Using Abbreviations ‘Abbreviations are used as a time and space saver while writing notes, In order to ensure that everyone in the hospital can understand what has been written in the chart by others, most medical facilities have a list of approved abbreviations, and these are the only abbreviations that should be used in a medical record in that particular facility. This list of abbreviations is approved by the medical records department of each facility. The list of acceptable abbreviations varies from one facility to the next, particularly terminology specific to allied health fields such as physical and ‘occupational therapy. ‘The list of abbreviations that follows will be used as the approved list for all of the worksheets in this book. It is a compilation of the most common abbreviations used by over 13 different healthcare facilities, Any abbreviations not on this list will be considered unacceptable for these worksheets. As you begin to write notes during your time in the clinic, please remember that the list of acceptable abbreviations for your clinical facility must be used. During orientation to any iinical facility in which you practice, you should ask about the location of the approved abbre- viations list and become particularly familiar with the abbreviations used frequently by the facility. For further reference on abbreviations, see Appendix E. Approved Abbreviations and Symbols for Hospital XYZ A: assessment AAROM active assistive range of motion abd abduction ac before meals AC joints acromioclavicular joints ACTH adrenocorticotrophic hormone add adduction ADL activities of daily living ad lib at discretion adm admission AE above elbow AFO ankle foot orthosis AIDS autoimmune deficiency syndrome AUS anterior inferior iliac spine Ay ankle jerk. 3 13Writing SOAP Notes 14 AK AMA amb ant ar AROM ASA ASAP ASHD ASIS assist. BIS BE bid bilat, BK BM BP bpm BRP : BUN c Ces cA case cap eal cBc cer ces ccc ce CHE CNS clo co, coLD cont. corp COTA cp cPR CSF cv cvA cwr Cysto dept. pip above knee Tiorning, against medical advice ambulation, ambulating, anterior anterior-posterior active range of motion aspirin 88 soon as possible arteriosclerotic heart discs = anterior superior iliac sp assistance, assistive 2:24, ambulate, amet: bedside below elbow twice a day bilateral, bilaterally below knee bowel movement blood pressure beats per minute bathroom privileges blood urea nitrogen (blood :- Centigrade culture and sensitivity ‘cancer, carcinoma coronary artery bypass gralt coronaty 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 discos. continue chronic obstructive pulmonary disease certified occupational therapy assistant cerebral palsy. cardiopulmonary resuscitation cerebral spinal fluid cardiovascular cerebrovascular accident crutch walking instructions cystoscopic examination department distal interphalangeal jointDic DM DO DTR Dx ECF ECG, EKG EEG EENT EMG ER. eval. ext. FBS FH flex ft. FUO EWB fx cB cI gm GYN hy hr. Hau, HH H&P HA, HA Hb, Hgb HCVD HEENT HEP HI HIV HNP HOB HR hr. hs he, Ht Htn Hx 1&0 Icu IM imp. discontinued or discharged diabetes mellitus 2 doctor of osteopathy deep tendon reflex diagnosis extended care facility electrocardiogram electroencephalogram ear, eyes, nose, throat electromyogram, electromyography emergency room, evaluation extension fair (muscle strength, balance) fasting blood sugar family history flexion foot, feet (the measurement, not the body part) fever, unknown origin full weight bearing fracture good (muscle strength, balance) gallbladder gastrointestinal gram gynecology hour hematocrit and hemoglobin istory 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 at bedtime height hematocrit hypertension history intake and output intensive care unit intramuscular impression Using Abloreviaions 15Lk Tb. LBP LE Loc LP max ™MD MED Meds. ‘MET mg, Mi mm MMT mo. mod MP, MCP NDT neg. NEL noc po NSR NWB OB oBs od oF. OR. ORF oT inches independent inferior intravenous kilocalories kilogram kenee jerk Kidney, ureter, bladder liter left pound low back pain lower extremity Joss of consciousness jumbar puncture meter maximal jnedical doctor; doctor of medicine minimal erythemal dose medications ‘muscle function test milligram myocardial 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 cecupational therapy, occupational therapistOTR oz P P: PA. PA para pe per er 0s, p.o. PERRLA PH. pan. PNE PNI POMR pos. poss post post-op PRE pre-op pn PROM PsIs PT PreTt Pt, pt PTA PTA PTB PvD PWB Using Abbreviations occupational therapist (used to follow official signature of the occupational therapist) x ounce poor (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, physical 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 partial weight bearing every every day every hour four times a day every night quart right rheumatoid arthritis red blood cell count registered dietician regarding rehabilitation repetitions respiratory, respiration registered nurse rule out (In order to make a good diagnosis, the physician will try to rule the disease/condition named out; if he or she cannot, this will become the diagnosis.) 7‘writing SOAP Notes 18 ROM ROS: RROM RT. Rx SACH scl SCj SED sig si) SLE SLR SNF SOAP SOB sp spec stat. Sx tab 1B tbsp. ‘TENS, TNS THR TIA tid TKR ™O TNR to. TPR tsp. TUR UA UMN URI us utr vb vol. wie Wem? WBC 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 fac subjective, objective, assessment, plan shortness of breath ‘status post (example: $/P © hip fx means Pt. fx her hip in the recent past) specimen immediately, at once symptoms trace (muscle strength) tablet tuberculosis tablespoon transcutaneous electrical nerve stimulator total hip replacement transient ischemic attack three times daily total knee replacement temporomandibular (joint) tonic neck reflex (also ATNR, STNR) telephone order temperature, pulse é& respiration teaspoon transurethral resection 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 signs wheelchair ‘watts per square centimeter white blood cell countUsing Abbreviations wk. week 19 WNL within normal limits ~ wt. weight x number of times performed (x2 = twice, x3 = 3 times) yloory.o. years old yd. yard yr year 41, 42 assistance (assistance of 1 person given; also written “assistance of 1") (Examples: amb ...min + 1 assist,, or amb... € +1 min assist, or amb - min assist. 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.) # furber (#1 = number 1), pounds (SH wt, = 5 pound weight; also abbreviated Ibs.) i per % percent +, ke, et. and =, toand from = to, progressing toward, approaching r primary x secondary, secondary to 0m a PB @ A > = Using Abbreviations: Examples ‘The following are examples of the use of abbreviations in medical records. 1, In the doctor's notes, you may find the fol- Translation: The patient has a history of hy- lowing: Pt. has hx of Htn, ASHD, CHF, MI pertension, arteriosclerotic heart disease; Com in 1993, TIA in 1994. gestive heart failure, myocardial infarction in 1993, transient ischemic attack in 1994. 2. Orders written in the chart: ‘Translation: Upad lib Up at discretion (patient's discretion) ASA q 4 hrs. Aspirin every 4 hours BRP prn Bathroom privileges when necessary NPO midnight Nothing by mouth after midnight v.o. Dr. Smith/Janice Jones, OTR Verbal order given by Dr. Smith to Janice Jones, occupational therapist‘whiting SOAP Notes 20 3, In PT note: Rx: AROM ® ankle bid ‘Translation: Treatment: Active range of mo- : tion right ankle twice per day. 4. In chart in doctor's initial note:imp:COPD; Translation: Impression: Chronic obstructive R/O lung CA pulmonary disease; rule out lung cancer. 5. Physician's orders: ‘Translation: record I & O Record intake and output all meds per IV ‘All medications through intravenous (tube) NPO Nothing by mouth transfer pt. to ICU Transfer patient to the intensive care unit. ‘You will be expected to be able to both interpret and use abbreviations in the medical record. ‘You will encounter most of the abbreviations listed in this chapter when you practice in the clinic, ‘Any time you write a note, you will be expected to use abbreviations properly.