Personal History

Smoking

Alcohol

Tobacco

Drug abuse

Hypertension

Type 2 diabetes mellitus (DM)

HBsAg

HCV

HIV I & II

From Nursing History & Physical Assessment No Nursing H&P prefill found

History & Physical Note (HPI)

Women Related LMP

Last Baby

Pregnancy Related

Women Related Problems

Complaints with Duration and Reason for Admission

#	Complaint	Frequency	Severity	Duration

Pain Measurement Scale

No Pain Mild Pain Moderate Intense Worst Pain Possible

Drug Allergy / ADR (NABH)

Drug Allergy Status

Drug Allergy Details (when status = Known)

ADR History

Current Medications

Co-Morbidities

Diabetes mellitus (DM) high blood pressure (HTn) Coronary artery disease (CAD) Chronic Obstructive Pulmonary Disease cerebral vascular accident (CVA)

Other Co-Morbidities

Other Complaints / Detailed History

Examination on Admission

General Examination

Pulse /min

Respiration /min

BP mmHg

Height cm

Weight kg

Pallor

Jaundice/Icterus

Cyanosis

Clubbing

SPO2

RBS

Temp F

Edema

JVP

Sensorium

Oedema

Lymphadenopathy

HC inch

CNS

CVS

Pupils

Chest

GCS

P/A

Neurological Deficit

Other / Systemic Examinations

Other / Systemic Examinations (Single Editor)

Clinical Investigation Reports

Clinical Investigation (In-Hospital Lab) Blood Hb, Blood Sugar, Renal Function, Serum Bilirubin, Urine Test

[31-05-2026] Eosinophils,Hemoglobin,Lymphocytes,Mean Corpuscular Hemoglobin,Mean Corpuscular Hemoglobin Concentration,Mean Corpuscular Volume,Monocytes,Neutrophils,Packed Cell Volume,Platelet Count,Red Blood Cells,Total Leukocyte Count

Clinical Investigation (X-Ray / ECG / Sonography / CT / MRI) Select finalized impression-based reports during this admission

No non-pathology impression reports found between admission and discharge dates.

Hb %

TLC

DLC

ESR

Mx Test

RBS

HbA1C

B.group & RH factor

BT

CT

PT

LFT

KFT

S.Electrolytes

S.Amylase

S.Lipase

HBsAG

HCV

HIV I & II

X-ray

E C G

Sonography : USG

C T Scan

M R I

Urine (R/M)

Other Investigations

Other Examinations / Provisional Diagnosis

Admission / Discharge Information

Department

Patient Status

Discharge Date

Discharge Time

Surgery / Procedure / delivery if any

Surgery

Name	Date	Remark	Action
LML	2026-06-04

Procedure

Name	Date	Remark	Action
Procedure TEST	2026-06-03

Final Diagnosis

Diagnosis	Remark	Action
No diagnosis rows.

Tip: if ICD match exists, selected value appends code in diagnosis text.

Final Diagnosis (Narrative)

Summary of key investigation during Hospitalization

Course / Treatment in the hospital

Course	Remark	Action
No course rows.

Course / Treatment in Hospital (Narrative)

Condition at the time of Discharge

Pulse /min

Respiration /min

BP mmHg

Height cm

Weight kg

Pallor

Jaundice/Icterus

Cyanosis

Clubbing

SPO2

RBS

Temp F

Edema

JVP

Sensorium

Oedema

CNS

CVS

Lymphadenopathy

Pupils

Chest

GCS

P/A

Neurological Deficit

HC inch

Discharge Medicine Prescribed

No Rx-Group selected

Select group and preview medicines before add.

Medicine	Type	Dose	When	Freq	Days	Qty	Remark	Action
No medicine added

Discharge Instructions / Advice

Selected Dietary Advice (Hindi print preview)

No dietary advice selected.

Other Advice

Discharge Instructions / Advice

Review After (days/text)