CLINICAL FACE SHEET

______________________

Case Number

Name: Age: Date of Birth: Place of Birth: Category of

Patient:

Home Address: Sex: Civil Status: Religion: Nationality:

Next of Kin: Relationship: Address: Contact No.:

Date Admitted: Time: Date of Discharge: Time: No. of Hospital Days:

________ A.M. ________ A.M.
________ P.M. ________ P.M.

Ward: Attending Physician: Admitting Nurse:

ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS: ICD 10 Code:

Condition on Discharge: Disposition:

[ ] recovered [ ] died [ ] discharged [ ] absconded

[ ] improved [ ] autopsied [ ] transferred [ ] referred to OPD
[ ] unimproved [ ] not autopsied [ ] home against for follow up advice

COMPLICATIONS:

OPERATION/PROCEDURE DONE:

Review for completeness:

___________________________________________ __________________________________________
Signature over Printed Name Signature over Printed Name
of Attending Physician (Record Officer)
 VITAL SIGNS MONITORING SHEET

Name:___ ____________________________________Age/Sex/CS:__Ward/Room:_________

Date Time Shift BP PR RR Temp 02 sat REMARKS

 INTAKE & OUTPUT MONITORING SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:_________

INTAKE OUTPUT
Date Time Shift IVF Drain/
Oral/NGT TOTAL Urine stool TOTAL
Surgery
OR
PACU
SURGERY
 PATIENT’S DATA
1. Name of Patient 2. PIN

Last Name First Name Middle Name 3. Age

5. Chief Complaint

4. Sex
Male Female
6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

8. b. 2nd Case Rate Code

9. a. Date Admitted: 9. b. Time Admitted:

l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
10. a. Date Discharged: 10. b. Time Discharged:
l___l___l ¯ l___l___l ¯ l___l___l___l___l l___l___l ¯ l___l___l AM PM
month day year hour min
REASON FOR ADMISSION
1. History of Present Illness:

2. a. Pertinent Past Medical History:

2. b. OB/GYN History:
G_____ P_____ (_____-_____-_____-_____) LMP:_________________ NA

3. Pertinent Signs and Symptoms on Admission (Check applicable box/es):

 Altered Mental Sensorium  Diarrhea  Hematemesis  Palpitations

 Abdominal cramp/pain  Dizziness  Hematuria  Seizures
 Anorexia  Dysphagia  Hemoptysis  Skin rashes
 Bleeding gums  Dyspnea  Irritability  Stool, bloody/black tarry/mucoid
 Body weakness  Dysuria  Jaundice  Sweating
 Blurring of vision  Epistaxis  Lower extremity edema  Urgency
 Chest pain/discomfort  Fever  Myalgia  Vomiting
 Constipation  Frequent urination  Orthopnea  Weight loss
 Cough  Headache  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)

General Survey:  Awake and alert  Altered sensorium,_______________________

Vital Signs: BP:_______________ HR:_______________ RR:_______________ Temp.;_______________ Wt.:_______________ (pedia patients)

HEENT:  Essentially normal  Abnormal pupillary reaction  Cervical lymphadenopathy  Dry mucous membrane
 Icteric sclerae  Pale Conjunctiva  Sunken eyeballs  Sunken fontanelle

Others:_____________________________________
 GRAPHIC RECORD

Name:___________________________________________Age/Sex/CS:______________Ward/Room:_____________
DATE
No. of Days in
Hospital
7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7 7 3 4 11 12 7
RR PR T

42

41

160 40

150 39

140 38

130 37

120 36

110 35

100

90

50 80

40 70

30 60

20 50

10
 7-3

URINE 3-11

11-7

7-3
STOO 3-11
L
11-7

BP
 IV FLUID SHEET

Name:________________________________________Age/Sex/CS:___________Ward/Room:_________

MAIN LINE
Time Time
Date IV Fluids Regulation Started Consumed
REMARKS

ANOTHER LINE / SIDE DRIP

Time Time
Date IV Fluids Regulation Started Consumed
REMARKS
 DOCTOR’S ORDER

Name:_______________________________________Age/Sex/CS:___________Ward/Room:__________

Date C A R E D TIME POSTED

And Progress Notes Doctor’s Order AND
SIGNATURE
time


 C-Carried-out
A-Administered
R- Requested
E-Endorsed
D-Discontinued

MEDICATION SHEET

Name:_______________________________________Age/Sex/CS:___________Ward/Room:__________

Name of Drug, Dosage, Date and Time Given:

Route, & Frequency
 NURSE’S NOTES
Name:_________________________________________Age/Sex/CS:___________Ward/Room:__________

Date-Shift FOCUS Data – Action – Response

 KARDEX
NAME: ________________________________ AGE:____ SEX:_____ STATUS:__________WARD.__________

ADDRESS:_______________________________________ CLASSIFICATION:___________ WEIGHT:________

ADMITTING PHYSICIAN:__________________________ DATE/TIME ADMITTED:________BLOOD TYPE:_____

ATTENDING PHYSCIAN:_____________________CONSULTATION PHYSICIAN:___________________________

COMPLAINT:______________________________________________________________________________

IMPRESSION DIAGNOSIS:____________________________________________________________________

SURGERY DONE:____________________________________________________DATE/TIME: SURGERY_____

MENTAL STATUS: Activities: Diet: Tubes: Special Info:

___Conscious ___ambulant ___NPO ___Foley Catheter ___Weigh Daily
___drowsy ___dangle and sit up ___DAT ___thoracic tube ___BP q shift
___stupor ___bedrest with BRP ___Soft ___NGT ___Neuro V/S
___unconscious ___CBR w/o BRP ___clear liquids ___CVP ___abdominal girth
___comatose Others:___________ ___ gen. liquids Others:__________ Others:__________
Others:_________

Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND

ordered Ordered TIME
DISCONTINUED

DATE PRN TREATMENTS/MEDICATION DATE Medical Treatment/ Date Done

 Ordored ORDERED Laboratories/Diagnostics

CONSENT FOR SURGERY

KNOWN ALL MED BY THESE PRESENTS:

That I, ____________________________ ______________ Filipino, of legal age,

Single/married/widow, and a resident of _________________ ____________________, do
Hereby submit myself freely and voluntarily, without any influence, coercion, for or intimidation by any person to
have an operation performed to me/my __________________________________________,
For the following operation/s________ _____________
By Dr. ____ __________ and Anesthesia by Dr. _____ ____________

These said operation has been fully explained to me by the surgeon as to the type of operation; its necessity;
its complications that may arise, directly or indirectly therefrom. Likewise, the type of anesthesia and all its
complication directly and indirectly, have been explained to me by my anesthesiologist.

It is understood that the surgeon/ anesthesiologist performing the operation/anesthesia will not be liable for
any charge that I oy my relative/s or guardian may claim as a result of the operation/ anesthesia or treatment.

IN WITNESS WHEREOF, I have hereunto set my hand this _ _____day of ____,

20_ ___ at Vigan, Ilocos Sur.

IN THE PRESENCE OF

__________________
Witness         Signature of patient/
         person giving consent

PREOPERATIVE CHECKLIST
Last Name: Age:       Hospital #:
Given Name: Sex: Ward/Room:

N/
YES NO REMARKS
A
1. Consent for surgery signed, witnessed and documented
2. Consent for blood transfusion signed, typed and cross-matched ______unit/s
confirmed
3. CP clearance/ Pedia clearance done and on chart
4. Laboratory reports on chart
5. ECG report on chart
6. X-ray/ CT scan report on chart
7. Identification bracelet accurate and affixed to wrist/ ankle
8. Allergies checked and documented on chart.
9. Patient shower/ bath completed as ordered, dressed in hospital gown
10. Jewelries, hairpin, contact lenses, prosthesis, underwear removed.

11. Oral Hygiene/care completed

12. Operative site prepared
13. Cleansing enema done
14. Nail polish/ make-up removed
15. Vital signs taken and recorded
BP- PR- T- RR O2Sat-

16. Patient voided at _____

Has Foley catheter: ______

17. Dentures removed

18. Patient on NPO since _______
19. OR notified: time _______ whom:
20. Anesthesiologist notified
21. Pre-op medication/s given:
___________________________
___________________________

_________________________
Nurse of Duty
________________________
Date and Time

OR SLIP
NAME: ___________
AGE: __ SEX: __ RM NO.____
ATTENDING PHYSICIAN: ________________
Procedure: __________________
DATE: TIME:____
SURGEON: _________
ANESTHESIOLOGIST: _____________
TYPE OF ANESTHESIA: ________________
CP CLEARANCE: ________________
PREPARED BY: ________________
SIGNATURE:

IV TAG
NAME OF PATIENT: _____________
WARD: ________________
TYPE OF FLUID: ____________
IV RATE: ________________
DATE AND TIME STARTED: ________________
PREPARED BY: ________________