SOLICITUD DE OXIGENO DOMICILIARIO

GESTIN CIENTIFICA

Cdigo:
GCF-FO-026
Versin: 1

Fecha: Ao___________ Mes__________________ Da_____ FFD:____________________________

Historia Clnica: _________________________________________________ Edad:_________________
Nombre completo: ________________________________________________ Cedula: _______________
Si es nio(a)
Tarjeta de identidad o Registro: ________________________Cedula Responsable: __________________
Direccin: __________________________________________Telfono(s):_________________________
Diagnostico:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
Gases Arteriales: _______________________________________________________________________
Pulso Oximetra: ________________Sin Oxigeno: _______________Con Oxigeno: __________________
Ecocardiograma:________________________________________________________________________
_____________________________________________________________________________________
RX Trax: _____________________________________________________________________________
Curva Flujo / Volumen: ___________________________________________________________________
Indicacin Oxigeno Domiciliario: ____________________________________________________________
______________________________________________________________________________________
Concentracin: _________________________________________________________________________
Tipo de Equipo Solicitado: ________________________________________________________________
_____________________________________________________________________________________
Nombre completo y/o sello Medico Tratante:__________________________________________________
Autorizacin de Oxigeno: _________________________________________________________________
RENOVACION
Fecha: Ao___________ Mes__________________ Da_____ Vo.Bo:___________________________
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