Patient Chart Records/ATD Review #6 PDF
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Uploaded by OptimisticAzalea6206
University of the Fraser Valley
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Summary
This document is a review of patient chart records and hospital procedures. It covers various topics such as cleaning, infection control, patient files, and different department procedures in a hospital.
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# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD Review #6 1. Which department in the hospital maintains a clean hospital through proper cleaning methods aimed at preventing the spread of infection? - **Housekeeping** 2. State 14 forms that are assembled by the Unit Clerk in a pa...
# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD Review #6 1. Which department in the hospital maintains a clean hospital through proper cleaning methods aimed at preventing the spread of infection? - **Housekeeping** 2. State 14 forms that are assembled by the Unit Clerk in a patient's admission chart pack: - Kardex - POS - MOST - Allergy Record - Physician Progress Note/Consult - Signature Record - Communication Record - Vital Sign Record - DIC Summary - Nursing Admission History - Die Instructions - MAR - Patient Care Flow Sheet - Med. Profile 3. When filing reports the Unit Clerk must remember to: - **Place the chart copy "RN to check reports, file in correct chart"** 4. Patients who require more specialized care than given at most nursing units, but do not require intensive care will go to a **high acuity** unit. 5. Which department provides patients with purposeful activities that are designed to evaluate and treat those who are impaired? - **Occupational Therapy** 8. **Universal Precautions** are the barrier between health care workers and patients body fluids. 9. Are all patients admitted to the hospital treated using universal precautions? - **Yes** 10. Who is responsible for ordering a diet for a newly admitted patient or changing existing diets for current patients as directed by the doctor or nurse? - **Unit Clerk** 11. Who would the Unit Clerk notify if there was a new admission and the bed was not clean and ready? - **Housekeeping** 12. Is the Unit Clerk permitted to take report on a new admission? - **No** 13. Patients who are hospitalized for treatment of diseases of the circulatory system would be placed on a **Cardiovascular** nursing unit. 14. The **Social Services** department provides service to patients & families when emotional and environmental difficulties impede the patient's recovery. 15. When the Bed Booking notifies the Unit Clerk of a new admission, where would she record that information? - **ATD form** 16. Care of children (generally 16 yrs. and under) who are hospitalized for medical or surgical treatment would go to a **Pediatric** nursing unit. 17. When thinning a patients chart state the 3 steps that are important to keep these removed forms in order on the unit: - Place with old charts - Put forms in envelope with Name, "Chart thinned", Chart" & dates - Label chart binder & "Chart thinned" and the date 18. State the name of the department that is in charge of maintenance, care and implementation of computer systems: - **Information Systems or IT dept.** 19. State 6 surgical forms that may be added to a patient's chart if they are having surgery: - Pre-op checklist - Peri-Operative Nursing Record - Patient Questionnaire - OR Surgical Count Sheet - Anaesthetic Record - Post Anaesthetic Care Unit Record 20. Are transfers from one hospital to another, treated as a discharge from the hospital sending the patient and an admission to the hospital receiving the patient? - **Yes** 21. State 15 hospital departments the Unit Clerk will need to interact with: - Admitting - Diagnostic Imaging - Infection Control - Food Services - Information Services - Bio Medical - Health Records - Laboratory - Central Supply - Housekeeping - Maintenance - Occupational Therapy - Pastoral Care - Pharmacy - Stores - Social Services - Respiratory 22. State 11 common diets for patients: - Clear fluids - Diabetic - Vegetarian - Full fluids - Maternity - Regular diet - NPO - NAS - DAT - Sips & Chips - Paediatric - Cardiac 23. State the Unit Clerks responsibility for ordering and updating a patient's diet: - Update the Kardex - Order entry/diet Kardex / diet census = the new diet - If the cut off time has passed-call dietary. - Symbolize POS with K, dietary aware 24. State the information that might be found on the Admission Record: - Name - Diagnosis - Admit date - DOB - Doctors - NOK - Age - PHN - Address - Allergies - Phone Number - CCI 25. State the full term for the following abbreviations: - Tx - Treatment - Post Op - Post operative - Peds - Paediatrics - D/C - Discharge/daycare/discontinue - TID - Three times per day - Mat - Maternity - NOK - Next of Kin - MAR - Medication administration Record - ADC - Ambulatory day care - RMO/Req - Requisition made out, requisition as necessary/ whenever necessary - PRN - As necessary - Q4H - Every 4 hours - Anaes - Anaesthetic - PAC - Pre-admission clinic - SDA - Same day admission - MVA - Motor vehicle accident - PAR - Post anaesthetic recovery - AAT - Activity as tolerated - c/o - Complaining of - AFB - Acid fast bacilli - K - Kardex, potassium - ELOS - Expected length of stay (estimated)
