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PT100 Study > Chapter 2 Abbreviations and Symbols > Flashcards

Chapter 2 Abbreviations and Symbols Flashcards

1
Q

A&O

A

alert and oriented

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2
Q

ā

A

before

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3
Q

ac

A

before meals

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4
Q

LTG

A

Long-Term Goal

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5
Q

Meds

A

medication

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6
Q

Noc

A

night, at night

TIP: nocturnal

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7
Q

ad lib.

A

as desired, at discretion

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8
Q

NPO or npo

A

Nothing by Mouth

where does p come from

Not permitted orally?

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9
Q

ADLs

A

Activities of Daily Living

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10
Q

OOB

A

Out Of Bed

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11
Q

AMA

A

Against Medical Advice

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12
Q

OTC

A

Over The Counter

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13
Q

B/S

A

BedSide

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14
Q

p̄

A

after

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15
Q

Bid

A

twice a day
Bi = twice
D = day

bid

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16
Q

pc

A

after meals

a= before
ac = before meals
p = after
pc = after meals

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17
Q

BRP

A

BathRoom Privileges

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18
Q

PE

A

Physical Examination

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19
Q

c̄

A

with

TIP
c = con = with

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20
Q

per

A

by / through

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21
Q

c/o

A

complains of

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22
Q

PLOF

A

Prior Level Of Function

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23
Q

CC or C/C

A

Chief Complaint

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24
Q

PO

A

by mouth

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25
Q

cont.

A

continue

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26
Q

post-op

A

after surgery (operation)

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27
Q

DNR

A

Do Not Resuscitate

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28
Q

pre-op

A

before surgery (operation_

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29
Q

DOB

A

Date Of Birth

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30
Q

prn

A

as needed

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31
Q

Dx

A

diagnosis

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32
Q

Pt. or pt.

A

patient

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33
Q

ELOS

A

Estimated Length Of Stay

34
Q

PTA

A

Prior To Admission

35
Q

EOB

A

Edge Of Bed

36
Q

q

A

every

37
Q

eval.

A

evaluate, evaluation

38
Q

qid

A

four times a day

39
Q

FH

A

Family History

40
Q

qh

A

every hour

41
Q

h or hr.

A

hour

42
Q

q2h

A

every two hours

43
Q

H&P

A

History and Physical

44
Q

re:

A

regarding, concerning

45
Q

h/o

A

History Of

46
Q

R/O or r/o

A

Rule Out

47
Q

HOB

A

Head Of Bed

48
Q

ROS

A

Review Of Systems

49
Q

ht.

A

HeighT

50
Q

Hx

A

history

51
Q

s̄

A

without

52
Q

LOS

A

Length Of Stay

53
Q

S/P or s/p

A

Status Post

54
Q

sig

A

directions for use, give as follows, let it be labeled

55
Q

TO or t.o.

A

telephone order

56
Q

tol

A

tolerate, tolerated, tolerance

57
Q

S
O
A
P

A

Subjective
Objective
Assessment
Plan

58
Q

stat.

A

immediate(ly)

59
Q

Tx

A

treatment, traction

60
Q

STG

A

Short-Term Goal

61
Q

VO or v.o.

A

Verbal Order

62
Q

Sx

A

symptoms

63
Q

y/o or y.o

A

year old

64
Q

tid

A

three times a day

65
Q

wt.

A

weight

66
Q

Symbols
~ or ≈

A

approximately

67
Q

Symbols
×

A

number of times (×5, 5×) or minutes (×5 min)

68
Q

Symbols
Δ

A

change

69
Q

Symbols
1°

A

PRIMARY

70
Q

Symbols
↓

A

down, downward, decreased, diminished

71
Q

Symbols
→

A

to, progressing toward, approaching

72
Q

Symbols
♀

A

female

73
Q

Symbols
♂

A

Male

74
Q

Symbols

2°

A

secondary, secondary to

75
Q

Symbols

↔

A

to and from

76
Q

Symbols
#

A

number (#5) or pounds (5# wt.)

77
Q

Symbols

↑

A

up, upward, increased

78
Q

SOAP (extended info)

Subjective (S)

A

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
Q

SOAP (extended info)

Objective (O)

A

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
Q

SOAP (extended info)

Assessment (A)

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
Q

SOAP (extended info)

plan (P:)

A

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.

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