Tanchuling General Hospital

Legazpi City
PATIENT’S CLINICAL DATA RECORDS SSS/PHILHEALTH
PATIENT’S NAME (Last) (Given) (Middle)
Mrs. Buban
PERMANENT ADDRESS: Binogsacan, Guinobatan Albay
CONTACT NO. NATIONALITY: AGE: SEX: BIRTHDAY: CIVIL STATUS:
Filipino 30 __Male 11/16/1990 __Child __∕_Single __Married
_∕_Femal _/_ Window/Widower
e __Separated
Date and Time of Admission:

CONDITIONAL ON ARRIVAL TEMPERATURE: 39.7 BLOOD PRESSURE: 70/60

__∕__Axilla ___Anal CARDIAC RATE: 72
____Oral RESPIRATORY RATE: 34
WEIGHT:__47kgs_______
CHIEF COMPLAINT: dizziness, vomiting ALLERGIES: O2 Sat-98%
4x a day
PHYSICAL FINDINGS: ADMITTING DIAGNOSIS:
Hypotension, PU 38 Weeks AOG,cephalic in labor
SURGICAL OPERATION:

ANESTHESIS AND ANESTHESIOLOGIST:

DISCHARGE ICD-10______________________________________________
A) Date: ________________________ Time: ____________________________________________________
B) Final Diagnosis: __________________________________________________________________________
C) Signature of Attending Physician: ____________________________________________________________
Surgeon: ______________________________ Anesthesiologist: ____________________________________
DATE OF DISCHARGE: CONDITION ON DISCHARGE:
______________________________ _________ Improved
TIME OF DISCHARGE: _________ Recovered
______________________________ _________ Home/Discharged Against Medical Advice
_________ Absconded
_________ Expired
_________ Transferred/Referred
Right Thumbmark

SIGNATURE OR RIGHT THUMBMARK OF PATIENT OR HIS/HER REPRESENTATIVE

_________________________________
Signature

__________________________________________ _______________________________________________
NURSES NAME (SIGNATURE OVER PRINTED NAME) SIGNATURE OVER PRINTED NAME OF ADMITTING OFFICER