model notice of critical illness 1
notice of serious illness (danger)
relative:
hospitalized in _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Nevertheless, we will still take effective measures < P > to give active treatment. At the same time, I would like to inform you that the hospital will
use and adopt the necessary instruments, equipment and treatment sections for emergency treatment according to the needs of the rescue work if you can't get your consent in advance in order to rescue patients.
Please understand, cooperate and support them. If you have other requirements, please receive them at? Notice of critical illness (danger)?
tell our department immediately.
department of Chaoyang branch of yingshang union medical college hospital: internal medicine
physician's signature: date: year, month, day and hour
signature of relatives/guardians: date: year, month, day and hour
relationship between relatives and patients:
ID number:
sample of critical illness notice 2
patient's name, gender and age medical record number
. Your family is now hospitalized in our hospital. At present, the diagnosis is that although the medical staff actively treat the patient, the patient's condition is critical and may deteriorate further, and one or more of the following life-threatening complications may occur at any time: 1. Pulmonary encephalopathy, severe arrhythmia, heart failure, myocardial infarction and hypertensive crisis; 2. Upper gastrointestinal bleeding leads to hemorrhagic shock, cerebral hemorrhage, cerebral infarction and cerebral hernia; 3. Toxic shock, anaphylactic shock and cardiogenic shock caused by infection; 4. Diffuse intravascular coagulation (DIC); 5. Multiple organ failure; 6. Diabetic ketosis, acidosis, hypoglycemia coma and hyperosmotic coma; 7. Others. Once the above situation happens, it will seriously threaten the life of the patient, and the medical staff will do their best to rescue him, including tracheotomy, ventilator-assisted breathing, electric defibrillation, heart massage, installation of temporary pacemakers and other measures. According to the laws of our country, in order to rescue patients, doctors can take rescue measures according to the needs of rescue work without your consent, and use the necessary instruments, equipment and treatment methods for emergency treatment, and then fulfill the obligation of informing. Please understand and actively cooperate with the hospital for rescue treatment. If you have other questions and requirements, please take the initiative to consult a doctor after receiving this notice. Please leave your accurate contact information so that the medical staff can communicate with you at any time. In addition, limited by the current medical science and technology conditions, although the medical staff in our hospital have tried their best to treat patients, there is still the possibility that patients will die unfortunately due to diseases. Please ask the patient's family to understand. Physician's statement: I have informed the patient's family members or the patient's legal guardian and authorized client in detail about the patient's current critical condition, possible risks and consequences, and the treatment measures taken by medical staff when the patient is in critical condition. Comments of the patient's family or the patient's legal guardian and authorized client on the signature date of the doctor: The medical staff have informed me in detail about the patient's current critical condition, possible risks and consequences, and the treatment measures taken by medical staff when the patient is in critical condition. I understand that the patient is in critical condition and agree with the medical staff to carry out (agree to plan? Don't agree to row? ): □ Tracheotomy □ Ventilator-assisted breathing □ Electrical defibrillation □ Temporary pacemaker □ Cardiac compression □ Other invasive treatment measures □ Drug treatment We will be responsible for all the consequences of refusing treatment.
Signature of authorized client or legal guardian of patient and signature of patient relationship
Date, month, day, month, and year
Model piece of critical notice 3
Relatives:
The patient (Mr. and Ms.) is being treated in our central department for emergency treatment. After examination, it is preliminarily diagnosed that although he has been actively treated, his condition is critical and may endanger his life at any time, and a notice of serious illness and critical illness is hereby issued. Nevertheless, we will make every effort to actively treat patients; At the same time, I would like to inform you that in order to rescue patients, our center will use and adopt the necessary instruments, equipment and treatment methods (except in special circumstances) according to the needs of rescue work with the consent of family members as far as possible, so please give reasonable cooperation and support; If you and other family members have other requirements (such as transfer, etc.), please receive them at? Critical notice? Tell our center immediately after, and our center will try its best to help.
comments from family members:
signature of relatives/guardians: relationship: date: year, month, day
signature of informing doctors: date: year, month, day, note: (This notice is in duplicate, The hospital and the patient's relatives each hold one copy)
XXX Hospital
Year Month Day
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