Patient Chart Records Review #4 PDF

# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD - REVIEW #4 1. When a patient is being transferred to another facility, which forms are generally photocopied and sent? - Admission Record - Dr. History/Progress Notes - Consult Reports - Lab/Diagnostic Results - Cu...

# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD - REVIEW #4 1. When a patient is being transferred to another facility, which forms are generally photocopied and sent? - Admission Record - Dr. History/Progress Notes - Consult Reports - Lab/Diagnostic Results - Current MAR Medofile 7 days of Nurses Notes - Other info requested by Dr. 2. State the different ways in which a patient can be admitted and registered into the hospital: - Elective Admission - planned in advance usually for surgery - Direct Admission - pt bypasses Registration and ER. can be a Maternity pt. or from office - Emergency Admission - resulting from an accident or sudden illness 3. The purpose of this form, completed by the nurse, 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. A patient who is hospitalized for treatment or disorders of the mind would be placed on a **psychiatry** nursing unit. 6. Information found on a Kardex may include: - Activity orders - Treatments - Lab tests - Diagnostic tests - IV's - Diet - MOST - History - Care Plans - Procedures - Pt Name - physicians - Allergies 7. State 7 responsibilities of the Unit Clerk for maintaining the patient's chart: - Know the identity of those with access - Print forms with correct patient - Keep charts in chart rack when not in use - File results & reports in correct divider - Thin patients' charts when too full - Review charts frequently for orders - Assist Drs & other professionals to locate charts. 8. If a patient has any allergies to medication or food an **allergy band** is worn by the patient. 9. The **Health Records** department is responsible for the care of all patient's records after discharge from the hospital and the transcription of all reports dictated by the physicians and other diagnostic areas. 10. What type of admission would bypass the Registrations and Emergency Dept. and go directly to the nursing unit? **Direct Admission** 11. State the Unit Clerk responsibility for assembling the patient's chart: - Print chart pack/extra forms file in proper dividers - Label chart with patient name physician - If necessary attach Allergy label, Name Alert or AvB (purple dot). 12. The **Physician Orders Sheet (or Pos)** is the only form written on to record all orders given by the physician or medical staff. Medical staff and RN's can write orders on this form only under the direction of the physician. 13. The purpose of the **Vital Signs Record** record is to record graphic representation of the patient's vital signs which include the temperature, pulse, respirations and blood pressure. 14. Define Process/Transcribe Physicians Orders: **Stat orders first, copy to Pharmacy, Kardex, MAR, Nurse or dept aware, Regs, phone calls, recheck for accuracy, sign off, Flag the chart, nurse to check.** 15. State 5 additional forms that may be found on a patient's chart: - Braden Risk Assessment - Consultation Request - MRSA/MRDO - Diabetes Record - Anticoagulant Record 16. State 4 common characteristics of patient chart forms: - Space for patient's name & information - Name of chart form - Name of hospital or health authority - Four code identifying the form 17. State 6 forms that can be found on a patient's chart when they are admitted through Emergency: - ER/Ambulatory Care Record - ER Department Assessment - Ambulance crew report - Nurses Notes - Intake-out/fluid balance record - Nurse to Nurse Report - Triage form 18. Define Transcribing Symbols: The symbols we use to indicate an order has been carried out. 19. State the purpose of having a chart for every patient: To provide a medical & legal record of pt's events. 20. State two types if reports that are filed under Diagnostic: - Cardiology - Respiratory 21. State three types of Admissions: - Direct - Elective - Emergency 22. State the full term for the following abbreviations: - VO - verbal order - PACU - post anaesthetic care unit - DAT - diet as tolerated - CCU - cardiac / coronary care unit - TPR - Temperature Pulse Respiration - D/C - discharge/discontinue/daycare - K - Kardex, potassium - Hx - history - ICU - Intensive Care Unit - P - Para Pulse, Phosporous - R - Right, Rectal, Respirations - BRP - bathroom privileges - PO - by mouth or per ora - NPO - nothing by mouth - DNR - do not resuscitate - PT - patient, physiotherapist, prothrombin time - PARR - post anaesthetic recovery room - MAR - Medication Administration Record - ARO - Antibiotic Resistant Organism - RMO - requisition mode out.