APPROVED ABBREVIATIONS POLICY

Policy:
Only abbreviations and symbols approved by Century Rehab will be used in the Medical Record.

Procedure:

A copy of the approved abbreviations and symbols are listed on the next page.

Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 1 of 6
company intranet website. Retention: 2 years
 APPROVED ABBREVIATIONS POLICY
AAA Abdominal Aortic Aneurysm bilat. or Bilateral
abd. Abduction BKA Below the knee amputation
abs. Absent BM Bowel movement
ABGs Arterial blood gases B/M Black male
a.c. Before meals BMU Basic Medical Unit
ACL Anterior Cruciate Ligament BP Blood pressure
ACLF Adult congregate Living Facility BR Bathroom
add. Adduction BSC Bedside Commode
ADL Activities of Daily Living or w/ With
ad lib. As much as desired C0 Centigrade
adm. Admission CA Carcinoma
AFO Ankle Foot Orthosis Ca Calcium
AIDS Acquired Immune Deficiency Syndrome CAD Coronary artery disease
aka Also known as CAPD Continiuous ambulatory peritoneal Dialysis
AKA Above the knee amputation cal Calorie
amb Ambulatory cath Catheter
A.M. Morning cc. Cubic centimeter
AMA Against medical advice CDC Center for Disease Control
A.M.A. American Medical Association cert Certification
amt. Amount CP Care Plan
ant. Anterior CP Cerebal Palsy
A-P Anteroposterior CMS Centers for Medicaid/Medicare Services
A-P&L Anteroposterior and lateral CMT Certified Medication Techinician
approx. Approximate CNA Certified Nursing Assistant
appt. Appointment CHF Congestive heart failure
APTA American Physical Therapy Association Cl Chloride
ARC AIDS Related Complex CLF Current Level of Function
ARD Assessment Reference Date cm. Centimeter
ARDS Adult Respiratory Distress Syndrome CNS Central nervous system
ARNP Advanced Registered Nurse Practitioner c/o Complains of
AROM Active range of motion CO2 Carbon dioxide
ASA Aspirin cont. Continued
Asst. or Assist COPD Chronic obstructive pulmonary disease
ASAP As soon as possible COTA Certified Occupational Therapy Assistant
ASCVD Arteriosclerotic cardiovascular disease CPAP Continuous positive airway pressure
ASHA American Speech-Language & Hearing CPM Continuous Passive Motion Machine
Association
ASHD Arterioclerotic heart disease CPT Chest physical therapy
a.u. Both ears CPT codes Current Procedural Terminology
aud. Auditory CPR Cardiopulmonary Resuscitation
AV Atrial ventricular node CSF Cerebrospinal fluid
BDAE Boston Diagnostic Aphasia Examination C-T scan Computer Axial Tomography Scan
B/F Black female CTRS Certified Therapeutic Recreation Specialist
bicarb. bicarbonate CVA Cerebrovascular accident
b.i.d Twice daily ā Before

Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 2 of 6
company intranet website. Retention: 2 years
 APPROVED ABBREVIATIONS POLICY
CVP Central venous pressure HD Hemodialysis
cx Cervix HEP Home Exercise
CXR Chest X-Ray HEENT Head, ears, eyes, nose and throat
D/C Discontinue Hgb Hemoglobin
d/c or Discharge HHA Hand Held Assist
disch.
decub. Decubitus HIC Health Insurance Carrier
diam. Diameter HIV Human Immune Virus
DJD Degenerative joint disease HOB Head of Bed
DM Diabetes mellitus HMO Health Maintenance Organization
DO Doctor of Osteopathy H&P History and physical
Dr. Doctor h.s. Hours of sleep (bedtime)
DRGs Diagnostic Related Groups ht Height
dsgs. or Dressings HTN Hypertension
dsg.
DTR Deep tendon reflexes Hx History
Dx. Diagnosis Ind. Independent
E.C.F Extended care facility ICD-9-CM International Classification of Disease 9th
edition) - Clinical Modification
EEG Electroencephalogram ICF Intermediate Care Facility
ENT Ear, nose and throat ICH Intracranial hemorrhage
EKG, ECG Electrocardiogram ICU Intensive Care Unit
ELOS Estimated length of stay IDDM Insulin Dependent Diabetes Mellitis
EMG Electromyogram IDT Interdisciplinary team
Endo Endoscopy i.e. In example
epith. Epithelium I&D Incision and Drainage
EPS Extra-pyramidal symptoms ihs Integrated Health Services, Inc.
ER Emergency room incont Incontinent
ESRD End Stage Renal Disease info. Information
et and Int. Rot. Internal Rotation
/ IR
ET Enterostomal Therapist IPD Intermittent peritoneal dialysis
ETOH Alcohol irrig. Irrigation
ext Extract IV Intravenous
ext or / Extension INH Intraventricular hemorrhage
ext. rot. or External rotation JCAHO Joint Commission on the Accreditation of
E.R. Health Care Organizations
FES Functional Electrical Stimulation LOB Loss of Balance
FIM Functional independence measurement JODM Juvenile Onset Diabetes Mellitus
Flex or / Flexion Lt. or L Left
freq. Frequent L. Liter
F/U Follow Up lat. Laternal
FWB Full weight bearing lb or # Pound
Fx Fracture LE Lupus Erythematosis
gen app General appearance Liq Liquid
GMMT Gross Manual Muscle Test LLE Left lower extremity
GSW Gun shot wound LLL Left lower lobe (lung)
hr. Hour LLQ Left lower quadrant
HCFA Health Care Financing Administration LOC Level of consciousness
Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 3 of 6
company intranet website. Retention: 2 years
 APPROVED ABBREVIATIONS POLICY
LOS Length of stay Neuro. Neurology
LP Lumbar puncture Neuro. Neuro surgery
Surg.
LPN Licensed Practical Nurse NGT or NG Nasogastric tube
L/S Lumbar Sacral Area N.I.D.D.M. Non-Insulin Dependent Diabetes Mellitus
LTC Long term care NKA No known allergies
LUE Left upper extremity Noc Night
LUL Left upper lobe (lung) Norm. Normal
LUQ Left upper quadrant NOS Not otherwise specified
LV Left ventricle npo Nothing by mouth
LTG Long Term Goal NS Normal saline
LVN Licensed Vocational Nurse NT Not Tested
MAR Medication Administration Report NWB Non-weight bearing
MARSA Multiple Antibiotic Resistant Staphylococcus O2 Sats. Oxygen saturation
Aureus
MAX Maximum O2 Oxygen
MAX Maximum Assistance OBS Organic brain syndrome
MBD Minimal brain dysfunction Occ Occasionally
MBS Modified Barium Swallow O.D. Overdose
MC or MCR Medicare ODR Outcome Data Report
MCL Mid-clavicular line OOB Out of bed
MD Medical Doctor OPD Outpatient Department
MDS Minimum Data ORIF Open reduction internal fixation
MED Medicine Orth. Orthopedic
mg. Milligram OT Occupational Therapy, Occupational Therapist
MI Myocardial infarction Ox3 Orientation x 3
MIN Minimum oz. Ounce
min Minimal or pW after
MIN Minimum Assistance p Pulse
ML Midline P.A. Physician Assistant
mm Millimeter P-A Posteroanterior
MMT Manual Muscle Test Path. Pathology
MI Moderately Independent p.c. After Meals
MOD Moderate PEG Percutaneous endoscopic gastrostomy
MOD Moderate Assistance Peri Perineal
MRI Magnetic Resonance Imaging Ph.D. Doctor of Philosophy
MRSA Methicillin-Resistant Staphylococcus Aureus PLOF Prior Level of Function
mms Manual Muscle strength P.M. Afternoon
MS Multiple sclerosis PMD Primary medical doctor
MSE Mental Status Exam PMV Past medical history
MSU Medical Specialty Unit p.o. or per By mouth
os
Mtg. Meeting POC Plan of care
mult. Multiple post. Posterior
MVA Motor vehicle accident post-op Postoperative
N/A Not applicable pre-op Preoperative
N/C Nasal cannula prep Prepare of
neg. Negative PRN As often as needed or requested
Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 4 of 6
company intranet website. Retention: 2 years
 APPROVED ABBREVIATIONS POLICY
PROM Passive range of motion SBQC Small Base Quad Cane
PROG Prognosis sec Second
Pron. Pronation SLB Short Leg Brace
Psy.D. Doctor of Psychology SLR Short Leg Raising
Psych. Psychiatric SLP Speech-Language Pathology, Speech-Language
Pathologist
P.T. Physical Therapy, Physical Therapist SLPA Speech Language Pathology Assistant
Pt. Patient SNF Skilled Nursing Facility
P.T.A. Physical Therapist Assistant SOB Shortness of breath
Pulse Ox Pulse oximeter SOC Start of Care
Pvt Private S/P Status Post
PWBAT Partial weight bearing as tolerated SPA Speech Pathologist Assistant
q Every or w/o Without
q.a.m. Every morning SR Side rails
q.d Every day S/S Signs and symptoms
q.h.s. Every night at bedtime ST Speech Therapy, Speech Therapist
q.i.d. Four times a day stat. Immediately
q.o.d. Every other day STG Short Term Goal
q.o.h. Every other hour suct. Suction
q.h. Every hour Surg. or Sx Surgery or surgical
Rt. or R Right Sup. Supination
RD Registered Dietitian susp. Suspension
Re: Regarding SX Symptoms
Rehab. Rehabilitation T or temp. Temperature
reg. Regular TC Tactile Cues
Resp. Respirations tbsp. Tablespoon
RHR Resting heart rate TF Tube feeding
RLE Right Lower Extremity TIA Transient ischemic attack
RLL Right lower lobe (lung) t.i.d. Three times a day
RLQ Right lower quadrant (abdomen) TKA Three knee arthroplasty
RML Right middle lobe (lung) TKR Total knee replacement
R.N. Registered Nurse TO Telephone order
RNAC Registered Nurse Assessment Coordinator tol. Tolerated
R/O Rule out TPN Total parenteral nutrition
ROM Range of motion T.R. Therapeutic recreation
Rot. rotation Trach Tracheostomy
RR Respiratory rate tsp. Teaspoon
RT Respiratory Therapy, Respiratory Therapist T.W.B. Toe touch weight bearing, touch down weight
bearing
RUE Right Upper Extremity Tx Treatment
RUL Right upper lobe (lung) US Ultrasound
RUQ Right upper quadrant UTI Urinary tract infection
R.W. or RW Rolling walker vag. Vagina or vaginal
RX Prescription VC Verbal cueing
S Supervision vent Ventilator
SAT Saturation (oxygen) via By Way of
SBA Stand by Assistance VO Verbal Order

Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 5 of 6
company intranet website. Retention: 2 years
 APPROVED ABBREVIATIONS POLICY

vol. Voluntary
VS Vital Signs
WBAT Weight bearing as tolerated
WBC White blood count
WBQC Wide Base Quad Cane
W/C Wheelchair
W/D Warm and dry
W/F White female
WFL Within Functional Limits
W/in Within
W/M White male
WNL Within normal limits
NQC Narrow Base Quad Cane
wt. Weight
Wk. Week
X Times
yr. Year

@ At
1º First degree, primary
2º Second degree, secondary
3º Third degree
< Under or less than
> Over or more than
Increase
Decrease
Ø None
_ Changed to
_/ No change
+ Positive
// bars Parallel bars
To and From
- Negative
√ Check
hr Hour
min Minute
1:1 One-on-one interaction
= Equals
Male
Female

Confidential information of Century Rehabilitation for Revision Date: October 31, 2017
use by its employees for internal purposes only. The
current policy and/or procedure is available on the Page 6 of 6
company intranet website. Retention: 2 years