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Sticker. Tmax:. Date/Time Seen. HD. AB. POD. Antibiotic(s). S:. IV Type and Rate. I/Os:. Total In. Total Out. Urine. (Foley). NG tube. Drain. VS:. Tc:. HR:. RR:. BP:. Imaging. Date and Time. Date and Time. PT. LDH. Bili. Wound. AST. PTT. Amylase. ALT. INR. Lipase.

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  1. Sticker Tmax: Date/Time Seen HD AB POD Antibiotic(s) S: IV Type and Rate I/Os: Total In Total Out Urine (Foley) NG tube Drain VS: Tc: HR: RR: BP: Imaging Date and Time Date and Time PT LDH Bili Wound AST PTT Amylase ALT INR Lipase GGT

  2. PE: Afternoon General: S: HEENT: NC/AT; no LAD; PERRLA, EOMi Pulmonary: CTAB, -W/R/C VS: CV: Tc: HR: RR: BP: RRR, Nl S1S2, no M/R/G; +2 Pulses GI: Soft, NT/ND, NABS+4; No HSM New Labs GU: Extrem: WWP, -c/e/c; Reflexes ____; LTSI, NVI Neuro: A&Ox3; MMSE; CNi Other: PE: Pulmonary: A/P CV: 1. GI: 2. Changes from Previous Plan 3. 4. 5. 6.

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