University Of The Fraser Valley Patient Chart Records/ATD Review #5 PDF

# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD Review #5 1. State the name of the form that is completed by the nursing or auxiliary staff recording their observations of the patient; * **Patient Care Flowsheet** 2. If the patient being admitted came in through Emergency what d...

# UNIVERSITY OF THE FRASER VALLEY ## Patient Chart Records/ATD Review #5 1. State the name of the form that is completed by the nursing or auxiliary staff recording their observations of the patient; * **Patient Care Flowsheet** 2. If the patient being admitted came in through Emergency what documents and information will they arrive on the unit with? * Emergency Record * ER Department Assessment * Ambulance Crew Report * Nurses Notes * Intake-output Record * Nurse to Nurse Report * Triage form * POS * Admission Record 3. State the 4 steps to correct an improperly labeled form on a patient's chart that is documented on; * X across the incorrect pt information * Record the word _error_ * Record your 1st initial, last name & status * Re-write or relabel with correct patient 4. Patients who are hospitalized for treatment of diseases of the nervous system would be placed on a **Neurodogy** nursing unit. 5. Which department of the hospital establishes policies and oversees personnel standards? * **Administration** 6. If the emergency physician writes an order for a patient to be admitted, who must the Unit Clerk notify to see if a bed is available? * **Bed Booking** 7. Do most nursing units discard the kardex when the patient goes home? * **yes** 8. State the responsibilities of the Unit Clerk for an admission; * Record information on **ATD** form * Make the nurse aware of new admit * Do you need to transfer patients to accomodate * Check if bed is ready, if not call housekeeping * Greet the patient or escort to room * Notify the nurse of pt. arrival * Get report from sending unit * Create the chart 9. The Admission Record is generally completed by the **Registration/Bedbooking Dept.** and contains information such as: * **name** * **NOK** * **address** * **doctor(s)** * **diagnosis** * **PHN** * **admission date** 10. Patients who are hospitalized for treatment of cancer would go to a/an **Oncology** nursing unit. 11. State which department in the hospital is responsible for rehabilitation and provides treatment by way of exercise, massage, heat, light and other methods; **Physiotherapy** 12. What type of admission is unplanned and usually the result of an accident or sudden illness? **Emergency Admission** 13. A specialist who diagnoses and treats diseases of the digestive tract is referred to as a **Gastroenterologist** 14. Patients who are hospitalized for treatment or disease of the male reproductive or urinary system or of the female urinary system would go to a/an **Urology** nursing unit. 15. State 7 types of reports that are filed under Medical Imaging in a patient's chart; * Xrays * Ultra sound * Interventional Radiology * CT scan * Nuclear Medicine * MRI * Fluroscopy 16. The purpose of the Kardex is; * reference tool * Identifies pertinent information 17. State the Unit Clerks responsibility for reports that have been sent to your unit after the patient has left; * If transfered - forward to new unit * If D/C - send to Health Records 18. Where on the unit is the old chart placed? * In a designated area, often with thinned charts 23. State the full term for the following abbreviations; * Rx - **Perscription** * BID - **twice a day** * LOC - **Level of consciousness, Laxative of choice** * DOA - **Dead on Arrival** * N & V - **Nausea and vomiting** * ATD - **admission transfer discharge** * Psych - **psychiatry** * Appt - **appointment** * DPU - **discharge planning unit** * CP - **chest pain, copy to pharmacy, ** * ICU - **Intensive Care Unit** * PHN - **personal health number** * ABD - **abdominal** * SDC - **surgical day care** * FNS - **food and nutrition services** * # - **fracture** * K - **Kardex, Potassium ** * NYD - **not yet diagnosed** * Dx - **diagnosis** * Q - **every** * MRP - **most responsible physician** * VRE - **vancomycin resistant enterococci** * ELOS - **expected length of stay** * MRSA - **Methicillin Resistant staphylococcus aureus** * MRO - **Multidrug Resistant Organism**