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CF3 Patient's Clinical Record
PhilHealth form for patient's clinical record
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CF3
(Claim Form)
revised November 2013
PART I - PATIENT'S CLINICAL RECORD
1. PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider:
2. Name of Patient
3. Chief Complaint / Reason for Admission:
Last Name,
First Name,
Middle Name
4. Date Admitted:
(example: Dela Cruz, Juan Jr., Sipag)
Time Admitted:
Month
Day
Year
Month
Day
Year
5. Date Discharged:
AM
hh-mm
Time Discharged:
hh-mm
PM
hh-mm
AM
hh-mm
PM
6. Brief History of Present Illness / OB History:
7. Physical Examination ( Pertinent Findings per System )
General Survey:
Vital Signs
:
HEENT
BP :
CR:
RR:
Temperature:
Abdomen
:
:
GU ( IE )
:
Chest/Lungs
:
Skin/Extremities
:
CVS
:
Neuro Examination
:
8. Course in the Wards (attach additional sheets if necessary):
9. Pertinent Laboratory and Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )
10. Disposition on Discharge:
Improved
Transferred
HAMA
Absconded
Expired
PART II- MATERNITY CARE PACKAGE
PRENATAL CONSULTATION
1. Initial Prenatal Consultation
Month
Day
Year
2. Clinical History and Physical Examination
c. Menstrual History LMP
a. Vital signs are normal
Age of Menarche __________
Month
b. Ascertain the present Pregnancy is low-Risk
Day
G
d. Obstetric History
Year
P
(
,
T
3. Obstetric risk factors
,
P
)
,
A
L
a. Multiple pregnancy
d. Placenta previa
g. History of pre-eclampsia
b. Ovarian cyst
e. History of 3 miscarriages
h. History of eclampsia
c. Myoma uteri
f. History of stillbirth
i. Premature contraction
a. Hypertension
d. Thyroid Disorder
g. Epilepsy
j. History of previous cesarian section
b. Heart Disease
e. Obesity
h. Renal disease
k. History of uterine myomectomy
c. Diabetes
f. Moderate to severe asthma
i. Bleeding disorders
4. Medical/Surgical risk factors
5. Admitting Diagnosis
6. Delivery Plan
a. Orientation to MCP/Availment of Benefits
b. Expected date of delivery
yes
no
Month
Day
Year
9th
10th
7. Follow-up Prenatal Consultation
a. Prenatal Consultation No.
2nd
3rd
4th
5th
6th
7th
8th
11th
b. Date of visit (mm/ dd/ yy)
c. AOG in weeks
d. Weight & Vital signs:
d.1. Weight
d.2. Cardiac Rate
d.3. Respiratory Rate
d.4 Blood Pressure
d.5. Temperature
DELIVERY OUTCOME
Date
8. Date and Time of Delivery
Time
Month
Day
Year
hh-mm
AM
hh-mm
PM
Pregnancy Uterine,
9. Maternal Outcome:
AOG by LMP
Manner of Delivery
Presentation
Sex
Obstetric Index
Birth Weight (grm)
APGAR Score
10. Birth Outcome:
Fetal Outcome
11. Scheduled Postpartum follow-up consultation 1 week after delivery
Month
12. Date and Time of Discharge
Date
Time
Month
Day
Year
hh-mm
Day
AM
hh-mm
Year
PM
POSTPARTUM CARE
done
Remarks
13. Perineal wound care
14. Signs of Maternal Postpartum Complications
15. Counselling and Education
a. Breastfeeding and Nutrition
b. Family Planning
16. Provided family planning service to patient (as requested by patient)
17. Referred to partner physician for Voluntary Surgical Sterilization (as requested by pt.)
18. Schedule the next postpartum follow-up
28. Certification of Attending Physician/Midwife:
19. Certification of Attending Physician/Midwife:
I certify that the above information given in this form are true and correct.
___________________________________________________
Signature Over Printed Name of Attending Physician/Midwife
Date Signed (Month / Day / Year)
12th
