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Abbreviations
SOAP note abbreviations -Jill W's list
| Question | Answer |
|---|---|
| ā | before |
| A | assessment |
| (A) (circled A) | assist |
| A/ | active |
| AAA | abdominal aortic aneurysm |
| AAROM | active assistive range of motion |
| abd/add | abduction/adduction |
| ABG | arterial blood gases |
| abn | abnormal |
| ac | before meals |
| AC joint | acromioclavicular joint |
| ACL | anterior cruciate ligament |
| ADA | American with Disabilities Act, American Diabetes Association |
| ADL | activities of daily living |
| ad lib | at discretion |
| afib | atrial fibrillation |
| AFO | ankle foot orthosis |
| AIDS | acquired immune deficiency syndrome |
| AIIS | anterior inferior iliac spine |
| A/K | above knee |
| AKA | above knee amputation |
| AKS | arthroscopic knee surgery |
| A-line | arterial line |
| ALS | amyotrophic lateral sclerosis |
| AKFO | ankle knee foot orthosis |
| am, a.m. | morning, before noon |
| AMA | against medical advice |
| amb. | ambulation |
| amt | amount |
| ANS | autonomic nervous system |
| ant | anterior |
| A-P | anterior-posterior |
| appts | appointments |
| APTA | American Physical Therapy Association |
| ARDS | adult respiratory distress syndrome |
| AROM | active range of motion |
| ASAP | as soon as possible |
| ASIS | anterior superior iliac spine |
| assist. | assistance |
| ATNR | asymmetrical tonic neck reflex |
| AVM | avascular necrosis |
| AVR | aortic valve replacement |
| ax. cr | axillary crutches |
| (B) (circled B) | bilateral, both |
| BBA | Balanced Budget Act of 1997 |
| BBB | bundle branch block |
| b/c | because |
| bid | twice a day (star this one) |
| bil. | bilateral |
| biw | twice a week |
| BK | below knee |
| BKA | below knee amputation |
| BLE | both lower extremities |
| BM | bowel movement |
| BOS | base of support |
| BP | blood pressure |
| BPM, bpm, b.p.m. | beats per minute |
| BR | bedrest |
| B/S, B.S. | beside, bedside |
| BS | breath sounds, bowel sounds |
| BUE | both upper extremities |
| BUN | blood urea nitrogen |
| c (with a line over it) | with |
| CA | carcinoma, cancer |
| CABG | coronary artery bypass graft |
| CAD | coronary artery disease |
| CAPTE | Commission on Accreditation for Physical Therapy Education |
| CARF | Commission on Accreditation of Rehabilitation Facilities |
| CBC | complete blood count (star this one) |
| C/C, C/Cs | chief complaint, chief complaints |
| cc | cubic centimeter |
| CCU | coronary care unit |
| CF | cystic fibrosis |
| CGA | contact guard assist |
| CHD | congenital heart disease, congenital hip dislocation |
| CHF | congestive heart failure |
| CHI | closed head injury |
| CiTx | cervical intermittent traction |
| cm | centimeter(s) |
| CMS | Center for Medicare and Medicaid Services |
| CN | cranial nerve |
| CNS | central nervous system |
| c/o | complains of, complaint(s) of |
| CO | cardiac output |
| cont | continue |
| coord | coordination |
| COPD | chronic obstructive pulmonary disease |
| COTA | certified occupational therapist assistant |
| CP | compression pump, cerebral palsy |
| CPAP | continuous positive airway pressure |
| CPM | continuous passive motion machine |
| CPR | cardiopulmonary resuscitation |
| CPT | current procedural terminology, chest physical therapy |
| CRF | chronic renal failure |
| C-Section | cesarean section |
| CSF | cerebral spinal fluid |
| CT scan | computerized axial tomography |
| CVA | cerebral vascular accident |
| c/w | consistent with |
| CW | continuous wave |
| CX | cancel |
| CXR | chest x-ray |
| D1, D2 | diagonal 1, diagonal 2 (proprioceptive neuromuscular facilitation [PNF] patterns) |
| d/c | discharged, discontinued |
| DEP | data, evaluation, performance goals |
| dept | department |
| DF | dorsiflexion |
| DIP | distal interphalangeal joint |
| DJD | degenerative joint disease |
| DM | diabetes mellitus |
| DME | durable medical equipment |
| DNR | do not resuscitate |
| DOB | date of birth |
| DOD | date of discharge |
| DOE | dyspnea on exertion |
| DPT | diphtheria-pertussis-tetanus (vaccine), Doctor of Physical Therapy |
| DRGs | diagnosis related groups |
| drsg | dressing |
| DSD | dry sterile dressing |
| DTR | deep tendon reflex |
| DVT | deep venous thrombosis |
| Dx | diagnosis |
| ECF | extended care facility |
| ECG, EKG | electrocardiogram |
| EEG | electroencephalogram |
| elec. | electrical |
| EMG | electromyogram |
| ENT | ear, nose, throat |
| EOB | edge of bed |
| equip. | equipment |
| ER | emergency room |
| E.S., E-stim | electrical stimulation |
| ESRD | end-stage renal disease |
| ETT | endotracheal tube |
| Ev, ev | eversion |
| Eval | evaluation |
| ex. | exercise |
| ext., / | extension |
| F | female, fair muscle strength grade |
| (F) (circled F) | father |
| FAQ | full arc quads |
| FAROM | functional active range of motion |
| FDA | Food and Drug Administration |
| FES | functional electrical stimulation |
| FIM | functional independence measure |
| flex. (with a checkmark) | flexion |
| FOR | functional outcome report |
| ft | foot, feet |
| FTP | failure to progress |
| FTSG | full-thickness skin graft |
| F/U | follow up |
| FUO | fever unknown origin |
| FWB | full weight-bearing |
| FWW, fw/w | front wheeled walker |
| Fx, fx | fracture(d) |
| G | good (muscle strength, balance) |
| gastrocs | gastrocnemius muscles |
| GBS | Guillain Barré Syndrome |
| GCS | Glasgow Coma Scale |
| GERD | gastroesophageal reflux disease |
| GI | gastrointestinal |
| gluts. | gluteals |
| gm | gram |
| G-tube | gastrostomy tube |
| gt. | gait |
| (H) (circled H) | husband |
| HBP | high blood pressure |
| HCFA | Health Care Financing Administration |
| H & P | history and physical |
| HA, H/A | headache |
| Hb, Hgb, HGB | hemoglobin |
| HCT, hct | hematocrit |
| HEENT | head, ears, eyes, nose, throat |
| Hemi | hemiplegia |
| Hep. | heparin |
| HEP | home exercise program |
| HHA | hand held assist, home health aide |
| HI | head injury |
| HIV | human immunodeficiency virus |
| HMO | health maintenance organization |
| HNP | herniated nucleus pulposus |
| h/o | history of |
| HO | heterotopic ossification |
| HOB | head of bed |
| HP | hot pack |
| HR | heart rate |
| hr | hour |
| h.s. | at bedtime |
| HS | hamstring(s) |
| ht. | height |
| HTN | hypertension |
| HWR | hardware removal |
| HX, Hx, hx | history |
| (I) (circled I), indep. | independent |
| IBS | irritable bowel syndrome |
| ICBG | iliac crest bone graft |
| ICD-9 | International Classification of Diseases |
| ICH | intracranial hemorrhage |
| ICIDH | International Classification of Impairments, Disabilities, and Handicaps |
| ICF | International Classification of Functioning, Disability, and Health |
| ICP | intracranial pressure |
| ICU | intensive care unit |
| IDDM | insulin dependent diabetes mellitus |
| I/E ratio | inspiratory/expiratory ratio |
| IEP | individual education program |
| IFC | extended care unit |
| IFSP | individual family service plan |
| ILV | independent lung ventilation |
| IM | intramuscular |
| IMV | intermittent mandatory ventilation |
| in. | inch(es) |
| inf. | inferior |
| int. | internal |
| IP | inpatient, interphalangeal |
| IPA | Individual Practice Association |
| IRDS | infant respiratory distress syndrome |
| IS | incentive spirometer |
| IV | intravenous |
| JAMA | Journal of the American Medical Association |
| JCAHO | Joint Commission on Accreditation of Healthcare Organizations |
| J-tube | jejunostomy tube |
| JRA | juvenile rheumatoid arthritis |
| jt. | joint |
| K | potassium |
| Kcal | kilocalories |
| kg | kilogram |
| L | liter |
| (L) (circled L), lt | left |
| L5 | 5th lumbar vertebra |
| LAQ | long arc quadriceps |
| lat. | lateral |
| lb | pound |
| LBBB | left bundle branch block |
| LBP | low back pain |
| LE, LEs | lower extremity, lower extremities |
| lg | large |
| lic. | license |
| LL | long leg braces |
| LLC | long leg cast |
| LLE | left lower extremity |
| LLL | left lower lobe |
| LMN | lower motor neuron |
| LOA | leave of absence |
| LOB | loss of balance |
| LOC | loss of or level of consciousness |
| LP | lumbar puncture |
| LPN | licensed practical nurse |
| LTC | long-term care |
| LTG | long-term goals |
| LUE | left upper extremity |
| M | male |
| (M) (circled M) | mother |
| MAP | mean arterial pressure |
| m., mm. | muscle |
| max. | maximum |
| MCA | middle cerebral artery, motorcycle accident |
| MCO | managed care organization |
| M.D. | medical doctor, doctor of medicine |
| MD | muscular dystrophy |
| MDS | minimum data set |
| mech | mechanical |
| MED | minimal erythemal dose |
| meds. | medications |
| mg | milligram(s) |
| MH | moist heat |
| MHz | megahertz |
| MI | myocardial infarction |
| min | minute(s) |
| min. | minimum, minimal |
| mm | millimeter(s) |
| mm Hg | millimeters of mercury |
| MMT | manual muscle test |
| mo | month(s) |
| mod. | moderate |
| MP, MCP | metacarpophalangeal |
| MRI | magnetic resonance imaging |
| MRSA | methicillin resistant staph aureus |
| MS | multiple sclerosis |
| mtr. | motor |
| MVA | motor vehicle accident |
| N, nL | normal (muscle strength) |
| N/A | not applicable, not able |
| NAD | no acute distress |
| N & V | nausea & vomiting |
| NBQC | narrow-based quad cane |
| NCV | nerve conduction velocity |
| NDT | neurodevelopmental treatment |
| NEC | necrotizing enterocolitis |
| neg. | negative |
| NG | nasogastric |
| NICU | newborn intensive care unit |
| NIDDM | noninsulin dependent diabetes mellitus |
| NKA | no known allergies |
| nn | nerve |
| noc. | night, at night |
| NPO | nothing by mouth |
| NTT | nasotracheal tube |
| NWB | non-weight bearing |
| O: | objective data |
| O2 sat | oxygen saturation |
| OA | osteoarthritis |
| OASIS | outcome and assessment information sets |
| OB | obstetrics |
| OBS | organic brain syndrome |
| occ | occasional |
| OCD | obsessive compulsive disorder |
| OD | overdose |
| OGT | oral gastric tube |
| OM | otitis media |
| OOB | out of bed |
| OOT | out of town |
| OP | outpatient |
| OR | operating room |
| ORIF | open reduction, internal fixation |
| ortho | orthopedics |
| OT | occupational therapist |
| OTR | registered occupational therapist |
| oz | ounce(s) |
| p (with a line over it) | post, after |
| P | poor (muscle strength, balance) |
| P/ | passive |
| P: | plan (treatment plan) |
| PA | posterior/anterior |
| para | paraplegia |
| p.c. | after meals |
| PC | pressure control |
| PCA | patient controlled analgesia |
| PCL | posterior cruciate ligament |
| PCP | primary care physician |
| PCO2 | partial pressure of carbon dioxide |
| PD | postural drainage |
| PDA | patent ductus arteriosus |
| PDR | physician desk reference |
| PE | pulmonary embolus |
| peds | pediatrics |
| PEEP | positive end expiratory pressure |
| PF | plantar flexion |
| PFT | pulmonary function test |
| P.H., PH, PMH | past history, past medical history |
| pH | hydrogen-ion concentration |
| PHO | physician/hospital organizations |
| PIP | proximal interphalangeal |
| PiTx | pelvic intermittent traction |
| PKU | phenylketonuria |
| pm, p.m. | afternoon |
| PNF | proprioceptive neuromuscular facilitation |
| PO | by mouth |
| POC | plan of care |
| POD | post-operative day |
| POE | prone on elbows |
| polio | poliomyelitis |
| POMR | problem-oriented medical record |
| POS | point of service plan |
| post. | posterior |
| post | after |
| post-op | after surgery or operation |
| PPO | preferred provider organization |
| pps | pulses per second |
| PPS | prospective payment system |
| Pr | problem |
| PRE | progressive resistive exercise |
| pre-op | before surgery or operation |
| prn | whenever necessary, as needed |
| PROM | passive range of motion |
| pro time | prothrombin time |
| prox. | proximal |
| Prx | prognosis |
| PSIS | posterior superior iliac spine |
| PSP | problem, status, plan |
| PSPG | problem, status, plan, goals |
| pt | protime |
| PT | physical therapist, physical therapy |
| Pt., pt. | patient |
| PTA | physical therapist assistant, prior to admission |
| PUW | pick up walker (standard walker) |
| PVD | peripheral vascular disease |
| PWB | partial weight-bearing |
| q (with a line over it) | every |
| qd | every day |
| qh | every hour |
| qhs | at bedtime |
| qid | four times a day |
| qm | every minute |
| qod | every other day |
| qt | quart |
| quad | quadriplegic |
| quads | quadriceps |
| qw | once weekly |
| (R) (circled R) | right |
| RA | rheumatoid arthritis |
| RAD | reactive airway disease |
| RBBB | right bundle branch block |
| RBC | red blood cells |
| R.D. | registered dietician |
| RDS | respiratory distress syndrome |
| re: | regarding |
| re-ed | reeducation |
| REM | rapid eye movement |
| reps | repetitions |
| ret. | return |
| RLE | right lower extremity |
| RLL | right lower lobe |
| rm | room |
| RN | registered nurse |
| R/O, R.O. | rule out |
| ROM | range of motion |
| rot. | rotation |
| rr | respiratory rate |
| RROM | resistive range of motion |
| RT | respiratory therapist |
| RUE | right upper extremity |
| RUGs | resource utilization groups |
| RUL | right upper lobe |
| Rx | therapy, treatment |
| s (with a line over it) | without |
| S | supervision |
| S: | subjective data |
| SAH | subarachnoid hemorrhage |
| SAQ | short arc quadriceps |
| SB | spontaneously breathing |
| SBA | standby assist |
| SCI | spinal cord injury |
| SDH | subdural hematoma |
| sec | second(s) |
| SEC | single-end cane |
| SGA | small for gestational age |
| SICU | surgical intensive care unit |
| SIDS | sudden infant death system |
| SLB | short leg brace |
| SLC | short leg cast |
| SLE | systemic lupus erythematosus |
| SLP | speech language pathologist |
| SLR | straight leg raise |
| SNF | skilled nursing facility |
| SO | significant other |
| SOAP | subjective, objective, assessment, plan |
| SOB | shortness of breath |
| SOMR | source-oriented medical record |
| S/P | status post |
| SPTA | student physical therapist assistant |
| SSI | supplemental security income |
| stat. | immediately, at once |
| STG | short term goal |
| str. | strength |
| strep | Streptococcus |
| STSG | split-thickness skin graft |
| sup. | superior |
| SWD | shortwave diathermy |
| Sx | symptoms |
| T | trace muscle strength |
| T & A | tonsillectomy and adenoidectomy |
| TB | tuberculosis |
| TBI | traumatic brain injury |
| TCO | total contact orthosis |
| TDD | tentative discharge date |
| TDP | tentative discharge plan |
| TDWB | touchdown weight-bearing |
| T.E.D.s | antiembolitic stockings |
| temp. | temperature |
| TENS | transcutaneous electrical nerve stimulation |
| TF | tube feeding |
| TFs | transfers |
| ther. ex. | therapeutic exercise |
| THR (THA) | total hip replacement (total hip arthroplasty) |
| TIA | transient ischemic attack |
| tid | three times a day |
| TKE | terminal knee extension |
| TKR (TKA) | total knee replacement (total knee arthroplasty) |
| TLC | total lung capacity |
| TMJ | temporomandibular joint |
| TO | telephone order |
| tol. | tolerate |
| trach | tracheostomy |
| train., trng. | training |
| TSS | toxic shock syndrome |
| TT | tilt table |
| TTWB | toe-touch weight-bearing |
| TWB | touch weight bearing |
| tx | treatment |
| TV | tidal volume |
| UA | urinalysis |
| UCR | usual, customary, and reasonable payment |
| UE, UEs | upper extremity, upper extremities |
| UED1 | upper extremity diagonal 1 |
| UGI | upper gastrointestinal |
| UMN | upper motor neuron |
| UPIN | unique physician identification number |
| URI | upper respiratory infection |
| U/S, US | ultrasound |
| UTI | urinary tract infection |
| UV | ultraviolet |
| v.c. | verbal cues |
| VC | vital capacity |
| VD | venereal disease |
| vent | ventilator |
| VO | verbal order |
| VO2 | oxygen consumption |
| VP | ventricular peritoneal shunt |
| v.s. | vital signs |
| VSD | ventricular septal defect |
| VSU | venous stasis ulcer |
| (w) (circled w) | wife |
| w/ | with |
| WB | weight-bearing |
| WBAT | weight-bearing as tolerated |
| WBC | white blood cell |
| WC, w/c | wheelchair |
| W/cm2 | watts per square centimeter |
| WBQC | wide-based quad cane |
| WFL | within functional limits |
| WHO | World Health Organization |
| WNL | within normal limits |
| wk | week |
| wlp | whirlpool |
| w/o | without |
| wt. | weight |
| X | number of times performed |
| XR | x-ray |
| xfer (transf) | transfer |
| YO, y/o | years old |
| yr | year |
| YOM | year-old-male |
| Z | zero |
| Tx | traction |
| tx | treatment |
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