PATIENT’S PERSONAL HISTORY - increase-project.eu · M 2-A15 Modul 2 - Anhänge INCREASE-Weiterbildungscurriculum | Intellectual Output 2 Projektnr. 2015-1-AT02-KA205-001199 MINISTRY

M2-A15

Modul 2 - Anhänge INCREASE-Weiterbildungscurriculum | Intellectual Output 2

Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι1 REGIONAL HEALTH DIRECTORATE 401

GENERAL HOSPITAL

DEPARTMENT/ SECTION:

Patient’s ID during hospitalization.:

Ward: Bed:

PATIENT’S PERSONAL HISTORY

PATIENT’S INFORMATION

Surname: Name: Father’s name:

Address: P.C. – City: Tel.:

Age: Profession: Marital status:

CLOSEST RELATIVE’S INFORMATION

Surname: Name: Tel.:

Relation:

CAUSE OF ADMISSION

CURRENT DISEASE

CONTACT INFORMATION (ADDRESS – P.C. - CITY - TEL. – FAX)

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FAMILY HISTORY

Father – mother - siblings

husband/wife - children

other relatives - twins

FORMER STATE OF HEALTH Childhood-venereal diseases Hospital admission -

operations Injuries

Gynecological History Menses (beginning - end -

duration) Labours – abortions etc.

Medication

Allergies

PERSONAL AND SOCIAL HISTORY Place of birth - residence Religion - education -

profession Family life - problems

Hobbies - pets

Nutrition – alcohol consumption

Smoking – substance use Exposition to harmful

environmental factors PERSONAL HISTORY

(by system) general skin head-neck eyes ears-nose-mouth-pharynx breasts respiratory cardiovascular digestive hematopoiesis – lymph node urogenital skeletal nervous mental functions

FINDINGS ON EXAMINATION VITAL SIGNS: temperature – blood pressure

- pulses – breaths within normal limits BODY ASSESSMENT: structure -

appearance – nutrient status height – weight – Β.Μ.Ι (body mass

index) confined to bed/ walkability

swelling MENTAL STATE:

poor/good information provider emotional - sluggish – confusive –

in coma attention - orientation - memory –

speech difficulty


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SKIN: colour - turgor - hair -

rushes etc

HEAD: eyes - nose - ears - mouth -

pharynx

NECK: movements - thyroid - trachea –

lymph nodes – great vessels

TRUNK:

UPPER LIMBS: hand - palm - fingers - nails – muscle strength –reflex provocation- joints - vessels LOWER LIMBS: foot - soles - toes - nails - ankles

- calves – muscle strength - joints

- vessels

BREASTS:

LYMPH NODES: cervical - supraclavicular -

axillary - inguinal - other

RESPIRATORY: Observation - percussion - palpation

- auscultation

CARDIOVASCULAR: Heart: impulse-sounds- murmur-

buzzing

Vessels: pulses - murmur

ABDOMEN: Observation - percussion - palpation

- auscultation liver - spleen - kidney

Digit examination

UROGENICAL

SKELETAL

Muscle tone – muscles

strength joints

NERVOUS consciousness - communication - orientation

- posture - walking

sensitivity - mobility cerebral nerves -

cerebellum


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CONTACT INFORMATION (ADDRESS – P.C. - CITY - TEL. - FAX

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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITA


Patient’s ID during hospitalization:

Ward: Bed:

DISEASE COURSE



Age: Profession: Ward:

HISTORY – DISEASE COURSE

Date

CONTACT INFORMATION (ADDRESS – P.C. - CITY - TEL. - FAX)

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Projektnr. 2015-1-AT02-KA205-001199 HISTORY – DISEASE COURSE


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

DEPARTMENT/

SECTION:


Ward: Bed:

LABORATORY TEST FORM



TEST DATE

Hematocrit

Hemoglobin

Blood platelets

White blood cells

Type of white blood cells (Neu/Lym/Μono/Eos/...)

Blood sugar

Urea

Creatinine

Pseudocholinesterase

Νa

K

Ca

P

Bilirubin total

Direct bilirubin

SGOT(AST)

SGPT(ALT)

gGT

Amylase

CPK

CK-MB

Troponin

LDH

Alkaline phosphatase

Total cholesterol

TRiglyceride

HDL

LDL

Uric acid

CEA

CA 19-9

CA 125

CA 15-3

αFP


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Projektnr. 2015-1-AT02-KA205-001199 TEST DATE

General Urine test

Ferritin Β12 Folic acid Ferritin

Albumin Serum globulins Protein electrophoresis

Lipoprotein elestrophoresis

Τ3 Τ4 ΤSH

Widal Wright Wright-Coombs Mono-Test

PT / INR aPTT Fibrinogen FDP / DD

CRP RF ANA anti-DNA AMA ASMA anti-ENA Scl-70 Immunoglobulins cANCA pANCA

Pregnancy test


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GENERAL HOSPITAL

Patient’s ID during

hospitalization.:

DEPARTMENT/

SECTION:

Ward: Bed:

FORM OF SPECIFIC MONITORING



In this sheet you may note, for monitoring reasons, the examinations’ findings that are not numerical (ex. histological, imaging, endoscopical

examinations, etc.)

EXAMINATION:

Date: Date: Date:

EXAMINATION:

Date: Date: Date:

EXAMINATION:

Date: Date: Date:


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EXAMINATION:

Date: Date: Date:

EXAMINATION:

Date: Date: Date:

ΕΞΕΤΑΣΗ:

Date: Date: Date:

EXAMINATION :

Date: Date: Date:


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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι1 REGIONAL HEALTH DIRECTORATE 411

GENERAL HOSPITAL

OBSTETRICAL AND GYNECOLOGIC DEPARTMENT

Patient’s ID during hospitalization.:

Ward: Bed:

GYNECOLOGIC HISTORY FORM


Surname: Name: Father’s

name:


Nationality: Citizenship: Cree:


WIFE’S/HUSBAND’S INFORMATION


name:


RELATIVE’S INFORMATION


CAUSE OF ADMISSION

GYNECOLOGIC – OBSTETRINAL HISTORY

MENSES ANAMNESIS: LAST MENSES.:

PREGNANCY HISTORY: MISSED ABORTIONS: INDUCED ABORTION:

DIAGNOSED ABRASIONS: TERM PREGNANCIES:

LABOUR HISTORY: NORMAL LABOUR:

FORCEPS DELIVERY: CESAREAN SECTION:

OBSTETRICAL OPERATIONS:

CURRENT DISEASE

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FAMILY HISTORY

father – mother - siblings


other relatives - twins

FORMER STATE OF HEALTH childhood diseases – hospital admissions - operations injuries Medication - Allergies PERSONAL & SOCIAL HISTORY Religion-education-profession

family life - problems – hobbies

Nutrition – alcohol use

Smoking – substance use Exposure to harmful

environmental factors PERSONAL HISTORY

(by system) skin head-neck eyes ears-nose-mouth-pharynx breasts respiratory cardiovascular digestive hematopoiesis-lymph nodes urogenital skeletal nervous mental functions

FINDINGS ON EXAMINATION VITAL SIGNS: Temperature – blood pressure -

pulses – breaths within normal limits BODY ASSESSMENT: structure - appearance – nutrient status - height – weight

confined to bed/walkability

BREASTS: LYMPH NODES: cervical - supraclavicular - axillary

- inguinal - other


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ABDOMEN- Digit examination – Culdoscopy – Cyst - Rectum

Perineum - Vulva

Vagina – Neck of uterus – Uterus

Adnexae

ABDOMEN Observation - percussion - palpation

- auscultation liver - spleen - kidneys

Digit examination

CONTACT INFORMATION (ADDRESS –P.C. - CITY - TEL. - FAX)

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SKIN: colour - turgor - hair -

rushes etc HEAD: eyes - nose - ears - mouth -

neck NECK: movements - thyroid - trachea – lymph nodes – great vessels TRUNK: UPPER LIMBS: hand - palms - fingers - nails – muscle strength - joints - vessels LOWER LIMBS: foot - soles - toes - nails - calves

- ankles – muscle strength -

joints - vessels

RESPIRATORY: Observation - percussion - palpation

- auscultation

CARDIOVASCULAR: Heart: impulse-sounds-murmur-

buzzing


SKELETAL:

Muscle tone – muscle strength

joints

NERVOUS: Consciousness -

communication orientation posture - walking

sensitivity - mobility

cerebral nerves - cerebellum


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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι1 412

GENERAL HOSPITAL

OBSTETRICAL AND GYNECOLOGIC DEPARTMENT


hospitalization.:

Ward:

Bed:

DELIVERY FORM

PARTURIENT’S

INFORMATION



Nationality: Citizenship: Creed:


Social security organisation:

Social security number.:

HUSBAND’S/FATHER’S INFORMATION


name:


ADMISSION DATE: ADMISSION

HOUR: CHECK-OUT DATE:

PARTURIENT’S MEDICAL HISTORY

Heart diseases: Hepatitis:

Hypertension: Thyroid diseases:

Diabetes: Other diseases:

Nephropathy: Family history:

Operations:

Husband’s health:

Blood transfusions in the past: YES: NO: Reactions:

Allergy in medication: YES: NO: Specify:

Other allergies:

Medication taken:

OBSTETRICAL HISTORY:

Beginning of menses: Cycle characteristics: Labours : Live birth:

Last Menses.:

Expected date of Labour.: LABOUR:

Inflammation: Test PAP:

Obstetrical operations – Complications history at previous pregnancy:

Notes:

CURRENT SITUATION

Blood group - Rh: Pulses: Cervical dilation: Pain:

Shape : Projection: Proj.angle – height: Position:

Embryonic membrane: from Prenatal amniocentesis – trophoblast taking:

Blood Pressure.: Diabetes:

HIV: Hypertension:

HCV: (Urine) Protein:

HBsAg: Pulses:

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Projektnr. 2015-1-AT02-KA205-001199 Listeriae tox.: Bleeding:

CMV Smoking:

Red blood cells: Heterozygous Β Mediterranean anemia:

Weight: Initial: Final: Weight gain:

Medication:

Follicle: Atretic: Ruptured: Date: Time:

Amniotic fluid: Clear: Coloured: Notes:


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Projektnr. 2015-1-AT02-KA205-001199 LABOURS

Pregnancy Year Pregnancy week Type of labour Sexe Weight Complications

PARTOGRAM

Complete Elimination

10cm

9cm

8cm

7cm

6cm

CER

VIC

AL

DIL

ATIO

N

5cm

4cm

3cm

2cm

1cm

0cm

Without Elimination 0 1 2 3 4 5 6 7 8 9 10 11 12

160

150

PU

LSES 140

130

120

110

100

PAINS /10’

AMNIATIC FLUID

OXYTOCIN

ANALGESIA


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APGAR SCORE

1’ 5’ NOTES

HEARTBEATS

NONE BELOW 100/1’ MORE THAN 100/1’ 0 1 2

BREATH

NONE SLOW & IRREGULAR INTENSE CRY 0 1 2

MUSCLE TONE

ABSENT REDUCED ACTIVE MONEMENTS 0 1 2

COLOUR

MILDLY CYANOSED BLUE LIMBS ROSY 0 1 2

REACTION TO NONE LIMITED SNEEZΕ-CRY

STIMULI 0 1 2

TOTAL:

LABOUR

Normal:

Expulsion of the placenta: Episiotomy: YES: NO:

Vacuum extraction: Because

Extraction:

Forceps delivery:

Cesarean section:

Person in charge:

Acting person:

Midwife:

Anesthesiologist:

CESAREAN SECTION:

Date: Time: Surgeon:

Book number: Surgeon:

Anesthesiologist: Surgeon:

Nurse:

NEWBORN

Number: Gender: Alive: Dead: Stillborn: Mature: Premature: Post-term:

Blood group – Rh: Weight: Kg Height: cm Weight placenta: Kg

Direct COOMBS: ANTI–Dserrum YES: NO: Breast feeding YES: NO:

MOTHER’S-NEWBORN’S IDENTIFICATION

MOTHER’S RIGHT FOREFINGER PRINT NEWBORN’S SOLE PRINT

The staff nurse present at the labour:

Name - signature


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Projektnr. 2015-1-AT02-KA205-001199 DISEASE COURSE

CHECK-OUT DIAGNOSIS Date of check-out: Type of labour:

Medical treatment:

Instructions:

The ward’s officer The head of the Section The head of the Department

signature signature signature


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Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SECURITY

Ι1

REGIONAL HEALTH DIRECTORATE

GENERAL HOSPITAL



hospitalization:

Ward: Bed:

NEWBORN’S HISTORY

MOTHER’S INFORMATION

Surname: Maria : Father’s name :

Age: Marital Status: Profession:

Address: P.C. – City: Tel:

Ward: Bed: Social Security Organisation:

Social Security Number:

FATHER’S/HUSBAND’S

INFORMATION

Surname: Name : Father’s name :

Address: P.C. – City: Tel:

LABOUR INFORMATION (Completed by the obstetrician)

Date of Labour: Time of Labour: Sexe:

ER:

Expected Date of Labour: Pregnancy week: LABOUR:

LABOUR: Normal:

Vacuum extraction: Extraction:

Forceps Delivery:

Cesarean Section:

Because of:

Amniotic fluid: (coloured, bloody, odorant etc.)

Placenta (weight etc.) Funiculus:

History of current pregnancy: (medication, diabetes, thyroid disease etc.)

Ultrasound findings during pregnancy:

Time of follicle rupture:

At birth:

Weight:

Length:

Head Circumference:

At check-out: Weight: Length: H.C.:

Obstetrician: Midwife:

MOTHER’S HISTORY (Completed by the ostetrician)

Group: Rh: EMM. COOBS:

HBsAg: Other hepatitides:

Rubella: did it suffer? Vaccine? Toxoplasmosis: CMV:

Herpes of the genital organs: Other:

Heterozygous Β Mediterranean anemia:

Heterozygous sickle-cell anemia:

Other hemoglobinopathies:

History information on previous gestations, abortions, congenital anomalies:

Smoker: NO YES Number of cigarettes:

NEWBORN APGAR

Newborn’s group: Newborn’s Rh: AM. COOBS: G6PD:

APGAR

Cried immediately:

Breathed immediately:

Pulses:

Breaths:

Atresia: Esophagus: Anus: Choanae: Heart beat

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Konakion (Vit.K): Eyedrops: Temperature: Dextro: Breath:

Midwife’s name: Colour:

RESUSCUTATION Sound

Ο2 mask: Intubation: Reflexes.

Endotrachial Sunction: Medication:

Άλλα: TOTAL

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FIRST EXAMINATION BY THE PEDIATRICIAN

Date: Time:

Measurement: Weight: Length: Head circumference:

Weight estimation: Underweight: Normal: Overweight:

Atresia: Esophagus: Anus: Choanae:

MEDICAL EXAMINATION

Overall status:

Circulatory:

Respiratory:

Digestive:

Urogenital:

Nervous:

Skeleton – Joints:

Integument:

Head (fontanelle – suture):

Other findings:

Medical treatment:

Other:

(signature – stamp)

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NEWBORN’S MONITORING DIAGRAM

Section: Position

: Ward: ID during hospitalization:

DATE

DAYS OLD

WEIGHT TEMP. 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12 9 12 5 12

00 40Ο

00 39Ο

00 38Ο

00 37Ο

00 36Ο

00 35Ο

EVACU

ATIO

N

NUTRITION

TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT TIME QUANT

TIM

E A

ND

QU

AN

TIT

Y O

F

MEALS

TOTAL

CALORIES

FLUIDS

NATURE

NUMBER

UREA

VOMITING


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DATE NEWBORN’S COURSE MEDICAL TREATMENT


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Projektnr. 2015-1-AT02-KA205-001199 THE PHYSICIAN’S ORDERS

DATE INSTRUCTIONS THE PHYSICIAN PERFORMER (Signature) (Nurse’s signature)


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Projektnr. 2015-1-AT02-KA205-001199 LAB FINDINGS

Date

Examination Hematocrit Hemoglobin Blood platelets White blood cells Type of white blood cells (Π/Λ/Μ/Η/…)

Blood sugar Urea Creatinine Na K Ca P bilirubin total Direct bilirubin SGOT (AST) SGPT (ALT) gGT CPK CK-MB Alkaline phosphatase Triglyceride Uric acid General urine test

Ferritin Iron fe

Albumin Serum globulins Protein electrophoresis

PT/INR aPTT Fibrinogen FDP/DD

CRP Pseudocholinesterase


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Projektnr. 2015-1-AT02-KA205-001199 ADMISSION TO NEONATAL INTENSIVE CARE UNIT

SITUATION ON ADMISSION

Date of admission: Time of

admission:

Temperature: Dextrostix: Pulses Breaths Blood pressure

Atresia of choanae? Esophagus? Anus?

Blood group: Mother: Father: Newborn: Direct Coombs: G – 6 – PD:

BY SYSTEM MONITORING

Overall situation:

Clinical findings:

Pregnancy duration according to last menses: week PARKIN estimation: week

PROBLEMS ON ADMISSION

1.

2.

3.

4.

5.

6.

The newborn is admitted for hospitalization in the for monitoring.

The physician performing the admission

(SIGNATURE)

CONTACT INFORMATION (ADDRESS – P.C. – CITY – TEL. – FAX.)

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Projektnr. 2015-1-AT02-KA205-001199 MOTHER’S NEWBORN’S ID

MOTHER’S RIGHT FOREFINGER PRINT NEWBORN’S SOLE PRINT

The staff nurse present at labour:

(Name – signature)

PHYSICIAN’S CHECK-OUT APPROVAL Check-out is approved. Reexamination was

suggested after diagnosis: Outcome:

Date: The physician

(signature)

NEWBORN’S COLLECTION

on

I collected my child Boy: Girl: date

The person who collected Mother/father:

ID.: Parent’s signature


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

PEDIATRICS DEPARTMENT Patient’s ID during

hospitalization:

Ward: Bed:

PEDIATRICS HISTORY FORM




Age: Profession: Marital Status:



ADMISSION CAUSE

CURRENT DISEASE


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FAMILY HISTORY

Father – Mother - siblings

Husband/wife - children

Other relatives - twins

PERINATAL HISTORY Place of birth - date

Mother’s Age – labour ranking Mother’s health during pregnancy (gestational diabetes – infections – medication – placental aberrations - etc) Age of gestation (weeks) Labour:(premature – prolonged -

cesarean - forceps) Newborn: weight at birth–height –

head circumference - Apgar score Newborn’s problems (respiratory

difficulties –cyanosis – convulsions –

jaundice – vomiting etc ) NUTRITION-MEDICATION Breast feeding (beginning

- end) Formula

Creme - fruit - soup - meat - fish

- egg - other Vitamins Medication PSYCHOSOCIAL DEVELOPMENT Head support -grasping

observes – smiles

sits - stands

walks - talks Sphincter control (day/night)

VACCINS Diphtheria/tetanus/pertussis (DΤP)

measles/mumps/rubella (MMR)

poliomyelitis (IPV) haemophilus influenzae (HIB)

hepatitis Β - hepatitis Α

Mantoux - vaccin BCG other (cerebrospinal meningitis,

pneumococcal infection,

influenza, chickenpox etc) FORMER STATE OF HEALTH Childhood diseases Hospitalization - operations Injuries

Medication

Allergies PERSONAL HISTORY Place of birth – residence

Religion - education - profession

Family life – problems

Hobbies - pets

Nutrition

Harmful habits

Exposure to harmful

environmental factors


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PERSONAL;HISTORY (by system)

general skin head-neck eyes ears-nose-mouth-pharynx breasts respiratory cardiovascular digestive hematopoiesis – lymph nodes urogenital skeletal nervous mental functions

FINDINGS ON EXAMINATION BODY ASSESSMENT: Weight

– height – B.M.I. Head circumference

VITAL SIGNS: Temperature – Blood pressure - pulses – breaths

GENERAL IMPRESSION:

structure - appearance –

nutrient status - height – weight – dentition –

adolescence

MENTAL STATE: SKIN: colour - turgor - hair -

rushes etc

HEAD: eyes - nose - ears - mouth - pharynx

NECK: movements - thyroid - trachea –

lymph nodes – great vessels

TRUNK: UPPER LIMBS: hand - palm - fingers - nails -muscle strength - joints – vessels LOWER LIMBS: foot - soles - toes - nails - ankles


- vessels

BREASTS:

LYMPH NODES: cervical - supraclavicular - axillary

– inguinal - other

RESPIRATORY: observation - percussion - palpation -

auscultation

CARDIOVASCULAR: heart: impulse-sounds-murmur-

buzzing



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ABDOMEN observation - percussion - palpation -

auscultation liver - spleen - kidneys

UROGENITAL

SKELETAL

Muscle tone – muscle

strength - joints

NERVOUS consciousness -

communication -

orientation - posture - walking

sensitivity - mobility

cerebral nerves - cerebellum


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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE GENERAL HOSPITAL PSYCHIATRY DEPARTMENT

Ι1 419

Patient’s ID during : hospitalization

Ward: Bed:

PSYCHIATRY HISTORY FORM



Address: C.P. – City: Tel.:

Age: Profession: Marital Status:

Date of admission Name Guardian:

Admission: voluntary: Unvoluntary: Note the way of admission:



ADMISSION CAUSE

CURRENT DISEASE (symptoms and life event’s recording)


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Projektnr. 2015-1-AT02-KA205-001199

FAMILY HISTORY

Father – mother - siblings


Other relatives - twins

FORMER STATE OF HEALTH Childhood-venereal diseases Hospital admission -

operations Injuries

Medication taken

Allergies

PERSONAL AND SOCIAL HISTORY Place of birth - residence

Labour-birth conditions First ages of development (walking, speech, Sphincter control, with whom did the patient grow up)

Family composition

Family relationships

(patient’s description)

(family’s description)

Childhood School years

Adolescence

Sexual tendencies and experiences

Gynecological history

Military service Marriage

Professional activity Religion - education -

occupation Hobbies – pets

Substance use-addictions

PERSONALITY DESCRIPTION Patient’s self-description

Other people’s description of the

patient

PERSONAL ANAMNESIS

(By system) general skin head-neck eyes ears-nose-mouth-pharynx breasts respiratory cardiovascular digestive hematopoiesis – lymph nodes urogenital skeletal nervous


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FINDINGS ON EXAMINATION VITAL SIGNS: Temperature – Blood

pressure - pulses - breathes BODY ASSESSMENT:

Structure - appearance – nutrient status -height –

weight Confined to bed /

walkability MENTAL STATE:

Good/poor information provider emotional - sluggish -

confusive – in coma attention - orientation - memory –

speech difficulty SKIN: colour - turgor - rushes etc

HEAD: eyes - nose - ears - mouth -

pharynx NECK: movements - thyroid - trachea –

lymph nodes – great vessels TRUNK: UPPER LIMBS: hand - palm - fingers - muscle

strength - joints - vessels LOWER LIMBS: foot - soles - toes - nails - ankles


- vessels BREASTS: LYMPH NODES: cervical - supraclavicular -

axillary - inguinal - other

RESPIRATORY: observation - percussion - palpation -

auscultation

CARDIOVASCULAR: heart: impulse-sounds-murmur-

buzzing

vessels: pulses - murmur

ABDOMEN: observation - percussion - palpation -

auscultation liver - spleen - kidneys

Digit examination UROGENITAL: SKELETAL: Muscle tone – muscle

strength- joints

NERVOUS: consciousness - communication orientation - posture - walking

sensitivity - mobility cerebral nerves -

cerebellum CONTACT INFORMATION (ADDRESS – P.C. - CITY - TEL. - FAX)

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PERSONAL PSYCHIATRY HISTORY

SEMIOTICS INVESTIGATION

Semiotics of behaviour

Appearance-face expression

- posture during examination

Information on everyday life

(personal and social)

Body care/control of constrictor muscles

Nutrition – sleep – sexual behaviour

Family – social – professional

life

Suicidal tendencies -aggressiveness

Semiotics of current mental

activity

Breath and clarity of Consciousness - self consciousness

Orientation in space/time - attention-concentration

Memory

Judgement

Thought (fluency-content)

Perception

Emotion

Will and psychosocial function


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GENERAL HOSPITAL

OUTPATIENT’S DEPARTMENT

CLINIC:


OUTPATIENT’S DEPARTMENT’S FORM



name:

Address: C.P. – City: Tel:

Age: Social Security

Organization: Social Security

number.:

Way of admission: Marital Status:

DATE EXAMINATION – DIAGNOSIS - TREATMENT


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DATE EXAMINATION – DIAGNOSIS - TREATMENT


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GENERAL HOSPITAL

EMERGENCY WARD Patient’s ID during hospitalization.:

EMERGENCY ROOM PATIENT’S FORM



name:



Organization: Social Security number

DATE OF ADMISSION

TIME OF ADMISSION

CAUSE OF ADMISSION - CURRENT DISEASE

ANAMNESIS

FINDINGS ON EXAMINATION

LAB FINDINGS

PROBABLE DIAGNOSIS

TREATMENT – INSTRUCTIONS

THE PHYSICIAN


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Projektnr. 2015-1-AT02-KA205-001199 MEDICAL INSTRUCTIONS

Name – The physician’s signature

NURSING CARE

VITAL SIGNS MEASUREMENTS

Time 0C Blood pressure Pulses Breaths Time 0C Blood pressure Pulses Breaths

ADMINISTRATION OF MEDICATION

Name Dose – way of administration Time Nurse’s signature

SERRUM ADMINISTRATION Quantity Fluency (ml/h) Time Nurse’s signature

OTHER NURSING CARE

The nurse The unit nursing officer


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Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι1

REGIONAL HEALTH DIRECTORATE 423

GENERAL HOSPITAL

SHORT-TERM TREATMENT UNIT


Ward: Bed:

SHORT-TERM TREATMENT FORM






number:



HISTORY - EXAMINATION

DATE OF

ADMISSION: TIME OF ADMISSION:

REFERRER:

ADMISSION CAUSE – CURRENT DISEASE:

ANAMNESIS FAMILY HISTORY

FORMER STATE OF HEALTH

Diseases - Admissions - Operations Injuries

Medication – Allergies

SOCIAL HISTORY

Residence - education - profession

Smoking – alcohol – substance use

ANAMNESIS BY SYSTEM

head - neck - ears - eyes respiratory - cardiovascular digestive - urogenital hematopoiesis - lymph nodes skeletal - nervous

FINDINGS ON EXAMINATION

VITAL SIGNS MENTAL STATE

Structure - appearance - nutrient status - skin HEAD-NECK

Eyes-nose-ears-mouth-pharynx

TRUNK-LIMBS-BREASTS-LYMPH NODES RESPIRATORY- CARDIOVASCULAR ABDOMEN - DIGESTIVE

Liver - spleen – kidneys -digit examination UROGENITAL

SKELETAL - NERVOUS


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Projektnr. 2015-1-AT02-KA205-001199 LAB FINDINGS

Hematocrit Bilirubin

Hemoglobulin SGOT(AST)

Blood platelets SGPT(ALT)

White blood cells gGT

Type of white blood cells Amylase

CPK

Κ CK-MB

Νa LDH

Urea Alkaline phosphatase

Blood sugar

Creatinine Cholesterol

Uric acid Triglyceride

HDL

General urine test LDL

ELECTROCARDIOGRAM

X-RAYS

OTHER EXAMINATIONS

DIAGNOSIS

TREATMENT

The physician


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Projektnr. 2015-1-AT02-KA205-001199

NURSING CARE

TIME MEDICAL INSTRUCTIONS PERFORMER SIGNATURE

MEDICATION ADMINISTRATION

NAME DOSES-WAY OF ADMINISTRATION

Time-signature

Time-signature

Time-signature

Time-signature

Time-signature

Time-signature

FLUIDS BALANCE

INTRAVENOUS FLUIDS (Type) Quantity Flow (ml/h) Time of application Signature

OUTPUT FLUIDS

Ώρα URINARY CATHETER LEVIN DIARRHEA - VOMITING

Quantity Quantity Quantity

NURSING MONITORING


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Projektnr. 2015-1-AT02-KA205-001199

VITAL SIGNS MONITORING

Temperature

Breaths

Pulses

Blood pressure

٭

๐

x

42

240

41 220

200

40 180

39 160

140

38 120

37 100

80

36 60

35 40

20

34

VITAL SIGNS MEASUREMENT

Time 0C Blood pressure Pulses Breaths Time 0C

Blood pressure Pulses Breaths

OUTPUT

DISCHARGE NOTE: At the physician’s order

Checks-out at his/her own responsibility

The physician’s signature Patient’s signature

ADMISSION: AT THE

DEPARTMENT:

TRANSPORT: To another hospital:

To a private clinic:

At home:

Elsewhere (where?):

Date of check-out: Time of check-out:

INSTRUCTIONS ON CHECK-OUT

The unit nursing officer The physician

CONTACT INFORMATION (ADDRESS - C.P. - CITY - TEL. - FAX)

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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE GENERAL HOSPITAL

DEPARTMENT/SECTION

Referrer:

I2 431

Patient’s ID

during hospitalization:

Ward: Bed:

FORM FOR CLINICAL EXAMINATION BY A REGISTRAR



name:



Organisation: Social Security

number: REQUESTED EXAM

To the department:

To be examined by a physician of (specialty):

CLINICAL INFORMATION

FINDINGS

Date Date

The referrer The physician


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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE GENERAL HOSPITAL DEPARTMENT/

SECTION:

Referrer:

I2 432

Patient’s ID

During hospitalization:

Ward: Bed:

DOCUMENT FOR SPECIFIC INVESTIGATION



name:




number: ASKED EXAMINATION

To the department:

Examination asked:


Date The physician


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Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι2


GENERAL HOSPITAL

OTORINOLARYNGOLOGY DEPARTMENT Patient’s ID during

hospitalization:

Ward:

Bed:

OTORINOLARYNGOLOGICAL EXAMINATION



name:


Age: Profession: Social Security


number: ΚΛΙΝΙΚΕΣ ΠΛΗΡΟΦΟΡΙΕΣ

CURRENT DISEASE

EARS:

Otoscopy Tuning fork Rinne, Weber Audiogram Phonetic, tonic test of hearing Tympanometry Sonic reflexes Evoked potential

NYSTAGMUS – tests

electronystagmography

CRANIAL NERVES Facial Nerve examination

Other cerebral nerves

NOSE - rhinoscopy

BUCCAL CAVITY PHARYNX

LARYNX (THROAT)

NECK Thyroid gland Cervical lymph nodes

Date: The physician

M2-A15


Projektnr. 2015-1-AT02-KA205-001199 (ADDRESEL. - FA MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι2


GENERAL HOSPITAL

OPHTHALMOLOGY DEPARTMENT Patient’s ID during

hospitalization.

Ward:

Bed:

OPHTHALMOLOGICAL EXAMINATION




Age: Profession: Social Security


number: OPHTHALMOLOGICAL EXAMINATION

CURRENT DISEASE

CLINICAL EXAMINATION

Visual acuity

Tune

Pupil’s reflexes

Eye movements

Eyelids-conjunctiva

Cornea

Anterior chamber

Iris - pupil - lens

Vitreous body

Fundus (eye ground)

Date: The physician

ΧΕΙΑ ΕΠΙΚΟΙΝΩΝΙΑΣ (ΔΙΕΥΘΥΝΣΗ - C.P. - ΠΟΛΗ - TEL. - FAX)

Ι2

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MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH

DIRECTORATE

435

GENERAL HOSPITAL

VASCULAR SURGERY DEPARTMENT

Patient’s ID during hospitalization

Ward: Bed:

VASCULAR EXAMINATION



name:


Age: Profession: Social Security Organization:

Social Security number.:


KNOWN RISK FACTORS

Hypertension: Hypercholesterolemia: Diabetes:

Obesity (BMI): Smoking: Other

VESSELS’ PALPATION - AUSCULTATION

Α Α Α

Carotid artery Axillary artery Femoral vein

Ventral aorta Brachial artery Popliteal artery

Renal artery Radial artery Posterior tibial vein

Ulnar artery Dorsalis pedis artery

Date The physician


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

OBSTETRICS AND GYNAECOLOGY DEPARTMENT


PREGNANCY MONITORING FORM

PREGNANT’S INFORMATION


Husband’s/Wife’s

Name: Married: Profession:

Address: C.P. – City: Tel

Age: Social Security Organization:

Social Security number:

MEDICAL INFORMATION

Last

menses:

Expected

Date of

Labour: Labour:

HBsAg HCV HIV VDRL/RPR Diabetes:

Blood group: Mother’s Rh: Father’s Rh:

General blood test: Red blood cells:

Hb:

Ht:

White

blood cells:

Type:

Date

Serum Fe:

Electrophoresis Hb:

Date of Month of Height of Shape – Foetus’es Body

Blood pressure

General Examinatio

n pregnancy

uterus

projection

pulses

weight

Urine test


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL



Ward:

Bed:

REPORT OF SPECIFIC MONITORING

TYPE OF EXAMINATION





number: Section:

CONCLUSION

Date The physician

ΣΤΟΙΧΕΙΑ ΕΠΙΚΟΙΝΩΝΙΑΣ (ΔΙΕΥΘΥΝΣΗ - C.P. - ΠΟΛΗ - TEL. - FAX)

M2-A15


Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE GENERAL HOSPITAL DEPARTMENT/

SECTION Referrer:

Ι2 441


hospitalization:

Ward: Bed:

DOCUMENT FOR GASTROINTESTINAL ENDOSCOPY





ΑΙΤΟΥΜΕΝΗ ΕΞΕΤΑΣΗ

GASTROSCOPY ERCP COLONOSCOPY

ORTHOSIGMOID ENDOSCOPY ENTEROSCOPY

CLINICAL INFORMATION : (short history, examination findings, rationale)

ANAMNESIS

FORMER ENDOSCOPY :

FORMER GASTROINTESTINAL OPERATIONS:

MEDICAL HISTORY: Respiratory diseases

Endocarditis – valvulitis – arrhythmia –

coronary artery disease – congenital

cardiopathy

epilepsy – myasthenia – chronic renal failure

Diabetes – thyroid disease –

History of serious bleeding

Infectious diseases – ΗBV – HCV – HIV – other

Pregnancy - Allergies

MEDICAL TREATMENT: Anticoagulants – aspirin – anti-thrombocytes -

Nonsteroidal anti-inflammatory drugs - other

IMAGING FINDINGS: x-ray, barium enema – ultrasonography-

-Computerized axial tomography – etc.

LAB FINDINGS :

Hct: Hb: MCV: WBC: PLT:

Blood sugar: urea: creatinine: Na: K:

Dilirubin total.: direct: SGOT: SGPT : gGT:

Thrombin time : INR: ΑΡΤΤ: Ca 19-9: CEA

other:

Date: The physician


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

GASTROINTESTINAL DEPARTMENT Patient’s ID during

hospitalization:

Ward:

Bed:

ENDOSCOPY REPORT




Social Security number: Department:

CONCLUSION

Date The physician


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

PNEUMOLOGY DEPARTMENT Patient’s ID during

hospitalization:

Ward:

Bed:

BRONCHOSCOPY REPORT




Social Security number: Department:

Smoker: Profession: Marital Status:

CONCLUSION

Date The physician


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Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι2 REGIONAL

HEALTH

DIRECTORATE

444

GENERAL HOSPITAL

CARDIOLOGY DEPARTMENT


Ward: Bed:

ECHOCARDIAGRAM REPORT



name:

Age:

Social

Security Organization:


Department:

CONCLUSION

IMAGING PARAMETERS

DIMENSIONS

NORMAL VALUES (cm) DIMENSIONS

NORMAL VALUES (cm)

EDD-RV <3.0 end-diastolic IVS 0.6 - 1.1

EDD-LV 3.9 - 5.6 end-diastolic PWLV 0.5 - 1.1

ESD -LS 2.5 - 4.5 end-diastolic Aortic diameter 2.0 - 3.8

% S.F. 25 - 50% End-systolic Left sinus 2.0 - 3.8

% E.F.

PERICARDIAL CAVITY:

DOPPLER PARAMETERS

Findings Vmax - Vmed Surface (cm2) Pressure

Aortic valve

Systolic pressure of pulmonary valve mmHg+CVP

Mitral valve

Diastolic pressure of pulmonary valve mmHg+CVP

Tricuspid Systemic

circulation of blood

L/min

valve

Pulmonary Pulmonary circulation

L/min

valve

Shunt ratio

INTERPRETATION

COLOURED MAPPING OF DOPPLER

EDD: End-diastolic diameter, IVS: Interventricular Septum, PWLV: Posterior Wall of Left Ventricle, SF: Shortening Fraction, Ejection Fraction, LV: Left

ventricle, RV: Right ventricle, Ls: Left sinus, Rs: Right sinus, ΑΟ: Aorta, RVOT: Right Ventricular Outflow Tract

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Projektnr. 2015-1-AT02-KA205-001199

Date The physician

ΜΙNISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι2 REGIONAL HEALTH DIRECTORATE 445

GENERAL HOSPITAL

HEMODYNAMIC LABORATORY Patient’s ID during

hospitalization:

Ward:

Bed:

HEMODYNAMIC TEST REPORT





number: Departm

ent:

CONCLUSION INDICATIONS FOR CATHETERIZATION – SHORT HISTORY:

ACCESS:

CATHETERS:

PRESSURES mmHg SO2

Right Sinus

Right ventricle

Pulmonary valve

Pulmonary Capillary Wedge Pressure

(CAWP)

Left ventricle

Aorta

Date The

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Projektnr. 2015-1-AT02-KA205-001199

physician

ΤΟΙΧΕΙΑ ΕΠΙΚΟΙΝΩΗ - TEL. - FAX)

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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

OBSTETRICS AND GYNAECOLOGY DEPARTMENT


hospitalization:

ULTRASOUND GESTATIONAL MONITORING REPORT



Address: ΤΚ – City: Tel.:


Social Security


number:

PREGNANCY HISTORY

Date of visit:

Reason of examination: Check:

Other reason:

Last menses: Expected Date of

Confinement:

Gestational age: Week according to

last menses

Labour: Number of fetuses:

CONCLUSION

Gestational Sac:

Volume (GSV):

Shape – projection: Mean Sac diameter (MSD):

Position: Crown-rump length (CRL):

Heart beats: Biparietal diameter (BPD):

Movements: Head circumference (HC):

Respiratory movements:

Abdominal circumference (AC):

Sexe: Femoral length (FL):

Amniotic fluid:

Quantity:

Placenta:

Position:

Maturity:

DIAGNOSIS:

Gestational weight estimation: gr ± 10% Gestational age by ultrasound:

Notes:

Date The physician


M2-A15


Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE

GENERAL HOSPITAL

DEPARTMENT: Date:

SURGERY: ROOM:

SURGERY’S SCHEDULE

Ι2 451

# WARD

DEPARTMENT

PATIENT’S ID NAME AGE DIAGNOSIS TYPE OF OPERATION

SURGEON ASSISTANTS TYPE OF ANESTHESIA ANESTHSIOLOGIST

DURING HOSPITALIZATION

The unit nursing officer The head of Anesthesiology The head of the Department


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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL Patient’s ID during

hospitalization:

ANESTHESIOLOGY

Ward: Bed:

PRE-ANESTHESIA EVALUATION – ANESTHESIA DIAGRAM



name:

Age: Weight: Treating Department:

Preoperative diagnosis:

Estimated operation:

First anesthesia evaluation:

Date: Anesthesiologist: Ε.Ι. Department

Second anesthesia evaluation:

Date: Anesthesiologist: Ε.Ι. Department

ASA physical status

Heart Rate

Blood pressure Breaths Temperature

Glascow coma scale Blood Units Blood group - Rh

1 2 3 4 5 E

FINDINGS Last meal:

Hemoglobin Proteins total Alkaline Phosphatase Urine analysis

Hematocrit Albumins ΡΤ Allergies:

White blood cells Globulins ΡΤΤ

Blood platelets Bilirubin total Fibrinogen

Κ+ Direct bilirubin FiO2 Current medical treatment

Να+ Indirect bilirubin pH

Blood sugar LDH PO2

Urea SGOT PCO2

Creatinine SGPT HCO3 Uric acid CPK BE

Ca++ g9GT SaO2

Radiographic inspection

ECG

History of anesthesia

Personal history - Clinical examination

Respiratory - Circulatory

ANESTHESIA SCHEDULE:

PREMEDICATION PREOPERATIVE INSTRUCTIONS

Time Medicine Dose Way of administration

POSTOPERATIVE VISIT

Date – Time: Anesthesiologist: Name - signature

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Projektnr. 2015-1-AT02-KA205-001199 ANESTHESIA DIAGRAM Patient’s Name: Surg.room:

Diagnosis – Operation:

Surgeons:

Anesthesiologists:

Operation date: Time: Time of anesth.: Time of oper.:

Anesthetic technique:

Pronarcosis result: Good Moderate

Insatisfactory Venous lines: Levin

Airways: Patient’s posture: Awake Folley

Other information:

time Total

VT/RR

FiO2

gas

EtCO2 PIP/Pplat

CVP/PCWP

PAP

Fluids

Blood/prod

Urea

Loss

symbols

CIV220

43

CIV200

42

CIV180

41

CIV160

40

140

39

120

38

100

37

80

36

60

35

40

34

20

33

pH

PaO2

PaCO2

HCO3 /BE

Na/K

Ht/Hb

MEDICATION INTUBATION – BREATH CHECKOUT STATUS Pain assessment I II III IV V

Consciousness level: Postoperative anelgesia - support:

Mobility of lower limbs:

SPO2

Level of anesthesia: Blood pressure/pulses:

Time of checkout:

Anesthesiologist’s notes – incidents – complications: The physician

(sign)

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Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

ANESTHESIOLOGY DEPARTMENT


PATIENT’S POSTANESTHETIC RESUSCITATION PATIENT’S INFORMATION



Age: Weight: INTRODUCTION TO RESUSCITATION Received to resuscitation by:

Time of introduction: Time of checkout:

Anesthesia: Total: Spinal: Epidural: Elsewhere:

Anesthesiologist: Surgeon:

Operation:

INTRAOPERATIVE COURSE

Α. Important changes of vital signs: Temperature: Blood press: Breaths: Pulses:

Β. Other changes: CVP: PAP: WP:

SvO2: SaO2: EtCO2:

Γ. Fluids administration: Fluids: Blood: Plasma:

. Ο2 Administration: F1O2: Beginning

: End: Method:

Respiratory tracks, tracheotomy etc:

RESUSCITATION COURSE

LABORATORY MONITORING FLUIDS BALANCE

TIME:

FLUIDS ADMINISTRATION QUANTITIES TOTAL

CVP Blood:

Ht Fluids:

K FLUIDS LOSS

Na Vomiting

Blood sugar Evacuations

SaO2 Urea

PaO2 Gastric Aspiration

PaCO2 Chest Drainage

PH Wound Drainage

VITAL SIGNS DRUG ADMINISTRATION

TIME: TIME MEDICINE,DOSE, WAY THE PHYSICIAN THE NURSE

٭

42

240

Θε

ρμ οκ ρα σί α

180

41 220

40

200

x

39 160

Πίεσ

η

38

140

120

80

Σ φ ύ ξ ε ι ς

37 100

ASSESSMENT - POSTANESTHESIA RESUSCITATION OUTCOME– INSTRUCTIONS

๐ 36

60

Αναπ

ν

οές

35 40

34 20

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Projektnr. 2015-1-AT02-KA205-001199

Checkout from resuscitation: Transfer to ward:

Transfer to Intensive Care Unit: Other:

Checkout date: Time: The

physician


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Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY REGIONAL HEALTH DIRECTORATE

GENERAL HOSPITAL ANESTHESIOLOGY DEPARTMENT

Ι2 454

Patient’s ID


Ward: Bed:

ANESTHESIOLOGIC PRACTICES BEYOND O.R.



Referral clinic:

Escorting Physician: YES NO Name:

Guardian: YES NO Name:

Patient’stransport:

Walking

Private transport

NEAC Internal patient

Anesthesiologists:

Department where the anesthesia is performed:

(axial, magnetic, introspection, OC, ER, clinical, etc)

Reason for anesthesia:

Magnetic Axial

Cardiopulmonary resuscitation

Bronchoscopy

Patient’s transport within hospital Preoperative assessment at the OC

Angiography Electrical Cardioversion Lithotrity Intubation

Introspection: Specify:

Subarachnoid έγχυση cytostatic

Postoperative analgesia

Patient’s transport outside hospital

Preoperative assessment at the department

Various

HISTORY – CLINICAL EXAM History of Anesthesia Personal history Clinical exam Findings

ALLERGY HISTORY: YES NO In what? OXYGEN ADMINISTRATION: YES NO

Other notes:

ANESTHESIA: Beginning:

End:

EVENTS:

ΤΙΜΕ 240

BLOOD PRESSURE

220

Υ

200

DRUGS:

Α

180

160

140

HEART RATE

120

100

80

60

BREATH

40

20

TEMP

0

SpO2

Date: The physician


M2-A15


Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL

HEALTH

DIRECTORATE

461

GENERAL HOSPITAL

DEPARTMENT/ SECTION

Date:

Prot.Number:

DECLARATION OF MEDICAL TREATMENT DENIAL



Age: Address: Tel.:

INFORMATION OF THE DECLARANT OF MEDICAL TREATMENT DENIAL

The patient: Relative: Degree of relationship:


Reason of non declaration by the patient him/herself:

I DECLARE THAT:

I refused to be submitted to the diagnostic tests

or medical treatment I was advised, despite the opposite recommendations of the attending physicians and of the Hospital’s

Administration, even though the risks of such denial where explained to me.

For this reason, I leave the hospital at my own responsibility (signature)

Or I wish to continue my treatment according to further recommendations by the physicians.

(signature)

Furthermore, I release my attending physicians and their assistants from any responsibility for the eventual consequences of my denial to comply with their recommendations.

(signature)

Witnes/es Patient’s, husband’s/wife’s

Relation or other relative’s signature


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Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL

HEALTH

DIRECTORATE

462

GENERAL HOSPITAL



Ward: Bed:

DECLARATION OF PATIENT’S CONSENT



Age: Address: Tel.:

INFORMATION OF THE CONSENT GIVER

The patient: Relative: Degree of relation:

Surname: Name: Tel: Reason of non declaration by the patient him/herself:

DECLARATION OF CONSENT

The undersigned, being fully aware and having completely understood the content of the explanations given as to the

necessity, the purpose, the nature, the process, the eventual complications or side effects of the suggested, by the

attending physicians, diagnostic test or medical treatment:

Medical treatment

I declare that I give the attending physicians my full consent:

Physician’s name:

Physician’s name: 1. To proceed to the performance of the aforementioned diagnostic test or medical treatment, as well as of

any operation may be necessary during this treatment.

2. To be administered, if necessary, any kind of anesthesia or mild sedation. 3. To be administered blood or blood products that may be necessary according to the attending physicians.

4. So that any examination needed be performed to the removed tissue. 5. To take photos or video of the operation for reasons of training or research and I agree that students or other

physicians are present during the operation for educational reasons.

INFORMATION ON THE MEDICAL TREATMENT

Type of medical treatment - necessity - purpose:

Procedure Method:

Eventual complications:

Eventual complications due to anesthesia: (delete whatever is not true) (a) Complications in the respiratory and cardiovascular system, leading even to death. (b) Medical reaction or reaction due to the administration of blood. (c) Complications due to eventual injury of nerves or infection due to regional anesthesia. (d) The event of injury of the teeth, the vocal cords or the trachea due to the insertion of the endotracheal ventilation tube.

Date:

Patient’s signature

Husband’s/wife’s or other relative's signature

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MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL HEALTH DIRECTORATE 463

GENERAL HOSPITAL

DEPARTMENT/ SECTION: Date:

Patient’s ID


DECLARATION OF CONSENT FOR OPERATION AND ANESTHESIA ADMINISTRATION



Age: Address: Tel.:




WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

DECLARATION OF CONSENT The undersigned, being fully aware and having completely understood the content of the explanations given as to the


attending physicians operation or administered anesthesia:

Type of operation

I declare that I give the attending physicians my full consent:

Physician’s name: Surgeon

Physician’s name: Anesthesiologist

1. To proceed to the operation and to any operation deemed necessary during the operation.

2. To be administered total or regional anesthesia or mild repression, or so that, if necessary, the anesthesiologists

change the method of anesthesia during the operation, since they have explained in simple words and in detail the risks, the side effects and the eventual complications of the anesthesia.

3. To be administered blood or blood products and/or other graft that may be deemed necessary according to the attending physicians.

INFORMATION ON THE OPERATION AND THE ANESTHESIA Type of operation - necessity - purpose:

Eventual complications of the operation: Eventual complications of the anesthesia:

(a) Complications in the respiratory and cardiovascular system, leading even to death. (b) Medical reaction or reaction due to the administration of blood. (c) Complications due to eventual injury of nerves or infection due to regional anesthesia. (d) The event of injury of the teeth, the vocal cords or the trachea due to the insertion of the endotracheal ventilation tube.

Patient’s signature Signature of relative

giving consent


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MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL HEALTH DIRECTORATE 464α

GENERAL HOSPITAL



Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR ANGIOCARDIOGRAM



Age: Address: Tel.:




WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E




attending physicians ANGIOCARDIOGRAM, I declare that I give my full consent to the attending physicians: Physician’s name 1. To proceed to the performance of the angiocardiogram and to every action deemed necessary during the

aforementioned.

2. To be administered, if necessary, mild repression or some kind of anesthesia. 3. To be administered, if necessary, any treatment or blood transfusion, in the physicians’ estimation. 4. To take photos or video of the examination for educational or research reasons.

INFORMATION ABOUT THE ANGIOCARDIOGRAM Necessity - purpose: Angiocardiogram is the radiographic image of heart’s coronary vessels, which is performed in order to check the status of the coronary vessels, the possible constrictions, their position, their degree of gravity. This information cannot be gathered by any other test. The benefit of the angiocardiogram is that it allows to determine the right medical treatment (drugs, angiocardiogram, by pass). Procedure Method: The angiocardiogram is performed by introducing a fine catheter (tube) with diameter 2-3 mm, through a peripheral artery towards the heart. The radiopaque agent is introduced to the coronary vessels through this catheter and this is how the vessels are depicted. Possible complications by catheterization: Angiocardiogram is nowadays a common examination, but it can have a low percentage

of complications, that in some cases may be severe. These complications are: 1. Sudden death. 2. Myocardial infarction. 3. Cerebral attack. 4. Local complications of the vessels. 5. Allergic reactions caused by the radiopaque agent. It has to be clear that the risk for these complications is extremely lower than the danger of the absence of diagnosis. Danger is caused by the disease and not by the angiocardiogram. Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.

2. Medical reactions or reactions by blood administration. 3. Complications of possible nerves’ injuries or inflammation due to anesthesia.

Date:


giving consent


M2-A15


Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL


Patient’s ID during hospitalisation:

Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR ANGIOCARDIOGRAM



Age: Address: Tel.:




WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E




attending physicians ANGIOCARDIOGRAM, I declare that I give my full consent to the attending physicians: Physician’s name 1. To proceed to the performance of the angiocardiogram and to every action deemed necessary during the

aforementioned.

2. To be administered, if necessary, mild repression or some kind of anesthesia. 3. To be administered, if necessary, any treatment or blood transfusion, in the physicians’ estimation. 4. To take photos or video of the examination for educational or research reasons.

INFORMATION ABOUT THE ANGIOCARDIOGRAM Necessity - purpose: Angiocardiogram is the radiographic image of heart’s coronary vessels, which is performed in order to check the status of the coronary vessels, the possible constrictions, their position, their degree of gravity. This information cannot be gathered by any other test. The benefit of the angiocardiogram is that it allows to determine the right medical treatment (drugs, angiocardiogram, by pass). Procedure Method: The angiocardiogram is performed by introducing a fine catheter (tube) with diameter 2-3 mm, through a peripheral artery towards the heart. The radiopaque agent is introduced to the coronary vessels through this catheter and this is how the vessels are depicted. Possible complications by catheterization: Angiocardiogram is nowadays a common examination, but it can have a low percentage

of complications, that in some cases may be severe. These complications are: 1. Death, with a percentage of 1 out of 1000. 2. Myocardial infarction, up to 3 out of 1000. 3. Cerebral attack, up to 6 out of 1000. 4. Local complications of the vessels, about 4 out to 1000. 5. Allergic reactions caused by the radiopaque agent. It has to be clear that the risk for these complications is extremely lower than the danger of the absence of diagnosis. Danger is caused by the disease and not by the angiocardiogram. Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.


Date:


giving consent


M2-A15


Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL HEALTH

DIRECTORATE

465α

GENERAL HOSPITAL

DEPARTMENT/

SECTION:


hospitalization:

Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR ANGIOPLASTY



name:

Age: Address: Tel.:







attending physicians ANGIOPLASTY, I declare that I give my full consent to the attending physicians:

Physician’s name:

Physician’s name: 1. To proceed to the performance of angioplasty and to every action deemed necessary during the aforementioned.

2. To be administered, if necessary, any kind of anesthesia or mild repression. 3. To be administered, if necessary, any treatment or blood transfusion or blood’s products, in the physicians’ estimation. 4. To take photos or video of the examination for educational or research reasons and I give my consent so that student

or other physicians are present to the operation for educational reasons.

INFORMATION ON ANGIOPLASTY

Necessity - purpose: Angioplasty is a curative intervention, aiming at the incision of strictures of the heart’s coronary vessels. The benefit we have from angioplasty is that it offers a curative solution, avoiding a heart surgery. Procedure Method: Angioplasty is done by inserting a thin tube (sheath) through a peripheral artery to the heart, through which the catheters are threaded to the heart. When the catheter-ballon gets to the narrowed vessel, the balloon is blown on the stricture. At that moment it is possible to feel some pain, which goes away as soon as the balloon is blown off.

Possible complications by catheterization: Angioplasty is nowadays a common examination, but it can have a low percentage

of complications, that in some cases may be severe. These complications are: 1. Sudden death. 2. Myocardial infarction. 3. Cerebral attack. 4. Local complications of the vessels. It has to be clear that the possibility for these complications is much lower than the medical benefit from it. Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.


Date:


giving consent


M2-A15


Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY I3 REGIONAL HEALTH

DIRECTORATE

465

GENERAL HOSPITAL

DEPARTMENT/

SECTION:


hospitalization:

Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR ANGIOPLASTY



name:

Age: Address: Tel.:







attending physicians ANGIOPLASTY, I declare that I give my full consent to the attending physicians:

Physician’s name:

Physician’s name: 1. To proceed to the performance of angioplasty and to every action deemed necessary during the aforementioned. 2. To be administered, if necessary, any kind of anesthesia or mild repression. 3. To be administered, if necessary, any treatment or blood transfusion or blood’s products, in the physicians’

estimation. 4. To take photos or video of the examination for educational or research reasons and I give my consent so that student

or other physicians are present to the operation for educational reasons.

INFORMATION ON ANGIOPLASTY

Necessity - purpose: Angioplasty is a curative intervention, aiming at the incision of strictures of the heart’s coronary vessels. The benefit we have from angioplasty is that it offers a curative solution, avoiding a heart surgery. Procedure Method: Angioplasty is done by inserting a thin tube (sheath) through a peripheral artery to the heart, through which the catheters are threaded to the heart. When the catheter-ballon gets to the narrowed vessel, the balloon is blown on the stricture. At that moment it is possible to feel some pain, which goes away as soon as the balloon is blown off.

Possible complications by catheterization: Angioplasty is nowadays a common examination, but it can have a low percentage

of complications, that in some cases may be severe. These complications are: 1. Death, with a percentage of up to 1 per cent. 2. Myocardial infarction, up to 2 per cent. 3. Cerebral attack, up to 6 out of 1 thousand. 4. Local complications of the vessels 5. It has to be clear that the possibility for these complications is much lower than the medical benefit from it.

Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.


Date:


giving consent


M2-A15


Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E

MINISTRY OF HELATH AND SOCIAL SOLIDARITY I3 REGIONAL HEALTH DIRECTORATE 466α

GENERAL HOSPITAL



Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR CARDIAC CATHETERIZATION



name:

Age: Address: Tel.:







attending physicians cardiac catheterization, which is performed for

Angiocardiogram Angioplasty Electrophysiological study of the

heart

I declare that I give my full consent to the attending physicians:

Physician’s Name

1. To proceed to the performance of cardiac catheterization and to every action deemed necessary during the aforementioned. 2. To be administered, if necessary, any kind of anesthesia or mild repression. 3. To be administered, if necessary, any treatment or blood transfusion in the physicians’ estimation.

4. To take, if necessary, sample of myocardial tissue for examination. 5. To take photos or video of the examination for educational or research reasons.

INFORMATION ON CARDIAC CATHETERIZATION

Necessity - purpose: Cardiac catheterization is performed either for diagnosis or treatment. The usual screening technique is angiocardiogram, which is the radiographic image of heart’s coronary vessels, that is performed in order to examine the condition of coronary vessels, eventual strictures, their position, their severity, in order to determine the appropriate medical treatment

(medication, angioplasty, bypass). Another screening method is electrophysiological study of the heart, by which it is examined the

operation of the centres giving heartbeat. Angioplasty (stent) is a curative intervention, aiming at the incision of strictures of the heart’s coronary vessels, avoiding a heart surgery. Procedure Method: Cardiac catheterization is the insertion of a thin catheter (tube) of 2-3 mm, through a peripheral artery to the heart. In angioplasty, a thin tube (sheath) is inserted first through which catheters are threaded to the heart. When the catheter-ballon gets to the narrowed vessel, the balloon is blown for the incision of the stricture.

Possible complications by catheterization: Cardiac catheterization is nowadays a common examination, but it can have a low

percentage of complications, that in some cases may be severe. These complications are: 1. Sudden death. 2. Myocardial infraction. 3. Cerebral attack. 4. Local complications of the vessels 5. Allergic reactions caused by the radiopaque agent (at angiocardiogram).

It has to be clear that the risk for these complications is extremely lower than the danger of the absence of diagnosis. Danger is caused by the disease and not by the angiocardiogram. Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.

2. Medical reactions or reactions by blood administration (if necessary). 3. Complications of possible nerves’ injuries or inflammation due to anesthesia.

Date: Patient’s signature Relative’s signature ΣΤΟΙΧΕΙΑ ΕΠΙΚΟΙΝΩΝΙΑΣ (ΔΙΕΥΘΥΝΣΗ - C.P. - ΠΟΛΗ - TEL. - FAX)

M2-A15


Projektnr. 2015-1-AT02-KA205-001199

WH

ITE

: CLIN

IC

PIN

K:

PATIE

NT

YE

LLO

W:

PATIE

NT’S

FIL

E


GENERAL HOSPITAL



Ward: Bed:

PATIENT’S DECLARATION OF CONSENT FOR CARDIAC CATHETERIZATION



name:

Age: Address: Tel.:







attending physicians cardiac catheterization, which is performed for

Angiocardiogram Angioplasty Electrophysiological study of the

heart

I declare that I give my full consent to the attending physicians:

Physician’s Name

1. To proceed to the performance of cardiac catheterization and to every action deemed necessary during the aforementioned. 2. To be administered, if necessary, any kind of anesthesia or mild repression. 3. To be administered, if necessary, any treatment or blood transfusion in the physicians’ estimation.

4. To take, if necessary, sample of myocardial tissue for examination. 5. To take photos or video of the examination for educational or research reasons.

INFORMATION ON CARDIAC CATHETERIZATION

Necessity - purpose: Cardiac catheterization is performed either for diagnosis or treatment. The usual screening technique is angiocardiogram, which is the radiographic image of heart’s coronary vessels, that is performed in order to examine the condition of coronary vessels, eventual strictures, their position, their severity, in order to determine the appropriate medical treatment (medication, angioplasty, bypass). Another screening method is electrophysiological study of the heart, by which it is examined the operation of the centres giving heartbeat. Angioplasty (stent) is a curative intervention, aiming at the incision of strictures of the heart’s coronary vessels, avoiding a heart surgery. Procedure Method: Cardiac catheterization is the insertion of a thin catheter (tube) of 2-3 mm, through a peripheral artery to the heart. In angioplasty, a thin tube (sheath) is inserted first through which catheters are threaded to the heart. When the catheter-ballon gets to the narrowed vessel, the balloon is blown for the incision of the stricture.

Possible complications by catheterization: Cardiac catheterization is nowadays a common examination, but it can have a low

percentage of complications, that in some cases may be severe. These complications are: 1. Death, with a percentage of 1 out of 1 thousand for angiocardiogram, or up to 1 per cent for angioplasty. 2. Myocardial infraction, up to 3 out of 1 thousand for angiocardiogram, or up to 2 per cent for angioplasty. 3. Cerebral attack, up to 6 out of 1 thousand. 4. Local complications of the vessels 5. Allergic reactions caused by the radiopaque agent (at angiocardiogram).

It has to be clear that the risk for these complications is extremely lower than the danger of the absence of diagnosis. Danger is caused by the disease and not by the angiocardiogram. Possible complications from the eventual anesthesia: Usually no anesthesia is needed, but if this is the case, the possible complications are: 1. Complications of the respiratory and the cardiovascular system.


Date: Patient’s signature Relative’s signature


M2-A15


Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL

Patient’s ID during:

Section/ Department: Blood Group Rh:

Head of the Department: HBsAg:

MEDICAL REPORT Medical Report is to be carried every time you see the physician


Surname: Name: Age:


Date of

admission:

Date of

checkout:

HISTORY – EXAMINATION FINDINGS

COURSE OF THE DISEASE

CHECKOUT DIAGNOSIS

MEDICAL TREATMENT - OPERATIONS

INSTRUCTIONS ON CHECKOUT - COMMENTS


M2-A15


Projektnr. 2015-1-AT02-KA205-001199 LABORATORY FINDINGS

Hematocrite Neu. RET

White Blood cells Lym.

Blood platelets Mono.

ESR Eos.

Hemoglobin

Blood sugar SGOT

Urea SGPT

Creatinine gGT

Κ Alkaline Phosphatase

Na CPK

Ca LDH

Bilirubin total

Bilirubin direct

SCREENING ECG

Radiographic screening

Other exams (cardiology, endoscopy, histology, nuclear medicine etc)

The Head of the Department The Registrar The assistant

CAUTION: Specific examinations reports can be attached or recorded at the back of the present.

M2-A15


Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL


Patient’s ID during Hospitalization:

MEDICAL CERTIFICATE - ADVICE



name:

Address: C.P. –

City: Tel:

Age:

Social Security

Organism: Social Security

number.:

PHYSICIAN’S INFORMATION

The undersigned physician certifies that the

aforementioned patient

was examined in Outpatients Department or Emergencies Department on

was hospitalized in our hospital,

• in the Department from to

• in the Department from to

IT IS CERTIFIED THAT:

The aforementioned patient suffers from

The patient was subject to

Medication – Instructions

The present certificate is administered in

response to the application dated , to be used:

The present was attested for the authenticity of the signature

The Manager The physician ΤΟΙΧΕΙΑ ΕΠΙΚΟΙΝΩΝΙΑΣ (ΔΙΕΥΘΥΝΣΗ - C.P. - ΠΟΛΗ - TEL. - FAX)

M2-A15


Projektnr. 2015-1-AT02-KA205-001199

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι4 REGIONAL HEALTH

DIRECTORATE

473

GENERAL HOSPITAL


Prot.Number:

ATTESTATION FOR SOCIAL SECURITY ORAGIZATION/MEDICAL COMMITTEE



name:



Social Security number.:

PHYSICIAN’S INFORMATION

The undersigned physician

certifies that the aforementioned

patient

Was examined in Outpatients Department

or Emergency Room on

Was hospitalized in the Department

from to

IT IS CERTIFIED THAT: The aforementioned patient suffers from

Findings have shown

THE PATIENT IS IN NEED OF:

(code)

(code)

(code)

The present attestation is administered in

response to the application dated , to be used

For the Social Security Organization’s Approval

For the Health Committee’s Approval

The present was attested for the authenticity of the signature

The Manager The physician

ΚΟΙΝΩΝΙΑΣ (ΔΙΕΥΘΥΝΣΗ - C.P. - ΠΟΛΗ - TEL. - FAX)

M2-A15


Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL



hospitalization.:

MEDICAL CERTIFICATE FOR COMPENSATION FOR PRIVATE NURSE*





number.:

ΣΤΟΙΧΕΙΑ ΙΑΤΡΟΥ

The attending physician :

The Head of the Department:

I CERTIFY THAT:

code

code

The aforementioned patient hospitalized in my department from

needs an exclusive nurse for

night hours and more precisely for the nights from to

because he/she suffers from

And for this reason his/her life is at risk.

The head of the Department

SOCIAL SECURITY ORGANIZATION’S APPROVAL

The placement of exclusive nurse is approved for nights from to

(Date)

Supervisor Physician

INSTRUCTIONS – CONSULTATION:

1. It is necessary to have the supervisor physician’s prior authorization (for the Greek Social Security Institute) within 3 (three) days from the day that the private nurse takes on her duties (night). This expense is not approved if the term of three days is not respected (Article C99/1/88).

2. It is justified to have a private nurse only for acute and exceptional cases and not for chronic diseases.

3. For your transactions with the Social Security Institution it is necessary to have your health record.


M2-A15


Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY

REGIONAL HEALTH DIRECTORATE GENERAL HOSPITAL CARDIOLOGY DEPARTMENT

Ι4 475

Date:

Prot.Number:

MEDICAL CERTIFICATE FOR INSERTION OF PACEMAKER



name:

Resident: Social Security

Organization:

CERTIFICATE

The undersigned physician

certify that the patient

mentioned above, suffering from

a permanent cardiac PACEMAKER with the following caracteristics: was given today

1. Type of Pacemaker Guarantee

2. Manufacturer

3. Number of Pacemaker

4. Type of electrode

5. Subclavicular inserter

6. Other

The physician


M2-A15


Projektnr. 2015-1-AT02-KA205-001199


GENERAL HOSPITAL


Prot.Number:



M2-A15


Projektnr. 2015-1-AT02-KA205-001199 MINISTRY OF HEALTH AND SOCIAL SOLIDARITY Ι5


GENERAL HOSPITAL



M2-A15


Projektnr. 2015-1-AT02-KA205-001199 CONTACT INFORMATION (ADDRESS - C.P. - CITY - TEL. - FAX)

Documents

PATIENT’S PERSONAL HISTORY - increase-project.eu · M 2-A15 Modul 2 - Anhänge INCREASE-Weiterbildungscurriculum | Intellectual Output 2 Projektnr. 2015-1-AT02-KA205-001199 MINISTRY