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Questions and Answers
What form is used to document all orders given by physician and medical staff?
What form is used to document all orders given by physician and medical staff?
Which form is used to record the patient's allergies?
Which form is used to record the patient's allergies?
What information is NOT found on the Admission Record?
What information is NOT found on the Admission Record?
Which form is used to communicate non-urgent information to the doctor?
Which form is used to communicate non-urgent information to the doctor?
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What information is typically NOT found on the Kardex?
What information is typically NOT found on the Kardex?
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What information is found on the Medication Profile?
What information is found on the Medication Profile?
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Who is responsible for completing the Discharge Summary?
Who is responsible for completing the Discharge Summary?
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What information is NOT required on the Signature Identification Record?
What information is NOT required on the Signature Identification Record?
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What is the primary purpose of the MAR in healthcare?
What is the primary purpose of the MAR in healthcare?
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Which form is primarily used to provide a summary of a patient’s past and present history upon admission?
Which form is primarily used to provide a summary of a patient’s past and present history upon admission?
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Which term is a potential misconception for identifying a patient who has been admitted overnight?
Which term is a potential misconception for identifying a patient who has been admitted overnight?
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What is the correct method for transcribing physician's orders onto the Kardex?
What is the correct method for transcribing physician's orders onto the Kardex?
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Which of the following is NOT included in the 14 forms assembled in an admission chart pack?
Which of the following is NOT included in the 14 forms assembled in an admission chart pack?
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What does the abbreviation 'LPN' stand for?
What does the abbreviation 'LPN' stand for?
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Which of the following abbreviations refers to the location where surgery is performed?
Which of the following abbreviations refers to the location where surgery is performed?
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What does the abbreviation 'NKA' indicate regarding a patient's medical history?
What does the abbreviation 'NKA' indicate regarding a patient's medical history?
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Flashcards
Medical Nursing Unit
Medical Nursing Unit
A unit for patients hospitalized for medical treatment.
Medication Profile
Medication Profile
A reference for drugs patients are on, discontinued, or put on hold.
Medication Administration Record (MAR)
Medication Administration Record (MAR)
A document detailing doses, time, and route for patient medication delivery.
Vital Sign Record
Vital Sign Record
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Discharge Summary
Discharge Summary
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Kardex
Kardex
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Admission Record
Admission Record
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Allergy/Adverse Reaction Record
Allergy/Adverse Reaction Record
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MAR
MAR
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In Patient
In Patient
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Name Alert
Name Alert
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Nursing Admission History
Nursing Admission History
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Pencil for Orders
Pencil for Orders
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Unit Clerk (UC)
Unit Clerk (UC)
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IV
IV
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NKA
NKA
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Study Notes
Patient Chart Records
- Patients hospitalized for medical treatment are admitted to a nursing unit.
- Medication Profile: quick reference of drugs the patient is taking (current and hold).
- Orders/Directives: recorded on Physician's Order Sheet (POS).
- Medication Administration Record (MAR): personalized document for each patient, used to record dose, time, route, and record of medications given.
- Vital Sign Record: graphic representation of temperature, pulse, respirations/respiration rate, and blood pressure.
- Patient Label/Form/Form Imprint: must be used when adding a physician's order form to a patient's chart.
- Allergies: are noted for each patient.
- Kardex: kept in a Kardex holder at the nursing unit.
Discharge Summary
- Completed by the physician when a patient is discharged.
- Brief summary of the patient's care and history.
- Kardex information may include Activity, In's, Care Plans, Lab Tests, Diagnostic Tests, Treatments, Diet, and Degree of Intervention (most).
- Admission Record: the first form completed.
- Allergy / Adverse Reaction Record: completed by nursing staff.
- Discharge Summary: completed by physician.
- Communication Sheet: used for communicating urgent information to the doctor.
- Additional information on Admission Record: includes Name, Physician(s), Next of Kin (NOK), Admission Date, Address, and PHN.
- Discharge Instructions: completed by nursing staff.
- Signature Identification Record: includes initials, printed name and signature, and designation for staff.
Medication Administration Record (MAR)
- MAR: Used to record medications – dose, time, and route.
Name Alert
- Method for alerting staff to patients with the same last name in the same nursing unit.
Inpatient Treatment
- Patient admitted to a health care facility for at least one night.
Nursing Admission History
- Form completed by the nurse to give overall past and present history of the patient upon admission.
Kardex Update Method
- Pencils are used to update physician orders on the Kardex; it's easier to update and make changes with pen.
Admission Chart Pack Forms
- Forms assembled in an admission chart pack by the Unit Clerk include: Progress Notes, Signature Record, Nursing Admission History, Nursing Flowsheet, MAR, Medication Profile, Orders Directives, Kardex and Vital Sign Record.
Abbreviations
- UC: Unit Clerk
- HX: History
- NAS: No Added Salt
- T: Temperature
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Description
Test your knowledge on patient chart records and the process surrounding discharge summaries. This quiz covers essential documents such as Medication Administration Records, vital signs, and the completion of discharge summaries by physicians. Perfect for nursing students and healthcare professionals.
