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Look at my patient note

11K views 16 replies 12 participants last post by  hasini 
#1 · (Edited)
VS- WNL
HEEENT- NC/A, PERRLA, EOMI.
CHEST- CTA&P. REST EXCURSION, PERCUSSION AND FREMITUS - NL
HEART- RRR. S1/S2 NL. NO M,R,G. PMI-NL
ABD- SOFT, NT,ND, NO HSM/NO PALPABLE MASS. BS+
CNS- A&O X3
GAIT NL
SENSATION FOR PINPRICK AND LIGHT TOUCH NL IN ALL 4 EXT.
STRENGTH 5/5 IN all 4 EXT.
DTR- 2+ IN ALL 4 EXT.
BABINSKI- -VE
ROMBERG- -VE
IN ALL 4 EXT- STRENGTH 5/5, DTR 2+ AND SENSATION FOR LIGHT TOUCH AND PINPRICK NL
CN 2 TO 12 INTACT

and if pt of Resp or CVS

NECK- NO JVD, NO LYMPHADENOPATHY
EXT- NO CYANOSIS/CLUBBING. PERIPHERAL PULSES- 2+/SYMMETRIC

AND CAN I WRITE JUST P/E IN CAPITALS AND everything else in Normal Letters????
 
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#8 ·
normocephalic, atraumatic.

But, all these abbreviations are not on the list with abbreviations that we can use. I'm confused here. I know, FA uses some of them, but I think in the real thing we probably shouldn't use that many abbreviations and just write some of them.
 
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