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PTA 101 writing patient/client notes
Abbreviations chapters 4,5,6
331
Health Care
11/06/2010
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Term
A
 Definition
Assessment
Term
ABI
 Definition
Acquired brain injury
Term
afib
 Definition
atrial fibrillation
Term
A-line
 Definition
Arterial line
Term
A-V
 Definition
arteriovenous
Term
AAA
 Definition
abdominal aortic aneurysm
Term
AAROM
 Definition
active assisted range of motion
Term
Abd or    abd
 Definition
abduction
Term
ABG
 Definition
arterial blood gases
Term
ac
 Definition
before meals
Term
AC joint
 Definition
acromioclavicular joint
Term
ACL
 Definition
anterior cruciate ligament
Term
ACTH
 Definition
adrenocorticotrophic hormone
Term
add  or Add
 Definition
adduction
Term
ADL
 Definition
activities of daily living
Term
ad lib
 Definition
at discretion
Term
adm
 Definition
admission, admitted
Term
AE
 Definition
above elbow
Term
AFO
 Definition
ankle foot orthosis
Term
AIDS
 Definition
ACQUIRED IMMUNE DEFICIENCY SYNDROME
Term
AIIS
 Definition
anterior inferior iliac spine
Term
AJ
 Definition

ankle jerk

 
Term
AK
 Definition

above knee

 
Term
ALS
 Definition
amyotrophic lateral sclerosis
Term
a.m.
 Definition
morning
Term
AMA
 Definition
against medical advice
Term
amb
 Definition
ambulation, ambulating, ambulated, ambulate, ambulates
Term
ANS
 Definition
auttonomic nervous system
Term
ant
 Definition
anterior
Term
AP
 Definition
anterior-posterior
Term
ARDS
 Definition
adult respiratory disease syndrome
Term
ARF
 Definition
acute renal failure
Term
AROM
 Definition
active range of motion
Term
ASA
 Definition
aspirin
Term
ASAP  or asap
 Definition
as soon as possible
Term
ASCVD
 Definition
arteriosclerotic cardiovascular disease
Term
ASHD
 Definition
arteriosclerotic heart disease
Term
ASIS
 Definition
anterior superior iliac spine
Term
assist.
 Definition
assistance, assistive
Term
AVM
 Definition
arteriovenous malformation
Term
B/S
 Definition
Bedside
Term
BBB
 Definition
bundle branch block
Term
BE
 Definition
Below elbow
Term
BID  or bid
 Definition
twice a day
Term
bilat   or   B
 Definition
bilateral, bilaterally
Term
BK
 Definition
below knee
Term
BM
 Definition
bowel movement
Term
BOS
 Definition
Base of support
Term
BP
 Definition
Blood Pressure
Term
bpm
 Definition
beats per minute
Term
BR
 Definition
bedrest
Term
BRP
 Definition
bathroom privileges
Term
BS
 Definition
Breath sounds or bowel sounds
Term
BUN
 Definition
Blood urea nitrogen   (blood test)
Term
C
 Definition
centigrade
Term
C&S
 Definition
culture and sensitivity
Term
c/o
 Definition
complains of
Term
CA
 Definition
cancer, carcinoma
Term
CABG
 Definition
coronary artery bypass graft
Term
CAD
 Definition
coronary artery disease
Term
cal
 Definition
calories
Term
CAT
 Definition
computerized axial tomography
Term
CC   or  C/C
 Definition
chief complaint
Term
CBC
 Definition
complete blood cell (count)
Term
CF
 Definition
cystic fibrosis
Term
CHF
 Definition
congestive heart failure
Term
cm
 Definition
centimeter
Term
CMV
 Definition
cytomegalovirus
Term
CNS
 Definition
central nervous system
Term
CO
 Definition
cardiac output
Term
CO2
 Definition
carbon dioxide
Term
COPD
 Definition
chronic obstructive pulmonary disease
Term
COTA
 Definition
certified occupational therapy assistant
Term
CP
 Definition
cerebral palsy
Term
CPAP
 Definition
continuous positive airway pressure
Term
CPR
 Definition
cardiopulmonary resuscitation
Term
CRF
 Definition
chronic renal failure
Term
CSF
 Definition
cerebrospinal fluid
Term
CV
 Definition
cardiovascular
Term
CWI
 Definition
crutch walking instructions
Term
CXR
 Definition
chest x-ray
Term
Cysto
 Definition
cystoscopic examination
Term
D/C
 Definition
discharged  or discontinued
Term
dept
 Definition
department
Term
DIP
 Definition
distal interphalangeal joint
Term
DJD
 Definition
degenerative joint disease
Term
DM
 Definition
diabetes mellitus
Term
DNR
 Definition
do not resuscitate
Term
DO
 Definition
doctor of osteopathy
Term
DOB
 Definition
date of birth
Term
DOE
 Definition
dyspnea on exertion
Term
DTR
 Definition
deep tendon reflex
Term
DVT
 Definition
deep vein thrombosis
Term
Dx
 Definition
diagnosis
Term
ECF
 Definition
extended care facility
Term
ECG  or EKG
 Definition
electrocardiogram
Term
ED
 Definition
emergency department
Term
EEG
 Definition
electroencephalogram
Term
EENT
 Definition
ear,eyes,nose, throat
Term
EMG
 Definition
electromyogram, electromyography
Term
E.R.
 Definition
Emergency Room
Term
eval
 Definition
evaluation
Term
ext
 Definition
extension
Term
FBS
 Definition
fasting blood sugar
Term
FEV
 Definition
forced expiratory volume
Term
FH
 Definition
family history
Term
flex
 Definition
flexion
Term
FRC
 Definition
functional residual capacity
Term
ft
 Definition
foot, feet  (the measurment not the body part)
Term
FUO
 Definition
fever of unknown origin
Term
FVC
 Definition
forced vital capacity
Term
FWB
 Definition
full weight bearing
Term
fx
 Definition
fracture
Term
GB
 Definition
gallbladder
Term
GI
 Definition
gastrointestinal
Term
g
 Definition
gram
Term
GSW
 Definition
gunshot wound
Term
GYN
 Definition
gynecology
Term
h, hr.
 Definition
hour
Term
H&H    or   H/H
 Definition
hematocrit and hemoglobin
Term
H&P  
 Definition
history and physical
Term
h/o
 Definition
history of
Term
HA   or H/A
 Definition
headache
Term
Hb  or Hgb
 Definition
hemoglobin
Term
Hc
 Definition
hemotocrit
Term
HCVD
 Definition
hypertensive cardiovascular disease
Term
HEENT
 Definition
head, ear, eyes, nose, throat
Term
HEP
 Definition
home exercise program
Term
HIV
 Definition
human immunodificiency virus
Term
HNP
 Definition
herniated nucleus pulposus
Term
HOB
 Definition
head of bed
Term
HR
 Definition
heart rate
Term
hs
 Definition
at bedtime
Term
ht
 Definition
height
Term
Ht
 Definition
hematocrit
Term
htn  or HTN
 Definition
hypertension
Term
Hx
 Definition
history
Term
I&O
 Definition
intake and output
Term
IADL
 Definition
instumental activities of daily living
Term
ICU
 Definition
intensive care unit
Term
IDDM
 Definition
insulin dependent diabetes millitus
Term
IM
 Definition
intramuscular
Term
imp.
 Definition
impression
Term
in.
 Definition
inches
Term
indep
 Definition
independent
Term
IMV
 Definition
intermittent mandatory ventilation
Term
inf
 Definition
inferior
Term
IRDS
 Definition
infant respiratory distress syndrome
Term
IS
 Definition
incentive spirometry
Term
IV
 Definition
intravenous
Term
KAFO
 Definition
knee ankle foot orthosis
Term
kcal
 Definition
kilocalories
Term
kg
 Definition
kilogram
Term
KJ
 Definition
knee jerk
Term
KUB
 Definition
kidney ureter bladder
Term
L   or  l
 Definition
Liter  or left
Term
lat
 Definition
lateral
Term
lb
 Definition
pound
Term
LBBB
 Definition
left bundle branch block
Term
LBP
 Definition
low back pain
Term
LE
 Definition
lower extremity
Term
LOC
 Definition

loss of consciousness 

level of consciousness
Term
LMN
 Definition
lower motor neuron
Term
LOS
 Definition
length of stay
Term
LP
 Definition
lumbar puncture
Term
m
 Definition
meter
Term
MAP
 Definition
mean arterial pressure
Term
max
 Definition
maximal
Term
MD
 Definition
medical doctor
Term
MED
 Definition
minimal erythemal dose
Term
Meds
 Definition
medications
Term
mg
 Definition
milligram
Term
MI
 Definition
myocardial infarction
Term
min
 Definition

minimal

 

min.  = minute
Term
poss
 Definition
possible
Term
ml
 Definition
milliliter
Term
mm
 Definition
millimeter
Term
MMT
 Definition
manual muscle test
Term
mo.
 Definition
month
Term
mod
 Definition
moderate
Term
MP  or  MCP
 Definition
metacarpophalangeal joint
Term
MRSA
 Definition
methicillin resistant staphylococcus aureus
Term
MVA
 Definition
moter vehicle accident
Term
NDT
 Definition
neurodevelopmental treatment
Term
neg.
 Definition
negative
Term
NG  or ng
 Definition
nasogastric
Term
N.H.
 Definition
nursing home
Term
NIDDM
 Definition
non insulin dependent diabetes millitus
Term
nn
 Definition
nerve
Term
noc
 Definition
night
Term
NPO  npo
 Definition
nothing by mouth
Term
NSR
 Definition
normal sinus rhythm
Term
NWB
 Definition
non weight bearing
Term
O.
 Definition
objective
Term
OA
 Definition
osteoarthritis
Term
OB
 Definition
obstetrics
Term
OBS
 Definition
organic brain syndrome
Term
od
 Definition
once daily
Term
OOB
 Definition
out of bed
Term
O.P.
 Definition
outpatient
Term
O.R.
 Definition
operating room
Term
ORIF
 Definition
open reduction internal fixation
Term
oz
 Definition
ounce
Term
p
 Definition
poor
Term
P:
 Definition
Plan , intervention plan, plan of care
Term
P.A.
 Definition
Physician's assistant
Term
para
 Definition
paraplegia
Term
pc
 Definition
after meals
Term
PCL
 Definition
posterior cruciate ligament
Term
PE
 Definition
pulmonary embolus
Term
PEEP
 Definition
positive end expiratory pressure
Term
per
 Definition
by/through
Term
p.o.
 Definition
by mouth
Term
PERRLA
 Definition
Pupils equal, round, reactive to light, and accommodation
Term
P.H.
 Definition
past history
Term
p.m.
 Definition
afternoon
Term
PMH
 Definition
past medical history
Term
PNF
 Definition
proprioceptive neuromuscular facilitation
Term
PNI
 Definition
peripheral nerve injury
Term
POMR
 Definition
problem oriented medical record
Term
pos.
 Definition
positive
Term
 Definition
Term
post
 Definition
posterior
Term
post-op
 Definition
after surgery
Term
PRE
 Definition
progressive-resistive exercise
Term
pre-op
 Definition
before surgery
Term
prn
 Definition
whenever necessary as often as neccessary
Term
PROM
 Definition
passive range of motion
Term
PSIS
 Definition
posterior superior iliac spine
Term
PT
 Definition
Physical therapy or physical therapist
Term
PT or PTT
 Definition
prothrombin time  or partial thromboplastin time
Term
Pt.  or  pt
 Definition
patient
Term
PTB
 Definition
patellar tendon bearing
Term
PVD
 Definition
peripheral vascular disease
Term
PWB
 Definition
partial weight bearing
Term
q
 Definition
every
Term
qid
 Definition
four times a day
Term
qh
 Definition
every hour
Term
qn
 Definition
every night
Term
qt
 Definition
quart
Term
R
 Definition
right
Term
RA
 Definition
rheumatoid arthritis
Term
RBBB
 Definition
right bundle branch block
Term
RBC
 Definition
red blood cell count
Term
R.D.
 Definition
registered dietician
Term
re:
 Definition
regarding
Term
rehab
 Definition
rehabilitation
Term
reps
 Definition
repititions
Term
resp
 Definition
respiratory, respiration
Term
Rn
 Definition
registered nurse
Term
R/O   or    r/o
 Definition
rule out
Term
ROM
 Definition
range of motion
Term
ROS
 Definition
review of systems
Term
RR
 Definition
respiratory rate
Term
RROM
 Definition
resistive range of motion
Term
RT
 Definition
respiratory therapist
Term
Rx
 Definition
intervention plan, prescription, therapy
Term
SACH
 Definition
solid ankle cushion bed
Term
SCI
 Definition
spinal cord injury
Term
SC joint
 Definition
sternoclavicular joint
Term
sec.
 Definition
seconds
Term
SED
 Definition
suberythemal dose
Term
sig
 Definition
directions for use, give as follows, let it be labeled
Term
SI(J)
 Definition
sacroiliac joint
Term
SLE
 Definition
systemic lupus  erythematosus
Term
SLP
 Definition
speech-language pathologist
Term
SLR
 Definition
straight leg raise
Term
SNF
 Definition
skilled nursing facility
Term
SOAP
 Definition
subjective, objective, assessment, plan
Term
SOB
 Definition
shortness of breath
Term
S/P
 Definition
status post
Term
spec
 Definition
specimen
Term
stat.
 Definition
immediately  at once
Term
sup
 Definition
superior
Term
Sx
 Definition
ymptomss
Term
tab
 Definition
tablet
Term
TB
 Definition
tuberculosis
Term
TBI
 Definition
traumatic brain injury
Term
tbsp
 Definition
tablespoon
Term
TENS,  TNS
 Definition
transcutaneous electrical nerve stimulator
Term
THA
 Definition
total hip arthroplasty
Term
ther ex
 Definition
therapeutic exercise
Term
TIA
 Definition
transient ischemic attack
Term
tid
 Definition
three times a day
Term
TKA
 Definition
total knee arthroplasty
Term
TMJ
 Definition
temporomandibular joint
Term
TNR   or ATNR  or STNR
 Definition
tonic neck reflex
Term
t.o.
 Definition
telephone order
Term
TPR
 Definition
temperature, pulse, and respiration
Term
tsp
 Definition
teaspoon
Term
TUR/TURP
 Definition
transurethral resection
Term
Tx
 Definition

traction

 

i've seen this before as treatment
Term
TV
 Definition
tidal volume
Term
UA
 Definition
urine analysis
Term
UE
 Definition
upper extremity
Term
UMN
 Definition
upper motor neuron
Term
URI
 Definition
upper respiratory infection
Term
US
 Definition
ultrasound
Term
UTI
 Definition
urinary tract infection
Term
UV
 Definition
ultraviolet
Term
VC
 Definition
vital capacity
Term
VD
 Definition
venereal disease
Term
v.o. VO
 Definition
verbal orders
Term
vol.
 Definition
volume
Term
v.s.
 Definition
vital signs
Term
w/c
 Definition
wheelchair
Term
W/cm2
 Definition
watts per square centimeter
Term
WBC
 Definition
white blood cell (count)
Term
wk.
 Definition
week
Term
WNL
 Definition
within normal limits
Term
wt.
 Definition
weight
Term
X
 Definition

number of times

x3 is three times
Term
y/o or y.o.
 Definition
years old
Term
yd.
 Definition
yard
Term
yr
 Definition
year
Term
+1, +2 etc...
 Definition

assistance given.  

examples:  amb c min +1 assist.  amb c mod assist +2
Term
↓
 Definition
decrease
Term
↑
 Definition
increase, up, upward, augmented
Term
\\
 Definition
parallel or parallel bars also written \\ bars
Term
≈
 Definition
approximately
Term
Δ
 Definition
change
Term
=
 Definition
equal
Term
1°
 Definition

primary

1 degree
Term
2°
 Definition
secondary
Term
→
 Definition
progressing toward, approaching
Term
↔
 Definition
to and from
Term
+    &    et.
 Definition
and
Term
%
 Definition
percent
Term
/
 Definition
per
Term
+ 
 Definition
Plus,  positive
Term
-
 Definition
negative also abbrev.  neg.