Chapter 2 Abbreviations and Symbols Flashcards
1
Q
A&O
A
alert and oriented
2
Q
ā
A
before
3
Q
ac
A
before meals
4
Q
LTG
A
Long-Term Goal
5
Q
Meds
A
medication
6
Q
Noc
A
night, at night
TIP: nocturnal
7
Q
ad lib.
A
as desired, at discretion
8
Q
NPO or npo
A
Nothing by Mouth
where does p come from
Not permitted orally?
9
Q
ADLs
A
Activities of Daily Living
10
Q
OOB
A
Out Of Bed
11
Q
AMA
A
Against Medical Advice
12
Q
OTC
A
Over The Counter
13
Q
B/S
A
BedSide
14
Q
p̄
A
after
15
Q
Bid
A
twice a day
Bi = twice
D = day
bid
16
Q
pc
A
after meals
a= before
ac = before meals
p = after
pc = after meals
17
Q
BRP
A
BathRoom Privileges
18
Q
PE
A
Physical Examination
19
Q
c̄
A
with
TIP
c = con = with
20
Q
per
A
by / through
21
Q
c/o
A
complains of
22
Q
PLOF
A
Prior Level Of Function
23
Q
CC or C/C
A
Chief Complaint
24
Q
PO
A
by mouth
25
cont.
continue
26
post-op
after surgery (operation)
27
DNR
Do Not Resuscitate
28
pre-op
before surgery (operation_
29
DOB
Date Of Birth
30
prn
as needed
31
Dx
diagnosis
32
Pt. or pt.
patient
33
ELOS
Estimated Length Of Stay
34
PTA
Prior To Admission
35
EOB
Edge Of Bed
36
q
every
37
eval.
evaluate, evaluation
38
qid
four times a day
39
FH
Family History
40
qh
every hour
41
h or hr.
hour
42
q2h
every two hours
43
H&P
History and Physical
44
re:
regarding, concerning
45
h/o
History Of
46
R/O or r/o
Rule Out
47
HOB
Head Of Bed
48
ROS
Review Of Systems
49
ht.
HeighT
50
Hx
history
51
s̄
without
52
LOS
Length Of Stay
53
S/P or s/p
Status Post
54
sig
directions for use, give as follows, let it be labeled
55
TO or t.o.
telephone order
56
tol
tolerate, tolerated, tolerance
57
S
O
A
P
Subjective
Objective
Assessment
Plan
58
stat.
immediate(ly)
59
Tx
treatment, traction
60
STG
Short-Term Goal
61
VO or v.o.
Verbal Order
62
Sx
symptoms
63
y/o or y.o
year old
64
tid
three times a day
65
wt.
weight
66
Symbols
~ or ≈
approximately
67
Symbols
×
number of times (×5, 5×) or minutes (×5 min)
68
Symbols
Δ
change
69
Symbols
1°
PRIMARY
70
Symbols
↓
down, downward, decreased, diminished
71
Symbols
→
to, progressing toward, approaching
72
Symbols
♀
female
73
Symbols
♂
Male
74
Symbols
2°
secondary, secondary to
75
Symbols
↔
to and from
76
Symbols
#
number (#5) or pounds (5# wt.)
77
Symbols
↑
up, upward, increased
78
SOAP (extended info)
Subjective (S)
PATIENT FOCUSED
Subjective (S:) data include what the patient said. This section includes the patient’s chief complaint as well as statements regarding any changes in their condition since their last visit. It is not observable or measurable information. Statements in this section often begin with, “Patient states,” “Patient reports,” or “Patient complains of.” Here are some examples of subjective information:
S: Patient complains of pain at right lateral ankle and notes she is unable to put any weight on right foot.
S: Patient reports pain and swelling in right ankle is improving.
S: Patient states pain in her right ankle is “much better.”
79
SOAP (extended info)
Objective (O)
INFORMATION THAT CAN BE OBSERVED, MEASURED, OR QUANTIFIED IN SOME WAY
objective (O:) data include information that can be observed, measured, or quantified in some way. Examples of objective information are a patient’s temperature, blood pressure, or pain level. If the patient has a wound, the location, size, depth, and amount of drainage would be entered into the objective portion of the SOAP note. The objective section also includes all treatments provided by the medical professional. In addition, anything the patient did during the visit, such as exercises, is considered objective data. Here are some examples of objective information:
O: Pain at right ankle 8/10. Noted redness, heat, and swelling. Instructed patient in RICE protocol.
O: Volumetric measurement right ankle 600 mL
O: Patient walked on treadmill for 30 minutes with an increase in speed to 2.5 and a 10% incline.
80
SOAP (extended info)
Assessment (A)
WHERE THE MEDICAL PROFESSIONAL SYNTHESIZES THE SUBJECTIVE AND OBJECTIVE INFORMATION
The assessment (A:) section of the SOAP note is where the medical professional synthesizes the subjective and objective information. This section can include expectations, or treatment goals, as well as how the patient is reacting to the current treatment and whether he or she is or is not making progress toward the treatment goals. In one of the previous examples, a patient complained of pain at the right ankle and inability to walk on the right foot. In the observation portion of the SOAP note, the medical professional wrote the signs of inflammation that were observed, and the instructions given to the patient to help relieve the pain and swelling. In the assessment portion of this SOAP note, the medical professional may write an expectation for “decreased pain and swelling within 1 week.” On subsequent visits, assessment statements may include, “right ankle swelling has decreased since last visit” and “patient able to tolerate increased speed and incline on treadmill with no complaints of increased ankle pain.”
81
SOAP (extended info)
plan (P:)
WRITE WHAT YOU WILL DO TO HELP THE PATIENT MAKE PROGRESS TOWARD THE TREATMENT GOALS
The plan (P:) section of the SOAP note is where you write what you will do to help the patient make progress toward the treatment goals. This part includes statements about continuing with the current treatment or making changes to the treatment. It also includes recommendations for consultation or collaboration with other medical professionals. “Continue as per plan of care” and “will contact orthotist regarding ankle brace adjustment” are examples of statements that belong in the plan section of the SOAP note. Most facilities provide guidelines regarding the specific information they want included in the medical record as well as how they want it documented.
