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Abbreviations
Clinical Documentation PTS2
376
Other
Professional
02/12/2012
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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 assistive range of motion
Term
Abd or abd
 Definition
abduction
Term
ABG
 Definition
arterial blood gases
Term
ac
 Definition
before meals (antes de comer)
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
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
AMA
 Definition
against medical advice
Term
amb
 Definition
ambulation, ambulating, ambulated, ambulate, ambulates
Term
ANS
 Definition
autonomic nervous system
Term
ant
 Definition
anterior
Term
AP
 Definition
anterior-posterior
Term
ARDS
 Definition
adult respiratory distress 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 (bi=two)
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
CBC
 Definition
complete blood cell count
Term
CC, C/C
 Definition
chief complaint
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
cont.
 Definition
continue
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
discontinued, discharged
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, EKG
 Definition
electrocardiogram
Term
ED
 Definition
emergency department
Term
EEG
 Definition
electroenchephalogram
Term
EENT
 Definition
ear, eyes, nose, and 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 (measurement)
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, H/H
 Definition
hematocrit, hemoglobin
Term
H&P
 Definition
history and physical
Term
h/o
 Definition
history of
Term
HA, H/A
 Definition
headache, headache
Term
Hb, Hgb
 Definition
hemoglobin
Term
Hct
 Definition
hematocrit
Term
HCVD
 Definition
hypertensive cardiovascular disease
Term
HEENT
 Definition
head, ears, eyes, throat
Term
HEP
 Definition
home exercise program
Term
HIV
 Definition
human immunodeficiency virus
Term
HNP
 Definition
herniated nucleus pulposus
Term
HOB
 Definition
head of bed
Term
HR
 Definition
heart rate
Term
hs
 Definition
at bedtime (hora de sueno)
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
instrumental activities of daily living
Term
ICU
 Definition
intensive care unit
Term
IDDM
 Definition
insulin-dependent diabetes mellitus
Term
IM
 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
Term
L
 Definition
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 pressure
Term
m
 Definition
meter
Term
MAP
 Definition
mean arterial pressure
Term
max
 Definition
maximal
Term
MD
 Definition
medical doctor; doctor of medicine
Term
MED
 Definition
minimal erythemal dose
Term
Meds.
 Definition
medications
Term
mg
 Definition
milligram
Term
MI
 Definition
myocardial infarction
Term
min
 Definition
minimal
Term
min.
 Definition
minute
Term
ml
 Definition
milliliter
Term
mm
 Definition
millimeter
Term
MMT
 Definition
manual muscle test
Term
mo.
 Definition
month
Term
mod
 Definition
moderate
Term
MP, MEP
 Definition
metacarpophalangeal
Term
MRSA
 Definition
methicillin-resistant (Staphylococcus aureus)
Term
MVA
 Definition
motor 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, at night
Term
NPO or 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
OT
 Definition
occupational therapist
Term
OTR
 Definition
occupational therapist (used to follow official signature)
Term
oz.
 Definition
ounce
Term
P
 Definition
poor
Term
P:
 Definition
plan, intervention plan, plan of care
Term
P.A.
 Definition
physician assistant
Term
PA
 Definition
posterior/anterior
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
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
poss
 Definition
possible
Term
post
 Definition
posterior
Term
post-op
 Definition
after surgery (operation)
Term
PRE
 Definition
progressive-resistive exercise
Term
pre-op
 Definition
before surgery (operation)
Term
prn
 Definition
as necessary, as often as necessary
Term
PROM
 Definition
passive range of motion
Term
PSIS
 Definition
posterior-inferior iliac spine
Term
PT/PTT
 Definition
prothrombin time/partial thromboplastin time
Term
Pt., pt.
 Definition
patient
Term
PTA
 Definition
prior to admission
Term
PTB
 Definition
patellar tendon bearing
Term
PVD
 Definition
peripheral vascular disease
Term
PWB
 Definition
peripheral 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
reps
 Definition
repetitions
Term
resp
 Definition
respiration, respiratory
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, respiratory therapy
Term
Rx
 Definition
intervention plan, prescription, therapy
Term
SACH
 Definition
solid ankle cushion heel
Term
SCI
 Definition
spinal cord injury
Term
SC joint
 Definition
steroclavicular 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
SLR
 Definition
straight leg facility
Term
SOAP
 Definition
subjective, objective, assessment, plan of care
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
symptoms
Term
tab
 Definition
tablet
Term
TB
 Definition
tuberculosis
Term
TBI
 Definition
traumatic brain injury
Term
TENS, tns
 Definition
transcutaneous electrical nerve stimulator/stimulation
Term
THA
 Definition
total hip arthroplasty
Term
ther ex
 Definition
therapeutic exercise
Term
TIA
 Definition
transient ischemic attack
Term
tid
 Definition
three times daily
Term
TKA
 Definition
total knee arthroplasty
Term
TM(J)
 Definition
temporomandibular (joint)
Term
TNR; ATNR; STNR
 Definition
tonic neck reflex
Term
t.o.
 Definition
telephone order
Term
TPR
 Definition
temperature, pulse, and respiration
Term
TUR/TURP
 Definition
transurethral resection
Term
Tx
 Definition
traction
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. or 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 performed (X2 is twice; 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 (assistance of 1 person given; also written assistance of 1)
Term
~
 Definition
approximately
Term
/
 Definition
per
Term
+, &, et.
 Definition
and
Term
1*
 Definition
primary
Term
2*
 Definition
secondary
Term
-centesis
 Definition
surgical puncture to aspirate or remove fluid
Term
-lysis
 Definition
process of loosening, freeing, or destroying
Term
-pexy
 Definition
surgical fixation
Term
-plasty
 Definition
surgical repair
Term
-rrhaphy
 Definition
suture
Term
-stomy
 Definition
formation of opening
Term
-tome
 Definition
an instrument used for cutting
Term
-tomy
 Definition
incision
Term
-tripsy
 Definition
surgical crushing
Term
ando
 Definition
gland
Term
angi
 Definition
vessel
Term
blephar
 Definition
eyelid
Term
cerebro, encephal
 Definition
brain
Term
chir
 Definition
hand
Term
cutane,derm,dermato
 Definition
skin
Term
nephr, ren
 Definition
kidney
Term
osteo
 Definition
bone
Term
tonsill
 Definition
tonsil
Term
vas
 Definition
vessel
Term
-algia
 Definition
pain
Term
-dynia
 Definition
pain
Term
-ectasia, ectasis
 Definition
dilatation
Term
-emesis
 Definition
vomit
Term
-malacia
 Definition
softening
Term
-megaly
 Definition
enlargement
Term
-oid
 Definition
resembling
Term
-penia
 Definition
deficiency
Term
-rrhage, rrhagia
 Definition
excessive bleeding or hemorrhage
Term
-rrhea
 Definition
flow or discharge
Term
rrhexis
 Definition
rupture
Term
-stasis
 Definition
stopping, controlling
Term
onc
 Definition
tumor
Term
-cele
 Definition
hernia
Term
-emia
 Definition
condition of the blood
Term
-itis
 Definition
inflammation
Term
-ia, -iasis
 Definition
condition
Term
-lith
 Definition
stone or calculus
Term
-oma
 Definition
tumor
Term
-osis
 Definition
condition
Term
-ptosis
 Definition
prolapse
Term
-opia
 Definition
vision
Term
albo, leuk, leuc
 Definition
white
Term
chlor
 Definition
green
Term
cyan
 Definition
blue
Term
erythr
 Definition
red
Term
melan
 Definition
black
Term
xanth
 Definition
yello
Term
hist
 Definition
tissue
Term
nas,rhin
 Definition
nose
Term
ne
 Definition
new
Term
pod
 Definition
foot
Term
pyr
 Definition
fire
Term
therm
 Definition
heat
Term
algesi
 Definition
sensitivity to pain
Term
esthesi
 Definition
feeling or sensation
Term
narc
 Definition
stupor
Term
brady
 Definition
slow
Term
eu
 Definition
good, normal
Term
pro
 Definition
favoring, supporting
Term
tachy
 Definition
fast
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