MODUL CHIRURGIE

ONCOLOGICA/GENERALA
NUME
ani
CI:

Identificator internare:
Tip internare
criteriu
Data internarii:

Cetatenie:

Stare civila:

Medic:
Sectia:

PRENUME

Sex:
Virsta:
CNP:
Domiciliu legal
Mediul
Loc munca:
Telefon pacient

Dosar unic
nr.

Ocupatia:

Apartinator ref:

Data externarii: ___ / ___ / _____

telefon

Asigurat<status asig> tipasigurare<tip asig>

card national <cs>

Nr card europ<nr ce> / nr. Pasaport<nr pas> / Formular European <form eur>
Boli asociate:
______________________________________________________________________
_________________________________________________________________________________

CM la externare: ____ zile

GRUP SINGE:
Seria
_____
Nr.
ALERGII
1.
2.
3.
4.
Inaltimea:
cm
G=
Kg

Diagnostic la internare:____________________________________________________________________________________COD
DRG____________
Formulare libera:
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Evolutia (de la ultimul consult), motvele internarii actuale:
_________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
TA =

mm Hg; AV =

EXAMEN CLINIC GENERAL

/ min ; Tranzit intestinal: prezent/absent; Diureza: prezenta/absenta; Hemoragii

= normal

Tegumente si
mucoase________________________Fanere______________________________
Ap. Locomotor _______________________
Sist.Nervos__________________________________
Tes. conjunctivoadipos_____________________________________________________________
Ap.
Respirator____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Ap.
Cardiovascular_________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Ap.
Digestiv______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
EXAMEN LOCAL

Tumora:
__________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Adenopatii:
_______________________________________________________________
_________________________________________________________________________
Metastaze:

STATUS: RC
PROGR

RP

STAT

Sist.
Endocrin_________________________
Ficat, splina, cai
biliare__________________
______________________________________
______________________________________
Stare
generala________________________
Stare de
nutritie_______________________
Stare de
constienta____________________
Tuseu
vaginal_________________________
______________________________________
______________________________________
______________________________________
______________________________________
Tuseu rectal,
prostata___________________
______________________________________
______________________________________
______________________________________
______________________________________
Altele______________________________
______________________________________
_
Examen cu

ANTECEDENTE
CHIRURGICALE:______________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
___
TRATAMENTE
CRONICE:___________________________________________________________________________________________
EXAMENE PARACLINICE /IMAGISTICE
ANTERIOARE INTERNARII:

ALTE EXAMENE DE SPECIALITATE:

Dg. la 72 de
ore:__________________________________________________________________________________________________
_______________________________________________________________________________________________________________
SUSTINEREA DIAGNOSTICULUI SI TRATAMENTULUI (INDICATIA
OPERATORIE):_______________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_____________________

Semnatura si parafa medicului curant:

TRANSFERURI INTRE SECTII:

SECTIA
DIAGNOSTIC

DATA INTRARII (ORA)

DATA IESIRII (ORA)

NR.ZILE
SPITALIZARE

Consimtamantul pacientului/apartinatorului pentru toate investigatiile si tratamentele considerate necesare de

medical curant (inclusive transfuzii sangvine/produse de sange), precum si cu interventia chirurgicala propusa si
anestezie, ale caror beneficii, riscuri si posibile complicatii au fost explicate
DATA:
SEMNATURA:

Interventia chirurgicala principala si interventiile

concomitente:__________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Echipa
operatorie:________________________________________________________________________________________________
Medic ATI:____________________Asistent/a:_____________________________Tipul
anesteziei:_______________________________
Data:_________________Ora inceperii:________________Ora terminarii:__________________
Alte interventii chirurgicale:
1._____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_
Echipa
operatorie:________________________________________________________________________________________________
Medic ATI:____________________Asistent/a:_____________________________Tipul
anesteziei:_______________________________
Data:_________________Ora inceperii:________________Ora terminarii:__________________
Examen histopatologic extemporaneu Data:____________ Medic examinator:_________________Nr.
buletin____________________
Piesa
trimisa:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Rezultat:______________________________________________________________________________________________________
__
Examen histopatologic la parafina Data:____________ Medic examinator:_________________Nr.
buletin________________________
Piesa
trimisa:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Rezultat:______________________________________________________________________________________________________
__
Examen citologic intraoperator Data:____________ Medic examinator:_________________Nr.
buletin__________________________
Piesa
trimisa:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Rezultat:______________________________________________________________________________________________________
__
Examen Bacteriologic intraoperator Data:____________ Medic examinator:_________________Nr.
buletin______________________
Piesa
trimisa:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Rezultat:______________________________________________________________________________________________________

PROTOCOL OPERATOR Nr.

/Data
Ora inceperii:
Ora terminarii:
Dg. Preoperator:
______________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Dg.
Postoperator:____________________________________________________________________________________________
_
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Echipa
operatorie:_____________________________________________________________________________________________
Medic ATI:____________________________Tipul de anestezie:____________________________Urgenta: DA/NU
Septica DA/NU
Denumirea interventiei chirurgicale:
_____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Caracterul interventiei: RADICALA / PALEATIVA / SECOND-LOOK/ CITOREDUCTIVA
Descrierea
interventiei:________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Starea la externare:______________________Tipul externarii:____________________Data si ora
decesului___________________
Deces: intraoperator
postoperator 0-23h
24-47h
>48h

Dg. principal la
externare:____________________________________________________________________COD______________
___________________________________________________________________________________________________________
Dg. secundare:
1._________________________________________________________________________________________COD___________
__
2._________________________________________________________________________________________COD___________
__
3._________________________________________________________________________________________COD___________
__
4._________________________________________________________________________________________COD___________
__
5._________________________________________________________________________________________COD___________
__
6._________________________________________________________________________________________COD___________
__
7._________________________________________________________________________________________COD___________
__
8._________________________________________________________________________________________COD___________
__
EPICRIZA

Medic Sef Sectie

Medic curant

CODURI PROCEDURI:
1._________________________________________________________________________________________COD___________
__
2._________________________________________________________________________________________COD___________
__
3._________________________________________________________________________________________COD___________
__
4._________________________________________________________________________________________COD___________
__
5._________________________________________________________________________________________COD___________
__
6._________________________________________________________________________________________COD___________
__
7._________________________________________________________________________________________COD___________
__
8._________________________________________________________________________________________COD___________
__
9._________________________________________________________________________________________COD___________
__
10.________________________________________________________________________________________COD___________
__
11.________________________________________________________________________________________COD___________
__
Concediu medical la externare Serie___________Nr._____________Nr. de zile acordate_____
Adeverinta de la angajator din data de_________; Numele
angajatorului__________________________________________________________ Zile de concediu in ultimele 12 luni ____
La externare pacientului/apartinatorului i s-au inmanat:
Bilet de externare
Scrisoare medicala
Decontul cheltuielilor
Concediu medical DA/NU
pacientului/apartinatorului:
Recomandari la externare explicate
Programul supravegherii periodice oncologice
Explicarea posibilelor tratamente ulterioare si complicatii
Bilete de trimitere catre_____________________________
Altele_____________________________________________

Data:
Semnatura

Prezenta FO cu Dosar unic cu nr. ___________/_________ si nr. identificator de internare__________________________

are toate documentele atasate numerotate, iar ultima pagina are numarul _____
Prezenta FO contine ca documente atasate si numerotate:
Copie BI/CI
Bilet de trimitere
Dovada calitatii de asigurat/ coasigurat
Consimtamant pacient/ apartinator pt. interventie
Consimtamant pacient/ apartinator pt. anestezie
Consimtamant pacient/ apartinator pt. investigatii/tratamente/transfuzii
Consimtamant pacient/apartinator pt. folosirea datelor medicale anonim in lucrari stiitifice, studii si pentru
prezentarea cazului in scopuri didactice (inclusiv examinarea si preluarea anamnezei de catre studentii aflati in stagii
de pregatire in clinica sau in stagii practice)

Rezultate investigatii radiologice

Rezultate investigatii ecografice/CT/RMN
Rezultate investigatii de laborator
Altele ________________________________________________________
________________________________________________________

________________________________________________________

Verificarea si numerotarea documentelor anexate a fost realizata in data de ____/____/______ de catre

Nume__________________________________________Semnatura____________________________________

DATA

EVOLUTIE, ANALIZE CERUTE

Medicatie simptomatica

FOAIE DE MONITORIZARE CLINICA

CHIRURGIE_______________________________________________________SAL._________Mcp__________/_________
Data
TA
AV
TC
41
40
39
38
37
36
Diureza
Tranzit
intestinal

Abdomen
Drena
je

Debit
fistula
Pansament
SNG
Hemoragii
Reactii
alergice
Manifestare
Severitate
Substanta
Tratament

Medicatie
Data
Anticoagulant
Anticoagulant oral
Antiagregant
Antibiotic
Antibiotic
Antibiotic
Antibiotic
Antibiotic
Antialgic major

Anticonvulsivant
Altele