Category 1
Category 2
Category 3
Category 4
Category 5
100
PRN
What is : as needed
100
RBC
Red Blood Cells
100
I & O
What is : Input and Output
100
q
What is : every
100
s/s
What is : signs and symptoms
200
Transport pt to OT tid via W/C.
What is: transport patient to occupational therapy three time a day via wheel chair
200
elevate head of bed to 20 degrees and nothing by mouth after 12 midnight.
What is Elevate HOB to 20 degrees and NPO after 2400
200
MOM po qod
What is : milk of Magnesia orally every other day
200
H&H
What is : hemoglobin and hematocrit
200
A & O x 3
What is : Alert and Oriented to person, place, & time
300
The ENT M.D. noted yellow disch from pt’s AS.
What is : The ear, nose, and throat medical doctor noted yellow discharge from the patient’s left ear.
300
Admin Ambian 10mg PO at Hs.
What is : Administer Ambian 10 milligrams by mouth at hour of sleep.
300
rule out human immunodeficiency virus and influenza
What is R/O HIV & flu.
300
send pt for CXR stat
What is : Send Patient for chest x-ray immediately
300
The pt reports pain to the RUQ
What is : The patient reports pain in the right upper quadrent.
400
pt reports sx of sharp pain to ABD in LLQ
What is : patient reports symptoms of sharp pain to abdomen in left lower quadrent
400
pt. OOB q2h
What is : Patient out of bed every 2 hours.
400
Admin 2 gtts OU QID x 7 days
What is : Administer 2 dropps, both eyes four times a day for 7 days.
400
CBC and ABG stat
What is : complete blood count and arterial blood gas immediately
400
Pt CC is pain to AU
What is: Patients chief complaint is pain to both ears
500
Pt c/o chest pain. Had EKG & cardiac enzymes done in ER to R/O MI
What is : Patient complaining of chest pain. Had electrocardiogram and cardiac enzymes done in emergency room to rule out myocardial infarction.
500
Pt has a hx of CHF, & IDDM. admitted through ER c elevated B/P, elevated BS, and N&V x 3 days.
What is: Patient has a history of congestive heart failure, and insulin dependent diabetes mellitus. Admitted through emergency room with elevated blood pressure, elevated blood sugar, and nausea and vomiting for 3 days.
500
Pt is post op AKA to R leg & has a BSC. P/T to perform ROM exercises.
What is : Patient is post operative above knee amputation to right leg and has a bedside cammode. Physical Therapy to perform range of motion exercises.
500
Lungs CTA except to LUL slight wheezing noted upon expiration.
What is : Lungs clear to auscultation except to left upper lobe slight wheezing noted upon expiration
500
Pt has BRP but must be NWB to L leg.
What is : Patient has bathroom privileges but must be non weight bearing to left leg.
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