| gen | appearing stated age in no acute distress |
| heent | tms normal, nose and throat normal, neck no nodes |
| eye | eyes sclera and conjunctiva normal, perrla, fundi benign |
| ch | chest clear to ausc and percussion, heart nsr no murmur, pmi not displaced |
| abd | abdomen soft no masses or organomegaly |
| geni | genitalia - penis, scrotum, testes normal, no hernia |
| r | rectal normal, stool hematest normal, prostate normal size and shape |
| p | pelvic bus normal, cx normal, uterus nss, adnexa no masses, nontender, vagina normal |
| rv | rv confirms stool hematest neg |
| cn | cn 2–12 wnl, fundi normal, neck supple |
| ref | reflexes equal and symmetric, strength and sensation intact |
| st | straight leg raising neg, reflexes equal and symmetric, strength and sensation intact |
| ext | extremities within normal limits, no deformities |
| palp | palpitations |
| Diagnostic codes | Linked AutoText |
| htn | HYPERTENSION |
| di | DIABETES |
| iddm | INSULIN DEPENDENT DIABETES MELLITUS |
| ms | MULTIPLE SCLEROSIS |
| bom | BILATERAL OTITIS MEDIA |
| narc | CHRONIC PAIN SYNDROME, NARCOTIC DEPENDENCY |
| mig | MIGRAINE HEADACHE |
| Instruction code | Linked AutoText |
| rice | rest, ice, elastic compression bandage, elevation |