SOGOD RURAL HEALT UNIT
Sogod, Southern Leyte
HOSPITAL CODE: ___________________
MEDICAL RECORD NO. ______________
ADMISSION AND DISCHARGE RECORD
PATIENT’ NAME
(LAST)
(GIVEN)
PERMANENT ADDRESS
(MIDDLE)
WARD/SERVICE
TELEPHONE
SEX
CIVIL STATUS
☐M
☐F
BIRTHDATE
AGE
BIRTHPLACE
NATIONALITY
RELIGION
☐S
☐D
☐M
☐W
☐ SEP
OCCUPATION
EMPLOYER (Type of Business)
ADDRESS
TELEPHONE
SPOUSE NAME
ADDRESS
TELEPHONE
FATHER’S NAME
ADDRESS
TELEPHONE
MOTHER’S NAME
ADDRESS
TELEPHONE
ADMISSION:
DATE:
TIME:
TYPE OF ADMISSION:
☐
DISCHARGE:
DATE:
TIME:
☐
NEW
ALERT
ALLERGIC TO:
☐
OLD
SOCIAL SERVICE CLASSIFICATION
A
TOTAL NO. OF
DAYS
REFERRED BY:
(Physician/Agency)
FORMER OPD
B
C
HOSPITALIZATION PLAN
COMMUNITY/INDUSTRIAL NAME
DATA FURNISHED BY:
ADMITTING PHYSICIAN:
D
HEALTH INSURANCE
MEDICARE:
☐ SSS
☐ GSIS
ADDRESS OF INFORMANT
RELATION TO THE PATIENT
ADMISSION DIAGNOSIS
PRINCIPAL DIAGNOSIS
OTHER DIAGNOSIS:
LMP
1ST TRI
2ND TRI
3RD TRI
DISPOSITION:
RESULTS:
DATE
☐ Discharged
☐ Unrecovered ☐ Improved
AOG
☐ Transferred
☐ Died
☐ Unimproved
☐ DAMA
☐ - 48 Hours
☐ Autopsy
☐ ABSCONDED
☐ + 48 Hours
☐ No Autopsy
WT
PR
RR
BP
TEMP
____________________________MD
Attending Physician
RURAL HEALTH UNIT
Sogod, Southern Leyte
I HEREBY AUTHORIZE DR. ISABELITA B MATO and the staff of SOGOD RHU/BHS
_____________________________ to perform these treatment and procedure deemed necessary for
any care.
Also give authorization for the hospital to supply information for my medical record to my
insurance carrier or to my attorney.
____________________________
SIGNATURE OF WITNESS
__________________________
SIGNATURE OF WITNESS
_______________________________________________________________________________
THIS AUTHORIZATION MUST BE SIGNED BY THE PATIENT’S OR BY THE NEXT OF KIN IN CASE OF
MINOR OR WERE PATIENTS PHYSICALLY AND MENTALLY INCOMPETENT.
PATIENT IS UNABLE/MINOR _________ YEARS
PATIENT IS UNABLE TO SIGN BECAUSE ______________________________________________
I, __________________________________ BEING THE NEXT KIN of _________________________
HEREBY AUTHORIZE DR. ISABELITA B. MATO AND THE STAFF OF SOGOD RHU/BHS _____________TO
PERFORM NECESSARY TREATMENT.
_________________________________
SIGNATURE OF WITNESS
DATE: ___________________________
_____________________________
SIGNATURE OF NEXT KIN
_____________________________
RELATION TO THE PATIENT
COMMITMENT TO BREATFEEDING & NEWBORN
SCREENING
I, _____________________________, a resident of
______________________________,
having
been
informed of the Breastfeeding and Newborn Screening
Policy of this unit, duly commit myself to exclusively
breastfeed up to six (6) months and to continue
thereafter with the proper weaning and complementary
foods. And submit to Newborn Screening my newborn
baby immediately after. This is in line with the
implementation of Rural Health Unit’s Breastfeeding
Program and in compliance of the Department of Health.
_________________
_________________
Signature of Witness
Signature of Patient
RURAL HEALTH UNIT AND BIRTHING FACILITY
BAGARES ST., ZONE IV, SOGOD, SOUTHERN LEYTE
PHYSICAL EXAMINATION
Vital Signs:
BP: ___________ HR: ___________ RR: ___________ T: _____________
Skin: ____________________________________________________________________
HEENT: _________________________________________________________________
Chest/Lungs: _____________________________________________________________
Cardiovascular: ___________________________________________________________
Abdomen:
Leopolds M1
a. Breech
b. Cephalic
Leopolds M2
Fetal Back _____side
Leopolds M3
a. Breech
C. Others
Fetal small parts _______side
b. Cephalic
C. Others
Fetal Heart Beat: ______beats/minute
Pelvic Exam:
Internal Exam:
Cervix:
Dilatation: _______Effacement:_________Presenting part __________
Engaged _________________ Floating_________________________
Membranes: Intact _____ Ruptured (date) __________ Time _______
Position _____________________ Station ______________________
Extremities:
________________________________________________________
Admitting Impression: ______________________________________________________
________________________________________________________
________________________________________________________
Attending Physician/Nurse/Midwife
____________________________
Signature over Printed Name
RURAL HEALTH UNIT AND BIRTHING FACILITY
BAGARES ST., ZONE IV, SOGOD, SOUTHERN LEYTE
ADMISSION HISTORY
NAME: _____________________________________________________ AGE: _____ SEX: ____ CIVIL STATUS: _____
ADDRESS: _________________________________________________________________________ BED NO. ______
Name of Husband/Significant Others: ___________________________________________________________________
CHIEF COMPLAINT: _______________________________________________________________________________
HISTORY OF PRESENT ILLNESS
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Past Personal/Health History
Past hospitalization _______________________________ If Yes, what reason? ______________________________
When? __________________________________________ Medication? _____________________________________
Any allergies to food? _____________________________ Allergies to meds? _______________________________
History of Hypertension __________ if Yes, since when _____________ Medications taken ____________________
Diabetes ______________ if Yes, since when _____________ Medications taken ___________________
Asthma ________________ if Yes, since when _____________ Medications taken ___________________
Family History
Hypertension ________________________ Diabetes _____________________ Asthma _________________
Menstrual History
Age of menarche: _______ Duration: _____________ Amount of flow: ________________ Dysmenorrhea ____________
Interval of subsequent menses: ______________ Amount of flow: ___________________ Dysmenorrhea ____________
OB HISTORY
G ________ P _______ A ________
LMP _________________________
EDC _________________________
AOG _________________________
Month/Year
FT/PT/Abortion
Live/Dead
Sex
Place of Delivery, if CS, where?
Assisted by
G1
G2
G3
G4
G5
Any Prenatal check-up? ______ No. of Prenatal Check-ups _______ Where? _________________________
Last date of PNCU ___________ Toxoid received? Yes/No How many TT? _______ When? ______________
Medications taken during pregnancy _________________________________________________________
Any illness during pregnancy? ______________________________________________________________
RURAL HEALTH UNIT AND BIRTHING FACILITY
BAGARES ST., ZONE IV, SOGOD, SOUTHERN LEYTE
OBSTETRICAL RECORD
NAME OF PATIENT:
AGE:
Case Record N o.
SEX:
Gravida:
Chief Complaint
Para:
Term:
Preterm:
Abortion:
Live
History of Present Illness:
Menstrual History:
Menarche: ________
Duration: ______________________
Past Medical Illness:
HPN ( )
DM ( )
Surgery ( )
Allergy ( )
Bronchial Asthma ( )
OB History
G#
NSD/CS
SEX
YEAR OF BIRTH
ROS
First Day of LMP : _____________ EDC: __________________ AOG: _______________________
Morning Sickness:
☐ Mild
☐ Moderate
☐ Severe
Headache
☐ Dizziness
☐ Blurring of Vision
☐ Jaundice
Vaginal Bleeding
☐ Edema
Others:___________________________________________________________________________
___________________________________________________________________________________
Physical Examination:
General Examination:_______________________________________________________________
_________________________________________________________________________________
BP: ________________ Pulse: _____________ Temperature: ___________ Weight: ____________
Head:____________________________________________________________________________
Abdomen: Fundic Height:____________________________________________________________
Fetal Heart Rate: __________________________________________________________________
Uterine Contraction on Admission: Interval: _________________ Duration: _____________________
Internal Examination:
Time: __________________ Date: ____________________ By Whom: _______________________
Cervix: __________________________________________ Effacement: ______________________
Membrane:
☐ Intact
☐ Ruptures
Time: ________________________
Position: ___________________________________________ Station: ______________________________________________
Impression: _______________________________________________________________________________________________
Attending MD/RN/RHM:
______________________________
Signature over Printed Name
RURAL HEALTH UNIT
Sogod, Southern Leyte
Patient’s Name: _____________________________________ Age: ______ Sex: _______
TIME/DATE PROGRESS
NOTES
TIME:
DATE:
BP:
G: _____ P: _____ A: _____
LMP:
AOG:
FHB:
FH:
IE:
DOCTOR’S ORDER
RURAL HEALTH UNIT AND BIRTHING FACILITY
Sogod, Southern Leyte
Patient’s Name: _______________________________________
MEDICATION GIVEN
DATE
SHIFT
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
Time
Signature
AM
PM
AM
PM
Sex: ________
AM
PM
RURAL HEALTH UNIT
Patient’s Name: ___________________________________ Age: _____ Sex: ________
Address: ________________________________________________________________
The Patient is about to leave the hospital and may confirm a favor to Hospital Administration
for necessary comment and recommendation in order to improve the services.
Please check excellent being the highest and poor being the lowest rate
Services
1. Food Served and Service
2. Medical Service Staff
3. Nursing Service Staff
4. Ancillary Service
Poor
Fair
Good
Very Good
Excellent
5. Complaints/Comments: ______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. Recommendation: _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. Have you given voluntary contribution or donation either in cash or in kind? _____________
If so, please note the amount given and per official receipt no. _________________________
If donation is in kind, state what kind of articles and to whom it is given ___________________
8. Did you pay for these services during your confinement?_____________________________
________________________________
Printed Name and Signature of Patient
Witness: _____________________________
Note: if the patient desires to have this confidential without necessary witness, this form should be sent directly
to the MHO.
SOGOD RURAL HEALTH UNIT AND BIRTHING FACILITY
BAGARES ST., ZONE IV SOGOD, SOUTHERN LEYTE
ADMISSION AND DISCHARGE RECORD
FACILITY CODE: M08015574
MEDICAL RECORD NO. ____
PATIENT’S NAME
(LAST)
(GIVEN)
CELLPHONE #
PERMANENT ADDRESS
BIRTHDATE
AGE
NATIONALITY
BIRTHPLACE
ROOM
(MIDDLE)
SEX
CIVIL STATUS
☐M
☐F
☐ S ☐ SEP ☐ D
RELIGION
OCCUPATION
☐M
FATHER’S NAME
ADDRESS:
CELLPHONE #
MOHTHER’S MAIDEN NAME
ADDRESS:
CELLPHONE #
ADMISSION:
DATE:
TIME:
TYPE OF ADMISSION
TOTAL NO. OF
DAYS
DISCHARGE:
DATE:
TIME:
☐ NEW
☐ OLD
SOCIAL SERVICE CLASSIFICATION
☐ FORMER OPD
ADMITTING PHYSICIAN:
REFERRED BY:
(Physician/Agency)
☐ PHIC (No.) __________________________________
Informant: __________________________________________________
Address of Informant: _________________________________________
ADMISSION DIAGNOSIS
☐ NON PHIC
Relation to Patient:
DISCHARGE DIAGNOSIS:
DISPOSITION:
ICD CODE NO.
ICD CODE NO.
RESULTS:
☐ DISCHARGE
☐ RECOVERED
☐ IMPROVED
☐ TRANSFERRED
☐ DIED
☐ UNIMPROVED
☐ DAMA
☐ - 48 HOURS
☐ AUTOPSY
☐ ABSCONDED
☐ + 48 HOURS
☐ NO AUTOPSY
Attending Physician
.
DR. ISABELITA B. MATO
Signature
☐W
RURAL HEALTH UNIT
Sogod, Southern Leyte
Patient’s Name: _____________________________________ Age: ______ Sex: _______
TIME/DATE PROGRESS
NOTES
TIME:
DATE:
BABY:
M
F
WEIGHT: _______________ grams
BL: ____________________ cm
CC: ____________________ cm
HC: ____________________ cm
DOCTOR’S ORDER
RURAL HEALTH UNIT
Sogod, Southern Leyte
Patient’s Name: _____________________________________ Age: ______ Sex: _______
DATE/TIME
NURSE’S NOTES
RURAL HEALTH UNIT
Sogod, Southern Leyte
LAST NAME: _______________________________________
CASE NUMBER: __________
GIVEN NAME: __________________________ AGE: ______ SEX: ______
☐ MALE ☐ FEMALE
WARD: _______________________________________________________
SURNAME
AGE
HOSPITAL NO.
GIVEN NAME
SEX
WARD/ROOM
☐ M ☐ F
NEWBORN RECORD
PHYSICAL EXAMINATION
APGAR SCORE AT BIRTH:
APGAR SCORE MIN. AFTER
APGAR SCORE 10 MIN. AFTER
GENERAL CONDITION:
DATE: __________________ HOUR AFTER BIRTH: _____________________
______
MEASUREMENT
____________
HEAD ____________
______
CIRCUMFERENCE
____________
CHEST ____________
______
ABDOMEN
____________
______
BIRTH WEIGHT
____________
BIRTH LENGTH
____________
GENERAL MUSCULAR TONUS: ____________________________________________________________________________
SKIN:
COLOR
TURGOR
RASH
DESQUAMATION
HEAD
HOLDING
____________________
INGUINAL HERNIA
_______________
SCALP
____________________
DIASTASIS RECTI
_______________
FONTANELLS
____________________
OTHER FINDINGS
_______________
SUTURE
____________________
________________________________
CONJUNCTIVITIS
____________________
GENITALS
_______________
SCLERA
____________________
MALE TESTES
_______________
PUPILS
____________________
ABNORMALITIES
_______________
DISCHARGE
____________________
_________________________________
VAGINAL BLEEDING
_______________
_________________________________
ABNORMALITIES
_______________
LIP
_____________________
EXTREMITIES
_______________
TONGUE
_____________________
CLUBFOOT
_______________
PALATE
_____________________
HIP DISCOLORATION _______________
__________________________________
GENERAL PULSE
_______________
STERNOCLEIDOMASTOID
SPINE
_______________
__________________________________
FISTULA
_____________________
OTHER FINDINGS
_____________________
__________________________________
RESPIRATION
CLAVICLES
BREAST
HEART
LUNGS
_______________________________________________________________________________________
FACE:
EYES:
EARS:
NOSE:
MOUTH:
NECK:
CHEST SHAPE
IMPRESSION:
DOCTOR:
____________________
____________________
____________________
____________________
ABDOMEN
SPLEEN
KIDNEYS
LIVER
UMBILICAL CORD
_______________
_______________
_______________
_______________
_______________
_______________________________________________________________________________________