Medical Abbreviations

The use of medical abbreviations has been used since the development of medicine and is a longstanding practice. They are thought to save time and space when writing medical records. Additionally, they are cost effective and can be customized. While many healthcare facilities have gone to electronic records, the practice of handwritten records still exists, thus the continuance of handwritten medical abbreviations.  

Paper records are prone to errors. Illegible writing causes confusion and at times, a delay in care due to a need for follow up with the author for clarification; especially when it comes to medication orders and dispensing. Many abbreviations may have more than one meaning and the staff interpreting the record may not be familiar with the abbreviation being used.  

In 2005 The Joint Commission, an enterprise that accredits and certifies healthcare organizations, adopted a list that is forbidden to be used by Joint Commission accredited facilities. Below is the list along with an explanation of the potential problem.  

*DO NOT USE POTENTIAL PROBLEM USE INSTEAD  
U, u Mistaken for “0” (zero), the number “4” (four) or cc Write “unit” 
IU (international unit) Mistaken for IV (intravenous) or the number ten (10) Write “International Unit” 
Q.D., QD, q.d., qd (daily)   Mistaken for each other  Write ‘daily” 
Q.O. D., QOD, q.o.d., qod Period after the Q mistaken for “I” and the “O” mistaken for “I” Write “every other day” 
Trailing zero (X.o mg) (Applies to medication orders) Decimal point is missed  Write X mg Write 0.X mg 
MS     MSO4 and MgSo4 Can mean Morphine Sulfate or Magnesium Sulfate   Confused for one another  Write “morphine sulfate” Write “magnesium sulfate” 

 2020 The Joint Commission Fact Sheet 

*List does not apply to preprogrammed health information technology systems.  

The Joint Commission has made a recommendation to not sure the symbols for “greater than” or “less than” as they may be interpreted for the letter L or the number 7. The symbol for at (@) is discouraged because it may be misinterpreted as the number 2. Instead, providers should write out the words, “greater than”, “less than” or “at” as they appropriately apply in the chart.  

Misinterpretation of abbreviations may result in patient harm to include death. R&G nurses are skilled at reading handwritten records and recognized when a contributing error has occurred. If you are an attorney and need help with your case, please contact R&G at 1-888-486-2245. 

Medical Cannabis

Medical Cannabis

Medical cannabis remains a controversial topic throughout the United States as many states are repealing associated restrictions. Both recreational and medicinal cannabis is now available in a handful of states.  Despite the growing research supporting cannabis as a pain management and rehabilitation tool, the federal government continues to classify cannabis as a Schedule 1 drug. This makes cannabis federally illegal, as well as limits medical studies that would better explore the benefits. 

Cannabis and cannabis derivatives are used to treat the symptoms of many ailments and illnesses, such as cancer, PTSD, AIDS, epilepsy, and more.  According to a 2017 study published in Cancer Chemotherapy and Pharmacology, pharmaceutical cannabis can decrease nausea caused by chemotherapy and almost eliminate vomiting. Cannabis has also been found to relieve the spasticity of the muscles that is sometimes associated with multiple sclerosis and can help treat appetite loss and “wasting” associated with conditions such as HIV/AIDS and certain types of cancers. One chemical compound of the cannabis plant, Cannabidiol (CBD), has been used to treat and reduce seizures in people with epilepsy (specifically Lennox-Gastaut syndrome and Dravet syndrome). Cannabis is used to treat chronic pain, and in some cases may be used instead of opioids for pain management. (Opioids are highly addictive and are typically not recommended for long-term use in treating chronic pain.)  Cannabis may also be beneficial in symptom management of some mental health conditions, such as PTSD.

While there are many benefits to using cannabis, there is still much we do not know about this plant and its long-term usage. For example, studies have shown that frequent use may seriously affect short-term memory, as well as impair cognitive ability. While there are many ways to ingest cannabis, smoking anything can seriously damage your lung tissue. Immediate side effects of cannabis use may include paranoia, elevated heart rate, anxiety, and impaired motor function.  Long-term effects may include mood swings, lung infections, panic attacks, and memory loss.  Signs of impairment may include red eyes, delayed reaction time, poor hand-eye coordination, lack of concentration, and decreased perception of time and distance.

Cannabis has been implicated in a high percentage of automobile crashes and workplace accidents. A review of the medical record and summary of care often provides insight into the extent and timing of cannabis use in relation to a mishap.  R&G is here to help with reviews of cases involving cannabis.  Please call 623-566-3333 or 1-888-486-2245 for more information about case reviews. 

Virtual Nurse Associate

Virtual Nurse Associate

What is a virtual nurse associate?  
A virtual associate is an independent contract worker who works remotely in support of clients nationally. Typical tasks include administrative, technical, and business support services. Legal Nurse Consultants are well suited to work in a similar capacity serving law firms who may need assistance on a regular or per diem basis. This allows firms to scale staffing to their immediate needs and “right-size” when/if workflow subsides.  

What does a virtual office assistant do?  
Virtual nurse associates do many things including records analysis, case summaries, chronologies, identifying missing records and/or gaps in care, as well as identifying experts. A virtual nurse can do almost anything an in-house nurse can do. A virtual nurse associate can easily maintain office hours consistent with their clients or work in an asynchronous fashion, whichever benefits the client the most.   

Skills Set of a Virtual Nurse Associate  

Working virtually can be a challenge and is not a good fit for everyone.   Some people find working remotely to be isolating and stressful and prefer to work in an office environment.  Nurses are adaptable and are well suited to virtual work.  Characteristics of most nurses include:  

  • Self-starter 
  • Ability to set and see goals through fruition. 
  • Able to manage multiple competing priorities. 
  • Problem-solving skills.  
  • Excellent oral and written communication skills  

Benefits of Working with a Virtual Nurse Associate  

Communication virtually with a nurse associate need not be a challenge. The nurse can adapt their online hours to match that of the client. Should short notice taskings arise the nurse is available, just as an in-house nurse would be.  

Working with a virtual nurse associate is cost-effective in that they can be used as much or as little as needed. No doubt this model increases profits for firms. For example, the nurse could be used for a working surge before trial. If a client needs to “right-size,” no-layoff will occur as the nurse is an independent contractor without any benefits typical of an employee. The Virtual Nurse Associate does not require other benefits from their clients such as sick time, paid time off, vacation time, health insurance, or retirement benefits.  

A virtual nurse is an excellent fit for a firm who is searching for their “best fit” but needs assistance in the interim. If a less experienced nurse is hired, a virtual nurse could also serve as a mentor to the new nurse. Should the new nurse turn out not to be the best fit, the virtual nurse continues to service the firm seamlessly.  

R&G Medical Legal Solutions, LLC has a virtual nurse program, and no job is too big or too small. R&G nurses have a wide variety of backgrounds to include medical-surgical, emergency department, critical care, and long-term care, just to name a few. This allows firms to take a variety of cases knowing R&G can match the virtual nurse to the background of the case. Please contact Pamela Showers, COO at 623-566-3333 for rates and any questions.  

How Chronologies Can Assist the Client in Litigation

May 2021 

Chronologies provide an exact and easy to read timeline of medical events. They are an efficient means to parse out relevant data related to a case. When records are voluminous, or a precise and detailed identification of critical events are needed, a chronology may be warranted.  

There are many styles and formats for creating a chronology. Information such as the date, time, place, and provider of care are identified. Further customizable details such bates numbers, an explanation of medical terms/abbreviations, imbedding of pdf medical record pages, and comments regarding standard of care are sometimes included per client preference. Chronologies can be written in a partial verbatim format whereas the nurse utilizes exact words from the chart, or can a summary be written in the nurse’s own words as an interpretation of events. There is no one size fits all chronology. Sometimes a combination of verbatim and pertinent verbatim can be used to produce the most efficient work product.  Pertinent style may be used for events surrounding the alleged injury, while a summary is used for related but noncritical information. Headers within the chronology can be used to identify information such as the source document and author. 

Microsoft Word or Excel can be used as the foundation for a chronology.  The table format is Word is most common.  There is also specialized software to create work products however, given chronologies are sometimes shared, compatibility can be an issue. 

BATES DATE /TIME SOURCE COMMENT 
Pdf 00123 of 000150  Or  JDOE-WAVERLYMED-00010 03/23/2021  0700 Waverly Medical Center / Bill Smith, MD   23 yo presents to ER with cough x3 days & fever 103.2. SOB, unable to complete sentences without cough  SOB = shortness of breath 
Example of a Chron entry

Small, seemingly unrelated events are often a precursor to an injury. Non-medical staff may lack insight and real-world experience needed to understand the relevance to injury and thus, these details are often omitted from the work product. Nurse provided chronologies are a cost-effective way to obtain relevant case data. Through training and education, nurses have in-depth medical knowledge regarding standards of care and the ability to analyze data and link events to breaches in the standard of care, Missing and tampered records as well as gaps in medical care are easily identifiable to a nurse.  

R&G Medical Legal Solution’s nurses provide accurate chronologies and customizable work products. Please call 623-555-3333 today to find out more information about obtaining case related chronologies.