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29 Terms
S (subjective)
patient’s experiences, personal views, or feelings
O (objective)
Observable signs & the results of tests that the clinician has performed
A (Assessment)
Evaluation of the patient’s signs/symptoms & progress
P (Plan)
Determination of how to proceed or alter the plan of care
pt
patient
CC
chief complaint
y.o.
year old
c/o
complains of
WDWN
well developed & well nourished
CP
chest pain
WNL
within normal limits
Hx
history
s/p
status post
sx
symptoms
R/o
rule out *needs to be determined
D/C
Discharge/discontinue
SOB
shortness of breath
RRR
Regular rate & rhythm
T
temperature
UE
upper extremity
LE
lower extremity
R
respiration
BP
blood pressure
BP
blood pressure
P
pulse
ETOH
Alcohol
NKDA
No known drug allergies
RTC
Return to clinic
RTO
Return to office
Note 
Flashcards (31)