Card Set Information
Routine admissions are
those that are scheduled in advance.
Emergency admission is
one for which there was no prior planning.
These occur when
sudden illness, injury, or abrupt worsening of an existing condition requires emmediate admission for treatment.
Routine admissions normally take place
the day of the scheduled procedure. Come in a day or two before admin to complete administrative paperwork and have any labs or studies completed.
Mangaged care plans are
health care plans in which all medical care except emergency care is managed and must be preauthorized by the insuring group
Health Maintenance Organizations HMO's
organizations that provide most outpatient care at organization clinics, may provide inpatient care at organization hospitals and must authorize usage of outside services.
state medical care coverage for low-income individuals and families
medical care coverage provided through social security administration primarily for people age 65 and over.
Tricare previously called CHAMPUS
coverage in civilian facilities for military staff, family, and retirees.
Deductibles and copays are
the amounts the insurance carrier may require the patient to pay for care.
Lab work and examinations are
done before routine admissions.
Never assume that
a patient wishes to be called by his or her first name. They are entitled to addressed in the manner that is most comfortable for them.
THe patient must also be
given ample opportunity to have questions answered and procedures explained.
It is important to
notify the physician of any medications the patient has been taking at home that are not included in the present orders.
The nursing assessment in an acute care facility is
written by the RN, but the LPN,LVN can greatly assist in this process by data gathering during the initial contact.
frequently charge nurses in skilled facilities and are responsible for completing the written assessment and care plan.
The nurse who reviews the orders must
verify that each order has been processed and that the transcription is accurate.
This means the nurse
must read every lab slip, procedure request, and consent form, correcting as necessary.
When the patient is to be transferred,
the patient's physician must be notified and approve the transfer.
it is also important that
the family or signifcant other be notified, preferable prior to the actual transfer. In emergency situations, notification should be made ASAP.
All equipment brought to the hospital by the patient,
should be clearly labeled, usually with a wide piece of tape on which the patients name is written in large letters.
Discharge planning begins at admission
particularly when the diagnosis indicates the patient will need rehab or long term assitance.
Discharge planner is
an RN who implements and organizes the plan for patient discharge.
Actual discharge orders are
written by the physician.
The discharge planner will use this information,
as well as information gathered from the patient, the family, and the physician, to make appropriate discharge arrangements for the patient.
Written discharge instructions are
prepared by the RN and reviewed with the patient and often with family members as well.
The discharge form lists
medications, activity restrictions, special diet instructions, and ordered follow-up appointments.
Home health services include
skilled nursing, such as wound care, diabetic care and teaching, and intravenous medication administration.
Medical Social Worker (MSW) helps with
counseling and information regarding long-term planning, financial assistance, or community services available.
Medicare, Medicaid, and some insurance and managed care plans
provide for payment of portions or all of these services when ordered by a physician.
Against Medical Advice
the patient has the right to leave and must sign a form.
If patient refuses to sign,
document, date and sign that patient refused and patient's stated reasons for leaving are written in the nursing notes.
Important gift we can give the bereaved is
just being there, simply sit and listen while they talk of their loss and the fears about the changes it will bring.
is required to pronounce death in most states.
Nursing notes must have
the time life signs ceased, the time death was pronounced, and the name of the person making the official pronouncement.
an examination of the remains by a pathologist to determine cause of death.
Usually performed when a patient has died of
unknown causes, has died at the hands of another, or has not been seen within a specific period of time by a physician.
city/county medical officer responsible for investigating unexplained death.
Autopsy on performed
for specific reasons and must be ordered by the coroner or authorized by next of kin.