Frequency
every 2 hours
q2h
immediately
stat
What the pt is reporting- symptoms
Subjective
Rx
prescription
ROM
range of motion
after meals
pc
I & O
intake and output
A record made after a visit to an urgent care
Clinic note
Tx
treatment
CPR
cardiopulmonary resuscitation
when necessary
prn
Chronic
An ongoing problem, not new
Part of record that includes a diagnosis/differential diagnosis
Assessment
Hx
history
as desired
ad lib
every night at bedtime
qhs
WNL
Within Normal Limits
Part of record that includes your physical assessment and lab work/ diagnostic test
Objective
Dx
diagnosis
nothing by mouth
npo
four times a day
qid
without
_
s
The P part of S.O.A.P
Plan
C/C
Chief Complaint
both sides
Bilateral