Title Page

  • Patient Name

  • Assigned Medical Practitioner

  • Conducted on

  • Location

Subjective Data

  • Chief complaint

  • History of Present Illness

  • Past Medical History

  • Family History

  • Social History

  • Review of Systems

  • Is the patient taking any medication?

  • Please specify

  • Patient has no allergies

Objective Data

  • Age

  • Gender

  • Height (in)

  • Weight (lbs)

  • BMI

  • Temperature
  • Blood Pressure (BP)

  • General Appearance

  • EENT (Eyes, Ears, Nose, Throat)

  • Cardiovascular

  • Respiratory

  • Integument/ Lymphatic Inspection

  • Laboratory Results

Assessment

  • General Observations

  • Differential Diagnosis

Plan

  • Nurse's notes

Completion

  • Attending Nurse's Name & Signature

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