Resident is a married White 84-year old woman admitted to My Better Nursing Home on 1/1/11 with Dx of Supercalifragilisticexpialidocious. ∅ psychotropic meds. Resident was born in NY, has a PhD in psychology, and worked in nursing homes until her retirement. Involved family. Chart reviewed and resident discussed with staff.
Resident was alert, Ox3, and cooperative with the interview. She reported some anxiety related to future events, and acknowledged occasional sleep disturbance. Some irritability noted. Prior MH tx; stated it was part of her training. No HSI. No ETOH. Speech logical and goal-directed; normal rate and tone. Fund of information good. No A/V hallucinations. ADLs good. Sense of humor intact.
Dr. El,
Short and to the point!
At the risk of sounding ignorant, what is HSI?
Thanks for asking, Sue. Here's the jargon dictionary:
Ox3 = oriented to person, place, and time
MH tx = mental health treatment
No HSI = no homicidal or suicidal ideation (thoughts)
No ETOH = no history of alcoholism
No A/V hallucinations = no audio/visual hallucinations (not seeing or hearing things other people don't see or hear)
ADLs = activities of daily living (such as personal grooming and getting dressed)
Dr.El,
I read your blog frequently and this entry caught my attention. Staff within long term care can communicate in a clinical nature (like your blog post). How would you communicate this the "involved family"?
Thanks,
Glenn
Hi Glenn,
I'm not sure I understand your question. Can you rephrase it? Thanks.
Dr. El,
I realize you labeled this post a personal reflection, but I often see long-term care professionals communicate in a similar fashion.
My challenge to you is rephrase this post as if you were talking to the son or daughter of this make-believe resident. The language does not feel very person centered.
Hope that helps
Thanks for clarifying, Glenn. I labeled this post as a personal reflection because I often think of how a clinician might write about me one day when I'm 84 and in a nursing home. You're right, it isn't person-centered language. In my evaluations, I try to capture the essence of the people I'm meeting — to make them whole, not just their diagnoses — and then put it into clinical language suitable for a medical chart. The residents and their families feel the love; my charting is symptom- and intervention-based.