[RPN_2006]

I have been nursing for about eight months in home health. We always send follow-up reports with client to physician visits for further instructions. I can actually read this one, but am unsure about some of the abreviations used. I feel silly asking, but can you help?

Client is recieving simple packing to a pilonidal cyst. Drainage recently became ++foul smelling and green. I refered to physician, who apparently decided wound was healing nicely by peeling back the outer dressing and peeking inside, without removing the packing to visualise the wound....but that's another issue.

F/U report from physician states:

O/E pilonidal cyst
AA(*seenote) healing of pilonidal cyst
P/CCM :f/u if worsens

*does not actually appear as AA but rather a symbol that resembles two capital As overlapping


The only O/E I know is 'on exertion'
strange symbol is unknown to me but my interpretation is it must refer to the goal
P/CCM ? I don't know
follow up of worsens I understand just fine.

As an aside, no swab was taken or abx tx started.

Can anybody help me fill in the blanks?

[CritterLover]

Originally Posted by RPN_2006

I have been nursing for about eight months in home health. We always send follow-up reports with client to physician visits for further instructions. I can actually read this one, but am unsure about some of the abreviations used. I feel silly asking, but can you help?

Client is recieving simple packing to a pilonidal cyst. Drainage recently became ++foul smelling and green. I refered to physician, who apparently decided wound was healing nicely by peeling back the outer dressing and peeking inside, without removing the packing to visualise the wound....but that's another issue.

F/U report from physician states:

O/E pilonidal cyst objective exam
AA(*seenote) healing of pilonidal cyst Assessment
P/CCM :f/u if worsens plan (not sure what the ccm stands for)

*does not actually appear as AA but rather a symbol that resembles two capital As overlapping


The only O/E I know is 'on exertion'
strange symbol is unknown to me but my interpretation is it must refer to the goal
P/CCM ? I don't know
follow up of worsens I understand just fine.

As an aside, no swab was taken or abx tx started.

Can anybody help me fill in the blanks?

my interpretation

[jjjoy]

I'd think it's observation/examination
P for plan; ccm... continuing case management? (totally guessing there!)

AA?? yeah, maybe something with assessment...

how frustrating, huh?

[ZippyGBR]

o/e - on examination ? especially alone with a slash or dash between

P for plan ?

[classicdame]

Always best to ask the MD since you are liable for your actions after you interpret the order

[CritterLover]

Originally Posted by classicdame

Always best to ask the MD since you are liable for your actions after you interpret the order

I don't think it is an order --- more like a progress note. Nothing to "act" on.

[RPN_2006]

Thanks all for your replies.

Examination, assesment, plan...it makes perfect sense now.

I did not contact MD as I did not feel it was an order, and moreover it was late Friday aftenoon and the office was closed for the weekend. On a side note, I spend so much time chasing doctors and their office staff for clarification of written orders, I could pull my hair out. Is it against the law to write legibly? Even if they wrote every third letter legibly I could manage. It is embarrasing to be unable to read the orders while the homecare client is watching...they expect you to know...you ARE the NURSE!

I really appreciate your time, thanks again.

Angela.

[P_RN]

Just thinking "aloud" here: I wonder if your AA could have been zero (0) and a triangle med shorthand for change) or in this case No Change.

I've seen med students and residents use this abbreviation.

[KJRN79]

my first thought for CCM is Continue Case Management. Or something case management. That may make sense for a plan.

[allantiques4me]

I would definetly request for the DR to clarify the orders!That is your legal responsibility as a nurse.