Sample ACS Provider Intake Assessment and Clinical ...
Last Name:____________________ First Name: ______________________ DOB______________ Age____Allergies: Chief Complaint: Past Medical/Surgical History:Medications:Presenting Vitals:BP:____________ HR: _______ Temp: _______ RR: ________ Sp02: ________Physical ExamOther Notes:Cognitive:AAOx_____ Cooperative Agitated Lethargic Confused UnconsciousCardiovascularRRR Normal S1,S2 Irregular Rate Irregular Rhythm Chest Pain Murmur RespiratorySymmetrical Non Labored CTA Rales Rhonchi Wheeze DiminishedLaboredGI/GUUnremarkable Tender Distended Rigid Rebound Masses MusculoskeletalWNL deformity __________SkinWarm, Dry, Intact Cyanotic PaleJaundice Clammy Diaphoretic PsychiatricDenies SI/ HI Hallucinations Delusions Other Notes: Provider Signature: ___________________________ Printed Name: ____________DateTimeClinical Progress Notes ................
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