Приложение N 1. Форма N 01-ТБ/у "Медицинская карта лечения больного туберкулезом"

Региональный регистрационный номер: _____ Год ______ Квартал____                                             Приложение N 1

Наименование учреждения здравоохранения (по месту диспансерного учета): _____________________________        Утверждено

                                                                                                             приказом Минздрава РФ

Медицинская карта лечения больного туберкулезом                                                              от 13 февраля 2004 г. N 50

              +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+          Медицинская документация учетная 

1. ФИО        | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |          форма N 01-ТБ/у

              +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+

2. Адрес и телефон (фактич. проживание, район) ____________________________________________________

3. ФИО, адрес и телефон одного из близких родственников или друзей:   7. Дата возникновения симптомов_____

___________________________________________________________           8. Дата первого обращ. к любому врачу по поводу этих симптомов_____

           +-+      +-+

4. Пол:   м| |     ж| | 5. Дата рождения:________    6. Возраст____   9. Дата установления диагноза___________________

           +-+      +-+

 

10. Диагноз                                                                 12. Стандартные режимы химиотерапии в интенсивной фазе

+-----------------------------------+----------------------------------+   +-----------------------+--------------------+--------------+

|                               +-+ |                              +-+ |   |       Режим 1/3       |      Режим 2       |   Режим 4    |14. Ре

|Легочный туберкулез      10.1  | | |Внелегочный туберкулез  10.2  | | |   |                   +-+ |                    |          +-+ |зульта-

|                               +-+ |Орган (ы) ___________________ +-+ |   | 2HRZE(S)    12.1  | | |  2А-2HRZES+1 HRZE  |     12.4 | | |ты ис-

|                                   |                                  |   |                   +-+ |                    |          +-+ |следо-

|                                   |                                  |   |                       |                +-+ |              |ваний

|                                   |                                  |   |                       |          12.2  | | |              |

|                                   +----------------------------------+   |                       |                +-+ |              |

|Клиническая форма туберкулеза      |Туберкулез ВДП, бронхов, плевры и |   |                       |                    |              |

|легких: _______________________    |внутригрудных лимфоузлов          |   |                       |2Б* - 3HRZE + Pt +  |              |

|                                   |                                  |   |                       |    Cap(K) + Fq     |              |

|                                   |                              +-+ |   |                       |                    |              |

|                                   |                        10.3  | | |   |                       |                +-+ |              |

|                                   |                              +-+ |   |                       |          12.3  | | |              |

|                                   |                                  |   |                       |                +-+ |              |

+-----------------------------------+----------------------------------+   +-----------------------+--------------------+--------------+

11. Группы больных                                                          13. Интенсивная фаза. Режим химиотерапии и дозировки

+-----------------------------------------------------------------------    противотуберкулезных препаратов**    (укажите дозу препарата

|Впервые выявленный                                                         в г)

|больной туберкулезом    Лечение после неэффективного КХТ    11.3

|(новый случай)

|                       +----------------------------------------------+   +------------------+---+----+---+---+---+---+---+---+---+---+

|                   +-+ |                                          +-+ |   | Дата назначения  | Н | R  | Z | Е | S |   |   |   |   |   |

|              11.1 | | |Лечение после прерывания КХТ        11.4  | | |   |                  |   |    |   |   |   |   |   |   |   |   |

|                   +-+ |                                          +-+ |   |                  |   |    |   |   |   |   |   |   |   |   |

+-----------------------+----------------------------------------------+   +------------------+---+----+---+---+---+---+---+---+---+---+

|Рецидив            +-+ |                                          +-+ |   |        1         | 2 | 3  | 4 | 5 | 6 | 7 | 8 | 9 |10 |11 |

|              11.2 | | |Переведенный (для продолж. лечения) 11.5  | | |   +------------------+---+----+---+---+---+---+---+---+---+---+

|                   +-+ |                                          +-+ |   |                  |   |    |   |   |   |   |   |   |   |   |

|                       +----------------------------------------------+   +------------------+---+----+---+---+---+---+---+---+---+---+

|                       |                                          +-+ |   |                  |   |    |   |   |   |   |   |   |   |   |

|                       |Прочие                              11.6  | | |   +------------------+---+----+---+---+---+---+---+---+---+---+

|                       |                                          +-+ |   |                  |   |    |   |   |   |   |   |   |   |   |

+-----------------------+----------------------------------------------+   +------------------+---+----+---+---+---+---+---+---+---+---+

 

------------------------------

* Режим 2Б используется только в специализированных областных центрах

** Н: Изониазид, R: рифампицин, Z: пиразинамид, S: стрептомицин, Е: этамбутол

 

+-----------------------------+------------------------------------------------------------------+------------------------+----------+

|      Месяц/фазы лечения     |                 Результаты исследований мокроты                  |        Рентген         | Вес (кг) |

|                             +--------+-------------+--------+------+---------------------------+                        +----------+

|                             | Лаб N  |Дата регистр,|Микрос- |Посев |                           |                        |          |

|                             |        |  материала  | копия  |      |                           |                        |          |

|                             |        |             |        |      +-----+----+-----+----+-----+-------+----------------+----------+

|                             |        |             |        |      |  Н  | R  |  S  | Е  |     | Дата  |Результат (+\-) |          |

+-----------------------------+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|              1              |   2    |      3      |   4    |  5   |  6  | 7  |  8  | 9  | 10  |  11   |       12       |    13    |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|0, (ОЛС)                | 1  |        |             |        |  X   |  X  | X  |  X  | X  |  X  |       |                |     X    |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|0, (противотуб. служба) | 2  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|2/3, интенсивная фаза   | 3  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|3/4, инт.ф. (продление) | 4  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|5, фаза продолжения     | 5  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|                        | 6  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

|В конце лечения         | 7  |        |             |        |      |     |    |     |    |     |       |                |          |

+------------------------+----+--------+-------------+--------+------+-----+----+-----+----+-----+-------+----------------+----------+

 

15. Прием суточных доз, интенсивная фаза

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      | 1 | 2 | 3 | 4 | 5 | 6 | 7  |8 | 9  |10| 11 |12 |13 |14 |15 |16 |17 |18 |19 |20 |21 | 22 |23 |24 |25 |24 |27| 28 |29 |30 |31 | Число |Число  |

| День |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |приня- |пропу- |

|месяц |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |тых доз|щенных |

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |доз    |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+       |       |

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|      |   |   |   |   |   |   |    |  |    |  |    |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |  |    |   |   |   |       |       |

+------+---+---+---+---+---+---+----+--+----+--+----+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+--+----+---+---+---+-------+-------+

|Формы отметок о приеме препарата: Контролируемый прием инициалы м/с, Прием без контроля: (---),         |                      Итого|       |       |

|Препараты не приняты: оставить клетку пустой                                                            |                           |       |       |

+--------------------------------------------------------------------------------------------------------+---------------------------+-------+-------+

 

16. Стандартные режимы химиотерапии в фазе продолжения                             17. Фаза продолжения. Режим химиотерапии и дозировки

                                                                                   противотуберкулезных препаратов (укажите дозу препарата в г.)

 

+--------------------------------+---------------------------------+-----------+   +------------------+------+----+------+-----+-----+-----+-----+

|           Режим 1/3            |      Режим 2                    |  Режим 4  |   | Дата назначения  |  Н   | R  |  Е   |     |     |     |     |

|                                |                            +-+  |           |   |                  |      |    |      |     |     |     |     |

|4 HR  или  4H R    или   6НЕ    |2A: 5HRE            16.4    | |  |           |   |                  |      |    |      |     |     |     |     |

|             3 3                |                            +-+  |           |   +------------------+------+----+------+-----+-----+-----+-----+

|                                |                            +-+  |           |   |                  |      |    |      |     |     |     |     |

|16.1       16.2          16.3   |или 5 Н R Е         16.5    | |  |   16.7    |   |                  |      |    |      |     |     |     |     |

|                                |       3 3 3                +-+  |           |   +------------------+------+----+------+-----+-----+-----+-----+

|+-+        +-+           +-+                                 +-+       +-+    |   |                  |      |    |      |     |     |     |     |

|| |        | |           | |     2Б: зависит от ЛУ   16.6    | |       | |    |   |                  |      |    |      |     |     |     |     |

|+-+        +-+           +-+                                 +-+       +-+    |   |                  |      |    |      |     |     |     |     |

+------------------------------------------------------------------------------+   +------------------+------+----+------+-----+-----+-----+-----+

 

18. Прием суточных доз, фаза продолжения

 

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

| День | 1  | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |11 |12 |13 | 14 |15 |16 |17 |18 |19 |20 |21 |22 |23 |24 |25 |26 |27 |28 |29 |30 |31 | Число | Число |

|Месяц |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |приня- |пропу- |

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |тых доз|щенных |

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |  доз  |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|      |    |   |   |   |   |   |   |   |   |   |   |   |   |    |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |       |       |

+------+----+---+---+---+---+---+---+---+---+---+---+---+---+----+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+---+-------+-------+

|Формы отметок о приеме препарата: Контролируемый прием, инициалы м/с, Прием без контроля: (---), Препараты не приняты:        Итого |       |       |

|оставить клетку пустой                                                                                                              |       |       |

+------------------------------------------------------------------------------------------------------------------------------------+-------+-------+

 

19.   Исход курса химиотерапии                                                         Дата             20. Примечания

 

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 1  |Эффективный курс х/т, подтвержденный микроскопией мокроты/              |                    |    |                                            |

|    |                                                                        +--------------------+    +--------------------------------------------+

|    |                       подтвержденный посевом                           |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 2  |Эффективный курс к/т, подтвержденный только клинико-рентгенологически   |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 3  |Неэффективный курс х/т, подтвержденный микроскопией мокроты/            |                    |    |                                            |

|    |                                                                        +--------------------+    +--------------------------------------------+

|    |                       подтвержденный посевом                           |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 4  |Неэффективный курс х/т, подтвержденный только клинико-рентгенологически |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 5  |Умер                   от туберкулеза/                                  |                    |    |                                            |

|    |                                                                        +--------------------+    +--------------------------------------------+

|    |                       от других причин                                 |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 6  |Прерывание курса химиотерапии                                           |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 7  |Выбыл                                                                   |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+

| 8  |Диагноз туберкулеза снят                                                |                    |    |                                            |

+----+------------------------------------------------------------------------+--------------------+    +--------------------------------------------+