URGELLO STREET, CEBU CITY, PHILIPPINES 6000

+63 32 4188410 to 14
EMERGENCY ROOM RECORD

PATIENT DATA:
First name: Feliciano Middle Name: Aranas Last Name: Bugtay
Age: 80 Sex: M Status: Married Religion: Roman Catholic Hospital Unit No.
Address: Guadalajara Cebu City
Student No. Occupation: Birth Date: September 18, 1939
Birth Place: Cebu City Citizenship: Filipino Spouse:
Name of Mother: Deceased Name of Father: Deceased

PATIENT’S ACCOMPANIES:
Full Name of Accompanying: Gina Bugtay Relation: wife
Address: Guadalajara Cebu City
Contact Details:

PATIENT’S PROBLEM:
Complaints(s) Cogh and Dyspnea
Vital Signs: BP: 130/90 HR: 121 RR: 36 Temp: 36.7 O2 Sat: 75% Weight:
If Medico-Legal: NOI: DOI: TOI:
POI:
Pt./Family’s Choice COC/HC:
Date: 8/11/20 Physician: Dr. Fernandez
Department: IM Time Arrived:
Time Seen: 3:53 PM Time out:
Brief Clinical History, Physical Examination, laboratories, Impression, Management:
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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DOCTOR’S ORDER SHEET

PATIENT’S NAME :___________________________________ AGE:_________ ROOM:_________CASE NUMBER:______________

DATE DOCTOR’S ORDERS PROGESS

NOTES
8/11/20  Please admit to COVID unit under the service of Dr. Quijano, co-managed with
4:00PM Dr. Fernandez (ID on deck)
 Secure consent to care
 Problem: Dyspnea
 Condition: Guarded
 Activity: CBR w/o TP provide commode
 Diet: NPO Temporarily
 Venoclysis: c̅ PNSS 1L at 10 cc/hr
 Diagnostics:
 CBC, UA
 Na, K, Crea, BUN, ALT BUA
 LDH, CRP, Pro-calcitonin,
 Ferritin, D-Dimer, Blood Typing
 Protime, clotting/ bleeding time
 Blood c/s x 2 sites
 FBS, Lipid Panel
 Medications:
1. Ceftriaxone (Trizeto) 2 gm IV Drip q 24H ANST
2. Azithromycin (Zenith) 500 mg/cap, 1 cap OD PO
3. Dexamethasone 6 mg IVTT OD, 1st dose now
4. Colchicine 0.5 g/tab, 1 tab BID
5. Melatonin 3 mg/tab, 2 tabs BID PO
6. Lopinavir/Ritonavis 200 mg/50g/tab, 2 tabs BID
7. Famotidine 20 mg/tab, 2 tabs OD PO may use Ranitidine 150 mg/tab, 1 tab BID
If Famotidine is not available
8. Tocilizumab Drip: 400 mg in 100 cc PNSS to run for 2 hours, provide consult
Pre-medicate with
1. Paracetamol 300 mg IVTT 30 mins prior
2. Diphenhydramine 50 mg IVTT 30 mins prior
9. Vitamin C + Zinctab, 1 tab OD
 Dr. Quijano and Dr. Fernandez informed of this admission with acknowledgement
 V/S q hourly to include O₂ Sat

___________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS
NOTES
 I/O q 4 hours in absolute figure
 Please inform Dr. Adlawan once patient is at the ward
 Refer for unusualities

8/11/20  Dr. Quijano updated

4:50 PM  Please give Furosemide 40 mg IVTT now
 Repeat ABG after 6 hours

8/11/20  Please insert FBC

7:58 PM
8/11/20  I & O q hourly, refer I & O q 4 to IM ROD
10:02 PM  O2 @ 15L via non rebreather mask
 Limit OFI to 800 cc/day

8/11/20  Start ISMN 60 mg tab ½ OD PO

 May have soft diet c̅ aspiration precaution
 Moderate High back rest at all times
 Repeat ECG 12 L now
 Trimetazidine (Vastarel MR) 35 mg/tab, 1 tab po BID
 Attach Pro BNP results once in
 UTZ WAB to include prostate
 Facilitate 2D ECHO
 Give Furosemide 40 mg slow IVTT now then OD with BP precautions

8/12/20  Rounds with Dr. Fernandez

9:00 AM  Case and Plans discussed
 Start Enoxoparin (Clexane) 0.4 SC OD give one dose now
 Lactulose 30 cc OD HS, hold for BM >2x/day
 Inform MROD if still w/o stock of Lopi/Rito by noontime

8/12/20  SO requested to transfer to VSMMC due to financial constraints; AP updated, no objection

4:45 PM For transfer
 Please Facilitate
 Awaiting Dr. Fernandez response

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

DOCTOR’S ORDER SHEET

DATE DOCTOR’S ORDERS PROGESS
NOTES
8/12/20  Dr. Fernandez no objection to transfer
4: 50 PM  Please Facilitate

8/13/20  AP updated
 Start Atorvastatin 40 mg/tab 1 tab OD PO give 1 dose now

8/13/20  Defer FBC insertion

7:00 AM  Decrease O₂ inhalation to 10 LPM NRM
 APS updated
 Please Facilitate transfer
 FF up Pro BNP, D-Dimer, and Ferritin results

8/13/20  Please Facilitate transfer after hospital letter pro-BND

 Repeat creatinine now

8/13/20  May transfer to VSMMC

11:53PM  Dr. Quijano updated
 Please Facilitate

_________________________ _____________________________
ATTENDING PHYSICIAN RESIDENT IN CHARGE

DOH-SWUMed-NSD-F-005 Rev
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

MONITORING SHEET
Name: _________________________________ Age: _______________________________________ Attending Physician:
________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No.
______________________

Date Time BP PR RR Temp. Mental Status Remarks Signature

O₂ Sat
8/11/20 2 130/90 121 36 36.7 75%
3 120/80 118 40 36.9 81%
4 120/80 110 38 36.4 82%
5 110/70 101 40 36.8 90%
6 110/70 105 43 36.5 91%
7 100/60 109 26 35.8 93%
8 100/60 102 29 35.4 98%
9 130/80 97 35 36.1 99%
10 110/80 102 37 36.4 93%
11 130/80 102 32 36.0 93%
12 130/60 101 34 36.2 92%
1 130/70 103 34 36.4 95%
2 130/60 105 36 36.4 93%
3 130/80 108 32 36.2 92%
4 140/70 110 36 36.5 93%
5 140/70 94 30 36.1 95%
6 140/80 94 30 36.1 95%
8/12/20 7 130/80 89 36 36.0 98%
8 120/80 91 332 36.3 97%
9 140/80 91 32 36.1 99%
10 140/80 88 34 36.0 98%
11 130/80 92 32 36.0 97%
12 130/70 91 35 35.8 95%
1 130/70 88 34 36.1 97%
2 130/80 83 30 35.9 98%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

MONITORING SHEET
Name: _________________________________ Age: _______________________________________ Attending Physician:
________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No.
______________________

Date Time BP PR RR Temp. Mental Status Remarks Signature

O₂ Sat
8/12/20 3 110/80 85 31 36.1 96%
4 110/70 89 32 35.7 99%
5 100/60 85 30 36.2 95%
6 110/60 86 29 36.1 99%
7 110/60 82 28 36.1 99%
8 110/70 83 29 36.5 98%
9 100/60 85 27 36.7 98%
10 100/60 84 28 36.5 99%
11 110/70 73 24 36.6 96%
12 110/70 82 23 36.5 97%
1 110/70 85 23 36.5 95%
2 110/70 63 22 36.5 95%
3 110/70 67 23 36.4 96%
4 110/70 72 22 36.5 95%
5 110/70 75 22 36.5 95%
6 110/70 69 22 36.4 95%
8/13/20 7 120/80 66 19 36.0 99%
8 120/80 67 21 36.1 99%
9 120/70 80 20 36.0 99%
10 110/80 80 21 36.2 99%
11 100/70 80 22 36.4 98%
12 120/80 88 20 36.3 98%
1 100/80 63 21 36.4 99%
2 100/80 69 21 36.0 97%
97%

DOH-SWUMed-NSD-F-073 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

FLUID INTAKE & OUTPUT MONITORING RECORD

Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________

DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTERAL ORAL OTHERS URINE DRAINAGE OTHERS
8/11/20 2-6 20 0 - 20 0 0
6-10 40 NPO - 40 500 500
10-6 80 NPO - 80 200 200
TOTAL: 140 TOTAL: 700

6-2 = 6-2 =
2-10 = 2-10 =
10-6_ __=______________ 10-6 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________

DOH-SWUMed-NSD-F-012 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

FLUID INTAKE & OUTPUT MONITORING RECORD

Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________

DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTERAL ORAL OTHERS URINE DRAINAGE OTHERS
8/12/20 6-7 10 NPO 10 - -
7-8 10 NPO 10 70 70
8-9 10 NPO 10 - -
9-10 10 150 160 100 100
10-11 10 100 110 - -
11-12 10 100 110 120 120
12-1 10 100 110 80 80
1-2 10 - 10 - -
TOTAL: 530 370
8/12/20 3 10 - 10 260 260
4 10 105 115 160 160
5 10 - 10 - -
6 10 - 10 - -
7 10 210 210 - -
8 10 200 200 80 80
9 10 - - - -
10 10 - - - -
TOTAL: 595 TOATL: 440
10-11 10 50 50
11-12 10 50 50
12-1 10 0 0
1-2 10 0 0
2-3 10 0 0
3-4 10 50 50
4-5 10 0 0
5-6 10 0 0
TOTAL: 150

6-2 = 6-2 =
2-10 = 2-10 =
10-6_ __=______________ 10-6 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________

DOH-SWUMed-NSD-F-012 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

FLUID INTAKE & OUTPUT MONITORING RECORD

Name: _________________________________ Age: _______________________________________ Attending Physician: ____________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ___________________

DATE TIME INTAKE TOTAL OUTPUT TOTAL

PARENTERAL ORAL OTHERS URINE DRAINAGE OTHERS
8/13/20 6-10 40 NPO 40 300 300
10-2 40 560 600 200 200
TOTAL: 640 TOTAL: 500

6-2 = 6-2 =
2-10 = 2-10 =
10-6_ __=______________ 10-6 =_________________
24H Total = 24H Total =
Fluid Balance = _____________________________

DOH-SWUMed-NSD-F-012 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

MEDICATION ADMINISTRATION RECORD (MAR)

Name: _________________________________ Age: _______________________________________ Attending Physician:
________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No.
______________________

MEDICATION: Dosage, Date: Date: Date: Date:

Route, Frequency Time NOD NOD Time NOD NOD Time NOD NOD Time NOD NOD
1 2 1 2 1 2 1 2

Signature Specimens:
(Provide signature beside full name in print)
DOH-SWUMed-NSD-F-013 Rev.2
 URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

NURSES NOTES
Name: _________________________________ Age: _______________________________________ Attending Physician: ________________________________________
Sex: ______________________Civil Status: ___________________________ Room No. /Bed No. ______________________ Hospital No. ______________________
Date Shift Focus Time D = Date / A = Action / R = Response

DOH-SWUMed-NSD-F-004 Rev. 2
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14

Laboratory Results
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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URGELLO STREET, CEBU CITY, PHILIPPINES 6000
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URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14
URGELLO STREET, CEBU CITY, PHILIPPINES 6000
+63 32 4188410 to 14