SNF Glossary

ADLs: Activities of Daily Living. The 6 core ADLs are bathing/showering, dressing/grooming, eating/feeding, mobility/transferring, and toileting.

Compliance: Refers to following all state, federal, and Medicare rules and guidelines. If a facility is not following a rule, then they are considered “out of compliance”.

Care Plan Meeting: A team meeting with rehab, nursing, social work, the patient, and family to discuss the patient’s plan of care.

Custodial Care: When a patient is receiving non-medical, long term care at a facility.

Director of Nursing (DON): Manager of the nursing staff.

Director of Rehab (DOR): Manager of the rehab department.

EMR: Electronic Medical Record. Point Click Care (PCC) is often used in SNFs for the nursing staff, and NetHealth is often used for rehab staff. These are just two very common examples, there are many others.

IADLs: Instrumental Activities of Daily Living. These are complex ADLs required to successfully live independently in a community. IADLs include, but are not limited to, finance management, medication management, shopping, meal prep, transportation, and housework.

Interdisciplinary Team (IDT): The group of professionals in a SNF who manage patient care as a team, including but not limited to, the medical director, nurses, dieticians, physical therapists, speech-language pathologists, occupational therapists, nursing assistants, social workers, MDS coordinator, building administrator, and activities director.

MDS: Minimum Data Set; an evaluation that must be completed for all residents.

MDS Coordinator: Minimum Data Set Nurse, whose job is to manage the assessment, care-planning, and documentation for residents. The MDS nurse can add things to a patient’s care plan for you—such as if they always need to be out of bed for meals or have oral care 3x/day. The MDS nurse can also add diagnoses to the patient’s diagnoses list if you find something documented during your chart review that is missing from the list in the patient’s EMR.

Notice of Medicare Non-Coverage (NOMNC): A form given to patients receiving therapy to inform them that therapy services will be ending. This form must be given to the patient at least 48 hours before services end. The patient or their legal representative signs the form to acknowledge they received it, and they have the right to appeal if they disagree with being discharged.

Patient Driven Payment Model (PDPM): This is the name for the current reimbursement system for SNFs. The payment amount that a facility receives for a specific patient is dependent on their clinical diagnoses and care needs. This system uses information from the Minimum Data Set (MDS) to classify patients by needs such as nursing, PT, ST, etc. to determine how much the facility is paid per day.

Power of Attorney (POA): The person appointed to make decisions on behalf of your patient in the event that they are unable to make decisions for themselves. This can also be called a patient’s legal representative. Someone can be appointed as a medical POA (only makes medical decisions), financial POA (only makes financial decisions), or both. This is determined by a legal document that the person fills out and signs while they are still competent.

Risk Meeting: Review of residents at risk for decline, readmission, weight loss, etc.

Section GG: You will hear PT/OT mention GG a lot. It is the portion of the MDS relating to functional abilities such as ambulating, toileting, dressing, etc.

Section K: A specific part of the MDS where an SLP, dietician, or the MDS nurse answers questions related to the patient’s dysphagia and swallowing. It depends on your specific building who fills it out. Many companies have the Section K questions built into an SLP’s evaluation so the MDS nurse can just open the SLP eval and copy over the answers. The dietician or MDS nurse may ask you these questions about a specific patient to help ensure their documentation is accurate. Section K is part of the Minimum Data Set that determines reimbursement under PDPM.

Skilled Care: When a patient is receiving medical care at a facility, whether that be from nursing staff, rehab staff, or both.