HOPS & SOAP Medical Assessment: Key Terms and Abbreviations for Clinicians

What does HOPS stand for?

History, Observation, Palpation, Special tests

What does SOAP stand for?

Subjective, Objective, Assessment, Plan

What does History mean in HOPS?

Asking the patient questions to learn what happened, where it hurts, and if they had the injury before.

What does Observation mean in HOPS?

Things you can see: bruising, swelling, redness, deformity, limping.

What does Palpation mean in HOPS?

Using hands to feel for pain, swelling, heat, tightness, or deformity.

What are Special Tests in HOPS?

Tests specific to diagnose injuries, like ligament or muscle strength tests.

What does Subjective mean in SOAP?

What the patient feels or reports; may not be measurable.

What does Objective mean in SOAP?

Observations and measurements the clinician can see or test.

What does Assessment mean in SOAP?

Clinician's evaluation or diagnosis based on findings.

What does Plan mean in SOAP?

Recommended course of treatment or rehab.

What does Hx stand for?

History

What does Tx stand for?

Treatment

What does Dx stand for?

Diagnosis

What does Fx stand for?

Fracture

What does Pt stand for?

Patient

What do + / - signify?

Positive / Negative

What does WNL stand for?

Within Normal Limits

What does C/O stand for?

Complains Of

What do R / L / B stand for?

Right / Left / Bilateral

What does PROM stand for?

Passive Range of Motion

What does AROM stand for?

Active Range of Motion

What does MMT stand for?

Manual Muscle Test

What does RROM stand for?

Resistive Range of Motion

What is Edema?

Swelling caused by excess fluid in tissue

What is Ecchymosis?

Bruising or discoloration

What is Effusion?

Swelling inside a joint

What is Atrophy?

Decrease in muscle size or strength

What is Hypertrophy?

Increase in muscle size

What is Flexion?

Bending a joint

What is Extension?

Straightening a joint