Subjective
Patient comments or complaints, nursing comments
Objective
Vitals: BP, HR, RR, T, Wt, O2 sats.
Ins/Outs: IVF, Po intake, emesis, urine, stool, drains
Exam: Physical findings
Meds: Pertinent routine or new meds
Labs: New lab or procedure results
Assessment
Assessments based on data above
Plan
medication changes, lab tests, procedures, consults, discharge.