VALENZUELA MEDICAL CENTER

Padrigal St., Karuhatan, Valenzuela City FM-ND-054

Telephone No. 294-6711 Rev 1 – 09/03/21

CLINICAL ABSTRACT/DISCHARGE SUMMARY

PATIENT NAME: (Last, First, Middle Name) AGE/SEX: BIRTHDATE: ROOM/BED: HOSPITAL
NUMBER:

DATE AND TIME OF ADMISSION: DATE AND TIME OF DISCHARGE:

ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS:

OPERATION/PROCEDURES PERFORMED:

CHIEF COMPLAINT:

SIGNIFICANT HISTORICAL DATA:

SIGNIFICANT PHYSICAL EXAMINATION:

COURSE IN THE WARD:

LABORATORIES:

MEDICATIONS:

DISPOSITION AND CONDITION UPON DISCHARGED:

HOME INSTRUCTIONS:

DATE OF FOLLOW UP:

ATTENDING PHYSICIAN: SIGNATURE OVER PRINTED NAME: DATE ACCOMPLISHED:

**THIS IS ALSO CONSIDERED AS THE PATIENT’S CLINICAL ABSTRACT AND CLINICAL SUMMARY **