DR. PABLO O. TORRE B.S.

Aquino Drive, Bacolod City

MEMORIAL HOSPITAL
Neg. Occ. 6100, Philippines DISCHARGE SUMMARY/
Tel. Nos. (6334) 705-0000
(6334) 433-7331 MEDICAL ABSTRACT
File copy in the chart

NAME: LAST FIRST MIDDLE AGE GENDER CIVIL STATUS ROOM NO. HOSP. NO.

PERMANENT ADDRESS: STREET BRGY. CITY/TOWN COUNTRY CONTACT #:

ADMISSION DATE: (mm/dd/yyyy) DISCHARGE DATE: (mm/dd/yyyy) DISCHARGE DIAGNOSES AND CO-MORBIDITIES:
OPERATION DONE (IF APPLICABLE)
ADMITTING DIAGNOSIS:

ClinicaC CLINICAL COURSE:

TestTes MEDICATIONS:

M SIGNIFICANT LABORATORY, X-RAY AND CONSULTATION FINDINGS:

NUTRITIONAL STATUS:
. 

√ PHYSICAL ACTIVITY: pls. check
√ 
REGULAR/FULL SOFT LOW SALT LOW FAT NO RESTRICTION WITH RESTRICTION
ORAL TUBE TPN ADDITIONAL DISCHARGE INSTRUCTIONS:
OTHERS:
OUTCOME:
. 
√ RECOVERED IMPROVED UNIMPROVED DIED

DISPOSITION: STILL ADMITTED DISCHARGED TRANSFERRED ABSCONDED AGAINST ADVISE

PHYSICIANS: (SIGNATURE OVER PRINTED NAME)
PREPARED BY: NOTED BY:

, M.D. , M.D.
POST GRADUATE INTERN RESIDENT ON DUTY ATTENDING PHYSICIAN
LICENSE #___________
PTR #______________
*Use black ink only

MRD-OF-012 * This document is NOT ADMISSIBLE IN COURT.

REV. NO.: 0
DATE EFFECTIVE: 12-01-17