SOAP- abbreviations Flashcards
A:
assessment
AAROM
active assistive range of motion
abd
abduction
ac
before meals
AC joints
acromioclavicular joints- is a joint at the top of the shoulder. It is the junction between the acromion (part of the scapula that forms the highest point of the shoulder) and the clavicle.[1] It is a plane synovial joint.
ACTH
adrenocorticotrophic hormone
add
adduction
ADL
activities of daily living
ad lib
at discretion
adm
admission
AE
above elbow
AFO
ankle foot orthosis
AIDS
autoimmune deficiency syndrome
AIlS
anterior inferior iliac spine
AJ
ankle jerk
AK
above knee
a.m.
morning
AMA
against medical advice
amb
ambulation, ambulating, ambulated, ambulate, ambulates
ant
anterior
AP
anterior-posterior
AROM
active range of motion
ASA
aspirin
ASAP
as soon as possible
ASHD
arteriosclerotic heart disease
ASIS
anterior superior iliac spine
assist.
assistance, assistive
B/S
bedside
BE
below elbow
bid
twice a day
bilat.
bilateral, bilaterally
BK
below knee
BM
bowel movement
BP
blood pressure
bpm
beats per minute
BRP
bathroom privileges
BUN
blood urea nitrogen (blood test)
C
Centigrade
C&S
culture and sensitivity
CA
cancer, carcinoma
CABG
coronary artery bypass graft
CAD
coronary artery disease
cal
calories
CBC
complete blood count
CBI
closed brain injury
CBS
chronic brain syndrome
CC,C/C
chief complaint
cc
cubic centimeter
CHF
congestive heart failure
cm
centimeter
CNS
central nervous system
c/o
complains of
CO2
carbon dioxide
COLD
chronic obstructive lung disease
cont.
continue
COPD
chronic obstructive pulmonary disease
COTA
certified occupational therapy assistant
CP
cerebral palsy
CPR
cardiopulmonary resuscitation
CSF
cerebral spinal fluid
CV
cardiovascular
CVA
cerebrovascular accident
CWI
crutch walking instructions
Cystro
cystoscopic examination
dept.
department
DIP
distal interphalangeal joint
D/C
discontinued or discharged
DM
diabetes mellitus
DO
doctor or osteopathy
DTR
deep tendon reflex
Dx
diagnosis
ECF
extended care facility
ECG, EKG
electrocardiogram
EEG
electroencephalogram
EENT
ear, eyes, nose, throat
EMG
electromyogram, electromyography
E.R.
emergency room
eval.
evaluation
ext.
extension
F
fair (muscle strength, balance)
FBS
fasting blood sugar
FH
family history
flex
flexion
ft.
foot, feet (the measurement, not the body part)
FUO
fever, unknown origin
FWB
full weight bearing
fx
fracture
G
good (muscle strength, balance)
GB
gallbladder
GI
gastrointestinal
gm
gram
GYN
gynecology
h, hr.
hour
H&H, H/H
hematocrit and hemoglobin
H&P
history and physical
HA, H/A
headache
Hb, Hgb
hemoglobin
HCVD
hypertensive cardiovascular disease
HEENT
head, ear, eyes, nose, throat
HEP
home exercise program
HI
head injury
HIV
human imlIlunodeficiency virus
HNP
herniated nucleus pulposus
HOB
head of bed
HR
heart rate
hr.
hour
hs
at bedtime
ht.
height
Ht
hematocrit
Htn
hypertension
Hx
history
I & 0
intake and output
ICU
intensive care unit
IM
intramuscular
imp.
impression
in.
inches
indep
independent
inf
inferior
IV
intravenous
kcal
kilocalories
kg
kilogram
KJ
knee jerk
KUB
kidney, ureter, bladder
L or l (lower case L)
liter
LFT or LT or a” L” in a circle
left
lb.
pound
LBP
low back pain
LE
lower extremity
LOC
loss of consciousness
LP
lumbar puncture
m
meter
max
maximal
MD
medical doctor; doctor of medicine
MED
minimal erythemal dose
Meds.
medications
MFT
muscle function test
m g
milligram
MI
myocardial infarction
min
minimal
min.
minutes
ml
milliliter
mm
millimeter
MMT
manual muscle test
mo.
month
mod
moderate
MP, MCP
metacarpalphalangeal
MS
multiple sclerosis
N
normal (muscle strength)
NDT
neurodevelopmental treatment
neg.
negative
N.H.
nursing home
noc
night, at night
npo
nothing by mouth
NSR
normal sinus rhythm
NWB
non-weight-bearing
0:
objective
OB
obsetrics
Latin obstare, “to stand by”) is the health science that deals with pregnancy, childbirth, and postpartum period 1
OBS
organic brain syndrome
od
once daily
O.P.
outpatient
O.R.
operating room
ORIF
open reduction, internal fixation
OT
occupational therapy, occupational therapist
OTR
occupational therapist (used to follow official signature of the occupational 17 therapist)
oz.
ounce
P
poor (muscle strength, balance)
P:
plan (treatment plan)
P.A.
physician’s assistant
PA
posterior/anterior
para
paraplegia
pc
after meals
per
by/through
per os, p.o.
by mouth
PERRLA
pupils, equal, round, reactive to light and accommodation
P.H.
past history
p.m.
afternoon
PNF
proprioceptive neuromuscular facilitation
PNF or proprioceptive neuromuscular facilitation stretching, is a set of stretching techniques commonly used in clinical environments to enhance both active and passive range of motion with the ultimate goal being to optimize motor performance and rehabilitation
PNI
peripheral nerve injury
POMR
problem-oriented medical record
a method of recording data about the health status of a patient in a problem-solving system
pos.
positive
poss
possible
post
posterior
post-op
after surgery (operation)
PRE
progressive resistive exercise
pre-op
before surgery (operation)
prn
whenever necessary
“pro re nata”
PROM
passive range of motion
PSIS
posterior superior iliac spine
PT
physical therapy, physical therapist (used after therapist’s signature; varies from facility to facility)
PT/PTT
protime/prothrombine time
Pt., pt.
patient
PTA
physical therapist assistant
PTA
prior to admission
PTB
patellar tendon bearing
PVD
peripheral vascular disease
PWB
partial weight bearing
q
every
qb
every day
qh
every hour
qid
four times a day
qn
every night
qt.
quart
®
right
RA
rheumatoid arthritis
RBC
red blood cell count
R.D.
registered dietician
re:
regarding
rehab
rehabilitation
reps
repititions
resp
respiratory, respiration
RN
registered nurse
R/O
rule out (In order to make a good diagnosis, the physician will try to rule the disease/condition named out; if he or she cannot, this will become the diagnosis.)
ROM
range of motion
ROS
review of systems
RROM
resistive range of motion
R.T.
respiratory therapist, respiratory therapy
Rx
treatment, prescription, therapy
SACH
solid ankle cushion heel
SCI
spinal cord injury
SC joint
sternoclavicular joint
sec.
seconds
SED
suberythemal dose
sig
directions for use, give as follows, let it be labeled
SI(J)
sacroiliac (joint)
SLE
systemic lupus erythematosus
is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body’s cells and tissue, resulting in inflammation and tissue damage
SLR
straight leg raise
SNF
skilled nursing facility
SOAP
subjective, objective, assessment, plan
SOB
shortness of breath
S/P
status post (example: S/P hip fx means Pt. fx her hip in the recent past)
spec
specimen
stat.
immediately, at once
Sx
symptoms
T
trace (muscle strength)
tab
tablet
TB
tuberculosis
tbsp.
tablespoon
TENS, TNS
transcutaneous electrical nerve stimulator
THR
total hip replacement
TlA
transient ischemic attack
tid
three times daily
TKR
total knee replacement
TM(J)
temporomandibular (joint)
TNR
tonic neck reflex (also ATNR, STNR)
t.o.
telephone order
TPR
temperature, pulse & respiration
tsp.
teaspoon
TUR
transurethral resection
(TUR) of the bladder is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder.
UA
urine analysis
UE
upper extremity
UMN
upper motor neuron
URI
upper respiratory infection
US
ultrasound
UTI
urinary tract infection
UV
ultraviolet
VD
venereal disease
v.o.
verbal orders (example: v.o. Dr. Smith/your signature)
vol.
volume
v.s.
vital signs
w/c
wheelchair
W/cm2
watts per square centimeter
WBC
white blood cell count
wk.
week
WNL
within normal limits
wt.
weight
x
number of times performed
y/o or y.o
years old
yd.
yard
yr.
year
encephalo
pertaining to the brain
erythema /er·y·the·ma/
redness of the skin due to congestion of the capillaries
