w ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan

Tel. No. (044) 791-3025
VITAL SIGNS MONITORING SHEET
Name of Patient: Patient 1 Adm. No.__________________

Date/ Blood Temp. SpO2 Cardiac Date/ Blood Temp. SpO2 Cardiac
Time Pressure Time Pressure
Rate Rate
01/2/19

(5:30 pm)

01/2/19

(7:30 pm)

01/2/19

(9:30 pm)

01/2/19

(11:30
pm)

01/3/19

(1:30 am)

01/3/19

(3:30 am)

01/3/19

(5:30 am)

01/3/19

(7:30 am)

01/3/19

(9:30 am)

01/3/19

(11:30
am)

01/3/19

(1:30 pm)

01/3/19

(3:30 pm)

01/3/19

(5:30 pm)

01/3/19

(7:30 pm)
 01/3/19

(9:30 pm)

01/3/19

(11:30
pm)

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025

PATIENT INFORMATION SHEET

Last Name: Velasco Whom to notify in case of emergency:

First Name: Betty Name:___________________________________
Middle Name:Bobier Address:_________________________________
Age:71 years old
Birthday:April 26, 1947 Tel./Cel. No.______________________________
Gender:Female Relationship to Patient:______________________
Address:San Gabriel, City Of Malolos
Civil Status: Married Responsible for Hospital Account:
Religion:Catholic Name:__________________________________
Nationality:Filipino Address:________________________________
Father’s Name:______________________________ _______________________________________
Mother’s Name:_____________________________ Tel./Cel. No:_____________________________
Spouse Name:_______________________________ Relationship to Patient:_____________________

CONSENT FOR ADMISSION

I am freely and voluntary giving my consent to submit my self Betty Velasco to any medical test treatment
and / or operation by private Physician Dr.Santiago.

I also consent to the Administration of Anesthesia appropriate to the operative procedures and condition of the
patient.

I fully understand that as consequences of going through this voluntary consent the RCH, the members of its
medical staff or any said Private Physician shall not be liable to whatever happen to or to _________________________
whom I am responsible in the course of as result or while conducting the test, treatment and operation, except in clear
and manifest negligence of the doctor and / or his staff.

This consent is given after I have been informed with the use of a simple adequate and understandable
language, the nature of the ailment, purpose of the operation. Other alternative methods of treatment, the risks
involved and other possible consequences of the operation.
SIGNED ON MALOLOS CITY, PHILIPPINES

BETTY VELASCO
Signature over printed Name

Complete Address:
San Gabriel, City of Malolos

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025
ADMISSION AND DISCHARGE RECORD
(PRIVATE PATIENT)
Account No. Admission No. Room & Rate: PHILHEALTH

NH:___ NN:____

LAST NAME: FIRST NAME: MIDDLE NAME: AGE: SEX: CIVIL STATUS

Velasco Betty Bobbier 71 F Married

ADDRESS:

San Gabriel, City of Malolos

PLACE OF BIRTH DATE OF BIRTH TEL. NO. HOW PATIENT WAS ADMITTED:
 April 26, 1947

CITIZENSHIP: RELIGION: OCCUPATION

Filipino Catholic

FATHER

MOTHER

SPOUSE:

WHOM TO NOTIFY IN CASE OF EMERGENCY: RELATIONSHIP TO PATIENT:

ADDRESS: TEL.NO.

EMPLOYER ADDRESS: TEL. NO.

ACCOUNT NAME: HOSPITAL PLAN

SSS/GSIS NO.:

RESPONSIBLE FOR HOSPITAL ACCOUNT: EMPLOYER:

ADDRESS: TEL. NO.

ADMISSION DATE: 1/2/19 ADMITTING CLERK: DISCHARGE DATE: 1/5/19

TIME: 5:15 PM Apple TIME:

I CERTIFY THAT THE FACTS HAVE GIVEN ARE TRUE TO THE BEST OF MY KNOWLEDGE

INFORMANT: ADDRESS:

RELATIONSHIP TO PATIENT: TEL. NO.

REFFERING DOCTOR: REFFERED FROM:

ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS: ICD CODE NO.:

Pulmonary Tuberculosis

PROCEDURE / OPERATION:

NOTE: ALWAYS INDICATE DIAGNOSIS / PROCEDURE IN ORDER OF IMPORTANCE: ALSO INDICATE IF PROCEDURE IS MINOR / MAJOR

METHODS OF DISCHARGE: RESULT: DISPOSITION: SERVICE:

[ / ] Wheel Chair [ ] With Doctor’s Permission [ ] Recovered [ ] Autopsy [ / ] Discharged [ ] Medicine [ ] New Born

[ ] Stretcher [ ] Released against advised [ ] Improved [ ] Not Autopsy [ ] Transferred [ ] Surgery [ ] Pediatric
 [ ] Ambulatory of doctor [ ] Unimproved [ ] HAMA [ ] Gynecology [ ] Orthopedic

[ ] In Arm [ ] Died [ ] Absconded [ ] Obstetric [ ] EENT

I have reviewed this record and found it to be accurate and complete

DR. SANTIAGO__________________________ _________________________________________ _______________________
ATTENDING PHYSICIAN SIGNATURE OF ATTENDING PHYSICIAN DISCHARGED BY:
ROMEL CRUZ HOSPITAL
702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025

PHYSICIAN’S ORDER SHEET

Patient’s Name: Betty Velasco Admission No.

Attending Physician: Dr. Santiago Age: 71 Gender: _____M__/___F Room. No.

DATE/TIME/ PHYSICIAN’S ORDER

PROGRESS NOTES

1/2/2019
➢ Please admit under the service of Dr. Santiago
5:30 PM
➢ Secure consent for admission and management

➢ NPO temporarily

➢ Lab: CBC c PC , Na, K, BUN, Creatinine, Trop I.

➢ Ultrasound of the abdomen

➢ 12 Lead ECG

➢ Chest X-ray PA

➢ IVF:

PNSS 1L x KVO

Meds:

Ceftriaxone 1g IV q12 ANST ( )

Omeprazole 40mg IV now then OD

Paracetamol 300mg IV q4 to fever

Salbutamol + ipatropium nebulize q8

Clopidogrel

Trimetazidine

Digoxin 0.25 mg ½ tab

 ➢ O2 inhalation now to run for 2-3LPM

➢ Monitor I and O q shift

➢ Monitor vital signs q2

➢ To room of choice

➢ Refer

DATE/TIME/ PHYSICIAN’S ORDER

PROGRESS NOTES

1/3/2019  Paracetamol 1 tab q 6 hrs

 Ketorolac 1 amp IV for severe headache
3:00 PM
 Paracetamol 300 mg IV now
Temp: 38.4 C  Diamicron 1 tab OD
 Diphenhydramine 50 mg IV now
 Metoclopramide 1 amp IV stat
Severe headache

DATE/TIME/ PHYSICIAN’S ORDER

PROGRESS NOTES
 DATE TIME NOTES

1/2/2019 5:30 pm Seen and examined by Dr. Santiago

1/4/2019
Received a 71-year-old patient under the service of Dr. Santiago
3:00 PM Home meds:
conscious and coherent

Consent signed and attached50mg

 Diphenhydramine to chart
OD/HS
 signs
Vital Melatonin cap
taken and OD/HS
recorded q2
MGH
 Gliclazide (Diamicron) 50mg tab OD
Skin tested (-), done and recorded
 Heracline OD
PNSS
 1L IVF started,
Mosegor vitaregulated
cap ODand secured @10 gtts/min KVO
6:00pm Ceftriaxone IV ANST 1mg q12

Medications started and recorded

NPO as advised

Laboratory extraction requested

For UTZ of abdomen - requested

For 12L ECG with request send to radiology department

For chest x-ray with request send to radiology department

O2 inhalation given, regulated at 2-3 lpm

For I and O monitoring q shift

Increased coughing was noted

(+) chest pain was observed

7:30pm For vital signs monitoring q2

meds prescribed

c ongoing IV OF PNSS 1L regulated at 10gtts/min.

c ongoing 02 inhalation via nasal cannula regulated at 2 to 3 lpm

ROMEL CRUZ HOSPITAL
NPO as instructed
702 Matimbo, City of
meds given as ordered Malolos, Bulacan
Tel. No. (044) 791-3025
9:00 pm Receive pt. on bed, conscious and coherent
NURSES NOTES
c an ongoing IVF of PNSS 1L regulated at 10 gtts./min is intact and
Patient’s Name:Betty Velascoinfused well Admission No.
c an ongoing 02 inhalation viaAge:
nasal71cannula regulated at 2 to_____Male___/__Female
Gender: 3 lpm
Attending Physician: Dr. Santiago
Vital signs were supposed to be taken and recorded

CBC c PC, Na, K, BUN, Crea, Trop 1, result secured and recorded

Meds given as ordered

11:pm For I and O monitoring

Health needs attended

Endorsed with the same IVF, infusing well for continuity of care
DATE TIME NOTES

1/3/19 3:00pm Received on bed Conscious and coherent

38.4 C

Initial V.S. taken and recorded q2 hr.

I.&O. taken and recorded

Inspected IV site for kinks and Phlebitis

Paracetamol 300mg T.I.V given

Metoclopramide 1mg pushed

DueMeds taken as ordered

Ceftriaxone IV ANST 1mg

6:00pm Salbutamol & ipratropium neb. given as ordered

Paracetamol 1tab 6q/hrs. taken and recorded

Difficulty of sleeping referred to Dr. Santiago

11:00pm Diphenhydramine 50mg T.I.V given

Ketorolac 1amp for severe headache Referred to NOD

Health Needs Attended

Endorsed with the same IVF, infusing well for continuity of care

Lemuel Gian Dela Merced, SN

DATE TIME NOTES

1/3/19 6:00pm Received on bed Conscious and coherent

38.4 C

Initial V.S. taken and recorded q2 hr.

I.&O. taken and recorded

Inspected IV site for kinks and Phlebitis

PNSS discontinued, removed and recorded

Salbutamol & ipratropium neb. given as ordered

Paracetamol 1tab 6q/hrs. taken and recorded

Meds taken and recorded as ordered

MGH as per DR. Santiago ordered

-Dephenhydramine 50mg OD/HS

-Glicazide (Diamicron) 50mg tab OD

-Mosegar vita cap OD

-Heraclene OD

Lemuel Gian Dela Merced, SN

 ROMEL CRUZ HOSPITAL
702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025
MEDICATION RECORD SHEET
MEDICATIONS DATE 1/2/19 1/6/19 1/7/19 1/8/19

AM PM AM PM AM PM AM PM

NAME DOSE FREQ. 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8

2 6 10 2 6 1 2 6 10 2 6 1 2 6 1 2 6 10 2 6 1 2 6 10
0 0 0 0

Ceftriaxone IV ANST 1g q12 /

Omeprazole IV 40 mg OD /

Paracetamol IV 300 mg q4 / /

Salbutamol nebulize q8 /

ipratropium nebulize q8 /

Clopidogrel /

Digoxin 0.25 /
mg ½
tab

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025
MEDICATION RECORD SHEET
 MEDICATIONS DATE 1/2/19 1/3/19 1/4/19 1/5/19

AM PM AM PM AM PM AM PM

NAME DOSE FREQ. 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8

2 6 10 2 6 1 2 6 10 2 6 1 2 6 1 2 6 10 2 6 1 2 6 10
0 0 0 0

Ceftriaxone IV ANST 1g q12 / /

Omeprazole IV 40 mg OD / /

Paracetamol IV 300 mg q4 / / / / / / /

Salbutamol nebulize q8 / / / /

ipratropium nebulize q8 / / / /

Clopidogrel / /

Digoxin 0.25 / /
mg ½
tab

Metoclopramide 1mg STAT /

Ketorolac 1mp PRN

Diamicron 1tab OD /

Diphenhydramine 50mg STAT /

VELASCO BETTY
LAST NAME FIRST NAME MIDDLE NAME ADMISSION NO.
ROMEL CRUZ HOSPITAL
702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025
INTRAVENOUS RECORD SHEET

Patient’s Name: Betty Velasco Admission No.

Bottle No. IVF/REGULATION/ REMARKS TOTAL AMOUNT TIME ACTUAL LEVEL

INFUSED
TIME STARTED

Intact and well 5:30 pm 1L

infused
DATE: 1/2/19

PNSS 1L
1 SHIFT: _3pm-11pm

T.S: 5:30 pm
Cc/hr: 10 cc/hr.

5:30pm 1L

DATE: 1/3/19

SHIFT: 3-pm11pm
2 PNSS 1L Intact and well
infused
Cc/hr: 10cc/hr.

T.S:5:30pm

DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:

DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:

DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:

DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:
 DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:

DATE:___________

SHIFT:___________

Cc/hr:___________

T.S:

DATE:___________

SHIFT:___________

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025

LABORATORY FINDINGS

CLINICAL CHEMISTRY

Blood urea showed 15.2, Sodium is 135.7, Potassium at 4.27 and creatinine is .96 which are all at
average/normal ranges. Also Trop. I showed negative results. While the hematocrit,hemoglobin is slightly
lower than normal for the hematology.

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025

PATIENT DISCHARGE PLAN

NAME: Betty Velasco AGE: 71 years old DATE OF DISCHARGE:

ADDRESS:San Gabriel, City of Malolos GENDER: Female

FINAL DIAGNOSIS: Pulmonary Tuberculosis secondary secondary to congestive heart failure

HOME MEDICATION:
 Diphenhydramine 50mg OD/HS
 Melatonin cap OD/HS
 Gliclazide (Diamicron) 50mg tab OD
 Heracline OD
 Mosegor vita cap OD

ADVICE (HOME CARE)

N/A

TO COME BACK ON _______________________ AT ______________________ AM/PM

ROMEL CRUZ HOSPITAL

702 Matimbo, City of Malolos, Bulacan
Tel. No. (044) 791-3025
DISCHARGE SUMMARY
PATIENT’S NAME: Betty Velasco AGE: 71 SEX: F

ADDRESS: San Gabriel, City of Malolos

ADMISSION NO: ROOM NO: DATE ADMITTED: Jan. 2 2019

CHIEF COMPLAINT/S: Chest pain, cough and fever DATE DISCHARGE: Jan 5, 2019

BRIEF CLINICAL HISTORY AND PERTINENT PHYSICAL EXAMINATION:

Patient has PTB and with chest pain

Has cough and fever on the second day

Had difficulty in sleeping.

LABORATORY FINDINGS: (INCLUDING ECG, X-RAY, AND OTHER DIAGNOSTIC PROCEDURES)

OPERATION PERFORMED: (INDICATE DATE)

N/A

COURSE IN THE WARD/ROOM: (INCLUDE MEDICATION)

Patient was cooperative in the course of healing. She followed the doctors’ orders accordingly and has improved
because of it she had chest pains and a slight fever of 38.4c and experienced difficulty of sleeping which was remedied
by the doctor giving her diphenhydramine. On the 3 rd day she is now being discharged due to her improved vitals and
condition and now the doctor has prescribed her home medications if symptoms persist.

FINAL DIAGNOSIS: Pulmonary Tubercolosis

Pulmonary Tuberculosis

FINAL DISPOSITION: (INDICATE HOME MEDICATION, SPECIAL INSTRUCTION AND FOLLOW-UP)

Home meds:

 Diphenhydramine 50mg OD/HS

 Melatonin cap OD/HS
  Gliclazide (Diamicron) 50mg tab OD
 Heracline OD
 Mosegor vita cap OD

RESIDENT IN CHARGE:___________________________M.D. DATE:1-5-19____________________ Signature over printed Name

Kardex
Name: Betty VelascoDate of Admission:1/2/19
Address : San Gabriel, City of MalolosOperations: N/A
Age: 71 Diet:N/A
Diagnosis: Pulmonary TubercolosisIVF:PNSS 1L
Attending Physician: Dr. SantiagoIVF T/F: N/A

Endorsement Medication

 Omeprazole 40mg IV now then OD

 Paracetamol 300mg IV q4 to fever
 Monitor I & O q shift  Clopidogrel
 Monitor vital signs q2  Trimetazidine
 PNSS 1L IVF REG. @ 10 gtts.  Digoxin 0.25 mg ½ tab
 Ceftriaxone 1g IV q12 ANST
 Ketorolac 1 amp IV for severe headache
 Salbutamol + ipratropium nebulizes q8
 Paracetamol 300 mg IV now
 Paracetamol 1 tab q 6 hrs
 Diamicron 1 tab OD
 Omneprazole 40mg IV OD
 Diphenhydramine 50 mg IV now
 Ketorolac 1amp IV for severe headache
  Metoclopramide 1 amp IV stat
