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Medical Abbreviations > Documentation abbreviations page 22-25 > Flashcards

Documentation abbreviations page 22-25 Flashcards

Abbreviations to medical terms from "The OTA's guide to writing SOAP notes" pgs. 22-25

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USMLE® Step 1 flashcards
1
Q

AK

A

above knee

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2
Q

ALS

A

amyotrophic lateral sclerosis

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3
Q

ant

A

anterior

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4
Q

appt.

A

appointment

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5
Q

ASHD

A

arteriosclerotic heart disease

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6
Q

BADL

A

basic activity of daily living

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7
Q

BE

A

below elbow

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8
Q

BK

A

below knee

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9
Q

BKA

A

below knee amputation

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10
Q

BM

A

bowel movement

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11
Q

BP

A

blood pressure

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12
Q

BRP

A

bathroom privileges

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13
Q

C

A

celsius; centrigrade

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14
Q

C&S

A

culture and sensitivity

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15
Q

CA

A

carcinoma;cancer

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16
Q

CABG

A

coronary artery bypass graft

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17
Q

CAD

A

coronary artery disease

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18
Q

CAT

A

computerized axial tomography

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19
Q

CBC

A

complete blood count

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20
Q

CCU

A

coronary(cardiac) care unit

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21
Q

CGA

A

contact guard assist

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22
Q

CHF

A

congestive heart failure

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23
Q

CHI

A

closed head injury

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24
Q

CHT

A

certified hand therapist

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25
Q

cm

A

centimeter

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26
Q

CMC

A

carpometacarpal

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27
Q

CNS

A

central nervous system

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28
Q

CO2

A

carbon dioxide

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29
Q

℅

A

complains of

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30
Q

cont.

A

continued; continue

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31
Q

COPD

A

chronic obstructive pulmonary disease

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32
Q

COPM

A

canadian occupational performance measure

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33
Q

COTA

A

certified occupational therapy assistant

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34
Q

CP

A

cerebral palsy

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35
Q

CPM

A

continuous passive motion

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36
Q

CPR

A

cardiopulmonary resuscitation

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37
Q

CRPS

A

complex regional pain syndrome

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38
Q

CSF

A

cerebrospinal fluid

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39
Q

CST

A

crainosacral therapist

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40
Q

CT

A

computed tomography

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41
Q

CTD

A

cumulative trauma disorder

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42
Q

CTR

A

carpal tunnel release

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43
Q

CTRS

A

certified therapeutic recreational therapist

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44
Q

CTS

A

carpal tunnel syndrome

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45
Q

CVA

A

cerebrovascular accident

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46
Q

CXR

A

chest x-ray

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47
Q

d

A

day

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48
Q

D&C

A

dilation and curettage

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49
Q

DD

A

developmental disability

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50
Q

DIP

A

distal interphalangeal joint

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51
Q

DJD

A

degenerative joint disease

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52
Q

DM

A

diabetes mellitus

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53
Q

DME

A

durable medical equipment

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54
Q

DNR

A

do not resuscitate

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55
Q

D.O.

A

doctor of osteopathic medicine

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56
Q

DOA

A

date of admission; dead on arrival

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57
Q

DOB

A

date of birth

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58
Q

DOE

A

dyspnea on exertion

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59
Q

DPT

A

doctor of physical therapy

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60
Q

DRG

A

diagnostic related group

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61
Q

DRUJ

A

distal radioulnar joint

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62
Q

DTR

A

deep tendon reflex

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63
Q

Dx

A

diagnosis

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64
Q

DVT

A

deep vein thrombosis

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65
Q

ECG

A

electrocardiogram

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66
Q

ECHO

A

echocardiogram

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67
Q

ECT

A

electroconvulsive therapy

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68
Q

EEG

A

electroencephalogram

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69
Q

EKG

A

electrocardiogram

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70
Q

EMG

A

electromyogram

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71
Q

ER

A

external rotation; emergency room

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72
Q

EOB

A

edge of bed

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73
Q

ENT

A

ears, nose, throat

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74
Q

e-stim

A

electrical stimulation

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75
Q

etc.

A

etcetera

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76
Q

ETOH

A

ethyl alcohol

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77
Q

eval.

A

evaluation

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78
Q

exam

A

examination

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79
Q

ext.

A

extension

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80
Q

F

A

Fahrenheit; fair(muscle strength grade of 3)

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81
Q

f

A

female

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82
Q

F.A.C.P.

A

fellow of the american colleague of physicians

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83
Q

F.A.C.S.

A

fellow of the american colleague of surgeons

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84
Q

FBS

A

fasting blood sugar

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85
Q

FCE

A

functional capacity evaluation

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86
Q

FIM

A

functional independence measure

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87
Q

flex.

A

flexion

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88
Q

fl oz

A

fluid ounce

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89
Q

FM

A

fine motor

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90
Q

FROM

A

functional range of motion

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91
Q

ft.

A

foot, feet(measurement)

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92
Q

F/U

A

follow-up

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93
Q

FUO

A

fever of unknown origin

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94
Q

FWB

A

full weight bearing

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95
Q

Fx

A

fracture

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96
Q

G

A

good (muscle strength grade of 4)

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97
Q

GI

A

gastrointestinal

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98
Q

gm

A

gram

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99
Q

GSW

A

gunshot wound

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100
Q

GYN

A

gynecology

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101
Q

h

A

hour

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102
Q

HA, H/A

A

headache

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103
Q

H&P

A

history and physical

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104
Q

HBV

A

hepatitis B virus

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105
Q

HEENT

A

head, eyes, ears, nose, throat

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106
Q

HEP

A

home exercise program

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107
Q

HHA

A

home health agency, home health aide

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108
Q

HIPAA

A

health insurance portability and accountability act

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109
Q

HIV

A

human immunodeficiency virus

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110
Q

HOB

A

head of bed

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111
Q

HOH

A

hand over hand, hard of hearing

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112
Q

HP

A

hot pack

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113
Q

hr.

A

hour

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114
Q

HR

A

heart rate

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115
Q

HRT

A

hormone replacement therapy

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116
Q

HS

A

bedtime

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117
Q

Ht

A

height

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118
Q

HTN

A

hypertension

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119
Q

HVPC

A

high volt pulsed current

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120
Q

Hx

A

history

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121
Q

I&O

A

intake and output

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122
Q

IADL

A

instrumental activities of daily living

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123
Q

ICU

A

intensive care unit

124
Q

i.e.

A

that is

125
Q

IEP

A

individualized education program

126
Q

IM

A

intramuscular

127
Q

in.

A

inches

128
Q

int.

A

internal

129
Q

IP

A

inpatient, interphalangeal

130
Q

IR

A

internal rotation

131
Q

IV

A

intravenous

132
Q

KAFO

A

knee-ankle-foot orthosis

133
Q

kg

A

kilogram

134
Q

lb.

A

pound

135
Q

LD

A

learning disability, learning disorder

136
Q

LE

A

lower extremity

137
Q

LLQ

A

lower left quadrant

138
Q

LOC

A

loss of consciousness, level of consciousness

139
Q

LRTI

A

ligament reconstruction tendinous interposition

140
Q

LTG

A

long-term goal

141
Q

LUQ

A

left upper quadrant

142
Q

m

A

murmur; meter; male maximum

143
Q

max

A

maximum

144
Q

MD

A

muscular dystrophy; medical doctor

145
Q

meds.

A

medications

146
Q

MET

A

basal metabolic equivalent

147
Q

mg

A

milligram

148
Q

MHz

A

megahertz

149
Q

MI

A

myocardial infarction

150
Q

min

A

minutes; minimum

151
Q

ml

A

milliliter

152
Q

mm

A

millimeter

153
Q

MMT

A

manual muscle test

154
Q

mo.

A

month

155
Q

mod

A

moderate

156
Q

MP, MCP

A

metacarpophalangeal

157
Q

MRI

A

magnetic resonance imaging

158
Q

MS

A

multiple sclerosis

159
Q

MVA

A

motor vehicle accident

160
Q

N

A

normal (muscle strength grade 5)

161
Q

NA

A

not applicable, not available

162
Q

N/A

A

not applicable

163
Q

NAD

A

no acute distress

164
Q

NDT

A

neurodevelopmental treatment

165
Q

neg.

A

negative

166
Q

NG

A

nasogastric

167
Q

NICU

A

neonatal intensive care unit

168
Q

NKA

A

no known allergy

169
Q

NKDA

A

no known drug allergy

170
Q

NMES

A

neuromuscular electrical stimulation

171
Q

NOS

A

not otherwise specified

172
Q

NPO

A

nothing by mouth

173
Q

NS

A

no show, not seen

174
Q

NSAID

A

nonsteroidal anti-inflammatory drug

175
Q

NSR

A

normal sinus rhythm

176
Q

NWB

A

nonweight bearing

177
Q

O

A

objective; oriented

178
Q

O2

A

oxygen

179
Q

OA

A

osteoarthritis

180
Q

OB

A

obstetrics

181
Q

OBS

A

organic brain syndrom

182
Q

OCD

A

obsessive compulsive disorder

183
Q

OOB

A

out of bed

184
Q

OP

A

outpatient

185
Q

OR

A

operating room

186
Q

ORIF

A

open reduction, internal fixation

187
Q

OT

A

occupational therapist/therapy

188
Q

OTA

A

occupational therapy assistant

189
Q

OTAS

A

occupational therapy assistant student

190
Q

OTC

A

over the counter

191
Q

OTR

A

registered occupational therapist

192
Q

oz

A

ounce

193
Q

P

A

plan; posterior; pulse; poor(muscle strength grade of 2)

194
Q

PA

A

posterior anterior, physicians assistant

195
Q

PADL

A

personal activity of daily living

196
Q

PAM

A

physical agent modality

197
Q

PDD

A

pervasive developmental disorder

198
Q

PE

A

physical examination; physical education

199
Q

per

A

by

200
Q

peri

A

perineal

201
Q

PET

A

positron emission tomography

202
Q

Ph.D.

A

doctor of philosophy

203
Q

PIP

A

proximal interphalangeal

204
Q

p.m., PM

A

afternoon, evening

205
Q

PMH

A

past medical history

206
Q

PNF

A

proprioceptive neuromuscular facilitation

207
Q

PNI

A

peripheral nerve injury

208
Q

PNS

A

peripheral nervous system

209
Q

POMR

A

problem oriented medical record positive

210
Q

pos.

A

positive

211
Q

post op

A

postoperative

212
Q

PRE

A

progressive resistive exercise

213
Q

pre op

A

preoperative

214
Q

PRN

A

as needed

215
Q

pro

A

pronation

216
Q

PROM

A

passive range of motion

217
Q

pt.

A

patient

218
Q

PT

A

physical therapy, physical therapist

219
Q

P/T

A

part time

220
Q

PTA

A

physical therapist assistant; prior to admission

221
Q

PTSD

A

post traumatic stress disorder

222
Q

PWB

A

partial weight bearing

223
Q

Px

A

physical examination

224
Q

qt.

A

quart

225
Q

R

A

respiration

226
Q

RA

A

rheumatoid arthritis

227
Q

RBC

A

red blood cells

228
Q

R.D.

A

registered dietician

229
Q

re:

A

regarding

230
Q

rehab

A

rehabilitation

231
Q

reps

A

repetition

232
Q

resp

A

respiratory; respiration

233
Q

RICE

A

rest, ice, compression, elevation

234
Q

R.Ph.

A

registered pharmacist

235
Q

RLQ

A

right lower quadrant

236
Q

R/O

A

rule out

237
Q

ROM

A

range of motion

238
Q

ROS

A

review of symptoms

239
Q

R.T.

A

respiratory therapist

240
Q

RTC

A

return to clinic

241
Q

RTO

A

return to office

242
Q

RUQ

A

right upper quadrant

243
Q

RSD

A

reflex sympathetic dystrophy

244
Q

Rx

A

recipe

245
Q

S

A

subjective

246
Q

SBA

A

stand by assistance

247
Q

SCI

A

spinal cord injury

248
Q

SH

A

social history

249
Q

SI

A

sensory integration

250
Q

SIDS

A

sudden infant death syndrome

251
Q

Sig:

A

instruction to patient

252
Q

SLE

A

systemic lupus erythematosus

253
Q

SLP

A

speech language pathologist

254
Q

SOC

A

start of care

255
Q

SOAP

A

subjective, objective, assessment, plan

256
Q

SOB

A

shortness of breath

257
Q

SNF

A

skilled nursing facility

258
Q

S/P

A

status post

259
Q

SSRI

A

selective serotonin reuptake inhibitor

260
Q

STAT

A

immediately

261
Q

STD

A

sexually transmitted disease

262
Q

STG

A

short term goal

263
Q

STM

A

short term memory

264
Q

suppos

A

suppository

265
Q

sup

A

supination

266
Q

T

A

temperature; Trace (muscle strength grade 1)

267
Q

TB

A

tuberculosis

268
Q

TBI

A

traumatic brain injury

269
Q

TEDS

A

thrombi-embolic disease stockings

270
Q

TENS

A

transcutaneous electrical nerve stimulation

271
Q

TFCC

A

traingular fibrocartilage complex

272
Q

ther ex

A

therapeutic exercise

273
Q

THR

A

total hip replacement

274
Q

TIA

A

transient ischemic attack

275
Q

TKR

A

total knee replacement

276
Q

T M (J)

A

temporomandibular (joint)

277
Q

TNR

A

tonic neck reflex

278
Q

t.o.

A

telephone order

279
Q

TOS

A

thoracic outlet syndrome

280
Q

TPR

A

temperature, pulse, and respiration

281
Q

TTWB

A

toe touch weight bearing

282
Q

tx.

A

treatment; traction

283
Q

UA

A

urinalysis

284
Q

UE

A

upper extremity

285
Q

UMN

A

upper motor neuron

286
Q

URI

A

upper respiratory infection

287
Q

US

A

ultrasound

288
Q

UTI

A

urinary tract infection

289
Q

VC

A

vital capacity

290
Q

VD

A

venereal disease

291
Q

v.o.

A

verbal orders

292
Q

vol.

A

volume

293
Q

VS

A

vital signs

294
Q

W

A

watt

295
Q

WBC

A

white blood cells

296
Q

WBAT

A

weight bearing as tolerated

297
Q

w/c

A

wheelchair

298
Q

WDWN

A

well developed; well nourished

299
Q

wk.

A

week

300
Q

WFL

A

within functional limits

301
Q

WNL

A

within normal limits

302
Q

wt

A

weight

303
Q

x or X

A

times

304
Q

y.o.

A

year old

305
Q

yr.

A

year

Medical Abbreviations (1 decks)

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