Request for Admission

Admitted Under

Dr.Sumit Singh

Type of Admission:	First Time
Reason for Admission :	Treatment & Observation

Referral By:	XYZ HEALTHCARE PVT. LTD
Patient Identification Band tied:	Yes
Patient Made aware of surroundings and safety measures:	Yes

Created & Updated

By :Dr.Sumit Singh

At : 2024-08-23 23:03:19

 

Vulnerability Assessment

Level of Consciousness :	SemiConscious
Dependency :	Partially Dependent
Mode of Movement :	Ambulatory
Vulnerability Assessment/ Triage :	Immediate_Care
Pain Assessment :	/10
Pain Location :

Fall Risk

High fall risk:	Yes
History of more than one fall within 6 months before admission:	Yes
Patient has experienced a fall during the hospitalization:	Yes
Patient is deemed high fall-risk per protocol such as seizure precaution:	No

Created & Updated

By :Priya Singh

At : 2024-09-14

 

Covid 19 Checklist

Do you have symptoms such as fever, cough, sneezing, sore throat, fatigue, sense of smell, changes in taste, and body aches?:	Yes
Do you have difficulty of breathing?:	Yes
Have you travelled outside the country in the last 30 days?:	Yes
Have you traveled to other cities in India in 15 days?:	No
Were you a Covid-19 positive patient in the last two weeks? or suspect in a case of covid-19 ?:	Yes
Have you visited a health care facility in the past two weeks?:	No

Created & Updated

By :Dr.Sumit Singh

At : September 14, 2024 / 05:40:56 PM

Medical Surgical History

Medical Assessment	Status
Diabetes	Active

Allergies	Category
peanuts	Drug

Information Obtained from

Family-Other

Addiction

Alcohol:
Smoking:

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-14

Vitals

BMI	193.77
SPo2	45
RBS	112
Temperature	122
Pulse	112
Blood Pressure:	12/11

Created & Updated

By :Dr.Sumit Singh

At : September 14, 2024 / 05:41:42 PM

Medical Assessment

Fever:	Yes	2 days
Cough:	Yes	1 week
Sore Throat :	Yes	4 days

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-14

Nutritional Screening

Does the patient have any weight loss/ Weight gain?:	No
Does the patient appear emaciated or BMI is Below <18.5 ?:	Yes
Does the patient look Obese or BMI is above >30:	No
Does the patient have any GL Symptoms like Constipation, Nausea, Diarrhea, Anorexia, Vomiting, chewing/swallowing difficulty affecting oral intake in last 2 weeks:	Yes
Does the patient have any enteral tube feeding :	No
Does the patient have any parenteral tube feeding:	Yes
Food Pattern Followed :	Vegetarian
Appetite	Fair

Created & Updated

By :Dr.Sumit Singh

At : 2024-09-14

General Consent

General Consent Signed

Prescription

Type of Admission::	First Time
Reason for Admission :	Treatment & Observation

Level of Consciousness :	SemiConscious
Vulnerability Assessment :	Immediate_Care
Pain Assessment :
Pain Location :

Vitals

SPo2(%)	RBS(mg/dl)	Temp(C*)	Pulse(Min)	BP(mmHg)
45	112	122	112	12/11

BMI Result

193.77

Chief Complain

Fever:		2 days
Cough:		1 week
Sore Throat :		4 days
Other Symptoms :

Investigation

Date Time	Investigation	Result	Evidence (Upload)
September 14, 2024 / 05:46:13 PM	CT + 3D -PELVIS-Hip Joint

Rx

Drug & Dose	Route	Note	Frequency	Duration
OVIGYN - D3 TAB-2000 DEHYDROEPIANDROSTERONE SR VITAMIN D3 CALCIUM METHYLTETRAHYDROFOLATE TABLET	Orally	none	OD (Once Daily)	5 Days
VBLASTIN 10MG INJECTION-10 VINBLASTINE (10MG)	Orally	none	OD (Once Daily)	3 Days

Plan Of Care

good

Dr.Sumit Singh (MBBS, MD)	September 14, 2024 / 05:43:21 PM