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2- N
º
2
GU
IA D
E R
ESU
MO
DE
INTE
RN
AÇ
ÃO
24 -
Car
áter
da
Inte
rnaç
ão
|___
| E
- E
letiv
a U
- U
rgên
cia/
Em
ergê
ncia
28 -
Tipo
Inte
rnaç
ão
|___
| 1-C
línic
a 2
-Ciru
rgic
a 3
-Obs
tétri
ca
4-P
ediá
trica
5-
Psi
quiá
trica
Dad
os d
a Sa
ída
da In
tern
ação
37-C
ID 1
0 Pr
inci
pal
|___
|___
|___
|___
|___
|
41 -
Indi
cado
r de
Aci
dent
e
|___
| 0
-Aci
dent
e ou
doe
nça
rela
cion
ado
ao tr
abal
ho
1-T
râns
ito
2-O
utro
s
38 -
CID
10
(2)
|___
|___
|___
|___
|___
|
40 -
CID
10
(4)
|___
|___
|___
|___
|___
|
39 -
CID
10
(3)
|___
|___
|___
|___
|___
|
25 -
Tipo
Aco
mod
ação
Aut
oriz
ada
|___
|___
|
Dad
os d
a In
tern
ação
42 -
Mot
ivo
Saíd
a
|_
__|_
__|
26 -
Dat
a/H
ora
da In
tern
ação
|___
|___
| / |_
__|_
__| /
|___
|___
| |_
__|_
__|:|
___|
___|
27 -
Dat
a/H
ora
da S
aída
Inte
rnaç
ão
|___
|___
| / |_
__|_
__| /
|___
|___
| |_
__|_
__|:|
___|
___|
30 -
Inte
rnaç
ão O
bsté
tric
a - (
sele
cion
e m
ais
de u
m s
e ne
cess
ário
com
"X"
)
|___
|-Em
ges
taçã
o |_
__|-A
borto
|__
_|-T
rans
torn
o m
ater
no re
laci
onad
o a
grav
idez
|_
__|-C
ompl
ic. P
uerp
ério
|_
__|-A
tend
. ao
RN
na
sala
de
parto
|_
__|-C
ompl
icaç
ão N
eona
tal
|___
|-Bx.
Pes
o <2
,5 K
g.
|___
|-Par
to C
esár
eo
|_
__|-P
arto
Nor
mal
34 -
Qtd
e. N
asc.
Viv
os a
Ter
mo
|_
__|_
__|
35 -
Qtd
e. N
asc.
Mor
tos
|
___|
___|
36 -
Qtd
e. N
asc.
Viv
os P
rem
atur
o
|___
|___
|
31 -
Se ó
bito
em
mul
her
|___
| 1-
Grá
vida
2
- at
é 42
dia
s ap
ós té
rmin
o ge
staç
ão
3 -
de 4
3 di
as a
12
mes
es a
pós
térm
ino
gest
ação
32 -
Se ó
bito
neo
nata
l
|_
__| -
Qtd
e. ó
bito
neo
nata
l pre
coce
|_
__| -
Qtd
e. ó
bito
neo
nata
l tar
dio
43 -
CID
10
Óbi
to
|___
|___
|___
|___
|___
|
44 -
Nº D
ecla
raçã
o do
Óbi
to
|_
__|_
__|_
__|_
__|_
__|_
__|_
__|
74 -
Tota
l Pro
cedi
men
tos
R$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
73 -
Tipo
Fat
uram
ento
R$
|___
| - T
otal
|_
__| -
Par
cial
75 -
Tota
l Diá
rias
R$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
76 -
Tota
l Tax
as e
Alu
guéi
s R
$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
77 -
Tota
l Mat
eria
is R
$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
78 -
Tota
l Med
icam
ento
s R
$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
79- T
otal
Gas
es M
edic
inai
s R
$
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
80 -
Tota
l Ger
al R
$
|___
|___
|___
|___
|___
|___
|___
|,|__
_|__
_|
3 - N
º Gui
a de
Sol
icita
ção
||
||
||
||
||
||
||
||
||
||
1 - R
egis
tro
AN
S
9
9999
-97
- Dat
a de
Em
issã
o da
Gui
a
|_
__|_
__| /
|___
|___
| / |_
__|_
__|
Dad
os d
o B
enef
iciá
rio
15- C
ódig
o C
NES
16-T
.L.
17-1
8-19
- Lo
grad
ouro
- N
úmer
o - C
ompl
emen
to20
- M
unic
ípio
21 -
UF
23- C
EP22
- C
ód. I
BG
E
13 -
CN
PJ
|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|__
_|
Dad
os d
o C
ontr
atad
o Ex
ecut
ante
14 -
Nom
e do
Con
trat
ado
11 -
Nom
e
9 - P
lano
P
RO
-SO
CIA
L10
- Va
lidad
e da
Car
teira
|_
__|_
__| /
|___
|___
| / |_
__|_
__|
12 -
Núm
ero
do C
artã
o N
acio
nal d
e Sa
úde
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|
29 -
Reg
ime
de In
tern
ação
|___
| 1
- Hos
pita
lar
2 - H
ospi
tal-d
ia
3 - D
omic
iliar
33 -
Nº D
ecl.
Nas
c. V
ivos
Proc
edim
ento
s e
Exam
es R
ealiz
ados
Iden
tific
ação
da
Equi
pe
5-Se
nha
6 - D
ata
Valid
ade
da S
enha
|_
__|_
__| /
|___
|___
| / |_
__|_
__|
4 - D
ata
da A
utor
izaç
ão
|_
__|_
__| /
|___
|___
| / |_
__|_
__|
8 - N
úmer
o da
Car
teira
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|___
|
83-
Dat
a e
Ass
inat
ura
do(s
) Aud
itor(
es) d
a O
pera
dora
|__
_|__
_|/|_
__|_
__|/|
___|
___|
82-D
ata
e A
ssin
atur
a do
Con
trat
ado
|__
_|__
_| /
|___
|___
| / |_
__|_
__|
57-S
eq.R
ef
58-G
r.Par
t.
5
9-C
ódig
o na
Ope
rado
ra/C
PF
60-
Nom
e do
Pro
fissi
onal
61-C
onse
lho
Prof
.
62-
Núm
ero
Con
selh
o
63
-UF
64-C
PF
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45-
Dat
a
46-
Hor
a In
icia
l
47-
Hor
a Fi
nal
48-T
abel
a
49-C
ódig
o do
Pro
cedi
men
to
5
0-D
escr
ição
51-
Qtd
e.
52
-Via
53-
Tec.
54
-% R
ed. /
Acr
esc.
55
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or U
nitá
rio -
R$
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6-Va
lor T
otal
- R
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TRIB
UN
AL
REG
ION
AL
FED
ERA
L D
A 1
ª REG
IÃO
PR
OG
RA
MA
DE
AS
SIS
TÊN
CIA
AO
S M
AG
ISTR
AD
OS
E S
ER
VID
OR
ES
PCTT
: 26.
107.
14-B