This Monday after Easter we continue our abbreviation series with another type of post hospitalization care.
This is the most common area outside of the hospital that personal injury attorneys see malpractice cases, because of the long term patient stays, low and inappropriate staffing levels, and general lack of funds.
Without further ado:
SNF- Skilled Nursing Facility
Pronounced "SNIFF" like when you have the sniffles.
A SNF is more commonly called a nursing home, and outside of the medical community you will not hear them referred to as SNF's. The reason for the term is to differentiate them from assisted living facilities (next week's abbreviation).
A SNF has nursing care (RN) around the clock even if they don't have an appropriate numbers. A SNF can take patients who are not as sick as those who need LTAC services, but still require nursing care.
As with LTAC the most common place to see or hear the abbreviation is in the case management notes or in the discharge notes and instructions.
Examples
Electronic information about admission transferred to three SNF for admission approval.
Discharge to SNF once accepted.
Monday, March 28, 2016
Monday, March 21, 2016
Abbreviation
Spring came yesterday to the northern hemisphere, and in the DC area was rung in with a last fight for winter. So with spring comes dieting because summer is just around the corner and everyone wants to look their best when wearing the least amount of clothing.
Today's abbreviation came from there. Again, a title. This is someone whom you may not want to depose in a medical malpractice case as they make recommendations but usually have very little influence in the application of their recommendations. Tomorrow I'll elaborate on their recommendations as I finally pick back up our series on pressure ulcers.
Without further ado:
RD- registered dietitian
The registered dietitian is a specially trained person who addresses the dietary needs of our clients. They make recommendations to the best diet to meet the nutritional needs of the client, including healing.
Many times they have their own section of a chart where they along with the staff that works in the dietary office comments on the status of the clients dietary needs and makes suggestions.
Examples
Debbie Dieter RD
Seen by RD recommendations reviewed and approved by MD.
These are about the only places that you see RD in the records, however frequently you see the word dietitian. The registered dietitian like the nurse has specialized training in the dietary needs of the clients they see.
Today's abbreviation came from there. Again, a title. This is someone whom you may not want to depose in a medical malpractice case as they make recommendations but usually have very little influence in the application of their recommendations. Tomorrow I'll elaborate on their recommendations as I finally pick back up our series on pressure ulcers.
Without further ado:
RD- registered dietitian
The registered dietitian is a specially trained person who addresses the dietary needs of our clients. They make recommendations to the best diet to meet the nutritional needs of the client, including healing.
Many times they have their own section of a chart where they along with the staff that works in the dietary office comments on the status of the clients dietary needs and makes suggestions.
Examples
Debbie Dieter RD
Seen by RD recommendations reviewed and approved by MD.
These are about the only places that you see RD in the records, however frequently you see the word dietitian. The registered dietitian like the nurse has specialized training in the dietary needs of the clients they see.
Monday, March 14, 2016
Abbreviations
Today we're going to look at another title. This will be the first in looking at 3 titles leading up to another longer post, where having an understanding of the individual titles will help with understanding of the healthcare system rather than a specific encounter in the medical record. I find that having an excellent understanding of the healthcare system allows the client and attorney to communicate better and the attorney achieve better outcomes for the client.
Today's abbreviation:
LTAC- Long term acute care
An LTAC is a type of hospital. When it is abbreviated it is pronounced el-tack. A long term acute care hospital is similar to a traditional acute care hospital but the patients need ongoing acute care. The patients tend to be in these hospitals for months at a time. Patients are very sick, but stable. Many places feature an OR, ICU, and other critical care needs, but they do not necessarily feature absolutely everything that is in an traditional acute care hospital, such as MRI machines, ER's and other diagnostic services. Not all long term acute care hospitals have operating rooms or intensive care units, so many times the sickest of the sick are transferred back to a traditional acute care hospital.
The most common area to see this information is in the discharge planning from an acute care hospital.
Examples
Pt. to be transferred to LTAC when cleared by surgery.
Insurance approved LTAC stay, pt. to be discharged on Thursday to LTAC.
Today's abbreviation:
LTAC- Long term acute care
An LTAC is a type of hospital. When it is abbreviated it is pronounced el-tack. A long term acute care hospital is similar to a traditional acute care hospital but the patients need ongoing acute care. The patients tend to be in these hospitals for months at a time. Patients are very sick, but stable. Many places feature an OR, ICU, and other critical care needs, but they do not necessarily feature absolutely everything that is in an traditional acute care hospital, such as MRI machines, ER's and other diagnostic services. Not all long term acute care hospitals have operating rooms or intensive care units, so many times the sickest of the sick are transferred back to a traditional acute care hospital.
The most common area to see this information is in the discharge planning from an acute care hospital.
Examples
Pt. to be transferred to LTAC when cleared by surgery.
Insurance approved LTAC stay, pt. to be discharged on Thursday to LTAC.
Monday, March 7, 2016
Abbreviation
Over the course of our lifetime we come into contact with a number of seemingly duplicate abbreviations, and today our abbreviation is one that we need to look at when examining people who provided patient care.
This abbreviation is a person's role at the institution in which they are currently employed and may change if they move to another institution or get promoted within the institution, so it is important to identify when speaking to them, that you are interested in speaking with them in that particular role because that was the role they served for the patient.
With that:
CM- case manager or case management
A key note about this abbreviation, unless it is the person's writing style to inconsistently capitalize letters, this abbreviation is always capitalized to help differentiate it from cm (centimeters).
Examples
Pt. was seen by CM staff today ahead of d/c to ensure all HH needs were addressed.
(Patient was seen by case management staff today ahead of discharge to ensure all home health needs were addressed).
Nancy Nurse RN, MSN, CM
This abbreviation is a person's role at the institution in which they are currently employed and may change if they move to another institution or get promoted within the institution, so it is important to identify when speaking to them, that you are interested in speaking with them in that particular role because that was the role they served for the patient.
With that:
CM- case manager or case management
A key note about this abbreviation, unless it is the person's writing style to inconsistently capitalize letters, this abbreviation is always capitalized to help differentiate it from cm (centimeters).
Examples
Pt. was seen by CM staff today ahead of d/c to ensure all HH needs were addressed.
(Patient was seen by case management staff today ahead of discharge to ensure all home health needs were addressed).
Nancy Nurse RN, MSN, CM
Monday, February 22, 2016
Abbreviations
Today's abbreviation is leading to an article I hope to post in the next couple of weeks that deals with the ethics of death and dying. Death and dying and the ethics involved have been on my mind lately, and I am working on an interesting piece.
So ahead of that an important abbreviation.
POLST or MOLST
POLST- Physician's Orders for Life Sustaining Treatment
MOLST- Medical Orders for Life Sustaining Treatment
These are not likely to be abbreviations that are common in the medical record, as the use of this form is relatively new. But understanding how they work is important for the medical provider, lawyer, and anyone involved in the client's care.
A living will is a way to speak for yourself if you become incapacitated. It is NOT physician's orders and is designed to guide your family and your physician to your wishes. A POLST or MOLST is a set of physicians orders which dictates exactly what to do in an emergency situation or decline. A fully filled out POLST or MOLST also includes information about tube feeding, long term mechanical ventilation, antibiotics, and other measures that may be desired by the patient. They are discussed in detail with a physician and carry the weight of physician's orders.
Like DNR forms these are bright colored forms that go with clients or patients as they move through the healthcare system and many times photocopies of this form are acceptable. In most of healthcare a photocopied form is not accepted as a physicians order, but DNR forms as well as a few other forms they are accepted.
Although these are less than 10 years old, not only with the increased connections due to digitization of the medical record, and living longer with more complex medical conditions, these will become more common.
You will likely see these abbreviation as follows:
EXAMPLE
Pt. has a POLST and verified with physician.
Discussed MOLST form with patient and family and began completion on this visit.
So ahead of that an important abbreviation.
POLST or MOLST
POLST- Physician's Orders for Life Sustaining Treatment
MOLST- Medical Orders for Life Sustaining Treatment
These are not likely to be abbreviations that are common in the medical record, as the use of this form is relatively new. But understanding how they work is important for the medical provider, lawyer, and anyone involved in the client's care.
A living will is a way to speak for yourself if you become incapacitated. It is NOT physician's orders and is designed to guide your family and your physician to your wishes. A POLST or MOLST is a set of physicians orders which dictates exactly what to do in an emergency situation or decline. A fully filled out POLST or MOLST also includes information about tube feeding, long term mechanical ventilation, antibiotics, and other measures that may be desired by the patient. They are discussed in detail with a physician and carry the weight of physician's orders.
Like DNR forms these are bright colored forms that go with clients or patients as they move through the healthcare system and many times photocopies of this form are acceptable. In most of healthcare a photocopied form is not accepted as a physicians order, but DNR forms as well as a few other forms they are accepted.
Although these are less than 10 years old, not only with the increased connections due to digitization of the medical record, and living longer with more complex medical conditions, these will become more common.
You will likely see these abbreviation as follows:
EXAMPLE
Pt. has a POLST and verified with physician.
Discussed MOLST form with patient and family and began completion on this visit.
Monday, February 8, 2016
Post Superbowl Abbreviation
I hope everyone enjoyed the Super Bowl. For me my favorite was all the Super Bowl Babies, and seeing that guy from Carolina flying over both teams for the touchdown, even though Carolina went on to lose.
So because the Super Bowl usually involves snacks I thought we'd do a post Super Bowl food related definition.
CHO - Carbohydrate
Basically a carbohydrate is not a protein, but most people associate carbohydrates with bread products and sweets because they're what our body recognizes first as carbohydrates, in other words the body doesn't have to much to break down carbohydrates into usable sugars.
The most common space to see this abbreviation is in diet orders or discussions about diet. For any number of reasons patients can be on what's called a carbohydrate controlled diet, limiting the amount of carbohydrates that the person eats in an attempt to either control a disease process or for health promotion.
Example
Diet Order: CHO controlled
Pt reports decreased BG levels on CHO controlled diet. (Patient reports decreased blood glucose levels on carbohydrate controlled diet).
So because the Super Bowl usually involves snacks I thought we'd do a post Super Bowl food related definition.
CHO - Carbohydrate
Basically a carbohydrate is not a protein, but most people associate carbohydrates with bread products and sweets because they're what our body recognizes first as carbohydrates, in other words the body doesn't have to much to break down carbohydrates into usable sugars.
The most common space to see this abbreviation is in diet orders or discussions about diet. For any number of reasons patients can be on what's called a carbohydrate controlled diet, limiting the amount of carbohydrates that the person eats in an attempt to either control a disease process or for health promotion.
Example
Diet Order: CHO controlled
Pt reports decreased BG levels on CHO controlled diet. (Patient reports decreased blood glucose levels on carbohydrate controlled diet).
Tuesday, January 26, 2016
Pressure Ulcers
This is where things get tricky. If they weren't tricky before, they get tricky now. Stage 1 and two pressure ulcers are only at the surface of the skin.
Stage III pressure ulcers are the first pressure ulcer that does not involve intact skin that involves more than damage to the skin surface. The difference between a stage III and a stage IV ulcer is the not the size (the total area of the ulcer) but the depth of the ulcer. A stage 3 ulcer involves the fat that lies below the skin, and there is some debate as to whether or not it involves the musculature, but it absolutely does NOT involve bone exposure or that the clinician can feel the bone through the tissue. (sometimes called palpable).
Once you get away from the surface ulcers (stage 1 and stage II) size NO LONGER MATTERS.
Let me repeat that SIZE NO LONGER MATTERS.
I'll say it one more time SIZE NO LONGER MATTERS.
I'm pretty sure I cannot emphasize this point enough, because its hard to wrap your head around. The idea that a stage 3 pressure ulcer that is the size of your entire back is actually not worse than a stage 4 pressure ulcer the size of a pencil that goes all the way to the bone on your leg. This is because the one on across your back looks worse than the one on your leg. In truth the one on the back is NOT worse than the one on the leg.
I'll get into the multitude of problems that a stage IV pressure ulcer can cause next week, because that's not our focus, our focus is the stage III ulcer.
Stage III ulcers like stage I ulcers tend not to last terribly long if they're not caught and treated almost immediately. Its not long before a stage III ulcer without treatment develops into a stage 4 ulcer.
Depending on the depth, treatment usually involves keeping the wound bed moist and clean to promote healthy tissue generation, and the surrounding tissues dry to prevent additional breakdown, and regular turning and repositioning of the client. If the client's nutritional status has not been previously evaluated, it is CRITICAL to get their nutritional status evaluated and start nutritional support if it's needed. This is because the body puts it's energy into healing these wounds, and it has been my finding, as it has been many others, that patients without adequate nutritional support not only take longer to heal but also are at significantly increased risks for developing additional pressure ulcers and infections.
Pressure ulcers are a slippery slope and once started down them if a stop is not put in place immediately it can lead to death.
For all pressure ulcer cases it is important to have at least one nurse evaluate the case, because the first line of prevention is the nurse providing day to day care. A wound nurse is ONLY called in once a wound has formed.
Stage III pressure ulcers are the first pressure ulcer that does not involve intact skin that involves more than damage to the skin surface. The difference between a stage III and a stage IV ulcer is the not the size (the total area of the ulcer) but the depth of the ulcer. A stage 3 ulcer involves the fat that lies below the skin, and there is some debate as to whether or not it involves the musculature, but it absolutely does NOT involve bone exposure or that the clinician can feel the bone through the tissue. (sometimes called palpable).
Once you get away from the surface ulcers (stage 1 and stage II) size NO LONGER MATTERS.
Let me repeat that SIZE NO LONGER MATTERS.
I'll say it one more time SIZE NO LONGER MATTERS.
I'm pretty sure I cannot emphasize this point enough, because its hard to wrap your head around. The idea that a stage 3 pressure ulcer that is the size of your entire back is actually not worse than a stage 4 pressure ulcer the size of a pencil that goes all the way to the bone on your leg. This is because the one on across your back looks worse than the one on your leg. In truth the one on the back is NOT worse than the one on the leg.
I'll get into the multitude of problems that a stage IV pressure ulcer can cause next week, because that's not our focus, our focus is the stage III ulcer.
Stage III ulcers like stage I ulcers tend not to last terribly long if they're not caught and treated almost immediately. Its not long before a stage III ulcer without treatment develops into a stage 4 ulcer.
Depending on the depth, treatment usually involves keeping the wound bed moist and clean to promote healthy tissue generation, and the surrounding tissues dry to prevent additional breakdown, and regular turning and repositioning of the client. If the client's nutritional status has not been previously evaluated, it is CRITICAL to get their nutritional status evaluated and start nutritional support if it's needed. This is because the body puts it's energy into healing these wounds, and it has been my finding, as it has been many others, that patients without adequate nutritional support not only take longer to heal but also are at significantly increased risks for developing additional pressure ulcers and infections.
Pressure ulcers are a slippery slope and once started down them if a stop is not put in place immediately it can lead to death.
For all pressure ulcer cases it is important to have at least one nurse evaluate the case, because the first line of prevention is the nurse providing day to day care. A wound nurse is ONLY called in once a wound has formed.
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