Government of Nepal Ministry of Health and Population Department of Health Services

Write the name of Hospital ADMISSION AND SUMMARY RECORD

Unit and Dr-in-charge Name of the Patient Patient's First Name First name of Patient Referred from Address District Municipality/VDC Ward write the name write the name of the patient's write the name of the patient's Municipality/VDC of the patient's district Ward Father's/Spouse's/Guardian's Name Emergency Address (Local) Village/Tole write the name of the patient's Village or tole Telephone No. Ward/Unit Name of the Ward/Unit where patient to be admitted Last Name Last Name of patient Caste/ethnicity code
code that has been catagorised by Nepal Government

Bed No.

Inpatient No.

Registraton/admission number of Patient Number of bed Age Sex Marital Status Religion Occupation
Age of yhe patient Sex of married, write the occupation of the the unmarried,widow,d Write the religion of the patient patient patient ivorsed

Write the name of that institute or hospital from where the patient was refered.

write the name of the patient's father/spouse/guardian's

Temporary/Local address near to the Hospital should be fill here

write Telephone/ mobile number of patient's related person or relative

Date and time of Admission dd/mm/yyyy, Time (Arrival time of Pt.)

Date and Time of Discharge dd/mm/yyyy, Time (Departual time of Pt.)

Duration of stay write the hospital stay days of patient.

Description Provisional Diagnosis Final diagnosis Secondary diagnosis Cause of Death Operative Procedure Outcome
write the condition of patient at the time of Discharge & tick the given boxes on slip

ICD Code
Write Disease code no. Write Disease code no. Write Disease code no. Write Disease code no.

Write the patient's condition/Disease at the time of arrival, it should be filled by Duty Dr. Write the decription of treatment at the time discharge it should be filled by Duty Dr. Write if any secondary Disease is suspected should be filled by Duty Dr. Write the Cause of Death in the case of expire of patient it should be filled by Duty Dr.
Write the name of operation and short description should be filled by Dr if patient was operated tick wether the operation was minor intermediate or major

Minor Absconded

Intermediate LAMA/DOR
(Left Against Medical Advice/Discharge on request)

Major Expired (Date and time)

Cured

Improved/ Recovered

Unchanged

Worse

Referred

FINAL CASE SUMMARY : To be written by medical staff concerned at time of Discharge on the basis detail report to be attached Brief complaint write the brief complaint of patient at the time of admission

For doctor's use only

Brief history

write the previous history of patient.

Treatment

write treatment of the patient provided by hospital at the time of hospital stay

Surgery

Write the name of surgery if done.

Instructions given

Write the instruction given to the patient.

Discharge summary

Write the discharge summary of the patient

Investigation (all)

Describe brief about investigation of patient

Name and Signature of Doctor (in full)

Name and sign of Duty Dr. in full

Whether medicolegal or police case

Mention the case is Police Case or Not

ADMISSION & SUMMARY RECORD

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