4980 Clin Eval

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mizzoupt
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31029
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4980 Clin Eval
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2010-08-24 11:38:45
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Abbreviations - Ch. 4 of Writing pt./client Notes
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  1. A:
    Assessment
  2. ABI
    Acquired Brain Injury
  3. afib
    atrial fibrillation
  4. A-line
    arterial line
  5. A-V
    arteriovenous
  6. AAA
    abdominal aortic aneurysm
  7. AAROM
    active assistive range of motion
  8. Abd or abd
    abduction
  9. ABG
    arterial blood gases
  10. ac
    before meals
  11. AC joint
    acromioclavicular joint
  12. ACL
    anterior cruciate ligament
  13. ACTH
    adrenocorticotrophic hormone
  14. Add or add
    adduction
  15. ADL
    activities of daily living
  16. ad lib
    at discretion
  17. adm
    admission, admitted
  18. AE
    above elbow
  19. AFO
    ankle foot orthosis
  20. AIDS
    acquired immune deficiency syndrome
  21. AIIS
    anterior inferior iliac spine
  22. AJ
    ankle jerk
  23. AK
    above knee
  24. ALS
    amyotrophic lateral sclerosis
  25. a.m.
    morning
  26. AMA
    against medical advice
  27. amb
    ambulation, ambulating, ambulated, ambulate, ambulates
  28. ANS
    autonomic nervous system
  29. ant
    anterior
  30. AP
    anterior-posterior
  31. ARDS
    adult respiratory distress syndrome
  32. ARF
    acute renal failure
  33. AROM
    active range of motion
  34. ASA
    aspirin
  35. ASAP or asap
    as soon as possible
  36. ASCVD
    arteriosclerotic cardiovascular disease
  37. ASHD
    arteriosclerotic heart disease
  38. ASIS
    anterior superior iliac spine
  39. assist.
    assistance, asstistive
  40. AVM
    arteriovenous malformation
  41. B/S
    bedside
  42. BBB
    bundle branch block
  43. BE
    below elbow
  44. BID or bid
    twice a day
  45. bilat. or B
    bilateral, bilaterally
  46. BK
    below knee
  47. BM
    bowel movement
  48. BOS
    base of support
  49. BP
    blood pressure
  50. bpm
    beats per minute
  51. BR
    bedrest
  52. BRP
    bathroom privileges
  53. BS
    breath sounds or bowel sounds
  54. BUN
    blood urea nitrogen (blood test)
  55. C
    centigrade
  56. C&S
    culture and sensitivity
  57. c/o
    complains of
  58. CA
    cancer, carcinoma
  59. CABG
    coronary artery bypass graft
  60. CAD
    coronary artery disease
  61. cal
    calories
  62. CAT
    computerized axial tomography
  63. CBC
    complete blood cell (count)
  64. CC, C/C
    chief complaint
  65. CF
    cystic fibrosis
  66. CHF
    congestive heart failure
  67. cm
    centimeter
  68. CMV
    cytomegalovirus
  69. CNS
    central nervous system
  70. CO
    cardiac output
  71. CO2
    carbon dioxide
  72. cont.
    continue
  73. COPD
    chronic obstructive pulmonary disease
  74. COTA
    certified occupational therapy assistant
  75. CP
    cerebral palsy
  76. CPAP
    continuous positive airway pressure
  77. CPR
    cardiopulmonary resuscitation
  78. CRF
    chronic renal failure
  79. CSF
    cerebral spinal fluid
  80. CV
    cardiovascular
  81. CWI
    crutch walking instructions
  82. CXR
    chest x-ray
  83. Cysto
    cytoscopic examination
  84. D/C
    discontinued, discharged
  85. dept.
    department
  86. DIP
    distal interphalangeal joint
  87. DJD
    degenerative joint disease
  88. DM
    diabetes mellitus
  89. DNR
    do not resuscitate
  90. DO
    doctor of osteopathy
  91. DOB
    date of birth
  92. DOE
    dyspnea on exertion
  93. DTR
    deep tendon reflex
  94. DVT
    deep vein thrombosis
  95. Dx
    diagnosis
  96. ECF
    extended care facility
  97. ECG, EKG
    electrocardiogram
  98. ED
    emergency department
  99. EEG
    electroencephalogram
  100. EENT
    ear, eyes, nose, throat
  101. EMG
    electromyogram, electromyography
  102. E.R.
    emergency room
  103. eval.
    evaluation
  104. ext.
    extension
  105. FBS
    fasting blood sugar
  106. FEV
    forced expiratory volume
  107. FH
    family history
  108. flex
    flexion
  109. FRC
    functional residual capacity
  110. ft.
    foot, feet (the measurement, not the body part)
  111. FUO
    fever of unknown origin
  112. FVC
    forced vital capacity
  113. FWB
    full weight bearing
  114. fx
    fracture
  115. GB
    gallbladder
  116. GI
    gastrointestinal
  117. g
    gram
  118. GSW
    gunshot wound
  119. GYN
    gynecology
  120. h, hr.
    hour
  121. H&H, H/H
    hematocrit and hemoglobin
  122. H&P
    history and physical
  123. h/o
    history of
  124. HA, H/A
    headache
  125. Hb, Hgb
    hemoglobin
  126. Hct
    hematocrit
  127. HCVD
    hypertensive cardiovascular disease
  128. HEENT
    head, ear, eyes, nose, throat
  129. HEP
    home exercise program
  130. HIV
    human immunodeficiency virus
  131. HNP
    herniated nucleus pulposus
  132. HOB
    head of bead
  133. HR
    heart rate
  134. hs
    at bedtime
  135. ht.
    height
  136. Ht
    hematocrit
  137. Htn or HTN
    hypertension
  138. Hx
    history
  139. I&O
    intake and output
  140. IADL
    instrumental activities of daily living
  141. ICU
    intensive care unit
  142. IDDM
    insulin-dependent diabetes mellitus
  143. IM
    intramuscular
  144. imp.
    impression
  145. in.
    inches
  146. indep
    independent
  147. IMV
    intermittent mandatory ventilation
  148. inf
    inferior
  149. IRDS
    infant respiratory distress syndrome
  150. IS
    incentive spirometry
  151. IV
    intravenous
  152. KAFO
    knee-ankle-foot orthosis
  153. kcal
    kilocalories
  154. kg
    kilogram
  155. KJ
    knee jerk
  156. KUB
    kidney, ureter, bladder
  157. L or l.
    liter
  158. L
    left
  159. lat
    lateral
  160. lb.
    pound
  161. LBBB
    left bundle branch block
  162. LBP
    low back pain
  163. LE
    lower extremity
  164. LOC
    loss of consciousness, level of consciuosness
  165. LMN
    lower motor neuron
  166. LOS
    length of stay
  167. LP
    lumbar puncture
  168. m
    meter
  169. MAP
    mean arterial pressure
  170. max
    maximal
  171. MD
    medical doctor; doctor of medicine
  172. MED
    minimal erythemal dose
  173. meds.
    medications
  174. mg
    milligram
  175. MI
    myocardial infarction
  176. min
    minimal
  177. min.
    minute
  178. ml
    millileter
  179. mm
    millimeter
  180. MMT
    manual muscle test
  181. mo.
    month
  182. mod
    moderate
  183. MP, MEP
    metacarpophalangeal
  184. MRSA
    methicillin-resistant Staphyloccocus aureus
  185. MVA
    motor vehicle accident
  186. NDT
    neurodevelopment treatment
  187. neg.
    negative
  188. NG or ng
    nasogastric
  189. N.H.
    nursing home
  190. NIDDM
    non-insulin dependent diabetes mellitus
  191. nn
    nerve
  192. noc
    night, at night
  193. NPO, npo
    nothing by mouth
  194. NSR
    normal sinus rythm
  195. NWB
    non-weight bearing
  196. O:
    objective
  197. OA
    osteoarthritis
  198. OB
    obstetrics
  199. OBS
    organic brain syndrome
  200. od
    once daily
  201. OOB
    out of bed
  202. O.P.
    outpatient
  203. O.R.
    operating room
  204. ORIF
    open reduction, internal fixation
  205. OT
    occupational therapy, occupational therapist
  206. OTR
    occupational therapist (used to follow official signature of the occupational therapist)
  207. oz.
    ounce
  208. P
    poor
  209. P:
    plan, intervention plan, plan of care
  210. P.A.
    physician's assistant
  211. PA
    posterior/anterior
  212. para
    paraplegia
  213. pc
    after meals
  214. PCL
    posterior cruciate ligament
  215. PE
    pulmonary embolus
  216. PEEP
    positive end expiratory pressure
  217. per
    by/through
  218. p.o.
    by mouth
  219. PERRLA
    pupils equal. round, reactive to light, and accomodation
  220. P.H.
    past history
  221. p.m.
    afternoon
  222. PMH
    past medical history
  223. PNF
    priprioceptive neuromuscular facilitation
  224. PNI
    peripheral nerve injury
  225. POMR
    problem-oriented medical record
  226. pos.
    postive
  227. poss
    possible
  228. post
    posterior
  229. post-op
    after surgery (operation)
  230. PRE
    progressive-resistive exercise
  231. pre-op
    before surgery (operation)
  232. prn
    whenever necessary, as often as necessary
  233. PROM
    passive range of motion
  234. PSIS
    posterior-superior iliac spine
  235. PT
    physical therapist, physical therapy
  236. PT/PTT
    prothrombin time / partial thromboplastin time
  237. Pt., pt.
    patient
  238. PTA
    physical therapy assistant
  239. PTB
    patellar tendon bearing
  240. PVD
    peripheral vascular disease
  241. PWD
    partial weight bearing
  242. q
    every
  243. qid
    four times a day
  244. qh
    every hour
  245. qn
    every night
  246. qt.
    quart
  247. R
    right
  248. RA
    rheumatoid arthritis
  249. RBBB
    right bundle branch block
  250. RBC
    red blood cell (count)
  251. R.D.
    registered dietician
  252. re:
    regarding
  253. rehab
    rehabilitation
  254. reps
    repitions
  255. resp
    respiratory, respiration
  256. RN
    registered nurse
  257. R/O or r/o
    rule out
  258. ROM
    range of motion
  259. ROS
    review of systems
  260. RR
    respiratory rate
  261. RROM
    resistive range of motion
  262. RT
    respiratory therapist, respiratory therapy
  263. Rx
    intervention plan, prescription, therapy
  264. SACH
    solid ankle cushion heel
  265. SCI
    spinal cord injury
  266. SC joint
    sternoclavicular joint
  267. sec.
    seconds
  268. SED
    suberythemal dose
  269. sig
    directions for use, give as follows, let it be labeled
  270. SI(J)
    sacroiliac (joint)
  271. SLE
    systemic lupus erythematosus
  272. SLP
    speech-language pathologist
  273. SLR
    straight leg raise
  274. SNF
    skilled nursing facility
  275. SOAP
    subjective, objective, assessment, plan
  276. SOB
    shortness of breath
  277. S/P
    status post (e.g. "S/P hip fx" means Pt. fx her hip in the recent past)
  278. spec
    specimen
  279. stat.
    immediately, at once
  280. sup
    superior
  281. Sx
    symptoms
  282. tab
    tablet
  283. TB
    tuberculosis
  284. TBI
    traumatic brain injury
  285. tbsp.
    tablespoon
  286. TENS, TNS
    transcutaneous electrical nerve stimulator/stimulation
  287. THA
    total hip arthroplasty
  288. ther ex
    therapeutic exercise
  289. TIA
    transient ischemic attack
  290. tid
    three times daily
  291. TKA
    total knee arthroplasty
  292. TM(J)
    temporomandibular (joint)
  293. TNR
    tonic neck reflex (also ATNR, STNR)
  294. t.o.
    telephone order
  295. TPR
    temperature, pulse, and respiration
  296. tsp.
    teaspoon
  297. TUR/TURP
    transurethral resection
  298. Tx
    traction
  299. TV
    tidal volume
  300. UA
    urine analysis
  301. UE
    upper extremity
  302. UMN
    upper motor neuron
  303. URI
    upper respiratory infection
  304. US
    ultrasound
  305. UTI
    urinary tract infection
  306. UV
    ultraviolet
  307. VC
    vital capacity
  308. VD
    veneral disease
  309. v.o. or VO
    verbal orders
  310. v.s.
    vital signs
  311. w/c
    wheelchair
  312. W/cm2
    watts per square centimeter
  313. WBC
    white blood cell (count)
  314. wk.
    week
  315. WNL
    within normal limits
  316. wt.
    weight
  317. X
    number of times performed (e.g. X2 is twice)
  318. y/o or y.o.
    years old
  319. yd.
    yard
  320. yr.
    year
  321. +1 (+2, etc.)
    assitance (assistance of 1 person given)

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