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NAME

DOB
Rm#
Admit Date

Diagnosis

Wt:
ISO:

CODE:

PMD:

1900

Consults:

_____________________
2000

ALLERGIES

Medical Hx

_____________________
2100

Procedure/Surgery

_____________________
2200

POD#
Diet
IV

NEURO

BP
P
RR
T
SpO2
RESP O2:
Vent Settings:

_____________________
2300

LABS

_____________________
0000
Tx:

CARDIAC Tele/Rhythm
Pacemaker

_____________________
0100
_____________________
0200

SKIN

GI/GU

MUSC

Activity

_____________________
0300
_____________________
0400
_____________________
0500

Orders/Plan:

NOTES

_____________________
0600
_____________________
0700

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