Document Control

CRITICARE HOSPITAL & RESEARCH INSTITUTE
MRD INDEX
CHRI/MRD/000 MRD CHECKLIST
CHRI/MRD/001 EMERGENCY ASSESMENT
CHRI/MRD/002 ICU ADMISSION AND DISCHARGE CRITERIA
CHRI/MRD/003 ADMISION FORM/GENERAL CONSENT
CHRI/MRD/004 CONSENT FOR HOSPITAL ADMISION
CHRI/MRD/005 PATIENT & FAMILY RIGHTS
CHRI/MRD/006 INITIAL ASSESMENT OF PATIENT'S
CHRI/MRD/007 PRIMARY CONSULTANT CARE PLAN
CHRI/MRD/008 NURSING ASSESMENT SHEET
CHRI/MRD/009 NURSING CARE PLAN
CHRI/MRD/010 NUTRITIONAL SCREENIGS &NEEDS ASSESSMENT FORM
CHRI/MRD/011 PHYSIOTHERAPY FORM
CHRI/MRD/012 DIABETES CHART
CHRI/MRD/013 MEDICATION CHART
CHRI/MRD/014 MEDICAL RECONCELLATION FORM
CHRI/MRD/015 DAILY MONITORING CHART
CHRI/MRD/016 MEWS SCORE
CHRI/MRD/017 DOCTOR SHEET
CHRI/MRD/018 VISITING CONSULTANT NOTES
CHRI/MRD/019 COUNSELLING FORM
CHRI/MRD/020 PATIENT'S COUNSELLING FORM
CHRI/MRD/021 NURSES PROGRESS NOTES
CHRI/MRD/022 INVESTIGATION SHEET
CHRI/MRD/023 APACHI SCORE
CHRI/MRD/024 INFECTION CONTROL CHECK LIST
CHRI/MRD/025 DVT SCORE
CHRI/MRD/026 CATHETER INSERTION BUNDLE FORM
CHRI/MRD/027 CENTRAL LINE INSERTION BUNDLE FORM
CHRI/MRD/028 VENTILATOR CARE BUDLE FORM
CHRI/MRD/029 HIGH END ANTIBIOTIC
CHRI/MRD/030 SEDATION SCORECARD
CHRI/MRD/031 ABG ANALYSIS FORM
CHRI/MRD/032 BRADEN SCALE / SSI CHECKLIST
CHRI/MRD/033 INFORMED CONSENT FOR BLOOD TRANSFUSION
CHRI/MRD/034 INFORMED CONSENT FOR HEMODAILYSIS (ICU)
CHRI/MRD/035 HIV CONSENT FORM
CHRI/MRD/036 RESTRAINT CONSENT FORM
CHRI/MRD/037 CPR NOTES
CHRI/MRD/038 PROCEDURE CONSENT
CHRI/MRD/039 PATIENT TRANSFER CONSENT
CHRI/MRD/040 TRANSFER SHEET
CHRI/MRD/041 PATIENT MOVEMENT FORM (SHIFTING)
CHRI/MRD/042 O.T BOOKING FORMAT
CHRI/MRD/043 INFORMED CONSENT FOR SURGERY
CHRI/MRD/044 HIGH RISK CONSENT FORM
CHRI/MRD/045 INFROMED CONSENT :ANESTHESIA
CHRI/MRD/046 PRE-ANAESTHETIC CHECK -UP
CHRI/MRD/047 ANESTHESIA CARE PLAN
CHRI/MRD/048 PRE OPERATIVE CHECKLIST
CHRI/MRD/049 ANAESTHESIA SAFETY CHECKLIST
CHRI/MRD/050 CHECK LIST FOR CORRECT PATIENT /SITE /SURGERY
(SURGICAL SAFETY CHECKLIST)
CHRI/MRD/051 INTRA OPRATIVE NURSING RECORD
CHRI/MRD/052 ANESTHESIA CHART
CHRI/MRD/053 INTRAOPERATIVE MONITORING CHART
CHRI/MRD/054 POST ANESTHESIA MANAGEMENT
CHRI/MRD/055 OPERATION NOTES
CHRI/MRD/056 POST OPERATIVE CARE PLAN
CHRI/MRD/057 OTHER NOTES
CHRI/MRD/058 BILLING INFORMATION CHART
CHRI/MRD/059 FEEDBACK FORM
CHRI/MRD/060 DAMA / LAMA CONSENT FORM
CHRI/MRD/061 DISCHARGE SUMMARY
CC/AAC/01 CC/AAC/01
C RITI C ARE C RITI C ARE

TM TM
4th Floor "Dhanashree Complex"
Sitabuldi, Nagpur-440012.
Hospital & Research Institute Date :_____________________ Hospital & Research Institute
CONSENT FOR HOSPITAL ADMISSION 4th Floor "Dhanashree Complex"
1. I have been explained in my own language about facilities available at Criti Care Hospital and Research
Institute, it's rules and regulations, I have understood the same and I am ready for my relative's admission. GENERAL CONSENT / ADMISSION FORM Date:
2. I undertake to pay in advance / deposits as and when deemed necessary by the hospital and agree that I will settle gm‘mÝ¶ gh‘{V/AñnVmc ‘| Xm{Icm ànÌ {XZm§H$ …
all my bills including stay in hospital, pharmacy and laboratory before discharge.
Time:
3. I understand that there will be no discount or leeway given in relation to hospital bills.
4. I understand that the charges for laboratory investigation and pharmacy are separate from the hospital bill. g‘¶ …
5. I have given the estimate my treatment / procedure / diagnosis. I / We agree to pay it.
6. I give my consent for providing professional and/or any other information for medical records as may be deemed Full Name of the Patient :
necessary in accordance with policies, rules and regulation of the hospital. ‘arO H$m nwam Zm‘ …........................................................................................................................................
7. I give my consent to the hospital to administer the necessary drugs to patient by oral, Injectable or any other
route deemed necessary. Age: Sex :
8. I understand that in case of emergency the doctors here may perform the any life saving procedure deemed Am¶w …................................................................................qcJ …...................................................................
necessary without consent unless and until otherwise specified.
9. I understand that when Dr. Deepak Jeswani is not available any members of his team are fully empowered to Permanant Address :
treat the patient and make decision regarding his medical or surgical management. ñWm¶r nVm …..................................................................................................................................................
10. I understand that I will be updated once a day about the patient's medical status and progress by consultant
Occupation : Buisness / Employed.
Intensivist and also that only one visitor will be allowed to visit the patient at a time in ICU during visiting hours. ì¶dgm¶ … ì¶mnma/amoOJma/AÝ¶ ….....................................................................................................................
11. I also understand that only one relative or attendent will be allowed to stay with the patient and I will follow the
regulation regarding patients visiting time. Phone No.: Mobile No. :
12. I understand that I am supposed to wear face mask while visiting patient in ICU and agree that I will not touch Xÿa^mf H«$‘m§H$ …...................................................................^«‘U XÿaÜdZr H«$‘m§H$ …............................................
the patient, the bed or any accessory of patient care.
13. I understand that in ward also I am not allowed to sit on the patient's bed. Referred by :
14. I understand that any act causing damage or loss to the property of hospital or any act of violence against any of ................................................................................ìXmam g§X{^©V …
the employees of the hospital is a cognisable offence. Any attempt to damage hospital property and disturbing
Category : Self Paying / Insurance / Empanelled :
peace and harmony of the medical institution is prohibited as per Maharashtra Medicare Service, Persons and
dJ© … ñd¶§ ^wJVmZ / ~r‘m / gyMr~ÜX
Medicare Service Institution (Prevention of Violence & Damage or loss of property) Act 2010.
15. I agree not to talk loudly in the hospital premises and not to disturb peace and tranquility of the premises. If Insurance, Specify TPA :
16. I understand that for any problem related to administration or treatment of the patient I should contact any of ¶{X ~r‘m h¡ Vmo V¥Vr¶ nj àemgH$ H$m {ddaU X|................................................................................................
the consultants
17. I agree to avoid water and electricity wastage and to maintain cleanliness of the hospital premises. If Empanelled, Specify :
18. I understand that the original medical records will not be given to the relatives except the reports of the ¶{X gyMr~ÜX h¡, {ddaU X|...............................................................................................................................
investigation done. The photocopies of the medical records can be requested after the application from MRD
department by the patient or by his consent. Admitted by : Mobile No.
19. I understand that for the patients safety purposes any type of alterative medicine will not be allowed to be given to Xm{Icm H$aZo dmco H$m Zm‘ …........................................................ ^«‘U XÿaÜdZr H«$‘m§H$ …...................................
the patient during hospital stay.
20. I also understand that use of mobile phones is strictly prohibited in the Hospital premises.
21. Any sort of photography will not be allowed inside the premises. Emergency Contacts :
22. If the patient leave against the medical advice or if the patient dies, then the original report from the hospital will AmnmVH$mcrZ gånH©$ …
not be given to the patient the photocopy of the report will be given to the patient after the application to MRD
Name :
Department
Zm‘.............................................................................
Phone No. :
XþaÜdZr H«$..............................................................................
Name ____________________ Relation with the Patient :
Witness Signature ‘arO Ho$ gmW [aíVm.............................................................................
Mob.:____________________
Name____________________________ Relation :_________________ Patient Relatives Signature
FORM NO. B20 FORM NO. B20
CC/AAC/01 CC/AAC/01
CnMma hoVw gm‘mÝ¶ gh‘{V … ‘¡ {ZåZ hñVmj[aV (¶m ‘oao ìXmam A{YH¥$V ‘oao dmñVo/H¥$Vo) {H«$Q>r Ho$Aa hm°pñnQ>c A°ÊS> [agM© g|Q>a d CgHo$
C RITI C ARE
TM
H$‘©Mmar dJ© H$mo ‘oao ñdmñÏ¶ H$mo ~ZmE aIZo Ed§ CgH$m à^mdr ‘yë¶m§H$Z hoVw Amdí¶H$ amoJ{ZXmZ narjU, Om±M Ed§ à{H«$¶m gånÝZ
H$amZo {cE, Am¡f{Y¶m§ àXmZ H$aZo Ho$ {cE, CnMma ¶m Amdí¶H$ {M{H$Ëgm H$aZo hoVw A{YH¥$V H$aVm hÿ± & Am¡a ‘oar ~r‘mar Ho$ CnMma /
MmoQ> Ho$ ‘yë¶m§H$Z {ZXmZ hoVw A{YH$ma XoVm hÿ± ‘¡ g‘PVm hÿ± {H$ ‘oao CnMma, ñdmñÏ¶ H$s XoI^mc godm àXmZ H$aZo dmco H$s {Oå‘oXmar h¡ Hospital & Research Institute Date :_____________________
{H$ dh ‘oao {d{eîQ> amoJ{ZXmZ narjU, Om±M ¶m à{H«$¶m {H$g H$maU H$s Om ahr h¡ BgH$m ‘wPo H$maUg{hV g§kmZ X|, gmW hr n¶m©¶r Demhelee} ces Yejleer mebceleer he$e
CncãY CnMma d d¡H$pënH$ CnMma nÜXVr d Ad{Y H$s OmZH$mar ‘wPo Xr JB© h¡ & 1) cegPes/nces Deheveer Yee<ee ceW ef›eâšerkesâDej Demhelee} Deewj mebçeesOeve mebmLee ces Ghe}yOe megefJeOeeDees kesâ yeejs ces hegjer peevekeâejer oer ieF& nw leLee Demhelee} kesâ efveÙeceeW Deewj efJeveerÙecees keâer
General Consent to treatment : By signing below, I (or my authorised representive on my behalf) authorize Criti Care yeejs ces mecePeeÙee ieÙee nw ~ Ùen meye mecePeves kesâ yeeo cew/nce Deheves efjçlesoej keâes ef›eâšer kesâDej ne@efmheš} ces Yejleer keâjJeeves kesâ ef}S leÙeej ngB/nw ~
Hospital & Research Center and their Staff to conduct any diagnostic examinations, tests and procedures and to provide 2) cew Demhelee} keâes De«eerce jkeâce, Demhelee} keâceeaÙees Éeje pe®jer mecePeves hej pecee keâjves kesâ ef}S ceevÙe keâjlee ngB leLee cejerpe keâer Demhelee} mes Úgóer nesves mes hen}s Demhelee}
any medications, treatment or therapy necessary to effectively assess and maintain my health, and to assess, diagnose keâe efye} efpemeces Demhelee} ces ®keâves keâe KeÛee&, heâece&meer leLee ØeÙeesieçee}e keâe efye} Yegieleeve keâjves kesâ ef}S ØeefleyebOeerle jngbiee ~
and treat my illness or injuries. I Understand that it is the responsibility of my individual treating healthcare providers to
explain to me the reasons for any particular diagnostic examination, test or procedure, the available treatment options as
3) cew Ùen Yeer mecePelee ngB efkeâ Demhelee} kesâ efye} ces keâesF& Úgš vener efce}sieer ~
well as alternative courses of treatment. 4) cew Ùen Yeer mecePelee ngB efkeâ cejerpe keâer peeBÛees keâe leLee ØeÙeesieçee}e ces nesves Jee}s šsmš keâe KeÛee& Demhelee} efye} mes De}ie jnsiee ~
5) cegPes / nces mebceeCÙe Devegceefle KeÛe& keâer peevekeâejer os oer ieF& nw ~ cewb / nce Deew<eOeesheÛeej / GheÛeej Øe›eâerÙee / peeÛe heÌ[lee} / hejer#eCe Deeefo kesâ ef}S nesvesJee}s Øeefleefove kesâ KeÛe&
^wJVmZ hoVw gh‘{V … ‘¢ (¶m ‘oao ìXmam A{YH¥$V à{V{ZYr/‘oao dmñVo/H¥$Vo ¶h KmofUm H$aVm hÿ±, AñnVmc go {ZJ©‘Z go nyd© g‘ñV àH$ma kesâ JÙeÙe keâe Yegieleeve keâjves kesâ ef}S mencele ng/nw ~
Ho$ ^wJVmZ H$a Xÿ±Jm &) 6) cew Demhelee} keâer efveleerÙees Deewj efveÙecees Devegmeej DeeJeçÙekeâ mecePes peeves hej keâesF& Yeer DeeJeçÙekeâ peevekeâejer pees ces[erkeâ} jskeâe@[& kesâ ef}S DeeJeçÙekeâ jnsieer, Demhelee} keâes
Consent to Payment : I, (or my authorized representative on my behalf) shall clear all the payments before the Ghe}yOe keâjeTbiee ~
discharge. 7) cew Deheves cejerpe kesâ DeÛÚs mJeemLe kesâ ef}S pe®jer keâesF& Yeer oJeeF& pe®jer ceeie& mes (ceewKeerkeâ, me}eFveÉeje, vemees mes) osves keâer mebceleer oslee ngB ~
CnMma go B§H$ma H$m A{YH$ma … ‘oao AñnVmc ‘| Xm{Ic hmoZo d CnMma H$amZo hoVw ‘¢Zo gm‘mÝ¶ gh‘{V Xr JB© h¡, ‘¢ g‘PVm h°ÿ§ {H$ ‘¢§ {H$gr 8) cew ÙenYeer mecePelee ngB efkeâ, Deeheelekeâe}erve efmLeleer ces Demhelee} kesâ efÛekeâerlmekeâ efyevee efkeâmeer Fpeepele kesâ peerJeveeJeçÙekeâ Øeef›eâÙee keâj mekeâles nw ~ pees cejerpe keâer peeve yeÛeeves nsleg
{d{eîQ> Om±M, à{H«$¶m H$s Om±M, {M{H$Ëgm ¶m XdmB© Omo ^r ‘oao ì¶p³VJV CnMma hoVw ñdmñÏ¶ godm àXmZ H$aZo dmco H$mo B§H$ma H$aZo H$m DeeJeçÙekeâ nesieer ~
A{YH$ma aIVm hÿ± & ‘¢ g‘PVm h±ÿ {H$ Am¡f{Y¶m| H$m [admO ¶WmW© ‘| {dkmZ Zht h¡ Am¡a ‘oao ‘yë¶nmZ ¶m/Am¡a CnMma Ho$ ZVrOm| H$s H$moB© 9) cew Ùen Yeer mecePelee ngB efkeâ, [e@. efohekeâ pesmeJeeveer Ghe}yOe vener nesves hej Gvekeâer efšce kesâ yeekeâer meomÙe cejerpe kesâ mebyebOeer efkeâmeer Yeer Øekeâej keâe ces[erkeâ} Ùee mepeeakeâ} efš^šcesvš
Jma§Q>r, [H$gr ^r àH$ma Zht Xr JB© h¡ & Je Gmekesâ ef}S hewâme}e }sves kesâ ef}S hegjer lejn mes me#ece jnWies ~
10) cew Ùen Yeer mecePelee ngB efkeâ efove ces Skeâ yeej Demhelee} kesâ me}enkeâej efÛekeâerlmekeâ cejerpe keâer efmLeleer leLee Øeieleer kesâ yeejs ces nces yeleeSbies leLee Deefleo#elee efJeYeeie ces Yejleer
Right to Refuse Treatment : In giving my general consent to admission and treatment, I understand that I retain the cejerpe keâes efmehe&â efveOee&jerle meceÙe ces Skeâ yeej Skeâ ner JÙekeäleer efce} Skeâlee nw ~
right to refuse any particulars examination, test procedure treatment, therapy and medication recommended or deemed
medically necessary by my individual treating health care providers. I also understand that the practice of medicine is not 11) cew Ùen Yeer mecePelee ngB efkeâ Demhelee} ces Yejleer cejerpe kesâ meeLe efmehe&â Skeâ efjçlesoej Ùee heefjÛej Demhelee} ces ®keâ mekeâlee nw leLee cejerpe kesâ efce}ves kesâ meceÙe mebyebOeer meYeer
an exact science and that no guarantees have been made to me as the results of my evaluation and/or treatment. efveÙecees keâe hee}Ce keâjWies ~
12) cew Ùen Yeer mecePelee ngB efkeâ DeeÙe.efme.Ùeg. ceW Yejleer cejerpe keâes efce}les meceÙe ceemkeâ henvekeâj ner DeeÙe.efme.Ùeg. ces peevee nesiee leLee cejerpe, efyemlej Ùee efkeâmeer Yeer Ûeerpe keâes Úgvee
cevee nw ~
Name & Signature Name and Signature of 13) cegPes Ùen yeleeÙee ieÙee nw keâer Jee[& ces Yejleer cejerpe kesâ efyemlej hej yew"vee cevee nw ~
of Patient / authorised representative IPD personnel 14) cegPes Ùen Yeer yeleeÙee ieÙee nw efkeâ keâesF& Yeer keâeÙe& efpememes Demhelee} keâer mebheòeer keâes #eleer nes Ùee efheâj keâesF& Yeer efnbmeelcekeâ keâeÙe&Jeener efpememes Demhelee} kesâ keâeÙe&jle keâesF& Yeer
‘arO/A{YH¥$V à{V{Z{Y H$m Zm‘ Ed§ hñVmja VWm [aíVm AÝV©{d^mJ H$‘©Mmar H$m Zm‘ Ed§‘ hñVmja JÙekeäleer keâes neveer hengBÛes Ùen keâevegve pegce& nw ~ Demhelee} keâer mebheòeer keâes efkeâmeerYeer Øekeâej keâer #eleer keâjvee Ùee keâjves keâe ØeÙeeme keâjvee leLee Demhelee} ces çeebleer Yebie keâjvee ceneje°^
Details of the valuables of the patient handed over to the patient's family members efÛekeâerlmee mesJee DeefYeveerÙece 2010 kesâ lenle ØeefleyebOeerle nw ~
‘arO Ho$ nm[adm[aH$ gXñ¶m| H$mo gm¢no JE ‘yë¶dmZ dñwAm| Ho$ {ddaU 15) cegPes peevekeâejer nw efkeâ Demhelee} ces peesj mes yeele vener keâjvee ÛeenerÙes leLee çeebleer yejkeâjej jKevee ÛeenerS Ùen ceevelee ngB ~
16) cejerpe kesâ GheÛeej mebyebOeer Ùee keâesF& Yeer ØeçeemeefkeâÙe mecemÙee nesves hej Demhelee} ces keâeÙe&jle me}enkeâej efÛekeâerlmekeâeW mes mebheke&â keâjs ~
.................................................................................................................................................................
17) cegPes Ùen peevekeâejer nw keâer heeveer leLee efyepe}er keâe DeheJÙeÙe vener keâjvee ÛeeefnS ~
................................................................................................................................................................. 18) ‘¢ g‘PVm hÿ§ {H$ Om§M H$s [anmoQ>© H$mo N>m‹oS>H$a [aíVoXmam| H$mo Am°a{JZc ‘o{S>H$c [aH$m°S>© Zht {XE OmE§Jo& amoJr ìXmam ¶m CgH$s gh‘{V go E‘.Ama.S>r.
{d^mJ go AmdoXZ Ho$ ~mX {M{H$Ëgm A{^coIm| H$s ’$moQ>moH$m°nr Xr Om¶oJr&
Name & Signature of the sister on duty Received by Name &
19) ceefjpeeW efkeâ mJeemLe megj#ee keâes osKeles ntS Demhelee} ces Yejleer efkeâmeerYeer cejerpe efÛekeâerlmekeâ keâer yeleeF& ngF& oJeeF& kesâ De}eJee ogmejer oJeeF&ÙeeB osves keâer Devegceleer vener nw, pewmes
Zg© H$m Zm‘ / hñVmja Signature of patient's relative keâer DeeÙegJexoerkeâ, nesceerÙees he@Leerkeâ oJeeF&ÙeeB Jepeeale nw ~
àmßVH$Vm© H$m Zm‘ / hñVmja 20) Demhelee} kesâ Deboj ceesyeeF&} heâesve keâe GheÙeesie Jepeeale nw ~
21) efkeâmeer Yeer Øekeâej keâer heâesšes«eeheâer Demhelee} ces keâjvee cevee nw ~
Relation with the patient / ‘arO Ho$ gmW [aíVm 22) AJa ‘arO d¡ÚH$s¶ gcmh Ho$ {déÜX Ny>Å>r coVm h¡ ¶m {’$a ‘arO H$s ‘¥Ë¶w hmoVr h¡ Vmo AñnVmc go Amo[aOZc [anmoQ>© Zht Xr OmEJr ‘arO H$mo [anmoQ>© H$s
n[a{eîQ> - ""H$'' H$m°nr Xr OmEJr E‘.Ama.S>r. {d^mJ Ho$ AmdoXZ Ho$ ~mX&
{~c / AÝ¶ ì¶¶ Ho$ IM© Ho$ {cE AZw‘{V - nÌ
‘wPo/h‘| g§^mì¶ AZw‘{V IM© H$s OmZH$mar Xo Xr JB© h¡& ‘¡/h‘ Am¡fYmonMma / CnMma à{H«$¶m / Om±M à{H«$¶m / Om±M nS>Vmc / narjU
Am{X Ho$ {cE hmoZodmco à{V{XZ Ho$ IM© Ho$ ì¶¶ H$m ^wJVmZ H$aZo Ho$ {cE gh‘V h±ÿ/h¡ & veece :
‘arO H$m Zm‘ …..................................................................... ‘arO Ho$ hñVmja [añVoXma Ho$ hñVmja ceesyeeF&ue :
[añVoXma H$m Zm‘ d nËVm …....................................................... mee#eeroej kesâ nmlee#ej efjMlee :
............................................................................................ ~m¶o hmW H$m A§JwR>m ~m¶o hmW H$m A§JwR>m
veece
All disputes are subject to Nagpur Jurisdiction (g‘ñV {ddmX ZmJnwa Ý¶m¶m{cZ Ho$ A§VJ©V) hesçebš kesâ heefjpeveeW kesâ nmlee#ej
FORM NO. B20 FORM NO. B20
CC/AAC/01
C RITI C ARE
TM
Hospital & Research Institute Date :_____________________
CONSENT FOR HOSPITAL ADMISSION
1. I have been explained in my own language about facilities available at Criti Care Hospital and Research
Institute, it6s rules and regulation, I have understood the same and I am ready for my relative's admission.
2. I undertake to pay in advance / deposits as and when deemed necessary by the hospital and agree that I will settle
all my bills including stay in hospital, pharmacy and laboratory before discharge.
3. I understand that there will be no discount or leeway given in relation to hospital bills.
4. I understand that the charges for laboratory investigation and pharmacy are separate for the hospital bill.
5. I have given the estimate my treatment / procedure / diagnosis. I / We agree to pay it.
6. I give my consent for providing professional and/or any other information for medical records as may be deemed
necessary in accordance with policies, rules and regulation of the hospital.
7. I give my consent to the hospital to administer the necessary drugs to patient by oral, Injectable or any other
route deemed necessary.
8. I give my consent for blood or blood product transfusion as and when necessary.
9. I understand that in case of emergency the doctors here may perform the any life saving procedure deemed
necessary without consent unless and until otherwise specified.
10. I give my consent to the hospital to perform medical of surgical procedures on me as and when deemed necessary.
11. I understand that when Dr. Deepak Jeswani is not available any members of his team are fully empowered to
treat the patient and make decision regarding his medical or surgical management.
12. I give my consent to the hospital to perform investigation including HIV, HBsAg, HCV and VDRL which may be
done at any stage of my hospitalization for treatment, purpose.
13. I understand that I will be updated once a day about the patient's medical status and progress by consultant
Intensives and also that only one visitor will be allowed to visit the patient at a time in ICU during visiting hours.
14. I also understand that only one relative or attender will be allowed to stay with the patient and I will follow the
regulation regarding patients visiting time.
15. I understand that I am supposed to wear face mask while visiting patient in ICU and agree that I will not touch
the patient, the bed or any accessory of patient care.
16. I understand that in ward also I am not allowed to sit on the patient's bed.
17. I understand that any act causing damage or loss to the property of hospital or any act of violence against any of
the employees of the hospital is a cognisable offence. Any attempt to damage hospital property and disturbing
peace and harmony of the medical institution is prohibited as per Maharashtra Medicare Service, Persons and
Medicare Service Institution (Prevention of Violence & Damage or loss of property) Act 2010.
18. I agree not to talk loudly in the hospital premises and not to disturb peace and tranquility of the premises.
19. I understand that for any problem related to administration or treatment of the patient I should contact any of
the consultants i.e. Dr. Deepak Jeswani, is not available any members of his team
20. I agree to avoid water and electricity wastage and to maintain cleanliness of the hospital premises.
21. I understand that the hospital records will not be given to the relatives except the reports of the investigation
done.
22. I understand that for the patients safety purposes any type of alterative medicine will not be allowed to be given to
the patient during hospital stay.
23. I have understood charges the various changes applicable for the patients care and I am willing to incur those
charges for my patients care.
24. I also understand that use of mobile phones is strictly prohibited in the relatives.
25. Any sort of photography will not be allowed inside the premises.
26. I understand that for patients Safely purpose, he may need to be restrained in ICU or ward.
27. We/I have given handed over all the valuable of one patients.
Name ____________________
Witness Signature Mob.:____________________
Name____________________________ Relation :_________________ Patient Relatives Signature
FORM NO. B20
CC/AAC/01
C RITI C ARE
TM
Hospital & Research Institute Date :_____________________
Demhelee} ces Yejleer mebceleer he$e
1) cegPes/nces Deheveer Yee<ee ceW ef›eâšerkesâDej Demhelee} Deewj mebçeesOeve mebmLee ces Ghe}yOe megefJeOeeDees kesâ yeejs ces hegjer peevekeâejer oer ieF& nw leLee Demhelee} kesâ efveÙeceeW Deewj efJeveerÙecees keâer
yeejs ces mecePeeÙee ieÙee nw ~ Ùen meye mecePeves kesâ yeeo cew/nce Deheves efjçlesoej keâes ef›eâšer kesâDej ne@efmheš} ces Yejleer keâjJeeves kesâ ef}S leÙeej ngB/nw ~
2) cew Demhelee} keâes De«eerce jkeâce, Demhelee} keâceeaÙees Éeje pe®jer mecePeves hej pecee keâjves kesâ ef}S ceevÙe keâjlee ngB leLee cejerpe keâer Demhelee} mes Úgóer nesves mes hen}s Demhelee}
keâe efye} efpemeces Demhelee} ces ®keâves keâe KeÛee&, heâece&meer leLee ØeÙeesieçee}e keâe efye} Yegieleeve keâjves kesâ ef}S ØeefleyebOeerle jngbiee ~
3) cew Ùen Yeer mecePelee ngB efkeâ Demhelee} kesâ efye} ces keâesF& Úgš vener efce}sieer ~
4) cew Ùen Yeer mecePelee ngB efkeâ cejerpe keâer peeBÛees keâe leLee ØeÙeesieçee}e ces nesves Jee}s šsmš keâe KeÛee& Demhelee} efye} mes De}ie jnsiee ~
5) cegPes / nces mebceeCÙe Devegceefle KeÛe& keâer peevekeâejer os oer ieF& nw ~ cewb / nce Deew<eOeesheÛeej / GheÛeej Øe›eâerÙee / peeÛe heÌ[lee} / hejer#eCe Deeefo kesâ ef}S nesvesJee}s Øeefleefove kesâ KeÛe&
kesâ JÙeÙe keâe Yegieleeve keâjves kesâ ef}S mencele ng/nw ~
6) cew Demhelee} keâer efveleerÙees Deewj efveÙecees Devegmeej DeeJeçÙekeâ mecePes peeves hej keâesF& Yeer DeeJeçÙekeâ peevekeâejer pees ces[erkeâ} jskeâe@[& kesâ ef}S DeeJeçÙekeâ jnsieer, Demhelee} keâes
Ghe}yOe keâjeTbiee ~
7) cew Deheves cejerpe kesâ DeÛÚs mJeemLe kesâ ef}S pe®jer keâesF& Yeer oJeeF& pe®jer ceeie& mes (ceewKeerkeâ, me}eFveÉeje, vemees mes) osves keâer mebceleer oslee ngB ~
8) cew Deheves cejerpe keâes DeeJeçÙekeâlee nesves hej jkeäle Ùee jkeäleIeškeâ osves keâer mebceleer oslee ngB ~
9) cew ÙenYeer mecePelee ngB efkeâ, Deeheelekeâe}erve efmLeleer ces Demhelee} kesâ efÛekeâerlmekeâ efyevee efkeâmeer Fpeepele kesâ peerJeveeJeçÙekeâ Øeef›eâÙee keâj mekeâles nw ~ pees cejerpe keâer peeve yeÛeeves nsleg
DeeJeçÙekeâ nesieer ~
10) cew pe®jle he[ves hej efkeâmeer Yeer Øekeâej keâe Dee@hejsçeve keâjves keâer mebceleer oslee ngB ~
11) cew Ùen Yeer mecePelee ngB efkeâ, [e@. efohekeâ pesmeJeeveer Ghe}yOe vener nesves hej Gvekeâer efšce kesâ yeekeâer meomÙe cejerpe kesâ mebyebOeer efkeâmeer Yeer Øekeâej keâe ces[erkeâ} Ùee mepeeakeâ} efš^šcesvš
Je Gmekesâ ef}S hewâme}e }sves kesâ ef}S hegjer lejn mes me#ece jnWies ~
12) Demhelee} keâes cejerpe kesâ Yejleer jnles meceÙe efkeâmeer Yeer Jekeäle pe®jle he[ves hej HIV, HBSAG, VDRL menerle meYeer peeBÛe keâjves keâer menceleer oslee ngB ~
13) cew Ùen Yeer mecePelee ngB efkeâ efove ces Skeâ yeej Demhelee} kesâ me}enkeâej efÛekeâerlmekeâ cejerpe keâer efmLeleer leLee Øeieleer kesâ yeejs ces nces yeleeSbies leLee Deefleo#elee efJeYeeie ces Yejleer
cejerpe keâes efmehe&â efveOee&jerle meceÙe ces Skeâ yeej Skeâ ner JÙekeäleer efce} Skeâlee nw ~
14) cew Ùen Yeer mecePelee ngB efkeâ Demhelee} ces Yejleer cejerpe kesâ meeLe efmehe&â Skeâ efjçlesoej Ùee heefjÛej Demhelee} ces ®keâ mekeâlee nw leLee cejerpe kesâ efce}ves kesâ meceÙe mebyebOeer meYeer
efveÙecees keâe hee}Ce keâjWies ~
15) cew Ùen Yeer mecePelee ngB efkeâ DeeÙe.efme.Ùeg. ceW Yejleer cejerpe keâes efce}les meceÙe ceemkeâ henvekeâj ner DeeÙe.efme.Ùeg. ces peevee nesiee leLee cejerpe, efyemlej Ùee efkeâmeer Yeer Ûeerpe keâes Úgvee
cevee nw ~
16) cegPes Ùen yeleeÙee ieÙee nw keâer Jee[& ces Yejleer cejerpe kesâ efyemlej hej yew"vee cevee nw ~
17) cegPes Ùen Yeer yeleeÙee ieÙee nw efkeâ keâesF& Yeer keâeÙe& efpememes Demhelee} keâer mebheòeer keâes #eleer nes Ùee efheâj keâesF& Yeer efnbmeelcekeâ keâeÙe&Jeener efpememes Demhelee} kesâ keâeÙe&jle keâesF& Yeer
JÙekeäleer keâes neveer hengBÛes Ùen keâevegve pegce& nw ~ Demhelee} keâer mebheòeer keâes efkeâmeerYeer Øekeâej keâer #eleer keâjvee Ùee keâjves keâe ØeÙeeme keâjvee leLee Demhelee} ces çeebleer Yebie keâjvee ceneje°^
efÛekeâerlmee mesJee DeefYeveerÙece 2010 kesâ lenle ØeefleyebOeerle nw ~
18) cegPes peevekeâejer nw efkeâ Demhelee} ces peesj mes yeele vener keâjvee ÛeenerÙes leLee çeebleer yejkeâjej jKevee ÛeenerS Ùen ceevelee ngB ~
19) cejerpe kesâ GheÛeej mebyebOeer Ùee keâesF& Yeer ØeçeemeefkeâÙe mecemÙee nesves hej Demhelee} ces keâeÙe&jle me}enkeâej efÛekeâerlmekeâeW ces mes Ùeeveer [e@. efohekeâ pesmJeeveer Ghe}yOe vener nesves hej
Gvekeâer efšce kesâ yeekeâer meomÙe Je DevÙe [e@keäšme& Fvemes mebheke&â keâjs ~
20) cegPes Ùen peevekeâejer nw keâer heeveer leLee efyepe}er keâe DeheJÙeÙe vener keâjvee ÛeeefnS ~
21) Demhelee} ces efkeâS ieS peeBÛees kesâ efjheesš&dme kesâ De}eJee efjçlesoejeW keâes Demhelee} jskeâe@[& hesheme& vener efoS peeSbies ~
22) ceefjpeeW efkeâ mJeemLe megj#ee keâes osKeles ntS Demhelee} ces Yejleer efkeâmeerYeer cejerpe efÛekeâerlmekeâ keâer yeleeF& ngF& oJeeF& kesâ De}eJee ogmejer oJeeF&ÙeeB osves keâer Devegceleer vener nw, pewmes
keâer DeeÙegJexoerkeâ, nesceerÙees he@Leerkeâ oJeeF&ÙeeB Jepeeale nw ~
23) Demhelee} ces cejerpe keâes oer peeves Jee}er efJeYeerVe mesJeeDeeW kesâ KeÛex kesâ yeejs ces cegPes hegjer lejn mes DeJeiele keâjeÙee ieÙee nw Deewj cew Fme KeÛex keâe Yegieeleve keâjves kesâ ef}S leÙeej ngB ~
24) Demhelee} kesâ Deboj ceesyeeF&} heâesve keâe GheÙeesie Jepeeale nw ~
25) efkeâmeer Yeer Øekeâej keâer heâesšes«eeheâer Demhelee} ces keâjvee cevee nw ~
26) nce Ùen Yeer mecePeles nw efkeâ cejerpe keâer megj#ee kesâ ef}S keâYeer keâYeer cejerpe keâes peyejomleer jeskeâvee he[ mekeâlee nw ~ Gmekesâ neLe hewj yeeBOeves keâer Yeer pe®jle he[ mekeâleer nw ~
27) nces cejerpe efkeâ cetuÙeJeeve Jemleg Jeeheme keâj oer ieF& nw ~
veece :
ceesyeeF&ue :
mee#eeroej kesâ nmlee#ej efjMlee :
veece
hesçebš kesâ heefjpeveeW kesâ nmlee#ej
FORM NO. B20
C RITI C ARE
TM
Hospital & Research Institute
‘arO Am¡a nm[adm[aH$ A{YH$ma
1. {M{H$Ëgm àmá H$aZo H$m A{YH$ma
2. gå‘mZ Am¡a J[a‘m H$m A{YH$ma
3. JmonZr¶Vm H$m A{YH$ma
4. {M{H$Ëgm AñdrH¥$[V H$aZo H$m A{YH$ma
5. ì¶{º$JV gwajm H$m A{YH$ma
6. ì¶{º$Ëd Ho$ godm à~§Y OmZZo H$m A{YH$ma
7. OmZH$mar àmá H$aZo H$m A{YH$ma
8. {ejm àmá H$aZo H$m A{YH$ma
9. gh‘{V coZo VWm Xþgar am¶ coZo A{YH$ma
10. nam‘e© boZo Am¡a Xÿgar am¶ boZo H$m A{YH$ma
11. ñWmZm§VaU VWm {Za§Va XoIaoI H$m A{YH$ma
12. {eH$m¶V H$aZo H$m A{YH$ma
13. ‘o{S>H$b [aH$m°S>© H$s H$m°nr nmZo H$m A{YH$ma
14. BbmO H$s AZw‘m{ZV bmJV na OmZH$mar OmZZo H$m A{YH$ma.
‘arO Ho$ H$V©ì¶
1. ghr VWm nyU© OmZH$mar XoZo H$m H$V©ì¶
2. Amkm nmbZ H$aZo H$m H$V©ì¶
3. Am{W©H$ Xm{¶Ëdm| H$m H$V©ì¶
4. gå‘mZ VWm ‘hËd XoZo H$m H$V©ì¶
5. {M{H$Ëgm AñdrH¥${V VWm n[aUm‘ ñdrH$ma H$aZo H$m H$V©ì¶
6. {M{H$Ëgmb¶ Ho$ H$mZyZ VWm {Z¶‘m| H$mo nmbZ H$aZo H$m H$V©ì¶
7. ì¶{º$JV gån{V Ho$ XoIaoI H$m H$V©ì¶
8. emoa Am¡a [aíVoXmam| H$s g§»¶m H$mo {Z¶§{ÌV H$aZo H$s H$V©ì¶
9. nhMmZ nÌ CnbãY H$amZo H$s H$V©ì¶ (gaH$ma ‘mÝ¶Vm àmá)
10. AñnVmb ‘| S>m°ŠQ>a, H$‘©Mmar VWm Mb/AMb g§n{Îm H$mo {H$gr ^r àH$ma H$m ZwH$gmZ
Zht nhþ§MmZo H$m H$V©ì¶
‘wPo AnZo A{YH$mam| Am¡a H$V©ì¶ H$mo g‘Pm¶m J¶m h¡, ‘¢ dh g‘P J¶m hÿ§ &
hñVmja
[XZm§H$ …................................... ì¶{º$ H$m Zm‘
FORM NO. B88 (BACK)
CHRI/MR/46
C RITI C ARE
TM
Patient and Family Rights
1. Right to access to care
2. Right to respect and dignity
3. Right to privacy and confidentiality
4. Right to refusal to treatment
5. Right to personal and security
6. Right to know the identity of individual providing services to him/ her
7. Right to information
8. Right to education
9. Right to consent
10. Right to consultation and second opinion
11. Right to transfer and continuity of care
12. Right to complaint
13. Right to get copy of medical record.
14. Right to know the information on the expected cost of treatment.
Patient Responsibility
1. Responsibility of providing accurate and complete information
2. Responsibilities for following instructions
3. Responsible for financial obligations
4. Responsible for respect and consideration
5. Responsible for refusal of treatment and accepting consequences
6. Responsible for following hospital rules and regulation
7. Responsible for personal belongings.
8. Responsibility to control noise and number of relatives
9. Responsibility to provide ID Proof (Government Recognized)
10. Responsibility of not causing any loss to the doctor, employee and
movable/immovable property of the hospital
I have been explained my Rights and Responsibilities, I have understood the same.
Date:..................................... Signature
Name of Person
FORM NO. B88 (FRONT)
C RITI C ARE
TM
Ph.: 2522281, 2522282
Hospital & Research Institute Web : www.criticarenagpur.com
PAIN ASSESMENT SCALE
FORM NO. B38 (Front)

FORM NO. B38 (Back)
CHRI/MR/51
C RITI C ARE
TM

4th Floor "Dhanashree Complex" Sitabuldi, Nagpur-440012.
Ph.: 2522281, 2522282 Web : www.criticarenagpur.com
PRIMARY CONSULTANT NOTES

PATIENT NAME AGE/SEX IP NO.
PROVISIONAL DIAGNOSIS /DIAGNOSIS :
PLAN OF CARE :
PREVENTIVE MEASURES :
EXPECTED OUTCOME (PROGNOSIS) :
SIGNATURE WITH NAME :
DATE : TIME :
Note - To be filed and signed by Primary Consultant as soon as possible or within 24 hours of Admission
''CONFIDENTIAL''
FORM NO. B73
CHRI/MR/51
C RITI C ARE
TM

PATIENT NAME AGE/SEX IP NO.
DATE & PRIMARY CONSULTANT NOTES SIGN WITH

TIME CHANGE IN PLAN OF CARE NAME
Note - To be filed and signed by Primary Consultant whenever there is a change in Plan of care
(both initial plan and subsequent change in plan)
""CONFIDENTIAL''
FORM NO. B73
C RITI C ARE
TM
Hospital & Research Institute Ph.: 2522281, 2522282

Web : www.criticarenagpur.com
Height _______________
Weight _______________
PAIN ASSESMENT SCALE

FORM NO. B50 (BACK)
CC/AAC/6
C RITI C ARE
TM
Hospital & Research Institute Ph.: 2522281, 2522282

Web : www.criticarenagpur.com
NUTRITION ASSESSMENT FORM
NUTRITIONAL SCREENING
FORM NO. B54 Green Paper (Front)

CC/AAC/4
DIETARY NOTES / RE-ASSESSMENT
FORM NO. B54 Green Paper (Back)

Inspiring Care Diabetes Chart
Fractional Dose of Insulin
C RITI C ARE
TM
- Upto 120 - Nil

Hospital & Research Institute - 120 - 160 - 4 Unit
- 160 - 200 - 8 Unit
Patient's Name : - 200 - 250 - 10 Unit
- 250 - 300 - 12 Unit
I.P.No.: - 300 - 350 - 14 Unit
Age / Sex : - 350 - 400 - 16 Unit
if 400 & Above them Inform
DATE TIME BLOOD SUGAR URINE KETONES DOSAGE OF INSULIN SIGNATURE
FORM NO. B7 (Front)

FORM NO. B7 (Back)
TM
CRITI CARE Sitabuldi, Nagpur-440012.

Ph.: 2522281, 2522282
Patient's Name :_____________________________________________________________________________________________

Age :__________ Sex : M / F IPD No.:_________________________ Room No./Bed No.:______________________
Diagnosis :_______________________________________________Allergy________________________________
MEDICATION CHART
TO BE FILLED BY DOCTOR BY NURSES
Sign. Sign. Sign. Sign. Verified
Sr. Date & Name of the Drug Dose Route Freq. Sign. With
Time With Time With Time With Time With By
No. Time Name of DMO Name Name Name Name
Signature Of Doctor On Duty_________________________________ Name :________________________________________________________________

I.V. FLUIDS : ___________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
BLOOD ORDER :_______________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
NON-DRUG ORDERS :__________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
OTHER ADVISED :______________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
DIET ORDER :__________________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
BLOOD SUGAR MONITORING
TIME :
READING :
TREATMENT :
INVESTIGATIONS ADVISED :____________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
DRAINS / RT ASPIRATE : ________________________________________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________
DISCHARGE/TRANSFER ADVICE :_______________________________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
FORM NO. B41 (Back)

C RITI C ARE
TM
VISITING CONSULTANT'S NOTES
PATIENT NAME :
CONSULTANT NAME :
DATE & TIME :
History :
Clinical Findings :
Lab Report :
Provisional Diagnosis :
Suggestions :
FORM NO. B14 (Paper Pink Color)

C RITI C ARE
TM

COUNSELLING FORM
Concert / Councelling of critically ill patient in ICU / Ward
‘arO H$m Zm‘ / NAME OF PATIENT :
XoI^mc H$s ¶moOZm / PLAN OF CARE :
‘wpíH$co / COMPLICATION
B©cmO / MEDICATION :
FORM NO. B56

CRITI CARE
TM
INVESTIGATION SHEET
Blood Group HIV HBsAg HCV
Date :
Time :
Hb
WBC
Platelets
P.T.
P.T.T.
Fibrinogen
F.D.P.
Bilirubin
S.G.O.T.
S.G.P.T.
4
Alk Po
T. Proteins
Albumin
+
Na
K+
++
CI
++
Ca
Mg++
Urea
Creatinine
Uric Acid
FiO2 (%)
pH
pCO2
pO2
HCO3
BE
SaO2
Sr Amylase
Sr Lipase
L.D.H.
C.P.K. (Total)
C.P.K. (MB)
Troponin
LDH
Ammonia
MIMS/MR/14 (1-1)

ANTIBIOTICS
DATE DRUG DOSE FROM TO TOTAL DAYS REMARK / COMPLICATION
SAMPLE DATE CULTURES
URINE
SPUTUM
BLOOD
BODY FLUIDS
MIMS/MR/14 (1-1)
FORM NO. B42 (Back)

CHRI/MR/45
C RITI C ARE
TM

INFECTION CONTROL CHECK LIST
Name of Patient :....................................................................................................
Age:.............. Sex:.............. IP No.:.................................
INSERTION DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE REMARK
Vasofix
FOLEYS CATHETER
RYLES TUBE
CENTRAL LINE
ARTERIAL LINE
TT TUBE
INTUBATION
B-PAP
SURGICAL SITE INFECTION
STAFF SIGNATURE
Prepared by ICN
FORM NO. B70
CHRI/MR/45
C RITI C ARE
TM

INFECTION CONTROL CHECK LIST
Name of Patient :....................................................................................................
Age:.............. Sex:.............. IP No.:.................................
INSERTION DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE REMARK
Vasofix
FOLEYS CATHETER
RYLES TUBE
CENTRAL LINE
ARTERIAL LINE
TT TUBE
INTUBATION
B-PAP
SURGICAL SITE INFECTION
STAFF SIGNATURE
Prepared by ICN
FORM NO. B70
CCH/ICD/14
C RITI C ARE
TM

CENTRAL LINE INSERTION BUNDLE

Date..................... Time............... Department .............................
CENTRAL LINE INSERTION BUNDLE
PROCEDURE AND PROCESS YES / NO REMARK
Optimal site selection (SUB, IJV / FEMORAL)
Hand washing!!! Surgical mask & cap sterile Gloves, Gown,
Full body drape (sterile field)
Chlorhexidine 2% skin prep
Immediate dressing application (dated)
Aseptic precautions
Dressing type transparent/gauze/microspore
After procedure hand wash
CENTRAL LINE DAILY MAINTENANCE BUNDLE
CHECKLIST
Hand washing before access
Standard dressing changes
(date & time)
Swab ports with
Chlorhexidine 2% swabs
Changes IV bags/bottle 24
hours
Changes of tubing for TPN
q24 hours
Change IV tubing q72 hours
Daily review of necessity/
Early removal
Purulence or redness at local
site
Fever
MICROBIOLOGICAL DATA
Blood culture (central/peripheral/tip)
Date
fever (Y/N)
Organism
C/S
Rx
Line removed or not
Consultant / RMO Signature Staff Nurse Signature
Name :- Name :-
Date :- Date :- Time :-

FORM NO. B69
CCH/ICD/16
C RITI C ARE
TM

VENTILATOR CARE BUNDLE

(Please tick in all relevant boxes when activity is Completed)
Intubation indication : Emergency/Elective : Intubation performed by :
Date of Intubation :
*Hand Washing for every contact with patient
Date of Extubation :
Date
Check list
Oral Care
Pup at 30-40 Degree (in the

absence of medical
contraindication)
Patient turning on rotation

(2nd hourly/as needed)
Daily awaking sedation

vacation
Daily Assessment of
readliness for weaning
ventilator mode
DVT prophy laxix
Suctioning (2nd hourly / as

needed)
Cuff pressure (2nd hourly / as

needed)
Continuous subglotial
Contact isolation
FORM NO. B68

CC/PRE/08
C RITI C ARE
TM
Ph.: 2522281, 2522282
a³V àXmZ gh‘{V nÌ
amoJr H$m Zm‘ …................................................................................................... Am¶w/qcJ......................
Am¶.nr. H«$‘m§H$ …................................................. {XZm§H$ / g‘¶ ….................................
‘¢ ........................................................................................... ‘arO go [aíVm.......................................
‘wPo ‘oar AmgmZ ^mfm ‘| a³V àXmZ H$s OéaV H$mo g‘Pm¶m J¶m h¡ &
BgHo$ Acmdm a³V àXmZ go hmoZo dmco Omo{I‘ Am¡a gmW OwS>r O{Q>cVmAm| Ho$ ~mao ‘| ‘wPo nyar OmZH$mar Xr J¶r h¡ …
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
‘¢Zo a³V àXmZ go g§å~§{YV {ddaU H$mo R>rH$ Vah go g‘P {c¶m h¡ Am¡a a³V àXmZ Ho$ {cE AnZr gh‘{V Xo ahm hÿ± &
[aíVoXma H$m Zm‘ Am¡a hñVmja …......................................................
amoJr H$m Zm‘ ….............................................................................
VmarI …..............................................
g‘¶ …...............................................
Jdmh ….............................................. hñVmja …................................................
{M{H$ËgH$ H$m Zm‘ Am¡a hñVmja ….............................................................................................................
FORM NO. B62 (Back)

CHRI/MR/24
C RITI C ARE
TM
Ph.: 2522281, 2522282
a³V/a³V O{ZV nXmW© Ho$ g§MaU Ho$ {c¶o gh‘Vr / Agh‘Vr nÌ &
‘wPo ‘oar / ‘oao ê$½U H$s {M{H$Ëgm H$aZo dmbo
{M{H$ËgH$
Ûmam gw{MV {H$¶m J¶m h¡ {H$, ê$½U H$s {M{H$Ëgm AWdm eë¶{H«$¶m Ho$
Xm¡amZ ‘wPo / ‘oao ê$½U H$mo ~ohVa {M{H$Ëgm hoVw aº$/aº$ O{ZV nXmW© H§$ g§MñWm H$s Amdí¶H$Vm nS> gH$Vr h¡ &
‘wPo ~Vm¶m J¶m h¡ {H$, {H$gr {~‘mar, AmKmV AWdm eë¶{H«$¶m H$s dOh go {Vd« ¶m A{YH$ aº$ñÌmd AWdm ê$½U
H$mo nwamZr a³V{jUVm ¶m {H$gr AÝ¶ dOh go aº$ g§MaU H$s Oê$aV nS> gH$Vr h¡ &
h‘mao {M{H$ËgH$ Ûmam ‘wPo ~Vm¶m J¶m h¡ {H$, g^r aº$XmVmAm| H$s g§nwU© Om§M d à¶moJembm ‘| aº$XmVm H$s
honoQ>mB©Q>rg, ES>g² d {g’$crg O¡gr {~‘mar¶m| H$s Om§M Ho$ nümV ^r aº$ g§MaU H$s à{H«$¶m Ho$ Hy$N> {dn[aV n[aUm‘
hmo gH$Vo h¡ & ‘¡ ¶h ^r OmZVm hþ§ H$s Cnamoº$ Om§M à{H«$¶m VWm gmdYm{Z¶m| Ho$ ~mdOyX ^r ê$½U Ho$ eara ‘o ‘m¡OyX
AÝ¶ {H$Q>mUwAm| AWdm g§H«$‘U ({OZH$m nVm Zhr bJ¶m Om gH$Vm) Ho$ H$maU {H$gr {dn[aV n[aUm‘ H$s g§^mdZm
H$mo nwar Vah ZH$mam Zht Om gH$Vm &
Am‘ Vm¡a na aº$/aº$ O{ZV nXmW© Ho$ g§MaU go Am‘ Vm¡a na ~wIma, IwObr, Iam|M bJZo O¡gm ‘hgwg hmoZm O¡go
{dH$ma AWdm gm¡å¶ àH$ma H$s naoem{Z¶m CËnÞ hmoVr h¡ d CZH$s ghO {M{H$Ëgm ^r CnbãY h¡ & aº$/aº$ O{ZV
nXmW© Ho$ g§MaU go Am‘ go EbOu, gm§g boZo ‘o VH$br’$, honoQ>mB©Q>rg/EoS>g² O¡go g§H«$‘U, ê$½U H$s ‘¥Ë¶w ¶m AÝ¶
àH$ma Ho$ J§^ra n[aUm‘ AË¶ën à‘mU Zo CËnÞ hmoZo H$r g§^mdZm ^r ahVr h¡ & eara H$s àmUdm¶w H$s Amdí¶H$Vm
AWdm aº$ Ho$ O‘Zo H$s à{H«$¶m H$mo nwU©Vm hoVw aº$/aº$ O{ZV nXmW© Ho$ g§MaU go A{V[aº$ H$moB© AÝ¶ ~ohVa
{dH$ën ‘m¡OyX Zht h¡ & ê$½U H$s Oê$aV Ho$ AZwgma aº$/aº$ O{ZV nXmW© Ho$ g§MaU H$mo ZH$maZo go ê$½U H$mo
àmUdm¶w H$s H$‘r, eara Ho$ {H$gr {hñgo ¶m Ad¶d H$mo hmZr n§hþMZo, öX¶mKmV H$s g§^mdZm Ho$ gmW hr a³VñÌmd
amoH$Zo ‘o {X¸$V AWdm ê$½U H$s ‘¥Ë¶w O¡go n[aUm‘ ^r g§^{dV ahVo h¡ &
pñdH¥${V
‘¢Zo Cnamoº$ gh‘Vr/Agh‘Vr nÌ nwar Vah nT>H$a CgZo {X JB© (OmZH$mar H$mo g‘P {b¶m h¡ & (¶h ‘wPo nT>H$a
AÀN>r Vah g‘Pm {X¶m J¶m h¡) & aº$/aº$ O{ZV nXmW© Ho$ g§MaU Ho$ n[aUm‘m| d Bgo ZH$maZo go g§~YrV ‘oao g^r
àH$ma Omo àíZm| nwN>Zo H$m ‘wPo nwam ‘m¡H$m {X¶m J¶m d CZH$m g‘w{MV g‘mYmZ {H$¶m J¶m h¡ & ‘wPo nwU© {dídmg h¡ {H$,
Bg Ho$ nümV ^r Bg {df¶ ‘o {H$gr AÝ¶ OmZH$mar AWdm àíZm| ¶m e§H$mAm| Ho$ g‘w{MV g‘mYmZ h‘mao {M{H$ËgH$
H$s Am¡a go h‘o àmá hm|Jo & ' '‘wPo a³V/aº$ O{ZV nXmW© Ho$ g§MaU H$mo ZH$maZo Ho$ n[aUm‘m| H$s ^r nwU© OmZH$mar h¡
& Bg ~mao ApñdH¥$Vr XoZo na ‘¡, {H«$Q>rHo$Aa hm°ñnrQ>c Cggo g§~{YV {M{H$ËgH$m| AWdm CZHo$ H$‘©Mm[a¶m| H$mo {H$gr
^r àH$ma go {Oå‘oXma Zht ‘mZw§Jm Eogm A{^dMZ XoVm hþ§ &
‘¡ aº$/aº$ O{ZV nXmW© Omo g§MaU Ho$ {b¶o AnZr pñdH¥$Vr àXmZ H$aVm hþ§
‘¡ aº$/aº$ O[ZV nXmW© Ho$ g§MaU Ho$ {c¶o AnZr Agh‘r ì¶º$ H$aVm hþ§
gmjr … ‘arO … ‘ZmoZrV …

hñVmja … hñVmja … hñVmja …
Zm‘ … Zm‘ … Zm‘ …
VmarI … VmarI … VmarI …
CHRI/MR/43
C RITI C ARE
TM
Ph.: 2522281, 2522282
CONSENT/REFUSAL FOR BLOOD/BLOOD PRODUCT TRANSFUSION

I, .............................................................................. have been informed by the treating
cIinician...........................................................that in course of my/ my patient's medical/surgical
treatment I / my patient may need to be transfused blood or blood products in interest of my / my
patient health care.
I have been explained that blood transfusions are used to treat acute blood loss (from disease, trauma
of surgery), acute or chronic anaemia and other conditions. The treating clinician has informed me
that there are risks associated with the therapy even though all donors are carefully screened by
medical history and their blood has been tested by laboratory analysis for diseases such as Hepatitis,
AIDS, and syphilis. I understand that these measures can not completely eliminate the risk that there
are antibodies, antigens and infectious agents which have yet to be identified by scientists, and
therefore cannot be detected.
Complications or reactions to transfusions are usually very mild and easily treatable. Some of the
more common complications associated with blood and blood product infusions include, but are
limited to bruising, fever, hives and/or rash.
Serious consequences associated with blood or blood product infusions are extremely rare but
sometimes do happen. These include, but are not limited to, anaphylactic reaction (severe allergic
reactions including difficulty in breathing), transmission of infectious diseases such as
Hepatitis,AIDS, and /or death.
There are no good alternatives to blood or blood products to accomplish the purpose of carrying
oxygen and providing the ability to clot. If blood or blood product is required but refused, risks may
include organ damage from inadequate oxygen, such as heart attack or stroke, in some cases
inability to control bleeding and sometimes death.
ACKNOWLEDGEMENT
I acknowledge that I have read this consent form (or it has been read to me) and I understand the
information contained in it, and that I have been given reasonable opportunity to ask whatever
questions I may have about blood or blood product transfusions, including the risk of refusal of blood
transfusion and that my questions have been answered in satisfactory manner. I understand that the
treating clinician will be available to answer any additional questions or concerns I may have
regarding blood or blood product infusions.
I am fully aware of the risk of refusing the transfusion of blood or blood products and agree NOT to
hold its staff, employees and physicians responsible, should I refuse.
I CONSENT to transfusion of blood /blood products
I REFUSE Transfusion of blood/blood products
Witness : Paitient : NOK / Relative :
Signature :_______________ Signature :_______________ Signature :_______________
Name :__________________ Name :__________________ Name :__________________
Date :___________________ Date :___________________ Date :___________________

CHRI/MR/54
C RITI C ARE
TM
Ph.: 2522281, 2522282
BLOOD / BLOOD PRODUCTS TRANSFUSION MONITORING RECORD

Patient Name :_______________________________ Consultant I/C :_____________________
UHID :_______________________________ Blood Group :_____________________
Age / Sex :_______________________________ Location : (Room/Ward/Bed)___________
Indication for Transfusion :__________________________________________________________
DETAILS OF TRANSFUSION
Date No. of Component Blood Units Trans. Trans. Reason for Total
Units Group Received Started Stopped stopping Amount
at (Time) at (Time) at (Time) Transfused
MONITORING OF VITAL SIGNS

Time from 0.00 0:15 1:00 2:00 3:00 4:00 Post
Transfusion Transfusion
Pulse
BP
RR
Temp
SPO2
Reaction
REACTION/REACTION (If reaction noted; give time first observed and duration)
Rigors :.......................................... Anxiety :................................... Haematuria :............................. Pain in legs :...............................
Chills :............................................ Restlessness :....................... Oliguria :..................................... Pain in Back :.............................
Fever :.......................................... Headache :............................. Anuria :....................................... Pallor :............................................
Sweating :.................................. Urticaria :................................ Icterus :...................................... Dyspnoea :...................................
Nausea :..................................... Erythema :.............................. Shock :...................................... Bronchospasm :........................
Vomiting :.................................. Pruritus :................................. Cyanosis :.......................... Pericardial/restrosternal discomfort
Pulmonary Oedema :............................
If reaction noted please fill the transfussion reaction form behind and hand it over to the quality improvement
committee after patient is discharged
Materials to be sent to blood bank :

Patients post transfusion sample : Y/N
Donor Unit with tubing intact Y/N
Post Transfusion urine sample Y/N
Name & Signature of Assigned Staff Nurse Name & Signature of Doctor
Date : Date :
CHRI/MR/55
C RITI C ARE
TM
Ph.: 2522281, 2522282
REPORTING OF BLOOD TRANSFUSION REACTION FORM

Patient Name :_______________________________ Age / Sex :_________________________
UHID :_______________________________ Location : (Room/Ward/Bed___________
Consultant I/C :_______________________________
Indication for Blood Tranfusion :________________________________________________________

Date and Time the Transfusion started :__________________________________________________
Name of person starting transfussion :___________________________________________________
Date and Time of Transfusion reaction first observed/complained by patient____________________
Name of person first observed the reaction :______________________________________________
Detailed Description of Reaction :________________________________________________________
___________________________________________________________________________________
Blood Transfusion terminated at (Date & Time)____________________________________________
Action Taken :
Transfusion Termination at :_________________________________
Removal and storage of blood products and IV lines :_________________________________
Consultant informed at : Time :_________________________________
Investigations sent to lab/blood bank :__________________________________
__________________________________________________________________________________
Details of Treatment given to the Patient :________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Likely Causes : 1._______________________2._______________________3.__________________
Response of Patient to treatment :______________________________________________________
Vital signs record :
Pulse :_____________________________ BP :_________________ Respiration :________________
Oxygen saturation :__________________ Kidney Functions :________________________________
Final Outcome of Patient :_____________________________________________________________
Signature of Staff Nurse I/C :_________________________ Signature of RMO :_________________

Remarks of consultant :_______________________________________________________________
Recommendations for corrective/preventive actions :_______________________________________
Signature :________________ Name :______________________________________ Date :_________

Submitted to Quality Coordinator on date :______________________
FORM NO. B83 (BACK)
CC/PRE/06
C RITI C ARE
TM 4th Floor "Dhanashree Complex"
Ph.: 2522281, 2522282
BLOOD TRANFUSION CONSENT
Name of patient :_____________________________________________Age/Sex :_________
IP Number :_____________________________ Date / Time :__________________________
I _________________________________________ relation with patient _________________
Have been explained in the language I understand the need of blood transfusion.
Also I have been explained the and complications associated with blood transfusion which
is as follows :
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I have understood all the details pertaining to blood transfusion and I hereby give my willful
consent.
Name of relative :___________________________________________
Name of patient :___________________________________________
Date :________________________
Time :________________________
Witness :___________________________________________________________
Name and Signature of Doctor :_________________________________________

CRITI CARE
TM
MR Number :........................................................................................................
Hospital & Research Institute Patient Name :.....................................................................................................
4th Floor "Dhanashree Complex" Sitabuldi, Nagpur-440012. Age :....................... Admt. Doct.:..........................................................................
Ph.: 2522281, 2522282 Web : www.criticarenagpur.com Address :...................................................................Telephone No.:......................
Consent For Hemodialysis

1. I authorised the performance upon Mr./Mrs./Ms................................................................................................................
(My self Name of Patient) the following precedure(s) - Himodialysis./..................................................................................
2. The doctor has fully explained to me the kind of procedure he/she will perform and has answered my question about
my procedure to my satisfaction, The doctor has also explained the risks involved in the procedure, and I understand
those risks and am willing to undergo the procedure. This I consent to by my own free act and will.
3. The doctor has also explained other methods of treatment to me and I have decided to undergo the procedure,
including the administration of blood products, If necessary as the best means of trying to correct/ alleviate my
condition.
4. I understand that during the procedure, the doctor may find other unhealthy conditions in me that may need treatment.
I therefore also authorize the doctor to perform such other procedures which he/she ma find necessary to do in order
to improve or correct these conditions.
5. My doctor has also explained that, in performing the procedure, he/she may use assistants, such as hospital residents,
or other physicians, technicians and nurses and I give my consent to do so.
6. No guarantee have been given to me by my doctor about the results of the procedure and also I understand that there
are times when more that one procedure may be necessary to complete the treatment o my condition.
7. I consent to the observing. photographing or televising of the procedure to be performed, to be performed, including
appropriate portions of my body, for medical, scientific, or educational purpose, provide my identity is not revealed
by the pictures or by descriptive text accompanying them.
8. I also agree to co-operate fully eith my doctor and to follow, to the best of my ability his/her instructions and
recommedations about my care and treatment.
9. I have been explained about the risk involved in Hemodialysis I have been told that vast majority of patients do not
experience any problems or complications with procedure. However the risk of complications is always present and
must be kept in mind.
10. I have also been told and explained following things about Hemodialysis. Some of complication of Hemodialysis are
as follows - nausea, vomiting, pain, fever, shivering, bleeding, convulsion, chest discomfort, Hypotension & cramps etc.
It is not possible to list every conceivable complications. these complications occur rarely and can often be treated
without serious effects. However the risk of complications and/or death is always present. Patients with pre-existing
medical problems have a greater risk of developing complications during and following Hemodialysis.
11. I understand that nearphrologist is not available all the time. He has to go out to attend other patients or meetings. In
case of emergency during dialysis, I have been informed that emergency response team will treat me.
12. I have seen the facilities available in the hospital and limitations. I know there may be other hospitals with more
facilities in town and also that there are government hospitals where treatment is given free of charge or at
concessional rate. Knowing these fully I want to undergo treatment in this hospital.
13. The medicines prescribed do have adverse side effects, There are some restrictions to be followed during these
treatments. I will abide by these restrition as told by doctor, I know that doctor is prescribing medicines or doing the
procedures as per his skill and judgement in good faith.
14. The result or outcome of these treatment procedures are often unpredictable, some unforseen complications can
appear during the treatment.
15. Occasionally blood transfusion is required for the patient. It is responsibility of blood banks to check for transmissible
diseases like malaria, hepatitis (including hepatitis B and C), HIV etc. Though the blood banks may certify that the
donated blood is free of these disease causing pathogens but I do understand that during some period of illness,
which is called as window period the result of the tests done by blood banks may be negative even though the blood
may actually carry these organisms. I shall not hold the dialysis unit/the hospital responsible for the same.
16. I understand & agree to abide by the decision of my trating nephrologist to undergo dialysis twice /Thrice  (tick
where applicables) per week.
I certify that the entire briefing has been done in the language which I understand i.e._________________________
Despite my being told these risks, I still desire to have and consent to this procedure/treatment.
‘¡ ¶h à‘m{UV H$aVm hÿ± H$s, ‘wPo ‘oar ^mfm ‘|................................................({hÝXr/‘amR>r/B§p½ce/AÝ¶) AÀN>r Vah go g‘Pm {X¶m J¶m h¡ Ed§ ‘oar
g^r e§H$mAm| H$m g‘mYmZ AÀN>r Vah go H$a {X¶m h¡ & BZ go Omo{I‘m| Ed§ VÏ¶m| H$s AÀN>r Vah go g‘PZo Ed§ OmZZo Ho$ ~mdOyX ‘¢/h‘, ‘oam/‘oao n[aOZ H$m Om
‘arO h¡, H$m Am°naoeZ/BcmO H$amZo Ho$ {c¶o V¡¶ma h¡ Am¡a BgHo$ {c¶o nyU© én go gh‘{V XoVo hÿ¶o nyar {Oå‘oXmar coVm hÿ± &
Name of the Patient/Substitute decision maker and relationship with patient ‘arO/‘arO Ho$ n[aOZ H$m Zm‘
____________________________________________________________________________________
Signature / hñVmja_______________________________________________________________________
Date/ [XZm§H$/Time _______________________________________________________________________________
Signature of witness / Jdmh Ho$ hñVmja___________________________________________________________

DOCTORS / HEMODIALYSIS TECHNICIAN STATEMENT
S>m°³Q>a (Primary Consultant)/ [h‘moS>m¶co{gg Q>oH${Zer¶Z H$m H$WZ
I have explained the patient's condition, need for treatment, the procedure and the risks, relevant treatment options and
there risks, likely consequences if those risks occur, and the significant risks and problems specific to the patient.
I I have given the patient/substitute decision maker an opportunity to ask quastions about any of the above matters and
raise any other conserns which I have answred as fully as possible
I am of the opinion that the patient/Substitute decision maker understood the above information
‘¢Zo ‘oao ‘arO / [aíVoXma H$s pñWVr, BcmO H$s OéaV, Am°naoeZ H$s O¶aV, CnMma à{H«$¶m go g§~§{YV OmZH$mar V[ Bggo g§~§{YV g^r Omo{I‘m|/d¡H$pënH$ VWmm
AÝ¶ g§~§{YV g^r Omo{I‘m|/d¡H$pënH$ VWm AÝ¶ g§~§{YV BcmO à{H«$¶m Ed§ BZ g~ go g§~§{YV Omo{I‘m| go hmoZodmco n[aUm‘, {deof Omo{I‘ Am¡a {deof naoem{Z¶m±
BË¶mXr Ho$ ~mao ‘| CZH$s ‘mV¥^mfm / ^mfm Omo dh g‘PVo h¡§, ‘¢ nyar Vah go g‘Pm {X¶m h¡ &
‘¡Zo CÝho / [aíVoXma H$mo CZH$s e§H$mAm| Ho$ g‘mYmZ Ho$ {c¶o nyU© Adga àXmZ {H$¶m Ed§ CZHo$ ìXmam nyN>o J¶o g^r àíZm| H$m nyU©én go g‘mYmZ {H$¶m J¶m Ed§ ‘oao AZwgma
‘arO / [aíVoXma H$mo R>rH$ go g‘P ‘| Am J¶m h¡ & CÝho Cnamo³V {c{IV OmZH$mar ^r AÀN>r Vah go g‘P ‘| Am J¶r h¡ &
Name of the Doctor / Dialysis Technician :______________________________________________________________

Signature ______________________________________________________________________________________
Date :_________________________________________________________________________________________
FORM NO. B52 (BACK)

CRITI CARE
TM
MR Number :........................................................................................................
Hospital & Research Institute Patient Name :.....................................................................................................
4th Floor "Dhanashree Complex" Sitabuldi, Nagpur-440012. Age :....................... Admt. Doct.:..........................................................................
Ph.: 2522281, 2522282 Web : www.criticarenagpur.com Address :...................................................................Telephone No.:......................
Consent For Hemodialysis ho‘moS>m¶{b{gg Ho$ {bE gh‘{V

1. I authorise the performance upon Mr./Mrs./Ms__________________________________________________
(My self Name of Patient) the following procedure(s) Hernodialysis./
‘¡ Mr./Mrs./Ms________________________________________________ ho‘moS>m¶{b{gg à{H«$¶m ‘oao D$na / ‘oao
[aíVoXma (amoJr H$m Zm‘) BZna H$aZo H$s gh‘{V.
2. The doctor has fully explained to me the kind of procedure he/she will perform and has answered my question
about my procedure to my satisfaction, The doctor has also explained the risks involved in the procedure, and I
understand those risks and am willing to undergo the procedure. This I consent on my own free act and will.
S>m°ŠQ>a Zo ‘wPo nyar Vah go g‘Pm¶m h¡ {H$ dh {H$g Vah H$s à{H«$¶m H$aoJr/H$aoJr Am¡a CÝhmoZo ‘oao gdmb H$m Odm~ {X¶m h¡ ‘oar g§Vw{ï> Ho$
{bE S>m°ŠQ>a Zo à{H«$¶m ‘| em{‘b OmopI‘m| H$mo ^r g‘Pm¶m h¡, Am¡a ‘¢ CZ OmopI‘m| H$mo g‘PVm hþ Am¡a à{H«$¶m go JwOaZo H$mo V¡¶ma hÿ§& ¶h ‘¢
AnZo ñd¶§ H$s BÀN>m go gh‘{V XoVm hÿ§&
3. The doctor has also explained other methods of treatment to me and I have decided to undergo the procedure,
including the administration of blood products, if necessary as the best means of trying to correct/ alleviate my
condition.
S>m°ŠQ>a Zo ‘wPo BbmO Ho$ AÝ¶ VarH$m| Ho$ ~mao ‘| ^r ~Vm¶m h¡ Am¡a ‘¢Zo Bg à{H«$¶m go JwOaZo H$m ’$¡gbm {H$¶m h¡, aº$ aº$ VWm aº$ KQ>H$
OéaV hmoZo na
4. I understand that during the procedure, the doctor may find other unhealthy conditions in me that may need
treatment.I therefore also authorize the doctor to perform such other procedures which he/she may find necessary
to do in order to improve or correct these conditions.
‘¢ g‘PVm hÿ§ {H$ à{H«$¶m Ho$ Xm¡amZ, {M{H$ËgH$ H$mo ‘wP ‘| AÝ¶ AñdmñÏ¶H$a pñW{V¶m| H$m nVm bJ gH$Vm h¡ {OÝh| CnMma H$s Amdí¶H$Vm
hmo gH$Vr h¡& Bg{bE ‘¢ S>m°ŠQ>a H$mo Eogr AÝ¶ à{H«$¶mE§ H$aZo Ho$ {bE ^r A{YH¥$V H$aVm hÿ§, Omo BZ pñW{V¶m| H$mo gwYmaZo ¶m R>rH$ H$aZo Ho$
{bE CÝh| Amdí¶H$ bJVm h¡&
5. My doctor has also explained that, in performing the procedure, he/she may use assistants, such as hospital
residents, or other physician, technician and nurses and I give my consent to do so.
‘oao S>m°ŠQ>a Zo ¶h ^r g‘Pm¶m h¡ {H$, Bg à{H«$¶m H$mo H$aZo ‘|, ghm¶H$ H$m BñV‘mb H$a gH$Vo h¡ ,O¡go H$s {Zdmgr S>m°ŠQ>a ¶m AÝ¶
{M{H$ËgH$, Q>oŠZs{e¶Z ¶m Zg© Am¡a ‘¢ Eogm H$aZo Ho$ {bE AnZr gh‘{V XoVm hÿ§
6. No guarantee have been given to me by my doctor about the results of the procedure and also I understand that
there are times when more that one procedure may be necessary to complete the treatment in my condition.
à{H«$¶m Ho$ n[aUm‘m| Ho$ ~mao ‘| ‘oao S>m°ŠQ>a Ûmam ‘wPo H$moB© Jma§Q>r Zht Xr JB© h¡,Am¡a ‘wPo ¶h ^r g‘P ‘| Am¶m h¡ {H$ H$^rH$^r Eogo g‘¶ hmoVo h¢
O~ CnMma H$mo nyam H$aZo Ho$ {bE EH$ go A{YH$ à{H«$¶m H$aZo H$s OéaV nS> gH$Vr h¡&
7. I consent to the observing. photographing or televising of the procedure to be performed, including appropriate
portions of my body, for medical, scientific, or educational purpose, provided my identity is not revealed by the
pictures or by descriptive text accompanying them.
‘¡ AnZo D$na hmoZo dmbr à{H«$¶m H$m AdbmoH$Z H$aZo, Vñdra {ZH$mbZo ¶m àXe©Z H$aZo Ho$ {bE gh‘Vr XoVm hþ, {Og‘o ‘oao eara H$m Cn¶wº$
A§J ¶m {hñgm Cg‘o AmEJm& BgH$m Cn¶moJ {M{H$Ëgm d¡km{ZH$ ¶m e¡j{UH$ CXXoe H$aZo H$s ^r AZw‘Vr XoVm h¡ bo{H$Z Bg‘| ‘oar nhMmZ
’$moQ>mo ¶m CgHo$ gmW Ho$ {ddaU ‘| Zm hmo&
8. I also agree to co-operate fully either my doctor and to follow, to the best of my ability his/her instructions and
about my care and treatment.
‘¡ ‘oar XoI^mb Am¡a CnMma Ho$ ~mao ‘| AnZo {M{H$ËgH$ H$mo nwar Vah ghH$m¶© XoZm VWm CgHo$ g^r {ZX}e ¶m gwPmd ‘oar nwar ¶mo½¶Vm AZwgma
nmbZ H$aZo H$mo gh‘V hþ&
FORM NO. B52 (1)
9. I have been explained about the risk involved in Hemodialysis I have been told that vast majority of patients do
not experience any problems or complications with procedure. However the risk of complications is always present
and must be kept in mind.
‘wPo ho‘moS>m¶{b{gg ‘| em{‘b OmopI‘ Ho$ ~mao ‘| g‘Pm¶m J¶m h¡, ‘wPo ~Vm¶m J¶m h¡ {H$ A{YH$m§e amoJr¶m| ‘| H$moB© ^r g‘ñ¶m ¶m O{Q>bVm
Zht hmoVr h¡& hmbm§{H$ O{Q>bVmAm| H$m OmopI‘ H$s g§^mdZm h‘oem hmoVr h¡ Am¡a Bgo Ü¶mZ ‘| aIm OmZm Mm{hE&
10. I have also been told and explained following things about Hemodialysis. Some of complication of
Hemoclialysis are as follows - nausea, vomiting, pain, fever, shivering, bleeding, convulsion, chest discomfort,
!Hypotension & cramps etc. It is not possible to list every conceivable complications. These complications occur
rarely and can often be treated without serious effects. However the risk of complications and/or death is always
present. Patients with pre-existing medical problems have a greater risk of developing complications during and
following Hemodialysis.
‘wPo ho‘moS>m¶{b{gg Ho$ ~mao ‘o {dñVma go g§‘Om¶m J¶m h¡& ho‘moS>m¶{b{gg Ho$ Xm¡amZ AmZo dmbr Hw$N> O{Q>bVmE Am¡a g‘ñ¶m O¡go {H$, Or
{‘MbmZm, CëQ>r, XX©, ~wIma, H§$nH§$nr, aº$òmd, {’$Q> AmZm, gmoZo ‘o ~oM¡Zr, aº$Mmn H$‘ hmoZm ¶m {’$a n¡amo ‘o EoR>Z AmZm, Ho$ ~mao ‘o
{dñVma go g‘Om¶m J¶m h¡& Bg à{H«$¶m Ho$ Xm¡amZ AmZo dmbr g^r g‘ñ¶mAmo Ho$ ~mao ‘o ~VmZm Vmo ‘wíH$sb h¡, bo{H$Z ¶h g^r g‘ñ¶mE
AŠga hmoVr Zhr h¡& O~{H$ Bg à{H«$¶m ‘| H$^r H$^r J§^ra/ O{Q>b g‘ñ¶mE AmZo H$m ¶m OmZ H$m IVam hmoZo H$m S>a ^r hmoVm h¡& ‘arO
{OZH$mo nhbo go hr Hw$N> ~r‘m[a¶m hmoVr h¡, CZ‘o ¶h g‘ñ¶mE/ O{Q>bVmE AmZo H$s g§^mdZm OmXm hmoVr h¡&
11. I understand that nearphrologist is not available all the time. He has to go out to attend other patients or
meetings. In case of emergency during dialysis, I have been informed that emergency response team will treat me.
{H$S>Zr Ho$ {deofk S>m°ŠQ>a, S>m¶b{gg à{H«$¶m Ho$ Xm¡amZ nwam g‘¶ ‘m¡OwX Zhr ah gH$Vo& AmnmVH$m{bH$ n[apñW{V ‘o AmnmVH$mbrZ Q>r‘
‘arO H$m B©bmO H$aoJr&
12. I have seen the facilities available in the hospital and limitations. I know there may be other hospitals with more
facilities in town and also that there are government hospitals where treatment is given free of charge or at
concessional rate. Knowing these fully I want to undergo treatment in this hospital.
‘¢Zo AñnVmb ‘| CnbãY gw{dYmAm| Am¡a gr‘mAm| H$mo XoIm h¡& ‘wPo nVm h¡ {H$ A{YH$ Ho$ gmW AÝ¶ AñnVmb ^r hmo gH$Vo h¢ eha ‘|
gw{dYmE§ Am¡a ¶h ^r {H$ dhm± gaH$mar AñnVmb h¢ Ohm± CnMma ‘wâV ¶m [a¶m¶Vr Xa na {X¶m OmVm h¡& BZH$mo nyar Vah go OmZZo Ho$ ~mX ‘¢
Bg AñnVmb ‘| AnZm BbmO H$amZm MmhVm hÿ§
13. The medicines prescribed do have adverse side effects, There are some restrictions to be followed during these
treatments. I will abide by these restrition as told by doctor, I know that doctor is prescribing medicines or doing the
procedures as per his skill and judgement in good faith.
ha XdmB© Ho$ Xþîn[aUm‘ hmoVo h¡, bo{H$Z ¶h Xþîn[aUm‘ g^r ‘arOmo ‘o Zhr hmoVo h¡, ¶h ‘wPo/h‘o ~Vm¶m h¡& B©bmO Ho$ Xm¡amZ Hw$N> à{V~§Ym|H$m
nmbZ H$aZm Oéar hmoVm h¡& c ‘o Eogm H$ê$§Jm& ‘wPo ¶h ^r nVm h¡ {H$,S>m°ŠQ>a AnZr H$m¡eb Am¡a {ZU©¶ boZo H$s j‘Vm go ‘oao hrV Ho$ {bE hr
XdmB© X|Jo ¶m Amdí¶H$ à{H«$¶m H$a|Jo&
14. The result or outcome of these treatment procedures are often unpredictable, some unforseen complications
can appear during the treatment.
BZ CnMma à{H«$¶mAm| Ho$ n[aUm‘ ¶m n[aUm‘ AŠga AàË¶m{eV hmoVo h¢, Hw$N> AàË¶m{eV O{Q>bVmE§ hmo gH$Vr h¢ Am¡a CnMma Ho$ Xm¡amZ
{XImB© X|&
15. Occasionally blood transfusion is required for the patient. It is responsibility of blood banks to check for
transmissible diseases like malaria, hepatitis (including hepatitis B and C), HIV etc. Though the blood banks may
certify that the donated blood is free of these disease causing pathogens but I do understand that during some
period of illness, which is called as window period the result of the tests done by blood banks may be negative even
though the blood may actually carry these organisms. I shall not hold the dialysis unit/the hospital responsible for
the same.
H$^r-H$^r amoJr H$mo aº$AmYmZ H$s Amdí¶H$Vm hmoVr h¡& ¶h aº$ ~¢H$m| H$s {Oå‘oXmar h¡ {H$ do g§àofU Ho$ {bE Om±M H$a| ‘bo[a¶m,
honoQ>mB{Q>g (honoQ>mB{Q>g ~r Am¡a gr g{hV), EMAmB©dr Am{X O¡gr ~r‘m[a¶m§ hmbm§{H$ ãbS> ~¢H$ ¶h à‘m{UV H$a gH$Vo h¢ {H$ XmZ {H$¶m
J¶m aº$ BZ amoJm| go ‘wº$ h¡, Omo amoJOZH$m| H$m H$maU ~ZVm h¡, bo{H$Z ‘¢ g‘PVm hÿ§ {H$ ~r‘mar Ho$ Hw$N> g‘¶ Ho$ Xm¡amZ, {Ogo qdS>mo Ad{Y
H$hm OmVm h¡ aº$ ~¢H$m| Ûmam {H$E JE narjUm| H$m n[aUm‘ ZH$mamË‘H$ hmo gH$Vm h¡, hmbm§{H$ aº$ dmñVd ‘| BZ Ordm| H$mo bo Om gH$Vm h¡& ‘¢
S>m¶{b{gg ¶y{ZQ> / AñnVmb H$mo Cgr Ho$ {bE {Oå‘oXma Zht R>hamD$§Jm&
16. I understand & agree to abide by the decision of my treating nephrologist to undergo dialysis twice❑/Thrice ❑
(tick where applicables) per week.
‘¡ ¶h g‘PH$a {H$, ‘wPo S>m¶{b{gg H$mo amoO/háo ‘o Xmo~mam/ háo ‘o VrZ ~ma ho‘moS>m¶{b{gg H$aZo Ho$ ‘oao {H$S>Zr amoJ {deofk Ho$ {ZU©¶ go
gh‘V hþ&
FORM NO. B52 (2)
C RITI C ARE
TM
Ph.: 2522281, 2522282
INFORMED CONSENT FOR HIV TESTING
Name of Patient :____________________________________________UHID No.:__________________
Age :________________ Sex :_______________________ Date :_____________________
I.............................................................................................../Relative/NOK of above patient, hereby give my

consent for the screening/ confirmatory investigations for HIV Testing which has been advised by
Dr..........................................................
I understand the implications of the same and also understand that these investigations are required to aid in
diagnosis of my/my relative's ailments or as safety measure for any procedure that may be taken by my clinician
and is in my interest.
I have been counselled by my clinician before I undergo for this investigations. I also understand that post
investigation counselling will be done by my clinician upon receiving the result of the investigations.
I shall not hold the Hospital / laboratory authorities responsible in any way for conducting the above investigations
and provide their expert judgement to help clinicians in diagnosing my aliment.
I also authorize the laboratory to pass the investigation reports to the requester fo the investigations who in this
case is my clinician.
I expect all concerned to maintain confidentiality as regards to the result of investigations.
The contents of this consent have been explained to me in the language that I understand.
Date :__________________________
Signature of Patient/ Relative :___________________________
Relationship with Patient :___________________________
Name & Address :___________________________
___________________________________________________
___________________________________________________
___________________________________________________
Countersigned by Consultant pathologist / Physician :_____________________________________________
Name :_______________________________________ Date :______________________

FORM NO. B44
Ref.: PHH/PRE/F/04
é½U H$s EM.Am¶.ìhr. Om§M hoVw gh‘Vr

noe§Q> H$m Zm‘ … ¶w.EM.Am¶.S>r.H«$.
C‘« … df© ctJ … ñÌr / nwéf {XZm§H$ …
‘¡,...............................................................................Cnamo³V é½U H$m [aíVoXma / ZOXrH$s ì¶p³V

EVX² ìXmam S>m°. H$s gcmh Ho$ AZwén é½U H$s EM.Am¶.ìhr. Om§M /ñH«$sZtJ hoVw AnZr gh‘Vr gh‘Vr àXmZ H$aVm hþ§ &
‘¡ Bg Om§M Ho$ à^md H$mo g‘PVm hþ§ d OmZVm hþ§ H$s Om§M ‘oao/é½U Ho$ amoJ {ZXmZ hoVw Amdí¶H$ h¡ ! gmW hr Bg Om§M Ho$
n[aUm‘ é½U H$s CËV‘ {M{H$Ëgm Ho$ {c¶o {M{H$ËgH$m| ìXmam H$s OmZo dmcr {H$gr Oéar à{H«$¶m hoVw Amdí¶H$ gmdYmZr ~aVZo
‘o ghm¶H$ hm|Jo &
‘wPo {M{H$ËgH$ ìXmam Om§M Ho$ nwd© hr Bg Om§M Ho$ ~mao ‘o nwar OmZH$mar XoH$a g‘Pm¶m J¶m h¡ ! gmW hr do ‘wPo Bg Om§M Ho$
n[aUm‘ àmßV hmoZo Ho$ níMmV Cggo ^r do ‘wPo R>rH$ Vah go AdJV H$am¶|Jo Bg ~m~V ‘¡ AmídñV hþ§ &
amoJ {ZXmZ hoVw Amdí¶H$ Bg Om§M hoVw AnZr gh‘Vr ìXmam ‘¡ AñnVmc AWdm Om§Mo à¶moJemcm d CZHo$ A{YH$m[a¶m| H$mo Bg
Om§M H$aZo AWdm CgHo$ n[aUm‘mo§ na CZH$s am¶, Omo H$s é½U Ho$ amoJ {ZXmZ ‘o ghm¶H$ ahoJr, Ho$ {c¶o {H$gr ^r àH$ma go
O~m~Xma Zhr ‘mZw§Jm &
‘¡ Om§M à¶moJemcm H$mo Bg Om§M Z‘wZo H$mo CZHo$ nmg {ÔdmZo dmco ‘oao {M{H$ËgH$ H$mo {gYo {ÔdmZo Ho$ {c¶o ^r AnZr
gh‘Vr àXmZ H$aVm hÿ§ &
‘¡ Anojm H$aVm hþ§ H$s, g^r g§~§YrV ì¶p³V Bg Om§M Ho$ n[aUm‘m| Ho$ ~mao ‘o ¶Wmg§^d A{YH$V‘ Jmon{Z¶Vm~aVZo H$m à¶mg
H$a|Jo &
¶h gh‘Vr nÌ ‘wPo ‘oar ^mfm ‘| g‘Pm¶m J¶m h¡ &

é½U/[aíVoXma Ho$ hñVmja …
é½U Ho$ gmW [aíVm …
Zm‘ Ed§ nVm …
{XZm§H$ …
[M{H$ËgH$ / n°Wmocm°{OñQ> Ho$ hñVmja …

Zm‘ … {XZm§H$ …
FORM NO. B44
CC/PRE/03
C RITI C ARE
TM
Ph.: 2522281, 2522282
INFORMED CONSENT FOR RESTRAINS
Doctors and clinical care team of Criti Care Hospital & Research Institute recommend that
Patient Name :____________________________ Age / Sex ___________ IP No.___________
Departments : ____________________________ Bed No.:_____________________________
be restrained with the following devices / medicines ___________________________________
This recommendation is based on their professional judgment and on a fall predecting test that
identifies Patient as being at an increased risk or failing due to (circle all that apply) :
• History of failing
• Sedating Medications
• Impaired mobility
• Impaired Cognition
• Impaired Sight
• Impaired Mental Status
POTENTIAL BENIFITS POTENTIAL RISKS

In certain situations and/or time frames • Accidental Injury, Falls,
• Protection from the removal of Strangulation,
tubes and tracks Entrapment
• Protection from accidents or injuries • Chronic constipation,

incontinence
• Protection of other residents/staff from
physical harm • Pressure sores, Incidence of
infections
• The resident may experience
increased feeling of safety and • Increased agitation or delirtum
security
• Assists to attain or maintain the

highest practicable physical and
psycho social well-being
With these understanding, I consent to be restraining the above mentioned patient as recommended.
Time of Restraint :_________________________________ Date :_______________________________
Signature of person giving the consent :______________ Relationship with Patient__________________
Doctor Name :_________________________________ Signature :______________________________

CC/PRE/08
C RITI C ARE
TM
Ph.: 2522281, 2522282
[Z¶§{ÌV / g§¶{‘V H$aZo Ho$ {cE gh‘{VnÌ
{H«$Q>r Ho$Aa hm°pñnQ>c A°ÊS> [agM© B§pñQ>Q²>¶wQ> Ho$ S>m°³Q>am| Ed§ gh¶moJr H$‘©Mmar¶m|Zo h‘mao ‘arO
lr/lr‘Vr................................................................................................. C‘«........... qcJ................. H$mo

{Z¶§{ÌV / g§¶{‘V H$aZo H$m gwPmd {X¶m h¡ & Bg Ho$ {cE {ZåZ{c{IV Cnm¶m|H$m à¶moOZ {H$¶m Om¶oJm &
¶h {ZU©¶ ‘arO H$s gwajm H$mo Ü¶mZ ‘| aIH$a hr {c¶m Om ahm h¡& é½U/‘arO H$s ~oS> go ZrMo JraZo H$s g§^mdZm h¡ &
³¶m|{H$ …
* BgHo$ nhco Eogm hmo MwH$m h¡ & / ‘arO H$mo {JaZo H$m B{Vhmg h¡ &
* ‘arO H$mo ZtX H$s XdmB©¶m± {X Om ahr h¡ &
* McZo ‘| Ag‘W©Vm h¡ / ApñWaVm h¡ &
* g‘PZ| ‘o Ag‘W©Vm h¡ &
* {XIZo ‘| naoemZr h¡ &
* ~m¡pÜXH$ AdñWm ñdñW Zhr h¡ &
g§^m{dV cm^ g§^m{dV OmoIr‘

* Z{cH$mE§, gcmB©Z Z {ZH$mcZo go ~Mmd & * ~oS> (eoæ¶m) go ZrMo {JaZm, ’§$g OmZm,
Jco H$m X~Zm &
* AnKmmV Ed§ O»‘ hmoZo go ~Mmd &
* ‘c~ÜXVm ‘yÌ Ë¶mJ na {Z¶§ÌU Z ahZm &
* AñnVmc Ho$ AÝ¶ H$‘©Mmar¶m| H$mo hm{Z
nhþ±MmZo go ~Mmd & * A{YH$ X~mddmco OJh na ’$moS>o/O»‘
hmoZm, g§H«$‘U hmoZm &
* em[a[aH$ Ed§ ‘mZ{gH$ éngo A{YH$
j{VJ«ñV hmoZo go ~Mmd & * AmH«$‘H$Vm, Ag~X²YVm H$m ~T>Zm &
¶h g~ g‘PZo Ho$ níMmV ‘| h‘mao é½U / ‘arO H$mo {Z¶§{ÌV / g§¶{‘V H$aZo Ho$ {cE gh‘{V XoVm hÿ±/XoVr hÿ± &
{XZm§H$ …..................................................... g‘¶ …................................................
gh‘{V XoZodmco H$m Zm‘ …................................................................. ‘arO go [aíVm...................................
S>m°³Q>a H$m Zm‘ …....................................................... hñVmja ................................................................

FORM NO. B61 (Back)
CC/PRE/07
C RITI C ARE
Ph.: 2522281, 2522282
PROCEDURE CONSENT
Name of patient :__________________________________________ Age/Sex :_________
IP Number :___________________________ Date / Time :__________________________
I _________________________________________ Relation with Patient :_____________
Have been explained in the language I understand that my patient is

undergoing the following procedure for treatment :
_________________________________________________________________________
_________________________________________________________________________
Also I have been explained the need of the procedure to be performed
________________________________________________________________________
And the risk and complication associated with procedure which is as follows :
________________________________________________________________________
________________________________________________________________________
I have understood all the details pertaining ______________________________________

to and I hereby give my willful consent.
Name of relative :_______________________________________
Name of Patient :_______________________________________
Date :____________________
Time :____________________
Witness :_________________
Name and Signature of doctor :______________________________________________

CC/MRD/30
C RITI C ARE
Ph.: 2522281, 2522282
à{H«$¶m gh‘{V
amoJr H$m Zm‘ ….......................................................................................... Am¶w / qcJ.......................
AmB©nr H«$‘m§H$ …....................................................... {XZm§H$/g‘¶ ….....................................................
‘¢¡ …...................................................................................... amoJr Ho$ gmW g§~§Y …..............................
‘wPo ‘oar AmgmZ ^mfm ‘| g‘Pm¶m / ~Vm¶m J¶m h¡ H$s ‘oao é½U H$mo {ZåZ{c{IV à{H«$¶m hoVw...........................
....................................................................................................................................................
Am¡a ~Vm¶r J¶r à{H«$¶m H$s OéaV H$mo h‘o g‘Pm¶m J¶m h¡ &
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
‘¡ Bg à{H«$¶m go g§~§{YV....................................................................................................................
OmZH$mar¶mo H$mo {R>H$ Vah go g‘P J¶m hÿ Am¡a Bg à{H«$¶m H$mo H$aZo H$s BOmOV XoVm hÿ± &
[aíVoXma H$m Zm‘ ….......................................................................... ‘arO go aríVm …............................
hñVmja …........................................... g‘¶ / {VWr ….....................................
‘arO H$m Zm‘ …............................................................................
Jdmh H$m Zm‘ ….............................................................................
{M{H$ËgH$ H$m Zm‘ …..........................................................................................................................
hñVmja ….............................................

CC/PRE/08
C RITI C ARE
Ph.: 2522281, 2522282
PATIENT TRANSFER CONSENT
I____________________________________________________________ Understand that
the Doctors at Criti Care Hospital & Research Institute intend to transfer me/my
patient for further care.______________________________________________________
I have been informed that the reason for transfer is as follows or for the following diagnostic
procedure :________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I have been informed of the following associated risks and / or benefits of this transfer :
_________________________________________________________________________
_________________________________________________________________________
The above information has been fully explained to me and I agree to be transferred.
Date :_______________________ Time :_________________
Name of patients relative :__________________________
_______________________________________________ Signature :______________
Doctors Name :__________________________________
_______________________________________________ Doctors Sign.:____________
Witness :
1. Name :_______________________________ 2. Name :__________________________
Signature :____________________________ Signature :_______________________
Relation to the Patient :_________________ Relation to the Patient :_________________

C RITI C ARE
TM

TRANSFER SHEET
FORM NO. B64

CHRI/MR/50
C RITI C ARE
TM

Patient Details :
Age : Sex : M/F IPD No.:
Date of Discharge / Death / LAMA :
Final Diagnosis :
Signature of the Patient :
Signature of Attendant :
PATIENT MOVEMENT (SHIFTING) INFORMATION :

Sr. Shifted Patient Handed over to Shifted to Patient taken over Date Time Remark
No. From by (Sign with Name) by (Sign with Name) (if any)
FORM NO. B77

CHRI/MR/52
C RITI C ARE
TM

Hospital & Research Institute Ph.: 2522281, 2522282 Web : www.criticarenagpur.com
O.T. BOOKING FORMAT
Patient Name :______________________________________________________________
Age _____________________ Sex :____________________
IP No.:____________________________________________________________________
Room No.__________________ Bed No.:_________________
Surgeon Name :_____________________________________________________________
Anaesthetist Name :__________________________________________________________
Diagnosis:_________________________________________________________________
Procedure :________________________________________________________________
On Date :__________________________________________________________________
Date :_____________________________________Time :___________________________
Date Of Booking :___________________________________________________________
Consultant Name :___________________________________________________________
Received OT SISTER Sign. RMO Sign. Name
FORM NO. B76

CHRI/MR/43
C RITI C ARE
TM
Ph.: 2522281, 2522282
LAMA (Leave against Medical Advise) FORM / DOR (Discharge on request)
Patient Name :________________________________________________________
Age/Sex :____________________________
IP Number :____________________________
Ward :____________________________
Diagnosis :___________________________
This is to certify that I am leaving Criti Care Hospital at my own insistence and against the advise of my
physicians and the Medical Center. I have been advised of the possible dangers to my life or health from this
departure, and I hereby assume the risks and consequences involved and release my physicians and the
Medical Center from any liability in connection with my leaving the Medical Center against their advice.
DATE :_______________ TIME : __________________
Name :_________________________________ Relation with patient :___________________
Signature of Party Leaving Against Medical Advise)
Doctor's Name :__________________________ Doctor's Signature :____________________
Witness
1. Name :_____________________________ 2. Name :___________________________
Signature :__________________________ Signature :________________________
Relation to the patient ________________ Relation to the patient :_____________
INSTRUCTIONS :
This demand for discharge should be signed by the patient or authorized party if he/she insists on
leaving the Medical Center against medical advise. If the patient or authorised party not only demands to
leave but also refuses to sign. this form the following should be completed.
_____________________________________________________ (Name of Party Demanding Discharge

has not only demanded discharge but also has refused to sign this form documenting his/her demand
DATE :____________________________ TIME :____________________________
SIGNATURE OF DOCTOR :_______________________________________________________

CHRI/MR/43
C RITI C ARE
TM
Ph.: 2522281, 2522282
S>m_m ({M{H$ËgH$ Ho gbmh {déÜX Nw>Å>r) ’$m°‘©/S>r Amo Ama (AZwamoY na {Zdm©hZ) / cm‘m
amoJr H$m Zm‘ …

Am¶w …
Am¶.nr. H«$‘m§H$ …
dmS>© …
amoJ H$m Zm‘ …
‘¡ ‘oar AnZr {Oå‘oXmar na {H«$Q>rHo$Aa hm°pñnQ>c ZmJnwa, ¶hm go {M{H$ËgH$ H$s gcmh {déÜX Nw>Å>r coH$a Om ahm hþ§
Bggo hmoZo dmco Omo{I‘ Ed§ Xþînn[aUm‘ ‘wPo Am¡a ‘oao [aíVoXmamo H$mo ~Vm {XE J¶o h¡ Am¡a ¶h g~ ‘wPo ñdrH$ma h¡
Bgr{cE ‘¢ AnZr IwX H$s {Oå‘oXmar na Nw>Å>r coH$a Om ahm hþ Am¡a Bg gå~ÝY ‘¡ hm°pñnQ>c ‘¡ hmpñnQ>c ¶m S>m°³Q>a ¶m
S>m°³Q>a {H$gr ^r Xm{¶Ëd Ho$ {cE {Oå‘oXma Zhr§ ah|Jo &
{VWr … g‘¶ …
Zm‘ … amoJr go [aíVm …
({M{H$ËgH$ Ho$ gcmh {déÜX Nw>Å>r coZodmco Ho$ hñVmja)
{M{H$ËgH$ H$m Zm‘ … {M{H$ËgH$ Ho$ hñVmja
Jdmh
1) Zm‘ … 2) Zm‘
hñVmja … hñVmja …
amoJr go [aíVm … amoJr go [aíVm
AJa {H$gr ^r ¶m é½U ¶m é½U Ho$ [aíVoXma {M{H$ËgH$ H$s gcmh {déÜX Nw>Å>r H$s ‘m§J H$aVo h¡ Vmo CZHo$ hñVmja
coZm Oéar h¡ AJa é½U Ed§ é½U Ho$ [aíVoXma hñVmja H$aZo Ho$ {cE V¡¶ma Zm hmo Vmo hm°pñnQ>c H$‘©Mmar¶m|
H$mo {ZåZ{c{IV OmZH$mar nyU© H$aZm A{Zdm¶© h¡ …
{M{H$ËgH$ Ho$ gcmh
{déÜX Nw>Q²>Q>r cr h¡ co{H$Z hñVmja H$aZo go ‘Zm H$a aho h¡
[VWr …
{M{H$ËgH$ Ho$ hñVmja …
g‘¶ …
FORM NO. B80 (BACK)

C RITI C ARE
TM
FEEDBACK FORM
Dear Patients/Relative/Visitor,
Your Continuing suggestion and support help to make our Hospital a better organiation, Kindly spare a
few moments to complete the following, so that we can strive to fulfill your expectations please drop the
completed feedback form in the collection box or Hand it over personally to floor Manager.
Warm Regards,
Director's Office - Criti Care Hospital & Research Institute, Nagpur.
I came as a (Please Tick ) Patients Relative Visitor
Name _______________________________________________________________ Age _________Sex M/F
Address _________________________________________________________________________________
_______________________________________________________________Phone No.________________
My Hospital Stay at Criti Care Hospital & Research Institute was
Because of Following Factors Pleasant Satisfactory Unpleasant
The Hospital Environment is Good Average Poor

The Ward Facility are Good Average Poor
The Toilet(s) are Good Average Poor
Service of attendant Dr. is Good Average Poor
Service of attendant Nurses is Good Average Poor
The Hospital Billing is Good Average Poor
The Reception / Enquiry Service Good Average Poor
The Admission Process is Good Average Poor
The Discharge Process is Good Average Poor
Overall I rate Criti Care Hospital Good Average Poor
& Research Institute as
Special Comments :-_____________________________________________________________________

______________________________________________________________________________________
Signature with Date

FORM NO. B23

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CRITICARE HOSPITAL & RESEARCH INSTITUTE

C RITI C ARE C RITI C ARE

PAIN ASSESMENT SCALE

FORM NO. B38 (Front)

Hospital & Research Institute

PRIMARY CONSULTANT NOTES

PROVISIONAL DIAGNOSIS /DIAGNOSIS :

EXPECTED OUTCOME (PROGNOSIS) :

SIGNATURE WITH NAME :

Hospital & Research Institute

PATIENT NAME AGE/SEX IP NO.

DATE & PRIMARY CONSULTANT NOTES SIGN WITH

Hospital & Research Institute Ph.: 2522281, 2522282

PAIN ASSESMENT SCALE

FORM NO. B50 (FRONT)

Hospital & Research Institute Ph.: 2522281, 2522282

NUTRITION ASSESSMENT FORM

FORM NO. B54 Green Paper (Front)

DIETARY NOTES / RE-ASSESSMENT

FORM NO. B54 Green Paper (Back)

- Upto 120 - Nil

DATE TIME BLOOD SUGAR URINE KETONES DOSAGE OF INSULIN SIGNATURE

FORM NO. B7 (Front)

CRITI CARE Sitabuldi, Nagpur-440012.

Patient's Name :_____________________________________________________________________________________________

Signature Of Doctor On Duty_________________________________ Name :________________________________________________________________

BLOOD ORDER :_______________________________________________________________________________

NON-DRUG ORDERS :__________________________________________________________________________

OTHER ADVISED :______________________________________________________________________________

DIET ORDER :__________________________________________________________________________________

BLOOD SUGAR MONITORING

INVESTIGATIONS ADVISED :____________________________________________________________________

DRAINS / RT ASPIRATE : ________________________________________________________________________

DISCHARGE/TRANSFER ADVICE :_______________________________________________________________

FORM NO. B41 (Back)

DATE & TIME :

FORM NO. B14 (Paper Pink Color)

Hospital & Research Institute

‘arO H$m Zm‘ / NAME OF PATIENT :

XoI^mc H$s ¶moOZm / PLAN OF CARE :

FORM NO. B56

FORM NO. B42 (Front)

SAMPLE DATE CULTURES

FORM NO. B42 (Back)

Hospital & Research Institute

Hospital & Research Institute

Hospital & Research Institute

CENTRAL LINE INSERTION BUNDLE

Consultant / RMO Signature Staff Nurse Signature

Date :- Date :- Time :-

Hospital & Research Institute

VENTILATOR CARE BUNDLE

Pup at 30-40 Degree (in the

Patient turning on rotation

Daily awaking sedation

DVT prophy laxix

Suctioning (2nd hourly / as

Cuff pressure (2nd hourly / as

FORM NO. B68

Hospital & Research Institute Web : www.criticarenagpur.com

a³V àXmZ gh‘{V nÌ

amoJr H$m Zm‘ …................................................................................................... Am¶w/qcJ......................

Am¶.nr. H«$‘m§H$ …................................................. {XZm§H$ / g‘¶ ….................................

‘¢ ........................................................................................... ‘arO go [aíVm.......................................

Signature Of Doctor On Duty_ Name :________________________________

Signature :_______ Signature :_ Signature :_________

Name : Name : Name :__

Date :_________ Date :_ Date :___________

Signature of Staff Nurse I/C :_________ Signature of RMO :_

Signature : Name :______________ Date :_

Name of patient :_____________________________________Age/Sex :_

IP Number :___ Date / Time :

I _________________________ relation with patient _

Name of Patient :__________________________UHID No.:

Age :____ Sex :_ Date :___________

Name :_________________ Date :

Time of Restraint :___ Date :_

Signature of person giving the consent : Relationship with Patient____

Doctor Name :___ Signature :

Name of patient :__________________________________ Age/Sex :_

IP Number :_ Date / Time :

I _____________________________ Relation with Patient :_