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Admissions/Transfers/Discharges > Vocabulary > Flashcards

Vocabulary Flashcards

1
Q

Written instructions by doc for care & treatment of the patient upon entry into the hospital

A

admission orders

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2
Q

a patient that has been admitted and assigned a bed on the nursing unit

A

inpatient

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3
Q

a pt. admission panned in advance, ti may be urgent or elective

A

scheduled admission

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4
Q

a form used by nursing staff to maintain a current pt. profile and is disposed of upon pt. leaving

A

kardex

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5
Q

chart forms that are in addition to the standard chart forms and are added to the patient’s chart according to specific care needs

A

supplemental forms

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6
Q

form completed by the Physician which gives a brief summary of the patient’s care and history while in the hospital

A

Physician Progress Notes

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7
Q

form used by nursing staff to advise the Physician of any important information regarding the pt.

A

notes to Physician

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8
Q

completed at time of pt admission to the unit by the Nursing Staff

A

Nursing Assessment/History form

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9
Q

the process of obtaining info and partially preparing admitting forms before the time of pt arrival at the HCF

A

Pre Admit

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10
Q

Main purpose for having a chart

A
  1. written record of pt illness treatment care & outcome from hospitalization
  2. means of communication btwn nursing staff and medical staff
  3. plan for future plan
  4. legal purposes
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11
Q

Guidelines for entries in pt chart

A
  1. black ink
  2. transcribing symbols in red ink
  3. legible and accurate
  4. printed or written
  5. abbreviations from list of approved
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12
Q

Assembling Chart

A

Addressograph all forms and put behind corresponding divider
Name labels and other pertinent labels on chart binder
Do in timely accurate manner

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13
Q

Forms that accompany pt from admitting

A 
Admission-Separation
Consent for Treatment
Information Collection Authorization
Pt. Release form
Discharge Summary
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14
Q

Forms in a Chart Pack

A 
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
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15
Q

Admission-separation Record

A 
pt. full name
DOB
diagnosis
Doctor
PHN
NOK
allergies
address
CCI's
contact person 
type of admission
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16
Q

Form completed by Physician and nursing staff giving the pts. D/C instructions and RX

A

Discharge Medications & Instructions

17
Q

4 forms that may be on clipboard by pts. bed

A

V/S Record
24 Hr Flow Sheet
Neurovascular Checklist
Fluid Balance Record

18
Q

Additional or Supplemental Chart Forms

A 
History/Physical Update
Neurovascular Checklist
Diabetic Record
Anticoagulant Chart
Fluid Balance Record
19
Q

Info found on a Kardex

A 
Activity Level
Diet
Code status
Allergies
History
Lab Tests
IV's
Treatments
20
Q

Thinning

A

MAR
24 Hr Flow Sheet/Nurses Notes
V/S & Clinical Records
base care records

21
Q

Types of Discharges

A 
Home
Home with Assistance
LAMA
Tsf to another HCF
Death
22
Q

Maintaining Pt. Chart

A
  • 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
23
Q

Forms to copy & send to HCF pt transferring to

A

Admission-Separation
History/Consults
Diagnostic/Lab results
Current MAR & Drug Profile

24
Q

Reports under Laboratory

A 
chemistry
toxicology
blood bank 
blood gasses
ECG
cultures
25
Q

CCI’s

A

ARO Antibiotic Resistant Organism
DNA Do Not Acknowledge
AVB Aggressive Violent Behavior

26
Q

Components of Admission Orders

A
  • Admitting Dx
  • pt. code status
  • diet
  • activity
  • meds
  • diagnostic and treatment orders
  • request for old records
  • misc.
  • observation
27
Q

Admitting gives NUC for new admission

A
  • type of admission
  • pt.name
  • pt. Dx
  • pt. Doctor
  • pt.sex & age
  • room & bed #
28
Q

What does NUC receive from Admitting if pt. is elective/routine admission

A
  • Admission-Separation Record
  • “A” card
  • ID armband
  • Allergy armband
  • Discharge Summary
  • Consent for Tx
  • Info Collection Auth.
  • Pt. Release Form
  • Preferred Accom.
  • ARO screening
29
Q

Emergency Admission

A

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
30
Q

Activity Orders

A 
AAT
CBR
BR with BRP
Dangle
up in hall
up in chair with assist
up as tol
up ad lib
31
Q

DNR

A

All info entered into computer
Transcribe code on Kardex in red ink
Green sleeve in front of chart

32
Q

Types of Isolations

A

Precautionary
Strict
Reverse
Respiratory

33
Q

Why put in isolation

A

Prevent spread of disease-causing organisms

Protect pts. with limited resistance to disease

34
Q

Types of Precautions

A

Contact
Droplet
Droplet/Contact
Airborne

35
Q

3 Types of Admissions

A

Routine/Elective- planned in advance.
Direct- bypass admitting & emerg. & go directly to nursing unit.
Emergency- unplanned; result of accident or sudden illness.

36
Q

Roles of FNS

A

Prepare & serve food to pts.
Meet dietary needs & preferences of pts.
Be part of pts. care & Tx plan
Provide dietary info to pts. & families

37
Q

Diet Orders

A 
NPO
DAT
Diabetic
Sips & Chips
Soft 
CF
Regular
Soft
FF

Admissions/Transfers/Discharges (1 decks)

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