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Discussion

Abbreviation Help

So..was wondering if someone could enlighten me on abbreviations...

NEC

NOS

S/P (im guessing this means surgical procedure.?)

SIADH (couldve been SIAPH also, couldnt really read it)

Also..how can "longterm steroids" be a diagnosis? I saw this on a clients chart and was slightly confused...

Thanks for ANY help!!

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Longterm steroids, can cause slow wound healing, etc.

s/p is status post

SIADH--syndrome of inappropriate antidiuretic hormone--you might want to look that up so you know what it is if your patient has it

NEC and NOS I an not sure about...were they used in a sentence?

When NEC and NOS appear in the same context, NEC is most likely "not elsewhere classified" and NOS would be "not otherwise specified." They are terms used in ICD-9 diagnosis coding, but you wouldn't usually see them in nurses notes or elsewhere in the patient's chart.

We also use NEC in the NICU for "necrotizing enterocolitis" - not likely to be what they're looking for here though.

A patient on long-term steroid therapy is likely to require medical care for the adverse effects of the drugs even if the original condition improves. In addition to wound healing issues, steroids can raise the blood sugar, cause marked weight gain, and precipitate major mood problems. It's likely that the patient requires steroids for a chronic condition but came to the clinic or hospital for one of these side effects.

A patient on long-term steroid therapy is likely to require medical care for the adverse effects of the drugs even if the original condition improves. In addition to wound healing issues, steroids can raise the blood sugar, cause marked weight gain, and precipitate major mood problems. It's likely that the patient requires steroids for a chronic condition but came to the clinic or hospital for one of these side effects.

And potential for GI bleeding...which is the kind of pt I see all the time.

suspect it should have read " long term USE of steroids"......resulting in .... and stated whatever the actual reasons were

  • Experts

this doctor must have gotten a couple of "talkings to" by medical billers because physician documentation is important to the billing for medical services. they must have had problems billing for him at one time or he himself was very involved in the billing.

  • nec - stands for "not elsewhere classified" and is a term used in the icd-9-cm diagnosis coding manual
  • noc - stands for "not otherwise specified" and is also a term used in the icd-9-cm diagnosis coding manual
    • doctors really shouldn't be using these two terms in their documentation. it is up to the coding people to apply codes to what the physician says a person's diagnosis is. some of those codes end up having these abbreviations after them and they are for clerical purposes only (but don't try to lecture the doctor about this). most doctors probably don't even know that nec and noc designations exist.

    [*]s/p - stands for "status post", as in status post a surgery or procedure of some sort. it just indicates that the patient had what follows the "s/p" done to them and is either currently recovering from it or fully recovered from it

    [*]siadh - stands for "syndrome of inappropriate antidiuretic hormone". this is a true medical diagnosis.

    [*]doctors are allowed to write their medical conclusions as well as diagnoses in their dictations in the "diagnosis" box on the face sheet of a patient's chart. "longterm steroids" would be taken by the medical coders in medical records, if that even ended up having to be coded for billing purposes, as a history of the effect of long term steroid use. if i had to bill this doctor's services i would have to ask the doctor to document a more specific diagnosis since "longterm steroids" isn't something we can code and there is no icd-9-cm diagnosis code for it. i would interpret that "longterm steroid" for your purposes on your school work as effects of longterm steroid use. to be on the safe side, i would ask your instructor how to interpret it as well. the doctor may have given more specific details on this (like the name of the drug and the symptoms that prompted the admission) in his dictated history and physical. you should also look at this post on gathering data from a patient's medical record: https://allnurses.com/forums/2228927-post5.html

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When NEC and NOS appear in the same context, NEC is most likely "not elsewhere classified" and NOS would be "not otherwise specified." They are terms used in ICD-9 diagnosis coding, but you wouldn't usually see them in nurses notes or elsewhere in the patient's chart.

We also use NEC in the NICU for "necrotizing enterocolitis" - not likely to be what they're looking for here though.

A patient on long-term steroid therapy is likely to require medical care for the adverse effects of the drugs even if the original condition improves. In addition to wound healing issues, steroids can raise the blood sugar, cause marked weight gain, and precipitate major mood problems. It's likely that the patient requires steroids for a chronic condition but came to the clinic or hospital for one of these side effects.

For NEC/NOS, it says things like :

Emphysema NEC

Hyperlipidemia NEC

Hypothyroidism NOS

For the steroids it just says:

longterm steroids

which is why I was confused...

Thanks for all the help!!;)

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