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Red Module
Reverse Definitions Clinical Secretary
| Term | Definition |
|---|---|
| subdural hematoma | a blood clot under the dura mater, the fibrous membrane forming the outer envelope of the brain and spinal cord, usually resulting from trauma to the head |
| electronic health record/patient intervention screening (PI screen) | a computer-based client-care document containing the same information as a Kardex. This is an electronic version of the traditional Kardex |
| stethoscope | a device that amplifies sound, used by doctors and other health care professionals to listen to heart and take blood pressure |
| otoscope | a device used to examine the ears |
| opthalmoscope | a device used to examine the eyes |
| sphygmomanometer | a device used to take blood pressure |
| admitting (provisional) diagnosis | a diagnosis subject to change after an actual diagnosis has been established |
| prophyloctic | a measure taken to prevent a problem from developing |
| loading dose | a medication ordered as a single-order stat medication with a dose that is higher than the ususal or routine dose |
| P chart | a paper chart |
| credentialling | a process whereby a peer group judges an individual's qualifications to perform certain services |
| pre-admission | a process wherein clients who are booked for surgery recieve preoperative and postoperative teaching and fill in documents ahead of time |
| emesis basin/kidney basin/K basin | a small basin usually kidney shaped , used for clients to vomit into or cough up sputum or phlegm. |
| head injury routine | a special assessement for a client who has had head trauma or surgery, including checks on neurological functioning, such as verbal response and pupil dilation |
| dressing tray | a specially prepared sterile tray containing the basic equipment to change a dressing on a wound or surgial incision. Contains K basin, 4x4 gauze dressings, a galley cup and usually two sets of disposable forceps |
| suture removal tray | a specially prepared sterile tray similar to the dressing tray but containing suturer removal scissors or clip removers. Can also include disposable suture removal blade or prepackaged clip removers |
| ultrasongrapher | a technican who operates an ultrasound machine |
| critical value | a test result that so deviates from normal taht it causes concern for the client's immediate well being |
| terminal cleaning | a thorough wash with a disinfectant solution of all equipment used by a client upon discharge |
| laproscopy | a type of endoscope that allows surgeons to visualize internal structures. |
| hospital number | a unique number assigned to each client admitted to hospital |
| AMA | Acronym for "against medical advice" Refers to a patience discharging himself from hospital without physician approval |
| clinical secretary/ward clerk | an administrative health professional working in a hospital; who assumes responsibilities for the secretarial, clerical, communications and other designated needs of a hospital unit |
| E chart | electronic chart |
| discharge | any release from a healthcare facility by doctor's orders |
| acute care | care for a client who is acutely ill, that is very ill but an illness that is expected to run a short course. Proved for clients with a variety of health problems |
| palliative care | care for a person with a terminal illness who is in hospital to die, or have condition stabilized or for pain control |
| chronic care | care for a person with a chronic illness, that is , one that typically progresses slowly but lasts for along time, often life long |
| rationalization of services | centralizing certain services particularly those that require specialized care, to one hospital region |
| shift report | essential client information passed on to the next shift of nurses |
| Kardex | commonly used proprietary name for a paper based patient care document or health record |
| endoscopy | examination of a canal, such as the colon, with an endoscope: thin tube with lenses to allow visualization |
| subacute, transitional, step down | medical and nursing care less intensive than traditional acute-care hospital treatment |
| cross-coverage | moving from one area to another or covering two units |
| elective surgery | nonemergency, planned surgery, booked in advance |
| day surgery | surgery conducted with a hospital stay of less than 24 hours |
| transfer | the act of moving a client from one place to another within the same healthcare facility |
| order entry | process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented |
| collaborative partnership | the relationship among hospitals that have entered into a agreement to form a partnership sharing clinical and administrative responsibilities |
| bolus | the usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client |
| flag | to draw attention to a new entry by sticking a coloured marker in, placing a coloured sticker on he back, or using some other device to visually draw attention |
| doctor's orders | written or oral direction given by a physician to the nursing staff ad other health professionals regarding the care, medications, treatment and laboratory and diagnostic tests a patient is to receive while hospital. |
| tuning fork | device for checking hearing |
| ID wrist band | a plastic bracelet used on every admission |
| consultation report | specialist dictates his/her findings |
| Medication Administration Records (MAR) | where medication given to a client is recorded and signed for |
| Acute Care | care for client with an illness expected to run a short course |
| Palliative Care | care for a person with a terminal illness |
| Chronic Care | care for a person with a chronic/ long term illness |
| admission sheet | first sheet in client chart also known as "face chart" |
| critically ill | medical crisis |
| signature sheet | sheet in client chart that provides a method of tracking initials |
| Pharmacy | responsible for all medications used in the hospital |
| hospital number | a unique number assigned to each client when admitted to hospital |
| cross-coverage | covering two medical units |
| shift report | essential client information passed to the next shift of nurses |
| admission interview/assessment form | gathers basic health history |
| Risk Management | over sees infection control policies and procedures within facility |
| Nutritional Services | overs see all a client meals |
| Information Services | responsible for all communication/ computer systems within the hospital |
| Public Relations | responsible for community liaison |
| Employee Heath Services | responsible for employees work related medical needs |
| Sterile Processing Dept/Central Supply-Materials Management | responsible or sterilizing and distributing sterile equipment |
| Purchasing | responsible for taking inventory |
| Housekeeping/ Environmental Services | responsible for cleanliness of the facility |
| Maintenance | ensures all equipment is safe and operational |
| Doctor's order sheets | sheets in client chart that must be dated and signed each time a new order is given |
| Physician's Progress notes | assessment of client's response to treatment |
| Medical Records/Heath Information Services | responsible for all chart generated within the hospital |
Created by:
amatt
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