AH
auditory hallucinations
AK (A)
above knee amputation
AMA
against medical advice
amt
amount
ant
anterior
AOB
alcohol on breath
approx
approximately
APS
adult protective services
AROM
active range of motion
as tol
as tolerated
AT
assistive technology
bilat
bilateral
BD
bipolar disorder
bal
balance
BE (A)
below elbow/trans-radial (amputation)
A
assistance
AA
Alcoholics Anonymous
AAOx3
awake, alert, oriented to person, place & time
AAROM
active assisted range of motion
abd
abduction - movement away from midline
ADL
activities of daily living
adm
admission
add
adduction
bid
twice a day
BK (A)
below knee/trans-tibial (amputation)
AE (A)
above elbow amputation
BM
bowel movement
BOS
base of support
BP
blood pressure
BPM
beats per minute
BSC
bedside commode
C
Celsius
C#
cervical vertebra 2nd, 3rd, etc
CA
cancer
CAD
coronary artery disease
CC
chief complaint
CNS
central nervous system
c/o
complains of
COG
center of gravity
cont.
continuously
coord
coordination
COTA
certified occupational therapy assistant
CP
cerebral palsy
CPR
cardiopulmonary resuscitation
CPS
child protective services
CSF
cerebrospinal fluid
DD
developmentally disabled
demo
demonstrate
dep
dependent
DME
durable medical equipment
DMHP
designated mental health professional
DSHS
department of social & health services
DV
domestic violence
Dx
diagnosis
ea
each
e.g.
for example
EMS
emergency medical service
EOB
edge of bed
ETOH
alcohol
eval
evaluation
ex
exercise
ext
extension
IADL
instrumental activities of daily living
ICE
ice, compression, elevation
ICU
intensive care unit
ID
identification
IF
index finger
incont
incontinence
inf
inferior
jt
joint
kg
kilogram (2.205 lbs)
L#
lumbar vertebrae #
lat
lateral
LB
lower body
LBP
lower back pain
LE
lower extremity
lig
ligament
LLE
left lower extremity
LOB
loss of balance
LOC
loss of consciousness
LOS
length of stay
LTC
long term care
LTG
long term goal
LUE
letf upper extremity
m
meter
max
maximum
max A(in circle)
maximal assistance
meds
medications
MF
middle finger
mg
miligram
MICA
mentally ill, chemically addicated
min
minute
min A(in circle)
minimal assistance
ml
milililiter
mm
mililimeter
MMPI
Minnesota Multiphasic Personality Inventory
MMSE
Mini-Mental Status Examination
mod A(in circle)
moderate assistance
mod I
modified independence
MR
mental retardation
MS
multiple sclerosis
MSE
mental status exam
n
nerve
N/A
not available/applicable
MVA
motor vehicle accident
neg
negative
NICU
neonatal intensive care unit
NKA
no known allergies
NKDA
no known drug allergy
NPO
nothing by mouth
nsg./Nsg.
nursing
NT
not tested
NWB
non-weight bearing
O2
oxygen
OOB
out of bed
OP
outpatient
OT
occupational therapy (NOT occupational therapist)
Ox3
oriented to person, place, time
oz
ounce
PDD
pervasive developmental disorder
ped/peds
pediatrics
per
by
PM
afternoon
RTW
return to work
RUE
right upper extremity
Rx
prescription
PMH/PMHx
past medical history
pos
positive
post
posterior
post op
post operative
S or in circle
supervision
s
without
pre-op
preoperative
PRN
as needed
SBA
stand-by assist
SCI
spinal cord injury
sec
second
shld
shoulder
proprio
prorioception
pros
prosmial
psych
psychiatry
PT
physical therapy
pt
patient
SLP
Speech Language Pathologist
PWB
partial weight bearing
SNF
skilled nursing facility
SOAP
subjective, objective, assessment, plan
SOB
short of breath
SOC
start of care
soc hx
social history
S/P or s/p
status post
SSDI
social security disability insurance
R or in circle
right
STG
short term goal
re:
regarding
reg
regular
rep/s
repetition/s
req
required
sup
superior
Sx
symptom
RF
ring finger
RICE
rest, ice, compression, elevation
RLE
right lower extremity
R/O or r/o
rule out
ROM
range of motion
T#
thoracic vertebrae #
TB
tuberculosis
TBI
traumatic brain injury
RPT
rating of perceived exertion
RR
respiratory rate
temp
temperature
THR or THA
total hip replacement
WBAT
weight bearing as tolerated
W/C or w/c
wheelchair
WFL
within functional limits
wk (s)
week(s)
WNL
within normal limits
THP
total hip precautions
w/o
without
TKR (or TKA)
total knee replacement
wt
weight
x1, x2, etc
number of persons for assistance or repetitions
tol
tolerated
tox
toxicology
yo
year old
yr
Year
TTWB
toe touch weight bearing
tx('d)
treatment (treated)
UB
upper body
UE
upper extremity
URI
upper respiratory infection
UTI
urinary tract infection
VH
visual hallucinations
voc
vocational
vol
volume
vs
versus
AFO
ankle foot orthosis
ALS
amyotrophic lateral sclerosis
amb
ambulation or ambulate
delta sign
change
CHF
congestive heart failure
COPD
chronic obstructive pulmonary disease
CGA
contact guard assistance
CVA
cerebrovascular accident
fx
fracture
F/U
follow up
HOB
head of bed
KELS
Kohlman Evaluation of Living Skills
HR
heart rate
ORIF
open reduction, internal fixation
NG
nasogastric
PVD
peripheral vascular disease
PROM
passive range of motion
AAC
augmentative and alternative communication
CABG
coronary artery bypass graft
CMV
cytomegalovirus
DBP
diastolic blood pressure
CN
cranial nerve
EMG
electromyogram
EEG
electroencephalogram
ER
external rotation
CTS
carpal tunnel syndrome
FES
functional electric stimulation
FIM
Functional Independence Measurement
freq.
frequency
fwd
forward
FWW
front wheeled walker
fx dis.
fracture dislocation
GI
gastrointestinal
GH
glenohumeral
H&P
history and physical
HA
headache
HEP
home exercise program
HHA
home health aide
HH
home health
lac
laceration
IV
intravenous
h/o
history of
HTN
hypertension
NDT
neurodevelopmental treatment
NIDDM
non-insulin dependent diabetes mellitus
NTG
nitroglycerin
OA
osteoarthritis
MI
myocardial infarction
MMT
Manual Muscle Test
MP or MCP
metacarpophalangeal
MRI
magnetic resonance imaging
MRSA
methicillin resistant staph. aureus
PERRLA
pupils equal, round, reactive to light and accommodation
PET
positron emission tomography
pro
pronation
SSRI
selective serotonin reuptake inhibitor
RA
rheumatoid arthritis
RC
rotator cuff
supin
supination
TD
tardive dyskinesia
voc
vocational