‫المملكة العربية السعودية‬

‫وزارة الصحة‬
URGENT CASES ‫مديرية الشئون الصحية بالرياض‬
‫مجمع إرادة للصحة النفسية بالرياض‬
‫قسم أهلية العالج والتنسيق الطبي‬

Day ‫األربعاء‬ Date 28-09-2022 Time 7:29 ‫ص‬

Referring Hosp.
Attend. Mobile
<DOC_AUTHOR> <DOC_AUTHOR_MOBILE>
Physician #

Patient's Name <PATIENT_NAME> Nat. <NAT> Age <AGE> Sex <SEX>

DIAGNOSIS <OTHER_DIAG> - <DIAG>

<CLINICAL_HISTORY>
Brief Report

Reasons of <REASON_FOR_REFERRAL>
Referral

Patient need  ICU  General Ward

Chest
 Gen.Surgery  Neuro-Surgery  Burn Unit  Surgery.  Vascular Surg.

 Medical  Pediatric  Maxillo-fascial  Obst. Gyne.  Orthoped.

 Ophth.  Urology  ENT  Others

The Serious Problem <SERIOUS_PROBLEM>

The First Aids

Medications Given <TREATMENT>

) ) …Patient Referred For

Consultation Treatment Admission
Further Invest. Others

Doctor's Name Date Time

<DOC_APPROVAL>\ <DOC_AUTHOR>