Occupational Therapy documentation is full of abbreviations that can look like alphabet soup. Whether you are a student on your first fieldwork rotation or a clinician switching to a new setting, knowing these shorthand terms will keep your notes accurate and your charting much faster. Below is a quick reference that you can bookmark for your future self.
Understanding and documenting ADLs is critical for treatment planning, progress tracking, and communicating with the healthcare team. When it comes to your evaluation + progress notes, these three will show up almost every time:
Documenting a patient’s level of assistance tells the team how much support a patient really needs. These levels of care follow a standard scale used across rehab settings. Here’s a breakdown of the most common you’ll need to know:
Abbreviation | Level | What It Means |
I | Independent | Patient performs the activity safely with no help. |
MOD I | Modified Independent | Patient completes the task independently but needs an assistive device or extra time. |
SBA | Stand-By Assist | The therapist is within arm's reach for safety but does not provide physical contact. |
CGA | Contact Guard Assist | The therapist maintains hands-on contact for safety but provides no physical support. |
MIN A | Minimal Assist | Patient performs 75% or more of the activity. |
MOD A | Moderate Assist | Patient performs 50-74% of the activity. |
MAX A | Maximal Assist | Patient performs 25-49% of the activity. |
DEP / Total A | Dependent/Total Assist | Patient requires full assistance to complete the task. |
In occupational therapy, we are constantly measuring movement. ROM measurements are often used in rehabilitation, hand therapy, and orthopedic settings. The most common abbreviations you will need to know are:
Lower-extremity patients often have specific restrictions that are prescribed directly by a doctor. Getting them wrong can put a patient at serious risk. You’ll need to understand these abbreviations to ensure safe therapy, progression, and accurate documentation.
Abbreviation | Status | Description |
NWB | Non-Weight-Bearing | No weight on the affected limb at all. |
TTWB | Toe-Touch Weight-Bearing | Patient can contact the ground with their toes for balance, but not for support. |
PWB | Partial Weight-Bearing | A limited percentage of body weight is allowed on the limb. |
WBAT | Weight-Bearing as Tolerated | Patients bear as much weight as they can handle without increased pain. |
FWB | Full Weight-Bearing | No restrictions. Full weight on the limb is permitted. |
As an Occupational therapist, you will encounter a wide variety of conditions. These diagnoses can come up regularly, no matter what setting you work in:
Abbreviation | Condition |
CVA | Cerebrovascular Accident (stroke) |
TBI | Traumatic Brain Injury |
SCI | Spinal Cord Injury |
CHF | Congestive Heart Failure |
COPD | Chronic Obstructive Pulmonary Disease |
BKA | Below-Knee Amputation |
CTS | Carpal Tunnel Syndrome |
DJD | Degenerative Joint Disease (osteoarthritis) |
DM | Diabetes Mellitus |
IDDM | Insulin-Dependent Diabetes Mellitus (Type 1) |
NIDDM | Non-Insulin Dependent Diabetes Mellitus (Type 2) |
HNP | Herniated Nucleus Pulposus (Herniated Disc) |
FX | Fracture |
PD | Parkinson’s Disease |
MS | Multiple Sclerosis |
ALS | Amyotrophic Lateral Sclerosis |
DVT | Deep Vein Thrombosis |
OTs work in many different healthcare environments, and each setting has its own shorthand.
As an Occupational Therapist, you will rely on a variety of devices and equipment to help your patients regain function, improve mobility, and reclaim their independence. This list goes on, but here are some you will often find used in OT settings for documentation, communication, and treatment planning:
Clear documentation is a must. Using the correct abbreviations will help save time and ensure that your team receives treatment plans, progress notes, and goals accurately.
Abbreviation | Meaning | Description |
H&P | History and Physical | Doctor’s initial comprehensive examination. |
IE | Initial Evaluation | OT’s first assessment of the patient |
STG | Short-Term Goal | Goal for days/weeks |
LTG | Long-Term Goal | Goal by discharge |
Tx | Treatment | Provided therapy/interventions |
S/P | Status Post | Indicates patient’s condition after an event or surgery (e.g., S/P left THA). |
PMH | Past Medical History | Patient’s previous illnesses, surgeries, or significant health events. |
Hx | History | Patient’s medical history |
HEP | Home Exercise Program | Exercises or activities assigned for home |
POC | Plan Of Care | Documented treatment that includes goals, interventions, and frequency |
D/C | Discharge | End of services; includes outcomes and recommendations |
BID | Twice a Day | (From Latin “bis in die”) Often used to indicate the frequency of exercises or interventions |
ECT | Energy Conservation Techniques | Strategy to help your patients manage fatigue and optimize their energy during day-to-day tasks |
SPT | Stand-Pivot Transfer | A safe technique to help a patient move from one place to another (e.g., bed to wheelchair) |
Occupational therapy uses a variety of tools to evaluate strength, cognition, mobility, and a person’s ability to complete both basic self-care and more complex tasks needed for independent living. Here are the abbreviations for some of the common tools used:
Abbreviation | Credential |
OT | Occupational Therapist |
OTA | Occupational Therapy Assistant |
COTA | Certified Occupational Therapy Assistant |
OTR/L | Occupational Therapist, Registered/Licensed |
OTD | Doctor of Occupational Therapy |
MOT | Master of Occupational Therapy |
MSOT | Master of Science in Occupational Therapy |
FAOTO | Fellow of the American Occupational Therapy Association |
BCG | Board Certified Gerontology |
BCMH | Board Certified Mental Health |
BCP | Board Certified Pediatrics |
BCRP | Board Certified Physical Rehabilitation |
To become an OTR or COTA, therapists must complete an ACOTE-accredited OT or OTA program, pass the NBCOT certification exam, and get licensed in their state.
The Joint Commission established its official "Do Not Use" list in 2004 to prevent medication errors in accredited healthcare facilities. These abbreviations are banned from handwritten orders and handwritten medication-related documentation.
Do Not Use | Potential Problem | Use Instead |
U or u (unit) | Mistaken for 0, 4, or "cc" | Write "unit" |
IU (International Unit) | Mistaken for IV or the number 10 | Write "International Unit" |
Q.D., QD, q.d., qd (daily) | Can get confused for one another; Period after Q mistaken for "I" and “O” mistaken for “I” | Write "daily" |
Q.O.D., QOD, q.o.d, qod (every other day) | Can get confused for one another; Period after Q mistaken for "I" and “O” mistaken for “I” | Write "every other day" |
Trailing zero (X.0 mg) | Decimal point missed; this can lead to overdosing | Write X mg |
Lack of leading zero (.X mg) | Decimal point missed | Write 0.X mg |
MS, MSO4, MgSO4 | MS can mean morphine sulfate or magnesium sulfate; MSO4 and MgSO4 can get confused for one another | Write "morphine sulfate" or "magnesium sulfate" |
Here are some additional abbreviations that are best to avoid in documentation:
Getting OT abbreviations down takes some time and can be overwhelming at first, but with practice, they will become second nature. Keep this reference handy, spell it out when unsure, and remember it all comes back to helping your patients reach their goals safely!