This medical record document contains information about a patient's clinical history, current illness, physical exam findings, hospital treatment course, diagnoses, and discharge conditions. The patient presented with [blank] as their chief complaint and was diagnosed with conditions coded as [blank] based on their exam and workup. They received [blank] treatment during their hospital stay and were discharged with a prognosis of [blank] and prescribed outpatient follow up of [blank] treatments.

1. HTD Nombres:__________________________ Sexo: ____ Edad: _______ Historia Clínica Nº: _____________
1. RESUMEN DEL CUADRO CLÍNICO
MOTIVO DE CONSULTA: ________________________________________________________________________________________________
ENFERMEDAD ACTUAL: ___________________________________________________________________________________
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APP: ______________________________________________________________________________________________________
APF: ______________________________________________________________________________________________________
EXAMEN FÍSICO:____________________________________________________________________________________________
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2. RESUMEN DE LA EVOLUCIÓN Y COMPLICACIONES
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3. EXÁMENES – PROCEDIMIENTOS: DIAGNÓSTICOS Y TERAPEÚTICOS E INTERCONSULTAS.
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4. RESUMEN DE TRATAMIENTO
TRATAMIENTO HOSPITALARIO
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TRATAMIENTO AL ALTA
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5.DIAGNÓSTICOS INGRESO CIE 6.DIAGNÓSTICOS EGRESO CIE
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7. CONDICIONES DE EGRESO Y PRONÓSTICO
CONDICIÓN:_______________________________________________________________________________________________
PRONÓSTICO:_______________________________________________________________________________________________
FECHA
INGRESO SALA
EGRESO CAMA