Get Medical Case Sheet

Filling out the medical case sheet online is a crucial step in documenting patient information and medical history. This guide will provide you with detailed instructions to ensure that you accurately complete each section of the form.

Follow the steps to fill out the Medical Case Sheet effectively.

1. Click ‘Get Form’ button to access the medical case sheet and open it in the editor.
2. Enter the hospital name, district, ward number, and bed number accurately in the designated fields.
3. Complete the personal information section by filling in the name, OPD/IPD number, age, date of admission (DOA), sex, date of discharge (DOD), religion, unique ID through TMS, education, marital status, occupation, Samagra ID number, Golden Card ID, and postal address.
4. Detail the main complaints by listing the presenting complaints and any associated complaints that are related.
5. Provide a comprehensive history by filling in details of the current illness, past illnesses, family history, personal history, treatment history, and any relevant sexual or social history.
6. Conduct a thorough examination by noting physical examination findings such as pulse, respiration, temperature, blood pressure, weight/height, and other physical characteristics.
7. Complete the systemic examination sections, detailing respiratory, cardiovascular, gastrointestinal, central nervous system findings, and any necessary neurologic assessments.
8. List any investigations advised, including blood, urine, sputum, X-ray, CT, MRI, or other tests as required.
9. Document the provisional diagnosis, including specialty code and package code.
10. Record treatment given, daily notes or operation notes, investigation report findings, and the final diagnosis with relevant codes.
11. Fill out the discharge summary with information related to admission, discharge, attending and treating physicians, course during treatment, and final diagnosis.
12. List the details of the medical team involved in surgical or medical procedures.
13. Indicate follow-up information if applicable.
14. Save your changes, download the completed form, print it, or share it as needed.

Start filling out your medical case sheet online today and ensure all vital information is captured accurately.