Name:

Doctor/Resident/PA:

Room:

Diagnosis:

Code Status:

Date of Admission:

Precautions:

Allergies:

Mentation:

Oxygen:

PMH:

Labs
WBC
Hg/Hct
Platelets
PTT
PT/INR
Na
K
BUN/Cr
Ca

Phos

IV:
Due to change:____

Mg
Albumin

Wounds/Incisions/Drains/Skin/Edema:

RBC
Diagnostics/Tests:

Diet:

Accu Check:
Intake

Output

Vitals & Frequency:

T:
P:
R:
BP:
Last BM:

O2:
Activity:

Tele/Rhythm:
Pain/Last Pain Med:

Meds:

Tube
Accu
StrIO

SCD