What's the Abbreviation?
Blood Pressure
BP
Pt co abd pain
Patient complains of abdominal pain
Height, weight, blood pressure, and temp belong in this SOAP section
Objective
How do you correct a mistake?
Cross it through with a single line, write the correct information and annotate with initials and date
Can be mistaken for a zero, use "unit"
Last Menstrual Period
LMP
Pt has hx of thyroids, has also had thyroid sx
Patient has history of thyroids, has also had thyroid symptoms
This SOAP section includes the chief complaint and history
Subjective
How do you sign a chart note?
PNV
Prenatal vitamins, often mistaken as penicillin
With / Without
C (with a line over it)
S (with a line over it)
Pt has gone s̄ menstruation for 6 months, LMP 07/15/2025
Patient has gone without menstruation for 6 months, last menstrual period 07/15/2025
Objective
What is undocumented care?
If it isn't documented, legally this means it didn't happen.
x1
Administer once, mistaken for administer for 1 day
Appearance, pulse, grimace, activity, respiration
APGAR
Pt takes 15 mg Vicodin tid
Patient takes 15 mg Vicodin three times day
The providers diagnosis is documented in this SOAP section
Assessment
This should always be included when documenting medications
Medication name, dose, route, and frequency
APAP
Acetaminophen (Tylenol), not recognized as acetaminophen
Antibiotics
Abx
Patient has taken over the counter nausea medication as needed for the past week. Patient has been nothing by mouth for the past 6 hours prior to surgery.
Pt education, follow up instructions and treatments are documented here
Plan
Temperature vital signs should always include units of what measurement
Farenheit (F) or Celsius (C)
IJ
Injection, mistaken as IV or inter jugular