Patient'S Record: University of Northern Philippines

Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986
PATIENT’S RECORD
Case No. ___________
Dr. _______________________________ Room No.
________
Name:_______________________________ Date Admitted:________ Time: -

______AM/PM
Address: __________________________________________ Tel. No:
___________________
Age: ________ Sex: __________ Civil Status:____________ Nationality:
________________
Date of Birth: _______________ Place of Birth:
_____________________________________
Religion: ___________________ Occupation:
_______________________________________
Incase of Emergency:
___________________________________________________________
Address:___________________________________________________________________
___
Name of Nearest Relative:
_______________________________________________________
Address: __________________________________________ Tel. No:
___________________
Condition on Arrival: _______________________________ Brought by:
________________
Admitted by: ______________________________________ Discharge
by:_______________
Final Diagnosis:
Operation of Treatment:
Discharge on: _________________ Time: _________AM/PM Discharge
by:______________
Condition on Discharge: ( ) Improved ( ) Unimproved ( ) Stable ( ) HAMA ( ) Died ( ) Others__-
____
Remarks:
( ) Private Patient
( ) Walk-in Case
( ) Medico-Legal Case
( ) PHIC
____________________,MD
( ) HMO_________________________ Signature of Physician
( ) Senior Citizen ID No. ___________
( ) Service Patient

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
CONSENT FOR ADMISSION AND RELEASE FROM

RESPONSIBILITY FOR UNADVISED DISCHARGE
DATE: ________________
TO WHOM IT MAY CONCERN:
I, _________________________________, __________years old, single/married/ widow,
hereby
Name of Patient or Nearest Relative Age (Tawen, awanan asawa/ addaan asawa/balo
mangted)
(Pasyente Wenno Kabagyan)
consent the ADMISSION of _____________________________________ who is my
______________
pammalubos ti pannakaospital ni Myself or Name of Patient Relationship
(Nagan ti Pasyente)
authorizing any medical Staff of Northside Doctor’s Hospital to provide Hospital services
(sipapalubosak kadaguiti doktor ken nurses iti NDH nga mangted kadagiti serbisyo iti ospital)
which deemed NECESSARY OR ADVISABLE according to the Attending Physician (s).

(nga kasapulan ti pasyente nga ipakaammoti mangtaming a doktor)
Nurse on Duty:_________________________________ ________________________________

Patient’s Signature or “thumb mark”
or person giving free consent.
RELEASE FROM RESPONSIBILITY FOR UNADVISED DISCHARGED

(Pannagawid nga mailabsing ti pammagbagati doctor)
DATE: ________________
TO WHOM IT MAY CONCERN:
I, ____________________________________, __________years old, single/married/
widowed,
Name of Patient or Nearest Relative Age (Tawen, awanan asawa/ addaan
asawa/balo,
(Pasyente Wenno Kabagyan)
hereby consent the DISCHARGED of _____________________________________ who is my
______________
pammalubos ti pannakaospital ni Myself or Name of Patient Relationship
(Nagan ti Pasyente)
being DISCHARGE AGAINST THE ADVISE of the Attending Physician of the Hospital
Admission.
(ket AGAWID NGA MAILABSING TI PAMMAGA TI MANGTAMING NGA DOKTOR ITI PANNAKANAN ITI OSPITAL)
I acknowledge that I have been informed of the risk involved and hereby release the Attending Physician
and
(Maawatak ti naipakammo kaniak nga narisgo iti agawid ket awan ti pakabasolan ti doktor nga
nangtaming
Northside Doctor’s Hospital from all the responsibility and all effect which may result from
ken NDH kadaguiti responsibilidad ken amin nga epekto
such discharge.
iti panagawidna).
Nurse on Duty:_________________________________ ________________________________

Patient’s Signature or “thumb mark”
or person giving free consent.
SIGNED IN THE PRESENCE OF:

Witness:______________________________________
Address:_________________________________
Witness:______________________________________
Address:_________________________________
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
Vital Sign Sheet

Last Name: _____________________________ Age:_________ Hospital No. ____-
____
Given Name: ____________________________ Sex:__________
Ward/Room:________
Date BP PR RR Temp. Intake Total Output Total

Time mmHg bpm cpm ℃
IVF/BT Oral/OF 24 Urin Stool 24
Hours Hours
e
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
DOCTOR’S ORDER AND PROGRESS NOTES SHEET

Family Name First Name Middle Name Room No. Bed No.
Hospital No.
Attending Physician Age Sex Civil

Status
Date/Time ORDERS C A R E D
Progress Notes
C- Carried A- AdministeredR- Requested E- Endorsed
Discontinued
Date/Time ORDERS C A R E D
Progress Notes
C- Carried A- AdministeredR- Requested E- Endorsed
Discontinued

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
MEDICATION TREATMENT SHEET
Last Name: First Name: Middle Date Admitted Room Bed No. Hospital No.
Name: No.
Attending Physician Co-Manage Age: Sex Civil Status

Physician
Date
Dat Date Dat Date Dat Date Date
Ordere Medication e e e
d Dose Route Freq Time
.
AM
PM
N
AM
PM
N
AM
PM
N
AM
PM
N
AM
PM
N
AM
PM
N
AM
PM
N
AM
PM
N
Date Trea Freq Time Dat Date Dat Date Dat Date Date
Ordered e e e
tment .
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
Parenteral Fluid Sheet

____
Given Name: ____________________________ Sex:__________
Ward/Room:________
Date IVF/BT (Rate) Date/Time IVF/ Level Nurse’s

Remarks
Started Consumed Received
Endorsed
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
NURSES NOTES
____
Given Name: ____________________________ Sex:__________
Ward/Room:________
Date/Shift Focus D-Data A-Action R-

/Time Response
Date/Shift Focus D-Data A-Action R-
/Time Response
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
PREOPERATIVE CHECKLIST
Last Name: ____________________________ Age:_________ Hospital No. ________
Given Name: _________________________ M.I.:_____ Sex:_____Ward/Room:________
AM PM NIGHT REMARKS
1. Kind of operation/procedure
2. Consent for the Operation signed
3. Medical clearance updated
4. Materials and medicines completed
5. Available blood properly cross-matched
6. Operative area prepared
7. Bowel prep done
8. With pre-op orders
9. NPO post-midnight maintained
10. Hair prepared, combed if necessary
11. Oral hygiene done
12. Nail polish/ make-up/ contact lens remove
13. Jewelries removed
14. Dentures removed
15. Dressed in gown/ camisa
16. Underwear removed
17. With wrist identification tag
18. Vital signs taken before and after pre-op
medications
_____BP _____PR _____RR _____Temp. _____Wt.
19. Pre-op medications administered
20. OR notified
_________________________________ _______________________________
Nurse Signature over Printed Name OR Personnel
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
CONSENT TO SURGERY
1. I hereby authorize Dr. ________________________________________ and the staff of Pira

Hospital
(Siak palubusak ni Dr. ken dagiti staff ti Pira Hospital
to perform _____________________________ and such additional operations and procedures as

are
nga mangaramid (Operation or Procedure) ken amaman nga operasyon ken “procedures”
considered necessary on the basis of there being a threat to life found during the course of said
mapanggep ti pagsyaatan wenno saan nga pagdaksan iti biag ti pasyente bayat ti
operation to __________________________________, who is my ___________________________.

pannakaopera ni Myself or Name of Patient (Nagan ti pasyente) isu nga Relationship (pannakaibagi)
2. The nature and purpose of the operation, the risk involved, and possibility of complications have
(Iti maited nga pagsayaatan ti operasyon, narisgo nga mapasamak ken posibilidad nga komplikasyon ket
been explained to me in my dialect or in a language which I understand. I acknowledge that

naipakaammo iti pagsasao nga naawatak. Awatek nga adda
guarantee has been made as to the results that may be obtained.

garantisado ken nasayaat nga resulta na.
__________________________________
___________________________________
Signature of Witness over Printed Name Signature of Witness over Printed
Name
or person giving free consent
__________________
Date
This authorization must be signed by the patient or by the next of kin in the case of a
minor or where the patient is physically or mentally incompetent.
Patient is minor of _________ years.
Patient is unable to sign because
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
CONSENT TO ANESTHESIA
1. I hereby authorize Dr. ________________________________________ and the staff of Pira

Hospital
(Siak palubusak ni Dr. ken dagiti staff ti Pira
Hospital
to give _______________________________ anesthesia to enable the surgeon perform operation

nga mangaramid (Spinal, regional, general) pampaturog tapno maaramid ti siruhano ti
operasyon
to ______________________________________, who is my ________________________________

ni Myself or Name of Patient (Nagan ti pasyente) isu nga Relationship (pannakaibagi)
3. The nature and purpose of the operation, the risk involved, and possibility of complications have
(Iti maited nga pagsayaatan ti operasyon, narisgo nga mapasamak ken posibilidad nga komplikasyon ket
been explained to me in my dialect or in a language which I understand. I acknowledge that

naipakaammo iti pagsasao nga naawatak. Awatek nga adda
guarantee has been made as to the results that may be obtained.

garantisado ken nasayaat nga resulta na.
__________________________________
___________________________________
Signature of Witness over Printed Name Signature of Witness over Printed
Name
or person giving free consent
__________________
Date
This authorization must be signed by the patient or by the next of kin in the case of a
minor or where the patient is physically or mentally incompetent.
Patient is minor of _________ years.

Patient is unable to sign because

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
OPERATING ROOM RECORD

Name: _______________________________ Age: ______ Sex: _____ Civil Status: ______
Ward:_____________________ OPD No.:_________________ Hospital No.: ___________
Operating Diagnosis: _________________________________________________________
___________________________________________________________________________
Surgeon: ______________________________ 1st Asst. ______________________________
Anesthesiologist: _______________________ 2nd Asst.______________________________
Anesthetic: ____________________________ Time Anesthesia Begun: _______________
Operating Date: ________________________ Time Anesthesia Ended: _______________
Operating Begun: _______________ AM/PM Surgical Nurse: _______________________
Operating Ended: _______________AM/PM Circulating Nurse: _____________________
Title of Operation (s) Performed: ________________________________________________
___________________________________________________________________________
Tissue to Lab: ( ) Yes

( ) No
Description of Procedure:
Findings:
O.R. Medication Order: __________________________,MD

Sponge Count Verified
______________________________
Signature
Drains: _____________________________
Kind & Number
____________________________
Comments
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
WHO Surgical Safety Checklist

DATE & TIME: _______________________________ WARD/ROOM: ____________
PATIENT’S NAME: _____________________ AGE: ______ HOSP. NO.:__________

Prepared by: _______________________________
Nurse-In-charge
Noted by: __________________________________

Anesthesiologist
_______________________________________
Surgeon
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986
NOTICE FOR OPERATION
DATE: ________________
___________________________________________________________________________
FIRST NAME MIDDLE NAME LAST NAME
WARD ______________________________ CLASSIFICATION __________________
AGE _____________________ SEX ____________________________________________
NAME OF OPERATION: ____________________________________________________
___________________________________
SURGEON
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
CP# 09177148749, 09175785986

Patient'S Record: University of Northern Philippines

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Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Name:_______________________________ Date Admitted:________ Time: -

Republic of the Philippines

CONSENT FOR ADMISSION AND RELEASE FROM

which deemed NECESSARY OR ADVISABLE according to the Attending Physician (s).

Nurse on Duty:_________________________________ ________________________________

RELEASE FROM RESPONSIBILITY FOR UNADVISED DISCHARGED

Nurse on Duty:_________________________________ ________________________________

SIGNED IN THE PRESENCE OF:

Vital Sign Sheet

Date BP PR RR Temp. Intake Total Output Total

DOCTOR’S ORDER AND PROGRESS NOTES SHEET

Attending Physician Age Sex Civil

Republic of the Philippines

Attending Physician Co-Manage Age: Sex Civil Status

Parenteral Fluid Sheet

Date IVF/BT (Rate) Date/Time IVF/ Level Nurse’s

Date/Shift Focus D-Data A-Action R-

Last Name: ____________________________ Age:_________ Hospital No. ________

Given Name: _________________________ M.I.:_____ Sex:_____Ward/Room:________

1. I hereby authorize Dr. ________________________________________ and the staff of Pira

to perform _____________________________ and such additional operations and procedures as

operation to __________________________________, who is my ___________________________.

been explained to me in my dialect or in a language which I understand. I acknowledge that

guarantee has been made as to the results that may be obtained.

1. I hereby authorize Dr. ________________________________________ and the staff of Pira

to give _______________________________ anesthesia to enable the surgeon perform operation

to ______________________________________, who is my ________________________________

been explained to me in my dialect or in a language which I understand. I acknowledge that

guarantee has been made as to the results that may be obtained.

Patient is minor of _________ years.

Republic of the Philippines

OPERATING ROOM RECORD

Tissue to Lab: ( ) Yes

O.R. Medication Order: __________________________,MD

WHO Surgical Safety Checklist

PATIENT’S NAME: _____________________ AGE: ______ HOSP. NO.:__________

Noted by: __________________________________

NOTICE FOR OPERATION

WARD ______________________________ CLASSIFICATION __________________

AGE _____________________ SEX ____________________________________________

NAME OF OPERATION: ____________________________________________________

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Name:_______________________ Date Admitted: Time: -

Nurse on Duty:_

Nurse on Duty:_

Last Name: ________________________ Age:_ Hospital No. ____

Given Name: _______________________ M.I.:_ Sex:_Ward/Room:______

operation to ________, who is my _.

to ______, who is my

PATIENT’S NAME: _________ AGE: HOSP. NO.:

WARD ____________ CLASSIFICATION

AGE _ SEX ________________________