Subjective:
Chief Complaint
Hx Present Illness
Past Medical Hx
Medications
Allergies
Family Hx
Social Hx (Alcohol, Street drugs, Tobacco)
Surgical Hx
Review of Systems

or

24hr hx
Overnight events
Patient subjective
Nurse subjective

Objective:
Vital signs (febrile/afebrile, BP, HR, RR, SaO2 on RA/NC/vent)
Physical Exam***
General: awake, alert, oriented x3, in no distress, cooperative
HEENT: PERRL, conjunctiva clear, sclera anicteric
Neck: supple without lymphadenopathy or thyromegaly
Chest: lungs clear to auscultation bilaterally, no rales, rhonchi or wheezes
Cardiovascular: regular rhythm, normal rate, normal S1/S2, no m/r/g
Abdomen: soft, nontender,nondistended, +bs
Extremities: no edema BLE, pedal and radial pulses 2+ and equal bilaterally
Musculoskeletal: no swollen or inflamed joints, no joint deformities
Skin: warm, dry, well-perfused, no lesions or rashes appreciated
Neuro: CN 2-12 intact bilaterally, strength & sensation grossly intact without focal deficits
Labs
UA
Imaging

Assessment/Plan:
One liner: (#-year-old male/female admitted for ...)

# 1st Dx/Problem/Finding/Abnormality/Sx
DDx (likely, probable, possible, less likely, unlikely); hx, supporting evidence, home regimen
- Verb (Admit to ...)
- Verb (F/U lab)
- Verb (... consulted, appreciate recs)
- Verb (Continue/start/hold/stop med)

# 2nd Dx/Problem/Finding/Abnormality/Sx
DDx (likely, probable, possible, less likely, unlikely); hx, supporting evidence, home regimen
- Verb (F/U lab)
- Verb (… consulted, appreciate recs)
- Verb (Continue/start/hold/stop med)