CLINICAL FACE SHEET

______________________

Case Number

Name: Patient A.C Age: Date of Birth: Place of Birth: Category of

18 Patient:

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

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

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

8:13 A.M. ________ A.M.

________ P.M. ________ P.M.

Ward: Attending Physician: Admitting Nurse:

DR. JENNIE KIM, M.D KYLE AUDRIE A. ARCALAS, RN.

ADMITTING DIAGNOSIS:

APPENDICITIS

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

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

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD

 [ ] unimproved [ ] not autopsied [ ] home against for follow up advice

COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

JENNIE KIM SHIELA ROSAL

Signature over Printed Name Signature over Printed Name

of Attending Physician (Record Officer)

VITAL SIGNS MONITORING SHEET

Name: PATIENT A.C_______________________Age/Sex/CS:_18_Ward/Room:_________

Date Time Shift BP PR RR Temp 02 sat REMARKS

11-02-2021 12:2 12-3 130/90 90 26 39 98 Abnormal Blood Pressure, Abnormal

°C Respiratory Rate, Abnormal
1
Temperature

11-02-2021 1:24 12-3 120/90 85 18 38. 4 97 Abnormal temperature

11-02-2021 2:17 12-3 120/80 89 17 37.3 98
11-02-2021 3:15 12-3 120/80 87 20 37.2 99
 INTAKE & OUTPUT MONITORING SHEET

Name:_PATIENT A.C____________________________Age/Sex/CS:__18_______Ward/Room:_________

INTAKE OUTPUT

Date Time Shift IVF Drain/

Oral/NGT TOTAL Urine TOTAL
stool

11-02-21 12-3 815 cc 0 815 cc 50 cc 50 cc

 PATIENT’S DATA

1. Name of Patient 2. PIN

Patient A.C

Last Name First Name Middle Name 3. Age

5. Chief Complaint 18

Severe right lower quadrant pain 4. Sex

Male Female

6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

8. b. 2nd Case Rate Code

APPENDICITIS

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

l_1_l0__l ¯ l2__l_5_l ¯ l2_l 0_l2_l1_l l_0l8_l ¯ l_1_l_3_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:___130/90_____ HR:_____90______ RR:____26________ Temp.;_____39 degrees celcius________ 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:_PATIENT A.C__________________________________Age/Sex/CS:____18_______Ward/Room:_____________
DATE

No. of Days in
Hospital

7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
R
PR T
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
 thric
7-3 e

URINE 3-11

11-7

7-3 (-)

STOO
3-11
L
11-7

130/90
BP
 IV FLUID SHEET

Name:___PATIENT A.C ___________________________Age/Sex/CS:___________Ward/Room:_________

MAIN LINE

Time Time
Date IV Fluids Regulation REMARKS
Started Consumed

11-02-21 D5LR 1L x 8hrs 62-63 gtts/min 12:15 STARTED

ANOTHER LINE / SIDE DRIP

Date IV Fluids Regulation Time Time REMARKS

 Started Consumed

DOCTOR’S ORDER

Name:_____PATIENT AC______________________Age/Sex/CS:___________Ward/Room:__________

Date C A R E D TIME POSTED

Progress Notes Doctor’s Order AND
And time SIGNATURE

/
Post-Operative  VS and urine output
11-02-21 monitoring Q1 /
12:15
 Maintain NPO
 IVF to follow D5LR 1L /
INITIAL VS: x8hrs
 FOB for 6 hours /
/
BP: 130/90
 Continue antibiotic:
Cefuroxime 750 mg IV Q8 /
PR: 90
 Continue pain medication:
RR: 26
o Ketorolac 30mg IV
TEMP: 39°C Q8 x 6 doses
o Tramadol 50mgIV
PAIN SCALE: 10/10
Q6 PRN
   Refer accordingly
 / 12:14/KAAA

Dr. Kim
/
Lic No. 08976
MEDICATION SHEET

Name:PATIENT AC ________________________Age/Sex/CS:___________Ward/Room:__________

Date and Time Given:

Name of Drug, Dosage,
Route, & Frequency

Ketorolac 30mg IV Q8 12:30

x 6 doses PM/KAAA

Tramadol 50mgIV Q6 12:30

PRN PM/KAAA
 NURSE’S NOTES

Name: PATIENT A.C __________________________Age/Sex/CS:___________Ward/Room:__________

Date-Shift FOCUS Data – Action – Response

10-25-21/7-3 POST-OPERATIVE Data: Received from PACU per stretcher with ongoing IVF infusing
CARE
well. With complaint of pain at post operative site. Pain scale
12:15 PM
10/10.------------------------------------------------------------------------------------
--------KAAA

Action: placed patient flat on bed until 6 pm, moderate high back rest
thereafter. NPO instructed. Encouraged deep breathing exercise and
proper relaxation technique. Pain medication given as ordered. Vs
and urine output monitored q1 and recorded.
--------------------------------------------
----------------------------------------------------------------------------------KAAA

Response: patient verbalized relief from pain. Pain scale of

6/10------------
------------------------------------------------------------------------------------KAAA
Kyle Audrie A. Arcalas

UNP, CN
 KARDEX
NAME: PATIENT A.C_____________________ AGE::18__ SEX:_____ STATUS:__________WARD.__________

ADDRESS:_______________________________________ CLASSIFICATION:___________ WEIGHT:________

ADMITTING PHYSICIAN:Dr. Jennie Kim_____________ DATE/TIME ADMITTED:10-25-21BLOOD TYPE:_____

ATTENDING PHYSCIAN:Dr. Jennie Kim CONSULTATION PHYSICIAN:_Dr.Joan Rosal _________

COMPLAINT:_ severe right lower quadrant pain, _____________________________________

IMPRESSION DIAGNOSIS:_APPENDICITIS____________________________________________________

SURGERY DONE:_APPENDECTOMY__________________________________DATE/TIME: SURGERY: 10-25-21/9:00AM

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:__vs q4__

Others:_________

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

Ordered TIME
ordered
DISCONTINUED

11-02-21 Cefuroxime 750mgIV 10-25-21 D5LR 1L x8hrs (62-63 gtts/min.)

11-02-21 Ketorolac 30mg IV Q8 x 6 doses

11-02-21 Tramadol 50mgIV Q6 PRN

DATE PRN TREATMENTS/MEDICATION DATE Medical Treatment/ Date Done

Ordored
ORDERED Laboratories/Diagnostics

10-25-21 Ultrasound 10-25-21

Result: APPENDICITIS

10-25-21 Urinalysis 10-25-21

color (yellow); specific gravity

1.031 (1.005-1.030)

10-25-21 CBC 10-25-21

WBC: 15,000 (5,000-10,000)

 CONSENT FOR SURGERY

KNOWN ALL MED BY THESE PRESENTS:

That I, __Patient A.C_______ ______________ Filipino, of legal age, 18

Single/married/widow, and a resident of _________________ ____________________, do
Hereby submit myself freely and voluntarily, without any influence, coercion, for or intimidation by any person to
have an operation performed to me/my ____Patient A.C___________________,
For the following operation/s________ _____________
By Dr. Kim and Anesthesia by Dr. Azcueta

These said operation has been fully explained to me by the surgeon as to the type of operation; its necessity;
its complications that may arise, directly or indirectly therefrom. Likewise, the type of anesthesia and all its
complication directly and indirectly, have been explained to me by my anesthesiologist.

It is understood that the surgeon/ anesthesiologist performing the operation/anesthesia will not be liable for
any charge that I oy my relative/s or guardian may claim as a result of the operation/ anesthesia or treatment.

IN WITNESS WHEREOF, I have hereunto set my hand this October day of 25

2021 at Vigan, Ilocos Sur.

IN THE PRESENCE OF

Witness         Signature of patient/

        person giving consent
 PREOPERATIVE CHECKLIST
Last Name: Age: 18 Hospital #:
Given Name: Sex: Ward/Room:
YE N
N/A REMARKS
S O
1. Consent for surgery signed, witnessed and documented /
2. Consent for blood transfusion signed, typed and cross-matched ______unit/s Not ordered
confirmed
3. CP clearance/ Pedia clearance done and on chart /
4. Laboratory reports on chart /
5. ECG report on chart Not ordered
6. X-ray/ CT scan report on chart Not ordered
7. Identification bracelet accurate and affixed to wrist/ ankle /
8. Allergies checked and documented on chart. /
9. Patient shower/ bath completed as ordered, dressed in hospital gown /
10. Jewelries, hairpin, contact lenses, prosthesis, underwear removed. /

11. Oral Hygiene/care completed /

12. Operative site prepared /
13. Cleansing enema done Not ordered
14. Nail polish/ make-up removed Not ordered
15. Vital signs taken and recorded /
BP-130/90 PR-90 T-39°C RR-26 O2Sat-98%

16. Patient voided at _8:35 am_ /

Has Foley catheter: __Yes__

17. Dentures removed /

18. Patient on NPO since _8:24 am_ /
19. OR notified: time _8:24am__whom: Dr. Kim /
20. Anesthesiologist notified /
21. Pre-op medication/s given: /
__Cefuroxime 750mg IV ANST (-)_______

__Kyle Audrie A. Arcalas, RN__

Nurse of Duty
_____10-25-21/9:00 am_____
Date and Time
 OR SLIP
NAME: PATIENT A.C
AGE: __18 SEX: __ RM NO. 12
ATTENDING PHYSICIAN:
_DR. JENNIE KIM
Procedure:
DATE: 10-25-21 TIME:10:00
SURGEON: DR. JENNIE KIM
ANESTHESIOLOGIST:
DR. LINDA AZCUETA
TYPE OF ANESTHESIA:
CP CLEARANCE: DR. ROSAL
PREPARED BY: Kyle Audrie Arcalas,
RN
SIGNATURE:

IV TAG
NAME OF PATIENT: PATIENT A.C
WARD: MVH NS 3
TYPE OF FLUID: D5LR
IV RATE: 61 gtts/min
DATE AND TIME STARTED:11-02-
21/12:15
PREPARED BY: Kyle Audrie Arcalas,
RN