AbdomenList AppetiteList AbdPalpationList OstomyTypeList MouthCareList UrineCharacterList FundusLocationList
Long Names Short Names Long Names Short Names Long Names Short Names Long Names Short Names Long Names Short Names Long Names Short Names Long Names Short Names
Flat Flat Refused Refused Relaxed Relaxed Colostomy Colost Teeth Brushed Brushed Clear Clear Umbilicus Umbilcs
Rounded Rounded Poor Poor Rigid Rigid Jejunostomy Jejun Mouthwash MthWash Cloudy Cloudy Umbilicus Right Umb R
Obese Obese Fair Fair Tense Tense Ileostomy Ileost Swab Swab Sediment Sedimnt Umbilicus Left Umb L
Protuberant Protub Good Good Other*/Remark Other Mucous Fistula Fistula Toothette Tthette Blood Clots Clots Umbilicus Above Umb Up
Scaphoid Scaph Excellent Excelnt Other*/Remark Other Oral Suction Suction Other*/Remark Other Umbilicus Below Umb Dwn
Other*/Remark Other Other*/Remark Other GastricDrngeList Other*/Remark Other Other*/Remark Other
Long Names Short Names StomaAppearList BladderList
AbdAuscultateList FeedingList Bile Bile Long Names Short Names WeightsList Long Names Short Names LochiaList
Long Names Short Names Long Names Short Names Bloody Bloody Beefy Red Bfy/Red Long Names Short Names Flat Flat Long Names Short Names
All 4 Quandrants All 4 Qu Self Self Charcoal Chrcoal Bleeding Bleedng Q Day QD Distended Distend Rubra Rubra
Other*/Remark Other Assist Assist Clear Clear Detached Detach Q HS Q HS Other*/Remark Other Serosa Serosa
Feeder Feeder Coffee Ground CofGrnd Edematous Edema QOD QOD Alba Alba
AbdominalToneList Other*/Remark Other Partial Digested Prt/Dig Flush Flush Pre&Post Dialys P/PDial AbnormalGUList Other*/Remark Other
Long Names Short Names Undigested Undigst Moist Moist Post Dialysis PostDia Long Names Short Names
Soft Soft OralMucosaList Other*/Remark Other Necrotic Necrotc Pre&Post Surgery P/PSurg Appliance Applnce GUTeachingNeedsList
Tender Tender Long Names Short Names Pale Pale Post Surgery PostOp Dysuria Dysuria Long Names Short Names
Rebound Tender Rebound  Pink/Intact Pnk/Int OralLesionList Pink Pink Other*/Remark Other Hesitation Hesitat Medications Meds
Distended Distend Pink/Moist Pnk/MST Long Names Short Names Retracted Retract Incontinence Incont Diet Diet
Ascites Ascites Pink/Dry Pnk/Dry White Coating Wht Other*/Remark Other EnemaTypeList Retention Retent Foley Care  F Care
Other*/Remark Other Pink/Lesion Pnk/Les Canker Sore Cnk Long Names Short Names Urgency Urgency Foley Care Self F Car S
Pale/Intact Pal/Int Yellow Coating Yel AltComfortR/Tlist Fleets Fleets Other*/Remark Other Straight Cath StrCath
BowelSoundsList Pale/Moist Pal/Mst Blister Bls Long Names Short Names Tap Water Tap H2O Strt Cath Self S Cth S
Long Names Short Names Pale/Dry Pal/Dry Petechiae Pet Nausea Nausea Soap Suds SoapSud UrinaryFrequencyList CAPD Care CAPD
Normoactive Normal Pale/Lesion Pal/Les Other*/Remark Oth Vomiting Vomit Oil Retention Oil Long Names Short Names Stoma Care Stoma
Hyperactive Hyper Other*/Remark Other Diarrhea Diarrh Other*/Remark Other Polyuria Poliuri Hygeine Hygeine
Hypoactive Hypo OralMucosaSite Constipation Constip Oliguria Oliguri Other*/Remark Other
Absent Absent StoolColorList Long Names Short Names Cramping Cramps GIReferralsList Anuria Anuria
Other*/Remark Other Long Names Short Names Tongue Tng Flatulence Flatus Long Names Short Names Nocturia Nocturi
Brown Brown Cheek Right ChR Nausea/Vomiting N/V Nutrition Nutritn Other*/Remark Other
DietList Black Black Cheek Left ChL Nausea/Diarrhea N/D OT OT
Long Names Short Names Clay Colored Clay Palate Upper PlU Nausea/Constip N/C ST ST IncontinenceList
NPO NPO Green Green Palate Lower PlL Vomit/Constip V/C Swallow Eval Swallow Long Names Short Names
NPO Except Meds NPO X M Blood,Bright Red BRB Other*/Remark Oth Vomit/Diarrhea V/D Other*/Remark Other Functional Functnl
Sips/Ice Chips SipsIce Maroon Maroon Naus/Vom/Diar N/V/D Overflow Overflo
Clear Liquids Clr Liq Tan Tan AbnormalEliminationList Naus/Vom/Cons N/V/C UrineSourceList Reflex Reflex
Regular Regular Tarry Tarry Long Names Short Names Drains/NGT/OGT Drain/s Long Names Short Names Stress Stress
Full Liquids Fl Liq Yellow Yellow Appliance Applnce Other*/Remark Other Self Void Void Total Total
Bari Stage I Bari I Other*/Remark Other Constipation Constip InDwelling Cath InCath Urge Urge
Bari Stage II Bari II Diarrhea Diarrh GITeachingNeedsList Condom Cath Condom Other*/Remark Other
Bari Stage III BariIII StoolConsistencyList Impaction Impact Long Names Short Names Incontinent Incont
Soft Soft Long Names Short Names Other*/Remark Other Diet Diet IleoConduit IleoCnd UrineOdorList
Pureed Pureed Formed Formed Disease Process Disease Nephrostomy Nephro Long Names Short Names
Cardiac Cardiac Fatty Fatty BowelApplianceList Drain/s Drain/s Suprapubic Cath SP Cath Faint Faint
No Added Salt NAS Liquid Liquid Long Names Short Names Fd/Drug Interact Fd/Drug Straight Cath StrCath Ammoniac Ammonia
Tube Feeding Tb Feed Loose Loose Ostomy Ostomy Hygiene Hygiene Urostomy Urost Offensive Offensv
TPN/PPN TPN/PPN Mucoid Mucoid Rectal Pouch R/Pouch Medication/s Med/s Other*/Remark Other Acetonic Acetone
Low Protein LoProt Pasty Pasty Rectal Tube R/Tube Procedure/s Procedr Other*/Remark Other
Other*/Remark Other Semi-Formed S-Form Other*/Remark Other Stoma Care Stoma UrineColorList
Soft Soft Surgery Surgery Long Names Short Names BladderIrrigationList
Other*/Remark Other Other*/Remark Other Yellow Yellow Long Names Short Names
Amber Amber Intermittent Intermt
AbdPercussionList TubeFeedHoldList Clear Clear Continuous Cont
Long Names Short Names Long Names Short Names Rose Rose Held Held
Hypertympanic Hyper Hold/Residual Hld/Res Tea Colored Tea D/C'd D/C'd
Hypotympanic Hypo Hold/Procedure Hld/Pro Orange Orange Other*/Remark Other
Normotympanic Normal Hold/Discomfort Hld/Dis Bloody Bloody
Other*/Remark Other Resume Resume Other*/Remark Other DialysisType
D/C'd D/C'd Long Names Short Names
Other*/Remark Other Hemodialysis Hemo
CAPD CAPD
CRRT CRRT
CVVH CVVH
SLED SLED
Other*/Remark Other