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Name: Age/Gender: Bed No.

Chief Complaint: Birthday: Weight:


Admitting Date: Admitting Diagnosis:
DATE MEDICATIONS Date Started Date Ended DIET:

IVF

XRAY/UTZ:

LABORATORY:

OXYGEN
Started Ended
VITAL SIGNS
TIME
Temp
BP
CR
URINE
STOOL
TIME
Temp
BP Special Endorsement:
CR
URINE
STOOL
TIME
Temp
BP
CR
URINE
STOOL
MONITORING SHEET
NAME: Age: Bed No:

Date / Temp BP CR RR O2 Others Date / Temp BP CR RR O2 Others


time Sat time Sat

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