Chapter 2 Abbreviations and Symbols Flashcards
A&O
alert and oriented
ā
before
ac
before meals
LTG
Long-Term Goal
Meds
medication
Noc
night, at night
TIP: nocturnal
ad lib.
as desired, at discretion
NPO or npo
Nothing by Mouth
where does p come from
Not permitted orally?
ADLs
Activities of Daily Living
OOB
Out Of Bed
AMA
Against Medical Advice
OTC
Over The Counter
B/S
BedSide
p̄
after
Bid
twice a day
Bi = twice
D = day
bid
pc
after meals
a= before
ac = before meals
p = after
pc = after meals
BRP
BathRoom Privileges
PE
Physical Examination
c̄
with
TIP
c = con = with
per
by / through
c/o
complains of
PLOF
Prior Level Of Function
CC or C/C
Chief Complaint
PO
by mouth
cont.
continue
post-op
after surgery (operation)
DNR
Do Not Resuscitate
pre-op
before surgery (operation_
DOB
Date Of Birth
prn
as needed
Dx
diagnosis
Pt. or pt.
patient
ELOS
Estimated Length Of Stay
PTA
Prior To Admission
EOB
Edge Of Bed
q
every
eval.
evaluate, evaluation
qid
four times a day
FH
Family History
qh
every hour
h or hr.
hour
q2h
every two hours
H&P
History and Physical
re:
regarding, concerning
h/o
History Of
R/O or r/o
Rule Out
HOB
Head Of Bed
ROS
Review Of Systems
ht.
HeighT
Hx
history
s̄
without
LOS
Length Of Stay
S/P or s/p
Status Post
sig
directions for use, give as follows, let it be labeled
TO or t.o.
telephone order
tol
tolerate, tolerated, tolerance
S
O
A
P
Subjective
Objective
Assessment
Plan
stat.
immediate(ly)
Tx
treatment, traction
STG
Short-Term Goal
VO or v.o.
Verbal Order
Sx
symptoms
y/o or y.o
year old
tid
three times a day
wt.
weight
Symbols
~ or ≈
approximately
Symbols
×
number of times (×5, 5×) or minutes (×5 min)
Symbols
Δ
change
Symbols
1°
PRIMARY
Symbols
↓
down, downward, decreased, diminished
Symbols
→
to, progressing toward, approaching
Symbols
♀
female
Symbols
♂
Male
Symbols
2°
secondary, secondary to
Symbols
↔
to and from
Symbols
#
number (#5) or pounds (5# wt.)
Symbols
↑
up, upward, increased
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.”
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.
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.”
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.
