Request for Admission


Covid 19 Checklist                                               

Covid 19 Checklist

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Do you have symptoms such as fever, cough, sneezing, sore throat, fatigue, sense of smell, changes in taste, and body aches?:
Do you have difficulty of breathing?:
Have you travelled outside the country in the last 30 days?:
Have you traveled to other cities in India in 15 days?:
Were you a Covid-19 positive patient in the last two weeks? or suspect in a case of covid-19 ?:
Have you visited a health care facility in the past two weeks?:

Request for Consultation                                                

Request for Admission

Ward & Bed General ward - GW-1 - Bed no: 1

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        Type of Admission: First Time
        Reason for Admission : Emergency
Admitted Under Dr.Sumit Singh
        Referral By: SANTUSHTI HOSPITAL PVT LTD
        Patient Identification Band tied:
        Patient Made aware of surroundings and safety measures:

MLC Record                                                

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        MLC No : 65858
        MLC Slip : MLC Slip

Trauma checklist

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    Trauma Care Checklist

    Immediately after primary & secondary surveys

      Yes

      No

  1. Is There A Tension Pneumo-Haemothorax ?

    2.   Yes, Chest Drain Placed

      No

  2. IS The Pulse and Fluids Started ?

    3.   Yes

      Not Available

  3. Large-bore IV placed and fluids started

    4.   Yes

      Not indicated

       Not Available

  4. Full Survey For (and control of)External bleeding, Including :

    5.    Scalp

       Perineum

       Back

  5. Assessed For Pelvic Fracture by:

    6.   Exam

      X-ray

      CT

  6. Assessed For Internal Bleeding By:

    7.    Exam

       Ultrasound

       CT

       Peritoneal lavage

  7. Is Spinal Immobilization Needed?

    8.   Yes,Done

      Not Indicated

  8. Neurovascular Status of all 4 limbs Checked?

    9.   Yes

      Not Indicated

  9. IS the patient Hypothermic?

    10.   Yes, Warming

      No

  10. Does the Patient Need(if no contraindication)

    11.    Urinary Catheter

       Nasogastric Tube

       Chest Drain

       None Indicated

Before team leaves patient

  1. Has the Patient been Given

    2.    Tetanus Vaccine

       Analgesics

       Antibiotics

       None Indicated

  2. Have All tests and imaging been Reviewed

    3.  Yes

     No, Follow-up Plan in Place

  3. Which serial Examinations Are Needed

    4.   Neurological

      Abdominal

      Vascular

      None

  4. Plan of care discussed with:

    5.   Patient/Family

      Receiving Unit

      Primary team

      Other Specialists

  5. Relevant Trauma Chart or Form Comleted?

    6.  Patient/Family

     Not Available

Medical and surgical History


Medical Assessment Status Action
 Diabetes  Active Edit
 Low Blood Pressure  Cured Edit
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Allergies Category Action
 peanuts  Food Edit
 Cold Drink  Drug Edit
 peanuts  Food Edit
Add More

Vaccination Date Given Note
 Pneumococcal.  2024-09-18  good
 RNA vaccines  2024-09-02  next vaccine
 Pneumococcal.  2024-09-20  good
Add More

      Insulin dependent diabetes mellitus

Obstetric History

Title of the document

Gravida :     0 Para :     0 Abortion :     0
Cesarean :     0 Child alive :     0 Death :     0
Miscarriage :     0

DateTowordsAction

Vulnerability Assessment

Vulnerability Assessment

Level of Consciousness

      Conscious
      Semi Conscious
      Un-conscious



         Fall Risk

Vitals

Document

Weight :
Height :
BMI Result 24000
Weight :
SPo2 :
RBS :
Temperature:
Pulse:
Blood Pressure:



Medical Assessment

Initial Assessment

Chief Complain

         Body Pain
Fever
Loss
of Smell
Diarrhoea
Facial
Deformity
Cough
Loss
of Taste
Weakness
Breathle
ssness
Shivering
Power
Loss in
Limbs
Sore
Throat
Vomitting
Slurred
Voice
Nausea
Loss of
Appetite
Delusion
Fits of
Anger
Depression
Memory Loss
Bleeding
Disorder
Migraine
Frequent
Urination
Swollen Join
Weight Gain
Weight loss
Body pain
Physical
Injury
Other
Symptoms


Nutritional Screening

Title of the document Document

Nutritional Screening

BMI Result 24000
Does the patient have any weight loss/ Weight gain?
Does the patient appear emaciated or BMI is Below <18.5 ?
Does the patient look Obese or BMI is above >30
View BMI Chart

Does the patient have any GL Symptoms like Constipation, Nausea, Diarrhea, Anorexia, Vomiting, chewing/swallowing difficulty affecting oral intake in last 2 weeks
Does the patient have any enteral tube feeding
Does the patient have any parenteral tube feeding
Food Pattern Followed
Appetite

General Consent Signed                                               

;

General Consent Signed

Document