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    F3 Malaria In-Patient Registry Form

    Uploaded by

    Jumar Carpe
    This document is a malaria in-patient registry form used to collect clinical and diagnostic information about malaria patients admitted to hospitals in the Philippines. It collects identifying and demographic information about the patient, details about their symptoms, laboratory test results, treatment provided during hospitalization, and outcome at discharge. The form is used to classify cases as indigenous or imported and determine if an investigation was conducted.

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    F3 Malaria In-Patient Registry Form

    Uploaded by

    Jumar Carpe
    85 views1 page
    This document is a malaria in-patient registry form used to collect clinical and diagnostic information about malaria patients admitted to hospitals in the Philippines. It collects identifying and demographic information about the patient, details about their symptoms, laboratory test results, treatment provided during hospitalization, and outcome at discharge. The form is used to classify cases as indigenous or imported and determine if an investigation was conducted.

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    Original Title

    F3 Malaria in-Patient Registry Form

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    This document is a malaria in-patient registry form used to collect clinical and diagnostic information about malaria patients admitted to hospitals in the Philippines. It collects identifying and demographic information about the patient, details about their symptoms, laboratory test results, treatment provided during hospitalization, and outcome at discharge. The form is used to classify cases as indigenous or imported and determine if an investigation was conducted.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    85 views1 page

    F3 Malaria In-Patient Registry Form

    Uploaded by

    Jumar Carpe
    This document is a malaria in-patient registry form used to collect clinical and diagnostic information about malaria patients admitted to hospitals in the Philippines. It collects identifying and demographic information about the patient, details about their symptoms, laboratory test results, treatment provided during hospitalization, and outcome at discharge. The form is used to classify cases as indigenous or imported and determine if an investigation was conducted.

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    of 1

    Philippine Malaria Information System (PhilMIS)

    F3

    Malaria In-Patient Registry Form (MIPRF)

    Case Classification:

    Indigenous

    NAME OF HOSPITAL

    Induced With Case Investigation?

    TRANSACTION ID
    TO BE FILLED OUT BY DATA ENCODER

    DATE OF ADMISSION

    Date Blood Examined

    YEAR

    DAY

    MONTH

    NAME OF PATIENT

    Imported

    MONTH

    FIRST NAME

    M.I.

    DATE OF BIRTH

    FEMALE

    YEAR

    DAY

    RESULT

    YEAR OLD)

    MALE

    WEIGHT

    MONTH

    MONTH (IF BELOW 1

    YEAR

    SEX

    YEAR

    DAY

    Date Result Released

    LAST NAME

    AGE

    MONTH

    PREGNANT

    DAY

    YES

    YEAR

    RDT

    Microscopy

    NO

    IP GROUP

    Pf
    Non-Pf

    Pv

    Pf

    kilo

    Pm

    Po

    Pf/Pv

    NMPS

    Pf/Non-Pf
    Pv

    Pf/Pm

    SOURCE OF INCOME/ OCCUPATION

    Pf/Pv

    Pv/Pm

    ADDRESS

    NEGATIVE

    Slide Number

    PUROK/SITIO/ZONE

    BARANGAY

    CHIEF COMPLAINT

    MUNICIPALITY

    Parasite/ blood

    Fever, if yes temp?


    Others

    RDT Number

    Clinical Diagnosis
    (BSMP) RESULTS DURING CONFINEMENT

    ONSET OF SYMPTOMS

    SPECIES
    MONTH

    YEAR

    DAY

    Parasite/ L blood

    BSMP 1

    HISTORY OF TRAVEL FOR THE PAST TWO WEEKS?

    YES

    NO

    BSMP 2
    BSMP BEFORE
    DISCHARGE

    WHERE?
    HISTORY OF BLOOD TRANSFUSION 2 WEEKS PRIOR TO ONSET OF ILLNESS?
    IF NO, 6 MONTHS PRIOR TO ILLNESS?
    OTHER SIGNS AND SYMPTOMS DURING HOSPITALIZATION
    Jaundice
    Weak pulse/low BP

    YES

    NO

    YES

    NO

    Convulsion/history of convulsion

    Delirium

    Respiratory Distress

    Comatose

    Reddish/tea colored urine

    Poor urine output

    Hyperthermia

    Others

    ANTI-MALARIAL DRUGS GIVEN


    TOTAL QTY

    DATE STARTED

    PREPARATION

    TOTAL QTY

    Artemether-Lumefantrine

    Tetracycline

    Chloroquine

    Doxycycline

    Primaquine

    Clindamycin

    Quinine tab

    No Medicine Given

    Quinine ampules
    PATIENT'S DISPOSITION (CHECK ONE)
    IMPROVED
    Final Diagnosis (using ICD-10 Code for malaria)

    REFERRED TO ANOTHER HOSPITAL


    REASON FOR REFERRAL

    ABSCONDED
    HAMA (Home Against Medical Advice)
    DIED

    FINAL DIAGNOSIS (Using ICD-10 Code for malaria)


    UNDERLYING CAUSE OF DEATH:

    MALARIA
    OTHERS (Please specify)

    CONCOMITANT DISEASE
    DATE OF DISCHARGE/DEATH
    MONTH

    DAY

    YEAR

    Prepared by:

    Reviewed by:

    Position:

    Position:

    Date Prepared:

    Date Reviewed:

    DATE STARTED

    PREPARATION

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