Report
Conditions 1
Conditions 2
Symptoms
Tests
Report 2
100

DNI

Do Not Intubate 

100

DM

Diabetes 

100

CHF

Congestive Heart Failure 

100

N/V

Nausea/Vomiting 

100

CXR

Chest X-ray

100

Hx

History

200
r/t

Related To

200

CVA

Cerebral Vascular Accident (Stroke)


200

AKI

Acute Kidney Injury

200

SOB

Shortness of Breath


200

ABG

Arterial Blood Gas

200

NPO

Nothing By mouth

300

d/t

Due to

300

MI

Myocardial Infarction (heart attack)
300

Fx

Fracture

300

CP

Chest Pain

300

BMP/CBC

Basic Metabolic Panel/Complete Blood Count

300

Q.I.D

4x a day

400

POD

Post-op-day

400

PE

Pulmonary Embolism

400

CABG

Coronary Artery Bypass Graft

400

DOE

Dyspnea on exertion

400

H&H

Hemoglobin and Hematocrit 

400
CIWA

Clinical Institute Withdrawal Assessment 

500

TMAX

Max Temperature (pt. had during shift/day. Depends on context)

500

AKA/BKA

Above knee amputation/Below Knee Amputation

500

PNA

Pneumonia 

500

LOC

Loss of Consciousness 

500

ECHO

Echocardiogram. 

Bonus! What are we looking at and what data point are we looking for? What's normal? 

500

Ad Lib

"At ones pleasure." now days we say "independent" to describe the walking ability of a pt. 

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