SOAP note abbreviations -Jill W's list
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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ā | before
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A | assessment
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(A) (circled A) | assist
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A/ | active
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AAA | abdominal aortic aneurysm
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AAROM | active assistive range of motion
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abd/add | abduction/adduction
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ABG | arterial blood gases
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abn | abnormal
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ac | before meals
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AC joint | acromioclavicular joint
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ACL | anterior cruciate ligament
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ADA | American with Disabilities Act, American Diabetes Association
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ADL | activities of daily living
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ad lib | at discretion
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afib | atrial fibrillation
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AFO | ankle foot orthosis
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AIDS | acquired immune deficiency syndrome
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AIIS | anterior inferior iliac spine
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A/K | above knee
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AKA | above knee amputation
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AKS | arthroscopic knee surgery
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A-line | arterial line
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ALS | amyotrophic lateral sclerosis
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AKFO | ankle knee foot orthosis
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am, a.m. | morning, before noon
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AMA | against medical advice
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amb. | ambulation
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amt | amount
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ANS | autonomic nervous system
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ant | anterior
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A-P | anterior-posterior
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appts | appointments
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APTA | American Physical Therapy Association
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ARDS | adult respiratory distress syndrome
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AROM | active range of motion
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ASAP | as soon as possible
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ASIS | anterior superior iliac spine
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assist. | assistance
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ATNR | asymmetrical tonic neck reflex
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AVM | avascular necrosis
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AVR | aortic valve replacement
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ax. cr | axillary crutches
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(B) (circled B) | bilateral, both
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BBA | Balanced Budget Act of 1997
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BBB | bundle branch block
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b/c | because
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bid | twice a day (star this one)
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bil. | bilateral
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biw | twice a week
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BK | below knee
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BKA | below knee amputation
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BLE | both lower extremities
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BM | bowel movement
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BOS | base of support
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BP | blood pressure
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BPM, bpm, b.p.m. | beats per minute
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BR | bedrest
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B/S, B.S. | beside, bedside
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BS | breath sounds, bowel sounds
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BUE | both upper extremities
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BUN | blood urea nitrogen
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c (with a line over it) | with
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CA | carcinoma, cancer
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CABG | coronary artery bypass graft
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CAD | coronary artery disease
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CAPTE | Commission on Accreditation for Physical Therapy Education
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CARF | Commission on Accreditation of Rehabilitation Facilities
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CBC | complete blood count (star this one)
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C/C, C/Cs | chief complaint, chief complaints
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cc | cubic centimeter
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CCU | coronary care unit
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CF | cystic fibrosis
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CGA | contact guard assist
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CHD | congenital heart disease, congenital hip dislocation
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CHF | congestive heart failure
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CHI | closed head injury
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CiTx | cervical intermittent traction
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cm | centimeter(s)
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CMS | Center for Medicare and Medicaid Services
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CN | cranial nerve
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CNS | central nervous system
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c/o | complains of, complaint(s) of
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CO | cardiac output
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cont | continue
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coord | coordination
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COPD | chronic obstructive pulmonary disease
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COTA | certified occupational therapist assistant
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CP | compression pump, cerebral palsy
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CPAP | continuous positive airway pressure
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CPM | continuous passive motion machine
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CPR | cardiopulmonary resuscitation
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CPT | current procedural terminology, chest physical therapy
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CRF | chronic renal failure
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C-Section | cesarean section
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CSF | cerebral spinal fluid
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CT scan | computerized axial tomography
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CVA | cerebral vascular accident
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c/w | consistent with
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CW | continuous wave
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CX | cancel
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CXR | chest x-ray
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D1, D2 | diagonal 1, diagonal 2 (proprioceptive neuromuscular facilitation [PNF] patterns)
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d/c | discharged, discontinued
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DEP | data, evaluation, performance goals
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dept | department
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DF | dorsiflexion
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DIP | distal interphalangeal joint
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DJD | degenerative joint disease
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DM | diabetes mellitus
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DME | durable medical equipment
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DNR | do not resuscitate
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DOB | date of birth
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DOD | date of discharge
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DOE | dyspnea on exertion
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DPT | diphtheria-pertussis-tetanus (vaccine), Doctor of Physical Therapy
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DRGs | diagnosis related groups
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drsg | dressing
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DSD | dry sterile dressing
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DTR | deep tendon reflex
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DVT | deep venous thrombosis
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Dx | diagnosis
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ECF | extended care facility
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ECG, EKG | electrocardiogram
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EEG | electroencephalogram
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elec. | electrical
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EMG | electromyogram
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ENT | ear, nose, throat
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EOB | edge of bed
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equip. | equipment
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ER | emergency room
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E.S., E-stim | electrical stimulation
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ESRD | end-stage renal disease
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ETT | endotracheal tube
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Ev, ev | eversion
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Eval | evaluation
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ex. | exercise
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ext., / | extension
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F | female, fair muscle strength grade
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(F) (circled F) | father
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FAQ | full arc quads
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FAROM | functional active range of motion
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FDA | Food and Drug Administration
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FES | functional electrical stimulation
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FIM | functional independence measure
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flex. (with a checkmark) | flexion
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FOR | functional outcome report
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ft | foot, feet
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FTP | failure to progress
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FTSG | full-thickness skin graft
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F/U | follow up
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FUO | fever unknown origin
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FWB | full weight-bearing
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FWW, fw/w | front wheeled walker
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Fx, fx | fracture(d)
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G | good (muscle strength, balance)
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gastrocs | gastrocnemius muscles
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GBS | Guillain Barré Syndrome
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GCS | Glasgow Coma Scale
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GERD | gastroesophageal reflux disease
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GI | gastrointestinal
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gluts. | gluteals
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gm | gram
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G-tube | gastrostomy tube
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gt. | gait
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(H) (circled H) | husband
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HBP | high blood pressure
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HCFA | Health Care Financing Administration
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H & P | history and physical
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HA, H/A | headache
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Hb, Hgb, HGB | hemoglobin
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HCT, hct | hematocrit
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HEENT | head, ears, eyes, nose, throat
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Hemi | hemiplegia
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Hep. | heparin
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HEP | home exercise program
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HHA | hand held assist, home health aide
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HI | head injury
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HIV | human immunodeficiency virus
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HMO | health maintenance organization
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HNP | herniated nucleus pulposus
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h/o | history of
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HO | heterotopic ossification
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HOB | head of bed
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HP | hot pack
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HR | heart rate
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hr | hour
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h.s. | at bedtime
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HS | hamstring(s)
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ht. | height
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HTN | hypertension
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HWR | hardware removal
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HX, Hx, hx | history
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(I) (circled I), indep. | independent
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IBS | irritable bowel syndrome
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ICBG | iliac crest bone graft
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ICD-9 | International Classification of Diseases
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ICH | intracranial hemorrhage
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ICIDH | International Classification of Impairments, Disabilities, and Handicaps
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ICF | International Classification of Functioning, Disability, and Health
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ICP | intracranial pressure
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ICU | intensive care unit
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IDDM | insulin dependent diabetes mellitus
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I/E ratio | inspiratory/expiratory ratio
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IEP | individual education program
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IFC | extended care unit
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IFSP | individual family service plan
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ILV | independent lung ventilation
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IM | intramuscular
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IMV | intermittent mandatory ventilation
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in. | inch(es)
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inf. | inferior
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int. | internal
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IP | inpatient, interphalangeal
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IPA | Individual Practice Association
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IRDS | infant respiratory distress syndrome
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IS | incentive spirometer
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IV | intravenous
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JAMA | Journal of the American Medical Association
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JCAHO | Joint Commission on Accreditation of Healthcare Organizations
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J-tube | jejunostomy tube
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JRA | juvenile rheumatoid arthritis
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jt. | joint
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K | potassium
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Kcal | kilocalories
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kg | kilogram
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L | liter
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(L) (circled L), lt | left
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L5 | 5th lumbar vertebra
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LAQ | long arc quadriceps
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lat. | lateral
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lb | pound
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LBBB | left bundle branch block
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LBP | low back pain
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LE, LEs | lower extremity, lower extremities
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lg | large
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lic. | license
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LL | long leg braces
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LLC | long leg cast
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LLE | left lower extremity
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LLL | left lower lobe
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LMN | lower motor neuron
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LOA | leave of absence
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LOB | loss of balance
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LOC | loss of or level of consciousness
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LP | lumbar puncture
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LPN | licensed practical nurse
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LTC | long-term care
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LTG | long-term goals
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LUE | left upper extremity
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M | male
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(M) (circled M) | mother
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MAP | mean arterial pressure
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m., mm. | muscle
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max. | maximum
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MCA | middle cerebral artery, motorcycle accident
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MCO | managed care organization
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M.D. | medical doctor, doctor of medicine
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MD | muscular dystrophy
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MDS | minimum data set
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mech | mechanical
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MED | minimal erythemal dose
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meds. | medications
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mg | milligram(s)
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MH | moist heat
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MHz | megahertz
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MI | myocardial infarction
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min | minute(s)
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min. | minimum, minimal
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mm | millimeter(s)
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mm Hg | millimeters of mercury
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MMT | manual muscle test
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mo | month(s)
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mod. | moderate
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MP, MCP | metacarpophalangeal
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MRI | magnetic resonance imaging
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MRSA | methicillin resistant staph aureus
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MS | multiple sclerosis
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mtr. | motor
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MVA | motor vehicle accident
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N, nL | normal (muscle strength)
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N/A | not applicable, not able
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NAD | no acute distress
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N & V | nausea & vomiting
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NBQC | narrow-based quad cane
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NCV | nerve conduction velocity
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NDT | neurodevelopmental treatment
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NEC | necrotizing enterocolitis
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neg. | negative
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NG | nasogastric
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NICU | newborn intensive care unit
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NIDDM | noninsulin dependent diabetes mellitus
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NKA | no known allergies
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nn | nerve
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noc. | night, at night
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NPO | nothing by mouth
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NTT | nasotracheal tube
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NWB | non-weight bearing
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O: | objective data
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O2 sat | oxygen saturation
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OA | osteoarthritis
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OASIS | outcome and assessment information sets
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OB | obstetrics
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OBS | organic brain syndrome
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occ | occasional
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OCD | obsessive compulsive disorder
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OD | overdose
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OGT | oral gastric tube
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OM | otitis media
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OOB | out of bed
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OOT | out of town
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OP | outpatient
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OR | operating room
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ORIF | open reduction, internal fixation
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ortho | orthopedics
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OT | occupational therapist
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OTR | registered occupational therapist
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oz | ounce(s)
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p (with a line over it) | post, after
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P | poor (muscle strength, balance)
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P/ | passive
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P: | plan (treatment plan)
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PA | posterior/anterior
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para | paraplegia
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p.c. | after meals
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PC | pressure control
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PCA | patient controlled analgesia
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PCL | posterior cruciate ligament
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PCP | primary care physician
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PCO2 | partial pressure of carbon dioxide
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PD | postural drainage
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PDA | patent ductus arteriosus
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PDR | physician desk reference
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PE | pulmonary embolus
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peds | pediatrics
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PEEP | positive end expiratory pressure
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PF | plantar flexion
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PFT | pulmonary function test
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P.H., PH, PMH | past history, past medical history
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pH | hydrogen-ion concentration
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PHO | physician/hospital organizations
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PIP | proximal interphalangeal
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PiTx | pelvic intermittent traction
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PKU | phenylketonuria
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pm, p.m. | afternoon
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PNF | proprioceptive neuromuscular facilitation
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PO | by mouth
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POC | plan of care
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POD | post-operative day
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POE | prone on elbows
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polio | poliomyelitis
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POMR | problem-oriented medical record
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POS | point of service plan
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post. | posterior
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post | after
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post-op | after surgery or operation
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PPO | preferred provider organization
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pps | pulses per second
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PPS | prospective payment system
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Pr | problem
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PRE | progressive resistive exercise
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pre-op | before surgery or operation
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prn | whenever necessary, as needed
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PROM | passive range of motion
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pro time | prothrombin time
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prox. | proximal
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Prx | prognosis
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PSIS | posterior superior iliac spine
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PSP | problem, status, plan
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PSPG | problem, status, plan, goals
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pt | protime
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PT | physical therapist, physical therapy
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Pt., pt. | patient
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||||
PTA | physical therapist assistant, prior to admission
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|
||||
PUW | pick up walker (standard walker)
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PVD | peripheral vascular disease
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PWB | partial weight-bearing
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q (with a line over it) | every
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qd | every day
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qh | every hour
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qhs | at bedtime
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qid | four times a day
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qm | every minute
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qod | every other day
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qt | quart
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quad | quadriplegic
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||||
quads | quadriceps
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||||
qw | once weekly
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(R) (circled R) | right
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||||
RA | rheumatoid arthritis
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|
||||
RAD | reactive airway disease
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|
||||
RBBB | right bundle branch block
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RBC | red blood cells
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R.D. | registered dietician
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RDS | respiratory distress syndrome
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re: | regarding
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re-ed | reeducation
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REM | rapid eye movement
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reps | repetitions
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ret. | return
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RLE | right lower extremity
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RLL | right lower lobe
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rm | room
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RN | registered nurse
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R/O, R.O. | rule out
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ROM | range of motion
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rot. | rotation
🗑
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rr | respiratory rate
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RROM | resistive range of motion
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|
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RT | respiratory therapist
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RUE | right upper extremity
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|
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RUGs | resource utilization groups
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|
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RUL | right upper lobe
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Rx | therapy, treatment
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||||
s (with a line over it) | without
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|
||||
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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
ladylore
Popular Physical Therapy sets