Endorsing Room No:

Patient’s Name/Age/Sex:
Consultant:
Referred Consultant:

CC:

HPI:

Baseline:
ROS:

Past Medical History + Current Medications: Family History: Allergy:

Social History:

AT THE ER
VS

PHYSICAL EXAMINATION
Conscious, coherent, not in distress
Clear breath sounds
Normal rate regular rhythm
Abdomen soft, non-tender
No edema
MSE
Neuro PE
LABS MEDICATIONS / WORK-UP IN THE ER
CBG -
CXR -
CBC
Na –
K-
Crea –
SGPT –
UA

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ADMITTING ORDERS

LATEST UPDATE OF THE PATIENT (PRE-ENDORSEMENT):

This morning:

LVS -

S>

O>

IVF –

I&O–

Latest CBG

NEW ORDERS:

PENDING LABS

kimpo