Name Age RM Name Age RM

Dx: Dx:
C/O: C/O:
Cultural Cons. Cultural Cons.
Admit Dt. Code Status Admit Dt. Code Status
PHY. ATT. PHY. ATT.
Consults Consults
Hx Hx
Isolation PT/OT RT Diet Isolation PT/OT RT Diet
Allergies Allergies
V/S: V/S:
IV: IV fluid/rate IV: IV fluid/rate
AOx PERRLA Edema AOx PERRLA Edema
Last BM: Skin: Last BM: Skin:
NPO/PEG/PO/TPN Foley: I/O: B/S NPO/PEG/PO/TPN Foley: I/O: B/S
Diag./Img. Labs Diag./Img. Labs

New orders: New orders:

DC Plan: DC Plan:

Name Age RM Name Age RM

Dx: Dx:
C/O: C/O:
Cultural Cons. Cultural Cons.
Admit Dt. Code Status Admit Dt. Code Status
PHY. ATT. PHY. ATT.
Consults Consults
Hx Hx
Isolation PT/OT RT Diet Isolation PT/OT RT Diet
Allergies Allergies
V/S: V/S:
IV: IV fluid/rate IV: IV fluid/rate
AOx PERRLA Edema AOx PERRLA Edema
Last BM: Skin: Last BM: Skin:
NPO/PEG/PO/TPN Foley: I/O: B/S NPO/PEG/PO/TPN Foley: I/O: B/S
Diag./Img. Labs Diag./Img. Labs

New orders: New orders:

DC Plan: DC Plan:

Name Age RM Name Age RM

Dx: Dx:
C/O: C/O:
Cultural Cons. Cultural Cons.
Admit Dt. Code Status Admit Dt. Code Status
PHY. ATT. PHY. ATT.
Consults Consults
Hx Hx
Isolation PT/OT RT Diet Isolation PT/OT RT Diet
Allergies Allergies
V/S: V/S:
IV: IV fluid/rate IV: IV fluid/rate
AOx PERRLA Edema AOx PERRLA Edema
Last BM: Skin: Last BM: Skin:
NPO/PEG/PO/TPN Foley: I/O: B/S NPO/PEG/PO/TPN Foley: I/O: B/S
Diag./Img. Labs Diag./Img. Labs

New orders: New orders:

DC Plan: DC Plan: