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RM# _______ PT: ____________________ age: ____ M / F Dr.

__________________
DX: ________________________________________diet: ________________ d/weight
Allergies: ______________________________________________________________
O2 : _____ nebs

activity: ad lib / bed rest / in chair / PT / walker / assist x

IV fluids: __________________________ access: ______________ PCA (dem / morph)

DNR

pain meds (last dose?): _____________________________________________

voids: BRP / foley / BSC / urinal / diaper


UA / C&S (need / done)

SNF / rehab consult (need / done)

stool x ___ for guiac / c-diff / WBC

precautions: contact / fall / seizure / aspiration (HOB ___ ) / neuro


FSBS: ac&hs / q ___ hrs / SS: regular insulin / Novolog
2100: ____________ 0730: ____________ 1130: ____________ 1630: _____________
labs: CBC / __MP / CE / BNP / Mag / Phos / K / Lytes / H&H / PT/INR / PTT / ________
CXR / EKG / Echo / MRI / US / CT _____________________ permit? Y / N list? Y / N
VS 0600 T ______ P ______ R ______ BP ____________ O2 ______
_____ T ______ P ______ R ______ BP ____________ O2 ______
Notes:_________________________________________________________________
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______________________________________________________________________
______________________________________________________________________
Hx : __________________________________________________________________
Labs:
Na: _________
K: __________
BUN: ________
Creat: _______
WBC: _______
H/H: ________
Plat: ________