INTERNATIONAL HEALTH

CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182
FLUID BALANCE CHART
NAME:_____________________________________ IP NO.____________________
DOCTOR: ________________________ WARD____________ BED NO____________
AGE:__________________WEIGHT___________ kgs DATE:___________________
INTAKE (m/s) OUTPUT (m/s)
Intravenous Alimentary Urine
Time Type Bo le Infused Type Amount Vomit Stool N/Gast Others Amount Sp.Grav
6-7 am
8
9
10
11
12MD
1
2
3
4
5
6
7
TOTAL
8
9
10
12 MIN
1
2
3
4
5
TOTAL
24HRS TOTAL
INTRAVENOUS TOTAL INTAKE VOMIT
ALIMENTARY TOTAL OUTPUT STOOL
TOTAL BALANCE NASO GAST
OTHERS
URINE
TOTAL OUTPUT

Intravenous Infusion:

Other Instruc ons:

 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

INPATIENT DISCHARGE CLEARANCE FORM

ENSURE THAT ALL MEDICINE, SURGICALS, PROCEDURES, LABORATORY CHARGES.
ACCOMMODATION AND OTHER FEES ARE CORRECTLY CHARGED BEFORE GIVING THE
FINAL BILL TO THE CUSTOMERS.
INITIAL DEPOSIT PAID: ________________________
1. DOCTOR
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

2. LABORATORY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

3. RADIOLOGY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
4. NURSING
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

5. PHARMACY
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
6. HOUSEKEEPING
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

7. CLAIMS MANAGER
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................

8. BILLING MANAGER
NAME ..................................................................................................................

COMMENT ....................................................... TIME........................................

SIGN .....................................................................................................................
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

CONTINUATION SHEET

IP NO:..................................................... WARD:......................................................

NAME:.............................................................AGE:.................... WT:................................
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

BED-HEAD TICKET:................................................... IP NUMBER:.....................................

NAME:..........................................................................................................D.O.B....................................
SEX:................................. AGE:.................................................. WT:.....................................................
PARENT/GUARDIAN:........................................................................TEL:..............................................
D.O.A:.............................................................................................TIME:.................................................
ADMITTING DOCTOR:............................................................................................................................
COMPLAINTS:..........................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
HISTORY:...................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
P.M.H:..........................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
FAMILY HISTORY:
.....................................................................................................................................................................
.....................................................................................................................................................................
DRUG HISTORY:
.....................................................................................................................................................................
.....................................................................................................................................................................

R.O.S...........................................................................................................................................................
.....................................................................................................................................................................

PHYSICAL EXAMINATION:
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
DIAGNOSIS................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

INPATIENT CHARGE SHEET

NAME............................................. IP/NO.......................................DATE...........................

ITEM COST @ ITEM QUANTITY TOTAL COST

DOCTOR’S ROUND
NURSING CARE
BED CHARGE
NEEDLES & SYRINGES
OTHERS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

TOTAL COST
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

NURSING PROGRESS REPORT

PATIENT NAME.....................................................................DATE OF ADMISSION...........................................

DATE TIME NAME

 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

IN-PATIENT VITAL SIGNS SHEET

NAME................................................................................................ IP NO....................................

DATE TIME TEMP RESP BP PULSE COMMENTS SIGN

 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

WARD CHECKLIST -
ENTRY ITEM NO: CONDITION EXIT NO: CONDITION
DATE DATE
ADJUSTABLE BED WITH SIDE RAILS
ADJUSTABLE BED
FLAT BED
TABLE
TEA TROLLEY
COFFEE TABLE
SOFA CHAIR
BEDSIDE LOCKER
MATTRESS
BEDSHEET
PILLOW
PILLOW CASE
BLANKET
BED COVER
MOSQUITO NET
BULB
SOCKET
CURTAINS
WINDOW PANE
TV
DRIP STAND (OLD AND NEW)
TOILET
SHOWER
SINK
OXYGEN CYLINDER
OXYGEN FLOW METER
HUMIDIFIER
VITAL MONITOR
MORTEIN DOOM
BUCKET DUSTBIN

PATIENT’S SIGNATURE: PATIENT’S SIGNATURE:

NURSE’S SIGNATURE: NURSE’S SIGNATURE:
1. HOW DID YOU FIND OUR SERVICE IN THE HOSPITAL? (KINDLY LET US KNOW)
....................................................................................................................................................
....................................................................................................................................................
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

NURSING CARDEX
BIODATA:
NAME________________________________ DATE OF ADMISSION:_____________
AGE:_________________________________PHONE NUMBER:__________________
NEXT OF KIN’S NAME:_________________PHONE NUMBER:__________________
DIAGNOSIS:

PRESENTING ILLNESS/CHIEF COMPLAINS:

PAST MEDICAL AND SURGICAL HISTORY:

FAMILY HISTORY:
 INTERNATIONAL HEALTH
CENTRE LIMITED
Tenth Street 2nd Avenue, Eastleigh, Nairobi
P.O. Box 41238-00100
Tel: 0796 529 181| 0796 529 182

DISCHARGE SUMMARY AND CLINICAL ABSTRACT

SURNAME: IP. No. Age:

OTHER NAMES: Ward: Sex (M/F):

ATTENDING PHYSICIAN / SURGEON DATE OF ADMISSION DATE OF DISCHARGE

GP/PP

FINAL DIAGNOSIS HOSPITAL BILL

RECEIPT No.
OTHER ILLNESSES
CLINIC

CLINIC
COMPLICATION
CLINIC

OPERATION 1 CLINIC

2 CLINIC

CLINICAL SUMMARY:

INVESTIGATIONS:

MANAGEMENT:

DISCHARGE PRESCRIPTIONS:

RECOMMENDATIONS:

DOCTOR’S NAME: SIGN: DATE:

 INTERNATIONAL HEALTH CENTRE LIMITED NOTE: (i) The Treatment Sheet is to be used only NAME:
TENTH STREET 2ND AVENUE, EASTLEIGH, NAIROBI for the prescribing and recording of medication. REG NO:
P.O.BOX 41238-00100 (ii) ALL prescriptions must be rewritten weekly SEX: AGE: WARD:
TEL: 0796529181-0796529182 not later than Monday mid-day. CONSULTANT:
IN-PATIENT TREATMENT SHEET
DRUG ALLERGIES:
ONCE ONLY PRESCRIPTIONS, STAT DOSES, PRE-MED ETC. A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M
DATE DRUG DOSE ROUTE TIME SIGN
1
2
3
4
5
6
REGULAR PRESCRIPTIONS
DATE DRUG DOSE ROUTE TIME SIGN A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M
1
2
3
4
5
6
7
8
9
10
Doctor’s Name: Sign: