Dr. Jose P. Rizal Memorial District Hospital: Philhealth Accredited

REPUBLIC OF THE PHILIPPINES
PROVINCIAL GOVERNMENT OF LAGUNA

DR. JOSE P. RIZAL MEMORIAL DISTRICT HOSPITAL
BUCAL, CALAMBA CITY, LAGUNA
Surname: ___________________________ Age: __________ Hospital No.: ________________

Given Name: ___________________________ Sex: __________ Ward/ Room No.: ________________
HISTORY
Chief Complaint: ______________________________________________________________________________________

History of Present Illness: ______________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Review of Systems
( ) Fever ( ) Jaundice ( ) Cough ( ) Chest Pain ( ) Diarrhea ( ) Polyuria

( ) Body Malaise ( ) Pallor ( ) Colds ( ) Palpitation ( ) Constipation ( ) Polydypsia
( ) Muscle Pain ( ) Cyanosis ( ) Dyspnea ( ) Orthopnea ( ) Hematochezia ( ) Polyphagia
( ) Joint Pain ( ) Rash ( ) Hemoptysis ( ) PND ( ) Melena ( ) Dysuria
( ) Weight Loss ( ) Edema ( ) Easy Fatigability ( ) Abdominal Pain ( ) Hematemesis ( ) Hematuria
( ) Easy Bruisability
Past Medical History
( ) Food Allergy ( ) HPN ( ) Surgeries ( ) Cancer ( ) Drug Allergies, Specify: _____________________

( ) Asthma ( ) DM ( ) TB ( ) Other Disease: ____________________________
( ) Previous Hospitalization: ____________________________________________________________________________
Family Medical History: _______________________________________________________________________________
Personal / Social History
Current Profession: _______________________ ( ) Smoker ( ) Alcoholic Drinker
OB – Gyne History (If Applicable)
Menarche _________ Interval _________ Duration ________ Associated Symptoms __________

G ___ P ___ (T__ P__ A__ L__) LMP: ________ PMP: __________
Physical Examination BP= _____ CR=_____ RR=_____ T=_____
General _____________________________________________________________________________
Survey:
HEENT: _____________________________________________________________________________
C / L: _____________________________________________________________________________
C /S: _____________________________________________________________________________
Abdomen: _____________________________________________________________________________
Extremities: _____________________________________________________________________________
Genitalia: _____________________________________________________________________________
Neuro: _____________________________________________________________________________
PHILHEALTH ACCREDITED
LABORATORY SHEET
ATTENDING WARD NO.
FAMILY NAME FIRST NAME
PHYSICIAN BED NO.
DOCTOR’S ORDER SHEET
NAME: _________________________ AGE: ______ SEX: _____ CIVIL STATUS: ___________

WARD: ________________ BED NO.: _____ HEALTH RECORD NO.:__________________________
ALL ORDERS MUST BE SIGNED BY THE PHYSICIAN
DATE / TIME PROGRESS NOTES DOCTOR’S ORDER
ALL ORDERS MUST BE SIGNED BY THE PHYSICIAN

DATE / TIME PROGRESS NOTES DOCTOR’S ORDER
MEDICATION SHEET
(NAME OF PATIENT) (PHYSICIAN)
MEDICATION TREATMENT DATE DATE DATE DATE DATE
Sedative and Diabetes Medication
Diet= Full-F Soft-S

Liquid-L
Appetite= Good-G Fair-F Poor-
P
AM
General Care
PM
Diet Good= Fair-F Poor-P
Patient Weak - W Fair - F
Condition = Fairly Weak - FW

PARENTERAL FLUID SHEET
Type of Solution, Rate, Site,

TIME Started Medication Amount Discontinued
DATE Started
Mode of Administration, Size
by: Added: Infused: by:
REMARKS
and Kind of Needle/Cannula

FLUID INTAKE AND OUTPUT CHART
DIAGNOSIS: _________________________________________________________________________________
_____________________________________________________________________________________________
DATE: INTAKE OUTPUT

TIME ORAL PARENTERAL TOTAL URINE DRAINAGE OTHERS TOTAL
6-2
2-10
10-6
TOTAL
DATE: INTAKE OUTPUT

6-2
2-10
10-6
TOTAL
DATE: INTAKE OUTPUT

6-2
2-10
10-6
TOTAL
DATE: INTAKE OUTPUT

6-2
2-10
10-6
TOTAL
DATE: INTAKE OUTPUT

6-2
2-10
10-6
TOTAL
VITAL SIGNS RECORD

Bed no. ____________
Case No. ______________ Doctor ______________________
Year ______________ Month ______________ Name ______________________
Day of Month
Day of Disease
Number of Days in
Hospital
Weight
Respir
r-ature
Tempe
a-tion
Pulse
42
41
40
107
39
105
180
38
104
37
102
160 36
100
35 98
140
96
95
120
100
80
6-2
Urine
2-10
Output
10-6
6-2
Stool 2-10
10-6
Blood Pressure

VITAL SIGNS MONITORING SHEET
DATE / TIME BP CR RR TEMP. REMARKS
NUTRITION AND DIETETICS SERVICE

NUTRITIONAL ASSESSMENT FORM
I. Patient’s Information
Last Name First Name Middle Name Date Ward / Room
Address: Age: Sex: Status:
Religion: Occupation: Height: Weight:
Diagnosis: Attending Physician
Diet Description:
II. Physical Data:

Food Intake / Appetite EXCELLENT GOOD FAIR POOR
Nutritional Status: Well Nourished Moderately Malnourished
Severely Malnourished Malnutrition
Functional Capacity: __________ Ambulatory __________ Bedridden

Bowel Movement: __________ Regular __________ Irregular
III. Recommendations:
Shift Diet To: _________________________________________________________________
Nutrition Education / Counseling: _________________________________________________________________
Request for Laboratory Data: _________________________________________________________________
Other Restrictions: _________________________________________________________________
IV. Follow-up:
Assessed By: ____________________________________
Name: _______________________________________________ Physician: _________________________________

Address: _____________________________________________ Date: _____________________________________
NURSES’ PROGRESS NOTES
DATE/TIME FOCUS DATA / ACTION / RESPONSE
DATE/TIME FOCUS DATA / ACTION / RESPONSE
SURNAME: __________________________ AGE: _____ HEALTH RECORD NO.:___________________________

GIVEN NAME: _______________________ SEX: M F WARD / RM: ________________________________
ADDRESS: ___________________________________________________________________________________________
DISCHARGE SUMMARY / CLINICAL ABSTRACT
Date Admitted: ____________________________ Date of Discharge: _____________________________

Attending Physician: __________________________________________________________________________
Admitting Diagnosis: __________________________________________________________________________
Final Diagnosis: __________________________________________________________________________
Chief Complaints: __________________________________________________________________________
Brief Clinical History and Pertinent P.E __________________________________________________________
_____________________________________________________________________________________________
Laboratory Findings :( Including EKG, X-ray and other diagnostic procedure)

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Course in the Ward :( Include medications)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Disposition: (Indicate home medication, special instruction and follow- up)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________ _________________________________
Date Accomplished Resident In-charge
DISCHARGE PLAN
Health Record No. _______________

Name of Patient: _______________________________________________ Age: _______ Sex: ______
Address: ____________________________________________________________________________
Date of Admission: _____________________ Date of Discharge: ___________________
Admitting Diagnosis: __________________________________________________________________
Final Diagnosis: ______________________________________________________________________
HOME MEDICATIONS:
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
5. _________________________________________________________________________________
6. _________________________________________________________________________________
7. _________________________________________________________________________________
8. _________________________________________________________________________________
9. _________________________________________________________________________________
10. _________________________________________________________________________________
HOME CARE/ADVISE: ___________________________________________________________

___________________________________________________________
Follow-up at:
_____________________
Follow-up on:
_____________________ ________________________
(Date and Time) Physician
** Note: Dadalhin sa araw ng konsulta **
Client Satisfaction Survey Form

1. Upon my admission, I was received well by the medical, nursing and admitting staff. (Maayos akong
tinanggap ng mga doctor, nars at admitting section noong ako ay nagpa-admit)
Yes (Oo) No (Hindi)
2. The Hospital staff conducted themselves in a professional manner. (Maayos at propesyonal ang mga
doctor, nars at iba pang kawani ng ospital)
Yes (Oo) No (Hindi)
3. My privacy was respected and I felt secure during my hospital stay. (Iginalang at nirespeto ang aking
pagkatao at seguridad sa kabuuan ng aking pagka-ospital)
Yes (Oo) No (Hindi)
4. I was satisfied with the food served to me. (Nasiyahan ako sa pagkaing inihain sa akin)
Yes (Oo) No (Hindi)
5. The medicines and supplies I needed were readily available in the hospital. (Ang mga gamot at kagamitan
para sa aking gamutan ay mabilis at maayos na nakuha mula sa ospital)
a. Drugs were readily available in the hospital.
Yes (Oo) No (Hindi)
b. Laboratory services were available in the hospital
Yes (Oo) No (Hindi)
6. The assistance of the Medical Social Service Section was made available to me. (Ipinakilala at
pinaliwanag sa akin/amin ang mga serbisyo ng Medical Social Service)
Yes (Oo) No (Hindi)
7. The staff of the Medical Social Service section was professional, helpful and accommodating to my needs
and concerns. (Ang mga kawani ng ospital sa Medical Social Service ay propesyonal, matulungin at
maasikaso sa pakikitungo sa akin/amin)
Yes (Oo) No (Hindi)
8. My condition and other instructions related to my care were well explained to me by my healthcare team.
(Maayos na naipaliwanag sa akin ng doctor, nars at iba pang kawani ng ospital ang aking kalagayan at
mga plano ng aking pagpapagamot)
Yes (Oo) No (Hindi)
9. I was satisfied with the overall cleanliness of my room and toilets in the hospital. (Nasiyahan ako sa
pangkalahatang kalinisan ng aking kwarto o ward at banyo sa ospital)
Yes (Oo) No (Hindi)
10. I was satisfied with the process of my discharge. (Nasiyahan ako sa proseso ng aking pag-uwi)
a.My bill was complete and accurate (Kumpleto at tama ang aking hospital bill)
Yes (Oo) No (Hindi)
b. The staff of the Billing and Cashier’s section were professional and accommodating.
(Propesyonal at maayos ang pakikitungo sa akin/amin ng mga kawani ng ospital sa Billing at
Cashier’s Section)
Yes (Oo) No (Hindi)
c.I was instructed on the date of my follow-up schedule. (Sinabihan ako kung kailan ako babalik para
sa aking check-up)s
Yes (Oo) No (Hindi)
 Karagdagang komento: ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
CONSENT FOR ADMISSION
Name: ______________________________ Date: ___________________

Address: ______________________________ Ward: ___________________
All authorized must be assigned by the patient or by the nearest relatives in case of minor or
when patient is physically or mentally incompetent.
BE IT KNOWN THAT I, ________________________, of legal age hereby authorized any

member of the medical staff of Dr. J.P. Rizal Memorial District Hospital, Bucal, Calamba City, Laguna
to administer any treatment as may deemed necessary or advisable in diagnosis or treatment of the
illness of _______________________________.
Date: _________________________ ____________________________________

(Signature of Patient or Relative)
Address: ______________________ ____________________________________

(Relationship to Patient)
Admitting Clerk: ____________________________________

(Printed Name and Signature)
RELEASE FROM RESPONSIBILITY FROM DISCHARGES
I hereby certify that I am leaving or taking out from Dr. J.P. Rizal Memorial District
Hospital, Bucal, Calamba City, Laguna, ______________________________ of my own free
will and against the advise of the Physician and/or hereby release the hospital authorities and
attending Physician of all responsibility from the result of the action.
_________________________________
(Signature of nearest relative)

Dr. Jose P. Rizal Memorial District Hospital: Philhealth Accredited

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Dr. Jose P. Rizal Memorial District Hospital: Philhealth Accredited

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Copyright:

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REPUBLIC OF THE PHILIPPINES

PROVINCIAL GOVERNMENT OF LAGUNA

Surname: ___________________________ Age: __________ Hospital No.: ________________

Chief Complaint: ______________________________________________________________________________________

( ) Fever ( ) Jaundice ( ) Cough ( ) Chest Pain ( ) Diarrhea ( ) Polyuria

Past Medical History

( ) Food Allergy ( ) HPN ( ) Surgeries ( ) Cancer ( ) Drug Allergies, Specify: _____________________

Family Medical History: _______________________________________________________________________________

Personal / Social History

Current Profession: _______________________ ( ) Smoker ( ) Alcoholic Drinker

OB – Gyne History (If Applicable)

Menarche _________ Interval _________ Duration ________ Associated Symptoms __________

Physical Examination BP= _____ CR=_____ RR=_____ T=_____

DOCTOR’S ORDER SHEET

NAME: _________________________ AGE: ______ SEX: _____ CIVIL STATUS: ___________

ALL ORDERS MUST BE SIGNED BY THE PHYSICIAN

(NAME OF PATIENT) (PHYSICIAN)

MEDICATION TREATMENT DATE DATE DATE DATE DATE

Sedative and Diabetes Medication

Diet= Full-F Soft-S

NAME: _________________________ AGE: ______ SEX: _____ CIVIL STATUS: ___________

PARENTERAL FLUID SHEET

Type of Solution, Rate, Site,

NAME: _________________________ AGE: ______ SEX: _____ CIVIL STATUS: ___________

FLUID INTAKE AND OUTPUT CHART

DATE: INTAKE OUTPUT

DATE: INTAKE OUTPUT

DATE: INTAKE OUTPUT

DATE: INTAKE OUTPUT

DATE: INTAKE OUTPUT

VITAL SIGNS RECORD

NAME: _________________________ AGE: ______ SEX: _____ CIVIL STATUS: ___________

VITAL SIGNS MONITORING SHEET

DATE / TIME BP CR RR TEMP. REMARKS

NUTRITION AND DIETETICS SERVICE

Address: Age: Sex: Status:

Religion: Occupation: Height: Weight:

Diagnosis: Attending Physician

II. Physical Data:

Nutritional Status: Well Nourished Moderately Malnourished

Severely Malnourished Malnutrition

Functional Capacity: __________ Ambulatory __________ Bedridden

Assessed By: ____________________________________

Name: _______________________________________________ Physician: _________________________________

NURSES’ PROGRESS NOTES

DATE/TIME FOCUS DATA / ACTION / RESPONSE

DATE/TIME FOCUS DATA / ACTION / RESPONSE

SURNAME: __________________________ AGE: _____ HEALTH RECORD NO.:___________________________

DISCHARGE SUMMARY / CLINICAL ABSTRACT

Date Admitted: ____________________________ Date of Discharge: _____________________________

Laboratory Findings :( Including EKG, X-ray and other diagnostic procedure)

Health Record No. _______________

HOME CARE/ADVISE: ___________________________________________________________

** Note: Dadalhin sa araw ng konsulta **

Client Satisfaction Survey Form

CONSENT FOR ADMISSION

Name: ______________________________ Date: ___________________

BE IT KNOWN THAT I, ________________________, of legal age hereby authorized any

Date: _________________________ ____________________________________

Address: ______________________ ____________________________________

Admitting Clerk: ____________________________________

RELEASE FROM RESPONSIBILITY FROM DISCHARGES

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Surname: _________ Age: Hospital No.:

Menarche _____ Interval _ Duration Associated Symptoms ______

Physical Examination BP= ___ CR=_ RR=_ T=___

NAME: _____________________ AGE: SEX: _ CIVIL STATUS: _________

NAME: _____________________ AGE: SEX: _ CIVIL STATUS: _________

NAME: _____________________ AGE: SEX: _ CIVIL STATUS: _________

NAME: _____________________ AGE: SEX: _ CIVIL STATUS: _________

Functional Capacity: Ambulatory Bedridden

Name: _______________ Physician: _

SURNAME: ________________________ AGE: _ HEALTH RECORD NO.:_________________________

Date Admitted: Date of Discharge: _

Note: Dadalhin sa araw ng konsulta

Name: ____________ Date: _

Date: _ ____________

Address: ______________