Republic of the Philippines

Department of Health
UNIVERSITY OF THE CORDILLERAS HOSPITAL
logo Baguio City
Form No.:
KARDEX Revision No.:
Effectivity Date:

DATE SPECIAL ENDORSEMENT DATE REMARKS

DATE DIET
ORDERED (Ordered Procedures, Monitoring, Referrals, etc.) ORDERED (Patient’s status upon receiving)

DATE MEDICATION/TREATMENT DATE MEDICATION/TREATMENT

ORDERED (Indicate to start, on hold, revised, discontinued, etc.) ORDERED (Indicate to start, on hold, revised, discontinued, etc.)
11-30-21 Cefalexin 500 mg TID
MFA 500 mg TID
Oxytocin

DATE DATE
INTRAVENOUS FLUID (Main Line) NO. INTRAVENOUS FLUID (Side Drip)
ORDERED ORDERED
IVF + 20U oxytocin x 30 gtts to consume

DATE
NO. BLOOD TRANSFUSION
ORDERED

NAME: HOSPITAL NO.: 31161

DIAGNOSIS: AGE: 29 SEX: F