Abbreviations for Occupational Therapy Documentation – Flashcards
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AA
answer
Alcoholics Anonymous
question
AAROM
answer
Active Assisted Range of Motion
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abd
answer
abduction
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add
answer
adduction
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ADD
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Attention Deficit Disorder
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ADHD
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Attention Deficit Hyperactivity Disorder
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ADL
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Activity of Daily Living
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ad lib.
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as desired
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AE
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above elbow
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AFO
answer
ankle-foot orthosis
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AIDS
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Acquired immunodeficiency syndrome
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AK
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above knee
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AKA
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above knee amputation
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ALS
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amyotrophic lateral sclerosis
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AMA
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against medical advice; American Medical Association
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AMB
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ambulation
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amt.
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amount
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ant
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anterior
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AP
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anterior-posterior
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appt.
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appointment
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AROM
answer
active range or motion
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ASHD
answer
arteriosclerotic heart disease
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BADL
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basic activity of daily living
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BE
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below elbow
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BK
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below knee
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BKA
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below knee amputation
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BM
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bowel movement
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BP
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blood pressure
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BRP
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bathroom privileges
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c
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with
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C&S
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culture & sensitivity
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CA
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carcinoma; cancer
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CABG
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coronary artery bypass graft
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CAD
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coronary artery disease
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CAT
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computerized axial tomography
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CBC
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complete blood count
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CCU
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coronary (cardiac) care unit
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CGA
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contact guard assist
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CHF
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congestive heart failure
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CHT
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certified hand therapist
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CHI
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closed head injury
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CMC
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carpometacarpal
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CNS
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central nervous system
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c/o
answer
complains of
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COPD
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chronic obstructive pulmonary disorder
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cont.
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continue
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COPM
answer
Canadian Occupational Performance Measure
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CP
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cerebral palsy
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CPM
answer
continuous passive motion
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CPR
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cardiopulmonary resuscitation
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CRPS
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complex regional pain syndrome
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CSF
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cerebrospinal fluid
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CST
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craniosacral therapist
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CT
answer
computed tomography
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CTD
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cumulative trauma disorder
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CTR
answer
carpal tunnel release
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CTS
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carpal tunnel syndrome
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CVA
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cerebrovascular accident
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CXR
answer
chest x-ray
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d
answer
day
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D&C
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dilation and curettage
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DD
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developmental disability
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DIP
answer
distal interphalangeal joint
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DJD
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degenerative joint disease
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DM
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diabetes mellitus
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DME
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durable medical equipment
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DNR
answer
do not resuscitate
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D.O.
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doctor of osteopathic medicine
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DOA
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date of admission; dead on arrival
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DOB
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date of birth
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DPT
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doctor of physical therapy
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DRG
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diagnostic related group
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DRUJ
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distal radioulnar joint
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DVT
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deep vein thrombosis
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DTR
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deep tendon reflex
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Dx
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diagnosis
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ECG
answer
electrocardiogram
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ECHO
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echocardiogram
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ECT
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electroconvulsive therapy
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EEG
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electroencephalogram
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EKG
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electrocardiogram
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EMG
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electromyogram
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ENT
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ear, nose, throat
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EOB
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edge of bed
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ER
answer
external rotation; emergency room
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e-stim
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electrical stimulation
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ETOH
answer
ethyl alcohol
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eval.
answer
evaluation
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ext.
answer
extension
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F
answer
fair; fahrenheit
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f
answer
female
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FBS
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fasting blood sugar
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FCE
answer
functional capacity evaluation
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FIM
answer
functional independence measure
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flex.
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flexion
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FM
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fine motor
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FROM
answer
functional range of motion
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f/u
answer
follow-up
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FUO
answer
fever of unknown origin
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FWB
answer
full weight bearing
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Fx
answer
fracture
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G
answer
good
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GI
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gastrointestinal
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gm
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gram
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GSW
answer
gunshot wound
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h
answer
hour
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HA
answer
headache
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H&P
answer
history and physical
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HEENT
answer
head, eyes, ears, nose, throat
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HEP
answer
home exercise program
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HHA
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home health aide; home health agency
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HIPPA
answer
Health Insurance Portability and Accountability Act
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HIV
answer
human immunodeficiency virus
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HOB
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head of bed
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HOH
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hand over hand; hard of hearing
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HP
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hot pack
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hr.
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hour
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HR
answer
heart rate
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HRT
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hormone replacement therapy
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HS
answer
bedtime
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Ht
answer
height
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HTN
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hypertension
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HVPC
answer
high volt pulsed current
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Hx
answer
history
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I&O
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intake and output
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IADL
answer
instrumental activity of daily living
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ICU
answer
intensive care unit
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i.e.
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that is
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IEP
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individualized education program
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IM
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intramuscular
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int.
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internal
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IP
answer
inpatient; interphalangeal
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IV
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intravenous
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IR
answer
internal rotation
question
KAFO
answer
knee-foot-ankle orthosis
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LD
answer
learning disability
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LE
answer
lower extremity
question
LLQ
answer
lower left quadrant
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LOC
answer
loss of consciousness; level of consciousness
question
LRTI
answer
ligament reconstruction tendinous interposition
question
LTG
answer
long-term goal
question
m
answer
murmur; meter; male; maximum
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max
answer
maximum
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MD
answer
muscular dystrophy
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meds.
answer
medications
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MET
answer
basal metabolic equivalent
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MI
answer
myocardial infarction
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min
answer
minimum
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MMT
answer
manual muscle test
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mo.
answer
month
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mod
answer
moderate
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MRI
answer
magnetic resonance imaging
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MS
answer
multiple sclerosis
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MVA
answer
motor vehicle accident
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N
answer
normal
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NA
answer
not applicable
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NAD
answer
no acute distress
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NDT
answer
neurodevelopmental treatment
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neg.
answer
negative
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NICU
answer
neonatal intensive care unite
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NG
answer
nasogastric
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NMES
answer
neuromuscular electrical stimulation
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NOS
answer
not otherwise specified
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NPO
answer
nothing by mouth
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NS
answer
no show; not seen
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NSAID
answer
nonsteroidal anti-inflammatroy drug
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NSR
answer
normal sinus rhythm
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NWB
answer
nonweight bearing
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O
answer
objective; oriented
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OA
answer
osteoarthritis
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OB
answer
obstetrics
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OBS
answer
organic brain syndrome
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OCD
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obsessive compulsive disorder
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OOB
answer
out of bed
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OP
answer
outpatient
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OTC
answer
over the counter
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OX4
answer
oriented to time, place, person, situation
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p
answer
after
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P
answer
plan; posterior; pulse; poor
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PA
answer
posterior anterior; physician's assistant
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PADL
answer
personal activity of daily living
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PAM
answer
physical agent modality
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PDD
answer
pervasive developmental disorder
question
PE
answer
physical examination; physical education
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per
answer
by
question
peri.
answer
perineal
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PET
answer
positron emission tomography
question
PIP
answer
proximal interphalangeal
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PMh
answer
past medical history
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PNF
answer
proprioceptive neuromuscular facilitation
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PNI
answer
peripheral nerve injury
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PNS
answer
peripheral nervous system
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POMR
answer
problem oriented medical record
question
pos.
answer
positive
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post op
answer
postoperative
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PRE
answer
progressive resistive exercise
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pre op
answer
preoperative
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PRN
answer
as needed
question
pro
answer
pronation
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PROM
answer
passive range of motion
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pt.
answer
patient
question
p/t
answer
part time
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PTSD
answer
post traumatic stress disorder
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PWB
answer
partial weight bearing
question
Px
answer
physical examination
question
R
answer
respiration
question
RA
answer
rheumatoid arthritis
question
RBC
answer
red blood cell count
question
re:
answer
regarding
question
reps
answer
repetitions
question
RICE
answer
rest, ice, compression, elevation
question
RLQ
answer
right lower quadrant
question
r/o
answer
rule out
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ROM
answer
range of motion
question
ROS
answer
review of symptoms
question
RTC
answer
return to clinic
question
RUQ
answer
right upper quadrant
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RTO
answer
return to office
question
RSD
answer
reflex sympathetic dystrophy
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Rx
answer
prescription
question
s
answer
without
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S
answer
subjective
question
SBA
answer
stand by assistance
question
SCI
answer
spinal cord injury
question
SH
answer
social history
question
SI
answer
sensory integration
question
SIDS
answer
sudden infant death syndrome
question
sig:
answer
instruction to patient
question
SLE
answer
systemic lupus erythematosus
question
SLP
answer
speech-language pathologist
question
SOC
answer
start of care
question
SOAP
answer
subjective, objective, assessment, plan
question
SOB
answer
shortness of breath
question
SNF
answer
skilled nursing facility
question
s/p
answer
status post
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SSRI
answer
selective serotonin reuptake inhibitor
question
STAT
answer
immediately
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STD
answer
sexually transmitted disease
question
STG
answer
short-term goal
question
STM
answer
short-term memory
question
suppos
answer
suppository
question
sup
answer
supination
question
T
answer
temperature
question
TB
answer
tuberculosis
question
TBI
answer
traumatic brain injury
question
TEDS
answer
thrombo-embolic disease stockings
question
TENS
answer
transcutaneous electrical nerve stimulation
question
TFCC
answer
triangular fibrocartilage complex
question
there ex
answer
therapeutic exercise
question
THR
answer
total hip replacement
question
TIA
answer
transient ischemic attack
question
TKE
answer
total knee replacement
question
TMJ
answer
temporomandibular joint
question
TNR
answer
tonic neck reflex
question
t.o.
answer
telephone order
question
TOS
answer
thoracic outlet syndrome
question
TPR
answer
temperature, pulse, respiration
question
TTWB
answer
toe touch weight bearing
question
tx.
answer
treatment
question
UA
answer
urinalysis
question
UE
answer
upper extremity
question
UMN
answer
upper motor neuron
question
URI
answer
upper respiratory infection
question
US
answer
ultrasound
question
UTI
answer
urinary tract infection
question
VC
answer
vital capacity
question
VD
answer
venereal disease
question
v.o.
answer
verbal orders
question
vol.
answer
volume
question
VS
answer
vital signs
question
W
answer
watt
question
WBC
answer
white blood cell
question
WBAT
answer
weight bearing as tolerated
question
w/c
answer
wheelchair
question
WDWN
answer
well developed; well nourished
question
wk.
answer
week
question
WFL
answer
within functional limits
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WNL
answer
within normal limits
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wt
answer
weight
question
x
answer
times
question
y.o.
answer
year old
question
1
answer
primary
question
2
answer
secondary
