MRN No.

:-
Bed No. :-
Adm. Date & Time :-
Active
ActiveFile
FileAudit
Audit Consultant :-

Date:-
TO,
The Medical Officer/Nurse Administrator . (Unit / ICU)
The Following Documents are Missing/Incomplete.

Status
Sr. [Y-Yes Page
Parameters
No. N-No No.
"-" = N.A.]

1 Consent for Hospitalization and Conditions of Service

2 MEDICO-LEGAL CASE INTIMATION

Consent for Anaesthesia -Reason of Anaesthesia

3 -Type of Anaesthesia
-Language

Consent for Surgery -Reason of Surgery

4 -Name of Surgery
-Language

-Cardiac Procedure
5 Other Consent
-Procedure

-High Risk
6 Other Consent
-DAMA

-HIV
7 Other Consent
-Blood Product

8 Other Consent
 Pre Operative Checklist Ward Nurse
Name Sign.
Date Time
9

Pre Surgery Checklist Allocated Nurse

Name Sign.
Date Time
10

Surgical Safety Checklist OT Nurse

Name Sign.
11

Anesthesia Record - Anesthesia Start Time

12
End Time
OR Nursing Record Circulating Nurse
Name Sign.
13 Date Time

Recovery Room Chart Data

Not
14 Capture

15 ICU Chart

16 ICU Chart

17

Nurse Administrator ...

Emp. Code No. : . Dr. Rahul Indalkar (GAT00
Electronic Medical Recor
 #N/A
#N/A
#N/A
#N/A
#N/A
Friday, May 05, 2017

Remark

- Pt.'s Sign. Date & Time

- Relative Sign. Date & Time
- Bed & Deposit details
- Pt.'s relative Information
-Reason Pt. is unable to sign.

-Pt.'s Sign Name Date

-Doctor Sign. Name Date

-Pt.'s Sign Name Date

-Doctor Sign. Name Date

Doctor Patient
Name Sign. Name Sign.
Date Time Date Time

- Incomplete Details
- Language

Doctor Patient
Name Sign. Name Sign.
Date Time Date Time

- Risk factor missing

- Language

Doctor Patient
Name Sign. Name Sign.
Date Time Date Time

- Incomplete Details
- Language

Doctor Patient
Name Sign. Name Sign.
Date Time Date Time
- Incomplete Details
- Language
 OT Nurse
Name Sign.
Date Time

- Incomplete Details

Technician Anesth.
Name Sign. Name Sign.
Date Time Date Time

- Incomplete Details

Anesth. Surgeon
Name Sign. Name Sign.

- Doctor Name & Sign.

Surgeon Scrub Nurse

Name Sign. Name Sign.
Date Time Date Time

- Incomplete Details

Consultant Nurse
Name Sign. Name Sign.
Date Time Date Time

Doctor Patient
Name Sign. Name Sign.
Date Time Date Time
- Nurse sign. after treatment
Doctor Patient
Name Sign. Name Sign.
Date Time Date Time
- Nurse sign. after treatment

....
r. Rahul Indalkar (GAT00310)
ronic Medical Record Dept.