A/C Summary

Date of Admission : - …….……………………………………………………………….

Admission Fees : - .…………………………………………………………………….
Name : - …………………………………………………………………….
Package : - …………………………………………………………………….
OT Fees : - …………………………………………………………………….
OT Medicine : - …………………………………………………………………….
Ward Medicine : - …………………………………………………………………….
DR. Visiting Charge : - …………………………………………………………………….
Nursing Charge : - …………………………………………………………………….
RMO Charge : - …………………………………………………………………….
okdj@csYV@dzsiCkS.Mst@ekbdzksiksj@Likbjks ehVj@NqV~Vh
dh nok@[kwu p<kus dk pktZ@vU; Mk0 ijke’kZ@vks0Vh0 ds ckn
tkWp vkSj Msflax@vksjy esfMflu@vko’;drkuqlkj vkbZ0lh0;w0
pktZ @uscqykbtj iSdst esa ugha gS A
Refundable deposit = Zero/2000/3000/4000
Signature: - Date: -

Signature: - Date: -

IB WM : - ……………………………………………………………………………….
Kit : - ……………………………………………………………………………….
IB OTM : - ……………………………………………………………………………….
IMPLANT : - ……………………………………………………………………………….
IPD/UHD. No. ……..................….. WARD\BED No. ……………….…. Date …………………
Patient Name ……………………………………………………………………………………………………
Consultant Name ……………………………………………………………………………………………..
Diagnosis ………………………………………………………………………………………………………….
Name of Surgery ………………………………………………………………………………………………

PHYSICIAN’S ORDER AND PROGESS NOTES

DATE ORDERS PROGESS NOTE BY RESIDENT
Clinical Finding

Investigation

IPD/UHD. No. ……..................….. WARD\BED No. ……………….…. Date …………………

Patient Name ……………………………………………………………………………………………………
Consultant Name ……………………………………………………………………………………………..
Diagnosis ………………………………………………………………………………………………………….
Name of Surgery ………………………………………………………………………………………………

INPUT/OUTPUT CHART
INPUT OUTPUT
Date Time Oral IV Fluids Blood Drain Urine Other

Calculation/Corrective Step/Signature

Calculation/Corrective Step/Signature