Documentation abbreviations page 22-25 Flashcards
Abbreviations to medical terms from "The OTA's guide to writing SOAP notes" pgs. 22-25 (305 cards)
1
Q
AK
A
above knee
2
Q
ALS
A
amyotrophic lateral sclerosis
3
Q
ant
A
anterior
4
Q
appt.
A
appointment
5
Q
ASHD
A
arteriosclerotic heart disease
6
Q
BADL
A
basic activity of daily living
7
Q
BE
A
below elbow
8
Q
BK
A
below knee
9
Q
BKA
A
below knee amputation
10
Q
BM
A
bowel movement
11
Q
BP
A
blood pressure
12
Q
BRP
A
bathroom privileges
13
Q
C
A
celsius; centrigrade
14
Q
C&S
A
culture and sensitivity
15
Q
CA
A
carcinoma;cancer
16
Q
CABG
A
coronary artery bypass graft
17
Q
CAD
A
coronary artery disease
18
Q
CAT
A
computerized axial tomography
19
Q
CBC
A
complete blood count
20
Q
CCU
A
coronary(cardiac) care unit
21
Q
CGA
A
contact guard assist
22
Q
CHF
A
congestive heart failure
23
Q
CHI
A
closed head injury
24
Q
CHT
A
certified hand therapist
25
cm
centimeter
26
CMC
carpometacarpal
27
CNS
central nervous system
28
CO2
carbon dioxide
29
℅
complains of
30
cont.
continued; continue
31
COPD
chronic obstructive pulmonary disease
32
COPM
canadian occupational performance measure
33
COTA
certified occupational therapy assistant
34
CP
cerebral palsy
35
CPM
continuous passive motion
36
CPR
cardiopulmonary resuscitation
37
CRPS
complex regional pain syndrome
38
CSF
cerebrospinal fluid
39
CST
crainosacral therapist
40
CT
computed tomography
41
CTD
cumulative trauma disorder
42
CTR
carpal tunnel release
43
CTRS
certified therapeutic recreational therapist
44
CTS
carpal tunnel syndrome
45
CVA
cerebrovascular accident
46
CXR
chest x-ray
47
d
day
48
D&C
dilation and curettage
49
DD
developmental disability
50
DIP
distal interphalangeal joint
51
DJD
degenerative joint disease
52
DM
diabetes mellitus
53
DME
durable medical equipment
54
DNR
do not resuscitate
55
D.O.
doctor of osteopathic medicine
56
DOA
date of admission; dead on arrival
57
DOB
date of birth
58
DOE
dyspnea on exertion
59
DPT
doctor of physical therapy
60
DRG
diagnostic related group
61
DRUJ
distal radioulnar joint
62
DTR
deep tendon reflex
63
Dx
diagnosis
64
DVT
deep vein thrombosis
65
ECG
electrocardiogram
66
ECHO
echocardiogram
67
ECT
electroconvulsive therapy
68
EEG
electroencephalogram
69
EKG
electrocardiogram
70
EMG
electromyogram
71
ER
external rotation; emergency room
72
EOB
edge of bed
73
ENT
ears, nose, throat
74
e-stim
electrical stimulation
75
etc.
etcetera
76
ETOH
ethyl alcohol
77
eval.
evaluation
78
exam
examination
79
ext.
extension
80
F
Fahrenheit; fair(muscle strength grade of 3)
81
f
female
82
F.A.C.P.
fellow of the american colleague of physicians
83
F.A.C.S.
fellow of the american colleague of surgeons
84
FBS
fasting blood sugar
85
FCE
functional capacity evaluation
86
FIM
functional independence measure
87
flex.
flexion
88
fl oz
fluid ounce
89
FM
fine motor
90
FROM
functional range of motion
91
ft.
foot, feet(measurement)
92
F/U
follow-up
93
FUO
fever of unknown origin
94
FWB
full weight bearing
95
Fx
fracture
96
G
good (muscle strength grade of 4)
97
GI
gastrointestinal
98
gm
gram
99
GSW
gunshot wound
100
GYN
gynecology
101
h
hour
102
HA, H/A
headache
103
H&P
history and physical
104
HBV
hepatitis B virus
105
HEENT
head, eyes, ears, nose, throat
106
HEP
home exercise program
107
HHA
home health agency, home health aide
108
HIPAA
health insurance portability and accountability act
109
HIV
human immunodeficiency virus
110
HOB
head of bed
111
HOH
hand over hand, hard of hearing
112
HP
hot pack
113
hr.
hour
114
HR
heart rate
115
HRT
hormone replacement therapy
116
HS
bedtime
117
Ht
height
118
HTN
hypertension
119
HVPC
high volt pulsed current
120
Hx
history
121
I&O
intake and output
122
IADL
instrumental activities of daily living
123
ICU
intensive care unit
124
i.e.
that is
125
IEP
individualized education program
126
IM
intramuscular
127
in.
inches
128
int.
internal
129
IP
inpatient, interphalangeal
130
IR
internal rotation
131
IV
intravenous
132
KAFO
knee-ankle-foot orthosis
133
kg
kilogram
134
lb.
pound
135
LD
learning disability, learning disorder
136
LE
lower extremity
137
LLQ
lower left quadrant
138
LOC
loss of consciousness, level of consciousness
139
LRTI
ligament reconstruction tendinous interposition
140
LTG
long-term goal
141
LUQ
left upper quadrant
142
m
murmur; meter; male maximum
143
max
maximum
144
MD
muscular dystrophy; medical doctor
145
meds.
medications
146
MET
basal metabolic equivalent
147
mg
milligram
148
MHz
megahertz
149
MI
myocardial infarction
150
min
minutes; minimum
151
ml
milliliter
152
mm
millimeter
153
MMT
manual muscle test
154
mo.
month
155
mod
moderate
156
MP, MCP
metacarpophalangeal
157
MRI
magnetic resonance imaging
158
MS
multiple sclerosis
159
MVA
motor vehicle accident
160
N
normal (muscle strength grade 5)
161
NA
not applicable, not available
162
N/A
not applicable
163
NAD
no acute distress
164
NDT
neurodevelopmental treatment
165
neg.
negative
166
NG
nasogastric
167
NICU
neonatal intensive care unit
168
NKA
no known allergy
169
NKDA
no known drug allergy
170
NMES
neuromuscular electrical stimulation
171
NOS
not otherwise specified
172
NPO
nothing by mouth
173
NS
no show, not seen
174
NSAID
nonsteroidal anti-inflammatory drug
175
NSR
normal sinus rhythm
176
NWB
nonweight bearing
177
O
objective; oriented
178
O2
oxygen
179
OA
osteoarthritis
180
OB
obstetrics
181
OBS
organic brain syndrom
182
OCD
obsessive compulsive disorder
183
OOB
out of bed
184
OP
outpatient
185
OR
operating room
186
ORIF
open reduction, internal fixation
187
OT
occupational therapist/therapy
188
OTA
occupational therapy assistant
189
OTAS
occupational therapy assistant student
190
OTC
over the counter
191
OTR
registered occupational therapist
192
oz
ounce
193
P
plan; posterior; pulse; poor(muscle strength grade of 2)
194
PA
posterior anterior, physicians assistant
195
PADL
personal activity of daily living
196
PAM
physical agent modality
197
PDD
pervasive developmental disorder
198
PE
physical examination; physical education
199
per
by
200
peri
perineal
201
PET
positron emission tomography
202
Ph.D.
doctor of philosophy
203
PIP
proximal interphalangeal
204
p.m., PM
afternoon, evening
205
PMH
past medical history
206
PNF
proprioceptive neuromuscular facilitation
207
PNI
peripheral nerve injury
208
PNS
peripheral nervous system
209
POMR
problem oriented medical record positive
210
pos.
positive
211
post op
postoperative
212
PRE
progressive resistive exercise
213
pre op
preoperative
214
PRN
as needed
215
pro
pronation
216
PROM
passive range of motion
217
pt.
patient
218
PT
physical therapy, physical therapist
219
P/T
part time
220
PTA
physical therapist assistant; prior to admission
221
PTSD
post traumatic stress disorder
222
PWB
partial weight bearing
223
Px
physical examination
224
qt.
quart
225
R
respiration
226
RA
rheumatoid arthritis
227
RBC
red blood cells
228
R.D.
registered dietician
229
re:
regarding
230
rehab
rehabilitation
231
reps
repetition
232
resp
respiratory; respiration
233
RICE
rest, ice, compression, elevation
234
R.Ph.
registered pharmacist
235
RLQ
right lower quadrant
236
R/O
rule out
237
ROM
range of motion
238
ROS
review of symptoms
239
R.T.
respiratory therapist
240
RTC
return to clinic
241
RTO
return to office
242
RUQ
right upper quadrant
243
RSD
reflex sympathetic dystrophy
244
Rx
recipe
245
S
subjective
246
SBA
stand by assistance
247
SCI
spinal cord injury
248
SH
social history
249
SI
sensory integration
250
SIDS
sudden infant death syndrome
251
Sig:
instruction to patient
252
SLE
systemic lupus erythematosus
253
SLP
speech language pathologist
254
SOC
start of care
255
SOAP
subjective, objective, assessment, plan
256
SOB
shortness of breath
257
SNF
skilled nursing facility
258
S/P
status post
259
SSRI
selective serotonin reuptake inhibitor
260
STAT
immediately
261
STD
sexually transmitted disease
262
STG
short term goal
263
STM
short term memory
264
suppos
suppository
265
sup
supination
266
T
temperature; Trace (muscle strength grade 1)
267
TB
tuberculosis
268
TBI
traumatic brain injury
269
TEDS
thrombi-embolic disease stockings
270
TENS
transcutaneous electrical nerve stimulation
271
TFCC
traingular fibrocartilage complex
272
ther ex
therapeutic exercise
273
THR
total hip replacement
274
TIA
transient ischemic attack
275
TKR
total knee replacement
276
T M (J)
temporomandibular (joint)
277
TNR
tonic neck reflex
278
t.o.
telephone order
279
TOS
thoracic outlet syndrome
280
TPR
temperature, pulse, and respiration
281
TTWB
toe touch weight bearing
282
tx.
treatment; traction
283
UA
urinalysis
284
UE
upper extremity
285
UMN
upper motor neuron
286
URI
upper respiratory infection
287
US
ultrasound
288
UTI
urinary tract infection
289
VC
vital capacity
290
VD
venereal disease
291
v.o.
verbal orders
292
vol.
volume
293
VS
vital signs
294
W
watt
295
WBC
white blood cells
296
WBAT
weight bearing as tolerated
297
w/c
wheelchair
298
WDWN
well developed; well nourished
299
wk.
week
300
WFL
within functional limits
301
WNL
within normal limits
302
wt
weight
303
x or X
times
304
y.o.
year old
305
yr.
year
