Professional Documents
Culture Documents
Pastrano Rico Escasinas 11-16-23
Pastrano Rico Escasinas 11-16-23
1. Name of Patient:
PASTRANO RICO ESCASINAS
Last Name First Name Name Suffix Middle Name (example: Dela Cruz, Jr Juan, Sipag)
2. Was patient referred by another Health Care Institution (HCI)?
[~z] NO Q] YES
Name of Referring Health Care Institution Building Number and Street Name City/Municipaftty Province Zip Code
year
J d. Absconded Biilding Number and Street Name City/Municipality Province Zip Code
6. Admission Diagnosis/es:
2ND DEGREE BURN 2ND TO INDUSTRIAL INJURY
Diagnosis ICD-10Code/s Related Procedure/s (if there's any) RVSCode Date of Procedure Laterality (check applicable boxes)
a- BURN SECOND DEGREE NECK T20 j Dressings and/or debridement, initial or subsequent
16010 11-18-2023 Left Right Both
ii. Left Right Both
iii. Left Right Both
b. i. Left Right Both
ii. Left Right Both
iii. Left Right Both
8. Special Considerations:
a. For the following repetitive procedures, check box that applies and enumerate the procedure/session dates [mm-dd-yyyy]. For chemotherapy, see guidelines.
Hemodialysis Blood Transfusion
J Peritoneal Dialysis Brachytherapy
e. For Animal Bite Package (write the dates [mm-dd-year] when the following doses of vaccine were given) NOTE: Anti Rabies Vaccine (ARV), Rabies Immunoglobulin (RIG)
f. For Newborn Care Package | j Essential Newborn Care | | Newborn Screening i Newborn Hearing Screening For Newborn Screening,
please attach NBS Filter Sticker
For Essential Newborn Care, (check applicable boxes) | here
Immediate drying of newborn etc. Timely cord clamping Weighing of the newborn BCG vaccination Hepatitis B vaccination
Early skin-to-skin contact Eye prophylaxis Vitamin K administration Non-separation of mother/baby for early breastfeeding initiation
9. PhilHealth Benefits
Accreditation Number / Name of Accredited Health Care Professional / Date Signed Details
Accreditation No.: - ! 4
Accreditation No.:
Accreditation No.:
PART III - CERTIFICATION OF CONSUMPTION OF BENEFITS AND CONSENT TO ACCESS PATIENT RECORD/S
NOTE: Member should sign only after the applicable charges have been filled-out
□ No purchases of drugs/medicines, supplies, diagnostics, and co-pay for professional fees by the member/patient.
Grand Total
The benefit of the member/patient was completely consumed prior to co-pay OR the benefit of the member/patient is not completely consumed BUT with
purchases/expenses for drugs/medicines, supplies, diagnostics and others.
Amount P 31,172.36
Total Health Care
Institution Fees P 36,072.36 P 36,072.36 P 4,900.00 Paid by (Check all that applies):
Member/Patient j | HMO
| Z| Others(i.e.,PCSO, Promissory note, etc.)
Total cost of purchase/s for drugs/medicines and/or medical supplies bought by the
patient/member within/outside the HCI during confinement | y<| None J Total Amount
DINAH GONZALJ IELLA, MD, FPOGS, FPCS, CFP, MBA-HHA MEDICAL DIRECTOR
Date Signed:
month day year
Signature Over Printed Name of Authorized Official Capacity / Designation
HCI Representative