INFORME MEDICO PROTOCOLIZADO

COMPIN

Subsecretara de Salud Pblica

Ministerio de Salud

INFORME MEDICO

(Se solicita escribir con letra imprenta, legible y llenar todos los campos)1. Nombre trabajador(a): _____________________________________________________

RUN :_______________________

2. DIAGNOSTICO(S)

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Breve historia con fundamentos clnicos y/o de laboratorio y/o de imagenologa en que se basa el diagnstico:

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Evolucin, tratamientos mdicos y/o quirrgicos efectuados (fecha de operacin, si procede), resultados obtenidos:

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Indicar pronstico de la enfermedad desde el punto de vista laboral y fecha probable de alta.

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3. Conclusin u otros comentarios

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En caso de irrecuperabilidad:

Debe iniciar trmite de invalidez a contar de:____________________________

4. Datos del mdico tratante:

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Direccin de la consulta o Institucin a la cual pertenece._____________________________________________________________________________Nombre, firma y timbre de mdico tratante.

(Favor no poner el timbre sobre el nombre)Telfono:_____________________Fecha del informe : _____/_____/____

Correo electrnico: __________________________________________