General info Flashcards
ALC
alternate level of care
What are the most common health care professionals who discusses alternate levels of care for the patient?
- social worker
- patient care coordinator
- rehabilitation services
- physicians
- dietary
This team is not restricted to these disciplines
What is the 3 step process for reclassifying a patient?
- The PCC or Social Worker is the person who lets the unit clerk know which patient is to be reclassified. The Physician will write the order, Ex. “Transfer to TCU”
- The Unit Clerk must then notify Admitting of this reclassification. This is done through OE on the computer.
- The patient will then be transferred to a more appropriate unit
BC Emergency Health Services (BC Ambulance) provides the following types of patient transfers:
- Pre-booked inter-facility patient transfers that require an ambulance and paramedic care
- Critical care transfers between health care facilities for critically ill or injured patients who need highly specialized care from a paramedic, or who are travelling long distances
- Infant Transport Team critical care transfers for pediatric, neo-natal and high-risk obstetrics patients
Is it possible for a family member to travel with the patient to another facility?
Depends on the amount of space and weight capacity available in the ambulance. The decision for a family member to join the patient cannot be made until the paramedics arrive. BCEHS highly recommends family members make their own travel arrangements.
What information does the NUC need to have prepared before booking an ambulance?
- Patient name
- Personal Healthcare Number
- Date of birth
- Gender
- Pick-up facility, unit & telephone #
- Drop-off facility, unit & telephone #
- Date & time of appt./return home
- Reason for transfer
- Specialized equipment required, ex. cardiac monitor, oxygen, IV
- Contact precautions
- Weight of patient
- Escort/RN
What is the best description of the Surgical Pathology chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Completed if a Bx sample was obtained during surgery
What is the best description of the Authorization for Surgical Procedure chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Gives the surgeon authority to perform the operation
What is the best description of the Surgical Count Sheet chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Used by nursing staff to record number of instruments used
What is the best description of the PAR Record chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Used by nursing staff to record patient’s vital signs following surgery
What is the best description of the Pre-op Checklist chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Used to record all pre-op preps which are completed
What is the best description of the Anesthesia Record chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Used by anesthetist to record the patient’s vital signs during surgery
What is the best description of the Operation Report chart form?
- Used to record all pre-op preps which are completed
- Used by anesthetist to record the patient’s vital signs during surgery
- Completed if a Bx sample was obtained during surgery
- Gives the surgeon authority to perform the operation
- Used by nursing staff to record number of instruments used
- Surgeon’s report indicating events of surgery
- Used by nursing staff to record patient’s vital signs following surgery
- Surgeon’s report indicating events of surgery
What is the purpose of the Vital Signs Record chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Used to record vital signs
What is the purpose of the Physician’s Order chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Serves as a blueprint of the medical care received
What is the purpose of the History Sheets chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Used by the medical staff to record the patient’s progress
What is the purpose of the MAR chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Record of routine med orders
What is the purpose of the Nurse’s Notes chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Used by nursing staff to record patient responses to Tx and care
What is the purpose of the Fluid Balance Record chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Used to record patient’s fluid intake and output
What is the purpose of the Patient Admission Assessment chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Completed by the nurse on admission to the nursing unit
What is the purpose of the Lab Records chart form?
- Serves as a blueprint of the medical care received
- Used by nursing staff to record patient responses to Tx and care
- Record of routine med orders
- Used to file Provincial Lab results
- Used to record vital signs
- Completed by the nurse on admission to the nursing unit
- Used to record patient’s fluid intake and output
- Used by the medical staff to record the patient’s progress
- Used to file Provincial Lab results
When would a group of health care professionals get together to discuss alternate levels of care that may benefit the patient?
When the patient has been in acute care for a while and alternatives may now be accessible to the patient
List some examples of health care professionals that make up the patient’s team for alternate level of care
- social worker
- patient care coordinator
- rehabilitation services
- physicians
- dietary
Not restricted to these disciplines
What is the process for reclassifying a patient (alternate level of care)?
- The PCC or Social Worker is the person who lets the unit clerk know which patient is to be reclassified. The Physician will write the order, Ex. “Transfer to TCU”
- The Unit Clerk must then notify Admitting of this reclassification. This is done through OE on the computer.
- The patient will then be transferred to a more appropriate unit
ALC
alternate level of care
BC Emergency Health Services provides what types of patient transfers?
- Pre-booked inter-facility patient transfers that require an ambulance and paramedic care
- Critical care transfers between health care facilities for critically ill or injured patients who need highly specialized care from a paramedic, or who are travelling long distances
- Infant Transport Team critical care transfers for pediatric, neo-natal and high-risk obstetrics patients
Will family members be allowed to travel in the ambulance to the patient’s destination health care facility?
Not always. It’s strongly recommended that the family members arrange for their own travel.
What information does the NUC need to have when booking an ambulance to transfer a patient?
- Patient name
- Personal Healthcare Number
- Date of birth
- Gender
- Pick-up facility, unit & telephone #
- Drop-off facility, unit & telephone #
- Date & time of appt./return home
- Reason for transfer
- Specialized equipment required, ex. cardiac monitor, oxygen, IV
- Contact precautions
- Weight of patient
- Escort/RN
When will a NUC have to photocopy parts of a patient’s chart with pertinent information on it?
When a patient is discharged to another healthcare facility, the attending physician may request that specific information be photocopied and sent with the patient to ensure continuity of care.
A patient is transferring to another healthcare facility. The doctor has not advised you of which chart forms they want sent with the patient’s file. What are the copies you would provide?
- MOST Orders
- Admission/Separation Record
- Relevant History
- Recent Consultation Reports
- Lab Results
- Diagnostic Reports
- Current Medication Administration Record
- Allergy Sheet
When faxing documents to another facility, hospital, physician’s office, etc. are you supposed to use a cover page with the documents?
Yes
Why is it important to accurately key in the fax number for the other facility?
The information being sent is confidential.
What is the purpose of the Neurological Record?
- Used to record the patient’s BG level and insulin admin.
- Used to record the patient’s PT and anticoagulant admin.
- Used to record the patient’s motor movement and LOC
- Used to record the patient’s vital signs
- Used to record patient’s fluid intake and output
- Used to record the patient’s motor movement and LOC
What is the purpose of the Anticoagulant Record?
- Used to record the patient’s BG level and insulin admin.
- Used to record the patient’s PT and anticoagulant admin.
- Used to record the patient’s motor movement and LOC
- Used to record the patient’s vital signs
- Used to record patient’s fluid intake and output
- Used to record the patient’s PT and anticoagulant admin.
What is the purpose of the Diabetic Record?
- Used to record the patient’s BG level and insulin admin.
- Used to record the patient’s PT and anticoagulant admin.
- Used to record the patient’s motor movement and LOC
- Used to record the patient’s vital signs
- Used to record patient’s fluid intake and output
- Used to record the patient’s BG level and insulin admin.
What is the purpose of the Daily Fluid Balance chart form?
- Used to record the patient’s BG level and insulin admin.
- Used to record the patient’s PT and anticoagulant admin.
- Used to record the patient’s motor movement and LOC
- Used to record the patient’s vital signs
- Used to record patient’s fluid intake and output
- Used to record patient’s fluid intake and output
What is the purpose of the Clinical Chart?
- Used to record the patient’s BG level and insulin admin.
- Used to record the patient’s PT and anticoagulant admin.
- Used to record the patient’s motor movement and LOC
- Used to record the patient’s vital signs
- Used to record patient’s fluid intake and output
- Used to record the patient’s vital signs
What is a day pass?
A long-term patient is given the opportunity to leave the hospital for a few hours or overnight
What are some reasons why a day pass is granted to the patient?
This gives the family a chance to see how the patient can function in a home atmosphere. It also helps the physician evaluate the patient’s progress.
Does a day pass need to be approved by the patient’s physician?
Yes, the physician must write an order granting the day pass
What form is completed when a day pass is approved by the physician?
Patient Pass Record
Does the Patient Pass Record need to be signed each time the patient leaves the hospital?
Yes
What is the day pass process once the physician has granted it?
- Ensure Day Pass is ordered by Physician.
- Record Day Pass on the Kardex – ex June 1 day pass 0900 - 2200
- Notify Dietary (to hold meal tray)
- Send copy of Physician’s Order to Pharmacy if meds are required to go with patient. They will send a bag of “Pass Meds” to the unit.
- Place the Day Pass that is signed by patient in the designated section of the chart.
What is a DNR?
This order is not a complete refusal of care, but means that no resuscitative measures will be performed in the event of a cardiac or respiratory arrest.
Who can request a DNR?
Patient or family member
Who writes up a DNR order?
The physician
Where is a DNR form placed in the patient’s chart?
In the front of the patient’s chart
What is the NUC’s responsibility with the DNR information?
Enter the information into the computer database. Write DNR in red on the patient’s Kardex.
Where do hospitals within the Fraser Health Authority place the completed DNR orders?
In a “green sleeve” so they are easily seen
What happens to the DNR form once a patient has been discharged?
The form (and green sleeve) is sent to Health Records along with the rest of the chart
What happens to the DNR order (and green sleeve) if the patient is readmitted to the facility?
The DNR form is removed from the old chart and placed in the front of the current chart.
