...

...

(tI-lled -52'/•..............................................................•

QUICK GUIDE IN ACCOMPLISHINGTHE OPB UTILIZATIONMONITORING FORMS

For use of PhilHealth Accredited

Rural Health units, Health Centers,and Authorized Hospitals

. Version January 2003 .. ............................................................ . ..f(

...

...

...

...

•...................................................•

BRIEFER ON THE OPB

What is the OPB?

The Outpatient Consultation and Diagnostic Benefit Package (OPB) is

an additional benefit initially for the beneficiaries of PhilHealth's

Indigent Program or ~/11eqic.p-e p,/:, 5., ;11.}5.,. ,. Beneficiaries refer to

the members and their qualified dependents which may include their

spouse, parents, and children.

\IV~() .a.~~ .tile..p.royi(j~rs .Of .th.e. Cl.P.B.? .

The package is administered, managed, and delivered thru accredited

rural helth units/health centers (RHU/HC) owned by the LGU where

the indigent enrollees reside. The benefits are non-portable. Members

are assigned to accredited RHUs/HCs in their locality where they may

exclusively avail the OPB.

In case the RHUs/HCs of a Municipality or City are not yet ready to

provide the OPB, a PhilHealth Accredited Hospital owned by the

province, may be authorized by PhilHealth to temporarily provide the

package.

...................................................................................•1

•.................................................... .................•. .

What are the benefits under the OPB?

PhilHealth '!11eL!ic7/'{:;'1',:;/::; 5" ;11,.75,7 " members of an LGU implementing

the OPB are entitled to the following:

o Free primary consultation with the physician

o Free laboratory services:

• chest x-ray

• complete blood count (CBC)

• fecalysis

• urinalysis

• sputum microscopy

o Free preventive services such as health screening activities,

health education and counseling including:

• Visual acetic acid screening for cervical cancer

• Regular blood pressure measurements

• Annual digital rectal exam

• Body measurements

• Periodic clinical breast examination

• Counselling for cessation of smoking

• Lifestyle modification counseling

•........................................

2................. ·111

...

...

..

...

III·················································································.•

How are the OPB seavices paid?

PhilHealth uses the capitation scheme of payment for the delivery of

OPS services. Capitation works like a pre-payment scheme. PhilHealth

already pays the amount of P300 per annum for each family enrolled

to the dilled/cm.'F,I:, V IIL,S.}·· before the OPS services are rendered

by the accredited and authorized providers. To ensure that it will be

utilized properly, the capitation fund is released on a quarterly basis,

subject to the submission of OPS Form 1 (Monthly Report Form) for

the previous calendar quarter.

Referrals

o Chest x-ray services maybe referred by an accredited RHUfHC to

another PhilHealth accredited facility. Referral fees must however

be paid by the RHU using the capitation fund it will receive from

philHealth.

o In case an RHU/HC is accredited on the basis of its affiliation with

a central or zonal laboratory, payment of diagnostic procedures

that it refers to the laboratory shall come from the capitation fund

it will receive from philHealth.

o If the health center physician believes that the patient needs a

higher level of care, the patient should be referred to any

PhilHealth accredited hospital. In case of admission, the confine

ment shall be reimbursed by PhilHealth as an in-patient claim.

•..................................................................................•3

•............................... .................................•

Where can the capitation fund be used ?

Before the OPB is implemented, the LGU shall pass an ordinance for

the creation a PhilHealth Capitation Fund (PCF). The capitation fund

shall become a trust fund that can be used for the following

purposes:

• Purchase medical supplies and equipment needed to provide the

OPB including referral fees

• Drugs and medicines listed in the Philippine National Drug

Formulary

• Up to 20% for administrative cost

What are the advantages of implementing the OPB?

• Essential pUblic health services are ensured

• RHUs/HCS will be empowered to serve as gatekeeper which will

eventually minimize overutilization of hospital facilities for

unnecessary confinements

• A functional referral system shall be institutionalized among the

local health providers and promote integration of health services

• Through capitation LGU bUdget for health Is augmented, hence the

beneficiaries are assured of available quality health services

For more information on '/i1ed/c7/"C.'Fil<75:7 11-1:;5:7 ", please contact any Phi/Health Office

in your locality.

•....................................................... ....•4

...

""

•................................................•

MONITORING THE UTILIZATION OF THE OPB

Why monitor the utilization of OPB?

• To provide the LGU and PhilHealth with a basis for evaluating

the program

• To serve as inputs in making policy decisions on benefit

development, benefit payment, and quality assurance.

• •••••••••••••••••••••••••••••••••••••••• •• \ 1/ •: '- /' Therefore, complete and correct information :~ ':y....:..... would facilitate the enhancement of the program~• •• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

The Monitoring Forms

There are two monitoring forms that a health center should fill up:

1. OPB Form 1 - Monthly Report Form

• contains the summary of information on OPB services availed

by PhilHealth "/l/cc!icpc"P.ll"..;5} /11.-75,;" beneficiaries

(members pIus dependents).

• submitted on or before the 7th day of the first month of the

succeeding calendar quarter to the PhilHealth Regional Office

2. OPB Form 1A - OPB Patient Treatment Summary:

• contains details of OPB availments of each PhilHealth

~iVfcdic.;;-e f'ell', s;/1!.r5.; ~ beneficiaries. These details shall be

the basis for accomplishing the OPB Form 1.

• filled every time a PhilHealth 'il 1I:</1:..:,/c'!'-,/;, .':' .! !.r.':1

beneficiary seeks OPB services from the RHU!HC.

...

...

.. •........................................5

.......................................•

•...................................... .........•

FOR EACH FORM, MAKE SURE TO FILL UP

THE FOLOWING:

ow Name of the RHU/HC lifthe RHU/HC has no name, write

the name of the City/Mucinipality and type of facility.

e.g., Bindoy RHU or Bindoy Health Center)

ow Name of the municipality and province

ow Period covered (start date, end date, year)

ow Name and signature of nurse or midwife accomplishing

the form

ow Name and signature of physician certifying the correctness

of information

-

•••••••• •• • • • • • • • • • • • • • • • • • • • • • • • • • • 0 • ~ • • • •

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • $ • • • •• ••: \ I / REMEMBER:. '9/: '- :: Incomplete forms will cause delay--- "-: / in the release of capitation.

•

....OPB Forms 1 and 1A are available in electronic format at philHealth. The electronic versionautomatically feeds data encoded in Form 1a into Form 1. Health centers with computers mayrequest for an electronic version of the forms from Phi/Health. -

•.......... ~

6

...

...

...

...

•.................................................................................•

Form 1A. OPB patient Treatment summary

A sample blank form is in page 9. A sample filled form is in page 16.

I. For each row, make sure that the following entries are filled:

A. Date - indicate the day and month of the patient's visit to

the RHU/HC

B. PhilHealth number of the member

C. Name of the beneficiary - write the first name, the middle

initial, and last name

D. Status

1. Membership: encircle M if the patient is the PhilHealth

member himself/herself. and D If the patient is a

dependent of the PhilHealth member

2. Sex: Encircle M if the patient is male and F if female

3. Age: Indicate age in years

E. Diagnosis as determined by the RHU Physician - State

primary disease or condition followed by co-morbidity,

complications. May also include status of disease, e.g.,

URTI, resolved; PTB; MDR

F. Benefits given - encircle letter/s of benefit/s given. More

than one letter may be encircled.

G. Disposition: encircle the number/s of the corresponding

disposition. More than one number may be encircled.

lit· .............................................................................. ...•7

•................................................. .II. At the bottom of each table, indicate the subtotals:

A. Total number of patients seen

B. Total number of PhilHealth members and total number of

dependents seen

C. Sex: total no. of males and total no. of females

D. Benefits given: total for each column

E. Disposition: total for each column

'-

....

•••••••••••

REMINDER:total no. members and dependents should be equal

to total no. of males and females

e.g. 6 members and 15 dependents = 21

9 males and 12 females = 21

............................~ ...............••

••• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

•• \ 1//••~V-•

• ..... '-• / "-••••••••

III. The health center may use as many pages of the form as needed,

since each page can only accommodate 15 entries. Final totals

must be provided on the last page aside from the subtotals.

•........................................ .•8

.. I I I ( I. I ( I I. ( I I ( I

•...................................................................................................•

"".-f\br'Ied~b)'IhFociUI'f

~> PhIlippine Hedth Insmmce Corpor<tIOflOPSFORM1A

oroPAnavr TFBITM:NrSLMMRY

"

OCll"lllll1133..,'C0­.,Cll

3..>

"

'0

",I,

,l!i

aSPOSlllONBENEFITS-GVl:N

0"'"''''

STAn.<

MOl reKl!'GEU OJ 'I .' I.~ !8 '-'" _ E 'Q '" ... l5 ~ ~ l3" M'__ I!UIJE~. i iIi! ~ i j!)~Hd ~ J] I!!;i K

~o "J ' , A 8 C 0 E F G H 1 J K L M N 0 P 1 2 3 4 5 (I

. :,~:' ",0 N J ~~:: ~~~-~.:- ... : A.8 C 0 E F, G H I J K L M N 0 P 1 2 3 4 5 6

",,", ABC 0 E F G HII J K l M N 0 P '23 4 5 (I

._"_.,~~,=~~.. r--- ~:A 8 .C ,0 E F. G H I J, K L M N 0 P 1 2 3 4 5 6

. -I~.l.'l/f ",".... ABC 0 E F G H I J K L M N 0 P 1 2 3 4 5 6

",ol/'rF" .. .,:.::~_.~_~. ':' fA '6;.C 0 E F ,0 H I J K L M N 0 P 1 2 3 4 5 6

I~ol;'l' "'" _.A 6 C 0 E F 0 H I J K L M N 0 P , 2 3 4 5 G

,~",,_:·I/ol/h__: 1_.: •..:_,., _ ABC 0 E F: G H I J. K L M N 0 P 1 2 3 4 5 6

I~l/~. ABCOEFGHIJKLMNOP123456

IXI./: ',_ _;:.A BCD E F, ,0 H I J 'K .L, M N 0 P 1 2 3 4 5 6

1.x,l:X. ABCOEFGHIJKLMNOP123456

........_..'.:..::J~[;6 . '-·.A BCD E F G H I J K L M N 0 P 1 2 3 4 5 6

Ihl./';- ABCDEFGHIJKLMNOP123456

~~ Ix~." .._ ._" A. IJ C 0 E 1'.0. H I J, K L M N 0 P 1 2 3 4 5 6

_~_[~J.'6. A 11 C 0 E f: G H r J K L M N 0 P 1 23 4 5 G

lM 1"",,:,:,,;,,\:1 I I I I I I I I I I 1III I ifill II

NM\E

PAllENT

FHlH-:ALlH"'-""ER

O'\T"E

1~\'U(M ~nM I1I)o&IG'h If""O'II"' .. ~ Ikr'4l~

I\QoI(lOO

Qillitdtl\l('lto:! o::rrCd'

1\0'> .n._u. rJ _nn._M:fth cJ •__"n"

fAklOlcJ :,l((ti'

----iW;--"---"'J.... - ...,.,~-,',...~,.., ...."..'....,... " ..

."..

f\('Jlfl't(lf)l

"'1 ...........,·,~..·",....,·,...._-(,,·.... , ....

h""rU(.11(ln"I.:;;;o:;;~;;;;;;;"'iHmill -,;;;;;"":;;;:;;:;;;;;;;;;;:;;;;;;;; •:MO';j.ff;o."-'I"'I'_IIlM"Mf1lll'O.CUTlI:OIf tft'of'"'~(M'U-fI'OOllj(lfti"''''''I./1 ]1tt'.l,fff Mf~IIlI.Wr...,,.ffM/IIf, (lrltrt~(MN'"~"\o'f"jll:..._fl,.t..ll,1J,{>f., ..1o:0! ,,~ ,

iI······································· ·······································································iI

•........................................... ..: OPB F.e>rr11 1. .fVIe>nt~l.y. ~~P.e>rt. F.e>rl11....

A sample blank form is in page 12. A sample filled form is in page 17.

Health Facility Data

I. Covered Period

Indicate start: date and end date of the month and year.

II. Health Center Accreditation NO./Hospital Authorization No.

II. Health Center Accreditation No.1Hospital Authorization No.

Write the accreditation number of the RHU/HC or hospital

authorization no. of hospital. This can be found in the certificate of

accreditation/authorization.

III. Municipality/City and Province

Ill. M unicipality/City and Province

Indicate name of municipality or city and province.

•............... ..............................................•

10

-...

•.................................................................................•

IV. Diagnosis

DIAGNOSIS FRECU;::~Y

,,,•••,•,"

Indicate the top ten diagnosis for ";lfedic;re p;lo;5.; ;1/.;5.;

beneficiaries, ranked according to frequency during the month.

This may be obtained from Form 1A.

...V. Total # of Visits by 'Medicp-ep:;;-:; 5:; ;1{;5.; Beneficiaries:

V.Total # of Visits by ";-l/cJ!~-.:;rc P.i!:"] 53 /1'L;'~:7'"

Beneficiaries:

...

Refers to total no. of visits made by members and dependents. This

may be obtained from the number of rows filled in Form 1A. Hence, it:

is the number of visits that is counted here, not the number of

persons. For instance, a dependent visits or avails of services five

times during the month, then these are counted as five visits even if

all visits were made by the same person.

•..................................................................................•11

·._._-------_._._-_._._....._------------

•..........................................................•

sampleOPBForm 1

ThiS form m.y bf r.produced .nd Is NOT FOR SALE.

ti Philippine Hearth Insurance CorporationOPB FORM 1

MONTHL Y REPORT FORM

Name or Health ConlorlHospilal

HEALTH FACILITY DATAI.Covered period II. Health Canter Accreditation No.1

1'"

Municipality/City and Provincefrom Hospital Authorlwtion No.10

SUMMARY OF BENEFITS AVAILMENTIV. Diagnosis. ranked according to frequency ( ~ ieJq,"c',"Je' >.1 ..11;>,/ 'beneficiaries only)

DIAGNOSIS FREOUENCY V.Tolal # of Visits by ;.ifcc/I~:lI<'I'.lI.j.;./ ,I-!.;>./

, Beneficiaries:

, Male: Members:, Female: Deoendents:, VI. Tolal # of ,lh-</lo/O-.'/'.7.. /5.I·tf.!"1

, Families Served:

,, V/Llolal # of Patients Served ,P""'..." " .....·P.;IH."" B,.",J''''r

,,"

SUMMARY OF BENEFITS PROVIDED

VIII. BENEFITS GIVEN TOTAL IX. DlSPOSITION TOTAL'

A. ConSUltation Onlv 1. Advised Onl

B. Visual Acetic Acid Screenin" 2. Given Prescrl lion

C Reaular BP Measurements 3. Given Medicinefs

D. Annual Diaital Rectal Exam 4. Referred for Other labaratorv Services

E. Bodv Measurements 5. Referred for Hi her lev(!1 of Care

F. PeriOdic Clinical Breast Examination 6. Others

G. Caunselin for Cessation of SmakinQ

H, Lifest Ie Modification Adviso, Com lete 8100d Counl CBO

J. Urinal sis

K. Fecalvsis

L. S utum Microsca

M. Chest X-HI

N. Referred for Chest X-rav

o. Referred for OPS DiaanOSllc Services

p Others

TOTAL BENEFITS GIVEN

CERTIFICATION

X. Prepared by Nurse or Midwife of ttle facility; I certify lhat the foregoing informalion are true and correct.

Printed name and s;gnatvre of Midw~elNursa OglO Signoo

XI. Approved by Ihe Physician of Ihe facility; I certify Ihat the foregoing Informallol'l are lrue and correct.

Prinled nama and s;gnalura of Phy$i(:lan Dala Signed

•.......................................12

......................................•

•................................................... ............•

VI. Total # of "/1 !Cd/~~7i"C !'.1i:7 .':7 i1l.7s1 Families served

VI. Total # of:I!<·J":'!"c'':''f:; .';. Il;.'; .

Families SelVed:

...

Refers to no. of PhilHealth /lled!L:71"C!'.l!:75.7 ;lh':7 . families served.

This may be obtained from the number of PhilHealth 10 numbers that

appear in Form 1A. (Note that a member and his/her dependents

have the same PhilHealth 10 number. Hence. one 10 number refers to

one family.) Therefore. be careful not to double count an 10 number.

Welloo.the last two numbers are important in determining the

"reach" of the OPB to the PhilHealth '~I!edic1J"e pH:} 5..1

/11..15:; "members. Each family is composed of a member and

his/her dependents. For instance, if 200 families comprised of a

total of 950 members and dependents are assigned to a health

center, then the breakdown of 950 is 200 members and 750

dependents.

If data shows, for example, that a total of 50 visits from Phil Health indigent

beneficiaries are made by members and dependents belonging to only 3 families,

then this indicates that there are 197 Phil Health illedicm: P.7/:7 5.1 /1/.t5.1

families not visiting the health center. Furthermore, this signals a need to analyze

why the three families made numerous visits to the health center within the month

and what their illnesses were.~ /

YOU ARE PROBABLY WONDERING WHY PHILHEALTH REQUESTS YOU TO

TALLYTHESE.

•..................................................................................•13

----_._----- -_.._-----

•............................................... ....•VII. Total # of Patients Served

IVII.Total # of Patients Served (Phll""lIh,,' Noo·Phll""lIh B,,,'d,",,),

Indicate the total number of patients served by the RHU!HC during

the month, whether PhilHealth //I1ec/ic.:;Nc /7'7/<':; );:; ;1.1'75'7" beneficiaries

or not.

AGAIN, THIS IS AVERY IMPORTANT INFORMATION.

We would be able to know here the ratio of Phi/Health Indigent

Program members to the total no. of patients served. This shall

give an indication of the healthcare-seeking behavior of

Phi/Health /j\1ec//G.:;te 5'7/11,:;5,7" beneficiaries vis-a-vis the

general population.

VIII. Benefits Given:

VIII. BENEFITS GIVEN TOTAL

D. P«ua/ r«:la(f>3nlc _

F.Ptri<>:lIed'__"""'-_

G. Co!.nsd; ":r<OSMti<rlol_

K. Ul_nnlll<:atC<ladvlSO'V

I. "'e B'oOO CC<rt

J. Uin ",

N. P>:fu'r«!forO>osl

o. Rd..,.".rcrCf'llD n<lio:se.wm

''''"'

Based on the totals in Form 1A, indicate the no. of times each benefit

was given to the PhilHealth "Medicare para sa Masa" beneficiaries.

•................................................................................. ·M14

...

-

.....................................................................................

IX. Disposition

... IX.OISPOSITION TOTAL

2, G;~~n r..<" "on

3. (li".n "'odIe;"."

•. Ihl.".d '0' OIn.' I." "''''c..S. R.'.".d lor 1>1 no' I••• , 0' cu.

\

In tha same manner indicate the number of times each type of

disposition was given, based on the totals in Form 1A.

Finally••• the last two poriions of the form (paris VIII and IX)

would indicate whether the OPB package generally addresses the

healfh conditions of PhilHealfh '~11cdiGl!"t' P1J:l 5<1 ;11.15.1 .

beneficiaries as indicated in Pari IV. ,I

---------------c---cc---c-----~/

....

(I,

iIII

~

. .•..................................................................................•

15

•............................... . •

Nm"e cJ I-e<¥th Focilrty: C<W<rolllU

h> PH1iWre I-ixml nsmn::eD::fp::faiooCHlFCR\l1A

a=BFr1TlBJTTF£fJ.TWENr8.MMRf

Q:te: fran MclJ 1,2C02 to Mro>31. 2Xl2

."t/l::e>1D3c."Co1D"'IIlU."o3...l>

DATE PAllENT

N<I'E

STATUS! 1 ......13GMN---

0""""",,• E ~

.. , ti ~_B,

g ~. ~ ~ s ~f !l ~~ E ~i! ~H

f~p""I roI ""I I~ ~ • ~

~.z ill , ~~

'l1J)

~~ $1~"""""" ~("iii a. p '; 18 ..

c% 8" ~~ ~ £ > ,"ff c 0";:: <I>

~t< 0 l i~ j! (5g '~3 8 g ••0 " a ~j Ju > 1Ii m •

rro=;M""" f"hI~ 471 <J>lID',RTIiRIIlS,ln' I(All 61(11101(1')1 FIG I(R)I , I J I KI LIM NloNloNloNTO

P 1(1)1@131 4 I 5 I,;p:I{]121(3'l1 41 516

~p -ICYI@}-Sf4TsT6

N 1o P 1(1)12131 4 I@ I 6N J-o pRYI!>131 41 516

'"AWlEm<IFZ' J%J~,;i1lIA1EriiMrnnu;'<'.I(&I'6Ic 1'0 1<Si/'FIGI <Bil,' 'T~I K1 LIMN 1oNt 0

pl0)12113i141516P IGJI@13j@i1 5 16

llMl'LlNTAIAN 1"/..1'"/'1 47 I taIIE~ I®fBl@T(9i1 ElF I GI "I ' I J I®I LIMOfilE<J\lm<A' 1"/.1':61',,1 <EMaJ1Sc-.> .... ···'·I~I®rcIO·IEIFIGI" I' 101 KI LIMJ:l6.NA0'ImERA l'%1AQ 2 I IIDUlALASTIM\ 10\)1 B I c I DIE I FIG I HI I I J I KI LIM

amnN4.CIl'Q.AI.ES '2S Ti'HODFlM'R.' - . ® J .1 KI LIMGEFAROOR..N¥IL 45 liYFf.RfEN';ICN ® J KTLT'M

N 1oNloNloNloNIoNloNIo

P 1i1lI@hl 4 I 5 16

pIGJI@131@1516P 1!1lI@bl 4 I 5 I 6

P 6p 6

6

6

....................................•

B8'a:nsEMN-a.;rde~ktlms.

Oll-IR~a:sGM:N.En:i:deq:pe,tlllnntms.

14 J 2 J 3 J I J 2 J 2 J 2 J 3 J 2 J 4 J I J 1 J 2 J 0 I 0

"""_'_d_8_M::rthd ~l

S3iesd~

,1°1°""+1 2

""/>mh3lD.ll

certffiedtroo<n:lM...---.---

~~M)S9U'<""""""'''''''''_'''''''''Y'O__

I

~

""

1'11'11V'V' I

~",,__<f_I;Inr~rr...... """

Instructla's:

'ffiSS.\o.~R<

3.ttct<'l ~lrrb::rcfPitieis~lrt~

""'''''

IMD_ En:i'deM~l"'6<rtisMM:l3faDlc::a:l3"ONr

l

sox. &ciIeM~lJ'MtisMII..En;lFlFtM'lEK?E. rdcaeogon\<=

-,,~

•

[ [ r f f I: [ I: I: (' r r ( f (

...................•

sampleFilled OPR Form 1

TMs form msy /:I. r.prcd"Ud .nd u NOT FOR SAlE.

t~ Philippine Health Insurance Corporalion

OPS FORM 1MONTHLY REPORT FORM

Oranbo RHU

HEALTH FACILITY DATAI.Covered pt"i¢d

from )"...cb 1 'Of)'

to ,"",rh 11 ' ...'"

II. Hearll\ Cenler Aeered':itl>Qn NoJHospital A,,\i'lol>:zal,on NO.

IOlll.fOO~

IV. Diagnosis. ranked aCeo"jing to frequency (

SUMMARY OF BENEFITS AVAILMENT

DIAGNOSIS

1 URTI

FREQUENCY V.TOlar:; 01 Visits by

Beneficiaries: J lQ

...

2 ACUTE GASTROENTERITIS

3 UTI

~ PTa

5 HYPERTENSION

5 OSTEOARTHRITIS

7 TYPHOID FEVER

8 ACUTE rOSILlTIS

!I DIABETES MELLITUS

10 HYPERSESSITIVITY

"10

Male: 65 I Members:

Female: ':5 De e"::~:s:

VI. Total ~ of '.:." "0 ':."._'

Famiiies Served: 9.:

IVll.TO!;)I. of Pa:;e"ls Ser.-e;1 ';h._", .",,,,,,,,~......,,, ._... ,

'"

SUMMARY OF BENEFITS PROVIDED

...

....

...

Vltl. BENEFITS GIVEN

A. Consullalion Onlll

B. Visual AceHc Ac>:! Screenin

C. Reoular BP Measurements

D. Annual Dicilal Reelal Eum

E. Bod MeasuremenlS

F. Periodic Clinical S.easl Eumitlalion

G. COlmselin lor CeSSalion of Smo~in

H. lilesMe Modif,cation A<:!lIiSO

I. Com lele SIOOd Count (CSCl

J. Urinalllsis

K. Fecalvsis

L. S ulum MicrOSCOllII

M. Chest X·.all

N. Relerre<:!lor Chesl X·'av

O. RelerreO 10' OPS Dia noslie Services

P. Olllers

TOTAL BENEFITS GIVEN

TOTAL

100

10

20

10

I'

,,oo

207

IX. DISPOSITION

1. A<:"lIiSeclOM

2_ Gillen Prescriolion

S. Relet."" lor HiallH Lea·1 of Care

TOTAl..

...CERTIFICATION

X PrepareCl byN~ llle fac~,ty, I cerMy III.. llhe fore~o"'>l "'1"""' ..:;0-... "'lI :",;11 a~~ CC."""':l

nss ... D. "'lL·W". RN !>~a"h )1. ::'(·)2Prv>ted 1>3"" and ''Qna;"'" of Uo;l..""Jt<y,.. O~... s-o;-.....::

XI. Approved by llle P~(:itr o~ III~aCilllY: I cert,fy IlIallllelo'ego,ng ,nfo.mal<o" are lroe and coneel

OLl\'lA~.MD !.hl(~31.2(,(l2P,onto<! na.." eM ,~n"Yfeof Pn~oc.." 0"" So;->..:!

•.................................................................................•17