1. Chapter 3
1.1. Medical terminology
1.1.1. A
1.1.1.1. Afferent
1.1.1.1.1. Conducting toward a structure
1.1.1.2. Analgesia
1.1.1.2.1. "Without pain" - acts in various ways to affect the peripheral and central nervous system, including:
1.1.1.3. Anesthesisa
1.1.1.3.1. "Without sensation" (drug induced loss of consciousness during which patients are not arousable, even by painful stimulation)
1.1.1.4. Anterior or ventral
1.1.1.4.1. Front of the body
1.1.1.5. Aphasia
1.1.1.5.1. Lack of speech (loss of language ability due to mental injury)
1.1.1.6. Arthralgia
1.1.1.6.1. "Joint pain" - swelling, injury, or infection of the joints
1.1.1.7. Arthritis
1.1.1.7.1. Joint inflammation
1.1.1.8. Arthrodesis
1.1.1.8.1. Fusion of a joint (artificial induction of joint ossification between two bones via surgery)
1.1.1.9. Arthroscopy
1.1.1.9.1. Inspection of joint with a scope
1.1.1.10. Ataxia
1.1.1.10.1. Lack of coordination
1.1.2. B-C
1.1.2.1. Bilateral
1.1.2.1.1. Affecting both sides
1.1.2.2. Bradykinesia
1.1.2.2.1. "Slow movement" - used to refer to slowly-progressing diseases
1.1.2.3. Cardiomegaly
1.1.2.3.1. Enlargement of the heard
1.1.2.4. Cephalad
1.1.2.4.1. Toward the head
1.1.2.5. Cerebromalacia
1.1.2.5.1. Softening of the brain
1.1.2.6. Chondroma
1.1.2.6.1. Cartilaginous tumor (benign, encapsulated with a lobular growing patter)
1.1.2.7. Chondromalacia
1.1.2.7.1. Softening of cartilage
1.1.2.8. Contralateral
1.1.2.8.1. Opposite sides
1.1.2.9. Costochondral
1.1.2.9.1. Pertaining to the rib and rib cartilage
1.1.2.10. Craniotomy
1.1.2.10.1. Surgical opening of the skull (part of the skull-a bone flap is removed in order to access the brain
1.1.3. D-L
1.1.3.1. Dispnea
1.1.3.1.1. Difficult or bad breathing
1.1.3.2. Dorsal
1.1.3.2.1. Pertaining to the back of your body
1.1.3.3. Dysphagia
1.1.3.3.1. "Difficult to eat" - refers to a patient that has difficulty swallowing
1.1.3.4. Encephalitis
1.1.3.4.1. Inflammation of the brain
1.1.3.5. Erythema
1.1.3.5.1. Abnormal redness of the skin
1.1.3.6. Hemiplegia
1.1.3.6.1. Paralysis of one half of the body
1.1.3.7. Hypertension
1.1.3.7.1. Abnormally high blood pressure (chronically elevated)
1.1.3.8. Hypoglycemia
1.1.3.8.1. Abnormally low blood sugar
1.1.3.9. Intercostal
1.1.3.9.1. Between the ribs
1.1.4. M-Z
1.1.4.1. Meningioma
1.1.4.1.1. Tumor of the meninges
1.1.4.2. Meniscectomy
1.1.4.2.1. Removal of cartilaginous tissue that makes up the meniscus
1.1.4.3. Myopathy
1.1.4.3.1. Disease of a muscle
1.1.4.4. Neurology
1.1.4.4.1. Study of the nervous system and/or nervous disorders
1.1.4.5. Osteoma
1.1.4.5.1. Tumor of the bone
1.1.4.6. Phlebitis
1.1.4.6.1. Inflammation of a vein (usually in the legs)
1.1.4.7. Subclavicular
1.1.4.7.1. Beneath the clavicle
1.1.4.8. Subcutaneous
1.1.4.8.1. Beneath the skin
1.1.4.9. Suprapubic
1.1.4.9.1. Above the symphysis pubis
1.1.4.10. Symphysis pubis
1.1.4.10.1. Fusion of the pubis bones medially
1.1.4.11. Tendinitis
1.1.4.11.1. Inflammation of a tendon (usually due to overuse)
2. Chapter 2
2.1. Effective writing style
2.1.1. Accuracy
2.1.1.1. This information is permanent, so do not:
2.1.1.1.1. Lie
2.1.1.1.2. Exaggerate
2.1.1.1.3. Guess at...
2.1.1.1.4. Include irrelevant data
2.1.2. Brevity
2.1.2.1. Use standard abbreviations
2.1.2.2. Some facilities permit sentence fragments
2.1.2.3. If a flow sheet or table is used for the results of tests and measures...
2.1.2.3.1. Additional information demonstrating the therapist's clinical judgment must be documented in addition
2.1.3. Clarity
2.1.3.1. Avoid sudden shifts of tense
2.1.4. Punctuation
2.1.4.1. Hyphens can be confused for minus signs and should be avoided
2.1.4.2. Semicolons are very useful in reducing word redundancy
2.1.4.3. Colons can be used instead of "is"
2.1.5. Correcting errors
2.1.5.1. Do not use correction fluid or tape
2.1.5.2. Put a single line through the error
2.1.5.3. Write the date
2.1.5.4. Initial above the error
2.1.6. Signing notes (Authentication)
2.1.6.1. Use legal name
2.1.6.2. Follow with initials indicating your status as a therapist
2.1.7. Referring to yourself
2.1.7.1. If necessary, do so in third person
2.1.8. Blank/empty lines
2.1.8.1. These can render your note vulnerable to tampering
2.1.9. General format for writing physician notes in a chart:
2.1.9.1. date/time/order v.o. physician's name/therapist's signature, PT
2.1.9.1.1. Once written, the physician cosigns
3. Chapter 1
3.1. Methods of documentation
3.1.1. (P)SOAP Note
3.1.1.1. Commonly used throughout the country
3.1.1.2. Acronym:
3.1.1.2.1. (Problem)
3.1.1.2.2. Subjective
3.1.1.2.3. Objective
3.1.1.2.4. Assessment
3.1.1.2.5. Plan
3.1.2. Patient/Client Management Note
3.1.2.1. Used by some clinicians as physical therapy practitioners become familiar with the Guide to Physical Therapy Practice
3.1.2.2. History
3.1.2.3. Systems review
3.1.2.4. Tests and measures
3.1.2.5. Evaluation
3.1.2.6. Diagnosis
3.1.2.7. Prognosis
3.1.2.8. Plan of care
3.2. Purposes of documentation
3.2.1. Record
3.2.1.1. Helps to legally protect the rights of the therapist and patient
3.2.1.2. Patient care notes are considered legal documents
3.2.1.3. Ensures legitimate testimony from the PT if/when the need arises
3.2.2. Communication
3.2.2.1. Goal is to provide consistency and coordination among the services provided by various health care professionals
3.2.2.2. Communicates:
3.2.2.2.1. Results of examination
3.2.2.2.2. Therapist's evaluation
3.2.2.2.3. Diagnosis
3.2.2.2.4. Prognosis
3.2.2.2.5. Therapist's expected outcomes and anticipated goals
3.2.2.2.6. Intervention plan
3.2.3. Advocacy
3.2.3.1. Assisting the patient in obtaining insurance coverage for physical therapy
3.2.3.1.1. Must justify the need for therapy services
3.2.3.1.2. Third party payers make decisions based on therapy notes
3.2.4. Discharge Planning
3.2.5. Helps to encourage as well as reflect structured clinical decision making
3.2.6. Quality assurance/improvement
3.2.7. Outcomes research
3.2.7.1. Consistency of format is important
3.2.8. Education
3.2.8.1. Informs others about the services that physical therapy can provide
3.2.9. Demonstration of Compliance
3.3. Types of Notes
3.3.1. Initial
3.3.1.1. Written after the first patient examination and evaluation
3.3.1.2. Documents the examination, evaluation, diagnosis, prognosis, and plan of care
3.3.2. Progress
3.3.2.1. Written periodically, reporting:
3.3.2.1.1. Results of re-examination
3.3.2.1.2. Results of re-evaluation
3.3.2.1.3. Changes in prognosis
3.3.2.1.4. Changes in plan of care
3.3.3. Discharge
3.3.3.1. Written when therapy is discontinued or the patient is discharged
3.3.3.2. After final examination and evaluation
3.3.3.3. Addresses:
3.3.3.3.1. Results of final examination and evaluation
3.3.3.3.2. Outcomes and goals achieved
3.3.3.3.3. Summary of the interventions received
3.3.3.3.4. Final disposition
3.4. Process of clinical decision making
3.4.1. Examination
3.4.1.1. SOAP
3.4.1.1.1. Gathering information from:
3.4.1.2. Patient/Client Management
3.4.1.2.1. Nature of data
3.4.2. Evaluation
3.4.2.1. This is where the therapist's clinical decision-making processes are evident
3.4.2.2. SOAP
3.4.2.2.1. Assessment section
3.4.2.3. Patient/Client Management
3.4.2.3.1. Evaluation section
3.4.3. Diagnosis
3.4.3.1. Includes a discussion of the relationship of the patient's functional deficits to the patient's impairments
3.4.3.2. Can include a discussion of the relationship of the patient's disability to functional deficits and impairments
3.4.3.3. SOAP
3.4.3.3.1. Assessment section
3.4.3.4. Patient/Client Management
3.4.3.4.1. Diagnosis section
3.4.4. Prognosis
3.4.4.1. Can include:
3.4.4.1.1. Predicted level of improvement that the patient will be able to achieve and the predicted amount of time to achieve that level of improvement
3.4.4.1.2. Therapist's professional opinion of the patient's rehabilitation potential
3.4.4.1.3. Future therapy that the therapist believes will be needed
3.4.4.1.4. Proposed duration of therapy
3.4.4.1.5. Projected final outcomes, if not listed in the Expected Outcomes part of the Plan of Care
3.4.4.1.6. Plans for discharge may be listed in subsection
3.4.4.2. SOAP
3.4.4.2.1. Assessment section
3.4.5. Plan of care
3.4.5.1. Includes:
3.4.5.1.1. Expected outcomes
3.4.5.1.2. Anticipated goals
3.4.5.1.3. Interventions
3.4.5.2. Some may include with prognosis
3.4.5.3. SOAP
3.4.5.3.1. Plan of Care section
4. Chapter 4
4.1. Abbreviations
4.1.1. Symbols
4.1.1.1. 2°
4.1.1.1.1. secondary
4.1.1.2. 1°
4.1.1.2.1. primary
4.1.1.3. →
4.1.1.3.1. progressing toward, approaching
4.1.1.4. ↔
4.1.1.4.1. to and from
4.1.1.5. +, &, et.
4.1.1.5.1. and
4.1.1.6. %
4.1.1.6.1. percent
4.1.1.7. /
4.1.1.7.1. per
4.1.1.8. #
4.1.1.8.1. number, pounds (5# weight = 5 lbs weight)
4.1.1.9. - or (-)
4.1.1.9.1. minus, negative
4.1.1.10. + or (+)
4.1.1.10.1. plus, positive
4.1.1.11. =
4.1.1.11.1. equal
4.1.1.12. Δ
4.1.1.12.1. change
4.1.1.13. ~
4.1.1.13.1. approximately
4.1.1.14. a(bar)
4.1.1.14.1. before
4.1.1.15. p(bar)
4.1.1.15.1. after
4.1.1.16. s(bar)
4.1.1.16.1. without
4.1.1.17. c(bar)
4.1.1.17.1. with
4.1.1.18. //
4.1.1.18.1. parallel or parallel bars
4.1.1.19. ↑
4.1.1.19.1. Up
4.1.1.20. ↓
4.1.1.20.1. Down
4.1.1.21. ♀
4.1.1.21.1. Female
4.1.1.22. ♂
4.1.1.22.1. Male
4.1.1.23. +1 (+2, etc.)
4.1.1.23.1. assistance (assistance of 1 person given; also written"assistance of 1."
4.1.2. A-Ai
4.1.2.1. A:
4.1.2.1.1. assessment
4.1.2.2. ABI
4.1.2.2.1. acquired brain injury
4.1.2.3. afib
4.1.2.3.1. atrial fibrillation
4.1.2.4. A-line
4.1.2.4.1. arterial line
4.1.2.5. A-V
4.1.2.5.1. arteriovenous
4.1.2.6. AAA
4.1.2.6.1. abdominal aortic aneurysm
4.1.2.7. AAROM
4.1.2.7.1. active assistive range of motion
4.1.2.8. Abd or abd
4.1.2.8.1. abduction
4.1.2.9. ABG
4.1.2.9.1. arterial blood gases
4.1.2.10. ac
4.1.2.10.1. before meals
4.1.2.11. AC joint
4.1.2.11.1. acromioclavicular joint
4.1.2.12. ACL
4.1.2.12.1. anterior cruciate ligament
4.1.2.13. ACTH
4.1.2.13.1. adrenocorticotrophic hormone
4.1.2.14. Add or add
4.1.2.14.1. adduction
4.1.2.15. ADL
4.1.2.15.1. activities of daily living
4.1.2.16. ad lib
4.1.2.16.1. at discretion
4.1.2.17. adm
4.1.2.17.1. admission, admitted
4.1.2.18. AE
4.1.2.18.1. above elbow
4.1.2.19. AFO
4.1.2.19.1. ankle foot orthosis
4.1.2.20. AIDS
4.1.2.20.1. acquired immune deficiency syndrome
4.1.2.21. AIIS
4.1.2.21.1. anterior inferior iliac spine
4.1.3. Ag-Az
4.1.3.1. AJ
4.1.3.1.1. ankle jerk
4.1.3.2. AK
4.1.3.2.1. above knee
4.1.3.3. ALS
4.1.3.3.1. amyotrophic lateral sclerosis
4.1.3.4. a.m
4.1.3.4.1. morning
4.1.3.5. AMA
4.1.3.5.1. against medical advice
4.1.3.6. amb
4.1.3.6.1. ambulation, etc
4.1.3.7. ANS
4.1.3.7.1. autonomic nervous system
4.1.3.8. ant
4.1.3.8.1. anterior
4.1.3.9. AP
4.1.3.9.1. anterior-posterior
4.1.3.10. ARDS
4.1.3.10.1. adult respiratory distress syndrome
4.1.3.11. ARF
4.1.3.11.1. acute renal failure
4.1.3.12. AROM
4.1.3.12.1. active range of motion
4.1.3.13. ASA
4.1.3.13.1. aspirin
4.1.3.14. ASAP or asap
4.1.3.14.1. as soon as possible
4.1.3.15. ASCVD
4.1.3.15.1. arteriosclerotic cardiovascular disease
4.1.3.16. ASHD
4.1.3.16.1. arteriosclerotic heart disease
4.1.3.17. ASIS
4.1.3.17.1. anterior superior iliac spine
4.1.3.18. assist.
4.1.3.18.1. asisitance, assistive
4.1.3.19. AVM
4.1.3.19.1. arteriovenous malfomation
4.1.4. B
4.1.4.1. B/S
4.1.4.1.1. bedside
4.1.4.2. BBB
4.1.4.2.1. bundle branch block
4.1.4.3. BE
4.1.4.3.1. below elbow
4.1.4.4. BID or bid
4.1.4.4.1. twice a day
4.1.4.5. bilat. or B
4.1.4.5.1. bilateral, bilaterally
4.1.4.6. BK
4.1.4.6.1. below knee
4.1.4.7. BM
4.1.4.7.1. bowel movemen
4.1.4.8. BOS
4.1.4.8.1. base of support
4.1.4.9. BP
4.1.4.9.1. blood pressure
4.1.4.10. bpm
4.1.4.10.1. beatsper minute
4.1.4.11. BR
4.1.4.11.1. bedrest
4.1.4.12. BRP
4.1.4.12.1. bathroom priviliges
4.1.4.13. BS
4.1.4.13.1. breath sounds or bowel sounds
4.1.4.14. BUN
4.1.4.14.1. blood urea nitrogen
4.1.5. C-Cn
4.1.5.1. C
4.1.5.1.1. centrigrade
4.1.5.2. C&S
4.1.5.2.1. culture and sensitivity
4.1.5.3. CA
4.1.5.3.1. cancer, carcinoma
4.1.5.4. CABG
4.1.5.4.1. coronary artery bypass graft
4.1.5.5. CAD
4.1.5.5.1. coronary artery disease
4.1.5.6. CAT
4.1.5.6.1. computerized axial tomography
4.1.5.7. cal
4.1.5.7.1. calories
4.1.5.8. CBC
4.1.5.8.1. complete blood cell count
4.1.5.9. CC, C/C
4.1.5.9.1. chief complaint
4.1.5.10. CF
4.1.5.10.1. cystic fibrosis
4.1.5.11. CHF
4.1.5.11.1. congestive heart failure
4.1.5.12. cm
4.1.5.12.1. centimeter
4.1.5.13. CMV
4.1.5.13.1. cytomegalovirus
4.1.5.14. CNS
4.1.5.14.1. central nervous system
4.1.6. Cm-Cz
4.1.6.1. c/o
4.1.6.1.1. complains of
4.1.6.2. CO
4.1.6.2.1. cardiac output
4.1.6.3. CO2
4.1.6.3.1. carbon dioxide
4.1.6.4. cont.
4.1.6.4.1. continue
4.1.6.5. COPD
4.1.6.5.1. chronic obstructive pulmonary disease
4.1.6.6. COTA
4.1.6.6.1. certified occupational therapy assistant
4.1.6.7. CP
4.1.6.7.1. cerebral palsy
4.1.6.8. CPAP
4.1.6.8.1. continuous positive airway pressure
4.1.6.9. CPR
4.1.6.9.1. cardiopulmonary resuscitation
4.1.6.10. CRF
4.1.6.10.1. chronic renal failure
4.1.6.11. CSF
4.1.6.11.1. cerbrospinal fluid
4.1.6.12. CV
4.1.6.12.1. cardiovascular
4.1.6.13. CWI
4.1.6.13.1. crutch walking instructions
4.1.6.14. CXR
4.1.6.14.1. chest x-ray
4.1.6.15. Cysto
4.1.6.15.1. cystoscopic examination
4.1.7. D-E
4.1.7.1. D/C
4.1.7.1.1. discontinued or discharged
4.1.7.2. dept.
4.1.7.2.1. department
4.1.7.3. DIP
4.1.7.3.1. distal interphalangeal
4.1.7.4. DJD
4.1.7.4.1. degenerative joint disease
4.1.7.5. DM
4.1.7.5.1. diabetes mellitus
4.1.7.6. DNR
4.1.7.6.1. do not resuscitate
4.1.7.7. DO
4.1.7.7.1. doctor of osteopathy
4.1.7.8. DOB
4.1.7.8.1. date of birth
4.1.7.9. DOE
4.1.7.9.1. dyspnea on exertion
4.1.7.10. DTR
4.1.7.10.1. deep tendon reflex
4.1.7.11. DVT
4.1.7.11.1. deep vein thrombosis
4.1.7.12. Dx
4.1.7.12.1. diagnosis
4.1.7.13. E.R.
4.1.7.13.1. emergency room
4.1.7.14. ECF
4.1.7.14.1. extended care facility
4.1.7.15. ECG, EKG
4.1.7.15.1. electrocardiogram
4.1.7.16. ED
4.1.7.16.1. emergency department
4.1.7.17. EEG
4.1.7.17.1. electroencephalogram
4.1.7.18. EENT
4.1.7.18.1. ear, eyes, nose, throat
4.1.7.19. EMG
4.1.7.19.1. electromyogram
4.1.7.20. eval.
4.1.7.20.1. evaluation
4.1.7.21. ext.
4.1.7.21.1. extension
4.1.8. F-G
4.1.8.1. FBS
4.1.8.1.1. fasting blood sugar
4.1.8.2. FEV
4.1.8.2.1. forced expiratory colume
4.1.8.3. FH
4.1.8.3.1. family history
4.1.8.4. flex
4.1.8.4.1. flexion
4.1.8.5. FRC
4.1.8.5.1. functional residual capacity
4.1.8.6. ft.
4.1.8.6.1. foot, feet (measurement)
4.1.8.7. FUO
4.1.8.7.1. fever of unknown origin
4.1.8.8. FVC
4.1.8.8.1. force vital capacity
4.1.8.9. FWB
4.1.8.9.1. full weight bearing
4.1.8.10. fx
4.1.8.10.1. fracture
4.1.8.11. g
4.1.8.11.1. gram
4.1.8.12. GB
4.1.8.12.1. gallbladder
4.1.8.13. GO
4.1.8.13.1. gastrointestinal
4.1.8.14. GSW
4.1.8.14.1. funshot wound
4.1.8.15. GYN
4.1.8.15.1. gynecology
4.1.9. H
4.1.9.1. H&H, H/H
4.1.9.1.1. hematocrit and hemoglobin
4.1.9.2. H&P
4.1.9.2.1. history and physical
4.1.9.3. H, Hgb
4.1.9.3.1. hemoglobin
4.1.9.4. HA, H/A
4.1.9.4.1. headache
4.1.9.5. HCVD
4.1.9.5.1. hypertensive cardiovascular disease
4.1.9.6. HEENT
4.1.9.6.1. head, ear, eyes, nose, throat
4.1.9.7. HEP
4.1.9.7.1. home exercise program
4.1.9.8. HIV
4.1.9.8.1. human immunodeficiency virus
4.1.9.9. HNP
4.1.9.9.1. herniated nucleus pulposus
4.1.9.10. h/o
4.1.9.10.1. history of
4.1.9.11. HOB
4.1.9.11.1. head of bed
4.1.9.12. h, hr.
4.1.9.12.1. hour
4.1.9.13. HR
4.1.9.13.1. heart rate
4.1.9.14. Hct
4.1.9.14.1. hematocrit
4.1.9.15. hs
4.1.9.15.1. at bedtime
4.1.9.16. ht.
4.1.9.16.1. height
4.1.9.17. Ht
4.1.9.17.1. hematocrit
4.1.9.18. Htn or HTN
4.1.9.18.1. hypertension
4.1.9.19. Hx
4.1.9.19.1. history
4.1.10. I-K
4.1.10.1. KUB
4.1.10.1.1. kidney, ureter, bladder
4.1.10.2. KJ
4.1.10.2.1. knee jerk
4.1.10.3. kg
4.1.10.3.1. kilogram
4.1.10.4. kcal
4.1.10.4.1. kilocalories
4.1.10.5. KAFO
4.1.10.5.1. knee-ankle-foot orthosis
4.1.10.6. IV
4.1.10.6.1. intravenous
4.1.10.7. IS
4.1.10.7.1. incentive spirometry
4.1.10.8. IRDS
4.1.10.8.1. infant respiraotry distress syndrome
4.1.10.9. inf
4.1.10.9.1. inferior
4.1.10.10. indep
4.1.10.10.1. independent
4.1.10.11. in.
4.1.10.11.1. inches
4.1.10.12. IMV
4.1.10.12.1. intermittent madatory ventilation
4.1.10.13. imp.
4.1.10.13.1. impression
4.1.10.14. IM
4.1.10.14.1. intramuscular
4.1.10.15. IDDM
4.1.10.15.1. insulin-dependent diabetes mellitus
4.1.10.16. ICU
4.1.10.16.1. intensive care unit
4.1.10.17. IADL
4.1.10.17.1. instrumental activities of daily living
4.1.10.18. I&O
4.1.10.18.1. intake and output
4.1.11. L
4.1.11.1. LP
4.1.11.1.1. lumbar puncture
4.1.11.2. LOS
4.1.11.2.1. length of stay
4.1.11.3. LOC
4.1.11.3.1. lossof consciousness, level of consciousness
4.1.11.4. LMN
4.1.11.4.1. lower motor neuron
4.1.11.5. LE
4.1.11.5.1. lower extremity
4.1.11.6. LBP
4.1.11.6.1. low back pain
4.1.11.7. LBBB
4.1.11.7.1. left bundle branch block
4.1.11.8. lb.
4.1.11.8.1. pound
4.1.11.9. lat
4.1.11.9.1. lateral
4.1.11.10. L or l.
4.1.11.10.1. liter
4.1.11.11. L
4.1.11.11.1. left
4.1.12. M
4.1.12.1. m
4.1.12.1.1. meter
4.1.12.2. MAP
4.1.12.2.1. mean arterial pressure
4.1.12.3. max
4.1.12.3.1. maximal
4.1.12.4. MD
4.1.12.4.1. medical doctor
4.1.12.5. MED
4.1.12.5.1. minimal erythemal dose
4.1.12.6. Meds.
4.1.12.6.1. medications
4.1.12.7. mg
4.1.12.7.1. milligram
4.1.12.8. MI
4.1.12.8.1. myocardial infarction
4.1.12.9. min
4.1.12.9.1. minimal
4.1.12.10. min.
4.1.12.10.1. minute
4.1.12.11. ml
4.1.12.11.1. milliliter
4.1.12.12. mm
4.1.12.12.1. millimeter
4.1.12.13. MMT
4.1.12.13.1. manual muscle test
4.1.12.14. mod
4.1.12.14.1. moderate
4.1.12.15. mo.
4.1.12.15.1. month
4.1.12.16. MP, MEP
4.1.12.16.1. metacarpophalangeal
4.1.12.17. MRSA
4.1.12.17.1. methicillin-resistant Staphylococcus aureus
4.1.13. N
4.1.13.1. NWB
4.1.13.1.1. non-weight bearin
4.1.13.2. NSR
4.1.13.2.1. normal sinus rhythm
4.1.13.3. NPO or npo
4.1.13.3.1. nothing by mouth
4.1.13.4. noc
4.1.13.4.1. night, at night
4.1.13.5. nn
4.1.13.5.1. nerve
4.1.13.6. NIDDM
4.1.13.6.1. non-insulin-dependent-diabetes mellitus
4.1.13.7. N.H.
4.1.13.7.1. nursing home
4.1.13.8. nasogastric
4.1.13.8.1. NG or ng
4.1.13.9. neg.
4.1.13.9.1. negative
4.1.13.10. NDT
4.1.13.10.1. neurodevelopmental treatment
4.1.14. O
4.1.14.1. oz.
4.1.14.1.1. ounce
4.1.14.2. OTR
4.1.14.2.1. occupational therapist (used to follow official signature of the occupational therapist
4.1.14.3. OT
4.1.14.3.1. occupational therapy, occupational therapist
4.1.14.4. ORIF
4.1.14.4.1. open reduction, internal fixation
4.1.14.5. O.R.
4.1.14.5.1. operating room
4.1.14.6. O.P.
4.1.14.6.1. outpatient
4.1.14.7. OOB
4.1.14.7.1. out of bed
4.1.14.8. od
4.1.14.8.1. once daily
4.1.14.9. OBS
4.1.14.9.1. organic brain syndrome
4.1.14.10. OB
4.1.14.10.1. obstetrics
4.1.14.11. OA
4.1.14.11.1. osteoarthritis
4.1.14.12. O:
4.1.14.12.1. objective
4.1.15. P-Pn
4.1.15.1. PNI
4.1.15.1.1. peripheralnerve injury
4.1.15.2. PNF
4.1.15.2.1. proprioceptive neuromuscular facilitation
4.1.15.3. PMH
4.1.15.3.1. past medical history
4.1.15.4. p.m.
4.1.15.4.1. afternoon
4.1.15.5. P.H.
4.1.15.5.1. past history
4.1.15.6. PERRLA
4.1.15.6.1. pupils equal, round, reactive to light, and accommodation
4.1.15.7. p.o
4.1.15.7.1. by mouth
4.1.15.8. per
4.1.15.8.1. by/through
4.1.15.9. PEEP
4.1.15.9.1. positive end expiratory pressure
4.1.15.10. PE
4.1.15.10.1. pulmonary embolus
4.1.15.11. PCL
4.1.15.11.1. posterior cruciate ligament
4.1.15.12. pc
4.1.15.12.1. after meals
4.1.15.13. para
4.1.15.13.1. paraplegia
4.1.15.14. PA
4.1.15.14.1. posterior/anterior
4.1.15.15. P.A.
4.1.15.15.1. physician's assistant
4.1.15.16. P:
4.1.15.16.1. plan, intervention plan, plan of care
4.1.15.17. P
4.1.15.17.1. poor
4.1.16. Po-Pz
4.1.16.1. POMR
4.1.16.1.1. problem-oriented medical record
4.1.16.2. pos.
4.1.16.2.1. positive
4.1.16.3. poss
4.1.16.3.1. possible
4.1.16.4. post
4.1.16.4.1. posterior
4.1.16.5. post-op
4.1.16.5.1. after surgery
4.1.16.6. PRE
4.1.16.6.1. progressive-resistive exercise
4.1.16.7. pre-op
4.1.16.7.1. before surgery
4.1.16.8. prn
4.1.16.8.1. whenever necessary, as often as necessary
4.1.16.9. PROM
4.1.16.9.1. passive range of motion
4.1.16.10. PSIS
4.1.16.10.1. posterior-superior iliac spine
4.1.16.11. PT
4.1.16.11.1. physical therapy, physical therapist
4.1.16.12. PT/PTT
4.1.16.12.1. prothrombin time/partial thromboplasitn time
4.1.16.13. Pt., pt.
4.1.16.13.1. patient
4.1.16.14. PTA
4.1.16.14.1. physical therapist assistant
4.1.16.15. PTA
4.1.16.15.1. prior to admission
4.1.16.16. PTB
4.1.16.16.1. patellar tendon bearing
4.1.16.17. PVD
4.1.16.17.1. peripheral vascular disease
4.1.16.18. PWb
4.1.16.18.1. partial weight bearing
4.1.17. Q-R
4.1.17.1. Rx
4.1.17.1.1. intervention plan, prescription, therapy
4.1.17.2. RT
4.1.17.2.1. respiratory therapist, respiratory therapy
4.1.17.3. RROM
4.1.17.3.1. resistive range of motion
4.1.17.4. RR
4.1.17.4.1. respiratory rate
4.1.17.5. ROS
4.1.17.5.1. review of systems
4.1.17.6. ROM
4.1.17.6.1. range of motion
4.1.17.7. R/O or r/o
4.1.17.7.1. rule out
4.1.17.8. RN
4.1.17.8.1. registered nurse
4.1.17.9. resp
4.1.17.9.1. respiratory, respiration
4.1.17.10. reps
4.1.17.10.1. repetitions
4.1.17.11. rehab
4.1.17.11.1. rehabilitation
4.1.17.12. re:
4.1.17.12.1. regarding
4.1.17.13. R.D.
4.1.17.13.1. refistered dietician
4.1.17.14. RBC
4.1.17.14.1. red blood cell count
4.1.17.15. RBBB
4.1.17.15.1. right bundle branch block
4.1.17.16. RA
4.1.17.16.1. rheumatoid arthritis
4.1.17.17. R
4.1.17.17.1. right
4.1.17.18. qt.
4.1.17.18.1. quart
4.1.17.19. qn
4.1.17.19.1. every night
4.1.17.20. qh
4.1.17.20.1. every hour
4.1.17.21. qid
4.1.17.21.1. four times a day
4.1.17.22. q
4.1.17.22.1. every
4.1.18. S
4.1.18.1. Sx
4.1.18.1.1. symptoms
4.1.18.2. sup
4.1.18.2.1. superior
4.1.18.3. stat.
4.1.18.3.1. immediately, at once
4.1.18.4. spec
4.1.18.4.1. specimen
4.1.18.5. S/P
4.1.18.5.1. status post (e.g., "S/P hip fx" means "Pt. fx her hip in the recent past."
4.1.18.6. SOB
4.1.18.6.1. shortness of breath
4.1.18.7. SOAP
4.1.18.7.1. subjective, objective, assessment, plan
4.1.18.8. SNF
4.1.18.8.1. skilled nursing facility
4.1.18.9. SLR
4.1.18.9.1. straight leg raise
4.1.18.10. SLP
4.1.18.10.1. speech-language therapist
4.1.18.11. SLE
4.1.18.11.1. systemic lupus erythematosus
4.1.18.12. SI(J)
4.1.18.12.1. sacroiliac (joint)
4.1.18.13. sig
4.1.18.13.1. directions for use, give as follows, let it be labeled
4.1.18.14. SED
4.1.18.14.1. suberythemal dose
4.1.18.15. sec.
4.1.18.15.1. seconds
4.1.18.16. SC joint
4.1.18.16.1. sternoclavicular joint
4.1.18.17. SCI
4.1.18.17.1. spinal cord injury
4.1.18.18. SACH
4.1.18.18.1. solid ankle cushion heel
4.1.19. T
4.1.19.1. TV
4.1.19.1.1. tidal volume
4.1.19.2. Tx
4.1.19.2.1. traction
4.1.19.3. TUR/TURP
4.1.19.3.1. transurethral resection
4.1.19.4. tsp.
4.1.19.4.1. teaspoon
4.1.19.5. TPR
4.1.19.5.1. temperature, pulse, and respiration
4.1.19.6. t.o
4.1.19.6.1. telephone order
4.1.19.7. TN
4.1.19.7.1. tonic neck reflex
4.1.19.8. TM(J)
4.1.19.8.1. temporomandibular (joint)
4.1.19.9. TKA
4.1.19.9.1. total knee arthroplasty
4.1.19.10. tid
4.1.19.10.1. three times daily
4.1.19.11. TIA
4.1.19.11.1. transient ischemic attack
4.1.19.12. ther ex
4.1.19.12.1. therapeutic exercise
4.1.19.13. THA
4.1.19.13.1. total hip arthroplasty
4.1.19.14. TENS, TNS
4.1.19.14.1. transcutaneous electrical nerve stimulator/stimulation
4.1.19.15. tbsp.
4.1.19.15.1. tablespoon
4.1.19.16. TBI
4.1.19.16.1. traumatic brain injury
4.1.19.17. TB
4.1.19.17.1. tuberculosis
4.1.19.18. tab
4.1.19.18.1. tablet
4.1.20. U-Z
4.1.20.1. UA
4.1.20.1.1. urine analysis
4.1.20.2. UE
4.1.20.2.1. upper extremity
4.1.20.3. UMN
4.1.20.3.1. upper motor neuron
4.1.20.4. URI
4.1.20.4.1. upper respiratory infection
4.1.20.5. US
4.1.20.5.1. ultrasound
4.1.20.6. UTI
4.1.20.6.1. urinary tract infection
4.1.20.7. UV
4.1.20.7.1. ultraviolet
4.1.20.8. VC
4.1.20.8.1. vital capacity
4.1.20.9. VD
4.1.20.9.1. venereal disease
4.1.20.10. v.o. or VO
4.1.20.10.1. verbal orders
4.1.20.11. vol.
4.1.20.11.1. volume
4.1.20.12. v.s.
4.1.20.12.1. vital signs
4.1.20.13. w/c
4.1.20.13.1. wheelchair
4.1.20.14. W/cm^2
4.1.20.14.1. watts per square centimeter
4.1.20.15. WBD
4.1.20.15.1. white blood cell count
4.1.20.16. wk.
4.1.20.16.1. week
4.1.20.17. WNL
4.1.20.17.1. within normal limits
4.1.20.18. wt.
4.1.20.18.1. weight
4.1.20.19. X
4.1.20.19.1. number of times performed
4.1.20.20. y/o or y.o.
4.1.20.20.1. years old
4.1.20.21. yd.
4.1.20.21.1. yard
4.1.20.22. yr.
4.1.20.22.1. year