OT Abbreviations—and Other Documentation Hacks

OT abbreviations help save therapists time, but can be confusing for the reader. This article breaks down how you can have the best of both worlds!

I probably don’t need to remind you that we OTs do incredible work every day.

We help our clients regain agency over their health and their lives—and, in the process, we are able to instill a degree of hope that many have not felt in a long time.

But, at the end of the day, we have to document our treatment sessions—and that part is not always quite as thrilling as the treatments themselves :-)

Important as it is, documentation can be time-consuming—which is likely why our profession has come to rely quite heavily on the use of OT abbreviations.

When we’re furiously typing our notes between patients, or cramming our documentation in at the end of the day, it’s such a relief to be able to type “CGA” instead of “Contact Guard Assist,” and have peace of mind knowing that our peers and insurance reviewers will understand what we’re talking about.

Abbreviating commonly used phrases can save us hours by the end of the week, and this article serves to cover the most frequently used ones—that means you can use them with confidence and spend less time documenting!

A few caveats about OT abbreviations

It’s important to keep a few things in mind when you use OT abbreviations, though.

First of all, documentation is very facility-specific. What might make total sense to a team of OTs working at an inpatient rehab facility might look like Greek to a team of OTs working in a hands clinic.

Similarly, some insurance reviewers might not recognize lesser-known OT abbreviations, which could lead to hold-ups in your reimbursements (or could even lead to denials altogether!).

Plus, as you can probably imagine, it’s even more challenging to decipher OT lingo when you’re not in the rehab field. After we’re done typing our notes, they’re often sent to other health practitioners down the road, and these clinicians might have no idea what our shorthand lingo means.

At best, this can cause delays in care—but at worst, this can cause dangerous miscommunications about patients’ health.

And we’d never want that to happen.

Why I created this article

I put this OT abbreviations article together so that you’d have a reference to help save you time and eliminate headaches during your documentation process.

However, please keep in mind that while I tried to limit this list to abbreviations that pretty much any rehab professional would recognize, many of these terms will still be very confusing to non-therapy professionals.

For this reason, I’ve also included some hacks to help you speed up your documentation without relying on questionable OT abbreviations.

Tip #1) Try using auto-fill technology

Instead of using questionable shorthand that could lead to confusion, I recommend that you use a text expander!

You can create custom shortcuts in some EMRs—these custom shortcuts will automatically fill out your intended phrase when you type a pre-designated abbreviation for it. For example, you can set “ADL” to expand into “activity of daily living” or “b/c” into “because.”

Fusion Web and WebPT both offer this capability! I’m also curious to know of EMRs that do this, so please comment below if your clinic’s software has this convenient feature!

You can use the OT abbreviations list below to create your shortcuts, and also come up with ones of your own if you’d like.

If you use the Google Chrome web browser for your documentation, you can install the auto text expander extension, which allows you to easily create these custom shortcuts! Here’s the auto text expander.

Here’s how to use the Auto Text Expander for Google Chrome™

  1. Download the chrome extension for free from the Google chrome web store.

  2. Under the “shortcuts” section, click the “+ add” button and set up the shortcuts or abbreviations you want to use (I used “HTN” as an example for “hypertension”). Be sure to hit save after you add your abbreviations! And keep in mind that it’s case specific, meaning you must type HTN; htn will not work.

  3. Use the exact (case-sensitive) shorthands that you pre-designated in the extension, and see how your typing automatically expands...it’s like magic!

This is an example of how to use the Chrome Auto Text Expander!

Keep in mind that this hack only works for browser-based EMRs like WebPT, and if you use other documentation systems like Epic, Centricity, or Cerner, you may or may not be able to do something similar. So here’s what I recommend in those cases.

Tip #2) Speak with your IT department or EMR educator about using shortcuts

I strongly recommend that you ask your IT department or software liaison if you can do something similar to what is possible in those web-based EMRs.

For example, PhraseExpress integrates with systems like Allscripts, Cerner, and NEXTGEN. Chances are, whatever software you’re using for your EMR, there is an option for you out there that will make your life way easier.

The benefit of acting as de facto EMR liaison for your department

Yes, I realize that taking the time to work with an already-busy IT department or EMR trainer means extra work for you.

And it might be one of those things that takes months to accomplish.

But don’t give up!

Not only will your coworkers and supervisor sing your praises from the top of the hills when this is all over, you’re quietly establishing yourself as a key problem-solver on your team during the process.

You’re demonstrating your ability to collaborate and liaise between departments––and to streamline processes and improve departmental productivity by eliminating documentation bottlenecks. Taking on these types of roles helps immensely when pursuing non-traditional or non-clinical OT roles in the future, and your initiative will likely score major points, should you have your eye on a leadership role down the line.

Without further ado, here’s the list of therapy abbreviations! Remember, use them wisely, and try to use fully formed phrases whenever possible, in order to prevent confusion!

Common OT abbreviations

ABD - Abduction

ACA - Anterior Cerebral Artery

ADD - Adduction

AD - Assistive Device

ADLs - Activities of Daily Living

AFO - Ankle Foot Orthosis

AKA - Above Knee Amputation

ALS - Amyotrophic Lateral Sclerosis

AMA - Against Medical Advice

AROM - Active Range Of Motion

AAROM - Active Assistive Range Of Motion

AMA - Against Medical Advice

A/P - Anterior Posterior

A&O - Alert And Oriented

B - Bilateral

Bed Mob - Bed Mobility

BID - Twice Per Day

BKA - Below Knee Amputation

BOS - Base of Support

BP - Blood Pressure

BPM - Beats Per Minute

CABG - Coronary Artery Bypass Graft

CAD - Coronary Artery Disease

CGA - Contact Guard Assistance

CHF -  Congestive Heart Failure

CMC - Carpometacarpal

CNS - Central Nervous System

C/O - Complains Of

Cont - Continue

COTA - Certified Occupational Therapy Assistant

COPD - Chronic Obstructive Pulmonary Disease

CP -  Cerebral Palsy (or Cold Pack)

CPAP - Continuous Positive Airway Pressure

CPM - Continuous Passive Motion

CTS - Carpal Tunnel Syndrome

CVA - Cerebral Vascular Accident

CX - Cancel

D/C - Discharge

DDD -  Degenerative Disc Disease

DIP - Distal Interphalangeal Joint

DJD - Degenerative Joint Disease

DME - Durable Medical Equipment

DOB - Date Of Birth

DVT - Deep Vein Thrombosis

DX - Diagnosis

DM - Diabetes Mellitis

ECC, EKG - Electrocardiogram

EOB  - Edge Of Bed

ETOH - Ethanol (Alcohol)

Eval - Evaluation

FES - Functional Electronic Stimulation

FOB - Foot Of Bed

F/U - Follow Up

FWB - Full Weight Bearing

Fx - Fracture

GCS - Glasgow Coma Scale

GERD - Gastroesophageal Reflux Disease

GH - Glenohumeral

GI - Gastrointestinal

GSW - Gunshot Wound

H/A - Headache

Hemi - Hemiplegia or Hemiparesis

HEP - Home Exercise Program

HHA - Home Health Aide

HKAFO - Hip Knee Ankle Foot Orthosis

HNP - Herniated Nucleus Pulposus

H/O - History Of

HOB - Head Of Bed

H&P - History And Physical

HR - Heart Rate

HTN - Hypertension

HX - History

ICU - Intensive Care Unit

IDDM - Insulin Dependent Diabetes Mellitus

I&O - Intake And Output

IR - Internal Rotation

ITB - Iliotibial Band

Jt - Joint

I/Indep - Independent

KAFO - Knee Ankle Foot Orthosis

L - Left

LB - Lower Body

LBP  - Low Back Pain

LE - Lower Extremity/Extremities

LOS - Length Of Stay

LQ - Lower Quadrant

LTG - Long Term Goal

L/S - Lumbar Spine

LUE - Left Upper Extremity

Max - Maximum

Max A - Maximum Assistance

MCP - Metacarpophalangeal Joint

MHP - Moist Heat Pack

MI - Myocardial Infarction

Min A - Minimum Assistance

Mm. - Muscle

MMT - Manual Muscle Test

Mod A - Moderate Assistance

MRI - Magnetic Resonance Imaging

MRSA - Methicillin-Resistant Staphylococcus Aureus

MTP - Metatarsophalangeal Joint

MVA - Motor Vehicle Accident

NBQC - Narrow Based Quad Cane

NG - Nasogastric

NIDDM - Non-Insulin Dependent Diabetes Mellitus

NICU - Neonatal Intensive Care Unit

NPO - Nothing By Mouth

N&V - Nausea And Vomiting

NVD - Nausea, Vomiting, Diarrhea

NWB - Non-Weight Bearing

O2 - Oxygen

OA - Osteoarthritis

OOB - Out Of Bed

OT - Occupational Therapy

OTA - Occupational Therapy Assistant

PA - Physician’s Assistant

PACU - Post Anesthesia Care Unit

PD - Parkinson’s Disease

PE - Pulmonary Embolism

PF - Plantarflexion

PIP - Proximal Interphalangeal Joint

PMH - Past Medical History

PNF - Proprioceptive Neuromuscular Facilitation

POC - Plan Of Care

Post-Op - Postoperative

Pre-Op - Preoperative

PRN - As Needed

PROM - Passive Range Of Motion

Pt - Patient

PT - Physical Therapy, Physical Therapist

PTA - Physical Therapist Assistant

PVD - Peripheral Vascular Disease

PWB% - Partial Weight Bearing (With Percent)

Quad - Quadriceps

R - Right

RA - Rheumatoid Arthritis

RBC - Red Blood Cell/Count

Rehab. - Rehabilitation

Reps. - Repetitions

RLA - Rancho Los Amigo Scale

RLE - Right Lower Extremity

RN - Registered Nurse

R/O -  Rule Out

ROM - Range Of Motion

RTC - Rotator Cuff

RUE - Right Upper Extremity

RW - Rolling Walker

Rx - Treatment

SBA - Standby Assist

SBQC - Small Base Quad Cane

Script - Prescription

SCI - Spinal Cord Injury

SICU - Surgical Intensive Care Unit

SLP - Speech-Language Pathology/Pathologist

SLPA - Speech-Language Pathology/Pathologist Assistant

SOB - Shortness Of Breath

S/P - Status Post

SPC - Single Point Cane

S/S - Signs And Symptoms

ST - Speech Therapy

STG - Short Term Goals

Sup - Supervision/Supervised (Level Of Assist)

SW - Standard Walker

T-Band - Theraband

TBI - Traumatic Brain Injury

TDWB - Touch Down Weight Bearing

TENS - Transcutaneous Electrical Nerve Stimulator

THA - Total Hip Arthroplasty

THR - Total Hip Replacement

Therex - Therapeutic Exercise

TIA - Transient Ischemic Attack

TKA - Total Knee Arthoplasty

TKR - Total Knee Replacement

TLSO - Thoracolumbosacral Orthotic

TMJ - Temporomandibular Joint

T/S - Thoracic Spine

TTWB - Toe Touch Weight Bearing

UB - Upper Body

UBE - Upper Body Ergometer

UE - Upper Extremity

UQ - Upper Quadrant

US - Ultrasound

UTI - Urinary Tract Infection

VC - Verbal Cue

Vent. - Ventilator

VO - Verbal Order

WB - Weight Bearing

WBQC - Wide Based Quad Cane

WBAT - Weight Bearing As Tolerated

W/C - Wheelchair

WFL - Within Functional Limits

WNL - Within Normal Limits

4WW - Four Wheeled Walker

(Check, Slash) - Flexion, Extension

# - Pound

Here’s the thing. You might not have seen some of your favorite therapy terminology on this list. I left some things off the list because they’re likely facility-specific, and use might lead to confusion. For example, “tx” could mean “traction” or “treatment,” and using traction when it’s contraindicated could be very dangerous.

That’s why I recommend that even when you use well-known abbreviations, you consider using the aforementioned text expander features whenever possible. After all, the less confusion we have between medical professionals, the better!

Conclusion

I truly believe that leveraging technology in a thoughtful way will eliminate many of the communication barriers traditionally seen in medicine!

I plan to update this article over time, and I’d love for you to comment below! Please indulge me and share whether your facility and/or EMR allows you to create your own custom shortcuts! Do you have any tools or hacks you use to make your documentation more legible? I’m also curious to learn whether you’ve ever had an issue from using too much shorthand or too many abbreviations!

Thanks, in advance, for your input!