On conducting of medical interference
(diagnostic inspection and manipulation treatments)
I_________________________, by this document confirm the fact of grant
(patient’s last name, name, year and place of birth)
the offered me consent on the plan of inspection and medical treatment, that includes:
| № | Diagnostic research and manipulation treatment |
| Intravenous, intramuscular and hypodermic injections of medications | |
| Drip infusions |
I confirm that in a fully clear form the information on my disease, order of inspection, diagnosis, possible prognosis, risks and complications of medical treatment, and also methods of medical treatment most effective for me was given to me. Possibility of all questions was given to me, that I was interested in relation to subsequent medical interferences, and also to get on them the answers exhaustive and clear for me.
Doctor_________________________________________________________ ( last name, name)
which will carry out interference, and other medical workers of Sumy region infectious clinical hospital named after Z.Y. Krasovitsky, where it will be carried out. I agree with the plan of inspection and manipulation treatments offered me. Text of this consent is readed by me and the own signature I certify that I fully agree with all, that it is marked in it.
_________________________ __________________
(signature) (patient’s last name, name)
Date_______________200__year.
This document is readed and signed by a patient____________________
(patient’s last name, name)
Doctor_____________________ ___________________
(signature) (patient’s last name, name)
With the item 19, 20, 38 of the law of Ukraine “About defence of population from infectious diseases” in relation to persons’ rights and duties which have infectious diseases or are bacteriacarriers and responsibility of the failure of sanitary norms and rules is acquainted.
Signature of the patient________________________
TEMPERATURE LIST (example)
| Card № 1021 Last name, name of the patient Pilipenco Philip Ward № 6 | ||||||||||||||||||||||||||
| Date | 1.03.08 | 2.03.08 | 3.03.08 | 4.03.08 | 5.03.08 | 6.03.08 | 7.03.08 | 8.03.08 | 8.03.08 | 9.03.08 | 10.03.08 | 11.03.08 | ||||||||||||||
| Day of illness | ||||||||||||||||||||||||||
| Day of staing at the department | ||||||||||||||||||||||||||
| Pulse | AT | T 0С | m | iv | m | iv | m | iv | m | iv | m | iv | m | iv | m | iv | m | iv | m | iv | r | in | r | in | r | in |
| exanthema | ||||||||||||||||||||||||||
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| hepatosplenomegaly | ||||||||||||||||||||||||||
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| Breathing / min | ||||||||||||||||||||||||||
| Mass, kg | ||||||||||||||||||||||||||
| Liquids are used, ml | ||||||||||||||||||||||||||
| Diuresis Color | ||||||||||||||||||||||||||
| yellow | yellow | yellow | yellow | yellow | l. yellow | l. yellow | l. yellow | l. yellow | ||||||||||||||||||
| Stool / day Admixtures: blood mucus | - | - | 1 of. | |||||||||||||||||||||||
| - | - | - | - | - | - | - | ||||||||||||||||||||
| - | - | - | - | - | - | - |
| Ministry of health of Ukraine | MEDICAL DOCUMENT FORM №003- 4/o | |||||||||||
| LIST OF MEDICAL SETTING № card_________ Last name, name, _____________________________ № ward_________________ | ||||||||||||
| Setting | Implementation | | Marks | ||||||||||
| Regimen | Date | |||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Doctor | ||||||||||||
| Nurse | ||||||||||||
| Signatures | Doctor | |||||||||||
| Nurse | ||||||||||||
Reverse page Of The LIST of medical setting
| Inspections | Intubations | Consultations | Date | Implementation | ||||
| Clinical and biochemical | Inspection | Date | Implementation | Cardiologist | ||||
| Inspection | Date | Implementation | Gastric intubation | Neuropathologist | ||||
| Clinical blood examination | Duodenal intubation with bacteriological inspection of B,C portions | Oculist | ||||||
| Blood glucose | ENT | |||||||
| Clinical urine examination | Endoscopic | Pulmonologist | ||||||
| Urine glucose | Fibroesophago-gastroscopy | Urologist | ||||||
| Examination of feces on the eggs of intestinal parasites | Colonoscopy | |||||||
| Coprogramm | Rectoromanoscopy | |||||||
| Urine amylase | ||||||||
| Prothombin index, coagulation time, bleeding time | Roentgenological | Diet № | ||||||
| Nechiporenco’s urine examination | Photoroentgeno-graphy | |||||||
| Zimnitski’s urine examination | Stomach X-ray | |||||||
| Irrigoscopy | ||||||||
| Occult blood in feces | Chest X-ray | Physical therapy procedures | ||||||
| Blood examination to malaria | Abdomen X-ray | |||||||
| Scraper to pinworms |
LAST PAGE OF MEDICAL CARD
| Scabies yes no Pediculosis yes no Date____ Signature____ | With the day regimen and prohibition of smoking is acquainted Signature_______ |