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283 terms

Abbreviations for Occupational Therapy Documentation

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