Patient Chart Records Review #4
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Questions and Answers

What is the primary purpose of the Vital Signs Record?

  • To analyze patient demographics
  • To record graphical representation of the patient's vital signs (correct)
  • To document medication orders
  • To provide a detailed medical history

    • Which of the following is NOT a characteristic of patient chart forms?

  • Patient insurance details (correct)
  • Four code identifying the form
  • Name of the hospital or health authority
  • Space for the patient's name & information

    • Which order should be processed first according to the transcribing process?

  • Recheck for accuracy
  • Copy to Pharmacy
  • Flag the chart
  • Stat orders (correct)

    • What type of report is categorized under Diagnostic?

    <p>Cardiology report (D)</p> Signup and view all the answers

    Which abbreviation stands for 'verbal order'?

    <p>VO (D)</p> Signup and view all the answers

    How many forms typically appear on a patient's chart upon admission through Emergency?

    <p>6 (D)</p> Signup and view all the answers

    What is the purpose of having a patient chart?

    <p>To provide a medical &amp; legal record of the patient's events (A)</p> Signup and view all the answers

    Which of the following is a type of admission for patients?

    <p>Direct (D)</p> Signup and view all the answers

    Which form is completed by the nurse to provide a brief overview of a patient's history upon admission?

    <p>Nursing Admission History (A)</p> Signup and view all the answers

    What is the role of the Health Records department after a patient is discharged from the hospital?

    <p>Caring for all patient records and transcribing reports (A)</p> Signup and view all the answers

    Which type of admission allows a patient to access the nursing unit without going through the Registration or Emergency Department?

    <p>Direct Admission (B)</p> Signup and view all the answers

    What does a Kardex provide for the nursing staff?

    <p>A quick reference to patient care information (D)</p> Signup and view all the answers

    Which responsibility does NOT belong to the Unit Clerk in maintaining the patient's chart?

    <p>Conduct patient assessments upon admission (B)</p> Signup and view all the answers

    What information can typically be found on a patient's Kardex?

    <p>Allergies, care plans, and activity orders (A)</p> Signup and view all the answers

    Which of the following is a form of admission that is typically planned in advance?

    <p>Elective Admission (D)</p> Signup and view all the answers

    What is the purpose of an allergy band worn by a patient?

    <p>To indicate allergies to medication or food (D)</p> Signup and view all the answers

    Flashcards

    Forms for Patient Transfer

    Admission Record, History/Progress Notes, Lab Results, etc., are sent during transfer.

    Types of Admissions

    Elective, Direct, and Emergency Admissions describe how patients enter the hospital.

    Nursing Admission History

    A form completed by the nurse providing patient's past and present history upon admission.

    Kardex

    A patient reference tool in nursing units containing essential patient information.

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    Responsibilities of Unit Clerk

    Including managing access, filing reports, and assisting doctors with charts.

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    Allergy Band

    A band worn by patients indicating allergies to medications or food.

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    Health Records Department

    Responsible for managing patient records after discharge and report transcriptions.

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    Direct Admission

    A type of admission bypassing registration and ER, going straight to the nursing unit.

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    Physician Orders Sheet (POS)

    The form used to record all orders given by a physician or medical staff.

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    Vital Signs Record

    A record that graphically shows a patient's vital signs: temperature, pulse, respirations, and blood pressure.

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    Transcribing Physicians Orders

    The process of recording orders including Stat orders and confirming with various departments.

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    Braden Risk Assessment

    A form assessing a patient's risk of developing pressure ulcers.

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    DNR

    Do Not Resuscitate; a directive for not performing CPR.

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    MAR

    Medication Administration Record; a document that tracks medications given to a patient.

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    Transcribing Symbols

    Symbols used to indicate that a medical order has been completed.

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    Study Notes

    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).

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    Patient Chart Records Review #4 PDF

    Description

    This quiz covers essential aspects of patient chart records, including various admission methods, nursing history, Kardex usage, and unit clerk responsibilities. It's designed to reinforce knowledge about managing patient information effectively in a healthcare setting. Perfect for nursing students and medical professionals.

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