Deciphering the MD follow-up report

CritterLover, BSN, RN · Jul 20, 2007

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, LPN · Jul 20, 2007

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, BSN, RN · Jul 20, 2007

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

P for plan ?

classicdame, MSN, EdD · Jul 20, 2007

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

CritterLover, BSN, RN · Jul 20, 2007

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 · Jul 20, 2007

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, ADN, RN · Jul 20, 2007

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 · Jul 21, 2007

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

allantiques4me · Jul 21, 2007

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

TazziRN, RN · Jul 21, 2007

it was late Friday aftenoon and the office was closed for the weekend.

I was in this position yesterday. I saw a pt who had just been given an insulin pen, and a note that said "Increase Lantus by 5 units." Pt and Husband were confused about the dose so I called the NP who had seen her and changed her dose. She told me on the phone "Have her take 45 units every morning."

I get back to the office a few hours later and someone hands me a faxed order from the same NP: "Instruct pt on use of insulin pen and increase Lantus to 60 units every morning."

Uh.....called the office and they had closed early for the weekend.

MAISY, RN-ER, BSN, RN · Jul 21, 2007

CCM continue close monitoring?