;$ffi#llo tfiifl{,ffil| ilE i/#

lM rNlT|ALs AGE GENDER WT VS@_:T P R BP 02 pain :peRST

qDM NDx VS@_:T P R Bp 02 pain :peRST
:ODE STATUS ALLERGIES NEURO/LOC (PERRLA, gait, speech)
)IET % EATEN
)RECAUTIONS FLUTD REsrRtcIoNs
VS FREQ
\CTIVITIES 02: Type: @ _ LpM
O2 SAT: CALL MD lF < _% RESPIRATORY (lung sounds, cough, RR/rhythm, chest movement)

tV: Type_ @_
Type_ @_

CARDIAC (Apical/Peripheral pulses, rhythm, CMS, cap refill, skin)

RN REPORT @ [uss from _ @

/s@-:T_P_R_ Na_ (13s-14s)
BP_ o2- Pain_ cL_ (96-106) GI (Abdomen, Bowel sounds, LBM, NG/GTlTube feedings, Residual)
&o_ (3.s-s.0)
-BM co2_ (23-29)
Cr_ (0.6-1.3) GU (incontinence, l&O: amount, color, consistency, odor, catheter type)
{ISTORY BUN_ (7-20)
Glu_ (70-100)
NOTES: (PROCEDU RE/MEDS/TRENDSI wBc_ (4-11) M U SCU LOSKE LEfAL (CMS, ROM, swelling, tenderness, deform ities, ADLs)
RBC _ M(4.3-s.7) F(3.8-s.1)
HgB _ M(13.2-17.3) F(11.7-1s.s)

Hct _ M(3e-so%) F(3s-47%l

S(IIV (Describe lV site, pressure ulcers)

RM
T
-4
INITIALS AGE GENDER WT t/S@_:T P R Bp 02 pain :peRST
ADM NDx t/S@_:T P R Bp 02 pain :peRST
:ODE STATUS ALLERGIES NEURO/LOC (PERRLA, gait, speech)
DIET % EATEN
PRECAUTIONS FTUID RESTRICTIoNS

VS FREQ
ACTIVITIES 02: Type: @ _ LpM
02 SAT: CALL MD lF < _% RESPIRATORY (lung sounds, cough, RR/rhythm, chest movement)

lV: Type_ @_
Type_ @_

CARDIAC (Apical/Peripheral pulses, rhythm, CMS, cap refill, skin)

RN REPORT @ -ABS from @ _

/s@-:T_P_R_ Na_ (135-145)
BP_ o.2- Pain_ cL_ (96-106) GI (Abdomen, Bowel sounds, LBM, NG/GTITube feedings, Residual)
&o_ (3.s-s.0)
-BM co2_ (23-291
Cr_ (0.5-1.3) GU (incontinence, l&O: amount, color, consistency, odor, catheter type)
JISTORY BUN_ (7-2Ol
Glu_ (70-100)
NOTES: (PROCEDU RE/MEDS/TRENDSI wBc_ (4-11) MUSCU LOSKELETAL (CMS, ROM, swelling, tenderness, deform ities, ADLs)
RBC _ M(4.3-s.7) F(3.8-s.1)
HgB _ M(13.2-17.3) F(11.7-1s.s)

Hct _ M(39-so%) F(3s-47%l

l(lN (Describe lV site, pressure ulcers)