S1_L3: Documentation Flashcards by MindMed Official

Notes that serve as records of skilled interventions provided and records of time taken to provide the interventions in order to justify billing codes being used. To document what occurred during a session or encounter and may or may not follow the SOAP format.

Treatment notes / Daily PT notes

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Provides justification for the medical necessity of treatment and to justify ongoing services. Notes done in specific time periods.

Progress notes

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Notes performed when there are significant changes in the patient’s status in comparison to baseline; a separately billable service

Re-evaluation notes

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Re-evaluation notes (RE) is typically done on the ___ session before the follow-up check up to the rehabilitation medicine doctor or referring MD

Last

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TRUE OR FALSE: In the re-evaluation notes, any test and measure describing an impairment or any functional deficit in the IE should be re-examined. Signal words “now” or “still” are used.

True

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A:
This abbreviation / symbol stands for

assessment

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ABI
This abbreviation / symbol stands for

acquired brain injury

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afib
This abbreviation / symbol stands for

atrial fibrillation

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A-line
This abbreviation / symbol stands for

arterial line

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A-V
This abbreviation / symbol stands for

arteriovenous

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AAA
This abbreviation / symbol stands for

abdominal aortic aneurysm

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ABG
This abbreviation / symbol stands for

arterial blood gases

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ac
This abbreviation / symbol stands for

before meals

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ACTH
This abbreviation / symbol stands for

adrenocorticotrophic hormone

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ACL
This abbreviation / symbol stands for

anterior cruciate ligament

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AC joint
This abbreviation / symbol stands for

acromioclavicular joint

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AAROM
This abbreviation / symbol stands for

active assistive range of motion

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ad lib
This abbreviation / symbol stands for

at discretion

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adm
This abbreviation / symbol stands for

admission, admitted

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ADL
This abbreviation / symbol stands for

activities of daily living

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AE
This abbreviation / symbol stands for

above elbow

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AFO
This abbreviation / symbol stands for

ankle foot orthosis

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AIDS
This abbreviation / symbol stands for

acquired immune deficiency syndrome

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AJ
This abbreviation / symbol stands for

ankle jerk

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AK This abbreviation / symbol stands for

above knee

AIIS This abbreviation / symbol stands for

anterior inferior iliac spine

ALS This abbreviation / symbol stands for

amyotrophic lateral sclerosis

AMA This abbreviation / symbol stands for

against medical advice

amb This abbreviation / symbol stands for

ambulation, ambulating, ambulated, ambulate, ambulates

AP This abbreviation / symbol stands for

anterior-posterior

ARDS This abbreviation / symbol stands for

adult respiratory distress syndrome

This serves as a record of the patient’s final subjective and objective status and provides the final or discharge plan

Discharge notes (D/C)

This serves as a tool for improving care by identifying and investigating problems as they arise and provides an internal account in case legal action results from the adverse event.

Incident Report

This is prepared for the following circumstances: (1), In case of the absence / scheduled leave of the therapist in charge, and (2), when there is a change of therapist.

Endorsement notes

ARF This abbreviation / symbol stands for

acute renal failure

AROM This abbreviation / symbol stands for

active range of motion

ASA This abbreviation / symbol stands for

aspirin

ASAP or asap This abbreviation / symbol stands for

as soon as possible

ASCVD This abbreviation / symbol stands for

arteriosclerotic cardiovascular disease

ASHD This abbreviation / symbol stands for

arteriosclerotic heart disease

ASIS This abbreviation / symbol stands for

anterior superior iliac spine

assist. This abbreviation / symbol stands for

assistance, assistive

AVM This abbreviation / symbol stands for

arteriovenous malformation

B/S This abbreviation / symbol stands for

bedside

BBB This abbreviation / symbol stands for

bundle branch block

BE This abbreviation / symbol stands for

below elbow

BID or bid This abbreviation / symbol stands for

twice a day

bilat. or B This abbreviation / symbol stands for

bilateral, bilaterally

BK This abbreviation / symbol stands for

below knee

BM This abbreviation / symbol stands for

bowel movement

BOS This abbreviation / symbol stands for

base of support

BP This abbreviation / symbol stands for

blood pressure

a.m. This abbreviation / symbol stands for

morning

ANS This abbreviation / symbol stands for

autonomic nervous system

ant This abbreviation / symbol stands for

Abd or abd This abbreviation / symbol stands for

abduction

Add or add This abbreviation / symbol stands for

adduction

bpm This abbreviation / symbol stands for

beats per minute

BR This abbreviation / symbol stands for

bedrest

BRP This abbreviation / symbol stands for

bathroom privileges

BS This abbreviation / symbol stands for

breath sounds or bowel sounds

BUN This abbreviation / symbol stands for

blood urea nitrogen (blood test)

C This abbreviation / symbol stands for

centigrade

C&S This abbreviation / symbol stands for

culture and sensitivity

c/o This abbreviation / symbol stands for

complains of

CA This abbreviation / symbol stands for

cancer, carcinoma

CABG This abbreviation / symbol stands for

coronary artery bypass graft

CAD This abbreviation / symbol stands for

coronary artery disease

cal This abbreviation / symbol stands for

calories

CAT This abbreviation / symbol stands for

computerized axial tomography

CBC This abbreviation / symbol stands for

complete blood cell (count)

CC, C/C This abbreviation / symbol stands for

chief complaint

CF This abbreviation / symbol stands for

cystic fibrosis

CHF This abbreviation / symbol stands for

congestive heart failure

cm This abbreviation / symbol stands for

centimeter

CMV This abbreviation / symbol stands for

cytomegalovirus

CNS This abbreviation / symbol stands for

central nervous system

CO This abbreviation / symbol stands for

cardiac output

CO2 This abbreviation / symbol stands for

carbon dioxide

cont. This abbreviation / symbol stands for

continue, continuous

COPD This abbreviation / symbol stands for

chronic obstructive pulmonary disease

COTA This abbreviation / symbol stands for

certified occupational therapy assistant

CP This abbreviation / symbol stands for

cerebral palsy

CPAP This abbreviation / symbol stands for

continuous positive airway pressure

CPR This abbreviation / symbol stands for

cardiopulmonary resuscitation

CRF This abbreviation / symbol stands for

chronic renal failure

CSF This abbreviation / symbol stands for

cerebrospinal fluid

CV This abbreviation / symbol stands for

cardiovascular

CWI This abbreviation / symbol stands for

crutch walking instructions

CXR This abbreviation / symbol stands for

chest x-ray

Cysto This abbreviation / symbol stands for

cystoscopic examination

D/C This abbreviation / symbol stands for

discontinued or discharged

dept. This abbreviation / symbol stands for

department

DIP This abbreviation / symbol stands for

distal interphalangeal (joint)

DJD This abbreviation / symbol stands for

degenerative joint disease

DM This abbreviation / symbol stands for

diabetes mellitus

DNR This abbreviation / symbol stands for

do not resuscitate

DO This abbreviation / symbol stands for

doctor of osteopathy

DOB This abbreviation / symbol stands for

date of birth

DOE This abbreviation / symbol stands for

dyspnea on exertion

DTR This abbreviation / symbol stands for

deep tendon reflex

DVT This abbreviation / symbol stands for

deep vein thrombosis

Dx This abbreviation / symbol stands for

diagnosis

ECF This abbreviation / symbol stands for

extended care facility

ECG, EKG This abbreviation / symbol stands for

electrocardiogram

ED This abbreviation / symbol stands for

emergency department

EEG This abbreviation / symbol stands for

electroencephalogram

EENT This abbreviation / symbol stands for

ear, eyes, nose, throat

EMG This abbreviation / symbol stands for

electromyogram, electromyography

E.R. This abbreviation / symbol stands for

emergency room

eval. This abbreviation / symbol stands for

evaluation

ext. This abbreviation / symbol stands for

extension

FBS This abbreviation / symbol stands for

fasting blood sugar

FEV This abbreviation / symbol stands for

forced expiratory volume

FH This abbreviation / symbol stands for

family history

flex This abbreviation / symbol stands for

flexion

FRC This abbreviation / symbol stands for

functional residual capacity

ft. This abbreviation / symbol stands for

foot, feet (the measurement, not the body part)

FUO This abbreviation / symbol stands for

fever of unknown origin

FVC This abbreviation / symbol stands for

forced vital capacity

FWB This abbreviation / symbol stands for

full weight bearing

fx This abbreviation / symbol stands for

fracture

GB This abbreviation / symbol stands for

gallbladder

GI This abbreviation / symbol stands for

gastrointestinal

g This abbreviation / symbol stands for

gram

GSW This abbreviation / symbol stands for

gunshot wound

GYN This abbreviation / symbol stands for

gynecology

h, hr. This abbreviation / symbol stands for

hour

H&H, H/H This abbreviation / symbol stands for

hematocrit and hemoglobin

H&P This abbreviation / symbol stands for

history and physical

h/o This abbreviation / symbol stands for

history of

HA, H/A This abbreviation / symbol stands for

headache

Hb, Hgb This abbreviation / symbol stands for

hemoglobin

Hct, Ht This abbreviation / symbol stands for

hematocrit

HCVD This abbreviation / symbol stands for

hypertensive cardiovascular disease

HEENT This abbreviation / symbol stands for

head, ear, eyes, nose, throat

HEP This abbreviation / symbol stands for

home exercise program

HIV This abbreviation / symbol stands for

human immunodeficiency virus

HNP This abbreviation / symbol stands for

herniated nucleus pulposus

HOB This abbreviation / symbol stands for

head of bed

HR This abbreviation / symbol stands for

heart rate

hs This abbreviation / symbol stands for

at bedtime

ht. This abbreviation / symbol stands for

height

Htn or HTN This abbreviation / symbol stands for

hypertension

Hx This abbreviation / symbol stands for

history

I&O This abbreviation / symbol stands for

intake and output

IADL This abbreviation / symbol stands for

instrumental activities of daily living

ICU This abbreviation / symbol stands for

intensive care unit

IDDM This abbreviation / symbol stands for

insulin-dependent diabetes mellitus

IM This abbreviation / symbol stands for

intramuscular

imp. This abbreviation / symbol stands for

impression

in. This abbreviation / symbol stands for

inches

indep This abbreviation / symbol stands for

independent

IMV This abbreviation / symbol stands for

intermittent mandatory ventilation

inf This abbreviation / symbol stands for

inferior

IRDS This abbreviation / symbol stands for

infant respiratory distress syndrome

IS This abbreviation / symbol stands for

incentive spirometry

IV This abbreviation / symbol stands for

intravenous

KAFO This abbreviation / symbol stands for

knee-ankle-foot orthosis

kcal This abbreviation / symbol stands for

kilocalories

kg This abbreviation / symbol stands for

kilogram

KJ This abbreviation / symbol stands for

knee jerk

KUB This abbreviation / symbol stands for

kidney, ureter, bladder

L or l. This abbreviation / symbol stands for

liter

L This abbreviation / symbol stands for

left

lat This abbreviation / symbol stands for

lateral

lb. This abbreviation / symbol stands for

pound

LBBB This abbreviation / symbol stands for

left bundle branch block

LBP This abbreviation / symbol stands for

low back pain

LE This abbreviation / symbol stands for

lower extremity

LOC This abbreviation / symbol stands for

loss of consciousness, level of consciousness

LMN This abbreviation / symbol stands for

lower motor neuron

LOS This abbreviation / symbol stands for

length of stay

LP This abbreviation / symbol stands for

lumbar puncture

m This abbreviation / symbol stands for

meter

MAP This abbreviation / symbol stands for

mean arterial pressure

max This abbreviation / symbol stands for

maximal

MD This abbreviation / symbol stands for

medical doctor; doctor of medicine

MED This abbreviation / symbol stands for

minimal erythemal dose

Meds. This abbreviation / symbol stands for

medications

mg This abbreviation / symbol stands for

milligram

MI This abbreviation / symbol stands for

myocardial infarction

min This abbreviation / symbol stands for

minimal, minimum

min. This abbreviation / symbol stands for

minute

ml This abbreviation / symbol stands for

milliliter

mm This abbreviation / symbol stands for

millimeter

MMT This abbreviation / symbol stands for

manual muscle test

mo. This abbreviation / symbol stands for

month

mod This abbreviation / symbol stands for

moderate

MP, MEP, MCP This abbreviation / symbol stands for

metacarpophalangeal

MRSA This abbreviation / symbol stands for

methicillin-resistant Staphylococcus aureus

MVA This abbreviation / symbol stands for

motor vehicle accident

NDT This abbreviation / symbol stands for

neurodevelopmental treatment

neg. This abbreviation / symbol stands for

negative

NG or ng This abbreviation / symbol stands for

nasogastric

N.H. This abbreviation / symbol stands for

nursing home

NIDDM This abbreviation / symbol stands for

non–insulin-dependent diabetes mellitus

nn This abbreviation / symbol stands for

nerve

noc This abbreviation / symbol stands for

night, at night

NPO or npo This abbreviation / symbol stands for

nothing by mouth

NSR This abbreviation / symbol stands for

normal sinus rhythm

NWB This abbreviation / symbol stands for

non–weight bearing

O: This abbreviation / symbol stands for

objective

OB This abbreviation / symbol stands for

obstetrics

OBS This abbreviation / symbol stands for

organic brain syndrome

OA This abbreviation / symbol stands for

osteoarthritis

OOB This abbreviation / symbol stands for

out of bed

od This abbreviation / symbol stands for

once daily

O.P. This abbreviation / symbol stands for

outpatient

O.R. This abbreviation / symbol stands for

operating room

ORIF This abbreviation / symbol stands for

open reduction, internal fixation

OT This abbreviation / symbol stands for

occupational therapy, occupational therapist

OTR This abbreviation / symbol stands for

occupational therapist (used to follow official signature of the occupational therapist)

oz. This abbreviation / symbol stands for

ounce

P This abbreviation / symbol stands for

poor

P: This abbreviation / symbol stands for

plan, intervention plan, plan of care

P.A. This abbreviation / symbol stands for

physician’s assistant

PA This abbreviation / symbol stands for

posterior/anterior

para This abbreviation / symbol stands for

paraplegia

pc This abbreviation / symbol stands for

after meals

PCL This abbreviation / symbol stands for

posterior cruciate ligament

PE This abbreviation / symbol stands for

pulmonary embolus

PEEP This abbreviation / symbol stands for

positive end expiratory pressure

per This abbreviation / symbol stands for

by/through

p.o. This abbreviation / symbol stands for

by mouth (per orem)

PERRLA This abbreviation / symbol stands for

pupils equal, round, reactive to light, and accommodation

P.H. This abbreviation / symbol stands for

past history

p.m. This abbreviation / symbol stands for

afternoon

PMH, PMHx This abbreviation / symbol stands for

past medical history

PNF This abbreviation / symbol stands for

proprioceptive neuromuscular facilitation

PNI This abbreviation / symbol stands for

peripheral nerve injury

POMR This abbreviation / symbol stands for

problem-oriented medical record

pos. This abbreviation / symbol stands for

positive

poss This abbreviation / symbol stands for

possible

post This abbreviation / symbol stands for

posterior

post-op This abbreviation / symbol stands for

after surgery (operation)

PRE This abbreviation / symbol stands for

progressive-resistive exercise

pre-op This abbreviation / symbol stands for

before surgery (operation)

prn This abbreviation / symbol stands for

whenever necessary, as often as necessary

PROM This abbreviation / symbol stands for

passive range of motion

PSIS This abbreviation / symbol stands for

posterior-superior iliac spine

PT This abbreviation / symbol stands for

physical therapy, physical therapist (used after therapist’s signature)

PT/PTT This abbreviation / symbol stands for

prothrombin time/partial thromboplastin time

Pt., pt. This abbreviation / symbol stands for

patient

PTA This abbreviation / symbol stands for

physical therapist assistant; prior to admission

PTB This abbreviation / symbol stands for

patellar tendon bearing

PVD This abbreviation / symbol stands for

peripheral vascular disease

PWB This abbreviation / symbol stands for

partial weight bearing

q This abbreviation / symbol stands for

every

qid This abbreviation / symbol stands for

four times a day

qh This abbreviation / symbol stands for

every hour

qn This abbreviation / symbol stands for

every night

qt. This abbreviation / symbol stands for

quart

R This abbreviation / symbol stands for

right

RA This abbreviation / symbol stands for

rheumatoid arthritis

RBBB This abbreviation / symbol stands for

right bundle branch block

RBC This abbreviation / symbol stands for

red blood cell (count)

R.D. This abbreviation / symbol stands for

registered dietician

re: This abbreviation / symbol stands for

regarding

rehab This abbreviation / symbol stands for

rehabilitation

reps This abbreviation / symbol stands for

repetitions

resp This abbreviation / symbol stands for

respiratory, respiration

RN This abbreviation / symbol stands for

registered nurse

R/O or r/o This abbreviation / symbol stands for

rule out

ROM This abbreviation / symbol stands for

range of motion

ROS This abbreviation / symbol stands for

review of systems

RR This abbreviation / symbol stands for

respiratory rate

RROM This abbreviation / symbol stands for

resistive range of motion

RT This abbreviation / symbol stands for

respiratory therapist, respiratory therapy

Rx This abbreviation / symbol stands for

intervention plan, prescription, therapy

SACH This abbreviation / symbol stands for

solid ankle cushion heel

SCI This abbreviation / symbol stands for

spinal cord injury

SC joint This abbreviation / symbol stands for

sternoclavicular joint

sec. This abbreviation / symbol stands for

seconds

SED This abbreviation / symbol stands for

suberythemal dose

sig This abbreviation / symbol stands for

directions for use, give as follows, let it be labeled

SI(J) This abbreviation / symbol stands for

sacroiliac (joint)

SLE This abbreviation / symbol stands for

systemic lupus erythematosus

SLP This abbreviation / symbol stands for

speech-language pathologist

SLR This abbreviation / symbol stands for

straight leg raise

SNF This abbreviation / symbol stands for

skilled nursing facility

SOAP This abbreviation / symbol stands for

subjective, objective, assessment, plan

SOB This abbreviation / symbol stands for

shortness of breath

S/P This abbreviation / symbol stands for

status post (e.g., “S/P hip fx” means “Pt. fx her hip in the recent past.”)

spec This abbreviation / symbol stands for

specimen

stat. This abbreviation / symbol stands for

immediately, at once

sup This abbreviation / symbol stands for

superior

Sx This abbreviation / symbol stands for

symptoms

tab This abbreviation / symbol stands for

tablet

TB This abbreviation / symbol stands for

tuberculosis

TBI This abbreviation / symbol stands for

traumatic brain injury

tbsp. This abbreviation / symbol stands for

tablespoon

TENS, TNS This abbreviation / symbol stands for

transcutaneous electrical nerve stimulator/stimulation

THA This abbreviation / symbol stands for

total hip arthroplasty

ther ex, thera ex This abbreviation / symbol stands for

therapeutic exercise

TIA This abbreviation / symbol stands for

transient ischemic attack

tid This abbreviation / symbol stands for

three times daily

TKA This abbreviation / symbol stands for

total knee arthroplasty

TM(J) This abbreviation / symbol stands for

temporomandibular (joint)

TNR This abbreviation / symbol stands for

tonic neck reflex (also ATNR, STNR)

t.o. This abbreviation / symbol stands for

telephone order

TPR This abbreviation / symbol stands for

temperature, pulse, and respiration

tsp. This abbreviation / symbol stands for

teaspoon

TUR/TURP This abbreviation / symbol stands for

transurethral resection

Tx This abbreviation / symbol stands for

traction

TV This abbreviation / symbol stands for

tidal volume

UA This abbreviation / symbol stands for

urine analysis

UE This abbreviation / symbol stands for

upper extremity

UMN This abbreviation / symbol stands for

upper motor neuron

URI This abbreviation / symbol stands for

upper respiratory infection

US This abbreviation / symbol stands for

ultrasound

UTI This abbreviation / symbol stands for

urinary tract infection

UV This abbreviation / symbol stands for

ultraviolet

VC This abbreviation / symbol stands for

vital capacity

VD This abbreviation / symbol stands for

venereal disease

v.o. or VO This abbreviation / symbol stands for

verbal orders (e.g., v.o. Dr. Smith/ assistant’s signature)

vol. This abbreviation / symbol stands for

volume

v.s. This abbreviation / symbol stands for

vital signs

w/c This abbreviation / symbol stands for

wheelchair

W/cm^2 This abbreviation / symbol stands for

watts per square centimeter

WBC This abbreviation / symbol stands for

white blood cell (count)

wk. This abbreviation / symbol stands for

week

WNL This abbreviation / symbol stands for

within normal limits

wt. This abbreviation / symbol stands for

weight

X This abbreviation / symbol stands for

Number of times performed (e.g., 2 is twice; 3 is 3 times)

y/o or y.o. This abbreviation / symbol stands for

years old

yd. This abbreviation / symbol stands for

yard

yr. This abbreviation / symbol stands for

year

+1 (+2, etc.) This abbreviation / symbol stands for

Assistance (assistance of 1 person given; also written “assistance of 1.” Examples: amb ... c min + 1 assist., or amb ... c +1 min assist., or amb ... c min assist. of 1)

♂ This abbreviation / symbol stands for

Male

♀ This abbreviation / symbol stands for

female

↓ This abbreviation / symbol stands for

down, downward, decrease, diminished

↑ This abbreviation / symbol stands for

up, upward, increase, augmented

// This abbreviation / symbol stands for

parallel or parallel bars (also written “// bars”)

c This abbreviation / symbol stands for

with

s This abbreviation / symbol stands for

without

p This abbreviation / symbol stands for

after

a This abbreviation / symbol stands for

before

~ or ≈ This abbreviation / symbol stands for

approximately

Δ This abbreviation / symbol stands for

change

= This abbreviation / symbol stands for

equal

+ or (+) This abbreviation / symbol stands for

plus, positive (positive also abbreviated “pos.”)

(-) or - This abbreviation / symbol stands for

minus, negative (negative also abbreviated “neg.”)

↔ This abbreviation / symbol stands for

to and from

→ This abbreviation / symbol stands for

to progressing toward, approaching

1° This abbreviation / symbol stands for

primary

2° This abbreviation / symbol stands for

secondary, secondary to

/ This abbreviation / symbol stands for

per

% This abbreviation / symbol stands for

percent

+, &, et. This abbreviation / symbol stands for

and

Hashtag # This abbreviation / symbol stands for

number (#1 = number 1), pounds (5# wt. = 5 pound weight; pound also abbreviated “lbs.”)

Common used to substitute for ‘is’

Colon (:)

TRUE OR FALSE: In documentation, never use correction fluid or tape. The proper way to correct an error is to strike a line through the error, then write the date and initials above the error.

True

In documentation, the dont's are: Don't leave (1)___ after each entry and leave (2)___ in between words. Don't use derogatory statements and don't use first person singular pronouns. Don't include unnecessary and irrelevant facts.

1. empty lines 2. big spaces

This provides a method of communication, keeps record of PT management given, and serves as a business record, for billing and for legal aspects. It also assists in obtaining insurance coverage and in decision making and discharge planning.

Documentation

Has precise descriptions. Vague statements and confusing use of words are avoided. A. Accuracy B. Brevity C. Clarity

C. Clarity

States information in a factual manner and never records falsely, exaggerate, guess or make up data. Statements are proofread for incorrect spelling, grammar, and punctuation. A. Accuracy B. Brevity C. Clarity

A. Accuracy

Information is stated concisely, using short, succinct sentences. Long-winding statements are avoided. A. Accuracy B. Brevity C. Clarity

B. Brevity

This punctuation is a common substitute for ‘through’ or 'to’. It also may be confused with the minus/negative sign.

Hyphen (-)

This punctuation is used to connect two related statements in documentation.

Semicolon (;)

T/c This abbreviation / symbol stands for

To consider

WFL This abbreviation / symbol stands for

Within functional limits

PTC This abbreviation / symbol stands for

Prior to consultation

S1_L3: Documentation Flashcards

(363 cards)