HIS2KRGIPD1

Republic Of Namibia

Ministry of Health and Social Services

Rev. 08/00

Inpatient Department

(IPD ) Register

Serial

Regis-

Admis-

Dis-

Length

State

Patient Name

Address/Place

Citizen-

Age

Sex

Admission

Admission

Ward/

T r e a t m e n t

Discharge

Discharge

--------------- Provider ---------------

------------- Remarks ----------------

No.

tration

sion

charge

Of Stay

or

ship

(    )

Parameters

Diagnosis

Room

Diagnosis

Diagnosis

For

Number

Date

Date

(Days)

Private

(If NOT

M

F

Code

Name

Signature

Year

Namibian)

1

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

9

10

10