I
YourName:
Reason for Being There:
Your Title:
INTRODUCE
YOURSELF
Patient:
His
History
tory of Curr
Current
ent Probl
Problem:
em:
Age:
Gender:
Heigh
Height/W
t/W
t/Wei
ei
eight:
ght:
S
Allergies:
SITUA
SITUATION
TION
Code stat
status:
us:
Pri
Privac
vac
vacyy Code
Code::
Time:
Atten
Attending
ding Physician:
Patient Chief Complaint
Complaint:
Chief Informant: Family History:
Current Medications:
Past Medic
Medical
al His
History:
tory:
Social History:
B
BACKGROUND
VIT
VITAL
AL SIGNS:
B/P
HR
TEMP
RR
SP02
PAIN
A
ASSES
ASSESSMENT
SMENT
FALLS RISK
Y
N
ISOL
ISOLA
ATION
IV Site:
Isolation Precautions:
IV Fluids:
Accu check:
Y
N
Contact
HEENT
RESPIRA
RESPIRATORY
TORY
CARDIOV
CARDIOVASCULAR
ASCULAR
NEUROLOGICAL
GI/GU
I&O
MUSCULOSKELET
MUSCULOSKELETAL
AL
INTEGUMENT
INTEGUMENTARY
ARY
LYMPHA
YMPHATIC
TIC
ENDOCRINE
PSYC
PSYCHOLO
HOLO
HOLOGICAL
GICAL FAM
AMIL
IL
ILYY SUP
SUPPORT
PORT
SAFET
SAFETY
Y
LABS/TEST
Hand of
offf rep
report
ort to:
Pendi
Pending:
ng: Ordered
Abnorma
Abnormal:
l:
From:
Air
Droplet