18
2- Nº Guia no Prestador
12345678901234567890
GUIA DE RESUMO DE INTERNAÇÃO
Dados da Internação
3 - Número da Guia de Solicitação de Internação
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1 - Registro ANS
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Dados do Beneficiário
13 - Código na Operadora
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Dados do Contratado Executante
14 - Nome do Contratado
10- Nome
9 - Validade da Carteira
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11 - Cartão Nacional de Saúde
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Procedimentos e Exames Realizados
Identificação da Equipe
5 - Senha
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6 - Data de Validade da Senha
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4 - Data da Autorização
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8 - Número da Carteira
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64-Assinatura do(s) Auditor(es) da Operadora
62- Data da assinatura do contratado
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46-Seq.Ref 47-Grau Part. 48-Código na Operadora/CPF 49-Nome do Profissional
50-Conselho Profissional 51-Número no Conselho 52-UF 53-Código CBO
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
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|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
|___|___|___|___|___|___|
|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| _________________________________________________________________________________________________
|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|
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Logo da Empresa
34-Data 35-Hora Inicial 36-Hora Final 37-Tabela 38-Código do Procedimento 39-Descrição
40-Qtde. 41-Via 42-Téc 43-Fator Red/Acresc 44-Valor Unitário (R$) 45-Valor Total (R$)
01-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
02-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
03-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
04-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
05-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
06-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
07-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
08-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
09-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
10-|___|___|/|___|___|/|___|___|___|___| |___|__|:|___|___|
a
|___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| ______________________________________________________ |___|___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___| |___|___|___|___|___|___|,|___|___|
15 - Código CNES
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16 - Caráter do Atendimento
|__|
22- Tipo de Internação
|__|
18- Data do Início do Faturamento
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20- Data do Fim do Faturamento
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23- Regime de Internação
|__|
17 - Tipo de Faturamento
|__|
19- Hora do Início do Faturamento
|___|___|:|___|___|
21- Hora do Fim do Faturamento
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63- Assinatura do contratado
30-Número da declaração de nascido vivo
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12-Atendimento a RN
|___|
59 - Total de Medicamentos (R$)
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60 - Total de Gases Medicinais (R$)
|___|___|___|___|___|___|___|___|,|___|___|
61 - Total Geral (R$)
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58 - Total de OPME (R$)
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57 - Total de Materiais (R$)
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56 - Total de Taxase Aluguéis (R$)
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55 - Total de Diárias (R$)
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54 - Total de Procedimentos (R$)
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24 - CID 10 Principal
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28 -
Indicação de Acidente
(acidente ou doença relacionada)
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27 - CID 10 (4)
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26 - CID 10 (3)
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29 - Motivo de Encerramento da Internação
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31 - CID 10 Óbito
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33 -Indicador D.O. de RN
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32 - Numero da declaração de óbito
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65
-
Observações / Justificativa
7- Número da Guia Atribuído pela Operadora
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25 - CID 10 (2)
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