Ph lc 1: Phiu tm tt bnh n ni tr

Khoa:............................................................................... S bnh n:............................................

PHIU TM TT BNH N NI TR
I. THNG TIN BNH NHN

1 H v tn: Tui:.. Cn nng: kg

2 Gii tnh: Nam N
3 a ch:.
4 Ngy vo vin:/./2017 Ngy ra vin:/./2017
5 L do vo vin:
6 Chn on:
Bnh chnh:............................................................................................................................
Bnh mc km:......................................................................................................................
8 Kt qu iu tr
Khi Khng thay i T vong
Gim Nng hn Chuyn vin
9 Bin chng
C Khng

II. THNG TIN S DNG KHNG SINH

Phc KS ban u:....................................................................................................................
S ln thay i phc khng sinh:.(ln)
L do thay i:.............................................................................................................................
Cc loi khng sinh s dng:

T Hot cht, hm lng Liu dng Cch dng Thi gian Lu

T

III. GIM ST LM SNG V CN LM SNG

1. Cc xt nghim huyt hc :
 Ngy / / /
Bnh thng BT T BT T BT T
RBC
HCT
PLT
WBC
NEU %
LYM %
MON %
EOS %
BAS %
PT
aPTT

2. Cc xt nghim sinh ha

Ngy / / /
Bnh thng BT T BT T BT T
Ure
Creatinin
Calci
ASAT
ALAT
Bilirubin TP
LDH
ALP

3.Cc xt nghim khc

Ngy Cc xt nghim khc

IV.BIN C C HI LIN QUAN N THUC C GHI NHN TRONG BA

C quan Biu hin Ngy xut hin X tr Kt qu

Da, min dch
Tim mch
H hp
Tiu ha
Mu
Gan
Thn kinh
Thn/Tit niu
Sinh dc
Mt
Khc