Medical Terminology
Decode clinical language one meaningful piece at a time.
Lesson 11 of 12
Common clinical abbreviations
Abbreviations save space in records, but their meanings can vary by setting and profession. Read the surrounding note before expanding an abbreviation, and follow the clinic's approved documentation standards. SOAP is a structure for organizing a note; it does not make an observation objective merely by placing it in a section. When meaning is unclear, spell out the term or ask rather than guessing.
Key points
- ROM means range of motion; document the movement and method clearly.
- SOAP stands for Subjective, Objective, Assessment, and Plan.
- Hx commonly means history; Dx means diagnosis; Rx may mean prescription or treatment depending on context.
- PRN means as needed; it may appear in medication directions, which therapists should not change.
- BID and TID commonly mean twice daily and three times daily in medication instructions.
- R and L may mean right and left, but ambiguous shorthand should be avoided.
- Use only abbreviations accepted by the workplace and relevant regulations.
Key terms
- ROM
- Range of motion.
- SOAP
- Subjective, Objective, Assessment, Plan note format.
- Hx
- History.
- Dx
- Diagnosis.
- Rx
- Prescription or treatment, according to context.
- PRN
- As needed.
- BID
- Twice daily, commonly in medication directions.
Memory tip
If two readers might expand an abbreviation differently, write it out.
Clinical note
Medication abbreviations are included for recognition, not to authorize medication advice.
Unit checkpoint
Lock it in: match the terms, then test yourself.