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Relatório de Admissão #ULTIMAS 24

HORAS:_____________________________________________________________________
_________________________________________________________________________

Paciente: ______________________________________________________________ Sono: ( )boa ( )regular ( )ruim devido:


Data da admissão: _______________________________________________________ Diurese: ( ) ausente ( ) presente __________ml ( )12hrs ( )24 hrs
Natural: _______________________________________________________________ Evacuação: ( ) ausente ( ) presente ________episódios
Procedência: ___________________________________________________________ Aceitação dieta: ( )boa ( )regular ( )ruim
Data de nascimento: _____________________________________________________ Motivo:
Enfermaria/Leito: _______________________________________________________ _________________________________________________________________________
_
QP: __________________________________________________________________ EXAME FÍSICO
Ectoscopia___________________________________________________________________
HDA:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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_________________________________________________________________________
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_________________________________________________________________________ ACV:
_________________________________________________________________________ _________________________________________________________________________
_________________________________________________________________________ _________________________________________________________________________
_________________________________________________________________________ _________________________________________________________________________
_________________________________________________________________________ _________________________________________________________________________
_________________________________________________________________________ ___________________________________________ FC:__________
_________ AR:
_________________________________________________________________________
HPP:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
__________________________________________SatO2: __________ FR: __________
__HS: ABD:
_________________________________________________________________________ _________________________________________________________________________
_________________________________________________________________________ _________________________________________________________________________
__ ____________________________
MEMBROS:
_________________________________________________________________________
#EM USO: _________________________________________________________________________
_________________________________________________________________________ ____________________________
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__ EXAMES DE IMAGEM DATA:_____/_____/______