WardBed..................

Admitdate....D/C..

PatientProfile

PE:

DemographicandadministrativeInformation
Name:
HN:
Address:
HtcmWtkg
Age:years
:

V/S

Gen:

Lung

CC:

ABD

HPI:

Ext

Neuro

Other

HEENT
Heart

PMH:

SH:
ALL:

Problemlist:

Page2

VitalSign:

VitalSign:

Date
Temp
HR
RR
BP
Wt/Ht
I
O
S
U

Date
Temp
HR
RR
BP
Wt/Ht
I
O
S
U

Date
Temp
HR
RR
BP
Wt/Ht
I
O
S
U

Date
Temp
HR
RR
BP
Wt/Ht
I
O
S
U

ClinicalChemistry

Hematology

Date
Hb
Hct
WBC

Normal
1418
3754
3.8
10.8
Plt
130
400
Band
PMN 6070
Lym
1848
Mono 09
Eos
16
Baso 0.51
ESR

PT

PTT
1015
INR

MCV 8095
MCHC 3236
MCH 2731
RDW

Date
BS
BUN
Cr
Uric
Na
K
HCO3
Cl
Ca
PO4
Chol
TP
Alb
Glob
TB
DB
ALT
AST
ALP
LDH
CK
CKMB
Mg

Normal
70100
5.819.1

0.51.5
2.77.0
130147
3.44.7
20.628.2

96107
8.410.2
2.54.6
127262
6.58.8
3.85.4
2.63.4
0.251.5
00.5
436
1232
42121
89221
25200
<25
1.62.6

Page3

Page4

Urinalysis
Test

Sp.gr
1.0201.1025
pH
4.68.0
Alb

Sugar

WBC
05/HPE
RBC
02/HPE
cast

cystal

Sp.Equi

Blood

others

StoolExamination
TEST/DATE

Consistency

Grossy

OccountBl

Bloodgasanalysis

TEST/DATE

Spon/machine

FIO2

TidalV

RR

PEEP

PH

WBC
RBC
Parasites
Others

Bacteriologicalstudy
DATE

Specimen

Organism

Amikacin
Ampicillin
Carbenicillin
Cephalothin
Chloram
Cotrimox
Gentamicin
Kanamycin
Tetracycline
Erythromycin
Lincomycin
Methicillin
Penicillin
Tobramycin

Miscellaneous
Date

Specimen

Examination

Page5

Medicationforoneday
Date
Drug/Dosageregimen

Page6

Medicationforcontinue
Date
Drug/Dosageregimen