Frequency

• ODOnce daily
• BD / BIDTwice daily
• TDS / TIDThree times daily
• QDS / QIDFour times daily
• PRNAs required
• STATImmediately
• AC / PCBefore / after meals
• HS / NocteAt bedtime

Route

• POBy mouth (per os)
• IVIntravenous
• IMIntramuscular
• SCSubcutaneous
• SLSublingual
• PRPer rectum
• PVPer vagina
• NEBNebulised
• INHInhaled
• TOPTopical

Clinical

• SOBShortness of breath
• DOEDyspnoea on exertion
• PNDParoxysmal nocturnal dyspnoea
• N/VNausea / vomiting
• LOCLoss of consciousness
• FROMFull range of motion
• BOBowels open
• PUPassing urine

Documentation

• HPI / HPCHistory of presenting illness / complaint
• PMHPast medical history
• DHDrug history
• SHSocial history
• FHFamily history
• ROSReview of systems
• O/EOn examination
• NADNo abnormality detected
• NKDANo known drug allergy
• ICEIdeas, concerns, expectations

Cardiology

• ACSAcute coronary syndrome
• STEMI / NSTEMIST-elevation / non-ST-elevation MI
• AFAtrial fibrillation
• CHFCongestive heart failure
• MIMyocardial infarction
• LBBB / RBBBLeft / right bundle branch block
• PCIPercutaneous coronary intervention

Respiratory

• COPDChronic obstructive pulmonary disease
• CAP / HAPCommunity- / hospital-acquired pneumonia
• PEPulmonary embolism
• PEFRPeak expiratory flow rate

GI

• GORDGastro-oesophageal reflux disease
• IBDInflammatory bowel disease
• UGIB / LGIBUpper / lower GI bleed
• SBPSpontaneous bacterial peritonitis

Renal

• AKI / CKDAcute kidney injury / chronic kidney disease
• RRTRenal replacement therapy
• eGFREstimated glomerular filtration rate

Neurology

• CVACerebrovascular accident (stroke)
• TIATransient ischaemic attack
• GCSGlasgow Coma Scale
• ICPIntracranial pressure

Endocrine

• DMDiabetes mellitus
• DKADiabetic ketoacidosis
• HHSHyperosmolar hyperglycaemic state
• TFTThyroid function test

Investigations

• FBCFull blood count
• U&EUrea & electrolytes
• LFTLiver function tests
• CRPC-reactive protein
• ABG / VBGArterial / venous blood gas
• CXR / AXRChest / abdominal X-ray
• CT / MRIComputed tomography / magnetic resonance imaging
• USSUltrasound scan
• ECGElectrocardiogram
• MC&SMicroscopy, culture & sensitivity

Care

• DNACPRDo not attempt CPR
• NEWS2National Early Warning Score 2
• VTEVenous thromboembolism
• MDTMultidisciplinary team
• TTO / TTATo take out / away (discharge meds)
• SBARSituation, background, assessment, recommendation