SOAP notes and abbreviations Flashcards
1
Q
S in SOAP
A
Subjective - patient’s experiences, personal views or feelings
2
Q
O in SOAP
A
Objective: Observable signs and the results of tests that the clinician has performed
3
Q
A in SOAP
A
Assessment: evaluation of the patient’s signs/symptoms and progree
4
Q
P in SOAP
A
Plan: determination of how to proceed or alter the plan of Care
5
Q
pt
A
Patient
6
Q
CC
A
Chief complaint
7
Q
y.o.
A
years old
8
Q
c/o
A
complains of
9
Q
WDWN
A
well-developed and well nourished
10
Q
CP
A
chest pain
11
Q
WNL
A
within normal limits
12
Q
Hx
A
history
13
Q
s/p
A
status post
14
Q
Sx
A
Symptoms
15
Q
R/O
A
Rule out *meaning that this needs to be determined
16
Q
D/C
A
discharge, discontinue
17
Q
SOB
A
shortness of breath
18
Q
T
A
temperature
19
Q
RRR
A
regular rate and rhythm
20
Q
UE
A
Upper Extremity
21
Q
LE
A
Lower extremity
22
Q
R
A
respiration
23
Q
BP
A
Blood Pressure
24
Q
P
A
pulse
25
ETOH
alcohol
26
NKDA
No known drug allergies
27
RTC
return to the clinic
28
RTO
Return to the Office
