[Hospital Name]
[HospitalAddr1][HospitalAddr2]
[HospitalAddr3]
[HospitalAddr4]
[HospitalPhone]
[HospitalEmail]
[HospitalWeb]
[Hospital Name][HospitalAddr1][HospitalAddr2] [HospitalAddr3] [HospitalAddr4] [HospitalPhone] [HospitalEmail] [HospitalWeb] |
|
[DoctorName] [DocQualification] [Department] [ConsultType] [Speciality] |
|
Admn. History Physical Exam. & Treatment Plan |
| Patient ID | [PatientID] | Visit Date | [DoVisit] |
| Patient Name | [PatientName] [Sex] / [Age] | ||
| Address |
[Address1] [Address2] |
Mobile | [Mobile] |
| PRESENT COMPLAINTS : [Complaints] |
| HISTORY : [History] |
| PHYSICAL EXAMINATION |
|---|
| RR(/min) | PULSE(/min) | BP(mm/hg) | TEMP | WEIGHT(kg) |
|---|---|---|---|---|
| [Resp] | [Pulse] | [SBP]/[DBP] | [Temp] | [Weight] |
| [Exam] |
| ASSESSMENT/DIAGNOSIS: [Diagnosis] |
| ADMISSION ORDERS & PATIENT CARE PLAN |
|---|
| Isolation if any | : | [Isolation] |
| Vital Signs | : | [Vital] |
| Diet | : | [Diet] |
| Activity | : | [Activity] |
| Plan | : | [Plan] |
|
Approximate cost has been explained to the Patient/Relative. Rs. [Cost] ./- |
|
[Prepared] Doctor's Name & Signature |
[Date] |
|
[DoctorName] Doctor's Name & Signature (To be signed within 24 hours of admission) |
[Date] |
| Printed Date : [PrintDate] |