Situation
Notes: _______________________________
Patient Name______________________ Date / Time of Admission __________ ____________________________________________
Age _______ Physician _____________ Room _______ Allergies ____________
Admitting Diagnosis _______________ Secondary Diagnosis _______________ ____________________________________________
(Briefly describe the current situation)
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Background
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Date / Time last seen by Physician________________________________________
Allergy ___________________________ Vital Signs B/P___________________
Code Status /DNR _________________ T _____ P _____ R _____ O2 Sat. ______
Medications (pertinent issues)
__________________________________ Pain Status _______ Location ________
Recent Interventions / Effectiveness
__________________________________ IV type _________ Amount _________
Patient / Family Concerns ___________ Site ____________ Issues ____________
Abnormal Labs ____________________
Wounds / Dressings (Type-Location-Color-Edema-Temp-Change in size)
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Neurological / Mental Status (LOC/Speech Patern/Depression) _____________________
Lungs / Respiratory(Lung Sounds/Cough/SOB/Rep Rate) ___________________________
Cardiovascular (HR/Regular/SOB/Edema) ______________________________________
GI (Distention/ V/N /Last Bowl Movement/ Constipation)_______________________________
GU (Catheter/Urine Color/Frequency/Last UTI) ______________________________________
Musculoskeletal (Pain/Mobility Issues/Fall Risk Status)_____________________________
Assistive Devices (Wheel Chair/Cane/Walker)___________________________________
Skin (Temp/Condition/Edema/Hematoma)_________________________________________
Discharge Plan / Issues (Case Management/ Patient-Family Education) _________________
Other _________________________________________________________________
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(Briefly state the patient history)
Assessment
Patient is progressing within normal limits; no complications apparent
I am concerned about:_________________________________________________
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Recommendation / Request
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I suggest or request that you _____________________________________________
Watch for ______________________________________________________________
Any orders/ Tests/ or changes for current treatment plan?
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