Chapter 6 Flashcards
patient rights acknowlegement
a listing of guarantees that a patient should expect, including the right to privacy, the right to make one’s own medical decisions, the right to refuse treatment, and the right t be treated fairly
nursing assessment
the documentation of nursing interview and exam performed immediately or shortly after admission that details information such as means of admission (by wheelchair, ambulatory, etc.), reason for admission, events leading to admission, presence of chronic conditions, current medications, drug allergies, person to contact in case of emergency, and whether the patient can perform typical activities of daily living
advance directive
a document listing a patient’s wishes, should he or she be unable to make decisions for him- or herself, or the naming of an individual who is authorized to do so.
property and valuables inventory
a listing of all the personal property (Clothing, jewelry, prosthetic devices, wallet, money etc.) the patient had on his or her person when arriving in the hospital room
charting by exception
documentation based on occurrences that are out of the norm or documentation of complaints voiced by the patient. Examples include:
- patient stating that his pain is worse than it had been
- the fact that a patient was combative
- the fact that a patient walked to the bathroom without calling for assistance, even thought he was to be non-ambulatory
template
a preformatted document, found in software, that prompts structured responses in the EHR
Medication Administration Record (AMR)
documentation of each medication administered, the dosage, the rout of administration, the time and date administered, and the name of the person administering the medication
Attending Physician
the physician responsible for the care of a patient while hospitalized
Hospitalist
a physician, employed by a hospital and is typically a board-certified internist or family practitioner, responsible for admitting patients, following and assessing patients as needed, and writing orders as necessary
verbal order
an order given to a nurse either in person or over the phone, then later authenticated by the physician or the physician extender
observation
a patient status used when the patient’s condition does not warrant an inpatient level of care but does require observation by medical personnel. Observation typically lasts from 24 hours to no more than 48 hours.
History of present illness (HPI)
the symptoms or circumstances leading the patient to seek medical intervention
Review of systems (ROS)
a system by system set of questions asked of a patient regarding symptoms he or she may be experiencing
Pathologist
a physician whose specialty is dealing with the analysis of a tissue sample to establish a diagnosis
autopsy
an examination performed after death to examine organs and tissue in order to determine cause of death
post- anesthesia care unit (PACU)
the unit to which a patient is transferred following surgery for monitoring of vial signs and condition post-surgery
durable medical equipment (DME)
medical equipment meant to be used for long periods, such as hospital beds, hearing aids, orthotics, and protheses
apgar score
a newborn assessment done at one minute and five minutes after birth to assess the newborn’s respiratory function, heart rate, muscle tone, reflexes, and skin color
computerized physician order entry (CPOE)
electronic means of ordering tests and medications that also provides clinical advice about the drug, the dosage, and any contraindications
admission, discharge, and transfer (ADT) system
electronic tracking of the registrations, admissions, discharges, and transfers occurring in a hospital at nay given time. It is sometimes referred to as RADT (R for registration)
patient census
the number of inpatients occupying beds at any given time
bar code
a machine-readable code consisting of vertical parallel bars and white space. Every scanned document contains a bar code identifying the patient and the encounter to which the document belongs. the bar code then matches that document to the correct patient and encounter within the EHR
point of care
the physical location where a health care professional delivers services to a patient
interface
a program that allows two or more similar or different devices to communicate and be interoperable
claims data
billing codes that physicians, pharmacies, hospitals, and other healthcare providers submit to payers. these data have the benefit of following a relatively consistent format and of using a standard set of ICD-9/10 codes.
