Guru Nanak Hospital, EMR

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Guru Nanak Hospital, EMR

Inpatient Records & Living Discharge Engine

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Patient Clinical File

UHID: -- | IP: --

MEDICO-LEGAL CASE (MLC) ASSESSMENT

Non-MLC MLC Case

Chief Complaints

History of Presenting Illness (HPI)

Past Medical / Surgical History

Drug Allergies (Stamps Red in Doc)

Clinical Examination on Admission

Systemic Examination

Discharge Medications Table Exact rows will be formatted and dynamically built inside the Google Doc

#	Medicine Name	Salt Name	Frequency	Days	Remarks / Instructions	Action

General Advice on Discharge

Diet Advice

Follow-Up Instructions

Ready.

DISCHARGE SUMMARY

UHID:	Name:
Age/Gender:	Visit No:
Provider:	Date of admission:
Date of discharge:

PROVISIONAL DIAGNOSIS :

FINAL DIAGNOSIS :

ICD CODE :

PROCEDURE DONE :

CHIEF COMPLAINTS :

HISTORY OF PRESENTING ILLNESS :

ALLERGIES :

COURSE IN HOSPITAL :

CONDITION AT DISCHARGE :

Stable and hemodynamically normal.

ADVICE ON DISCHARGE :

MEDICATIONS AT DISCHARGE :

S.No.	Medicine Name	Salt name	Frequency	Days	Remarks

DIET ADVICE :

WHEN AND HOW TO OBTAIN URGENT CARE :

In case of fever, vomiting, report to the emergency or contact duty doctor on +91 7503102102

FOLLOW UP :

DR. INDERJIT SINGH

MBBS, D. Ortho | MCI 12-46855

(Physically Checked & Verified)