Indoor Paper

FRONT PAGE
While the patient is being admitted
Head of service
Patient’s full name, address, age, sex, marital status, occupation, economic class, telephone number and name and address of the relative
IPD and OPD number
If brought by police, name of the P.C on duty and P.C number
Stamp, in case of a medicolegal case
Ward
Date and time of admission
While the patient is in the ward
In the columns of house officer, registrar and honorary
Provisional diagnosis
Secondary diagnosis
For post delivery patients, check entries made by staff with red ink (confinement number, mode of delivery—LSCS or Vaginal, APGAR Score, date and time of delivery, sex of the baby, baby's weight, placental weight, name of the doctor, entries of the procedures performed---
With date, name of the operating surgeon, the assistants, staff assistant, anesthesia with name of the anesthetists and proper indication of the procedure (procedures may include operative procedures, induction of labor or administration of injectables like Anti-D etc,)
Payment entry at the top
In case of death, exact date and time of death, signature of the person to whom body was shown
In case patient transferred to another ward, date and time of transfer, ward number, signature of the concerned unit registrar with a transfer summary
While discharging the patient
All above mentioned entries made in respective columns
Discharge summary attached with sign of the registrar or qualified
Date and time of discharge
Stamp with signatures of the doctor, staff and patient/relative with date in case patient is discharged against medical advice
Indoor file arrangement
For ANC patients, ANC charts (properly filled) attached at the front of the file
For gynaec patients posted for any procedure, pre-operative and investigations chart attached at the front of the file
Steppler pins not to be used
All investigations (blood,urine,stools) attached in chronological order at the inner side of the front flap of the file
All ultrasonography reports attached in chronological order at the back of the file
Treatment sheet
Daily houseman ward rounds followed by registrar rounds with proper date and time and signature.
Lecturer or qualified round followed by the round of the unit in charge with signature.
TPR chart
Daily record by the ward staff
Any deviation from normal, inform respective unit
Intake and output chart
Daily record by the ward staff
Under indicated cases, check entry for urine albumin, urinary sugars and ketones, HGT.
Check: all other investigations like ct scan, mri, chest x-ray, ecg, previous blood investigations with opd paper or the casualty paper attached at the back, after tpr and intake-output charts.