Occupational therapy (OT) involves numerous abbreviations essential for effective communication and documentation. This guide covers crucial abbreviations to enhance understanding and facilitate better patient care.
Key Occupational Therapy Abbreviations
ADL: Activities of Daily Living
- BADL: Basic Activities of Daily Living (e.g., grooming, bathing)
- IADL: Instrumental Activities of Daily Living (e.g., managing finances, driving)
Assistive Devices (AD)
- Tools that help compensate for impairments (e.g., walkers, canes)
- AT: Assistive Technology (e.g., software programs for disabilities)
Assist Levels
- I: Independent - Patient can perform activities without help.
- MOD I: Modified Independent - Patient uses an assistive device.
- SBA: Stand-by Assist - Therapist stands by for safety.
- CGA: Contact Guard Assist - Therapist provides occasional physical support.
- MIN A: Minimal Assist - Patient performs 75% or more of the activity.
- MOD A: Moderate Assist - Patient performs 50-74% of the activity.
- MAX A: Maximal Assist - Patient performs 25-49% of the activity.
- DEP: Dependent - Patient needs full assistance.
ROM: Range of Motion
- AROM: Active Range of Motion - Measures voluntary movement capabilities without assistance. Used in initial evaluations and progress assessments.
- AAROM: Active Assisted Range of Motion - Combines patient's active movement with assistance. Helps evaluate the need for support in motion.
- PROM: Passive Range of Motion - Assesses movement when the patient's muscles are relaxed. Important for determining joint flexibility.
Weightbearing Status
- NWB: Non-Weightbearing - No weight on the affected limb.
- TTWB: Toe-Touch Weightbearing - Only toes touch the ground for balance.
- PWB: Partial Weightbearing - Partial weight is allowed.
- WBAT: Weightbearing as Tolerated - Weight as pain allows.
- FWB: Full Weightbearing - Full weight on the limb is permitted.
Other Important Abbreviations
- BID: Twice a day - Common in medication schedules.
- BOS: Base of Support - Refers to the area beneath a person including points of contact.
- BPM: Beats Per Minute - Used in monitoring heart rate.
- C/O: Complains Of - Commonly used in patient reports.
- DME: Durable Medical Equipment - Includes items like wheelchairs.
- DOE: Dyspnea on Exertion - Shortness of breath during activity.
- ECTs: Energy Conservation Techniques - Strategies to reduce energy use.
- EtOH: Alcohol Use Disorder - Refers to alcohol consumption issues.
- FX: Fracture - Break in bone continuity.
- H/A: Headache - Common symptom noted in records.
- HH: Home Health - Services provided in the patient's home.
- HOB: Head of Bed - Positioning reference in care settings.
- EOB: Edge of Bed - Position for exercises or assessments.
- H&P: History and Physical - Comprehensive initial examination.
- Hx: History - Patient's medical history.
- IDDM: Insulin-Dependent Diabetes Mellitus - Type 1 diabetes.
- IRF/IRU/IRC/ARU: Inpatient Rehab Facilities/Units/Centers/Acute Rehab Units - Different rehab settings.
- LTC: Long Term Care - Extended care for chronic conditions.
- MMT: Manual Muscle Testing - Assesses muscle strength.
- ORIF: Open Reduction and Internal Fixation - Surgical fracture treatment.
- PMH: Past Medical History - Previous medical conditions.
- SNF/SAR: Skilled Nursing Facility/Subacute Rehab - Types of rehab facilities.
- S/P: Status Post - Condition following an event (e.g., surgery).
- SPT: Stand-Pivot Transfer - Technique for moving patients.
- STG/LTG: Short-term Goal/Long-term Goal - Planning patient progress.
- THR/THA: Total Hip Replacement/Arthroplasty - Hip joint surgery.
- TKR/TKA: Total Knee Replacement/Arthroplasty - Knee joint surgery.
- Tx: Treatment - General term for therapeutic interventions.
- WFL: Within Functional Limits - Functional abilities within normal range.
- WNL: Within Normal Limits - Normal range for tests or measures.
- UE: Upper Extremity (RUE: Right Upper Extremity, LUE: Left Upper Extremity) - Refers to arms and hands.