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Rm:

Pt:

Rm:

Pt:

Age: Code: Dx: Allergies: MD: Health Hx:

Age: Code: Dx: Allergies: MD: Health Hx:

Vitals: Neuro: Resp: Cardio: Skin: GI/GU: CMS: Pain: IV: Drain/Drsg: Activity: O2: I&O: Diet: Discharge: BS Checks: PRNs: H/H: WBC: Plts: INR: PTT: BNP: Other: Na: K: Cl: CO2: Ca: Mg: Creat: BUN: BS: Other:

Vitals: Neuro: Resp: Cardio: Skin: GI/GU: CMS: Pain: IV: Drain/Drsg: Activity: O2: I&O: Diet: Discharge: BS Checks: PRNs: H/H: WBC: Plts: INR: PTT: BNP: Other: Na: K: Cl: CO2: Ca: Mg: Creat: BUN: BS: Other:

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Rm: Pt: DOB: Code: Allergies:

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