Pt: Code: Pt: Code:

Dx: Allergies: Dx: Allergies:

MD: Up: MD: Up:
Consults: BG: Consults: BG:
Plan: Strict I/O: Plan: Strict I/O:
Diet: Foley: Diet: Foley:
Lines: Tele: Lines: Tele:
IV Fluids: O2: IV Fluids: O2:

Labs Labs
K+: _______ Mg: _______Na+: _______WBC: _______ PLT: ________ K+: _______ Mg: _______Na+: _______WBC: _______ PLT: ________
Hgb: _______ Cr: ________INR: ________ PTT: ________ Hgb: _______ Cr: ________INR: ________ PTT: ________

07 08 VS 09 10 07 08 VS 09 10
Pager # Pager #

11 12 VS 13 14 I/O 11 12 VS 13 14 I/O
Charge Charge

15 16 VS 17 18 15 16 VS 17 18
Tele Tele

Assess ___/___ Assess ___/___

POC ____ POC ____
Cardex ____ Cardex ____
Educate ____ Educate ____