Busy. Please wait.
Log in with Clever
or

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever
or

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

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.
        Help!  

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  
🗑


   

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.

 
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how
Created by: ladylore
Popular Physical Therapy sets