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(1) Fundamentals of Physical Therapy > S1_L3: Documentation > Flashcards

S1_L3: Documentation Flashcards

1
Q

Notes that serve as records of skilled interventions provided and records of time taken to provide the interventions in order to justify billing codes being used. To document what occurred during a session or encounter and may or may not follow the SOAP format.

A

Treatment notes / Daily PT notes

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2
Q

Provides justification for the medical necessity of treatment and to justify ongoing services. Notes done in specific time periods.

A

Progress notes

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3
Q

Notes performed when there are significant changes in the patient’s status in comparison to baseline; a separately billable service

A

Re-evaluation notes

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4
Q

Re-evaluation notes (RE) is typically done on the ___ session before the follow-up check up to the rehabilitation medicine doctor or referring MD

A

Last

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5
Q

TRUE OR FALSE: In the re-evaluation notes, any test and measure describing an impairment or any functional deficit in the IE should be re-examined. Signal words “now” or “still” are used.

A

True

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6
Q

A:
This abbreviation / symbol stands for

A

assessment

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6
Q

ABI
This abbreviation / symbol stands for

A

acquired brain injury

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7
Q

afib
This abbreviation / symbol stands for

A

atrial fibrillation

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8
Q

A-line
This abbreviation / symbol stands for

A

arterial line

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9
Q

A-V
This abbreviation / symbol stands for

A

arteriovenous

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10
Q

AAA
This abbreviation / symbol stands for

A

abdominal aortic aneurysm

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11
Q

ABG
This abbreviation / symbol stands for

A

arterial blood gases

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12
Q

ac
This abbreviation / symbol stands for

A

before meals

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13
Q

ACTH
This abbreviation / symbol stands for

A

adrenocorticotrophic hormone

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14
Q

ACL
This abbreviation / symbol stands for

A

anterior cruciate ligament

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15
Q

AC joint
This abbreviation / symbol stands for

A

acromioclavicular joint

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16
Q

AAROM
This abbreviation / symbol stands for

A

active assistive range of motion

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17
Q

ad lib
This abbreviation / symbol stands for

A

at discretion

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18
Q

adm
This abbreviation / symbol stands for

A

admission, admitted

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19
Q

ADL
This abbreviation / symbol stands for

A

activities of daily living

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19
Q

AE
This abbreviation / symbol stands for

A

above elbow

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20
Q

AFO
This abbreviation / symbol stands for

A

ankle foot orthosis

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21
Q

AIDS
This abbreviation / symbol stands for

A

acquired immune deficiency syndrome

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22
Q

AJ
This abbreviation / symbol stands for

A

ankle jerk

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23
Q

AK
This abbreviation / symbol stands for

A

above knee

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24
Q

AIIS
This abbreviation / symbol stands for

A

anterior inferior iliac spine

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25
Q

ALS
This abbreviation / symbol stands for

A

amyotrophic lateral sclerosis

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26
Q

AMA
This abbreviation / symbol stands for

A

against medical advice

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27
Q

amb
This abbreviation / symbol stands for

A

ambulation, ambulating, ambulated,
ambulate, ambulates

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28
Q

AP
This abbreviation / symbol stands for

A

anterior-posterior

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29
Q

ARDS
This abbreviation / symbol stands for

A

adult respiratory distress syndrome

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30
Q

This serves as a record of the patient’s final subjective and objective status and provides the final or discharge plan

A

Discharge notes (D/C)

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31
Q

This serves as a tool for improving care by identifying and investigating problems as they arise and provides an internal account in case legal action results from the adverse event.

A

Incident Report

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32
Q

This is prepared for the following circumstances: (1), In case of the absence / scheduled leave of the therapist in charge, and (2), when there is a change of therapist.

A

Endorsement notes

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33
Q

ARF
This abbreviation / symbol stands for

A

acute renal failure

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34
Q

AROM
This abbreviation / symbol stands for

A

active range of motion

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35
Q

ASA
This abbreviation / symbol stands for

A

aspirin

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36
Q

ASAP or asap
This abbreviation / symbol stands for

A

as soon as possible

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37
Q

ASCVD
This abbreviation / symbol stands for

A

arteriosclerotic cardiovascular disease

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38
Q

ASHD
This abbreviation / symbol stands for

A

arteriosclerotic heart disease

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39
Q

ASIS
This abbreviation / symbol stands for

A

anterior superior iliac spine

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40
Q

assist.
This abbreviation / symbol stands for

A

assistance, assistive

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40
Q

AVM
This abbreviation / symbol stands for

A

arteriovenous malformation

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41
Q

B/S
This abbreviation / symbol stands for

A

bedside

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42
Q

BBB
This abbreviation / symbol stands for

A

bundle branch block

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43
Q

BE
This abbreviation / symbol stands for

A

below elbow

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44
Q

BID or bid
This abbreviation / symbol stands for

A

twice a day

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45
Q

bilat. or B
This abbreviation / symbol stands for

A

bilateral, bilaterally

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46
Q

BK
This abbreviation / symbol stands for

A

below knee

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47
Q

BM
This abbreviation / symbol stands for

A

bowel movement

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48
Q

BOS
This abbreviation / symbol stands for

A

base of support

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49
Q

BP
This abbreviation / symbol stands for

A

blood pressure

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50
Q

a.m.
This abbreviation / symbol stands for

A

morning

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51
Q

ANS
This abbreviation / symbol stands for

A

autonomic nervous system

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52
Q

ant
This abbreviation / symbol stands for

A

anterior

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53
Q

Abd or abd
This abbreviation / symbol stands for

A

abduction

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54
Q

Add or add
This abbreviation / symbol stands for

A

adduction

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55
Q

bpm
This abbreviation / symbol stands for

A

beats per minute

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56
Q

BR
This abbreviation / symbol stands for

A

bedrest

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57
Q

BRP
This abbreviation / symbol stands for

A

bathroom privileges

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58
Q

BS
This abbreviation / symbol stands for

A

breath sounds or bowel sounds

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59
Q

BUN
This abbreviation / symbol stands for

A

blood urea nitrogen (blood test)

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60
Q

C
This abbreviation / symbol stands for

A

centigrade

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61
Q

C&S
This abbreviation / symbol stands for

A

culture and sensitivity

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62
Q

c/o
This abbreviation / symbol stands for

A

complains of

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63
Q

CA
This abbreviation / symbol stands for

A

cancer, carcinoma

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64
Q

CABG
This abbreviation / symbol stands for

A

coronary artery bypass graft

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65
Q

CAD
This abbreviation / symbol stands for

A

coronary artery disease

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66
Q

cal
This abbreviation / symbol stands for

A

calories

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67
Q

CAT
This abbreviation / symbol stands for

A

computerized axial tomography

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68
Q

CBC
This abbreviation / symbol stands for

A

complete blood cell (count)

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69
Q

CC, C/C
This abbreviation / symbol stands for

A

chief complaint

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70
Q

CF
This abbreviation / symbol stands for

A

cystic fibrosis

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71
Q

CHF
This abbreviation / symbol stands for

A

congestive heart failure

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72
Q

cm
This abbreviation / symbol stands for

A

centimeter

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73
Q

CMV
This abbreviation / symbol stands for

A

cytomegalovirus

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74
Q

CNS
This abbreviation / symbol stands for

A

central nervous system

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75
Q

CO
This abbreviation / symbol stands for

A

cardiac output

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76
Q

CO2
This abbreviation / symbol stands for

A

carbon dioxide

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77
Q

cont.
This abbreviation / symbol stands for

A

continue, continuous

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78
Q

COPD
This abbreviation / symbol stands for

A

chronic obstructive pulmonary disease

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79
Q

COTA
This abbreviation / symbol stands for

A

certified occupational therapy assistant

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80
Q

CP
This abbreviation / symbol stands for

A

cerebral palsy

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81
Q

CPAP
This abbreviation / symbol stands for

A

continuous positive airway pressure

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82
Q

CPR
This abbreviation / symbol stands for

A

cardiopulmonary resuscitation

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83
Q

CRF
This abbreviation / symbol stands for

A

chronic renal failure

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84
Q

CSF
This abbreviation / symbol stands for

A

cerebrospinal fluid

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85
Q

CV
This abbreviation / symbol stands for

A

cardiovascular

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86
Q

CWI
This abbreviation / symbol stands for

A

crutch walking instructions

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87
Q

CXR
This abbreviation / symbol stands for

A

chest x-ray

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88
Q

Cysto
This abbreviation / symbol stands for

A

cystoscopic examination

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89
Q

D/C
This abbreviation / symbol stands for

A

discontinued or discharged

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90
Q

dept.
This abbreviation / symbol stands for

A

department

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91
Q

DIP
This abbreviation / symbol stands for

A

distal interphalangeal (joint)

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92
Q

DJD
This abbreviation / symbol stands for

A

degenerative joint disease

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93
Q

DM
This abbreviation / symbol stands for

A

diabetes mellitus

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94
Q

DNR
This abbreviation / symbol stands for

A

do not resuscitate

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95
Q

DO
This abbreviation / symbol stands for

A

doctor of osteopathy

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96
Q

DOB
This abbreviation / symbol stands for

A

date of birth

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97
Q

DOE
This abbreviation / symbol stands for

A

dyspnea on exertion

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98
Q

DTR
This abbreviation / symbol stands for

A

deep tendon reflex

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99
Q

DVT
This abbreviation / symbol stands for

A

deep vein thrombosis

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100
Q

Dx
This abbreviation / symbol stands for

A

diagnosis

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101
Q

ECF
This abbreviation / symbol stands for

A

extended care facility

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102
Q

ECG, EKG
This abbreviation / symbol stands for

A

electrocardiogram

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103
Q

ED
This abbreviation / symbol stands for

A

emergency department

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104
Q

EEG
This abbreviation / symbol stands for

A

electroencephalogram

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105
Q

EENT
This abbreviation / symbol stands for

A

ear, eyes, nose, throat

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106
Q

EMG
This abbreviation / symbol stands for

A

electromyogram, electromyography

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107
Q

E.R.
This abbreviation / symbol stands for

A

emergency room

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108
Q

eval.
This abbreviation / symbol stands for

A

evaluation

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109
Q

ext.
This abbreviation / symbol stands for

A

extension

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110
Q

FBS
This abbreviation / symbol stands for

A

fasting blood sugar

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111
Q

FEV
This abbreviation / symbol stands for

A

forced expiratory volume

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112
Q

FH
This abbreviation / symbol stands for

A

family history

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113
Q

flex
This abbreviation / symbol stands for

A

flexion

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114
Q

FRC
This abbreviation / symbol stands for

A

functional residual capacity

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115
Q

ft.
This abbreviation / symbol stands for

A

foot, feet (the measurement, not the
body part)

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116
Q

FUO
This abbreviation / symbol stands for

A

fever of unknown origin

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117
Q

FVC
This abbreviation / symbol stands for

A

forced vital capacity

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118
Q

FWB
This abbreviation / symbol stands for

A

full weight bearing

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119
Q

fx
This abbreviation / symbol stands for

A

fracture

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120
Q

GB
This abbreviation / symbol stands for

A

gallbladder

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121
Q

GI
This abbreviation / symbol stands for

A

gastrointestinal

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122
Q

g
This abbreviation / symbol stands for

A

gram

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123
Q

GSW
This abbreviation / symbol stands for

A

gunshot wound

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124
Q

GYN
This abbreviation / symbol stands for

A

gynecology

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125
Q

h, hr.
This abbreviation / symbol stands for

A

hour

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126
Q

H&H, H/H
This abbreviation / symbol stands for

A

hematocrit and hemoglobin

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127
Q

H&P
This abbreviation / symbol stands for

A

history and physical

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128
Q

h/o
This abbreviation / symbol stands for

A

history of

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129
Q

HA, H/A
This abbreviation / symbol stands for

A

headache

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130
Q

Hb, Hgb
This abbreviation / symbol stands for

A

hemoglobin

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131
Q

Hct, Ht
This abbreviation / symbol stands for

A

hematocrit

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132
Q

HCVD
This abbreviation / symbol stands for

A

hypertensive cardiovascular disease

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133
Q

HEENT
This abbreviation / symbol stands for

A

head, ear, eyes, nose, throat

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134
Q

HEP
This abbreviation / symbol stands for

A

home exercise program

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135
Q

HIV
This abbreviation / symbol stands for

A

human immunodeficiency virus

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136
Q

HNP
This abbreviation / symbol stands for

A

herniated nucleus pulposus

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137
Q

HOB
This abbreviation / symbol stands for

A

head of bed

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138
Q

HR
This abbreviation / symbol stands for

A

heart rate

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139
Q

hs
This abbreviation / symbol stands for

A

at bedtime

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140
Q

ht.
This abbreviation / symbol stands for

A

height

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141
Q

Htn or HTN
This abbreviation / symbol stands for

A

hypertension

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142
Q

Hx
This abbreviation / symbol stands for

A

history

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143
Q

I&O
This abbreviation / symbol stands for

A

intake and output

144
Q

IADL
This abbreviation / symbol stands for

A

instrumental activities of daily living

145
Q

ICU
This abbreviation / symbol stands for

A

intensive care unit

146
Q

IDDM
This abbreviation / symbol stands for

A

insulin-dependent diabetes mellitus

147
Q

IM
This abbreviation / symbol stands for

A

intramuscular

148
Q

imp.
This abbreviation / symbol stands for

A

impression

149
Q

in.
This abbreviation / symbol stands for

A

inches

150
Q

indep
This abbreviation / symbol stands for

A

independent

151
Q

IMV
This abbreviation / symbol stands for

A

intermittent mandatory ventilation

152
Q

inf
This abbreviation / symbol stands for

A

inferior

153
Q

IRDS
This abbreviation / symbol stands for

A

infant respiratory distress syndrome

154
Q

IS
This abbreviation / symbol stands for

A

incentive spirometry

155
Q

IV
This abbreviation / symbol stands for

A

intravenous

156
Q

KAFO
This abbreviation / symbol stands for

A

knee-ankle-foot orthosis

157
Q

kcal
This abbreviation / symbol stands for

A

kilocalories

158
Q

kg
This abbreviation / symbol stands for

A

kilogram

159
Q

KJ
This abbreviation / symbol stands for

A

knee jerk

160
Q

KUB
This abbreviation / symbol stands for

A

kidney, ureter, bladder

161
Q

L or l.
This abbreviation / symbol stands for

A

liter

162
Q

L
This abbreviation / symbol stands for

A

left

163
Q

lat
This abbreviation / symbol stands for

A

lateral

164
Q

lb.
This abbreviation / symbol stands for

A

pound

165
Q

LBBB
This abbreviation / symbol stands for

A

left bundle branch block

166
Q

LBP
This abbreviation / symbol stands for

A

low back pain

167
Q

LE
This abbreviation / symbol stands for

A

lower extremity

168
Q

LOC
This abbreviation / symbol stands for

A

loss of consciousness, level of
consciousness

169
Q

LMN
This abbreviation / symbol stands for

A

lower motor neuron

170
Q

LOS
This abbreviation / symbol stands for

A

length of stay

171
Q

LP
This abbreviation / symbol stands for

A

lumbar puncture

172
Q

m
This abbreviation / symbol stands for

A

meter

173
Q

MAP
This abbreviation / symbol stands for

A

mean arterial pressure

174
Q

max
This abbreviation / symbol stands for

A

maximal

175
Q

MD
This abbreviation / symbol stands for

A

medical doctor; doctor of medicine

176
Q

MED
This abbreviation / symbol stands for

A

minimal erythemal dose

177
Q

Meds.
This abbreviation / symbol stands for

A

medications

178
Q

mg
This abbreviation / symbol stands for

A

milligram

179
Q

MI
This abbreviation / symbol stands for

A

myocardial infarction

180
Q

min
This abbreviation / symbol stands for

A

minimal, minimum

181
Q

min.
This abbreviation / symbol stands for

A

minute

182
Q

ml
This abbreviation / symbol stands for

A

milliliter

183
Q

mm
This abbreviation / symbol stands for

A

millimeter

184
Q

MMT
This abbreviation / symbol stands for

A

manual muscle test

185
Q

mo.
This abbreviation / symbol stands for

A

month

186
Q

mod
This abbreviation / symbol stands for

A

moderate

187
Q

MP, MEP, MCP
This abbreviation / symbol stands for

A

metacarpophalangeal

188
Q

MRSA
This abbreviation / symbol stands for

A

methicillin-resistant Staphylococcus aureus

189
Q

MVA
This abbreviation / symbol stands for

A

motor vehicle accident

190
Q

NDT
This abbreviation / symbol stands for

A

neurodevelopmental treatment

191
Q

neg.
This abbreviation / symbol stands for

A

negative

192
Q

NG or ng
This abbreviation / symbol stands for

A

nasogastric

193
Q

N.H.
This abbreviation / symbol stands for

A

nursing home

194
Q

NIDDM
This abbreviation / symbol stands for

A

non–insulin-dependent diabetes mellitus

195
Q

nn
This abbreviation / symbol stands for

A

nerve

196
Q

noc
This abbreviation / symbol stands for

A

night, at night

197
Q

NPO or npo
This abbreviation / symbol stands for

A

nothing by mouth

198
Q

NSR
This abbreviation / symbol stands for

A

normal sinus rhythm

199
Q

NWB
This abbreviation / symbol stands for

A

non–weight bearing

200
Q

O:
This abbreviation / symbol stands for

A

objective

201
Q

OB
This abbreviation / symbol stands for

A

obstetrics

202
Q

OBS
This abbreviation / symbol stands for

A

organic brain syndrome

203
Q

OA
This abbreviation / symbol stands for

A

osteoarthritis

204
Q

OOB
This abbreviation / symbol stands for

A

out of bed

205
Q

od
This abbreviation / symbol stands for

A

once daily

205
Q

O.P.
This abbreviation / symbol stands for

A

outpatient

206
Q

O.R.
This abbreviation / symbol stands for

A

operating room

207
Q

ORIF
This abbreviation / symbol stands for

A

open reduction, internal fixation

208
Q

OT
This abbreviation / symbol stands for

A

occupational therapy, occupational
therapist

209
Q

OTR
This abbreviation / symbol stands for

A

occupational therapist (used to follow
official signature of the occupational therapist)

209
Q

oz.
This abbreviation / symbol stands for

A

ounce

210
Q

P
This abbreviation / symbol stands for

A

poor

211
Q

P:
This abbreviation / symbol stands for

A

plan, intervention plan, plan of care

212
Q

P.A.
This abbreviation / symbol stands for

A

physician’s assistant

213
Q

PA
This abbreviation / symbol stands for

A

posterior/anterior

214
Q

para
This abbreviation / symbol stands for

A

paraplegia

215
Q

pc
This abbreviation / symbol stands for

A

after meals

216
Q

PCL
This abbreviation / symbol stands for

A

posterior cruciate ligament

217
Q

PE
This abbreviation / symbol stands for

A

pulmonary embolus

218
Q

PEEP
This abbreviation / symbol stands for

A

positive end expiratory pressure

219
Q

per
This abbreviation / symbol stands for

A

by/through

220
Q

p.o.
This abbreviation / symbol stands for

A

by mouth (per orem)

221
Q

PERRLA
This abbreviation / symbol stands for

A

pupils equal, round, reactive to light, and accommodation

222
Q

P.H.
This abbreviation / symbol stands for

A

past history

223
Q

p.m.
This abbreviation / symbol stands for

A

afternoon

224
Q

PMH, PMHx
This abbreviation / symbol stands for

A

past medical history

225
Q

PNF
This abbreviation / symbol stands for

A

proprioceptive neuromuscular facilitation

226
Q

PNI
This abbreviation / symbol stands for

A

peripheral nerve injury

227
Q

POMR
This abbreviation / symbol stands for

A

problem-oriented medical record

228
Q

pos.
This abbreviation / symbol stands for

A

positive

229
Q

poss
This abbreviation / symbol stands for

A

possible

230
Q

post
This abbreviation / symbol stands for

A

posterior

231
Q

post-op
This abbreviation / symbol stands for

A

after surgery (operation)

232
Q

PRE
This abbreviation / symbol stands for

A

progressive-resistive exercise

233
Q

pre-op
This abbreviation / symbol stands for

A

before surgery (operation)

234
Q

prn
This abbreviation / symbol stands for

A

whenever necessary, as often as necessary

235
Q

PROM
This abbreviation / symbol stands for

A

passive range of motion

236
Q

PSIS
This abbreviation / symbol stands for

A

posterior-superior iliac spine

237
Q

PT
This abbreviation / symbol stands for

A

physical therapy, physical therapist
(used after therapist’s signature)

238
Q

PT/PTT
This abbreviation / symbol stands for

A

prothrombin time/partial thromboplastin time

239
Q

Pt., pt.
This abbreviation / symbol stands for

A

patient

240
Q

PTA
This abbreviation / symbol stands for

A

physical therapist assistant;
prior to admission

241
Q

PTB
This abbreviation / symbol stands for

A

patellar tendon bearing

242
Q

PVD
This abbreviation / symbol stands for

A

peripheral vascular disease

243
Q

PWB
This abbreviation / symbol stands for

A

partial weight bearing

244
Q

q
This abbreviation / symbol stands for

A

every

245
Q

qid
This abbreviation / symbol stands for

A

four times a day

246
Q

qh
This abbreviation / symbol stands for

A

every hour

247
Q

qn
This abbreviation / symbol stands for

A

every night

248
Q

qt.
This abbreviation / symbol stands for

A

quart

249
Q

R
This abbreviation / symbol stands for

A

right

250
Q

RA
This abbreviation / symbol stands for

A

rheumatoid arthritis

251
Q

RBBB
This abbreviation / symbol stands for

A

right bundle branch block

252
Q

RBC
This abbreviation / symbol stands for

A

red blood cell (count)

253
Q

R.D.
This abbreviation / symbol stands for

A

registered dietician

254
Q

re:
This abbreviation / symbol stands for

A

regarding

255
Q

rehab
This abbreviation / symbol stands for

A

rehabilitation

256
Q

reps
This abbreviation / symbol stands for

A

repetitions

257
Q

resp
This abbreviation / symbol stands for

A

respiratory, respiration

258
Q

RN
This abbreviation / symbol stands for

A

registered nurse

259
Q

R/O or r/o
This abbreviation / symbol stands for

A

rule out

260
Q

ROM
This abbreviation / symbol stands for

A

range of motion

261
Q

ROS
This abbreviation / symbol stands for

A

review of systems

262
Q

RR
This abbreviation / symbol stands for

A

respiratory rate

263
Q

RROM
This abbreviation / symbol stands for

A

resistive range of motion

264
Q

RT
This abbreviation / symbol stands for

A

respiratory therapist, respiratory therapy

265
Q

Rx
This abbreviation / symbol stands for

A

intervention plan, prescription, therapy

266
Q

SACH
This abbreviation / symbol stands for

A

solid ankle cushion heel

267
Q

SCI
This abbreviation / symbol stands for

A

spinal cord injury

268
Q

SC joint
This abbreviation / symbol stands for

A

sternoclavicular joint

269
Q

sec.
This abbreviation / symbol stands for

A

seconds

270
Q

SED
This abbreviation / symbol stands for

A

suberythemal dose

271
Q

sig
This abbreviation / symbol stands for

A

directions for use, give as follows, let it
be labeled

272
Q

SI(J)
This abbreviation / symbol stands for

A

sacroiliac (joint)

273
Q

SLE
This abbreviation / symbol stands for

A

systemic lupus erythematosus

274
Q

SLP
This abbreviation / symbol stands for

A

speech-language pathologist

275
Q

SLR
This abbreviation / symbol stands for

A

straight leg raise

276
Q

SNF
This abbreviation / symbol stands for

A

skilled nursing facility

277
Q

SOAP
This abbreviation / symbol stands for

A

subjective, objective, assessment, plan

278
Q

SOB
This abbreviation / symbol stands for

A

shortness of breath

279
Q

S/P
This abbreviation / symbol stands for

A

status post (e.g., “S/P hip fx” means “Pt. fx her hip in the recent past.”)

280
Q

spec
This abbreviation / symbol stands for

A

specimen

281
Q

stat.
This abbreviation / symbol stands for

A

immediately, at once

282
Q

sup
This abbreviation / symbol stands for

A

superior

283
Q

Sx
This abbreviation / symbol stands for

A

symptoms

284
Q

tab
This abbreviation / symbol stands for

A

tablet

285
Q

TB
This abbreviation / symbol stands for

A

tuberculosis

286
Q

TBI
This abbreviation / symbol stands for

A

traumatic brain injury

287
Q

tbsp.
This abbreviation / symbol stands for

A

tablespoon

288
Q

TENS, TNS
This abbreviation / symbol stands for

A

transcutaneous electrical nerve
stimulator/stimulation

289
Q

THA
This abbreviation / symbol stands for

A

total hip arthroplasty

290
Q

ther ex, thera ex
This abbreviation / symbol stands for

A

therapeutic exercise

291
Q

TIA
This abbreviation / symbol stands for

A

transient ischemic attack

292
Q

tid
This abbreviation / symbol stands for

A

three times daily

293
Q

TKA
This abbreviation / symbol stands for

A

total knee arthroplasty

294
Q

TM(J)
This abbreviation / symbol stands for

A

temporomandibular (joint)

295
Q

TNR
This abbreviation / symbol stands for

A

tonic neck reflex (also ATNR, STNR)

296
Q

t.o.
This abbreviation / symbol stands for

A

telephone order

297
Q

TPR
This abbreviation / symbol stands for

A

temperature, pulse, and respiration

298
Q

tsp.
This abbreviation / symbol stands for

A

teaspoon

299
Q

TUR/TURP
This abbreviation / symbol stands for

A

transurethral resection

300
Q

Tx
This abbreviation / symbol stands for

A

traction

301
Q

TV
This abbreviation / symbol stands for

A

tidal volume

302
Q

UA
This abbreviation / symbol stands for

A

urine analysis

303
Q

UE
This abbreviation / symbol stands for

A

upper extremity

304
Q

UMN
This abbreviation / symbol stands for

A

upper motor neuron

305
Q

URI
This abbreviation / symbol stands for

A

upper respiratory infection

306
Q

US
This abbreviation / symbol stands for

A

ultrasound

307
Q

UTI
This abbreviation / symbol stands for

A

urinary tract infection

308
Q

UV
This abbreviation / symbol stands for

A

ultraviolet

309
Q

VC
This abbreviation / symbol stands for

A

vital capacity

310
Q

VD
This abbreviation / symbol stands for

A

venereal disease

311
Q

v.o. or VO
This abbreviation / symbol stands for

A

verbal orders (e.g., v.o. Dr. Smith/
assistant’s signature)

312
Q

vol.
This abbreviation / symbol stands for

A

volume

313
Q

v.s.
This abbreviation / symbol stands for

A

vital signs

314
Q

w/c
This abbreviation / symbol stands for

A

wheelchair

315
Q

W/cm^2
This abbreviation / symbol stands for

A

watts per square centimeter

316
Q

WBC
This abbreviation / symbol stands for

A

white blood cell (count)

317
Q

wk.
This abbreviation / symbol stands for

A

week

318
Q

WNL
This abbreviation / symbol stands for

A

within normal limits

319
Q

wt.
This abbreviation / symbol stands for

A

weight

320
Q

X
This abbreviation / symbol stands for

A

Number of times performed (e.g., 2
is twice; 3 is 3 times)

321
Q

y/o or y.o.
This abbreviation / symbol stands for

A

years old

322
Q

yd.
This abbreviation / symbol stands for

A

yard

323
Q

yr.
This abbreviation / symbol stands for

A

year

324
Q

+1 (+2, etc.)
This abbreviation / symbol stands for

A

Assistance (assistance of 1 person
given; also written “assistance of 1.”
Examples: amb … c min + 1 assist.,
or amb … c +1 min assist., or amb
… c min assist. of 1)

325
Q

♂
This abbreviation / symbol stands for

A

Male

326
Q

♀
This abbreviation / symbol stands for

A

female

327
Q

↓
This abbreviation / symbol stands for

A

down, downward, decrease, diminished

328
Q

↑
This abbreviation / symbol stands for

A

up, upward, increase, augmented

329
Q

//
This abbreviation / symbol stands for

A

parallel or parallel bars (also written “// bars”)

330
Q

c
This abbreviation / symbol stands for

A

with

331
Q

s
This abbreviation / symbol stands for

A

without

332
Q

p
This abbreviation / symbol stands for

A

after

333
Q

a
This abbreviation / symbol stands for

A

before

334
Q

~ or ≈
This abbreviation / symbol stands for

A

approximately

335
Q

Δ
This abbreviation / symbol stands for

A

change

336
Q

=
This abbreviation / symbol stands for

A

equal

337
Q

+ or (+)
This abbreviation / symbol stands for

A

plus, positive (positive also abbreviated “pos.”)

338
Q

(-) or -
This abbreviation / symbol stands for

A

minus, negative (negative also
abbreviated “neg.”)

339
Q

↔
This abbreviation / symbol stands for

A

to and from

340
Q

→
This abbreviation / symbol stands for

A

to progressing toward, approaching

341
Q

1°
This abbreviation / symbol stands for

A

primary

342
Q

2°
This abbreviation / symbol stands for

A

secondary, secondary to

343
Q

/
This abbreviation / symbol stands for

A

per

344
Q

%
This abbreviation / symbol stands for

A

percent

345
Q

+, &, et.
This abbreviation / symbol stands for

A

and

346
Q

Hashtag #
This abbreviation / symbol stands for

A

number (#1 = number 1), pounds
(5# wt. = 5 pound weight; pound
also abbreviated “lbs.”)

347
Q

Common used to substitute for ‘is’

A

Colon (:)

348
Q

TRUE OR FALSE: In documentation, never use correction fluid or tape. The proper way to correct an error is to strike a line through the error, then write the date and initials above the error.

A

True

349
Q

In documentation, the dont’s are:
Don’t leave (1)___ after each entry and leave (2)___ in between words. Don’t use derogatory statements and don’t use first person singular pronouns. Don’t include unnecessary and irrelevant facts.

A
  1. empty lines
  2. big spaces
350
Q

This provides a method of communication, keeps record of PT management given, and serves as a business record, for billing and for legal aspects. It also assists in obtaining insurance coverage and in decision making and discharge planning.

A

Documentation

351
Q

Has precise descriptions. Vague statements and confusing use of words are avoided.
A. Accuracy
B. Brevity
C. Clarity

A

C. Clarity

352
Q

States information in a factual manner and never records falsely, exaggerate, guess or make up data. Statements are proofread for incorrect spelling, grammar, and punctuation.
A. Accuracy
B. Brevity
C. Clarity

A

A. Accuracy

353
Q

Information is stated concisely, using
short, succinct sentences. Long-winding statements are avoided.
A. Accuracy
B. Brevity
C. Clarity

A

B. Brevity

354
Q

This punctuation is a common substitute for ‘through’ or ‘to’. It also may be confused with the minus/negative sign.

A

Hyphen (-)

355
Q

This punctuation is used to connect two related statements in documentation.

A

Semicolon (;)

356
Q

T/c
This abbreviation / symbol stands for

A

To consider

357
Q

WFL
This abbreviation / symbol stands for

A

Within functional limits

358
Q

PTC
This abbreviation / symbol stands for

A

Prior to consultation

(1) Fundamentals of Physical Therapy (11 decks)

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