Vocabulary Flashcards
Written instructions by doc for care & treatment of the patient upon entry into the hospital
admission orders
a patient that has been admitted and assigned a bed on the nursing unit
inpatient
a pt. admission panned in advance, ti may be urgent or elective
scheduled admission
a form used by nursing staff to maintain a current pt. profile and is disposed of upon pt. leaving
kardex
chart forms that are in addition to the standard chart forms and are added to the patient’s chart according to specific care needs
supplemental forms
form completed by the Physician which gives a brief summary of the patient’s care and history while in the hospital
Physician Progress Notes
form used by nursing staff to advise the Physician of any important information regarding the pt.
notes to Physician
completed at time of pt admission to the unit by the Nursing Staff
Nursing Assessment/History form
the process of obtaining info and partially preparing admitting forms before the time of pt arrival at the HCF
Pre Admit
Main purpose for having a chart
- written record of pt illness treatment care & outcome from hospitalization
- means of communication btwn nursing staff and medical staff
- plan for future plan
- legal purposes
Guidelines for entries in pt chart
- black ink
- transcribing symbols in red ink
- legible and accurate
- printed or written
- abbreviations from list of approved
Assembling Chart
Addressograph all forms and put behind corresponding divider
Name labels and other pertinent labels on chart binder
Do in timely accurate manner
Forms that accompany pt from admitting
Admission-Separation Consent for Treatment Information Collection Authorization Pt. Release form Discharge Summary
Forms in a Chart Pack
Risk Alert Discharge Summary Notes to Physician Allergy Caution Orders & Directives Nurses Notes 24 Hour Flow Sheets Patient Data Base Clinical Record Fluid Balance Record Fall Prevention MAR Signature Sheet
Admission-separation Record
pt. full name DOB diagnosis Doctor PHN NOK allergies address CCI's contact person type of admission
Form completed by Physician and nursing staff giving the pts. D/C instructions and RX
Discharge Medications & Instructions
4 forms that may be on clipboard by pts. bed
V/S Record
24 Hr Flow Sheet
Neurovascular Checklist
Fluid Balance Record
Additional or Supplemental Chart Forms
History/Physical Update Neurovascular Checklist Diabetic Record Anticoagulant Chart Fluid Balance Record
Info found on a Kardex
Activity Level Diet Code status Allergies History Lab Tests IV's Treatments
Thinning
MAR
24 Hr Flow Sheet/Nurses Notes
V/S & Clinical Records
base care records
Types of Discharges
Home Home with Assistance LAMA Tsf to another HCF Death
Maintaining Pt. Chart
- know ID of persons that have access to chart
- “A” with pts name and add forms when needed
- put chart in rack when not in use
- thin chart when needed
- file diagnostic results & reports
- review for new orders
- assist in locating
Forms to copy & send to HCF pt transferring to
Admission-Separation
History/Consults
Diagnostic/Lab results
Current MAR & Drug Profile
Reports under Laboratory
chemistry toxicology blood bank blood gasses ECG cultures
CCI’s
ARO Antibiotic Resistant Organism
DNA Do Not Acknowledge
AVB Aggressive Violent Behavior
Components of Admission Orders
- Admitting Dx
- pt. code status
- diet
- activity
- meds
- diagnostic and treatment orders
- request for old records
- misc.
- observation
Admitting gives NUC for new admission
- type of admission
- pt.name
- pt. Dx
- pt. Doctor
- pt.sex & age
- room & bed #
What does NUC receive from Admitting if pt. is elective/routine admission
- Admission-Separation Record
- “A” card
- ID armband
- Allergy armband
- Discharge Summary
- Consent for Tx
- Info Collection Auth.
- Pt. Release Form
- Preferred Accom.
- ARO screening
Emergency Admission
Same as an Elective/Routine plus:
- crew report
- Short Stay Emergency Assessment Record
- Nurses notes/Flow Sheet
- Lab Reports
- Physicians order form
- Emergency Record
- Old Chart
Activity Orders
AAT CBR BR with BRP Dangle up in hall up in chair with assist up as tol up ad lib
DNR
All info entered into computer
Transcribe code on Kardex in red ink
Green sleeve in front of chart
Types of Isolations
Precautionary
Strict
Reverse
Respiratory
Why put in isolation
Prevent spread of disease-causing organisms
Protect pts. with limited resistance to disease
Types of Precautions
Contact
Droplet
Droplet/Contact
Airborne
3 Types of Admissions
Routine/Elective- planned in advance.
Direct- bypass admitting & emerg. & go directly to nursing unit.
Emergency- unplanned; result of accident or sudden illness.
Roles of FNS
Prepare & serve food to pts.
Meet dietary needs & preferences of pts.
Be part of pts. care & Tx plan
Provide dietary info to pts. & families
Diet Orders
NPO DAT Diabetic Sips & Chips Soft CF Regular Soft FF
