20ll-2012 Orientation Guide for COMLEX-USA Level2-PE

SOAP NOTE

Gommon Abbreviations

It is recommended that you print out names and terms rather than abbreviate when writing your SOAP notes. However, if you desire, you may use common abbreviations when writing your notes, similar to those listed below. Avoid abbreviations that miqht lead to medical errors.
Abd AIDS ETOH b BUN BMI CCU CPR CVA Cspine CXR cc: COPD CTA c/o CBC CT CHF CABG DTR DM ENT ECG or EKG ED EMT E EOM Ext FH f or ? F Gl GU HEENT HVLA hx h/o HIV HTN JVD KUB LMP L
abdomen acquird immune deliciency syndrome
alcohol

black
blood ursa nitrogen

body mass index

cardiac care unit

cardiopulmonary resuscitation
ceaebrovascular accident

cervicalspane

chestx-ray
chief complaint chronic obstructive pulmonary disease clear to auscultation complaining of complete blood count computed tomography congestive heart failure coronary artery bypass grafting
deep tendon reflexes

diabetes mellitus
ears, nose and throat

ebctrocardiogram emergency department emergency medical technician eltended

extraocular muscles

extremilies family history femate flexed gastrointestinal genitourinary

head, eyes, ears, nose and throat high velocity, low amplitude history history of

LP lumbar puncture Lspine lumbar spine MRI magnetic resonance imaging m or d mate meds medications MVA motor vehiclo accident Ml myocardial infarction negative Neulo neurologic NKA no known allergies NKDA no known drug allergies NIDDM noninsulin-dependenldiabetesmellitus NSR normalsinus rhythm po ora y OMT osteopathicmanipulativekealment ppd packs per day partial thromboplastin timo PTT PMH past medical history PSH past surgical history physical examination PE + positive prothrombin time PT DUoils eaual. ract to lioht and PERLA ici:ommbaation ROM range of motion RBC red blood cells RRR reglrlar rate and rhythm ROS review of systems R right ROT rotated RO rub out SB side bent SH sociat history Tspine thoracic spine TIA kansient ischemic attack US uhasound URI upper respiratory tract infeclion U/A udnalysis WBC WNL O Yo
whlte btood cetts within normat ttmits without or no
year-old

hunan immunodellciency virus

hypertension Jugular venous distention kidney, ureter, and bladder last menstrual period

left

lt