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    Admission Discharge Card Front and Back

    Uploaded by

    Adane Belay
    gfgf

    Copyright:

    © All Rights Reserved
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    Admission Discharge Card Front and Back

    Uploaded by

    Adane Belay
    121 views2 pages
    gfgf

    Original Title

    admission discharge card front and back

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    © © All Rights Reserved

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    gfgf

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    121 views2 pages

    Admission Discharge Card Front and Back

    Uploaded by

    Adane Belay
    gfgf

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Federal Ministry of Health

    JeúM ¾N=dw Te¨mÁ l.


    ______________________ HOSPITAL CASH SHEET NO. _________________
    ¾QSU}™‹ SkuÁ ካ`É
    ADMISSION CARD
    ¾I¡U“ ካ`É lØ`
    Medical Record Number (MRN) __________________
    eU ¾›vƒ eU
    Name ______________________________________ Father’s Name _______________________
    ¾›Áƒ eU ï
    Grand Father’s Name __________________________ Sex ___________________
    ›É^h ¡MM ¨[Ç/¡õK-Ÿ}T
    Address: Region ______________________ Woreda/Subcity ________________
    kÖ“/ÔØ kuK?
    Katena/Gott _________________ Kebele_______________________
    ¾u?ƒ lØ` eM¡ lØ`
    House Number________________ Phone Number ________________
    ¾¡õK< lØ` ¾›MÒ lØ`
    Ward No. ______________________________ Bed No. ______________________
    c=Ñv ¾QSS< G<’@
    Admission Diagnosis ____________________________________________________________
    ¾}[ÒÑÖ¨< QSS<
    Discharge Diagnosis ____________________________________________________________
    ŸJeúM c=¨× ¾’u[¨< G<’@
    Condition on discharge
    ŸISS< É•/}iKAƒ V„ ¨Å K?L Ö?“ É`σ }M¢
    Improved Dead Referred
    ŸNŸ=U ðnÉ ¨<ß uѳ ðnÆ H@Ê Öõ„
    left against medical advice Absconded
    JeúM ¾Ñvuƒ k” ¾}kuK¨< NŸ=U ò`T
    Date of admission _________________ Signature of Admitting Dr. _________________________
    ¾¨×uƒ k” Ác“u}¨< NŸ=U
    Date of Discharge _________________ Discharged by ___________________________________

    ¾S˜ ¡õM Lòª ’`e ò`T KSÓv~ ¾S˜ ¡õM Lòª ’`e ò`T KS¨<×~
    Sign. Of Ward Nurse for Admission ____________ Sign. Of Ward Nurse for Discharge ___________
    ¾Ç_¡}\ ò`T KSÓv~ (›eðLÑ> ŸJ’) KS¨<×~ (›eðLÑ> ŸJ’)
    Director’s Sign. For Admission (if required) _____________ For Discharge (if required) ___________

                  ¾›=ƒ/w` X
    Birr Cts.
    ¾}—uƒ k” w³ƒ ¾›”É k” ¡õÁ w`
    Number of days admitted __________________ Amount per day in birr ______________________
    ¾›?¡e_Ã U`S^ N=dw
       
    For X-Ray Examination ________________________________________________________________

    SÉኃ’>ƒ N=dw
    For Medicine _________________________________________________________________________
       
    ¾*ý^c=Ä” N=dw
    For Operation ________________________________________________________________________
       
    ¾Lx^„` N=dw
    For Laboratory _______________________________________________________________________
       
    M¿ M¿ ›ÑMÓKAƒ N=dw
    For Various Services ___________________________________________________________________
       
    }ŸóÃ
    Total Payment
    uSÁ¹ ›ekÉV ¾}ŸðK
    Deposited
    ¾_Ïeƒ^\ ò`T
    Signature of Registrar
    }SLi
    _____________________ Amount to be Reimbursed
    }ÚT] ¡õÁ
    Amount to be paid
    ¾N=Xw g<U ò`T
    Signed by The Chief Accountant ____________________________________

    FMOH Ver 02/02


    Federal Ministry of Health
    KQ¡U“¨< H>Xw }ÖÁm
    FINANCIAL RESPONSIBILITY

    ¾Ñ”²w Ÿóà eU
    Name of Individual Responsible for bill ____________________________________________________

    ¾Y^ x ¾eM¡ lØ`


    Occupation _____________________________________________ Tel. ________________________

    kuK? ¨[Ç/¡õK-Ÿ}T ¾u?ƒ lØ` ¾eM¡ lØ`


    Kebele _____________ Woreda/Subcity _____________ House No. _________ Tel. __________

    ¾´UÉ“¨< ¯Ã’ƒ ¨Å JeúM ÁSר<


    Relationship ____________________________ Brought to Hospital by __________________________

    eT@ ŸLà ¾}ÑKì¨< ŸLà ¾}Ö¾k¨<” Ñ”²w uS<K< ¾S¡ðM Lò’ƒ ”ÇKw˜ uò`T ›[ÒÓ×KG<::

    I the above Named person accept full responsibility for payment of the charges incurred during this period of Hospitalization.

    ò`T
    Signature__________________________

    FMOH Ver 02/02

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