Professional Documents
Culture Documents
F4b
REPORT NO.
(To be filled-up by Data Encoder)
NAME OF FACILITY
PROVINCE
MUNICIPALITY
BARANGAY
DATE SUBMITTED
SUBMITTED TO
NAME OF PATIENT
DISPOSITION
FINAL DIAGNOSIS
(ICD 10 CODE)
REMARK(S)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
NO. OF SLIDES EXAMINED :
NO. OF RDT DONE :
NO. OF POSITIVES:
NO. OF CLINICAL DIAGNOSIS:
PREPARED BY:
DESIGNATION:
RECEIVED IN THE RHU BY :
POSITION:
DATE RECEIVED:
RECEIVED IN THE PHO BY: (IF APPLICABLE)
POSITION:
DATE REVIEWED: