Abbreviations for Chart or S.O.A.P. Notes
@-at
ADL-activities of daily living
AMB-ambulatory
A+O-alert and oriented
ARDS-adult respiratory distress syndrome
ASCVD-arteriosclerotic cardiovascular disease
ASHD-arteriosclerotic heart disease
ASST-assistance
BID-twice per day
BP-blood pressure
C-with
CA-cancer
CAD-coronary artery disease
CAHD-coronary arteriosclerotic heart disease
CAT-computerized axial tomography
C/B-characterized by
CCU-coronary care unit
CHF-congestive heart failure
CHR-chronic
CNS-central nervous system
C/O-complains of
CONV-convalescent
COPD-chronic obstructive pulmonary disease
CVA-cerebral-vascular accident; stroke
D/C or DC-discharge
DC’d-discontinued
DM-diabetes mellitus
DNR- do not resuscitate
DX-diagnosis
D or DY-day
ETOH-alcohol
EVAC-evacuation
FO-field of
FREQ-Frequency
FUO-fever unknown origin
FX-fracture
GT-gastrostomy tube
HA-headache
HEENT-head, eyes, ears, nose, throat
HEMI-hemiplegia, hemisphere, hemiparesis
HOH-hard of hearing
H + P-history and physical
H/HR-hour
HTN-hypertension (high blood pressure)
HX-history
I-independent
ICF-intermediate care facility
ICH-intracranial hemorrhage
ICU-intensive care unit
ID-identify
IMP-impression
IV-intravenous
(L) or L-left side
LLE-left lower extremity
LLL-left lower lobe (left lung, lower lobe)
LTG-long term goal
LUL-left upper lobe (left lung, upper lobe)
LUE-left upper extremity
MAX-maximum
MAX A-maximum assistance
MI-myocardial infarction
MIN-minimum
MIN A-minimal assistance
MOD-moderate
MOD A-moderate assistance
MO or MOS-months
MRI-magnetic resonance imaging
MRSA-multi drug resistant staphylococcus aurieus
MSW-master social work
NC-no change
NEG-negative
NG-nasogastric
NICU-neonatal intensive care unit
NPO-nothing by mouth
O2 or O2-oxygen
O2 SAT or O2 SAT-oxygen saturation level
OCC-occasional
O-M-oral motor
OP-out patient
P-post
PCG-primary caregiver
PEG-percutaneous endoscopic gastrostomy (surgical procedure for G-tube placement)
PO-post operative or by mouth
POS-positive
PROG-prognosis
PRN-as needed
PVD-peripheral vascular disease
PX-problem
Q or Qs-question/questions
Q’D-questioned
QD-once per day
QID-four times per day
(R) or R-right side
R/I-reverse isolation
RLE-right lower extremity
RLL-right lower lobe (right lung, lower lobe)
RUE-right upper extremity
RUL-right upper lobe (right lung, upper lobe)
S or S-without
SAH-subarachnoid hemorrhage
SDAT-senile dementia of the Alzheimer’s type
SNF-skilled nursing facility
S/P-status post
STAT-immediately
ST or STG-short term goal
SX-surgery
TID-three times per day
TMJ-temporal mandibular joint
TO-telephone order
TPN-total parenteral nutrition
TX or RX-treatment
URI-upper respiratory infection
UTI-urinary tract infection
W/C-wheel chair
WBC-white blood cell
WFL-within functional limits
WK/WKS-week/weeks
WNL-within normal limits
X-times; duration
Y/O-years old
YR/YRS-year/years
20-due to (secondary to)
∆-change
↑-increase, improve
↓-decrease; diminish
ä-up to
æ-down to