Panchayat:Repo18/vol2-page1139

GOVERNMENT ORDERS — 2015-6)oj ი Joejiფqთვ?იí പരിചരണ പ്രവർത്തനങ്ങൾ 11:39 അനുബന്ധം 12 SECONDARY LEVEL PALLIATIVE CARE PROGRAMME Monthly Report:........................, 20........ (See Para 7.4) Name of Institution...................................................................................................................................... 1. Registration Description Total at This Month Patients under the end Coverage of Last Month New Expired Transfer out (2+3)-(4+5) (1) (2) (3) (4) (5) (6) Registered Patients Patient needed Follow up Home care Patients depend OP for Medicine 2. HomeCare Date Team members Starting Ending No. of time time Patients Seen No. of NHC/No. of patients seen: No. of DHC/No. of patients seen: 3. Out Patients No. of volunteers who participated: No. of Health staff who participated: Date Total patient attendance No. of new patients No. of patients Remarks given Morphine Total: 4. In Patients Number of patient admitted inwards for additional care Week 1 Week 2 Week3 Week 4 Week 5 Total: In institutions with separate IP: No. of patients admitted total number of patients admitted during the month: ....................