INFORME DE HOSPITALIZACION
Historia Clínica

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Rendición indiv o reg (N de Lote)
 
Establecimiento
Código
 
 
Obra Social
Código

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DATOS DEL BENEFICIARIO
Nro. de Beneficiario
Apellido y Nombre

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Documento
Fecha Nacimiento
Edad Ingreso
Sexo
Estado Civil
Ocupación

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Masculino
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Femenino
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Domicilio Habitual Completo
Teléfonos

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Apellido y Nombre Familiar Responsable
Domicilio Familiar

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                            INTERNACION
Ingreso
Fecha
Hora
Sector-Servicio
Tipo de Pensión
Días
Ingreso
 
 
 
 
 
1° Pase
 
 
 
 
 
2° Pase
 
 
 
 
 
3° Pase
 
 
 
 
 
4° Pase
 
 
 
 
 
5° Pase
 
 
 
 
 
Egreso
Tipo Ingreso
Fecha Hora

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Certificación de Internación

Firma Beneficiario, Familiar o 3ro Responsable

Aclaración

Total Días Estadía
 
En caso de Lesiones
 
Operación Principal
 
Egreso Por
 
Lugar Donde ocurrió
 
Parte Policial
NO X
SI  
Otras Operaciones
 
Diagnóstico Principal
Código

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Otros Diagnósticos
Código
 
 
Observaciones:
MP: