Abbreviations
BID
Twice daily
Subjective, objective, assessment, and plan
High blood pressure
Hypertension
Edema
Swelling
Crepitus
"Joints crackling"
TID
Three times a day
What goes in S?
HPI, ROS
HBP
High blood pressure
Bradycardia
Slow heart rate
swelling
Inflammation or edema
WNL
Within normal limits
What goes in O?
Physical exam
Diplopia
Double vision
Emesis
Vomiting
Ecchymosis
Bruise
NWB
Non weight bearing
What goes in A/P?
Assessment, plan, instructions
Tinnitus
Ringing in ears
Tachycardia
Fast heart beat
Partial dislocation
Subluxation
HI
Head injury
True or False? The SOAP note is universal to all healthcare providers
True!
N/T
Numbness and tingling
Atrophy
muscle wasting away (deteriorating)
Feeling ill