APPROVED

ABBREVIATIONS Clinical
Documentation
BOS base of support
30SCST 30 second chair stand test 2MST BP blood pressure
2 minute step test BPH benign prostatic hypertrophy BR
2MWT 2 minute walk test bathroom
6MWT 6 minute walk test BRP bathroom privileges
5TSST 5 times sit to stand test B/S bowel sounds
A active BS blood sugar
AAA abdominal aortic aneurysm AAROM BSC bedside commode
active assisted range of motion Abd abduction BUE bilateral upper extremities BUN
ABD abdomen blood urea nitrogen
ABG arterial blood gases (C) changed
ABX antibiotic C Centigrade
ac before Ca++ Calcium
ACH acute care hospitalization ACL Anterior CA Cancer
Cruciate Ligament ACLS Advanced Cardiac CABG coronary artery bypass graft CAD
Life Support A/D assistive device coronary artery disease
ADD adduction CAP capsule
ADA American Disability Act / American CAT/CT computerized axial tomography
Diabetic Association CATH/CATH catheter, catheterization
ADL activities of daily living CBA community based alternative program CBC
AD LIB as desired complete blood count
AEA above elbow amputation cc cubic centimeter
AEB as evidenced by CCC certificate of clinical compliance CERT
AFO ankle foot orthotic/orthosis Aide certification
Home Health CEU continuing education unit CFSS Clinical
AIDS acquired immune deficiency syndrome AKA Field Staff Supervisor CG caregiver / contact
above the knee amputation ALF Assisted living facility guard (PT) CGA contact guard assist
ALS amyotrophic lateral sclerosis AMB CHF congestive heart failure
ambulatory CHB complete heart block
AM morning △ change
AMT amount CHOL cholesterol
ANT anterior CIHD chronic ischemic heart disease CK
AP apical pulse check
APPROX approximate CLASS community living assistive &
APPT appointment supportive services
APS Adult Protective Services AROM CM case manager
active range of motion CMS Center for Medicare and Medicaid Services
ARROM active resisted range of motion ASA (formerly HCFA)
acetylsalicylic acid (aspirin) ASAP as soon as CNA certified nurse aide
possible CNS central nervous system
ASCVD arteriosclerotic cardiovascular disease ASHD COG center of gravity
arteriosclerotic heart disease ASST assistant CONT continue
AUSC ausculation COPD chronic obstructive pulmonary disease C/O
AX axillary complains of
BBB bundle branch block CPAP continuous positive airway pressure CPK
BD Branch Director creatinine phosphokinase CPM continuous passive
BE barium enema motion (for total joints)
BEA below the elbow amputation BID twice CPR cardiopulmonary resuscitation CPS child
a day protective services
BIL/BILAT bilateral C&S culture and sensitivity
BKA below the knee amputation BLE CRF chronic renal failure
bilateral lower extremities BUL bilateral CSF cerebrospinal fluid
upper lobes CSR Cheyne-Stokes Respiration CTA clear
BLL bilateral lower lobes to auscultation
BLS basic life support CV cardiovascular
BM bowel movement CVA cerebro vascular accident CVC
 central venous catheter GS gluteal sets
CXR chest x-ray GSW gun shot wound
C-# cervical vertebra & number DC G/T gait training
discharged GT/G-tube gastric tube
DEPT department GTT glucose tolerance test
DHS Department of Human Services DIFF GU genitourinary
differential HA, H/A headache
DJD degenerative joint disease DKA HAZ hazard / hazardous
diabetic ketoacidosis HCT hematocrit
DM diabetes mellitus HCVD hypersensitive cardiovascular HDL
DME durable medical equipment DNR do high density lipoprotein
not resuscitate HEENT head, eyes, ears, nose, throat HEMI
DOB date of birth hemiplegia, or partial
DOE dyspnea on exertion HEMO pertaining to blood
DON Director of Nurses HEP home exercise program
DOT Director of Therapy Services HF heart failure
DSG/DRSG dressing H&H hemoglobin & hematocrit HHA
D/T due to home health agency /aide HCA home
DVT deep vein thrombosis care aide
DX diagnosis HHC home health care
EC emergent care HIC# health insurance claim
ECF extended care facility HIPAA Health Insurance Portability and
EEG electroencephalogram Accountability Act
EENT eye, ear, nose and throat HIV human immunodeficiency virus HMO
EKG/ECG electrocardiogram health maintenance organization HOB head of
EMS emergency medical system ER bed
Emergency Room HOH hard of hearing
ESC encourage self care H&P History & Physical
ESNV extra skilled nurse visit H/P hemiparesis
ESV extra skilled visit HR hour
ESRD end stage renal disease hs hour of sleep
ET enterostomal HT height
ETC. and so on HTN hypertension
EX exercise H20 water
EXAC exacerbation H202 hydrogen peroxide
Exam examination HYPER increased
EXT external/extension HYPO decreased
F fahrenheit HX history
FAB femoral artery bypass I independent
FBS fasting blood sugar IADL instrumental activities of daily living ICD
FCM Functional Communication Measures Fe+ iron international classification of diseases codes
FIB fibrillation INCONT incontinent
FL flexion/fluid IDDM insulin dependent diabetes mellitus IM
FR french intramuscular
FREQ frequency/ frequent INDEP independent
FSBS finger stick blood sugar INFO information
FT feet/foot INJ injection
FUO fever of unknown origin FWB full INR internal reference
weight bearing INS insurance
FX fracture INTRA within
F/U follow-up IPPB intermittent positive pressure breathing I&O
G good (muscle grade) intake and output
GB gallbladder IRREG irregular
GERD gasto-esophageal reflux disease GG IRRIG irrigation
gamma globulin IRF Inpatient Rehab Facility
GGT gamma-glutamul transferase GI IV intravenous
gastrointestinal IVPB IV piggy back
GLF ground level fall I&D incision and drainage
GM/Gm gram JVD jugular vein distension
GR grain J-TUBE jejunostomy tube
KAFO knee, ankle, foot arthrosis/orthotic K+
 potassium mitral regurge
KCL potassium chloride MRI magnetic resonance imaging MSS
KG kilogram medical social services
KUB kidney/ureter/bladder MSW medical social worker
L left MVA motor vehicle accident
L1 left hand, fourth finger, medial site L2 left hand, MVI multiple vitamin
fourth finger, lateral site L3 left hand, third finger, MAX maximal assistance
medial site L4 left hand, third finger, lateral site L5 N normal (muscle grade)
left hand, second finger, medial site L6 left hand, N/A not applicable
second finger, lateral site L7 left hand, first finger, NEG / σ negative
medial site L8 left hand, first finger, lateral site L9 NEURO neurological
left hand, thumb, medial site L10 left hand, thumb, NG nasogastric
lateral site L# lumbar vertebrae & number LAQ NH nursing home
long arc quad NKA no known allergies
LAX laxative NKDA no known drug allergies
LB low back NMT neuro muscular therapy
LBFE left back flexion exercise LBM last NOCT nocturnal/night
bowel movement NOMS national outcomes measurement sys. NOS
LBP lower back pain not otherwise specified
LC licensed clinician NPO nothing by mouth
LDL low density lipoprotein NS normal saline
LE lower extremity NSR normal sinus rhythm
LG large NST nutrition screening tool
LLE left lower extremity NTG nitroglycerin
LLL left lower lobe NWB non-weight bearing
LLQ left lower quadrant N&V; N/V nausea and vomiting
LOB loss of balance OA osteoarthritis
LOC level of consciousness / level of care LOS O/A observation/assessment
length of stay O2 oxygen
LP Licensed Professional OBS organic brain syndrome
LPM liters per minute O&A observation and assessment ONC
LPTA licensed physical therapist assistant LS oncology
lumbar sacral OOB out of bed
LTAC long term acute care ORIF open reduction internal fixation ORTHO
LTG long term goals orthopedic
LUE left upper extremity OZ ounce
LUL left upper lobe OTC over the counter
LUQ left upper quadrant P/A/SE purpose, action, side effects PAC
LVAD left ventricular assist device LVN Professional Advisory Committee PALP palpable
Licensed Vocational Nurse LW living will PAT paroxysmal atrial tachycardia PCH
M or MO month (as in 1MO1 or 1m1) MAE personal care home
moves all extremities PCP primary care provider
MAP medication assistance program PDE pre-discharge evaluation PE
MAX/MAX maximum pulmonary embolism
MCA Medicare PEEP positive end-expiratory pressure PEG
MA moderate assistance percutaneous endoscopic gastrostomy PER by
MCG microgram PERI perineal
MED Medicaid PERRLA pupils equal, round reactive to light PHC
MEDS medications primary home care
M&E/MECP management and evaluation of care PHI Protected Health Information PICC Peripherally
plan Inserted Central Catheter PKU phenylketonuria
MGM milligram PLOF previous level of function PLT
MI myocardial infarction platelets
ML milliliter PM night/evening
MM millimeter PMH past medical history
MN midnight PND paroxysmal nocturnal dyspnea PNF
MIN minimal assistance proprioceptive neuromuscular facilitation
MMT manual muscle test PNS phrenic nerve stimulation POA
MOD I modified independent power of attorney
MOW Meals on Wheels POC plan of care
MPOA Medical Power of Attorney MR POS/+ positive
POST after R/T related to
POSTOP postoperative RT respiratory therapy
PO/P.O. by mouth RUE right upper extremity
POT plan of treatment RUL right upper lobe
PPB positive pressure breathing PPBS post RUQ right upper quadrant
prandial blood sugar PPD purified protein RW rolling walker
derivative (TB test) PPP palpable pedal pulses S# sacral spine & number
PR per rectum SaO2 oxygen saturation level
PRE progressive resistive exercises PRN as SAQ short arc quad
needed SBA stand by assistance
PROD productive SBS stand by supervision
PROG prognosis SCIC Significant Change in Condition SE or
PROM passive range of motion PT S/E side effects
patient SED RATE sedimentation rate
P.T. physical therapy SERO SANG serosangulous
PTT partial thromboplastin time PVD SGOT serum glutamic oxaloacetic SGPT
peripheral vascular disease PWB partial serum glutamic pyruvic test SL sublingual
weight bearing SLB short leg brace
Q every SLE systemic lupus erythematosus SLP speech
QA quality assurance language pathology/pathologist SLR straight leg raises
QC quad cane SLS single leg stance
QH every hour SM small
QHS every night/at bedtime SN skilled nursing
QI quality improvement SNF skilled nursing facility
QID 4 times a day SNS sterile normal saline
QS quad set (PT) SNV skilled nurse visit
QTA cotton tipped applicator QUAD SOB short of breath
quadrant/quadriplegic/quadriceps R SOC start of care / admission
right/respirations S/P status post
R1 right hand, fourth finger, medial site R2 right ST speech therapy
hand, fourth finger, lateral site R3 right hand, third STC straight tip cane
finger, medial site STG short term goals
R4 right hand, third finger, lateral site R5 right hand, SPEC specimen
second finger, medial site R6 right hand, second SR side rails
finger, lateral site R7 right hand, first finger, medial SRMC safety risk management committee SSE
site R8 right hand, first finger, lateral site R9 right soap suds enema
hand, thumb, medial site R10 right hand, thumb, STAPH staphylococcus
lateral site RA rheumatoid arthritis STAT immediately
RBB right bundle branch STREP streptococcus
RBBB right bundle branch block RBC STS sit to stand
red blood cells SUPP suppository
RBS random blood sugar SV supervisory visit
RDA recommended daily allowance RDS SVT supraventricular tachycardia S/P status
respiratory distress syndrome RECERT/RCT post
recertification SX; S/S signs and symptoms
REG regular S/W standard walker
REHAB rehabilitation SWA social work associate
REPS repetitions TB tuberculosis
RESP respirations / respiratory RLE T# thoracicspine & number
right lower extremity TTWB toe touch weight bearing
RLL right lower lobe TEMP temperature
RLQ right lower quadrant TAB tablet
RML right medial lobe TBSP tablespoon
RN Registered Nurse TECH technique
R/O rule out TENS transcutaneous electrical nerve
ROC Resumption of Care stimulation
ROM range of motion THA total hip arthroplasty
RPE rated perceived exertion
THER EX therapeutic exercise
THR total hip replacement
TIA transient ischemic attack TID 3
times a day
TIF Transfer to Inpatient Facility TKA total
knee arthroplasty
TKR total knee replacement
TMJ temporomandibular joint TOP
topical
TPN total parenteral nutrition TPR
temperature, pulse respirations TRACH
tracheostomy
TSH thyroid stimulation hormone TSP
teaspoon
TSA total shoulder arthroplasty TTWB toe
touch weight bearing TUR transurethral
resection
TURP transurethral resection of the prostate TX
treatment
U/A urinalysis
UE upper extremity
UGI upper gastrointestinal
UR utilization review
URI upper respiratory infection US
ultrasound
UTI urinary tract infection
UV ultraviolet
VAD vascular access device
VAS visual analog scale
VC verbal cues
VIT vitamin
V/O verbal order
V/P venipuncture
V/S vital signs
W or wk week (as in 1 wk 4
W/A walker
WBC white blood count
WBAT weight bearing as tolerated WFL
within functional limits
WK week (as in 3 wk 8)
WNL within normal limits
WT weight
W/C wheelchair
WD wound
W/I within
W/O week of
X times
YOA years of age
↑ increase
↓ decrease
♀ female
♂ male
= equal to