Module 4 Flashcards
The use of the term ”client-care unit “ is used to more accurately reflect the language used in the hospital and other health care facilities.
F
Routine hospital admissions are referred to as elective.
T
Often a patient admitted for surgery will be admitted the morning of surgery.
T
The provincial health insurance plan ( OHIP ) covers semi-private accommodation.
F
If Jeff has only standard accommodation coverage and he is admitted to a semi-private room because there is no other, Jeff will have to pay the difference.
F
patient admitted to hospital will have only one hospital number ( MRN ) which will remain the same for all admissions to that hospital.
T
The admission sheet will contain an account number that is the same number as the hospital number.
F
Never let anyone enter information on a form that is not labelled.
T
The head nurse on the unit is responsible for creating a patient’s chart on admission and disassembling it on discharge.
F
“Old charts” ( paper ) are retrieved from Medical Records ( Health Information Services ).
T
The admission sheet records a patient’s provisional diagnosis.
T
The provisional diagnosis may differ from the actual diagnosis.
T
If you need to contact someone to make a decision about the patient’s medical care when the patient is unable to do so , you must contact the patient’s next of kin.
F
The person assigned the “power of attorney relating to health-care decisions “ is the next-of-kin.
F
In a manual environment the care plan is called a Kardex, and it is a separate entity from the chart.
T
DAR charting refers to Date, Assessment, and Revision.
F
Charting by Exception means that only essential information is charted.
T
SOAP charting stands for Subjective assessment, objective assessment, assessment, plan.
T
When using voice activation software for transcribing dictated reports, a transcriptionist must edit the report before it is added to the chart.
T
In a manual environment, the administrative assistant would add an intake/output sheet to the post-operative chart.
T
Every time a chart leaves the floor ( unit ) it is the responsibility of the clinical secretary to keep a written record of where it went, using an outguiding system
T
A patient transfer occurs whenever a patient is moved from one hospital to another facility.
F
A terminal cleaning of the bed and other furniture used by a patient is done 2x per week.
F
I f a nurse calls in sick on a unit it may be the responsibility of the clinical secretary to find a replacement from a staffing list.
T
A hospital policy manual includes visiting hour policies, and policies related to the use of electrical equipment.
T
The ability to process orders manually is no longer a necessary skill for the clinical secretary.
F
Orders are typically written by the hospitalist.
T
When checking physicians’ orders which you are unsure about, it is better to deal with a grumpy physician than with an inaccurate order.
T