Indoor Paper


While the patient is being admitted

Head of service

Patient’s full name, address, age, sex, marital status, occupation, economic class, telephone number and name and address of the relative

IPD and OPD number

If brought by police, name of the P.C on duty and P.C number

Stamp, in case of a medicolegal case


Date and time of admission

While the patient is in the ward

In the columns of house officer, registrar and honorary

Provisional diagnosis

Secondary diagnosis

For post delivery patients, check entries made by staff with red ink (confinement number, mode of delivery—LSCS or Vaginal, APGAR Score, date and time of delivery, sex of the baby, baby's weight, placental weight, name of the doctor, entries of the procedures performed---

With date, name of the operating surgeon, the assistants, staff assistant, anesthesia with name of the anesthetists and proper indication of the procedure (procedures may include operative procedures, induction of labor or administration of injectables like Anti-D etc,)

Payment entry at the top

In case of death, exact date and time of death, signature of the person to whom body was shown

In case patient transferred to another ward, date and time of transfer, ward number, signature of the concerned unit registrar with a transfer summary

While discharging the patient

All above mentioned entries made in respective columns

Discharge summary attached with sign of the registrar or qualified

Date and time of discharge

Stamp with signatures of the doctor, staff and patient/relative with date in case patient is discharged against medical advice

Indoor file arrangement

For ANC patients, ANC charts (properly filled) attached at the front of the file

For gynaec patients posted for any procedure, pre-operative and investigations chart attached at the front of the file

Steppler pins not to be used

All investigations (blood,urine,stools) attached in chronological order at the inner side of the front flap of the file

All ultrasonography reports attached in chronological order at the back of the file

Treatment sheet

Daily houseman ward rounds followed by registrar rounds with proper date and time and signature.

Lecturer or qualified round followed by the round of the unit in charge with signature.

TPR chart

Daily record by the ward staff

Any deviation from normal, inform respective unit

Intake and output chart

Daily record by the ward staff

Under indicated cases, check entry for urine albumin, urinary sugars and ketones, HGT.

Check: all other investigations like ct scan, mri, chest x-ray, ecg, previous blood investigations with opd paper or the casualty paper attached at the back, after tpr and intake-output charts.