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SOAP note abbreviations -Jill W's list

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
Created by: ladylore



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