APSO
assessment, plan, subjective, and objective
Bx
biopsy
CC
chief complaint (presenting problem, main reason for the patient’s visit)
Dx
diagnosis
GI
gastrointestinal
HEADSS
home and environment; education, employment, eating; activities; drugs; sexuality; suicide/depression
HPI
history of present illness
Hx
history
OLDCARTS
onset, location, duration, characterization, alleviating and aggravating factors, radiation, temporal factor, severity
Rx
prescription
SOAP
subjective, objective, assessment, and plan (an organizational scheme for clinic notes)
Tx
treatment or therapy