PRF report format Flashcards
List abbreviation for
PC HPC S/E CVS RS GIT GUS CNS LOC
PMH MEDs ALL FH SH
O/E CVS RS GIT GUS CNS LOC
IMP
DD
PLAN
What does S/E stand for
Systemic Enquiry question to ask patient before examination
What does S/E CVS stand for and what things to ask
systemic enquiry cardiovascular system
ask patient what usual before examination
? SOB, Palpitation, Oedema
What does S/E RS stand for
and what things to ask
S/E systemic enquiry
RS Respiratory system
ask patient what usual before examination
asthma TB COAD COPD Smoker
What does S/E GIT stand for and what things to ask
S/E systemic enquiry
GIT Gastrointestinal Tract
ask patient what usual before examination
? weight loss gain B/O reg
What does S/E GUS stand for and what things to ask
S/E systemic enquiry
GUS Genitourinary system
ask patient what usual before examination
? urine problems catheter prostatism dysuria
What does S/E CNS stand for and what things to ask
S/E systemic enquiry
CNS central nervous system
ask patient what usual before examination
? headaches dizziness visual distrub
What does S/E LOC stand for and what things to ask
S/E systemic enquiry
LOC locomotion
ask patient what usual before examination
? joint pain FROM
what does PMH
past medical history
what does ALL
Allergies
what does FH
family history
what does SH
Social history
jobs ? exercise
what does O/E stand for
and what things to document
On Examination
Eg obese 48yom cold sweaty A-pyrexia
J.A.C.Ci.Oe.L
what does O/E CVS stand for
and what things to document
O/E on examination
CVS cardiovascular system
hr,bp jvp H/s
pps palpable
what does O/E RS stand for
and what things to document
O/E on examination
RS respiratory system
B/S bilat basal creps bronch breathing
what does O/E GIT stand for
and what things to document
O/E on examination
GIT gastrointestinal tract
eg abdo soft epigastric tenderness B/S hernia liver palable
what does O/E GUS stand for
and what things to document
O/E on examination
GUS Genitourinary system
pud colour pain
what does O/E CNS stand for
and what things to document
O/E on examination
CNS central nervous system
A/Ox4 PERRL CNs
what does O/E LOC stand for
and what things to document
O/E on examination
LOC locomotion
FROM NAD
what does IMP stand for
and what things to document
IMP impression
55yof chest pain anxious drugs alcohol
what does DD stand for
and what things to document
DD diagnosis
IM OD
what does Plan stand for
and what things to document
PLAN
take to hospital