De La Salle

College of N
Pres. J.P. Highway, Lipa

Patient Pr
Patient Registration
Name: E.B.
Age: 56
Sex: Female
Birthdate: N/A
Address: N/A
Phone: N/A
Religion: Roman Catholic
Occupation: N/A
Email Address: N/A
Chief Complaint: Abdominal pain

History of Present Illness: Patient HB has been experiencing abdominal pain for 3 days. She has a presence of H.p
the intestinal gut and has undergone gastroscopy.

Admitting Diagnosis: Hydrops of Gallbladder; Hiatal Hernia

 De La Salle-Lipa
College of Nursing
Pres. J.P. Highway, Lipa City, Batangas

Patient Profile
Vital Signs
Vital signs
BP: 120/80 mmHg
RR: 19 bpm
PR: 72 bpm
Temp: 36°C
Ht: 175 cm
Wt: 82 kg
Oxygen Saturation: N/A
Pain scale: N/A
GCS: N/A E: N/A M: N/A V: N/A
Allergies: N/A
Immunization: N/A

been experiencing abdominal pain for 3 days. She has a presence of H.pylori in
y.

tal Hernia
 lle-Lipa
f Nursing
ipa City, Batangas

Profile

Past Medical History Medications

( - ) Asthma: Metronidazole ( Dazomet ) , 500 mg
( - ) CVA:
( - ) Cancer:
( + ) Diabetes:
( - ) Heart Disease:
( + ) Hypertension:
( ) OTHERS:
( - ) Previous Surgery:

P/S History Laboraties:

( - ) Tobacco Use : Packs
Quits: Yes: or No: ✓
( - ) Alcohol Use : Bottles/Glass
Quits: Yes: or No: ✓
( - ) Subtance Use :
Quits: Yes: or No: ✓

OB History
G P ( N/A ) Philhealth ( - )
LMP: N/A EDC: N/A HMO: N/A
 De La Salle-Lipa
College of Nursing
Pres. J.P. Highway, Lipa City, Batangas

VS Monitoring Sheet
Patient Name: E.B. Attending Physician: Not Specified

Date Time Blood Pressure Temperature Pulse Rate Respiratory Rate

02/15/2019 120/80 mmHg 36°C 72 bpm 19 bpm

pa
sing
Batangas

Sheet
Physician: Not Specified Room No.

O2 Saturations Pain Scale Remarks Signature

N/A N/A N/A

 De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas

VS Graphing Sheet
Patient Name: Evelyn Borromeo Attending Physician: Not Specified

Date
Number of Days
RR CR T

12

12

12

12

12

12

12

12
4
8

4
8

4
8

4
8

4
8

4
8

4
8

4
180
41
170
40
160
39
150
38
140
37
130
36
120
35
110

100
70
70
90
60
80
50
70
40
60
30
50
20
40
10

BLOOD PRESSURE
6-2pm
Urine times 2-10pm
10-6am
6-2pm
Stool No. 2-10pm
10-6am
hysician: Not Specified Room No.
12

12

12

12

12

12
8

4
8

4
8

4
8

4
8

4
8

4
8
 De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas

I & O Monitoring Sheet

Patient Name: Evelyn Borromeo Attending Physician: Noy Room No.

INTAKE OUTPUT
DATE
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
 Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
Date
NGT/
Oral IV Fluid NGT Others Total Urine Stool Others
Vomitus
6-2pm
2-10pm
10-6am
Total
 Room No.

TPUT

Total Sign

Total Sign

Total Sign

Total Sign
Total Sign

Total Sign
 De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas

Neurological Evaluation
Patient Name: Attending Physician:

Date
Time
Best To Verbal Command Obey 6
Motor Localizes Pain 5
Response Flexion Withdrawal 4
Flexion Abnormal 3
Extension 2
No Response 1

Best Oriented and Converses 5

Verbal Disoriented and Converses 4
Reponse Inappropriate Words 3
Incomprehensives Words 2
No Response 1

Eye Spontaneously 4
Opening To Verbal Command 3
To Pain 2
No Response 1

Pupil 10
Size 9
and 8
Rection 7
 6
5
4
3
2
1

Brisk
Sluggish
Non Reactive
Room No.
 De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas

KARDEX
Date Diagnostic Exam Request Specimen Result In Date No. IVF/ Blood Trans

OR Slip Received by
Date Operation to be Preformed / Radiological Procedure Consent Slip Signed NOD Surgeon/OB

Date Medications Dose Route Frequency Date Treat

02/15/2019 Metronidazole ( Dazomet ) 500 mg Intravenous q8h

Date PRN Med

Diet: Allergies: No known allergies

Age: 56 Sex: Female Status: 56

Date and Time of Admission: Adm Dx: Hydrops of Gallbladder; Hiatal Hernia Procedure Performed (if any): Bioph
February 11, 2019 , 1100 H

Room No: Not Specified Name of the Patient: E.B. Attending Physician: Not Specified

Page 1
STAT DOSE
Date Stat Medication Time Given Given By

Diagnotic/Radiologic Procedure
Date Procedure Preparation Instruments
Contraptions (if any)
Contraptions Date and Time Inserted Date and Time Removed

Other/Special Orders
Date and Time Endorsement Date and Time
Page 2
IVF/ Blood Transfusion/Side Drip Remarks

Anesth Pedia Remarks

Treatment Frequency

PRN Medications Frequency

 Nationality: Not Specified Wt: 82 kg Ht: 175 cm

Status: 56 Religion: Roman PhilHealth ⃝

Catholic
HMO: N/A
e Performed (if any): Biophysical, Psychosocial & Functional Assessment, Pa

n: Not Specified Referrals: None

Given By Remarks

Instruments Remarks
and Time Removed Remarks

Endorsement
 De La Salle - Lipa
College of Nursing
Pres. J.P Laurel Highway, Lipa City, Batangas

Medication Chart
Patient Name: E.B. Attending Physician: Not Specified Room No:

Date and Time Given Stat Medication Signature

Standing Order Time Dates:

Medications: Metronidazole ( Dozomet ) 12mn
4am
6am
8am
12nn
Date and time of Order: 4pm
Signature 8pm

Medications: 12mn
4am
6am
8am
12nn
Date and time of Order: 4pm
Signature 8pm

Medications: 12mn
4am
6am
8am
12nn
Date and time of Order: 4pm
Signature 8pm

Medications: 12mn
4am
6am
8am
12nn
Date and time of Order: 4pm
Signature 8pm

PRN Medication
Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given
Medications:

Date and time of Order: Signature Signature Signature Signature Signature Signature Signature Signature
Signature

PRN Medication
Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given
Medications:

Date and time of Order: Signature Signature Signature Signature Signature Signature Signature Signature
Signature

PRN Medication
Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given Date and Time Given
Medications:

Date and time of Order: Signature Signature Signature Signature Signature Signature Signature Signature
Signature
IV FLUIDS
Date No. Time Started Time to be IVF Signature
Consumed

Side Drips

Date No. Time Started Time to be IV Side Drip Signature

Consumed

Blood Products
Time to be
Date No. Time Started Blood Products Signature
Consumed
 De La Salle - Lipa
College of Nursing
Pres. J.P. Laurel Highway, Lipa City, Batangas

NURSES NOTES
Patient Name: Admitting Diagnosis:

Date and Shift

 Salle - Lipa
e of Nursing
ghway, Lipa City, Batangas

SES NOTES
Admitting Diagnosis: Room Number

Date and Shift

 De La Salle
College of N
Pres. J.P. Highway, Lipa

Discharge Ins
Patient Name: E.B

Medication Names
Metronidazole ( Dazomet )

Special Instruc
 De La Salle-Lipa
College of Nursing
Pres. J.P. Highway, Lipa City, Batangas

Discharge Instruction
Age: 56 Sex: Female

Dosage Frequency
500 mg Intravenous, Every 8 Hours

Special Instructions
as

n
Room Number: Not Specified

Discharge Instructions
Inform that brown urine may occur and complete the course of medication.