CLINICAL FACE SHEET

______________________
Case Number

Name: Sheena Doque Age: Date of Birth: Place of Birth: Bangued, Category of
14 9/12/2007 Abra Patient: Pedia

Home Address: Bangued, Abra Sex: F Civil Status: Religion: n/a Nationality:
Single Filipino

Next of Kin: n/a Relationship: n/a Address: Bangued, Abra Contact No.: n/a

Date Admitted: 3/9/20 Time: Date of Discharge: Time: No. of Hospital Days:
8:30 A.M. n/a ________ A.M.
________ P.M. ________ P.M.

Ward: Attending Physician: Admitting Nurse:

Pedia C Dr. Lazaro

ADMITTING DIAGNOSIS:
Dengue Fever

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
(HAMA)
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:__Sheena Doque Age/Sex/CS: 14 / F / Single Ward/Room:_Pedia Ward C

Date Time Shift BP PR RR Temp 02 sat REMARKS

3/9/202 8:30am AM 100/80 82 17 38.3 °C 97%

1
9:30am AM 100/70 97 18 37.8 °C 97%
1:00pm AM 110/80 95 19 38.0 °C 98% Paracetamol 500mg/tab given
2:00pm AM 110/80 83 19 37.3 °C 98%
3:00pm AM 120/80 78 18 37.1 °C 98%
 INTAKE & OUTPUT MONITORING SHEET

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

INTAKE OUTPUT
Date Time Shift IVF Drain/
Oral/NGT TOTAL Urine stool TOTAL
3/9/2021 7-3 AM 700cc IVF 980cc 1,680cc 4x(1,020cc) 1x 1,020cc
 PATIENT’S DATA
1. Name of Patient 2. PIN
Sheena Doque n/a
Last Name First Name Middle Name 3. Age
5. Chief Complaint 14
On and off fever
4. Sex
Male Female
st
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1 Case Rate Code
Dengue Fever

8. b. 2nd Case Rate Code

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

L3l ¯ l__0__l__9__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  Dyspnea  Irritability  Stool, bloody/black tarry/mucoid
 Body weakness  Dysuria  Jaundice  Sweating
 Blurring of vision  Epistaxis  Lower extremity edema  Urgency
 Chest pain/discomfort  Fever  Myalgia  Vomiting
 Constipation  Frequent urination  Orthopnea  Weight loss
 Cough  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 3/9/2021
No. of Days in
Hospital
R 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
PR T
R

42

41

160 40

150 39

140 38

130 37

120 36

110 35

100

90

50 80

40 70

30 60

20 50

10

7-3 4X

URINE 3-11
11-7
7-3 1X
STOO 3-11
L 11-7
100 120
BP
80 80
 IV FLUID SHEET

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

MAIN LINE
Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
3/09/21 D5LRS 1L x 10h 33gtts/min 9am/NMT

ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
 DOCTOR’S ORDER

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

Date C A R E D TIME POSTED

And Progress Notes Doctor’s Order AND
SIGNATURE
time



C-Carried-out
A-Administered
R- Requested
E-Endorsed
D-Discontinued
MEDICATION SHEET

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

Name of Drug, Dosage, Date and Time Given:

Route, & Frequency 3/9/2021
Paracetamol tablet 8:45/NMT
500mg q4 PRN for
temp 37.5 and above

Ampicilin 500mg IV 9:25/NMT

q8 ANST

Ascorbic Acid plus 12:00/NMT

Zinc (Ceelin Plus) 1
tablet OD AM

NURSE’S NOTES
Name:_________________________________________Age/Sex/CS:___________Ward/Room:__________
Date-Shift FOCUS Data – Action – Response

KARDEX
NAME: Sheena Doque AGE: 14 SEX: F 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 Ordered TIME
DISCONTINUED
3/9 Paracetamol tablet 500mg, 1 tab q4 3/9 D5LRS 1L x 10h (33gtts/min)
PRN for temp:37.5 and above
Ampicilin 500mg IV q8 ANST
Ascorbic Acid plus Zinc (Ceelin Plus) 1
tablet OD AM

DATE Medical Treatment/ Date Done

ORDERED Laboratories/Diagnostics
3/9 Urinalysis 3/9
CBC 3/9
Chest x-ray APL view
Dengue Duo 3/9

DOQUE, SHEENA 14/F 3/09/2021

R Paracetamol 500mg/tablet
O 1 tab q4 PRN for temp: 37.5 and above
O
M
DOQUE, SHEENA 14/F 3/09/2021

R Paracetamol 500mg/tablet
O 1 tab q4 PRN for temp: 37.5 and above
O
M

N. TEODORO