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