Professional Documents
Culture Documents
CF4
(Claim Form 4)
February 2020
Series #
IMPORTANT REMINDERS
PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
CALAMBA DISTRICT HOSPITAL H10016751
3. Address of HCI
NAT. HIGHWAY, CALAMBA, MISAMIS OCCIDENTAL, 7210 REGION X, PHILIPPINES
Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code
II. PATIENT'S DATA
1. Name of Patient 2. PIN
MATUNOG MELQUIADES DESCALLAR 151751439189
Last Name First Name Middle Name 3. Age
5. Chief Complaint 88
FEVER AND CHILLS 4. Sex Male Female
4. Referred from another health care institution (HCI): No Yes, Specify Reason ______________________________________________
Name of Originating HCI _________________________________________
HEENT Essentially Normal Iceteric Sclerae Abnormal Pupillary Reaction Pale Conjunctivae
Others: __________________
5. Physical Examination continued (Pertinent Findings per System)
CHEST/LUNGS Essentially normal Lump/s over breast(s) Asymmetrical chest expansion Rales/crackles/rhonchi
Others: __________________
CVS Essentially normal Irregular rhythm Displaced apex beat Muffled heart sounds
Others: TACHYCARDIC
Others: __________________
GU (IE) Essentially normal Blood stained in exam finger Cervical dilatation Presence of abnormal discharge
Others: (+)KPS
Others: __________________
NEURO-EXAM Essentially normal Abnormal gait Abnormal position sense Poor/altered memory
Others: __________________
IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s)
Date DOCTOR'S ORDER/ACTION
06-12-2021 Initially patient was relatively weak, in pain (hypogastric area) and febrile. PE: (+) tenderness hypogastric area: (+) KPS.
Vital signs: BP=120/80 mmHg, CR= 104/min, RR= 24/min, T=38 C. Working diagnosis: cute Pyelonephritis. Due
medicines were given.
06-15-2021 Patient improves progressively and subsequently discharged with take home medicines prescribed.
I certify that the above information given in this form, including all attachments, are true and correct.
________________________________________________________________________ -- --
Signature over Printed Name of Attending Health Care Professional
month day year