| Question | Answer |
| A: | Assessment;
denotes Assessment portion of a SOAP note |
| A or a | Assist
(type of assistance required; example: MinA or Min+A) |
| AAROM | Active Assisted Range of Motion
(Assisting a patient’s extremity through ROM) |
| Abn | Abnormal |
| ADLs | Activities of Daily Living |
| APTA | American Physical Therapy Association |
| AROM | Active Range of Motion;
Patient can independently move extremity through ROM |
| Assist | Assistance;
(also see A above) The amount of help a patient requires |
| B or (B) | Bilateral or both
(Bil. Also acceptable but not preferred) |
| Bid | Twice a day |
| biw | Twice a week |
| B/S or BS | Bedside |
| ͞c | With |
| CCU | Coronary (Cardiac) Care Unit |
| CG or CGA | Contact Guard
(having 1or 2 hands on patient but provide assistance as needed) |
| c/o | Complains of |
| D/C or d/c | Discharged or discontinued |
| DNR | Do not resuscitate |
| DOB | Date of birth |
| Dx | Diagnosis |
| EOB | Edge of the bed |
| Eval | Evaluation |
| Ex | Exercise
(commonly seen as TherEx=Therapeutic Exercise) |
| ext or / | Extension |
| flex or √ | Flexion |
| ft | Feet or foot (measure) |
| f/u | Follow up |
| fx | Fracture |
| gt | Gait |
| HEP | Home Exercise Program |
| HHA | Hand Held Assistance |
| Hx or hx | History |
| (I) | Independent or independently
{ ex: patient performs HEP (I) } |
| IP | Inpatient (or when referring to the hand it is the Interphalangeal joint, IP jt) |
| LTG | Long term goal |
| Max or max | Maximal or maximum
(ex- maxA+2: means maximum assist with 2 people) |
| Min or min | Minimal assistance;
requires patient to perform 75% and therapist 25% assistance |
| Mod or mod | Moderate, (ex: ModA =level of assistance 50% patient & 50% therapist assists) |
| MVA | Motor Vehicle Accident |
| neg or - | Negative
(Symbol more commonly used in therapy) |
| NPO | Nothing by mouth |
| NWB | Non weight bearing
(patient cannot bear weight on the specified extremity) |
| O: | Objective;
denotes objective portion of the SOAP note |
| O2 or O2 Sat | Oxygen; or Oxygen saturation level measured by pulse oxsymetry |
| OOB | Out of bed |
| OP | Out patient |
| ͞p | Following, after
{ rememeber p as in posterior } |
| ͞a | Before
{ remember a for anterior } |
| P: | Plan;
denotes plan portion of the SOAP note |
| PLOF | Prior level of function |
| PMH | Past medical history |
| POC | Plan of care |
| post op | After / following surgery |
| PRE | Progressive resistive exercises |
| PT | Physical therapist or therapy |
| Pt. or pt. | Patient |
| PTA | Physical Therapist assistant |
| ® | Right
{ left is the the same with L } |
| reps | Repetitions
(example: 3x10 means 3 sets 10 reps each) |
| ®LL; ® LE | Right lower lobe; right lower extremity |
| R/O | Rule out |
| ROM | Range of motion |
| Rx | Prescription
( can be medication or exercise prescription) |
| ͞s | without |
| S | Supervision |
| S: | Subjective,
(denotes the subjective portion of a SOAP note) |
| SNF | Skilled nursing facility |
| SOAP | Subjective, objective, assessment, plan- a form of documentation of treatment |
| SOB | shortness of breath |
| S/P or s/p | Status post;
(means following= usually used “following surgery”) |
| Stat. or stat. | Immediately or right away! |
| STG | Short term goal |
| Sx or sx | Symptoms |
| tid | Three times a day or 3x/day |
| tiw | Three times in week or 3x/wk |
| tol. | Tolerate or tolerated |
| tx | Treatment, can also mean traction
(example: mech tx- is mechanical traction) |
| UE, UEs | Upper extremity(ies) |
| VCs | Verbal cues;
means using words to instruct or correct patient (pt needs VCs 50% to..) |
| VO | Verbal order
(Dr's order) |
| W/C | wheelchair |
| X | Times
(example 3X10 means 3 sets of 10 reps) |
| ↑ ↨ | Increase(d) or up; up and down (example: pt able to go ↨ stairs) |
| ↓ | Decrease(d) or down |
| ↔ → | To and from, can also mean side to side. To (example: sit →stand means sit to stand) |
| ≠ | Not equal |
| ∆ | Change |
| 1° | Primary |
| 2° | Secondary or secondary to (example: Pt has ®LE pain 2° to DDD) |
| + | Positive or plus (example: +MRI for ACL tear) |
| - | Negative or minus (example: -MRI R/O ACL tear) |
| # | Number |
| ♂ | Male |
| ♀ | Female |
