WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER

JARO, ILOILO CITY

ADMITTING NOTES

Name:
Age: Sex: Marital Status:
Chief Complaint:
HISTORY
History of Present Illness:

Past Medical History:

Family History:

Personal, Social, and Environmental History:

OB-Gyne History:

Perinatal History
Pre-natal History:

Natal History:

Post-natal History:

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

PHYSICAL EXAMINATION
General Survey:
Vital Signs: BP= CR= RR= Temp= O2 Sat=
Anthropometric Measurement: Wt.= Ht.= HC=
Head and Neck:

Chest and Lungs:

Heart:

Abdomen:

Genito-urinary:

Digital Rectal Exam:

Extremities:

Internal and Bimanual Exam

Cervix:
Uterus:
Adnexa:
Leopold’s Maneuver:
L1 L2 L3 L4

NEUROLOGIC EXAMINATION
Mental Status Exam:

Cranial Nerves Exam

I:
II, III:
III, IV, VI:
V:
VII:
VIII:
IX, X:
XI:
XII:
Motor Examination: Sensory Examination:

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

Deep Tendon Reflexes:

Abnormal Reflexes:

Meningeal Signs:

Autonomics:

Admitting Diagnosis:

Diagnostic Plans:

Therapeutic Plans:

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
LABORATORY FLOW SHEET

DATES
CBC
Hemoglobin
Hematocrit
WBC
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelets
Clinical Chem
Creatinine
BUN
Uric Acid
Sodium
Potassium
Calcium
Magnesium
Phosphorus
Ferritin
RBS
FBS
T. Cholesterol
Triglycerides
LDL
HDL
Acid Phos.
Alk Phos.
SGPT
SGOT
Total Protein
Albumin
Globulin
Anti-HAV
Coagulation
Prothrombin
INR
APTT
Clotting Time
Bleeding Time
ABG
pH
PO2
pCO2
HCO3
O2 Sat
Base excess

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

Urinalysis
Color
Transparency
pH
Specific Gravity
Sugar
Albumin
Pus Cells
Red Blood Cells
Casts
RBC
Urates
Hyaline
Broad
Crystals
Fecalysis
Consistency
Pus Cells
Red Blood Cells
Organisms
Occult Blood

OTHER DIAGNOSTICS
Radiography
Date:

Ultrasound
Date:

Electrocardiography
Date:

2D Echocardiography
Date:

Arterial/Venous Doppler Ultrasound

Date:

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WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
PROBLEM LISTS

Symptom Date of Onset Date Resolved

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WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
THERAPEUTIC FLOW SHEET

Medication Date Started Date Discontinued

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
THERAPEUTIC INDEX

1 Medication: 4 Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

2 Medication: 5 Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

3 Medication: 6 Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
THERAPEUTIC INDEX

Medication: Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

Medication: Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

Medication: Medication:
Generic: Generic:
Adverse Reaction: Adverse Reaction:

Indications: Indications:

Contraindications: Contraindications:

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 WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER
JARO, ILOILO CITY

CLINICAL CLERKS
PROGRESS NOTES

Date: Date:
Subjective Complaint: Subjective Complaint:

Objective Findings: Objective Findings:

T- T-
PR- PR-
RR- RR-
BP- BP-
O2 Sat- O2 Sat-

Assessment: Assessment:

Plans: Plans:

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