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By Corporate FVR TEAM Diarrhea / acute gastro enteritis • Verify the initial admission complaints of the patient • Frequency of the stools , quantity of the stool • Indication for hospitalization • verify for Dehydration symptoms • To verify Vitals at the time of admission • Line of management • Whether patient took out patient treatment if so details of the treatment Fever •Verify the indication of hospitalization •Verify the temperature , vitals , dehydration status •Verify Exact duration of fever •To verify TPR chart •To get Positive investigation reports •Reports of outpatient treatment ,if any •To verify indication for hospitalization •Verify for vitals at the time of admission lower respiratory • To verify the resp rate ,saturation level-02 saturation infection • To verify whether oxygen / nebulisation given • To verify the x ray or ct chest report • To rule out whether any underlying bronchial asthma, copd Typhoid Leptospirosis • Indication for hospitalization • verify for fever , vitals , dehydration status • Exact duration of fever /TPR chart •Positive inv reports diagnosis, blood culture rpt ( confirmatory ) • Indication for hospitalization • To verify for fever , vitals , dehydration status of the patient • Exact duration of fever/ TPR chart • Positive inv reports diagnosis • MAT TEST rpt ( mandatory ) Persistent vomiting Dehydration Abdominal tenderness Hepatomegaly Ascites edema Dropping trend of platelets to <50000 Comorbid conditions: Heart disease, Bronchial Asthma, DM, HTN, Peptic Ulcer, Hemolytic anemias, Pregnancy, Infancy, Old age,. along with ns1 antigen. Dengue : Mucosal bleed Respiratory distress Pleural effusion Hypotension/shock Oliguria Rising Haematocrit> 60% If any one of the above condition is met, then admission is indicated Chronic kidney disease •How and when was the symptoms started • What was the initial symptom •When was it first diagnosed? • First consultation report and creatinine value at the time of diagnosis • Serial urea and creatinine values with hemoglobin rpt , usg , ct rpt • Any biopsy done if yes result ( mandatory ) •Any past history of kidney disease • If dm /ht - what was the duration Hypertension • How and when diagnosed as hypertension • Initial consultation report and medications given •What was the current medication taken •Ecg, Rft, echo reports Acute pancreatitis • Usg or ct report along with Liver function test reports , s.amylase, s.lipase • To verify whether patient has any previous history of similar pain and admission details • To check for alcohol history Diabetes • How and when was the dm diagnosed • Exact duration of DM • All past inv reports • HBA1C reports • Treatment taken so far for DM. Asthma •To enquire regarding exact duration of asthma •To verify whether patient was taking any steroid treatment if yes duration • Whether any PFT report available all past medications including x ray previously taken •PRESENT- x ray , ct report / •oxygen given / any nebulisation done Heart Disease /CAD • Exact duration of heart disease •To ask any previous episodes/hospitilisation for similar illness • Previous ECG, Echo,Tmt ,Cag report •( If available) HISTORY OF asprin intake • Plan of management. •Whether Pt Had Any Rheumatic Fever Heart Disease • Past H/O Hospitalisation FOR RH.FEVER •Any Penicillin prophylaxis taken before ,If /RHD Yes – Duration •Echo Report • Holter monitor report Heart disease / • Any regular intake of any anti arrythmic conduction drugs defects • Any past history of Syncope ,Tia, Palpitation • Verify the exact circumstance of injury • Whether two wheeler vs two wheeler , or four wheeler • Whether patient was riding or sitting in the back • Whether pt. was under influence of alcohol, If late night suspect alcohol Mlc/Ar copy, check x-rays. Back Pain • To verify Indication for hospitalization • If trauma look for any other Soft tissue injury • Exact duration of symptoms • confirm whether previous hospitalization done • To verify the previous treatment details. • • Etiology for giddiness • To ask whether Patient a known case of DM/HT/IHD or any other systemic disorder Giddiness • CT or MRI reports • Any other medication for vertigo or any other illness Knee Replacement • To verify How and when did the knee pain started for the patient • All past treatment records including medicines taken for • To verify Pre operative , post operative x ray • Verify for Vitals ,fever at the time of admission • Verify for Usg report and urine routine analysis Urinary Infection • Cbc report ,urine culture • To verify for any history of calculus • To verify whether any treatment or investigation previously done for urinary infection Stomach Pain • To verify for exact duration of Pain • Whether pt had previous similar pain • Whether any endoscope was done(with report) • To verify whether patient was on any proton pump inhibitors • Any investigation or treatment taken with records • Current Usg report • To verify for alcohol history Head Injury • Exact mode of injury like any fall from height( what was the height ) • Any associated leg fracture • To rule out any suicidal attempt • Any AR / MLC / FIR copy done • To collect the Ct or Mri report • To verify any alcohol history if RTA • To verify treatment plan. Burns • Exact Circumstance how burns occurred for the patient • To verify if any mlc / fir done • Exact duration of the abdominal pain Acute appendicitis • To verify for fever , vomiting , cbc count , • To verify for vitals on admission • Investigation - usg report or ct report , • Whether any previous abdominal surgery was done if so all those details , any other co morbid conditions for the patient Cholelithiasis / gall bladder calculi •Exact duration of abdominal pain • First/past consultation report • Cbc count with usg abdomen report or ct scan report /Ercp/Mrcp Calculus of kidney and ureter • Exact duration of the pain • First consultation report for the pain • Usg or ct evidence for the calculus • Verify whether patient had done previous surgery ( laser therapy ) or medical treatment for calculus Benign neoplasm of uterus / fibroid uterus /dub • What was the initial complaint ( like heavy bleeding or abdominal pain with duration ) and duration since when the patient had those problems • First consultation report and the usg done at the time with prescription report • Duration of dub /medical treatment for dub /usg rpt • Any previous gynaecological consultation was done for the patient for any complaints. Hernia • What was the exact type of hernia ( whether inguinal , umbilical , incisional or femoral hernia ) • Exact duration of hernia symptoms with the first consultation report • Usg report • Any past history of any previous abdominal surgery done if yes all those details including cesearean surgery • If the patient is a child ask mother when the swelling was noticed Neoplasm of the breast • Verify the patient when exactly did the patient noticed the swelling • First consultation report for the same • Mammogram report , fnac and hpe report • Whether pt had done previous surgery or treatment for the other breast in the past Haemorroids • To verify for the exact duration of pain , bleeding per rectum for the patient • Any medical management taken for the same • Any past history of previous surgery done for hemorrhoids ( laser surgery /stapler surgery ), • Proctoscopy report Deviated nasal septum • What was the initial complaint for the patient • What was the medical treatment taken • Ct scan reports / x ray para nasal sinus Exact Duration of the Abdominal pain. To verify for Fever, Vomiting, CBC count, To verify for Vitals on Admission. Investigation - USG Report or CT Report, Whether any previous Abdominal Surgery was done if so all those details, any other co-morbid conditions for the patient. Exact Duration of Abdominal Pain First / Past Consultation Report CBC Count with USG Abdomen Report or CT Scan Report /Ercp/Mrcp. Exact Duration of the pain First Consultation Report for the pain USG or CT evidence for the calculus Verify whether Patient had done previous surgery ( laser therapy ) or medical treatment for calculus. What was the initial complaint ( like heavy bleeding or abdominal pain with duration ) and duration since when the patient had those problems First consultation report and the USG done at the time with prescription report Duration of DUB /Medical Treatment for DUB / USG Report Any previous Gynecological consultation was done for the patient for any complaints. What was the exact type of hernia ( whether inguinal , umbilical , incisional or femoral hernia ) Exact duration of Hernia Symptoms with the First Consultation Report. USG Report. Any past history of any previous abdominal surgery done if yes all those details including cesarean surgery. If the patient is a child ask mother when the swelling was noticed. Verify the Patient when exactly did the patient noticed the swelling. First consultation Report for the same. Mammogram Report , FNAC and HPE Report. Whether Patient had done previous surgery or treatment for the other breast in the past. To verify for the exact duration of pain, bleeding per rectum for the patient. Any medical management taken for the same Any past history of previous surgery done for hemorrhoids ( laser surgery /stapler surgery ) Proctoscopy Report. What was the initial complaint for the patient What was the medical treatment taken Ct scan reports / x ray para nasal sinus AS PER FOR RTA CASES ( PREVIOUS SLIDES ) LOOK FOR OTHER INJURIES , IN THE OTHER SITES LIKE BRUISE , LACERATED WOUND LOOK FOR X RAY FILM , ANY PAST HISTORY OF PREVIOUS FRACTURE ANY EVIDENCE OF OLD HEALED FRACTURE WHEN WAS THE INJURY OCCURRED ANY ASSOCIATED INJURIES LIKE HEMATOMA , BRISE IF POLICY IS IN 1 ST YEAR , GET ALL THE DETAILS OF INJURY LIKE WHEN IT OCCURRED , FIRST CONSULTATION PAPER ( ACL TEAR CAN BE OPERATED UP TO 6 MONTHS ) MRI RPTS ( LOOK FOR THE DATE OF MRI )