Vital Signs
Medications
Symptoms
Diagnostics/Tests/Labs
Diagnosis
100

T

Temperature 

100

Abx

antibiotics

100

BRB

bright red blood 

100

Bx

Biopsy

100

MI

Myocardial infarction

200

BP

blood pressure 

200

ASA 

Aspirin

200

HA

headache

200

CBC 

Complete blood count 

200

DM

diabetes mellitus

300

P

Pulse 

300

IV

intravenous

300

LBP

lower back pain

300

MRI

Magnetic Resonance Imaging 

300
CHF 

congestive heart failure 

400

R

Respirations

400

NKDA

No known drug allergies

400

N

nausea

400

PSA 

Prostate specific antigen

400

COPD 

Chronic obstructive pulmonary disease 

500

HR

heart rate

500

OTC 

Over the counter

500

C/o

Complains of 

500

ECG

Electrocardiogram

500

GERD 

gastroesophageal reflux disease 

M
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