Reporting, Management, and Referral

Date Time Name Age Sex Grade & Teacher Chief Complaint(s) Doctor's Order Treatment Administered By Remarks Follow-up
Admitted Section Adviser [Reason(s) for the [To be initialed by the Medical [Indicate how the instructions of Status [As
clinic visit/reported Officer upon visit]/ Supported the doctor were followed, as well needed;
symptom(s)] by the doctor's as other actions taken; e.g., Date/Status]
Prescription/Instruction ordered to return to classroom,
Slip what time; reported to BHERT,
specify contact number; informed
the parent about
instructions, fetched by; etc.]
_ Administer treatment Paracetamol 5ml,
_ Contact the parents given at 10:30 am
_ Refer to health facility
_ Report to BHERT

Prepared by: Checked by: Noted by: Validated by:

_____________________ _____________________ _____________________ _____________________

Name of School Head Name of District Supervisor Name of Nurse-in-Charge Name of SDO Coordinator for F2F