N AME :

CC HPI PQRSTAAA + ED COURSE

M/F

A GE :
ROS

DOB

MR#
PE
T 02Sats BP

PMD
HR RR

RM#

C ONTACT : P ROBLEM L IST

P LAN

Pertinent Pos PMH X

Pertinent Neg

General: fever fatigue N/V wtchange Skin: rashes sores lumps itch Head: HA injury Ears: pain tinnitus drainage hearing Eyes: vision blurry pain glaucoma Nose: bleeds stuffy d/c itch sinus Throat: teeth gums bleed sores dry pain Neck: pain stiff lumps swollen Breasts: lumps pain d/c (BF) Resp: cough SOB wheeze pain blood CV:pain tight palp orthopnea edema PND GI: swallow hrtburn appet BM bleed Constipation diarrhea jaundice Urin: freq urg pain blood incont stream Male: pain hernia d/c sores dysfn STDs Fmale: pain dry flashes d/c itch STDs Vasc: claudication cramping MSK: muscle/jt pain stiff backpain Red jts swelling trauma Neur: dizzy faint sz weak numb trem Hem: bruising bleeding Endo: hot cold sweat polydypsia Psych: depression anxiety hallucinations

General: CV: Resp: Abd: L ABS / I MAGING / T ESTS

M EDS

D OSE

RT

T IME

S OCIAL H X ETOH

T OB

D RUGS

F AMILY H X M OM PSH X A LLERGIES S IBS

D AD

K IDS

This is a [age] year old M/F w/ a hx of [major hx] who presented on [date] with [major symptoms], and was found to have [working dx]. [Tests done] showed [results]. Yesterday pt [important changes, new plan, new tests, new meds]. This morning the pt feels [state pts words], & PE is significant for [state major findings]. Plan is [state plan].

N AME :
HD# S UBJECTIVE Improved Stable Worse

M/F

A GE :
HD# S UBJECTIVE Improved Stable

DOB
Worse

MR#
HD# S UBJECTIVE Improved

PMD
Stable Worse

RM#
HD# S UBJECTIVE Improved

C ONTACT :
Stable Worse

I NTERVAL E VENTS C ONSULTS T ESTS O BJECTIVE I/O: T BP 02Sats General: Lungs: Heart: Abdomen: Ext: HR RR

I NTERVAL E VENTS C ONSULTS T ESTS O BJECTIVE I/O: T BP 02Sats General: Lungs: Heart: Abdomen: Ext: HR RR

I NTERVAL E VENTS C ONSULTS T ESTS O BJECTIVE I/O: T BP 02Sats General: Lungs: Heart: Abdomen: Ext: HR RR

I NTERVAL E VENTS C ONSULTS T ESTS O BJECTIVE I/O: T BP 02Sats General: Lungs: Heart: Abdomen: Ext: HR RR

I MAGING : A SSESSMENT /P LAN : Dispo

I MAGING : A SSESSMENT /P LAN : Dispo

I MAGING : A SSESSMENT /P LAN : Dispo

I MAGING : A SSESSMENT /P LAN : Dispo

This is a [age] year old M/F w/ a hx of [major hx] who presented on [date] with [major symptoms], and was found to have [working dx]. [Tests done] showed [results]. Yesterday pt [important changes, new plan, new tests, new meds]. This morning the pt feels [state pts words], & PE is significant for [state major findings]. Plan is [state plan].

N AME :

M/F

A GE :

DOB

MR#

PMD

RM#

C ONTACT :

This is a [age] year old M/F w/ a hx of [major hx] who presented on [date] with [major symptoms], and was found to have [working dx]. [Tests done] showed [results]. Yesterday pt [important changes, new plan, new tests, new meds]. This morning the pt feels [state pts words], & PE is significant for [state major findings]. Plan is [state plan].