c h a p t e r

4 Using Abbreviations

A bbreviations are used to save time and space

while writing notes. To ensure that everyone involved in
a.m.
AMA
morning
against medical advice
the patient’s care can understand what others have written amb ambulation, ambulating, ambulated,
in the medical record, most medical facilities have a list of ambulate, ambulates
approved abbreviations, and these are the only abbrevia- ANS autonomic nervous system
tions that should be used in that particular facility.1,2 A ant anterior
committee at each facility approves this list. The list AP anterior-posterior
of acceptable abbreviations varies from one facility to ARDS adult respiratory distress syndrome
the next. ARF acute renal failure
The list of abbreviations that follows will be used as AROM active range of motion
the approved list for all of the worksheets in this book. ASA aspirin
Any abbreviations not on this list are considered unac- ASAP or asap as soon as possible
ceptable for these worksheets. When you begin your ASCVD arteriosclerotic cardiovascular disease
career, please remember that the list of acceptable abbre- ASHD arteriosclerotic heart disease
viations for your clinical facility must be used. During ASIS anterior superior iliac spine
orientation to any clinical facility in which you practice, assist. assistance, assistive
you should ask about the location of the approved AVM arteriovenous malformation
abbreviations list and become particularly familiar with B/S bedside
the abbreviations used frequently by the facility. BBB bundle branch block
BE below elbow
BID or bid twice a day
Approved Abbreviations and Symbols bilat. or B bilateral, bilaterally
for Hospital XYZ3,4 BK below knee
BM bowel movement
A: assessment BOS base of support
ABI acquired brain injury BP blood pressure
afib atrial fibrillation bpm beats per minute
A-line arterial line BR bedrest
A-V arteriovenous BRP bathroom privileges
AAA abdominal aortic aneurysm BS breath sounds or bowel sounds
AAROM active assistive range of motion BUN blood urea nitrogen (blood test)
Abd or abd abduction C centigrade
ABG arterial blood gases C&S culture and sensitivity
ac before meals c/o complains of
AC joint acromioclavicular joint CA cancer, carcinoma
ACL anterior cruciate ligament CABG coronary artery bypass graft
ACTH adrenocorticotrophic hormone CAD coronary artery disease
Add or add adduction cal calories
ADL activities of daily living CAT computerized axial tomography
ad lib at discretion CBC complete blood cell (count)
adm admission, admitted CC, C/C chief complaint
AE above elbow CF cystic fibrosis
AFO ankle foot orthosis CHF congestive heart failure
AIDS acquired immune deficiency syndrome cm centimeter
AIIS anterior inferior iliac spine CMV cytomegalovirus
AJ ankle jerk CNS central nervous system
AK above knee CO cardiac output
ALS amyotrophic lateral sclerosis CO2 carbon dioxide
17
18 p a r t I Background Information

cont. continue HCVD hypertensive cardiovascular disease

COPD chronic obstructive pulmonary disease HEENT head, ear, eyes, nose, throat
COTA certified occupational therapy assistant HEP home exercise program
CP cerebral palsy HIV human immunodeficiency virus
CPAP continuous positive airway pressure HNP herniated nucleus pulposus
CPR cardiopulmonary resuscitation HOB head of bed
CRF chronic renal failure HR heart rate
CSF cerebrospinal fluid hs at bedtime
CV cardiovascular ht. height
CWI crutch walking instructions Ht hematocrit
CXR chest x-ray Htn or HTN hypertension
Cysto cystoscopic examination Hx history
D/C discontinued or discharged I&O intake and output
dept. department IADL instrumental activities of daily living
DIP distal interphalangeal (joint) ICU intensive care unit
DJD degenerative joint disease IDDM insulin-dependent diabetes mellitus
DM diabetes mellitus IM intramuscular
DNR do not resuscitate imp. impression
DO doctor of osteopathy in. inches
DOB date of birth indep independent
DOE dyspnea on exertion IMV intermittent mandatory ventilation
DTR deep tendon reflex inf inferior
DVT deep vein thrombosis IRDS infant respiratory distress syndrome
Dx diagnosis IS incentive spirometry
ECF extended care facility IV intravenous
ECG, EKG electrocardiogram KAFO knee-ankle-foot orthosis
ED emergency department kcal kilocalories
EEG electroencephalogram kg kilogram
EENT ear, eyes, nose, throat KJ knee jerk
EMG electromyogram, electromyography KUB kidney, ureter, bladder
E.R. emergency room L or l. liter
eval. evaluation L left
ext. extension lat lateral
FBS fasting blood sugar lb. pound
FEV forced expiratory volume LBBB left bundle branch block
FH family history LBP low back pain
flex flexion LE lower extremity
FRC functional residual capacity LOC loss of consciousness, level of
ft. foot, feet (the measurement, not the consciousness
body part) LMN lower motor neuron
FUO fever of unknown origin LOS length of stay
FVC forced vital capacity LP lumbar puncture
FWB full weight bearing m meter
fx fracture MAP mean arterial pressure
GB gallbladder max maximal
GI gastrointestinal MD medical doctor; doctor of medicine
g gram MED minimal erythemal dose
GSW gunshot wound Meds. medications
GYN gynecology mg milligram
h, hr. hour MI myocardial infarction
H&H, H/H hematocrit and hemoglobin min minimal
H&P history and physical min. minute
h/o history of ml milliliter
HA, H/A headache mm millimeter
Hb, Hgb hemoglobin MMT manual muscle test
Hct hematocrit mo. month
 c h a p t e r 4 Using Abbreviations 19

mod moderate prn whenever necessary, as often as necessary

MP, MEP metacarpophalangeal PROM passive range of motion
MRSA methicillin-resistant Staphylococcus PSIS posterior-superior iliac spine
aureus PT physical therapy, physical therapist
MVA motor vehicle accident (used after therapist’s signature)
NDT neurodevelopmental treatment PT/PTT prothrombin time/partial thrombo-
neg. negative plastin time
NG or ng nasogastric Pt., pt. patient
N.H. nursing home PTA physical therapist assistant
NIDDM non–insulin-dependent diabetes mellitus PTA prior to admission
nn nerve PTB patellar tendon bearing
noc night, at night PVD peripheral vascular disease
NPO or npo nothing by mouth PWB partial weight bearing
NSR normal sinus rhythm q every
NWB non–weight bearing qid four times a day
O: objective qh every hour
OA osteoarthritis qn every night
OB obstetrics qt. quart
OBS organic brain syndrome R right
od once daily RA rheumatoid arthritis
OOB out of bed RBBB right bundle branch block
O.P. outpatient RBC red blood cell (count)
O.R. operating room R.D. registered dietician
ORIF open reduction, internal fixation re: regarding
OT occupational therapy, occupational rehab rehabilitation
therapist reps repetitions
OTR occupational therapist (used to follow resp respiratory, respiration
official signature of the occupa- RN registered nurse
tional therapist) R/O or r/o rule out
oz. ounce ROM range of motion
P poor ROS review of systems
P: plan, intervention plan, plan of care RR respiratory rate
P.A. physician’s assistant RROM resistive range of motion
PA posterior/anterior RT respiratory therapist, respiratory therapy
para paraplegia Rx intervention plan, prescription, therapy
pc after meals SACH solid ankle cushion heel
PCL posterior cruciate ligament SCI spinal cord injury
PE pulmonary embolus SC joint sternoclavicular joint
PEEP positive end expiratory pressure sec. seconds
per by/through SED suberythemal dose
p.o. by mouth sig directions for use, give as follows, let it
PERRLA pupils equal, round, reactive to light, be labeled
and accommodation SI(J) sacroiliac (joint)
P.H. past history SLE systemic lupus erythematosus
p.m. afternoon SLP speech-language pathologist
PMH past medical history SLR straight leg raise
PNF proprioceptive neuromuscular SNF skilled nursing facility
facilitation SOAP subjective, objective, assessment, plan
PNI peripheral nerve injury SOB shortness of breath
POMR problem-oriented medical record S/P status post (e.g., “S/P hip fx” means
pos. positive “Pt. fx her hip in the recent past.”)
poss possible spec specimen
post posterior stat. immediately, at once
post-op after surgery (operation) sup superior
PRE progressive-resistive exercise Sx symptoms
pre-op before surgery (operation) tab tablet
20 p a r t I Background Information

TB tuberculosis yd. yard

TBI traumatic brain injury yr. year
tbsp. tablespoon ⫹1 (⫹2, etc.) assistance (assistance of 1 person
TENS, TNS transcutaneous electrical nerve given; also written “assistance of 1.”
stimulator/stimulation Examples: amb ... c̄ min + 1 assist.,
THA total hip arthroplasty or amb ... c̄ +1 min assist., or amb
ther ex therapeutic exercise ... c̄ min assist. of 1)
TIA transient ischemic attack 么 male
tid three times daily 乆 female
TKA total knee arthroplasty ↓ down, downward, decrease, diminished
TM(J) temporomandibular (joint) ↑ up, upward, increase, augmented
TNR tonic neck reflex (also ATNR, STNR) // parallel or parallel bars (also written
t.o. telephone order “// bars”)
TPR temperature, pulse, and respiration c̄ with
tsp. teaspoon s̄ without
TUR/TURP transurethral resection p̄ after
Tx traction ā before
TV tidal volume ⬃ or 艐 approximately
UA urine analysis Δ change
UE upper extremity ⫽ equal
UMN upper motor neuron ⫹ or (⫹) plus, positive (positive also abbreviated
URI upper respiratory infection “pos.”)
US ultrasound ⫺ or (⫺) minus, negative (negative also
UTI urinary tract infection abbreviated “neg.”)
UV ultraviolet # number (#1 = number 1), pounds
VC vital capacity (5# wt. = 5 pound weight; pound
VD venereal disease also abbreviated “lbs.”)
v.o. or VO verbal orders (e.g., v.o. Dr. Smith/ / per
assistant’s signature) % percent
vol. volume ⫹, &, et. and
v.s. vital signs ↔ to and from
w/c wheelchair → to progressing toward, approaching
W/cm2 watts per square centimeter 1° primary
WBC white blood cell (count) 2° secondary, secondary to
wk. week
WNL within normal limits
wt. weight
⫻ number of times performed (e.g., ⫻2
is twice; ⫻3 is 3 times)
y/o or y.o. years old
 c h a p t e r 4 Using Abbreviations 21

Using Abbreviations: Examples

The following are examples of the use of abbreviations
in medical records.

1. In the physician’s notes, you may find Translation: The patient has a history of hypertension,
the following: Pt. has hx of Htn, ASHD, arteriosclerotic heart disease, congestive heart failure,
CHF, MI in 2005, TIA in 2006. myocardial infarction in 2005, transient ischemic attack
in 2006.
2. Orders written in the chart: Translation:
Up ad lib Up at discretion (patient’s discretion)
ASA q 4 hr. Aspirin every 4 hours
BRP prn Bathroom privileges when necessary
NPO p̄ midnight Nothing by mouth after midnight
v.o. Dr. Smith/Janice Jones, OTR Verbal order given by Dr. Smith to Janice Jones,
occupational therapist
3. In PT note: Rx: AROM R ankle bid Translation: Treatment intervention: Active range of
motion right ankle two times per day.
4. In chart in doctor’s initial note: imp: Translation: Impression: Chronic obstructive
COPD; R/O lung CA pulmonary disease; rule out lung cancer.
5. Physician’s orders: Record I&O; Translation: Record intake and output. All medications
all meds per IV; NPO; transfer through intravenous tube. Nothing by mouth. Transfer
Pt. to ICU patient to the intensive care unit.

You will be expected to be able to both interpret and use practice in the clinic. Any time you write a note, you will
abbreviations in the medical record. You will encounter be expected to use abbreviations properly.
most of the abbreviations listed in this chapter when you

1. Defensible Documentation for Patient/Client Management. 3. Acute Care Section of the American Physical Therapy Asso-
Accessed at http://www.apta.org/AM/Template. ciation: Common Terminology. Accessed at http://www.
cfm?Section=Documentation4&Template=/MembersOnly. acutept.org/commonterm.pdf on March 9, 2007.
cfm&ContentID=37776 on March 9, 2007. 4. The Joint Commission: Official “Do Not Use” List.
2. Kolber, M, and Lucado, AM: Risk management strategies in Accessed at http://www.jointcommission.org/NR/
physical therapy: documentation to avoid malpractice. rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/
International Journal of Health Care Quality Assurance 0/06_dnu_list.pdf
18(2):123–129, 2005.