Dosar nr.

______________
Data inregistrarii ________
Manager de caz _______________
Sef serviciu __________________

Fisa medicala sintetica

Nume ________________________ Prenume ______________________ Varsta ______

I. Anamneza ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
II. Diagnosticul medical(se specifica si nr. cod ICD 10)
- principal ______________________________________________________________
________________________________________________________________________
- altele _________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Certificatele medicale actuale( se specifica nr., data, institutia emitenta si numele
medicului care a eliberat certificatul)__________________________________________
________________________________________________________________________
________________________________________________________________________
III. Tratamente urmate si recomandate
Nr.
Tipul tratamentelor
Tratamente urmate
crt.
(scurta descriere)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10

Medicamentoase
Recuperare
neuromortorie
Chirurgicale
Ortopedice
Protezare
Psihoterapie
Recuperare psihica
Oftalmologie
Audiologie
ORL

Tratamente
recomandate
(se bifea

11.
12.
13.
14.
15.
16.

Cardiologie
Fizioterapie
Endocrinologie
Gastroenterologie
Neurologie
Altele(cu specificatie)

IV. Rezultatul tratamentelor urmate(per ansamblu)

_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
In cazul absentei oricarui tratament, enumerati motivele pe care le invoca familia:
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
V. Stadiul actual al bolii: de debut, de stare evolutiv sau stabilizat, terminal

Data completarii fisei ______________________

Semnatura medicului ______________________
Semnatura sefului de serviciu _______________