Patient Chart Records Review #4

Patient Chart Records/ATD - Review #4

• Transfer Forms: Admission Record, Dr. History/Progress Notes, Consult Reports, Lab/Diagnostic Results, Current Medication Profile (MAR), and 7 days of Nurses' Notes

• Patient Admission Methods: Elective Admission (planned in advance, often for surgery), Direct Admission (bypass registration, e.g., maternity, ER), Emergency Admission (accident/sudden illness).

• Nursing Admission History: Provides a brief overview of the patient's past and present medical history on admission.

• Kardex: A quick reference tool containing patient information.

• Psychiatric Unit: Patients with mental health disorders are placed on a psychiatry nursing unit.

• Kardex Information: Contains activity orders, lab tests, IVs, MOST, care plans, treatments, diagnostic tests, diet, history, and allergies.

• Unit Clerk Responsibilities: Know the patient's identity, print forms correctly, keep charts in the correct rack, file charts and results correctly, and assist professionals in finding patient charts.

• Allergy Band: Worn by patients with allergies to medications or food to prevent adverse reactions.

• Patient Records After Discharge: Health Records Department handles records after discharge.

• Direct Admission: Patient bypasses registration and goes directly to the nursing unit.

• Unit Clerk Chart Assembly: Prints charts, files them in proper dividers, labels charts with patient name, physician, and necessary allergy and alert labels.

• Physician Order Sheet: (or Pos) The only form for all physician-ordered procedures.

• Vitals Record: Records a patient's temperature, pulse, respirations, and blood pressure.

• Physicians Order Process: Orders are given to pharmacy, Kardex, MAR, nurse or dept aware, registration, phones and rechecked for accuracy.

• Patient Chart Forms: Includes Braden Risk Assessment, Consultation Request, MRSA/MRDO, Diabetes Record, Anticoagulant Record and others.

• Chart Characteristics: Includes space for patient name, chart form name, hospital/health authority name and form code.

• Emergency Admission Forms: ER/Ambulatory Care Record, ER Department Assessment, Ambulance Crew Report, Nurse's Notes, Intake/Output (I/O) records, and a Nurse to Nurse Report.

• Transcribing Symbols: Symbols used to indicate order changes.

• Purpose of Patient Chart: Provides a medical and legal record of patient events.

• Diagnostic Reports: Cardiology and Respiratory reports.

• Admission Types: Elective, Direct, and Emergency.

• Abbreviations: Verbal Orders (VO), Post-anesthetic care unit (PACU), Diet as Tolerated (DAT), Cardiac/Coronary care unit (CCU), Temperature Pulse Respiration, Discharge/Discontinue (D/C), Kardex, potassium (K), history, ICU intensive care unit, vital signs, prothrombin time (PT), post-anesthetic recovery room (PARR), medication administration record (MAR), antibiotic-resistant organism (ARO), requisition (RMO).