SOAP notes - 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!
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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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| 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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| 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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| 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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| ht. | height
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| HTN | hypertension
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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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| ICD-9 | International Classification of Diseases
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| ICU | intensive care unit
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| IDDM | insulin dependent diabetes mellitus
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| IEP | individual education program
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| IM | intramuscular
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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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| IV | intravenous
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| JCAHO | Joint Commission on Accreditation of Healthcare Organizations
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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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| 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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| 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. , mm. , ms. | muscle
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| MAP | mean arterial pressure
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| max. | maximum
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| M.D. | medical doctor, doctor of medicine
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| MD | muscular dystrophy
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| mech | mechanical
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| meds. | medications
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| mg | milligram(s)
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| MH | moist heat
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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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| 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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| NBQC | narrow-based quad cane
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| NDT | neurodevelopmental treatment
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| neg. | negative
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| NG | nasogastric
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| NIDDM | noninsulin dependent diabetes mellitus
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| NKA | no known allergies
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| noc. | night, at night
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| NPO | nothing by mouth
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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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| OCD | obsessive compulsive disorder
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| OD | overdose
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| OOB | out of bed
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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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