ATD Review #3 Answer Key PDF

## REVIEW III (NC03) PATIENT CHART RECORDS ### NURSING UNIT CLERK PROGRAM 1. State 7 responsibilities of the Unit Clerk for maintaining the patient's chart. - Know the identity of those who have access - Print, add forms & the correct patient identity - All charts put away when not in...

## REVIEW III (NC03) PATIENT CHART RECORDS ### NURSING UNIT CLERK PROGRAM 1. State 7 responsibilities of the Unit Clerk for maintaining the patient's chart. - Know the identity of those who have access - Print, add forms & the correct patient identity - All charts put away when not in use - File reports, results in correct chart behind correct divider - Thin chart when too full - Review charts frequently for orders - Assist doctors & other professionals in finding charts 2. The Consent to Health Care form must be signed by the patient, allowing the physician to perform surgery. 3. The purpose of this form is to give the nursing and medical staff a brief overall past and present history of the patient upon admission. ### Nursing Admission History 4. The __Kardex__ is a quick reference tool kept on each patient in the nursing unit. 5. Are unit clerks permitted to complete the information on a Consent Form? - Yes 6. This form is completed by the nurse caring for the patient in the Emergency Dept documenting the clinical observations and signs of illness or trauma. ### Emergency Department Assessment 7. The __Pre-Operative Checklist__ form is completed by the nurse to ensure all pre-operative tests and procedures have been done prior to the patient having surgery. 8. State 5 additional forms (not found in the admission chart pack) that may be found on a patient's chart. - Braden Risk Assess. - Diabetes Record - Consultation Request - Anticoagulant Record - MRSA/MDRO Screening 9. State the form used by the RN to record the amount of insulin given to a patient and the blood results. - Diabetes Record 10. If a patient comes in by Ambulance which form is completed by the Paramedics. - Ambulance Crew Report 11. Information found on a kardex may include; - Activity orders - W's - Treatments - History - MOST - Diagnostic tests - Nursing care plans - Diet - Procedures - Physicians - Lab tests - Allergies 12. State 7 forms that may be found on an Emergency patients chart. - ER/Ambulatory Care Clinical - ER Department Assessment - Ambulance Crew Report - Nurses Notes - Intake/Output Record - Nurse to Nurse Report - Triage Form 13. The purpose of the __Anti-Coagulant Record__ form is to record the type of anticoagulant administered to the patient and the daily blood results. 14. The __Patient Questionnaire__ form is completed by the patient allowing the anaesthetist and nurse to have current information on the patient's medical history and health. 15. The purpose of the __Vital Sign Record__ record is to record graphic representation of the patient's temperature, pulse, respirations and blood pressure. 16. The purpose of the __Signature Record__ record is to have an accurate check of the signature of any staff member who makes an entry in a patient's chart. 17. State 2 forms that may be found on a clipboard by the patient's bedside. - - 18. The purpose of the __patient chart__ is to maintain a current profile of patient information, doctors orders and the patient's nursing needs. 19. When a patient's chart begins very full and requires thinning which forms are taken out? - MAR - Vital sign record - Flowsheet/Nurses Notes - Basic Care records (CPT, Dietary, sw) 20. State 6 surgical forms that may be added to a patients chart if they are having surgery. - Pre-op checklist - Pt. Questionaire - Anaesthetic Record - Peri-Operative - OR Surgical Count Sheet - Post Anaesthetic Care Unit Record 21. State the Unit Clerk's responsibility for reports that have been sent to your unit after the patient has left. - For a transfer - forward to the new unit - For discharge - send to Health Records 22. This form is used for patients who have been previously admitted to any Health Care Facility in the last 6 months and are currently being swabbed to rule out MRSA and MDRO; - MRSA & MRDO Screening form 23. State 7 types of reports that are filed under Medical Imaging, in a patients chart. - X-rays - CT Scan - Ultrasound - Nuclear Medicine - Interventional Radiology - MRI - Fluroscopy 24. A/an __Braden__ scale is used to access the patient's __Skin__ condition and note any potential pressure points that might cause the skin to break down during their hospital stay. 25. The anaesthetist uses the __Anaesthetic Record__ record to record their observations and medications given to the patient during surgery. 26. Which specialty area would a patient be referred to who requires treatments such as blood transfusions, intravenous antibiotics etc. but not an overnight stay? - Ambulatory Daycare/General Day Care 27. A patient receiving care in a health care facility, but not staying in overnight is referred to as a/an __outpatient__. 28. State 12 regular nursing units located within a hospital. - Cardiovascular - Gynaecology Surgical - Medical - Neurology - Obstetrics - Oncology - Orthopaedics - Paediatrics - Psychiatry - Rehabilitation - Surgical - Urology 29. A patient who has been admitted to a health care facility at least overnight for care and treatment is referred to as a/an __inpatient__. 30. State the full term for the following abbreviations. - PRN - whenever necessary - ATD - admission transfer discharge - RLQ - right lower quadrant - REQ - requisition - POS - physician orders sheet - NOK - next of kin - Emerg/EM - Emergency - GCS - Glasgow Coma Scale - Q - every - HR - hour, heartrate, health records - G - gram - ER - emergency room - CP - copy to pharmacy, chest pain, care plan - LLQ - left lower quadrant - IM - intramuscular - RUQ - right upper quadrant - D/C - discharge, daycare, discontinue - LUQ - left upper quadrant - F/U - follow up - NICU - neonatal intensive care unit - GP - general practitioner - ARO - antibiotic resistant organism