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DOCUMENTAIE MEDICAL

Formular
nr. 027/e

Ministerul Sntii al RM

denumirea instituiei

Aprobat de MS al RM
PM

nr. 828 din 31.10. 2011

T R I M I T E R E - E X T R A S*
-
la ____________________________________________________________________________

denumirea i adresa instituiei unde se trimite


,

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1. Numele, prenumele bolnavului __________________________________________________
, ,

Numr de identificare__________________________________________________________

2. Data naterii _________________________________________________________________


3. Adresa la domiciliu ___________________________________________________________


4. Locul de munc (funcia), studii__________________________________________________


(),

5. Data: ) de ambulatoriu: afeciunii ________________________________________________


:

trimiterii:

la consultaie, investigaie, n staionar (a specifica)

, , ()

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b) de staionar:

internrii_______________________________________________

externrii (decesului) _____________________________________


()

6. Diagnosticul complet (afeciunea de baz, complicaii concomitente)


( , )

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* Se completeaz de instituiile medicale la trimiterea pacientului pentru consultaie, investigaie,
internare, externare (deces) i se prezint medicului de familie
,
, , ()

7. Anamneza scurt, investigaii diagnostice, tratamentul efectuat, evoluia bolii,


starea sntii la trimitere, la externare
, , , ,
,

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Recomandaii curative i de munc __________________________________________________

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_____ ______________________200__
Medic ________________________________________________________________________

numele, prenumele ...

Numr de identificare

semntura