On conducting of medical interference

(diagnostic inspection and manipulation treatments)

I_________________________, by this document confirm the fact of grant

(patient’s last name, name, year and place of birth)

the offered me consent on the plan of inspection and medical treatment, that includes:

Diagnostic research and manipulation treatment
Intravenous, intramuscular and hypodermic injections of medications
Drip infusions

 

I confirm that in a fully clear form the information on my disease, order of inspection, diagnosis, possible prognosis, risks and complications of medical treatment, and also methods of medical treatment most effective for me was given to me. Possibility of all questions was given to me, that I was interested in relation to subsequent medical interferences, and also to get on them the answers exhaustive and clear for me.

Doctor_________________________________________________________ ( last name, name)

which will carry out interference, and other medical workers of Sumy region infectious clinical hospital named after Z.Y. Krasovitsky, where it will be carried out. I agree with the plan of inspection and manipulation treatments offered me. Text of this consent is readed by me and the own signature I certify that I fully agree with all, that it is marked in it.

_________________________ __________________

(signature) (patient’s last name, name)

Date_______________200__year.

This document is readed and signed by a patient____________________

(patient’s last name, name)

Doctor_____________________ ___________________

(signature) (patient’s last name, name)

With the item 19, 20, 38 of the law of Ukraine “About defence of population from infectious diseases” in relation to persons’ rights and duties which have infectious diseases or are bacteriacarriers and responsibility of the failure of sanitary norms and rules is acquainted.

 

Signature of the patient________________________

 

TEMPERATURE LIST (example)

Card № 1021 Last name, name of the patient Pilipenco Philip Ward № 6
Date 1.03.08 2.03.08 3.03.08 4.03.08 5.03.08 6.03.08 7.03.08 8.03.08 8.03.08 9.03.08 10.03.08 11.03.08
Day of illness    
Day of staing at the department
Pulse AT T m iv m iv m iv m iv m iv m iv m iv m iv m iv r in r in r in
                                               
    exanthema                                      
                                         
                                             
    hepatosplenomegaly                                  
                                 
                                           
                                               
                                           
                                               
                                               
                                               
                                               
                                             
                                         
                                               
                                               
                                           
                                             
                                             
                                               
                                               
                                           
                                             
                                           
                                               
                                       
                                           
                                               
                                               
                                               
                                               
                                               
                                               
                                               
Breathing / min    
Mass, kg                
Liquids are used, ml    
Diuresis Color    
yellow yellow yellow yellow yellow l. yellow l. yellow l. yellow l. yellow      
Stool / day Admixtures: blood mucus - -   1 of.    
  -   -   - - - - -    
  -   -   - - - - -    

Ministry of health of Ukraine   MEDICAL DOCUMENT FORM №003- 4/o    
LIST OF MEDICAL SETTING № card_________ Last name, name, _____________________________ № ward_________________  
Setting   Implementation | Marks
Regimen Date            
  Doctor            
Nurse            
  Doctor            
Nurse            
  Doctor            
Nurse            
    Doctor            
Nurse            
    Doctor            
Nurse            
    Doctor            
Nurse            
    Doctor            
Nurse            
    Doctor            
Nurse            
    Doctor            
Nurse            
  Doctor            
Nurse            
  Doctor            
Nurse            
Signatures Doctor            
Nurse            
                         

 

 

 

Reverse page Of The LIST of medical setting

Inspections Intubations Consultations Date Implementation
Clinical and biochemical Inspection Date Implementation Cardiologist    
Inspection Date Implementation Gastric intubation     Neuropathologist    
Clinical blood examination     Duodenal intubation with bacteriological inspection of B,C portions     Oculist    
Blood glucose           ENT    
Clinical urine examination     Endoscopic   Pulmonologist    
Urine glucose     Fibroesophago-gastroscopy     Urologist    
Examination of feces on the eggs of intestinal parasites     Colonoscopy          
Coprogramm     Rectoromanoscopy          
Urine amylase                
Prothombin index, coagulation time, bleeding time     Roentgenological   Diet №
Nechiporenco’s urine examination     Photoroentgeno-graphy      
Zimnitski’s urine examination     Stomach X-ray      
      Irrigoscopy      
Occult blood in feces     Chest X-ray     Physical therapy procedures
Blood examination to malaria     Abdomen X-ray        
Scraper to pinworms              

 

LAST PAGE OF MEDICAL CARD

Scabies yes no Pediculosis yes no Date____ Signature____     With the day regimen and prohibition of smoking is acquainted   Signature_______