1
Q
Content of problem-oriented medical record. (POMR)
A
List of patient problems Database Series of status (progress notes) written in SOAP note format. Initial Interim Discharge
2
Q
a or ~a
A
Before, ante
3
Q
AAROM
A
Active assist range of motion
4
Q
Abduct or Abd
A
Abduction
5
Q
ACL
A
Anterior cruciate ligament
6
Q
AROM/A-ROM
A
Active range of motion
7
Q
Add
A
Adduction
8
Q
ADL
A
Activity of daily living
9
Q
AFO
A
Ankle foot orthosis
10
Q
AK
A
Above the knee
11
Q
AKA
A
Above knee amputation
12
Q
Amb
A
Ambulate
13
Q
ASHD
A
Arteriosclerotic heart disease
14
Q
ASIS
A
Anterior Superior Iliac Spine
15
Q
(B), bilat or bil
A
Bilateral
16
Q
BID
A
Twice daily
17
Q
BIW
A
Twice weekly
18
Q
BK
A
Below knee
19
Q
BKA
A
Below knee amputation
20
Q
BLE, BUE
A
Bilateral lower extremities, bilateral upper extremities
21
Q
BP
A
Blood pressure
22
Q
BPM
A
Beats per min
23
Q
B/S
A
Bedside
24
Q
CA
A
Cancer
25
CABG
Coronary artery bypass graft
26
CAD
Coronary artery disease
27
Card rehab
Cardiac rehabilitation
28
Cardio
Cardiology
29
CHF
Congestive heart failure
30
Contra
Against
31
CPM
Continuous passive motion
32
CVD
Cardiovascular disease
33
CXR
Chest X-ray
34
DC, dc, d'cont
Discontinue
35
D/c
Discharge
36
D&V
Diarrhea and vomiting
37
Dec, decr, or |
Decreased
38
Dep
Dependent
39
DF
Dorsiflexion
40
dx
Diagnosis
41
DM
Diabetes mellitus
42
DME
Durable medical equipment
43
Doc/docu
Document
44
DP
Dorsalis pedis
45
DRG
Diagnosis related group
46
D/T, d/t
Due to
47
DTR
Deep tendon reflex
48
DVT
Deep venous thrombus
49
Ea
Each
50
ELOS
Estimated length of stay
51
Ext
Extension
52
ER and IR
External rotation, internal rotation
53
FWB
Full weight bearing
54
Flx
Flexion
55
Fx or fx
Fracture
56
GSW
Gun shot wound
57
GT
Gait training
58
HA
Headache
59
HS
Hamstring
60
Hb
Hemoglobin
61
HBP
High blood pressure
62
HcL
Hydrochloric acid
63
HD
Heart disease
64
Hemi
Hemiplegia
65
HEP
Home exercise program
66
HgB
Hemoglobin
67
HKO
Hip-knee orthosis (splint)
68
HNP
Herniated nucleus pulposus
69
H/O
History of
70
HOB
Head of bed
71
Hosp
Hospital
72
HP
Hot packs
73
HR
Heart rate
74
Hr/hrs/hr/h
Hours
75
Ht/ht
Height
76
HTN
Hypertension
77
Hx
History
78
IDDM
Insulin dependent diabetes mellitus
79
JCHAO
Joint commission on accreditation of healthcare organization
80
KAFO
Knee ankle foot orthosis
81
LAQ
Long arc quad
82
LB
Low back
83
LBKA
Left below the knee amputations
84
LBP
Low back pain
85
LBQC
Large based quad cane
86
LE
Lower extremity
87
LLE
Left lower extremity
88
LOS
Length of stay
89
Lt, (L), L
Left
90
LTC
Long term care
91
LTG
Long term goal
92
LUE
Left upper extremity
93
LUL
Left upper lobe
94
LUQ
Left upper quadrant
95
LVN
Licensed vocational nurse
96
MI
Myocardial infarction
97
Min
Minute
98
Min A
Minimal assistance
99
Mod
Moderate
100
MVA
Motor vehicle accident
101
Na
Sodium
102
N/A
Not applicable
103
NaCl
Sodium chloride
104
NSAIDS
Non-steroidal anti-inflammatory drug
105
NWB
Non weight bearing
106
OA
Osteoarthritis
107
OOB
Out of bed
108
OP
Out patient
109
ORIF
Open reduction and internal fixation
110
O2
Oxygen
111
O2Sat
Oxygen saturation
112
OT
Occupational therapy
113
p--
Following
114
PMH
Past medical history
115
po
By mouth
116
PRE
Progressive resistive exercise
117
PRN/prn
As needed
118
Prog
Prognosis
119
PROM/P-ROM
Passive range of motion
120
Pulse ox
Pulse oximeter
121
PVD
Peripheral vascular disease
122
PWB
Partial weight bearing
123
q
Every
124
QC 4-cane
Quad cane
125
Quad
Quadriplegic
126
Quads
Quadriceps
127
(R), Rt.
Right
128
RA
Rheumatoid arthritis
129
RE
Right extremity
130
R-Hemi
Right sided Hemiplegia
131
RLE
Right lower extremity
132
R/o
Rule out
133
ROM
Range of motion
134
RR
Respiratory rate
135
RUE
Right upper extremity
136
RW
Rolling walker
137
Rx
Prescription
138
SBQC
Short based quad cane
139
SCI
Spinal cord injury
140
SI joint or SIJ
Sacroiliac joint
141
SLP
Speech language pathology
142
2 degree
Secondary or due to
143
SNF
Skilled nursing facility
144
SOAP
Subjective, objective assessment plan
145
S/P
Status post
146
STG
Short term goal
147
STM
Short term memory or soft tissue massage
148
SW
Standard walker
149
Tachy
Tachycardia
150
TB
Tuberculosis
151
TBand
Theraband
152
TBI
Traumatic brain injury
153
TDWD
Touch down weight bearing
154
TED
Anti embolism stockings
155
THA
Total hip arthroplasty
156
TKA
Total knee argtroplasty
157
Ther.Ex.
Therapeutic exercise
158
TIA
Transient Ischemic attack
159
TID
3x a day
160
TIW
3x weekly
161
Tib-fib/tib/fib
Tibia and fibula
162
TTWB
Toe touch weight bearing
163
Tx
Treatment
164
UE
Upper extremity
165
Unilat
Unilateral
166
US
Ultrasound
167
V.O.
Verbal order
168
VS
Vital signs
169
WB
Weight bearing
170
WBAT
Weight bearing as tolerated
171
WBC
White blood count
172
W/C
Wheelchair
173
C-, w, or w/
With; from Latin word contigo
174
S- or w/o
Without; from Latin word sine
175
WNL
Within normal limits
176
X-rays
Roentgens Rays
177
Yr
Year
178
YO
Year old
179
YTD
Year to date
PTA
flashcards
Decks in class (7)
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