Tag: SOAP note

Common Medical Abbreviations

Hello all!

This was a suggestion from a reader to list out some common abbreviations used in medical charting. By no means is it comprehensive, but a good place to start. If you are undergoing scribe training they should have a packet of abbreviations for you to learn; many of which will be similar. If you are in a medical professional school you will also be exposed to these terms. Hope this helps and good luck studying!

Common Charting:

  • CC: chief complaint
  • C/o: complains of
  • DDX: differential diagnosis
  • Dx: diagnosis
  • D/c: discharge or discontinue
  • HPI: history of present illness
  • h/o: history of
  • H&P: history and physical
  • ICU: intensive care unit
  • obs: observation unit
  • PMHx: past medical history
  • PSHx: past surgical history
  • All: allergies (not always used)
  • FHx: family history
  • ROS: review of systems
  • PE: physical exam/pulmonary embolism
  • MDM: medical decision making
  • NPO: nothing by mouth
  • PO: by mouth
  • PRN: as needed
  • qd: each day
  • q2h: every 2 hours
  • q3h: every 3 hours
  • qAM: every morning
  • qhs: every bedtime
  • qPM: every evening
  • BID: twice a day
  • TID: three times a day
  • QID: four times a day
  • qod: every other day
  • r/o: rule out
  • s/p: status post
  • nl: normal
  • WNL: within normal limits
  • Sx: symptoms
  • SubQ or SQ: subcutaneous
  • pt: patient

Common Symptoms/Complaints

  • F/C: fevers, chills
  • HL: hearing loss
  • PND: post-nasal drip/paroxysmal nocturnal dyspnea
  • CP: chest pain
  • SOB: shortness of breath
  • O2: oxygen
  • abd: abdominal
  • N/V: nausea/vomiting
  • N/V/D: nausea/vomiting/diarrhea
  • MSK: musculoskeletal
  • HA: headache
  • LOC: loss of consciousness
  • BM: bowel movement
  • MVA: motor vehicle accident

Physical Exam:

  • VSS: vital signs stable
  • RR: respiratory rate
  • HR: heart rate
  • SpO2: pulse ox
  • T or Temp: temperature
  • BP: back pain or blood pressure
  • HEENT: head, eyes, ears, nose, throat
  • AT/NC: atraumatic, normocephalic
  • PERRL: pupils equal, round, reactive to light
  • EOMI: extra-ocular movements intact
  • TM: tympanic membrane
  • EAC: external auditory canal
  • IAC: internal auditory canal
  • A&Ox3: alert and oriented x3
  • RRR: regular rate and rhythm
  • m/r/g: murmurs/rubs/gallops
  • tachy: tachycardic
  • brady: bradycardic
  • AKA: above the knee amputation
  • BKA: below the knee amputation
  • Ant: anterior
  • post: posterior
  • bil: bilateral
  • LUE: left upper extremity
  • RUE: right upper extremity
  • BUE: bilateral upper extremities
  • LLE: left lower extremity
  • RLE: right lower extremity
  • BLE: bilateral lower extremities
  • RUQ: right upper quadrant
  • LUQ: left upper quadrant
  • RLQ: right lower quadrant
  • LLQ: left lower quadrant
  • BPM: beats per minute
  • PAC: premature atrial contraction
  • PVC: premature ventricle contraction
  • CTAB: clear to auscultation bilaterally
  • s/nd/nt: soft, non distended, non-tender
  • c-spine: cervical spine
  • t-spine: thoracic spine
  • l-spine: lumbar spine
  • Fx: fracture
  • FB: foreign body
  • FHT: fetal heart tones
  • GI: gastrointestinal
  • GU: genitourinary
  • ICP: intracranial pressure
  • IM: intramuscular
  • IUD: intrauterine device
  • LMP: last menstrual period
  • NKA or NKDA: no known allergies or no known drug allergies

Labs and Imaging:

  • NSR: normal sinus rhythm
  • EKG: electrocardiogram
  • CXR: chest xray
  • CT: computed tomography
  • MRI: magnetic resonance imaging
  • Cx: culture
  • Bx: biopsy
  • FNA: fine needle aspiration
  • CBC: complete blood count
  • BMP: basic metabolic panel
  • CMP: comprehensive metabolic panel
  • LFT’s: liver function tests
  • ABG: arterial blood gas
  • LP: lumbar puncture
  • CSF: cerebral spinal fluid
  • ESR: erythrocyte sedimentation rate
  • EtOH: alcohol
  • H&H: hemoglobin and hematocrit
  • HCG: human chorionic gonadotropin
  • hct: hematocrit
  • Hgb or Hb: hemoglobin
  • KUB: kidneys, ureter, bladder (this is an X-ray)
  • LDH: lactate dehydrogenase
  • PT: prothrombin time
  • PTT: partial prothromboplastin time
  • UA: urinalysis
  • US: ultrasound
  • BUN: blood urea nitrogen
  • GFR: glomerular filtration rate

Common Diagnoses:

  • MI: myocardial infarction
  • CVA: cerebrovascular accident
  • DM: diabetes mellitus
  • NIDDM: non-insulin dependent diabetes mellitus
  • IDDM: insulin dependent diabetes mellitus
  • CAD: coronary artery disease
  • ACS: acute coronary syndrome
  • PID: pelvic inflammatory disease
  • SVT: supraventricular tachycardia
  • A fib: atrial fibrillation
  • UTI: urinary tract disease
  • URI: upper respiratory infection
  • SIDS: sudden infant death syndrome
  • SBO: small bowel obstruction
  • CA: cancer
  • ARDS: acute respiratory distress syndrome
  • AOM: acute otitis media
  • DT’s: delerim tremens
  • CHF: congestive heart failure
  • PNA: pneumonia
  • PTX: pneumothorax

Hope that was helpful!

Scribe Series: Full Chart Examples!

Hello hello!

I decided I was in a very giving mood and wanted to give some examples of full SOAP notes. Since a chunk of you who show up to my site are here for the scribing practice and explanations, I figured I’d try to give you some more resources.

I have added a blank or a general SOAP note template here. This full out SOAP note is pretty in-depth. It would likely be used more for general wellness exams at a family practice office, internal medicine visit, or possibly a pre-operative full H&P. Many other specialties do take the same format as this note, they just don’t necessarily have as much information or as detailed of information.

Here is an example of an ER note.  I based this one off of my posts *scribe series: HPI practice case 2*. Which you can check out by clicking the link.

Here is an example of an ENT focused note. It is not quite as in depth as the charts I used to write were simply because I can’t remember every detail of how I did those notes. The pathology for them as well is getting hazy too. I used to work in several ENT subspecialties and I have to tell you, this was one of the hardest scribing jobs I had. Each specialty was so incredibly specific yet all in the same small area of the body. I chose to do a hearing related one as neuro-otology was one of my favorite subspecialties. Rhinology/sinus was my second favorite, only because I then spent the most time here. It took me forever to cross train scribes as their providers also usually only worked 1-2 days a week. [Insert your favorite eye rolling emoji here].

Here is an example of an ortho follow up note.  This one is a little more rough (I know). It’s been a hot minute since I did an ortho note so take it with a grain of salt. But basically the first paragraph you want to summarize all the previous history/surgeries and the second HPI paragraph you want to give an update for how they are doing in the office the day you are seeing them. The goal is to continue to add on to the first paragraph with pertinent information from the last visit so you have it all in one note.

Here is an example of an urgent visit note . Say from a level 3 ER case, an urgent visit at the family/internal medicine office, or possibly at an urgent care.

What are some differences that you notice between these charting types? What are some similarities? Do you notice how the more focused notes don’t have as many ROS and PE systems as a full generalized well exam would?

Look at how I tend to word my HPI’s or how I might put things in the physical exam. There are definitely some findings that can go under multiple systems on the PE; pick one for that chart or try to pick one system that you would generally put it under.

I personally liked to bold the abnormal findings when doing charts in programs that do not automatically bold them or highlight them in red. As a scribe, this is a nice touch to help your provider or other medical staff see the abnormal findings more quickly. But by all means, this is not necessary to have in your chart.

*As a side note, these will be read only. You may feel free to print them off and mark them up. Or make a copy on your own drive and mess around with them.

Cheers!