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Veterans Memorial Medical Center: Medical Records Unit CR2

This document appears to be a medical record template for a patient at the Veterans Memorial Medical Center in the Philippines. It includes sections for identifying patient information like name, age, sex, race, claim number, and social security number. There are also sections to list diagnoses, operations performed, admission and discharge dates, and physical examinations. The summary at the bottom is meant to concisely describe the patient's history, pertinent findings, hospital course, treatments, condition at discharge, and recommendations.

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327 views3 pages

Veterans Memorial Medical Center: Medical Records Unit CR2

This document appears to be a medical record template for a patient at the Veterans Memorial Medical Center in the Philippines. It includes sections for identifying patient information like name, age, sex, race, claim number, and social security number. There are also sections to list diagnoses, operations performed, admission and discharge dates, and physical examinations. The summary at the bottom is meant to concisely describe the patient's history, pertinent findings, hospital course, treatments, condition at discharge, and recommendations.

Uploaded by

claverialc10
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

REPUBLIC OF THE PHILIPPINES

VETERANS MEMORIAL MEDICAL CENTER


PHIC ACCREDITED HEALTH CARE PROVIDER

MEDICAL RECORDS UNIT


CR2

PATIENT’S NAME AGE SEX RACE CLAIM NO. SOCIAL SECURITY NO. NAME OF HOSPITAL

VMMC

DIAGNOSES (List and number in order of clinical importance all established diagnoses for which treatment was given. ICDA CODE
Place the letter “X” before one diagnosis responsible for the major port if the patient’s stay. For Discharge to Nursing
Care, place the “N” before diagnosis responsible for Nursing Care placement.

Major Diagnoses Noted But Not Treated

OPERATIONS PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION Date

SUMMARY (Brief statement should include, if applicable, history, pertinent physical findings, course in the hospital, treatment give,
condition at discharge, date patient is capable of returning to full employment, period of convalescence, if required, recommendations for
follow-up treatment, medications furnished at discharge, competency opinion, and name of Nursing Home, if known

History of Present
Illness:

Review of Systems:

Past Medical
History:

Family Medical
History:

Personal/ Social
History:

Admission Date Discharge Date Type of Discharge Inpatient Days ABO Days Ward No. Signature of Physician

Page 1 of 3
REPUBLIC OF THE PHILIPPINES
VETERANS MEMORIAL MEDICAL CENTER
PHIC ACCREDITED HEALTH CARE PROVIDER

Physical Examination
On Admission:

Assessment:

Course In The Ward:

PREPARED BY: CONCURRED WITH:

(Resident) Service Consultant


VMMC-MR_MAS-MRU FORM CR-2

Page 2 of 3
REPUBLIC OF THE PHILIPPINES
VETERANS MEMORIAL MEDICAL CENTER
PHIC ACCREDITED HEALTH CARE PROVIDER

REVISED JULY 2019

Page 3 of 3

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