Chapter 2 Study Guide
1. Know what each letter in SOAP stands for and what kind of information you would find in that
section of a health record.
 S:

O:

A:

P:
2. What do these terms mean?
 Acute

 Symptom

 Genetic

 Malaise

 Noncontributory

 Marked

 Percussion

 Diagnosis

 Malignant

 Remission

 Systemic/Generalized 
 Prognosis

 Lesion

 Pending

 Prophylaxis

 Reassurance

Abrupt
Febrile
Hereditary
Chronic
Alert
Unremarkable
Palpation
Differential Diagnosis
Degeneration
Idiopathic
Morbidity
Occult
Recurrent
Disposition
Palliative
Supportive Care
















Exacerbation
Afebrile
Lethargic
Progressive
Oriented
Auscultation
Impression
Benign
Etiology
Localized
Mortality
Pathogen
Sequelae
Discharge
Observation
Sterile
3. Know the following body planes and orientation terms. Label the pictures below using these
terms.
 Anatomic Position
 Proximal
 Distal
 Lateral
 Medial
 Ventral/Antral/Anterior
 Dorsal/Posterior
 Cranial
 Caudal
 Superior
 Inferior
 Prone
 Supine
 Contralateral
 Ipsilateral
 Unilateral
 Bilateral
 Dorsum
 Plantar
 Palmar
 Sagittal
 Coronal
 Transverse
4. Know what the common subheadings in a health record describe
 Chief complaint
 History of present illness
 Review of systems
 Past medical history
 Past surgical history
 Family history
 Social history
5. Know the following abbreviation and symbol definitions
 CCU
 ECU

 ICU
 PICU

 PACU
 L&D

 Pre-op
 ♂


(B)

 (L)
 T

 VS
 Ht

 RR
 I/O
 DX

 RX
 H&P

 HPI
 ROS

 NKDA
 PE

 h/o
 PCP

 HEENT
 PERRLA

 RRR
 CTA

 WNL
 NOS

 NPO
 PR

 IV
 CVL

 BID
 TID

 AC
 PC

ER
NICU
OR
♀
↑
BP
Wt
DDX
Hx
PMHx
Pt
f/u
NAD
WDWN
NEC
IM
PICC
Q
Prn



















ED
SICU
Post-op
(R)
↓
HR
BMI
Tx
CC
FHx
y/o
SOB
CV
A&O
PO
SC
Sig
QHS
Ad lib
6. Be able to read through example health records carefully to look for information, interpret what
that information means, and identify in what part of the SOAP note that information would be
placed.