Name of Student: Name of Patient: Age: Chief complain: Marital Status: Medical Diagnosis: General Objectives: Religion: Date

of Adm: Attending Physician: VITAL SIGNS

Diet of your patient:

Special Endoresment:

Laboratory/diagnostic Exam Results:

Time

Temp

PR

BP

O2
Nursing Diagnosis (3 Priority):

No. of Stools: No. of Urine:
IVF/BLOOD
Name Order Reg. Time Level Amount IVF to Follow

I/O

Time

Oral

INTAKE Tubal

Parenteral

Total

Urine

OUTPUT Suction Others

Total

Patients Name:

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