            00                                                                                                                            @CK BIRLA HOSPITALS | CMRI
                                                                                                                                                 The Calcutta Medical Research institute
                                                                                                                                             7/2 Diamond Harbour Road, Kolkata 700027
                       C-478672                                   EMERGENCY DISPOSITION FORM

                 LEAVE AGAINST MEDICAL ADVICE (LAMA)
                                                                                              DISCHARGE                                                    TRANSFER
                 MRN: 1098                        DATE : 31/8/23
                                                                                         TRIAGE & BED NO, (IN ER) :                               MLC :
                                  Rahul Khemke
                 NAME :                                                                  AGE: 35                      SEX :                                 OF OTHERS
                 CHIEF COMPLAINTS:
                              Fall injury at home while climbing stairs

                                                                                       (7:00 PM, today)

                                                         ofE Afde Ges: 15/15
            CLINICAL FINDINGS :                                                                                                                                  Spo2:99%

                                                                  Temp : 98.9F                                        BP: 150/902 mm Hg

                                                                       PR: 90/min                                 RR: 21/ min.


           TREATMENT / PROCEDURE AT ER :                           1 Ini sumol (100)


                                                                               Ani Pan (10)

                                                                          3 Dny Zafer (1).


                                                                                 INVESTIGATION DONE / ADVICE

          BLOOD INVESTIGATIONS :                                    X-RAY / CT SCAN / USG :                                                  OTHERS :
                                                                                                             AP
                                                                       c - spine < lateral

                                                                       RAnkle- AP
                                                                                                   lateral

                               1 T. Chymoral
         ADVICE :
                                             T. Derada forte steb TDAC XSd.              DP - 1tab BDPC × 50l.
                                  2

                                            T. Pan (10) - 1 tab OD AC x 5dl.
                                      3

                                      4      Ice compression                                                             5 Uke crepe bandage.

                                                 Attend on                ortho- OPD/ER after 5days
Sshile      87683
         ACTOR'S SIGN :                                                                            PATIENT / SURROGATE'S SIGN : DE                                             DATE :
                                                             31/8/23
  NAME / REGN. NO. / DATE / TIME :                                                             NAME & RELATION : Alvest Vol                                                    TIME :
                                                                                9:20 PM.                                              Brother In law

                                                         DECLARATION OF LEAVE AGAINST MEDICAL ADVICE (LAMA)

  It has been explained In our spoken language that the patient needs to be admitted in the hospital for further treatment. We have
  been told about the possible consequences if the patient is not hospitalised. Having understood the above, we would not like to
 admit the patient / get the patient discharged at our own risk and doctors or hospital staff shall not be responsible for any
  consequences thereafter.

PATIENT SIGN / *SURROGATE SIGN :                                                                                                                          WITNESS SIGN :

PATIENT NAME / SURROGATE NAME :                                                                                                                           NAME OF WITNESS :

*RELATIONSHIP WITH PATIENT :                                                                                                     DATE & TIME :

                                                                                        REASON FOR LAMA


           FINANCIAL                         PERSONAL CHOICE                                                                                              OTHERS (Mention) :
                                                                                               SERVICE RELATED ISSUES


GRE NAME & SIGNATURE :                                                                                       DATE:               31       /8/25                       TIME :   9150

F-ER-F-7527                                                                                                                                                                                Vers-04-07/

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