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Medical Record No

In Time

Clearance Time

Shift

INJURY DEFINE

Complaints

Diagnosis

Examination Findings

DIVISION WHERE INCINDENT OCCURED

SUB DIVISION(DEPARTMENT) WHERE INCIDENT OCCURED

SUB STATION(UTE)

Case Type

Referred By

Remarks/Follow-up Investigation Details

Injury

Type	Part	Classification
,	,	,

Procedures (If Any):

Medicine Disbursement

Doctor Discussed?

Doctor Consulted?

Additional Recommendations(If Any)

Referral

Follow-up

Emergency? :

Heart Rate:

SBP:

DBP:

FBS:

RBS:

PPBS:

Temp:

SPOC2%:

Affected Body Parts

Health Advices

Doctor Recommended Tests

Additional Precautions

Follow-Up Remarks(If Any)

Test Result