Name: MRN: Room #: Day Admit: LOS:

CC:

HPI:
Note: Timeline when exactly, usual state of healthy, first unusual sign, progression, what
happened in ER?














PMHx: Previous hospitalizations:
Diabetes: Last A1C Last Eye Exam Neuropathy Medication Microalbumin


HLD: Last LDL Last TG Statin? _______ Dose: _______


CAD: MI? x _____; When? How many?
- CABG? ______ Stents Plavix? Last E. fraction ______ Last Echo:
- Medications


HTN: Last BP or range/Medication


CHF: Functional status on NML day, how is it worse? Baseline? Dry weight?
- SOB? Orthopnea pillows? Chest pain? JVD? Leg swelling


COPD: Smoking? ______ pack a DAY or YEARS. Inhaler? Last PFT.







PSHx:



FHx:




SHx:
- Live with? _________________ Person to contact:
1. Tobacco

2. EtOH

3. Marijuana ! Cocaine ! Meth ! Heroin ! Other

4. Received treatment for any drug problem?

ROS: (Ask about actual diagnoses)
Gen: Weight Loss Weight Gain Fever Chills Sleep Prblms Fatigue Malaise

HEENT: Headache Trauma Vertigo Passing out Seizures Memory

GI: !Appetite Nausea Vomiting Hematemesis Blood per rectum melena Diarrhea
Constipation Rectal pain Hernia

CV: Chest pain Palpitations Ascites Cyanosis Phlebitis

RESP: Dyspnea Orthopnea Wheezing Cough Sputum Hemoptysis # pillows Asthma

GU: Polyuria/Oliguria Pain with urination Blood BPH Incontinence Stones STD UTI

MSK: Muscle pain Weakness Joint swelling Joint pain Shoulder pain Back pain Gout

NEURO: Smell Visual Facial weakness Numbness/Tingle Balance Speech Swallowing

SKIN: Lesions Rash Itching Change in moles Change in Distribution

ENDO: Polyphagia Polydipsia Decreased energy/Fatigue

PSYCH: SIGECAPS MOOD: Depression Anxiety

HEME: Anemia Easy Bruising

Medications
Antibiotics: Start: Stop: Day:

Beta-blocker:

Diuretic:

Diabetes:

ACEI/ARB:

Anticoagulation:

Psychiatric:
Drugs: Schedule: Drugs: Schedule:
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV IM SQ
SL DAILY BID
TID QID PRN q4h
q8h q12h q24h
PO IV SQ SL
DAILY BID TID QID
PRN
q4h q8h q12h q24h
Additional Notes: (compliance, etc)

Time/Location:
Temp
BP
sitting or supine?

HR:
RR:
SaO2
room/O2








Imaging/Other Labs:





Physical Exam: Inspect, Palpate, Ausculatate, Percuss
Emphasize describe fully
Gen: Alert x O: Person Place and Time (Date year)? Distress/Pain?
Head/Mouth: Ulcers? Dry?
Eyes: Injection? Jaundice? EOMI? PERRL?
Nose/Ears: Dry, erythema
Neck/Throat: Thyroid?
CV: CHECK PEDAL PULSES. Tilt?
Pulm: CTAB
Abdominal: Percussion?
Musculoskeletal:
Lymph:
Skin:
Neuro:
Reflexes:
Strength: 3/5 is gravity only
+ / - Romberg



















Problem List:
Problem and DDx: Action/Plan/Work-up
#




#




#




#




#:






#:


#







Baselines:













Primary Care Physician:




_____________________________________________________






To do list: