Patient Chart Records/ATD Review #6
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Questions and Answers

Which department is primarily responsible for maintaining, caring for, and implementing computer systems within a hospital?

  • Biomedical
  • Information Services (correct)
  • Maintenance
  • Health Records
  • Which of these is NOT typically included on a patient's surgical chart?

  • Post Anaesthetic Care Unit Record
  • Pre-op checklist
  • OR Surgical Count Sheet
  • Patient's Billing Information (correct)
  • What is the Unit Clerk's responsibility when a patient's diet needs to be updated?

  • Prepare the patient's meals based on the new diet order.
  • Ensure the new diet is accurately reflected in the Kardex and diet census. (correct)
  • Contact the patient's doctor directly for diet modifications.
  • Inform the patient about their new diet choices.
  • Which of these departments is LEAST likely to require interactions with the Unit Clerk?

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

    Which of these is NOT a commonly encountered patient diet within a hospital setting?

    <p>Ketogenic (C)</p> Signup and view all the answers

    Which department is responsible for cleaning the hospital and preventing the spread of infection?

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

    What form would a Unit Clerk use to record the information about a new admission that they receive from Bed Booking?

    <p>ATD form (C)</p> Signup and view all the answers

    Who is responsible for ordering a patient's diet?

    <p>All of the above (D)</p> Signup and view all the answers

    Which department provides services to patients and families when emotional or environmental difficulties affect a patient's recovery?

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

    What are the three steps involved in thinning a patient's chart?

    <p>Place with old charts, put forms in envelope with name, label chart binder (B)</p> Signup and view all the answers

    What is the term for the barrier between healthcare workers and patients' body fluids?

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

    Which of these forms is NOT typically included in a patient's admission chart pack?

    <p>Patient Discharge Summary (C)</p> Signup and view all the answers

    What is the specific nursing unit designed for patients who require more specialized care than a regular unit but do not need intensive care?

    <p>High Acuity Unit (A)</p> Signup and view all the answers

    Flashcards

    Department in charge of computer systems

    The Information Systems or IT department oversees computer systems.

    Surgical forms in a patient's chart

    Forms include Pre-op checklist, OR Surgical Count Sheet, and more for surgery documentation.

    Transfer process between hospitals

    Transfers are treated as a discharge from one hospital and admission to another.

    Hospital departments for Unit Clerk interaction

    Unit Clerks interact with Admitting, Pharmacy, Lab, and more departments in a hospital.

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    Common diets for patients

    Includes Clear fluids, Diabetic, Vegetarian, and others tailored to patient needs.

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    Housekeeping

    Department maintaining cleanliness to prevent infection spread.

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    Unit Clerk's Role with Reports

    Must place the chart copy for RN to check and file in the correct chart.

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    High Acuity Unit

    For patients needing specialized care but not intensive care.

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    Universal Precautions

    Barriers between health care workers and patients' body fluids.

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    Cardiovascular Nursing Unit

    Unit for patients treated for circulatory system diseases.

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    Social Services Department

    Helps patients & families facing emotional and environmental issues.

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    ATD Form

    Form where the Unit Clerk records new admissions.

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    Pediatric Nursing Unit

    Unit for children (16 years and under) hospitalized for treatment.

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    Study Notes

    Patient Chart Records/ATD Review #6

    • Hospital Cleaning Department: Housekeeping is responsible for maintaining a clean hospital environment to prevent infection spread.
    • Patient Admission Chart Pack Forms: The Unit Clerk assembles 14 forms for patient admission, including the Kardex, physician progress notes, consultations, allergies, communication records, vital sign records, nursing admission history, medication administration records, dietary instructions, and patient profiles.
    • Specialized Care Units: Patients requiring more intensive care than general units are transferred to high-acuity units.
    • Occupational Therapy: This department provides purposeful activities to treat patients with impairments.
    • Universal Precautions: All patients are treated using universal precautions.
    • Diet Ordering: The Unit Clerk is responsible for ordering and changing patient diets as directed by the doctor or nurse.

    Additional Information

    • Unit Clerk Responsibilities: Filing reports correctly and ensuring proper completion and placement of patient charts.
    • Circulatory System Disease Patients: Patients with circulatory system diseases are placed on a specialized cardiovascular nursing unit.
    • Social Services: This department supports patients' emotional well-being and addresses environmental issues impacting recovery.
    • New Admission Recording: The Unit Clerk records new admission information on an ATD form.
    • Pediatric Patients: Patients under 16 years old are placed in a pediatric nursing unit.
    • Chart Management: Patient chart forms are organized using three steps: removing old forms, placing them in an envelope, and labeling.
    • Information Systems Department: The Information Systems department maintains computer systems.
    • Surgical Forms: Six surgical forms (pre-op checklist, peri-operative nursing record, patient questionnaire, OR surgical count sheet, anesthetic record, and post-anesthetic care record) are added to a patient's chart when undergoing surgery.
    • Hospital Transfers: Transfers between hospitals are treated as discharges from one and admissions to another.
    • Unit Clerk Interactions: The Unit Clerk interacts with 15 different hospital departments.
    • Dietary Information: Patients' dietary needs are managed and tracked by the Unit Clerk.
    • Admission Record Information: The admission record includes patient demographics (name, date of birth, diagnosis, doctor, next of kin information, allergies, phone numbers, etc).
    • Common Patient Diets: Common diets for patients include clear fluids, full fluids, NPO, maternity diets, regular diets, diabetic diets, vegetarian diets, and sips & chips.
    • Abbreviations: Definitions and full terms of medical abbreviations commonly used in hospital settings.

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    Description

    This quiz focuses on critical aspects of patient care management, including the roles of the housekeeping and Unit Clerk, as well as protocols for patient admission and diet ordering. It also covers specialized care units and universal precautions in the hospital setting. Test your knowledge on these essential healthcare practices.

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