Occupational Therapy Abbreviations and Jargon

You’ve received a copy of your occupational therapy notes so you can be more involved in your care, but now you are reading what seems to be gibberish.

As occupational therapists, we are conflicted in our note writing. We want to make the process efficient to maximize patient care time, but we also want to communicate clearly. Many occupational therapists’ notes then turn into a type of hybrid language.

Example note: Pt. performed supàsit with Mod A.

Translation: Patient performed supine to sitting position with moderate assistance.

Do not to let this intimidating language be a barrier to reading your notes and being more involved in your care. If needed, ask your occupational therapist for clarification. Below, we have compiled a list of common abbreviations to help you begin the deciphering process.

ADLs - Activities of Daily Living

ADLs are a cornerstone of occupational therapy treatment. ADLs refer to the daily activities needed for survival- feeding, dressing, toileting, etc. An OT’s goal is often to help clients participate in daily life as independently as possible, and ADLs are the most basic level that the therapist assesses.

Example note: Performed strengthening in order to increase ADL participation.

IADLs - Instrumental Activities of Daily Living

IADLs are daily tasks that are more complex than ADLs, but still essential to maintain a quality of life. These tasks are more easily delegated to another person or performed with the assistance of technology. IADls include tasks such as driving, communication management, financial management, meal preparation, shopping, etc.

Example note: Addressed cognitive skills in order to increase IADL participation.

MaxA/ModA/MinA/SBA/I - Maximum Assistance/Moderate Assistance/Minimal Assistance/Stand-by Assistance/Independent

These abbreviations comprise the common scale that OTs use to rate how much assistance is needed with ADLs, IADLs, and basic mobility. Many facilities will have set criteria for each category, for example, MaxA= more than 75% assistance required.

Example note: MinA required for feeding.

AROM - Active Range of Motion

In an OT evaluation for a client who has a physical condition, OTs will often measure the degree to which you can independently move your joints; this is referred to as AROM.

Example note: AROM shoulder flexion is WNL (within normal limits).

WNL - Within Normal Limits

There are two different scales OTs look at when measuring joint movement. The first is the normal range for movement of each joint.

Example note: Wrist extension is WNL.

WFL - Within Functional Limits

OTs may encounter clients who have joint range of motions that are less than average, for example, clients with arthritic shoulders. However, the client has dealt with this condition for long enough that the lack of motion does not impact their ability to function. The therapist may then designate this as WFL.

Example note: R shoulder flexion is WFL.

PROM - Passive Range of Motion

When AROM is not within normal limits, the OT will often further assess the joint by checking PROM, which is the extent to which your joint can move with assistance. This is helpful in assessing whether there is a problem with the muscle or at the joint itself.

Example note: Right wrist extension 0-30 degrees with PROM.

RUE/LUE - Right/Left Upper Extremity

This is the fancy OT way of saying right and left arm. In our defense, the upper extremity measurements do tend to include measurements of the shoulder, which the term “arm” alone may not connote. We do the same thing with the right and left lower extremities.

Example note: RUE AROM WNL.

LTG/STG - Long-term Goal/ Short-term Goal

Goal setting is part of almost every evaluation, and these goals are then referred to in progress notes.

Example note: LTG—Increase upper body dressing to MinA.

Occupational Therapy Jargon

Sometimes obscure words make their way into notes. Here are the most common:

• Doff - to remove (an article of clothing) from the body
• Don - to put on (an article of clothing)
• Supine - to lie flat on your back with the face upward

Additional Resources

This list of physical therapy abbreviations may be useful.