Subjective: Any problems and symptoms of the patient should be charted. Appetite, pain, headaches or insomnia may be included. Objective:

General appearance.

Vitals, including highest temperature over past 24 hours. Fluid I/O (inputs and outputs), including oral, parenteral, urine, and stool volumes.

Physical exam, including chest and abdomen, with particular attention to active problems. Emphasize changes from previous physical exams. Labs: Include new test results and circle abnormal values. Current medications: List all medications and dosages. Assessment and Plan: This section should be organized by problem. Writing a separate assessment and plan should be written for each problem.

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