Abbreviations for Chart or S



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

(-up to

(-down to

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download