Republic of the Philippines
Province of Benguet
KARDEX
Hospital Number:
Name: Age: Sex: _Ward: Room: ___
SURNAME GIVEN NAME MIDDLE NAME
Chief Complaint: ______ Admitting physician:
Admitting diagnosis:
Date of admission: Date of discharge:
SPECIAL INSTRUCTIONS/ENDORSEMENTS DATE LABORATORY
Diet:
DATE IV FLUIDS DATE PRN MEDICATIONS
DATE IV MEDICATIONS DATE ORAL MEDICATIONS
DATE NEBULIZATION
Republic of the Philippines
Province of Benguet
MONITORING SHEET
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
DATE & Input Output
TIME BP CR/PR RR TEMP (mL) (mL) Misc/NVS/Wt Remarks
Republic of the philippines
Province of Benguet
CLINICAL FACE SHEET
Hospital Number:________________
NAME: BIRTH DATE: AGE: SEX: WARD/ROOM
∕ ∕ □ MALE
□ FEMALE
MIDDLE
LAST FIRST NAME (MM/DD/YYYY)
ADDRESS: CIVIL STATUS PATIENT CLASSIFICATION ADMISSION TIME
DATE:
□ S □ Ch CLASS __________________ ______ AM
□ M □ W PHIC ______ MEMBER ______ PM
□ Sep. ______ DEPENDENT DISCHARGED TIME
BIRTHPLACE: RELIGION: ___SSS ___ Paying mem. DATE: ______ AM
___GSIS ___ Life Time mem. ______ PM
___ OWWA ___ Sponsored mem. TYPE OF ______ OLD
___ Non Member ADMISSION: _____ NEW
OCCUPATION: CONTACT NUMBER: NATIONALITY: TOTAL PATIENTS DAYS:
SERVICE
NAME OF EMPLOYER`S ADDRESS: CONTACT NUMBER: _______ OB _______ MEDICINE
EMPLOYER: _______ GYNE _______ SURGERY
INFORMANT: ADDRESS OF INFORMANT CONTACT NUMBER: RELATIONSHIP TO PATIENT
NEXT OF KIN OR WHOM TO ADDRESS OF NEXT OF KIN CONTACT NUMBER: TRANSFERRED DATE:
NOTIFY:
REFERRING HEALTH WORKER: REFERRING HEALTH WORKER`S ADDRESS:
ADMITTING DIAGNOSIS: ADMITTED BY:
PRINCIPAL DIAGNOSIS: CODE NUMBER
OTHER DIAGNOSIS: CODE NUMBER
OPERATIVE PROCEDURE:
DISPOSITION: □ DISCHARGED □ HAMA □ RECOVERED □ UNIMPROVED □ DIED □ -48 HRS
□ TRANSFERRED □ ABSCONDED □ IMPROVED □ AUTOPSIED □ +48 HRS
IN CASE OF ACCIDENTS: THE PATIENTS WAS BROUGHT BY: CONTACT NUMBER RELATIONSHIP TO PATIENT
DRIVER VEHICLE AND PLATE POLICE INVESTIGATOR ADDRESS CONTACT NUMBER
NUMBER
MEDICAL OFFICER III MEDICAL OFFICER III MEDICAL OFFICER III
MEDICAL MEDICAL
SPECIALIST II MEDICAL SPECIALIST II SPECIALIST I
CHIEF OF HOSPITAL
Republic of the Philippines
Province of Benguet
Hospital No.: __________________
CONSENT TO CARE
Note: This authorization must be signed by the patient or by the next of kin in case of a minor or when the patient is
physically and/or mentally incompetent.
I, , hereby authorized Dr. and other staff of Northern
(name of patient)
Benguet District Hospital to perform the treatment and procedures deemed necessary for my care.
I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.
I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.
Name & signature of witness Date Name & signature of patient
Hospital No.: __________________
Patient is a minor of .
Age
Patient is unable to sign because .
I, , being next of kin of hereby
(name of guardian or parent) (name of patient)
authorized Dr. and other staff of Northern Benguet District Hospital to perform the treatment and
procedure deemed necessary for his/her care.
I also give authorization for the staff to supply information from my medical record to my insurance carrier/or
lawyer.
I shall obey the rules, regulations and policies of the hospital and the instruction of the staff.
Name & signature of witness Date Name & signature of parent/guardian
Republic of the Philippines
Province of Benguet
ADULT HISTORY AND PHYSICAL EXAMINATION
Hospital Number:
Name: Age: Sex: Ward:
CHIEF COMPLAINT/S:
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL HISTORY:
FAMILY HISTORY:
SOCIAL/ENVIRONMENTAL/OCCUPATIONAL HISTORY:
PHYSICAL EXAMINATION:
GENERAL SURVEY:
VITAL SIGNS: BP:______mmHg PR: ____bpm RR: ____cpm T: ____°C WT: ____kg HT: ____cm
SKIN:
HEAD:
EENT:
NECK:
CHEST/BREAST/LUNGS:
HEART/CARDIOVASCULAR:
ABDOMEN:
GENITO-URINARY:
RECTAL:
MUSCULO-SKELETAL:
EXTREMITIES:
NEUROLOGICAL/NERVOUS:
LYMPHATIC:
ADMITTING IMPRESSION: ATTENDING PHYSICIAN:
Republic of the Philippines
Province of Benguet
DOCTOR’S ORDER
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
DATE TIME PROGRESS NOTES DOCTOR’S ORDER
Republic of the Philippines
Province of Benguet
LABORATORY RESULTS
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
(ATTACH FIRST LABORATORY RESULT ON THIS LINE)
Republic of the Phillipines
Province of Benguet
TEMPERATURE RECORD
Hospital Number: Bed No. Doctor:
Year: Month: Name of Patient:
Da y of Month
Da y of di s ea s e
No. of hospital days
Wei ght
R PU T
E L E
S S M
P E P
42 42
41
40
39
38
180 37
36
160 35
140
120
100
50 80
40
30 60
20
10
8-4 shift
URINE 4-12 shift
12-8 shift
8-4 shift
STOOL 4-12 shift
12-8 shift
Republic of the Philippines
Province of Benguet
TREATMENT SHEET
Hospital Number:
Name: Age: Sex: Ward:
Medicines/ Dosage/ Date
Route of
Administration &
Shift Time Time Time Time Time Time Time
Frequency
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
8-4
4-12
12-8
Republic of the Philippines
Province of Benguet
INTRAVENOUS FLUID SHEET
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
IV FLUID DATE & TYPE OF IV FLUID DRUG NEEDLE GAUGE & FLOW DATE & NURSE’S REMARKS
TIME AND VOLUME ADDITIVES SITE OF INSERTION RATE TIME SIGNATURE
BOTTLE STARTED CONSUMED
NO.
Republic of the Philippines
Province of Benguet
NURSE’S NOTES
Hospital Number:
Name: Age: Sex: Ward:
SURNAME GIVEN NAME MIDDLE NAME
DATE& TIME FOCUS DATA, ACTION, RESPONSE
Republic of the Philippines
Province of Benguet
DISCHARGE SUMMARY
NAME: AGE: SEX: HOSP. NO:
DATE ADMITTED: DATE DISCHARGE:
ADMITTING PHYSICIAN:
ADMITTING DIAGNOSIS:
CHIEF COMPLAINS:
BRIEF CLINICAL HISTORY AND PERTINENT P.E.:
LABORATORY FINDINGS (INCLUDE ECG, X – RAY, AND OTHER DIAGNOSTIC PROCEDURES):
COURSE IN THE WARD: (INCLUDE MEDICATIONS):
FINAL DIAGNOSIS:
DISPOSITIONS: (INDICATE HOME MEDICATIONS, SPECIAL INSTRUCTION AND FOLLOW-UP)
PREPARED BY:
_____________________________ _____________________ ____________________________ M.D.
(Signature Over Printed Name) Date ATTENDING PHYSICIAN
(Signature Over Printed Name)
