CLINICAL FACE SHEET

______________________

Case Number

Name: Age: Date of Birth: Place of Birth: Category of

Patient:

Home Address: Sex: Civil Status: Religion: Nationality:

Next of Kin: Relationship: Address: Contact No.:

Date Admitted: Time: Date of Discharge: Time: No. of Hospital Days:

________ A.M. ________ A.M.

________ P.M. ________ P.M.

Ward: Attending Physician: Admitting Nurse:

ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

 [ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD

[ ] unimproved [ ] not autopsied [ ] home against for follow up advice

COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

___________________________________________ __________________________________________

Signature over Printed Name Signature over Printed Name

of Attending Physician (Record Officer)

VITAL SIGNS MONITORING SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:_________

Date Time Shift BP PR RR Temp REMARKS

 INTAKE & OUTPUT MONITORING SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:_________

INTAKE OUTPUT
Date Time Shift
IVF Oral/NGT TOTAL Urine Drain TOTAL
PATIENT’S DATA
1. Name of Patient 2. PIN

Last Name First Name Middle Name 3. Age

5. Chief Complaint

4. Sex

Male Female

6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM

month day year hour min

10. a. Date Discharged: 10. b. Time Discharged:

l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM

month day year hour min

REASON FOR ADMISSION

1. History of Present Illness:

2. a. Pertinent Past Medical History:

2. b. OB/GYN History:

G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA

3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

• Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

• Abdominal cramp/pain  Dizziness  Hematuria  Seizures

• Anorexia  Dysphagia  Hemoptysis  Skin rashes

• Bleeding gums
 • Body weakness  Dyspnea  Irritability  Stool, bloody/black tarry/mucoid

• Blurring of vision  Dysuria  Jaundice  Sweating

• Chest pain/discomfort  Epistaxis  Lower extremity edema  Urgency

• Constipation  Fever  Myalgia  Vomiting

• Cough  Frequent urination  Orthopnea  Weight loss

 Headache  Pain, ____________ (site)  Others: _________________________

4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason _____________________________________________________

Name of Originating HCI ____________________________________________

5. Physical Examination on Admission (Pertinent Findings per System)

General Survey:  Awake and alert  Altered sensorium,_______________________

Vital Signs: BP:_______________ HR:_______________ RR:_______________ Temp.;_______________ Wt.:_______________ (pedia patients)

HEENT:  Essentially normal  Abnormal pupillary reaction  Cervical lymphadenopathy  Dry mucous membrane

 Icteric sclerae  Pale Conjunctiva  Sunken eyeballs  Sunken fontanelle

Others:_____________________________________

GRAPHIC RECORD

Name:___________________________________________Age/Sex/CS:______________Ward/Room:_____________
DATE

No. of Days in
Hospital

R
PR T
R

42

41
 7-3

URINE 3-11

11-7

7-3

STOO
3-11
L
11-7

BP
 IV FLUID SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:_________

MAIN LINE

Time Time
Date IV Fluids Regulation REMARKS
Started Consumed

ANOTHER LINE / SIDE DRIP

Date IV Fluids Regulation Time Time REMARKS

 Started Consumed

DOCTOR’S ORDER

Name:_______________________________________Age/Sex/CS:___________Ward/Room:__________

C A R E D TIME POSTED
Date Progress Notes Doctor’s Order AND
SIGNATURE
C-Carried

A-Administered

R- Requested

E-Endorsed

D-Discontinued

MEDICATION SHEET

Name:_______________________________________Age/Sex/CS:___________Ward/Room:__________

Date and Time Given:

Name of Drug, Dosage,
Route, & Frequency
 KARDEX
NAME: ________________________________ AGE:____ SEX:_____ HOSPITAL NO._____________________

ADDRESS:_______________________________________ CLASSIFICATION:___________ WEIGHT:________

ADMITTING PHYSICIAN:__________________________ DATE/TIME ADMITTED:________BLOOD TYPE:_____

ATTENDING PHYSCIAN:_____________________________________________________________________

COMPLAINT:______________________________________________________________________________

IMPRESSION DIAGNOSIS:____________________________________________________________________

SURGERY DONE:____________________________________________________DATE/TIME: SURGERY_____

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

___Conscious ___ambulant ___NPO ___Foley Catheter ___Weigh Daily

___drowsy ___dangle and sit up ___DAT ___thoracic tube ___BP q shift

___stupor ___bedrest with BRP ___Soft ___NGT ___Neuro V/S

___unconscious ___CBR w/o BRP ___clear liquids ___CVP ___abdominal girth

___comatose Others:___________ ___ gen. liquids Others:__________ Others:__________

Others:_________

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

Ordered TIME
ordered
DISCONTINUED
 DATE Medical Treatment/ Date Done

ORDERED Laboratories/Diagnostics