CLINICAL FACE SHEET

______________________
Case Number

Name: Age: Date of Birth: Place of Birth: Category of

Patient:

Home Address: Sex: Civil Status: Religion: Nationality:

Next of Kin: Relationship: Address: Contact No.:

Date Admitted: Time: Date of Discharge: Time: No. of Hospital Days:

________ A.M. ________ A.M.
________ P.M. ________ P.M.
Ward: Attending Physician: Admitting Nurse:

ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS: ICD 10 Code:

Hypertensive uncontrolled

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD
[ ] unimproved [ ] not autopsied [ ] home against for follow up advice
(HAMA)
COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

___________________________________________ __________________________________________
Signature over Printed Name Signature over Printed Name
of Attending Physician (Record Officer)

VITAL SIGNS MONITORING SHEET

Name:____ ____________________________________Age/Sex/CS:_______Ward/Room:_____
__
Tim REMARKS
Date Shift BP PR RR Temp 02 sat
e

INTAKE & OUTPUT MONITORING SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:________
_

Tim INTAKE OUTPUT

Date Shift IVF Drain/
e Oral/NGT TOTAL Urine stool TOTAL

PATIENT’S DATA
1. Name of Patient 2. PIN

Last Name First Name Middle Name 3. Age

5. Chief Complaint

4. Sex
Male Female
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged:
l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
REASON FOR ADMISSION
1. History of Present Illness:

2. a. Pertinent Past Medical History:

2. b. OB/GYN History:
G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA
3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

Altered Mental Sensorium Diarrhea Hematemesis Palpitations

Abdominal cramp/pain Dizziness Hematuria Seizures
Anorexia Dysphagia Hemoptysis Skin rashes
Bleeding gums Dyspnea Irritability Stool, bloody/black tarry/mucoid
Body weakness Dysuria Jaundice Sweating
Blurring of vision Epistaxis Lower extremity edema Urgency
Chest pain/discomfort Fever Myalgia Vomiting
Constipation Frequent urination Orthopnea Weight loss
Cough Headache Pain, ____________ (site) Others: _________________________

4. Referred from another Health Care Institution (HCI): No Yes, Specify Reason _____________________________________________________
Name of Originating HCI ____________________________________________
5. Physical Examination on Admission (Pertinent Findings per System)

General Survey: Awake and alert Altered sensorium,_______________________

Vital Signs: BP:_______________ HR:_______________ RR:_______________ Temp.;_______________ Wt.:_______________(pedia patients)

HEENT: Essentially normal Abnormal pupillary reaction Cervical lymphadenopathy Dry mucous membrane
Icteric sclerae Pale Conjunctiva Sunken eyeballs Sunken fontanelle

Others:_____________________________________

GRAPHIC RECORD
 Name:___________________________________________Age/Sex/CS:______________Ward/Room:__________
___
DATE 3/8
No. of Days in
Hospital
R P 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
T
R R

42

41

160 40

150 39

140 38

130 37

120 36

110 35

100

90

50 80

40 70

30 60

20 50

10

7-3
URINE 3-11
11-7
7-3
STOO 3-11
L 11-7

BP
 IV FLUID SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:________
_

MAIN LINE
Time Time
Date IV Fluids Regulation Started Consumed
REMARKS

ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
 DOCTOR’S ORDER

Name:_______________________________________Age/Sex/CS:___________Ward/Room:_________
_

Date C A R E D TIME POSTED

Progress AND
And Doctor’s Order
Notes SIGNATURE
time


C-Carried-out
A-Administered
R- Requested
E-Endorsed
D-Discontinued

MEDICATION SHEET

Name:_______________________________________Age/Sex/CS:___________Ward/Room:_________
_

Name of Drug, Dosage, Date and Time Given:

Route, & Frequency
 NURSE’S NOTES
Name:_________________________________________Age/Sex/CS:___________Ward/Room:__________

Date-Shift FOCUS Data – Action – Response

 KARDEX
NAME: ____ ____________________________ AGE:____ SEX:_____ HOSPITAL NO._____________________

ADDRESS:_____ __________________________________ CLASSIFICATION:___________ WEIGHT:________

ADMITTING PHYSICIAN:__________________________ DATE/TIME ADMITTED:________BLOOD TYPE:_____

ATTENDING PHYSCIAN:_____________________________________________________________________

COMPLAINT:______________________________________________________________________________

IMPRESSION DIAGNOSIS:____________________________________________________________________

SURGERY DONE:____________________________________________________DATE/TIME: SURGERY_____

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

___Conscious ___ambulant ___NPO ___Foley Catheter ___Weigh Daily
___drowsy ___dangle and sit up ___DAT ___thoracic tube ___BP q shift
___stupor ___bedrest with BRP ___Soft ___NGT ___Neuro V/S
___unconscious ___CBR w/o BRP ___clear liquids ___CVP ___abdominal girth
___comatose Others:___________ ___ gen. liquids Others:__________ Others:__________
Others:_________

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

ordered Ordered TIME
DISCONTINUE
D

DATE Medical Treatment/ Date Done

ORDERED Laboratories/Diagnostics