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Form001

Tellain Medical Hospital


Lapaz, Iloilo City
Admission Sheet

Room/Ward
#:

Date on
admission:

Name:

Sex:

Address:

Tel. No. :

Chief Complaint:

Allergy:

Method of admission:

Accompanied by:

Vital Signs: T_____ P_____ R_____ BP_____

Admitting Diagnosis:

Mental/Emotional Status upon admission:

History of Present Illness:

Birth date:

Doctor:

Age:

Civil
Status:

Pin #.
Religion:

Tellain Medical Hospital


Lapaz, Iloilo City

Form002

Form 003

Tellain Medical Hospital


Lapaz, Iloilo City
Autopsy Report
Name
Weight

Age
Length

Clothing:

External Examination:

Sex

Eyes

Doctor
Hair

Time:
Circumcis
ed
Yes No

Race:

X-ray:

History:

Pathological Diagnosis:

Cause of Death:

Gross Description:
Skin:

Pleura:

Peritoneum:

Pericardium:

Heart:

Aorta:

Neck Organs:

Lungs:

Lymph nodes:

Liver:

Gallbladder:

Spleen:

Pancreas:

Adrenal Glands:

GI Tract:

Kidneys:

Bladder:

Genitalia:

Brains and Meninges:

Skull:

Pelvis:

Ribs:

Vertebrae:

Extremities:

Microscopic Sections:

Other Lab Procedures:

Disposition of evidence
Toxicology:

Investigator:

Microscopic Description
Heart:

Lungs:

Liver:

Summary:

Manner of Death:

Form 004

Tellain Medical Hospital


Lapaz, Iloilo City

Form 005

Tellain Medical Hospital


Lapaz, Iloilo City

Diagnostic Radiology (X ray Report)


Name: _______________________________Age:________Sex:______Hospital No.:_______
Doctor: _____________________
Examination Desired:_____________________________________________________________
Reason for Exam: _______________________________________________________________

Report:

Date:____________

Exam:__________

Radiologist:

Form 006

Tellain Medical Hospital


Lapaz, Iloilo City

Doctors Order Sheet


Name

Age

Allergy:

Birthdate

Room/Ward
no:

Doctor:

Referrals:

Chief Complaint:

Date

Pin #

Time

Diagnosis:

Orders

Time
Ordered

AP/RIC/RN
Signature

Remarks

Form 007

Tellain Medical Hospital


Lapaz, Iloilo City
Doctors Progress Note

Name

Age

Birthdate

Chief Complaint

Date

Time

Pin #

Room/Ward no

Doctor

Diagnosis

Focus Problem

Progress Notes

Form 008

Tellain Medical Hospital


Lapaz, Iloilo City
Nurses Notes
Name

Age

Birthdate:

Pin #

Room/War

Doctor

d no
Allergy

Referrals

Chief Complaint

Diagnosis

Date

Shift
Time

Focus Problem

Progress Notes

Form 009

Tellain Medical Hospital


Lapaz, Iloilo City
Endoscopy Report

Name________________________________________________Age_____________Sex_________
____
Address_________________________________________RM/WD No:
_______________Date________
Attending
Physician________________________________Indication____________________________
Findings:

_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___
Diagnosis:

Recommendation:________________________________________________________________
______
____________________________MD
Colono
scopist
Form 0010

Tellain Medical Hospital


Lapaz, Iloilo City
Allergy Log Form
Name

Age

Birthdate:

Pin #

Room/War
d no

Doctor

Referrals
Chief Complaint

Diagnosis

Check the following:

Form 0011

Tellain Medical Hospital


Lapaz, Iloilo City
Discharge Summary
Name:__________________________________ Age: _____Sex_____Status: ____S____
M_____W____
Date of Admission ___________________

Date of Discharge _______________

Diagnosis _______________________

_____________________________________________________________________________________

Prepared by:
Consultant of Resident In-Charge
__________________________________
Nurse on Duty
__________________________________
(Signature over Printed)

Form 0012

Tellain Medical Hospital


Lapaz, Iloilo City
Intake and Output Chart
Name:_________________________________ Age/Status______________Room/Ward
#__________
Doctor:______________________________
Pin
#_______________
Time

Oral

NGT

IVF

Blood
Products

Stool

Urin
e

7:00
8:00
9:00
10:00
11:00
12:00
1:00
2:00
Total
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
Total
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
Total
24
hours

Total Intake 24 hours :_________________________________ Total Output 24


hours:_________________________________

Vomitus

Drainage

Form 0013

Tellain Medical Hospital


Lapaz, Iloilo City

Medication Record

Name

Birthdate:

Referrals
Allergy

Pin #

Room/Ward no

Age
Diagnosis

Doctor

Date
Ordere
d

MEDICATIONS

Hou
rs

DATE

DATE

DATE

DATE

DATE

DATE

NURSES NAME

Initi
al

NURSES NAME

Initi
al

NURSES NAME

Initial

Form 0014

Tellain Medical Hospital


Lapaz, Iloilo City
(EKG) Report
Name

Age

Birthdate:

Referrals
Chief Complaint

Diagnosis

Pin #

Room/Ward no

Doctor

Medication:

ECG Diagnosis:

Heart rate:

Main Frontal QRS axis: right-normal-left


Time Distance:

PQ

QRS

QT

Form Analysis:
P

QRS

ST-Segment:
Isoelectrical(normal)

Summary:

elevated
other

descending

Recommendations:

____________________________MD
Physician
Form 0015

Tellain Medical Hospital


Lapaz, Iloilo City
Electroencephalogram (EEC) Report
Name

Age

Birthdate:

Referrals
Chief Complaint

Diagnosis

Pin #

Room/War
d no

Doctor

FINDINGS:

IMPRESSION:

CLINICAL CORRELATION:

____________________________MD
Physician
Form 0016

Tellain Medical Hospital


Lapaz, Iloilo City
Vital Signs Graphic Report
Name

Age

Birthdate:

Allergy

Referrals

Chief Complaint

Diagnosis

Date

Time

Temp

BP

RR

Pin #

Room/War
d no

PR

CVP

Doctor

Pain
Scale

Form 0017

Tellain Medical Hospital


Lapaz, Iloilo City

Form 0018

Tellain Medical Hospital


Lapaz, Iloilo City
Request to blood bank Report
Name

Age

Birthdate:

Allergy

Referrals

Chief Complaint

Diagnosis

Pin #

Room/War
d no

Doctor

Form 0019

Tellain Medical Hospital


Lapaz, Iloilo City
Death Certificate

Form 0020

Tellain Medical Hospital


Lapaz, Iloilo City
APGAR Newborn Scoring Sheet
Name

Age

Birthdate:

Pin #

Room/War
d no

Doctor

Allergy

Referrals

Chief Complaint

Diagnosis

Form 0021

Tellain Medical Hospital


Lapaz, Iloilo City
Baby Feeding Schedule

Name

Age

Birthdate:

Pin #

Room/War
d no

Doctor

Allergy

Referrals

Chief Complaint

Diagnosis

Midni
ght
Da
y
1

Feedings

Da
y
2

Feedings

1 2 3 4 5 6 7 8 9 1
0

1
1

Noo
n

1 2 3 4 5 6 7 8 9 1
0

Diapers
Bowel
Movement

Diapers
Bowel
Movement

Da
y
3

Feedings
Diapers
Bowel
Movement

Da
y
4

Feedings
Diapers
Bowel
Movement

Da
y
5

Feeding
s
Diapers
Bowel
Movem
ent

Form 0022

Tellain Medical Hospital


Lapaz, Iloilo City
Laboratory Reports
Name

Age

Birthdate:

Pin #

Room/War
d no

Doctor

1
1

Allergy

Referrals

Chief Complaint

Diagnosis

Name of Test

Date

Test Result

Conducted
by

Diagnosis Summary

Form 0023

Tellain Medical Hospital


Lapaz, Iloilo City
TB Test Form
Name________________________________________Age:_______________
Address_______________________________________Sex:_______________
Select one from the option below:

Intra- dermal TB Test:

Chest X-ray:

Date:
Results:

Signature:
_________________________________
____________________________
Physician
Asst. Physician

______________________________
Nurse
Form 0024

Tellain Medical Hospital


Lapaz, Iloilo City
Baby Medicine List
Name________________________________________Age:_______________Doctor__________
_____
Address_______________________________________Sex:_______________Allergy_________
_____

Name of Medicine

Tim
e

Dat
e

Dose

Remarks

Form 0025

Tellain Medical Hospital


Lapaz, Iloilo City
BCG Chart
Name

Age

Birthdate:

Pin #

Room/War
d no

Doctor

Allergy

Referrals

Chief Complaint

Diagnosis

Dat
e

Morning

Lunch

Dinner

Bedtime

Physical
Activity