OT Abbreviations—and Other Documentation Hacks

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, OT 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.

This auto text expander has recently been updated to utilize artificial intelligence and is now called Magical: ChatGPT AI Writer & Text Expander. (If you are using AI in other ways to improve your documentation, please let me know!!)

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.

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
I/Indep – Independent

Jt – Joint

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!

Finally, our post Crafting the Ideal OT Note, is a great companion piece to this topic!