Chapter 8: Inpatient Care, Doctor Rounds & Discharge Summaries
This chapter details the complete inpatient (IPD) clinical lifecycle from admission desk to doctor daily rounds, nursing vitals, clinical discharge summaries, and patient gate passes.
1. Admitting an Inpatient (IPD Admission)
- Navigate to IPD > Admissions > New IPD Admission.
- Select the patient UHID.
- Choose the Admitting Consultant Doctor and Department.
- Set the Admission Type: Planned Elective, Emergency, Transfer, Day Care.
- Set the Medico-Legal Case (MLC) flag (Yes / No). If Yes, enter police station jurisdiction and MLC registration number.
- Allocate the Ward, Room, and Bed.
- Enter Primary Attendant Details (Name, Phone, Relationship).
- Record the Initial Advance Deposit Amount and payment mode (Cash/Card/UPI).
- Click Complete Admission & Print IPD Admission Card.
2. Doctor Daily Clinical Rounds
Consulting physicians and resident medical officers log inpatient progress through the Doctor Rounds Desk (include_ipd_round_modal.php):
- Round Date & Time: Timestamped clinical review.
- Subjective / Objective Progress Notes: Patient clinical condition, pain scale, recovery milestones.
- Treatment Modifications: Update daily IV fluids, antibiotic dosages, or add new orders.
- Dietary & Nursing Instructions: (e.g. Soft diabetic diet, Strict I/O charting, Bed rest).
3. Nursing Care & Continuous Vitals Charting
Ward nursing staff maintain round-the-clock charts:
- Periodic temperature, blood pressure, pulse, SpO2, and urine output logs.
- Medication administration timestamps (confirming morning, afternoon, and night doses administered).
- Surgical dressing, drain output, and catheter maintenance logs.
4. Discharge Workflow & Clinical Summary
When the patient is clinically fit for discharge:
- Open the patient's IPD file and select Prepare Discharge Summary.
- Fill the structured clinical discharge fields:
- Final Diagnosis: Primary and secondary clinical diagnoses. - Brief Clinical History & Examination: Summary of presentation. - Investigations Summary: Key lab and imaging findings during hospital stay. - Operative / Surgical Notes (if surgery performed): Procedure name, surgeon, anesthesia type, findings. - Hospital Course & Treatment Given: Clinical progress and management summary. - Condition at Discharge: Stable, Improved, Transferred, DAMA/LAMA, Expired. - Discharge Medications & Advice: Home prescription with dosage and food instructions. - Dietary Advice & Warning Signs: When to seek immediate emergency care. - Follow-up Date & Department.
- Click Finalize Discharge Summary & Print Document.
┌────────────────────────────────────────────────────────────────────────┐
│ SHAHU MAHARAJ MULTISPECIALTY HOSPITAL │
│ CLINICAL DISCHARGE SUMMARY │
├────────────────────────────────────────────────────────────────────────┤
│ Patient: Rajesh Kumar Verma (Age: 42Y / M) UHID: UHID-2026-08492 │
│ Admission Date: 26-Aug-2026 10:00 AM IPD No: IPD-2026-0412 │
│ Discharge Date: 31-Aug-2026 02:30 PM Bed: Deluxe Room 302 │
│ Consultant: Dr. S. K. Kulkarni (MD, Medicine) │
├────────────────────────────────────────────────────────────────────────┤
│ FINAL DIAGNOSIS: Acute Exacerbation of Bronchial Asthma with URTI │
│ COURSE IN HOSPITAL: Patient admitted with severe dyspnea and wheezing. │
│ Treated with IV Bronchodilators, Nebulization and Steroid cover. │
│ Condition markedly improved, chest clear on auscultation. │
│ │
│ DISCHARGE MEDICATIONS (HOME Rx): │
│ 1. Budesonide + Formoterol Inhaler (200/6) ➔ 2 Puffs BD x 30 Days │
│ 2. Tab Montelukast + Levocetirizine ➔ 1 Tab at Bedtime x 14 Days │
│ │
│ FOLLOW-UP: Review in OPD after 7 days (07-Sep-2026) with Dr. Kulkarni. │
└────────────────────────────────────────────────────────────────────────┘5. Settlement & Gate Pass Issuance
Once billing clearance is completed by the cashier, the system generates the Printable Security Gate Pass (ipd_gate_pass_print.php), allowing the patient to safely exit hospital premises.