Podcast
Questions and Answers
Which of the following documents would be considered a part of the patient's record when they are transferred from the Emergency department to a nursing unit?
Which of the following documents would be considered a part of the patient's record when they are transferred from the Emergency department to a nursing unit?
What department is responsible for checking the availability of beds for patients being admitted to the hospital?
What department is responsible for checking the availability of beds for patients being admitted to the hospital?
Which of the following is NOT a responsibility of the Unit Clerk for an admission?
Which of the following is NOT a responsibility of the Unit Clerk for an admission?
A patient admitted for treatment of a disease affecting their nervous system would most likely be admitted to which nursing unit?
A patient admitted for treatment of a disease affecting their nervous system would most likely be admitted to which nursing unit?
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What is the correct process for correcting an incorrectly labeled form on a patient's chart?
What is the correct process for correcting an incorrectly labeled form on a patient's chart?
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Which of the following professionals would diagnose and treat diseases of the digestive system?
Which of the following professionals would diagnose and treat diseases of the digestive system?
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Which department is responsible for establishing policies and overseeing personnel standards within the hospital?
Which department is responsible for establishing policies and overseeing personnel standards within the hospital?
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What type of admission is unplanned and usually the result of a sudden illness or accident?
What type of admission is unplanned and usually the result of a sudden illness or accident?
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What is the primary purpose of the Kardex in a nursing unit?
What is the primary purpose of the Kardex in a nursing unit?
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Which of the following reports is NOT typically filed under Medical Imaging in a patient's chart?
Which of the following reports is NOT typically filed under Medical Imaging in a patient's chart?
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When a patient is discharged, what is the Unit Clerk's responsibility regarding the patient's reports?
When a patient is discharged, what is the Unit Clerk's responsibility regarding the patient's reports?
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Where should the old patient chart typically be placed on the unit?
Where should the old patient chart typically be placed on the unit?
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What does the abbreviation 'BID' stand for in medical terms?
What does the abbreviation 'BID' stand for in medical terms?
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Flashcards
Patient Care Flowsheet
Patient Care Flowsheet
A form for nursing staff to document patient observations.
Admission Record
Admission Record
A document completed by Registration/Bedbooking Dept. at admission.
Neurodogy nursing unit
Neurodogy nursing unit
A nursing unit for treating nervous system diseases.
Emergency Admission
Emergency Admission
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Gastroenterologist
Gastroenterologist
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Physiotherapy Department
Physiotherapy Department
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Unit Clerk Responsibilities
Unit Clerk Responsibilities
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Bed Booking
Bed Booking
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Urology
Urology
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X-rays
X-rays
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Kardex
Kardex
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ICU
ICU
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BID
BID
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Study Notes
Patient Chart Records/ATD Review
- Patient Care Flowsheet: A form completed by nursing or auxiliary staff to record patient observations.
- Emergency Admission Documents: Emergency Record, ER Department Assessment, Ambulance Crew Report, Nurses Notes, Intake-output Record, and Nurse-to-Nurse Report, and Triage form.
- Correcting Incorrect Information: Four steps to correct improper labels:
- Mark "X" over the incorrect information.
- Write "error" next to the correction.
- Record the last initial and last name of the person who made the correction.
- Rewrite or relabel the information correctly.
- Nursing Units for Specific Conditions: Patients with nervous system diseases are admitted to a Neurology unit.
- Hospital Policy and Personnel Standards: Administration department establishes policies and oversees personnel standards.
- Physician Orders for Admission: If an emergency physician orders admission, the unit clerk notifies the bed booking to check for bed availability.
- Kardex Disposal: Most nursing units discard the patient's Kardex after discharge.
Admission Record
- Information Included in Admission Forms: The form includes patient name, doctor(s), diagnosis, registration information, address, admission date, and the hospital department (e.g., Oncology).
Rehabilitation Services
- Rehabilitation Department: The hospital department responsible for rehabilitation uses methods like exercise, massage, heat, light, and other techniques.
Types of Admissions
- Emergency Admission: An unplanned admission usually resulting from accidents or sudden illnesses.
Digestive System Specialist
- Gastroenterologist: Diagnoses and treats diseases of the digestive tract.
Other Units
- Urology: Unit for diseases of the male reproductive or urinary system, or of the female urinary system.
Medical Imaging Reports
- Medical Imaging Reports: Seven types of reports filed under Medical Imaging: X-rays, ultrasound, interventional radiology, CT scans, nuclear medicine, fluoroscopy, and MRI.
Kardex Purpose
- Kardex Function: A reference tool that provides pertinent patient information.
Unit Clerk Responsibilities
- Unit Clerk Responsibilities: Record admission information; inform nurses of a new admission; check bed availability; notify housekeeping if a bed is unavailable; greet patients, escort to rooms, check chart information, create charts; If patient transferred, then send record to Health Records; if the patient is discharged then send to Health records.
Abbreviations
- Rx: Prescription
- BID: Twice a day
- LOC: Level of consciousness
- DOA: Dead on Arrival
- N&V: Nausea and vomiting
- ATD: Admission – transfer – discharge
- Psych: Psychiatry
- Appt: Appointment
- DPU: Discharge planning unit
- CP: Chest pain
- ICU: Intensive Care Unit
- PHN: Personal health number
- ABD: Abdominal
- SDC: Surgical day care
- FNS: Food and Nutrition services
Other information
- MRP: most responsible physician
- VRE: vancomycin resistant enterococci
- ELOS: expected length of stay
- MRSA: Methicillin Resistant staphylococcus aureus
- MRO: Multidrug Resistant Organism
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Description
Test your knowledge on patient chart records and the key components involved in patient care. This quiz covers nursing documentation, emergency admission procedures, and correcting information in patient charts. Enhance your understanding of hospital policies and nursing standards.
