Patient’s Name ( Last Name, First, Middle ) : Age : Sex : Health Record No.

Attending Physician : Date of Birth : ( mm/dd/year ) : Room / Bed no :

CLINICAL ABSTRACT

DATE OF ADMISSION ( mm/dd/year ) : __________________ TIME : ______________

DATE OF DISCHARGE ( mm/dd/year ) : __________________ TIME : ______________

CHIEF COMPLAINT : ______________________________________________________________________________

INITIAL DIAGNOSIS : ______________________________________________________________________________
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FINAL DIAGNOSIS : _______________________________________________________________________________

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HISTORY OF ILLNESS : _____________________________________________________________________________

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PERTINENT PHYSICAL EXAMINATION : ______________________________________________________________

GENERAL SURVEY: ________________________________________________________________________________
VITAL SIGNS : _________________ BP : ___________________PR : ________________________T : _____________
HEENT : _______________________________________________________________________________________
CHEST : ________________________________________________________________________________________
HEART : ________________________________________________________________________________________
ABDOMEN : _____________________________________________________________________________________
PELVIC EXAMINATION : ____________________________________________________________________________
EXTREMITIES : ___________________________________________________________________________________
NEUROLOGIC : ___________________________________________________________________________________

OPERATION / PROCEDURE : ________________________________________________________________________

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COURSE IN THE WARD :

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CONDITION OF PATIENT UPON DISCHARGE : __________________________________________________________

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not valid Signature over printed name of
without dry seal Attending Physician
License No. : __________________
COURSE IN THE WARD : ___________________________________________________________________________
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PDMC – MRD – C/A – RV002