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{{H_Name}}{{H_address_1}}, {{H_address_2}} | Phone: {{H_phone_No}}
INPATIENT ADMISSION RECORD & FACE SHEET
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| 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 |
| Patient Name: {{PATIENT_NAME}} | UHID: {{UHID}} | IPD No: {{IPD_CODE}} | Age / Gender: {{AGE_GENDER}} |
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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: ______ |
| 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: ___________ |
{{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 | Start Date | 06:00 AM | 10:00 AM | 02:00 PM | 06:00 PM | 10:00 PM | 02:00 AM | Doctor Signature |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
{{H_Name}}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: ________________ |
| 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: ___________________________ | ||
|
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}} |
| 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: __________________ |
| 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 |
| 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 |
| 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 |
| 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] |
| 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 |
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| 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 |
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| 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।
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Signature / Thumb Impression of Patient / Attendant: Name: ____________________________________ Relationship with Patient: ___________________ Phone / Address: ___________________________ |
Treating Doctor / Resident Sign: ___________________ Witness 1 (Staff): _______________________________ Witness 2 (Attendant): ___________________________ |
| 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]. |
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| MEDICO-LEGAL STATUS: | |
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[ ] Non-MLC Case (Natural death) - Body handed over to family. [ ] Medico-Legal Case (MLC) - Local Police Station notified: ____________________. Body sent for Post-Mortem. |
|