pmsh - 01

PAMPANGA MEDICAL SPECIALIST HOSPITAL

San Antonio, Guagua, Pampanga

ADMISSION AND DISCHARGE RECORD

Patient's Name (Last) (Given) (Middle) Room No. Hospital No.

Permanent Address Telephone No. Sex Civil Status

( ) Male ( ) S ( ) D ( ) Sep
( ) Female ( )M ( )W
Birth Date Age Birthplace Nationality Religion Occupation

Employer Address Tel No.

Father's Name Address Tel No.

Mother's (Maiden) Name Address Tel No.

Admission Discharge Total No. of Days Attending Physician

Date Date
Time Time
Type of Admission PHIL HEALTH
( ) New ( ) Old Employed Individual Paying Pensioner Indigent
Social Service Health Insurance: SM
Classification GM SD P/RM IM
( )A ( )C GD OFM
( )B ( )D PM OFD P/RD ID
Allergic to PD OWM
OWD
OT
Date Given By: Address of Informant Telephone No. Relation to Patient

Admission Diagnosis: ICD Code No.

Final Diagnosis: ICD Code No.

Other Diagnosis: ICD Code No.

Principal operation / procedure

Other Operation (S) procedure (S) :
Accident / Injuries / Poisoning (E Code) ______________
Place of occurrence

Disposition Results Signature

( ) Discharge ( ) Recovered ( ) Improve
( ) Transferred ( ) Died ( ) Unimproved
( ) Dama ( ) -48 Hours ( ) Autopsy
( ) Discharge ( ) +48 Hours ( ) No Autopsy Attending Physician
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