Indoor case paper format for mediclaim: the hospital file a TPA reads before it pays. Free in Word, PDF and Excel.

One set, twelve pages, in the order they sit in the file:

1. Face sheet: hospital, patient, admission and discharge date and time, insurer and pre-auth number.
2. Admission note: complaints with duration, history, a chronic-illness table with “since”, alcohol and tobacco, examination, provisional diagnosis, why admission is needed, plan.
3. Nursing admission assessment and consents on file.
4. Doctor’s progress notes and orders, one note per day at least.
5. Drug administration chart, with each dose timed and initialled, plus IV fluids and blood.
6. TPR, BP and intake-output chart.
7. Nursing notes, shift by shift.
8. Investigation log.
9. Procedure / OT note, with the indication.
10. Discharge, transfer, LAMA or death note.
11. ICP completeness check, to run before the discharge request goes to the TPA.
12. Request for copies of indoor case papers, with consent, for the patient or attendant.

• Word (.docx), A4, editable; add your letterhead and registration number.
• PDF, print-ready A4 for a ward that writes by hand.
• Excel (.xlsx), one sheet per page; useful for the drug chart, vitals and the checklist.

Free to use and adapt. It is a working format, not a statutory form, and it does not replace your insurer’s claim form or pre-authorisation form.

Care Health’s claim form defines it better than most: a document “prepared by hospital on daily basis which maintains daily doctor notes, nursing notes, patient progress details and having patient condition summary from the date of admission till discharge.”

Checklists use several names for the same file: indoor case papers, ICP, IPD case sheet, indoor case sheet, treatment chart or treatment sheet; government schemes such as PM-JAY say clinical notes. In Gujarati and Hindi it is usually just the hospital’s case paper or file. It is not the discharge summary. The discharge summary is the signed digest the patient takes home; the case papers are everything it was written from.

Not on the standard form. The document checklists on the IRDAI standard claim form (Part A for the patient, Part B section D for the hospital, as used by New India Assurance and Care Health) list the bills, discharge summary, OT notes, ECG, investigation reports and prescriptions. Indoor case papers are not on either list. Insurers and TPAs add them, and their wording varies:

The bigger change is who asks. Para 17(c) of IRDAI’s Master Circular on Health Insurance Business (29 May 2024) says insurers and TPAs “shall collect the required documents from the Hospitals. Policyholder shall not be required to submit the documents.” So the practical answer for a hospital is: assume every IPD file may be read by a TPA, and write it so it stands on its own.

No Indian law sets one case-paper layout. What it has to contain comes from three places: the Gujarat Clinical Establishments Rules (Annexure-12 asks for “a detailed daily statement of the patient’s health and condition”, investigations, operations and treatment given, and all prescriptions), NABH’s 6th edition hospital standards, and the boxes on the insurer’s forms that the file has to prove.

The admission note does the most work. The pre-authorisation form asks the treating doctor for the “duration of the present ailment”, the date of first consultation, and a past history of diabetes, hypertension, heart disease and other chronic illness with the month and year it began. Claim form Part B asks whether the present ailment is a complication of a pre-existing disease and whether it was caused by alcohol or substance use. Every one of those ticks has to be provable from the case paper.

Insurance Ombudsman awards show the case paper deciding claims. These are older awards (2005 to 2014) and policy wordings have changed since, but the reasoning has not:

• “Since when” that contradicts the discharge card.In a 2005 Mumbai award, the discharge card said diabetes for 7 years, but the indoor case papers recorded it “since 1985”. The Ombudsman relied on the case papers, which “would always mention correct history of the patient”, held that a certificate obtained afterwards could not alter the hospital’s notings, and upheld the repudiation for pre-existing disease (Ombudsman compilation).
• “Investigation only”.In a 2010 Hyderabad award, the insurer said the indoor case sheets “contained only noting of Body Temperature, B.P., Pulse Rate and respiration”. The patient said she had been given IV fluids; the Ombudsman held that what was “not recorded in the case papers cannot be accepted” and allowed only an ex gratia payment (compilation). The same compilation has a claim lost because a 24-hour stay could not be shown.
• No indication for the procedure.In a 2014 Mumbai award about a curettage, the discharge card had its diagnosis and procedure boxes blank. The Forum called for the indoor case papers and found the notings “meager”: the reasons for the curettage were not recorded, and the story had to be pieced together from another hospital’s papers (compilation). The claim then failed on a policy exclusion, but the file had already stopped speaking for the hospital.
• Notes written at one sitting.In another 2014 Mumbai award, the insurer pointed out that all the indoor case papers were in a single handwriting, “suggesting that the papers were prepared at one stretch”, and that the admission papers did not mention the complaint the patient gave as the reason for admission (same compilation).

Government scheme reviewers use the same logic. Odisha’s claim adjudication manual, adapted from the PM-JAY manual, lists query reasons such as “Admission Notes not Submitted”, “Detailed Clinical Notes not Submitted”, “Documents not Signed by the Doctor” and “Indications for LSCS not Mentioned”, and checks that the name and age in the ICP match the card and the reports.

The same IRDAI master circular put clocks on cashless claims:

• Pre-authorisation:the insurer decides “immediately but not more than one hour of receipt of request” (para 15(b)).
• Discharge:final authorisation “within three hours” of the hospital’s request; if it takes longer, any extra amount the hospital charges is borne by the insurer from its shareholders’ fund (para 16(a) and (b)).

The clocks run on what the hospital sends. A pre-auth request built from an admission note that already answers duration, since-when and why-admission is less likely to come back as a query. At discharge, a file whose times match the bill and whose drugs match the drug chart gives the TPA nothing to ask about. The completeness check in our set is meant to be run at that moment.

Under Ayushman Bharat PM-JAY, the documents are uploaded rather than posted, but the expectation is the same. Uttarakhand’s State Health Agency claims FAQ says the rationale for a hospital stay of at least 24 hours “should be provided by the hospital through clinical documents”, asks for clinical notes for each full day in medical cases, and says that if a hospital does not provide mandatory documents, the claim “can be justifiably repudiated”. Rules differ by state and by package, so check your State Health Agency’s guidelines.

The patient, or an authorised attendant. Regulation 1.3.2 of the IMC (Professional Conduct, Etiquette and Ethics) Regulations, 2002 says that when a patient, authorised attendant or legal authority asks for medical records, the request is acknowledged and the documents issued within 72 hours.

An insurer or TPA gets them on the patient’s consent: the claim form’s declaration authorises the insurer to seek records from the hospital, and IRDAI requires the policyholder’s express consent for sharing medical records. Many hospitals release copies through the medical records department against a written request and ID, with each page stamped and signed as a true copy and a copying fee. The last page of our set is that request form.

In Gujarat, Rule 15(3) of the Clinical Establishments Rules requires IPD records to be kept for at least five years, and records of court, medico-legal and consumer forum cases until final disposal. The inspection checklist in Annexure-12 adds that for a maternity case, a full record of the pregnancy must be kept for at least ten years. Nationally, the IMC Regulations 2002 require indoor records for three years. See our Gujarat Clinical Establishments Act guide for the rest of Rule 15, and the OPD, IPD and operation register formats for the registers the case sheets are indexed in.

Paper is perfectly lawful, and many good hospitals run on it. The difficulty is not writing the file; it is producing it when a TPA asks a week later: finding the night nurse’s note, proving a time, explaining why the bill shows a drug the chart does not.

In MedStream an admission carries the indoor history, examination and diagnosis, treatment notes started from templates, and a TPR and vitals chart with the doctor’s orders alongside, on the same admission as the indoor bill and the discharge summary. The patient is flagged as insured with the name exactly as on the policy, from insurer and TPA masters, and the companion Insurance Claim Manager keeps the approval documents, tracks claim status and reconciles payments, with TDS and short-fall worked out. The hospital management software page shows the indoor workflow.