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CR Cardiorespiratory GU Genitourinary GYN Gynecology NP Neuropsychiatric GI Gastrointestinal EOMS Extra ocular movements HTN Hypertension or high blood pressure HEENT head, eyes, ears, nose, throat Gravida number of pregnancies Para number of births full block justified to the left side of the page modified block tabbed over and aligned PERLA pupils equally react to light and accommodation Dysmenorrhea bad/painful/abnormal menstrual flow Syncope fainting cholecystitis inflammation of the gallbladder tachycardia rapid heartbeat bradycardia slow heartbeat Hematemesis vomiting blood Tinnitus ringing in the ear Alopecia baldness Epistaxis nosebleed Menarche first period for female Metrorrhagia excessive uterine bleeding Glaucoma Atrophy of the optic nerve and increased intraocular pressure Conjunctivitis pink eye, inflammation of the mucous membranes of the eye Cephalocaudal head to foot Varicosities varicos veins, distended, knotted or swollen veins skin dryness, scaling, eruptions, rash, dicoloration, palor Diagnosis and Impression they have the same meaning on report also called assessment or conclusion 4 parts of PE Inspection, palpation, percussion, and auscultation short stay record used for outpatient or surgical center in place of an H&P Interval History patient returns to the hospital within a month demographic data name, address, phone #, SS, place of work 4 parts of a HX CC, ROS, HPI, PFSH CC Chief complaint ROS review of systems HPI history of present illness PFSH past family social history how do you list allergies on a report bold/ underline could be life or death to the patient