PATIENT NAME: BED NO.

: ATTENDING PHYCISIAN: SN:

AGE: DIET IV MEDICATIONS DIAGNOSTIC TEST SPECIAL N. VITAL SIGNS SAMPLE CHARTING
SEX: Running CONSIDERATION
AD. DX: G: Time
B: BP
D:F:R: TEMP
T:
RR
FINAL DX: PR
G:
B: I
D:F:R:
O
T:
BM
Procedure to be done:
G:
B: Time
D:F:R: BP
ADDRESS: T: TEMP
FAMILY HX: RR
B-DAY: ( ) Heart dse. G: PR
M.STATUS: ( ) CA B: I
EDUCATIONAL: ( ) DM D:F:R: O
OCCUPATION: ( ) HPN T: BM
( ) Obesity
REL: ( ) Asthma
G:
( ) Arthritis Time
CC: ( ) TB B:
BP
( ) Bleeding D:F:R:
TEMP
( ) Ulcer T:
Hx. O.P: ( ) Migraine RR
PMH Immunization: ( ) Alcoholism G: PR
B:
I
Allergies: ( ) Smoking D:F:R:
T: O
BM
Accident: G: Note for:
B:
Hospitalization:
D:F:R:
T:
fsmr