Todays Date: ___/___/___ Patient: __________________________ Age: ___ Sex: ___ Rm: ____ Admit Date: ___/___/___ HD:

________ LOS: _______ Allergies: __________________________ Admit Diagnosis: _________________________ Procedure: _____________ Code Status: ______ Comorbid Conditions\Hx: ____________________________________________________________
SIGNIFICANT HOSPITAL HISTORY
NEURO: Orientation: Psych/Soc: Pupils: Extremity Strength: Temp: Activity: Weight: Fall Precaution: Restraints: CV: Rhythm: HR: BP: A Line Swan Ganz: PA PAWP CVP: CO Pacer Wires: K+: CPK: CBC: Hct: PT: Mg+: MBs: Trop: Hgb: PTT: Ca: Edema (slight=+1/mod=+2/pitting=+3): Pulses (absent=0/weak=1/strong=2): (R) (L) PICC/Central line/ IJ: Hep Lock: DRIPS: cc/hr PULM: Extub: BS: Coughing: Chest Tubes: ABG: GI: BS: NG: Diet: Feeding: Chemstrip: GU: Foley: Urine Output: RR: Sputum: Bipap: Mode: FiO2: TV rate: Abd Contour: Flatus: pH: BM: Appetite: Cath Care: PD: Hemo: O2: Mask: Triflow: Cuff Pressure: GI: PLAN: VARIANCE

BODY SYSTEMS
NEURO: PLAN: VARIANCE

CV:

PLAN:

VARIANCE

RESP:

PLAN:

VARIANCE

SG:

GU: I&Os:

PLAN:

VARIANCE

Skin/Dressing/Incisions: Braden Scale: Other: Discharge Plan: Variance to Discharge Plan: Barrier Resolution: Consults:

Specimens: Tests/Labs: Proc/Hx/Preps: Other: Teaching/Learning: Consults: Special Needs:

Ca: Mg:

PTT: PT:

CPK: CKMB:

CKMB%: TROP: