MAO-AWEYS INTERNATIONAL

Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

FLUID BALANCE CHART

NAME:_____________________________________ IP NO.____________________
DOCTOR: ________________________ WARD____________ BED NO____________
AGE:__________________WEIGHT___________ kgs DATE:___________________
INTAKE (m/s) OUTPUT (m/s)
Intravenous Alimentary Urine
Time Type Bo le Infused Type Amount Vomit Stool N/Gast Others Amount Sp.Grav
6-7 am
8
9
10
11
12MD
1
2
3
4
5
6
7
TOTAL
8
9
10
12 MIN
1
2
3
4
5
TOTAL
24HRS TOTAL
INTRAVENOUS TOTAL INTAKE VOMIT
ALIMENTARY TOTAL OUTPUT STOOL
TOTAL BALANCE NASO GAST
OTHERS
URINE
TOTAL OUTPUT

Intravenous Infusion:

Other Instruc ons:

 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

ENSURE THAT ALL MEDICINE, SURGICALS, PROCEDURES, LABORATORY CHARGES.

ACCOMMODATION AND OTHER FEES ARE CORRECTLY CHARGED BEFORE GIVING THE
FINAL BILL TO THE CUSTOMERS.

INITIAL DEPOSIT PAID: ________________________

1. DOCTOR
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

2. LABORATORY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

3. RADIOLOGY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
4. NURSING
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

5. PHARMACY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
6. HOUSEKEEPING
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

7. CLAIMS MANAGER
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

8. BILLING MANAGER
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

CONTINUATION SHEET

IP NO:..................................................... WARD:......................................................

NAME:.............................................................AGE:.................... WT:................................
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

BED-HEAD TICKET:................................................... IP NUMBER:.....................................

NAME:..........................................................................................................D.O.B....................................
SEX:................................. AGE:.................................................. WT:.....................................................
PARENT/GUARDIAN:........................................................................TEL:..............................................
D.O.A:.............................................................................................TIME:.................................................
ADMITTING DOCTOR:............................................................................................................................
COMPLAINTS:..........................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
HISTORY:...................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
P.M.H:..........................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
FAMILY HISTORY:
.....................................................................................................................................................................
.....................................................................................................................................................................
DRUG HISTORY:
.....................................................................................................................................................................
.....................................................................................................................................................................

R.O.S...........................................................................................................................................................
.....................................................................................................................................................................

PHYSICAL EXAMINATION:
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
DIAGNOSIS................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

NAME............................................. IP/NO.......................................DATE...........................

ITEM COST @ ITEM QUANTITY TOTAL COST

DOCTOR’S ROUND
NURSING CARE
BED CHARGE
NEEDLES & SYRINGES
OTHERS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

TOTAL COST
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

NURSING PROGRESS REPORT

PATIENT NAME.....................................................................DATE OF ADMISSION...........................................

DATE TIME NAME

 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

IN-PATIENT VITAL SIGNS SHEET

NAME................................................................................................ IP NO....................................

DATE TIME TEMP RESP BP PULSE COMMENTS SIGN

COMMENTS.......................................................................................................................................
..............................................................................................................................................................
.............................................................................................................................................................
..............................................................................................................................................................
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

WARD CHECKLIST -
ENTRY ITEM NO: CONDITION EXIT NO: CONDITION
DATE DATE
ADJUSTABLE BED WITH SIDE RAILS
ADJUSTABLE BED
FLAT BED
TABLE
TEA TROLLEY
COFFEE TABLE
SOFA CHAIR
BEDSIDE LOCKER
MATTRESS
BEDSHEET
PILLOW
PILLOW CASE
BLANKET
BED COVER
MOSQUITO NET
BULB
SOCKET
CURTAINS
WINDOW PANE
TV
DRIP STAND (OLD AND NEW)
TOILET
SHOWER
SINK
OXYGEN CYLINDER
OXYGEN FLOW METER
HUMIDIFIER
VITAL MONITOR
MORTEIN DOOM
BUCKET DUSTBIN

PATIENT’S SIGNATURE: PATIENT’S SIGNATURE:

NURSE’S SIGNATURE: NURSE’S SIGNATURE:
1. HOW DID YOU FIND OUR SERVICE IN THE HOSPITAL? (KINDLY LET US KNOW)
....................................................................................................................................................
....................................................................................................................................................
 MAO-AWEYS INTERNATIONAL
Mao-Aweys HOSPITAL
INTERNATIONAL
HOSPITAL Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi
P.O. Box 2732-00610 | Tel: 0796 529 181 - 0796 529 182

NURSING CARDEX
BIODATA:
NAME________________________________ DATE OF ADMISSION:_____________
AGE:_________________________________PHONE NUMBER:__________________
NEXT OF KIN’S NAME:_________________PHONE NUMBER:__________________
DIAGNOSIS:

PRESENTING ILLNESS/CHIEF COMPLAINS:

PAST MEDICAL AND SURGICAL HISTORY:

FAMILY HISTORY: