Must-Know Occupational Therapy Medical Abbreviations - myotspot.com (2023)

The medical field is well-known for its lingo. It’s often said that chart notes look something like alphabet soup, even to those who are familiar with such terminology. It can make things even more difficult when occupational therapy medical abbreviations (and medical abbreviations in general!) enter the mix.

We learn a whole laundry list of abbreviations in OT school, but these can go out the window when you enter the field. New and seasoned therapists should be able to recognize a whole range of universal medical abbreviations, but in practice, you may typically use a standard few in your notes.

While we don’t include every single one in this list (you can find full medical abbreviation lists here and here), these are some of the most important occupational therapy medical abbreviations to know, especially if you’re new to working with adults.

Note: Your facility may have their own approved list, so be sure to check on this as well.

ADL

As an OT, you will get a very intimate knowledge of ADLs, or activities of daily living. This includes any and all self-care tasks that someone completes in order to take care of themselves on a daily (or otherwise regular) basis. Another common term that is often seen alongside ADL is a BADL, which refers to a basic activity of daily living. BADLs include anything under the umbrella of rudimentary bodily self-care, which involves grooming, bathing, dressing, toileting, and eating. Other tasks that fall under the category of ADLs, but not necessarily BADLs are sexual activity and functional mobility.

On the other end of this are IADLs, which refer to instrumental activities of daily living, since they are more complex and relate back to higher-level functions such as driving, medication management, budgeting, laundry, grocery shopping, managing health information or appointments, and more. OTs use all three of these terms quite frequently, both in conversation and in documentation such as daily notes and progress reports. Some facilities use BADLs more commonly than ADLs and this same term is more often seen within professional research papers and textbooks.

AD

Assistive devices, or AD, refer to any piece of equipment that a patient uses to compensate for a deficit in order to get a task done. More sophisticated pieces of AD are referred to as AT, or assistive technology, and these often contain software, computer programs, and the like as their main component.

AD itself can range from mobility aids (which have their own abbreviations), including walkers, wheelchairs, rollators, and canes; wearable devices such as orthotics and prosthetics; cognitive aids such as schedulers, personal assistants, and notification devices; and much more.

As you can see, this abbreviation can refer to a wide range of tools, so it’s important to be very specific when using this term so the reader knows exactly what type of AD you are referring to and what purpose it is being used for.

AROM/AAROM/PROM/ROM

Upper extremity joint range of motion (ROM) is an important measure used in OT evaluations and treatments, so you will see these used frequently. Here are the measures and their abbreviations:

AROM is the active range of motion of the joint (you are not assisting in the movement).

AAROM is active assisted range of motion (you provide some assistance but the person is able to help move the joint).

PROM is passive range of motion (in which you provide full assistance to move the joint, this is commonly seen in a hemiparetic arm after stroke).

OTs measure these ranges of motion with a goniometer or functionally through visual assessment. If you aren’t yet familiar with range of motion, don’t worry, you will learn how to do this in OT school and fieldwork.

Assist Level Abbreviations

Assist levels are used to assess and document how much assist a person needs with their ADLs and/or functional mobility. You will see them abbreviated in these ways:

I: Independent, the person does not require any physical assistance with ADLs or mobility nor do they use an assistive device.

MOD I: Modified Independent, the person is independent with ADLs/mobility with the use of an assistive device.

SBA: Stand-by assist. The person is able to complete the task themselves, but they still require the therapist or caregiver to “stand by” them for safety. They may also be provided with verbal cues or instructions.

CGA: Contact guard assist. The person is able to do the transfer or self-care task with the caregiver only providing a light touch (hence the term contact guard) for safety.

MIN A: Minimal assist. The caregiver provides the person with 25% or less physical assistance with a task or transfer.

MOD A: Moderate assist. The caregiver provides the person with 25% to 50% assistance with a task or transfer.

MAX A: Maximal assist. The caregiver provides the person with more than 75% physical assist.

DEP: Dependent, or total assist. The caregiver provides 100% assist for the task or transfer.

BID

BID is the medical term for “twice a day.” Twice a day/BID orders for OT treatments are commonly seen in an acute care orthopedics unit. While this used to be much more common for PTs, I’m seeing this ordered more and more for OTs as well, often following fast-track orthopedic surgeries.

BOS

Base of support, or BOS, may seem like more of a PT term but it relates heavily to the OT world as well. It pertains to body mechanics both with patients and therapists alike. It is important to maintain a wide base of support when lifting patients to prevent injury, so therapists learn about this in most training they receive for transfers and other types of patient contact.

In regards to patient treatment, BOS will be important to note, since it can shed light on a patient’s balance, environmental awareness, personal ergonomics, and ability to safely move from place to place. It is not unheard of for therapists to note that a patient had a wide (or appropriate) BOS or, more commonly, a narrow BOS that warrants additional training.

This is again most common in adult rehab facilities and potentially even community-based settings such as outpatient clinics. A therapist most often refers to BOS when treating geriatric or neuro patients, since this plays a big part in transfers.

C/O

C/O, short for complains of, is a commonly seen abbreviation in medical charts. It indicates what the patient’s chief medical complaint or symptoms are, such as new hip pain after a fall. OTs and other therapists often use this abbreviation when indicating that the patient does or does not complain of (c/o) pain during a treatment session.

DME

Another counterpart to ADs is durable medical equipment (DME). Durable medical equipment includes three-in-one commodes, hospital beds, power scooters, Hoyer lifts, and mobility aids such as walkers, wheelchairs, canes, crutches, and the like.

Therapists may mention DME in notes when assisting with wheelchair mobility or they may note it in an evaluation when patients have pre-existing equipment. However, therapists also often assist with completing evaluations to fit patients for wheelchairs, walkers, and other equipment. This entails taking body measurements, trialing equipment for goodness-of-fit, and making adjustments as needed.

DOE

DOE, dyspnea on exertion, is often used as an abbreviation when working with individuals who feel short of breath when they are doing more activity than resting. This can be mild or severe depending on how “out of breath” the person is feeling during the activity.

This phrase often seen in cardiopulmonary patients but can be used with anyone. When any patient is experiencing DOE, it is important to monitor their vitals, take rest breaks and educate them on energy conservation techniques (see below) when they are feeling better.

ECTs

ECTs, short for energy conservation techniques, are important work simplification methods to teach any clients in any setting who will benefit from conserving their energy during daily tasks. The biggest aspects of ECTs are teaching individuals to plan their most important activities first, pace themselves throughout the task and during the day, taking rest breaks, and/or modifying the task with adaptive equipment or other methods.

ECTs are important to know and practice if someone has high pain levels, DOE, or fatigue with activities. These will work with any individual that is having trouble carrying out their ADLs. OTs will commonly use these with COPD diagnoses, respiratory failure, MS, CHF and other cardiac conditions, chronic pain patients, ALS, and people receiving palliative care.

EtOH

This abbreviation is often seen in acute care and mental health settings, but it can certainly be part of a patient’s chart in other places. EtOH refers to alcohol use, but most commonly alcohol use disorder. Settings like psychiatric hospitals or units often have patients who are admitted to the facility to undergo a detox from alcohol and/or other substances.

A therapist may also note this in an orthopedic setting where they refer to the nature of a patient’s injury (“they were under the influence of EtOH when they fell and sustained a wrist fracture”). This is one of the more specific abbreviations, but it is still helpful for a therapist to know when they must make note of something alcohol-related. Patients with mental health concerns can present in any setting at one time or another. For this reason, therapists should have a good working knowledge of those abbreviations even if they think it might not pertain to them.

FX

Fractures, or FX, are another common term that is used in orthopedic settings, but this can also be noted in a patient’s medical history in any setting. Patients in assisted living facilities may have histories of fractures. It is not uncommon for therapists in these clinics to review documentation from a patient’s hospital trip following a fall that resulted in a fracture.

Fractures often come along with precautions, especially for therapists treating patients in the early phases of recovery from these injuries. So it’s important to be aware of medical documentation that relays important information from doctors and other providers involved in their care.

HH

HH is shorthand for Home Health, referring to services that a person receives in their own home, often following a hospital or rehab stay. HHOT refers to Home Health Occupational Therapy, HHPT refers to Home Health Physical Therapy, and HHA refers to Home Health Aide.

Side note: If you see HHA in a mobility context, this is an unofficial way to state “Handheld Assist,” but it is not a formal medical abbreviation.

HOB/EOB

Head of the bed, or HOB, is a common term within hospitals and skilled nursing facilities where treatments are likely to occur in a patient’s room. Patients with reflux may need to sleep with the HOB elevated, and this also may be part of surgery precautions.

In a similar vein is EOB, which refers to the edge of the bed. This is slightly more relevant to the therapy world, since therapists may ask a patient to complete bed mobility and move from supine to EOB. If a patient needs assistance with this, the therapist will need to make note of it using this term. Similarly, this may become a focus of therapy so they will need to incorporate it into each note to document a patient’s progress or lack thereof.

H&P, Hx

H&P refers to a person’s history and physical, which covers their full medical history and what their current medical evaluation is indicating. Hx is a patient’s medical history. These are both very important aspects to take note of before you see any patient for evaluation and/or treatment so you know what comorbidities and precautions to be aware of as well as what their current problem(s) may be.

IDDM

This one can be confusing, since IDD usually refers to someone with intellectual and developmental disabilities. So seeing this acronym can make your mind go to a completely different population and practice arena, when in fact it’s a diabetes term.

IDDM refers to insulin-dependent diabetes mellitus. An OT working in a skilled nursing facility or assisted living facility will need to take note of a patient’s medical history, and this is often part of that for a geriatric population. This becomes crucial to an OT’s job when they are providing education surrounding skin checks, complications associated with unmanaged diabetes (retinopathy, amputations, sensation loss, etc.), diet, exercise, and other healthy choices.

IRF/IRU/IRC/ARU

These are all abbreviations that refer to the acute inpatient rehab setting. Acute rehab is the most intensive rehab setting that is usually in a hospital setting with 24 hour nursing care and 3 hours of occupational therapy, physical therapy and occasionally speech therapy each day.

IRF stands for Inpatient Rehab Facility, IRU is Inpatient Rehab Unit, IRC is Inpatient Rehab Center, ARU is Acute Rehab Unit. It can be very confusing to see so many different rehab abbreviations, but just remember that they all mean the same thing.

LTC

LTC is short for Long Term Care, which is where people live if they need continuous care from caregivers and cannot live on their own. This can include skilled nursing facilities, group homes, and assisted living facilities.

MMT

You very likely already know that MMT is Manual Muscle Testing if you’re a few semesters into your OT program, but we felt that it needed to be added for those who aren’t yet familiar. Like range of motion, manual muscle testing is an important aspect of OT assessment.

It is the standard assessment of the muscles, for OTs this is most often done with the muscle groups in the upper extremity. If you don’t know about MMT yet, you will certainly learn all about it in OT school!

ORIF

ORIF, short for Open Reduction and Internal Fixation, is seen following this specific orthopedic repair of a fracture. This is commonly seen in orthopedic units, trauma units, and post-acute rehab settings. When you see this, be on the lookout for any weightbearing precautions that might go along with this procedure.

SNF/SAR

SNF is short for Skilled Nursing Facility, a care facility where a person will receive 24/7 skilled nursing care. Subacute rehab (SAR) always takes place in skilled nursing facilities, but not every person that is in a SNF will have subacute rehab services.

STG/LTG

STG: Short-term goal. These are written at evaluation with a shorter time frame in mind. The time frame varies between settings.

LTG: Long-term goal. Also written at evaluation, with the goal to be met by discharge of OT services and after meeting short-term goals.

THR/THA

THR, short for total hip replacement, also called THA, or total hip arthroplasty, is a surgical procedure done to remove damaged bone and cartilage in the hip and replaced with a prosthetic hip joint.

TKR/TKA

TKR is the abbreviation for total knee replacement, also called TKA (total knee arthroplasty), and is another common orthopedic surgery that removes damaged knee bone/tissue and replaces it with a prosthetic knee joint.

Tx

Tx is the abbreviation for treatment. You may see this in the orders “OT eval and tx,” which allows for OT to provide treatments to patients after evaluation if indicated.

WB

WB, short for weightbearing, refers to how much weight a person can put on an affected extremity after fracture or surgery. You will also see the following abbreviations related to weightbearing:

NWB (Non-weightbearing): 0% of body weight

TTWB (Toe-touch weight-bearing): Up to 20% of body weight

PWB (Partial weight-bearing): 20-50% of body weight

WBAT (Weight-bearing as tolerated): Bear weight “as tolerated,” this can be up to 100% if the patient is able to tolerate it.

FWB (Full weight-bearing): 100% of body weight

WFL

WFL is short for within functional limits. This is often used when assessing a person’s upper body strength or range of motion. The person does not have “normal” or 100% strength or range of motion, but they still are able to use the affected extremity functionally with their day to day tasks. This may look like someone with a shoulder injury that has 75% active shoulder flexion, which is limited but still enables them to do what they need to do.

WNL

WNL, or within normal limits, indicates, unlike above, that the extremity has normal or basically 100% of their strength or range of motion, with no limitations.

UE

Upper extremity (arm). You will also see BUE (bilateral upper extremities), RUE (right upper extremity), and LUE (left lower extremity. LE indicates lower extremity (leg).

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We hope this OT medical abbreviations list gave you some added clarity in your documentation and chart reviewing journey.

What is one universal abbreviation that you can never seem to decode? What common OT abbreviation would you add to this list? Let us know in the comments!

This article was cowritten by Sarah Stromsdorfer, OTR/L and Brittany Ferri, OTR/L.