APPENDIX 1-COMMONLY USED ABBREVIATIONS, ACRONYMS AND TERMS IN LONG-TERM CARE SETTINGS

Transcription

1 APPENDIX 1-COMMONLY USED ABBREVIATIONS, COMMONLY USED ABBREVIATIONS, ACRONYMS AND TERMS IN LONG-TERM CARE ADE Adverse Drug Event. ADL Activities of Daily Living. ADR Adverse Drug Reaction. AIMS Abnormal Involuntary Movement Scale. AL/ALF/ALC Assisted Living! Assisted Living Facilities/ Assisted Living Communities. ALC Assisted Living Community. AMDA American Medical Directors Association. BBA Balanced Budget Act. BBRA Balanced Budget Refinement Act. CARF Commission on Accreditation of Rehabilitation Facilities. CCRC Continuing Care Retirement Community. CFR Code of Federal Regulations. CGP Certified Geriatric Pharmacist.

2 CMD Certified Medical Director (through AMDA). CMN Certificate of Medical Necessity. CMS Centers for Medicare and Medicaid Services. CNA Certified Nurse Assistant. CNA Certified Nursing Assistant. CORF Comprehensive Outpatient Rehabilitation Facility. CP Consultant Pharmacist. CPT Common Procedural Terminology - uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. CQI Continuous Quality Improvement. DJD Degenerative Joint Disease. DME Durable Medical Equipment. DNR Do Not Resuscitate. DON Director of Nursing. Revised: August 20 lo

3 DRR Drug Regimen Review. DX Diagnosis. ECF Extended Care Facility. ERR Electronic Health Record. EMR Electronic Medical Record. EPS Extrapyramidal Symptoms. FQHMO Federally Qualified Health Maintenance Organization. F-tag A designation used by state survey agencies to identify particular tag sets within the state operation manual's interpretative guidelines. H&P History and Physical. HCPCS Healthcare Common Procedure Coding System. HE DIS Healthplan Employer Data and Information Set - An automated database for Managed Care; HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have information to compare the performance of managed health care plans. HHC Home Health Care - Care provided to individuals in their homes. Patients must need a skilled service (nursing, PT, OT, ST) to qualify for Medicare home health benefit; also have to be homebound and need help only intermittently. If patient qualifies, patient can also get assistance from a home health aide.

4 APPENDIX 1- COMMONLY USED ABBREVIATIONS, HOA Hours of Administration- facility-specific, scheduled times for administering medications (e.g., in one facility, 'BID' may have HOAs of9am and 5pm). Hospice Program of palliative (comfort) care for persons who are dying. Medicare covers hospice services, which may be provided at home or in a hospital or SNF. Individual must be certified by physician as having less than 6 months to live. ICF Intermediate Care Facility. ICF/MRDD Intermediate Care Facility for the Mentally Retarded/Developmentally Disabled. IPO Insured Product Option. LOA Leave of Absence; used to denote a time period during which a resident leaves a facility and stays with family. LPN Licensed Practical Nurse. LTC Long Term Care. LTCF Long Term Care Facility. MCO Managed Care Organization. MDS Minimum Data Set - used for assessment and care, quality assurance and improvement, reimbursement, and survey process. MLP Midlevel Practitioner. MMSE Mini-Mental State Examination. Revised: August 20 I 0

5 MR Medication Record. MRR Medication Regimen Review. MSS Medical Social Services. MSW Master of Social Work or Medical Social Worker. MTM Medication Therapy Management Services. NDC National Drug Code. NF Nursing Facility - can be used to denote a nursing home that is not certified for Medicare (e.g. not a SNF) Generally speaking, this term is synonymous with nursing home; As stated within the Nursing Facility Survey Interpretive Guidelines, for purposes of reimbursement and certification by CMS, a nursing facility is defined as an institution (or a distinct part of an institution) that is primarily engaged in providing: skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, heath-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases. They also must have in effect a transfer agreement with one or more hospitals having agreements under Section 1866 of the SOM and meet the requirements for a NF described in subsections (b), (c), (d). NF National Formulary. NHA Nursing Home Administrator. OASIS Outcome and Assessment Information Set (for home care).

6 OBQI Outbound-Based Quality Improvement (used by Medicare certified home health care agencies to measure patient outcomes). OBRA Omnibus Budget Reconciliation Act. OSCAR Online Survey Certification and Reporting- compilation of data elements collected by surveyors during the inspection survey, including operational characteristics, aggregate resident characteristics and deficiencies for each facility. PA Physician Assistant. PAC Post-acute care- services patients receive after an acute illness, usually entailing a hospital stay. Can refer to SNF/NF, and home health services, as well as other rehabilitation services. PASARR Preadmission Screening and Annual Record Review. PDP Prescription Drug Plan. POS Physician Order Sheet. POS Point of Service. PPS Prospective Payment System. PSRO Professional Standards Review Organization. QA Quality Assurance. QAAC Quality Assessment and Assurance Committee American Society of Consultant Pharmacists and MED-P ASS, Inc.

7 Ql Quality Improvement. Ql Quality Indicator. QI Qualified Individual (Medicare). QIO Quality Improvement Organization. QM Quality Measures - publicly reported measures of facility performance and quality of care derives from MDS data. QMB Qualified Medicare Beneficiary. RAI Resident Assessment Instrument. RAP Residential Assessment Protocol- used for decision making, care planning and implementation, and evaluation. RBRVS Resource Based Relative Value System. RNAC Registered Nurse Assessment Coordinator- collects information. RUGs Resource Utilization Groups - category-based classification system in which nursing facility residents are classified into a particular RUG group that designates the level of resource utilization necessary to care for that resident. RVUs Relative Value Units- components used in calculating Medicare Physician Fee Schedule. S&C Survey and Certification. scu Specialized Care Unit.

8 APPENDIX 1- COMMONLY USED ABBREVIATIONS, SLMB Specified Low-Income Medicare Beneficiary. SNF Skilled Nursing Facility - A nursing facility (or specially certified part of one) that participates in Medicare. Generally speaking, this term is synonymous with nursing home; As stated within the Nursing Facility Survey Interpretive Guidelines, for purposes of reimbursement and certification by CMS, an SNF is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing: skilled nursing care and related services for residents who require medical or nursing care, and rehabilitation services for the rehabilitation of injured, disabled, or sick persons. SNFs are not primarily for the care and treatment of mental diseases. They must have in effect a transfer agreement with one or more hospitals having agreements under Section 1866 of the SOM and meet the requirements for an SNF described in subsections (b), (c), (d). SOAP Subjective Objective Assessment and Plan- way to organize and document findings and care plan specifics in clinician's progress notes. SOM State Operations Manual. TAR Treatment Administration Record. UM Utilization Management. UR Utilization Review American Society of Consultant Pharmacists and MED-P ASS, Inc.