Module-3-Abbrev.pdf

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...

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.