Clinical documentation abbreviations

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BryanHimmel
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164926
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Clinical documentation abbreviations
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2012-08-18 16:17:26
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clinical abbreviations
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abbreviations
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  1. a (line over)
    before
  2. A
    Assist
  3. AAROM
    active assist range of motion
  4. abd/add
    abduction/adduction
  5. abn
    abnormal
  6. AC joint
    acromioclavicular joint
  7. ACL
    anterior cruciate ligament
  8. ADL
    activities of daily living
  9. Afib
    atrial fibrillation
  10. AFO
    Ankle foot orthosis
  11. AKA
    above knee amputation
  12. am,a.m.
    morning, before noon
  13. AMA
    against medical advice
  14. amb.
    ambulation
  15. amt
    amount
  16. ant
    anterior
  17. AROM
    active range of motion
  18. ASAP
    as soon as possible
  19. assist.
    assistance
  20. A&O x (1-4)
    alert and oriented to (person, place, time, situation)
  21. (B)
    bilateral, both
  22. b/c
    because
  23. bid
    twice a day
  24. bil
    bilateral
  25. biw
    twice a week
  26. BKA
    below knee amputation
  27. BLE
    both lower extremities
  28. BM
    bowel movement
  29. BOS
    base of support
  30. BP
    blood pressure
  31. BPM
    beats per minute
  32. B/S, B.S.
    bedside
  33. BUE
    both upper extremities
  34. c (with line over)
    with
  35. CA
    carcinoma, cancer
  36. CABG
    coronary artery bypass graft
  37. CAD
    Coronary artery disease
  38. CBC
    complete blood count
  39. C/C
    cheif complaint
  40. CGA
    Contact guard assist
  41. CHF
    congestive heart failure
  42. CNS
    central nervous system
  43. c/o
    complains of
  44. cont
    continue
  45. COPD
    Chronic obstructive pulmonary disease
  46. CVA
    cerebral vascular accident
  47. d/c
    discharge
  48. DF
    dorsiflexion
  49. DJD
    degenerative joint disease
  50. DME
    durable medical equipment
  51. DNR
    do not resuscitate
  52. DOB
    date of birth
  53. DTR
    deep tendon reflex
  54. DVT
    deep vein thrombosis
  55. Dx
    diagnosis
  56. ECF
    Extended care facility
  57. EOB
    edge of bed
  58. ER
    external rotation
  59. Eval
    evaluation
  60. ex.
    exercise
  61. ext., /
    extension
  62. F
    female, fair muscle strength
  63. FIM
    functional independent measure
  64. flex., (check mark)
    flexion
  65. F/U
    follow up
  66. FWB
    Full weight bearing
  67. FWW
    front wheeled walker
  68. Fx
    Fracture
  69. G
    good
  70. GI
    gastrointestinal
  71. gt.
    gait
  72. gluts
    gluteals
  73. H&P
    history and physical
  74. HA
    headache
  75. Hb, Hgb, HGB
    hemoglobin
  76. hemi
    hemiplegia
  77. HEP
    home exercise program
  78. HHA
    hand held assist
  79. h/o
    history of
  80. HOB
    head of bed
  81. HP
    hot pack
  82. HR
    heart rate or handrail
  83. h.s.
    at bedtime
  84. HTN
    HYPERTENSION
  85. Hx, HX, hx
    history
  86. I, indep.
    independent
  87. ICH
    Intracranial hemorrhage
  88. ICU
    Intensive Care Unit
  89. IDDM
    insulin dependent diabetes mellitus
  90. inf.
    inferior
  91. int.
    internal
  92. IR
    internal rotation
  93. L, lt.
    left
  94. LAQ
    long arc quad
  95. lat.
    lateral
  96. LBP
    Low back pain
  97. LE
    Lower extremity
  98. LLE
    left lower extremity
  99. LOB
    loss of balance
  100. LOC
    loss of consciousness
  101. LTG
    long term goal
  102. LUE
    left upper extremity
  103. LBQC
    large base quad cane
  104. M
    male
  105. m., mm
    muscle
  106. max.
    maximum
  107. MI
    myocardial infarction
  108. min.
    minimum, minimal
  109. MMT
    manual muscle test
  110. mod.
    moderate
  111. MVA
    motor vehicle accident
  112. mvmt
    movement
  113. N
    normal
  114. N/A
    not applicable
  115. N&V
    nausea & vomiting
  116. neg.
    negative
  117. NIDDM
    non-insulin dependent diabetes mellitus
  118. NPO
    nothing by mouth
  119. NWB
    non-weight-bearing
  120. N/T
    not tested
  121. O2 sat
    oxygen saturation
  122. OA
    osteoarthritis
  123. OOB
    out of bed
  124. OP
    outpatient
  125. ORIF
    open reduction internal fixation
  126. OTR
    registered occupational therapist
  127. P (line over)
    post, after
  128. P
    poor
  129. PA
    physical assist
  130. para
    paraplegia
  131. PE
    pulmonary emboli
  132. PF
    plantarflexion
  133. PMH
    past medical history
  134. pm, p.m.
    afternoon, evening
  135. PO
    by mouth
  136. POC
    plan of care
  137.  post-op
    after surgery or operation
  138. post.
    posterior
  139. PRE
    Progressive resistive exercise
  140. pre-op
    before surgery
  141. pn
    as needed
  142. PROM
    passive range of motion
  143. Pt., pt.
    patient
  144. PTA
    prior to admission, or physical therapist assistant
  145. PWB
     partial weight bearing
  146. q
    every
  147. qd
    everyday
  148. qid
    four times a day
  149. quad(s)
    quadriplegic, quadriceps
  150. R
    right
  151. RA
    rheumatoid arthritis
  152. re:
    regarding
  153. re-ed
    reeducation
  154. reps
    repetitions
  155. RLE
    right lower extremity
  156. R/O, R.O.
    rule out
  157. ROM
    range of motion
  158. rot.
    rotation
  159. RROM
    resistive range of motion
  160. RUE
    right upper extremity
  161. Rx
    therapy, treatment
  162. s (line over)
    without
  163. S
    Supervision
  164. SAQ
    Short arc quads
  165. SBA
    standby assist
  166. SCI
    spinal cord injury
  167. SLP
    speech language pathologist
  168. SLR
    straight leg raise
  169. SNF
    skilled nursing facility
  170. SOB
    shortness of breath
  171. SOB
    shortness of breath
  172. S/P
    status post
  173. STE
    steps to enter
  174. STG
    short term goal
  175. sup.
    superior
  176. SBQC
    small base quad cane
  177. T
    trace muscle strength
  178. TBI
    traumatic brain injury
  179. TFs
    transfers
  180. Ther. ex.
    therapeutic exercise
  181. THR (THA)
    total hip replacement/anthroplasty
  182. tid
    three times a day
  183. TKR (TKA)
    total knee replacement/arthroplasty
  184. tol.
    tolerate
  185. TTWB
    toe touch weight bearing
  186. tx
    treatment
  187. Tx
    traction
  188. tiw
    three times a week
  189. t/o
    through out
  190. TC
    Tactile cuing
  191. UA
    urinalysis
  192. UE
    Upper extremity
  193. U/S, US
    ultrasound
  194. UTI
    urinary tract infection
  195. (U)
    unilateral
  196. VC
    verbal cuing
  197. VG
    verbal guidance
  198. v.s.
    vital signs
  199. w/
    with
  200. WB
    weight-bearing
  201. WBAT
    weight-bearing as tolerated
  202. WC, w/c
    wheelchair
  203. WFL
    within funcitonal limits
  204. WNL
    within normal limits
  205. w/o
    without
  206. wk
    week
  207. xfer
    transfer
  208. XR
    x-ray
  209. X
    number of times performed
  210. y.o.
    years old
  211. //
    parallel, parallel bars

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