Patient Information Inpatient Medications: Daily Entries:

Name Name Dosage Start Stop Date Special

HD# Labs
MR Temp
Range
Room HR
Date Arrival Range

Vitals
Attending BP
DOB Age Range
Problem List Date RR
1)
O2 Sat
2)

Scheduled
3)
Morning
4)
Afternoon

CBGs
5)
Night
6)
I/Os
7)
8)
Weight
Code Status:
Lab Values
Allergies:
Date Reference
Diet:
Time Values
O2/Vent
WBC 4.5-10 103 /µl

IV/Fluids Hgb 14-18/12-16 g/dl

Hct 40-52/37-47%

Lines MCV 80-95 µm3

Hematology
Plt 150-400 10 3/µl
PRN

Consults Diff
Smear
Contact# PT 11-13 sec
INR 2.0-3.0
Radiology/Diagnostics/Other Labs:
PTT 25-35 sec
Date Study Results
Na+ 135-145 meq/l

K+ 3.5-5.1 meq/l

Cl- 92-109 meq/l

HCO3 - 24-31 meq/l

Chemistries
BUN 8-25 mg/dl
Cr 0.5-1.5 mg/dl

Glc 80-110 mg/dl

Ca++ 8.0-10.5 mg/dl

P 2.5-5 mg/dl
Mg++ 1.5-2.4 mg/dl

TPr 6-8 g/dl

Alb 4-6g/dl
Tbili 0-1 mg/dl
Alk P 30-120 U/L
Other

ASTSGOT 0-35 IU/L

ALT SGPT 0-35 U/L

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 Notes:
History & Physical
Date To Do Comments Name: Gen: Ht Wt
MR: Supine BP HR T
LABS Sitting
Age: Vitals BP HR RR
CC: Stand BP HR SaO2
7d’s HEENT:
NOTE
Neck:
LABS Heart:

PE
Lungs:
Breast/Back:

HPI
NOTE Abd:
GU:
LABS
Recta;/Guiac:
Extrem:
Neuro:
NOTE CAD RF’s: HTN / DM/ Tob / Chol / FHx / Obesity Heme: Chem: U/A:
WBC Na+
LABS
Hgb K+
Cl-

PMHx
Hct
MCV HCO3-
NOTE
HTN DM CAD MI CHF PVD CVA Tia Sz DJD CA COPD Plt BUN
Asthma TB GERD PUD Liver Dz Renal Dz Diff Cr
LABS
Smear Glc
PT Ca++

PSHx
INR P
NOTE
Appy GB Hernia Tonsil Back Hip CABG Vasc TAH aPTT Mg++

Labs/Stuies
LABS Allergies: ABG: TPr
1) 9) pH Alb

Outpatient Meds
2) 10) pCO2 Tbili
3) 11) pO2 Dbili
NOTE
4) 12) HCO3 Alk P
LABS 5) 13) Base X AST
6) 14) SaO2 ALT
7) 15) Card: Enz#1 Enz#2 Enz#3
NOTE 8) 16) CPK
Father: A/D Age: CK-MB
LABS
Mother: A/D Age: Trop
FHx

B/S: A/D Age:

ECG:
NOTE HTN DM CAD MI CVA Blood Rheum CA Asthma CXR:
M/S/D/W: Tob: A/P:
LABS
Home: EtOH:
SHx

Occ: Drugs:

Problem List/Plan
Sex:
NOTE F / C / NS / Wt Δ / Fatigue / HA / Stiff Neck
Vision / Audio / LAD / Vertigo / Sync / N-Sync
LABS SOB / Cough / Sputum / Hemoptysis / Wheeze
CP / Palp / DOE / Orthopnea / PND
ROS

Edema / Claudication / Phlebitis /

Abdominal Pain / N/V/D/C/ Reflux/ Jaundice / CGE
NOTE Hematemesis/ BRBPR /Melena / Dysuria / Hematuria
Nocturia / Ur Freq / LMP /Arthritis / Back pain/Rash

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 Daily Entries:
Date Special
Notes:
HD# Labs
Date To Do Comments Temp
Range
LABS
HR
Range

Vitals
BP
NOTE Range

LABS RR
O2 Sat

NOTE Morning
Afternoon

CBGs
LABS Night
I/Os

NOTE Weight

LABS Lab Values

Date Reference
Time Values
WBC 4.5-10 103 /µl
NOTE
Hgb 14-18/12-16 g/dl

LABS Hct 40-52/37-47%

MCV 80-95 µm3

Hematology
Plt 150-400 10 3/µl

NOTE Diff
Smear
LABS PT 11-13 sec
INR 2.0-3.0
PTT 25-35 sec
NOTE Na+ 135-145 meq/l

K+ 3.5-5.1 meq/l
LABS
Cl- 92-109 meq/l

HCO3 - 24-31 meq/l

Chemistries
BUN 8-25 mg/dl
NOTE
Cr 0.5-1.5 mg/dl

LABS Glc 80-110 mg/dl

Ca++ 8.0-10.5 mg/dl

P 2.5-5 mg/dl
Mg++ 1.5-2.4 mg/dl
NOTE
TPr 6-8 g/dl
LABS Alb 4-6g/dl
Tbili 0-1 mg/dl
Alk P 30-120 U/L

NOTE ASTSGOT 0-35 IU/L

Other

ALT SGPT 0-35 U/L

LABS

NOTE

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