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Ministerul Sănătăţii al Republicii Moldova Министерство здравоохранения Республики Молдова

DOCUMENTAŢIE MEDICALĂ Formular nr. Форма Aprobat de MS al RM Утверждена МЗ РМ

___________________________________________________ denumirea instituţiei наименование учреждения

088/e nr. 828 din 31.10. 2011

TRIMITERE LA CONSILIUL DE EXPERTIZĂ MEDICALĂ A VITALITĂŢII НАПРАВЛЕНИЕ НА КОНСИЛИУМ ВРАЧЕБНОЙ ЭКСПЕРТИЗЫ ЖИЗНЕСПОСОБНОСТИ 1. Numele, prenumele bolnavului______________________________________________________________________ Фамилия, имя, отчество больного ______________________________________________________________________________________________ Număr de identificare ____________________________________________________________________________ Идентификационный номер 2. Data naşterii _______________________________________________________ Sex________________________ Дата рождения Пол 3. Adresa la domiciliu_______________________________________________________________________________ Адрес местожительства 4. Invalid de gradul _________________ 5. Locul de muncă_______________________________________________ Инвалид группы Место работы 6. Adresa locului de muncă__________________________________________________________________________ Адрес места работы 7. Profesia_______________________________________ 8. Funcţia_______________________________________ Профессия Должность 9. Denumirea instituţiei medico-sanitare care a trimis bolnavul______________________________________________ Наименование учреждения здравоохранения, направившего больного _________________________________________________________________________________________________ 10. Supravegheat de instituţia medico-sanitară care a trimis de la «____»_______________________________20____ Под наблюдением направляющего учреждения здравоохранения с 11. N-a lucrat din cauza bolii ultimele 6 luni Не работал по болезни последние 6 месяцев De la şi pînă la ce zi a lunii С какого и по какое число месяца

Denumirea bolii Название болезни

12. Schimbarea profesiei sau a condiţiilor de muncă în ultimul an Изменение профессии или условий работы за последний год ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 1

13. Istoricul bolii actuale (debutul, dezvoltarea, evoluţia, datele acutizărilor, măsurile curativ-profilactice efectuate) История настоящего заболевания ( начало, развитие, течение, даты обострений, проведенные лечебнопрофилактические мероприятия) ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 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14.*) Starea bolnavului la trimitere la C E M V (acuzele, starea generală, starea pielii, ţesutului conjunctiv-adipos, muşchilor, oaselor, articulaţiilor, organelor aparatului respirator, circulator, digestiv, genito-urinar şi a sistemului neuro-psihic) Состояние больного при направлении в КВЭЖ (жалобы, общее состояние, состояние кожи, подкожной клетчатки, мышц, костей, суставов, органов дыхания, кровообращения, пищеварения, мочеполовой и нервно-психической систем) ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 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*) punctul 14 se completează de medicul de familie şi cel puţin 2 medici specialişti de profil 14 пункт заполняется семейным врачом и как минимум 2 врачами специалистами 3

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15. Investigaţiile de laborator şi instrumentale _____________________________________________________________ Данные лабораторных и инструментальных исследований ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 6

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16.

Diagnosticul la trimitere la CEMV: Диагноз при направлении на КВЭЖ : a) diagnosticul de bază (pentru bolnavii de TBC- caracteristica clinică conform clasificaţiei acceptate) основное заболевание (для ТБК- больных, клиническая характеристика по принятой классификации )

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b) boli concomitente____________________________________________________________________________ сопутствующие заболевания ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

с) complicaţii________________________________________________________________________________ осложнения ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

17. Trimiterea la C E M V în baza Основание для направления на КВЭЖ

(a specifica) (указать)

1. Existenţa semnelor de invaliditate Наличие признаков инвалидности

3. Reexaminare înainte de termen Досрочное переосвидетельствование

2. Expirarea termenului invalidităţii-reexaminare Окончание срока инвалидности-переосвидетельствование

4. Prelungirea certificatului de concediu medical Продление листка о медицинском отпуске

L.Ş. М.П.

Preşedintele CMC Председатель ВКК Membrii CMC Члены ВКК

___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

« ________» ______________________________20___________ 8

Ministerul Sănătăţii al Republicii Moldova Министерство здравоохранения Республики Молдова

DOCUMENTAŢIE MEDICALĂ

___________________________________________________

Formular Форма

denumirea instituţiei наименование учреждения

nr. 088/e

Aprobat de MS al RM Утверждена МЗ РМ

nr. 828 din 31.10. 2011

AVIZUL INSTITUŢIEI MEDICO-SANITARE PRIVIND DECIZIA CONSILIULUI DE EXPERTIZĂ MEDICALĂ A VITALITĂŢII ИЗВЕЩЕНИЕ УЧРЕЖДЕНИЯ ЗДРАВООХРАНЕНИЯ О РЕШЕНИИ КОНСИЛИУМА ВРАЧЕБНОЙ ЭКСПЕРТИЗЫ ЖИЗНЕСПОСОБНОСТИ

1. Denumirea instituţiei medico-sanitare unde se expediază avizul şi adresa Наименование учреждения здравоохранения куда направляется извещение и его адрес ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

2. Numele, prenumele bolnavului _______________________________________________________________________ Фамилия, имя, отчество больного __________________________________________________________________________________________________ Număr de identificare _________________________________________________________________________________________ Идентификационный номер 3. Data examinării la C E M V___________________________________________________________________________ Дата освидетельствования КВЭЖ 4. Procesul – verbal nr. ______________________________________________________________________________ Aкт 5. Diagnosticul C E M V______________________________________________________________________________ Диагноз КВЭЖ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

6. Concluzia C E M V_______________________________________________________________________________ Заключение КВЭЖ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

7. Locul de muncă recomandat _______________________________________________________________________ Рекомендуемое трудоустройство ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________

L.Ş. М.П.

Data trimiterii Дата отправки

Preşedintele C E M V Председатель КВЭЖ

«______» _______________________________________________20________ 9