Documentation
It takes GUTS
Needles and Pins
Basically
Potluck
100

H & P

What is a history and physical?

100

BS

What are bowel sounds?

100

IM

What is intramuscular?

100

VSS

What are the vital signs stable?

100

R/O

What is rule out?

200

D/C

What is discharge or discontinue?

200

GI

What is gastrointestinal?

200

SQ or SC

What is subcutaneous?

200

SX

What are symptoms?

200

RLQ

What is the right lower quadrant?

300

NKDA

What is no known drug allergies?

300

GU

What is genitourinary?

300

IV

What is intravenous?
300

STAT

What is immediate?

300

S/P

What is status post?

400

C/O

What is complains of?

400

KUB

What is the kidney, ureter, and bladder (x-ray)?

400

LP

What is a lumbar puncture?

400

NV

What is nausea and vomiting?

400

TPN

What is total parenteral nutrition?
500

BX

What is a biopsy?

500

ESRD

What is end stage renal disease?

500

KVO

What is keep vein open?

500

OOB

What is out of bed?

500

WNL

What is within normal limits?

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