[Hospital Name]

[HospitalAddress]
Admission & Discharge Record
Name Date & Time
Gender Room / Bed
DOB & Age Bed Type
Marital Status Pat. Type
[Relation] Dep. & Unit
Address    
   
   
   
Pin code    
Phone    
Religion Region [Region]
Ref Doctor [RefDoctor]
Occupation [Occupation] Doctor
Admission Order
To : Admitting office
Please Admit on [AdmitDate] At [AdmissionTime]
Dept. [ADepartment] Unit [AUnit]
Consultant [ConsultantName]
Signature of Admitting Dr [AdmitDocName]
Discharge Order
To : Nurse in Charge
Please Discharge on [DisDate] At [DisTime]
Dept. [ADepartment] Unit [AUnit]
Consultant [DisConsultentName]
Special instructions [SplInstructions]
[SplInstructions]
[SplInstructions]
Signature of Discharging Dr [DisDoctor]
For Admitting Office Only
Admitted under Dr [AdmittedUnder] Dept [Department] Unit [Speciality]
Date of Admission [AdmissionDate] IP No [IPNo] Time [AdmissionTime]
Allocated Room / Bed [BedNo]
Name & Signature of admitting officer [AdmittingOfficer]
(CAPITTAL LETTER) DOCTORS (Fill within 24Hrs of discharge) International Code
Provisional Diagnosis
[ProvisionalDiagnosis]
Final Diagnosis
(Main & Additional )
[FinalDiagnosis]
Discharge Status [DischargeStat]
If expierd cause of death [CauseOfDeath]
Name & Signature of Doctor [DocSign] Date [DocDate] Name & Signature of Unit Head [UnitHeadSign] Date  [UnitDate]

Medical Records Department

No. of sheets in the Record Sorting & Assembling By Deficiency Check By Coding By