Patient Gender Age Doctor

Diagnosis
Diet:
Lab:
Other tests:
Treatments:
IV Orders:
MEDICATION ORDERS: ALLERGIES:
Diabetes: Type I Insuin: Type II !edication:
"ood sugar ########## "ood sugar ########## "ood sugar##########
!edication$dose$route$%re&uency reason %or gi'ing Time(s) to gi'e
*+
,+
-+
.+
/+
0+
1+
2+
3+
CHIEF COMPLAINT/PRESENT ILLNESS (4hy the patient is here)
HISTORY (past iness5 in6uries5 hospitai7ations5 surgery5 seep patterns5 %amiy)
GENERAL: 8orma 9eight ##### "$P####### Puse##### Respirations###### Temperature#####
SKIN (rashes5 itching5 hi'es5 bruising5 ec7ema5 dryness5 s:in coor changes5 hair te;ture
changes5 nai te;ture changes5 appearance o% nais (incuding toes)5 pre'ious s:in disorders5
umps5 use o% hair dyes)
EYES, NOSE, EARS (eyegasses5 redness5 probems 4ith 'ision5 eye discharge5 gaucoma5
cataracts5 ast eye e;am5 eye in6uries5 nasa discharge5 nosebeeds5 sinus in%ections5 hay %e'er5
nasa obstruction5 %re&uency o% cods5 hearing aid5 hard o% hearing5 dea%ness5 ringing in ears5
di77iness5 ear discharge5 pain in ears)
PERRLA#####
MOUTH AND THROAT (condition o% teeth and gums5 bad breath5 probems 4ith che4ing
or eating5 ast denta e;am5 %re&uency o% sore throats5 changes in 'oice5 persistent hoarseness5
thyroid probems5 goiter5 umps5 pain in nec:5 s4oen gands)
BREAST (umps5 discharge5 pain5 %re&uency o% se% e;am)
CARDIOVASCULAR (chest pain5 papitations5 murmurs5 high bood pressure5 shortness o%
breath 4ith e;ertion or ying do4n5 history o% heart attac: or rheumatic %e'er5 'aricose 'eins5
pain in egs or ca'es 4ith 4a:ing5 s4eing in egs or %eet5 cooness o% an e;tremity5 oss o% hair
on egs5 discooration o% an e;tremity5 ucers)
<R reguar irreguar #####
S- #### S. #### murmur ####
RESPIRATORY (cough5 4hee7ing5 sputum amount and coor5 boody sputum5 shortness o%
breath5 asthma5 peurisy5 bronchitis5 T"5 ast chest =>ray5 ast T" s:in test)
Puse O;#### O,####
GASTROINTESTINAL (recent 4eight oss5 appetite5 heartburn5 beching5 nausea5
'omiting5 abdomina pain5 constipation5 change in coor or consistency o% stoo5 %re&uency o%
stoo5 hemorrhoids5 recta beeding5 use o% a;ati'es5 6aundice5 hepatitis5 gabadder probems)
%at$round$distended
bo4e sounds? yes no
Pain ocation
GENITOURINARY (coor and odor o% urine5 %re&uency5 urgency5 di%%icuty starting stream5
stress incontinence5 e;cessi'e5 pain%u or burning urination5 bood in urine5 %an: pain5 4a:ing at
night to urinate5 retention5 :idney stones5 @TIs5 STDs5 MALESprostate probems5 se% e;am o%
testices5 FEMALESonset o% menses5 %re&uency and ength o% periods5 date o% menopause5
pregnancies$miscarriages5 use o% birth contro5 date o% ast PAP)
Last "!#####
MUSCULOSKELETAL (pain or sti%%ness in 6oints5 4ea:ness5 de%ormities5 imitations in
abiity to ambuate and trans%er5 6oint cic:ing5 musce cramps or spasms5 use o% assisti'e
de'ices5 use o% prosthesis5 probems 4ith baance5 history o% gout5 arthritis5 bursitis or %ractures5
abiity to carry out ADLs)
NEUROLOGICAL (headache5 %ainting5 di77iness5 ata;ia5 bac:outs5 paraysis5 numbness5
tinging5 burning5 tremors5 memory oss5 mood changes5 ner'ousness5 speech probems5 oss o%
consciousness5 haucinations5 'isua disturbances5 disorientation5 history o% brain in6ury or
stro:e)
Orientation
<and grips? L R
Aacia symmetry
DISCHARGE PLANNING: