Medical Terms and Abbreviations Commonly Used in Long-Term Care Settings

Many medical terms and abbreviations are used by healthcare providers working in long-term care (LTC) settings. These terms can be confusing and may not be understood by the entire healthcare team. For example, a statement such as “this patient’s ADLs will be documented in the MDS, which will give us a better idea of her RUG category” may sound like a foreign language to someone who is not familiar with these acronyms. This review outlines and defines terms and abbreviations commonly used in LTC, which may serve as a useful resource for LTC staff, especially those who are new to this area of care.
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While I have attempted to make this list as comprehensive as possible, it is likely that some terms and abbreviations are not included. It should also be remembered that most medical abbreviations have multiple meanings (eg, CVA could stand for cerebrovascular accident or central venous access); thus, it is always important to consider the context in which an acronym is being used, and when in doubt, to ask for clarification. This article also outlines certain abbreviations that are now discouraged from being used in clinical practice, such as QD (quaque die, meaning once daily) or QID (quater in die, meaning 4 times daily) when prescribing medication, as they can be misinterpreted due to illegible writing, potentially leading to critical medication errors, such as an agent being underadministered or overadministered. These abbreviations, which appear in a boxed section, have been included in this article in an effort to explain what they stand for while also discouraging their use, as, despite serious concerns, these abbreviations are still routinely used by medical professionals. I would encourage you to review the terms outlined in this article and to discuss them with other members of the LTC healthcare team, who may not be familiar with them. To ensure proper communication between the entire LTC team, an understanding by all members of the terms and abbreviations outlined in this article is essential.

Medical Terms Used to Describe a Medical Diagnosis, Equipment, or Aspects of LTC

ADE Adverse drug event

An ADE is an unwanted, unpleasant, noxious, or potentially harmful reaction from a medication. This term is synonymous with an ADR, or adverse drug reaction.

ADLs Activities of daily living

ADLs refer to daily self-care activities, including bathing, dressing and undressing, toileting, functional mobility (eg, ambulating, getting in and out of bed), and eating. A variety of scales are commonly used to document a patient’s ability to perform ADLs and how much help the patient requires to perform a particular ADL.

ADR Adverse drug reaction

An ADR is the same as an ADE: an unwanted, unpleasant, noxious, or potentially harmful reaction from a medication.

BP Blood pressure

BP is a measurement of the force applied to the walls of the arteries as the heart pumps blood through the body. It is recorded as one number over another, with the upper number representing systolic pressure and the bottom number representing diastolic pressure (eg, 130/65 mm Hg). Systolic pressure represents the maximum pressure exerted when the heart contracts, whereas diastolic pressure represents the minimum pressure in the arteries when the heart is at rest.

CPR Cardiopulmonary resuscitation

CPR is the process of attempting to restore cardiac and/or pulmonary function in the event a patient’s heart stops beating and/or the patient stops breathing. It involves a combination of rescue breathing and chest compressions and often requires the additional administration of defibrillation if CPR alone is not successful.

CVA Cerebrovascular accident

CVA is another term for a stroke, which is a sudden interruption of blood flow, and, subsequently, oxygen to a localized part of the brain, resulting in damage to the brain.

H & P History and physical

H & P refers to the process of asking patients questions about their current and past medical problems, medication history, allergies, family history, social circumstances, and symptoms before proceeding with a physical examination. All new admissions to a skilled care nursing facility are required to have an H & P performed by a physician at the time of their admission.

IADL Instrumental activities of daily living

IADL relates to higher levels of functioning, such as managing finances, shopping for groceries, cooking, and using the telephone.

MI Myocardial infarction

MI is another term for a heart attack, which is a sudden interruption of blood supply to a part of the heart, resulting in damage to the heart.

PICC Line Percutaneous intravenous central catheter

PICC lines, also often referred to as peripherally inserted central catheters, are used when intravenous access is needed for a prolonged period of time, such as in patients who require total parenteral nutrition. Most patients who are given intravenous fluids or medications receive them through a peripheral vein. In some cases, however, a catheter is advanced through a smaller peripheral vein into a larger deep vein or directly into a large vein in the body; this is known as a PICC line, and it can be kept in place for a longer period of time than a peripheral catheter.

TIA Transient ischemic attack

TIA is a temporary, focal impairment of brain function caused by a temporary interruption of blood flow to a localized part of the brain. It is an indication that the patient is at risk for a stroke, or CVA.

WNL Within normal limits

WNL is used when a clinical finding is normal (eg, a skin examination shows normal skin, a laboratory examination shows a white blood cell count that is within the normal range).

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Clinical and Quality of Care Measures and Organizations

CAA Care Area Assessment

The CAA provides a framework for the review of areas of concern triggered by the completion of the Minimum Data Set (MDS; described later in this section). The MDS provides only a preliminary assessment of the patient, whereas the CAA provides a more comprehensive assessment of specific areas of concern, and each area of concern (eg, skin care) is a care area trigger (CAT; see next definition).

CAT Care Area Trigger

CATs identify conditions that require further evaluation before a care planning decision is made. CATs are identified by the Minimum Data Set (MDS; described later in this section) through the aforementioned CAA process. There is little difference between the old Resident Assessment Protocols (RAPs; described later in this section) and CATs.

CQI Continuous Quality Improvement

CQI is an effort to improve patient care by identifying areas of concern and implementing interventions to prevent poor outcomes.

HEDIS Healthcare Effectiveness Data and Information Set

HEDIS is a tool used by more than 90% of healthcare plans in the United States to measure performance on important dimensions of care and services. HEDIS measures address a broad range of important health issues (eg, blood pressure control) and make it possible to compare the performance of different health plans.

MDS Minimum Data Set

The MDS is part of the U.S. federally mandated process for clinically assessing all residents in Medicare- and Medicaid-certified nursing homes. This process provides a comprehensive assessment of each resident’s functional capabilities and helps nursing home staff identify health problems. The MDS is also used as a tool to calculate how much the nursing home will bill Medicare for the care provided. MDS Version 3.0 was recently introduced; more information can be found at https://bit.ly/CMS-MDS.

NPUAP National Pressure Ulcer Advisory Panel

NPUAP (www.npuap.org) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research. In collaboration with the European Pressure Ulcer Advisory Panel (EPUAP; www.epuap.org), NPUAP has published guidelines for pressure ulcer prevention and treatment, which can be purchased through the NPUAP Website.

OASIS Outcome and Assessment Information Set

OASIS is a key component of Medicare’s partnership with the home care industry to foster and monitor improved home healthcare outcomes, and is proposed to be an integral part of the revised Conditions of Participation for Medicare—certified home health agencies.

OMRA Other Medicare Required Assessment

OMRA is required for nursing home patients when the nursing home is receiving Medicare Part A payments for care and after all therapy ends, but Part A coverage continues for skilled nursing services.

PRO Peer Review Organization

The PRO is a physician group or other professional medical organization that assumes responsibility for reviewing the quality and appropriateness of services covered by Medicare and Medicaid. PROs determine whether services are medically necessary, provided in accordance with professional standards, and, in the case of institutional services, rendered in an appropriate setting.

QCI Quality of Care Indicator

QCIs are resident-centered outcome and process indicators constructed from calculations of downloaded MDS data and data collected onsite during a state survey. An example of a QCI is the number or percentage of patients in a skilled nursing facility who have unexplained weight loss.

QIO Quality Improvement Organization

QIOs seek to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. The Centers for Medicare & Medicaid Services (CMS; described in the next section) contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands, to serve as that state/jurisdiction’s QIO contractor. QIOs are private organizations, mostly nonprofits, that are generally staffed by physicians and other healthcare providers who are trained to review medical care, help beneficiaries with complaints about the quality of care, and implement improvements in the quality of care available throughout the care spectrum.

RAI Resident Assessment Instrument

RAI is a standardized approach that helps nursing home staff gather definitive information on a resident’s strengths and needs, ensuring appropriate care. RAI includes three components: MDS Version 3.0, the CAA process, and the RAI Utilization Guidelines, which outline how to use the RAI. Once a resident assessment protocol (RAP; see next definition) has been triggered, the RAI Utilization Guidelines are used to evaluate the problem and determine a care plan.

RAPs Resident Assessment Protocols

RAPs are the documents that form part of the RAI. These documents contain information about many healthcare topics (eg, pressure ulcers, asthma) and provide a structured, problem-oriented framework for organizing MDS information.

RUG Resource Utilization Group

A RUG is any of a number of groups into which a nursing home resident on Medicare is categorized based on his or her functional status and anticipated use of services and resources. Data are abstracted from the MDS to determine a RUG level, and the amount a nursing home is reimbursed by Medicare is determined by a patient’s RUG categorization. The newest version of RUG is RUG-IV; more information on RUG-IV is available at https://bit.ly/CMS-RUGIV-INFO.

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Payment, Government, and Regulatory Terms and Organizations

CDC Centers for Disease Control and Prevention

The CDC (www.cdc.gov) is a federal agency that works to provide guidelines for the prevention and treatment of infectious diseases.

CMS Centers for Medicare & Medicaid Services

CMS (www.cms.gov) is a branch of the U.S. Department of Health and Human Services that administers the Medicare program and monitors the Medicaid programs offered by each state.

DEA U.S. Drug Enforcement Administration

The DEA (www.justice.gov/dea) enforces the controlled substances laws and regulations of the United States. Healthcare providers who have prescribing authority are assigned a DEA number.

FDA U.S. Food and Drug Administration

The FDA (www.fda.gov) is a federal agency dedicated to protecting the U.S. public’s health by assuring the safety, effectiveness, and security of human and veterinary pharmaceuticals, vaccines and other biological products, medical devices, food and dietary supplements, cosmetics, and products that emit radiation.

HIPAA Health Insurance Portability and Accountability Act of 1996

HIPAA is a federal law that was passed in 1996 to help protect a patient’s medical information. According to HIPAA, patient information needs to remain confidential and should only be shared with those who have authority to see the information.

OBRA Omnibus Budget Reconciliation Act

OBRA, also known as the Nursing Home Reform Act of 1987, has dramatically improved the quality of care in nursing homes over the past 20 years by setting forth federal standards on how care should be provided to residents. Improvements include less use of antipsychotic drugs, a reduction in the use of chemical and physical restraints, and a reduction in the inappropriate use of indwelling urinary catheters.

OSCAR Online Survey and Certification and Reporting System

OSCAR is a data network maintained by CMS in cooperation with the state LTC surveying agencies. It serves to compile all of the data elements collected by surveyors during the inspection survey, which is conducted at nursing facilities for the purpose of certifying these facilities to participate in Medicare and Medicaid programs.

PPS Prospective Payment System

PPS is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. It resulted from the Balanced Budget Act of 1997, which mandated the implementation of a per diem prospective payment system for skilled nursing facilities covering all costs (routine, ancillary, and capital) related to the services furnished to beneficiaries under Medicare Part A.

TJC The Joint Commission

TJC (www.jointcommission.org), formerly the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), is an organization that assesses various levels of healthcare delivery, including hospitals and nursing homes, and certifies that these institutions meet certain standards of care.

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Professional Qualifications and Terms

APRN/APN Advanced Practice Registered Nurse (Nurse Practitioner)/Advanced Practice Nurse

APRN/APN defines a level of nursing practice that requires extended and expanded skills, including experience and knowledge in assessing, planning, and implementing the patient care required. In most states, an APRN/APN can prescribe medications, and, depending on the state in which he or she works, may or may not need to work under the supervision of a physician.

CEU Continuing Educational Unit

CEU is a standardized measure of educational effort. Many professionals and most healthcare professionals have to demonstrate their participation in educational endeavors to maintain their licensure.

CME Continuing Medical Education

CME is intended to keep physicians current with the knowledge and practices of their profession, and is a requirement to maintain their licensure. CME can be obtained through various means, including taking educational courses, through self-study, and by attending medical conferences.

CNA Certified Nurse Assistant

CNAs, also called patient care assistants (PCAs), perform a variety of services, including answering patient call signals, turning and repositioning patients, observing patients’ conditions, measuring and recording food and liquid intake and output, assessing vital signs, and reporting any observed changes to professional staff.

DON Director of Nursing

A DON is a registered nurse (RN; described later in this section) who supervises the care of all of the patients at a healthcare facility.

LPN Licensed Practical Nurse

In most LTC settings, LPNs can provide many of the same nursing services provided by a registered nurse (RN; described later in this section); however, an LPN cannot be a DON in a skilled care nursing facility.

MD Medical Doctor

MDs, also called physicians, are healthcare providers who assess and treat patients. MDs have the authority to order a full range of medical tests and prescribe a full range of medications. The medical director of a skilled nursing facility must be a physician.

MSW Medical Social Worker

MSWs provide a variety of services in LTC, including facilitating admissions to the facility, assisting residents and their family members with medical insurance and payment issues, and, in some instances, providing counseling.

PA Physician Assistant

A PA, also known as a physician associate, is a healthcare professional who is licensed to practice medicine under the supervision of a licensed physician. In LTC settings, PAs perform many of the same duties as APRNs/APNs. PAs can prescribe medications, conduct physical examinations, and diagnose and treat illnesses, among other duties.

RN Registered Nurse

An RN’s scope of practice is determined by each state’s Nurse Practice Act, which outlines what tasks the RN may or may not legally perform in that state. In general, RNs administer medications and monitor and assess patients.

SALSA Supervisor of Assisted Living Services Agency

SALSA refers to the head nurse at an assisted living services agency, which is a requirement in most states.

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Advocacy and Professional Organizations

AAHSA American Association of Homes and Services for the Aging

AAHSA, which is now referred to as LeadingAge (www.aahsa.org), is an association of approximately 5400 nonprofit organizations that are dedicated to improving the quality of life for older individuals by advancing policies, conducting research, and promoting practices that empower people to live fully as they age.

AALTCN American Association for Long Term Care Nursing

The AALTCN (https://ltcnursing.org) strives to unite all levels of nursing staff to advance excellence in LTC nursing by providing relevant educational opportunities to LTC nurses and advocating for LTC nursing.

AARP American Association of Retired Persons

AARP (www.aarp.org), formerly known as the American Association of Retired Persons, is a nonprofit, nonpartisan membership organization that seeks to help people 50 years and older to improve their quality of life.

ACCP American College of Clinical Pharmacy

ACCP (www.accp.com) is a professional and scientific society that provides leadership, education, advocacy, and resources to clinical pharmacists, enabling them to achieve excellence in practice and research.

AGS American Geriatrics Society

The AGS (www.americangeriatrics.org) is a nonprofit organization of approximately 6400 healthcare professionals who are devoted to improving the health, independence, and quality of life of all older people.

AHCA American Health Care Association

The AHCA (www.ahcancal.org) advocates for quality care and services for frail, elderly, and disabled individuals.

AMDA American Medical Directors Association

The American Medical Directors Association, formerly known simply as AMDA, is now referred to as AMDA – Dedicated to Long Term Care Medicine www.amda.com. This organization, which includes medical directors, attending physicians, and others practicing in the LTC continuum, strives to ensure excellence in LTC patient care by providing education, advocacy, information, and professional development to its members.

ANA American Nurses Association

The ANA (www.nursingworld.org) represents the interests of the nation’s 3.1 million RNs through its constituent member nurses associations, organizational affiliates, and the Center for American Nurses (https://centerforamericannurses.org), a workforce advocacy affiliate.

ASA American Society on Aging

The ASA (www.asaging.org) is an association of diverse individuals bound by a common goal: to support the commitment and enhance the knowledge and skills of those seeking to improve the quality of life of older adults and their families.

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Abbreviations Used for Ordering Medications

The use of these abbreviations is discouraged in clinical practice, as they can frequently be misinterpreted and lead to prescribing errors. For example, QD may easily be interpreted on a prescription as QID, which can result in a medication being underadministered or overadministered, as previously mentioned. These abbreviations, which are derived from Latin terms, may appear in uppercase or lowercase and with or without periods on prescriptions.

AC Ante cibum

AC means before meals and refers to a medication being administered preprandially.

BID Bis in die

BID means twice a day.

PRN  Pro re nata

PRN means when necessary (eg, a medication may be administered PRN for pain).

QD Quaque die

QD means once a day.

QHS Quaque hora somni

QHS means at bedtime.

QID Quater in die

QID means 4 times a day.

TID Ter in die

TID means 3 times a day.

The author reports no relevant financial relationships. Dr. Coll is professor, Family Medicine, and associate director for clinical program, Center on Aging, University of Connecticut Health Center, Farm