Dosar nr._____________________________________________ Data inregistrarii ______________________________________ Numele medicului _____________________________________ Sef serviciu___________________________________________

FIŞĂ MEDICALĂ SINTETICĂ

Nume __________________ Prenume _____________________ Vârstă _________

I. Anamneza_________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. Diagnosticul medical (se specifica si nr. cod ICD 10) - principal___________________________________________________________________________________________________________________________________________________________________________ - altele ____________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________

Certificatele medicale actuale (se specifică nr., data, instituţia emitentă şi numele medicului care a eliberat certificatul) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. Tratamente urmate şi recomandate

IV. Rezultatul tratamentelor urmate ( per ansamblu): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

În cazul absenţei oricărui tratament, enumeraţi motivele pe care le invocă familia : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V. Stadiul actual al bolii (înconjuraţi etapa care se potriveşte): de debut, de stare evolutiv sau stabilizat, terminal. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VI. Concluzii şi recomandări __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Data Semnătura şi parafa medicului _________ _________ ___________________