Admission and Discharge Data Retain With Chart
Patient ID IP Adm.Code Adm.Date Time Ward Bed Type & Bed No [PatientCode] [IPAdmCode] [AdmDate] [Time] [Ward] [BedTypeBedNo] Patient Details Patient Name : [pname] Sex : [Sex] Date Of Birth : [DOB] Age : [Age] Nationality : [Nationality] Marital Status : [Marital] Address : [Address] Guardian : [Guardian] Relation : [Relation] State : [State] Mobile : [Mobile] Residence Phone : [Residence] Insurance Details TPA Company Policy Policy/Card No Valid From Valid Upto [TPA] [Company][TopUp] [Policy] [Policy/CardNo] [ValidFrom] [ValidTo] Visit Details Department : [Department] Admitting Provider : [AP] Reference Provider : Pay Type : [Paytype] Source of Admission : 1. Elective 4. Transfer 2. Emergency 5. Born Here 3. Direct From Clinic 6. Other DIAGNOSIS ON ADMISSION : Discharge Details Date Of Discharge : Disposition : 1. Discharged Home 4. Discharged on Request 2. Transfer Other Hospital 5. Deceased Length Of Stay : 3. Discharged Against Medical Advice(DAMA) MEDICAL SUMMARY FINAL DIAGNOSIS CODE NUMBER Primary Diagnosis Secondary Diagnosis OPERATIONS AND PROCEDURES : CONSULTANT SIGNATURE :
(For office use only)
Entered By : [User]
Patient Signature	Patient Attentant/Guardian Signature	Signature of the Front Office Staff