Communication & Abbreviations- ANSC 4410

S.O.A.P. components

Subjective, Objective, Assessment, Plan

Subjective

chief complaint, history, initial impressions/observations, clinical signs noted

Objective

vital signs, findings from exam, lab data & results, imaging results, recognition, review, and recording of other doctor’s observations, any other diagnostic data

Assessment

consolidation of subjective and objective data, problems list, differential diagnosis list, diagnosis, prognosis

Plan

course of action recommended to address the chief complaint, diagnosis, treatment, procedures (include risks), advise, instructions, follow up recommendations

AD

right ear

AS

left ear

AU

both ears

BAR

bright, alert, responsive

BID

twice daily

BG

blood glucose

Bx

Biopsy

C/S

culture and sensitivity

CBC

complete blood count

CC

chief complaint

CHEM

chemistry panel

Cs

clinical signs

D (abbrev.)

diarrhea

D/C

discontinue

DDX (DDx)

differential diagnosis

DNR

do not resuscitate

Dx

diagnosis

FB

foreign body

HBC

hit by car

Hct

hematocrit

Hx

history

M1

mild

M2

moderate

M3

severe

NPO

Nothing Per Os (no food or water)

NR

no response

OA

osteoarthritis

OD

right eye

OS

left eye

OU

both eyes

OVH

ovariohysterectomy

PROM

passive range of motion

PT

physical therapy

PU/PD

polyuric/polydypsic

PVx

prevention

Px

prognosis

QID

4 times daily

QD

every day

QOD

every other day

R/O

rule-out

RTO

returne(ed) to owner

Rx

prescription

SID

once daily

Tx

treatments

SOAP

subjective, objective, assessment, plan

Sx

surgery

TTJ

transfer to jesus

TTO

talked to owner

U (abbrev.)

urine

UR

UnRemarkable

URI

upper respiratory infection

UTD

up to date

UTI

urinary tract infection

V (abbrev.)

vomiting

Vax, Vx

Vaccines; vaccinate

V/D

vomiting; diarrhea

WCS

worse case scenario

WNL

within normal limits

WT

weight