SOAP Note Abbreviations

HEENT
normocephalic atraumatic NCAT
extra ocular movements intact EOMI
pupils equal, round, reactive to light, accommodation PERRLA
tympanic membrane intact TMI
septum and turbinates normal

CARDIO
regular rate and rhythm RRR
normal heart sounds S1, S2, no murmurs, gallops, or rubs

LUNGS
clear to auscultation CTA
normal lung sounds no wheezes, rhonchi, or rales

ABDOMEN
positive bowel sounds + BS
distended, non-tender
hepatospenomegaly
masses

BACK
spine
CVA tenderness

MSK
range of motion ROM
5/5 muscle strength
gait

EXTREMITIES
cyanosis
deformities
edema

NEURO
CN 2-12
Romberg
Pronator drift
tandem walking
sensation
deep tendon reflexes DTR

SPECIAL TESTS
straight leg raise SLR
urinary analysis UA
ultrasound US

DRUGS
once a day qd
twice a day bid
every 2 hours q2h
every 12 hours q12h
every night qhs
as needed prn