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Lopez, Gian Carlo Burlaza IP23-004536 - 00045685: Walk-In - House Case

The document is a clinical cover sheet for a 15-year-old male patient admitted to the pediatric surgery ward of Viacrucis Medical Hospital. It includes his personal details, admission details, emergency contacts, attending physician, and spaces for diagnosis and surgical procedures.

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victor
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9 views

Lopez, Gian Carlo Burlaza IP23-004536 - 00045685: Walk-In - House Case

The document is a clinical cover sheet for a 15-year-old male patient admitted to the pediatric surgery ward of Viacrucis Medical Hospital. It includes his personal details, admission details, emergency contacts, attending physician, and spaces for diagnosis and surgical procedures.

Uploaded by

victor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
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Viacrucis Medical Hospital

Osmeña Street, Poblacion 2, Bansalan, Davao Del Sur


CLINICAL COVER SHEET
Personal Data PEDIATRIC SURGERY
Name : LOPEZ, GIAN CARLO BURLAZA Hospital No. : 00045685
Address : PRK WALING-WALING, Tubod, BANSALAN Pat. No.| Case No. IP23-004536 |
Room|Bed|Type : MW3|4|WARD - Php448.00
Birthday : July 25, 2008 Age : 15Y3M15D How Admitted : Emergency Room
Sex : Male Civil Status : Single PhilHealth : Sponsored^
Occupation : STUDENT Religion : Roman Catholic
Birth Place : RHU BANSALAN Nationality : FILIPINO
Spouse : N/A Spouse Occ. : N/A
Father : ALBERTO LOPEZ Tel. No. : +639122929097
Mother : AVA LOPEZ Insurance :

Admission Details Type Of Admission And Doctor Case


Admission Date : 11/10/2023 Discharge Date :  New Patient  Old Patient
Admission Time : 12:00 PM Discharge Time : Walk-In - House Case
Admitted by : V.L. SENAPILO Discharge by : Adm. Staff/Nurse: K.P. RELATADO

Notify In Case Of Emergency Allergies, Precaution and Others


Name : ALBERTO LOPEZ Allergy :
Relationship: Father Precaution :
Contact|Email: +639122929097 | N/A Med. Alert :
Address : PRK. WALING WALING, TUBOD, Smoker : No
BANSALAN,DVO DEL SUR
Employer's Details Attending Physician
Name : N/A Name : IRENE C. VIACRUCIS, M.D.
Contact No. : Transferred to :
Diagnosis
Chief Complaint: - Social Service Classification
Admission Diagnosis: -
ICD Code
Final Diagnosis
1.
1.
2.
2.
3.
3.
4.
4.
Surgical Procedure RVS Code
1. 1.
2. 2.
Complication

Disposition Attending Physician


 Discharged  Died Name|Signature
 RECOVERED  -48 HOURS
  Transferred
IMPROVED  +48 HOURS
 UNIMPROVED
 Absconded  AUTOPSIED IRENE C. VIACRUCIS, M.D.
 HAMA  NOT AUTOPSIED Signature Over Printed Name

PRIVACY NOTICE: In compliance with the Data Privacy Act 2012, the protection
and confidentiality of your personal data is our utmost concern. Date/Time Printed: 11/10/2023 12:03 PM

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