NSD-ER-001

St. Jude General Hospital & Medical Center

Dimasalang cor. Don Quijote Sts., Sampaloc, Manila
Tel. Nos. 731-2761 to 65/740-4163/740-4160/740-4159

EMERGENCY ROOM NOTES

Hospital Number: ______________

Name: ________________________________________________________________________Type: New ( ) Old ( )

Last Name First Name Middle Name

Address: ________________________________________________ Contact No. _____________ Religion: __________

Age: ________ Sex: ________ Civil Status: _________ Weight: __________ Date of Birth: _____________________
Vital Signs: BP: ________ HR: ________ RR: _________ Temp.: _________ Date: ______________ Time : ________

Chief Complaint: ___________________________________________________________________________________

__________________________________________________________________________________
HISTORY (Subjective) DOCTOR’S ORDER/PLAN OF MANAGEMENT
Pertinent Past Medical Hx: (include birth/maternal hx if applicable) OPD

Pertinent Family Hx.

Pertinent Physical Assessment (Objective) ADMISSION

MSE/NEURO
ER NURSE REMARKS/NOTES
Time In:
NUTRITIONAL STATUS:

HEAD/NECK:

CHEST:

ABDOMEN:

G/U:

CLINICAL IMPRESSION (Assessment)

Time Out
 NSD-ER-001

AUTHORIZATION FOR EMERGENCY TREATMENT

The undersigned has been informed of the emergency treatment considered necessary for the patient whose name appears on
the reverse hereof and that the treatment and procedure will be performed by the physician, members of the house, staff and
employees of the hospital. Authorization is hereby granted for such treatment and procedures.

The undersigned understands that a personal physician is selected by or on behalf of the patient within 24 hours of
hospitalization and further treatments are required, or immediately if complication arises.

The undersigned has read the above authorization and understand the same and certifies that no guarantee or assurance has
been made as to the result that maybe obtained.

Date: ________ Time: ________AM/PM Signed___________________________________

Witness:
Nurse on Duty: ____________________
Signature over Printed Name

Doctor: ___________________
Signature over Printed Name

Authorized Person: _________________________

Signature Over Printed Name
Relationship to Patient: __________________

REFUSED ADMISSION/ TREATMENT

The undersigned refuses patient’s admission even after the through explanation by the medical staff on the need for such
procedure and treatment. The undersigned understands and is willing to take full responsibility for whatever may happen as a result of
his/ her refusal to undergo the treatment, procedure and/ or admission. The undersigned agrees to free the hospital and its staff from
any liability for the result from his/ her refusal to undergo the necessary treatment and procedures explained prior to my refusal.

Date: ____________Time: ________AM/PM Signed_____________________________

Witness:
Nurse On Duty: _____________________
Signature Over Printed Name

Doctor: ___________________
Signature Over Printed Name

Authorized Person: ______________________

Signature over Printed Name
Relationship to Patient: _________________