Patient
@NAME@
Date & Time of Admission
@ADMITDTTM@
Current Length of Stay: @LOS@
SYNOPSIS
@CHIEFCOMPLAINT@
Admitted for
@HOSPROB@ .
@NAME@ is a @AGE@ @SEX@ ***
@NOTESUMMARIES(1&0&0)@
ASSESSMENT
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@
LAST VS:
@VS@
LABS
@RESUFAST(NA,K,CL,Co2,MG)@
@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@
@LABBRIEF(CA,MG,PHOS)@
@LABBRIEF(ALB,LACTICACID,LACTWBVENPC,TROPONINHS,HGBA1C)@
@LABRCNT24(POCGLUCOSE:*)@
@LABRCNT(GLUCOSE:*)@
NOTES ENDORSED TO RECEIVING NURSE:
•
NEURO:
Aoxo4
Sedated?
RESPIRATORY:
No SOB
@VENTDRAG@
CARDIAC:
NSR
GI:
swallows pills ok?
@DIETORDER@
@DIETTUBEFEEDING@
@IOBRIEF@
GU:
uses urinal
SKIN:
normal
Skin check done with … RN.
-skin intact and blanchable
-breaks in skin found:
FAMILY/SOCIAL:
at bedside
LDA
Infusing fluids:
@MEDSINFUSIONS@
LABS & IMAGING
Telemetry monitor placed
-heart rhythm is:
@LASTEKG@
Recent Images
@ORDEREDRAD@
@IMAGES@
PLAN
ACTIVE ORDERS
@ACTIVEORD@