Patient Chart Records Quiz

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