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Ayushman Bharat ‘Niramayam’ Madhya Pradesh
Medical Case Sheet
Hospital Name ……….…… ……………. District ……………….…..
Ward No. ……..….. Bed No. ……….
Name : OPD/IPD No. :
Age : DOA :
Sex : DOD :
Religion : Unique ID Though TMS : ……………...
Education :
Marital Status:
Occupation :
Samagra ID No.:
Golden Card ID:
Postal Address:
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Main Complaints–
1. Presenting Complaint 1…………………. 2…………………. 3…………………………..
1. Associated Complaints (related to main complaints)
1.…………………………. 2…………………..3 ………………………….
I. History
1. History of present illness
2. History of past illness
3. Family History
4. Personal History
5. Treatment History
6. Sexual/Social/Occupational etc.
II. Examination
1. Physical Examination –
Pulse……………, Respiration……………, Temperature…………., Blood Pressure…………
Weight/Height…….Built……….Scalp………..Eyes………Nose……Oral Cavity………………….
Tongue……….. Neck Glands……… Nails……….. Edema…...... Lymph Nodes…….…Pallor/
Anemia……………. Cyanosis…….. Jaundice …….. Pigmentations……other……………………..
2. Systemic Examination -
2.1 Respiratory System-
a. Inspection-
Respiratory Rate & Rhythm……………………………………………………………………….
Shape and symmetry of the chest………………………………………………………………….
Nose ………………………………………………………………………………………………..
Throat ………………………………………………………………………………………………
Cyanosis …………………………………..others ………………………………………………...
b. Palpation -
Confirmation of respiratory moments ……………………………………………………………..
Position of Mediastinum ………………………………..………………………………...............
Tenderness ……………………………… others …………………………………………………
c. Percussion -
Resonant - normal …………………………………abnormal ……………………………………
Cardiac dullness - normal …………………………abnormal ……………………………………
Liver dullness - normal …………………………. abnormal …………………………………….
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VI. Daily Notes / Operation Notes –
(Details of surgical procedures)
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VIII. Investigation report (Finding) –
IX. Final Diagnosis–
Specialty code…………………………………………………………………………………
Package code …………………………………………………………………………………
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X. Discharge summary
IPD No.: ……………………………………………………………………………..
Patient Name: ……………………………………………………………………….
S/o…………………............................................................................M/F…………
Admission Date: ………………………..Time of Admission: ……………………
Discharge Date: ……………………..….Time of Discharge: …………………….
Attending Physician (Primary doctor): …………………………………………...
Treating Physician: …………………………………………………………………
Consulting Physician: ………………………………………………………………
Course during Treatment (From Condition on Admission to Condition on
Discharge during Hospital stay)……………………………………………………
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Final diagnosis with Specialty code: ………………………………………………
Procedures with Package code: ……………………………………………………
Treatment advised on discharge: ………………………………………………….
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Details of Doctors Team:
For Surgical Procedures
1. Surgeon: ……………………………………………..............................................
2. Anesthetist: ……………………………………………………………………….
3. Assistant Surgeon: ………………………………….............................................
4. Pathologist and Radiologist: ……………………………………………………
For Medical Procedures
1. Medical Specialist/MO (Treating Physician): ………………………………….
2. Assistant Medical Officer: ………………………………………………………
3. Pathologist and Radiologist: ……………………………………………………
XI. Follow up