Download Acronyms - Medical Record Terminology

Commonly Used Medical Acronyms and Terminology
0/5
1/5
2/5
3/5
4/5
5/5
A
A+Ox3
ABDuction
Absent Strength
A.D.
ADDuction
ADL
AEA
AFO
AKA
ALS
Amb
Anterior
AROM
ASIA
ASIS
B
BEA
BID
BKA
BLE
BOS
BP
BS
BUE
c
c/o
CAD
CGA
CHF
COG
COPD
CP
CTA
CVA
D
d/c
Dependent Balance
Distal
DM
Dorsiflexion
Dx
Dyspnea
ELR
EtOH
Extension
Fair Balance
Fair Strength
FIM score of 0
FIM score of 1
1
Absent Strength- no observable movement
Trace Strength- able to activate the muscle group, movement may or may not occur
Poor Strength- able to move with gravity eliminated or some movement against gravity
Fair Strength- able to move against gravity but cannot accept resistance to movement
Good Strength- able to move against gravity and accept some resistance
Normal Strength- able to move against gravity and accept full resistance
increased
decreased
Assist
Alert and Oriented to person, place and time
Movement AWAY from the middle
0/5- no observable movement
Assistive device
Movement TOWARD the middle
Activities of daily living
Above Elbow Amputee
Ankle-Foot-Orthosis (brace)
Above Knee Amputee
Amyotrophic Lateral Sclerosis
Ambulation
Front of the body
Active range of motion
American Spinal Cord Association
Anterior Superior Iliac Spine- a bony landmark on the pelvis
Bilateral or Both
Below Elbow Amputee
twice a day
Below Knee Amputee
Bilateral (or Both) Lower Extremities
Base of Support
Blood Pressure
Bowel Sounds or Breath Sounds
Bilateral (or Both) Upper Extremities
with
complains of
Coronary Artery Disease
Contact Guard Assistance (touching)
Congestive Heart Failure
Center of gravity
Chronic Obstructive Pulmonary Disease
Cerebral Palsy
Clear to Auscultation (lungs)
Cerbral Vascular Accident (stroke)
Dependent
discharge
Unable to move within the base of support, full external support required
Away from the trunk (ie; hands and feet)
Diabetes Mellitus
Flexion of the ankle
Diagnosis
Shortness of breath
Elevating leg rest
Alcohol
Straightening of a limb
Able to move within the base of support and accept minimal to no balance challenges
3/5- able to move against gravity but cannot accept resistance to movement
The activity does not occur
Total Assistance-The patient expends less than 25% of the effort
Commonly Used Medical Acronyms and Terminology
FIM score of 2
FIM score of 3
FIM score of 4
FIM score of 5
FIM score of 6
FIM score of 7
Flexion
FWW
Good Balance
Good Strength
h/o
HTN
Hx
I
IADL
Inferior
KAFO
L
Lateral
LE
LLE
LOB
LUE
MAX
Maximal Assistance
MD
Medial
MI
MIN
Minimal Assistance
MMT
MOD
Moderate Assistance
MOD I
MS
MRADL
MVA
MWC
NIIDM
NKA
Normal Balance
Normal Strength
OA
OI
PAD
PCA
Plantarflexion
PMD
Poor Balance
Poor Strength
Posterior
POV
ppt
PRN
PROM
Proximal
pt.
PVD
2
Maximal Assistance- The patient expends 25% - 49% of the effort
Moderate Assistance- The patient expends 50% - 75% of the effort
4- The patient expends more than 75% of the effort
Supervision- Standby, cueing or coaxing, without physical contact
Modified Independence- The patient uses an adaptive or assistive device
Complete Independence
Bending of a limb
Front wheeled walker or Four wheeled walker
Able to move outside the base of support and accept mild balance challenges
4/5- able to move against gravity and accept some resistance
history of
Hypertension (high blood pressure)
History
Independent
Instrumental avtivities of daily living
Toward the foot
Knee-Ankle-Foot Orthosis (brace)
Left
Further from the midline of the body
Lower Extremity
Left Lower Extremity
Loss of balance
Left Upper Extremity
Maximal assistance
2- The patient expends 25% - 49% of the effort
Muscular Dystrophy
Nearer to the midline of the body
Myocardial Infarction (heart attack)
Minimal assistance
4- The patient expends more than 75% of the effort
Manual muscle (strength) test
Moderate assistance
3- The patient expends 50% - 75% of the effort
Modified independent
Multiple Sclerosis
Mobility related activities of daily living
Motor vehicle accident
Manual wheelchair
Non-Insulin Dependent Diabetes Mellitus
No known allergies
Able to move outside the base of support and accept full balance challenges
5/5- able to move against gravity and accept full resistance
Osteoarthritis
Osteogenesis Imperfecta
Peripheral Artery Disease (same as PVD)
Personal Care Assistant
Extension of the ankle (pointing the toe)
Power mobility device
Able to move within the base of support with the assistance of external support (holding on)
2/5- able to move with gravity eliminated or some movement against gravity
Rear of the body
Power operated vehicle (scooter)
Posterior Pelvic Tilt (slouched sitting posture)
As needed
Passive range of motion
Near the trunk (upper arm, thigh)
patient
Peripheral Vascular Disease (same as PAD)
Commonly Used Medical Acronyms and Terminology
PWC
QID
R
r/o
RA
RLE
ROM
RUE
s
s/p
s/t
Sx
SBA
SCI
SMA
SOB
Superior
Supervision
TBI
TID
Total Assistance
Trace Strength
UE
WC
WFL
WNL
3
Power wheelchair
Four times a day
Right
rule out
Rheumatoid Arthritis
Right Lower Extremity
Range of Motion
Rght Upper Extremity
without
status post
stated that
Symptoms
Stand By Assistance (near but not touching)
Spinal Cord Injury
Spinal Muscular Atrophy
Shortness of Breath
Toward the head
5- Standby, cueing or coaxing, without physical contact
Traumatic Brain Injury
Three times a day
1- The patient expends less than 25% of the effort
1/5- able to activate the muscle group, movement may or may not occur
Upper Extremity
Wheelchair
Within Functional Limits
Within Normal Limits