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CC Subjective

O/N Events
HPI
Pt Concerns

ROS

Current Condition

Objective
Vitals Temp HR BP RR SaO2
Time
24 hr range

Physical Exam
Const
HEENT
Neck
CV
Pulm
Abdominal
GU
MSK
Neuro
Medical Hx Psych

Labs and Studies


ABG Other Labs
pH
PaCO2
PaO2
HCO3
Base
Surgical Hx Imaging

I/O
Date:
0700-1500 1500-2300 2300-0700 Other
IN PO Stool
IV
Family Hx Total
OUT Urine
Cath Emesis
Total
NET
Medications
Assessment
One liner HPI; trajectory
Major problems:

Plan
Diagnostics Intervention



Allergies

FEN
Social Hx
PPx

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