Name:

Age:
Sex:
Address:
Marital status: D/O: S/O: W/O:
Mode of admission:
Date/Time of admission:
MR no#

Comorbids: (e.g: A known case of CKD/DM/HTN/Asthma/), duration of comorbid, if taking any

pertinent drug related to comorb which is important for current presenting complaint of the
patient.

Presenting complaints: (Chronological order) + time duration

1.
2.
3.

HOPC: Elaborate individual complaints in detail, (duration, frequency, aggravating, relieving

factor, associating symptoms, any drugs taken so far, and any recent hospital admissions
relating to the presenting complaint. Any ER treatment that the patient received before
admission to the ward.

Past medical:
Past Surgical:
Drug history:
Any known allergies:
Family history:
Socioeconomic :(if pertinent to the case. For example if the patient has typhoid, one needs to
mention about sanitary conditions etc)

Systemic review: pertinent to the case

Examination of the patient: system wise

Investigations: (with dates)

Previous:
On admission:
Change in trends of lab reports (important for followups)
- It is important to correlate labs with the history and presenting complaints of the patient
Create a problem list encompassing your taken history, examination, investigations
-
-
-
-
-

Based on this problem list: create a plan for the patient.

Of course, all patients will be vitally monitored and provided with fluids. It is important to
mention what types of fluids will you be giving (normal saline, ringer lactate etc with their
doses/strengths). If antibiotics are to be given, know the generation, and dose. Mention
the name of the painkillers with the dose.
Any drugs that need to be altered/changed/stopped - should be mentioned in your plan
If there are any additional investigations that you would wanna get for the patient,
mention that too in your plan.
If its a follow-up patient and the patient seems: vitally stable, with normal investigations
and overall improving - you can also advise discharge - however do mention about what
meds will u discharge the patient on and when will u followup