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Chapter 2

SOAP, Records, & Abbreviations

TermDefinition
QID means... four times a day (quater in die)
QHS means... each night (quaque hora somni)
SOAP is an abbreviation for... S-subjective, O-objective, A-assessment, P-plan
NKDA is an abbreviation for... no known drug allergies
The 4 general parts of a medical record are called... the SOAP note
Which part of the medical record includes the patients chief complaint in their own words? Subjective
WNL means... within normal limits
SIG means... label (signa)
A record taken after the patient has reported their health history and has been physically examined is called... an Admission Summary
The sagittal plane divides the... right and left sides of the body
Created by: tasiaowens
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