Resources For Therapists Practice Management
Medical abbreviations for therapists
Medical abbreviations, in the field of therapy, are important to become familiar with.
Across different age populations and disorders, it’s common for therapists to work with clients who have atypical medical histories and characteristics requiring a basic knowledge of medical abbreviations. For example, therapists often treat children with medically complex conditions like Cerebral Palsy, genetic disorders, or chromosomal abnormalities.
Therapists working with adults might have clients on their caseload who have a history of stroke, Traumatic Brain Injury (TBI), or a progressive disease such as Parkinson’s.
In providing care for clients like these, providers often come across medical abbreviations when reading documentation from other providers, such as physicians or other medical specialists. It’s also expected that clinicians use medical abbreviations so they can complete documentation like treatment notes and reports more efficiently.
Keep this guide handy as a reference for some of the most commonly used medical terms and medical abbreviations.
A |
|---|
AAC: Augmentative and alternative communication AC: Before meals ADA Diet: American Diabetes Association Diet ADL: Activities of daily living A.Fib.: Atrial fibrillation ALS: Amyotrophic lateral sclerosis AMA: Against medical advice AMI: Acute myocardial infarction (heart attack) A&O: Alert and oriented A/P: Anterior-posterior ASAP: As soon as possible ASD: Autism spectrum disorder ASL: American Sign Language |
B |
|---|
BID: Twice a day B/L: Bilateral BM: Bowel movement BMI: Body mass index BP: Blood pressure BR: Bed rest bs: Bowel sounds BS: Breath sounds B/S: Bedside Bx: Biopsy |
C |
|---|
C̅: With C1, C2: First cervical vertebrae, second, etc. CA: Cardiac arrest ca: Cancer CABG: Coronary artery bypass graft CAD: Coronary artery disease cal: Calorie cath: Catheter CC: Chief complaint CHF: Congestive heart failure CCU: Coronary care unit CHI: Closed head injury CN: Cranial nerve c/o: Complains of COTA: Certified occupational therapy assistant COPD: Chronic obstructive pulmonary disease CP: Cerebral palsy CRNP: Certified registered nurse practitioner CT: Computerized tomography CVA: Cerebral vascular accident CXR: Chest X-ray |
D |
|---|
d: day d/c: Discontinue DC: Discharge DM: Diabetes mellitus DNK: Do not know DNKA: Did not keep appointment DNR: Do not resuscitate DNT: Did not test DOB: Date of birth DOE: Dyspnea on exertion d/t: Due to Dx: Diagnosis |
E |
|---|
EKG: Electrocardiogram ECHO: Echocardiogram EEG: Electroencephalogram EMG: Electromyography ENT: Ear, nose, and throat ESRD: End-stage renal disease ext: External, exterior |
F |
|---|
F: Farenheit FH: Family history Fib: Fibrillation fl: Fluid f/u: Follow up FWB: Full weight bearing FX: Fracture |
G |
|---|
GCS: Glasgow Coma Scale GE: Gastroenterology GERD: Gastroesophageal reflux disease G/E: Gastroenteritis gest.: Gestation G.I.: Gastrointestinal GNA: Geriatric nursing assistant GRAS: Generally recognized as safe GSW: Gunshot wound |
H |
|---|
h: Hour H/A: Headache HBP: High blood pressure h.d.: At bedtime HEENT: Head, eyes, ears, nose, throat Hgb: Hemoglobin HF: Heart failure H20: Water h/o: History of HOB: Head of bed H&P: History and physical HPI: History of present illness HR: Heart rate HTN: Hypertension Hx: History |
I |
|---|
ICP: Intracranial pressure ICU: Intensive care unit IDDM: Insulin-dependent diabetes mellitus imp.: Impression Incr.: Increased int.: Internal I&O: Intake and output irreg.: Irregular IV: Intravenously |
J |
|---|
J, jt. joint JODM: Juvenile onset diabetes mellitus |
K |
|---|
K: Potassium, kidney |
L |
|---|
L: Left, lower, light, liver, lumbar L&D: Labor and delivery L1, L2: Second lumbar vertebrae, third, etc… Lab: Laboratory lac.: Laceration lat.: Lateral LBW: Low birth weight L.E.: Lower extremities LGE: Large for gestational age liq.: Liquid LOC: Loss of consciousness, level of consciousness LOS: Length of stay LP: Lumbar puncture LPN: Licensed practical nurse LUE: Left upper extremity LV: Left ventricle Lx: Larynx L&W: Living and well |
M |
|---|
MA: Mental age max.: Maxillary, maximum MBC: Maximum breathing capacity MBSS: Modified barium swallow study MCA: Middle cerebral artery MD: Muscular dystrophy med.: Medicine MG: Myasthenia gravis MI: Myocardial infarction MICU: Medical intensive care unit mod: Moderate MRI: Magnetic resonance imaging MRSA: Methicillin-resistant Staphylococcus aureus MS: Multiple sclerosis MVA: Motor vehicle accident |
N |
|---|
n.: Nerve Neg.: Negative neur.: Neurology NG: Nasogastric NICU: Neonatal intensive care unit NKA: No known allergies NOS: Not otherwise specified NPO: Nothing by mouth NSA: No specific abnormality N&V: Nausea and vomiting NYD: Not yet diagnosed |
O |
|---|
o: None O: Oral O2: Oxygen O2 sat.: Oxygen saturation Obs: Observation ODD: Oppositional defiant disorder O/E: On examination O.M.: Otitis media O.M.E.: Otitis media with effusion OOB: Out of bed Op.: Operation OSHA: Occupational Safety and Health Administration ot.: Ear Oto: Otolaryngology OTC: Over-the-counter O.T.: Occupational therapy OR: Operating room |
P |
|---|
Path: Pathology p/c., p.c.: After meals PD Parkinson’s disease PE physical exam, pressure equalization (tubes) Ped.: Pediatrics PEG: Percutaneous endoscopic gastrostomy PH: Past history PI: Present illness PICU: Pulmonary intensive care unit PMH: Past medical history p.o.: By mouth pos.: Positive PSH: Past surgical history Psych.: Psychiatry Pt.: Patient PT: Physical therapy PTA: Prior to admission |
Q |
|---|
q: Every q.h.: Every hour q.i.d.: Four times a day quad.: Quadriplegic |
R |
|---|
R: Right RCA: Right coronary artery RD: Respiratory distress rehab.: Rehabilitation RLAS: Rancho Los Amigos Scale RN: Registered nurse R/O: Rule out ROM: Range of motion ROS: Review of symptoms RT: Radiation therapy RUE: right upper extremity Rx: Prescription, therapy |
S |
|---|
s: Without s.c.: subcutaneously SCD: Sudden cardiac death SCI: Spinal cord injury schiz: Schizophrenia SGA: Small for gestational age SL: Under the tongue SNF: Skilled nursing facility SOAP: Subjective, objective, assessment, plan SOB: Shortness of breath S/P: status post SW: Social worker Sx: Symptoms Sz: Seizure |
T |
|---|
T: Temperature T&A: Tonsils and adenoids; tonsillectomy and adenoidectomy TB: Tuberculosis TBI: Traumatic brain injury temp: temperature TIA: Transient ischemic attack TO: Telephone order TPN: Total parenteral nutrition TPR: temperature, pulse, respiration trach: Tracheostomy tw: Twice a week Tx: Treatment |
U |
|---|
UE: Upper extremity u/o: Under observation US: Ultrasound UTI: Urinary tract infection |
V |
|---|
v: Vein VFSS: Videofluoroscopic swallow study vit.: Vitamin VLBW: Very low birth weight VO: Verbal order VS: Vital signs |
W |
|---|
WAIS: Wechsler Adult Intelligence Scale W/C: Wheelchair WFL: Within functional limits WNL: Within normal limits wt.: Weight w/u: Workup |
X |
|---|
x: Multiplied by; times XRT: X-ray therapy |
Y |
|---|
y.o.: Years old yrs.: Years |
Z |
|---|
Zn: zinc |
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