STANDARD FORM USED IN DAY TO DAY PRACTICE

1. ACCIDENT / INJURY REPORT

2. DISCHARGED AGAINST MEDICAL ADVICE

3 DISCHARGED AGAINST MEDICA ADVICE

4. BIRTH REGISTER

5. M.T.P CONSENT FORM

6. BIRTH CERTIFICATE

7. MEDICAL CERTIFICATE FOR LEAVE

8. MEDICAL CERTIFICATE FOR FITNESS

9. CASE SHEET

10. INFORMED CONSENT FOR SURGICAL PROCEDURES AND ANESTHESIA

11. DANGEROUSLY ILL INFORMATION CONSENT FORM

12. VACCINATION SCHEDULE

13. EMERGENCY CASE REGISTER

14. POLICE INTIMATION

15. OP DEPARTMENT REGISTER

16. SURGERY RECORD

17. PRE ANESTHETIC CHECK LIST

18. SPECIFIC CONSENT FOR ANESTHESIA

19. SPECIFIC CONSENT FOR SURGICAL PROCEDURE

20. CONSENT FORM FOR THROMBOLYSIS AND DIL CONSENT

21. PRESCRIPTION FORMAT

 DISCHARGED AGAINST MEDICAL ADVICE

Name of Patient, Age, Sex IP No. Father’s Name Ward No.

Date of admission Referring Dr Diagnosis

BP PR TEMP SPO2 RR CONSCIOUS Ambulant Venflon Catheter Ryle’s Bedsores

Date Time of Discharge Auto / Ambulance / Car Wheel chair / Stretcher O2 GC at time of shift

I. .............................................................................. am getting my ............................................................................

Mr. / Mrs. ............................................................................. discharged from this Nursing Home against medical advice on
this day of .................................................................. due to personal reasons. I understand that the illness of the patient is
not yet cured and I undertake the risk of taking a sick patient out of the medical supervision.

I reiterate that I am wholly responsible for the harm / Deterioration / Injury caused to the patient on getting discharged
in such a condition and I will not hold the concerned Doctor / Consultant / Hospital staff responsible for any un toward
outcome.

I also understand that the Doctor or Nursing Home cannot provide me any Certificate in the regard.

Name, Age, Sex, Address, Phone No. Relationship Signature LTI Date Time
PERSON
WITNESS-2 WITNESS-1

Page - 1
 BIRTH CERTIFICATE (in triplicate)

Serial No________________________ IP No_________________________ Date___________________

This is to certify that Mrs.……....................……………………………………………… Aged…………………………… wife of

.......................………………………………….. Residing at …………………..…………………………………………………..

has delivered a live MALE / FEMALE baby in this hospital on Date ______________________ Time_________________

NAME OF THE M.O with Signature

MEDICAL CERTIFICATE FOR LEAVE / EXTENSION or COMMUTATION OF LEAVE

I, Dr………………………………………..............………………………, after careful examination of the case, do hereby

certify that ………………………………………………..……… working as ……………………………………………………. In

……………………………………………………………...………………………… whose signature is given below, is / was

suffering from ……………………………………………….……………………….. and I consider a period of absence in duty

of ……………………………………...………….. days with effect from …………………………….......…… is / was absolutely

necessary for the restoration of his / her health.

Patient Ref No: LTI or Signature of the patient:

( NAME OF THE M.O WITH REGN NO & SEAL)

 MEDICAL CERTIFICATE FOR FITNESS TO RETURN TO DUTY

I, Dr……………………………………………………………………, after careful examination of the case, do hereby

certify that ……………………………………………………… working as …………………………………………………….

In …………………………………………………………………………………………… whose signature is given below, has

recovered from his illness and is now fit to resume his / her duties from…………………….. . I also certify that, I examined

the original Medical Certificate and statement of the case (or certified copies thereof), on which the leave was granted and

have taken these into consideration in arriving at my decision.

Patient Ref No: LTI or Signature of the patient:

 IMA NHB CENTENARY MEET - 2014

CASE SHEET
IP No. MLC / non MLC

Name : Age / Sex :

F/H Name : Phone :

Address (Resi) Address (Off.)

DOA : TIME dIAGNOSIS :

DOS :
DOD : TIME
Blood Group : Allergies :

Refd by Dr.
PR : Drugs Taken so far : DOSE

Temp :
RR :

BP :
Ht :
Wt :
BMI

CASE NOTES

Proper History in chronological order

Proper General Examination

Proper System Wise Findings

Provitional Diagnosis

Base line Investigations and relevant special investigations

Treatment Schedule properly and legibly written with proper dosage ar and timings

Specialist consultation if needed

Periodical Notes with time, date, Instructions and Signature

Nurses record

Condition on Discharge. discharge Advice and Date of Review

 IMA NHB CENTENARY MEET - 2014

Pt. Name Father’s Name Age / Sex Ward IP. No.

Dr. Unit Diag

INFORMED CONSENT FOR SURGICAL PROCEDURES AND ANESTHESIA

PART 1 (GENERAL CONSENT)

I _________________________, ____________________________ of ___________________________ residing at
(Name of the person signing) (Relationship) (Relation Name)
______________________________________________________________________________________ under the
(Full address with Phone No.)
treatment of ___________________________________
(Name of hospital and primary Doctor who is now treating the patient)
do hereby give consent for SURGICAL PROCEDURE
DIAGNOSTIC PROCEDURE or _________________________ to be performed up on ___________________________
(Name of procedure) (Name of the Patient)
I declare that I am above 18 years of age. I have been informed about the inherent and potential risks of undergoing the
procedure.
I understand that the procedure may NOT be done by the Doctor treating __________________________________ so
(Patient’s Name)
far.
I also understand that any ADDITIONAL TESTS / PROCEDURES / TREATMENTS apart from the ones DESCRIBED in
this form will be done ONLY if it is absolutely necessary in the best interest of ______________________ and can be
(Patient’s Name)
justified for medical reasons.
PART 2 (ANAESTHETIC CONSENT)
I under that ________________________________________________________ anesthesia will be administered
(Route of Anesthesia)
upon ________________________ by Dr __________________________________, who is a qualified anaesthetist.
(Patient’s Name) (Anesthetist Name with Qualification)
I have been informed about the risks involved in this mode of anesthesia.
I also understand that additional or alternate mode of anaesthesia apart from the one DESCRIBED in this form may be
administered upon ONLY if it is absolutely necessary in the best interest of ___________________, and can be justified for
(Patient’s Name)
medical reasons.
I have signed this consent VOLUNTARILY out of my FREE WILL without any pressure and in my full senses.

Name, Age, Full Address, Phone No. Date / Time Signature with relationship
RELATIVE PATIENT

Name, Age, Full Address, Phone No. Date / Time Signature with relationship
WITNESS WITNESS

Name, Age, Full Address, Phone No. Date / Time Signature with relationship
1

Name, Age, Full Address, Phone No. Date / Time Signature

2

DATE TIME PLACE

SIGNATURE OF THE DOCTOR

 DANGEROUSLY ILL INFORMATION CONSENT FORM
Name of Patient, Age, Sex IP No. Father’s Name Ward No.

Date of admission Attenders Name & Address, Phone No Diagnosis

Time

BP PR TEMP SPO2 RR Conscious? GC

Existing Problems New Problem Investigation Reports information

I, ……………………………………....................…………… , _____________________ of the above mentioned

patient have admitted him / her under care of Dr………………………………………………..
Doctor after examining the patient thoroughly / going through the previous medical records / after the
investigation reports, has informed me that the condition of the aforesaid patient is VERY CRITICAL.
I am also informed and fully aware that the condition of the patient may worsen any time / there is no guarantee that
patient will become better / or cured / and the patient may not survive despite the best efforts of the doctor and his team.
I, upon my free will and in full senses, without any compulsion, give full consent and admit / continue further treatment in
this hospital under the treatment of the Doctor.
I am also aware that hospitals with better facilities are available / unavailable nearby, and I make a voluntary decision to
admit the above said patient in this hospital for treatment.
I reiterate that Doctor and his team cannot be held responsible for any UNTOWARD OUTCOME of the patient at any
time, despite his BEST EFFORTS to save the aforesaid patient.
I will also give assurance for the payment of the fees and other charges, as requested by the hospital, from time to time.

Name, Age, Full Address, Phone No. Relationship Signature Date Time
ATTENDER
WITNESS
1
WITNESS
2
 VACCINATION SCHEDULE

Baby Name D.O.B: REF No.

VACCINE AGE DUE DUE DATE GIVEN ON VACCINE AGE DUE DUE DATE GIVEN ON

BCG 0-3 month 0-Jan-00 Chicken Pox 15 Months 1-Apr-01

O’ dose OPV at birth o-Jan-00
Hepatitis-B at birth 0-Jan-00 HIB 15 Months 1-Apr-01
Mmr 15 Months 1-Apr-01
DPT+OPV+IPV 15-Feb-00
Hepatitis-B 1-1/2 Months 15-Feb-00 DPT+OPV+IPV 18 Months 1-Jul-01
HIB 15-Feb-00 Hepatitis - A 18 Months 1-Jul-01

DPT + OPV + IPV 16-Mar-00 Typhoid 2 yrs 31-Dec-01

HIB 2-1/2 Months 16-Mar-00 DPT + OPV 4-1/2 Yrs 1-Jul-04

DPT + OPV + IPV 16-Apr-00 Typhoid 5 yrs 30-Dec-04

Hepatities - B 3-1/2 Months 16-Apr-00
Typhoid 8 yrs 31-Dec-07
HIB 16-Apr-00
dT 10 yrs 31-Dec-09
OPV 4-1/2 Months 16-May-00
Typhoid 11 yrs 31-Dec-10

OPV 5-1/2 Months 15-June-00 Typhoid 14 yrs 31-Dec-13

MMR (girls) 15 yrs 31-Dec-14
Measles 9 Months 30-Sep-00
dT 16 yrs 31-Dec-15
Hepatitis-A 12 Months 30-Dec-00 Typhoid 17 yrs 30-Dec-16

STICK VACCINE LABELS HERE

VACCINATE AS PER THE SCHEDULE WISH YOUR BABY A LONG HEALTHY LIFE
 EMERGENCY CASE REGISTER

Date S. No. Name of Patient Age/Sex s/o w/o d/o with address Brought by Rx given
 POLICE INTIMATION

(Prepare in duplicate and obtain acknowledgment on second copy from the receiving police officer)

Time ___________ AM / PM

Date __________________

To,

(The Police Officer)

Dear Sir,

A patient with the following particulars has come / been brought to the Emergency / OPD and is being treated / Discharged /

has expired / is brought dead.

This is for your information and necessary action please.

Name _________________________________________________________________________________________

Father’s Name __________________________________________________________________________________

Age ____________________ Sex_________________________ I.P. No. ___________________ AR No. ___________

Address ________________________________________________________________________________________

______________________________________________________________________________________________

Brought By _____________________________________________________________________________________

Date & Time of admission __________________________________________________________________________

Diagnosis ______________________________________________________________________________________

RTA MLC Injuries Poisoning Burns Snake Bite

Site of Incident ___________________________________________________________________________________

(Signature of MO, Regn No. Name in capital letters)

 OP DEPARTMENT REGISTER

Service
Date S. No. Name of Patient Age/Sex s/o w/o d/o with address Fees Receipt Remarks
Rendered
 SURGERY RECORD

Name of Patient, Father’s / Spouse name, Age, Sex Ward No. IP No. Date

Pre operative Diagnosis Pre Op Anesthetists Notes

Surgeon Assistant Surgeon Anesthetist Type of Anesthesia

Pt Position Skin Prep Start time End Time

Findings

Operative Procedure Post Operative Orders

Incision Closure with Biopsy taken?

Blood loss (approx) Remarks

Surgeon Asst Surgeon Anesthetist

 PRE ANESTHETIC CHECK LIST
Name of the patient :
IP No. :
Weight of the pt:
Date of Admission:
Caste of the pt:
Identification Marks:

Allergies :
Informed about surgery? Time of last food intake :
Taken bath? Type of food taken last
Consent Form Signed? Approx. duration of surgery
Type of anasthesia: Alcoholism?
Dentures if any, removed? Loose teeth?
Jewels if any, removed? Smoker?
Serious illness in the past
Previous operations?
Problems with anasthesia?
Drug Allergy
BP Patient? Heart problem?
Joint swelling in past? Fainted?
Bleed excessively? Anemia?
Cold Now? Asthma / wheeze?
Nose block / sneeze Fits?
Drugs Taken so far: Recent injury?
Breathlessness?
Jaundice in past?
Kidney problem?

Blood Glucose: BP: PR:

Venflon working? TT inj: Xylo test Dose? Hb
Fundus examn: BT: CT:
Urine passed? Grp/Rh ECG:
Teeth : Grp x matched? Checked?
Blood reserved? CXR1: Temp: PCV:
Urine Acetone: u/s abd:
Platelet Count HBsAG: HIV:
CVS: Nose: Throath Teeth
RS: Abd:
CNS: Joints:
LMP: Skin infection? Beta HCG urine
Echo: TMT: Advance?

Page - 1
 SPECIFIC CONSENT FOR ANESTHESIA

Name of Patient Father’s Name IP NO

Room No Treating Doctor Diagnosis

Date Time Anesthetist Procedure

I__________ name of th person signing__________, ______relationship_____ of _____relation_______________ resident of

________________________________________________________________________ do hereby give consent for

administering ________________anesthesia upon___________________patient’s name________________________by

Dr ______________________________,
(ANESTHETIST NAME) a qualified anesthetist for the ___________________________________
(PROCEDURE)

I understand the following risks are involved in this mode of anesthesia. Doctor has clearly and without any bias

EXPLAINED in detail about these. I am aware of my predisposing diseases like which also has effect

on Anesthesia

RISKS OF _____________________________ ANESTHESIA

I have signed this consent out of my free will without any pressure and in my full sense.

Name, Father’s Name, Age, Sex,

Date, Time Relationship Signature
Full address, Phone No.

WITNESS 1

WITNESS 2
 SPECIFIC CONSENT FOR THE SURGICAL PROCEDURE

Name of Patient Father’s Name IP NO

Room No Treating Doctor Diagnosis

Date Time Anesthetist Procedure

I__________ name of th person signing__________, ______relationship_____ of _____relation_______________ resident of

________________________________________________________________________ do hereby give consent for
performing ________________procedure upon___________________patient’s name________________________by the
qualified surgeon Dr _______________________________________________, (Surgeon’s Name)

Nature of Ailment
Consequences of ailment
Consequences of not treating the ailment
Duration of Procedure
Nature of proposed procedure & alternative or additional procedures that are likely to be done (appox)

Success probability of Rx, Post procedure events that are likely

Risks of the intervention

Benefits of the intervention
Unfortunate results of the proposed intervention

Alternative methods of Rx
Risks, Benefits and likely outcomes of alternative Rx
Risk of unforeseen conditions within the body and methods to tackle them
Cost of the intervention, when uncomplicated (EXCLUDING DRUGS AND INVESTIGATIONS)
Approximate duration of stay, if uncomplicated
Additional Remarks, if any
I understand the above said INFORMATION & risks involved in this procedure. Doctor has clearly and without any bias
EXPLAINED in detail about them.
I have signed this consent out of my free will without any pressure and in my full senses.

NAME, FATHER’S NAME, AGE, SEX, FUL ADDRESS,

Date, Time PHONE No.
RELATIONSHIP SIGNATURE / LTI
RELATIVE PATIENT
WITNESS WITNESS
2 1
 CONSENT FROM FOR THROMBOLYSIS AND DIL CONSENT

Name of Patient, Age, Sex IP No. Father’s Name Ward No.

Date of admission Attenders Name & Address, Phone No. Diagnosis

Time

BP PR TEMP SPO2 RR Conscious? Ambulant GC

Existing Problems New Problems Investigation Reports information

Contra to Thrombolysis Relative CI Indications

b Internal Bleeding b H/o severe Presenting within12 hrs of chest plain
b Prolonged or Traumatic CPR b hypertension with
b Heavy vaginal Bleeding b Peptic ul cer ST->2mm in 3 chest leads
b Acute pancreatitis b H/O CVA ST->1mm in 3 limb leads
b Active lung disease with cavitation b Bleeding diathesis
b Recent surgery (<2 weeks) b Anti coagulants Postr Infarction (dominant R Waves
b Recent trauma (<2 weeks) with ST in V1-V3
b Cerebral Neoplasm
b Severe hypertension (>200/120) New onset LBBB
b Suspected Aortic dissection
b Previous allergic reaction Presenting within 12-24 hrs of chest pain
-
b Pregnancy if chest pain continuing +/- ST ongoing.
b <18 weeks post natal
b Server Liver disease
b Esophageal varices
b Recent head trauma
b Recent Hemorrhagic stroke

I, ………………………………………………… , ____________________ of the above mentioned patient have

admitted him / her under care of Dr………………………………………………..

Doctor after examining the patient thoroughly / going through the previous medical records AND after the preliminary
investigation reports, has informed me that the aforesaid patient is suffering from HEART ATTACK and his / her condition is
VERY CRITICAL.

I was informed that out of the three major blood vessels that supply the heart muscle, ONE is / TWO are TOTALLY
blocked by a BLOOD CLOT NOW. Because of this, the aforesaid patient has CHEST PAIN, BREATHLESSNESS /
SWEATING / COUGHS/ FAINTED. He/ She needs the Blocked Blood Vessel to be opened up IMMEDIATELY to save the
HEART MUSCLE which is dying due to lack of blood supply.
 For this the blocked blood vessel will have to be opened by a DIRECT method called PTCA. Dr informed me that urgent
PTCA is the best method to open up the blocked blood vessel of the heart. Or else, the drug STREPTOKINASE /
TENECTEPLASE has to be given immediately, to dissolve the clot, without wasting time. This drug is effective in about 60%
of the patients in completely opening up the blocked vessel. If this drug fails to open up the blocked vessel, then patient will
need PTCA as a rescue measure urgently.

I am fully aware that this Nursing Home has/ does not have Cardiac Cath lab facility to perform PTCA. But still I decide to
stay here and request the Doctor to administer STREPTOKINASE / TENECTEPLASE as the first line of treatment for the
patient now.

Doctor also told me that 4 out of 100 patients receiving the drug treatment for Heart attack may bleed anywhere inside
the body – BRAIN, STOMACH ULCER, URINARY TRACT etc. Sometimes blood transfusion may be necessary to make
good the loss of blood or stop bleeding. Brain bleed may even cause DEATH of the patient or if he survives may have one or
more parts PARALYSED for life.

Having known all the SIDE EFFECTS of the Drug treatment and the GRAVE NATURE of illness (HEART ATTACK), I
request Doctor to administer the drug to the patient.

Doctor has informed me about the COST of Streptokinase (Rs 4000.00) and TENECTEPLASE (Rs.) and I request Dr to
administer STREPTOKINASE / TENECTEPLASE. He also told me that the costly drug TENECTEPLASE causes lesser
bleeds elsewhere within the body, can be quickly administered, and is more effective than STREPTOKINASE.

I also understand that the condition of the patient and the urgency of sedation PRECLUDE him/her from giving a valid
informed consent and the ability to make choice between the TWO modalities of treatment. So I stand on his behalf and give
this consent to Doctor.

I am also informed and fully aware that the HEART function of the patient may worsen or stop any time and there is no
guarantee that patient will become better / or cured / and the patient may not survive despite the best efforts of the doctor
and his team.

I, upon my free will and in full senses, without any compulsion, give full consent and admit / continue further treatment in
this hospital under the treatment of the Doctor.

I reiterate that Doctor and his team cannot be held responsible for any UNTOWARD OUTCOME of the patient at any
time, despite his BEST EFFORTS to save the aforesaid patient.

I will also give assurance for the payment of the fees and other charges, as requested by the hospital, from time to time.

Name, Age, Full Address, Phone No. Relationship Signature Date Time
ATTENDER
WITNESS
1
WITNESS
2
 PRESCRIPTION FORMAT

DATE TIME Appt Residence Emergency House Vst Fees

Pt. Name Father’s name Age / Sex Ref. No.

Ht Wt PR BP SpO2 Temp RR Bp1 Bp2 RBG GC

Clinical History / Important lab reports Allergy Diagnosis

Rx name of Drug / Generic Name Strength Nos. Freq AF/BF Remarks

Special Instructions

Special Instructions

Special Instructions

Special Instructions

Special Instructions

Special Instructions

General Advice / Dos & Donts

Investigations Referrals Review on Report immediately if

Notes In Emergency contact

Emergency lab Reports

Pts Signature Drs Signature

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