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EXPH 452
SOAP notes abrev.
160
Medical
Undergraduate 4
12/10/2016
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Term
What does the S in SOAP stand for?
 Definition
Subjective
Term
what does the O in SOAP stand for?
 Definition
Objective
Term
What does the A in SOAP stand for ?
 Definition
Assessment
Term
What does the P in SOAP stand for?
 Definition
Plan
Term
ABI
 Definition
acquired brain injury
Term
afib
 Definition
atrial fibrillation
Term
AAROM
 Definition
active assistive range of motion
Term
abd
 Definition
abduction
Term
AC joint
 Definition
acromioclavicular joint
Term
ACL
 Definition
anterior cruciate ligament
Term
add
 Definition
adduction
Term
ADL
 Definition
activities of daily living
Term
ad lib
 Definition
at discretion
Term
adm
 Definition
admission
Term
AE
 Definition
above elbow
Term
AFO
 Definition
ankle foot orthosis
Term
AIIS
 Definition
anterior inferior iliac spine
Term
AK
 Definition
above knee
Term
a.m.
 Definition
morning
Term
amb
 Definition
ambulation
Term
ant
 Definition
anterior
Term
AP
 Definition
anterior posterior q
Term
ARF
 Definition
acute renal failure
Term
asap
 Definition
as soon as possible
Term
ASCVD
 Definition
arteriosclerotic cardiovascular disease
Term
ASIS
 Definition
anterior superior iliac spine
Term
assist
 Definition
assistance
Term
B/S
 Definition
bedside
Term
BE
 Definition
below elbow
Term
bid
 Definition
twice a day
Term
B or bilat
 Definition
bilateral
Term
BK
 Definition
below knee
Term
BOS
 Definition
base of support
Term
BP
 Definition
blood pressure
Term
bpm
 Definition
beats per minute
Term
C/o
 Definition
complains of
Term
CA
 Definition
cancer
Term
CABG
 Definition
coronary artery bypass graft
Term
CAD
 Definition
coronary artery disease
Term
CC
 Definition
chief complaint
Term
CHF
 Definition
congestive heart failure
Term
CO
 Definition
cardiac output
Term
CO2
 Definition
carbon dioxide
Term
cont
 Definition
continue
Term
COPD
 Definition
chronic obstructive pulmonary disease
Term
CP
 Definition
cerebral palsy
Term
D/C
 Definition
discontinued/discharge
Term
DJD
 Definition
degenerative joint disease
Term
DM
 Definition
diabetes mellitus
Term
DOB
 Definition
date of birth
Term
DOE
 Definition
dyspnea on exertion
Term
DVT
 Definition
deep vein thrombosis
Term
Dx
 Definition
diagnosis
Term
eval
 Definition
evaluation
Term
ext
 Definition
extension
Term
FH
 Definition
family history
Term
flex
 Definition
flexion
Term
ft.
 Definition
foot
Term
FUO
 Definition
fever of unknown origin
Term
FWB
 Definition
full weight bearing
Term
fx
 Definition
fracture
Term
h, hr
 Definition
hour
Term
H&P
 Definition
history and physical
Term
h/o
 Definition
history of
Term
HCVD
 Definition
hypertensive cardiovascular disease
Term
HR
 Definition
heart rate
Term
hs
 Definition
at bedtime
Term
ht.
 Definition
height
Term
Htn or HTN
 Definition
hypertension
Term
Hx
 Definition
history
Term
IADL
 Definition
instrumental activities of daily living
Term
IDDM
 Definition
insulin-dependent diabetes mellitus
Term
IM
 Definition
intramuscular
Term
in.
 Definition
inches
Term
indep
 Definition
independent
Term
inf
 Definition
inferior
Term
IV
 Definition
intravenous
Term
KAFO
 Definition
knee-ankle-foot arthrosis
Term
kg
 Definition
kilogram
Term
L
 Definition
left
Term
lat
 Definition
lateral
Term
lb.
 Definition
pound
Term
LBP
 Definition
low back pain
Term
LE
 Definition
lower extremity
Term
LOC
 Definition
loss/level of consciousness
Term
m
 Definition
meter
Term
max
 Definition
maximal
Term
Meds.
 Definition
medication
Term
MI
 Definition
myocardial infarction
Term
min.
 Definition
minute
Term
Mo.
 Definition
month
Term
mod
 Definition
moderate
Term
neg.
 Definition
negative
Term
NIDDM
 Definition
non-insulin-dependent diabetes mellitus
Term
noc
 Definition
night
Term
NWB
 Definition
non weight bearing
Term
OA
 Definition
osteoarthritis
Term
od
 Definition
once daily
Term
O.P
 Definition
out patient
Term
P
 Definition
poor
Term
P.A.
 Definition
physician assistant
Term
para
 Definition
paraplegia
Term
PCL
 Definition
posterior cruciate ligament
Term
per
 Definition
by/through
Term
P.H
 Definition
past history
Term
PMH
 Definition
past medical history
Term
PNF
 Definition
proprioceptive neuromuscular facilitation
Term
pos
 Definition
positive
Term
post
 Definition
posterior
Term
PRE
 Definition
progressive-resistive exercise
Term
prn
 Definition
whenever necessary, as often as necessary
Term
PROM
 Definition
passive range of motion
Term
PSIS
 Definition
posterior superior iliac spine
Term
pt
 Definition
patient
Term
PWB
 Definition
partial weight bearing
Term
q
 Definition
every
Term
qid
 Definition
four times a day
Term
qh
 Definition
every hour
Term
qn
 Definition
every night
Term
R
 Definition
right
Term
RA
 Definition
rheumatoid arthritis
Term
rehab
 Definition
rehabilitation
Term
reps
 Definition
repetitions
Term
R/O
 Definition
rule out
Term
ROM
 Definition
range of motion
Term
RR
 Definition
respiratory rate
Term
RROM
 Definition
resistive range of motion
Term
Rx
 Definition
intervention plan / prescription/ therapy
Term
SCI
 Definition
spinal cord injury
Term
sec
 Definition
second
Term
sig
 Definition
directions for use , five as follows
Term
SI (J)
 Definition
sacroiliac joint
Term
SLR
 Definition
straight leg raise
Term
SOAP
 Definition
subjective objective assessment plan
Term
SOB
 Definition
shortness of breath
Term
S/P
 Definition
status post
Term
stat
 Definition
immediately
Term
sup
 Definition
superior
Term
Sx
 Definition
symptoms
Term
TBI
 Definition
traumatic brain injury
Term
THA
 Definition
total hip arthroplasty
Term
ther ex
 Definition
therapeutic exercise
Term
tid
 Definition
three times a day
Term
TKA
 Definition
total knee arthroplasty
Term
TPR
 Definition
temperature, pulse and respiration
Term
Tx
 Definition
traction
Term
UE
 Definition
upper extremity
Term
URI
 Definition
upper respiratory infection
Term
UTI
 Definition
urinary tract infection
Term
v.s.
 Definition
vital signs
Term
w/c
 Definition
wheelchair
Term
wk
 Definition
week
Term
wt
 Definition
weight
Term
x
 Definition
number of times performed
Term
y/o
 Definition
years old
Term
+1,+2 etc
 Definition
how many ppl needed for assistance
Term
information received from the patient that is relevant to the patients present condition. this belongs in the _ section
 Definition
subjective
Term
current conditions/ complaints. prior level of function, patients goals, history, employment status, living environment, general health status, health habits , family health history, functional status, activity level, medical history, medications, growth and development, other clinical tests and response to treatment intervention belongs in the _ section
 Definition
subjective
Term
the results of test and measures as well as the therapists objective observation are placed in the _ section of SOAP notes
 Definition
objective
Term
evaluation, diagnosis and prognosis are part of the _ section
 Definition
assessment
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