VITAL SIGNS & ASSESSMENT
CONDITIONS & SYMPTOMS
PROCEDURES & TREATMENTS
ORDERS & MEDICATION INSTRUCTIONS
CHARTING & MEDICAL RECORDS
100

BP

Blood pressure

100

LBP

Low back pain

100

CPR

Cardiopulmonary resuscitation

100

p.o.

By mouth (per os)

100

H&P

History and physical examination

200

P

Pulse

200

SOB

Shortness of breath

200

I&D

Incision and drainage

200

b.i.d.

Twice daily (bis in die)

200

ROS

Review of systems

300

T

Temperature

300

COPD

Chronic obstructive pulmonary disease

300

IM

Intramuscular

300

p.r.n.

As needed (pro re nata)

300

H/O

History of

400

VSS

Vital signs are stable

400

URI

Upper respiratory infection

400

C&S

Culture and sensitivity

400

NPO

Nothing by mouth (nil per os)

400

R/O

Rule out

500

H&H

Hemoglobin and hematocrit

500

HA

Headache

500

AKA

Above-the-knee amputation

500

q.d.

Every day (quaque die)

500

DNR

Do not resuscitate

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