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Pt initials _________

Past Medical Hx:

Room # ________ Age ________


Chief complaint:

Gender _______

Ethnicity ______________

Psych Hold______________
Current Medical Dx:

ALLERGIES:

Textbook S/S

Pt Assessments:

Abnormal labs & Significance

Medications & Rationale

Pathophysiology: Diagnostics & Results / significance IV Fluids: Ordered Tx: Diet: Activity:

PROBLEM #1: Interventions:

PROBLEM #2: Interventions:

PC: Signs: PC: Signs:

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