When I was in my second year Of Pharm D, there was quite a difficulty in documenting the cases. For the most part, we use to do it in books. One fine day me, as well as my friends, came up with a solution to prepare a format for documenting the cases. So, we noted down all the factors involved in a patient proforma at the hospital and moreover searched all over the internet. Finally, we came to a conclusion of the inclusion and exclusion points of a case sheet and after 8 days of hard work, we designed a case sheet which was eventually approved by our college.

So, the case sheet is a documentation format with the help of which we collect and document the cases. For instance, Different types of studies or research require different types of criteria. So, This blog is about the criteria most commonly included in a case sheet. The case sheet, in particular, is divided into six main blocks which constitute the essential part. They are the following:

  • Demographic Details
  • Case Details
  • Systemic Examination
  • Laboratory Investigation
  • Radiology Investigations
  • Medication Chart

DEMOGRAPHIC DETAILS OF CASE SHEET

Undoubtedly, it involves all the demographic details of the patients. Such as:

  • Patient name
  • Age
  • Sex
  • I.P No.
  • Date of Admission
  • Date of Discharge
  • Height
  • Weight
  • Additionally, the Blood group of the patient
  • Name of the Consultant, in general
  • In particular, the Department in which the patient is admitted

CASE DETAILS OF CASE SHEET

So, this includes all the details of disease or the problem by which the patient is suffering from. To sum up, it includes:

  • Chief complaints
  • Past history
  • Medication history
  • Family history
  • Social history
  • Diagnosis
    • Provisional
    • Final

SYSTEMIC EXAMINATION

The systemic examination involves aspects like Blood Pressure, Pulse Rate, Temperature, SPO2 levels, Respiratory levels as well as the Heart rate of the patient.

LABORATORY INVESTIGATIONS

On the whole, this section includes all the laboratory tests which are done to assess the condition of the patient. In particular, it includes:

  • Complete blood picture
  • Renal function tests
  • Blood glucose
  • Complete urine examinations
  • Liver function tests
  • Last but not least, the Electrolytes

RADIOLOGY INVESTIGATIONS

It includes all the radiology tests which are done to assess the condition of the patient as well as aid in the diagnosis of the patient. For instance, some examples of radiology tests are 2D-Echo, Radiography, X-Ray, KUB scan etc.

MEDICATION CHART

Last but not least this is the section where all the medications prescribed to the patient are documented. In fact, it involves all the details of the drugs which are as follows:

  • Drug name
  • Generic name
  • Dose
  • Route of Administration
  • Frequency
  • Time
  • Last but not least, the Therapeutic use