EMERGENCY ROOM

(Emergency Room Medical Records)

PATIENT DATABASE
Date Time of Entry Previously admitted at BMC?PIN

AM PM  Yes  No

Patient’s Name (LAST, First, Middle Name) Birth date Age Birthplace

Sex Civil Status Citizenship Nationality Religion

Single Married
Widow Widower
Address Contact No(s):
Home: Office:
Mobile:

Type of Patient

 Private  Company  Social Service (pls specify)___________________________________  BMC Employee

Employer/Company Name Address Contact No.

Person to Notify in Case of Emergency Relation to Patient

Address (if other than the above-stated) Contact No.

Home: Office:
Mobile:

Attending Physician Service Name and Signature of Nurse

CONSENT FOR DIAGNOSTIC PROCEDURES, ADMINISTRATION OF MEDICATION AND TREATMENT

Permission is hereby given to Butuan Medical Center to institute and administer treatment/medications, to do
diagnosis/treatment/management procedures and to perform medical/surgical and other invasive or non-invasive procedures that
may require any kind of anesthetics or sedation and/or may use blood or blood products, as may be deemed necessary or advisable
by the physicians of this H ospital.

Consenting Party if patient cannot give

Patient’s Signature Date / Time Signature over Printed Name Date / Time

Relation to patient:
Reason(s) patient cannot give consent (please specify):

Witness Signature over printed name Date / Time

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Brought by How Admitted (please encircle) History obtained from
 Private Vehicle  Ambulance  Patient
 Others (please specify) _____________________________________  Others (please specify)

Chief Complaints (include duration of symptoms) Allergies

Height (ft)
 Drug  Food None
 Others please specify
Weight (kg)

VITAL SIGNS PAST MEDICAL HISTORY

 Neurological problem  Lung asthma  High blood pressure
TIME  CVA  Asthma
 Seizure disorder  Emphysema  Cancer
Temp  Cardiac disease  Diabetes  Other problems please
 Angina  Diet-controlled specify
BP  Heart attack (MI)  Insulin dependent
 Heart failure  Oral hypoglycemic
PR

RR

PS

MEDICAL HISTORY

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 Patient’s FULL NAME

PIN Birthday Age Sex

REVIEW OF SYSTEM
General  Body Weakness  Fever  Weight loss Urinary
Skin/Muscoskeletal  Dysuria  Frequency in urination  Hematuria
 Back pain  Joint Pain  Muscle pain
 Rashes (please specify)  Others (please specify)
 Others (please specify)
EENT
 Blurring of vision  Cough/Colds  Tinnitus Female Genital
 Hoarseness  Abnormal bleeding / discharge
 Others (please specify) _____________________________________  LMP ( Postmenopausal  Hysterectomy)
 Others (please specify) ______________________________________
Cardio-Pulmonary Neurologic
 Chest pain  Dyspea  Orthopnea
 Palpitations  Difficulty with speech  Difficulty in walking
 Others (please specify)  Double vision
Gastrointestinal  Headache  Loss of consciousness
 Abdominal pain  Black/bloody stools  Diarrhea  Loss of Sensation
 Nausea / Vomiting  Others (please specify)
 Others (please specify)

PHYSICAL EXAMINATION
General Appearance  Conscious  Coherent  No acute Distress ( Moderate  Severe)
Skin Cardiovascular System Abdomen
Normal Jaundice  Flat  Soft  Globular
 Warm, dry  Regular rate, rhythm  No organomegaly  Distended
 Cyanosis / Diaphoresis / Pallor  No murmur  Non-tender  Rigid
 Skin Lesions:  lrregularly irregular rhythm  Abnormal bowel sound
Others (please specify)  Extrasytoles ( occasional  frequent) ( increased  decreased  absent)
 Guarding
EENT  Gallop ( S3  S4)
 Hepatomegaly / Splenomegaly / Mass
 Normal  Murmur: grade(1-6). Sys/Dias:___)
 Rebound tenderness
Pale conjunctivae  Icteric sclera  PMI displaced laterally
 Others (please specify)
 Purulent nasal discharge  Tachycardia / Bradycardia Extremities
 Pharyngeal erythmea exudates  Others (please specify)  Full ROM  Calf tenderness
 Others:  No pedal edema  Pedal edema
 Others (please specify)
Neck Back Neurologic/Psychologic
 Inspection normal  Inspection normal  Oriented to 3 spheres
 Lymphadenopathy ( R  L)  CVA tenderness (O R O L)  No motor/sensory deficit
 Thyroid normal  Others (please specify)  CN normal
 Thyromegaly  Abnormal
 Others (please specify)  Disoriented to person/place/time
Respiratory Rectal  Facial droop / EOM palsy / Anisocoria
 Breath sounds normal  Crackles  Black/bloody stool  Weakness / Sensory loss
 Assymetric chest expansion  Negative stool  Depressed affect
Stridor  Tenderness/Mass/Nodule  Others (please specify)
 Decrease breathing sound  Others (please specify)
 Tachypnea
 Others (please specify)
CLINICAL IMPRESSION DISPOSITION
 Admitted -  COVID  NON-COVID
 Discharged as per doctor’s order
 Discharged against medical advice
 Transferred to Hospital of Choice

CONDITION ON DISCHARGE  Good  Fair  Unstable  Comatose

Date and Time of Discharge Name and Signature of Physician

F-MED-COC-003-00 Page 3 of 3

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