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CF4
(Claim Form 4)
February 2020
Series #
IMPORTANT REMINDERS
PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
CALAMBA DISTRICT HOSPITAL H10016751
3. Address of HCI
NAT. HIGHWAY, CALAMBA, MISAMIS OCCIDENTAL, 7210 REGION X, PHILIPPINES
Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code
II. PATIENT'S DATA
1. Name of Patient 2. PIN
MATUNOG MELQUIADES DESCALLAR 151751439189
Last Name First Name Middle Name 3. Age
5. Chief Complaint 88
FEVER AND CHILLS 4. Sex Male Female
6. Admitting Diagnosis 7. Discharge Diagnosis 8.a. 1st Case Rate Code
ACUTE PYELONEPHRITIS Pyelonephritis Acute N10
8.b. 2nd Case Rate Code
9.a. Date Admitted 9.b. Time Admitted
0 6 --
1 2 --
2 0 2 1 1 2 : 3 7 AM PM
hour min
month day year
10.a. Date Discharged 0 6 -- 1 5 -- 2 0 2 1 10.b. Time Discharged 0 3 : 0 0 AM PM
month day year hour min
III. REASON FOR ADMISSION
1. HIstory of present illness
Noted about 5 days PTA, when patient experienced intermittent low-moderate grade fever associated with chills, painful and scanty urination, flank pain, hypogastric
discomfort, nausea and vomiting, body malaise and loss of appetite. Due to its symptoms, prompted admission.
2.a. Pertinent Past Medical History
N/A
2.b. OB/GYN HIstory
G0 P 0 ( 0 - 0 - 0 - 0 ) LMP: ___________ NA
3. Pertinent Signs and Symptoms on Admission (tick applicable box/es):
Altered Mental Sensorium Abdominal Cramp Pain Anorexia Bleeding Gums
Body Weakness Blurring Of Vision Chest Pain/Discomfort Conspitation
Cough Diarrhea Dizziness Dysphagia
Dyspnea Dysuria Epistaxis Fever
Frequency in Urination Headache Hematemesis Hematuria
Hemoptysis Irritability Jaundice Lower Extremity Edema
Myalgia Orthopnea Palpitations Seizure
Skin Rashes Stool, Bloody/Black Tarry Mucoid Sweating Urgency
Vomitting Weight Loss Pain, _______________
FLANK PAIN (site) Others ____________________
4. Referred from another health care institution (HCI): No Yes, Specify Reason ______________________________________________
Name of Originating HCI _________________________________________
5. Physical Examination on Admission (Pertinent Findings per System)
168
Height ________ (cm)
General Survey Awake and Alert Altered Sensorium _______________________ 78
Weight ________ (kg)
Vital Signs BP: ______________________
120/80 HR: ______________________
104 RR: ____________________
24 Temp: __________________
38.60
HEENT Essentially Normal Iceteric Sclerae Abnormal Pupillary Reaction Pale Conjunctivae
Cervical Lympadenopathy Sunken Eyeballs Dry Muccous Membrane Sunken Fontanelle
Others: __________________
5. Physical Examination continued (Pertinent Findings per System)
CHEST/LUNGS Essentially normal Lump/s over breast(s) Asymmetrical chest expansion Rales/crackles/rhonchi
Decreased breath sounds Intercostal rib/clavicular retraction Wheezes
Others: __________________
CVS Essentially normal Irregular rhythm Displaced apex beat Muffled heart sounds
Heave and/or thrills Murmur Pericardial bulge
Others: TACHYCARDIC
ABDOMEN Essentially normal Palpable mass(es) Abdominal rigidity Tympanitic/dull abdomen
Abdominal tenderness Uterine contraction Hyperactive bowel sounds
Others: __________________
GU (IE) Essentially normal Blood stained in exam finger Cervical dilatation Presence of abnormal discharge
Others: (+)KPS
SKIN/EXTERMITIES Essentially normal Edema/swelling Rashes/petechie Clubbing
Decreased mobility Weak pulse Cold clammy Pale nailbeds
Cyanosis/mottled skin Poor skin turgor
Others: __________________
NEURO-EXAM Essentially normal Abnormal gait Abnormal position sense Poor/altered memory
Abnormal reflex(es) Poor muscle tone/strength Abnormal/decreased senstation Poor coordination
Others: __________________
IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s)
Date DOCTOR'S ORDER/ACTION
06-12-2021 Initially patient was relatively weak, in pain (hypogastric area) and febrile. PE: (+) tenderness hypogastric area: (+) KPS.
Vital signs: BP=120/80 mmHg, CR= 104/min, RR= 24/min, T=38 C. Working diagnosis: cute Pyelonephritis. Due
medicines were given.
06-13-2021 Urinalysis: WBC=loaded, Bacteria=loaded, Albumin=trace. Continue medications and hydration.
06-14-2021 Medications were continued.
06-15-2021 Patient improves progressively and subsequently discharged with take home medicines prescribed.
SURGICAL PROCEDURE/RVSCODE (Attached photocopy of OR technique):
V. DRUGS / MEDICINES Check box if there is/are additional sheet(s)
Generic Name Quantity/Dosage/Route Total Cost
D5 LR 1L / 1 / liter 1.00 pc/s 95
Frequency: OD Route: IV
CEFTRIAXONE / 1 / gm 3.00 pc/s 300
Frequency: every 12 hours Route: IVTT
PARACETAMOL / 500 / mg 4.00 pc/s 95
Frequency: every 4 hours PRN Route: Oral
SALBUTAMOL / 1/2 / nebule 6.00 pc/s 450
Frequency: every 8 hours Route: nebulization
PNSS 1L / 1 / liter 1.00 pc/s 8
Frequency: OD Route: IV
AMPICILLIN+SULBACTAM / 750 / mg 3.00 pc/s 108
Frequency: every 8 hours Route: IVTT
CIPROFLOXACIN / 1/2 / tablet 4.00 pc/s 304.50
Frequency: BID Route: Oral
D5 NM 1L / 1 / liter 3.00 pc/s 20
Frequency: OD Route: IV
BUDESONIDE / 1/2 / nebule 4.00 pc/s 354
Frequency: every 8 hours Route: nebulization
VI. OUTCOME OF TREATMENT
IMPROVED HAMA EXPIRED ABSCONDED TRANSFERRED Specify reason:
____________________
VII. CERTIFICATION OF HEALTH PROFESSIONAL
Certification of Attending Health Care Professional:
I certify that the above information given in this form, including all attachments, are true and correct.
________________________________________________________________________ -- --
Signature over Printed Name of Attending Health Care Professional
month day year
