Documentation Abbreviations

A

Assistance

pt

Patient

PLOF

Prior level of function

TBI

Traumatic brain injury

PICU

Pediatric intensive care unit

CHF

Congestive heart failure

THA

Total hip arthroplasty

SBA

Stand by assistance

CCU

Coronary (cardiac) care unit

HOB

Head of bed

AROM

Active range of motion

MMT

Manual muscle testing

ADL

Activities of daily living

ALS

Amyotrophic lateral sclerosis

PMH

Past medical history

Mod A

Moderate assistance

NICU

Neonatal intensive care unit

CHT

Certified hand therapist

add

Adduction

ORIF

Open reduction internal fixation

CA

Cancer

abd

Abduction

KAFO

Knee ankle foot orthosis

fx

Fracture

DJD

Degenerative joint disease

TDWB

touch down weightbearing

PACU

Post-anesthesia care unit

LTAC

Long-term acute care

PNS

Peripheral nervous system

MVA

Motor vehicle accident

HH

Home health or homonymous hemianopsia

OTS

Occupational therapy student

HTN

Hypertension

COTA/L

Certified occupational therapy assistant/licenced

ASIS

Anterior superior iliac spine

dx

diagnosis

ICU

Intensive care unit

PWB

Partial weightbearing

I

Independent

HEP

Home exercise program; heparin

PT

Physical therapist; physical therapy

GSW

Gunshot wound

H&P

History and physical

DOB

Date of birth

SOB

Shortness of breath

LE

Lower extremity

D

Dependent

AKA

Above knee amputation

LOS

Length of stay

CABG

Coronary artery bypass graft

HR

Heart rate

c/o

Complains of

BM

Bowel movement

OTR/L

Occupational therapist, registered/licensed

THR

Total hip replacement

FTT

Failure to thrive

COTA

Certified occupational therapy assistant

NC

Nasal cannula

w/c

Wheelchair

SNF

Skilled nursing facility

IV

Intravenous

SDH

Subdural hematoma

NKA

No known allergies

CGA

Contact guard assistance

CVA

Cerebrovascular accident

ADHD

Attention deficit hyperactivity disorder

SCI

Spinal cord injury

L

Left

TTWB

Toe touch weightbearing

UE

Upper extremity

DNR

Do not resuscitate

Mod I

Modified independent

EtOH

Alcohol use/abuse

CAD

Coronary artery disease

TKR

Total knee replacement

DME

Durable medical equipment

CNS

Central nervous system

PVD

Peripheral vascular disease

STG

Short term goal

I&O

Intake and output

D/C

Discharge

HEENT

Head, eyes, ear, nose, throat

IPR

In patient rehab

PEG

Percutaneous endoscopic gastrostomy

AFO

Ankle foot orthosis

NPO

Nothing by mouth

PTA

Prior to admission ; Post traumatic amnesia

Max A

Maximal assistance

WNL

Within normal limits

ant.

Anterior

PO

By mouth

BKA

Below knee amputation

tx

Treatment

HOH

Hand over hand

ER

Emergency room

MD

Medical doctor

OTR

Occupational therapist, registered

TIA

Transient ischemic attack

ED

Emergency department

R

Right