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Admission and Discharge

This document is an admission and discharge record form for Metro Pagadian Specialist Hospital. It includes fields to collect a patient's name, demographic information, insurance/payment classification, admitting and discharge dates and times, admitting and final diagnoses, surgical procedures, condition at discharge, disposition, and physician signatures. The form also lists the hospital's address in Pagadian City and contact information.

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IX Ramirez
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256 views2 pages

Admission and Discharge

This document is an admission and discharge record form for Metro Pagadian Specialist Hospital. It includes fields to collect a patient's name, demographic information, insurance/payment classification, admitting and discharge dates and times, admitting and final diagnoses, surgical procedures, condition at discharge, disposition, and physician signatures. The form also lists the hospital's address in Pagadian City and contact information.

Uploaded by

IX Ramirez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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METRO PAGADIAN SPECIALIST HOSPITAL, INC

V. SAGUN ST., LUMBIA DISTRICT, PAGADIAN CITY


LOCAL HOTLINE NUMBER: 1694; LOCAL LANDLINE NUMBER: 215-3693

MPSHI
ADMISSION: OLD NEW ADMISSION &DISCHARGE RECORD

HOSPITAL CASE NO.

ROOM #
NAME: (LAST) (FIRST) (MIDDLE)

AGE SEX CIVIL STATUS DATE OF BIRTH PLACE OF BIRTH NATIONALITY RELIGION

PRESENT ADDRESS PERMANENT ADDRESS


CLASSIFICATION
PHILHEALTH CHARITY
OCCUPATION CONTACT NUMBER/S
SENIOR CITIZEN PAY

INFORMANTS NAME RELATIONSHIP OTHERS:_______________________________________

ADDRESS AND CONTACT NUMBER ADMITTING CLERK

DATE ADMITTED: TIME: AM PM

AM PM
DATE DISCHARGED: TIME: ADMITTING PHYSICIAN
ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS:

COMPLICATION:

SURGICAL PROCEDURE: PATHOLOGICAL PROCEDURE:

CONDITION ON DICHARGED: RECOVERED: IMPROVED: UNIMPROVED: DIED:

DISPOSITION: DISCHARGED TRANSFERRED HOME AGAINST ADVICE REFERRED

APPROVED:
_________________________________________ __________________________________________

SIGNATURE OF RES/ ATTENDING PHYSICIAN SIGNATURE OF RES PHYSICIAN/CONSULTANT

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