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  • Census Template

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    JayricDepalobos
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    OB Census Template

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    OB Census Template

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    © All Rights Reserved
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    16 visualizzazioni3 pagine

    Census Template

    Caricato da

    JayricDepalobos
    OB Census Template

    Copyright:

    © All Rights Reserved
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
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    DEPARTMENT OF OBSTETRICS-GYNECOLOGY

    Drs. ____________/____________/_____________/_____________/_____________
    July 6 - 7, 2018
    Admissions: Referral: Discharges: ER: HAMA: Absconded: OPD: Mortality: TOS: SIGNED OUT: THOC:
    IN-PATIENTS:

    Date Admitted,
    Time Past Medical History OB Score & History Intervention w/
    Patient’s Data Age Chief Complaint/Admitting Diagnosis
    Rm. #; Hosp. #; Last Year of Pregnancy Anesthesia/Date Remarks/Outcome
    AP; Service
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________
    Date Name ( ) HPN G__P__ (______) ( ) NSD with rmler ( ) OB
    Time Address CC:_______________________ ( ) DM ( ) NSD with mer
    Room ( ) BA ( ) LTCS AS: BW:
    H# ( ) Allergy ( ) Primary BL: BS:
    AP Birthdate Admitting Diagnosis: ( ) Previous operations ( ) Repeat TOB: DOB:
    Contact # Secondary to:
    Parent/Partner/Guardian ( ) Gyne

    ( ) Others: ___________
    ____________________

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