Pt #_____ FSBG 1600 2000

Age
Admit date Insulin Insulin
Dx
Doc.
History In
Code
Activity
Diet Out
Allergies
Weight
Cardio Resp GI/GU Skin Neuro
Reg/Irreg
EKG O2___________________L/Min N/V Temp/color LOC
Pedal R_______ L______ %eaten Integrity Orient
Breath sounds________________
Radial R______ L______ Abm Turgur Speech
JVD______ Resp effort__________________ BS Wounds Follw. comnd
Cap refill_______________ Foley Pupil
COUGH_____________________
Edema____________ Urine desc. Musc Skel Swallow
BM Strength
ROM
sensation

IV Site_______________________ Labs 1600 2000

T
Solution_____________________Rate
P
Patentcy________________________ R
P
O
Pain
1600 1700 1800 1900 2000 2100 2200

PT. HX Assess Labs

Pt #_____ FSBG 1600 2000 Report
Age
Admit date Insulin Insulin
Dx
History
Code In
Activity Out
Diet
Allergies
 Cardio Resp GI/GU Skin Neuro
Reg/Irreg
EKG O2___________________L/Min N/V Temp/color LOC
Pedal R_______ L______ %eaten Integrity Orient
Breath sounds________________
Radial R______ L______ Abm Turgur Speech
JVD______ Resp effort__________________ BS Folw. comnd
Cap refill_______________ Foley Wounds Pupil
COUGH_____________________
Edema____________ BM Swallow

IV Site_______________________ Labs 1600 2000

T
Solution_____________________Rate
P
Patent________________________ R
P
O
Pain
1600 1700 1800 1900 2000 2100 2200