Name: Room #: Age:MRN:Date of Admission: Attending: CC: Allergies: HPI: Home Meds: PMH: PSH: IVF: ADMISSION ROS & PE: BP: / T: P: R: Gen HEENT Neck Chest.

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Presentation transcript:

Name: Room #: Age:MRN:Date of Admission: Attending: CC: Allergies: HPI: Home Meds: PMH: PSH: IVF: ADMISSION ROS & PE: BP: / T: P: R: Gen HEENT Neck Chest CVS Abd GU Ext Skin Msk Neu Other: Social Hx: Home Occupation Tobacco EtOHDrugs Family Hx: LABS ( : ) Ca P Mg N L RBC MCV Bili - TAlb - D Tot Prot ALT Pre-Alb AST CPK ALK PhosCKMB Amyl Troponin-I Lip Films: Other:

HOSPITAL MEDS: Started on: D/C’d on : ___________________________________________ / HD Time POD S General Pain Diet Ambulate Urine Flatus BM O Tm_______ BP ______ /_______ Tc_______ P_______ R _____ O2 Sat:_______ % on_______ I/O _________/___________ PE: Lungs Heart Extr Abd Labs: ( : ) Ca P Mg N RBC L MCV Bili - T - D ALTAlb ASTTot Prot ALK PhosPre-Alb Amyl Lip ABG (FiO2 - ) pO2CPK pH HCO3-CKMB pCO2 BETroponin-I A&P  Overnight:

/ HD Time POD S General Pain Diet Ambulate Urine Flatus BM O Tm_______ BP ______ /_______ Tc_______ P_______ R _____ O2 Sat:_______ % on_______ I/O _________/___________ PE: Lungs Heart Extr Abd Labs: ( : ) Ca P Mg N RBC L MCV Bili - T - D ALTAlb ASTTot Prot ALK PhosPre-Alb Amyl Lip ABG (FiO2 - ) pO2CPK pH HCO3-CKMB pCO2 BETroponin-I A&P  Overnight: / HD Time POD S General Pain Diet Ambulate Urine Flatus BM O Tm_______ BP ______ /_______ Tc_______ P_______ R _____ O2 Sat:_______ % on_______ I/O _________/___________ PE: Lungs Heart Extr Abd Labs: ( : ) Ca P Mg N RBC L MCV Bili - T - D ALTAlb ASTTot Prot ALK PhosPre-Alb Amyl Lip ABG (FiO2 - ) pO2CPK pH HCO3-CKMB pCO2 BETroponin-I A&P  Overnight:

/ HD Time POD S General Pain Diet Ambulate Urine Flatus BM O Tm_______ BP ______ /_______ Tc_______ P_______ R _____ O2 Sat:_______ % on_______ I/O _________/___________ PE: Lungs Heart Extr Abd Labs: ( : ) Ca P Mg N RBC L MCV Bili - T - D ALTAlb ASTTot Prot ALK PhosPre-Alb Amyl Lip ABG (FiO2 - ) pO2CPK pH HCO3-CKMB pCO2 BETroponin-I A&P  Overnight: / HD Time POD S General Pain Diet Ambulate Urine Flatus BM O Tm_______ BP ______ /_______ Tc_______ P_______ R _____ O2 Sat:_______ % on_______ I/O _________/___________ PE: Lungs Heart Extr Abd Labs: ( : ) Ca P Mg N RBC L MCV Bili - T - D ALTAlb ASTTot Prot ALK PhosPre-Alb Amyl Lip ABG (FiO2 - ) pO2CPK pH HCO3-CKMB pCO2 BETroponin-I A&P  Overnight: