Patient initials: Age:

Sex: Admission Date:

Room: Code:

MD: Allergies:

Diet: O2 L/min: via:

Diagnosis: History:

Intake: Output:
IV: ___________________ Void: ____________________
PO: ___________________ BM: _____________________
Meal: __________________ Hema: ___________________

Activity: Treatment:

LABS: BUN CBC: INR

Na K Creat Hct Hgb PTT
Ca Cl GFR Wbc Rbc
Plat RG

T: __________ ___________ __________ B/P: __________ ___________ __________

P: __________ ___________ __________ O2: __________ ___________ __________
R: __________ ___________ __________