CODE STATUS: ALLERGIES:

Room: _____ Date: ________________ Report Received: ________

Name: ___________________________Age:____ From: ________________________ Arrived: ________
Doctor: ___________________________________ From Prior to Hosp: ___________________________

Present Problem: __________________________________________________________________________

Past Hx:
_________________________________________________________________________________

Family: _______________________________________________ ADLs: ___________________________

Misc: _____________________________________________________________________________________

@: ________ @: _________ @: ________ MRSA: ____ VRE: ____ c-diff: ____ BC: ____ UC: ____
Na: _______ AST: _______ WBC: _____ Resp: ____
K: ________ ALT: _______ Hgb: ______
Ca: _______ SGOT: _____ HCT: _____
Mg: ______ PT: ________ Plt: _______ Imaging:
BUN: _____ PTT: _______
Cr: _______ INR: _______ Trop: _____
BS: _______ Dig: _______ CKMB:______

IVs: Skin - Dressings:

Temp: _____F

Vascular: Neuro/Muscular:

Cardio:
Renal:

GI:
BP:____/____ HR: ______ Rhythm: ____________

Resp:

Tube Feeding:__________________________________

G/U:
Pox:____%
RR: _____ BiPAP Vent: ______________________