Republic of the Philippines

Province of Benguet

KARDEX

Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME

Admitting diagnosis: Admitting physician:

Final diagnosis:

Date of admission: Date of discharge:

SPECIAL INSTRUCTIONS/ENDORSEMENTS DATE LABORATORY

Diet:

DATE IV FLUIDS DATE PRN MEDICATIONS

DATE IV MEDICATIONS DATE ORAL MEDICATIONS

DATE NEBULIZATION

Republic of the Philippines

Province of Benguet
 MONITORING SHEET

Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME

DATE & Input Output

TIME BP CR/PR RR TEMP (mL) (mL) Misc/NVS/Wt Remarks

Republic of the philippines

Province of Benguet
CLINICAL FACE SHEET
Hospital Number:________________
NAME:             BIRTH DATE:   AGE: SEX:   WARD/ROOM
    ∕ ∕   □ MALE
                    □ FEMALE
FIRS MIDDLE
LAST T NAME (MM/DD/YYYY)        
ADDRESS: CIVIL STATUS   PATIENT CLASSIFICATION ADMISSION TIME
DATE:
□ S □ Ch CLASS __________________ ______ AM
□ M □ W PHIC ______ MEMBER   ______ PM
DISCHARGED TIME
□ Sep.     ______ DEPENDENT   DATE:
BIRTHPLACE: RELIGION: ___SSS ___ Paying mem. ______ AM
___GSIS ___ Life Time mem. ______ PM
___ OWWA ___ Sponsored mem. TYPE OF ______ OLD
 ___ Non Member ADMISSION: _____ NEW
OCCUPATION: CONTACT NUMBER: NATIONALITY: TOTAL PATIENTS DAYS:

SERVICE
NAME OF EMPLOYER`S ADDRESS: CONTACT NUMBER: _______ OB _______ MEDICINE
EMPLOYER: _______ GYNE _______ SURGERY
INFORMANT: ADDRESS OF INFORMANT CONTACT NUMBER: RELATIONSHIP TO PATIENT

NEXT OF KIN OR WHOM TO ADDRESS OF NEXT OF KIN CONTACT NUMBER: TRANSFERRED DATE:
NOTIFY:

REFERRING HEALTH WORKER:   REFERRING HEALTH WORKER`S ADDRESS:

 
ADMITTING DIAGNOSIS: ADMITTED BY:

PRINCIPAL DIAGNOSIS: CODE NUMBER

OTHER DIAGNOSIS: CODE NUMBER

OPERATIVE PROCEDURE:

DISPOSITION: □ DISCHARGED □ HAMA □ RECOVERED □ UNIMPROVED □ DIED □ -48 HRS

    □ TRANSFERRED □ ABSCONDED □ IMPROVED □ AUTOPSIED □ +48 HRS
IN CASE OF ACCIDENTS: THE PATIENTS WAS BROUGHT BY: CONTACT NUMBER RELATIONSHIP TO PATIENT

DRIVER VEHICLE AND PLATE POLICE INVESTIGATOR ADDRESS CONTACT NUMBER

NUMBER
                             
 
MEDICAL OFFICER III MEDICAL OFFICER III MEDICAL OFFICER III
                             
MEDICAL MEDICAL
SPECIALIST II         MEDICAL SPECIALIST II     SPECIALIST I  
 
                             
              CHIEF OF HOSPITAL        

Republic of the Philippines

Province of Benguet

Hospital No.: __________________

CONSENT TO CARE

Note: This authorization must be signed by the patient or by the next of kin in case of a minor or when the patient is
physically and/or mentally incompetent.

I, , hereby authorized Dr. and other staff of Northern

(name of patient)
Benguet District Hospital to perform the treatment and procedures deemed necessary for my care.
 I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.

I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.

Name & signature of witness Date Name & signature of patient

Hospital No.: __________________

Patient is a minor of .
Age

Patient is unable to sign because .

I, , being next of kin of hereby

(name of guardian or parent) (name of patient)
authorized Dr. and other staff of Northern Benguet District Hospital to perform the treatment and
procedure deemed necessary for his/her care.

I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.

I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.

Name & signature of witness Date Name & signature of parent/guardian

Republic of the Philippines

Province of Benguet

ADULT HISTORY AND PHYSICAL EXAMINATION

Hospital Number:
Name: Age: Sex: Ward:

CHIEF COMPLAINT/S:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

FAMILY HISTORY:

SOCIAL/ENVIRONMENTAL/OCCUPATIONAL HISTORY:

PHYSICAL EXAMINATION:
GENERAL SURVEY:

VITAL SIGNS: BP:______mmHg PR: ____bpm RR: ____cpm T: ____°C WT: ____kg HT: ____cm

SKIN:

HEAD:

EENT:

NECK:

CHEST/BREAST/LUNGS:

HEART/CARDIOVASCULAR:

ABDOMEN:

GENITO-URINARY:

RECTAL:

MUSCULO-SKELETAL:

EXTREMITIES:

NEUROLOGICAL/NERVOUS:

LYMPHATIC:

ADMITTING IMPRESSION: ATTENDING PHYSICIAN:

Republic of the Philippines
Province of Benguet

DOCTOR’S ORDER
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME

DATE TIME PROGRESS NOTES DOCTOR’S ORDER

 Republic of the Philippines
Province of Benguet

LABORATORY RESULTS
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
(ATTACH FIRST LABORATORY RESULT ON THIS LINE)
 Republic of the Phillipines
Province of Benguet

TEMPERATURE RECORD
Hospital Number: Bed No. Doctor:
Year: Month: Name of Patient:

Da y of Month
Da y of di s e as e
No. of hospital days
Wei ght
R PU T
E L E
S S M
P E P
42 42

41

40

39

38

180 37

36

160 35

140

120

100

50 80

40

30 60

20

10
8-4 s hift
URINE 4-12 s hift
12-8 s hift
8-4 s hift
STOOL 4-12 s hift
12-8 s hift

DATE Medication, Dose and Frequency DATE and SIGNATURE

 Note and Administrative HOUR              
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   

Republic of the Philippines

Province of Benguet

TREATMENT SHEET
Hospital Number:
Name: Age: Sex: Ward:

Republic of the Philippines

Province of Benguet
 INTRAVENOUS FLUID SHEET

Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME

IV FLUID DATE & TYPE OF IV FLUID DRUG NEEDLE GAUGE & FLOW DATE & NURSE’S REMARKS
BOTTLE TIME AND VOLUME ADDITIVES SITE OF INSERTION RATE TIME SIGNATURE
NO. STARTED CONSUMED

Republic of the Philippines

Province of Benguet

NURSE’S NOTES
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME

DATE& TIME FOCUS DATA, ACTION, RESPONSE

 Republic of the Philippines
Province of Benguet

DISCHARGE SUMMARY

NAME: AGE: SEX: HOSP. NO:

DATE ADMITTED: DATE DISCHARGE:
ADMITTING PHYSICIAN:
ADMITTING DIAGNOSIS:

CHIEF COMPLAINS:

BRIEF CLINICAL HISTORY AND PERTINENT P.E.:

LABORATORY FINDINGS (INCLUDE ECG, X – RAY, AND OTHER DIAGNOSTIC PROCEDURES):

COURSE IN THE WARD: (INCLUDE MEDICATIONS):

FINAL DIAGNOSIS:

DISPOSITIONS: (INDICATE HOME MEDICATIONS, SPECIAL INSTRUCTION AND FOLLOW-UP)

PREPARED BY:

_____________________________ _____________________ ____________________________ M.D.

(Signature Over Printed Name) Date ATTENDING PHYSICIAN
(Signature Over Printed Name)