Admissions Flashcards
(193 cards)
1
Q
Who is usually the first person the patient encounters on the Nursing Unit?
A
unit clerk
2
Q
urgent or direct admission
A
Occurs when a patient is brought directly to patient registration from a doctor’s office or clinic. They bypass the admitting and emergency department and go directly to the nursing unit. Direct admissions may be routine or emergency admissions.
3
Q
routine, elective or scheduled admissions
A
Occurs when the patient and doctor elect when to schedule a non-emergency surgery or procedure and are planned in advance. When a physician sees a patient in their office and determines a procedure or surgery is necessary, the physician will contact the hospital and arrange a routine elective admission.
4
Q
pre-admission clinic
PAC
A
Patients admitted to the hospital for surgery are pre-admitted by the PAC unit clerk. ) The PAC Unit Clerk will contact the patient as to when to come to the hospital. At that time a nurse will complete a history, obtain a signed consent and direct the patient to the appropriate department for a pre-admission work-up. The patient will then be given a date and time to arrive at the hospital for their surgery/procedure.
5
Q
When are patients admitted for surgery or procedure?
A
The day of surgery/procedure or the day before
6
Q
Where is the patient taken after surgery?
A
Recovery Room
7
Q
What happens to the patient once their time in the Recovery Room is finished?
A
Admitted to the unit as an inpatient or discharged home if they are stable after day surgery
8
Q
How is a Unit Clerk able to keep an eye on which patients are coming into or leaving their unit?
A
Checking the OR Room slate
9
Q
emergency admission
A
These admissions are unplanned and are the result of an accident, sudden illness, or other medical crisis. Patients enter the hospital through the emergency department where they are assessed by a triage nurse. Some arrive by ambulance, others walking or by wheelchair. He/she will determine if the patient requires urgent care or those who are not urgent may have to wait longer to see a physician.
10
Q
In the Emergency Dept., who determines if a patient should be admitted to the hospital?
A
ER physician
11
Q
Who does the ER Unit Clerk contact if a patient is to be admitted?
A
Admitting Department
12
Q
Who transfers the patients?
A
Porter
13
Q
transfer from another facility
A
The patient will be admitted directly to the Unit from another hospital or Care Facility and is brought to the unit, often via ambulance.
14
Q
Some hospitals require _____ to perform the duties of the admitting department.
A
Unit Clerk
15
Q
When is the bed assignment made for emergency and direct admissions?
A
When the patient arrives at the hospital and is ready for a room
16
Q
When is the bed assignment determined for an elective admission?
A
The evening before or at the beginning of the shift of the patient’s expected arrival
17
Q
Where do you obtain current admitting information?
A
Admission-Separation Record
18
Q
What is a Face Sheet?
A
The first form completed for the patient. It originates in the admitting department and then is sent to the unit to be placed into the patient’s chart.
19
Q
What information is contained on a Face Sheet?
A
All of the patient’s pertinent information ex. patient’s full name, next of kin, address, doctor, diagnosis, personal healthcare number (PHN), allergies, etc.
20
Q
What is a Consent for Treatment Form?
A
This allows the physician and other medical staff to treat, care and diagnose the patient while the patient is in the hospital. If the patient requires any surgery or invasive procedure, another consent form will be obtained. This must be signed by the patient.
21
Q
What is the Discharge Summary Form?
A
A form that becomes part of the patient’s chart and when the patient is discharged from the hospital, the responsible physician will complete a brief summary of the patient’s care and history while in the hospital.
22
Q
What is the Information Collection Authorization Form?
A
A form that allows the patient to decide whether they wish to have information disclosed about them during their hospital stay as laid out by the Freedom of Information and Protection of Privacy Act (FIPPA). It must be signed by the patient.
23
Q
What is the Patient Release Form?
A
A form states the hospital is not responsible for personal effects brought into the hospital by the patient.
24
Q
Who keeps an up-to-date census of all empty beds and co-ordinate the appropriate admissions for those beds?
A
Bed Control, Bed Utilization
This department can have other names
25
Who does the Unit Clerk in Bed Control communicate with regarding discharges?
Admitting Department
26
addressograph card
Plastic card still used in some hospitals
27
Where are extra identification labels stored?
At the front of the patient's chart in a plastic sleeve
28
identification bracelet
A bracelet that is addressographed or labeled, then placed around the patient's wrist for the duration of the patient's stay
29
allergy bracelet
An additional bracelet to be worn by the patient if there are any allergies
30
hospital number
A number unique to that patient.
31
If a patient has been admitted to one particular hospital for the first time, what will they receive?
hospital number
32
If a patient is visiting the same hospital for a 2nd (or more) time, do they receive a new hospital number?
No, they use the same number as before.
33
There are 7 steps in the general process of admission. What are they?
1. The patient is admitted at patient registration.
2. A patient Admission-Separation form is completed.
3. If the patient goes to Emergency they will be assessed, have a history taken, then be seen by a Physician.
4. Prior to any procedures or bloodwork the patient will be given an identification armband.
5. Sometimes bloodwork and other diagnostic tests are performed in ER such as an ECG, or CXR.
6. If the patient is being admitted as an Inpatient to a Unit they will be assigned a bed in an appropriate Unit.
7. The porter will transport them, their belongings and any paperwork generated in Admitting and ER.
34
Records from Admitting to the Nursing Unit
1. Record of Admission/Separation
2. Consent for Treatment (Release of Responsibility)
3. Addressograph/Patient Identification Labels
4. Armband/I.D. Bracelet (Allergy band prn)
35
armbands
Form of patient identification
Helps hospital staff identify that they are working with the correct patient. Must be confirmed before beginning any diagnostics or procedures
36
Where is the armband worn?
On the patient's wrist
37
white armband
for inpatients, and is addressographed or labelled
38
red armband
For those patients with allergies. Worn on the opposite wrist from the white armband and the allergies are written in black permanent marker.
39
What are some things that Bed Control needs to take into account when making a decision?
- When a bed becomes available and then decide which patient to assign the bed to
- May require isolation, constant supervision, or specialty medical/surgical needs
40
List the 6 things that Bed Control needs to advise the Nursing Unit of for a new admission
1. Patient Name
2. Patient Age
3. Admitting Diagnosis
4. Attending Physician
5. Room & Bed Number (may be discussed with Unit)
6. If patient has any Isolation Precautions
41
What happens to the patient's personal belongings upon admission?
They are placed somewhere that is known and accessible to the patient
42
What are some forms of storage available for the patient's belongings?
A designated locker and bedside table in the patient's room
43
Patients are discouraged from keeping large amounts of money or expensive jewelry with them. The Nurse will suggest they do one of two things. What are they?
1. Be taken home by a family member
| 2. Placed in the hospital safe which is usually in the cashier's office
44
Does the NUC have responsibility for a patient's personal belongings?
Generally, no but they may be asked by the patient's nurse to assist in taking any valuables to the hospital safe for safekeeping
45
Where are the patient's personal belongings placed?
In a numbered valuables envelope
46
A form is included with the numbered valuables envelope. What needs to be done with this form?
All items in the envelope are listed on the form.
The form should be attached to the outside of the envelope with two carbon copies attached
47
Who signs the personal belongings envelope?
The patient or responsible party, as does the Nurse as a witness
48
What happens to all copies of the personal belongings form?
The original copy stays with the chart
Second copy goes to the patient
Third copy goes with the valuables
49
What happens to a patient's valuables upon discharge?
The valuables will only be surrendered to the person whose name appears on the face of the envelope or someone authorized to act on their behalf
50
Does the hospital charge to store valuables?
No
51
What happens after hours with a patient's valuables?
- They can sometimes be locked in the narcotics cupboard.
- Placed in a valuables envelope and the staff member (including the NUC) Patients are discouraged from keeping large amounts of money or expensive jewelry with them.
52
What happens if the patient does not claim their belongings?
Attempts are made by the hospital to contact the patient and arrange for these items to be picked up.
If unsuccessful or not followed up on by the patient, the items are sent to the Lost and Found Department
53
admission orders
Initial written directives by the doctor for the care and treatment of the patient.
54
What are the 9 common components of an admissions order?
Initial written directives by the doctor for the care and treatment of the patient.
55
hold tray
early tray
late tray
For patients going to or returning from OR, tests, or treatments
56
fluid restrictions
Patients retaining fluid in tissues (edema)
57
push or force fluids
Patients who are dehydrated and require additional juices, tea, etc.
58
natural laxatives
Bran, Fruitlax, etc. - ordered by the doctor.
59
calorie count
A 24 hour calorie count record. RN records each item the patient has eaten on the calorie count sheet
60
Patients on special diets receive a _______ between meals which is delivered to the patient by the _______.
Snack
RN
61
What do diabetic patients receive before bedtime?
A snack
62
Food and Nutrition Services delivers a quota of ______ to the unit.
Bottled water
63
What are some examples of food supplies ordered by the NUC?
- Juice
- Bread
- Becel / butter
- Jell-o
- Ice cream
- Milk
- Sugar
- Cheese
- Crackers
- Gingerale
- Popsicles
- Peanut butter
- Jam
64
What are the 3 methods of feeding?
1. Ingestion (po)
2. Enteral feeding – NG tube
- gastrostomy tube
* * liquid and semi-solid
3. Parenteral nutrition – TPN
* * carbohydrates, proteins, fats, electrolytes, vitamins & minerals
65
What are the 4 roles of Nutrition Services (Dietary)?
1. To meet the therapeutic needs and dietary preferences of the patient.
2. Preparing and serving food for patients.
3. To aid in development and monitoring of special therapeutic diets.
4. Providing dietary information to patients
66
There are 17 common dietary orders. Can you name some?
1. Regular / DAT / General
2. GI soft
3. Mechanical soft
4. Pureed / Minced
5. No thin liquids / thick fluids only
6. Diabetic diet
7. Renal diet
8. Neutropenic
9. Lactose controlled
10. Nothing by mouth (NPO)
11. Clear fluids
12. Full fluids
13. Cardiac diet
14. Controlled sodium
15. Controlled calorie
16. Tube feed
17. Dysphagia / Thickened
67
regular / DAT / general
For patients who have no dietary restrictions
68
GI soft
For patients with nausea and distention, usually post surgical patient
69
mechanical soft
For patients who have trouble chewing or swallowing
70
pureed / minced
For patients with problems chewing and swallowing, ex. no dentures
71
no thin liquids / thick fluids only
To prevent choking
72
diabetic diet
For patients who cannot produce enough insulin
73
renal diet
For patients with renal disease
74
neutropenic
To reduce the number of bacteria entering the stomach for patients on chemotherapy or those with immune deficiency diseases
75
lactose controlled
For patients who experience stomach disturbances after drinking/eating products containing milk
76
nothing by mouth (NPO)
For patients pre & post surgery, scheduled for procedures, tests or as indicated
77
clear fluids
For patients whose digestive system should not or cannot digest whole foods.
Ex. Pre and post surgery
78
full fluids
For patients who cannot eat solid foods
79
cardiac diet
Low sodium, no sugar, low cholesterol
80
controlled sodium
For patients with heart disease, high blood pressure, kidney disease, or may be using certain drugs
81
controlled calorie
Caloric intake is restricted to a certain number of calories per day
ex. 1,400 calorie reduced diet
82
tube feed
For patients who have been intubated or need to be fed via tube directly into the stomach
ex. Isosource 50 – 100 cc q2h
83
dysphagia / thickened
Thickened fluids for a patient with swallowing difficulties
84
What are the 8 steps needed to be performed prior to a patient arriving?
1. NUC will receive information from Bed Control by phone
2. Record information on the Daily Activity Sheet (Ward Memo)
3. Record information on the white board
4. Inform assigned nurse of pending admission
5. Prepare 3 labels (door, HOB, chart binder – or others prn) with the appropriate information
6. Prepare chart pack and binder as much as possible
7. Fill out Kardex as much as possible
8. Call housekeeping. If the bed is not already cleaned be sure it is cleaned prior to admitting patient.
85
What information will be provided by Bed Control before a patient arrives?
* Patient name
* Patient age
* Admitting diagnosis
* Attending physician
* Room & bed number
* Isolation precautions prn
* Special needs prn – such as telemetry
86
What are the 17 steps the NUC needs to perform once the patient arrives on the unit?
1. Greet the patient.
2. Direct porter to correct bed.
3. Obtain records from the porter:
a) Admission/Separation Record
b) Consent Form (Release from Responsibility)
c) Addressograph/ID Labels
d) Identification Bracelet (Armband)
4. Check off Daily Activity Sheet that patient has arrived.
5. Complete information on the white board.
6. Notify the assigned RN of patient’s arrival.
7. Addressograph/Label chart pack and place forms in correct sections of the binder.
8. Place Addressograph plate in the correct slot in the addressograph rack.
(according to room & bed #) or place labels in sleeve at front of chart
9. Check for any NAME ALERT and use alert stickers prn.
10. Place ALLERGY sticker on spine of chart prn.
11. On Kardex – indicate allergies in RED.
12. Make sure patient has ALLERGY wristband prn.
13. Complete the Kardex from the Admission Record.
14. Make sure the patient receives a tray, especially if they are arriving on the unit around mealtime.
15. Obtain old chart from Health Records prn.
16. Notify attending Physician prn.
17. Check and prioritize Doctor’s Orders (complete STAT orders first)
87
What are the 4 records from the porter that you need to obtain when a patient arrives on the unit?
a) Admission/Separation Record
b) Consent Form (Release from Responsibility)
c) Addressograph/ID Labels
d) Identification Bracelet (Armband)
88
What are the 18 steps needed for an emergency admission?
1. Receive information from Bed Control.
2. Record on Activity Sheet.
3. Record on White Board.
4. Notify assigned RN.
5. Greet patient.
6. Obtain records from Porter.
7. Check off Daily Activity Sheet, complete info on White Board prn.
8. Notify patient’s RN of their arrival.
9. Addressograph/label chart pack and put in binder.
10. Put addressograph/labels in correct location.
11. Labels – chart, HOB, door (med cart prn)
12. Allergy prn – chart, bracelet, forms, Kardex, etc.
13. File records from ER / Admitting. Check all records first before filing to make sure they have been completed.
14. Complete info on Kardex from the Admission Record.
15. Order old chart prn (sometimes it will come from ER with patient)
16. Ensure patient receives a tray, especially if they are admitted around mealtime. Call dietary prn, enter orders on computer.
17. Notify attending Physician (usually happens in ER)
18. Check and prioritize Doctor’s Orders
89
What are the 5 records needed to be obtained from emergency when the patient arrives into the Nursing Unit?
1. Emergency Physician’s Assessment (Hx)
2. Physician’s Orders
3. Emergency Nursing Assessment (Nurses’ Notes)
4. Crew Report – if by ambulance (Misc.)
5. Lab & Diagnostic Reports (Lab & Diagnostics)
90
What are the 7 steps of admitting a patient from another health care facility?
1. Bed Control will notify the unit
2. Record information on the Activity Sheet and the White Board
3. Notify the assigned RN
4. Telephone arrangements
a) Made by the RN with the other facility to arrange a mutually convenient time
b) Patient will arrive by ambulance and go directly to the unit
5. Notify assigned Nurse when patient arrives
6. Call Admitting. Tell them the patient has arrived and that you have the Admission Record from the HCF. Send to Admitting so they can use it to make a new Admission Record for your hospital
7. Continue procedures as per Elective Admission
91
What will the Ambulance Crew give you upon admittance of a patient from another health care facility?
- Copy of the Admission Record from other HCF
- Copy of Crew Report
- Photocopies of pertinent parts of patient's chart from other HCF
92
admission chart pack
Standard chart forms to be used upon the admission of a patient to the nursing unit and can be retrieved from the computer using Meditech/Form Imprint at Fraser Health facilities.
93
What are some examples of chart forms?
- Master Signature Sheer
- Record of Allergies
- Clinical Record (Graphics)
- Doctor's History / Progress notes
- Discharge Summary
- Nursing Assessment / History form
- Nursing notes / Progress record
94
Apart from the admission chart pack, what else does the NUC need to do upon admission of a new patient?
Gathers and completes labels for the chart, patient door, head of bed, and med cart.
95
Who completes the patient's Kardex?
The NUC
96
What are the 7 purposes of a patient's chart?
1. Provides a written record of the patient’s illness, care, treatment, and outcomes for the hospitalization.
2. Means of communication to members of the health care team.
3. Provides information for research.
4. Provides statistical information.
5. Educational tool for students.
6. If a patient is readmitted the chart may be retrieved from Health Records for review of past illnesses and treatment.
7. Protects the patient, doctor, staff, and hospital or health care facility as a legal document.
97
What are the 7 legalities regarding a patient's chart?
1. All entries must be in ink.
2. All written entries in the chart must be legible and accurate.
3. Recorded entries on chart may not be obliterated or erased (put line through, write ERROR, and initial)
4. All written entries on the chart forms must include the date and time the entry was made.
5. Abbreviations may be used according to the health care facility’s list of “approved abbreviations”.
6. Upon discharge of patient the chart is stored in the Health Records Department for a period of time as mandated by law.
7. The patient’s chart is a legal document, can be subpoenaed by court and therefore must be maintained in an acceptable manner.
98
What are the 6 components relevant to a patient's chart?
1. Chart rack
2. Chart binder
3. Chart label
4. Chart dividers
5. Chart flag system
6. Chart forms
99
What are the 3 responsibilities of the NUC regarding a patient's chart?
1. Any information in the patient’s chart is confidential.
2. The NUC must know the identification of all individuals who request access to the patient’s chart.
3. The patient’s chart is accessible to all those members of the patient’s health care team – Physician, RN, NUC, PT, OT, SLP, RT, Pharmacy, Radiology, etc.
100
What is the process for the patient and family members wishing to view a patient's chart?
1. The chart is the physical property of the hospital but the information contained within the chart is considered the property of the patient and according to law must be made available to the patient upon appropriate request.
2. The patient’s doctor must be consulted when a patient asks to see his or her record.
3. It is usually necessary to have the patient sign a Release of Information authorization form.
101
Who is responsible for maintaining the patient's chart?
The NUC
102
What are the 8 steps to maintain a patient's chart?
1. Place all charts in the proper sequence, by room and bed number, in the chart rack when they are not in use.
2. Add blank, labeled/addressographed chart forms to each patient’s chart before the immediate need arises. This process is called “stuffing the chart”.
3. When filing reports:
a) select the correct chart
b) match the patient’s name on the report with the patient’s name on the chart, do not depend on the room numbers because patients are often transferred to another room
c) file behind the correct divider in the chart
d) file the same type of reports together chronologically (by date order)
4. Review patient’s chart frequently for new orders. Always check each chart for new orders prior to returning them to the chart rack. Always check charts that are lying about for new orders then place in the rack.
5. Properly label the patient’s chart so that it can easily be located at all times.
6. Check the chart to be sure all forms are labelled or addressographed.
7. Check the chart for misfiled records and that all chart forms are in the proper sequence.
8. “Thin” charts when necessary.
103
Why would you need to thin a patient's chart?
The patient may remain in the health care facility for a long time, so their chart would become very full and unmanageable.
104
How long should you keep the Graphics Records / Clinical Records?
Keep the last 7 days
105
How long should you keep the Nurse's Progress Notes / Flowsheets?
Keep the last 7 days
106
How long should you keep the Medication Administration Record?
Keep the previous day's MAR in the patient's chart.
The current MAR will be in the MAR binder
107
Where should you check to verify the forms that may and may not be removed from a patient's chart at the health care facility where you are working?
The hospital policy and procedures manual
108
What should you do to the patient's records that you thinned from their chart?
Place a patient ID label (or addressograph imprint) on a blank piece of paper as well as writing “Thinned Chart” on the sheet of paper. Keeping removed records in correct chart order, place the labeled/addressographed sheet of paper on the top and secure with a rubber band and move to designated storage area.
109
After thinning a patient's chart, what should you do to the chart?
Place a blank label on the front cover of patient’s chart and write “Chart Thinned” and the date it was thinned.
110
If a patient is transferred to another unit, what happens to the "thinned chart"?
The thinned chart is sent with the current chart to the new unit.
111
What happens to the thinned charts if a patient is discharged?
The thinned charts and the current patient's chart to health records.
112
What are some Doctors' orders that you should expect to see?
- diagnostic orders
- medication
- surgical treatment
- diet
- patient activities
- discharge orders
113
Doctors' Orders are ______ ______ and become a ______ ______ of the patient's chart.
legal documents
permanent record
114
Doctors' orders are always written in pencil. True or false?
False
The doctor writes all of the orders in ink, writes the date and time, and signs each entry
115
How does the doctor indicate to the nursing staff that he or she has written a new set of orders?
Flagging the chart
116
How long are records retained for?
16 years
117
Every chart form must be _______ or _________
labelled
addressographed
118
Every chart form includes 3 things:
1. Name of the hospital
2. Title of the form
3. Space for the addressograph imprint or ID label
119
What forms are supposed to be on the front of the chart?
- Admission / Separation Record (facesheet)
- Master Signature Sheet
- Infection Control Screening Form
- DNR Orders (Green sleeve)
- Consents (surgical, treatment)
- Consent for Release of Information
- Patient Leave of Absence
- Against Medical Advice
120
Who signs the Master Signature Sheet and when is it signed?
Signed each shift by everyone documenting in the chart, except the Physician
121
When is the Infection Control Screening Form used?
Used for patients whose Antibiotic Resistant Organism (ARO) status is unknown. Patients who are colonized with ARO must be isolated on Contact Precautions.
122
When is the DNR Orders used?
Used when there has been a determination that the patient will not be resuscitated. It must be completed by the Physician.
123
What is a Record of Allergies?
Chart form that documents any hypersensitivities to medication, contrast media, food, environment, latex, etc
124
Who completes a Record of Allergies?
RN or Physician only
125
What is the Physician's Orders & Directives?
A written record of all orders to be transcribed by the NUC
a) When a new order is written, the chart is “FLAGGED”.
b) Each order must be dated & signed by the Physician.
c) RN’s may receive telephone orders (TO) or verbal orders (VO) and record them in the patient’s chart with their signature and the date.
126
What are some Physicians's Orders?
- bloodwork
- diagnostic tests
- dietary orders
- activity orders
127
What are some Graphic Chart / Clinical Records?
- neurological vital signs
- daily fluid balance
- intake and output record
128
clinical / graphic records
Record of patient's vital signs (T, P, R, BP), I&O record, etc
129
Medication Administration Record
| MAR
Chart form that records all medications being given to the patient. Computerized MAR sent to unit by Pharmacy daily.
130
Anticoagulant Administration Record
Record of a patient who is receiving anticoagulant medication. This includes relevant bloodwork and anticoagulant administration dosages and frequency
131
Glucose / Insulin Flowsheet - Diabetic Record
Record of a diabetic patient’s glucose level and insulin administration.
132
Who provides the Patient Profile (relating to medication)?
Pharmacy
133
Who provides Pharmanet?
Pharmacy
134
What are some Chemistry Laboratory Reports?
- Blood gases
- Chemistry
- Drug toxicity (screening)
- Urinalysis
- Body fluids analysis
135
What are some Hematology Laboratory Reports?
- Coagulation (PTT, INR)
| - Hematology
136
What are some Microbiology Laboratory Reports?
- Cultures (Urine, AFB, Fecal Culture, MRSA, VRE, C diff, etc)
- Mycology
- Parasitology
- Serology
- Virology
137
What are some Blood Bank Laboratory Reports?
- Transfusion Record
| - Consent for Transfusion
138
What are some Diagnostic Reports?
- X-ray reports
- ECG
- CAT scans
- EEG
- Nuclear Medicine scans
- Ultrasound reports
- Echocardiogram
- Pulmonary Function Test
- Stress tests
139
What are some Operative / Surgical Reports?
- Surgical Consent Form
- Pre-Operative Checklist
- Anesthesia Record
- Anesthesia Questionnaire
- Surgical Count Sheet
- OR Report (followed by written report)
- Other Operative Reports prn
- Post-Anesthetic Recovery Record
- Blood Product Administration prn
- Consent for Transfusion of Blood and/or Blood Products
140
What goes under the History and Physical sections of the patient's chart?
Used by the Physician to record past and present medical conditions and results of a physical examination.
- Consultation reports
- Relevant data from other hospitals
- History & Physical report
- Physician's Progress Notes
141
What are Nurse's Notes?
Nurses record their observations
142
What forms are placed under Nurse's Notes?
- ER Assessment Record
- Emergency Nursing Assessment Record
- Nursing Assessment / History Form
- Nursing Progress Notes
- Patient Care Flowsheet
- ICU Critical Care Flowsheet
143
What chart forms are placed under Interdisciplinary / Multidisciplinary Reports?
- Physical Therapy Reports
- Occupational Therapy Reports (MMSE)
- Respiratory Therapy Reports
- Spirometry
- Oximetry Studies
- Speech Language Pathology Reports
- Dietary Department (Dietician)
- Social Worker Reports
144
What chart forms are placed under Miscellaneous?
- Ambulance Crew Report
- Requests for Room Changes
- ALC Activity Reports
- Valuables in Safekeeping Copy
145
Which chart divider does the History chart forms go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
f) History / Consult
146
Which chart divider does the Surgical Procedures Performed chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
147
Which chart divider does the Diabetic Record chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
d) Graphic Charts
148
Which chart divider does the Surgical Pathology Report chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
149
Which chart divider does the Vital Signs Record chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
d) Graphic Charts
150
Which chart divider does the Lab Report chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
g) Microbiology
151
Which chart divider does the Patient Admission Assessment chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
e) Nursing Notes
152
Which chart divider does the Fluid Balance Sheet chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
d) Graphic Charts
153
Which chart divider does the Physician's Orders chart forms go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
b) Physician's Orders
154
Which chart divider does the Ambulance Crew Report chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
j) Miscellaneous
155
Which chart divider does the Anticoagulant chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
d) Graphic Charts
156
Which chart divider does the Operation Report chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
157
Which chart divider does the Recovery Room Record chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
158
Which chart divider does the MAR chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
c) Medications
159
Which chart divider does the Pre-op Checklist chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
160
Which chart divider does the Neurological Chart chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
d) Graphic Charts
161
Which chart divider does the Anesthesia Record chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
162
Which chart divider does the Nurse's Notes chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
e) Nursing Notes
163
Which chart divider does the Authorization for Surgical Operation chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
164
Which chart divider does the Surgical Pathology Bx Consultation chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
h) Report of Operation
165
Which chart divider does the Admission / Separation Report chart form go under?
a) Front of Chart
b) Physician's Orders
c) Medications
d) Graphic Charts
e) Nursing Notes
f) History / Consult
g) Microbiology
h) Report of Operation
i) Medical Imaging
j) Miscellaneous
a) Front of Chart
166
What chart forms are placed under the History & Physical divider of a patient's chart?
- Consultation Reports
- Relevant Data from Other Hospitals
- History & Physical Report
- Physician’s Progress Notes
167
What chart forms are placed under the Nurse's Notes section of a patient's chart?
- ER Assessment Record
- Emergency Nursing Assessment Record
- Nursing Assessment/History Form
- Nursing Progress Notes
- Patient Care Flowsheet
- ICU Critical Care Flowsheet
168
What chart forms are placed under the Interdisciplinary / Multidisciplinary Reports section of a patient's chart?
- Physical Therapy Reports
- Occupational Therapy Reports (MMSE)
- Respiratory Therapy Reports
- Spirometry
- Oximetry Studies
- Speech Language Pathology Reports
- Dietary Department (Dietician)
- Social Worker Reports
169
What chart forms are placed under the Miscellaneous divider of a patient's chart?
- Ambulance Crew Report
- Requests for Room Changes
- ALC Activity Reports
- Valuables in Safekeeping Copy
170
What is the Kardex?
A current record of all patient care - receiving or to be received
171
Who uses the Kardex frequently throughout the day?
Nurses
172
What writing utensils can be used when filling out the Kardex?
- Red ink: allergies, DNR
- Black ink: information that doesn't change (patient name, diagnosis, date of birth, etc)
- Pencil: any other information
173
Is the Kardex a permanent record?
No
174
What happens to the Kardex when a patient is discharged?
Shred the Kardex
175
What is the purpose of the Addressograph?
An important part of patient identification.
The plate is the most important part as it contains vital patient information. It reduces errors and helps with legibility and positive patient identification.
176
What information is listed on a patient's addressograph plate?
patient’s legal surname and given names
- age, gender
- date of birth
- hospital number
- encounter number
- date of admission
- admitting physician / consultant
- personal healthcare number
177
What are the 4 steps to using the addressograph plate and machine?
1. Select CORRECT addressograph. Two or more patients may have the same last name. In this situation NAME ALERT stickers are used on the addressograph, Kardex, and chart.
2. Ensure the imprint on every form is clear. If you make an error, draw a line through it and redo it beside it.
3. Ensure the form is addressographed in the correct spot – upper right hand corner.
4. Always return the addressograph to the correct slot in the addressograph holder.
178
Why should you be careful with patients addressograph plates and sticky labels?
1. A patient could receive a medication that was intended for another patient.
2. A patient’s chart may contain records addressographed with a plate for another patient.
179
What is a supplemental chart form?
Additional forms to the standard chart forms which are added to the patient's chart according to his/her specific care and treatment
180
What is the clinical chart?
Records patient's vital signs (V/S)
181
What is the Daily Fluid Balance?
Records patient's fluid intake and output over a 24 hour period
182
What is the Diabetic Record?
Added to the chart if the patient is diabetic. Records the amount of insulin administered to the patient, and patient's blood and urine glucose levels.
183
What is the Anticoagulant Record?
Records anticoagulants prescribed for the patient and patient's INR and PTT results
184
What is the Neurological Chart?
Records patient's neurological vital signs (NVS)
185
Where are supplemental chart forms filed in the patient's chart?
Graphics section
186
What are 7 Surgical Chart forms?
1. Surgical Consent form
2. Pre-op Checklist / OR Check Off List
3. Anesthetic Record
4. Surgical Count Sheet / OR Count Sheet
5. Perioperative Nursing Record
6. Physician's Operation Report (followed by transcribed report)
7. Post Anesthetic Recovery Room (PACU) Record
187
What is the Surgical Consent form?
The patient must sign a "Consent to Surgical / Investigative Procedure" authorizing the Surgeon to carry out the surgical / investigative procedure
188
What is the Pre-op Checklist / OR Check Off List?
The checklist is completed by the RN to ensure all pre-operative test and procedures have been done and the patient is prepared and ready for surgery
189
What is the Anesthetic Record?
Used by the Anesthetist to record their observations and record all medications given to the patient during surgery
190
What is the Surgical Count Sheet / OR Count Sheet?
The Operating Room Nurse records all instruments used during the surgical procedure and accounts for all instruments following the surgery
191
What is the Perioperative Nursing Record?
Used by the OR Nurse to record all information relevant to the surgical procedure, before, during, and after the procedure is completed
192
What is the Physician's Operation Report?
A report detailing all aspects of the surgical procedure from start to finish time, who was involved, findings, etc.
193
What is the Post Anesthetic Recovery Room (PACU) Record?
The PARR RN will record all observations, medications given and progress of the patient in the Recovery Room.
