615 lines
14 KiB
Plaintext
615 lines
14 KiB
Plaintext
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"DBFieldName":"病历号"
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"DBFieldName":"医护人员签字"
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"Type":"Binary",
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"DBFieldName":"患者签字"
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},
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"Name":"Agree",
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"DBFieldName":"是否同意"
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}
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"Text":"性别："
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"Text":"年龄："
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"Text":"医护人员签名"
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"Text":"签名时间"
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"Width":1.19063,
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"DataField":"Gender"
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"Font":{
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"Size":142500,
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},
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"TextAlign":"MiddleCenter",
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"Text":"急性缺血性卒中rt-PA静脉溶栓知情同意书"
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"Text":"病历号："
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"DataField":"Number"
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"Font":{
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"Name":"宋体",
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"Size":120000,
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"Weight":400,
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"Charset":134
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},
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"Text":"尊敬的患者家属或患者的法定监护人、授权委托人:"
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},
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{
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"Type":"StaticBox",
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"Name":"StaticBox13",
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"Left":0.396875,
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"Size":120000,
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"Weight":400,
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"Charset":134
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},
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"Text":"您好！您的家人"
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},
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{
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"Type":"FieldBox",
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"Name":"FieldBox12",
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"Left":3.41313,
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"Top":3.01625,
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"Styles":"[DrawBottom]"
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"DataField":"Name"
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"Left":5.21229,
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"Size":120000,
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"Weight":400,
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"Charset":134
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},
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"Text":"现在我院神内科住院治疗。目前诊断为急性脑梗死。"
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},
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"Type":"StaticBox",
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"Name":"StaticBox16",
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"Left":0.396875,
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"Top":3.70417,
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},
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"WordWrap":true,
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"Text":"患者此次脑梗死(从开始出现任何症状计算)在4.5小时以内,符合中华医学会神经病学分会发布的《中国脑血管病防治指南》中溶栓治疗适应证(年龄18~80岁;发病4.5h以内(rtPA)或6h内(尿激酶);脑功能损害的体征持续存在超过1h,且比较严重;脑CT 已排除颅内出血,且无早期大面积脑梗死影像学改变;患者或家属签署知情同意书,无溶栓禁忌症(①既往史有颅内出血,包括可疑SAH;近3个月有脑梗死或心肌梗死史,但陈旧小腔隙未遗留神经功能体征者除外;近3个月有头颅外伤史;近3周内有胃肠或泌尿系统出血;近2周内进行过大的外科手术;近1周内有不可压迫部位的动脉穿刺;②近3个月内有脑梗死或心肌梗死史,但不包括未遗留神经功能体征的陈旧小腔隙梗死。③严重心、肾、肝功能不全或严重糖尿病者。④体检发现有活动性出血或外伤(如骨折)的证据;⑤己口服抗凝药,且INR＞1.5;48小时内接受过肝素治疗( aPTT超出正常范围);⑥血小板计数<100,000/mm3,血糖＜2.7mmol/L(5Omg);⑦血压:收缩压>18Ommhg,或舒张压>100mmhg;⑧妊娠⑨不合作)。为了恢复或改善缺血脑组织的灌注,防止梗死扩大,缩小脑组织缺血范围,以抢救生命,改善预后,决定行静脉溶栓治疗,但溶栓有以下并发症:\r\n1.出血 包括皮肤粘膜出血、肉眼及显微镜下血尿或小量咳血、呕血等(穿刺或注射部位少量淤斑不作为并发症);大量咳血或消化道大出血、腹膜后出血等引起失血性低血压或休克;危及生命的出血:颅内、特网膜下腔、纵隔内或心包出血等。\r\n2.一过性低血压、少数过敏反应造成发热、药疹、甚至过敏性休克、死亡。\r\n3.溶栓失败\r\n4.需要说明的其他情况"
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"Left":0.396875,
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"WordWrap":true,
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"Text":"患者家属或患者的法定监护人、授权委托人意见:\r\n●我的医生已经告知我将要进行的溶栓治疗及治疗后可能发生的并发症和风险、可\r\n能存在的其它治疗方法并且解答了我关于此次治疗的相关问题\r\n●以上情况严重时可能危及生命。一旦发生,我的医生都会尽力抢救\r\n●请您仔细阅读,慎重考虑。"
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"Type":"StaticBox",
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"Name":"StaticBox18",
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"Left":2.98979,
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"WordWrap":true,
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"Text":"溶栓治疗并且保证不欠费,对所发生的一切后果我们自行承担责任。"
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},
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{
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"Type":"StaticBox",
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"Left":0.396875,
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"WordWrap":true,
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"Text":"●我"
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},
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"Left":1.40229,
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"WordWrap":true,
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"Text":"医护人员进行上述溶栓治疗"
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},
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{
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"Type":"StaticBox",
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"WordWrap":true,
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"Text":"●我"
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},
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"Name":"FieldBox15",
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"Left":1.40229,
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"DataField":"Agree"
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"Name":"StaticBox22",
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"Left":0.396875,
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"Top":16.1925,
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},
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"Text":"如果患者无法签署知情同意书,请其授权的亲属在此签名:"
|
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},
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{
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"Type":"StaticBox",
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"WordWrap":true,
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"Text":"患者/患者授权亲属签名"
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},
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{
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"Type":"PictureBox",
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"Name":"PictureBox1",
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"Size":120000,
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},
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"Text":"与患者关系"
|
||
},
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{
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"Type":"FieldBox",
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"Name":"FieldBox16",
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"Left":7.69938,
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