EAMC DFCM OPD Charting Guidelines As of March 2022

EAMC DFCM OPD Charting Guidelines as of March 2022
DISCLAIMER: Please use this only as a guide during EAMC DFCM rotation. Good clinical judgement and updated knowledge supersedes this guideline.
There are 4 Clerks/ Interns posts:
1. Triage
2. Vital Signs
3. Consults
4. Census
Patient Care Flow Chart
Triage Vital Signs Team Consultation Team Census Encoding
Brief HPI Vital Signs and Anthropometrics History and Physical Exam Checking of chart completion
Triaging of patients to different Referring of patients with abnormal Referring of patients to Residents on Encoding of Patient Charts on the
departments. vital signs and red flag symptoms. Duty Computer
ER referrals Logging and charting of time Checking of chart completion Checking of accuracy of orders:
recieved and time interviewed Takes note the Time referred to the spelling errors, correct prescriptions.
resident. Logging of time referred and time
Takes note the time discharged (time discharged.
when the resident is finished checking
the patient and the chart.
Carrying out Corrected Resident's
Orders (prescription, Lab requests,
Clinical abstracts or medical
certificates)
Checking of completion and correct
chart orders (prescription, Lab
requests, Clinical abstracts or medical
certificates).
Discussing Patient discharge
instructions to the patient.
Checking of chart completion prior to
encoding.
Checks completeness of time stamps.
(time recieved, time interviewed, time
referred, time discharged.)
CENSUS ASSISTANTS RESPONSIBILITIES

Assistant 1
1. Checks the completeness of the Daily census every after OPD hours. (with the encoder of the day)
2. Uploads the Census file on the Google drive link.
3. Checks and corrects spelling errors, dosages, and other encoding errors.
4. Every Tuesday, Converts OPD Daily Census Document files to DOH CENSUS Format. See DOH Census Editing Guidelines.
Assistant 2
1. Compiles Daily Morbidity Tally Sheets and encodes it to the Morbidity Census Excel file.
2. Copies Daily Census Summary information to Daily Census Summary File.
3. Every Tuesday, copies all the census on the Daily OPD census to the Master Monthly Census.
4. On the last day of the rotation, copies the Master monthly Census to the Master Annual Census.
Files to be submitted at the End of the rotation.

Soft copy of OPD Daily Census Summary.
Soft and Hard Copies of OPD Daily Morbidity Tally Summary.
FOR EAST AVENUE MEDICAL CENTER DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE USE ONLY
HISTORY OF PRESENT ILLNESS
PRIMARY SYMPTOM Associated symptoms Pertinent negatives Medications/consults
Timing: Associated with: List your differentials Medical Consults if any
Previous episodes, Include RELEVANT symptoms only. Then pertinent negatives. Ex. Sought consult at <private clinic, ER,
Onset, Other unrelated symptoms should be in UTI hospital, government hospital/ OPD>
Frequency, the Review of Systems. No dysuria, frequency, urgency, fever, Diagnosed with <diagnosis>
Duration chills, flank or suprapubic pain. Diagnostics done were <Tests>
Location Gynecologic Prescribed with <drug>
Quality or Character No vaginal discharge, vaginal pruritus, Self-medicated with <drug>
Severity dyspareunia With relief/no relief of symptoms.
Radiation FOR PATIENTS SEEN AT THE ER,
Relieving factors ALWAYS START THE HISTORY
Precipitating factors PRIOR TO THE ER CONSULT.
Progression
Interim history: Progression, if episodic, frequency, Timing of symptoms, relieving and aggravating factors,
Reason for consult: persistence, progression, severity, of symptoms prompted consult.
Minimum “Normal” Physical Exam findings

Neuro PE (Normal)
I Not assessed
General Conscious, coherent, not in cardiorespiratory distress II PERRLA
Survey III, IV, VI EOM- able to perform cardinal Eye ROM
V clenches teeth symmetrically, intact facial sensation
Skin Skin is brown moist with good skin turgor, no visible mass or
VII Symmetrical facie
lesions.
VIII Intact audition
HEENT Normocephalic, Pink palpebral Conjunctiva, anicteric sclera, IX, X Uvula in midline, (+) gag reflex
(Inspection, No Nasal nor aural discharge, no tonsillopharyngeal XI Shrugs both shoulders symmetrically
Palpation) congestion, Neck is supple with no CLAD and no JVD XII Tongue protrudes in midline, no fasc.
Chest/Lungs No mass or lesions, Symmetrical chest expansion, no

(Insp, Palp, retractions, no chest lagging, vesicular breath sounds.
Perc, Ausc)
Heart Adynamic Precordium, PMI at 5th ICS Left Midclavicular line,

(Inspe, Normal Rate, Regular Rhythm, distinct S1 and S2, No
Ausc) murmurs
Abdomen Globular, no visible mass or lesions, normoactive bowel

(Insp, Aus, sounds , soft, non-tender, no CVA tenderness, Negative
Palp, Perc) Murphy sign, tympanitic
Extremities No gross deformities, full and equal pulses, capillary refill

time <2 secs, No edema.
Genitalia Grossly Male/Female Adult Genitalia, no visible mass or

lesions, no visible discharge.
Internal Patent vaginal canal, cervix is closed, soft, smooth and Assessment Tools / Questionnaires Available for Printing
exam nontender. uterus in midline, smooth, firm, and non- tender, Cardiology: Heart Failure-Framingham Criteria, NYHA and Angina
no palpable right and left adnexal mass. Whitish discharge Headache: Tension Type, Migraine, Cluster Diagnostic Criteria
on examining finger upon withdrawal. Psychiatry DSM V criteria for MDD, GAD, Panic Disorder, Schizophrenia and
Mental Status Exam checklist.
Rectal No visible mass or lesions, good sphincter tone, smooth Thyroid Disorders: Burch Wartofsky for Thyroid Storm, Wayne’s Index for
rectal walls, 2 fingerbreadths prostate, non-tender, full/empty Hyperthyroidism, Billewics Scoring for Hypothyroidism
rectal vault, no palpable mass or lesions. Birmingham Vasculitis Activity Score.
Spine Spine is in midline, no visible lesions, abnormal curvature,

Straight Leg raise negative.
CHARTING GUIDELINES
Assessment 1. With comorbidities (HTN, DM, CKD) “for HTN/DM/Workup: 12 L ECG,

1. Medical Assessment FBS, Lipid Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN,
Primary diagnosis then from most significant (RELATED TO THE CHIEF Creatinine, SGPT SGOT”
COMPLAINT) For patients with comorbidities 3 Write “For HTN/DM workup: 12 L ECG, FBS, Lipid
to least significant diagnosis Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Creatinine, SGPT SGOT
Example: CC cough for 5 days
PMH: Hypertension Stage II When writing Imaging tests, do it in LIV format Location, Imaging modality, View
Assessment: (what type of view or special views)
CAP-LR (since it is the Main Diagnosis) Ex. Chest Xray PAL, HBT UTZ, Lumbosacral MRI, Cranial CT scan with contrast, 2D
Hypertension stage II controlled Echo with doppler studies, Arterial, Venous, AV duplex scan etc.
Warning: Always write pertinent history and physical exam on the Imaging
2. Psychosocial Assessment request, failure to do so has corresponding consequences.
Here is the list of acceptable Psychosocial assessment For 2D Echo/AV duplex scan patients, aside from the 2D Echo Request, make sure to
Tobacco use [ Z72.0] fill up the 2D Echo Physical Exam Form.
Alcohol use [ Z72.1] For laboratory requests that is not available in our standard request form, write the
Drug use [ Z72.2] request on the prescription pad. (For example Fecal Immunochemical Test, Nucleic
Abuse of non-dependent producing substances [F55] Acid Amplification Test)
Lack of physical exercise [ Z72.3]
Inappropriate diet and eating habits [Z72.4] Preventive/Screening recommendations:
Non organic insomnia – inadequate quantity or quality of sleep for a prolonged STI Screening
period [ F51.0] All ages, for High-risk individuals: HbsAg, HIV
Sleep disorders [G47] occupational exposures, high-risk
Insomnia [G47.0] behaviors, endemicity,
Insomnia due to medical condition (G47.01) immunodeficiency
High risk sexual behavior [Z72.5] Hypertension screening
Gambling and betting [Z72.6] 18-39 years old Every 3-5 years
Self damaging behavior [Z72.8] 40 years old Annual
Burnout [Z73.0] Cervical Cancer Screening
Lack of relaxation and leisure [ Z73.2] <21 years old No testing for HPV unless 3 years from
Stress Not elsewhere classified / Physical and mental strain [ Z73.3] coitarche.
Type A behavior pattern (characterized by unbridled ambition, a need for high
Female, 21 years old and above or 3 PAP smear and HPV screening every 3
achievement, impatience, competitiveness, and a sense of urgency) [Z73.1]
years from coitarche years
Social role conflict [Z73.5]
21-29 years old Cervical Cytology every 3 years
Inadequate social skills [ Z73.4]
Problems related to life management difficulty [ Z73. 9] 30-65 years old Cervical Cytology every 3 years
Limitation of activities due to disability [Z73.6] HPV High Risk Strain testing every 5 years
Problems related to care provider dependency [ Z74] Co-testing every 5 years
Problems related to medical facility and other health care – unavailable, inaccessible >65 years old with adequate prior No testing for HPV
[ Z76 ] testing
Malingering – person feigning illness with obvious motivation [ Z76.5] Dyslipidemia Screening
Example of Psychosocial Assessment Male 35 years old
S: Main chief complaint, Medical HPI then Female 40 years old
Patient came in seeking clinical abstract for her labs/medications. Breast Cancer Screening
O: Income: less than 5000 per month. Breadwinner of 5. Female, 40 years old and above Screening annual Mammography
A: Psychosocial Assessment: Problems related to medical facility and other health care 50-74 years old, Low Risk Biennial Mammogram
– unavailable, inaccessible [ Z76 ] due to financial constraints 40-74 years old, Moderate Risk Annual Mammogram
Plan: Usual medical plan. (Previous history of Cancer, First
Insert at nonpharmacologic management: “Clinical Abstract provided and was referred degree relative with breast Cancer,
to Social Services for further assistance.” Positive for BRCA genes)
DM Screening
Regardless of age: if with Family FBS, 75g OGTT, HBA1C
Plan History, PCOS, GDM, ethnicity
Follow the format Adults 40-70; Overweight and Obese HbA1c, OGTT
1. Diagnostics Rescreening if normal Every 3 years
2. Pharmacologic management >45 years old Blood-sugar monitoring
3. Non-Pharmacologic management Prostate Cancer Screening
4. Referrals Males, 50 years old and above Do Digital Rectal Exam
5. Follow up
Prostate Cancer: 55-69 years old PSA every 2 years
Colorectal Cancer Screening
DIAGNOSTICS
All >50 years old Endoscopy
Laboratory/Imaging Request should be clustered in to:
1. PRIORITY LAB WORKUP: Labs that are relevant to the diagnosis >40 years old Oral cavity inspection
For any patients >40 years old and above with Abdominal or Chest pain do STAT 12L Colorectal Cancer: 50-75 years old FOBT or FIT yearly
ECG to Rule out Ischemic Heart Disease, if the patient came back with Normal ECG Colonoscopy every 10 years given
results, Write Stat12 L ECG – DONE negative initial colonoscopy
If refused for any reason, fill up the “release of responsibility form” and indicate the Flexible sigmoidoscopy every 5-10 years
primary reason for refusing, then write STAT 12 L ECG – Refused, waiver signed. Lung Cancer Screening
LIST PRIORITY WORKUP FIRST BEFORE ROUTINE WORKUP. Smoking history (>10 pack years) Chest X-ray PAL
2. ROUTINE LAB WORKUP: All 55-80 years old with history of Annual screening with Low Dose CT Scan
12 L ECG, FBS, Lipid Profile, Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, smoking 30 pack years and currently
Creatinine, SGPT SGOT smoking or have quit within 15 years
Indications for routine workup
1. Obese at any age Preventive Medicines
2. 40 years old and above 1. Statins – 40-75 years old; >10% ASCVD Risk (Hypertension, Diabetes
3. Underweight at any age Mellitus, Dyslipidemia, Smoking)
For patients qualifying 1 and 2 Write “For Wellness: 12 L ECG, FBS, Lipid Profile, 2. Aspirin – 50-59 years old; CVD and Colorectal Ca
Blood Uric Acid, CBC with pc, UA, Na, K, Cl, BUN, Creatinine, SGPT SGOT 3. Immunizations
a. Anyone >55, Recommend PCV and influenza vaccine
Pre-Employment Workup. Adults 21-45 years old: accumulate 30-60 minutes of daily physical activity consisting
Routine: students, office, sales, etc.: CBC with PC, UA, Chest Xray PA-L of any one or a combination of the following activities. For fitness purposes, adults
Food handlers: CBC with PC, UA, Chest Xray PA-L, FA, Anti-HAV should work towards 20-30 minutes continuous physical activity for a minimum of three
For strenuous jobs: CBC with PC, UA, Chest Xray PA-L, 12-L ECG days per week
Employees above 35 years old: 12 Lead ECG
Activities of Daily Living Active travel
Exercise Prescription: - Walking
Formula: - Cycling
HRmax = 220-age - Stair climbing
Resting HR - average heart rate upon waking up on three consecutive mornings Active daily tasks
Target Heart Rate = [(HRmax – resting HR) x % intensity desired] + resting HR - Scrubbing/mopping floors
Level of fitness Intensity - Cleaning rooms
Light 50-60% - General carpentry
Moderate 60-70% - Fetching water in a pail
Vigorous 75-95% - Raking leaves
- Bathing dog
Per age: - Cleaning the car
Children 5-12 years old: at least 60 minutes of daily physical activity consisting of any - Rearranging household
one or a combination of the following activities: furniture
Exercise, Dance, and Recreational - Brisk walking
Active Daily Task Active travel Activities - Dancing
- Walking Goal: Moderate intensity aerobic - Cycling
- Cycling physical activity resulting in a - Swimming
- Stair climbing noticeable increase in heart rate and
Active daily task (household and school breathing continuously for a minimum
chores) of 30 minutes OR accumulated bouts
- scrubbing/ mopping floor of 10 minutes or longer
- fetching water in a pail For more active people with no risk - Jogging
- raking leaves factors, vigorous activity resulting in fast - Vigorous dancing
- bathing dog breathing and substantial increase in - Ballgames
- cleaning the car heart rate
- rearranging household Goal: done continuously and done at
furniture least three times a week with a future
goal of being able to do it 5-6 times
Exercise, Dance or Sports Sports Muscle Strengthening and Flexibility - Calisthenics
Goal: 20-30 minutes programmed Active games Activities - Stair Climbing
physical activity Goal: done at least thrice a week, non- - Weight training
High Impact Play (Unstructured - Running consecutive days
Spontaneous Play) - Jumping Activities in the Workplace - Walking
- Hopping Goal: two-minute physical activities for - Stair climbing
- Skipping every hour of sitting - Stretching
- Luksong tinik
- Patintero Older Adults 46-59 years old: accumulate at least 30 minutes daily physical activity
- Tumbang preso consisting of any one or a combination of the following activities
- Agawan base
- Stair climbing Activities for Daily Living Active Travel
- Playground activities - Walking
- Cycling
Adolescents to Young Adults 13-20 years old: at least 60 minutes of daily physical - Stair climbing
activity consisting of any one or a combination of the following activities: Active Daily Task (household cholres
Exercise, Dance, and Recreational - Brisk or race walking
Active Daily Task Active travel Activities - Dancing
- Walking Goal: Moderate intensity aerobic - Cycling
- Cycling physical activity resulting in a - Rowing
- Stair climbing noticeable increased heart rate and - Swimming
Active daily task (household and school breathing. Activities done continuously
chores) for a minimum of 30 minutes OR
- scrubbing/ mopping floor accumulated bouts of 10 minutes or
- fetching water in a pail longer
- raking leaves For more active people with no risk - Jogging
- bathing dog factors, vigorous activity resulting in fast - Vigorous dancing
- cleaning the car breathing and substantial increase in - Ball games
- rearranging household heart rate
furniture Goal: done continuously and done at
least three times a week with a future
Exercise, Dance or Sports (at least 40 Fitness-related goal of being able to do it 5-6 times
minutes programmed physical activities) Rhythmic activities Muscle Strengthening and Flexibility - Weight bearing calisthenics
Goal: continuous 20-30 minutes Sports activities Activities - Stair climbing
minimum for at least 3-5 times a week Goal: done at least thrice a week, - Weight training
High Impact Play (Unstructured - Brisk walking non-consecutive days
Spontaneous Play) - Jogging Balance and Coordination - Walking
Goal: at least 20 minutes of sustained - Indigenous games Goal: 2-4days/week - Gentle yoga
moderate to vigorous physical activities - Dancing - Tai-chi
resulting in rapid breathing - Dance
- Aquatic activities
Activities in the Workplace - Walking
Goal: two-minute physical activities for - Stair climbing
every hour of sitting - Stretching
Young Old 60-69 years old: at least 30 minutes daily physical activity consisting of any Vintage Old 80 years old and above
one or a combination of the different types of physical activities for the following:
Activities for Daily Living Active Travel
Activities for Daily Living Active Travel - Assisted walking and stair
- Walking climbing
- Cycling - Mild, easy daily tasks
- Stair climbing o Mild garden or yard
Active Daily Task (household chores work
and yard work) o Dusting furniture
Exercise, Dance, and Recreational - Moderate to brisk walking o Folding clothes
Activities - Dancing o Sweeping inside the
Goal: Moderate intensity aerobic - Cycling house
physical activity resulting in a - Calisthenics Exercise, Dance, and Recreational - Leisure walk around
noticeable increased heart rate and - Rowing Activities neighborhood, yard, living
breathing. Activities done continuously - Swimming Goal: Total of 20 minutes area
for a minimum of 30 minutes OR - Stair climbing continuously, three times weekly OR - Stationary biking
accumulated bouts of 10 minutes or accumulated bouts of 10 minutes or - Calisthenics
longer longer - Swimming
For more active people with no risk - Jogging, brisk or race Muscle Strengthening and Flexibility - Mild calisthenics
factors, low to moderate intensity walking Activities - Light weight training
activity resulting in fast breathing and - Vigorous dancing Goal: done at least twice a week, on - Elastic band exercises
substantial increase in heart rate - Step-aerobics non-consecutive days
Goal: done continuously for a - Swimming Balance and Coordination - Walking
minimum of 30 minutes, and done 3- Goal: at least three days per week - Gentle yoga
5x/week - Tai-chi
Muscle Strengthening and Flexibility - Body weight bearing - Slow Dancing
Activities calisthenics - Mild aquatic activities
Goal: done at least twice a week, non- - Stair climbing
consecutive days - Weight training WELL ADULT CHARTING:
Well-balanced diet
Balance and Coordination - Walking Adequate/Increase oral fluid intake
Goal: 2-4days/week - Gentle yoga Adequate rest and sleep
- Tai-chi Moderate intensity exercise 4-5x/week for 30 minutes
- Dance Follow-up schedule
- Aquatic activities Advised
Activities in the Workplace - Walking
Goal: two-minute physical activities for - Stair climbing PHARMACOLOGIC MANAGEMENT
every hour of sitting - Stretching Use standard format:
Generic name, stock dose, dosing, frequency, duration*.
Middle Old 70-79 years old USE OD, q8h for TID, q12h for BID, q6h for QID. NEVER USE, BID, TID, QID,
E.g. Co-amoxiclav 1 g/tab, 1tab q12 for 7 days
Activities for Daily Living Active Travel *No duration for maintenance medications
o Walking
o Assisted Stair climbing
Mild, easy daily Task (household NON-PHARMACOLOGIC MANAGEMENT
chores) SEE SAMPLE PLANS for other nonpharmacologic management
o Mild garden or yard work Smoker: Smoking cessation advised, patient in pre-contemplation stage, advised
o Dusting furniture patient that he can come back anytime if decided to quit.
o Folding clothes Fluid intake:
o Sweeping inside the house For well adults: Increase oral fluid intake.
Exercise, Dance, and Recreational - Leisurely walk around For CKD, CHF patients. Limit fluid intake to 1L/ day instead.
Activities neighborhood, parks, and Activity: Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for
Goal: Total of 30 minutes malls healthy patients who you think can tolerate exercise)
continuously, three times weekly OR, - Stationary biking DIET PLAN (compute for all Obese, DM and Hypertensive patients)
accumulated bouts of 10 minutes or - Calisthenics
longer - Swimming HOW TO COMPUTE FOR THE DIET PRESCRIPTION
For more active people with no risk - Walking 1. Ideal body weight using Tanhauser method.
factors, low to moderate intensity of - No impact aerobic dancing (Height in cms – 100) X 0.9 =
aerobic activity resulting in slight - Social dancing Eg. (169 – 100) = 69 X 0.9 = 62.1 kgs
elevation of breathing rate and heart - Swimming 2. Total Caloric Requirement = IBW X Activity factor
rate Activity factor
Goal: done continuously and done at 25 for bedridden, 30 for sedentary, 35 for moderate activity, 40 for strenuous.
least 30 minutes, and done three 3. Distribution:
days per week, on non-consecutive CHO: TC x 0.6, CHON: TC x 0.15, Fat: TC x 0.25
days
Muscle Strengthening and Flexibility - Mild calisthenics Sample Diet plan Order
Activities - Light weight training Refer to Nutrition Clinic for a diet plan
Goal: done at least thrice a week, on - Elastic band exercises Diet: E.g. Low Salt, Low Fat, and/or DM Diet (specific)
non-consecutive days TC: 1539, CHO: 923, CHON: 231, Fat: 385
Balance and Coordination - Walking If the patient already had a diet plan from nutrition clinic write:
Goal: 2-4days/week - Gentle yoga “Continue diet plan C/O Nutrition Clinic”
- Tai-chi If the patient has previous diet prescription but still unable to go to Nutrition clinic write:
- Dance “Still for Nutrition clinic referral”
- Aquatic activities
REFERRALS
Refer to <Department> for further evaluation and co-management.
NEVER write refer to <department> for Clinical abstract.
Refer to Ophthalmology for officia fundoscopy (all New DM and Hypertensive patients)
Refer to Ophthalmology for annual fundoscopy (for previously screened old patients)
Refer to HACT for counselling and testing (all urethritis and other STI’s) Follow up ASAP with For follow up laboratories
Refer to GI for possible colonoscopy results
Refer to Nutrition Clinic for Diet Plan: Write type of Diet (DM, DASH, Low purine, low
salt, low fat, low calorie etc) and for Obese or underweight compute diet prescription Follow up after 2 For Viral Exanthem T/C Varicella, Herpes zoster
HACT means HIV-AIDS Core Team. But writing “HIV” or “AIDS” on patient’s charts or weeks once lesions
requests is taboo so we use HACT instead. have DRIED
Follow up once seen For patients referred to other departments
Admissible Cases at the ER by <insert
- Hypertensive Urgency SBP > 180mmHg or DBP >120mmHg refractory despite department>
rest and giving maintenance medications, ask the patient to rest and take BP after
15 minutes, if still elevated, give long-acting oral anti-hypertensives(ARBS or NEVER WRITE ON THE CHART “FF UP ONCE WITH RESULTS” or “To come
ACEis) then re-check after 15 minutes, if still elevated, give CCBs then recheck, back”
is still elevated, ask assistance to Resident for coordination to ER (if not available, NEVER FORGET TO GIVE A PATIENT A FOLLOW UP CARD.
ask patient’s relative to buy Irbesartan 150mg/tablet or Telmisartan 40mg/tablet at Ask the patient to always bring the follow up card and his/her Hospital ID ”green”
the Pharmacy; if no companion, ask for assistance of a resident) Card.
- Hypertension with signs of end-organ damage (vascular and hemorrhagic stroke, IF IN DOUBT, USE 3 DAYS FOLLOW UP
retinopathy, myocardial infarction, heart failure, proteinuria and renal failure) ADVISED (always end your charting with it.)
- Congestive Heart Failure NYHA III or IV with unstable vital signs and has overt
signs of congestion (anasarca, rales, distended neck veins, difficulty of breathing) AT THE END OF EVERY PLAN DO NOT FORGET THE FOLLOWING:
- Community-Acquired Pneumonia, Moderate Risk and High Risk YOUR FULL NAME AND SIGNATURE
- Dengue with Warning Signs (No urine output for the past 6 hours, active bleeding, TIME RECEIVED
hypotension) TIME INTERVIEWED
- Leptospirosis moderate-severe (acute febrile illness, unstable vital signs, icteric TIME REFERRED TO THE RESIDENT
sclera or jaundice, abdominal pain, nausea, vomiting and diarrhea,
TIME DISCHARGED: TIME THE RESIDENT WAS FINISHED SEEING THE PATIENT.
oliguria/anuria, meningeal irritation, sepsis/septic shock, altered mental status,
EXCLUDE THE TIME YOU USED TO CORRECT AND CARRY OUT CORRECTED
difficulty of breathing, hemoptysis)
PATIENT PLANS.
- COVID-19, Suspect, Severe or Critical (with unstable vital signs, same signs and
symptoms with CAP-MR, difficulty of breathing)
- Bronchial Asthma in Acute Exacerbation refractory despite given three
PATIENT FOLLOW UPS
nebulizations and chest physiotherapy
Always review previous charting.
- Symptomatic Anemia (anemia with laboratory evidence with symptoms of pallor,
SOAP format
dyspnea, easy fatigability, lightheadedness); Anemia with evidence (CBC
<80mg/dl)
Subjective:
- Psychiatry patients with evidence of self-harm and violent behavior towards
Review previous complaints if still existing, progressing, regressing or resolved.
others, with suicidal ideations and concrete suicide plan
Ask for new symptoms/ Differential symptoms, Pertinent Negatives.
- Diabetic Ketoadcidosis/ Hyperglycemic Hyperosmolar State – CBG greater than
Ask for compliance to new/ current medications.
300 (?)
- Chronic Kidney Disease with signs of Uremia (nausea and vomiting, dizziness,
Objective
abdominal pain) and signs of fluid overload (anasarca, difficulty of breathing,
PE as per previous charting. NOTE ANY CHANGES.
decreased breath sounds)
Patient came in with laboratory results.
- Cerebrovascular Disease in evolution: acute presentation of slurring of speech,
Check for completion of laboratories, write the results legibly,
one-sided weakness, facial asymmetry, seizures, syncope, nausea and vomiting,
Use the mg/dl unit in writing lab results on the chart.
headache, dysarthria
Use MDCALC app on Android/IOS device
- Seizures
- Angina if with Creatinine, always compute for EGFR using CKD-EPI calculator and if
EGFR is Less than 60 (Categorize as CKD Stage __ or AKI)
compute for BUN/Creatinine Ratio. (Normal 12-20)
Same-Day Referrals Protocol if with Lipid profile, always compute for ASCVD risk score.
1. Confirm to the resident if the patient needs to be referred today. Assessment: note the NEW DIAGNOSIS if any, followed by the PREVIOUS
2. If confirmed, complete the charting, prescriptions, laboratory or imaging request, DIAGNOSIS.
and referral letter for the department. Add RESOLVING if patient is clinically improving.
3. Have the Census encoder take a picture of the chart. Add RESOLVED if patient’s symptoms have resolved.
4. Bring the patient and the chart to the receiving department and endorse the chart
to the nurse/intern on duty. Plan: Review previous and rewrite unless the resident in decides to change, shift, or
5. Ask the patient to wait for his/her name to be called at the department. discontinue current medications.
6. Ask the patient to come back to us once done with that department’s consultation.
7. Ask for updates regarding diagnostics, medications and possible surgical Patients for Clinical Abstract/ Medical Certificate.
procedures 1. Write in a sheet of small piece of paper the document (Clinical Abstract or Medical
Certificate) the patient needs.
REFERRED FROM: THIS ARE PATIENT’S THAT WAS REFERRED TO OUR 2. Ask the patient to proceed to the nurse’s station (in front of the elevator) to get the
DEPARTMENT FOR FURTHER EVALUATION AND MANAGEMENT: order of payment.
Write: Patient was referred from, <department>, advised to continue follow up with 3. Present Order of Payment and pay at the cashier (located at the underground of
<department> for continuity of care. And always write SOAP on the Referral Letter main building).
4. Ask the patient to bring the receipt back to the nurse’s station.
FOLLOW UP 5. Either the nurses or the Nurse assistant will bring the document to us.
Follow up after 3 for those in pain, infectious, started on antibiotics, (if you 6. Fill up the document as legibly as possible. Avoid erasures and spelling errors
days are not sure when to follow up its safe to use 3 days) particularly the patient’s name, address, and diagnosis. Use permanent ink in filling
for Chronic diseases like DM, HTN, CKD up the form to prevent scammers from abusing the document.
Follow up after 1
7. Have the resident on duty sign the document
week
SAMPLE PLANS
Respiratory Disorders
Community Acquired Pneumonia-Low Upper Respiratory Tract Infection Presumptive Pulmonary Bronchial Asthma, controlled or
Risk probably Viral Tuberculosis, Pulmonary uncontrolled not in acute
Cough >24 hours <2 weeks <Imaging/routine labs if indicated> Tuberculosis exacerbation, or COPD not in acute
Other constitutional signs and symptoms For non-hypertensive patients: Clinically/Bacteriologically Diagnosed exacerbation
Pulmonary auscultation findings Phenylephrine + paracetamol 10 Regimen I/II Treatment, __Month History of respiratory symptoms
Stable vital signs mg+500 mg/tab 1-tab q8 as needed for (Institution, Date Diagnosed) - wheeze, shortness of breath,
- RR < 30/min colds. For patients 15 years old and above, a chest tightness and cough
- PR <125/min For hypertensive patients: presumptive TB has any of the following: - vary over time and in intensity
- SBP >90 mmHg Gentinae radix et al. 6 mg/ tab 1-tab q8 Cough of at least 2 weeks duration - worse at night or on walking
- DBP >60 mmHg as needed for colds. with or without the following symptoms: - triggered by exercise, laughter,
- Temp >36C or <40C If bacterial: - Significant and unintentional weight allergens or cold air
No or Stable co-morbids Co-Amoxiclav 625 mg/tab 1-tab q8 for loss; Variable expiratory airflow limitation
No suspected aspiration 7 days. - Fever; Wheezing on auscultation especially on
No altered mental state of acute onset If with allergic component: - Bloody sputum (hemoptysis); forced expiration
Chest Xray Cetirizine 10 mg/tab, 1-tab once a day - Chest/back pains not referable to Spirometry with Bronchoprovocative test
- Localized infiltrates at bedtime for 1 week or any musculoskeletal disorders; (aka Metacholine Test)
- No pleural effusion Loratadine 10 mg/tab 1-tab once a day - Easy fatigability or malaise; Night <Imaging/routine labs if indicated>
For Chest Xray PAL for 1 week sweats; Reliever:
<Routine labs if indicated> If with dry cough - Shortness of breath or difficulty of Salbutamol 100 mcg/actuation
Co-amoxiclav 1g/tab 1-tab q12 for 7 Butamirate 50 mg/tab 1-tab every 8 breathing. Metered Dose Inhaler, 1-2 puffs Q8 for
days or hours a day as needed For Chest X-ray PAL / CXR Apicolordotic as needed for 3 days.
Cefuroxime 500 mg/tab 1-tab q 12 for view Salbutamol nebules, nebulize with 1
7 days If with allergic component: Allergen For Sputum GeneXpert nebule as needed for shortness of
And or Identification and avoidance. <Cough Meds if indicated> breath, may nebulize up to 3 times 15
Azithromycin 500 mg/tab 1-tab once a Proper cough etiquette, droplet 1. Plan to initiate anti-Koch’s minutes apart for 3 days
day for 3 days precaution, increase oral fluid intake treatment if with conclusive results Controller:
If with tenacious cough: Recommended pneumococcal and 2. N-Acetylcysteine 600mg/sachet Budesonide + Formoterol 160mg+4.5
N-Acetylcysteine 600mg/sachet influenza vaccines (age dependent) dissolve 1 sachet in 100 ml of water mcg MDI, 1 puff Q12 or
dissolve 1 sachet in 100 ml of water Follow up after 3 days. and drink once a day at bedtime for Salmeterol + Fluticasone 50+250 mcg
and drink once a day at bedtime or Advised. symptomatic relief of cough Metered Dose Inhaler, 1 puff Q12
Carbocisteine 500mg/tab 1-tab q8 as Proper cough etiquette, airborne Fluticasone furoate + Vilanterol
needed for tenacious cough precaution, trifenatate 100/200 mcg/25 mcg DPI, 1
Proper cough etiquette, droplet Encouraged screening of household puff once a day
precaution members Identify potential allergens, allergen
Increase oral fluid intake Refer to TB DOTS for GeneXpert, avoidance, hypoallergenic diet, proper
Recommended pneumococcal and evaluation, co-management cough etiquette, droplet precaution,
influenza vaccines (age dependent) Follow up ASAP once with result increase oral fluid intake
Follow up after 3 days Advised Recommended pneumococcal and
Advised influenza vaccines (age dependent)
Procedure done: Demo use of
metered dose inhaler / rotahaler /
asthma device
Follow up after 3 days
Advised
Acute Tonsillopharyngitis probably Allergy (Allergic Rhinitis, Allergic COPD, COPD suspect COVID suspect, mild/moderate
bacterial Cough) -Dyspnea at rest or with exertion For SARS-CoV-2 RT-PCR testing
Start Co-Amoxiclav 625 mg/ tab 1-tab Classify Allergic Rhinitis based on the -Chronic cough with or without sputum For CXR-PAL
Q8 for 7 days ARIA Guidelines: -History of Wheezing
<Routine labs if indicated>
Paracetamol 500 mg/ tab 1-tab q4 as Risk Factors:
Cetirizine 10 mg/tab, 1 tab once daily
needed for Fever > 37.8 -Older than 35 years old with significant
May gargle with Chlorhexidine oral smoking history at bedtime for 5 days
solution 3x a day after meals. -Alpha-antitrypsin deficiency Butamirate 50mg/tab, 1 tab every 8
Cold soft diet -History of Significant exposure to indoor hours for 5 days
Increase oral fluid intake <Routine labs if indicated> or outdoor air pollution, occupational N-Acetylcysteine 600mg/sachet,
Refer to ENT-OHNS for further Cetirizine 10 mg/tab, 1-tab once a day at dusts, or chemicals dissolve 1 sachet in 1/2 glass water
evaluation and management (If with bedtime for 1 week or -Smoking history of >40 pack years
and drink for 5 days
Hypertrophic tonsils) Loratadine 10 mg/tab 1-tab once a day Spirometry with Bronchoprovocative test
Follow up after 3 days (Metacholine Test) Well-balanced diet
for 1 week
Advised <Routine labs if indicated> Increase oral fluid intake to 2.5L/day
Hypoallergenic diet
Increase oral fluid intake Salbutamol + Ipratropium bromide Adequate rest and sleep
Allergen Identification and avoidance. nebules, nebulize with 1 nebule up to Moderate intensity exercise 5x a week,
Avoid exposure to cigarette smoke, pets, 3 doses 15 minutes apart as needed 30 minutes a day
and known allergens for shortness of breath then Q8 for 3- Home isolation for 7 days (Inquire about
Recommended pneumococcal and 5 days COVID immunization status)
influenza vaccines (age dependent) Start Indacaterol + Glycopyrronium
110/50 mcg/actuation, 1-2 puffs once Habilin form issued
a day Refer to LGU/BHERT for monitoring of
Advised
Identify potential allergens, allergen symptoms during isolation period
avoidance, hypoallergenic diet, proper COVID-19 minimum infection protocols:
cough etiquette, droplet precaution, droplet precaution, proper cough
increase oral fluid intake etiquette, wear mask at all times,
Recommended pneumococcal and
practice social distancing, regular hand
influenza vaccines (age dependent)
Procedure done: Demo use of hygiene
metered dose inhaler / rotahaler / Recommend influenza and
asthma device pneumococcal immunization once
Follow up after 3 days current infection is resolved
Advised WOF: Difficulty of breathing, O2
saturation <94%, worsening of
symptoms, may proceed to ER for
assessment
Follow-up after 3 days or anytime earlier
if with problems via telemedicine
Advised
COVID, Suspect, Severe are referred

to ERO for further evaluation
Cardiovascular disorders
Hypertension/HCVD Congestive Heart Failure ACCF/AHA Stage___ Typical/ Atypical Angina Pectoris rule out Ischemic
12 L ECG, FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, NYHA Class ____ Heart Disease
BUN, Crea, SGPT SGOT, TSH (if indicated) CHEST PAIN PROTOCOL
2D echo with doppler studies for HCVD FOR PATIENTS >40 YRS. OLD WITH CHEST PAIN,
Chest Xray PAL if indicated DO NOT COMPLETE THE CHART YET AND REFER
Irbesartan 150 or 300 mg/tab, 1-tab once a day THE PATIENT RIGHT AWAY TO THE RESIDENT ON
Telmisartan 40 or 80 mg/tab 1-tab once a day DUTY. DO HEART SCORE USING MDCALC AND
Losartan 50 or 100 mg/tab, 1-tab once a day or q12 THE ROD WILL DECIDE IF PATIENT IS FOR STAT 12
Amlodipine 5 or 10 mg/tab, 1-tab once a day (watch L ECG OR IMMEDIATE ER REFERRAL.
out for signs of edema) If patient came back with 12 L ECG strip photocopy
Strict compliance with medications within the day, write STAT 12 L ECG done.
Daily BP monitoring and record If patient refuses due to any circumstance, have the
Advised smoking cessation (if present) 12 L ECG, FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, patient signed Release of Responsibility Form and
Moderate to vigorous activity 3-4days/week averaging iCa, BUN, Crea, SGPT SGOT indicate the reason for refusal. Then write,
40 minutes per session 2D echo with doppler studies STAT 12 L ECG/ ER referral refused; waiver signed.
(If newly diagnosed HTN), Patient education on Chest Xray PAL For FBS, LP, BUA, CBC with PC, UA, Na, K, Cl, BUN,
hypertension, risk factors, compliance to medications, BNP, TSH Crea, SGPT SGOT
complications ARBS 2D echo with doppler studies
(If normal BMI) Maintenance of normal BMI Losartan 50 or 100 mg/tab, 1-tab once a day, q12 Chest Xray PAL
Encourage participation of patient and family members Irbesartan 150 or 300 mg/tab, 1-tab once a day Isosorbide Mononitrate 30 mg/tab 1-tab once a day
to community intervention programs Telmisartan 40 or 80 mg/tab 1-tab once a day Isosorbide Dinitrate 5 mg/ tab 1-tab sublingual as
Refer to Nutrition Clinic for a diet plan Betablocker needed for chest pain, may repeat up to 3 doses 15
Diet: Low Salt, Low Fat Diet, DASH (Dietary Carvedilol 6.25 mg/ tab half tab q12 minutes apart.
Approaches to Stop Hypertension) For asthmatics: Clopidogrel 75 mg/tab 1-tab once a day
Habilin Form Given Metoprolol Succinate 100 mg/tab 1 -tab once a day Atorvastatin 40 mg/tab 1-tab once a day at bedtime
TC: 1539, CHO: 923, CHON: 231, Fat: 385 Bisoprolol 5 mg/tab 1-tab once a day Watch out for chest pain not relieve by ISDN, advised to
Refer to Ophthalmology for official fundoscopy Atenolol 50 mg/tab 1-tab once a day go to ER if unrelieved after 30 minutes.
Follow up after 1 week If indicated: Watch out for severe headache may be a side effect of
Advised Atorvastatin 40mg/tab 1-tab once a day at bedtime nitrates. Follow up ASAP if with headache.
Hypertension suspect (single episode of BP >140/90 Antiplatelets Daily BP monitoring and record
mmHg in patients <60, 150/90 in patients ≥60 yrs. Aspirin 80 mg/tab 1-tab once a day or Fall precaution: Avoid sudden standing. Dangle legs at
old) Clopidogrel 75 mg/ tab 1-tab once a day the edge of the bed, if with no lightheadedness, may
No meds for now Strict compliance with medications stand up carefully.
Daily BP monitoring and record Daily BP monitoring and record Follow up after 3 days.
Refer to Nutrition Clinic for a diet plan Limit Fluid intake to 1 L/ day Advised
Diet: Low Salt, Low Fat Diet Refer to Nutrition Clinic for a diet plan
Habilin Form Given Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385 TC: 1539, CHO: 923, CHON: 231, Fat: 385
Follow up after 1 week with BP monitoring record. (NYHA Class III-IV) Refer to IM-Cardiology for
Advised further evaluation and management
Follow up after 3 days or once seen by IM
Advised
Gastroenterology Disorders
Dyspepsia/GERD/Laryngopharyngeal Reflux, ask HAVENBARP
H – Heartburn B – Bloatedness
A – Anorexia A – Abdominal pain
V – Vomiting R – Reflux/Regurgitation
E – Early Satiety P – Postprandial pain
N – Nausea
Dyspepsia with alarm features Dyspepsia without Alarm features, Gastroesopphageal Reflux disease
- >50 years old if 40 years old and above ALWAYS if 40 years old and above ALWAYS
- Family History of upper GI malignancy Rule out ACS if the setting of symptoms is acute Rule out ACS if the setting of symptoms is acute
- Unintended weight loss (days) warrants immediate ER referral (days) warrants immediate ER referral
- GI bleeding or Iron deficiency Anemia Rule out IHD if the setting of symptoms is Rule out IHD if the setting of symptoms is chronic
- Progressive Trouble Swallowing chronic (weeks to months) (weeks to months)
- Pain in swallowing ABDOMINAL PAIN PROTOCOL ABDOMINAL PAIN PROTOCOL
- Persistent vomiting FOR PATIENTS >40 YRS. OLD WITH FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL
- Palpable mass or lymphadenopathy ABDOMINAL PAIN, DO NOT COMPLETE THE PAIN, DO NOT COMPLETE THE CHART YET AND
- Jaundice CHART YET AND REFER THE PATIENT RIGHT REFER THE PATIENT RIGHT AWAY TO THE
Still follows ABDOMINAL PAIN PROTOCOL AWAY TO THE RESIDENT ON DUTY. THE ROD RESIDENT ON DUTY. THE ROD WILL DECIDE IF
ABDOMINAL PAIN PROTOCOL WILL DECIDE IF PATIENT IS FOR STAT 12 L PATIENT IS FOR STAT 12 L ECG OR IMMEDIATE ER
FOR PATIENTS >40 YRS. OLD WITH ABDOMINAL ECG OR IMMEDIATE ER REFERRAL. REFERRAL.
PAIN, DO NOT COMPLETE THE CHART YET AND If patient came back with 12 L ECG strip If patient came back with 12 L ECG strip photocopy
REFER THE PATIENT RIGHT AWAY TO THE RESIDENT photocopy within the day, write STAT 12 L ECG within the day, write STAT 12 L ECG done.
ON DUTY. THE ROD WILL DECIDE IF PATIENT IS FOR done. If patient refuses due to any circumstance, have the
STAT 12 L ECG OR IMMEDIATE ER REFERRAL. If patient refuses due to any circumstance, have patient signed Release of Responsibility Form and
If patient came back with 12 L ECG strip photocopy the patient signed Release of Responsibility indicate the reason for refusal. Then write
within the day, write STAT 12 L ECG done. Form and indicate the reason for refusal. Then STAT 12 L ECG/ ER referral refused; waiver signed.
If patient refuses due to any circumstance, have the write FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN,
patient signed Release of Responsibility Form and STAT 12 L ECG/ ER referral refused; waiver Crea, SGPT SGOT
indicate the reason for refusal. Then write signed. Omeprazole 40 mg/cap, 1 cap once a day 30 minutes
CBC with PC, Fecal Immunochemical Test c/o Gastro, FBS, LP, BUA, CBC with pc, UA, Na, K, Cl, BUN, before breakfast for 8 weeks
T, H. pylori stool antigen test. Crea, SGPT SGOT Avoid spicy, acidic, fatty, and caffeinated food and
<Routine labs if indicated> Omeprazole 40 mg/cap, 1 cap once a day 30 beverages, Small frequent meals, avoid skipping of
Omeprazole 40 mg/cap, 1 cap once a day 30 minutes minutes before breakfast for 2-4 weeks meals.
before breakfast for 4 weeks Avoid spicy, acidic, fatty, caffeinated food and Maintain upright position 2-3 hours after meals.
Dysmotility-like dyspepsia: Domperidone 10 mg/tab 1 tab q beverages Follow up after 3 days
8 as needed for abdominal pain Small frequent meals, avoid skipping of meals Advised
Avoid spicy, acidic, fatty, and caffeinated food and Follow up after 3 days
beverages, small frequent meals, avoid skipping of meals. Advised
Refer to IM-Gastro for possible endoscopy
Advised
Hemorrhoids (Internal or External) only Internal Acute Gastroenteritis without signs of Biliary cholic to consider Cholelithiasis
Hemorrhoids have grading system dehydration For Hepatobiliary Tree ultrasound,
- Always inspect to rule out thrombosed which For Fecalysis (if indicated: hematochezia) <Routine labs if indicated>
hemorrhoids which may warrant urgent consult Racecadotril 100 mg/tab 1-tab q8 until 2 consecutive Start Domperidone 10 mg/tab 1 tab q 8 as needed for
Diagnostics: none formed stools abdominal pain
Pharmacologic: ORS sachet dissolve in 200 ml of clean water and or Hyoscine n-butylbromide 10 mg q8 as needed for
1. Diosmin/Hesperidin 500mg/tablet 2 tablets drink 1 sachet for every bout of loose stool pain.
three times a day for 4 days, 2 tablets twice a Proper handwashing, proper food preparation. Avoid fatty food.
day for 3 days, 2 tablets once a day for 7 days WOF weakness, drowsiness, persistent vomiting, Watch out for fever, right upper quadrant pain.
for a total of 14 days decreased urination. Small frequent meals.
Nonpharmacologic: Follow up after 3 days. Follow up after 3 days
1. Warm sitz bath three times a day or as needed Advised
for 15 minutes
2. Soft, high fiber diet
3. Avoid straining
4. Increase oral fluid intake
Refer to General Surgery for further evaluation and co-
management
Follow-up once seen by General Surgery
Advised
Functional Constipation/ Primary Constipation R/O H. pylori infection Intra-abdominal Mass to consider or rule out
Large bowel Obstruction. - appropriate for patients with dyspepsia and low risk malignancy
Types: gastric cancer (younger than 55, no alarm symptoms - History and PE pointing to malignancy
1. Normal Transit constipation such as weight loss, progressive dysphagia, - PE findings of palpable mass anywhere in
2. Slow transit constipation odynophagia, recurrent vomiting, family history of GI the GI area
3. Disorders of defecation cancer, overt GI bleed, abdominal mass or IDA, or - Strong family history
2 or more for over 3 months: jaundice) - Identify risk factors
1. Fewer than three spontaneous bowel
movements per week Diagnostics:
2. Straining during at least 25% of defecations - Endoscopy for >55 or who have alarm
3. Lumpy or hard stools in at least 25% of symptoms
defecations PPI should be stopped for 2 weeks prior to:
4. Sensations of incomplete evacuation for at - H. pylori stool antigen test (c/o GI)
least 25% of defecations attempts - Urea breath test
5. Sensation of anorectal obstruction or blockage Pharmacologic:
for at least 25% of defecation attempts First Line:
6. Manual maneuvering required to defecate of r 1. PPI + Amoxicillin 1g + Clarithromycin
at least 25% of defecation attempts twice a day for 7-14 days
Imaging: Scout Film of the Abdomen, FIT or FOBT 2. PPI + Clarithromycin 500mg +
<Routine labs if indicated> Metronidazole 500mg twice a day for
Pharmacologic: Choose one and remember the MOA and 10-14 days
apply in accordance to patient needs 3. PPI + Amoxicillin 1g twice a day for 5
1. Polyethylene Glycol 17 g/ sachet dissolve in days then followed by PPI +
120 ml of water and drink once a day. Clarithromycin 500mg + Tinidazole
2. Psyllium powder 1 tsp or 1 packet once to 500mg or Metronidazole 500mg twice
thrice a day a day for another 5 days for a total of
3. Lactulose 15-30mg/day) 10 days
4. Magnesium hydroxide suspension 30-60ml/day
5. Docusate 100mg/tablet 1 tab twice a day
6. Bisacodyl 5-15mg/day
7. Senna tablet 15mg/tablet per day
Nonpharmacologic:
- Schedule toileting after meals
- Exercise
- Increase oral fluid intake (20-35g/day)
- Increase fiber intake
Follow up after 3 days.
Advised
Genitourinary/ Nephrology Disorders
Acute Uncomplicated Cystitis Complicated Urinary Tract Infection Urinary Tract Infection in Male Urethritis/Gonococcal Vaginitis
(pre-menopausal women, no prior history Acute pyelonephritis High risk sexual behavior [Z72.5]
of UTI within 2x in 6 mos, or 3 in 1 year) UA, Urine GSCS UA, Urine GSCS - Unprotected intercourse
No need for Urinalysis <Routine labs if indicated> <Routine labs if indicated> - Intercourse under influence
<Routine labs if indicated> Start one Start one of substances
Ideally for Nitrofurantoin as 1st line Ciprofloxacin 500 mg/tab 1-tab q12 for Ciprofloxacin 500 mg/tab 1-tab q12 for - Multiple sexual partners
treatment but patient opted for cheaper 7-10 days* 7-10 days - Intercourse with persons
drug Levofloxacin 250 mg/tab 1-tab once a Levofloxacin 250 mg/tab 1-tab once a with injecting drug use
Start one day for 7-10 days day for 7-10 days - Early age of initiation of
Cefuroxime 500 mg/tab 1-tab q 12 for Ofloxacin 400 mg/tab 1-tab once a day Ofloxacin 400 mg/tab 1-tab once a day intercourse (WHO before 15
7 days* for 5 days for 5 days years old)
Cefaclor 500 mg/tab 1-tab q8 for 7 Cefixime 400 mg/tab 1-tab once a day Cefixime 400 mg/tab 1-tab once a day - Engaging in unnatural and
days for 14 days for 14 days unprotected sex
Cefixime 200 mg/tab 1-tab q12 for 7 Increase oral fluid intake 2-2.5 L/day, Increase oral fluid intake greater than 2- - Intercourse with female sex
days proper perineal hygiene (for women 2.5 L/day workers/ paid sex/ casual
Ofloxacin 200 mg/tab 1-tab q12 for 3 only), avoid delays in voiding Avoid delays in voiding sex
days Follow up after 3 days Follow up after 3 days
Ciprofloxacin 250 mg/tab 1-tab q12 for Advised Advised Urethral Discharge GS/CS, UA, HBSAG,
3 days RPR, HACT
Levofloxacin 250 mg/tab 1-tab q12 for Recurrent UTI Ceftriaxone 250 mg TIM as a single
3 days -healthy non-pregnant woman with no known urinary tract abnormalities dose ANST (-)
Co-Amoxiclav 625 mg/tab 1-tab q12 -has 3 or more episodes of acute uncomplicated cystitis documented by urine culture PLUS
for 7 days during a 12-month period OR 2 or more episodes in a 6-month period. Doxycycline 100mg/tab 1-tab q12 for 7
Well-balanced diet days Avoid prolong sun exposure during
Increase oral fluid intake 2-2.5 L/day Urine GSCS prior to initiation of empiric antibiotics doxycycline treatment <if will be taking
Proper perineal hygiene <Routine labs if indicated> doxycycline>
Avoid delays in voiding OR
Follow up after 3 days Any of the antibiotics for acute uncomplicated cystitis may be used in the treatment of Azithromycin 500 mg/tab 2 tabs as a
Advised individual episodes of UTI in women with recurrent UTI. single dose (for better compliance)
Breakthrough infections during prophylaxis should be treated empirically with any of Alternative:
the antibiotics recommended for uncomplicated cystitis other than the antibiotic being Cefixime 400mg/tab PO single dose +
given for prophylaxis. Request for a urine culture and modify the treatment Azithromycin 1g PO single dose
accordingly. Allergy to Cephalosporins:
Gemfloxacin 320mg/tablet PO single
dose + Azithromycin 1g PO single
dose
OR
Gentamicin 240mg IM single dose +
Azithromycin 1g PO single dose
Avoid delays in voiding. Increase oral
fluid intake greater than 2.5 L/day,
Counselling done: increased patient ‘s
awareness on high risk activities, sexual
abstinence during treatment, encourage
sexual partner screening, and use
protective contraception (condoms)
Refer to HACT for further counselling
Increase oral fluid intake 2-2.5 L/day, proper perineal hygiene (for women only), avoid and testing
delays in voiding Follow up after 3 days
Follow up after 3 days Advised
Advised
Benign Prostatic Enlargement with End-Stage Renal Disease secondary Nephrolithiasis (confirmed by UTZ) To consider CKD Stage III -V
(Mild/Moderate/Severe Lower urinary to Chronic Glomerulonephritis or For UA (EGFR less than 60 mL/min/1.73m2)
tract Symptoms. Hypertensive Kidney Disease or Medical Expulsion therapy: Repeat Creatinine,
Use IPSS scoring Diabetic Kidney Disease Tamsulosin 0.4 (400mcg) mg/tab 1-tab Spot Urine Protein/Creatinine Ratio or
For KUBP Ultrasound, PSA Continue Hemodialysis (frequency)/ once a day 24-hour urine protein
<Imaging/routine labs if indicated> week Sambong tablet 1-tab q8h for 1 month Na, K, Cl, Ca, Mg, Ph,
Start Tamsulosin 0.4 (400mcg) mg/tab 1- Continue Medications: K citrate 1080 mg/tab 1-tab Q8 for 1 KUB Ultrasound with Doppler studies
tab once a day <Insert maintenance medications here> month Refer to Nutrition Clinic for a diet plan
Or Tamsulosin + Finasteride 0.4/5 Renal diet Increase oral fluid intake Diet: Low Salt
mg/tab 1-tab once a day (for Prostate Limit fluid intake to less than 1L/day Low salt diet TC: 1539, CHO: 923, CHON: 231, Fat:
greater than or equal to 40g in Strict compliance with medications Refer to Urology for further evaluation 385
ultrasound) Daily BP monitoring and record and management (for stones greater For possible referral to IM and
Decrease oral fluid intake at bedtime. Refer to Nutrition Clinic for a diet plan than 5 mm) Nephrology once with conclusive
Avoid delays in voiding Diet: Low Salt, Low Fat Diet Follow up after 1 month or anytime if with results.
Procedure done: Digital rectal TC: 1539, CHO: 923, CHON: 231, Fat: problems Follow up ASAP with results.
examination and prostate examination 385 Advised
Plan to refer to Urology for further Clinical abstract given and patient
evaluation once with results. referred to Social Services
Follow up after 1 week Refer to IM-Nephro for further
Advised evaluation and co-management.
Referral form given! <Impt because
some patients claim they were not given
referral letters)
Follow up with IM-Nephro
Advised
Neurology Disorders
Red Flag Signs for Acute Headache (always ask and check)
1. First or worst headache of patient’s life
2. Focal neurologic signs
3. Headache triggered by cough or exertion, or while engaged in sexual intercourse
4. Headache with change in personality, mental status, level of consciousness
5. Neck stiffness or meningismus
6. New onset of severe headache in pregnancy or postpartum
7. Older than 50 years old
8. Papilledema
9. Rapid onset with strenuous exercise
10. Sudden onset (maximal intensity occurs within seconds to minutes) thunderclap headache
11. Tenderness over temporal artery
12. Worsening pattern
13. New headache type in a patient with: Cancer, HIV, Lyme disease
Benign Paroxysmal Positional Vertigo S/P Cerebrovascular accident / Transient Bell’s Palsy rule out Cerebrovascular Acute Headache to consider Tension or
Rotatory: Always do HINTS (Head Ischemic Attack accident Migraine Headache with/without aura
Impulse, Nystagmus, Test of Skew) exam Limitation of activities due to disability For plain cranial CT scan Physical and mental strain [ Z73.3] if
before Dix-Hallpike Manuever [Z73.6] <Imaging/routine labs if indicated> there is any identifiable source of strain.
<Imaging/routine labs if indicated> Plain CT Scan/ MRI ask the resident in Start Prednisone 20 mg/ tab 1-tab q8h for 5 If with indication (Danger Signs):
Start Betahistine 24 mg/tab 1-tab q12 for 2 charge days then Cranial CT Scan with IV contrast
weeks <Imaging/routine labs if indicated> Prednisone 20 mg/ tab 1-tab q12h for 3 days <Imaging/routine labs if indicated>
Avoid sudden head movements Aspirin 80 mg/tab 1-tab once a day or then Celecoxib 200 mg/ tab, 1-tab q12 for 5
May do Anti-vertigo exercise (Semont Clopidogrel 75 mg/ tab 1-tab once a day Prednisone 20 mg/ tab 1-tab once a day for days
maneuver) with caution. Atorvastatin 40 mg/tab 1-tab once a day at 2 days Etoricoxib 60 or 90 mg/tab 1-tab once a
Fall precaution: bedtime Dextran+Hydroxypropyl methylcellulose day for 5 days
Observe for spinning sensation prior to Continue current medications (list down with eyedrops apply on affected eye every 3-4 Paracetamol + Orphenadrine 650+50
standing up. correct prescription format) hours. mg/tab, 1-tab q8 as needed for pain for 5
Betahistine may cause drowsiness so avoid Strict compliance with medications Tape affected eye to close during sleep. days or
risky activities such as driving or handling Daily BP monitoring and record Refer to Neurology for further evaluation Well-balanced diet
power tools and dangerous equipment. Refer to Nutrition Clinic for a diet plan and management. Increase oral fluid intake
Procedure done: Dix-Hallpike and Epley Diet: Low Salt, Low Fat Diet Refer to Rehab medicine for further Avoid triggers: lack of sleep, emotional
maneuver TC: 1539, CHO: 923, CHON: 231, Fat: 385 evaluation and co-management stress, and fatigue or any other known
Refer to ENT-OHNS for further evaluation Refer to Neurology for further evaluation Refer to Ophthalmology for further triggers mentioned in the HPI
and management and management. evaluation and co-management. Counselling done
Follow up after 3 days Referral to LGU for possible Follow up after 3 days Proper stress management.
Advised psychosocial disability certification. Advised Keep a headache diary (date, time, triggers,
Follow up after 1 week preceding symptoms, medication, relief)
Advised Regular exercise 30mins 5x a week or as
tolerated
Advised.
Psychiatry Disorders
Major Depressive Disorder/ Generalized Anxiety Psychotic Disorder: To consider Schizophrenia To consider Adjustment Disorder (with depressed
Disorder Limitation of activities due to disability [Z73.6] mood, anxiety or mixed anxiety and depressed mood)
Limitation of activities due to disability [Z73.6] 2 or more of the following for at t least 1 month period - Up to 3 months between stressor and development
<Imaging/routine labs if indicated> 1. Delusions of symptoms
Escitalopram 10mg/tab ½ tab once a day at bedtime for 2. Hallucinations - Symptoms don’t always subside as the stressor
first 4 nights 3. Disorganized speech ceases
then 1-tab once a day at bedtime thereafter. <Always ASK 4. Grossly disorganized or catatonic behavior Give medications for insomnia (if present)
the resident first> 5. Negative symptoms (flat affect, alogia, or avolution) 1. Escitalopram 10mg/tab ½ tab once a day at bedtime
Counselling done. Disturbance in 1 or more major areas of functioning such for first 4 nights then 1-tab once a day at bedtime
Deep breathing exercises, proper stress management. as work, interpersonal relations or self care are markedly thereafter. <Always ASK the resident first> OR
Suicide precaution. below the level of achieved prior to onset 2. Diphenhydramine 50mg/tablet 1 tablet once a day at
Procedure done: Mini Mental Status Exam Continuous signs of the disturbance persisting for at least 6 bedtime (not really included in the guidelines, have
Refer to Psychiatry for further evaluation and management. months which must include at least 1 month of other systemic adverse effects when taken for a long
For possible referral to LGU for possible psychosocial aforementioned symptoms time)
disability certification once certified by psychiatry. Disturbance is not due to direct physiological effects of a Counselling done with the family member
Follow up once seen by Psychiatry substance Identify possible source and counsel
Advised Procedure done: Mini Mental Status Exam
Schizophreniform Disorder: same signs and symptoms Refer to Psychiatry for further evaluation and co-
but at least 1 month but less than 6 months management and possible Psychotherapy (treatment of
choice)
<Imaging/routine labs if indicated> Follow-up once seen by Psychiatry
May require drug test and metabolic work-up (to rule out Advised
organic causes and drug induced psychosis)
Counselling done with the family member.
Keep company at all times.
Procedure done: Mini Mental Status Exam
Refer to Psychiatry for further evaluation and management.
For possible referral to LGU for possible psychosocial
disability certification once certified.
Follow up once seen by Psychiatry
Advised
Brief Psychotic Disorder Panic Disorder Major Depressive Disorder
A. Presence of one (or more) of the following At least one of the attacks has been followed by at least 1 Five (or more) of the following symptoms have been
symptoms: month of one or more of the following: present during the same 2-week period and represent a
- Delusions - Persistent concern about having additional change from previous functioning; at least one of the
- Hallucinations panic attacks symptoms is either (1) depressed mood or (2) loss of
- Disorganized Speech - Worry about the implications of the attack and interest or pleasure. Note: Do not include symptoms that
- Grossly disorganized or catatonic behavior its consequences are clearly attributable to another medical condition.
B. Duration of episode at least 1 day but less than 1 - Significant change in behavior related to the - Depressed mood most of the day, nearly every
month, with eventual full return to premorbid level of attacks day, as indicated by either subjective report
functioning Presence or absence of agoraphobia (e.g., feels sad, empty, hopeless) or
C. Disturbance is not better explained by MDD or - In the DSM-5, PD and agoraphobia are now observation made by others (e.g., appears
Bipolar disorder with psychotic features or another unlinked, this is a change from the previous tearful). (Note: In children and adolescents,
psychotic disorder such as schizophrenia or edition can be irritable mood.)
catatonia, and it not attributable to the psychological The panic attacks are not due to the direct physiologic - Markedly diminished interest or pleasure in all,
effects of a substance or another medical condition effects of a substance or general medical condition or almost all, activities most of the day, nearly
every day (as indicated by either subjective
<Imaging/routine labs if indicated> The panic attacks are not better accounted for by another account or observation).
May require drug test and metabolic work-up (to rule out mental disorder - Significant weight loss when not dieting or
organic causes and drug induced psychosis) weight gain (e.g., a change of more than 5% of
Counselling done with the family member. Symptoms of Acute Panic Attack: body weight in a month), or decrease or
Keep company at all times. ● Palpitations, pounding heart, or accelerated increase in appetite nearly every day. (Note: In
Procedure done: Mini Mental Status Exam heart rate children, consider failure to make expected
Refer to Psychiatry for further evaluation and management. ● Sweating weight gain.)
For possible referral to LGU for possible psychosocial ● Trembling or shaking - Insomnia or hypersomnia nearly every day.
disability certification once certified. ● Sensations of shourtness of breath or - Psychomotor agitation or retardation nearly
Follow up once seen by Psychiatry smothering every day (observable by others, not merely
Advised ● Feelings of choking subjective feelings of restlessness or being
● Chest pain or discomfort slowed down).
● Fear of dying - Fatigue or loss of energy nearly every day.
● Nausea or abdominal distress - Feelings of worthlessness or excessive or
● Feeling dizzy, unsteady, light-headed, or faint inappropriate guilt (which may be delusional)
● Chills or heat sensations nearly every day (not merely self-reproach or
● Paresthesia (numbness or tingling sensations) guilt about being sick).
● Derealization (feelings of unreality) or - Diminished ability to think or concentrate, or
depersonalization (being detached from indecisiveness, nearly every day (either by
oneself) subjective account or as observed by others).
● Fear of losing control or going crazy - Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a
<Imaging/routine labs if indicated> Thyroid labs if indicated specific plan, or a suicide attempt or a specific
Counselling done with the family member. plan for committing suicide.
Keep company at all times. The symptoms cause clinically significant distress or
Procedure done: Mini Mental Status Exam impairment in social, occupational, or other important areas
Refer to Psychiatry for further evaluation and management. of functioning.
disability certification once certified. The episode is not attributable to the physiological effects
Follow up once seen by Psychiatry of a substance or to another medical condition. Note:
Advised Criteria A–C represent a major depressive episode
<Imaging/routine labs if indicated>

Counselling done with the family member.
Keep company at all times.
Procedure done: Mini Mental Status Exam
Refer to Psychiatry for further evaluation and management.
disability certification once certified.
Follow up once seen by Psychiatry
Advised
Musculoskeletal Disorders
Musculoskeletal Disorder (MSD), <indicate location> Musculoskeletal Disorder (MSD), <indicate location> Arthritic Group of Diseases (AGD) to consider
or Arthritic Group of Diseases (AGD) to consider e.g. Plantar fasciitis, Low back pain> or Arthritic Gouty arthritis in flare
Osteoarthritis, <indicate specific joint> Group of Diseases (AGD) to consider Osteoarthritis <Imaging/routine labs if indicated except BUA, may do
For severe symptoms add <indicate specific joint> BUA when patient is no longer in flare>
Limitation of activities due to disability [Z73.6] For severe symptoms add Colchicine 500 mcg/tab 1-tab q8 until 6 days or
NON HYPERTENSIVE, LESS THAN 40 YRS OLD Limitation of activities due to disability [Z73.6] relief of symptoms or diarrhea occurs
Lumbar MRI if with radiculopathy symptoms >40 YRS OLD, HYPERTENSIVES, DIABETICS, CKD UNLESS THERE IS CONTRAINDICATION:
Scoliosis series if with scoliosis Lumbar MRI if with radiculopathy symptoms Uncontrolled hypertension, history of chest pain, MI,
Lumbosacral Xray APL if with visible spine deformity or Scoliosis series if with scoliosis stroke, Gastric or duodenal ulcers
crepitus Lumbosacral Xray APL if with visible spine deformity or Select one if without any contraindication.
Avoid imaging if symptoms are <6 weeks duration and crepitus Celecoxib 200 mg/ tab, 1-tab q12 for 5 days
NO alarm/red flags Avoid imaging if symptoms are <6 weeks duration and Etoricoxib 60 or 90 mg/tab 1-tab once a day for 5
Celecoxib 200 mg/ tab, 1-tab q12 for 5 days NO alarm/red flags days
Etoricoxib 60 or 90 mg/tab 1-tab once a day for 5 Paracetamol + tramadol 325+37.5mg/tab, 1-tab q8 as Diclofenac 50 mg/tab 1-tab q8 for 5 days
days needed for pain for 5 days or DO NOT START URICOSURIC AGENTS LIKE
Diclofenac 50 mg/tab 1-tab q8 for 5 days Paracetamol + Orphenadrine 650+50 mg/tab, 1-tab FEBUXOSTAT DURING ACUTE GOUTY ATTACKS
If with radiculopathy: q8 as needed for pain for 5 days or On follow up see Hyperuricemia.
Pregabalin 75mg/cap, 1 cap BID for 2 weeks Eperisone 50 mg/tab, 1-tab Q8 for 5 days Rest affected area, Elevate affected area when at rest
Eperisone 50 mg/tab, 1-tab Q8 for 5 days If with radiculopathy: Cold compress for 15 minutes 3x a day or more as
Proper body mechanics, avoid prolonged <insert Pregabalin 75mg/cap, 1 cap BID for 2 weeks tolerated
potential risk factor here>, Eperisone 50 mg/tab, 1-tab Q8 for 5 days Refer to Nutrition Clinic for a diet plan
Proper body posture, switch sitting position, take brief Proper body mechanics, avoid prolonged <insert Diet: Low purine Diet (if no other co-morbidities)
breaks (if applicable) potential risk factor here>, TC: 1539, CHO: 923, CHON: 231, Fat: 385
adequate rest and sleep, warm compress affected area Proper body posture, switch sitting position, take brief Follow up after 3 days
for 15 minutes 3x a day or as needed. breaks (if applicable) Advised
Refer to Rehab Medicine for further evaluation and adequate rest and sleep, warm compress affected area
management (If indicated: symptoms persist >6 for 15 minutes 3x a day or as needed.
weeks) Refer to Rehab Medicine for further evaluation and
Referral to LGU for possible psychosocial disability management (If indicated: symptoms persist >6
certification. weeks)
Follow up after 3 days Referral to LGU for possible psychosocial disability
certification.
Infectious Diseases
Viral Exanthem to consider Varicella Zoster / Herpes Dengue Fever Syndrome w/o warning signs
Zoster (Shingles)/ Herpes Zoster ophthalmicus For CBC with PC
<Routine labs if indicated> Fever for 3 days- Dengue NS
If within 48 hours from the onset of rash or vesicles. Fever for >3 days- Dengue IgG, IgM
Start Acyclovir 800 mg/tab 1-tab q4 hours (8 am, 12 nn, Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C
4 pm, 8 pm, 12 mn) for 7 days, ORS sachet dissolve in 200 ml of clean water and drink
<If in severe pain> Pregabalin 75mg/tab 1-tab q12 every 3-4 hours as tolerated
Keep lesions dry, proper handwashing, avoid scratching Avoid dark-colored foods
affected areas. WOF: Urination less than 4-6x per day, Abdominal pain
Isolate from household members, or tenderness, Persistent vomiting, Mucosal bleed
contact and droplet precaution. (gums, urine, vomitus)
For patients with Herpes Zoster ophthalmicus Follow up today with results or at the ER if OPD is
Refer to Ophthalmology for further evaluation and already closed.
management Advised.
Follow up after 2 weeks or once all lesions have DRIED. Have the patient sign on the chart that he/she will come
Advised back today with results or at the ER if OPD is closed
Example “Ako ay babalik sa OPD or sa ER dala-dala
ang resulta ngayong araw na ito”
Viral Exanthem to consider Rubeola Leptospirosis, Mild (Moderate- Severe, send to ER)
CBC with pc, Measles IgM, IgG c/o Public Health Unit CBC PC, UA, BUN, Crea, SGPT, SGOT, Lepto-MAT
Cetirizine 10 mg/tab 1-tab once a day at bedtimefor 2 Doxycycline 100 mg/tab 1-tab q12 for 7 days
weeks for pruritus Paracetamol 500 mg/tab 1-tab q4 for fever >37.8 C
Loratadine 10mg/tab 1-tab once a day for 2 weeks for ORS sachet dissolve in 200 ml of clean water and drink
pruritus every 3-4 hours as tolerated
Proper body hygiene, proper handwashing, Keep Increase oral fluid intake
lesions clean and dry. Avoid scratching affected areas. WOF: Urination less than 4-6x per day, tea colored
Airborne precaution: Isolate from household members, urine, Abdominal pain or tenderness, Persistent
wear mask if necessary. vomiting, or yellowing of the skin
Watch out for progressive cough, fever, difficulty of Follow up today with results or at the ER if OPD is
breathing or shortness of breath. closed.
Refer to PHU for surveillance and testing. Advised.
Follow up after 1 week. Have the patient sign on the chart that he/she will come
Advised back today with results or at the ER if OPD is closed
Example “Ako ay babalik sa OPD or sa ER dala-dala
ang resulta ngayong araw na ito”
Routine Patients
ESSENTIALLY WELL ADULT AT THE TIME OF CONSULT (pre-employment) Follow ups from ER (treat as NEW patient)
For pre-employment work-up: Chest X-ray PAL, CBC w/ PC, UA, Take note of the history of present Illness before the ER consult.
(for food handlers) add FA, Anti-HAV Then: Sought consult at <private clinic, hospital, government hospital/ OPD>
(for strenuous occupation) add 12 L ECG Diagnosed with <diagnosis>
Well balanced diet Diagnostics done were <Tests>
Adequate oral fluid intake Results were as follows <results>
Moderate intensity physical activity 30 mins/day 5x per week as tolerated. (for healthy Prescribed with <drug>
patients who you think can tolerate exercise) Self-medicated with <drug>
Follow up ASAP with result With Relief/no relief of symptoms
Advised Patient came in today as follow up per ED instructions.
Endocrine / Metabolic/ Hematology Disorders

Anterior Neck Mass to consider Multinodular Anterior Neck Mass to consider Hypothyroidism sec Diabetes Mellitus Type 2
Toxic/Non-Toxic Goiter, Hyperthyroidism, to (RAI/ Hashimoto Thyroiditis/ Multinodular Non- Diabetes Mellitus Type 2 suspect
Toxic Goiter/ Total Thyroidectomy) Diabetes Mellitus Type 2, insulin-requiring
If mass is small, do Thyroid Ultrasound Priority labs: FBS, HBA1C (if known DM prior to consult)
If mass is large or with CLAD, do Neck Ultrasound FBS only (if for DM suspect) LP, BUN, Crea, UA, 12 L
TSH, Free T4, Free T3, Calcium (if S/P total ECG.
Thyroidectomy), <then monitor every 6 weeks> BUA, CBC with pc, Na, K, Cl, SGPT SGOT
Hypothyroid medications: Chest X-ray PAL if indicated
Less than 65 yrs old: <insert current maintenance medications here>
Initial Low dose: Levothyroxine 50 mcg/tab 1-tab once a Or Start Metformin 500mg/tab 1-tab q8h
day Gliclazide 80 mg/tab 1-tab once a day/Q12
Full-dose Levothyroxine (1.6 to 1.7 mcg per kg) For CKD patients (EGFR less than 60)
65 years and older or who have ischemic heart Glimepiride 2 mg/tab 1-tab once a day/q12
For PATIENTS IN IMPENDING STORM: Compute disease, start with: Levothyroxine 25 to 50 mcg per day Sitagliptin 50 or 100 mg/tab 1-tab once a day
using the Burch-Wartofsky Scoring Avoid goitrogenic food such as brussel sprouts, For HBA1C >10 %: Insulin Glargine (0.1 to 0.2 IU/Kg)
If mass is small, do Thyroid Ultrasound radishes, cabbage, and cauliflower, iodine rich foods. or 10 IU SQ ODHS
If mass is large or with CLAD, do Neck Ultrasound Watch out for lack of energy, sleepiness, weight gain, or Atorvastatin 20 mg/ tab 1-tab once a day at bedtime
TSH, Free T4, Free T3, Calcium), lethargy (ALWAYS START FOR PTS WITH DM)
Prioritize TSH, FT4 For possible referral to ENT-OHNS once with results Strict compliance with medications
CBC with PC, SGPT, SGOT. Follow up ASAP with results. Daily foot care, proper foot gear
<then monitor TSH every 6 weeks (4-8 weeks)> Advised Procedure done: Comprehensive foot exam for DM
Antithyroid medications: patient
Methimazole 5mg/tab 1-tab q8h (then adjust accordingly Procedure done: Insulin therapy demonstration
at increments of 5mg) Refer to Nutrition Clinic for a diet plan
Propranolol 10/tab 1-tab once a day for palpitations, Diet: DM diet
tachycardia. TC: 1539, CHO: 923, CHON: 231, Fat: 385
Avoid goitrogenic food such as Brussel sprouts, Refer to Ophthalmology for official fundoscopy
radishes, cabbage, and cauliflower. Recommended pneumococcal and influenza vaccines
Watch out for fever, sore throat, generalized body (age dependent)
malaise, chest pain, severe palpitations, nervousness, Follow up after 1 week
fatigue. Advised
For possible referral to ENT-OHNS once with results
Follow up ASAP with results.
Advised Monitoring
Dyslipidemia Asymptomatic Hyperuricemia Every visit: Feet inspection
When to start? Repeat BUA after 2 months Annual:
1. All diabetics, Stroke (CVA), TIA or MI patients should <Imaging/routine labs if indicated> ● Urinary albumin, EGFR, Spot Albumin/Crea ratio
be started on a HIGH INTENSITY STATIN. WHEN TO START URICOSURIC AGENTS? ● 10g monofilament testing
If with history of gout or uric acid Nephrolithiasis Every 1-2 years: Comprehensive diabetic eye exam
2. ≥40 years of age ASCVD score >7.5%
7 mg/dl (416 umol/L) in men
3. ≥ 45 years with LDL-C ≥ 130 mg/dL AND ≥ 6 mg/dl (357 umol/L) in pre-menopausal women
2 risk factors* If without history of gout or uric acid nephrolithiasis.
9 mg/dl
Risk Factors: male sex, postmenopausal women, Febuxostat 40 mg/tab, 1-tab once a day
smoker, hypertension, obesity (BMI > 25 kg/m2), family Refer to Nutrition Clinic for a diet plan
history of premature CHD, microalbuminuria, Diet: Low Purine Diet
proteinuria, left ventricular hypertrophy TC: 1539, CHO: 923, CHON: 231, Fat: 385
Target: LDL-C level of < 70 mg/dL Follow up after 2 months
Anemia, etiology to be determined (IDA vs Anemia Anemia, secondary

of Chronic Disease) If with Abnormal uterine bleeding: Transvaginal
For CBC wit PC with Red cell indices, Reticulocyte sonogram
count, serum ferritin, Peripheral blood smear If with ETBD, R/O Colonic New Growth, add
Once confirmed with IDA, may start Fecalysis, Chest Xray PAL, Fecal Immunochemical test
FeSO4 325 mg/tab 1-tab once a day for 3 months c/o Gastro
Monitor CBC with PC monthly for increase 1 g/4 weeks Refer to Gastroenterology for further evaluation and
Dyslipidemia Iron-rich Diet: green leafy vegetables, organ or red management.
Diagnostics: Repeat Lipid Profile after 2 months meats. Follow up ASAP with results.
<Imaging/routine labs if indicated> Follow up after 1 month with CBC result.
Start Rosuvastatin 10 or 20 mg/tab 1-tab once a day at Advised
bedtime
Atorvastatin 20 or 40 mg/tab, 1-tab once a day at
bedtime
Simvastatin 40 mg/tab 1tab once a day at bedtime
Refer to Nutrition Clinic for a diet plan
Diet: Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385
Follow up after 2 months
Advised
Psychosocial Assessment
Tobacco use [ Z72.0] (_____Pack years) Insomnia [G47.0] Primary Obese I or II (BMI >=30)
Counselling done; smoking cessation advised. Patient (see DSM V Criteria) Lack of physical exercise [ Z72.3]
in ______ stage Melatonin 3 mg/tab 1-tab 30 minutes before bedtime. Inappropriate diet and eating habits [Z72.4]
Stages: Proper sleep hygiene: Avoid bright screens 1-2 hours Screen for Blood glucose levels, type 2 DM, high blood
For stages Pre contemplation and Contemplation. before bedtime. pressure, cardiovascular disease
Advised to come back anytime if decided to quit. Avoid caffeinated food and beverages and strenuous Moderate intensity physical activity 30 minutes per day,
For Preparation and Action activities 4-6 hours before bedtime. 5x per week as tolerated.
Refer to the Smoking Cessation Clinic for further Follow up after 1 week. Refer to Nutrition Clinic for a diet plan
counselling and management. Good Sleep Hygiene: Counselling done: identify barriers, self-monitoring of
For Maintenance - Consistent sleeping time weight, peer support, relapse prevention, smoking
Continue smoking cessation, avoid temptations and - Bedroom must be conducive for sleeping cessation [if present],USPSTF)
influences. - Remove electronic devices Diet: Well-balanced diet, Low Salt, Low Fat Diet, DM
- Avoid large meals, caffeinated, alcohol Diet, Low purine Diet if with co-morbidities,
drinks before bedtime TC: 1539, CHO: 923, CHON: 231, Fat: 385
- Being physically active during the day can Weight monitoring same time, same scale weekly and
help fall asleep easily at night record.
Follow up after 1 month
High risk sexual behavior [Z72.5]
- Unprotected intercourse
- Intercourse under influence of substances
- Multiple sexual partners
- Intercourse with persons with injecting drug
use
- Early age of initiation of intercourse (WHO
before 15 years old)
- Engaging in unnatural and unprotected sex
- Intercourse with female sex workers/ paid
sex/ casual sex
For HBSAG, RPR, HACT

5Cs: Chemical Treatment, Condom use, Counselling,
Contact Tracing, Coming back for review of compliance
with treatment
References:
1. American Academy of Family Physicians
2. Exercise Prescription: https://www.doh.gov.ph/sites/default/files/publications/HBEAT58a.pdf
3. Preventive Screening: https://www.uspreventiveservicestaskforce.org/uspstf/
4. Psychiatric Disorders: DSM V Criteria
GUIDELINES IN FILLING UP THE CENSUS FILE

1. Patient number. Make sure no skipping of numbers. You can use autofill (10 error pts)
2. Type: There are 3 patient types: (10 error pts)
a. NEW: These are patients interviewed for the first time at Family Medicine Department
b. FF UP: these are patients who came back for follow up of his/her previous diagnosis.
c. OLD/NEW: these are previous patients who came back with a new complaint/ or lost to follow up.
3. Time seen: This is the time that the patient was seen by the RESIDENT (10 error pts)
4. Time D/C: This is the time that the RESIDENT finished ordering on the chart, it does not include the time that the clerks/JI finished carrying out doctor’s orders. (10 error pts)
5. TAT or turnaround time: this is the total time spent by the resident for each patient. Please ask the CLERK or INTERN in charge if it goes beyond 40 minutes. (10 error
pts)
6. Hospital Number: Do not rely on the OPD form, Look for the Hospital number at the side of the folder. (10 error pts)
7. Patient’s Name: Data Privacy act requires us to use the LAST NAME, and initial of the First name. e.g. Dela Cruz, J (10 error pts)
8. Age: 19-100 only we don’t handle Pediatric (18 and below) patients for now. (10 error pts)
9. Sex: M for Male, F for Female (10 error pts)
10. Contact number: May be landline or Mobile number. (10 error pts)
if none, clarify with the Clerk or Intern in charge. (10 error pts)
11. Address: Brgy and City is sufficient, do not type the whole address. E.g Brgy Tatalon, Quezon City (10 error pts)
12. Diagnosis: One diagnosis per line.
E.g Hypertension Stage II
Diabetes Mellitus
AGD t/c Osteoarthritis
13. Plan: standard order of plan is
a. Diagnostics (10 error pts)
b. Medications (10 error pts)
c. Non-Pharmacologic management (10 error pts)
d. Referrals (10 error pts)
e. Follow up (10 error pts)
14. Disposition: (10 error pts)
a. Discharged: these are patient discharged from our department.
b. Referred: these are the patents referred to other specialties on the SAME day.
c. To ER: these are emergency cases that was referred to ER.
15. Senior RIC: Make sure all charts that you input on the excel file has the Senior RIC stamp, if it does not contain any stamp from Senior, clarify it with the
Resident/Intern/Clerk in charge. (10 error pts)
16. Junior RIC: Make sure all charts that you input on the excel file has the 1 st year RIC stamp, if it does not contain any stamp from Senior, clarify it with the
Resident/Intern/Clerk in charge. Exception: if the senior personally saw the patient and was not referred to a 1 st year resident. (10 error pts)
17. Referred: click referred to if the patient was referred to other departments. This different from REFERRED in disposition Column where patients were immediately referred
to other departments the same day. (10 error pts)
18. Referrals 1 to 3 indicate the departments where the patient was referred to. (10 error pts)
19. WELLNESS if the patient is Essentially Well at the time of Consult and Medical certificate was given. (10 error pts)
a. Wellness checkup: patients without disease who came in for checkup.
b. Illness resolved: patients previously diagnosed and disease is resolved, do not use for patients with chronic diseases. This is for acute illnesses only.
c. Occ Pre employment: use this for patients for pre employment purposes.
d. Occ Medical Certificate: For patients asking for medical certificate. Use this if the patient was seen at our department and was diagnosed immediately as
Essentially well adult.
20. Referral from other department: these are the patients seen at other departments and was referred to ours for co-management. (10 error pts)
21. Waiting time: always indicate the waiting time computed by the Vital Signs Clerks (10 error pts)
22. Color Codes
Pink - Well Adult (Resolved or Essentially Well Adult)
Green - Referred
Yellow - SHOULD NEVER BE EMPTY (WITH EXEMPTIONS)
Red - SHOULD NEVER BE EMPTY (200 error pts)
23. Before submitting the census file to Dr. Magbojos please make sure. (10 error pts)
a. All spelling errors are corrected
b. At least either Senior RIC or Junior RIC is filled up
c. No Empty Cells on columns A-P
24. If you have any questions or experiencing any errors, do not hesitate to call the attention of Dr. Adrian Magbojos. Merits will be given to those who will discover errors, and
demerits will be given to those who does not follow this guideline. *50 error pts = 1-hour demerit
DOH CENSUS EDITING GUIDELINES
1. Download a Copy of Census .DOCX from the Census folder link 4. Replace with ALLM (the Standard Initial of the Dr., See List
2. ADD DOH After the Date of the filename e.g (OPD Census October 1, 2019 DOH) for details) hit Replace all. Click Yes
3. Open the file
4. Click the “Type” column, hit delete. Type the Census Date e.g. October 1, 2019.
Highlight October 1, 2019, then Ctrl + C to copy. Click the whole column then Ctrl + V
to paste. Then Change the Column header to “Date”.
5. then Click OK.
5. Select the TAT column by click at the top of the column. Hit Backspace to delete the
entire column.
6. Select Plan Column by click at the top of the column. Hit Delete to delete the cell
contents. At the first cell of the column, type “None”. Highlight the word “None” and
copy (CTRL + C). Select the whole column then paste ( Ctrl + V). Change the Header
cell to Operations/ Procedures.
7. Change all the Names of the Residents to their Initials. INITIALS for DOH Census
4. At the Senior RIC or Junior RIC Column, Highlight the Name of the Doctor Consultants
you want to change. Ctrl + C to copy. Gillian Chris R. Maraña, MD GCM
Rosa Andrea C. Valencia, MD RAV
Assumption G. Vanguardia, MD AGV
Junior Consultants
Adrian Levi L. Magbojos, MD ALLM
Abegail A. Masangkay, MD AAM
April Quintua-Alimbuyuguen, MD AQA
Third Year
Jireh Knowell B. Alparas, MD JKBA
Eunice F. Cristobal, MD EFC
Sharmaine Rose L. Medel, MD SRLM
5. Find and click Replace. Manuel Karlo L. Parungo, MD MKLP
Cris John V. Supetran, MD CJVS
Second Year
Janella Jillian G. Abella, MD JJGA
Ana Beatriz D. Adviento, MD ABDA
Ma. Elka R. Bungay, MD MERB
Eron Allen C. Tan, MD EACT
Patricia Marie R. Tinio, MD PMRT
First Year
Jean Pauline P. Aledia, MD JPPA
Danielle B. Andrion, MD DBA
Edric Albert G. Felix, MD EAGF
Joshua V. Tunac, MD JVT
Racquel Justine A. Vasquez, MD RJAV
6. At the “find what Text Box, Paste the name of the Dr. you want to replace.
8. Your final table should look like this.

EAMC DFCM OPD Charting Guidelines As of March 2022

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EAMC DFCM OPD Charting Guidelines As of March 2022

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EAMC DFCM OPD Charting Guidelines as of March 2022

Triage Vital Signs Team Consultation Team Census Encoding

CENSUS ASSISTANTS RESPONSIBILITIES

Files to be submitted at the End of the rotation.

Minimum “Normal” Physical Exam findings

Chest/Lungs No mass or lesions, Symmetrical chest expansion, no

Heart Adynamic Precordium, PMI at 5th ICS Left Midclavicular line,

Abdomen Globular, no visible mass or lesions, normoactive bowel

Extremities No gross deformities, full and equal pulses, capillary refill

Genitalia Grossly Male/Female Adult Genitalia, no visible mass or

Spine Spine is in midline, no visible lesions, abnormal curvature,

Assessment 1. With comorbidities (HTN, DM, CKD) “for HTN/DM/Workup: 12 L ECG,

COVID, Suspect, Severe are referred

<Imaging/routine labs if indicated>

Endocrine / Metabolic/ Hematology Disorders

Anemia, etiology to be determined (IDA vs Anemia Anemia, secondary

For HBSAG, RPR, HACT

GUIDELINES IN FILLING UP THE CENSUS FILE

5. then Click OK.

8. Your final table should look like this.

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