2 3 2 = 8 2 a ACCIDENT & INJURY ABBREVIATIONS LEGEND A: assessment ABS : absent AAROM active assistive range of motion AC joint acromioclavicular joint Act activator (instrument) ADL activities of daily living Adj adjustment AE above elbow ‘AFO ankle foot orthotic AS ankle jerk AUS anterior inferior iliac spine AK above knee AMA against medical advice AP anterior-posterior AR active rehabilitation AROM active range of motion ASAP as soon as possible ASIS anterior superior iliac spine BE below elbow bid twiee a day BK below knee BP blood pressure bpm beats per minute BV blurred vision c cervical spine, continue (CNS Watch) ce chief complaint cr contraindication «. - . cut chiropractic inanipulative treatment CNS central nervous system do +. complains of cer continue current treatment cre Continie care ct computerized tomography CVA cerebrovascular accident D +. dizziness“: - : es DAGBR ~~ ‘diplomat of the chiropractic board of radiology. mepc Dc DIP DNP. Do DSEP pT DIR Dx ECG EEG EENT EMG EMS ER ESI FD FHx FTYROW FWB Fx GB GL cu _ byhr. 2 & By o 2 i doctor of chiropractic discontinued or discharged distal interphalangeal joint did not perform doctor of osteopathic medicine dermatomal sensory evoked potential drop table ~ deep tendon reflex diagnosis electrocardiogram electroencephalogram car, eyes, nose, throat electromyogram electrical muscle stimulation emergency room epidural steroid injection fair (muscle strength, balance) flexion/distraction, full duty (work status) family history foot (measurement, not body part) failure to yield right of way full weight bearing fracture good (muscle strength, balance). gallbladder : gastrointestinal genitourinary hour history and physical headache head, car, eyes, nose, throat herniated nucleus pulposus heart rate height historyIF imp. Fre LBP LE Loc MBP MD Meds. min. mo. MCP MP. MRB MRI “NAD NAN NCV _ NE neg. _NNFDA inoe Nev NSR Nss 2 2 3 @ 8 3 2 * 2° interferential impression knee jerk left lumbar spine pound Tow back pain lower extremity loss of consciousness mid-back pain medical doctor modified duty medications muscle fun minutes month metacarpalphalangeal motion palpation medical review board magnetic resonance ima; test normal (muscle strength), nausea (CNS Watch) no abnormalities detected no abnormalities notes nerve conduction velocity ot employed negative . 6 known food or drug allergies night, at night” next pat normal sinus rhythm no, signs or symptoms, - «non weight bearing, . anOBS ge PA PBSB PERRLA PHx PMT pa PNF PNI POMR pos. poss PRE prn PSIS Pt; pt. PWB ad. - gh gid qn © 3 = 3 3 3 ie £ objective obstetrics organic brain syndrome once daily off-work poor (muscle strength) plan (treatment plan) posterior/anterior pain between shoulder blades pupils, equal, round, reactive to light and accommodations past history perform manual therapy pain proprioceptive neuromuscular facilitation peripheral nerve injury problem oriented medical record positive possible progressive resistive exercise whenever necessary posterior superior iliac spine physical therapy patient — weight bearing every : every day - every-hour fouir times a day every night . right removed (ENS Watch) rheumatoid arthritis.re: R/O ROF ROM ROS RROM SAA SB sc sa sI SLE SLR SMT SOAP SOB SP. SP SSEP Sx TB TENS. THR - TMJ TNR TOR TPR UBP ° st 2 3 3 com & 3 regarding registered nurse rule out report of findings range of motion review of systems : resistive range of motion treatment, prescription, therapy subjective same as above shoulder blades (scapula) sternoclaviewlar joint sedentary duty sacroiliac systemic lupus erythmatosus straight leg raise spinal manipulative treatment subjective, objective, assessment, plan shortness of breath static palpation standard procedure somatosensory evoked potential symptoms thoracic spine tuberculosis transcutaneous electrical nerve stimulator total hip replacement temporomandibular joint tonic neck reflex .tenidér on palpation temiperature, pulse & respiration upper back pain . eo upper extremity.” . upper motor neuron itpper respiratory infectionwe wie wh wk. WNL wot wt ylo yr. 2 3 a 3 6 ts z ultrasound unable to determine urinary tract infection unable to perform unable to rate vomiting work conditioning Worker's Compensation work hardening week within normal without incident weight its number of times performed years old Year none positive negative ato with without, - same, no change progressing toward, leading to worse, increasing better, decreasing - .