Örnek Form Evde Sağlık Hizmetleri

ES.FR.003 - HASTA TEDAVİ PLANI FORMU

Doküman Kodu: ES.FR.003
Yayın Tarihi: 14.02.2019
Revizyon Tarihi: 02.09.2022
Revizyon No: 2

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DİKKAT! Buradaki bilgiler sağlık profesyonelleri için hazırlanmıştır. Arama motorları vs. ile bu sayfadaki bilgilere ulaştıysanız, sağlık profesyonellerine danışmadan, sadece buradaki bilgiler ile hareket etmeyiniz.

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Demo Hastanesi (Prokalite.Com) HASTA TEDAVİ PLANI FORMU

Doküman Kodu: ES.FR.003

Yayın Tarihi: 14.02.2019

Revizyon Tarihi: 02.09.2022

Revizyon No: 2

Sayfa: Otomatik

Hastanın Adı Soyadı:	Tarih: …../…../…….	Saat: …..:…..
……………….. Ziyaret:
Hekim Değerlendirmesi:
Anamnez / fizik muayene bulguları: …………………………...………….……………………………….……………............................. ……………….…………………………………………………………………….………………………….…………………........................... ……………….…………………………………………………………………….………………………….…………………........................... Hastaya yapılması planlanan tahlil / tetkik / tıbbi işlemler: ............………………………..…………………….............................. ……………….…………………………………………………………………….………………………….………………….………………...... ……………….…………………………………………………………………….………………………….…………………..………………...... Takiben yapılması önerilen değerlendirme: ………………..…………………………………………..………………..………………...... ……………….…………………………………………………………………….………………………….…………………..………………...... ……………….…………………………………………………………………….………………………….…………………..………………...... Nedeni: ……………….…………………………………………………………………….…………………………………..………………...... Teşhis: ………………………………………………………………………..…………….…………………………………..………………...... Tedavi: …………………………………………….……………………………………….…………………………………..………………...... ……………….…………………………………………………………………….………………………….…………………..………………...... ……………….…………………………………………………………………….………………………….…………………..………………...... ……………….…………………………………………………………………….………………………….…………………..………………......
Hemşire / Sağlık Memuru Değerlendirmesi:
Vücut Sıcaklığı (oC): …..……. Kan basıncı (mmHg): ………. Nabız: ………./dk…. Solunum: ………./dk…. Hemşirelik Girişimleri: …………………………………………………….……………………………….................................................... ……………….…………………………………………….…………………............................................................................................. Parenteral uygulamalar: …………………………….…..………………............................................................................................ ……………….……………………………………………….……………............................................................................................... Diğer: …………………………………………………........................................................................................................................ ……………….……………………………………………………………….…………...............................................................................
Diyetisyen / Fizyoterapist / Psikolog / Sosyal Çalışmacı / Diş Hekimi:
Değerlendirme ve uygulama bilgileri: …………………………………………………………………………….................................... ……………….…………………………………………………………………….……………….………………………................................. ……………….………………………………………………………………………………........................................................................ ……………….………………………………………………………………........................................................................................... ……………….……………………………………………………………...............................................................................................
Değerlendirmeyi Yapan Değerlendirme Esnasında Hazır Bulunan Yakını Adı Soyadı: Adı Soyadı: İmza: İmza: Tarih: Saat: Tarih: Saat:

(Evde sağlık hizmetine kabul edilen hasta değerlendirme formundaki bilgilerin devamı niteliğinde düzenlenir.)

Evde Sağlık Hizmetleri bölümündeki diğer form örnekleri

Tümünü gör (33)

ES.FR.001 EVDE SAĞLIK BİRİMİ KAYITLI HASTA BİLGİLENDİRME FORMU ES.FR.002 ODYOLOJİK TETKİK İSTEM FORMU ES.FR.004 BASI YARASI TAKİP VE DEĞERLENDİRME FORMU ES.FR.005 EVDE SAĞLIK HİZMETİNE KABUL EDİLEN HASTA DEĞERLENDİRME FORMU ES.FR.006 HASTA SONLANDIRMA FORMU ES.FR.007 HASTA MUAYENE DEĞERLENDİRME FORMU ES.FR.008 MNA (Mini Nutritional Assessment) DEĞERLENDİRME FORMU (Yaşlı Hastalar İçin) ES.FR.009 STRONGKİDS DEĞERLENDİRME FORMU

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<table style="border-collapse:collapse; width:882px" class=" cke_show_border" cellspacing="0"><tbody><tr><td style="border-bottom:none; border-left:2px solid black; border-right:2px solid black; border-top:2px solid black; height:21px; vertical-align:middle; width:490px"><span style="font-size:15px"><strong><span style="color:black">Hastanın Adı Soyadı:</span></strong></span></td><td rowspan="2" style="border-bottom:none; border-left:2px solid black; border-right:2px solid black; border-top:2px solid black; vertical-align:middle; width:139px"><span style="font-size:15px"><strong><span style="color:black">Tarih: …../…../…….&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></strong></span></td><td rowspan="2" style="border-color:black black currentcolor; border-style:solid solid none; border-width:2px 2px medium; vertical-align:middle; width:206px"><span style="font-size:15px"><strong><span style="color:black">Saat: …..:…..</span></strong></span></td></tr><tr><td style="border-bottom:none; border-left:2px solid black; border-right:2px solid black; border-top:none; height:21px; vertical-align:middle; width:490px"><span style="font-size:15px"><strong><span style="color:black">……………….. Ziyaret:</span></strong></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:71px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><strong><span style="color:black">Hekim Değerlendirmesi:</span></strong></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:310px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><span style="color:black">Anamnez / fizik muayene bulguları: …………………………...………….……………………………….…………….............................<br>……………….…………………………………………………………………….………………………….…………………...........................<br>……………….…………………………………………………………………….………………………….…………………...........................<br>Hastaya yapılması planlanan tahlil / tetkik / tıbbi işlemler: ............………………………..……………………..............................<br>……………….…………………………………………………………………….………………………….………………….………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......<br>Takiben yapılması önerilen değerlendirme: ………………..…………………………………………..………………..………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......<br>Nedeni: ……………….…………………………………………………………………….…………………………………..………………......<br>Teşhis: ………………………………………………………………………..…………….…………………………………..………………......<br>Tedavi: …………………………………………….……………………………………….…………………………………..………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......<br>……………….…………………………………………………………………….………………………….…………………..………………......</span></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:64px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><strong><span style="color:black">Hemşire / Sağlık Memuru Değerlendirmesi:</span></strong></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:153px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><span style="color:black">Vücut Sıcaklığı (oC): …..…….&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Kan basıncı (mmHg): ……….&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Nabız: ………./dk….&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Solunum: ………./dk….&nbsp;&nbsp;<br>Hemşirelik Girişimleri: …………………………………………………….………………………………....................................................<br>……………….…………………………………………….………………….............................................................................................<br>Parenteral uygulamalar: …………………………….…..………………............................................................................................<br>……………….……………………………………………….……………...............................................................................................<br>Diğer: …………………………………………………........................................................................................................................<br>……………….……………………………………………………………….…………...............................................................................</span></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:59px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><strong><span style="color:black">Diyetisyen / Fizyoterapist / Psikolog / Sosyal Çalışmacı / Diş Hekimi:&nbsp;</span></strong></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:107px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><span style="color:black">Değerlendirme ve uygulama bilgileri: ……………………………………………………………………………....................................<br>……………….…………………………………………………………………….……………….……………………….................................<br>……………….………………………………………………………………………………........................................................................<br>……………….………………………………………………………………...........................................................................................<br>……………….……………………………………………………………...............................................................................................</span></span></td></tr><tr><td colspan="3" style="border-color:black; border-style:solid; border-width:1px; height:86px; text-align:left; vertical-align:top; width:841px"><span style="font-size:15px"><span style="color:black">Değerlendirmeyi Yapan&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; Değerlendirme Esnasında Hazır Bulunan Yakını<br>Adı Soyadı:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Adı Soyadı:&nbsp;<br>İmza:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; İmza:<br>Tarih:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Saat:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Tarih:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Saat:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></span></td></tr></tbody></table><p><span style="font-size:10pt"><strong>(Evde sağlık hizmetine kabul edilen hasta değerlendirme formundaki bilgilerin devamı niteliğinde düzenlenir.)</strong></span>&nbsp;</p>