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DOCTORS ORDER
NURSES RECORD
PRE-OP. MEDICATION
O.T. NOTES
DISCHARGE SUMMARY
OTHER DOCUMENTS
MRD I/C
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph: 01652-502507, 94649-59146
1. I have been explained about the treatment planned, expected outcome and possible complications.
3. I authorize my treating doctor to take appropriate decision regarding my treatment if so required in any
unforeseen situation.
4. I have been informed that any cash, jewellery or other valuable kept with me during hospitalization will e
completely at my risk and shall not hold the hospital responsible for any loss or theft.
5. I have been informed that in case any I/my patient will require any surgery/invasive procedure, I shall be
informed for the same.
6. I undertake the responsibility of clearing all the dues payable to the hospital during the patient’s stay in
the hospital. In case of any eventuality happening to the patient, I promise to pay the full payment of due
amount either by me or by the legal heirs of the patient immediately.
Date ………………………………………………………..
Name ……………………………………………………………….
Date ….……………………………………………………
Time ……………………………………………………….
e[btzs Bof;zr j'w n?Av fJzv';e'ghe
;oiheb ;?ANo, wkB;k.
tkNo toe; o'v, B/V/ tkNo toe; wkB;k.
c'BL 01652^502507, 94649^59146
dkyb eoB ;pzXh ioBb ;fjwsh
;wK HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
e[btzs Bof;zr j'w n?Av fJzv';e'ghe
;oiheb ;?ANo, wkB;k.
tkNo toe; o'v, B/V/ tkNo toe; wkB;k.
wohi dk Bkw…………………………………………………………………………………………
:{Hn?uHnkJhHvh$nkJhHgh………………………………………………………………………………
T[wo$fbzr…………………………………………………ewok$tkov Bz……………………………
vhHUHJ/…………………………………………………ngq/;aB dh fwsh……………………………
fBod/;a ;fjwsh gZso pkfbr ns/ wkfB;e o{g ftZu ;t;E wohia d[nkok nkgD/ nkg
Goe/ nkg d;sys ehs/ ikD/ ukjhd/ jB. i/eo wohia c?;bk b?D ftZu n;woE j? sK
ihtB;kEh iK wksk fgsk iK tZvk Gok iK G?D (fJ; eqw ftZu gfjb fdZsh ikt/)
T[;d/ ;EkB s/ c?;bk b? ;edh j?. vkeNo iK T[;d/ d[nkok u[fDnk frnk T[g
vkeNo fJj ;fjwsh gZso GotkT[D bJh fizw/tko j?.
3H N?eB'b'ih gqfefonkL
wohi d/ gqshfBXh d[nkok fdZsh rJh c?ebfge ;fjwsh (i/eo bkr{ j't/ sK)
wohi n;woE j? ;fjwsh d/D bJh feT[Afe ……………………………………………………………………
(Bkpkbr, p/j';a, p/j';ah d/ sfjs, n;woE, e'Jh j'o, feogk ;gZ;aN eo')
Counselor's Commitment:
I hereby state that the patient / client has been counseled about the HIV test and has been explained about the
implication of the test result. All details pertaining to HIV, its transmission, prevention, testing procedures, its
limitations and interpretation of result have been explained and the patient / client has given his/her free and
informed consent to conduct an HIV test on him/her. I, the counselor, will do everything possible to assure that
the consent of the counseling session and the test result will be kept confidential.
This is to state that I have been counseled about the HIV test and have been explained about the implication
of
The test result. All the details pertaining to HIV, its transmission, prevention, test procedures, its limitation and
Interpretation of the result have been explained to me in a manner that I can understand,
I, hereby, give my consent for the test (s) to be conducted in order to ascertain my HIV sero-status.
ieh ik mYNnUM AYc.AweI.vI. tYst krn bwry smJw id~qw igAw Hy Aqy iesdy
tYst dy pRBwv bwry vI jwxU krvw
id~qwhY[ tYst sMbMDI swrI jwxkwrI, iesdy pRswrx, bcwA, tYst krn dw
qrIkw, iesdI sImw Aqy iesdy
cMgy mwVy nqIijAW bwry cMgI qrWH myrI AwpxI BwSw ivc smJw id~qw igAw
hY[
mYN swrI jwxkwrI qON bwAd ieh tYst krx dI mMjUrI idMdw/idMdI hW[
imqI: mrIj dy dsqKq
(Procedure(s) to be performed):
…………………………………………………………………………………………………………………………………………………................
I have been explained about this consent form, which I fully understand and have understood the information
provided to me.
Risks: The authorization is given with the understanding that any procedure involves some risk and hazards like
infection, bleeding, nerve injury, blood clots, heart attack, in rare situation death and allergic reactions etc. They
can be serious and possibly fatal.
Alternative, Benefit & Complication: Further, I have been explained in my own language that the intended
benefits, possible complication, and available alternative to the said operation/procedure. I am also aware that
result of any operation/procedure can vary patient to patient; and I declare that no guarantees have been made
to me regarding success of this operation/procedure. I am aware that while majority of patient have an
uneventful operation and recovery, few cases may be associated with complication. I am aware of the common
risk as explained and complications associated with the operation/procedure and also understand that it is not
possible to list all possible complications of any operation/procedure.
I,……………………………………………………………………. (Name of Doctor) hereby, state that the patient has been
explained about the implication of the operation in the vernacular.
Signature of Doctor: …………………………………………………..Date:……………………………... Time: …………………………
e[btzs Bof;zr j'w n?Av fJzv';e'ghe
;oiheb ;?ANo, wkB;k.
tkNo toe; o'v, B/V/ tkNo toe; wkB;k.
c'BL 01652^502507, 94649^59146
;oioh bJh ;{uBk$;fjwsh gZso
fwsh HHHHHHHHHHHHHHHHHHHHHHHHHH
wohi dk Bkw HHHHHHHHHHHHHHHHHHHHHHHHHHH T[wo$fbzrHHHHHHHHHHHHHdkyb/
dh fwshHHHHHHHHHHHHHHHHofiLBzLHHHHHHHHHHHHHHHHHHHHHH dkyb eoB tkb/
nfXekoh$eowukoh
dkBkwHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHphwkohHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHH
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HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHH
w? vkLHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH ns/ T[;dh ;w[Zuh Nhw
Bz{ j/m fbyh ftXh Bkb ;oioh$fJbki eoB bJh nfXekos eodk jK I' fe w/o/
y[d$w/o/ wohi d/ fJbki bJh io{oh j?.
ftXh I' fJbki bJh tosh ikDh j?
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHH
w?A fJj fpnkB eodk$eodh jK fe w?Bz{ ;oioh, fJ;dh ftXh ns/ fJ;d/
Bshi/ s'A j'D tkb/ gqGktk pko/ ;G e[M ;wMk fdZsk frnk j?. ;oioh j'D
d/ ekoB, fJ; s'A puD ;pzXh, ;oioh eoB dh ftfXnK, fJ; dhnK ;hwktK ns/
fJ; d/ Bshi/ dh ftnkfynk pko/ ;kohnK rZbK w?Bz{ dZ; fdZshnK rJhnK jB
ns/ w?A$w/o/ wohI B/ fJj ;kohnK rZbK uzrh soQK ;wM bJhnK rJhnK jB.
w/o/ d[nkok nkgDh fJj ;fjwsh fdZsh iKdh j? fe w?A Gbh Gks ikD{ jK fe
i/eo fJbki d'okB e'Jh th fJBc?ePB, y{B dk o;k ik iwkT[, fdwkr Bkb
;pzXs BkVk dk B[e;kB, joN nN?e, n?boih ik fe;/ ekoB w's j' iKdh j?
T[;dk e'Jh th eb/w Bjh eoKrk.
sohy
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHj;skyoHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHH
vkeNo dh x'PDk
w?A vkH HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHjbc Bkb fpnkB eodk jK
fe w?A wohI$T[;d/ foPs/dko Bz{ T[go/PB dh ftXh ns/ fJ;d/ gqGktK pko/
uzrh soQK dZ; fdZsk j?. fJ; ftZu e[M th b[e' S[g' e/ Bjh oZfynk frnk
j?.
sohyHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHj;skyoHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHH
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
5. PERSONAL HISTORY
5.1 Single/Married 5.2 Occupation
5.3 Appetite – Normal/Lost 5.4 Veg/Non-Veg/Eggtarian
5.5 Bowels-Regular/Irregular/Constipation
5.6 Micturition-Normal/Abnormal, Details
5.7 Know Allergies-No/Yes, Details
5.8 Habitas/Addictions
a. Alcohol – Regular/Occuaasion/Teetotaler
b. Tobacco – Sniff/Chewable/Smoking-Pack Years
c. Drug use – No/Yes, Details
d. Betel nut – No/Yes, Details e. Betal Leaf (plan)-No/Yes
6. FAMILY HISTORY
6.1 Diabeters-No/Yes, Details
6.2 Hypertension-No/Yes, Details
6.3 Heart disease-No/Yes, Details
6.4 Stroke-No/Yes, Details
6.5 Cancers-No/Yes, Details
6.6 Tuberculosis-No/Yes, Details
6.7 Asthama-No/Yes, Details
6.8 Any other hereditary Disease
6.9 Psychiatrist illness
6.10 Sibling History
6.11 Any other
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
PATIENT’S NAME …………………………… AGE/SEX ……………IP No……………..…..UHID No…………….……
_________________________________________________________________________________
PLAN OF CARE
______________________________________________________________________
PATIENT’S NAME …………………………… AGE/SEX ……….……IP No…….…………..UHID ..…………….……
_________________________________________________________________________________
PROVISIONAL DIAGNOSIS/DIAGNOSIS:
PLAN OF CARE:
NAME SIGNATURE
DATE TIME
Diagnosis: Alert/Allergies
Systemic Examination
CVS
Pulmonary
CNS
Venous Access
Investigations B.Sugar: S.Proteins X-Ray:
Albumin:
HB: B.Urea: Globulin: ECG:
TLC: S.Creatinine: HBsAG: ECHO:
DLC: SGOT/SGPT: HCV:
Platelets: Alk.Po4: HIV:
Urine C/E:
BT/CT: S.Amylase: Na+:
PTINR: K+:
Pre anesthetic Instructions Anesthetic Plan
Preoperative
Medications:
WHO safety check List Completed Yes No Sign & Name Anaesthetist
ANAESTHESIA NOTES
Diagnosis : ……………………………………………………………………………………………………………………………………….
Operation : ………………………………………………………………………………………………………………………………………
Pre Medication ……………………………………………………………………………………………………………………………….
Time
Pulse Rate
B.P
SPo2
I/V Fluids
I/V Drugs
Signature of Anaesthetist
Date:-
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
OPERATION NOTES
Consultant…………………………………………………………………………………………….
Diagnosis ……………………………………………………………………………………………..
Surgeon ………………………………………………………………………………………………
Anaesthetist …………………………………………………………………………………………..
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Consultant:_____________________________
Consultant:_____________________________
VITAL CHART
Patient’s Name …………………………………………Age/Sex………………Deptt………………………Bed No………….…..
Date and Pulse Blood Temp Resp SPO2 Pupil G.C.S Sign
Time Pressure
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
VITAL CHART
Patient’s Name …………………………………………Age/Sex………………Deptt………………………Bed No………….…..
Date and Pulse Blood Temp Resp SPO2 Pupil G.C.S Sign
Time Pressure
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146