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{This section will be copied and pasted into the Clinical Assessments Section} Neuro: patient remained with normal activity for age, not in distress, {pain well controlled },interacting with medical staff and mother Resp: RR: Cardiac: HR BP O2Sat: / FEN Total Input: ; Urine Output: ; SMA done showed Na K Cl CO2 Glu BUN Creat Ca, Nutrition On regular diet, no issues. Admission Wt: Today's Wt: gain/loss of Hema CBC done showed H/H of _____ Retic Ct. _____. No issues GI no vomiting or diarrhea. Last BM was Renal/GU good urine output, last UA was wnl Infxn Patient has been afebrile for > ___ hrs. Last CBC showed WBC of ____ with ____ shift . Vaccinations status. Psych Mother at bedside involved in patient care. No insurance issues. seen and evaluated by SW with no issues Others {Assessment / Plan Section} HD# / PICU Day# Assessment: {age,ethnicity/race,sex, # of hospitalizations,previous diagnoses/status, chronic conditions, reason for admission, acute/resolved or resolving conditions, current condition including new acute or active problems - number problems if necessary, overall condition} {Overall Condition Examples: Remains critical unstable OR Improving by still critical Serious, (respiratory failure, severe anemia,) slow improving OR worsening Or intermittent) Guarded (patient is better /stable but still condition may deteriorate) Improving Stable, (this will qualify a patient ready for discharge or transferred to floor.? Plan: Continue VS q { } hrs Continue I&O q { } hrs {Medications and changes} {Studies to be done} {Consults to be done or requested} Condition and current treatment discussed with parents Case seen and discussed with Attending Dr.