Basic Abbreviations for Medical Records







A-D  E-H  I-L M-P  Q-T  U-Z

A-D
"A"

A.A                  Activity Assistant
AAROM                Active Assistant Range of Motion
A.C.                 Activities Coordinator
Act                  Activities
A.D.                 Activities Director
ad. lib.             As resident can tolerate
ADL                  Activities of daily living
AEB/aeb              As evidenced by
A.K.                 Above the knee
aka                  also known as
A.M.                 Morning
AMA                  Against Medical Advice
amb                  Ambulation
AROM                 Active Range of Motion


"B"

B&B                    bowel & bladder
bid                    twice per day
BK                     below the knee
BM                     bowel movement
BP                     blood pressure


"C"

CA                  cancer
CHF                 congestive heart failure
CPR                 Cardiopulmonary Resuscitation
c/o                 complains of
cog.                cognitive
cont'd              continued
COPD                Chronic Obstructive Pulmonary Disease
COTA                Certified Occupational Therapy Assistant
CTRS                Certified Theraputic Recreation Therapist
CVA                 Cardiovascular respiration
c(with a line over it)with


"D"

d                     day
d/c                   discontinue
DM                    Diabetes Mellitus
DOA                   Dead on Arrival
DON                   Director of Nursing
Dr.                   doctor
d/t                   due to
Dx.                   diagnosis
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E-H
"E"

ETOH               alcohol
"F"
F                    female
FH                   family history
Ft.                  feet
f/u                  follow up
F.W.B.               full weight bearing
Fx.                  fracture
"G"
G/C                gerichair
GI                 gastrointestional
gm                 gram
grp.               group
'H"
                   hour
hb                   hemoglobin
H&P                  history and physical
HBV                  Hepatitis B virus
HIV                  Human Immunodeficiency Virus
HOB                  head of bed
HOH                  hard of hearing
ht.                  height
HTN                  hypertension
Hx.                  history of
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I-L
"I"

IDT                Interdisciplinary Team
I&O                 input and output
i.e.               example, such as
imp                 impaired
indep.             independent
IV                 intravenous
"J"

"K"
"L"

L                    left
lab                  labratory
lb,#                 pound
LE                   lower extremity
lg.                  large
LOB                  loss of balance
LPN                  Licensed Practical Nurse
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M-P
"M"
 

MD                  medical doctor
MDS                 Minimal Data Set
mg                  milligram
M.S.                multiple Sclerosis
 


"N"

Na                    Sodium
neg.                  negative
N.H.                  nursing home
NKA                   no kown allergies
no.,#                 number
NPO                   nothing by mouth
nsg.                  nursing
NWB                   non weight bearing
"O"
OBRA                  Omnibus Budget Reconcilitation Act
OOB                   out of bed
OT                    Occupational Therapy
1:1                   One to Ones
O2                    Oxygen
OBS                   Organic Brain Syndrome
OOF                   Out of Facility
"P"
PM                    afternoon, evening
POC                   plan of care
prn                   as needed
part.                 participates
prog.                 program
PROM                  passive range of motion
PT                    physical therapy/physical therapist
PWB                   partial weight bearing
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Q-T
"Q"

                    every
qd                    every day
"R"
rt.                  right
r/t                  related to
RAP                  Resident Assessment Protocol
rehab                rehabilitation
res.                 resident
ROM                  range of  motion
RT                   Recreational Therapist/Recreation Therapy
RN                   Registerd Nurse
R.O.                 Reality Orientation
r/o                  rule out
Rx                   prescription
RD                   Registered Dietician


"S"

s(with a line over it)with
SBA                   stand by assist
sens. stim.           sensory stimulation
SNF                   skilled nursing facility
SOB                   short of breath
SP/ST                 Speech Pathologist/Therapist
S/P                  status post
SSC/SSD              Social Service Coordinator/Director
stat                 immediately
"T"
t.i.d                three times a day
TIA                   Transient ischemic attack
TTWB                  Toe Touch weight bearing
TV                    television
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U-Z
"U"

UE                  Upper extremities
U.R.                Utilization Review
URI                 Upper Respiratory Infection
UTI                 Urinary Tract infection
"V"
vol.                  volunteer
"W"
w/c                   wheelchair
wk                    week
WNL                   within normal limits
wt.                   weight
"X"
x                   times
"Y"
yr.                  year
"Z"

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