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  #1  
Old 02-10-2013
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Arrow CS Patient Note Abbreviations

COMPLETE PHYSICAL EXAM ABBREVIATIONS:
Vital Signs: T (temperature) HR (pulse) RR (respiration rate) BP (systolic/diastolic) SPO2 pulse ox
SYSTEM Physical Exam Documentation Detailed Abbreviation Explanation
GEN: General NAD, AAOX4, WDWN (AAM, AAF, WM, WF) No acute distress, alert, awake, and oriented times 4 to name,
place, time, purpose, Well developed well nourished (African
American Male, African American Female, White Male,
White Female)

HEENT: Head,
eyes, ears, nose, throat
NCAT, MMM, EOMI, PERRLA, b/l TM intact &
reactive to light, b/l sclera anicteric,
conjunctival injection
Normocephalic atraumatic, mucous membranes moist,
extraocular muscles intact, pupils equally round and reactive
to light and accommodation bilaterally, bilateral tympanic
membrane intact and reactive to light, bilateral sclera
anicteric, no conjunctival injection

NECK: Supple, JVD, LAD, carotid bruit,
thyromegally
Supple, no jugular venous distention, no lymphadenopathy,
no carotid bruit

CV: cardiovascular RRR, S1S2nl, m/r/g, PMI non displaced/non
sustained, HJR, CR <2secs
Regular rate and rhythm, S1 and S2 are normal, no
murmurs/rubs/or gallops, point of maximal intensity non
displaced and non sustained, no Hepatojugular Reflux,
capillary refill less than 2 seconds

LUNGS: CTAB, r/r/w, egophany, tactile fremitus,
nl percussion
Clear to auscultation bilaterally, no rales/rhonchi/wheezes, no
egophany, no tactice fremitus, normal percussion

ABD: abdomen Obese, no pulsatile masses, +BS nl x4, high
pitched or tinkling sounds, resonant to
percussion, Soft, ND/NT, rebound/guarding,
CVA tenderness, HSM
Obese, no pulsatile masses, normal bowel sounds normal in
all four quadrants, no high pitched or tinkling sounds,
resonant to percussion, Soft, non-distended/non-tender, no
rebound or guarding, no costovertebral angle tenderness, no
hepatosplenomegaly

EXT: extremities c/c/e No cyanosis/clubbing/or edema

NEURO:
neurologic
CN II-XII intact, no focal deficit Cranial Nerve II through XII intact, no focal deficity

PSYCH: psychiatric nl affect, hallucinations, nl speech,
dysarthria
Normal affect, no hallucinations, normal speech, no
dysarthria

SKIN Intact, rashes, lesions, errythema Intact, no rashes, no lesions, no errythema

Tanya Oberoi Pandya D.O., M.B.A.

I GOT THESE ABBREVIATION FROM A FACEBOOK PAGE FOR CS. I JUST WANT TO CHECK WHETHER IT IS OK TO WRITE THEM IN THE CS EXAM OR NOT. THEY REALLY HELPED BUT IN THE MEAN TIME I WANT TO KNOW WHETHER THEY ARE ELIGIBLE TO USE OR NOT
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  #2  
Old 05-31-2013
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Default

Did you find out if these abbreviations were acceptable then?
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  #3  
Old 06-01-2013
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How can you write ??
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  #4  
Old 06-01-2013
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Quote:
Originally Posted by aknz View Post
How can you write ??
I don't know of any easy way of doing it.

However, I would write like this instead:

SKIN Intact, no rashes/lesions/erythema
__________________
A man doesn't know what he knows until he knows what he doesn't know.
What is man? He's just a collection of chemicals with delusions of grandeur.
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  #5  
Old 06-02-2013
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Quote:
Originally Posted by aknz View Post
How can you write ??
hold
Alt then press 0216 (using the num pad )
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