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EXPH 452
SOAP notes abrev.
160
Medical
Undergraduate 4
12/10/2016

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Cards

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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