Free tool
OPD case sheet format. Blank lines in the Appendix 3 order.
Free OPD case sheet for Indian doctors: complaints, history, examination, diagnosis, investigations, treatment and follow-up on Appendix 3 lines. A4 or A5.
Sheet
The clinical sections print as ruled blank lines for you to write in. Fill the patient lines below for one patient, or leave them empty and print a stack of blank sheets.
Patient (optional)
Clinic
Logo
Clinic logo only; a photograph of yourself on a letterhead is barred by clause 6.1.2. PNG or JPG, stays in this browser.
Doctor
Layout
Which records to keep and for how long: OPD register and record-keeping rules and how long to keep medical records.
Add the doctor's name and registration number to print.
Everything you type is kept only in this browser on this device and is never sent to Vitels. It is not encrypted and anyone using this browser can see it, so press Clear after printing on a shared computer. In the print window choose “Save as PDF” for a file.
Clinic name
Dr. Name
OPD case sheet
Presenting complaints
History
Examination
Provisional diagnosis
Investigations advised, with reports
Diagnosis after investigation
Treatment and advice
Fields follow Appendix 3 (format for medical record) of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Keep with the patient's file; copies are due within 72 hours of a request (regulation 1.3.2).
Preview at reduced size. Prints at full A4.
What the regulations ask of an OPD record
Regulation 1.3 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 and its Appendix 3 set the fields, the period and the 72-hour rule. The 2012 central rules add electronic records in Clinical Establishments Act states.
- IMC Regulations 2002, Appendix 3
Appendix 3 is the format
The 2002 regulations attach a format for medical record: name, age, sex, address, occupation, date of first visit, clinical note (summary) of the case, provisional diagnosis, investigations advised with reports, diagnosis after investigation, advice, follow up, date and observations. This sheet keeps that order.
- IMC Regulations 2002, Appendix 3
Signed in full, with the name
Appendix 3 ends with the signature in full and the name of the treating physician. This sheet prints your name, qualifications and registration number under the signature line, and the tool will not print until both the name and the number are filled in.
- IMC Regulations 2002, regulation 1.3.1
Three years, at least
Every physician shall maintain the medical records of indoor patients for 3 years from the date treatment began, in the Appendix 3 proforma. No regulation sets a shorter period for OPD records, so 3 years is the floor for an OPD case sheet too.
- IMC Regulations 2002, regulation 1.3.2
Copies within 72 hours
If the patient, an authorised attendant or a legal authority asks for medical records, the request is acknowledged and the documents are issued within 72 hours. A case sheet filed by OPD number and date can be found and copied in that time.
- IMC Regulations 2002, regulation 1.3.4
Paper is allowed; computers are encouraged
Efforts shall be made to computerise medical records for quick retrieval. The regulations ask for the effort, not for a switch away from paper, so a handwritten case sheet in the Appendix 3 order meets them.
- Clinical Establishments (Central Government) Rules 2012, rule 9(iv)
Clinical Establishments Act states
Where the central Act applies, a clinic shall maintain and provide Electronic Medical Records or Electronic Health Records of every patient as may be determined and issued by the Central or State Government from time to time. Check what your state has issued.
What the printed OPD case sheet has room for
Every clinical section prints as ruled blank lines. Nothing is pre-filled except the patient lines you choose to type.
Clinic letterhead with your name, qualifications and registration number
OPD number and visit date
Name, age, sex, address, occupation, phone and date of first visit
Presenting complaints
History
Examination
Provisional diagnosis
Investigations advised, with reports
Diagnosis after investigation, which you can switch off for more room
Treatment and advice
Follow-up date and observations
Signature of the treating doctor with date, name and registration number
The case sheet, without the paper file
Vitels keeps every patient's visits, prescriptions and receipts in one record, prints the prescription on your letterhead with the registration number, and lets the clinic admin export every record as CSV. Consultation and printing work offline.
Straight answers
Is there a prescribed OPD case sheet format in India?
The nearest thing is Appendix 3 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, the format for medical record. Regulation 1.3.1 ties it to indoor patients, and no separate OPD format exists in the regulations, so most clinics use the Appendix 3 fields for OPD visits. Your state's clinical establishments rules may ask for more.
How long should a clinic keep OPD case sheets?
Regulation 1.3.1 sets 3 years from the start of treatment for indoor records and nothing shorter for OPD, so keep OPD case sheets at least 3 years. Nothing in the regulations stops you keeping them longer. Our post on how long to keep medical records sets out the state rules that add to this.
Can I keep case sheets on a computer instead of paper?
Yes. Regulation 1.3.4 asks that efforts be made to computerise records, and in states that follow the central Clinical Establishments Act, rule 9(iv) of the 2012 rules refers to electronic medical records of every patient as the government issues. A digital record with the Appendix 3 fields that can be printed and handed over within 72 hours meets the regulations.
Is the patient entitled to a copy of the case sheet?
Regulation 1.3.2 says that when the patient, an authorised attendant or a legal authority asks for medical records, the request is acknowledged and the documents are issued within 72 hours. Keep the case sheet where the front desk can find it by OPD number and date, and keep a note of what was handed over and when.
Should the case sheet carry my registration number?
Regulation 1.4.1 names prescriptions, certificates and money receipts, not case sheets. Appendix 3 asks for your signature in full and your name. Printing the registration number under the signature costs nothing and identifies the treating doctor without doubt, so this sheet does it and asks for it before printing.
Does the tool store patient details?
Only the patient lines you type, and only in this browser session, unencrypted, on this device; closing the tab or pressing Clear removes them. The clinical sections cannot be typed in; they print blank. The letterhead is kept for next time. Nothing is sent to Vitels.
This tool only prints a blank layout. It adds no clinical content and does not check what is written on the sheet; the treating doctor is responsible for the record. This page summarises the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 and the Clinical Establishments (Central Government) Rules, 2012; it is general information, not legal advice. Your state rules may ask for more.
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