(SRCC CHILDRENS HOSPITAL NH

Managed by huateyaro eat

BILLING SHEET
Hap Ait Park
miba

Master Aasim Sayyed

Patient Name: 12520000036936
Male/4Y 11M 25D

Patient MRN INP-1252-2012000262

Age Genger
Bed No
Department
MEDICARE/ HEALTH INSURANCE

DEPT
DATE OF ADMISSION
2
cONSULCONSULTAN
BEDNO04
Apainku DIET

WARD TRANSFERS
Date Signature of Staff
Time From To

sdaeaS.30fm Scu
T2|2p CW

CONSULTANT VISIT CHART

(TO BE FILLED BY THE DOCTOR ONLY)

Primary Consultants Sub Consultants

Dr D h Dr Vauhw Dr.s)a Dr.ans

Date Sign Date
Date Sign Date Date

Version: 1
1A, Haji Ali Park, K. Khadye Marg, Mahalaxmi, Mumbai 400034 Format No.: NH/NUR/024

Phone: 022-71222222
 LABORATORY INVESTIGATIONS
OPERATION/ PROCEDURE CHART
(TO BE FILLED BY THE DOCTOR ONLY)
Particulars
Quantity Sign
Dato
Hoer
Name of the Operation Procedure OsP PrOtessional Docor's (Name) Sign
Date VO. olldigs
h 1 c k c7AP .CYaoinja, Llecdo b
Penenal fislh
A Lon
Ahanaghn
s AB
STON
ECG CHART
Date 2anho
NO
g
O
BLOOD TRANSFUSION CHART
Date sllat sl
No of Pnts
Pladek
Sign
Shcunesh oncs
- 3-
 oXYGEN AND VENTILATION CHART
Date Connecting Time Disconnecting Time Total Consumption Remarks
Signature

5
 RECENT INVESTIGATION CHART (Prior 24 hrs)

Radiology

LchellA-4lly
USG

CT/MRI

Hospital Diet (No of Days):

ANY OTHER INFORMATION

EF hldot(D

Date:

Time

Prepared by:,Dila Full Name & Signature of the Ward Staff

Note: To Ward Staff: Before

discharging the patient, get clearance from 1.P. Billing Office

- 6-

1A, Haji Ali Park, K. Khadye Marg, Mahalaxmi, Mumbai 400034 Phone: Version: 1
022-71222222 Format No.: NH/NUR/024
 (SRCC CHILDRENS HOSPITAL NH BILLING SHEET
Maraged by Plarayara tetaith Ha Ai Par
miba

VidiC/ 3U
INP-1252-2012000262
Patient Name

Patient MRN Gender

Age
Master Aim Sayyed
Bed No Departmeent
Cu . 125200006936
Male/SY

MEDICARE/ HEALTH INSURANCE

DEPT G. 2 CONSULTANT k UNIT

DATE OF ADMISSION 2<\alsBED NO 1S DIET

WARD TRANSFERS

Date Time From To Signature of Staff

CONSULTANT VISIT CHART

(TO BE FILLED BY THE DOCTOR ONLY)

Primary Consultants Sub Consultants

Dr Dr. 3.&G
Dr aps-pADr Drayle
Sign Date Sign Date Date Sign Date Sign

D6 Cayle|
cayle

Version: 1
1A. Haji Ali Park, K. Khadye Marg. Mahalaxmi, Mumbai 400034 Phone: 022-71222222 Format No.: NH/NUR/024
 LABORATORY INVESTIGATIONg
OPERATION/PROcEDURE CHART
FILLED SY
THE DOCTOR ONLY)
TO BE
arges ocors ame Sgr
ECG CHART
BLOOD TRANSFUSION CHART
 VENTILATION CHART
OXYGEN AND
Remarks
Total Consumption Signature
Connect1ng Time DISConnecting ime
Date

,1gn

5
 RECENT INVSTIGATION CHART (Prior 24 hrs)
Radiology Lhegb Inay 2 1
USG

CT/MRI

Hospital Diet (No of Days)

ANY OTHER INFORMATION

Bloccdclelails (onsivned with Mlaer

712
4/
5 PKOL2[PPli Pakelek

Date

Time
230 P
Prepared by:De n Full Name & Signature of the Ward Staff

Note To Ward Staff: Before discharging the patient, get clearancefrom I.P. Billing Office.

- 6-

Version: 1
1A, Haji Ali Park, K. Khadye Marg, Mahalaxmi, Mumbai 400034 Phone: 022-71222222 Format No. NH/NURI024