NSD-ER-001

St.Jude General Hospital and Medical Center, Inc.

Dimasalang cor Don Quijote Sts. Sampaloc, Manila
Tel Nos. 731 – 2761-65/740-4153/740-4159

EMERGENCY ROOM NOTES

Hospital Number:____________________

Name:______________________________________________________________ Type: New ( ) Old ( )

Last Name First Name Middle Name

Address: __________________________________________Contact No. _________ Religion:________

Age: ______ Sex: _______ Civil Status: __________Weight: _________ Date of Birth: _____________
Vital Signs: BP: ________ HR: _______ RR: _______ Temp.: ________ Date: _______ Time: ________

Chief Complaint: ______________________________________________________________________

________________________________________________________________________________________________
HISTORY (Subjective) DOCTOR’S ORDER/ PLAN OF MANAGEMENT
Pertinent Past Medical Hx: (include birth/ maternal hx if OPD
applicable)

Pertinent Family Hx.

Pertinent Physical Assessment (Objective) ADMISSION

MSE/NEURO
ER NURSE REMARKS/NOTES
Time In:
NUTRITIONAL STATUS:

HEAD/NECK:

CHEST:

ABDOMEN:

G/U:
 NSD-ER-001

CLINICAL IMPRESSION (Assessment)

Time Out:
AUTHORIZATION FOR EMERGENCY TREATMENT

The undersigned has been informed of the emergency treatment considered necessary for the patient whose name appeared on
the reverse hereof and that the treatment and procedure will be performed by the physician, member of the house, staff and
employees of the hospital. Authorization is hereby granted for such treatment and procedures.

The undersigned understands that a personal physician is selected by or on behalf of the patient within 24 hours of
hospitalization or further treatments are required, or immediately if complication arises.

The undersigned has read the above authorization and understand the same and certifies that no guarantee or assurance has
been made as to the result that maybe obtained.

Date:____________ Time: ___________ AM/PM Signed: ___________________________

Witness:
Nurse on Duty: ____________________________
Signature over Printed Name

Doctor: _______________________________________
Signature over Printed Name
Authorized Person: ______________________
Signature over Printed
Name

Relationship to Patient: ___________________

REFUSED ADMISSION TREATMENT

The undersigned refuses patient’s admission even after the thorough explanation by the medical staff on the need for such
procedure and treatment. The undersigned understand and is willing to take full responsibility for whatever may happen as a
result of his/her refusal to undergo the treatment, procedure and/ or admission. The undersigned agrees to free the hospital and its
staff from any liability for the result from his/her refusal to undergo the necessary treatment and procedures explained prior to my
refusal.

Date:____________ Time: ___________ AM/PM Signed: ___________________________

Witness:
Nurse on Duty: ____________________________
Signature over Printed Name

Doctor: _______________________________________
Signature over Printed Name
Authorized Person: ______________________
Signature over Printed
Name

Relationship to Patient: ___________________

NSD-ER-001