Medical Documentation
The Prior history of injuries goes in this part of the SOAP note.
What is Subjective?
This is the abbreviation for the word Negative.
- or NEG
This term means when a skins surface is scraped away.
What is Abrasion?
This Prefix means large and visible to the naked eye.
What is Macro?
This Suffix means the study of.
What is Ology?
The Clinical Diagnosis goes in this part of the SOAP note.
What is Assessment?
This is the abbreviation for the word rule out .
R/O
This term means a fluid filled sac.
What is Bursa?
This prefix means High or above normal.
What is Hyper?
This Suffix means the love of.
What is Philia?
The observation goes in this part of the SOAP note.
This is the abbreviation for the word pain.
What is P! or pn?
This term means when there is swelling in the tissue.
What is Edema?
What is Eu/Normo?
This Suffix means the fear of.
What is Pholola?
All of your goals goes in this part of the SOAP note.
What is Plan?
This is the abbreviation for the word Active Range Of Motion.
What is AROM?
This term means when there is a break in the bone.
What is Fracture?
This Prefix means absent or lacking.
What is A/An?
This Suffix means Pressure
This color ink can ONLY be used when doing a SOAP note.
What is Black Ink?
This is the abbreviation for the word Mechanism of Injury.
What is MOI?
This term means a collection of blood or blood tumor.
What is Hematoma?
This Prefix means large or larger than average.
What is Megalo?
This Suffix means Carbon Dioxide.
What is Capnea?