000474

MEDICAL CARD of in-patient № _____

Date and time of admission _____________________________________

The date and time of discharge ____________________________________

Department ____________________ ward No. ______________________

Transferred to the Department _____________________________________

Bed-days spent _________________________________________

Types of transportation: on a gurney, on a wheelchair, able to go

Blood type_________________ Rh accessory __________

Side effects of drugs (intolerance) _________________

______________________________________________________________

the name of the drug, the nature of the side effects

1. First name & surname ____________________________________

__________________________________ 2. Male or female ______________

3. Age ______ (full years, for children: up to 1 year-months,

up to 1 month-days

4. Permanent residence: town, village (underline) ____

______________________________________________________________

write the address, for visitors-region, district, town, address, relatives, and phone N

5. Place of work, profession or position _____________________

______________________________________________________________

for students-place of study; for children – the name of the child

______________________________________________________________

institutions, schools; for disabled persons – kind and group of disability

6. Who directed the patient _____________________________________

name of medical institution

7. Delivered to the hospital for emergency indications: Yes, no

through _________ hours after the onset of the disease, receiving

injury, hospitalized in a planned manner (to emphasize).

8. Diagnosis of the sending institution ___________________________

9. Diagnosis upon admission ___________________________________

10.Clinical diagnosis ¦ date of establishment

_______________________________________¦______________________

(a) basic: _________________________________________________

b) complication of the main: _____________________________________

C) accompanying: ____________________________________________

11. Hospitalized in this year about this

diseases: for the first time, repeatedly (to emphasize), all -… time.

Fig.2. Medical card of in-patient

Transportation of the patient to the Department

The method of transportation depends on the severity of the patient’s

condition.

In determining the possibility of transportation all patients are divided into

transportable (able to transfer the transportation of lying, sitting or half-sitting)

and non-transportable (whose lives may be threatened by transportation).