1, 'template_name' => 'Inpatient Admission Face Sheet & Registration Record', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

{{H_address_1}}, {{H_address_2}} | Phone: {{H_phone_No}}

INPATIENT ADMISSION RECORD & FACE SHEET

UHID / Patient ID: {{UHID}}	IPD Admission No: {{IPD_CODE}}	Admission Date & Time: {{ADMIT_DATETIME}}	Ward / Bed No: {{WARD_BED}}
Patient Name: {{PATIENT_NAME}}	Age / Gender: {{AGE_GENDER}}	Marital Status: {{MARITAL_STATUS}}	Contact No: {{MOBILE_NO}}
Father / Spouse: {{FATHER_SPOUSE}}	Relation: {{RELATION}}	Residential Address: {{PATIENT_ADDRESS}}
Treating Doctor: {{DOCTORS}}	Department: {{DEPARTMENT}}	Admission Type: Emergency [ ] / Elective [ ]	MLC Case: Yes [ ] / No [ ]
Referred By: {{REFERRED_BY}}		Insurance / TPA: {{TPA_NAME}} (Policy / Card: {{POLICY_NO}})

PROVISIONAL DIAGNOSIS & ALLERGY STATUS
Provisional Diagnosis at Admission: {{PROVISIONAL_DIAGNOSIS}}	Known Drug Allergies: [ ] None Known [ ] Penicillin [ ] Sulfa [ ] NSAIDs Others: ____________________

___________________________
Admission Staff Signature

___________________________
Patient / Attendant Signature

___________________________
Admitting Doctor Signature

HTML , 'status' => 1, ], // ================================================================= // Form #3: Informed Consent for Admission & Treatment (Bilingual) // ================================================================= [ 'form_no' => 3, 'template_name' => 'General Informed Consent for Admission & Treatment (Bilingual)', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

GENERAL INFORMED CONSENT FOR ADMISSION, INVESTIGATION & MEDICAL TREATMENT

सामान्य भर्ती, जांच एवं चिकित्सा उपचार सहमति प्रपत्र

Patient Name: {{PATIENT_NAME}}

UHID: {{UHID}}

IPD No: {{IPD_CODE}}

Age / Gender: {{AGE_GENDER}}

1. Consent for Medical Care & Nursing / सामान्य चिकित्सा सहमति:
I voluntarily authorize the physicians, nursing staff, and medical personnel of {{H_Name}} to administer medical care, perform diagnostic examinations, diagnostic blood/radiology tests, nursing procedures, administration of prescribed intravenous fluids and medications deemed medically necessary.
मैं स्वेच्छा से अस्पताल के डॉक्टरों और नर्सिंग स्टाफ को मेरे/रोगी के आवश्यक नैदानिक परीक्षण, रक्त जांच, एक्स-रे, आवश्यक दवाइयां तथा चिकित्सा उपचार करने की अनुमति देता/देती हूँ।

2. Emergency Procedures / आपातकालीन स्थिति में उपचार:
I understand that during hospitalization, medical emergencies may arise requiring immediate life-saving interventions (such as CPR, endotracheal intubation, defibrillation, or emergency medications). I authorize the clinical team to perform such emergent interventions.
मैं समझता/समझती हूँ कि अस्पताल में भर्ती के दौरान आपातकालीन स्थिति उत्पन्न होने पर आवश्यक जीवनरक्षक उपचार करने का अधिकार डॉक्टरों को होगा।

3. Valuables & Hospital Rules / कीमती सामान व अस्पताल के नियम:
The hospital will not be responsible for loss or damage of money, jewelry, mobile phones, or personal belongings kept by patient or attendant in ward rooms.
रोगी अथवा तीमारदार के पास रखे कीमती सामान (रुपये, गहने आदि) की सुरक्षा की जिम्मेदारी स्वयं की होगी।

Patient / Legal Guardian's Declaration:
Name / नाम: ___________________________
Relationship / सम्बंध: __________________
Signature / Thumb Impression / हस्ताक्षर:

Date / दिनांक: {{CURRENT_DATE}} Time / समय: ______

Healthcare Professional Witness:
Name / नाम: ___________________________
Designation / पद: ______________________
Signature / हस्ताक्षर:

Date / दिनांक: {{CURRENT_DATE}} Time / समय: ______

HTML , 'status' => 1, ], // ================================================================= // Form #5: Initial Nursing & Clinical Admission Assessment // ================================================================= [ 'form_no' => 5, 'template_name' => 'Initial Nursing & Clinical Admission Assessment', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

INITIAL NURSING & MEDICAL ADMISSION ASSESSMENT (NABH)

Patient Name: {{PATIENT_NAME}}

UHID: {{UHID}}

IPD No: {{IPD_CODE}}

Bed / Room: {{WARD_BED}}

1. BASELINE VITAL SIGNS AT ADMISSION
Temp: ___ °F	Pulse: ___ /min	BP: ___ / ___ mmHg	Resp Rate: ___ /min	SpO2: ___ % (RA/O2)	GRBS: ___ mg/dL

2. NURSING CLINICAL ASSESSMENT
Consciousness: [ ] Alert & Oriented [ ] Drowsy [ ] Unconscious Mobility / Gait: [ ] Ambulatory [ ] Assisted [ ] Bedridden Vision / Hearing: [ ] Normal [ ] Impaired Bowel / Bladder: [ ] Normal [ ] Incontinent [ ] Foley Catheterized	Pain Assessment (0-10 Scale): Score: ___ / 10 Pain Site: ___________________ Type: Dull / Sharp / Colicky Skin Condition: [ ] Intact [ ] Pallor [ ] Cyanosis [ ] Jaundice Pressure Ulcer (Bedsore): [ ] None [ ] Stage I/II/III/IV (Site: ___)

3. SAFETY & RISK ASSESSMENTS
Fall Risk (Morse Fall Scale): [ ] Low Risk (0-24) [ ] Moderate (25-44) [ ] High Risk (>= 45) Side rails up: Yes [ ] Call bell within reach: Yes [ ]	Nutritional Screening: Weight: ___ kg \| Height: ___ cm \| BMI: ___ kg/m2 Diet: [ ] Regular [ ] Diabetic [ ] Renal [ ] Liquid / NPO

Assessed by (Staff Nurse): __________________ Sign: ___________ Date/Time: _________

Counter-signed by (Doctor): __________________ Sign: ___________

HTML , 'status' => 1, ], // ================================================================= // Form #6: Medication Administration Record (MAR / Nurse Drug Chart) // ================================================================= [ 'form_no' => 6, 'template_name' => 'Medication Administration Record (MAR / 24-Hour Nurse Drug Chart)', 'page_size' => 'A4-L', 'custom_width_mm' => 297, 'custom_height_mm' => 210, 'page_margin_top_cm' => 0.70, 'page_margin_bottom_cm'=> 0.70, 'page_margin_left_cm' => 0.70, 'page_margin_right_cm'=> 0.70, 'margin_header_cm' => 0.40, 'margin_footer_cm' => 0.40, 'template_html' => <<

{{H_Name}} - MEDICATION ADMINISTRATION RECORD (MAR)

Patient: {{PATIENT_NAME}} | UHID: {{UHID}} | IPD No: {{IPD_CODE}} | Bed: {{WARD_BED}} | Age/Sex: {{AGE_GENDER}}

ALLERGIES: [ ] NONE KNOWN [ ] YES: _________________

S.No	Medication Name & Strength	Dose	Route	Freq
1	Inj. Ceftriaxone 1g	1 g	IV	BD
2	Inj. Pantoprazole 40mg	40 mg	IV	OD
3	Inj. Paracetamol 100ml IV	1 g	IV	SOS
4	Inj. Ondansetron 4mg	4 mg	IV	TDS
5	IV Fluids: RL / DNS 500ml	500 ml	IV	@ 75ml/hr
6	Tab. Pantocid 40mg	1 Tab	Oral	OD (Empty stomach)
7
8

* Nurse must sign with initials upon administration of each dose. Circle time if dose is omitted/refused with documented reason on reverse.

HTML , 'status' => 1, ], // ================================================================= // Form #8: Physician Daily Progress Notes (SOAP Format) & Order Sheet // ================================================================= [ 'form_no' => 8, 'template_name' => 'Physician Daily Progress Notes (SOAP Format) & Doctor Order Sheet', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

DOCTOR'S DAILY PROGRESS NOTES & ORDER SHEET

Patient: {{PATIENT_NAME}} ({{AGE_GENDER}})
UHID: {{UHID}} | IPD No: {{IPD_CODE}}
Bed: {{WARD_BED}} | Doctor: {{DOCTORS}}

Date & Time	CLINICAL PROGRESS NOTES (S-O-A-P)	DOCTOR'S ORDERS / TREATMENT PLAN
Date: ___/___/2026 Time: ___:___ AM/PM	S (Subjective): Patient complaints / symptoms... O (Objective): Vitals: BP ___/___, P ___, T ___, SpO2 ___% Systemic exam: CVS / RS / PA / CNS... A (Assessment): Clinical impression / status... P (Plan): Investigations / consultation...	1. Diet: ___________________________ 2. IV Fluids: ______________________ 3. Medications: ____________________ 4. Investigations: __________________ 5. Nursing monitoring: ______________ Doctor Signature: ________________
Date: ___/___/2026 Time: ___:___ AM/PM	S: O: A: P:	1. 2. 3. 4. Doctor Signature: ________________

HTML , 'status' => 1, ], // ================================================================= // Form #12: High Risk Surgical & Anaesthesia Consent (Bilingual) // ================================================================= [ 'form_no' => 12, 'template_name' => 'High-Risk Surgical & Anaesthesia Informed Consent (Bilingual)', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

INFORMED CONSENT FOR SURGERY, ANAESTHESIA & SPECIAL PROCEDURES

शल्य चिकित्सा (ऑपरेशन) एवं बेहोशी (एनेस्थीसिया) विशिष्ट सहमति प्रपत्र

Patient: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD No: {{IPD_CODE}}	Age / Sex: {{AGE_GENDER}}
Proposed Procedure: {{PROCEDURE_NAME}}		Operating Surgeon: {{DOCTORS}}
Proposed Anaesthesia: [ ] General [ ] Spinal [ ] Epidural [ ] Local/Block		Anaesthetist: ___________________________

1. Nature & Purpose of Surgery / ऑपरेशन का विवरण एवं उद्देश्य:
The operating surgeon has explained in understandable language the nature, anticipated benefits, alternative treatment options, and inherent risks associated with the procedure.
ऑपरेशन के उद्देश्य, लाभ, विकल्प एवं उससे जुड़े सम्भावित जोखिमों के बारे में डॉक्टर द्वारा मुझे सरल भाषा में पूरी तरह समझा दिया गया है।

2. Surgical & Anaesthetic Risks / सम्भावित जोखिम व जटिलताएं:
I understand that surgery and anaesthesia involve unforeseen complications including but not limited to hemorrhage, wound infection, adverse drug reaction, deep vein thrombosis, cardiovascular collapse, and respiratory depression.
मैं समझता/समझती हूँ कि किसी भी सर्जरी व एनेस्थीसिया में रक्तस्राव, संक्रमण, दवाओं का प्रतिकूल प्रभाव अथवा अन्य जटिलताओं का जोखिम हो सकता है।

3. Blood Transfusion Consent / रक्त चढ़ाने की सहमति:
I consent to the administration of blood or blood products if deemed life-saving by the operating surgeon/anaesthetist.
आवश्यकता पड़ने पर रक्त अथवा रक्त घटक चढ़ाने की भी सहमति देता/देती हूँ।

Patient / Attendant Signature / हस्ताक्षर:

Name: ___________________________
Relation with patient: ____________
Contact: ________________________
Date & Time: {{CURRENT_DATE}}

Surgeon / Anaesthetist Certification:
I confirm that I have explained the procedure, risks, benefits, and alternatives to the patient/guardian.

Doctor Name: _____________________
Signature: _______________________
Date & Time: {{CURRENT_DATE}}

HTML , 'status' => 1, ], // ================================================================= // Form #13: WHO Surgical Safety Checklist // ================================================================= [ 'form_no' => 13, 'template_name' => 'WHO Surgical Safety Checklist (OT Safety Protocol)', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.70, 'page_margin_bottom_cm'=> 0.70, 'page_margin_left_cm' => 0.70, 'page_margin_right_cm'=> 0.70, 'margin_header_cm' => 0.40, 'margin_footer_cm' => 0.40, 'template_html' => <<

{{H_Name}} - OPERATION THEATRE

WHO SURGICAL SAFETY CHECKLIST (NABH SAFE SURGERY PROTOCOL)

Patient: {{PATIENT_NAME}}

UHID: {{UHID}}

IPD: {{IPD_CODE}}

OT Room: OT-___

Planned Procedure: {{PROCEDURE_NAME}}

1. SIGN IN (Before Induction of Anaesthesia)	2. TIME OUT (Before Skin Incision)	3. SIGN OUT (Before Patient Leaves OT)
[ ] Patient identity, surgical site & procedure confirmed. [ ] Surgical site marked: Yes [ ] N/A [ ] [ ] Anaesthesia safety check completed. [ ] Pulse oximeter on patient & functioning. Allergy check: [ ] Known allergy: No [ ] Yes [ ] Difficult Airway / Aspiration Risk: [ ] No [ ] Yes, equipment available Risk of > 500 mL Blood Loss: [ ] No [ ] Yes, IV access & blood ready. Nurse/Anaesthetist Sign: _________	[ ] All team members introduced by name & role. [ ] Surgeon, Anaesthetist & Nurse verbally confirm: - Patient name - Procedure - Incision site Anticipated Critical Events: - Surgeon: Critical steps, duration, blood loss. - Anaesthetist: Patient-specific concerns. - Nursing team: Sterility indicators confirmed. Antibiotic Prophylaxis: [ ] Administered within past 60 min. Essential Imaging Displayed: [ ] Yes [ ] N/A Team Leader Sign: ____________	Nurse Verbally Confirms with Team: [ ] Name of the procedure recorded. [ ] Instrument, sponge & needle counts are correct. [ ] Specimen labeled correctly with patient name & UHID. [ ] Equipment problems addressed. Key Concerns for Recovery: - Post-op vitals & airway plan reviewed. - Drain / pack details recorded. - Analgesia order written. Circulating Nurse Sign: _________ Surgeon Sign: __________________

HTML , 'status' => 1, ], // ================================================================= // Form #14: Diabetic Blood Sugar & Insulin Sliding Scale Chart // ================================================================= [ 'form_no' => 14, 'template_name' => 'Diabetic Blood Glucose & Insulin Sliding Scale Monitoring Flowsheet', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

{{H_Name}} - INPATIENT DIABETES MONITORING

BLOOD GLUCOSE & INSULIN SLIDING SCALE FLOWSHEET

Patient: {{PATIENT_NAME}}

UHID: {{UHID}}

IPD: {{IPD_CODE}}

Bed: {{WARD_BED}}

Target Glucose: 110 - 180 mg/dL

PHYSICIAN INSULIN SLIDING SCALE PROTOCOL (Regular / Rapid Acting Insulin SC)
Blood Sugar < 70 mg/dL	Hypoglycemia Protocol: Give 15-20g oral glucose / 25% Dextrose 100ml IV stat; recheck in 15 min.
Blood Sugar 70 - 140 mg/dL	No insulin correction required.
Blood Sugar 141 - 180 mg/dL	Give 2 Units Regular Insulin SC.
Blood Sugar 181 - 220 mg/dL	Give 4 Units Regular Insulin SC.
Blood Sugar 221 - 260 mg/dL	Give 6 Units Regular Insulin SC.
Blood Sugar 261 - 300 mg/dL	Give 8 Units Regular Insulin SC.
Blood Sugar > 300 mg/dL	Give 10 Units Regular Insulin SC and Notify Treating Doctor immediately.

Date	Time	Timing (Fasting/Pre-meal/Post)	GRBS (mg/dL)	Insulin Units Given	Nurse Initial	Remarks
	07:00 AM	Fasting
	12:30 PM	Pre-Lunch
	07:30 PM	Pre-Dinner
	11:00 PM	Bedtime / Post-meal
	03:00 AM	Night check

HTML , 'status' => 1, ], // ================================================================= // Form #15: Blood Transfusion Monitoring Record // ================================================================= [ 'form_no' => 15, 'template_name' => 'Blood & Blood Component Transfusion Monitoring Record', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

{{H_Name}} - TRANSFUSION SAFETY RECORD

BLOOD & BLOOD COMPONENT TRANSFUSION MONITORING SHEET

Patient Name: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD: {{IPD_CODE}}	Ward/Bed: {{WARD_BED}}
Patient Blood Group: ____ Rh: ____	Bag Blood Group: ____ Rh: ____	Bag / Unit No: _______________	Component: PRBC / FFP / Platelet / Cryo

PRE-TRANSFUSION DOUBLE-CHECK (By 2 Qualified Healthcare Professionals at Bedside):
[ ] Patient Name & UHID verified against wristband.
[ ] Blood group & Rh compatibility confirmed on crossmatch tag.
[ ] Bag expiry date, physical appearance, and seal checked.
Staff 1 Name & Sign: ________________________ Staff 2 Name & Sign: ________________________

Monitoring Interval	Time	Temp (°F)	Pulse (/min)	BP (mmHg)	Resp (/min)	SpO2 (%)	Nurse Initial
Pre-Transfusion Baseline
15 Minutes Post Start
30 Minutes Post Start
60 Minutes Post Start
Every 1 Hour Until End
Post-Transfusion End

ADVERSE REACTION WARNING: If fever, chills, rigors, rash, tachycardia, dyspnea, or loin pain occurs: STOP TRANSFUSION IMMEDIATELY, keep IV line open with 0.9% Normal Saline, notify Doctor and Blood Bank.

HTML , 'status' => 1, ], // ================================================================= // Form #2: Initial Medical Assessment & Clinical History // ================================================================= [ 'form_no' => 2, 'template_name' => 'Initial Medical Assessment & Clinical History (Doctor Admission Note)', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

INITIAL MEDICAL ASSESSMENT & CLINICAL ADMISSION RECORD (NABH)

Patient Name: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD No: {{IPD_CODE}}	Age / Sex: {{AGE_GENDER}}
Admit Date & Time: {{ADMIT_DATE}}	Ward / Bed: {{WARD_BED}}	Admitting Consultant: {{DOCTORS}}

CHIEF COMPLAINTS:	[Presenting symptoms with duration]
HISTORY OF PRESENT ILLNESS:	[Detailed chronological narrative of symptoms, progression, and treatment taken prior to admission]
PAST MEDICAL / SURGICAL HISTORY:	[ ] HTN [ ] DM [ ] CAD [ ] Asthma/COPD [ ] CKD [ ] Previous Surgeries: [Details]
ALLERGIES:	[ ] No Known Drug Allergies (NKDA) [ ] Known Allergy: ________________________________
GENERAL PHYSICAL EXAMINATION:	Temp: ____ °F \| Pulse: ____ /min \| BP: ____/____ mmHg \| RR: ____ /min \| SpO2: ____ % on RA Pallor: [ ] Icterus: [ ] Cyanosis: [ ] Clubbing: [ ] Edema: [ ] Lymphadenopathy: [ ]
SYSTEMIC EXAMINATION:	CVS: S1S2 heard, no murmurs. RS: Bilateral vesicular breath sounds, no added sounds. P/A: Soft, non-tender, no organomegaly. CNS: Conscious, oriented, no focal deficit. GCS: 15/15.
PROVISIONAL DIAGNOSIS:	1. ________________________________________________________________ 2. ________________________________________________________________
INITIAL PLAN OF CARE:	[Investigations ordered, IV fluids, medications, dietary instructions, monitoring frequency]

Doctor Name & Reg. No: ___________________________ Sign: ______________

HTML , 'status' => 1, ], // ================================================================= // Form #4: Pre-Anesthesia Checkup (PAC) Record // ================================================================= [ 'form_no' => 4, 'template_name' => 'Pre-Anesthesia Checkup (PAC) Evaluation & Clearance Record', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

PRE-ANESTHESIA EVALUATION & CLEARANCE RECORD (PAC)

Patient: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD No: {{IPD_CODE}}	Age / Sex: {{AGE_GENDER}}
Proposed Surgery: {{PROCEDURE_NAME}}		Operating Surgeon: {{DOCTORS}}

AIRWAY ASSESSMENT:
Mallampati Class: [ ] I [ ] II [ ] III [ ] IV	Mouth Opening: ____ cm (>3.5 cm)	Thyromental Distance: ____ cm (>6 cm)	Neck Mobility: [ ] Full [ ] Restricted
Teeth: [ ] Intact [ ] Loose [ ] Dentures	Anticipated Difficult Airway: [ ] No [ ] Yes (Preparation: Video laryngoscope/FOB)
SYSTEMIC COMORBIDITIES & INVESTIGATIONS:
Hb: ____ g/dL \| Platelets: ____ /cumm \| Blood Group: ____		PT/INR: ____ / ____ \| Blood Urea: ____ \| S. Creatinine: ____
ECG Findings: ________________________________		Chest X-Ray / Echo: ________________________________
ASA PHYSICAL STATUS CLASSIFICATION:
[ ] ASA I: Normal healthy patient [ ] ASA II: Patient with mild systemic disease (controlled HTN/DM) [ ] ASA III: Patient with severe systemic disease (stable angina, COPD) [ ] ASA IV: Severe systemic disease that is a constant threat to life [ ] ASA E: Emergency surgery modifier
PRE-OPERATIVE ANESTHETIC PLAN & INSTRUCTIONS:
Proposed Anesthesia: [ ] GA [ ] Spinal [ ] Epidural [ ] Regional Nerve Block [ ] MAC/Sedation NPO Orders: Solids: 6 hours prior \| Clear fluids: 2 hours prior. Premedication / Medications to continue on morning of surgery: ___________________________ PAC STATUS: [ ] FIT FOR SURGERY UNDER PROPOSED ANESTHESIA [ ] HIGH RISK [ ] PENDING CLEARANCE

Consultant Anesthesiologist Name & Sign: ___________________________

HTML , 'status' => 1, ], // ================================================================= // Form #16: LAMA / DAMA Declaration Form (Bilingual) // ================================================================= [ 'form_no' => 16, 'template_name' => 'Discharge Against Medical Advice (LAMA / DAMA) Form (Bilingual)', 'page_size' => 'A4', 'custom_width_mm' => 210, 'custom_height_mm' => 297, 'page_margin_top_cm' => 0.80, 'page_margin_bottom_cm'=> 0.80, 'page_margin_left_cm' => 0.80, 'page_margin_right_cm'=> 0.80, 'margin_header_cm' => 0.50, 'margin_footer_cm' => 0.50, 'template_html' => <<

LEAVING / DISCHARGE AGAINST MEDICAL ADVICE (LAMA / DAMA) DECLARATION

चिकित्सीय परामर्श के विरुद्ध अस्पताल छोड़ने (LAMA) का घोषणा पत्र

Patient Name: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD No: {{IPD_CODE}}	Age / Sex: {{AGE_GENDER}}
Admission Date: {{ADMIT_DATE}}	LAMA Date & Time: ____________________	Treating Doctor: {{DOCTORS}}

ENGLISH DECLARATION:
I, the undersigned patient / legal guardian / attendant, hereby declare that I am demanding discharge from {{H_Name}} against the explicit medical advice of the treating doctors. The attending physician has thoroughly explained to me the clinical condition, the ongoing treatment requirements, and the severe medical risks involved in premature discharge—including the possibility of worsening disease, permanent disability, organ failure, or death. I take full responsibility for any consequences arising from this decision and discharge the hospital and treating medical team of all clinical and legal liabilities.

हिन्दी घोषणा (HINDI DECLARATION):
मैं, अधोहस्ताक्षरी मरीज / अभिभावक, यह घोषित करता/करती हूँ कि मैं अपनी इच्छा से मरीज को डॉक्टरी सलाह के विरुद्ध (LAMA) ले जा रहा/रही हूँ। मुझे डॉक्टरों द्वारा मरीज की गंभीर बीमारी, आवश्यक इलाज तथा अस्पताल छोड़ने के दुष्परिणामों (जैसे कि बीमारी का अत्यधिक बिगड़ना, अपंगता या मृत्यु का खतरा) के बारे में भली-भांति समझा दिया गया है। मरीज के स्वास्थ्य पर पड़ने वाले किसी भी प्रतिकूल प्रभाव की पूरी जिम्मेदारी मेरी स्वयं की होगी, जिसके लिए अस्पताल या डॉक्टर जिम्मेदार नहीं होंगे।

Signature / Thumb Impression of Patient / Attendant:

Name: ____________________________________
Relationship with Patient: ___________________
Phone / Address: ___________________________

Treating Doctor / Resident Sign: ___________________

Witness 1 (Staff): _______________________________

Witness 2 (Attendant): ___________________________

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CLINICAL DEATH SUMMARY & MEDICAL CERTIFICATE OF CAUSE OF DEATH

Deceased Patient: {{PATIENT_NAME}}	UHID: {{UHID}}	IPD No: {{IPD_CODE}}	Age / Sex: {{AGE_GENDER}}
Admit Date & Time: {{ADMIT_DATE}}	Date & Time of Death: [DEATH_DATETIME]	Attending Doctor: {{DOCTORS}}

CAUSE OF DEATH (WHO Standard / Form 4/4A Format):
I. Immediate Cause of Death (a):	[Due to or as a consequence of] ________________________________
Antecedent Cause (b):	[Due to or as a consequence of] ________________________________
Underlying Cause (c):	________________________________________________________________
II. Other Significant Conditions:	[Contributing to death but not related to disease causing it] ________________
RESUSCITATION (CPR) DETAILS:
Cardiac arrest rhythm: [ ] Asystole [ ] VF/VT [ ] PEA. CPR initiated at: ____:____ hrs. Duration of CPR: ____ minutes. DC Shock delivered: [ ] Yes ([NUMBER] shocks) [ ] No. Intubation: [ ] Yes [ ] Already intubated. Emergency drugs administered (Adrenaline, Atropine, Bicarbonate): Yes. Despite full ACLS resuscitation measures, spontaneous circulation could not be restored. Pupils fixed and dilated, bilateral absent breath sounds, flat-line asystole on continuous ECG monitor. Patient declared clinically dead at: ____:____ hrs on [DATE].
MEDICO-LEGAL STATUS:
[ ] Non-MLC Case (Natural death) - Body handed over to family. [ ] Medico-Legal Case (MLC) - Local Police Station notified: ____________________. Body sent for Post-Mortem.

Doctor Name & Medical Council Reg. No: ___________________________ Sign: ______________

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