Glossary

Glossary of Terms

a

ABI

Acquired Brain Injury

ACO

An Accountable Care Organization is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.

ACLS

Advanced Cardiac Life Support

Activities Director

A member of the staff responsible for overseeing events and activities in assisted living and skilled nursing settings.

ADLS

Activities of Daily Living are basic actions that independently functioning individuals perform on a daily basis such as bathing, dressing, eating, transferring (to and from bed or chair) and caring for incontinence.

Acute Care

Healthcare in which a patient is treated for a brief but severe episode of illness or trauma. Usually given in a hospital by specialized personnel for a short period of time, unlike chronic care.

ADE

Adverse Drug Event

ADR

Adverse Drug Reaction

ADT

Admission, Discharge, Transfer

ABS

The Aggressive Behavior Scale measures items indicative of a resident's potential to disrupt/interfere with others. (MDS2.0/CCRS)

AIMS

Abnormal Involuntary Movement Scale

AL/ALF

Assisted Living/Assisted Living Facilities

Alzheimer’s Disease

Progressive, degenerative form of dementia that causes severe intellectual deterioration.

ARD

Assessment reference date

ATLS

Advanced Trauma Life Support

b

BIMS

Brief Interview for Mental Status

BLS

Basic Life Support

c

CAA

Care Area Assessment

CAM

Confusion assessment method

CAMH

Centre for Addiction and Mental Health (Canada)

CAP

Collections Action Plan

CAPs

Clinical Assessment Protocols (MDS2.0/CCRS)

Care Plan

Written plan of care for nursing care facility residents. Resident care plans are developed by an interdisciplinary care team and specify measurable objectives and service timetables to meet a resident's medical, nursing, mental and psychosocial needs.

CCC

Complex Continuing Care

CCD

Continuity of Care Document

CCH

Chronic Care Hospitals

CCRC

Continuing Care Retirement Community

CCRS

Continuing Care Reporting System

CDA

Clinical Document Architecture

Center for Medicare and Medicaid (CMS)

Element of the U.S. Department of Health and Human Services that finances and administers Medicare and Medicaid. Among other responsibilities, CMS establishes standards for the operation of nursing care facilities that receive funds under the Medicare or Medicaid programs.

CEU

Continuing Education Units

Certified Nursing Assistant

Trained, licensed nursing professional who assists with personal care needs, such as bathing, dressing or eating.

CF

Conversion Factor

CHESS

Changes in Health, End-Stage Disease and Signs and Symptoms. This scale detects frailty and health instability. It attempts to identify residents at risk of serious decline. (MDS2.0/CCRS)

CIHI

Canadian Institute for Health Information

CMA

Certified Medication Assistant

CME

Continuing Medical Education

CMI

Case mix index

CMT

Certified Medication Technician

CNN

CMS certification number

COMM

The Communication Scale brings together the two MDS items that tap expressive and receptive skills. (MDS2.0/CCRS)

CP

Care plan

CPS

Cognitive performance scale

d

D/C

Discontinue

Depressions Rating Scale (DRS)

This Depression Rating Scale can be used as a clinical indicator for depression. (MDS2.0/CCRS)

Director of Nursing (DON)

The nurse who oversees the care of all the residents at a health care facility. This nurse is responsible for the management of all fiscal and human resources required to provide around-the-clock care to the residents in the facility. The director of nursing has special training in health care management, and in some places, must hold a special license.

DHC

District Health Council

Director of Care (DOC)

The nurse who oversees the care of all residents at a health care facility. This nurse is responsible for the management of all fiscal and human resources required to provide around-the-clock care to the residents in the facility.

DOH

Department of Health

e

eINTERACT

The industry’s first initiative designed to improve care and reduce unnecessary hospital admissions by bringing the tools and quality improvement strategies of the INTERACT (Interventions to Reduce Acute Care Transfers) program to EHR software platforms through an industry-standard certification program.

Electronic Health Record (EHR)

An electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across different health care settings. In some cases this sharing can occur by way of network-connected, enterprise-wide information systems and other information networks or exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

Electronic Medical Administration Record (eMAR)

Medication administration in the long-term care setting represents a complex and often burdensome process. Providers have traditionally employed communication tools such as phone and fax in combination with paper-based record keeping for the ordering, distribution, and monitoring of medication and treatment to residents/patients. With PointClickCare eMAR, many innovative facilities have replaced these time-consuming processes with an easier and safer way to administer medications.

EMC

Enterprise management console

f

FUQ

Follow-up question

h

Health Level Seven International (HL7)

HL7 is the global authority on standards for interoperability of health information technology

HFA

Home for the Aged

HIE

Health Information Exchange

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) sets the standard for protecting sensitive patient data.

HIPPS

Health Insurance Prospective Payment System

HISP

Health Information Service Providers

HOA

Hours of Administration

Hospice

A care facility specializing in and providing end-of-life care.

HSO

Health Service Organization

i

ICD

International Classification of Diseases & Diagnosis

IHSP

Integrated Health Services Plan

Index of Social Engagement (ISE)

This scale is shown to be predictive of resident’s social engagement. (MDS2.0/CCRS)

Integrated Medication Management

A new standards-based solution that supports the seamless, real-time electronic exchange of medication information and pharmacy orders between PointClickCare’s electronic health record (EHR) platform and pharmacy systems.

INTERACT

Interventions to Reduce Acute Care Transfers: INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Inter-RAI

Inter-RAI is a collaborative network of researchers in over 30 countries committed to improving care for persons who are disabled or medically complex. The consortium strives to promote evidence-informed clinical practice and policy decision making through the collection and interpretation of high-quality data about the characteristics and outcomes of persons served across a variety of health and social services settings. Inter-RAI owns the MDS suite of tools outside of the US.

IRM

Inquiry Referral Management

l

LHIN

Local Health Integration Network

Licensed practical nurse (LPN)

Certified professional who provides basic bedside care under the direction of a registered nurse (RN) or physician.

LIP

Low Income Patient

LVN

Licensed Vocational Nurse

m

MAR

Medication Administration Record

MDS

Minimum Data Set

Medicare

Health insurance program administered by the federal government. Medicare is available to people who are age 65 or older, permanently disabled, or affected by kidney failure or long-term kidney disease. Medicare does not provide a comprehensive long-term care component.

Medicare Part A

Hospital insurance that helps pay for inpatient hospital care, limited skilled nursing care, hospice care, and some home health care. Most people get Medicare Part A automatically when they turn 65.

Medicare Part B

Medical insurance that helps pay for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover (like some in-home health care). Part B helps pay for these covered services and supplies when they are medically necessary. A monthly premium must be paid to receive Part B.

MOH

Ministry Of Health

MPI

Master Patient Index

MPPR

Multiple Procedure Payment Reductions

MREP

Medicare Revenue Enhancement Program

n

NF

Nursing facility

NH

Nursing home

NPI

National Provider identifier

NPUAP

National Pressure Ulcer Advisory Panel

o

OT

Occupational Therapist

OBRA

Omnibus budget reconciliation act

OMRA

Other Medicare required assessment

OSRA

Other State Required Assessment

p

PT

Physiotherapist

PURS

The Pressure Ulcer Risk Scale identifies a resident’s risk for pressure ulcer development. (MDS2.0/CCRS)

PHQ-9

PHQ-9 stands for Patient Health Questionnaire-9. A mood interview used to help diagnose the severity of depression.

PPS

Prospective payment system

Point of Care (POC)

Point of Care is the ability to electronically capture documentation at or near where care is provided, usually on a mobile device or a mounted device in the vicinity. Also known as proximity of care when the device is mounted and not mobile.

PN

Progress Note

PAT

Preference assessment tool

q

Q

Nursing referenced time frame (i.e. Q 2 weeks). From the Latin “quaque” meaning “every”.

r

RUG

Resource Utilization Groups

RT

Recreation Therapist

RPN

Registered Practical Nurse or Registered Psychiatric Nurse (Canada)

RN

A Registered Nurse has graduated from a formal nursing education program and passed a state-administered exam. RNs have completed more formal training than licensed practical nurses (LPNs) and have a wide scope of responsibility including all aspects of nursing care.

RAI

Resident Assessment Index

s

STRIVE

Staff Time and Resource Intensity Verification Project

STNA

State Tested Nursing Assistant

STNA

State Tested Nursing Assistant

STM

Staff time measurement

ST

Speech therapist

SSI

Supplemental security income

SOB

Short of breath

SNF

Skilled nursing facility

SME

Subject Matter Experts

SLA

Service Level Agreement

SCU

Special Care Unit

SAAS

Software as a Service

SAA

Service Accountability Agreement

t

TAR

Treatment Administration Record

u

UDA

User defined assessment

v

VA NH

Veterans' nursing home

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