 |
[Hospital Name][HospitalAddress] |
| Admn. History Physical Examn. & Treatment plan |
| Present Complaints |
|---|
| [PresentComplaint] |
| History |
|---|
| [History] |
| Physical Examination |
|---|
| VITAL SIGNS : | RR(/min) | PULSE(/min) | BP(mm/Hg) | [TEMP] | WT(kg) |
| [RR] | [PULSE] | [BP] | [TMP] | [WT] |
| [GENEXAM] |
| Assesment/Diagnosis | |
|---|---|
| [ASSESMENTDIAGNOSIS] |
| Admission orders & patient care plan |
|---|
| 1 | [ISOLATION] |
| 2 | [VITALSIGNS] |
| 3 | [DIET] |
| 4 | [ACTIVITY] |
| 5 | [PLAN] |
| Approximate cost has been explained to the patient / Relative | [APROXCOST] |
| [ENTDOCNAME] | [ENTDATETIME] |
| Doctor's Name & Signature | Date & Time |
| [DOCNAME] | [DATETIME] |
| Consultant Name & Signature(To be signed within 24 hours of admission) | Date & Time |