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Hx: Room #: __________ Age______ Sex _____ Activity: __________________ IV: _______________________

Name:________________________________ Meds Diet: _______________________________


Dx: ___________________________________ 08
Dr: ____________________________________ 09 B/P P RR O2 T
Adm. Date: ___________________________ 10 VS: ___________________________________________________
# Days Post-Op: _____________________ 11
Code Status: _________________________ 12
General Information/Follow-up: 13

Labs:
HGB
Na Cl BUN PT
Dx Tests: WBC Platelets
PTT
HCT K Ca Creat
INR

Hx: Room #: __________ Age______ Sex _____ Activity: __________________ IV: _______________________

Name:________________________________ Meds Diet: _______________________________


Dx: ___________________________________ 08
Dr: ____________________________________ 09 B/P P RR O2 T
Adm. Date: ___________________________ 10 VS: ___________________________________________________
# Days Post-Op: _____________________ 11
Code Status: _________________________ 12
General Information/Follow-up: 13

Labs:
HGB
Na Cl BUN PT
Dx Tests: WBC Platelets
PTT
HCT K Ca Creat
INR

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