2- Nº 2 GUIA DE RESUMO DE INTERNAÇÃO 24 - Caráter da Internação |___| E - Eletiva U - Urgência/Emergência 28 - Tipo Internação |___| 1-Clínica 2-Cirurgica 3-Obstétrica 4-Pediátrica 5-Psiquiátrica Dados da Saída da Internação 37-CID 10 Principal |___|___|___|___|___| 41 - Indicador de Acidente |___| 0-Acidente ou doença relacionado ao trabalho 1-Trânsito 2-Outros 38 - CID 10 (2) |___|___|___|___|___| 40 - CID 10 (4) |___|___|___|___|___| 39 - CID 10 (3) |___|___|___|___|___| 25 - Tipo Acomodação Autorizada |___|___| Dados da Internação 42 - Motivo Saída |___|___| 26 - Data/Hora da Internação |___|___| / |___|___| / |___|___| |___|___|:|___|___| 27 - Data/Hora da Saída Internação |___|___| / |___|___| / |___|___| |___|___|:|___|___| 30 - Internação Obstétrica - (selecione mais de um se necessário com "X") |___|-Em gestação |___|-Aborto |___|-Transtorno materno relacionado a gravidez |___|-Complic. Puerpério |___|-Atend. ao RN na sala de parto |___|-Complicação Neonatal |___|-Bx. Peso <2,5 Kg. |___|-Parto Cesáreo |___|-Parto Normal 34 - Qtde. Nasc. Vivos a Termo |___|___| 35 - Qtde. Nasc. Mortos |___|___| 36 - Qtde. Nasc. Vivos Prematuro |___|___| 31 - Se óbito em mulher |___| 1- Grávida 2 - até 42 dias após término gestação 3 - de 43 dias a 12 meses após término gestação 32 - Se óbito neonatal |___| - Qtde. óbito neonatal precoce |___| - Qtde. óbito neonatal tardio 43 - CID 10 Óbito |___|___|___|___|___| 44 - Nº Declaração do Óbito |___|___|___|___|___|___|___| 74 - Total Procedimentos R$ |___|___|___|___|___|___|,|___|___| 73 - Tipo Faturamento R$ |___| - Total |___| - Parcial 75 - Total Diárias R$ |___|___|___|___|___|___|,|___|___| 76 - Total Taxas e Aluguéis R$ |___|___|___|___|___|___|,|___|___| 77 - Total Materiais R$ |___|___|___|___|___|___|,|___|___| 78 - Total Medicamentos R$ |___|___|___|___|___|___|,|___|___| 79- Total Gases Medicinais R$ |___|___|___|___|___|___|,|___|___| 80 - Total Geral R$ |___|___|___|___|___|___|___|,|___|___| 3 - Nº Guia de Solicitação | | | | | | | | | | | | | | | | | | | | 1 - Registro ANS 99999-9 7 - Data de Emissão da Guia |___|___| / |___|___| / |___|___| Dados do Beneficiário 15- Código CNES 16-T.L. 17-18-19 - Logradouro - Número - Complemento 20 - Município 21 - UF 23- CEP 22 - Cód. IBGE 13 - CNPJ |___|___|___|___|___|___|___|___|___|___|___|___|___|___| Dados do Contratado Executante 14 - Nome do Contratado 11 - Nome 9 - Plano PRO-SOCIAL 10 - Validade da Carteira |___|___| / |___|___| / |___|___| 12 - Número do Cartão Nacional de Saúde |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| 29 - Regime de Internação |___| 1 - Hospitalar 2 - Hospital-dia 3 - Domiciliar 33 - Nº Decl. Nasc. Vivos Procedimentos e Exames Realizados Identificação da Equipe 5-Senha 6 - Data Validade da Senha |___|___| / |___|___| / |___|___| 4 - Data da Autorização |___|___| / |___|___| / |___|___| 8 - Número da Carteira |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| 83-Data e Assinatura do(s) Auditor(es) da Operadora |___|___|/|___|___|/|___|___| 82-Data e Assinatura do Contratado |___|___| / |___|___| / |___|___| 57-Seq.Ref 58-Gr.Part. 59-Código na Operadora/CPF 60-Nome do Profissional 61-Conselho Prof. 62-Número Conselho 63-UF 64-CPF |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ ________________________________ |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ ________________________________ |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ _______________________________ |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ ________________________________ |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ ________________________________ |___|___| |___|___| |___|___|___|___|___|___|___|___|___|___|___|___|___|___| __________________________________________________________________ ______________________________ ____________________________ _______ _________________________________ 45-Data 46-Hora Inicial 47-Hora Final 48-Tabela 49-Código do Procedimento 50-Descrição 51-Qtde. 52-Via 53-Tec. 54-% Red. / Acresc. 55-Valor Unitário - R$ 56-Valor Total - R$ 1-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 2-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 3-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 4-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| 5-|___|___|/|___|___|/|___|___| |___|__|:|___|___| a |___|___|:|___|___| |___|___| |___|___|___|___|___|___|___|___|___|___| _______________________________________________________ |___|___| |___| |___| |___|___|___|,|___|___| |___|___|___|___|___|,|___|___| |___|___|___|___|___|,|___|___| TRIBUNAL REGIONAL FEDERAL DA 1ª REGIÃO PROGRAMA DE ASSISTÊNCIA AOS MAGISTRADOS E SERVIDORES PCTT: 26.107.14-B
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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
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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
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53-
Tec.
54
-% R
ed. /
Acr
esc.
55
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or U
nitá
rio -
R$
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lor T
otal
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: 26.
107.
14-B
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