| Abbreviations |
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| F FBS FH flex ft. FUO FWB fx G GB GI gm GYN h, hr. H&H,H/H H&P HA, H/A Hb, Hgb HCVD HEENT HEP HI HIV HNP HOB HR hr. Ht Htn Hx I&O ICU imp. in. indep inf IV kcal kg KJ KUB L, l. L lb. LBP LE LOC LP m max MD MED Meds. MFT mg MI min min. ml mm MMT mo. mod MP, MCP MS N NDT neg. N.H. noc npo NSR NWB O: OB OBS od O.P. O.R. ORIF OT OTR oz. P P: P.A. PA para pc per per os, p.o. PERRLA P.H> p.m. PNF PNI POMR pos. poss post post-op PRE pre-op prn PROM PSIS PT PT/PTT Pt., pt. PTA PTA PTB PVD PWB q qd qh qid qn qt. ® RA RBC R.D. re: rehab reps resp RN R/O ROM ROS RROM R.T. Rx SACH SCI SC joint sec. SED sig SI(J) SLE SLR SNF SOAP SOB S/P spec stat. Sx T tab TB tbsp. TENS, TNS THR TIA tid TKR TM(J) TNR t.o. TPR tsp. TUR UA UE UMN URI US UTI UV VD v.o. vol. v.s. |
| fair (muscle strength, balance) fasting blood sugar family history flexion foot, feet (the measurement, not the body part) fever, unknown origin full weight bearing fracturegood (muscle strength, balance) good (muscle, strength, balance) gallbladder gastrointestinal gram gynecology hour hematocrit and hemoglobin history and physical headache hemoglobin hypertensive cardiovascular disease head, ear, eyes, nose, throat home exercise program head injury human immunodeficiency virus herniated nucleus pulposus head of bed heart rate hour hematocrit hypertension history intake and output intensive care unit Impression inches independent inferior intravenous kilocalories kilogram knee jerk kidney, ureter, bladder liter left Pound low back pain lower extremity loss of consciousness lumbar puncturemeter maximal medical doctor; doctor of medicine minimal erythemal dose Medications muscle function test milligram myocardinal infarction minimal minutes milliliter millimeter manual muscle test Month moderate metacarpalphalangeal multiple sclerosis normal (muscle strength) neurodevelopmental treatment negative nursing home night, at night nothing by mouth normal sinus rhythm non-weight-bearing objective obstetrics organic brain syndrome once daily outpatient operating room open reduction, internal fixation occupational therapy, occupational therapist occupational therapist (used to follow official signature of the occupational therapist) Ouncepoor (muscle strength, balance) plan (treatment plan) physician’s assistant posterior/anterior paraplegia after meals by/through by mouth pupils, equal, round, reactive to light and accommodation past history afternoon proprioceptive neuromuscular facilitation peripheral nerve injury problem-oriented medical record positive possible posterior after surgery (operation) progressive resistive exercise before surgery (operation) whenever necessary passive range of motion posterior superior iliac spine physical therapy, physcail therapist (used after therapist’s signature; varies from facility to facility protime/prothrombine time Patient physical therapist assistant prior to admission patellar tendon bearing peripheral vascular disease patial weight bearing every every day every hour four times a day every night quartright right rheumatoid arthritis red blood cell count registered dietician regarding rehabilitation repetitions respiratory, respiration registered nurse rule out (iIn order to make a good diagnosis, the physician will try to rule the disease / condition named out; if he or she cannon, this will become the diagnosis.) range of motion review of systems resistive range of motion respiratory therapist, respiratory therapy treatment, prescription, therapy solid ankle cushion heel spinal cord injury sternoclavicular joint seconds suberythemal dose directions for use, give as follows, let it be labeled sacroiliac (joint) systemic lupus erythematosus straight leg raise skilled nursing facility subjective, objective, assessment, plan shortness of breath status post (example: S/P L hip fx means Pt. Fx her hip in the recent past) specimen Immediately, at once symptoms trace (muscle strength) tablet tuberculosis Tablespoon transutaneous electrical nerve stimulator total hip replacement transient ischemic attack three times daily total knee replacement teporomandibular (joint) tonic neck reflex (also ATNR, STNR) telephone order temperature, pulse & respiration Teaspoon transurethral resectionurine analysis urine analysis upper extremity upper motor neuron upper respiratory infection ultrasound urinary tract infection ultraviolet venereal disease verbal orders (example: v.o. Dr. Smith/ your signature) Volume vital sings |
| +1,+2 ? ? ? ? // c s p ? ~ or » @ ? > < = + – # / % +,&,et. ?ÁÂ ? 1º 2º |
| assistance (assistance of 1 person given; also written “assistance of 1”) male female down, downward, decrease, diminished up, upward, increase, augmented parallel or parallel bars (also written // bars) with without after before approximately at (this symbol is not exclusively used for at) change greater than less than equals plus, positive (positive also abbreviated pos.) minus, negative (negative also abbreviated neg.) number (#1 = number 1), pounds (5# wt. = 5 pound weight; also abbreviated lbs.) per percent And to and from to, progressing toward, approaching primary secondary, secondary to |
| y/o or y.o. yd. yr. |
| years old yard Year |
| X |
| number of times performed (x2 = twice, x3 = 3 times) |
| wheelchair watts per squar centimeter white blood co |
| w/c W/cm2 WBC wk. WNL Wt. |
| A: AAROM abd ac AC joints ACTH add ADL ad lib adm AE AFO AIDS AIIS AJ AK a.m. AMA amb ant AP AROM ASA ASAP ASHD ASIS assist. |
| assessment active assistive range of motion abduction before meals acromioclavicular joints adrenocorticotrophic hormone adduction activities of daily living at discretion admission above elbow ankle foot orthosis autoimmune deficiency syndrome anterior inferior iliac spine ankle jerk above knee morning against medical advice ambulation, ambulating, ambulated, ambulate, ambulates anterior anterior-posterior active range of motion aspirin as soon as possible anteriosclerotic heart disease anterior superior iliac spine assistance, assistive |
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| B/S BE bid bilat. BK BM BP bpm BRP BUN |
| bedside below elbow twice a day Bilateral, bilaterally below knee bowel movement blood pressure beats per minute bedroom privileges blood urea nitrogen (blood test)Centigrade |
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| C C&S CA CABG CAD cal CBC CBI CBS CC,C/C cc CHF cm CNS c/o CO2 COLD cont. COPD COTA CP CPR CSF CV CVA CWI Cysto |
| Culture and sensitivity Cancer, carcinoma Coronary artery bypass graft Coronary artery disease Calories Complete blood count Closed brain injury Chronic brain syndrome Chief complaint Cubic centimeter Congestive heart failure Centimeter Central nervous system Complains of Carbon dioxide Chronic obstructive lung disease Continue Chronic obstructive pulmonary disease Certified occupational therapy assistant Cerebral palsy Cardiopulmonary resuscitation Cerebral spinal fluid Cardiovascular Cerebrovascular accident Crutch walking instructions Cystoscopic examination |
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| dept. DIP D/C DM DO DTR Dx |
| department distal interphalangeal joint discontinued or discharged diabetes mellitus doctor of osteopathy deep tendon reflex diagnosis |
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| extended care facility electrocardiogram electroencephalogram ear, eyes, nose, throat electromyogram, electromyography emergency room Evaluation extension |
| ECF ECG, EKG EEG EENT EMG E.R. eval. ext. |
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