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Chapter 2

soap notes

TermDefinition
supportive care treat the symptoms to make the patient feel better
palliative care treating the symptoms, but not getting rid of the cause
prophylaxis preventative treatment
proximal close to the center
distal farther away from the center
lateral out to the side
medial toward the middle
ventral antral anterior stomach , the front
dorsal posterior the back
cranial top
caudal bottom
superior above
inferior below
supine laying on the back
contralateral opposite side
ipsilateral same side
unilateral one side
bilateral both sides
dorsum top of the hand or foot
plantar sole of the foot
palmar palm of the hand
sagittal sliced in half left to right
coronal sliced from front to back
transverse divides top to bottom
CCU coronary care unit
ECU emergency care unit
ER emergency room
ED emergency department
ICU intensive care unit
PICU pediatric intensive care unit
NICU Neonatal intensive care unit
SICU surgical intensive care unit
PACU postanesthesia care unit
L&D labor and delivery
OR operating room
post-op after surgery
pre-op before surgery
VS vital signs
T temperature
BP blood pressure
HR heart rate
RR respiratory rate
Ht height
Wt weight
BMI body mass index
I/O intake/output
Dx diagnosis
DDx differential diagnosis
Tx treatment
Rx prescription
H&P history and physical
Hx history
CC chief complaint
HPI history of present illness
SOB shortness of breath
NAD no acute distress
RRR regular rate and rhythm
CTA clear to ascultation (normal sounding lungs)
WDWN well developed well nourished
A&O alert and oriented
WNL within normal limits
NOS not otherwise specified
NEC not elsewhere classfied
PO By mouth (per os)
NPO nothing by mouth (nil per os)
PR per rectum
IM intramuscular
SC subcutaneous
IV intravenous
CVL central venous line
PICC peripherally inserted central catheter
sig instructions short for SIGNA
ad lib as desired
BID twice daily "two in day" bis in die
TID three times daily "three in a day" ter in die
QD daily "each day" quaque die
QID four times daily" four times in a day" quater in die
QHS at night, at the hour of sleep
AC before meals "ante cibum"
PC after meals "post cibum"
prn as needed, per re nata, as need arises
Created by: heathersutton87