UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
KARDEX
NAME SEX AGE STATUS RELIGION WARD NO. HOSPITAL NO.
CHIEF ALLERGIES SPECIAL NURSING NEEDS DIAGNOSTIC PROCEDURE
COMPLAINT
DIET
DATE/TIME ADMITTED: ______________________________________________________________
ADMITTING DIAGNOSIS: _____________________________________________________________
ATTENDING PHYSICIAN: _____________________________________________________________
MEDICATIONS AND EVERYTHING ELSE
DATE STANDING ORDERS PIGGYBACK IV FLUID
ORDERED
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
VITAL SIGNS MONITORING SHEET
NAME SEX AGE STATUS RELIGION WARD NO. HOSPITAL NO.
DATE/TIME BP TEMP PR RR O2 SAT REMARKS
CBC/DIABETIC MONITORING SHEET
DATE TIME CBC/CBS TREATMENT REMARKS SIGNATURE
RESULTS
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
PATIENTS DATA SHEET
HOSPITAL NO: ____________
NAME: ________________________________________________________ R00M NO. ____________
(SURNAME) (GIVEN) (MIDDLE NAME)
ADDRESS: _________________________________________________________ CONTACT NO___________
DATE OF BIRTH: __________(MM/DD/YY) AGE:___ SEX:___ OCCUPATION:____________
NATIONALITY:______________ RELIGION:_______________ STATUS:__________
PHIC NON PHIC HMO HC PC
INCASEV OF EMERGENCY, NOTIFY:
FULL NAME:_________________________________ CONTACT NO:______________________________
PREVIOUS ADMISSION ADMISSION DISCHARGE
DATE TIME DATE TIME
YES NO _______ _____ _______ _____
ADMITTING DIAGNOSIS:
FINAL DIAGNOSIS: CODE NO:
OPERATION:
RESULTS: ATTENDING PHYSICIAN
RECOVERED IMPROVED
TRANSFER NOT IMPROVED ________________________________________
DIED HAMA Signature over Printed Name
AUTOPSY
Chart Completed:_____________Date/Time:________
UNIVERSITY OF CEBU - BANILAD
Form Designed For Student Nurses
CONSENT TO CARE
I hereby authorize any member of medical staff of University of Cebu - Banilad
Form Designed for Student Nurses in charge of the care __________________________________
as may be deemed necessary or advisable in the diagnosis and treatment of this patient.
________________________________ ______________
Signature over Printed Name Date
(Patient)
_______________________________
Signature over Printed Name
(Nearest Relative/Relationship to Patient)
UNIVERSITY OF CEBU - BANILAD
Form Designed For Student Nurses
RELEASE FROM AGAINST MEDICAL ADVICE
This is to certify that I ___________________________________________ a patient in
the University of Cebu - Banilad Form Designed for Student Nurses am being discharged
against the advice of the attending physician and the Hospital administration. I
acknowledge that I have been informed of the risks involved and hereby release the
attending physician and the hospital from all responsibility for ill effects which may
result from such discharged.
________________________________ ______________
Signature over Printed Name Date
(Patient)
_______________________________
Signature over Printed Name
(Nearest Relative/Relationship to Patient)
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
CONSENT FOR SURGICAL PROCEDURE
I,_______________________, hereby consent to undergo the surgical procedure known
as __________________________________________, to be performed by Dr. ___________________
and his/her surgical team at UNIVERSITY OF CEBU - BANILAD HOSPITAL.
1. Nature of the Procedure: The purpose of this procedure is to blah blah blah blah.
The procedure involves blah blah blah blah.
2. Risks of the Procedure: I have been informed of the potential risks and
complications associated with this procedure, including but not limited to:
• Infection
• Bleeding (hemorrhage)
• Blood clots (e.g., DVT, pulmonary embolism)
• Reaction to anesthesia
• Damage to nearby organs, nerves, or blood vessels
• Scarring
• Pain
• Failure of the procedure to achieve the desired outcome
• Need for additional surgery
• [Add any specific risks related to the procedure, e.g., "loss of organ function,"
"nerve damage leading to paralysis or numbness"]
• In rare cases, death.
3. Alternative Treatments: I have been informed of alternative treatments to this
surgery, which include blah blah blah. I understand the risks and benefits of these
alternatives and have chosen to proceed with the proposed surgery.
4. Anesthesia: I understand that a form of anesthesia will be administered for this
procedure. I have had a separate discussion with the anesthesiologist, Dr.
[Anesthesiologist's Name], regarding the type of anesthesia to be used and its associated
risks.
5. Right to Ask Questions: I have been given the opportunity to ask questions
regarding the nature and purpose of the procedure, its potential risks, and alternative
treatments. I believe that all my questions have been answered to my satisfaction.
6. No Guarantee of Results: I understand that medicine is not an exact science, and
no guarantee can be made regarding the results of the procedure. I understand that the
success of the surgery depends on many factors, and while every effort will be made to
achieve a positive outcome, there is no assurance of a perfect or guaranteed result.
7. Consent: By signing this document, I acknowledge that I have read and fully
understand the information provided above. I consent to the performance of the surgical
procedure and all associated medical and surgical treatments, including the administration
of anesthesia, blood transfusions (if deemed necessary), and disposal of any removed
tissue or body parts.
Patient's Signature: _______________________________________
Printed Name: _______________________________________
Date: _______________________________________
Witness's Signature: _______________________________________
Printed Name: _______________________________________
Date: _______________________________________
Surgeon's Signature: _______________________________________
Printed Name: _______________________________________
Date: _______________________________________
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
DOCTOR’S PROGRESS NOTES
HOSPITAL NO:____________
NAME: ____________________________ Sex: __ Age:__ Ward/Bed:_____ Physician:____________
Diagnosis: _________________________________________________________________________
DATE NOTES
UNIVERSITY OF CEBU - BANILAD
Form Designed For Student Nurses
LABORATORY RESULTS
(attach here)
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
GRAPHIC CHART
HOSPITAL NO:____________
NAME: ____________________________ Sex/Age:____ Ward/Bed:_____ Physician:____________
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
DOCTOR’S ORDER SHEET
NAME SEX AGE STATUS RELIGION WARD NO. HOSPITAL NO.
DATE /TIME ORDERS
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
MEDICATION SHEET
HOSPITAL NO:____________
NAME: _________________________________ Sex: ____ Age:____ Ward/Bed:_____
NURSES’ NAME 7-3 SIG NURSES’ NAME 3-11 SIG NURSES’ NAME 11-7 SIG
DOSAGE & MEDICATION D A T E S
FREQUENCY
SINGLE DOSE (PRN,
STAT, NOW)
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
FLUID INTAKE & OUTPUT CHART
HOSPITAL NO:____________
NAME: _________________________________ Sex: ____ Age:____ Ward/Bed:_____
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
DATE:__________ INTAKE OUTPUT
SHIIFT ORAL IV/BT TOTAL URINE STOOL OTHERS TOTAL
7-3
3-11
11-7
TOTAL
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
IV FLUIDS FLOW SHEET
HOSPITAL NO:____________
NAME: _________________________________ Sex: ____ Age:____ Ward/Bed:_____
DATE BOTTLE IV FLUIDS IVF RATE TIME REMARKS NURSE
NO. (gtts/min) SIGNATURE
(cc/hr) STARTED CONSUMED
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
NURSES NOTES SHEET
HOSPITAL NO: ____________
NAME: _________________________________ Sex: ____ Age:____ Ward/Bed:_____
DATE/ FOCUS NURSES MOTES
TIME (IVF, PROCEDURES,
MEDS)
UNIVERSITY OF CEBU - BANILAD
Form Designed for Student Nurses
MEDICATION TICKETS
Legends:
BLUE - prn
YELLOW – QID
WHITE – Stat, Q12H, Q8H, HS
ORANGE – BID
RED – OD
PINK - TID