Abbreviations
nothing by mouth
NPO
hours of sleep
HS
oxygen
02
the back surface of the body
posterior and/or dorsal
data, action, response, (plan)
DARP
short of breath
SOB
blood pressure
BP
four times a day
QID
closest to the middle of the body
medial
Where charting is applied when something out of the ordinary occurs
progress notes (nurses notes)
as needed
PRN
activity as tolerated
AAT
diet as tolerated
DAT
farthest away from the midline of the body
lateral
data that is provided by the resident
subjective data
bowel movement
BM
after meal
pc
before meal
ac
nearest to the trunk of the body or point of origin
proximal
data that is measurable
objective data
medical orders for scope of treatment
MOST
with
c with a line overtop
one - often used for marking bowel movements
T with a dot on top
the part farthest from the center or from the point of attachment
distal
what is everything a progress note needs (think of the form)
date, time, focus, DAR(P), nurse informed, initials, designation