MEDICAL SOCIAL SERVICE CLASSIFICATION OF ER PATIENTS

PHARMACY

CHART NO. 24 → ALL CONCERNED *OFFICIAL PRICE SCHEDULE DISTRIBUTION OF OFFICIAL PRICE SCHEDULE SEMESTRAL SUBMISSION OF REQUIRED MEDICINES FOR OFFICIAL PRICE SCHEDULE *OFFICIAL PRICE SCHEDULE PREPARATION OF OFFICIAL PRICE SCHEDULE BIDDING AND EVALUATION *APPROVED LIST PHARMACY APPROVAL RECOMMENDING APPROVAL *LIST CONSOLIDATION *LIST *LIST EVALUATION *LIST OF DRUGS NEEDED UNIT HEADS

REGULAR REQUISITION AND PROCUREMENT OF DRUGS AND MEDICINE PHARMACY

CHART NO. 27

PHARMACY FILLING OF PRESCRIPTIONS FOR IN-PATIENTS

PHARMACY DISPOSAL OF WASTE MATERIALS

DIETARY SERVICE MENU PLANNING

DIETARY SERVICE RECEIVING AND STORAGE

MEDICAL RECORDS SERVICE ISSUANCE OF MEDICAL AND MEDICO-LEGAL CERTIFICATES

MEDICAL RECORDS SERVICE ISSUANCE OF DEATH CERTIFICATES

ADMINISTRATIVE SERVICES

18.1 Budgeting

18.1.1 Preparation of the Work and Financial Plan

Responsibility	Action
Budget-Officer/ Administrative Officer (AO)	1	Prepares Work and Financial Plan (WFP) for the hospital using appropriate Budget Form.
	2.	Forwards it to the AO for review.
Administrative Officer (AO)	3.	Initials the WFP and forwards it to the COH.
Chief of Hospital (COH)	4.	Reviews and signs the WFP and returns it to the Budget Officer or AO.
Budget Officer/ Administrative Officer (AO)	5.	Submits it to the Central Office/Regional Office for appropriate action.

18.1.2 Budget Preparation (Chart No. 41)

Responsibility	Action
Budget Officer/ Administrative Officer (AO)	1.	Arranges budget meeting with the AO, COH, and Unit Heads.
	2.	Gives instructions on the details of the Budget Call.
ie.	3.	Requests Unit Heads to submit their respective plans of operations.
Unit Heads	4.	Submit plans of operations based on specific objectives including justifications for proposals to the Budget Officer.
Budget Officer/ Administrative Officer (AO)	5.	Discusses plans and proposals with the respective unit heads to ensure conformity with the hospital's objectives and targets.

Unit Heads	6.	Prepares and submit final plans and proposals to the Budget Officer.
Budget Officer/ Administrative Officer (AO)	7.	Reviews, consolidates plans and proposals, and accomplishes Budget Preparation Forms.
	8.	Forwards accomplished forms to the AO.
Administrative Officer (AO)	9.	Recommends approval and forwards it to the COH.
Chief of Hospital (COH)	10.	Signs budget and returns it to the Budget Officer.
Budget Officer/ Administrative Officer (AO)	11.	Gets file copies and sends them to the Central/Regional Office.

18.2 Billing and Medicare

18.2.1 Billing of Patient

Responsibility	Action
Admitting	1.	Notifies Billing Section of admissions for the day.
Billing Clerk	2.	Prepares jacket and ledger card for each patient.
Cost Centers	3.	Submit charge slips or notice of services rendered to the Billing Section.
Billing Clerk	4.	Records and files all charge slips received for the day.
Patient	5.	Upon discharge, presents discharge slip to the Billing Clerk.
Billing Clerk	6.	Retrieves jacket and ledger card and prepares the Statement of Accounts (2 copies).
	7.	Forwards Statement of Accounts (copy 2) to the Cashier.
Cashier	8.	Receives payment and issues an official receipt to the patient/ companion.
	9.	Forwards original copy of Statement of Accounts to the Billing Section.
Billing Clerk	10.	Files Statement of Account.

18.2.2 Processing of Philippine Medical Care Commission (PMCC) Forms (Chart 42)

222	**
11 000	ponsi	h	44.77
N P C	131 31 1 51	111	I V
7 100	CITOT

Action

Patient/Companion

1. Submits to Medicare Clerk the following required documents:

For Social Security System (SSS) member/dependent:

• a. Copy of PMCC Form 1
• b. Affidavit of support
• c. Duly stamped "received" E-1 or E-4 (photocopy)
• d. Other necessary papers if the patient is a dependent

For Government Service Insurance System (GSIS) member/dependent:

• a. Copy of PMCC Form 1
• b. Any of the following:
  • (1) Photocopy of the first page of the member's policy contract:
  • (2) A certificate of membership or term renewable insurance certified by the nearest GSIS office or the employer;
  • (3) The correct GSIS policy contract number verified by the Billing-Clerk for subsequent confinements of the member or any of his legal dependents;
  • (4) A certified true copy of the member's original appointment;
  • (5) A certified true copy of his service record; or
  • (6) Military field personnel who do not have ready access to any of the above requirements may submit instead a true copy of the following, certified by their Commanding Officer:
    • (a) ID Card; or
    • (b) Latest pay slip

Medicare/Billing Clerk	2.	Receives and checks if forms have been signed by the employer or his/her authorized representative.
	3.	Completes filling out PMCC Form 1 and checks completeness of the supporting papers by referring to the Medicare Guidelines.
	4.	Fills-up PMCC Form 2 (Medicare Claim for Payment).
	5.	Prepares Statement of Account and Certification of Medicines Issued and attaches it to PMCC Form 2.
	6.	Prepares transmittal letter and attaches to forms.
	7.	Sends papers to the attending Physician.
Attending Physician	8.	Fills-up the final diagnosis portion of PMCC Form 2 and indicates the services rendered.
	9.	Signs and forwards it to the COH or designate.
Chief of Hospital (COH) / Designate	10.	Signs PMCC Form 2 and transmittal letter.
Medicare/Billing Clerk	11.	Gets file copy, records it in the logbook and delivers it to the Addressee.
Personnel Officer	12.	Notifies patient of the arrival of check from PMCC.

ADMINISTRATIVE SERVICES BUDGET PREPARATION

APPENDICES

NAME OF HOSPITAL
ADDRESS	-

OUT-PATIENT RECORD

HOSPITAL NO. _____(Unit No.)

CLINICS			PATT	ENT CL	ASSIFICAT	TION
Pediati Surger Gyneco	rics [] y []	E.E.N.T Urology Dermatol Neurolog Dental	[] .ogy-[]	B [ ]			e
PATIE	nt's name				SEX:	Male []
مرا ۱۷	ECC		(First Nam
BIRTH	IDATE		AGE _	S'		D[] S M[] V
					OYER
NATIO	ONALITY _			,
DATE	DIAGNOSIS	SERVICES TREATMENT RENDERED	ATTENDING PHYSICIAN

NAME OF HOSPITAL
ADDRESS

OUT-PATIENT RECORD

HOSPITAL NO. ______(Unit No.)

CLINICS			PATII	ENT CL	ASSIFICAT	NOI
Pediatr Surger Gyneco	rics [] y[-]	E.E.N.T Urology ——Dermatol Neurolog Dental	[ ] ogy.[.]	B[]	C [] C 1 [] C 2 [] C 3 []
		(Surname)	(First Nam	ne) (N	AI)	Female [ ]
OCCL	JPATION		OFFIC	E/EMPL	OYER	M[] W	W [ ]
		SERVICES TREATMENT RENDERED	ATTENDING		OFFICIAL		REMARKS

_ _ GIVE	NAME - - - - - - - - - - - - - - - - - - -	MPI	] S [ [] AI.	_	] []]	F	HOSPITAL NO. _ _ _ _ _ WARD/RM. EET
C-Ca:		-Dis	con	R-I	Req	ues d	t made
Date Time	ORDER	С	A	R	Е	D	Time Posted Signature
	ft

NAME OF	HOSPITAL
ADE	DRESS

INFORMED CONSENT FOR SURGERY, ANESTHESIA OR OTHER PROCEDURES

TO WHOM IT MAY CONCERN:

I,(Given Name) (S	years old,
· ·
married/single/widowed, hereby co
	who is my(relation)
(myself/name of patient)	(relation)
the procedure/operation/anesthesi fully explained to me by the doctor and their alternative procedures:	a hereunder stated after these have been es concerned including the risks involved
Procedures/operation/anesthes	Explained by:
I also consent to the proper di	sposal by authorities of the
	of whatever tissue may be removed
(Name of Hospital)
from myself/the patient.
I also consent to the taking of pl or operation for the purpose of ad	notographs in the course of this treatment vancing medical knowledge.
IN WITNESS WHEREOF, I h	dereunto set my hand thisdayat
	Patient's signature or "thumb mark" or person giving free consent.
IN THE PRESENCE OF:
Witness	Address
Interpreter	Address

NAME OF HOSPITAL ADDRESS	HOSP. CODE MED. RECORD NO.
CLINICAL COVER SHEET
PATIENT'S NAME:(Last) (Given)	(Middle)		WARD/SERVICE
PERMANENT ADDRESS:	TEL. NO.	SEX []M []F	CIVIL STATUS []S []D []Sep []M []W
BIRTHDATE AGE BIRTH PLACE	NATIONALITY	RELIGION	OCCUPATION
EMPLOYER (Type of Business)	ADDRESS		TEL.NO.
FATHER'S NAME	ADDRESS		TEL. NO.
MOTHER'S (MAIDEN) NAME	ADDRESS		TEL. NO.
ADMISSION: DISCHARGE DATE: DATE: TIME: TIME:	TOTAL NO. OF DAYS	ATTENE	DING PHYSICIAN
			RRED BY: cian/Agency)
SOCIAL SERVICE CLASSIFICATION: []A []B []C []D
ALERT: HOSPITALIZATION ALLERGIC TO COMPANY/INDUST NAME:		HEALTH INSURAN NAME;
DATA FURNISHED BY: ADDRESS O	F INFORMANT	REL	ATION TO PATIENT
ADMISSION DIAGNOSIS:			ICD CODE NO.
PRINCIPAL DIAGNOSIS:			· ШШ [
OTHER DIAGNOSIS:
PRINCIPAL OPERATION/PROCEDU	IRE:		шшг
OTHER OPERATION(S) PROCEDURE(S):
ACCIDENT/INJURIES/POISONING (E.CODE)
PLACE OF OCCURENCE
	RESULTS:		ATTENDING Physician
[] DISCHARGE: [] RECOVERED [] TRANSFERED: [] DIED [] DAMA: [] 48 HOURS [] ABSCONDED: [] +48 HOURS	[] UNIMPRO	VED S	ignature M.D.

NAME OF	HOSPITAL
ADD	RESS

NOTIFICATION SLIP FOR OPERATION

	DATE:
MR/MRS/MS Ward/Room	Hosp. No
Indication for Operation Surgeon Anesthetist Requested Operation Requested Date/Time of Operation	Anesthesia
	Requested by:
	Name of A P

SURNAME	AGE	HOSPITAL NO.
_ _ _ _ _ GIVEN NAME	[ ] SEX	_ _ _ _ WARD/RM.
	[] M [] F

VITAL SIGNS RECORD

DATE			_			_		_					-
40	INTAKE			y 4	2 20	OUTPUT					SPEC
TIME	BP	т	p	R	ORAL	N/C	I.V.	BLOOT	MISC	URINE	N/G	STOOL	EMESIS	MISC	GRAV.	CV
	_	H		H		- 100	$\overline{}$
		П
	_	L			_		_				_	-			-	-
														_
											- 11	-
·				-
			L				_					_			-	-
_		H	-	H							_	-	-			1
		Г	Т	Г		_										Г
																_
																ı
	_	L		-		_	_		-	_	-		_		_	-
												1		1
	_		-	H							_					T
		Г	Г	Г
		_	L	L		(	_				_					-
	-	H	-	H	-	-	-	-	_			-	-		-	$\vdash$
		Т		Г												Г
		L														L

NAME	OF	HOSPITAL
A	DD	RESS

CLINICAL SUMMARY

SURNAME [	AGE [ ] SEX M [ ] F [ ]	Hosp. No. [
Date Admitted: Attending Physician: Admitting Diagnosis: Final Diagnosis: Chief Complaints: Brief Clinical History and Pertinent P.E
Laboratory Findings:(Including EKG, X-1
Course in the Ward: (Include medication
Disposition: (Indicate home medication,
Date Accomplished	3	lent In-charge

Republic of the Philippines Department of Health

	Name of Hospital
_
	Address

INTER-AGENCY-REFERRAL SLIP

Referred To:	Date:
Address:
Patient's Name:	Hospital No.:
Address:	Occupation:
Age: Sex: [] M [] F	C.S.: [] S [] M [] D [] W [] Sep
Working Diagnosis:
Management:
Reason for Referral:
Service Requested:
	×
	Referred by:
	Attending Physician/Resident
Noted:
Hospital Chief/Director
Loopital Ollicy Dilator	. 5

DISCHARGE SUMMARY

SURNAME [	AGE [ ] SEX M [] F []	Hosp. No. [
Date Admitted:
Laboratory Findings:(Including ECG, X	ray and other diag	nostic procedures)
Course in the Ward: (Include medicatio
Disposition: (Indicate home medication	ı, special instruction	n and follow-up)
Date Accomplished	Res	sident In-charge

HOSPITAL

CLEARANCE CERTIFICATE

Inis is to certify th	at	admitted to
	(Name of Patient)
RM/PW/ WARD	of the
	scharge	(Name of Hospital)
cleared of all Hospital a	(Date) ccounts, and all papers pertinent the	erto are duly accomplished.
	Nurse In-charge of Unit/	Date
As to Linens Issued:	In-Charge of Hospital Linens/	Date
As to X-ray Services:	X-ray Technician/	Date
As to Laboratory Service	s:` Laboratory Technician/	Date
As to Medicines:	Pharmacist/	Date
Ability to Pay:	Medical Social Worker/	Date
Other Hospital Accounts	Administrative Officer/	Date
Disposition:	Chief of Hospital	:

INSTRUCTIONS: This certificate must be accomplished and attached to the Clinical Chart presented to the Administrative Officer for final disposition. No patient may be discharged unless this data required is completed.

3.750

NAME OF HO	OSPITAL
ADDRE	SS

DISCHARGE AGAINST MEDICAL ADVICE

Form No. 11

I,	hereby certify that I am leaving/that
against medical advice. I have been i	Patient) nformed of the dangers involved, and I m all liability for any ill effects which
Signature of Witness	Signature of Patient
Date
The patient	left the hospital
notwithstanding medical advice the	he/she was not ready for discharge and ne was dangerous and might result in
Signature of Disinterested Witness	Signature of Nurse
Time and Date	Time and Date
	I am causing the discharge of (Name of against medical advice. I have been i release the hospital and its staff fro may result from this action. Signature of Witness Date The patient (Name notwithstanding medical advice the that leaving the hospital at this tirserious complications. The patient of Signature of Disinterested Witness

STATEMENT OF ACCOUNTS

			Bill No.:
Address:			Date: Nearest Relative Address
Date Admitted:		Dm No	Classification: No. of days
Discharge Date.		T	No. of days
	Total	Medicare	Net of Medicare
Accomodation
Medicare Service Fee
Operating Room Fee
Anesthesia
X-ray Fee
Laboratory	11.20001
Medicines
ECG
Medical Supplies
Electricity
Medical Certificate
Others
TOTAL
Less:			-
Medicare:		O.R. N	lo
Discount:
Deposit:			t
Please pay this amount _			,
Certified Correct:		Approve
Accountant		- Ac	Iministrative Officer

3.0

AUTOPSY REPORT

		100	11 NI
SURNAME		AGE	Hosp. No.
GIVEN NAME		SEX	WARD/RM.
		M[]F[]	[1111111]
Department	Ward	Phy	sician
Date			ate
Admission
Time	Death Time _	Aut	opsy Time
Death was caused Immediate C	l by: Cause (A)		IT
	(D)
Conditions if	· · · · · · · · · · · · · · · · · · ·
5 / 1 .
any, which give
rise to the
	/
ahove cause (A)	Due to (C)
above cause (11)	Duc to (G)
stating the	12
underlying	-
unucitying
cause last.
Other significant condition given		g to death but not	t related to the terminal disease
		· ·	Pathologist

2 5

LABORATORY - EXAMINATION

DATE	NATÚRE OF SPECIMENS	LABORATORY FINDINGS	REMARKS
	1
=

CERTIFICATE OF INDIGENCY

I Hereby Certify that I have inquired into the financial condition of the patient on the reverse side of this card and that I am convinced that he/she is an indigent person.

	Ch	ief (	of H	ospi	tal

INSTRUCTIONS

This record shall be kept for all patients receiving treatment in or outside the hospital dispensary. Hospital Form. 2 shall be used exclusively for in-patients.

All services rendered to outside patients shall be recorded on this card and also, in chronological order on Hospital Form No. 12.

Unless there is guaranty certificate on Hospital Form No. 13 or unless the certificate above is signed by the Chief of the Hospital, the patient shall be required to pay the usual charges to the cashier property clerk before treatment is begun.

2.90

NAI	ME OF H	OSPITAL
-	ADDRE	ESS	-
			Date:
INCO	ME PRO	OF SHEET	4
D	EBIT		CREDI	Т	MEDIO	CARE
IN PATIENT	OUT PATIENT	MEDICARE	INCOME	COST	INCOME	COST
		, R
				`

Certified Correct:

CHARGE SLIP NO.

PATTENT

$ . 3 m

	Name of Hospital
_	Address
	MEDICAL SOCIAL SERVICE (OPD Referral Slip)
	Action Taken by Social Service
(Patient's Name hereby request tor social service :evaluation)
	· ·
Signature of Patient
Date
	Medical Social Worker
Form No. 2
101111 1 10, 2

Form No. 16

	(Name of Hos	pital)
	(Address)	)
Date:		MSS Case No
	CERTIFICATE OF I	NDIGENCY
This is to certify	that(Name of Patient)
of	(Address)	is a needy patient with
a classification of C	class:
He/She is entitled t	to the medical privileges and	d other related benefits in this hospital:
	(Service Needed	()
		Attested by:
St.		Medical Social Worker
Noted:		•
Chief of Hospi	tal
MSS FORM NO. 1	4

Form No. 17

CHARGE SLIP

In-Patient Service	[] :/Ward		Out-Patient [ ] Clinic
Date	Quantity	Nature of Charge		Unit Cost	Total Cost
			-
·
TOTAL		`
			Prepai	red by:
			Signat	ture over P	rinted Name
			Enter	ed bv:

Name of Hospital
Address

BLOOD CROSS-MATCHING RESULT

	Date:
Patient Name
Hosp. No.	Ward/Rm
Serial No.
BLOOD TYPE
RH FACTOR:
POSITIVE []
NEGATIVE []
VDRL
REMARKS:
	Medical Technologist
Pathologist	_

_	Name of Hospital
				Add	ress
Surname [					Age [ ] Sex [ M ] F		Hospital No. [
			BLO	OD TRA	.NSFU	SION
Whole Blood RBC Suspension (250 ml. of cells) [] Fresh [] Preserved [] Concentrated (3				Plasma [] Liquid [] Dried 0ml.) [] Frozen			Amount Requested: ml.
For Use in [] Ward[] OR			Date and H	Iour Want	ted I	Date Requested	Dia	ignosis
Previously Transfu [ ] Yes [ ] No Number of Times	[]	Blood	ons to Prev l: [] Yes a: [] Yes	No No		s: If Patient is Still Birth _ Miscarriage	E	e is there history of Erythroblastosis
Known Rh Antibody Remarks Signature of Physician				ure of Physician
	C	ERT	IFICATIO	ON AND	CROS	S MATCHIN	IG
Serial Number of Blood Serology			Date Collected Source of Bloo			rce of Blood
PATIENT DONOR			CROSS MATCH
ABD Group ABD Group ABD
Rh Type			h Type
Remarks (If group	O Dioc	oa, gi	ve titer)
Reported By:				Entered	1 By:			Date:
Date of Transfusion	n H	lour I	Begun	Amount	Given	Time Requ	ired	Method Used
Reaction: [ ] None [ ] Urticaria [ ] Fever [ ] Shaking Chill If a hematolic react blood from opposi should be examine	te arm	Hen] Hen] Jaur suspe		Comme (Describ		reaction in det	·
Active Account of the Co.								on Urine Ordered on Blood Ordered
Signature of Physician			3.50

NAME OF HOSPITAL ADDRESS

LABORATORY REQUEST FORM

	Date:
Specimen	Clinic	al Impression
Patient Name	Hospit	al No.
	Male [] Service	Hospital No
	Female []	maru
•	· maio [ ]
Mark X on the box before of	desired test.
HEMATOLOGY	MICROSCOPY	CHEMISTRY
[] Peripheral Smear [] Others: BACTERIOLOGY [] Anaerobic Culture [] Aerobic Cul [] Fungal Culture [] Gram stain [] Sero Typing [] KOH smear [] AFB Stain [] India ink	[ ] Quanti. Albumin	[] BUN [] Creatinine [] Uric Acid [] Glucose [] Cholesterol [] Triglycerides [] Blood Gas Studies [] Sodium [] Chlorides [] Calcium [] Lithium [] Inorg. Phosphorus [] Bilirubin [] SGOT [] SGPT [] Alkaline Phosphatase [] Acid Phosphatase [] Arylase [] Lipase [] CK - Total [] CK - MB [] SLDH - Total [] Magnesium [] Total Protein, A/G rat [] Others:	[] RA [] Mono test [] VDRL [] Immunoglo, IgG, A, M, E [] Alpha feto protein [] HbsAg Hepatitis profile (ELISA) [] HBsAg [] Anti-HBs [] IgM Anti-HAV [] Anti-HBc [] HBeAg [] anti-Hbe IF
			[]TSH . [] Growth-hormone
	REQUESTING	DLIVCICIAN

2 50

Name of Hospital
Address

X-RAY REPORT

SURNAME		AGE	Hosp. No.
GIVEN NAME		SEX M[]F[]	WARD/RM.
[] In-patient [] Diagnostic x-ray Requested by:		[] E.R. [] Nuclear Medicine
Clinical Diagnosis:
	nation/Procedure:_		· ·
Radiological Finding:_
(
		;	Radiologist
Date

Form No. 22

(Name of Hospital)
(Address)

MEDICAL SOCIAL SERVICE INTAKE SURVEY SHEET

						ferred:
Date Admitted:			Date Dis	charged:
Diagnosis:			Ward/Rn	ı. No
Classification:	A []	B []	C [] C2 [] C3 []	D []
Name:				Age:	Sex:	Hosp. No	0
(Last)	(Given)	()	(I.N
City Address:	II D. II C	Provinc	ial Address:
C.S. [] S [] M [] W	Пр Прер	Religion:	(M.I) ncial Address:
Employer.			Income:
HOUSEHOLD MEMBERS 1.	AGE	CIVIL STATUS	RELATIO	ONSHIP	occui	PATION	INCOME
2
3
4
5	+
6
7			-
8.
Other Source of In Total Monthly Inc
iotal monthly inc	011101
MO	ONTHLY FAI	MILY EXPE	NDITURE
House and Lot:
Light: Water: Fuel: Food: Househelp: Education:			Clothing: Insurance Premium: Real Estate:
								Medical
			Others:
			, .
			Persons to be notifi	ied in case o	of emergen	cy:
Address: Problem presented a				a. No.:
rioniem presented a	и іптаке:
				-	Medica	1 Social W	orker

MSS Form No. 1

4,00

Republic of the Philippines Department of Health (Name of Hospital) (Address) MEDICAL SOCIAL SERVICE RESPONSIBILITY SLIP

This is to certify that I(Guardian)
(Address)
have taken(Name of Patient)	under/in my custody for
	and that I would b
responsible-for-whatever-may-happen to him.
The state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the state of the s
	Signature of Guardian
•	Relation to Patient
Attending Medical Social Worker
	Noted:
	Head, Medical Social Service
WITNESS:
1 2
MSS Form No. 7

$ ,500

	Department of Health
	(Name of Hospital)
-	(Address)
	MEDICAL SOCIAL SERVICE GO/NGO REFERRAL SLIP
Referral to:	Date: MSS NO
Name	Are Sev Hosp No
Address:	Age Sex Hosp. No C.S. [] S [] M [] W [] D [] Sep
11441633,	C.o. [] o [] w [] b [] Sep
Diagnosis:
Social Case Summary:
	Referred by:
	Medical Social Worker
Noted by:
MSS Form No. 4

Collateral Visit tisiV əmoH Ward Visit Referrals Letters Sent/Received Telephone Calls Interview with Family Collateral Team Consultation Interviews with Patient Case Closed MSS MONTHLY CASEWORK STATISTICS Carried Forward Transferred Case Study Ке-Орепеd Old Cases New Cases Intensive Cases Diagnosis Request for Referral Source of Referral Patient's Name

Recording

Name of Hospital

Address

MSS Form No. 9

	Department of Health
	(Name of Hospital)
	(Address)
MED	DICAL SOCIAL SERVICE PROGRESS REPORT
Name of Patient:
DATE
	·
	M 1: 10 : 1 mr 1
	Medical Social Worker

MSS Form No. 5

1.5

MEDICAL SOCIAL SERVICE HOME STUDY FORM

Name:		Age:	_ C.S.:	Sex:	Religion:
Date of Birth:		Place of Birth:			Religion:
O COMPACION.
City Addiess:
TIOVINCIAI MUUICSS
Previous Contacts Person(s) to be not	with Oth	ier Agencies:	0 4 44
reison(s) to be not	tinea in c	case of emergency	(including	g address):
Reason(s) for requ	est of Ho	me Visit:
Assessment of	(1) (2) (3) (4)	Family situation Emotional climathese affect parties	on n ate in the ho tient's atti	ome and fai tude towar	mily relationships as ds discharge from
	(5)	Areas in which difficulty and/	Areas in which worker can detect (a) present fami difficulty and/or anticipate future family difficulti
Number of room Number of peop Facilities:	ns: ble living Light Water Toilets Others	w/the patient () () () ()
Proximity to trav Proximity to near	eling stat rest Medi	tion, bus line etc. ical Clinic or Dis	spensary_
B) Financial Situat	ion:
a) Monthly Incor b) Other potentian c) Financial obligation	al sources	mily/salaries/wag s of income	es
TOTAL IVIO	onthly m	ing expenses edical expenses _ iscellaneous expe

Emotional climate of Fam	ily Environment:
a) Description of family re	elationships
Husband-Wife relations	ship	- :
b) Family's attitude toward	ds patient	_
	ling regarding patient's attitude toward his illness
	n feelings:	-
strengths and/or weakr	ne family and the patient (Emphasis on the family's nesses:	=: =: =: =:
REMARKS (This may	include action taken as well as worker's or recommendation).
	Medical Social Worker
Date

MSS Form No. 6

-	(Name of Ho	spital)
	(Address	s)
SOCIAL GROUP WORK ACTIVITY FOR
PARTICIPANTS	AGE	SEX	WARD/LOCATION
1.			,
2.
3.			·
4.
5.
6.
7.
8.
Narrative Recording:
		Submit	tted by:
		M	ledical Social Worker
MCC EODM NO. 10
	PARTICIPANTS 1. 2. 3. 4. 5. 6. 7.	SOCIAL GROUP WORK ACTIVIT	PARTICIPANTS AGE SEX

					1 1 1	1 1 1
NAME OF HOSPITAL ADDRESS		HOSP. CODE MED. RECORD NO.		Н
ADMISSION AND DISCHARGE RECORD
PATIENT'S NAME:(Last)	(Given)	(Middle)				ERVICÉ	Ť.
PERMANENT ADDRESS:		TEL. NO.	SEX []M []F	[] S	CIVIL STATUS []S []D []Sep []M []W		p
BIRTHDATE AGE BIRTH	I PLACE	NATIONALITY	RELIGION	OCC	CUPAT	ION
EMPLOYER (Type of Busin	ness)	ADDRESS	TEI	TEL.NO.
FATHER'S NAME		ADDRESS		TEI	TEL. NO.
MOTHER'S (MAIDEN) N.	AME	ADDRESS		TE	L. NO	).
ADMISSION: DISCHA DATE: DATE: TIME: TIME:	TOTAL NO. OF DAYS	ATTENI	DING PHYSICIAN
TYPE OF ADMISSION: [] NEW [] OLD [] F	ORMER OF	PD		REFERRED BY: (Physician/Agency)
SOCIAL SERVICE CLASSIFICATION: [] A [] B [] C [] D
ALERT: HOSPITALIZATION PLAN COMPANY/INDUSTRIAL NAME:			HEALTH INSURA NAME:	IRANCE [] SSS			3:
DATA FURNISHED BY:	F INFORMANT RELATION TO P.			PATTEN	VT
ADMISSION DIAGNOSIS	3:			IC	D CC	DE NO	O.
PRINCIPAL DIAGNOSIS:	,			П	П		Ц
OTHER DIAGNOSIS:
PRINCIPAL OPERATION/PROCEDURE:							Π
OTHER OPERATION(S) PROCEDURE(S):
ACCIDENT/INJURIES/POISONING (E CODE)							L
PLACE OF OCCURENCE				П	Ш	I
DISPOSITION RESULTS:				ATTENDING PHYSICIAN
[] TRANSFERED: [] DAMA: [] 4	RECOVEREI DIED 48 HOURS -48 HOURS	[ ] UNIMPROVED Sig			M.D.

	(Name of Hospital)
	(Address)
	NARRATIVE REPORT FOR
(Guide	in making the Narrative Report)
I.	Introduction: Social/Health situation in the agency/catchment area
II.	Highlights of Casework Activities
III.	Highlights of Group work Activities
IV.	Highlights of Community Organization Activities
V	Meetings, Trainings, Conferences, Workshop, Fora, Symposia, etc., attended and their significance to Medical Social Work Practice
VI.	Others: Social Action, social research, etc.
VII.	Intervening Functions, if any.
VIII.	Problems encountered
IX.	Plan of Action
Χ.	Recommendations
	Submitted by:
	Medical Social Worker
Approve	d:
Chi	ef of Hospital
MSS FO	RM NO. 12

Form No. 31

Republic of the Philippines Department of Health

MEDICAL SOCIAL SERVICE Statistical Report for _____ (Month)

	IN-PATIENT	OUT-PATIENT
I. CASEWORK SERVICE: A. Interview/Consultation 1. Patients 2. Physician/other team members 3. Family & Collateral B. Referrals: 1. To other agencies 2. From other agencies 3. From the wards C. Visits: 1. Ward 2. Home 3. Collateral D. Communications: 1. Letters sent 2. Letters received 3. Telephone calls (made & received) 4. Telegram (made & Received) 4. Telegram (made & Received) E. Cases Recorded: 1. Caseload 2. New cases 3. Old cases 4. Closed cases 5. Cases carried forward II. GROUPWORK SERVICE: A. Parents/Mothers/Watchers B. Groupwork in the wards C. Groupwork at OPD D. Group Therapy/Rehabilitation E. Livelihood Programs	IN-PATIENT	OUT-PATIENT
III.COMMUNITY ORGANIZATION: A. Coordination and Linkages B. Networking C. Community Outreach Program

_

-2-

0		10
Statistical Report for		19
	(Month)

	IN-PATIENT	OUT-PATIENT
IV. ELIGIBILITY SERVICE: A. Classification 1. Class A 2. Class B 3. Class C (C1,C2,C3) 4. Class D 5. Medicare Pay 6. Medicare Service 7. Veteran 8. Barangay Official 9. Health Worker		-
V. SPECIFIC SERVICES: 1. Blood Procurement 2. Medicine Procurement 3. Placement of Abandoned Patients 4. Paupers Burial 5. Transportation Assistance 6. Material Assistance (food, clothing, etc.) 7. Financial Assistance 8. Home Conduction 9. Orthopedic Appliances 10. Family Planning Motivation 11. Nutrition Motivation 12. MCH Motivation 13. Drug Control & Prevention 14. Family Life Counselling 15. HIV/AIDS Counselling 16. Others		,

Submitted by	y:

APPROVED:

Chief of Hospital

MSS FORM NO. 13

	ME OF HOSPITA	L
ADDRESS	ADDRESS

REPORT OF WASTE MATERIALS

On hand a	t
	(State Place of Sto	orage) (Bureau	, Province, City or 1	—————— Municipality)
				19
QUANTITY	UNIT	DECRIPTION	RECORD SAI	RECORD SALES
			OFFICIAL RECEIPT NUMBER	AMOUNT
1.			TYCHIDEK	1
2.
3.
2. 3. 4. 5. 6. 7.
5,
7
8.				-
9.		×
10.
TOTAL
			12
			Property Clerk	or Storekeeper
		First Endorseme	ent
	341		9	, 19
			Signature of Chief of	Bureau or Office
		,	Official Tit	le
		3.50

Form No. 33

NAME OF HOSPITAL

STATEMENT OF DAILY MARKET PURCHASES

	, 19	-		1	ъу
		TOTAL PRICE			ro	DISTRIBUTION OF CHARGES		PATIENTS
	PRICE	PAIGE	LVIMITAL	IMINERAL		STAFF	PERSONNEL	CHARITY	PRIVATE	PAY
					_
					+
					-
					+
										·
					-
-		-			+
if P		out o	r the lui	ius auv ,	ance		me for th
						N	utritionist-l	Dietitian-	Buyer
Noted and		===== ed: ====			Receivof P_	ved fro	om the Cas	hier the a	above an	ount day
Chief of H	iospital			9
					Nutri	tionis	t-Dietitian-I	Buyer,	H	lospita
urchases	inspected	d and fo	ound
Da	te							Inspecto
				Property Audit Department General Auditing Office

2.9

NAME OF HOSPITAL HOSPITAL DAILY CENSUS REPORT

Hospital F No. N		Patient's Name	Time		Room No.	Patient's Name	Time
No. N			Time				Time
Transfers I			-
Transfers I
Transfers I
Transfers I	- 1
	N fron	n other floor		Transfer	s OUT to	other floor
						al)
			DE	ATHS_
		OPNOT	c ci mara	ARY FOR	THE D	AV
Admissi Transfers Total of Discharg Transfer Deaths Total of Remaini	onss in from No. 1, ges (Allers out the state of 5,6,7	m yesterday's none other floor 2,3	day	report

1.1

	NAME OF HOSPI	ΓAL
	ADDRESS
		Cert. No
	MEDICAL CERTIFI	CATE
		Date
	TO WHOM IT MAY CONCERN:
	This is to certify that(Name of	Patient)
	1	was examined and treated/
	(Address)
	confined in this hospital on/from(Date adm	itted)
		owing findings and/or
	(Date Discharged)	Willia Illianigo ana, or
•	diagnosis:
	and would need medical attention for	days barring
	complications.
	Attending Ph	ysician
2.	(NOT VALID WITHOUT SEAL)
	(,

REQUEST FOR ACCESS TO MEDICAL RECORD

Re:	Patient Name
	Date of Birth
	Approximate date of treatment
	request that provide acces to make (name of facility)
medica	l record of the patient named above. I request this access as the:
	patient
	parent of the minor patient
	guardian of the minor patient
	conservator of the person, psychiatric
	conservator of the person
The t	type of access requested is:
	inspection
	copies of the record as follows:
I requ	uest access to:
	entire record
	following portions of the record only:
,
Nam	e:(please print)
Sign	ature: Date:

NAME OF HOSPITAL
ADDRESS

ADMISSION RECORD

Name:	Admiss Examined by	sion No.
Head & Neck:
Thorax Heart:B.PLungs	Pulse:	Respiration:
Abdomen F.U.	Presentation: Location _	Chapter
Admitting Diagnosis:

FOLLOW-UP OF LABOR

DATE	TIME	B.P.	PULSE	INTERNAL EXAMINATION	INTERNAL	UTERINE
				Findings	Duration	Internal	For	M.D.
	_	_					_
		_					-
								_
		-
-		$\rightarrow$	-

Name of Hospital

Address

REFERRAL SHEET (Institutional)

(111)	itutional)
Referred toName/Service	Attending Physician
Please Check Appropriate box (es)
[] Co-management [] Opinion and Recommendation [] Opinion and Follow-up as needed [] Cardiopulmonary Clearance [] Executive Check-up [-] Transfer-of-Service [] Others:	Procedure (s): [ ] Parancentesis [ ] Biopsy [ ] Endoscopy [ ] Proctosigmoidoscopy [ ] Thoracentesis [ ] Others:
COMMENTS/OPINIONS/RECOMMENDA	TIONS

Form No. 40

Signature of Referred Physician

NAME OF HOSPITAL ADDRESS

X-RAY REQUEST

		Date
Patient Name		Hospital No
Age Sex:	Male [] Female []	Status S [] D [] M [] W [] SEP []
Address
In-Patient [] Service/WardRm. No		Out-Patient []
Requested Examination
8
Clinical Diagnosis
		Requested by:

$ 180

NAME OF HOSPITAL
ADDRESS

REQUISITION ORDER SLIP OF DRUGS AND MEDICINES

TO:Please furnish the following	, Pharmacy Unit/Secting medicines for	ion	DATE;SECTION
COMPLETE DESC	CRIPTION OF ITEMS	QUANTITY	UNITS
	-	Requesting Of

2 5

NAME OF HOSPITAL

ADDRESS

CONSENT OF RECIPIENT TO OPERATION, TRANSPLANTATION OR GRAFTING OF TISSUE

CONSENT

1.	. I,	Given name	C		, hereby authorize
	Dr.	designate, to perfor	Surname	_ and such	n assistants as he/sh
	inay ——	designate, to perfor	m upon myseli	the following	operation:
	and oper	to do any additionation that his/her	onal or differ judgement n	ent procedur nay dictate.	es during the above
2.	I am the ti	informed that th issue or the transp	e above opera lantation of t	ation will inv	rolve the grafting of organs(s):
3.	altern to m	plantation, the ha	rure and effe procedure or tr or assurance	ct of the oper	afting, or organs for ration, and possible been fully explained en to me as to the
4.	adilli	able by the anest	hetist with t	may be consi he exception	I consent to the idered necessary or of
		(state "none" or	type of anest	thesia)
D	ated th	nis	{	day of	19 o Patient
Si	ignatur ignatur	re of Patient re of Witness	R	lelationship t	o Patient
LOIION	, 1116.				please complete the
to sign	n becai	s an infant at law,	being	years c	of age, or is unable
CO	NFIRI	MATION
I, patien the abo	t/perso	on legally responsi ocedure(s). In .my o	ble for the p pinion, he/sh	, have atient the na	described to the ture and effect of d this explanation.
Da Sig	ite this gnature	of Doctor	da	y of	19

(Name of Hospital)	(Name of Hospital)
,	` ,
(Address)	(

WARD REFERRAL TO MEDICAL SOCIAL SERVICE

Name:			Ward:	Bed No.:
Reason for	Referral	:
1. 2. 3.	Need fo	socio-economic evaluation. or medicine, blood, braces, etc. nent Problems:
	a. b. c. d.	Aggressiveness/hostility/stub Refusal to follow rules and re Going home against medical Withdrawal of patients such as	egulations. l advice.
4.	Emotio	nal problems met during treat	ment/hosp	italization:
	a. b. c. d. e. f.	Anxiety due to separation from Refusal to accept treatment. Over-dependent patient. Family disorganization. Unfounded fear of death, disorders, please specify.
5.	Dischar	ge Planning:
	a. b. c. d. e.	Abandoned patient (Institution Abandoned cadaver (Pauper's Transportation problem. Refusal of the family to take Need for home visit.	s burial).
6.	Family (	Counselling:
	a. b.	Marital Problem. Family Planning/Nutrition Ed Prevention, HIV/AIDS Coun		CH/Drug Control and
	C.	Family Life Education, Valu	es Orientat	ion.
7.	Others.	Please specify.
		_	Referring	Physician/Nurse
	e e		2.020111116
		-		Date

MSS Form No. 3

4.00

	(Name o	f Hospital)	=
		dress)	ē
COMMUNITY O	RGANIZATION A	ACTIVITY FOR	(Month)	19
Nature of Communit	y Organization Act	tivity:		6
Narrative Report:
				-
2
X.			•
		Submitted by:
		Medical	Social Worker	r

MSS FORM NO. 11

Form No. 45

30 Date 53 27 26 25 24 23 22 21 20 20 1 19 REPORT OF DAILY ACTIVITIES MEDICAL SOCIAL SERVICE 15 4 13 12 11 10 6 $\infty$ ~ 9 2 4 2 Groupwork Activities GO/NGO Linkages/Coordination/Network 2. Class B 3. Class C (C1, C2, C3) 8. Barangay Official 9. Health Worker 6. Medicare service 5. Medicare Pay Interview with Family/Collateral Encircle Sundays and Holidays 4. Class D I. Class A 7. Veteran Interview with Patients Telegram Sent/Received Phone Calls Home/Collateral Visit Ward Referral Community Outreach Letters Sent/Received Team Consultation From Re-Admission assification: Referral: To Admission Discharged Absconded Ward Visit Death

Name of Hospital

Address

REPORT OF DAILY ACTIVITIES MEDICAL SOCIAL SERVICE

Encircle Sundays and Holidays	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Specific Services:
1. Blood Procurement
2. Medicine
3. Placement of Abandoned Patients
4. Pauper's Burial
5. Transportation Assistance
6. Material Assistance
7. Financial Assistance
8. Home Conduction
9. Orthopedic Appliances
10. Family Planning
11. Nutrition Motivation
12. MCH Motivation
13. Drug Control and Prevention
14. Family Life Counselling
15. Discharge Planning
16. Others

Medical Social Worker

MSS Form No. 8

SEROLOGY

	Date:
Patient Name
Hosp. No
Serial No
	Medical Technologi
	· ·
Pathologist

2 10

Republic of the Philippines Department of Health (Name of Hospital) (Address) MEDICAL SOCIAL SERVICE HOSPITAL NETWORK REFERRAL SOCIAL CASE STUDY Date: MSS Case No.: Name of Patient: _ Hospital No.:_ Address: Age: ____ Sex: __ [] A [] B [] C [] D Classification: Ward: Nature of Referral: Source of Referral: Hospital Referred to:__ Social Case Abstract: Recommendation: _ Submitted by:

MSS FORM NO. 15

Chief of Hospital

Noted:

Medical Social Worker