|
Treating Doctor Name
|
|
Doctor Mobile
|
Date of Admission
|
Class of Accomodation
|
Estimated Days
|
|
|
|
|
|
|
|
Duration Of Ailment
|
ICD 10 Code
|
ICD 10 PCS Code
|
Date of First Consultation
|
Admission Type
|
|
|
|
|
|
|
|
|
|
Proposed Line of Treatment
|
|
Probable Diagnosis
|
|
|
|
lblProposedLineOfTreatment
|
|
|
lblPlanOfTreatment
|
|
|
Route of Drug Administration
|
PreExisting Disease
|
|
|
|
|
lblPreExistingDisease
|
|
Present Complaint
|
|
|
Investigation Results
|
|
|
|
lblPresentComplaint
|
lblInvestigationResults
|
|
In Case of Accident (Is it RTA)
|
Date of Injury
|
How Did Injury Occur
|
|
|
|
|
|
|
|
|
Reported To Police
|
FIR NO
|
In Case of Maternity
|
Date of Delivery
(dd/mm/yyyy)
|
|
|
|
|
|
G
G
P
P
L
L
A
A
|
lblEDD
|
|
|
|
Injury/Disease Caused due to substance abuse / alcohol consumption
|
Test Conducted to Establish this
|
|
|
|
|
|
|
|
|