Admission Chart 2023

DESERET SURGIMED HOSPITAL INC.
Nat’l Higway, Kabacan, North Cotabato

Contact no. (064) 5775770 / Email add: deseretsurgimed@gmail.com
“Let us handle your Health. The Deseret Way”
Hospital #
CLINICAL COVER SHEET
Case #
LAST GIVEN MIDDLE WARD/ROOM
PERMANENT ADDRESS CONTACT NO. SEX CIVIL STATUS

( ) M ( )CHILD ( )SINGLE
( ) F ( )WIDOW ( )MARRIED
BIRTHDATE AGE BIRTHPLACE:
NATIONALITY:
RELIGION:
EMPLOYER (TYPE OF BUSINESS) TEL NO.:
OCCUPATION:
FATHER’S NAME: ADDRESS:
MOTHER’S NAME: ADDRESS:
SPOUSE’S NAME: ADDRESS:
ADMISSION: DISCHARGED:
DATE:_______________ DATE:_______________ ADMITTING NOD:_________________________
TIME:________( )AM ( )PM TIME:________( )AM ( )PM
ADMITTING CLERK:________________________
TYPE OF ADMISSION REFERRED BY( PHYSICIAN/AGENCY)
( ) NEW ( ) OLD ( )FORMER OPD
SOCIAL SERVICE QUALIFICATION

ALLERGIC TO: HOSPITALIZATION PLAN HEALTH INSURANCE ( )PHIC
( )FOOD COMPANY/INDUSTRIAL NAME: ( )SSS
( )DRUGS ( )GSIS
( )OTHERS, SPECIFY
DATA FURNISHED BY: INFORMANT’S ADDRESS RELATION TP PATIENT
ADMISSION DIAGNOSIS ICD CODE
FINAL DIAGNOSIS ICD CODE
PRINCIPAL OPERATION PROCEDURE/S
OTHER OPERATION PROCEDURE/S
ACCIDENT/INJURIES/POISONING
PLACE OF OCCURANCE:
DISPOSITION RESULT
( )DISCHARGED ( )RECOVERED ( )IMPROVED ADMITTING M.D_________________________
( )TRANSFERRED ( )DIED ( )UNIMPROVED
( )DAMA ( )-48 HOURS ( )AUTOPSY) ATTENDING M.D_________________________
( )ABSCONDED ( ) 48 HOURS ( )NO AUTOPSY
AUTHORIZATION
“Revised 2023”
CONSENT FOR ADMISSION:

I,___________________________, of legal age, and a resident of ____________________ do hereby
give my consent for my own/on behalf of my parent/spouse/ child/ grandchild/ relative/ dependent/ friend/
employee/ employer’s admission and treatment at Deseret Surgimed Hospital.
CONSENT TO TREATMENT:
I voluntarily give my consent after being informed properly about the treatment/ procedures involved in
the medical/surgical management of my/my patient’s case and their consequences including the advantages,
complications, risks and costs, and reasonable alternatives.
I hereby authorize the physician/staff who is given authority and privilege by this hospital to examine,
diagnose, and institute proper management as deemed necessary for my/my patient’s case.
REFUSAL FOR TREATMENT:

I/My patient am/was given the freedom to refuse any form of treatment and was informed of its medical
consequences. And in the event of my/ my patient’s refusal against any medical advice, I/We shall not hold the
Deseret Surgimed Hospital and its staff responsible for the consequences of my/my patient’s decision.
MEDICATIONS/SUPPLIES:
I give my consent / on behalf of my parents/ spouse/ child/ grandchild/ relative/ dependent/ friend/
employee/ employer to Deseret Surgimed Hospital’s pharmacy to provide all medication and supplies
prescribed by the Attending Physician/s except only when for some reasons, they are beyond the capacity of
the hospital to procure. And in the event that I have to procure them outside, DSH Pharmacy has the right to
screen and refuse administration of said medicines for just cause.
RELEASE OF INFORMATION:
I hereby authorize Deseret Surgimed Hospital and its staff to disclose all or nay parts of the patient
record (1) to any person, corporation, or agency, which is legally responsible for all or any parts of the hospital
charges, including but not limited to hospital or medical service companies, insurance companies, workmen’s
compensation carriers, welfare fund or the patient employer and (2) to the patient’s personal or other physician
rendering professional care to the patient.
OTHERS:
I/My patient have/has been informed of my/his/her rights and responsibilities as a patient.
I guarantee my/my patient’s capability to pay all expenditures incurred during my/his/her hospital stay, and
should not leave the hospital without fully settling my/his/her accounts and providing for all the necessary
documents regarding my/his/her insurance.
I am fully aware of our responsibility for the safe-keeping of our personal belongings and valuable items
that we shall be bringing to the hospital during my/his/her confinement, and shall not hold Deseret Surgimed
Hospital responsible for their loss or destruction.
CERTIFICATION:
The undersigned certifies that he/she has read the forgoing has been explained to him/her in his/her
dialect, that he/she fully understands the nature and purpose of this authorization and that he/she is the patient
or is duly authorized by the patient as patient’s general agent to execute the above and accept its terms.
___________________________ ___________________________
Signature of Witness Signature of Patient
____________________
Date
Authorization must be signed by the patient or by the nearest relative in case of a minor or when patient
is physically unable or mentally incompetent.
Patient is minor _________________ years of age.
Patient is unable to sign because_____________________________.
_______________________ _________________________
Signature of Witness Signature of Representative
______________________ _________________________
Date Relationship to Patient
“Revised 2023”
Waiver for admisision
KNOW ALL MEN BY THESE PRESENTS:
The undersigned is the patient, or is/ are the relative(s) of patient (ang nakapirma sa ilalim ay
pasyente o kamaganak ng pasyente na si) ________________________________________ who is
presently confined in Deseret Surgimed Hospital for ( na naadmit sa Deseret Surgimed Hospital sa
sakit na). Date of confinement (petsa ng admisyon) _________________________________________,
under the service / care (sa pangangalaga/ serbisyo ni) Dr. ____________________________________.
Physician
I/We undertake that in case the diagnosis, sickness for confinement will not be covered by
PHILHEALTH (Ako/Kami ay naiintindihan na kung ang sakit na nagging sanhi ng kanyang pagka-admit
ay hindi mabayaran ng PHILHEALTH). I/We undertake to shoulder all expenses incurred during the
confinement period.(Ako/Kami ang magbabayad sa lahat ng bayarin sa panahong siya ay na admit sa
inyong hospital).
IN WITNESS WHEREFORE, I have hereunto set my hand this (bilang katunayan ako ay lumagda ditto ngayong ika-)
___________day of (sa araw ng) __________________________________ at Kabacan, Cotabato, Philippines. (Dito
sa bayan ng Kabacan Cotabato, Pilipinas).
__________________________________________
Name and Signature (Pangalan at Lagda)
Witnessed by ( Nakasaksi sila)
___________________________ ___________________________
Name/Signature Name/Signature
ER staff Relationship to patient
Date: Cp No. ________________
CLINICAL CASE RECORD

“Revised 2023”
Surname: Age/Sex: Physician:

Given Name: Ward/Rm: Admission No.:
MEDICAL EXAMINATION SHEET

PAST MEDICAL HISTORY: IMMUNIZATION:
OBGYNE HISTORY:
FAMILY/SOCIAL HISTORY:
FOOD AND DRUG ALLERGIES:
ADMITTING DIAGNOSIS:
CHIEF COMPLAINT:
REASON FOR ADMISSION:
____________________________________________________________________________________________________________________
History of Present Illness::
____________________________________________________________________________________________________________________
PHYSICAL EXAMINATION
General Survey:
Vital Signs: BP: __________ HR: _________ RR: _________ Temp: ________
HEENT:
Chest & Lungs:
Heart:
Abdomen:
GUT/ IE
Skin/Extremities:
Neuro Examination:
Review of Systems:
General:
Skin Respiratory Genitourinary
HEENT Cardiovascular Reproductive
Musculoskeletal Gastrointestinal Nervous
Admitting Physician

“Revised 2023”
LABORATORY/ X-RAY RESULT/ RESULT
Please attach 1st laboratory result here
Date
Day in Hospital
FLOOR AM PM AM PM AM PM AM PM AM PM AM PM
Time 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10 2 6 10
T 42
E
41
“Revised 2023”
40
39
38
M
P
E 37
R
A 36
T
35
U
200
190
180
170
160
Pulse rate
150
140
130
120
110
100
90
80
70
60
50
Respiratory 40
rate
30
20
10
>96
O2 94-95
Saturation
92-93
<91
Sys
Blood
Pressure Dias VITAL SIGN RECORD
PATIENT NAME: AGE/SEX PHYSICIAN

TPR MONITORING RECORD
“Revised 2023”
Date Time Temperature Cardiac Pulse Resp. Blood O2 Name & Signature
Rate Rate Rate Pressure Sturation

DOCTOR’S ORDER/ NURSES COMPLIANCE SHEET

(Authenticate all orders)
Date/ time Order C A R E D Date/Time
“Revised 2023”
Progress note Posted/

Signature

MEDICATION SHEET
MEDICINE FREQUENCY
“Revised 2023”
PRN MEDS
STAT/ SINGLE DOSE MEDS

DATE/ TIME MEDICINE SIGNATURE DATE/ TIME MEDICINE SIGNATURE
DATE NAME & SIGNATURE DATE NAME & SIGNATURE

INTRAVENOUS FLUID FLOW SHEET

NO. DATE & TIME SIGNATURE
NAME OF IVF VOLUME CONSUMED OF NOD REMARKS
(INCLUDE AND DATE &
RATE SIGNATURE
INCORPORATIONS) TIME OF NOD
HOOKED
“Revised 2023”

NURSESNOTES
DATE TIME FOCUS DATA /ACTION/ RESPONSE
“Revised 2023”

DISCHARGE SUMMARY
Date Admitted: _____________________ Date of Discharge: ________________________

Attending Physician: ____________________________________________________________
“Revised 2023”
Admitting Diagnosis:_____________________________________________________________
Final Diagnosis ________________________________________________________________
_____________________________________________________________________________
Brief Clinical History & Pertinent P.E:
Laboratory Finding: (incl. EKG, X-ray, and other diagnostic procedures)
Hematology: X-Ray/ CT-Scan: Urinalysis:
Fecalysis: Blood Chemistry: Others:
Course in the Ward: (incl. medications)
Disposition: (indicate home medications, special instructions and follow-up)
Please come back on ______________________ for follow up check-up. Please bring this form.
Date Accomplished : ________________ Received by: _______________

Nurse on duty: _______________________ Physician: __________________
SUMMARY CHART
FAMILY NAME: FIRST NAME: ROOM NO.:
ATTENDING PHYSICIAN:
MEDICAL PROFESSIONAL FEES Attending Physician________________________
Surgeon ________________________
Anesthesiologist ________________________
Date Item Quantity Remarks
“Revised 2023”
WAIVER FOR ADMISSION
KNOW ALL MEN BY THESE PRESENTS:
The undersigned is the patient, or is/are the relative(s) of patient (ang nakapirma sa ilalim ay ang pasyente o
kamaganak ng pasyente na si) ___________________________________________________ who is
“Revised 2023”
presently confined in Deseret SurgiMed Hospital for (na naadmit sa Deseret SurgiMed Hospital sa sakit na)
, under the service/ care ( sa pangangalaga/ serbisyo ni) Dr. ______________________________.
Physician
I/WE undertake that in case the diagnosis, sickness for confinement will not be covered by PHILHEALTH
(ako/kami ay naiintindihan na kung ang sakit na naging sanhi ng kanyang pagka-admit ay hindi mabayaran ng
PHILHEALTH). I/WE undertake to shoulder all expenses incurred during the confinement period. (Ako/Kami
ang magbabayad sa lahat ng bayarin sa panahong sya ay nadmit sa inyong ospital).
IN WITNESS WHEREFORE, I have hereunto set my hand this (bilang katunayan ako ay lumagda dito
ngayong ika-) day of (sa araw ng) At kabacan, North Cotabato,
Philippines (dito sa Bayan ng Kabacan,Hilagang Cotabato, Pilipinas).
Name and Signature (Pangalan at Lagda)
Witnessed by (nakasaksi sila):
Name and Signature Name and Signature

ER Staff: Relation to Patient
Date: Date:
ANTIMICROBIAL STEWARDSHIP COMMITTEE

RESTRICTED ANTIBIOTIC REQUEST FORM
This form is part of the Hospital Stewardship Program
Patient’s Name: AGE SEX: DEPT:

MALE WARD:
LAST NAME FIRST NAME MIDDLE NAME FEMALE HOSP. NO.
Clinical Diagnosis/Name of Surgey: Weight Creatinine Creatinine Clerance
“Revised 2023”
DRUGS REQUESTED
Drug Description Dose/ Frequency Duration Quantity Requested
(q/hr) (days) (tab/amp/vial)
JUSTIFICATION FOR REQUEST

Prophylactic Therapeutic: Empriric Definitive/Cutire-guided
Reason for Request:
SITE OF INFECTION
Blood CVS Skin Soft Tissue Others, pls specify:
Respiratory GIT Reproductive
CNS GUT Catheter Related (Urine/IV)
CULTURE/SENSITIVITY RESULT: (If indication for request is DEFINITIVE)

Date Specimen/Source Gram Stain Isolate(s) Sensitivity Pattern
Requested by:
______________________________ ______________________ ___________________

Signature over Printed Name of Physician Date of Signature Time of Signature
APPROVAL/RECOMMENDATION:
Start Continue Discontinue Revise as follows
Drugs Dose/ Frequency Duration Quantity Requested
(q/hr) (days) (tab/amp/vial)
Disapprove (State reason)
_________________________________________________________________________
________________ ________________
_________________________________________________________________________
Date of Signature Time of Signature
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
______________________________________
Department Chairman/Department Consultant
ANTIMICROBIAL STEWARDSHIP PROGRAM

7TH Day Antibiotic Stop Form
PLEASE STOP AND REVIEW YOUR ANTIBIOTIC
Patient Name: ____________________________________________ Age:___________ Sex: ___________

Address: ________________________________________________________________________________________________
Ward: ___________________ Admission Date: ___________________
Present Working Infectious Diagnosis:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Current Antibiotic/s:
ANTIBIOTIC NAME DOSE AND ROUTE FREQUENCY
“Revised 2023”
Is there a need to continue antibiotics?
Yes No
If yes, state reason and plan:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_____________________________________________________.
Resident in Charge: _____________________________________ ______/______/_______

Date
Approved by: (Service Consultant/Department Training Officer/ Department Chairman)
_____________________________________ ______/______/_______
(Signature above printed name) Date
“Revised 2023”

Admission Chart 2023

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Admission Chart 2023

Uploaded by

Copyright:

Available Formats

DESERET SURGIMED HOSPITAL INC.

Nat’l Higway, Kabacan, North Cotabato

“Let us handle your Health. The Deseret Way”

PERMANENT ADDRESS CONTACT NO. SEX CIVIL STATUS

SOCIAL SERVICE QUALIFICATION

ADMISSION DIAGNOSIS ICD CODE

FINAL DIAGNOSIS ICD CODE

PRINCIPAL OPERATION PROCEDURE/S

OTHER OPERATION PROCEDURE/S

“Let us handle your Health. The Deseret Way”

CONSENT FOR ADMISSION:

REFUSAL FOR TREATMENT:

“Let us handle your Health. The Deseret Way”

Waiver for admisision

KNOW ALL MEN BY THESE PRESENTS:

Witnessed by ( Nakasaksi sila)

CLINICAL CASE RECORD

“Let us handle your Health. The Deseret Way”

Surname: Age/Sex: Physician:

MEDICAL EXAMINATION SHEET

FOOD AND DRUG ALLERGIES:

REASON FOR ADMISSION:

Surname: Age/Sex: Physician:

“Let us handle your Health. The Deseret Way”

LABORATORY/ X-RAY RESULT/ RESULT

Please attach 1st laboratory result here

“Let us handle your Health. The Deseret Way”

Surname: Age/Sex: Physician:

TPR MONITORING RECORD

“Let us handle your Health. The Deseret Way”

Surname: Age/Sex: Physician:

DOCTOR’S ORDER/ NURSES COMPLIANCE SHEET

“Let us handle your Health. The Deseret Way”

Progress note Posted/

Surname: Age/Sex: Physician:

“Let us handle your Health. The Deseret Way”

STAT/ SINGLE DOSE MEDS

DATE NAME & SIGNATURE DATE NAME & SIGNATURE

Surname: Age/Sex: Physician:

INTRAVENOUS FLUID FLOW SHEET

“Let us handle your Health. The Deseret Way”

Surname: Age/Sex: Physician:

DATE TIME FOCUS DATA /ACTION/ RESPONSE

“Let us handle your Health. The Deseret Way”

Surname: Age/Sex: Physician:

Date Admitted: _____________________ Date of Discharge: ________________________

“Let us handle your Health. The Deseret Way”

Brief Clinical History & Pertinent P.E:

Laboratory Finding: (incl. EKG, X-ray, and other diagnostic procedures)

Hematology: X-Ray/ CT-Scan: Urinalysis:

Fecalysis: Blood Chemistry: Others:

Course in the Ward: (incl. medications)

Disposition: (indicate home medications, special instructions and follow-up)

Date Accomplished : ________________ Received by: _______________

“Let us handle your Health. The Deseret Way”

WAIVER FOR ADMISSION

KNOW ALL MEN BY THESE PRESENTS:

“Let us handle your Health. The Deseret Way”

Name and Signature (Pangalan at Lagda)

Witnessed by (nakasaksi sila):

Name and Signature Name and Signature

ANTIMICROBIAL STEWARDSHIP COMMITTEE

Patient’s Name: AGE SEX: DEPT:

Date Admitted: _ Date of Discharge: ____

Date Accomplished : __ Received by: _

__________ _

Patient Name: ______________________________________ Age:_ Sex: _______

Resident in Charge: _______________________________ //_