MEDICAL DEPARTMENT
PRESCRIPTION
MRN:
EMPLOYEE ID:
PATIENT NAME:
FATHER'S NAME:
AGE:
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GENDER:
DIVISION:
DEPARTMENT:
AREA/SECTION:
IN TIME:
CLEARANCE TIME:
Weight:
kg
Height:
cm
BMI:
BP:
/ mmhg
Pulse:
min
Temp:
C
SPO2%:
%
RBS:
mg/dl
FBS:
mg/dl
PPBS:
mg/dl
Respiratory Rate:
Urine Output:
AVPU:
Trama:
Mobility:
Oxygen Supplementation:
Glasgow coma scale:
Total Cholesterol:
Case Type:
Referred By:
Complaints :
Examination :
Remarks/Follow-up Investigation Details:
Ecg Finding:
Diagnosis:
Body System:
Disease Type:
Advices:
Heart Rate:
Urine:
Detention Details
Sr
Medicine
Admin. Route
Qty Issued
Rx
Additional Treatment Recommendations(if Any):
Referral:
Follow-up date:
Health Advices:
Recommended Tests:
Additional Precautions:
Chronic Illness:
Period Of Rest From:
Period Of Rest To:
Half Day:
Precautions:
Leave Remarks:
Status:
Followup-Remarks:
Observation Note
Previous Medical History:
Current Medical History:
Signature & Stamp
PREVENTION IS BETTER THAN CURE
NOTE: NOT FOR USE MEDICO LEGAL PURPOSES