PHINMA-Cagayan de Oro College

Max Suniel Street, Carmen, Cagayan de Oro City

College of Nursing

ADMISSION AND DISCHARGE RECORD

03-1920-00841
PATIENTS ID NO.

PRIVATE CASE HOUSE CASE MED NON MED

PATIENT’S NAME (LAST NAME, FIRST NAME MI.) ROOM NO: CASE NO:
LAPAZ, MARIA GRAY 104
1098
PERMANANET ADDRESS TEL. NO: SEX: CIVIL STATUS:
MANOLO FORTITCH BUKIDNON MALE SINGLE CHILD
FEMALE SEPARATED WIDOW
MARRIED
BIRTH DATE AGE BIRTHPLACE NATIONALITY RELIGION OCCUPATION
01/23/1975 55 CAGAYAN DE ORO, MIS OR. FILIPINO CATHOLIC TEACHER
FATHERS NAME ADDRESS TELEPHONE NO.
RODRIGO, DUTERTE DAVAO, CITY 0979
MOTHERS MAIDEN NAME ADDRESS TELEPHONE NO.
PASCO, ANABELLE CAGAYAN DE ORO 039737

NAME OF SPOUSE OCCUPATION TELEPHONE NO.

MARCOS, SANDRO ARTIST 092837
IN CASE OF EMERGENCY: ADDRESS/TELEPHONE NO. RELATIONSHIP
ILOCPOS HUSBAND
MARCOS, SANDRO
ADMISSION DISCHARGE TOTAL NO. CONDITION UPON ADMISSION ADMITTED BY
OF DAYS
Date: 02/27/22 Date:  gradual, painless vision loss. WARREN, RN
Time: 7AM Time:
ALLERGIES HOSPITALIZATION PLAN NAME OF HEALTH INSURANCE CLASSIFICATION
PHILHEALTH INDIGENT
NO KNOWN ALLERGIES
INFORMANT NAME: ADDRESS OF INFORMANT RELATIONSHIP TO PATIENT
SIGNATURE:

ADMITTING DIAGNOSIS

CATARACT

PRINCIPAL DIAGNOSIS

OTHER DIAGNOSIS

OTHER OPERATION/PROCEDURES
 PHINMA-Cagayan de Oro College
Max Suniel Street, Carmen, Cagayan de Oro City

College of Nursing

DISPOSITION RESULT ATTENDING PHYSICIAN

DISCHARGE TRANSFERRED RECOVERED <48HRS NO AUTOPSY DR. MANOLO
DAMA/HAMA ABSCONDED EXPIRED >48HRS AUTOPSY _____________________________________
NAME & SIGNATURE