DOC JO - AN LYING - IN CLINICCASE NO:

142 J. DIMABILING ST. BRGY. 4 INDANG, CAVITE ADMISSION:

(046) 889-3811 (SMART) 0969 - 622 - 2270 DATE:
TIME:
DISCHARGED:
ADMISSION AND DISCHARGE RECORD DATE:
TIME:
Patient's Name: (Last Name) (First Name) (Middle Name)

Address: Contact Number: Civil Status:

Date of Birth: Age: Place of Birth: Nationality: Religion: Occupation:

Name of Spouse: Address: Contact Number:

Type of Admission: Referred by: (Physician / Agency)

New Old Former OPD
ALERT! ALLERGIC TO: ATTENDING PHYSICIAN / MIDWIFE: PHILHEALTH:
Yes No
Admitting Diagnosis:

Discharge / Final Diagnosis:

Procedure/s Done:

Disposition:
Discharg
HAMA Recovered Improved
e
Transferre Absconde Unimprove
d d Died
d

Signature Over Printed Name of Midwife / Nurse Signature Over Printed Name of Consul
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

ADMISSION CONSENT

TO WHOM IT MAY CONCERN:

I, _________________________________________________, of legal age ______________ on my own volition and fre

will,do hereby give consent to this clinic to handle my case for maternal procedure such as giving birth to my child and
provide essential newborn care.

It is expressly agreed that my litigation or claim or whatever naturem whatever civil, criminal or administrative, under
this "consent" instrument shall be instituted before the competent court, prosecution office, board, or agnecy located
only and only in the municipality of INDANG, CAVITE and not elsewhere.

IN WITNESS WHEREOF, I have affixed my signature on this ______________ day of ______ 20____ at ________ AM/PM
in the presence of:

_________________________________________ ____________________________
WITNESS SIGNATURE / THUMBMARK OF PATIENT

_________________________________________ ____________________________
WITNESS DATE SIGNED
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

OB HISTORY CASE NO:

Name: Age: Civil Status:
Address: Date Admitted:
Admitting Impression:

Pertinent Surgical & Medical History: Family History:

Obstetrical History:

ravida ________________ Para ______________ ( T ____________ P _____________ A ____________ L ___________ )

No. if Pregnancy Date AOG Manner of Delivery Outcome Birthweight Sex Present Status Complication/s

Present Pregnancy:

LMP: _______________________________________AOG: ____________________EDC: ________________________

No. of Prenatal check - up: ______________________________Where: ______________________________________

 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

Physical Examination:

General Survery: ___________________________________________________________________________________

Vital Signs: BP:_______________HR:_______________RR:_______________TEMP:_____________
HEENT: ___________________________________________________________________________________________
CHEST / LUNGS: ___________________________________________________________________________________
CVS: _____________________________________________________________________________________________
ABDOMEN: Fundic Height:______________ Heart Fatal Tones: ___________EFW:_______________________

GU (IE): Cervical Dilatation __________ Effacement _________________BOW ______________________

Presentation _____________ Station ___________________

EXTREMITIES: _____________________________________________________________________________________

__________________________________________________ _________________________
Signature over Printed Name of Midwife / Nurse Signature over Printed Name of Consultant
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

ATTENDING PHYSICIAN / MIDWIFE ORDER SHEET

Name: Age:
ATTENDING PHYSICIAN / MIDWIFE:

DATE / TIME DOCTOR / MIDWIFE ORDER

 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

PROGRESS NOTES
NAME: AGE:
ATTENDING PHYSICIAN / MIDWIFE:
DIAGNOSIS:
DATE AND TIME OF DELIVERY:
GENDER OF THE BABY:

DATE AND TIME : PROGRESS NOTES

Patient came ambulatory , accompanied by ____________________ with lower back pain.

A case of G__P__ ( ) Pregnancy uterine, weeks Age of Gestation, Cepalic in labor.
P/E: BP:_________, HR:___________, RR: ___________, TEMP:__________, WT:__________
IE- _________cm dilated, cervix:_________% effaced, membrane______,cepalic,________
station____________ FHT:_____________, FT:_____________

Advised admission for further management.

Admission rendered, concent secured.
Ushered to ward and keep comfortable.
CTG attached, shows reactive tracing.
Advised breathing exercise. Labor watch done.

Patient well, awake, have mild to moderate lower abdominal pain.

Vitalsigns checked and recorded.
CTG attached, shows reactive tracing.
Uterine contraction noted.

Patient complains of moderate lower pains towards back.

IE done: ______dilated, membrane:_______, cepalic,_______ station,______.
informed attending physician, advised prepare VSD.
transferred to DR and started trial of labor.

Patient bearing down and delivered spontaneously to alive BB_______ ESSENTIAL_______

New born Care rendere. Conducted by: _________________,
cried afterbirth, cord clamp applied, uterus well contracted, bleeding normal.
OXYTINE IU IV given.
Placenta and Membrane out completely and spontaneous.
Vaginal bleeding normal, no hematoma and no foreign bodies.
Vitalsigns stable.
Patient tolerated the procedure. Transferred and monitored.
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

MONITORING SHEET
NAME: AGE:
ATTENDING PHYSICIAN/MIDWIFE: DATE OF ADMISSION:

Admitting Diagnosis:

Final Diagnosis:

DATE / TIME BP TEMP RR HR INTAKE URINE OUTPUT BM

 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

Name of Patient: Date:

PROGRESS OF LABOR
PARTOGRAPH
USE THIS FORM FOR MONITORING ACTIVE LABOUR
10cm

9cm

8cm

7cm

6cm

5cm

4cm

TIME
FINDINGS 1 2 3 4 5 6 7 8 9 10 11 12
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

MEDICATION SHEET
NAME: AGE:
ATTENDING PHYSICIAN/MIDWIFE: DATE OF ADMISSION:

MEDICATION DOSE / ROUTE DATE & TIME GIVEN SIGNATURE/NOTES

 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

Name of Patient: Date:

POSTPARTUM RECORD
MONITORING AFTER BIRTH EVERY 5 - 15 MIN FOR 1ST HOUR 2 HR 3 HR 4 HR 8 HR 12 HR 16 HR 20 HR 24 HR ADVISED AND COUNSEL
TIME MOTHER
RAPID ASSESMENT Postpartum care and hygine
BLEEDING Nutrition
UTERUS HARD / ROUND ? Birth spacing and Family planning
Danger Signs
MATERNAL BLOOD PRESSURE Follow up Visits
PULSE BABY
URINE VOIDED Exclusive breastfeeding
VULVA Hygine, cord care and warmth
NEWBORN BREATHING Special advice low birth weight
WARMTH Danger Signs
NEWBORN ABNORMAL SIGNS (LIST) Follow Visit
PREVENTIVE MEASURES
TIME FEEDING OBSERVED FEEDING WELL DIFFICULTY FOR MOTHER
COMMENTS: Iron
Vitamin A
PLANNED TREATMENT TIME TREATMENT GIVEN Sulphadoxine Pyrinethamine
MOTHER Tetanus Toxoid Immunization
RPR Test result and treatment
ARV
NEWBORN FOR BABY
IF REFERRED (MOTHER OR NEWBORN) RECORD TIME AND EXPLAIN. Risk of Bacterial infection and treatment
BCG, HEPA B, VITAMIN K
IF DEATH (MOTHER OR NEWBORN) DATE, TIME AND CAUSE. RPR Test result and treatment
TB test and prophylaxis
ARV
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

NEWBORN RECORD
Name of Newborn: Sex of Newborn:
Name of Mother: Age:
Name of Father: Age:
Date of Delivery: Time of Delivery:
Manner of Delivery: Anesthesia:
APGAR Score: Complications:
Attending Physician / Midwife:
Pediatrician:

DATE / TIME TREATMENT

MEDICATION/s GIVEN ROUTE OF ADMINISTRATION DATE & TIME

URINE:

STOOL: HEPA A - B VACCINE

VIT. K

BCG

NEWBORN SCREENING
NEWBORN SCREENING
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

APGAR SCORING SYSTEM

0 POINTS 1 POINTS 2 POINTS POINTS TOTALED

ACTIVITY (MUSCLE TONE) ABSENT ARM AND LEGS FLEXED ACTIVE MOVEMENT

PULSE ABSENT BELOW 100 bpm ABOVE 100

GRIMACE (REFLEX IRRITABILITY) FLACCID SOME FLEXION OF EXTREMITIES CRY, COUGH, SNEEZ

APPEARANCE (SKIN COLOR) BLUE, PALE BODY PINK, EXTREMITIES BLUE COMPLETELY PINK

RESPIRATION ABSENT SLOW, IRREGULAR VIGORIOUS CRY

SEVERELY DEPRESSED 0 - 3
MODERATELY DEPRESSED 4- 6
EXCELLENT CONDITION 7 - 10
 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

PEDIA NOTES
NAME OF NEWBORN:
PEDIATRICIAN:

DATE AND TIME : PEDIATRICIAN NOTES

 DOC JO-AN LYING - IN CLINIC
142 J. DIMABILING ST. BRGY.4 INDANG, CAVITE
(046) 889-3811 (SMART) 0969 - 622 - 2270

MATURATIONAL ASSESMENT OF GESTATIONAL AGE (NEW BALLARD SCORE)

NAME:______________________________________ SEX:_____________
HOSPITAL NO: ________________________________BIRTHWEIGHT:_______________
RACE:_______________________________________LENGTH:____________________
DATE/TIME OF BIRTH:__________________________HEAD CIRC.:_________________
DATE/TIME OF EXAM:__________________________EXAMINER:_________________
AGE WHEN EXAMINED:_________________________
APGAR SCORE: 1 MINUTE_________________ 5 MINUTES _________________ 10 MINUTES _________________