Common Medical Abbreviations

SOAP Note Parts

CC ROS PE HEENT Dx SH or SHx NKDA Chief Complaint Review of Systems Physical Exam Head Ears Eyes Nose Throat Diagnosis Social History No Known Drug Allergies HPI PMH c/o DOB FH or FHx SurgHx S/Sx History of Present Illness Past Medical History Complains of Date of Birth Family History Surgical History Signs/Symptoms

Vitals
RR HR Wt IBW Respiratory Rate Heart Rate Weight Ideal Body Weight T BP Ht ABW Temperature Blood Pressure Height Actual Body Weight

Lab Findings
ABG CBC Hgb SCr LDL TG UA VS Arterial Blood Gas Complete Blood Count Hemoglobin Serum Creatinine Low Density Lipoprotein Triglyceride Urine Analysis Vital Signs BUN H/H Hct CrCl HDL TC WBC WNL Blood Urea Nitrogen Hemoglobin/Hematocrit Hematocrit Creatinine Clearance High Density Lipoprotein Total Cholesterol White Blood Count Within Normal Limits
Justine E. Dickson, PharmD, TTS

Common Medical Abbreviations

Head Ears Eyes Nose Throat
EOMI IOP OD/OS Extraocular Muscles Intact Intraocular Pressure Right/Left Eye HA PERRLA OU Headache Pupils Equally Round and Reactive to Light and Accommodation Both Eyes

Cardiovascular
MI MRG ICD CP MVR RRR DBP CCE Myocardial Infarction Murmurs/Rubs/Gallops Implantable Cardioverter-Defibrillator Chest Pain Mechanical Valve Replacement Regular Rate and Rhythm Diastolic Blood Pressure Clubbing//Cyanosis/Edema CAD CABG CHF HTN NSR SBP HLD 3+ Coronary Artery Disease Coronary Artery Bypass Graft Congestive Heart Failure Hypertension Normal Sinus Rhythm Systolic Blood Pressure Hyperlipidemia Measure of pitting edema

Respiratory
DOE CTAB URI Dyspnea on Exertion Clear to Auscultation Bilaterally Upper Respiratory Infection COPD SOB PNA Chronic Obstructive Pulmonary Disease Shortness of Breath Pneumonia

Justine E. Dickson, PharmD, TTS

Common Medical Abbreviations

Medication Abbreviations
APAP NSAID HAART BB SNRI ASA PPI ARB Acetaminophen Non-steroidal Anti-Inflammatory Drug Highly Active Antiretroviral Therapy Beta Blockers Serotonin-Norepinephrine Reuptake Inhibitor Aspirin Proton Pump Inhibitor Angiotensin Receptor Blocker Abx BCP or OCP ACEI CCB SSRI PCN MVI OTC Antibiotics Birth Control Pill or Oral Contraceptive Pill Angiotensin Converting Enzyme Inhibitor Calcium Channel Blocker Selective Serotonin Reuptake Inhibitor Penicillin Multivitamin Over-the-Counter

Miscellaneous
ADE/ADR CVA s/p MVA DVT EtOH LOS NAD PPD A&Ox3 Adverse Drug Events/Reaction Cerebrovascular Accident Status post Motor Vehicle Accident Deep Vein Thrombosis Alcohol Length of Stay No Acute Distress Packs per day Alert and Oriented CKD d/c GSW DNR PE y/o POD NPO PRN AKA or BKA Chronic Kidney Disease Discontinue or Discharge Gun Shot Wound Do Not Resuscitate Pulmonary Embolism Years Old Post-op Day Nothing by Mouth As needed Above or Below
Justine E. Dickson, PharmD, TTS

Common Medical Abbreviations

I&O BRBPR CNII-XII intact ESRD N/V/D RUQ RA GI (to person, place, time) Ins and Outs Bright Red Blood Per Rectum Cranial Nerves II-XII intact End Stage Renal Disease Nausea/Vomiting/Diarrhea Right Upper Quadrant Rheumatoid Arthritis Gastrointestinal ARF AKI CXR GERD UE & LE OA TIA CNS Knee Amputation Acute Renal Failure Acute Kidney Injury Chest X-Ray Gastroesophageal Reflux Disease Upper/Lower Extremity Osteoarthritis Transient Ischemic Attack Central Nervous System

Justine E. Dickson, PharmD, TTS