This form may be reproduced and is NOT FOR SALE

CF4
(Claim Form 4)
February 2020
IMPORTANT REMINDERS: Series #
PLEASE FILL OUT APPROPRIATE FIELDS. WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.
This form, together with other supporting documents, should be filed within sixty (60) calendar days from date of discharge.
All information, fields and tick boxes in this form are necessary. Claim forms with incomplete information shall not be processed.
FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.
I. HEALTH CARE INSTITUTION (HCI) INFORMATION
1. Name of HCI 2. Accreditation Number
CANDELARIA DISTRICT HOSPITAL H03003554

3. Address of HCI
PUROK 3, YAMOT CANDELARIA, ZAMBALES 2212

Bldg No. and Name/Lot/Block Street/Subdivision/Village Barangay/City/Municipality Province Zip Code

II. PATIENT’S DATA
1. Name of Patient 2. PIN
QUILON, DIVINA, ESTELLA 072517408248

Last Name First Name Middle Name 3. Age

5. Chief Complaint 67 year(s) old
GENERALIZED BODY WEAKNESS
4. Sex Male Female

6. Admitting Diagnosis 7. Discharge Diagnosis 8. a. 1st Case Rate Code

CEREBROVASCULAR ACCIDENT T/C INFARCTION CEREBROVASCULAR ACCIDENT INFARCT RIGHT I63.9 (CEREBRAL INFARCTION,
HYPERTENSION STAGE II,CORONA RADIATA PERIOBITAL UNSPECIFIED)
AREA CELLULITIS LEFT LEG
8. b. 2nd Case Rate Code

9. a. Date Admitted 04-22-2024 9. b. Time Admitted 12:20 PM

10. a. Date Discharged 05-10-2024 10. b. Time Discharged 01:55 PM
III. REASON FOR ADMISSION
1. History of Present Illness
FEW HOURS PRIOR TO ADMISSION PATIENT STARTED TO HAVE GENERALIZED BODY WEAKNESS POSITIVE DYSPNEA

2.a. Pertinent Past Medical History

UNREMARKABLE

2.b. OB/GYN History

G P ( - - - ) LMP N/A
3. Pertinent Signs and Symptoms on Admission (tick applicable box/es)

Abdominal cramp/pain Diarrhea Hematemesis Palpitations

Altered mental sensorium Dizziness Hematuria Seizures
Anorexia Dysphagia Hemoptysis Skin rashes
Bleeding gums Dyspnea Irritability Stool, bloody/black tarry/mucoid
Blurring of vision Dysuria Jaundice Sweating
Body weakness Epistaxis Lower extremity edema Urgency
Chest pain/discomfort Fever Myalgia Vomiting/Nausea
Constipation Frequency of urination Orthopnea Weight loss
Cough Headache
Pain, (site)
Others

4. Referred from another health care institution (HCI)

No Yes, Specify Reason
Name of Originating HCI

5. Physical Examination on Admission (Pertinent Findings per System)

Height: 160 (cm)
General Survey Awake and alert Altered sensorium
Weight: 57 (kg)
Vital Signs BP 100/80 mmHg HR 95 per min RR 18 per min Temp 39.5 °C

HEENT Essentially normal Cervical lymphadenopathy Icteric sclerae Sunken eyeballs

Abnormal pupillary reaction Dry mucous membrane Pale conjunctivae Sunken fontanelle
Others
Chest/Lungs Essentially normal Crackles/rales Lumps over breast(s) Wheezes
Asymmetrical chest expansion Decreased breath sounds Retractions
Others DYSPNEA

This is a computer-generated document. Signature must be reflected in the Claim Signature Form (CSF)
Easy Claims v7.2.8353.26998 · Date and time generated: 06-27-2024 02:19:42 PM
Page 1 of 3
CVS Essentially normal Heaves/trills Muffled heart sounds Pericardial bulge
Displaced apex beat Irregular rhythm Murmurs
Others

Abdomen Essentially normal Abdominal tenderness Palpable mass(es) Uterine contraction

Abdominal rigidity Hyperactive bowel sounds Tympanitic/dull abdomen
Others

GU (IE) Essentially normal Blood stained in exam finger Cervical dilatation Presence of abnormal discharge
Others

Skin/ Essentially normal Cyanosis/mottled skin Pale nailbeds Rashes/Petechiae

Extremities
Clubbing Decreased mobility Poor skin turgor Weak pulses
Cold clammy Edema/swelling
Others BODY WEAKNESS

Neuro Exam Essentially normal Abnormal position sense Abnormal sensation Poor coordination
Abnormal gait Abnormal reflex(es) Poor/altered memory Poor muscle tone/strength
Others

IV. COURSE IN THE WARD (Attach photocopy of laboratory/imaging results) Check box if there is/are additional sheet(s).

Date Doctor's order/action

PATIENT ADMITTED TO FEMALE WARD
COMPLETE BLOOD COUNT PLATELET COUNT X RAY RANDOM BLOOD SUGAR SERUM ELECTROLYTE TROPONIN
04-22-2024
HOOKED IVF PNSS CITICOLINE AMP ATORVASTATIN TAB TRIMETAZIDINE TAB PARACETAMOL AMP LOSARTAN TAB AMLODIPINE
TAB VBC TAB CLONIDINE TAB
COMPLETE BLOOD CHEMISTRY URINALYSIS
04-23-2024 KCL TAB LACTULOSE SYRUP KETOROLAC AMP
CONTINUES MED
X RAY SERUM ELECTROLYTE TROPONIN
04-24-2024 CLINDAMYCIN CAP OMEPRAZOLE IV ASPIRIN TAB VBC AMP
CONTINUES MED
04-25-2024 CONTINUES MED AND MONITORING
ACYCLOVIR CELECOXIB CLINDAMYCIN AMP ATORVASTATIN 80MG TAB METFORMIN TAB CEFTRIAXONE IV
04-26-2024
CONTINUES MED
STERILE WATER
04-27-2024
CONTINUES MED
04-28-2024 CONTINUES MED AND MONITORING
ISDN TAB
04-29-2024
CONTINUES MED
FUROSEMIDE AMP
04-30-2024
CONTINUES MED
SERUM ELECTROLYTE
05-01-2024 SILVER SULFADIAZINE D5050
CONTINUES MED
05-02-2024 CONTINUES MED
DIBENCOZIDE TAB QUETIAPINE TAB
05-03-2024
CONTINUES MED
05-04-2024 CONTINUES MED AND MONITORING
05-05-2024 CONTINUES MED AND MONITORING
FECALYSIS
05-06-2024
CONTINUES MED
05-07-2024 CONTINUES MED AND MONITORING
ERCEFLORA NEB CLOPIDOGREL TAB
05-08-2024
CONTINUES MED
HBA1C
05-09-2024
CONTINUES MED
05-10-2024 PATIENT IMPROVED AND DISCHARGED
Surgical Procedure/RVS Code (Attach photocopy of OR technique)

This is a computer-generated document. Signature must be reflected in the Claim Signature Form (CSF)
Easy Claims v7.2.8353.26998 · Date and time generated: 06-27-2024 02:19:42 PM
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 V. DRUGS/MEDICINES Check box if there is/are additional sheet(s).

Generic Name Quantity/Dosage/Route/Frequency Total Cost

₱ 2,280.00
0.9% SODIUM CHLORIDE 19 SOLUTION, 1 L, 21 PER MINUTE, IV
(₱ 120.00 x 19)
₱ 30,625.00
CITICOLINE 49 SOLUTION, 1000 mg, EVERY 8 HOURS, IV
(₱ 625.00 x 49)
₱ 180.00
ATORVASTATIN 12 TABLET, 40 mg, ONCE A DAY, ORAL
(₱ 15.00 x 12)
₱ 270.00
TRIMETAZIDINE 27 TABLET, 35 mg, TWICE A DAY, ORAL
(₱ 10.00 x 27)
₱ 420.00
PARACETAMOL 12 SOLUTION, 2 mL, 150 mg/mL, EVERY 4 HOURS, IV
(₱ 35.00 x 12)
₱ 250.00
LOSARTAN 25 TABLET, 50 mg, ONCE A DAY, ORAL
(₱ 10.00 x 25)
₱ 70.00
AMLODIPINE 10 TABLET, 10 mg, ONCE A DAY, ORAL
(₱ 7.00 x 10)
₱ 120.00
VITAMIN B1 B6 B12 8 TABLET, 250 mg + 250 mg + 1000 mcg, TWICE A DAY, ORAL
(₱ 15.00 x 8)
₱ 45.00
CLONIDINE 3 TABLET, HYDROCHLORIDE, 75 mcg, AS NEEDED, ORAL
(₱ 15.00 x 3)
14 TABLET, 750 mg durules (equiv. to approximately 10 mEq), THREE TIMES A DAY, ₱ 420.00
POTASSIUM CHLORIDE
ORAL (₱ 30.00 x 14)
₱ 240.00
LACTULOSE 1 SYRUP, 120 mL, 3.3 g/5 mL, ONCE A DAY, ORAL
(₱ 240.00 x 1)
₱ 1,950.00
KETOROLAC 39 SOLUTION, 1 mL, TROMETHAMOL, 30 mg/mL, EVERY 8 HOURS, IV
(₱ 50.00 x 39)
₱ 540.00
CLINDAMYCIN 12 CAPSULE, HYDROCHLORIDE, 300 mg, EVERY 6 HOURS, ORAL
(₱ 45.00 x 12)
15 LYOPHILIZED POWDER + SOLVENT, 40 mg powder vial + 10 mL solvent, ONCE A ₱ 4,500.00
OMEPRAZOLE
DAY, IV (₱ 300.00 x 15)
₱ 85.00
ASPIRIN 17 TABLET, 80 mg, ONCE A DAY, ORAL
(₱ 5.00 x 17)
₱ 1,050.00
VITAMIN B1 B6 B12 14 SOLUTION, 3 mL, 100 mg + 100 mg + 1 mg, ICVO, IV
(₱ 75.00 x 14)
₱ 1,150.00
ACICLOVIR 23 TABLET, 400 mg, THREE TIMES A DAY, ORAL
(₱ 50.00 x 23)
₱ 360.00
CELECOXIB 18 CAPSULE, 100 mg, TWICE A DAY, ORAL
(₱ 20.00 x 18)
₱ 12,150.00
CLINDAMYCIN 81 SOLUTION, 2 mL, PHOSPHATE, 150 mg/mL, EVERY 6 HOURS, IV
(₱ 150.00 x 81)
₱ 75.00
ATORVASTATIN 3 TABLET, 80 mg, ONCE A DAY, ORAL
(₱ 25.00 x 3)
₱ 125.00
METFORMIN 25 TABLET, HYDROCHLORIDE, 500 mg, ONCE A DAY, ORAL
(₱ 5.00 x 25)
₱ 5,625.00
CEFTRIAXONE 25 SOLUTION, DISODIUM/SODIUM SALT, 1 g + 10 mL diluent, EVERY 12 HOURS, IV
(₱ 225.00 x 25)
₱ 1,100.00
STERILE WATER FOR INJECTION 11 SOLUTION, 20 mL, DILUENT, DILUENT
(₱ 100.00 x 11)
₱ 420.00
ISOSORBIDE DINITRATE 7 TABLET, 5 mg, AS NEEDED, ORAL
(₱ 60.00 x 7)
₱ 70.00
FUROSEMIDE 2 SOLUTION, 2 mL, 10 mg/mL, EVERY 8 HOURS, IV
(₱ 35.00 x 2)
₱ 165.00
SILVER SULFADIAZINE 1 CREAM, 5 g, 0.01, TWICE A DAY, RECTAL
(₱ 165.00 x 1)
₱ 600.00
5% DEXTROSE IN WATER 5 SOLUTION, 1 L, ICVO, IV
(₱ 120.00 x 5)
₱ 350.00
QUETIAPINE 5 TABLET, FUMARATE, 25 mg, ONCE A DAY, ORAL
(₱ 70.00 x 5)
₱ 100.00
CLOPIDOGREL 5 TABLET, 75 mg, ONCE A DAY, ORAL
(₱ 20.00 x 5)

VI. OUTCOME OF TREATMENT

Improved Recovered HAMA/DAMA Expired Absconded Transferred Specify reason:

VII. CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.
MARICRIS RESUELLO GALVEZ
Signature over Printed Name of Attending Health Care Professional Date Signed

This is a computer-generated document. Signature must be reflected in the Claim Signature Form (CSF)
Easy Claims v7.2.8353.26998 · Date and time generated: 06-27-2024 02:19:42 PM
Page 3 of 3