Patient Information Form

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{LOGO}
{NAME & ADDRESS OF THE HOSPITAL}
STANDARD
DISCHARGE SUMMARY
a. Patient’s Name*
: ________________________________________________
b. Telephone No / Mobile No*
: ________________________________________________
c. IPD No
: _________________ d. Admission No: ________________
e. Treating Consultant/s’ Name
: ________________________________________________
a. Contact Numbers
: ________________________________________________
b. Department/Specialty
: ________________________________________________
f. Date of Admission with Time
: ___/ ___/ _______
___:___ Hours
g. Date of Discharge with Time
: ___/ ___/ _______
___:___ Hours
h. MLC No*
: ________________
FIR No*: _____________________
i.
Provisional Diagnosis
at the time of Admission
: ________________________________________________
j.
Final Diagnosis at the
time of Discharge
: ________________________________________________
k. ICD-10 code(s) for Final Diagnosis*: _____________________________________________
l.
Presenting Complaints with
Duration and Reason for Admission: _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
m. Summary of Presenting Illness : ________________________________________________
________________________________________________
n. Key findings, on physical
examination at the time of admission: ____________________________________________
____________________________________________
____________________________________________
____________________________________________
o. History of alcoholism, tobacco or
substance abuse, if any
: ________________________________________________
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