This form may be reproduced and is NOT FOR SALE

CF3
(Claim Form)
revised November 2013

PART I - PATIENT'S CLINICAL RECORD

1. PhilHealth Accreditation No. (PAN) - Institutional Health Care Provider: H 0 3 0 2 0 2 2 2

2. Name of Patient
3. Chief Complaint / Reason for Admission:
BRIGINO, CHARMAINE COSTALES
LABOR PAINS
Last Name, First Name, Middle Name (example: Dela Cruz, Juan Jr., Sipag)

4. Date Admitted: 12 - 0 3 - 201 9 Time Admitted: 10:35 AM PM

Month Day Year hh-mm hh-mm

5. Date Discharged: 12 - 04 - 2 019 Time Discharged : AM 6 PM

Month Day Year hh-mm hh-mm

6. Brief History of Present Illness / OB History:

7. Physical Examination ( Pertinent Findings per System )

General Survey:

Vital Signs : BP: _120/70__ __CR: ___ 93 __ RR: ___ 22 __ Temperature: ___36.6 __ Abdomen :

HEENT : GU (IE) :

Chest/Lungs : E/N Skin/Extremities:

CVS : NeuroExamination:

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 - - 2 0 1 9
Month Day Year
2.Clinical History and Physical Examination - - 2 0 1 9
a. Vital signs are normal c. Menstrual History LMP Age of Menarche 12
Month Day Year
b. Ascertain the present Pregnancy is low-Risk d. Obstetric History G__1___ P ___ ( __ __, ____, _____, _____)
T P A L
3.Obstetric risk factors
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

4.Medical/Surgical risk factors

a. Hypertension d. Thyroid Disorder g. Epilepsy j. History of previos 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

5. Admitting Diagnosis G1 PU 37-38 WEEKS AOG, CORDCOIL

6. Delivery Plan
a. Orientation to MCP/Availment of Benefits b.Expected date of delivery - - 2 0 1 9
yes no Month Day Year
7. Follow-up Prenatal Consultation

a. Prenatal Consultation No. 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

b. Date of visit (mm/ dd/ yy)

c. AOG in weeks
d. Weight and Vital Signs:
d.1 Weight (KG)

d.2. Cardiac Rate

d.3. Respiratory Rate

d.4. Blood Pressure

d.5. Temperature

DELIVERY OUTCOME

8.Date and Time of Delivery Date 1 2 0 3 2 0 1 9 Time AM PM

Month Day Year hh:mm hh:mm
9. Maternal Outcome: G1P1 (1001) Pregnancy Uterine 37-38 WEEKS , NSD , CEPHALIC ,
Obstetric Index AOG by LMP Manner of Delivery Presentation
10. Birth Outcome: ALIVE , FEMALE , 2940 , 9.9 ,
Fetal Outcome Sex Birth Weight (gm) APGAR Score
11. Scheduled Postpartum follow-up consultation 1 week after deliver 12 1 1 2 0 1 9
Month Day Year
12.Date and Time of Discharge Date 1 2 04 2 01 9 Time AM 6 PM
Month Day Year hh:mm hh:mm
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
19. Certification of Attending Physician/Midwife:

I certify that the above information given in this form are true and correct.

GLENDELL A. BAUTISTA
Signature Over Printed Name of Attending Physician/Midwife Date Signed (Month / Day / Year)
 GUIGUINTO POLYMEDIC HOSPITAL INC.
(FORMERLY BULACAN POLYMEDIC HOSPITAL INC.)
113 CAGAYAN VALLEY ROAD STA. CRUZ GUIGUINTO, BULACAN
TELEPHONE NO. (044) 794-0788
TELEFAX NO. (044) 794-4881

MEDICAL CERTIFICATE

TO WHOM IT MAY CONCERN:

This is to certify that CHARMAINE BRIGINO, 25 years old from LUGAM MALOLOS
CITY BULACAN was admitted / treated in this hospital last DECEMBER 3,2019 with the
diagnosis of: G1 PU 37-38 WEEKS AOG, CIL

She was discharged improved with the following medications : 1. Ampisulbactam 750
mg BID x 1 week 2. Celecoxib 200 mg BID x 1 week for pain 3. Ferrous sulfate capsule OD x
30 days.

She underwent Normal Spontaneous Delivery with RMLE &Repair

She is advised bed rest for 105 days.

This certification has been issued per patient request for reference purposes except
medico legal cases.

GLENDELL BAUTISTA MD FPOGS, FPSUOG

OBGYN/OBGYN SONOLOGIST
Attending Physician
Lic 100631
 GUIGUINTO POLYMEDIC HOSPITAL INC.
(FORMERLY BULACAN POLYMEDIC HOSPITAL INC.)
113 CAGAYAN VALLEY ROAD STA. CRUZ GUIGUINTO, BULACAN
TELEPHONE NO. (044) 794-0788
TELEFAX NO. (044) 794-4881

CLINICAL ABSTRACT

NAME:, CHARMAINE COSTALES BRIGINO

AGE: 25 years old
ADDRESS :, LUGAM MALOLOS CITY
DATE ADMITTED: DECEMBER 3 , 2019
DATE DISCHARGED: DECEMBER 4 , 2019

CHIEF COMPLAINT: LABOR PAINS

HISTORY OF PRESENT ILLNESS:

PERTINENT PHYSICAL EXAMINATION

FH CM FHT 148 BPM

IE: cm , 50 % effaced, (+) cephalic, BOW, st-3

HOME MEDICATIONS: 1. Ampisulbactam 750 mg BID x 1 week 2. Celecoxib 200 mg

BID x 1 week for pain 3. Ferrous sulfate capsule OD x 30 days.

FINAL DIAGNOSIS: G1P1 (1001) PU TERM DELIVERED BY NSD TO ALIVE BB GIRL, BW

2940GM, A.S 9.9

GLENDELL BAUTISTA MD FPOGS, FPSUOG

OBGYN/OBGYN SONOLOGIST
Attending Physician
Lic 100631