[Enter subjective information]
Medications
|ACTIVE MEDICATIONS|
Physical Exam
Last Vitals
- Temp: |TEMPERATURE|
- Pulse: |PULSE|
- Resp: |RESPIRATION|
- BP: |BLOOD PRESSURE|
- Weight: |PATIENT WEIGHT|
- Height: |PATIENT HEIGHT|
- BMI: |BMI|
- Pain: |PAIN|
Exam Findings
- General: Alert and oriented x3, no distress, well appearing, well nourished
- Lungs: no respiratory distress or increased WOB
- CV: warm, well perfused
- Abdominal: soft, nontender
- |CBC|
- |CHEM 7|
- |COAG|
- |PSA|
Assessment and Plan
Add New
|AGE| |RACE| |SEX|
[Enter assessment and plan]