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Ministerul Sntii i Proteciei Sociale al Republicii Moldova

___________________________________________________________________________
denumirea IMSP

DOCUMENTAIE MEDICAL
Formular

Nr 089-3/e

Aprobat de MSPS al RM

nr. 828 din 31.10. 2011

AVIZ DESPRE BOLNAVUL CU DIAGNOSTICUL DE NEOFORMAIUNE


MALIGN DEPISTAT PRIMAR .
Se complecteaz de toate IMSP RM i se trimite la IMSP Institutul Oncologic
Cancer Registru, str. N. Testemanu, 30 , mun. Chiinu



, . . , 30, .
1. Numele, prenumele bolnavului ____________________________________________________________________
, ,
Numr de identificare
______________________________________________________________________

2. Data naterii ___________________________________ 3. Sexul : B . F.

: . .
4. Adresa la domiciliu _____________________________________________________________________________

5. Locul de munc (funcie)
() ______________________________________________________________________
6. Diagnosticul a fost stabilit: a) prin examenul profilactic
b) dup deces, inclusiv prin necropsie
:
,
7. Locul i data stabilirii diagnosticului: a) n condiii de ambulator __________________________________________
:
b) n staionar:
data internrii ____________________ data externrii (decesului) _________________
:
( )
8. Diagnosticul depistat primar ___________________________________________________________________

_______________________________________________________________________ T N M Stadiu_________

9. Diagnosticul histopatologic ________________________________________________________________________



______________________________________________________________________________________________
10. Diagnosticul confirmat: morfologic,
citologic,
radiologic,
endoscopic,
clinic
:
, , , ,
11. Tratament: a) intervenia: data, denumirea i volumul ________________________________________________
:
: ,
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------b) alte metode de tratament________________________________________________________________________

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Semntura