Medical abbreviations for SOAP notes
118 common medical abbreviations used in SOAP and progress notes, grouped by section: history (CC, HPI, ROS), vital signs and exam (BP, SpO2, NAD, CTAB), labs, diagnoses (HTN, T2DM), plan and dosing (PRN, PO, BID, q6h) and mental health (SI, HI, A&Ox3). Plus the Joint Commission "Do Not Use" list and a note written both ways.
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Checked on 23 October 2026. General information, not clinical advice: follow your organization's approved abbreviation list. All examples are fictional.
Quick answer
- By SOAP section: Subjective uses CC, HPI, PMH, ROS, c/o, s/p, NKDA; Objective uses VS, BP, HR, RR, SpO2, NAD, HEENT, RRR, CTAB; Assessment uses Dx, DDx and diagnosis abbreviations such as HTN, T2DM and URI; Plan uses Rx, f/u, RTC, PRN, PO and BID.
- In orders and medication-related documentation, avoid the Joint Commission "Do Not Use" abbreviations and dose designations: U, IU, QD, QOD, trailing zeros, missing leading zeros, and MS / MSO4 / MgSO4. Write the word or number in full. See the measurement-precision exception below for trailing zeros outside medication documentation.
- Spell out anything ambiguous. PE, RA, CVA and LAD each have two common meanings. Follow your organization's approved abbreviation list.
Subjective and history (HPI, PMH)
| Abbreviation | Meaning | Note |
|---|---|---|
| CC | Chief complaint | The reason for the visit, ideally in the patient's words. |
| HPI | History of present illness | |
| OLDCARTS | Onset, location, duration, character, aggravating factors, relieving factors, timing, severity | A mnemonic for structuring the HPI. |
| PMH | Past medical history | |
| PSH | Past surgical history | |
| FH | Family history | |
| SH | Social history | |
| ROS | Review of systems | |
| Hx | History | |
| h/o | History of | |
| s/p | Status post (after a procedure or event) | For example, "s/p appendectomy 2019". |
| c/o | Complains of | |
| y/o | Years old | |
| pt | Patient | |
| x | For (a duration) or times | "Cough x 4 days". Write the unit. |
| w/, w/o | With, without | |
| NKDA | No known drug allergies | |
| NKA | No known allergies | |
| OTC | Over the counter | |
| LMP | Last menstrual period | |
| EtOH | Alcohol (ethanol) | Record the amount and frequency in words. |
| SOB | Shortness of breath | |
| DOE | Dyspnea on exertion | |
| CP | Chest pain | |
| N/V | Nausea and vomiting | |
| HA | Headache | |
| Sx | Symptoms |
Objective: vital signs and physical exam
| Abbreviation | Meaning | Note |
|---|---|---|
| VS | Vital signs | |
| BP | Blood pressure | |
| HR | Heart rate | |
| RR | Respiratory rate | |
| T | Temperature | Give the unit (F or C). |
| SpO2 | Oxygen saturation by pulse oximetry | |
| RA | Room air | "SpO2 98% on RA". Also used for rheumatoid arthritis, so spell out the diagnosis. |
| BMI | Body mass index | |
| Wt, Ht | Weight, height | |
| PE | Physical exam | Also used for pulmonary embolism; spell out the diagnosis. |
| NAD | No acute distress | |
| WNL | Within normal limits | Say what was examined; "WNL" alone documents little. |
| HEENT | Head, eyes, ears, nose and throat | |
| PERRLA | Pupils equal, round, reactive to light and accommodation | |
| EOMI | Extraocular movements intact | |
| TM | Tympanic membrane | |
| MMM | Moist mucous membranes | |
| JVD | Jugular venous distension | |
| RRR | Regular rate and rhythm | |
| CTAB | Clear to auscultation bilaterally | |
| NT/ND | Non-tender, non-distended | |
| CVA | Costovertebral angle | "No CVA tenderness". Also used for cerebrovascular accident; spell out stroke. |
| ROM | Range of motion | |
| DTR | Deep tendon reflexes | |
| CN II-XII | Cranial nerves 2 to 12 | |
| UE, LE | Upper extremity, lower extremity | |
| b/l | Bilateral | |
| LAD | Lymphadenopathy | Also used for the left anterior descending artery; spell out in cardiac notes. |
Labs, tests and imaging
| Abbreviation | Meaning | Note |
|---|---|---|
| CBC | Complete blood count | |
| BMP | Basic metabolic panel | |
| CMP | Comprehensive metabolic panel | |
| LFTs | Liver function tests | |
| TSH | Thyroid-stimulating hormone | |
| A1c | Hemoglobin A1c | |
| BG | Blood glucose | |
| UA | Urinalysis | |
| POC | Point of care (test done in the clinic) | |
| RADT | Rapid antigen detection test (for example for group A strep) | |
| ECG / EKG | Electrocardiogram | |
| CXR | Chest X-ray | |
| CT | Computed tomography | |
| MRI | Magnetic resonance imaging | |
| US | Ultrasound |
Assessment: diagnoses
| Abbreviation | Meaning | Note |
|---|---|---|
| Dx | Diagnosis | |
| DDx | Differential diagnosis | |
| r/o | Rule out | In outpatient coding, a "rule out" diagnosis is not coded; document the symptom or finding. |
| HTN | Hypertension | |
| T2DM / DM2 | Type 2 diabetes mellitus | |
| HLD | Hyperlipidemia | |
| CAD | Coronary artery disease | |
| CHF / HF | Congestive heart failure / heart failure | |
| AFib | Atrial fibrillation | |
| COPD | Chronic obstructive pulmonary disease | |
| OSA | Obstructive sleep apnea | |
| GERD | Gastroesophageal reflux disease | |
| CKD | Chronic kidney disease | Give the stage. |
| UTI | Urinary tract infection | |
| URI | Upper respiratory infection | |
| OA | Osteoarthritis | |
| LBP | Low back pain |
Plan, orders and follow-up
| Abbreviation | Meaning | Note |
|---|---|---|
| Tx | Treatment | |
| Rx | Prescription | |
| f/u | Follow-up | |
| RTC | Return to clinic | Give the interval. |
| ED | Emergency department | |
| NPO | Nothing by mouth | |
| PT, OT | Physical therapy, occupational therapy | |
| PRN | As needed | For a medication, add what it is for, for example "PRN pain". |
| ASAP | As soon as possible |
Dosing frequency and route
| Abbreviation | Meaning | Note |
|---|---|---|
| PO | By mouth | |
| SL | Sublingual (under the tongue) | |
| IM | Intramuscular | |
| IV | Intravenous | |
| BID | Twice a day | Not necessarily every 12 hours; write "every 12 hours" if that is meant. |
| TID | Three times a day | |
| QID | Four times a day | |
| q4h, q6h, q8h | Every 4, 6 or 8 hours | |
| AC, PC | Before meals, after meals | |
| mg, mL | Milligram, milliliter | Use mL rather than cc (see below). |
Mental health and behavioral health
| Abbreviation | Meaning | Note |
|---|---|---|
| MSE | Mental status exam | |
| A&Ox3 | Alert and oriented to person, place and time | A&Ox4 adds situation (or event). Say which domains when it matters. |
| SI | Suicidal ideation | Document what was asked and the answer, for example "denies SI". |
| HI | Homicidal ideation | |
| AH, VH (AVH) | Auditory hallucinations, visual hallucinations | |
| MDD | Major depressive disorder | |
| GAD | Generalized anxiety disorder | Not the same as the GAD-7 screening score. |
| PTSD | Post-traumatic stress disorder | |
| ADHD | Attention-deficit/hyperactivity disorder | |
| SUD | Substance use disorder | |
| PHQ-9, GAD-7 | Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 (screening measures) | Record the score and the date. |
| CBT, DBT | Cognitive behavioral therapy, dialectical behavior therapy |
The Joint Commission "Do Not Use" list
The Joint Commission's official "Do Not Use" list applies to all orders and all medication-related documentation, whether handwritten, entered as free text in an electronic record, or on pre-printed forms. Accredited organizations must keep these abbreviations out of that documentation.
| Do not use | Potential problem | Use instead |
|---|---|---|
| U, u (unit) | Mistaken for 0 (zero), the number 4 or cc | Write "unit" |
| IU (International Unit) | Mistaken for IV (intravenous) or the number 10 | Write "International Unit" |
| Q.D., QD, q.d., qd (daily); Q.O.D., QOD, q.o.d., qod (every other day) | Mistaken for each other; the period after the Q can be read as an I, and the O as an I | Write "daily" and "every other day" |
| Trailing zero (X.0 mg)*; lack of a leading zero (.X mg) | Decimal point is missed: 1.0 mg read as 10 mg, .5 mg read as 5 mg | Write X mg and 0.X mg |
| MS, MSO4, MgSO4 | MS can mean morphine sulfate or magnesium sulfate; MSO4 and MgSO4 are confused with each other | Write "morphine sulfate" or "magnesium sulfate" |
* A trailing zero may be used only where it is needed to show the level of precision of a reported value, such as lab results, imaging studies that report the size of lesions, or catheter and tube sizes. It may not be used in medication orders or other medication-related documentation.
The Joint Commission also lists symbols and abbreviations it may add in the future, such as > and <, @, cc (write mL) and the microgram symbol (write mcg). The Institute for Safe Medication Practices (ISMP) publishes a longer list of error-prone abbreviations, symbols and dose designations; for example, it recommends "subcutaneous" or "SUBQ" (all uppercase, without spaces or periods) instead of SC or SQ, and "discharge", "discontinue" or "stop", as appropriate, instead of D/C. Writing "at bedtime" in full also avoids ambiguity. Check both lists and your organization's own policy.
Example: an abbreviated SOAP note and the same note written out
A fictional, shortened visit for illustration (no real patient). It is not treatment guidance.
Fictional example, abbreviated
S
34 y/o c/o sore throat x 3 days, subjective fever. No cough. NKDA.
O
T 101.0 F, HR 92, BP 118/76, RR 16, SpO2 99% on RA. NAD. Tonsillar exudate, tender anterior cervical LAD. Lungs CTAB. POC RADT positive.
A
Group A streptococcal pharyngitis.
P
Amoxicillin 500 mg PO BID x 10 days. Fluids, acetaminophen PRN fever or pain. RTC if not improving in 48 to 72 hours.
The same note, written out
Subjective
34-year-old who complains of a sore throat for 3 days, with subjective fever. No cough. No known drug allergies.
Objective
Temperature 101.0 F, heart rate 92, blood pressure 118/76, respiratory rate 16, oxygen saturation 99% on room air. No acute distress. Tonsillar exudate, tender anterior cervical lymphadenopathy. Lungs clear to auscultation bilaterally. Point-of-care rapid strep antigen test positive.
Assessment
Group A streptococcal pharyngitis.
Plan
Amoxicillin 500 mg by mouth twice a day for 10 days. Fluids, acetaminophen as needed for fever or pain. Return to clinic if not improving in 48 to 72 hours.
Both versions are acceptable to most clinicians. The written-out version is easier for a patient reading the note in a portal, and it avoids the two-meaning abbreviations (RA, LAD). For more full examples, see the family medicine SOAP note examples, and for diagnosis codes, the common ICD-10-CM codes for primary care SOAP notes. Nurses use the same shorthand in charting; see nursing notes examples for SOAPIE, DAR and PIE notes.
Tips for using abbreviations safely
- Use your organization's list. Most hospitals and practices keep an approved abbreviation list; use it alongside the "Do Not Use" rules and their scope described above.
- Spell out medication instructions. Dose, unit, route and frequency are where abbreviations cause the most harm: write "daily", "unit" and "every other day".
- Spell out two-meaning abbreviations. PE (physical exam or pulmonary embolism), RA (room air or rheumatoid arthritis), CVA (costovertebral angle or stroke), LAD (lymphadenopathy or an artery).
- Write the diagnosis in words in the Assessment. A code is chosen from what you write, and "T2DM, A1c 8.6" says less than "type 2 diabetes with hyperglycemia".
- Record risk findings in full. For suicidal or homicidal ideation, write what was asked, what was said and the plan.
Draft medical SOAP notes with MentalNote
MentalNote records the visit in your browser with the patient's consent and drafts a Medical SOAP note: Chief Complaint, History of Present Illness, Review of Systems, Objective, a numbered Assessment and Plan. MentalNote does not assign codes; the clinician chooses codes. It writes "Not documented." for anything the visit did not cover. You check, edit and sign every note, including any abbreviations.
MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month with no credit card; Premium is $99/month or $990/year (pricing). You can open a fictional medical visit in the editor without signing up. See also the Medical SOAP note generator.
Sources
- The Joint Commission. Official "Do Not Use" List (abbreviations, acronyms and symbols), with the list of possible future inclusions. jointcommission.org.
- Institute for Safe Medication Practices (ISMP). List of Error-Prone Abbreviations, Symbols, and Dose Designations. ismp.org.
Medical abbreviations: common questions
What does SOAP stand for in medical notes?
SOAP stands for Subjective, Objective, Assessment and Plan. Subjective is what the patient reports (chief complaint, HPI, history, ROS), Objective is what you measure and observe (vital signs, exam, test results), Assessment is your diagnosis or impression, and Plan is what happens next (treatment, orders, education, follow-up).
Which abbreviations should not be used in orders and medication-related documentation?
The Joint Commission's official "Do Not Use" list covers U or u for unit, IU for International Unit, Q.D. and Q.O.D. (and their variants) for daily and every other day, a trailing zero (X.0 mg) or a missing leading zero (.X mg), and MS, MSO4 or MgSO4 for morphine sulfate or magnesium sulfate. Write the full word or number instead. The list applies to orders and medication-related documentation, whether handwritten, typed as free text or on pre-printed forms. Outside medication documentation, trailing zeros may be necessary to show measurement precision; see the exception above.
What does PRN mean?
PRN means "as needed" (from the Latin pro re nata). In a medication order, add the reason and any limits, for example "ibuprofen 400 mg PO every 6 hours PRN pain, maximum 4 doses a day".
What is the difference between BID, TID and QID?
BID means twice a day, TID three times a day and QID four times a day. They are not the same as every 12, 8 or 6 hours: if the dose must be evenly spaced, write the hourly interval (for example q12h or "every 12 hours").
What does A&Ox3 mean?
A&Ox3 means the patient is alert and oriented to person, place and time. A&Ox4 adds orientation to situation (or event). Because people use the numbers differently, it is clearer to name the domains, for example "alert, oriented to person, place, time and situation".
What do SI and HI mean in a note?
SI means suicidal ideation and HI means homicidal ideation. "Denies SI/HI" records that the patient was asked and said no. If either is present, document what was said, the risk assessment and the safety plan in full words rather than abbreviations.
Can I use abbreviations in SOAP notes?
Yes, if they are standard and on your organization's approved list, and you follow the scope and trailing-zero exception described in the Joint Commission section above. Spell out terms that have more than one meaning (such as PE, RA, CVA or LAD) and anything a patient, payer or covering clinician could misread. Patients can often read their notes in a patient portal, so plain language helps.
Can MentalNote draft a medical SOAP note?
Yes. MentalNote records the visit in your browser with the patient's consent and drafts a Medical SOAP note with Chief Complaint, History of Present Illness, Review of Systems, Objective, and a numbered Assessment and Plan. You check, edit and sign every note. MentalNote is HIPAA-compliant, with a BAA included on every plan; the free plan includes 5 web-app scribe sessions a month, and Premium is $99/month or $990/year.
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