MIDSAYAP DOCTORS SPECIALIST HOSPITAL, INC.

145 Quezon Avenue, Población 6, Midsayap, Cotabato

A DOH & PhilHealth Accredited Health Care Facility

CLINICAL COVER SHEET

HOSPITAL CODE:
MEDICAL RECORD NO.

PATIENT’S NAME: (Surname, First Name, Middle Name) ROOM No.

PERMANENT ADDRESS: Contact No. SEX: CIVIL STATUS:

Male ( ) S( ) M( ) W( )
Female ( ) Sep. ( ) C ( )
BIRTHDATE: AGE: BIRTH PLACE: NATIONALITY: RELIGION: OCCUPATION:

EMPLOYER (Type of Business) ADDRESS: Contact No.

FATHER’S NAME: ADDRESS: Contact No.

MOTHER’S NAME: ADDRESS: Contact No.

ADMISSION: DISCHARGE: TOTAL NO. OF DAYS ATTENDING

DATE: TIME: DATE: TIME: PHYSICIAN

TYPE OF ADMISSION: ( )NEW ( )OLD ( )FORMER OPD

SOCIAL SERVICE CLASSIFICATION: ( ) A ( )B ( )C ( )D
ALLERGIES: HOSPITALI ZATION PLAN COMPANY/ HEALTH INSURANCE NAME:
INDUSTRIA L NAME: ( ) PHIC ( ) SSS ( )GSIS
( ) HMO ( ) Others:
ADMITTING DIAGNOSIS: ICD-10 CODE NO.

RVS CODE NO.

FINAL DIAGNOSIS:

PRINCIPAL OPERATION/PROCEDURE:
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OTHERS OPERATION(S) PROCEDURE(S):
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ACCIDENT/INJURIES/POISONING (E CODE):
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PLACE OF OCCURRENCE:
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DISPOSITION: RESULTS:
( ) Discharged ( ) DAMA ( ) Recovered ( ) – 48 Hours ( ) Improved ( ) Autopsy
( ) Transferred ( ) Absconded ( ) Died ( ) + 48 Hours ( ) Unimproved ( ) No Autopsy
ADMITTING CLERK ADMITTING NURSE ADMITTING PHYSICIAN ATTENDING
PHYSICIAN
______________________ ____________________, ____________________, MD
Name & Signature RN Name & Signature Name & Signature _________________,
MD Name &
Signature