OFELIA L.

MENDOZA MATERNITY AND GENERAL

HOSPITAL MOJON, CITY OF MALOLOS, BULACAN
TEL NO. (044) 794 - 7113
INTRAVENOUS AND BLOOD TRANSFUSION SET
NAME: AGE: ROOM NO.:
BLOOD TYPE OR DATE/TIME/SIGNATUR DATE/TIME/SIGNATURE
BOTTLE E
TOTAL AMT REMARKS
NAME OF IV DISCONTINUED INFUSED BY
NO. SOLUTION NO. STARTED
INCORPORATION OR CONSUMED EACH SHIFT

LEGEND:
NO. 1, 2, 3 = MAIN IV LINE I, II, III = BLOOD TRANSFUSION
SD = A. B, C = SIDE DRIP should be written in RED

NURSES NOTES
 OFELIA L. MENDOZA MATERNITY AND GENERAL
HOSPITAL MOJON, CITY OF MALOLOS, BULACAN
TEL NO. (044) 794 - 7113
NAME:
ROOM:
DATE:

NURSES NOTES NURSES NOTES

THERAPEUTIC SHEET
NAME: AGE/SEX: ROOM NO.:
 OFELIA L. MENDOZA MATERNITY AND GENERAL
HOSPITAL MOJON, CITY OF MALOLOS, BULACAN
TEL NO. (044) 794 - 7113
DATE
PARENTERA
L

ORAL
MEDS

P.R.N.
MEDS

TREATMENTS

VITAL SIGNS RECORD/INTAKE & OUTPUT RECORD

NAME: AGE/SEX: ROOM NO.:
DATE BP P R T FHT INTAK IV NGT MISC OUTPUT STOOL EMESIS NGT MISC
 OFELIA L. MENDOZA MATERNITY AND GENERAL
HOSPITAL MOJON, CITY OF MALOLOS, BULACAN
TEL NO. (044) 794 - 7113
TIME E URINE
ORAL

KARDEX
NAME: DATE OF ADMISSION:
ADDRESS: OPERATION:
 OFELIA L. MENDOZA MATERNITY AND GENERAL
HOSPITAL MOJON, CITY OF MALOLOS, BULACAN
TEL NO. (044) 794 - 7113
AGE: GENDER: DIET:
DIAGNOSIS: IVF:
ATTENDING PHYSICIAN: IVF T/F:

ENDORSEMENT MEDICATION