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Patient Case Sheet: Hospital Logo

This document contains a patient case sheet for a hospitalized patient. It includes fields for the patient's name, ID number, age, sex, admission details like date and time, emergency and permanent addresses, contact information, medical legal case details if applicable, diagnosis and treatment details, outcome at discharge like cured or expired, and areas for doctor signatures. The case sheet is used to document all relevant information for a patient during their hospital stay.

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Birupakshya Rout
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
5K views2 pages

Patient Case Sheet: Hospital Logo

This document contains a patient case sheet for a hospitalized patient. It includes fields for the patient's name, ID number, age, sex, admission details like date and time, emergency and permanent addresses, contact information, medical legal case details if applicable, diagnosis and treatment details, outcome at discharge like cured or expired, and areas for doctor signatures. The case sheet is used to document all relevant information for a patient during their hospital stay.

Uploaded by

Birupakshya Rout
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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HOSPITAL LOGO

PATIENT CASE SHEET















Name of the Patient :

UMR. No / IP No : __________________________________
Consultant Name :





(Hospital address)
HOSPITAL LOGO


PATIENTSS NAME............................................................................. GENDER
M/F


AGE


IPNO


ADMISSION RECORD

Name of Patient :

IP No:

Age :

Sex:

Date of Admission:

Time:

WAP No:

Unit : Ward : Claim No:

Fathers / Husbands Name :

Occupation :

Annual Income :

Emergency Address:

Permanent Address:

House no:

Street:

House no:

Street:

Village/Town:

Mandal:

Village/Town:

Mandal:

District:

Pincode:

District:

Pincode:

Mobile No:

Telephone No. :

Email id:

Prepared by :

Medico legal case: Yes/No
Details of Police information :

Name of the informant:
Police Station.......

PC No.& Name :
Date & Time of Discharge :

Hospital Stay :
Identification marks:1

2.

ICD :

Provisional Diagnosis On Admission:
Final Diagnosis :
Secondary Diagnosis :
Complications :
Operative Procedures / Medical Managment :
Consultans:
Discharge Status : Cured/RELIEVED / Not Relived/Improved/Referred to higher Center

LAMA : Signature of the Patient / Thumb impression]

Expired :

Date & Time :

AUTOPSY Yes/No


(Stamp & Signature of Treating doctor) : Date & Time

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