Common Abbreviations
- Hx — History
- Dx — Diagnosis
- Tx — Treatment
- Rx — Prescription
- Sx — Symptoms
- ROM — Range of Motion
- ADL — Activities of Daily Living
- MMI — Maximum Medical Improvement
- PRN — As needed (pro re nata)
- QD/BID/TID/QID — Once/twice/three times/four times daily
- WNL — Within Normal Limits
- C/O — Complains of
- R/O — Rule out
- F/U — Follow-up
Understanding SOAP Notes
Most clinical encounters are documented in SOAP format:
- S (Subjective) — What the patient reports: symptoms, pain levels, history.
- O (Objective) — What the provider observes: exam findings, vital signs, test results.
- A (Assessment) — The provider's clinical conclusion: diagnosis, prognosis.
- P (Plan) — Next steps: treatment, referrals, medications, follow-up schedule.
ICD-10 and CPT Codes
- ICD-10 — International Classification of Diseases codes identify diagnoses (e.g., M54.5 = Low back pain).
- CPT — Current Procedural Terminology codes identify services performed (e.g., 99213 = Office visit, established patient).
These codes appear on billing records and are essential for understanding the scope of treatment documented.
This guide is for informational purposes only and does not constitute medical or legal advice. See our Medical Disclaimer.