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Mercer County Community College Physical Therapist Assistant Program
Mercer County Community College Physical Therapist Assistant Program Approved Abbreviations for use in Documentation Category: Body Parts Abbreviation Description Abbreviation ACL Anterior Cruciate Ligament MCP C/S Cervical Spine mm DIP Distal Interphalangeal Joint MTP FCR Flexor Carpi Radialis Pec FCU Flexor Carpi Ulnaris PCL GH Gleno-Humeral PIP H/S Hamstring Quad ITB Ilio-tibial Band RTC Jt Joint SI LCL Lateral Collateral Ligament TMJ Lats Latissimus Dorsi T/S LE Lower Extremity UE L/S Lumbar Spine MCL Medial Collateral Ligament Category: Diagnosis Abbreviation Description Abbreviation AKA Above Knee Amputation H/o ALS Amyotrophic Lateral Sclerosis HNP BKA Below Knee Amputation HTN CA Cancer LBP CF Cystic Fibrosis MI CHF Congestive Heart Failure MS CVD Cardio-Vascular Disease MVA CVA Cerebral Vascular Accident OA Chronic Obstructive Pulmonary Disease COPD PD CP Cerebral Palsy PVD CRPS Complex Regional Pain Syndrome RA CTS Carpal Tunnel Syndrome RSD DDD Degenerative Disc Disease SOB DJD Degenerative Joint Disease TBI DM Diabetes Mellitus THA DMD Duchenne Muscular Dystrophy THR DVT Deep Vein Thrombosis TIA Fx Fracture TKA HA Headache TKR Description Metacarpophalangeal Joint muscle Metatarsophalangeal Joint Pectoral / Pectoralis Posterior Cruciate Ligament Proximal Interphalangeal Jt Quadriceps Rotator Cuff Sacroiliac Temporomandibular Joint Thoracic Spine Upper Extremity Description History of Herniated Nucleus Pulposus Hypertension Low Back Pain Myocardial Infarction Multiple Sclerosis Motor Vehicle Accident Osteoarthritis Parkinson’s Disease Peripheral Vascular Disease Rheumatoid Arthritis Reflex Sympathetic Dystrophy Shortness of Breath Traumatic Brain Injury Total Hip Arthroplasty Total Hip Replacement Transient Ischemic Attack Total Knee Arthroplasty Total Knee Replacement Category: Direction / Position Abbreviation ABD ADD Ant A/P Bwd Diag DF Ever ER Ext Flex Fwd FWB Hor Inf IR Lat Description Abduction Adduction Anterior Anterior Posterior Backward Diagonal Dorsiflexion Eversion External Rotation Extension flexion Forward Full Weight Bearing Horizontal Inferior Internal Rotation Lateral Abbreviation L Med M/L NWB P/A PWB PF Post Pron Prox R Rot SB Sup TTWB WB WBAT Description Left Medial Medial Lateral Non Weight Bearing Posterior Anterior Partial Weight Bearing Plantarflexion Posterior Pronation Proximal Right Rotation Sidebend Supination or Superior Toe Touch Weight Bearing Weight Bearing Weight Bearing as Tolerated Category: Equipment Abbreviation AFO CPM 4WW FWW KAFO LBQC NBQC RW Description Ankle foot orthosis Continuous passive motion Four wheeled walker Front wheeled walker Knee ankle foot orthosis Large based quad cane Narrow Based Quad Cane Rolling Walker Abbreviation SBQC SPC SW T-Band TLSO WBQC W/C // Bars Description Small based quad cane Single point cane Standard Walker Theraband Thoracolumbosacal orthotic Wide based quad cane Wheelchair Parallel Bars Category: Exercises Abbreviation AAROM ADL amb AROM BAPS HEP Isom LAQ PBall PRE Description Active Assistive Range of Motion Activities of Daily Living ambulate Active Range of Motion Biomechanical Ankle Platform System Home Exercise Program isometric Long Arc Quadriceps Physio-Ball Progressive Resistive Exercises Abbreviation PNF P/u QS ROM SAQ S/L SLR Ther Ex TM UBE Description Proprioceptive Neuromuscular Facilitation Push up Quadriceps Set Range of Motion Short Arc Quadriceps Sidelying Straight Leg Raise Therapeutic Exercise treadmill Upper Body Ergometer Category: Interventions (Modalities / Procedures) Abbreviation CP Dexa E-stim FES Ionto Mob MHP MFR NAGS Description Cold pack Dexamethazone Electrical Stimulation Functional Electrical Stimulation Iontophoresis Mobilization Moist Hot Pack Myofascial Release Natural Apophyseal Glides Abbreviation NMR Phono SNAGS STM TA TENS Tx US Description Neuromuscular re-education Phonophoresis Sustained Natural Apophyseal Glides Soft Tissue Mobilization Therapeutic Activities Transcutaneous Electrical Nerve Stimulation Traction Ultrasound Category: Miscellaneous Abbreviation ā @ A As tol B BID BIW B/L BOS BP bpm c CC CGA C/o COG Cont D/C DOB DOI DOS Dx ER EOB Eval Ex. Description Before At Assist or Assistance As tolerated Bilateral Twice a day Twice a week Bilateral Base of support Blood pressure Beats per minute With Chief Complaint Contact Guard Assist Complains of Center of gravity Continue Discharge Date of birth Date of injury Date of surgery Diagnosis Emergency Room Edge of bed Evaluation Exercise Abbreviation NS OOB OT p Prec. PRN Pt. PT PTA RTW r/o Rx S s Script SLP S/p STG Tol VC VIC WFL WNL y/o 2º < Description No Show Out of bed Occupational Therapist After Precautions As needed Patient Physical Therapist Physical Therapist Assistant Return to work Rule out Treatment Supervision Without Prescription Speech Language Pathologist Status post Short Term Goal Tolerated Verbal cues Verbalized informed consent Within functional limits Within normal limits Years old Secondary to or Due to Greater Than F/u HOB I IE LTG Max Min MMT mod MVA NF Follow up Head of bed Independent Initial evaluation Long term goal Maximum Minimum Manual Muscle Testing Moderate Motor vehicle accident No Fault > 1:1 // ‘ ‘’ # Less Than One to one Parallel Foot or Feet Inches Pounds Up, increased Down, decreased Flexion Extension To and from ↑ ↓ √ ∕ ↔ CPT CODES # 97001 97002 97010 Name Physical Therapy Evaluation Physical Therapy Re-evaluation Hot or Cold Packs 97012 Mechanical Traction 97014 97016 Electrical Stimulation (unattended) Vasopneumatic Device 97018 97022 97024 Paraffin bath Whirlpool Diathermy 97026 97028 97032 97033 Infrared Ultraviolet Electrical Stimulation (manual) Iontophoresis 97034 Contrast Bath 97035 Ultrasound 97036 Hubbard Tank 97110 Therapeutic Exercise 97112 Neuromuscular Re-education 97113 Aquatic Therapy 97116 97124 Gait Training Massage 97140 Manual Therapy Techniques Description Application of a modality to one or more areas; hot or cold packs Application of a modality to one or more areas; traction, mechanical Application of a modality to one or more areas; electrical stimulation (unattended) Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy (eg, microwave) Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to one or more areas; iontophoresis, each 15 minutes Application of a modality to one or more areas; contrast baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility. (Generally describes a service aimed at improving a single parameter, such as strength, ROM, etc.) Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercise Skilled improvement of gait, includes stair climbing Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Skilled manual therapy techniques (mobilization, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. ( PROM is NOT manual therapy) # 97530 Name Therapeutic Activity 97535 Self Care / Home Management 97542 Wheelchair Management 97760 Orthotic Management 97761 Prosthetic Management 97762 Orthotic/Prosthetic Checkout 97150 Group PTAP 1/2010 Description Use of dynamic activities to improve functional performance. Describes the activities that use multiple parameters (strength, ROM, balance, etc) together and focus and achieving functional activity. Self care/home management training (ADL and compensatory training, meal preparation, safety procedures and instructions in the use of assistive technology devices/adaptive equipment) Wheelchair Management (eg, assessment, fitting, training), each 15 minutes Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes Prosthetic training, upper and/or lower extremity(s), each 15 minutes Checkout for orthotic/prosthetic use, established patient, each 15 minutes Therapeutic procedure(s), group (2 or more individuals)
