Name:

Height:

DOB/Age:
Weight:

CC:
HPI:
PMH:
SH:
FH:
Allergies:
Medications from home:
Vitals:
Upon Admission
Date
Temp
Pulse
Resp
BP
Puls Ox
Physical Exam (Review of Systems):
Upon Presentation:
GEN:
HEENT:
RESP:
CV:
ABD/GI:
GU:
EXT:
NEURO:

Chems:
Chem 7: Upon admission:

Room #:
BMI:

Blood: Upon Admission

MCV:

MCH:

Neut:

Lymph:

Mono:

ANC:

Chems:
Glucose-fast:
IBW:

ABW:

CrCl:

Hematology:
Date
WBC
RBC
Hgb
Hct
MCV
MCH
Plt
Neut
Segs
Bands
Lymph
Mono
Eosino
Baso

11/12

11/13

11/14

11/15

11/16

ANC
Testing:
o Urine: 11/12, 11/14
o Protein:
o Glucose:
o Ketone:
o Blood:
o Leukocyte esterase:
o Microbio:

Assessment and Plan:

Clinical
significance

Pharmacotherapeutic
Goals

Recommended
Therapy

Monitoring
Parameters

Desired
Endpoint(s)

Monitoring
Frequency