1
Name of patient Age I.P. Number
Ward / Unit
HEALTH SERVICES DEPARTMENT,
GOVERNMENT OF KERALA
HOSPITAL:
Name of Patient
Ward No: Bed No:
CASE RECORD
ALLERGIC TO :
UHID :
(Unique Health ID)
ICD Code Number:
Age
Date of Admission :
Date of Discharge :
IP No
MLC : Yes No
(Printed and supplied by Hospital Management Committee/ Society)
Name of Hospital
2
Name of patient Age I.P. Number
Instructions to Doctors and staff directly involved in documentation
• Keep the record neat and clean
• Case record is the only written evidence of what the physician has accomplished to the
patient.
• All columns relevant to the case should be documented legibly, promptly and completely.
• Events / services rendered not recorded assumed as not done.
• Final diagnosis should be justifiable with treatment and end results and should record in
scientific terms.
• In death cases both Direct cause and Antecedent causes should be specifically noted in
the Case record, Death register Death notification and report forms.
• Whoever/whenever/whatever write in the Case record, should authenticate their
statements with their name, designation and dated signature.
The information contained in this case record is confidential
and should not be disclosed to any person other than treating
doctor or other healthcare providers like nurses and
paramedics. The information may be given directly to patients
if they request in writing. Parents of children below 18 years
may be given the information, if needed.
Name of Medical Records Officer :
Name of Medical Records Librarian :
(or officer in charge of Medical Records)
Name of Hospital
3
Name of patient Age I.P. Number
O.P. number:
SUMMARY SHEET
Head of Service / Unit Chief Ward Unit Admission
Date Time
Name of patient: Sex Occupation Monthly income
(in block letters)
Address:
Date of Birth Year Month Date
BPL: Yes / No
Diagnosis ICD Code
Number
(by MRD Staff)
Surgery if any
( specify nature of surgery/ procedure)
If Delivered, date and time of delivery: Sex of baby:
______________________________________________________Weight_ :__________
Date and time of Discharge :
________________________________________________________________________
If referred to another institution, name of that institution:
Cause of Referral :
________________________________________________________________________
If died, Cause of death 1. Direct cause :
(in block letters )
2. Antecedent cause :
Date and Time :
DISCHARGE SUMMARY
(or a copy of the discharge card may be attached)
Signature, Name and designation of M.O
Name of Hospital
4
Name of patient Age I.P. Number
Contact number of patient / Guardian
……………… ………………… …
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Name of Hospital
5
Name of patient Age I.P. Number
Present Complaints Duration
History of illness
________________________________________________________________________
Past History
(gestational / birth history in the case of infants)
Family history
________________________________________________________________________
Immunization
________________________________________________________________________
Socio-economic status
________________________________________________________________________
Personal History Smoking Alcohol Chewing
Vegetarian Non vegetarian
Other details
H/O Allergy
Current Medication if any
Name of Hospital
6
Name of patient Age I.P. Number
PHYSICAL EXAMINATIONS
General examination
Pulse /min Respiration /min BP mmHg Height cm Weight kg
Sensorium : Conscious/ Drowsy / Comatose
Pallor : Yes/ No Jaundice: Yes/ No Cyanosis: Yes/ No Oedema: Yes/ No
Clubbing: Yes/ No
Hair : Skin : Nails :
Systemic Examination: (Respiratory system/ Cardiovascular system/ Central Nervous system/ Alimentary
system/ Genito-urinary system/ Musculoskeletal system/ Endocrine system/ Lymphatic system)
Other examinations
Provisional
Diagnosis
Name of Hospital
7
Name of patient Age I.P. Number
CLINICAL INVESTIGATION REPORTS
Date Value Date Value Date Value
Blood Hb
TC
DC
ESR
Bleeding time
Clotting time
Platelet count
Blood Sugar
FBS
PPBS
RBS
Cholesterol
Renal Function
Urea
Creatinin
Sodium
Potassium
Serum Bilirubin
Blood grouping &
Rh typing
H B S Ag
HIV
Urine
Albumin
Sugar
Acetone
Bile Salt
Bile Pigment
Urobilirubin
Deposits
RESULT OF HISTOPATHOLOGY EXAMINATIONS
Name of Hospital
8
Name of patient Age I.P. Number
SPECIAL INVESTIGATION
X – ray
ECG
Sonology: U S S
C T Scan
MRI
Other Investigations
PLAN OF TREATMENT
Name of Hospital
9
Name of patient Age I.P. Number
OBSTETRIC & GYNECOLOGY EXAMINATIONS
Complaints
_______________________________________________________________________________
Family History
Previous History
Menstrual history: Age of onset LMP PMP
Inter menstrual symptoms
Menopause
Marital and Obstetric history
History of present illness
General examination (Page 6)
Pelvic Examination
Rectal examination
Provision Diagnoses
Investigations: (Page 7 & 8 )
Treatment advised
Name of Hospital
10
Name of patient Age I.P. Number
OBSTETRIC & GYNECOLOGY PATIENTS - ADMISSION NOTES
History of previous labours
Gravida Para L. C .B. L.M.P E. D. C
Complications in present pregnancy
_______________________________________________________________________
General examination (Page 6)
Important findings
_______________________________________________________________________
Onset of Pain: Hours: Show: Bleeding :
_______________________________________________________________________
Membranes: Intact / ruptured Hours ago:
_______________________________________________________________________
Abdomen palpation
________________________________________________________________________
Height of fundus: Condition of Uterus
Presentation: Position:
________________________________________________________________________
Relationship of presenting part to pelvis:
F.H. position and rate :
Vaginal Examination
LABOUR RECORD
------------------------------------------------------------------------------------------------------------
Ward Unit O.R. Number Provisional diagnosis
------------------------------------------------------------------------------------------------------------
Nature of Labour
------------------------------------------------------------------------------------------------------------
Name of Mother…………………………verified by(sig & name of Nurse)………………... …...
Date & time of delivery………………… verified by …………………………………….
Sex of baby (in capital letters) ………… verified by ……………………………………..
Confirmed by : sig. & name of the attending doctor
LABOUR NOTE :
Name & designation of M.O Name & Nurse attending the case
Name of Hospital
11
Name of patient Age I.P. Number
INFORMED CONSENT FOR SURGERY/ INVASIVE PROCEDURE
Name and signature of the patient :
Name and signature of the relative:
Name, Designation and Signature of the doctor informed the patient:
INFORMED CONSENT FOR ANESTHESIA
Name and signature of the patient :
Name and signature of the relative:
Name, Designation and Signature of the doctor informed the patient:
Name of Hospital
12
Name of patient Age I.P. Number
Name of patient: Verified Site of Surgery: Verified
Side of Surgery: Verified
REPORT OF SURGERY
Date :
Name of Surgeon : Anesthesiologist:
Name of Nurse :
Pre-operative Diagnosis
Pre – operative medications
Surgery- Major/ Minor Begins at : Ended at :
DESCRIPTION OF SURGERY
Post Operative Assessment and plan of Treatment
Name, designation and
Signature of Surgeon
Name of Hospital
13
Name of patient Age I.P. Number
PRE ANESTHESIA CHECK UP
Date: Time:
Planned procedure:
History
Physical Examination
PR /min BP mm Hg Pallor
Icterus
Airway
Mouth opening
TMJ Neck movements
Mallampattic class
Venous access
Spine
CVS
Respiratory System
CNS
Other systems
ECG/ X Ray and other investigations
Remarks
Instructions
Name of Hospital
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Name of patient Age I.P. Number
ANESTHESIA MANAGEMENT RECORD
Date: Time:
Procedure :
Name of Anesthesiologist: Name of Anesthesia Nurse:
Name of Surgeon:
Notes
Time PR BP RR PaO2 IV fluids Drugs Remarks
Reversal
Post Operative Instructions
Name of Hospital
15
Name of patient Age I.P. Number
PROGRESS NOTES AND DOCTORS ORDERS
Date& Progress Notes Doctors’ orders Name & sig.
Time of Doctor
Name of Hospital
16
Name of patient Age I.P. Number
PROGRESS NOTES AND DOCTORS ORDERS
Date& Progress Notes Doctors’ orders Name & sig.
Time of Doctor
Name of Hospital
17
Name of patient Age I.P. Number
PROGRESS NOTES AND DOCTORS ORDERS
Date& Progress Notes Doctors’ orders Name & sig.
Time of Doctor
Name of Hospital
18
Name of patient Age I.P. Number
PROGRESS NOTES AND DOCTORS ORDERS
Date& Progress Notes Doctors’ orders Name & sig.
Time of Doctor
Name of Hospital
19
Name of patient Age I.P. Number
SPECIAL CONSULTATIONS & REPORTS
Name of Hospital
20
Name of patient Age I.P. Number
SPECIAL CONSULTATION & REPORTS
Name of Hospital
21
Name of patient Age I.P. Number
NURSES RECORD & REPORTS
Date Hour Medicines / services given Remarks Name & Sig. of
Nurse
Name of Hospital
22
Name of patient Age I.P. Number
NURSES RECORD & REPORTS
Date Hour Medicines / services given Remarks Sig. of Nurse
Name of Hospital
23
Name of patient Age I.P. Number
Name of Hospital
24
Name of patient Age I.P. Number
GRAPHIC CHART & PAIN SCORE
Name of Hospital
25
Name of patient Age I.P. Number
HEALTH SERVICES DEPARTYMENT, KERALA
……………………….. Hospital , ………………………………..
DICHARGE CARD / DISCHARGE SUMMARY
Head of services Department/Specialty Head of the institution
Dr. Dr.
Name of patient : Age Sex
Address :
___________________________________________________________________________
I. P Number Unit / ward
____________________________________________________________________________
Date of admission Date of discharge
____________________________________________________________________________
Other Specialists / Consultants attended the case
____________________________________________________________________________
Final Diagnosis
Operation / delivery if any (if delivery, date & time of delivery and sex of baby)
____________________________________________________________________________
Brief history and Clinical Notes
____________________________________________________________________________
Investigations
____________________________________________________________________________
Treatment
Advice on discharge
____________________________________________________________________________
(To be reviewed on / after …………………… at ………………………………..OPD)
Name & Designation of Medical Officer
( Keep this card clean and neat ; don’t damage or destroy ; bring on subsequent visits )
Name of Hospital
26
Name of patient Age I.P. Number
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Name of Hospital
27
Name of patient Age I.P. Number
(carbon copy- to be retained in the case sheet)
HEALTH SERVICES DEPARTYMENT , KERALA
……………………….. Hospital , ………………………………..
DICHARGE CARD / DISCHARGE SUMMARY
Head of services Department/Specialty Head of the institution
Dr. Dr.
Name of patient : Age Sex
Address :
___________________________________________________________________________
I. P Number Unit / ward
____________________________________________________________________________
Date of admission Date of discharge
____________________________________________________________________________
Other Specialists / Consultants attended the case
____________________________________________________________________________
Final Diagnosis
Operation / delivery if any (if delivery, date & time of delivery and sex of baby)
____________________________________________________________________________
Brief history and Clinical Notes
____________________________________________________________________________
Investigations
____________________________________________________________________________
Treatment
Advice on discharge
____________________________________________________________________________
(To be reviewed on / after …………………… at ………………………………..OPD)
Name & Designation of Medical Officer
Name of Hospital
28
Name of patient Age I.P. Number
Name of Hospital
29
Name of patient Age I.P. Number
Back Cover (inside)
General Instructions
• Patients and/or family members should be explained about the proposed care, expected results,
possible complications and expected costs.
• The initial assessment for in patients should be documented within 24 hours or earlier as per the
patient’s condition. The initial assessment should include screening for nutritional needs.
• Document pan of care including preventive aspects of care, which should be monitored.
• All patients should be reassessed at appropriate intervals and documented, to determine their response
to treatment and to plan further treatment or discharge.
• Care of patients should be coordinated in all care settings within the organization.
• Patient discharge process should be planned in consultation with the patient and/or family.
• Summery of patient condition and the treatment given should be provided in case of transfer or
referral of patients.
• A discharge summary should be given to all the patients leaving the organization, including patients
leaving against medical advice at the time of discharge.
• Discharge summary should contains the reason for admission, significant finding, diagnosis,
investigation results, any procedure performed, medication and other treatment given, patient
condition at the time of discharge, follow up advice, medication and other instruction in an
understandable manner.
• Discharge summery incorporates instructions about when and how to obtain urgent care.
• The care and treatment orders should be signed, named, timed and dated by concerned doctor.
• The care plan should be countersigned by clinician in charge of the patient within 24 hours.
• Evidence based medicine and clinical practice guidelines are adopted to give patient care whenever
possible.
• Admission or discharge to home or transfer to another organization should also be documented.
• In case of cardiopulmonary resuscitation the events should be recorded.
• Informed consent should be obtained for donation and transfusion of blood and blood products.
• In case of transfusion reactions, it should be analyzed for preventive and corrective actions.
• Infection control practices should be followed
• High risk obstetric patient’s assessment also should includes maternal nutrition.
• Assessment of children should include detailed nutritional, growth, psychological and immunization
assessment.
• The children’s family members should be educated about nutrition, immunization and safe parenting
and this should be documented in the medical record.
• All patients for anesthesia should have a pre anesthesia assessment by a qualified doctor.
• The pre anesthesia assessment should results in formulation of an anesthesia plan which should be
documented.
• An immediate pre operative re evaluation should be documented.
• Informed consent for administration of anesthesia should be obtained by the anesthesiologist.
• Surgical patients should have a preoperative assessment and provisional diagnosis documented prior
to surgery.
• An informed consent should be obtained by a surgeon prior to the procedure.
• A brief operative note should be documented prior to transfer out of patient from recovery area.
• Surgeon documents the post operative plan of care. The plan also includes monitoring of surgical site
infection rates.
Name of Hospital
30
Name of patient Age I.P. Number
Back Cover
• Medication orders should be clear, legible, dated, timed, named and signed. Orders are written in
uniform location in the medical records.
• High risk medication orders should be verified prior to dispensing.
• Expiry date of drugs should be checked prior to dispensing.
• Patient should be identified prior to dispensing. Dosage, route and time should be verified from the
order prior to administration. Medication administration should be documented.
• Patient and family members should be educated about safe and effective use of medication and food
drug interactions.
• Patients are monitored after mediation administration. Any adverse drug events should be reported
within a specified time. Adverse drug events should be collected and analyzed.
• A proper record should be kept of the usage, administration and disposal of narcotic drugs and
psychotic substances.
• Chemotherapy should be prescribed by those who have the knowledge to monitor and treat the
adverse effect of chemotherapy. Chemotherapy should be prepared and administered by qualified
personnel. Chemotherapy drugs should be disposed off in accordance with legal requirements.
• General consent for treatment should be obtained when patient admitted to the hospital.
• Informed consent includes information on risks, benefits, alternatives and as to who will perform the
requisite procedure in a language that they can understand.
• Patient and families should be educated about the safe and effective use of medication and the
potential side effects of the medication.
• Patients and families should be educated about diet and nutrition, immunization, specific disease
process, complications, prevention strategies and preventing infections. Patients and family should be
taught in a language and format that they can understand.
• Patients and family should be educated about estimated costs of treatment. Patients and family should
be informed about the financial implications, when there is a change in the patient condition or
treatment setting.
• Every medical record should have a unique identifier. Every medical record entry should be dated and
timed.
• When patient is transferred to another hospital, the medical record contains the date of transfer, the
reasons for the transfer and the name of the receiving hospital.
• The medical records should contain information regarding reasons for admission, diagnosis and plan
of care.
• Operative and other procedures performed should be incorporated in the medical records.
• The medical records should contain a copy of the discharge note duly signed by appropriate and
qualified personnel.
• In case of death, the medical records should contain a copy of the death certificate indicating the
cause, data and time of death.
• Whenever medical autopsy is carried out, the medical records should contains a copy of the report of
the same.
Name of Hospital
