NAITIRI SUB- DISTRICT HOSPITAL

P.O BOX 200, NAITIRI

INPATIENT ADMISSION FORM

IP Number………………………………………………
1. NAME OF PATIENT……………………………………………………………………………………….
2. AGE………………………………………………… SEX………………………………………
3. P.O BOX………………………………………………………………………………………………………..
4. VILLAGE………………………………………………………………………………………………………..
5. S/LOCATION………………………………………………ASS. CHIEF…………………………………
6. LOCATION……………………………………………………CHIEF………………………………………
7. DIVISION……………………………………………………………………..
8. DISTRICT……………………………………………………………………..
9. MARITAL STATUS: (married, single, Divorced/Widowed)……………………………
10.OCCUPATION:……………………………………………….EDUCATION LEVEL…………………
11.RELIGION:………………………………………………ID NO./PASSPORT NO…………………

NEXT OF KIN

12.NAME: ………………………………………………….. ID NO………………………………………….

13.ADDRESS: ……………………………………………..RELATIONSHIP………………………………
14.EMPLOYER……………………………………………………………………………………………………
ADDRESS………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………….
BROUGHT BY (Name) …………………………………………………………………………………………….
ID NO. / FORCE NO. /P/NUMBER………………………………………………………………….
VEHICLE NUMBER: ………………………………………………………………………………………

DATE: ………………………………………………………………TIME…………………………………………….
FORM COMPLETED BY: ………………………………………………………………………………………….
DATE: …………………………. TIME: ………………………………… SIGNATURE…………………….....

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 1

 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI

MOH 304 A
I.P NO: …………………………………….......................…………
NAME…………………………………………….........................…
AGE: …………………………………….....................………………
ADDRESS………………………………………......................…….
DATE………………………….......................……………………….
IN-PATIENT/OUT-PATIENT
CONTINUATION SHEET

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 2

 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI
NAME: ……………………………………..........……………………….. AGE: ………..........................…………… SEX: ……........………
IP/NO: ……………………………………………. WARD: ……………………..............................……. DIAGNOSIS….............……….
D. O. A: …………………………………………………………………………………............................................……………………………….
NURSING EXPECTED
DATE TIME OBJECTIVES INTERVENTION RATIONALE EVALUATION SIGN
DIAGNOSIS OUTCOME

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 3

REBUBLIC OF KENYA - MINISTRY OF MEDICAL SERVICES
 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI

CARDEX
Name …………………………………………………. IP/ No…………………………………………………
Age ……………………………. Sex: MD FD (TICK) Ward ……………………… Bed …………………
Diagnosis ………………………………… Opera on ………………………………………………………..
D. O. A ………………………….. Time ……………….. D. O. D/Death ………… Time ……………….
Date Time Notes

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 5

 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI
FOUR – HOURLY TEMPERATURE CHART
 REPUBLIC OF KENYA REPUBLIC OF KENYA
MINISTRY OF HEALTH MINISTRY OF HEALTH

LAB. REQUEST REPORT FORM LAB. REQUEST REPORT FORM

Mark box “X” NAME: ……………… Mark box “X” NAME: ………………
Pathology Bacteriology ADDRESS: ……… Pathology Bacteriology ADDRESS: ………
Hematology Biochemistry AGE: ………… Hematology Biochemistry AGE: …………
SEX: ……… SEX: ………
Previous Report Previous Report
NUMBER: …… NUMBER: ……
Previous Lab No. Previous Lab No.
Report be sent to: Report be sent to:
Specimen of: Specimen of:
Collec on of (Date) at (Time) Collec on of (Date) at (Time)

Inves ga on required: - Inves ga on required: -

DIAGNOSIS: (dura on and site of lesson DIAGNOSIS: (dura on and site of lesson
History: (therapy including an bio cs) History: (therapy including an bio cs)

........................................ ........................................ ........................................ ........................................

Doctor’s NAME (PRINTED) Signature Doctor’s NAME (PRINTED) Signature

REPORT REPORT

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 7

 MINISTRY OF HEALTH
I.P NO. ………............................................… Date: ...............……… HOSPITAL M.O.H 307
NAME: …………………..............................................................…….. FLUID INTAKE AND OUTPUT CHART
WARD: ……...........................................................................……… TO BE COMPLETED BY NURSING STAFF
BODY WEIGHT: ……………….........................................................…
BALANCE YESTERDAY +..................................................……(m/s)

INSTRUCTION FOR INTRAVENOUS INFUSION

TODAY
………………………………………...........................................………........

....................................................................................................

....................................................................................................
INSTRUCTIONS FOR ALL FLUIDS TODAY
………………………………………...........................................………........

....................................................................................................

....................................................................................................
INSTRUCTION FOR NOSAGASTRIC SUCTION
TODAY
………………………………………...........................................………........

....................................................................................................

....................................................................................................

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 8

 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI
-
IN PATIENT NOTE NAME…………........................................…………
TREATMENT i. All prescrip ons must be re -wri en weekly
I.P No. …................................……..Sex...…………
SHEET Not later than Monday mid -day
ii. Use red pen for DDA AGE……......…WARD…..............……BED.....……….
iii. Drug Allergies CONSULTANT……………………............………………….
1. ONCE ONLY PRESCRIPTIONS, START DOSES, PRE-MED ETC
FREQUENCY/
DATE DRUG DOSE ROUTE DURATION NAME & SIGNATURE TIME
1
2
3
4
II. REGULAR PRESCRIPTIONS
DATE

DATE DRUG DOSE ROUTE FREQUENCY NAME/ 9 3 9 3 9 3 9 3 9 3 9 3 9 3 9 3 9 3 9 3 9 3 9 3

DURATION SIGN a p a p a p a p a p a p a p a p a p a p a p a p

1
2
3
4
5
6
7

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 9

 NAITIRI SUB- DISTRICT HOSPITAL
P.O BOX 200, NAITIRI
DISCHARGE SUMMARY FORM

Pa ent’s Name ……………………………………..… IP No. …………….......……………………

Age ……….. Sex……… Weight (kg) ………... Ward ………………........…………………

Date of admission ……………………………...…… Ward Doctor ………….........…………

Date of discharge ……………………………....…… Consultant I/C …………….......……..

Provisional Diagnosis (on admission): ……………………………………………………......................................………....………

Discharge Diagnosis: ………………………………………………………………………………………………………………………………………
......................................................................................…………………………………………………………………………………….
Other problems noted: ……………………………………………………………………………………….........................................….
………………………………………………………………………………………………………………………………..........................................
Opera ons/Procedures ……………………………………………………………………………………………………………………………………
......................................................................................…………………………………………………………………………………….
Presen ng Complaints ………………………………...........................................…………………………………………………………..
Examina on Findings: ……………………………………………………………………………………...........................................………
………………………………………………………………………………………………………………………………...........................................
……………………………………………………………………………………………………………………………..........................................….
Clinical and Management Summary: …………………................….............................………………………………………………
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
Laboratory Inves ga on Done …………………………………………………………………………………………………………………………
………………………………………………………………………………......................................................................................…….
Radiology Inves ga ons Done …………………………………………………………………………………………………………………………
……………………………………………………………………......................................................……………...............................….
Discharge Medica ons: ………………………………………………………………………………………..…………………………………………
…………………………………………………………………………………………………………………………………………………………………………
..................................................................................................................................………………………………………….
..............................................................................................................................................................................
..............................................................................................................................................................................
Discharge care plan and Instruc ons: …………………………………………………………............................................…………
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................

……………………………………………… …………………………………………………
Name of Discharging Doctor Signature of Discharging Doctor

NAITIRI SUB- DISTRICT HOSPITAL- IN PATIENT 10