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SPITAL

Observatii UNITATE PRIMIRE URGENTE PACIENT STARE PACIENT


1 2 3 Radiologice CT EKG NR fisa: DATA: Nume
36-Coloana cervicala Resuscit.
01-Hct 46-Craniu 56-Ritm sinusal
Z Z L L A A Prenume Critic
02-Hb 37-Coloana dorsala 47-Coloana cervicala 57-Frecventa Preluat de : La ora:
38-Coloana lombara M F Data nasterii: Urgent
03-H 48-Torace 58-ST-T normal ........................................... Varsta
39-Torace 49-Abdomen 59-FiA Non-urg.
04-L Ora prim consult medical: CNP S A A L L Z Z
40-Stern 50-Alte 60-FV/TV Consult
05-T Motivul prezentarii: Domiciliu:
06-Na 41-Bazin RMN 61-FIA Judet :
Ora
07-K 42-Abdomen 51-Craniu 62-Asistolie
Localitate G M
08-Cl 43-Membru superior 52-Coloana cervicala C V
44-Membru inferior 53-Torace Strada S
09-Ca O
10-Glicemie 45-Alte 54-Abdomen Nr. Bl.: Sc.: Et.: Ap.: GCS
11-Uree 55-Alte Fr res
Radiologie Functii vitale la preluare:
Adus de: Adus de la:
12-Creatinina Decedat Resuscitare la ora: AV
13-GOT/AST SAJ Domiciliu Puls
Stop CR Reusit
14-GPT/ALT SMURD Unitate sanitara TA
Cu manev. de Nereusit ora deces:
15-Amilaze Mijloace proprii Loc public resuscit. in curs SatO2
Alt: Loc munca de desfasurare Motivul neinceperii resuscitarii
16-pH Temp
17-HCO3 Fisa nr.: Alt: .......................................... Gli
15-Trauma
18-paO2 ANAMNEZA TRIAJ
19-paCO2 ANTECEDENTE PATOLOGICE Observatii General Ochi
20-BE CARDIACE 01-Talie(cm)............... 30-Pierdere ac. a ved.
21-Bilirubina T NEUROLOGICE 02-Greutate(kg)............. 31-Tulb. de vedere
22-Bilirubina D RENALE
03-Febra 32-Corp strain intraoc.
Ecografie 04-Astenie 33-Alte manif. oculare
23-CK PULMONARE
24-CK-MB TBC 05-Ameteli
25-ProBNP HEPATICE Torace-respiratie
26-TroponinaI Arsuri 34-Durere toracica
GASTRICE
06-Cai resp. s. afectate
27-Tn T DIABET ZAHARAT 35-Dispnee
07-Flacara
28-Mioglobina BOLI INF-CONTAGIOASE
36-Hemoptizie
08-Solid
29-D-dimer BOLI CU TRANSM SEXUALA
37-Tuse
09-Lichid
30- ALTELE 10-Vapori/ gaz 38-Expectoratie
31- 11-Chimic Gastrointestinal:
32- ANAMNEZA 39-Greata
Psihiatric
33- 12-Depresie 40-Voma
34- 13-Tulb comportament 41-Tulb. tranzit
Examen sumar de urina
35- 14-Suicid 42-Rectoragie
EVALUARE -RECOMANDARI Cod DG DIAGNOSTIC PREZUMTIV 15-Halucinatii/ delir 43-Melena
44-Hematemeza
Neurologic
45-Dureri abd.
16-Convulsii
17-Mioclonii Genito urinar
18-Cefalee 46-Tulb. mictionale
19-Paralizie 47-Disurie
48-Polakiurie
Tegumente 49-Oligurie
11-Ameliorat 13-Agravat 20-Calde 50-Hematurie
Stare pacient
14-Decedat 21-Reci 51-sang. vaginala
12-Stationar
22-Prurit
52-Sarcina
Refuz ora: BI/ CI/ CNP 23-Umede
20-Examinare (bolnav/apartinator):
24-Paloare Ap locomotor
20-Tratament
Asistent 1: 20-Internare Semnatura bolnav/ 25-Echimoze 53-Inflamatie
Medic 1: apartinator
26-Icterice 54-Tumefactie
Asistent 2: Alergic la: 55-Durere
Medic 2: Predat la ora: 22-Internat sectia 27-Cianotice
28-eruptii 56-imp. funct.
Asistent sef tura: 23-Transferat la:
Medic sef garda:
Tratament la domiciliu: 29-Arsuri
21-Pleaca cu recomandari/ RP