................................................................................................................................................
Gi, ngy

1. Tai bin PT

Phng php phu thut/v cm

2. Bin chng

1. Do PT

Phu thut vin

2. Do gy m

Bc s gy m

3. Do nhim khun

4. Khc

5. Hng iu tr v cc ch tip theo: ............................................................................................................................

H s, phim, nh
Loi
X - quang
CT Scanner
Siu m
Xt nghim
Khc.
Ton b h s

Ngi giao h s:
S t

Ngy.........thngnm
Bc s iu tr

H tn.
Ngi nhn h s:

H tn.

H tn.

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