NAM E

TTATIOTTATITY-
'rAruS-SEUGION
ADDRESS ADMITTED

CHIEF COMPLAI NT

Hl3tory of Prosent lllness

Pait Mcdlcal H

oB-GYNE and Sur3lcal

t{utrldon end lmmunizedon

Famlly and Soda! H
PERN ENT PHYSICAT EXAMINATION:
6rneral

8l P HN RR WT. Tem

Sldn
EENT

chest/

Abdomon
Genltal

t{Gurdollcel Eram
cUillcAt IMPRESSIOI{

ROD NAME & SIGNATURE

 SIiRNAITIE AGE HOSPTTALNO,

GTVENNAME SEX WARD,TM

lulu
DISCKARGE SUMIU-A.R.Y

Date Admitted Date of Dischage:

Atteuding Physiciar:
Admitting Diegtosis
Firal Diagrosis:
cnid Cmrplaints:
Bricf Cliaicd llistory md Pertinint P. E.:

Labordory Fitrditrts: Qacluding EKG, X-ray aod otier diagaostic poce&res)

Courec in tbe Wrd: finclude mcdications, opa'diolrs. etc.)

Dispositiolr:(lndicatc home medicdicrn, special isstructirn ad follow-up)

n^.^ A --*-t:^t.-I
r,/6t c Jr!L(,ruyrltucrr Physicia-La-Chrgc
 Petienfs Doctor Preference Sheet

Ih
Nu ofPrirc l\/ndrf,a. No._
Ilrrlc Cbc&
() I .h lot lm ry prticutr .locE rd I a ritrhg to tr r&itbd *tr Sr srvicr
ofttc CmIE On Dc& @orsr Crrr)
() IlrrfrrD.
s orygir& ll-.*l8 9fo6iciro.
() I hrrrey rgnr lf,* I will bt drcd rnda ltr rrnrim of
D. ia a*Itioa to lhr pe56icic curdy
eadlg to Ee ft. co-or.tto. /c6s*dim-

F G{E !l Or Dtt)
Pii.ot,
SEI.ilre over
Raldivo
pdlErl lae
 CONSENT FOR ADMISSION / CONFINEMENT

Ki{OW ALL iIEN BY THESE PRESENTS:

That I , oflegal age, maried/single, Filipino,

with residence and postal address at do
hereby voluntarily consent to be confined and/or admitted ot to have my
corfned or admitled 8t the-
(Daughter,Father,Mother,Son, Self,& others) (name of hospital)

That, in case of urgency or emergEncy, when my attending physician is not, for the
meantime, available, I am expressly consenting that any m€dical and nursing dafi of the
hospital may do and institule that whatever is necetsary for my condition at that particular time
of emergency;

That, in cas€ of my p€tbnt, in the cvent that there is urgency or ernergency when I am
not, or no one is available lo give consonl in my behalf or for my patient for a c€rlain prccedura,
I arn expressly consonting and I hereby authorize any staff of the hospital to do and institute thal
wtratever is r.leces-sary for the emergency condition of my paticnt for the meanlime that the
attending physician is not arcund;

That lwas expressly informed, and lfully undcrsiood that my attending physician shall
employ that which is the stindard of care required of my medical condilion and / or that of my
patieni's modical oondition 6wn as my attending physidan or the attending physicians of my
pstient, is or are not employeB but afe indopondent contractors of the hospital and I
understood that th€ hospitai hjs no control or supeNision over the m€dical managcment of my
conditbn or my pAient's medical condition. Further, it is my understanding that the nurses stafi
ar€ fully licenied to prac{ice their profussion and that lhey lvorc appc,inted according to the
credentials they have prssented to the hospital so that thair respecrive duties in the exercise of
their profession as licensed nunres are their sole rosponsibility and nd of the hospital;

That I fully underdard and do hereby consenl thet all medicin€s and suppl'res prescribed
by my attending'phFician/s shall, if available, come from the hospital pharmscy and that the
hirspiiat stratt frlve itre rilht to refuse to administer any rnedicine or medical supply thal is
evailabb but not acquireclfrom hoapital pharmacy, and that in the event that lshall purchase
medicines outskle of the hGpital pharmacy, I shall lake full responsibility br the consequences
thereof and I releasa the hosSital and ils staf from any liability resulling there from;

That, I wanant and guarantee my capatlility to pay all and any expenses in connec'tion
with my conhnement or the confinement of my/our patienl and the cost of the plocedure/s to bc
aone on me or on my patient, and that I or my pati€nt shell not leave tho hospital and/or its
premises without first-s;ttling my accounts and that for the moantime lhat I could not pay my
fiospital bill or that of my paf[nt, i shall deem my voluntary stay in the hospital as being withheld
sgainst my will;
 That, should I b€ incap€Us d paying any further hospital servic. or ,urthor cost d
medicin6/8 and/or procedurcy't, l, Or in behall ol my petbnt, axprcasly consant to be hansiotrsd
to a room or ward accordingly as dcorned appropriatc by the hospitd st and that from the
momotrt thereof, I shall be responsible for my foods and rvder whilc I am or my pdient is in the
hoErital;

It ie my full understanding that the trospilal is the o*rner of the originel copy of the
mcdical records, tho ancillary plat€, slidos in connedion with my confinom€nt, and that I shall
bo r€spoffiibh for any and all elgcnsea for the Eproduciion ol any docurnont or r€cod in
connection with my corfincment or my patient's confinement, and that, h€nceiorth, I shall not
hold th€ hosPitsl liablo or rrsPoNiblc for refusing lo Gloase a copy of !ak, docrrment or rEcord
withort my firrt having pai, the cost or expemc8 ior the reproduc,lbn thereof, and that furthor, I
heneUy adthorize the hospitel to rd6a86 3uch rdevant infomration or rrsulls or coPy ot any part
of my- meClical Goord to my insurer or to whomso6ver is r€sponsiHe fof th€ Paym8fit of my
hoepital bilUa.

likailiso expresaly acknorlcdge that I was adviled by tho hGpital against keGping any
I
cash or valuablcs insk e tho rmm where I am, or wher! my patbnt it, coffined so th8t
othsrwbo I sh8ll not hold the hoaprlal and any of its Str rssponsible or liable for the lo93 or
damrye thereof:

I expro$ly acknowledge that €\rery{hing containcd in this document was Explain6d to

me in a hnguagi and dhlcct-spoken and understood by rn€ and that I signed this documant
tE€ly and v6turit"rity, and tfiat thb doqiment shall bind my hoirs, assigns and_crJccassors and
that ihb documcnt shall provail ov€r any other oxisting or fulurs documenUs $at may appcar
the contontE of which are oontrary hercto.

Furthermore, in the interest of nursing education, I allow students to observe and

participate in my medical care as a part of their required experience, provided however that the
student performed their duties under supervlsion. (Delete words that is not applicable.)

WITNESS MY HAND this of here in

, PhiliPpino3.

-daY
Patient / Lawful Reprcaentative

Slgned ln the prEsonco of

Nurse lnterpreter
 INFECTION CONTROT PROTOCOT INFORMED CONSENT

We,-_--..--..-_-..- of legal age, who seeks admission to/a patient conflned at the
ZamboangaDoctors,Hospital(ZDH),locatedinZamboangaCity,and-.-.-.-.--.-
, of legal age, who will watch and provide company, aid, and comfort to the former while in
the
hospital, agree to submit ourselves for swabbing for Covid-l9 testing once deemed
recommended by the attending physician or lnfectious Disease Specialist. This measure will
fucilitate the early detection of the disease, and prom pt lsolation can be instituted.

We shall strictly abide by the hospital policy/protocol of wearing at all 6mes a facemask or any
other equipment, gear, or device required by the hospital, especially when any member of the
hosBital stafrenters the room of confinement. We fully understand that this policy is intended
for ou r safety and that ofthe hospital's personnel.

Any failure or refusal on our part to comply with the said policy,/protocol will render each of us
llableto pay the hospital a fine of Five Hundred (P5fl).00) Pesos perviolation.

Likewise, any failure or refusal on our part to submit to arid comply with the sald
policy/protocol wlll entitle the hospital to refuse admission or terminate confinement, as the
case be.

2020

Padentt Name in Print and Signature

Watcher's Name in Print and Signature

 TEMPERATURE, PULSE & RESPIRATION RECORD
Family Namo First Namo Anending Physiclan Ward tun. No. B€d No.

I I I I
Day of llonth I I I I

I I I I
oay of Di3oa!.
I I I I

Numbor of day(s) I I I I I I I
in Hospital I I I

Wdght I I I I I I

I TI I T I T
I II II I I
I I
E
Aa I I

E, I I

== t I
42 ==
= I 107,6

41

=l rl I 105.2

40
--
=t
-l
-
=T
- I 10'l

I
'tE0 39 102.3
- - -
38 = == 100.4
3
160 37
I t 98.6

36

35 ra3 I -
96.0

I
110 95
3
i =t I
r-
I
t I
'120
e
100
=
3 = I
rl r- I rl
50
80 ra
= l I -I
'10 3 I I -l
30
3 I
I l I
60
20

10
3 =- T
Udno
7-3 I = I = I I I I

&11 I I I I I
nm.s or CC
11.7 I I I I I

7.3 I I I I I
Stool
3.11 I I I I I I I
N03.
11.7 I I I I I I

I
 DOCTORS' ORDER/PROGRESS NOTES/SIDE NOTES

NAME RM. NO,

ATTENDING PHYSICIAN DATE:

Side Notes/Progress Notes Date/Time Doctors' Order

-
JapJo ,sJolroo aurluapo salo lsartot/sepN apls
 INTRAVENOUS FLUID SHEET

Name Vlbrd _ Rm. No. Physicran

' -Eed No
-
Bottle
-Attending
Started/Rernforced Consumed/Discontinued
Type of Solution/Orug Votume Dateffime Dateffime Remarks
Number lnc./Blood serial No. Name & Signature Name & Signature

Ir II
II II
II
I
II
II I
II II
II II
II
I
II
II II
II II
II
rI II
II II
II II
I I
II II
I I
LI I I
 I

I
I I
II
II
II
II
II
II
II
I I rI
I
I
II
I I
II
II
II
I
II II
gJnlBU6rS ? AUreN aJnlEuots ? aureN
I 'oN tEues pool€/'3ul
I JequnN
sveuJEu eul!..L/eleo euuJ€leo euJnlon onJo^ro$nlos Jo sdII atuoS
penu[uo3slo]peulnsuoc pecroluteu/paI4s
 ANTTMCNOBIAL TEIDIG..ITIOI| SEEEf

I{ame of Patient Date of Blrth Aee/Sex Room Attending Physician

Date Itame of Antimicrobial DATE

Ordered Dosage r DAY DAY DAY DAY DAY DAY DAY
Route I 1 2 3 4 5 6 7
Frequency M
E

tl

Date Name of Antlmicrobial DATE

Ordered Dosage T OAY DAY DAY DAY DAY DAY DAY
Route I I 2 3 4 5 5 7
Frequency M
E

III

R-Refused N-NPO V-vomiting NM+lo Medication D-Drowsy from Anesthesia

WRX-within 30 minutes upon order and prescription is issued

Zdharns2019
J
 MEDICATION AND TREATMEITIT SHEET
Room llo:-
DeE uedlcadon/lnlcdlon slt. sl& sL. sh, lii8. slt slg. sls. slp
M.rd Drte I D.tc I DaE D.tc m. O.t! Datc Data D&
I

I
I

R- REftticd il- trlPo G Out+atidt I SlcGpittg V- Vomldtg

t{M- f,o Mcdlcrtbn D- Drorfl!ry ftom AnesthcsL (po6t'opl

tltRX- wftl{n :tO mlnut s upon oder and grrccrtBbn Is lrsucd

 p.m{ q uogdUrrd pue rpro uodn rourupt 96 uFgir -xun
(rrerrodl :fsaqsalV urort&tolg { lrotrlclpeg on -nil
&rptruo1.-A tttPoa6 5 uFllr+ulo € (xll -x F.snl.U -U

I
I

I
i
I

I
i
p.{.p{,
.lco al&o irco rrto .r8o elto aro epo aulo
'&s '&s ,ts 'As 'tE 'tts {ls qs uoErlut/uop:qpogl llro
'ls
 NURSES PROGRESS NOTES

Physlcian Rm't{o.-
DatdTime Focus Data Ac{ion

I
I

I
 .. CD E C !0) -i dJ (E >\E
2
e t
- c
(u o
:+ iE:
dlc
$E -
E:;.EEE 7
E5e"-EE
Y : E E :P
6o= E -5
!-: = Hi;AEs
= o;

; .99+ _9 =h
=E E
=
6)rE -O ()(,)
Ei= S
hEo
-= : = .l
6 >E
> 6:
oJ:
:E EH 3".: EsrE, sg i*
J
F
d
* =il 5 I oc
EiEgEEE
a€I s
g* ae Ega fr ESESE
g;.=.i
al,
o
J-
&.
f a
Er -tsr
g 8Ef
-= =
6-dHd
u)
tg
oc= (l, -c(oo;d)
o.=Y-
c=* 3e
(r|)

E
*: elEi PEfiefr iet
o i EH=EiEsEF
o
F
trJ
,l
\
ht €

="3
-.: E ": o- o b 9; U
9
ESUio--eP68EE
$€ r..Fi
=
E BE
o
=
() |:< E c r: 6) V a^ O O.)

J I
=68€e=HsE93
E'=H88"'[6EH iEgEE IgEEE i EE E Brig;, EEgaE
IJJ IJ
5-.
=
g g
iD

E 3
o
g igg >g .b
E
'6
06H 9e - EUEE
J
o
tr
o
lr
5
!o P3
5
sx3 s €E r . .E stE
!!; ors s- - arflE
€€:E E E€E.EXEE
i EOE€

lr-
IJ
l!
co6 P.{
38E
9-b
;qEgE E
.6 !? -
ao
od
.?ri
9 - E:(.,6
-o. b .9 E'oo :
o o ,E '= -:
9,
-oE b --<.r.0
.9E'o:
o, o E'=
i c:9P olso
J:.=l c 9o!:
o- o
ooeE.i:E:i-=
EE
-9
UJ
l!
kP ptE ptx|: E Etrep ETEEEfE ETI&EfE PtB&€5=€P -:
ot tl =
tr otr tro g 8Otrtrtr EOt: tr tr trtrtrootro trtrtrtrotrtr trtrtrootrtrtrE
u,ll
F] (I o- (L (L (L (! L
<1
ul
o-
I(I
o- o-
I I I I I(r I(! I(L I
trl F
I(!
& o- o- TL o-
o o o o
o o
o o O
o
d o
o o
o o
o N.
o o
(o- q F--
O
lo- r.),
=t
ol F o) a\t r!
ol
trl z UJ

I ul
F tu tl
trJ F
ko F^
<a
>b
oa UJ
>c u€
xo [!oc <s
oo
= p,2
^O XE t9
o-b FE l
o
o trb 5H cb r& J
(r
(IJ
=o
d. = aoo-
<(L
)-
=6
O5. o-
lrJ o- uJ
O= aio- Eo-
O-
o =8
= Ec.r oe. a-
o
o
UJv
a o
UJ
t
CO
I LIJ
to-

ot
ull
ol
>t q,
EI F .g F o x u.l
e.
url
ol 'i
a,
6'
o
o tf q) tr
o o
{* l
F
(,l oo lt o (t, o o- o
CL
tgo z
zl I IJ 6
o,
r E
: E o oo (!O
OE Io
g utE o o
o
o (o o)
o '- o0. 5o o c
ol
=l
JI
d)
.o E9
, .! f IE o c o 2
JI
ot z c)
E
ul
tD
o E
o? oo E, IJJ o z
l!l
UI
z=
oA.
ru

-l =
E
FI 9?. o
=l
ol Io
.ttl N Y
dt c 28 0 t
o.
o
(, o- t
=l
oi io tr o
=2
z .E F
o lrJ o o
o I
G
1E o J
-!t 6 G G x o=
UJS lD o o o
o )o o o =
IJJ
.g
(\I
E o ,g
Eo, o tt )' F E 0,
UJ o lrE t G
o.
o .c, (l
E o. J o
o <E o =
f o E (D lo & o
d @
o1 o
o (,
ul uJx I.
l! LY E
lt th9 )
o c0
2
 s.=e '?s e es.) ee93 t.i J!
I r-
*
I [gF
'm
q2
+o
i6!
q>
of
Q- es;i EgE
sreiS
EEEE gEi
og|
om i +$ra
is
=,
oo 9g {E 9d g€ E
9i @
3o o.
o,

-q
!4-Po-
605J
?* oo(rdi
I,oo'
333 EEflHeEi
!)x'
: .:i
$fii qEr!
*;
al, N) !
aS BB8
td
-o
3i3 co :+i
=.a 6<

g
o
gB
o.< 3;
l , F
H
B
N
6
o
T
o
o
6E
=E
ae
T
=H
q

9!n I !, N .EE
B &87 o(lta,L
?1EE;qiEeI Fi$ r+gE P (6 ?:!. E iE9
o;=a
ges; Ag sss*il*ii Aef
:al ?5rt i8.d
q BE:I
oo6O-, - JET d aD.7 J
s q'€ -o
d-= I 6 e: i'ro
EsiigEEi[iE{i 71E
(a9!t 6 Eg
r arr icu5+i EC[E;5IigEEH
FIels*g;sl *ss
E:;d'!EH.6js iqE -o,
dE6
- =ta
Egd
< *==E
< (, 6 *d
6tg1

iles;rE3=aA 3ei
!af a
4 9.9 e3g lildsei
ii-q o 'r'
6 o"=
3?s
a!2- gEqaei
!rao ,_o
aFf6fiE3g5$
-Ie..,:BaH-* 5El
E=Ea{ee*il id;
1gE
69p
=c
o(o
H
=oo
oO!r
e9e. i i, dt*f i$r$iFiiiiiH
=-6;'o 6 9 o
rEarE:'E g;i
o-6' O.E'. q0 tn
s;$efid,ie geg a i=' q e-g o!2"r--lr
gg
98HlaH; 6i1
E *-
frFeBEe:H-; a:" 9d6
€3.t sii<a F: gH
5'3r[il#"BEi =si
€ E.E oo> + H.*a
i6;<5iD. ;- 13 ilE BEs fln
I99 9P cr.cl6 or { I I q9r no 9r,9 I \{
[i
!D
€€e=s I
FFFEB
€E gH; F
EFq TFF
q a 35 a E 7 8f;'888! I soigiisE: E
Sddtdo
6ato(Dr.
E

<i
g.U Ei:
E
i;r ig:':
EI
IE E
AABgB
EEdF= T
9dh9=i5
!!6rD60
=' too
o5
o,=
E o =
r o) E
83aHig == E
g
a
iSEEEEEiEF;
e
ul
It8
0l u
Eg$gE s36E E. 1893 F3 3 2
a

88,8td 3 4=..do
o !r{o
FEE €E ;fls
zE
a. €$BE*B q a
a
3
d
E H=
EsgSg ifdB
E
6 ri= ;s5 0i q;*ieE. EqEEE$Eig E. o E
I E'E O
g,E 1"
C
"
Es= ; 1d *sE o I g "g
'd si 6
E
5
q Fsi$ gi
u
";$
g HEE
E:€
!r,
g F F
F fl-E:= o a
=d
a.
.\) \) :
reE E
riDoEF" I

f;iIi
d,
3 c_q
i
53o_o-

19{
nE
=A
E-
B_r
3o
o
3 f,*.$gf; E
l-
H3

lrlr
J ln=
9')
aa,
Irr

L
u
ll IttrI ITlI It!
a
z
E3