Chronic Obstructive Pulmonary Disease Registry Form Page 3
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4DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
Input Instruction Form
Field
Field Name
Instruction
No.
1.
National Registry No.
Do not fill up. It is a system generated number to uniquely identify each record or data entered into the national registry.
2.
Name of Reporting Health Facility
Write the name of the Hospital, Center or Clinic who is submitting the report.
3.
Hospital Patient I.D. No.
Write the hospital-based issued I.D. or number to uniquely identify the patient.
4.
Hospital Registry No.
Write the hospital-based issued I.D. or number to uniquely identify the patient.
5.
Hospital Case No.
Write the hospital-based issued number to uniquely identify each case or incidence.
6
Type of Patient
Check the button for the corresponding type of patient the victim is.
7.
Name of Patient: Last Name, First
Write the patient’s Last name, First name and Middle name in the appropriate spaces provided.
Name, Middle Name
Note: None may be written if no informant can provide the information.
8.
Sex
Check the appropriate box for the sex of the injured by birth.
9.
Civil Status
Check the appropriate box for the civil status of the injured. Not legally separated still to be considered as “Married”
10.
Mother’s Maiden Name
Write the mother’s name of the patient before marriage. The full middle name must be entered. If there is no middle name,
write“N/A”.
11.
Permanent Address
Write the patient’s permanent address - House No. and Street, Barangay, Municipality/City and Province
11a.
Temporary Address
Write the patient’s temporary address - House No. and Street, Barangay, Municipality/City and Province
12,12a,
Landline #, Mobile #, Email Address
Write the patient’s contact details such as landline number, mobile number and email address.
12b
13.
Birth Date
Write the date of birth of the patient in the format mm/dd/yyyy (eg. July 1, 1970 should be entered as 07/01/1970 )
14.
If Date of Birth is not available
If date of birth cannot be provided then enter in the space provided the age of the patient in years or months or days.
(Yrs/Mos/Days)
15.
Place of Birth
Write the Province and the City/Municipality where the patient was born.
16.
Religion
Write the patient’s religion
17.
Nationality
Write the patient’s nationality
18.
Race
Write the race of the person which describes the skin color, i.e. American (Red Skin), Caucasian (White Skin), Ethiopian (Black
Skin), Malay (Brown Skin), Mongolian (Yellow Skin)
19.
Ethnicity
Write the ethnicity of the patient, e.g. Asian, Indian, Pacific Islander, or others
20.
Highest Educational Attainment
Write the highest educational attainment of the patient whether he is elementary, high school, vocational, college, post
graduate, or others.
21.
Occupation
Check the appropriate box for the occupation of the injured.
22.
Company
Write the name of the company where the injured is working.
23.
PhilHealth
Write the PhilHealth Number if member or dependent.
Write the Unified Multi-Purpose ID
24.
Common Reference #
Common Reference No. if the patient has any. (UMID CRN can be found in the
upgraded, present government IDs such as the SSS, GSIS and Philippine Health Insurance Corp. UMID-CRN is the primary
identifier of an individual transacting business or availing of services from any government agency.)
24
Contact Person (in case of
Write the name of the person that may be contacted should any emergency may happen to the patient.
24a-24d
emergency) , Address, Landline #,
Write the address and other contact details such as landline number, mobile number and the email address.
Mobile #, Email Address
25.
Smoking
Check the button if the patient is smoking cigarettes and how much the patient is consuming per day.
Write the age the patient started smoking and the number of years the patient has been smoking.
26.
Second Hand Smoke
Check the button if the patient is exposed to second hand smoke, write the number of years the patient has been exposed to
second hand smoking.
27.
Occupational Exposure
Check if the patient has been exposed to any kind of material in relation to the patient’s occupation.
28.
Pulmonary Infections
Check if the patient has an infection of TB, if others specify further.
29.
Indoor Air Pollution
Check the button if the patient has been exposed to Indoor Air Pollution. Write the type of Indoor Air Pollutant.
30.
Outdoor Air Pollution
Check the button if the patient has been exposed to Outdoor Air Pollution. Write the type of Outdoor Air Pollutant.
31.
Type of COPD
Write the patient’s diagnosed type of COPD.
32.
Referred From
Check the button if the patient came from other hospital or clinic, and was referred to the hospital.
33.
Name of Referring Health Facility
Write the name of the hospital or clinic where the patient came from.
34.
Reason for Referral
Write the reason why the patient was referred to the hospital.
35.
Date of Consultation/Admission
Write the date when the patient first came to the hospital in mm/dd/yyyy format.
36.
Date of Diagnosis
Write the date when the patient was diagnosed with any type or kind of COPD using mm/dd/yyyy format.
37.
Sign/Symptoms
Check the sign/symptoms the patient exhibited during the diagnosis.
38.
Treatment
Write the treatment given to the patient.
39.
Status of Severity
Check the status of severity of the patient’s COPD.
40.
Final Diagnosis
Write the patient’s final diagnosis.
41.
Final Diagnosis (ICD10-Code)
Write the corresponding ICD10 code for the patient’s final diagnosis.
42.
Patient Status
Check the Patient Status whether recovered, improved and unimproved upon discharge.
43.
If Died, underlying cause of death
Write the fundamental cause of death of the patient.
44.
If Died, underlying cause of death,
Write the ICD-10 code for the fundamental cause of death of the patient.
ICD-10 CODE
45.
Date of Death
Write the date when the patient died using mm/dd/yyyy format.
46.
Place of Death
Write the province and city/municipality where the patient died.
47.
Final Disposition
Write whether the patient was admitted, discharged, transferred,
Discharge against medical advice, treated and sent home, absconded and died.
48.
If transferred, Name of Health Facility
Write the name of the Health Facility where the patient was transferred.
49.
Reason for Referral
Write the reason why the Patient was transferred to another Health facility.
50.
Consultant in-charge
Write the name, position title /designation of the Consultant in-charge on this portion including the address and contact details
50a.
Address
(landline no., mobile no. and email address).
50b.
Landline #
50c.
Mobile #
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