NAME DATE: 11/11/2021

YR/GRP&SEC: Grp 2, 3BSN-A PROF:

KARDEX

HOSPITAL NO: DATE OF ADMISSION: TIME RECEIVED:

PATIENT NAME: AGE: GENDER:
ATTENDING PHYSICIAN: ROOM NUMBER:
DATE OF BIRTH: RELIGION: WEIGHT:
CHIEF COMPLAINT DIAGNOSIS

REMARKS: ( ) RED TAG ( ) RX MEDS ( ) ABSCOND PRECAUTION ( ) INFECTIOUS ( ) AVOID TRIGGERS

MEDICATIONS I.V. FLUIDS
DOSE & FREQUENCY TIME IVF TYPE OF FLUIDS & FLOW RATE TIME STARTED
NO

PRN/STAT MEDICATIONS SIDE DRIPS

TREATMENT DIAGNOSTIC PROCEDURES

PENDING PROCEDURE:

PROCEDURE WITH RESULTS:

DIET: ( ) CLEAR LIQUID ( ) GENERAL LIQUID ( ) SOFT DIET ( ) DAT-EDCF ( ) LOW SALT LOW
FAT
( ) DM DIET ( ) LOW PURINE ( ) HYPOALLERGENIC ( ) BRAT ( ) OTHERS PLS SPECIFY

KARDEX
HOSPITAL NO: DATE OF ADMISSION: TIME RECEIVED:
PATIENT NAME AGE: GENDER:
ATTENDING PHYSICIAN: ROOM NUMBER:
DATE OF BIRTH: RELIGION: WEIGHT:
CHIEF COMPLAINT DIAGNOSIS

REMARKS: ( ) RED TAG ( ) RX MEDS ( ) ABSCOND PRECAUTION ( ) INFECTIOUS ( ) AVOID TRIGGERS

MEDICATIONS I.V. FLUIDS
DOSE & FREQUENCY TIME IVF TYPE OF FLUIDS & FLOW RATE TIME STARTED
NO

PRN/STAT MEDICATIONS SIDE DRIPS

TREATMENT DIAGNOSTIC PROCEDURES

PENDING PROCEDURE:

PROCEDURE WITH RESULTS:

DIET: ( ) CLEAR LIQUID ( ) GENERAL LIQUID ( ) SOFT DIET ( ) DAT-EDCF ( ) LOW SALT LOW
FAT
( ) DM DIET ( ) LOW PURINE ( ) HYPOALLERGENIC ( ) BRAT ( ) OTHERS PLS SPECIFY