APPROVED ABBREVIATIONS

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