Republic of the Philippines

Department of Health
COTABATO REGIONAL AND MEDICAL CENTER
DIAGNOSTIC PROCEDURES STAT/REQUESTED DONE AT EMERGENCY ROOM

Hospital No.:___________

Patient Name: ____________________________________________Age:_________Date:_________________

Ward: ___________________________Diagnosis:_________________________________________________

REQUESTED PERFORMED RESULT IN

YES NO YES NO YES NO

1. Laboratory Examinations:
A. Haematology examination
I. CBC ( ) ( ) ( ) ( ) ( ) ( )
II. Blood Typing and Cross-Matched ( ) ( ) ( ) ( ) ( ) ( )
III. Protime ( ) ( ) ( ) ( ) ( ) ( )
IV. APTT ( ) ( ) ( ) ( ) ( ) ( )

B. Clinical Chemistry examination

I. Na ( ) ( ) ( ) ( ) ( ) ( )
II. K1 ( ) ( ) ( ) ( ) ( ) ( )
III. Calcium ( ) ( ) ( ) ( ) ( ) ( )
IV. Magnesium ( ) ( ) ( ) ( ) ( ) ( )
V. Phosphorous ( ) ( ) ( ) ( ) ( ) ( )
VI. BUN ( ) ( ) ( ) ( ) ( ) ( )
VII. Creatinine ( ) ( ) ( ) ( ) ( ) ( )
VIII. SGOT ( ) ( ) ( ) ( ) ( ) ( )
IX. SGPT ( ) ( ) ( ) ( ) ( ) ( )
X. HBSag ( ) ( ) ( ) ( ) ( ) ( )
XI. Trop I ( ) ( ) ( ) ( ) ( ) ( )
XII. Dengue NS1 ( ) ( ) ( ) ( ) ( ) ( )

C. Urinalysis ( ) ( ) ( ) ( ) ( ) ( )

D. Stool Exam ( ) ( ) ( ) ( ) ( ) ( )

2. ECG ( ) ( ) ( ) ( ) ( ) ( )

3. X-ray ____________ ( ) ( ) ( ) ( ) ( ) ( )

4. CT Scan _____________ ( ) ( ) ( ) ( ) ( ) ( )

5. Ultrasound ( ) ( ) ( ) ( ) ( ) ( )

YES NO
6. Nurse’s Note Documented ( ) ( )

Remarks: _________________________________________

_____________________________
Nurse on Duty

NS-F-34 Rev.0