DOCTOR’S ORDER

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ___________ WARD: ____________

PROGRESS NOTES ORDER ACTION TIME/SIG

 VITAL SIGNS GRAPHIC SHEET

SURNAME: _________________AGE: _______ SEX: ______ HOSP. NO: ___________

GIVEN NAME: ______________ MI:______________ WARD: ____________________

Days of the Month

No. of Days in Hospital
Height/weight
RESP PULSE TEMP

42
41
180 40
39
160 38
37
140 36
35
120

100
60
50 80
40
30 60
20
10

SHIFT BP U S BP U S BP U S BP U S
7-3
3-11
11-7
 MEDICATION SHEET - IV

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: _______ WARD: ___________

Date/Time Medication Dosage Route Freq Date

Ordered
Shift Time Sig Time Sig Time Sig
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast
Diet Lunch
Dinner
 MEDICATION SHEET-ORAL

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: _______ WARD: ___________

Date/Time Medication Dosage Route Freq Date

Ordered
Shift Time Sig Time Sig Time Sig
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast
Diet Lunch
Dinner
 VITAL SIGNS MONITORING SHEET

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ______ WARD: ____________

DATE/SHIFT/TIM BP PR RR CR T
E
 NURSE’S PROGRESS NOTES

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ___________ WARD: ____________

DATE/TIM FOCUS DATA ACTION RESPONSE

E
 RECORD OF FLUID INTAKE AND OUTPUT

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ___________ WARD: ________

SECRE VOMITU
DATE SHIFT CLYSIS BLOOD ORAL TOTAL URINE OTHERS TOTAL
TIONS S

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL
 INTRAVENOUS FLUID FLOW SHEET

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ___________ WARD: ________

Type of
Cannulae
I.V. Type of Flow
Date & /Needle Date &
Fluid Nurse’s I.V. Drug Rate / Nurse’s
Time & Time Remarks
Bottle Signature Fluid & Additives Infusion Signature
Started Location Consumed
. No. Volume Device
of
Insertion

LABORATORY REQUEST FORM

SURNAME:____________________ AGE: ______ HOSP.NO.: ______________________

GIVEN: ________________________ MI: ______________ SEX: ___________ WARD: ________

HEMATOLOGY Total Cell Count PANCREATIC PROFILE HEPATITIS C

Complete Blood Count Differential Count Amylase Anti-HCV Screening
Hemoglobin Glucose Lipase Anti-HCV ECLIA/EIA
Hematocrit Protein LIPID PROFILE THYROID FUNCTION TEST
Platelet count LDH Total Cholesterol T3
Clotting Time CLINICAL CHEMISTRY Triglyceride T4
Bleeding Time BONE/ JOINT ARTHRITIS TEST HDL- Cholesterol FT3
Clot Retraction Time Blood Uric Acid LDL – Cholesterol FT4
ABO-Rh Typing Rheumatoid Factor LIVER FUNCTION PROFILE TSH
 COAGULATION STUDIES CARDIAC MARKERS Total Protein TUMOR MARKERS
Prothrombin Time AST/SGOT Albumin AFP
APTT CK-MB Direct Bilirubin Beta-HCG
Fibrinogen Trop-T quantitative Total Bilirubin CEA
ANEMIA WORK UP Trop-I quantitative TEST FOR LIVER INJURY CA 19-9
Iron DIABETIC PROFILE AST/SGOT PSA
Total Iron Binding Capacity Fasting Blood Sugar/ FBS ALT/ SGPT CA 125
Unsaturated Iron Binding Random Blood Sugar/ RBS Alkaline Phosphatase/ALP SLE WORK-UP
Capacity
Folate OGTT _____75 g LDH Anti-Nuclear Antibody
_____100 g
Ferritin OGCT _____ 50g _____75 SEROLOGY/ IMMUNOLOGY SYPHILIS WORK UP
g
BLOOD BANKING HbA1C DENGUE WORK UP Anti T. pallidum rapid test
Direct Coomb’s test 2-HR Post-Prandial Blood Sugar DENGUE NS1 Antigen TPHA
Indirect Coob’s test Insulin Dengue IgG/IgM
DRUG TESTING Urine Ketone HIV TESTING OTHER TEST AVAILABLE
LABORATORY
Cannabinoids ELECTROLYTES Anti-HIV-1/ HIV-2 Complement3 (C3)
Screening/Rapid
Methamphetamine Sodium Anti-HIV-1/ HIV-2 EIA C-Reactive Protein
A.U.B.F./ PARASITOLOGY Potassium HEPATITIS VIRUS INFECTION Anti-streptolysin O (ASO)
MARKERS
24-h Urine HCG Titer ___Ionized/ ____Total Calcium HEPATITIS A Salmonella IgG/IgM
Pregnancy test Chloride
Routine stool examination Magnesium
Routine Urinalysis Phosphorous

TEMPLATE FOR MEDICATION CARDS

Medication card No. 1

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