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Introduction

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Abbreviations are used to save time and space while writing notes but they should be used sparingly. Extensive use of abbreviations is a major cause of confusion and poor communication in patient care. Using unclear abbreviations can threaten patient safety. For this reason The Joint Commission keeps a “Do Not Use” list of abbreviations.1 Using too many or incorrect abbreviations can also cause denial of payment if the reviewer at the reimbursement agency cannot understand what happened in physical or occupational therapy. A list of commonly used abbreviations should be attached to any documentation requested by third-party payors.

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To ensure that everyone involved in the patient's care can understand what others have written in the health record, most healthcare facilities have a list of approved abbreviations, and if they do, those are the only abbreviations that should be used in that particular facility.2 A committee at each facility approves this list. The list of acceptable abbreviations varies from one facility to the next and includes abbreviations used by many health professionals. This list should include the abbreviations used in physical and occupational therapy.

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The list of abbreviations that follows will be used as the approved list for all of the worksheets in this book. Any abbreviations not on this list are considered unacceptable to use in these worksheets. When on your clinical rotations and when you begin your career, remember to use the list of acceptable abbreviations for your clinical facility. During orientation to any clinical facility in which you practice, ask about the location of the approved abbreviations list and familiarize yourself with those abbreviations the facility uses frequently.

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Approved Abbreviations and Symbols for Healthcare Facility XYZ

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A:

indicating the beginning of the Assessment section of the SOAP note

AAROM

active-assistive range of motion

ABI

acquired brain injury

a-fib

atrial fibrillation

A-line

arterial line

AV

arteriovenous

AAA

abdominal aortic aneurysm

Abd or abd

abduction

ABG

arterial blood gases

ac

before meals

AC joint

acromioclavicular joint

ACL

anterior cruciate ligament

ACTH

adrenocorticotrophic hormone

Add or add

adduction

ADL

activities of daily living

ad lib

at discretion

adm

admission, admitted

AE

above elbow

AFO

ankle foot orthosis

AIDS

acquired immune deficiency syndrome

AIIS

anterior inferior iliac spine

AKA

above knee amputation

ALS

amyotrophic lateral sclerosis

a.m.

morning

AMA

against medical advice

amb

ambulation, ambulating, ambulated, ambulate, ambulates

ANS

autonomic nervous system

ant.

anterior

AP

anterior-posterior

ARDS

adult respiratory distress syndrome

ARF

acute renal failure

AROM

active range of motion

ASA

aspirin

ASAP or asap

as soon as possible

ASCVD

arteriosclerotic cardiovascular disease

ASHD

arteriosclerotic heart disease

ASIS

anterior superior iliac spine

assist.

assistance, assistive

AVM

arteriovenous malformation

BADL

basic activity of daily living

B/S

bedside

BBB

bundle branch block

BE

below elbow

BID or bid

twice a day

bilat. or Ⓑ

bilateral, bilaterally

BKA

below knee amputation

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