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Therapy EMR: Common SOAP Note Abbreviations & Acronyms

There is a bewildering array of abbreviations and acronyms you must know in order to execute your daily responsibilities effectively.  These abbreviations and acronyms are often used throughout your clinical documentation, in communications with business office staff and government agencies, and elsewhere.  A poor grasp on these abbreviations and acronyms can have a significant adverse impact on your practice.
  • Managing the quality of your clinical documentation is critical to achieving positive results when those documents are reviewed by MAC’s, RAC’s, or state surveyors.

  • Be prepared for these reviews and surveys.  Consistent use of “standardized” abbreviations and acronyms simplifies the internal review of those documents by physicians, rehab directors, or compliance managers.  This improves the quality of you clinical documentation.

  • Standardization of abbreviations and acronyms ensures positive survey results by improving the clarity of your clinical documentation and making them more “understandable” to reviewers who may not be clinicians themselves.

We have prepared a list of SOAP Note Abbreviations.  This list will assist you in preparing quality clinical documentation that “stands up” to medical review, complies fully with HIPAA regulations, and is prepared as efficiently as possible.  We have also included a section on CMS Acronyms as a reference.

SOAP Notes - CMS - Acronyms - Clinical Documentation - Therapy EMR


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