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PERTINENT LABS

Labs ( abn &

pertinent)

Normal value Patient’s value Explain signi!an!e

"IA#N$STI% ST"IES

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Labs ( abnormal &

pertinent)

Normal value Patient’s

value

Explain signi!an!e

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PAT'$P'SI$L$# (Include Signs and Symptoms)

E"I%AL %$N"ITI$NCurrent Medical Diagnosis:

Past Medical/Psychosocial Hx:

Pt/Client Initials: ______ oom: ______ !ge: ______Sex: _____ !llergies: ____________ 

ASSESSENTSu"#ecti$e:

%"#ecti$e:

NRSIN# "IA#N$SIS

PLANNIN#S&'

&'

E*ALATI$N('oal/%utcome !chie$ed)

S&'

&'

INTER*ENTI$NS RATI$NALE

+, +,

-, -,

., .,