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Download Acronyms - Medical Record Terminology
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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
