BAGUIO GENERAL HOS[ITAL AND MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

# 1 Gov Pack Road, Baguio City 2600

CLINICAL PATHWAY FOR PATIENT WELLNESS

INCLUSION CRITERIA:
1.
2.
3
4.
EXCLUSION CRITERIA:
1.
2.
3.
4

PATIENT’S NAME DATE OF BIRTH SEX: PHILHEALTH NUMBER

( )M ______________________________
______________________________________________________________ ________________ ( )F
LAST NAME FIRST NAME MIDDLE NAME MM/DD/ YYYY OPD HOSPITAL NUMBER

CLINICAL NOTES PHYSICIAN’S ORDER SIGNATURE VARIANCE

S OPD under the service of:

Chief Complaint ________________________________________

History
PMHx
FHx (Plan)
S & E Hx
OB Gyne (MOGS) Diagnostic Procedures:
(all those under the inclusion criteria: bulleted)
O  A__ B__ C__ D__
 A__ B__ C__ D__
Vital Signs
Pertinent PE Findings

Initial Assessment: Therapeutic Management:

(if needed only)
___________________________________  Start the following medications: A__ B__ C__ D__

Non Pharmacologic Management:

 A__ B__ C__ D__

Discharge Plans:
 Exit Pathway A__ B__ C__ D__

 Follow up after _____ days/weeks A__ B__ C__ D__

 With lab results A__ B__ C__ D__
 Follow up with A__ B__ C__ D__
 Hypertension Pathway A__ B__ C__ D__
 DM pathway A__ B__ C__ D__
 Other pathway A__ B__ C__ D__

Variances:

ACTIVATED BY: ACKNOWLEDGED BY:

_______________________ ____________________
Signature over Printed Name of Resident / Consultant/ Fellow Signature over Printed Name of NURSE-ON-DUTY
Date:_________Time:______ Date:_________Time_______