Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
PATIENTS CLINICAL RECORD
Admission No.:___________ Admission Date:_______________
Name: _______________________________________________________________________________________
Last Name First Name Middle Name
Address: _____________________________________________________________________________________
Purok/Zone Barangay Municipality Province
Date of Birth: __________________________________ Sex: ( ) Male () Female Age: __________
Chief Complaint: _______________________________________________________________________________
____________________________________________________________________________________________
Admitting Diagnosis: ____________________________________________________________________________
_____________________________________________________________________________________________
Date of Delivery: _____________________ Time of Delivery: ________________________
Date of Discharge: ______________________ Time of Discharge: ________________________
Final Diagnosis: ________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
ICD: __________ ( ) Improved
( ) Recovered
( ) Unimproved
Disposition: ( ) Died
( ) Absconded
( ) HAMA
( ) Transferred to
_____________________________________________
Signature of Attending Physician/Midwife
1
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
MATERNAL RECORD
Name: __________________________________ Admission Date: _____________________
Age: ____________ Admission Time: _____________________
Address: ___________________________________
MATERNAL HISTORY
1. Initial Prenatal Consultation ______/_______/____________
2. History of Present Condition
________________________________________________________________________________________
________________________________________________________________________________________
3. Obstetrical History and Physical Examination
a) Vital signs during prenatal consultation
Normal______________________
Abnormal______________________ specify
b) Menstrual History
LMP ______/_______/_______ Menarche ____________
mm dd yyyy
c) Obstetrical History
G________ P_________ (_________________________)
T P A
4. Obstetrical Risk Factor
______Multiple Pregnancy ______History of pre-eclampsia ______Placenta previa
______Ovarian Cyst ______History of eclampsia ______History of miscarriages
______Myoma Cyst ______Premature contraction ______History of stillbirths
5. Medical/Surgical Risk
______Hypertension ______Moderate to severe asthma
______Heart Disease ______Epilepsy
______Thyroid disorder ______Renal disorder
______Obesity ______Bleeding disorder
______Diabetes ______History of previous cesarean section
______History of uterine myomectomy
6. Expected Date of Delivery _________/_________/_____________
mm dd yyyy
2
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
Ako si ________________________________________, _________anyos, taga __________________,
Guindulman, Bohol, nagatugot nga maadmit ug manganak dire sa Guindulman Rural Health Unit Anakan Center.
Ako nakasabot sa maayong katayuan niining maong pamaagi. Ako nagatugot nga mahatagan ug anesthesia
kung kinahanglan. Ako gepasabot sa mga posibleng batiun/ o epekto human ang maong pamaagi ug dili kini
angay kabalak-an kay kini normal lamang.
Ako usab nakasabot na kining maong pamaagi walay bayad/o libre. Ako usab gipasabot sa mga staff na kung:
Adunay PhilHealth na aktibo, wala ako’y pagabayaran sa balay anakanan, apan
Kung walay PhilHealth adunay bayad na __________PhP ug Newborn Screening na
______Php
Ako nagapamatuod na ako gipasabot ug ayo sa staff sa mga maong pamaagi ug akong ibutang ang akong
ngalan ug pirma dinhi.
________________________________
Ngalan ug Pirma sa Pasyente
__________________________________________________________________________________________
PARA SA MGA MENOR DE EDAD (MINOR) 17 ANYOS PAUBOS
Ako si ____________________________________, _________ anyos, taga ______________________,
Guindulman, Bohol, ginakanan ni/ guardian ni ____________________________________________________
Pangalan sa Minor na Pasyente
nagatugot nga siya maadmit diri sa Guindulman Rural Health Unit Anakanan Center.
Ako nakasabot sa maayong katayuan niining maong pamaagi. Ako nagatugot nga mahatagan ug anesthesia
kung kinahanglan. Ako gepasabot sa mga posibleng batiun/ o epekto human ang maong pamaagi ug dili kini
angay kabalak-an kay kini normal lamang.
Ako usab nakasabot na kining maong pamaagi walay bayad/o libre. Ako usab gipasabot sa mga staff na kung:
Adunay PhilHealth na aktibo, wala ako’y pagabayaran sa balay anakanan, apan
Kung walay PhilHealth adunay bayad na __________PhP ug Newborn Screening na
______Php
Ako nagapamatuod na ako gipasabot ug ayo sa staff sa mga maong pamaagi ug akong ibutang ang akong
ngalan ug pirma dinhi.
________________________________
Ngalan ug Pirma sa Ginikanan/Guardian
3
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
CONSENT OF PATIENT/OR RESPONSIBILITY PARTY
TO WHOM IT MAY CONCERN
Be it known that I, _________________________________________, ________ years old, a resident of
___________________________, Guindulman, Bohol on my own volition without any intimidation whatsoever, hereby
consent to submit my _________________________ to be handled for normal spontaneous vaginal delivery or by my
physician or by any member of the medical staff of Guindulman Rural Health Unit Anakanan Center.
In witness hereof, I have set my hand this ________ day of _________________, 20______ at Guindulman Rural
Health Unit Anakanan Center, Guindulman, Bohol.
_____________________________
Signature of Patient
WITNESSES:
1. ____________________________________________
2. ____________________________________________
4
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
NEWBORN SCREENING CONSENT
Date: ________________________
To whom it may concern,
This to certify that the Newborn Screening was introduced me by my attending physician/ attending
midwife ________________________________________ and that the importance of such test was explained to
me clearly.
I refuse to subject my newborn child to a newborn screening due to following reasons:
I have intentions of subjecting my newborn child to newborn screening.
______________________________
Name and Signature of Mother
Witness:
_________________________________________
_________________________________________
5
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
MATERNAL DOCTOR’S ORDER
DATE POSTPARTUM ORDER
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
6
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
MATERNAL MEDICATION RECORD
Name:_____________________________________ Address: _____________________________
Age: ______________ Gravida, Parity: ________________________
Date of Delivery: ___________________________________
Diagnosis: ______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
DATE AND TIME GIVEN OR ADMINISTERED/
NAME OF DOSAGE AND ADMINISTERED BY
MEDICATION FREQUENCY
_____________________________________
Attending Physician
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
7
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
Nurse’s Notes/ Midwives’ Notes
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Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
8
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
POSTPARTURM RECORD
1 hour after delivery of placenta until discharge (D20.21)
Name: ________________________________ Age: _______ Dates: _____________
Date and Time of Delivery: ___________________________
Quick Check (B2)
Look Listen and Feel
( ) Bleeding ( ) convulsing
( ) looking very ill ( ) in severe pain
Rapid Assessment Management (RAM)
Check airways and breathing ( )very difficult breathing ( )Central cyanosis
( ) cold moist skin ( ) weak and fast pulse ( ) check blood pressure
Check for following
( ) fever ( ) convulsions ( ) vaginal bleeding ( )severe abdominal pain
ASK CHECK RECORD LOOK LISTEN FEEL
( )Bleeding more than 250ml Measure Temperature
( )Placenta and membranes complete Feel Uterus, is it hard and round?
( )Complications during delivery or postpartum Look for vaginal bleeding
( )Special treatment needs
( )Needs tubal ligation or IUD? Look at perinium
-is there a tear or cut
How are you feeling? -is it red, swollen or draining pus?
Do you have any pains? -Look for conjunctival pallor
Do you have any concerns? -Look for palmar pallor
How is your baby?
How do your breasts feel?
RESPOND TO PROBLEMS immediately postpartum
Vaginal bleeding (pad soaked <5 mins yes no
Fever (Temperature >38o yes no
Perineal Iaceration yes no
Bleeding from laceration or episiotomy yes no
Extends to anus or rectum yes no
Elevated diastolic BP (>90 mmHg) yes no
Severe headache yes no
Blurred vision yes no
Epigastric pain yes no
Urine protein yes no
Pallor on screening yes no
Hemoglobin <7 gm/L yes no
Palmar or Conjunctival pallor yes no
Some Pallor yes no Severe Pallor yes no
Mother severely ill or separated from the baby yes no
Baby stillborn or dead yes no
Give preventive measures (D25)
Advise on postpartum Care (D26)
Counsel on Birth spacing and family planning (D27)
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
9
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
NEWBORN RECORD
NAME: _________________________________________ ADMISSION NO.:___________
PHYSICIAN/MIDWIFE IN-CHARGE: ______________________________________________________
MOTHER’S NAME: __________________________ FATHER’S NAME:_______________________
BIRTHDATE: ____________________ TIME: __________________
NATIONALITY: _______________________ RELIGION: ______________________
SEX: BIRTHWEIGHT:
HEAD CIRCUMFERENCE: BIRTH LENGTH:
ABDOMINAL CIRCUMFERENCE: CHEST CIRCUMFERENCE:
APGAR SCORE (1-10) BALLARD SCORE:
AGE OF GESTATION: ________ PREMATURE: ______ POSTMATURE: ______ NORMAL: ______
WITH BIRTH DEFECTS (YES/NO)? _____________________________________
SPECIFY DEFECTS: __________________________________________________________________
COMPLICATIONS OF PREGNANCY: _____________________________________________________
TYPE OF DELIVERY: SPONTANEOUS ASSISTED PRECIPITATE
MEDICATION GIVEN DURING LABOR AND DELIVERY:
______________________________________
____________________________________________________________________________________
DATE AND TIME GIVEN: _______________________________________________________________
COMPLICATIONS DELIVERY:
___________________________________________________________
FINAL DIAGNOSIS: ___________________________________________________________________
10
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
APGAR SCORE
Name of Mother: ______________________________________ Date Delivered: _________________________
Baby: ____________________________________
1 2
ACRONYM CRITERIA/SIGN 0 1 2 MINUTE MINUTES
A APPEARANCE BLUE PINKBODY, BLUE ENTIRELY PINK
(SKIN COLOR) PALE EXTREMITIES
(ACROCYANOSIS)
B PULSE RATE ABSENT SLOW, LESS 100 OVER 100
BEATS/MIN. BEATS/MIN
C GRIMACE NO RESPONSE SOME CRYING
MOTION/AGGRESSIVE
STIMULATION FOR CRY
D ACTIVITY SOME FLEXION OF WELL FLEXED
(MUSCLE TONE) LIMP EXTRIMITIES
E RESPIRATORY WEAK/GASPING STRONG CRY OR
EFFORT ABSENT HYPOVENTILATION CRYING LUSTLY
TOTAL APGAR SCORE: ______________________________________
11
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
BALLARD’S MATURATIONAL SCORE
Name of Baby: ________________________________________ Date Delivered:_________________
Total Score: _____________
12
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
NEWBORN DOCTOR’S ORDER
DATE POSTPARTUM ORDER
Republic of the Philippines
13
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
NEWBORN MEDICATION RECORD
Name:_____________________________________ Address: _____________________________
Age: ______________ Gravida, Parity: ________________________
Date of Delivery: ___________________________________
Diagnosis: ______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________
DATE AND TIME GIVEN OR ADMINISTERED/
NAME OF DOSAGE AND ADMINISTERED BY
MEDICATION FREQUENCY
_____________________________________
Attending Physician
Republic of the Philippines
Province of Bohol
14
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
Nurse’s Notes/ Midwives’ Notes
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15
Republic of the Philippines
Province of Bohol
MUNICIPALITY OF GUINDULMAN
GUINDULMAN RURAL HEALTH UNIT ANAKANAN CENTER
NEWBORN CARE RECORD
FAMILY #: ________________ DATE:_______________
NAME: ________________________________ AGE:______ WEIGHT:_______ TEMP.: _______ PR: _______
MOTHER’S NAME:_______________________ INITIAL VISIT: ____________ FOLLOW-UP VISIT:____________
ADDRESS: _________________________________________
ASK CHECK RECORD LOOK LISTEN FEEL
CHECK MATERNAL AND NEWBORN RECORD OR ASSESS BREATHING
ASK MOTHER - LISTEN FOR GRUNTING___________
HOW OLD IS THE BABY? COUNT BREATHS—ARE THEY 60
PRETERM (LESS THAN 37 WEEKS OR 1 MONTH MORE OR LESS PER MINUTE? REPEAT COUNT
OR EARLY IF ELEVATED_____________
BREECH BIRTH? - LOOK AT THE CHEST FOR INDRAWING
DIFFICULT BIRTH? LOOK AT THE MOVEMENT ARE THEY
RESUSCITATED AT BIRTH? NORMAL AND SYMMETRICAL
HAS BABY HAD CONVULSIONS? LOOK AT THE PRESENTING PART - IS
ASK THE MOTHER: THERE SWELLING AND BRUISES
DO YOU HAVE CONCERNS?___________ LOOK AT THE ABDOMEN FOR PALLOR
HOW IS THE BABY FEEDING?__________ LOOK FOR MALFORMATIONS
IS THE MOTHER VERY ILL OR TRANSFERRED? FEEL THE TONE: IS IT NORMAL?
FELL FOR WARMTH. IF COLD, OR
VERY WARM, MEASURE THE
TEMPERATURE
WEIGH THE BABY
IS THERE PRESENCE OF DANGER SIGNS? YES NO
ANY OF THE FOLLOWING SIGNS:
FAST BREATHING (MORE THAN 60 BREATHS PER MINUTE) __________
SLOW BREATHING (LESS THAN 30 BREATHS PER MINUTE)__________
SEVERE CHEST INDRAWING __________
GRUNTING __________
FEVER (TEMPERATURE >38 DEGREE CELSIUS_________
TEMPERATURE <35 DEGREE CELSIUS OR NOT RISING AFTER REWARMING_________
CONVULSIONS_______
FLOPPY OR STIIFF________
UMBILICUS DRAINING PUS OR UMBILICUS REDNESS EXTENDING TO SKIN_______
>10 SKIN PUSTULES OR BULLAE, OR SWELLING, REDNESS, HARDNESS OF SKIN______
BLEEDING______
IF PRETERM, BIRTH WEIGHT <2500G OR TWIN
ASK, CHECK RECORD LOOK LISTEN FEEL
BABY JUST BORN
BIRTH WEIGHT <1500G OR 1500G TO 2500G
PRETERM <32WEEKS AOG OR 33 TO 36 WEEKS AOG
TWIN IF THESE IS REPEATED VISIT, ASSESS WEIGHT GAIN
CHESK FOR SPECIAL TREATMENT NEEDS:
ASK, CHECK RECORD
HAS THE MOTHER HAD WITHIN 2 DAYS OF DELIVERY
FEVER >38 DEGREE CELSIUS? _______
INFECTION TREATED WITH ANTIBIOTIC? ________
MEMBRANES RUPTURED >18 HOURS BEFORE DELIVERY?________
MOTHER TESTED RPR POSITIVE?________
MOTHER TESTED HIV+?________
HAS SHE RECEIVED INFANT FEEDING COUNSELING?________
IS THE MOTHER ON TB TREATMENT WHICH BEGAN <2MONTHS AGO?_______
ASSESS BREASTFEEDING
ASK, CHECK RECORD LOOK LISTEN FEEL
ASK THE MOTHER OBSERVED A BREASTFEED
HOW IS THE BABY BREASTFEEDING GOING________ IF THE BABY HAS NO FEED IN THE PREVIOUS
HAS YOUR BABY FED IN THE PREVIOUS HOURS?________ HOUR; ASK THE MOTHER TO PUT THE BABY
ON
IS THERE ANY DIFFICULY?________ HER BREASTS AND OBSERVE BREAST
FEEDING.
IS YOUR BABY SATISFIED WITH THE FEED?________
ASSESS CLASSIFY
16
17
