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RN Note for Joe Smith

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RN Note for Joe Smith Powered By Docstoc
					Emergency Department
Healdsburg District Hospital
1375 University Ave.
Healdsburg, CA 95448
707 431 6300

TRIAGE NURSING NOTES

PATIENT ID
Patient: Joe Smith, 32 years old
DOS: 6/24/2009. Admit time: 10:53. RN Eval time: See RN note, text note from rn.

ASSIGNMENTS
Bed assigned: H1, Triage RN: Dolores Dio, RN assigned: Beverly Bee,
ERMD: Steven C. Gabaeff, M.D.,

PREHOSPITAL COURSE


TRIAGE DATA
Triage data: contact number: 310-222-5555, arrived by emt, entered ED by gurney,
information by family.

VITAL SIGNS

STATIC: NOT NOTED
SPECIAL VS: N/A

EVAL:
CC/HPI:CC: Stomach Cramps. HPI: 32 years old WM with Stomach Cramps.

ROS: .Patient denies any other complaints.

PMFSH: Past Medical History: See RN note. ►Medications: See RN note. ►Allergies:
see RN note. ►Past Procedures: none noted. ►Family History: none noted. ►Social
History: PMD: SMITH. ►PMSFH otherwise n/c.

PE: Other than doumented no apparent abnl noted.

ORDERS ENTERED
Labs: N/A
Procedures: N/A
Imaging: N/A
ED Meds: N/A
Additional Orders: N/A
PROGRESS NOTES
NO PROGRESS NOTES


________________________
Beverly Bee, RN

				
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posted:10/20/2011
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