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DATE

(pt seen): Patient _________________


CC: Age/Gender ____________
HPI: Room # _______

PE: T: HR:

RR: BP:

Wt: SaO2:

General:
Skin:
ROS: URI sx / cough FH: Head:
Fever / chills / fatigue / wt D Mom
GI: N / V / D / C Eyes:
Rash / bruising Dad Ears/nose:
CP/palps/SOB/wheezing OP:
Abd pain/dysuria Siblings
Neck:
Muscle/joint complaints
Dizziness/HA/LOC/vision D Heart:
Lungs:
PMHx / PSurgHx: MEDS (dose/freq): Abd:
MSK:
Genital/Rectal:
Ext:

Neuro:

Social Hx: (Alcohol/smoking/rec drugs?) ALL:

RESULTS:
Imm UTD? Labs:


Diff Dx: Consults:
Imaging:




Other studies:

ORDERS: Procedures:
PIV/Meds/IVF Labs/Studies (documented?) ASSESSMENT/PLAN:
q q
q q D/C home Admit
q q q Pt edu q Bed request
q q q Scripts q Admit team-talk
q q q Follow-up q Eval complete
q q