Unit 3 Vocab

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Renicheal
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266177
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Unit 3 Vocab
Updated:
2014-03-13 00:59:32
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Vocab
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Unit 3 vocab and info
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  1. Admission Day Surgery
    Surgery scheduled the day of surgery, on patients arrival to hospital. AKA Same day surgery or Same day admit (SDA)
  2. Admission Orders
    Written instructions written by doctor for care and treatment
  3. Advance Directives
    Documents that indicate patients wishes in event patient becomes incapable of making decisions
  4. Allergy ID bands
    Orange plastic band patient with what allergy printed in black sharpie.
  5. Census Sheet
    Daily listing of all patients activity. (Admissions, discharges, transfers and deaths)
  6. Direct Admission
    A patient who was not schedules to be admitted, and gets admitted from dr's office or clinic. (Blue Paper)
  7. Elective Admission
    Surgery that is not an emergency or mandatory and can be planned and patients convenience.
  8. Emergency Admission
    An admission that's processed through the emergency department
  9. Medical Record Number
    • Number assigned to patient on or before admissions. Its used for records Id and used for all admissions to the hospital. AKA Health records number.
    • example: DJ0004356
  10. Patient account number
    • A number assigned each time patient is admitted.
    • Example: DJ0008965/12
  11. Post Op Orders
    Orders written after surgery. Post op orders cancel pre op orders
  12. Pre admit
    process of obtaining info and partially preparing admitting forms before patients arrival
  13. Registration
    Entering personal info into the system to enroll a person as a patient and create a patient record. Patients can be registered as impatient, outpatient, or observation patients
  14. Schedules medication
    Given at Scheduled times
  15. PRN medication
    as needed medication
  16. Medication profile goes where in chart
    1st page under Dr orders
  17. Patient transferred in goes
    under admit in chart
  18. patient transferred out goes
    under misc. in chart
  19. Surgery Schedule
    List of all surgeries to be performed on a particular day.
  20. Doctors on call schedule
    List of all drs on call for specific areas
  21. 4 types of wristbands
    • Orange (allergy)
    • Purple (fall risk)
    • Yellow (Do no resuscitate (DNR))
    • White (main ID for all patients)
  22. 8 steps for the admitting order
    • Admitting diagnosis
    • Diet
    • Activity
    • Diagnostic test/procedures
    • Medications
    • Treatment Orders
    • Request Old Charts
    • Level status (resuscitation)
  23. Health records Number
    1044
  24. 10 admission guidelines
    • 1. Determine appropriate room
    • 2. Greet
    • 3. Inform
    • 4.Complete chart
    • 5.locate old charts
    • 6. Enter patient name everywhere
    • 7. Fill in kardex and computer orders
    • 8. Allergy info in appropriate areas (kardex, outside of chart)
    • 9.Note code status on chart, OE and kardex
    • 10. Name Alert
  25. 5 types of discharges
    • 1. Discharge home
    • 2. Discharge to another facility
    • 3. Discharge home with assistance
    • 4. Discharge against Medical Assistance (AMA)
    • 5. Expiration - A death
  26. Expiration
    Death
  27. Autopsy
    Body examination after death
  28. 12 Discharge Guidelines
    • 1. Read entire order
    • 2. Notify patients nurse, other departments, dietary, housekeeping, transport
    • 3. Write on whiteboard
    • 6. book appts
    • 7. arrange transport
    • 9. Create transfer package
    • 10. Remove from census
    • 12.send chart to health records
  29. 6 transferring guidelines
    • 1. Notify nurse
    • 2. Notify admitting
    • 3. Communicate new unit and room to nurse
    • 4. Document on census, remove from floor census, send all records to new unit
    • 5. Notify housekeeping

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