SOAP- abbreviations Flashcards
(271 cards)
1
Q
A:
A
assessment
2
Q
AAROM
A
active assistive range of motion
3
Q
abd
A
abduction
4
Q
ac
A
before meals
5
Q
AC joints
A
acromioclavicular joints- is a joint at the top of the shoulder. It is the junction between the acromion (part of the scapula that forms the highest point of the shoulder) and the clavicle.[1] It is a plane synovial joint.
6
Q
ACTH
A
adrenocorticotrophic hormone
7
Q
add
A
adduction
8
Q
ADL
A
activities of daily living
9
Q
ad lib
A
at discretion
10
Q
adm
A
admission
11
Q
AE
A
above elbow
12
Q
AFO
A
ankle foot orthosis
13
Q
AIDS
A
autoimmune deficiency syndrome
14
Q
AIlS
A
anterior inferior iliac spine
15
Q
AJ
A
ankle jerk
16
Q
AK
A
above knee
17
Q
a.m.
A
morning
18
Q
AMA
A
against medical advice
19
Q
amb
A
ambulation, ambulating, ambulated, ambulate, ambulates
20
Q
ant
A
anterior
21
Q
AP
A
anterior-posterior
22
Q
AROM
A
active range of motion
23
Q
ASA
A
aspirin
24
Q
ASAP
A
as soon as possible
25
ASHD
arteriosclerotic heart disease
26
ASIS
anterior superior iliac spine
27
assist.
assistance, assistive
28
B/S
bedside
29
BE
below elbow
30
bid
twice a day
31
bilat.
bilateral, bilaterally
32
BK
below knee
33
BM
bowel movement
34
BP
blood pressure
35
bpm
beats per minute
36
BRP
bathroom privileges
37
BUN
blood urea nitrogen (blood test)
38
C
Centigrade
39
C&S
culture and sensitivity
40
CA
cancer, carcinoma
41
CABG
coronary artery bypass graft
42
CAD
coronary artery disease
43
cal
calories
44
CBC
complete blood count
45
CBI
closed brain injury
46
CBS
chronic brain syndrome
47
CC,C/C
chief complaint
48
cc
cubic centimeter
49
CHF
congestive heart failure
50
cm
centimeter
51
CNS
central nervous system
52
c/o
complains of
53
CO2
carbon dioxide
54
COLD
chronic obstructive lung disease
55
cont.
continue
56
COPD
chronic obstructive pulmonary disease
57
COTA
certified occupational therapy assistant
58
CP
cerebral palsy
59
CPR
cardiopulmonary resuscitation
60
CSF
cerebral spinal fluid
61
CV
cardiovascular
62
CVA
cerebrovascular accident
63
CWI
crutch walking instructions
64
Cystro
cystoscopic examination
65
dept.
department
66
DIP
distal interphalangeal joint
67
D/C
discontinued or discharged
68
DM
diabetes mellitus
69
DO
doctor or osteopathy
70
DTR
deep tendon reflex
71
Dx
diagnosis
72
ECF
extended care facility
73
ECG, EKG
electrocardiogram
74
EEG
electroencephalogram
75
EENT
ear, eyes, nose, throat
76
EMG
electromyogram, electromyography
77
E.R.
emergency room
78
eval.
evaluation
79
ext.
extension
80
F
fair (muscle strength, balance)
81
FBS
fasting blood sugar
82
FH
family history
83
flex
flexion
84
ft.
foot, feet (the measurement, not the body part)
85
FUO
fever, unknown origin
86
FWB
full weight bearing
87
fx
fracture
88
G
good (muscle strength, balance)
89
GB
gallbladder
90
GI
gastrointestinal
91
gm
gram
92
GYN
gynecology
93
h, hr.
hour
94
H&H, H/H
hematocrit and hemoglobin
95
H&P
history and physical
96
HA, H/A
headache
97
Hb, Hgb
hemoglobin
98
HCVD
hypertensive cardiovascular disease
99
HEENT
head, ear, eyes, nose, throat
100
HEP
home exercise program
101
HI
head injury
102
HIV
human imlIlunodeficiency virus
103
HNP
herniated nucleus pulposus
104
HOB
head of bed
105
HR
heart rate
106
hr.
hour
107
hs
at bedtime
108
ht.
height
109
Ht
hematocrit
110
Htn
hypertension
111
Hx
history
112
I & 0
intake and output
113
ICU
intensive care unit
114
IM
intramuscular
115
imp.
impression
116
in.
inches
117
indep
independent
118
inf
inferior
119
IV
intravenous
120
kcal
kilocalories
121
kg
kilogram
122
KJ
knee jerk
123
KUB
kidney, ureter, bladder
124
L or l (lower case L)
liter
125
LFT or LT or a" L" in a circle
left
126
lb.
pound
127
LBP
low back pain
128
LE
lower extremity
129
LOC
loss of consciousness
130
LP
lumbar puncture
131
m
meter
132
max
maximal
133
MD
medical doctor; doctor of medicine
134
MED
minimal erythemal dose
135
Meds.
medications
136
MFT
muscle function test
137
m g
milligram
138
MI
myocardial infarction
139
min
minimal
140
min.
minutes
141
ml
milliliter
142
mm
millimeter
143
MMT
manual muscle test
144
mo.
month
145
mod
moderate
146
MP, MCP
metacarpalphalangeal
147
MS
multiple sclerosis
148
N
normal (muscle strength)
149
NDT
neurodevelopmental treatment
150
neg.
negative
151
N.H.
nursing home
152
noc
night, at night
153
npo
nothing by mouth
154
NSR
normal sinus rhythm
155
NWB
non-weight-bearing
156
0:
objective
157
OB
obsetrics
Latin obstare, "to stand by") is the health science that deals with pregnancy, childbirth, and postpartum period [1](including care of the newborn)
158
OBS
organic brain syndrome
159
od
once daily
160
O.P.
outpatient
161
O.R.
operating room
162
ORIF
open reduction, internal fixation
163
OT
occupational therapy, occupational therapist
164
OTR
occupational therapist (used to follow official signature of the occupational 17 therapist)
165
oz.
ounce
166
P
poor (muscle strength, balance)
167
P:
plan (treatment plan)
168
P.A.
physician's assistant
169
PA
posterior/anterior
170
para
paraplegia
171
pc
after meals
172
per
by/through
173
per os, p.o.
by mouth
174
PERRLA
pupils, equal, round, reactive to light and accommodation
175
P.H.
past history
176
p.m.
afternoon
177
PNF
proprioceptive neuromuscular facilitation
PNF or proprioceptive neuromuscular facilitation stretching, is a set of stretching techniques commonly used in clinical environments to enhance both active and passive range of motion with the ultimate goal being to optimize motor performance and rehabilitation
178
PNI
peripheral nerve injury
179
POMR
problem-oriented medical record
a method of recording data about the health status of a patient in a problem-solving system
180
pos.
positive
181
poss
possible
182
post
posterior
183
post-op
after surgery (operation)
184
PRE
progressive resistive exercise
185
pre-op
before surgery (operation)
186
prn
whenever necessary
"pro re nata"
187
PROM
passive range of motion
188
PSIS
posterior superior iliac spine
189
PT
physical therapy, physical therapist (used after therapist's signature; varies from facility to facility)
190
PT/PTT
protime/prothrombine time
191
Pt., pt.
patient
192
PTA
physical therapist assistant
193
PTA
prior to admission
194
PTB
patellar tendon bearing
195
PVD
peripheral vascular disease
196
PWB
partial weight bearing
197
q
every
198
qb
every day
199
qh
every hour
200
qid
four times a day
201
qn
every night
202
qt.
quart
203
®
right
204
RA
rheumatoid arthritis
205
RBC
red blood cell count
206
R.D.
registered dietician
207
re:
regarding
208
rehab
rehabilitation
209
reps
repititions
210
resp
respiratory, respiration
211
RN
registered nurse
212
R/O
rule out (In order to make a good diagnosis, the physician will try to rule the disease/condition named out; if he or she cannot, this will become the diagnosis.)
213
ROM
range of motion
214
ROS
review of systems
215
RROM
resistive range of motion
216
R.T.
respiratory therapist, respiratory therapy
217
Rx
treatment, prescription, therapy
218
SACH
solid ankle cushion heel
219
SCI
spinal cord injury
220
SC joint
sternoclavicular joint
221
sec.
seconds
222
SED
suberythemal dose
223
sig
directions for use, give as follows, let it be labeled
224
SI(J)
sacroiliac (joint)
225
SLE
systemic lupus erythematosus
is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage
226
SLR
straight leg raise
227
SNF
skilled nursing facility
228
SOAP
subjective, objective, assessment, plan
229
SOB
shortness of breath
230
S/P
status post (example: S/P hip fx means Pt. fx her hip in the recent past)
231
spec
specimen
232
stat.
immediately, at once
233
Sx
symptoms
234
T
trace (muscle strength)
235
tab
tablet
236
TB
tuberculosis
237
tbsp.
tablespoon
238
TENS, TNS
transcutaneous electrical nerve stimulator
239
THR
total hip replacement
240
TlA
transient ischemic attack
241
tid
three times daily
242
TKR
total knee replacement
243
TM(J)
temporomandibular (joint)
244
TNR
tonic neck reflex (also ATNR, STNR)
245
t.o.
telephone order
246
TPR
temperature, pulse & respiration
247
tsp.
teaspoon
248
TUR
transurethral resection
(TUR) of the bladder is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder.
249
UA
urine analysis
250
UE
upper extremity
251
UMN
upper motor neuron
252
URI
upper respiratory infection
253
US
ultrasound
254
UTI
urinary tract infection
255
UV
ultraviolet
256
VD
venereal disease
257
v.o.
verbal orders (example: v.o. Dr. Smith/your signature)
258
vol.
volume
259
v.s.
vital signs
260
w/c
wheelchair
261
W/cm2
watts per square centimeter
262
WBC
white blood cell count
263
wk.
week
264
WNL
within normal limits
265
wt.
weight
266
x
number of times performed
267
y/o or y.o
years old
268
yd.
yard
269
yr.
year
270
encephalo
pertaining to the brain
271
erythema /er·y·the·ma/
redness of the skin due to congestion of the capillaries
