TÓM TẮT BỆNH ÁN

I. HÀNH CHÍNH
1. Họ và tên bệnh nhân:. .............................................................................Giới tính:..........................
2. Sinh ngày, tháng, năm:....................................................................…….Tuổi.................................
3. Địa chỉ:..............................................................................................................................................
4. Ngày vào viện: .................................................................................................................................
5. Ngày ra viện (nếu có):.......................................................................................................................
6. Khoa điều trị:....................................................................................................................................
II. THÔNG TIN BỆNH NHÂN
1. Lý do nhập viện:
...........................................................................................................................................................
...........................................................................................................................................................
2. Tiền sử bệnh:
+ PARA:............................................................................................................................................
+ Dự sanh: ........................................................................................................................................
+ Bệnh đã mắc: ................................................................................................................................
+ Dị ứng thuốc: ................................................................................................................................
3. Hướng điều trị:
.........................................................................................................................................................
III. KHÁM BỆNH

Mạch:......................... lần/phút
Ngôi: .......................................
Nhiệt độ: .............................℃
Nước ối: ..................................
Huyết áp: ......................mmHg
Cổ tử cung: .............................. Nhịp thở: ....................lần/phút
Tim thai: .................................. Cân nặng: ...........................Kg

Chiều cao: ………………..cm

 Chẩn đoán vào viện:..................................................................................................................

.....................................................................................................................................................
IV. CẬN LÂM SÀNG
 PHIẾU XÉT NGHIỆM HÓA SINH MÁU

KẾT QUẢ
XÉT NGHIỆM TRỊ SỐ BÌNH THƯỜNG

Urea 1.7 – 8.3 mmol/L

Glucose 3.9 – 5.6 mmol/L

Creatinine <84 µmol/L

K+ 3.5 – 5.1 mmol/L

Calci 1.0 – 1.4 mmol/L

GOT (AST) 0-40 U/L

GPT (ALT) 0-33 U/L

Các kết quả xét nghiệm khác (nếu có): ghi ngày và giá trị xét nghiệm

+ HbA1C: ................................................................................................................................

+ CRPhs: ...................................................................................................................................

+ Procalcitonin: .......................................................................................................................

PHIẾU XÉT NGHIỆM MIỄN DỊCH

KẾT QUẢ
XÉT NGHIỆM TRỊ SỐ BÌNH THƯỜNG

HbsAg 0.9- 1 COI

Anti-HIV 0.9- 1 COI

Treponema pallidum RPR < 1 COI

FT3 3.10-6.8 pmol/L

FT4 12-22.0 pmol/L

TSH 0.27 – 4.2µIU/mL

PHIẾU XÉT NGHIỆM HUYẾT HỌC

 KẾT QUẢ
XÉT NGHIỆM TRỊ SỐ BÌNH THƯỜNG

Số lượng hồng cầu Nữ (3.72 – 5.06 × 1012/l)

Huyết sắc tố Nữ: 110 – 147 g/l

Hematocrict Nữ ( 0.352 – 0.467 l/l)

MCV 87.1 – 102.4 fl

MCH 27 – 32 pg

MCHC 320 – 356 g/l

Số lượng tiểu cầu 150 – 400 × 109/l

Số lượng bạch cầu 4 – 10 × 109/l

PTs 9.4 – 12.5 giây

APTT 24 – 35 giây

Fibrinogen 1.7 – 4.2 g/l

Nhóm máu ABO, Rh(D)

KẾT QUẢ SIÊU ÂM

Siêu âm: .........................................................................................Ngày: ……………………………

Kết quả: ..................................................................................................................................................
.................................................................................................................................................................
Siêu âm: .........................................................................................Ngày: ……………………………
Kết quả: ..................................................................................................................................................
.................................................................................................................................................................

KẾT QUẢ MONITOR SẢN KHOA

Ngày:.………………………...Giờ:….……........ Ngày:.………………………...Giờ:….……........
 Kết quả:…………………………………………. Kết quả:………………………………………….

Ngày:.………………………...Giờ:….……........ Ngày:.………………………...Giờ:….……........
Kết quả:…………………………………………. Kết quả:………………………………………….

Ngày:.………………………...Giờ:….……........ Ngày:.………………………...Giờ:….……........
Kết quả:…………………………………………. Kết quả:………………………………………….

Ngày:.………………………...Giờ:….……........ Ngày:.………………………...Giờ:….……........
Kết quả:…………………………………………. Kết quả:………………………………………….

Ngày:.………………………...Giờ:….……........ Ngày:.………………………...Giờ:….……........
Kết quả:…………………………………………. Kết quả:………………………………………….

CÁC XÉT NGHIỆM KHÁC

+ Protein niệu 24 giờ: ......................................................................................................................
+ Kết quả Cấy vi sinh và Kháng sinh đồ: ........................................................................................
+ .......................................................................................................................................................
+ .......................................................................................................................................................
+ .......................................................................................................................................................
+ .......................................................................................................................................................
+ .......................................................................................................................................................

TỜ ĐIỀU TRỊ

Ngày/giờ Diễn biến bệnh Y lệnh

 TỜ ĐIỀU TRỊ

Ngày/giờ Diễn biến bệnh Y lệnh

 PHẦN BÌNH BỆNH ÁN

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