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Ministerul Sntii al Republicii Moldova

FI DE SOLICITARE
ASISTENEI MEDICALE DE URGEN

denumirea staiei AMU


Data

Nr. fiei

Ora sosirii la locul solicitrii



Nr. echipei

Ora sosirii la spital



Formular

nr. 110/e

Aprobat de MS RM
nr. 828 din 31.10. 2011
PM

Ora primirii solicitrii


Nr. substaiei

Ora transmiterii pacientului


DOCUMENTAIE MEDICAL

Ora transmiterii solicitrii echipei


Ora ncheierii solicitrii


Ora sosirii la substaie



GRADUL URGENEI, STABILIT PREALABIL DE DISPECERATUL 903:


, 903:

Urgen major

Urgen gradul II
II-

Transport specializat asistat


Urgen gradul III


III-

ADRESA PACIENTULUI: raionul (municipiul) __________________ oraul (satul) ___________________ strada ___________________ Nr._____
:
()
()

bl. ____ scara ____ etaj ____ apartament ________ Telefon _______________ Numele, prenumele ______________________________ Vrsta ____

DISPECER ________________________________________ PUNCTE DE REPER ____________________________________________________

Solicitant __________________________ Motivul solicitrii (simptomatologie relatat de ctre solicitant(): _________________________________

(, ():

Numele, prenumele bolnavului__ ____________________________________________________________ Vrsta ______ ani _______ luni_____ zile
,

Adresa ________________________________________________________Locul de munc ____________________________________________

SOLICITARE:
:
. 1. Primar

2. Repetat
1. Masculin

3. Concomitent

2. Feminin
4. Adresare de sine stttor

5. Activ
LOCALITATEA:

:
6. De echipa 903
903
1. Urban
7. De instituia de medicin

primar

2. Rural

8. De spital
3. Strintate

. 1. ntemeiat

SEX:
:

2. Nentemeiat

CATEGORII SOLICITRI URGENE MAJORE


. Catastrofe (urgene n mas)
( )

PRIMIT:
:

REZULTATUL SOLICITRII:
:

1. Personal

2. Prin telefon

3. Prin telefon mobil

1. Bolnavul e deservit

2. Lipsa bolnavului

3. Refuz de ajutor

4. Solicitare fals

5. Deces pn la sosirea AMU

6. Practic sntos

7. Nu se poate ajunge la locul
solicitrii

LOCUL SOLICITRII:
:
1. Apartament

2. Strad

3. Locul de munc

4. Instituie medical

5. Substaie

6. Loc public

7. coal

8. Instituie precolar

9. Poliia

10. Altele

STARE DE EBRIETATE:
:
1. Da

2. Nu


. Colective

. Individuale

2. Gravitate medie
3. Grav
STAREA GENERAL BOLNAVULUI: 1. Satisfctoare

4. Foarte grav

5. Depit

SOLICITAREA E TRANSMIS LA: CMF ________________________POLIIE __________________________ CSP ___________________


:

DIAGNOSTICUL _________________________________________________________________________________________________________

__________________________________________________________________________________________________
Cifrul Clasificaiei internaionale maladiilor (revizia X)
(10- )
Editura de Imprimate Statistica, 2a4 (1091). 06.05. t. 160.000

GRADUL DE URGEN A TRAUMEI l INTOXICAIEI ___________________________________________________________________________


GRADUL URGENEI, STABILIT DE ECHIPA DE ASISTEN MEDICAL DE URGEN


C,
URGEN MAJOR

TRANSPORT MEDICAL
URGEN GRADUL II
URGEN GRADUL III
AS1STAT
II- III-

COD

1.Asigurat Polia de asigurare medical nr.__________________seria__________codul personal____________________________________



2. Neasigurat

COMPLICAII:
:
1. Fibrilaie ventricular

2. Asistolie ventricular

3. Disociaie electromecanic

4. Com

5. Status astmaticus

6. Edem pulmonar

7. Embolie

8. oc

9. Asfixie

10. Aspiraie (sindromul Mendelson)


( )
11. Hemoragie acut

12. Colaps

EFICACITATEA MSURILOR N CAZ DE COMPLICAII: 1. Complicaiile sunt nlturate


:

2. Ameliorare

13. Anurie

14. Aritmii cardiace



15. Convulsii

16. Pneumotorax

3. Fr dinamic pozitiv

ANAMNEZA (ACUZE)
()

Tensiunea arterial

Pulsul

Frecvena respiraiei

Temperatura

CONTIINA:
:

PUPILELE:
:

TEGUMENTELE:
:

RESPIRAIA:
:

1. Clar

2. Obnubilare superficial

3. Obnubilare profund

4. Sopor

5. Com

1. Simetrice

2. Anizocorie

3. Reacia fotomotorie a) da b) nu

4. Reflexele

a) pstrate

b) lipsesc

) diminuate

1. Normale

2. Palide

3. Cianotice

4. Hiperemie

5. Uscate

6. Umede

7. Transpiraie abundent

1. Vezicular

2. Murmur vezicular diminuat


3. Respiraie aspr

4. Suflu bronic

5. Lipsete

RALURI:
:

PULSUL:
:

DISPNEE:
:

ZGOMOTELE CARDIACE:
:

1. Uscate (sibilante)
()
2. Umede:
:
) buloase mici

b) buloase mijlocii

) buloase mari

d) ronflante

3. Crepitaie

1. Normal

2. Accelerat

3. Slab

4. Filiform

5. Lipsete

1. Expiratorie

2. Inspiratorie

3. Mixt

l. Clare

2. Atenuate

3. Asurzite

4. Ritmice

5. Aritmice

6. Forma de aritmie

TULBURRI MENTALE:
:

1. Maniacale

2. Depresive

3. Catatonice

4. Psihomotorii

SCARA GLAZGOV

RSPUNSUL VERBAL

DESCHIDEREA OCHILOR

1. Spontan

2. La comand verbal

3. La stimul dureros

4. Lipsete

4 baluri

3 baluri

2 baluri

1 bal

1. Bolnavul este orientat



2. Bolnavul este dezorientat

3. Rspunsul este complet dezorientat

4. Rspuns nearticulat (nedesluit)
()
5. Lipsa contactului verbal

5 baluri

4 baluri

3 baluri

2 baluri

1 bal

REACII MOTORICE

1. Executarea micrilor la comand



2. Micri adecvate ca rspuns la excitare dureroas

3. Tragerea extremitii ca rspuns la excitare dureroas

LIMBA:
:

4. Flexiune patologic ca rspuns la excitare dureroas



5. Extensie patologic ca rspuns la excitare dureroas

6. Lipsa micrilor

6 baluri

5 baluri

4 baluri

ABDOMENUL:
:

1. Umed
1. Suplu
4. Dureros

2. Curat
2. Balonat
5. ncordat

3. Sabural
3. Asimetric
6. Obinuit

n actul de respiraie: a) particip b) nu particip


:

3 baluri

2 baluri

1 bal

FICATUL __________________________________________________________________

SPLINA ___________________________________________________________________

SCAUNUL _________________________________________________________________

MICIUNEA _______________________________________________________________

Date obiective suplimentare ________________________________ Starea general a nou-nscutului scara Apgar ________________

________________________________________________________

________________________________________________________

AJUTORUL MEDICAL ACORDAT



01

Subcutanate

Intramusculare

03

02

17
18
19
20

Intravenoase

21

04
05
06

INJECII

22
Intratraheale

Sublinguale

Perfuzii

23
24
25
26

07
08
09
10
11
12
13
14
15
16

Cateterizarea venei subclavia



Cateterizarea vezicii urinare

Aspiraia coninutului traheobronic

Electrocardiograma

Fonocardiograma

Oxigenoterapia

Cricotireotomia

Cricotireostomia

Neuroleptanalgezia

Masaj extern al cordului


27
28
29
30
31
32
33
34
35
36

Ventilaia pulmonar

Intubaie traheal

oc electric extern (defibrilare)
()
Puncie pericardic (pericardiocentez)
()
Imobilizare cervical

Imobilizare

Drenaj pleural

Lavaj gastric

Sonda Blakemore
Blakemore
Manevra Heimlich
Heimlich
Hemostaz

Toracocentez

Pansament aseptic

Pansament compresiv

Pantaloni antioc

Alte msuri

Anunat Departamentul de Urgen

Anunat medicul coordonator 903
903
Solicitat echipa specializat

Semntura pacientului


RITMUL ________________________________________________________________________________________________________________

F.C.C. ___________________________________________________ A.E.C. _________________________________________________________


...
...
MODIFICRI ____________________________________________________________________________________________________________

RCR (algoritm) ____________________________________________________________________________________________________________


()

STAREA DUP ACORDAREA AJUTORULUI MEDICAL



Tensiunea arterial _________________________________________________________________________________________________________

Pulsul ___________________________________________________________________________________________________________________

Respiraia ________________________________________________________________________________________________________________

Starea general ___________________________________________________________________________________________________________



________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

ACIUNILE BRIGZII LA FINAL



1. Transportat la spital _________________________________________________________________Medic _________________________________

2. Transportat la punctul traumatologic nr. ______________________________________________________________________________________



3. Lsat l _____________________________________________________________________________________________________________

4. Transportat acas ________________________________________________________________________________________________________

5. Transportat n instituia de medicin primar ___________________________________________________________________________________

6. Transportat la poliie ______________________________________________________________________________________________________

7. Transportat la expertiza medico-legal ________________________________________________________________________________________
-
8. Deservit i lsat n instituia medical _________________________________________________________________________________________

9. Deces n prezena echipei __________________________________________________________________________________________________

10. Refuz categoric de spitalizare ______________________________________________________________________________________________

MEDICUL _________________________________________________________________ COD _________________________________________

FELCERUL ________________________________________________________________ COD _________________________________________

INFIRMIERUL ___________________________________________________________________________________________________________

OFERUL _________________________________________________________________ Nr. AUTO ____________________________________


KILOMETRAJ ____________________________________________________________________________________________________________

eful staiei AMU


.

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