Adult Admission

Date Time Mode From

Chief Complaint CC Onset
Self TX Emer Contact
General
Hx Provider Resuscitation Status
Organ Donor POA
AdvanceDir/Onfile
Vital Signs
Wt/Ht/Allg
Inventory
Pharmacy

Neuro Disease CV Disease

GI Disease MS Disease
Learning/Health ENT Disease Psych Disease
History/Surgery Repro Disease Resp Disease
Hemo/STD Disease Cancer
Family Endo Disease

Support System Anxiety

Abuse Depression
Screenings Safe At Home Suicidal? Previous Suicide?
Substance Abuse Pt Appearance
SocSerConsult

OralCare Bathing Dressing Grooming

Feeding Toileting Ambul Devices
Diet Change Wt loss Wt gain Warfarin
Activity/Dietary/Fall
Method of transfer Sensory/Perception Deficit
Risk/LOC
Weakness Seizure Orientation <3/>85
A/O LOC Arousal to

Assessment HEENT Pupil Reaction Equal

Sclera Discharge Difficulty Glasses, etc
Ear Hear Aids Language Comprehension
Follow Directions Read Write Speech Speech Tools
Heart S1S2 Rhythm Jugular CapRefil
Edema Resp Effort Depth Retractions
Pattern Shape Expansion Sounds O2
Cough Sputum GI Shape Soft
Sounds N/V Tender BM Diarrhea
Constipation GU Void Brief S/S
Repro BreastExam ManExam Skin Color
Temp Breakdown Moist/Dry
Pain Rating Description
What improves/worsens