Departamento de Enfermeria

INGRESO DE ENFERMERA
FECHA:________________

HORA:_________SERVICIO:______________________________ MDICO/EQUIPO: ___________________________

DATOS GENERALES

N FICHA:_____________ PREVISION:__________

NOMBRE: ________________________________________________________________________EDAD: ____________________________________

PROFESIN U OFICIO: _____________________________________________________________FECHA ACCIDENTE:_________________________
MECANISMO ACC./ MOTIVO INGRESO:________________________________________________FONO FAMILIAR:____________________________
1 ATENCIN: _______________________________________________________________________________________________________________
DIAGNSTICOS:

1. _______________________________________________________________________________________________________
2. _______________________________________________________________________________________________________
3. _______________________________________________________________________________________________________

ANTECEDENTES MRBIDOS
D.M. _____________ C. V. ____ HTA __________ PULM. ___________RENAL ______ EPI ______ PRTESIS _________________________________
ANTECEDENTES QUIRRGICOS
OTROS__________________________________________________________
1._______________________________________________
3._______________________________________________________________
2._______________________________________________
4._______________________________________________________________
ALCOHOL _________TABACO ________ DROGAS________ ALERGIAS _____________________HRS. AYUNO _______________________________
MEDICAMENTOS EN USO :
1. _________________________________________ 3.________________________________________
2. _________________________________________ 4.________________________________________
CSV

HORA

P/A

PULSO

F/R

OXIGENOTERAPIA

SAT O2

GLASGOW

EXMEN FSICO
CABEZA __________________________________ PUPILAS______________________EESS _______________________________________________
CUELLO ___________________________VA AEREA___________________________ EEII ________________________________________________
TRAX ________________________________________________________________ DORSO _____________________________________________
ABDOMEN _____________________________________________________________ PIEL _______________ UPP (RIESGO)___________________
GENITALES________________________ DIURESIS____________________________ HERIDAS____________________________________________
OTROS_________________________________________________________________________________________________________
VIAS VENOSAS

HORA

N DIAS

SONDAS

N DIAS

EXMENES Y PROCEDIMIENTOS REALIZADOS

YESOS
PABELLN SUTURA
CURACIONES
EXMENES Y PROCEDIMIENTOS PENDIENTES

NOMBRE Y FIRMA EU URGENCIA/CAA/UCA

OBSERVACIONES INGRESO AL SERVICIO:

HORA:..........................

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NOMBRE Y FIRMA EU HOSPITALIZADOS/UPC

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ION:__________

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HORA

CIA/CAA/UCA

LIZADOS/UPC