What Does it Mean
Decode the Chart
Nursing in Action
100

BP HR RR T

Blood Pressure; Heart Rate; Respiratory Rate 

100

The chart states:"VSS"

Vital signs are stable 

100

Nurse document UA was collected. What does UA stand for? 

Urinalysis 
200

QD PRN BID 

Once a day; As needed; Two times a day

200
Pt c/o LBP

Patient complain of Lower Back Pain 

200

The provider reviews the patient’s H&P before planning care. What does H&P mean?

History and Physical 

300

N/V

Nausea and Vomiting 
300
F/U with PCP 

Follow up with Primary Care Provider 

300

The chart lists ETOH use in the social history. What does ETOH mean?

Alcohol 

400

DOE & SOB

Dypnea on Exertion & Shortness of Breath 

400

The provider orders: CBC and BMP 

Provider orders complete blood count and Basic metabolic profile. 
400

A patient has an ETT in place. What does ETT stand for?

Endotracheal Tube 

500
PERRLA 
Pupil are equal round and reactive to light and accomondation 
500

Pt PMHx of DM2, HTN, and CKD. Nurse elevated HOB to help pt breathe 

Patient has a past medical history of type 2 diabete, hypertension and chronic kidney disease. Nurse elevated head of bed to help patient breathe.

500

The nurse document: HEENT: WNL during assessment. What does HEENT and WNL stand for? 

Head, ear eye nose throat; Within normal limits 

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