GANDHI NATUROPATHIC MEDICAL COLLEGE
BEGUMPET
HOSPITAL MANAGEMENT & RESEARCH METHODOLOGY
RECORD
Name - ________________________________
Roll. No. _________________________
Gandhi Naturopathic Medical college
Balkampet, Begumpet
Hyderabad – 500016
GANDHI NATUROPATHIC MEDICAL COLLEGE
(Affiliated to Kaloji Narayana Rao University of Health Sciences, Warangal Telangana)
BACHELOR OF NATUROPATHY & YOGIC SCIENCES
BONAFIDE CERTIFICATE
Certified that this is a Bonafide Record work done by
_______________________ bearing hall ticket no.______________ under the
Department of _____________________________ prescribed by Kaloji
Narayana Rao University of Health Sciences, Warangal during the
academic year _________________
INTERNAL EXAMINER EXTERNAL EXAMINER
INDEX
[Link] Date TOPIC Page no. Signature
HOSPITAL MANAGMENT
RESEARCH METHODOLOGY
FORMS
MEDICAL CERTIFICATE OF FITNESS
I have examined Shri/Kumari/Smt. ___________________ Son/
Daughter of Shri _____________________________aged
__________Years, of Village:_____________________________
P.O._____________________________P.S________________________
______Dist.__________________________State___________________
___________PIN____________________________and certify that, he /
she is free from deafness, defective vision (including colour vision) or
any other infirmity, mental or physical, likely to interfere with the
efficiency of his / her work and found him / her possessing good
health. This certificate is being given to him /her for the purpose of
______________________________
Signature of Candidate ______________________________
(To be signed in presence of the Medical Officer)
Signature of Medical Officer:_____________________________
Name of Medical Officer: Dr. _____________________________
Registration No.______________________________
SICK CERTIFICATE
I, ............................................................................................................... after careful personal
examination of the case hereby certify that Shri / Smt. / Kumari
………………………………….
…………………………………………………, is suffering from and I consider that a period
of absence from duty of ………………….. day (s) with effect from is absolutely necessary
for the restoration of his / her health.
Authorized Medical Attendant
..…………………….Hospital/
Dispensary or other Registered
Dated………………... Medical Practitioner.
……………………………………………………………………………………………………..
MEDICAL CERTIFICATE O F F I T N E S S F O R
RETURN TO DUTY
I .................................................................................................... member of Medical Board /
Civil Surgeon / Staff Surgeon / Authorized Medical Attendant / Registered Medical
Practitioner of………………………………………………… Hereby certify that I / We have
carefully examined Shri / Smt. / Kumari ………………………………………………………
whose signature is given above and found that he / she has recovered from his / her illness
and now fit to resume duties. I / We also certify that before arriving at this decision, I / we
have examined the original medical certificate (s) and statement (s) of the case (or certified
copies thereof) on which leave was granted or extended.
Members of the Medical Board / Civil Surgeon /
Staff Surgeon / Authorised Medical Attendant /
Dated………………... Registered Medical Practitioner
PATIENT ADMISSION FORM
Today’s date: ADMISSION NO.
PATIENT INFORMATION
Patient’s name:
Marital status RELIGION-
Birth date: Age: Sex:
/ / M F Occupation:
address: phone no.:
Other family members
seen here:
Patient’s relationship to
Spous Ph No.
subscriber: Self Child Other
e
Patient’s relationship to
Spous Ph No.
subscriber: Self Child Other
e
IN CASE OF EMERGENCY
Name of local friend or relative (not Relationship to Home Work phone
living at same address): patient: phone no.: no.:
The above information is true to the best of my knowledge. I authorize my insurance
benefits be paid directly to the physician. I understand that I am financially responsible
for any balance. I also authorize [Name of Practice] or insurance company to release
any information required to process my claims.
Patient/Guardian signature Date
FOR OFFICE USE ONLY
DATE OF ADMISSION
DATE OF DISCHARGE
RECIEPT NO.
SIGNATURE
Consent for Medical/Surgical
Care/Emergency Treatment
Date:
I’m presenting myself for diagnosis and treatment of
NAME -
AGE -
SEX -
ADRESS -
I hereby voluntarily consent to the rendering of such care, including
diagnostic procedures, surgical and medical treatment and blood
transfusions, by authorized members of the hospital staff or their
designates, as may in their professional judgment be necessary.
I hereby acknowledge that no guarantees have been made to me
as to the effect of such examinations or treatment on my condition.
We/I acknowledge that we are (I am) responsible for all reasonable
charges in connection with care and treatment rendered during this
treatment period.
In case of emergency I can be reached at:
Signature
DISCHARGE SUMMARY
Name of Patient:
Tel No. Mobile No.
IPD No. Admission No.
Treating Consultant/s Name, contact
numbers
and Department/Specialty
Date of Admission Time of
Admission
Date of Discharge Time of
Discharge
MLC No. / FIR No.
Provisional Diagnosis at the time of Admission
Final Diagnosis at the time of Discharge
ICD-10 code(s) or any other codes, as
recommended by the Authority, for Final
diagnosis
Presenting Complaints with Duration and
Reason for Admission
Summary of Presenting Illness
Key findings, on physical examination at the
time of admission
History of alcoholism, tobacco or substance
abuse if any
Significant Past Medical and Surgical History, if
any
Family History if significant/relevant to
diagnosis or treatment
Summary of key investigations during
Hospitalization
Course in the Hospital including complications,
if any
Advice on Discharge
Name of treating Signature of
Consultant/ treating
Authorized Team Consultant/
Doctor Authorized
Team Doctor
Name of Patient / Signature of
Attendant Patient /
Attendant
MEDICAL BILL RECIEPT
Receipt Number: _________________
Date: _________________
Patient Information:
Name: ___________________________
Address: __________________________________
City/State/ZIP: ___________________________
[Link] Code Description of Qty Rate Line Total
Services/Medicine/Products
Subtotal: _________________
GST:_________________
Total: Rs_________________
Amount Paid:Rs _________________
Payment Method: _________________
Card/Check No.: _________________
Signature
