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Clinical Secretary
Clinical secretary reverse definitions
| Question | Answer |
|---|---|
| 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. | subdural hematoma |
| A computer-based client-care document containing the same info as a Kardex. This is an electronic version of the traditional Kardex. | electronic health record/ patient intervention screen (PI screen) |
| A device that amplifies sound, used by doctors and other healthcare professionals to listen to the heart and to take blood pressure. | stethoscope |
| A device used to examine the ears. | otoscope |
| A device used to examine the eyes. | othalmascope |
| A device used to take blood pressure. | sphygmemanometer |
| A diagnosis subject to change after an actual diagnosis has been established. | admitting (provisional) diagnosis |
| A measure taken to prevent a problem from developing. | prophylactic |
| A medication ordered as a single-order stat medication with a dose that is higher than the usual or routine dose. | loading dose |
| A paper chart | pchart |
| A process whereby a peer group judges an individual's qualifications to perform certain services. | credentially |
| A process wherein clients who are booked for surgery receive preoperative and postoperative teaching and fill in documents ahead of time. | pre-admission |
| A small basin, usually kidney shaped, used for clients to vomit into or cough up sputum or phlegm. It is also used to hold solutions for a variety of purposes. It may be ordered sterile or just clean. | emesis basin (kidney basin/ K-basin) |
| A special assessment for a client who has had head trauma or surgery, including checks on neurological functioning, such as verbal response and pupil dilation. | head injury routine |
| A specially prepared sterile tray containing the basic equipment to change a dressing on a wound or surgical incision. It contains a K-basin, 4x4 gauze dressings, a galley cup and usually two sets of disposable forceps. | dressing tray |
| A specially prepared sterile tray similar to the dressing tray, but containing suture removal scissors or clip removers. Some facilities use a dressing tray and nurses add a disposable suture removal blade or prepackaged clip removers. | suture removal tray |
| A technician who operates an ultrasound machine. | ultrasonographer |
| A test result that so deviates from normal that it causes concern for the client's immediate well-being. | critical value |
| A thorough wash with a disinfectant solution of all equipment used by a client upon discharge. | terminal cleaning |
| A type of endoscope that allows surgeons to visualize internal structures. Using this tool, surgery can be done through incisions often 5 cm in length or smaller. | laparoscope |
| A unique number assigned to each client admitted to hospital. | hospital number |
| Acronym means "against medical advice." This refers to a patient discharging himself from hospital without the physician's approval. | AMA (Against Medical Advice) |
| An administrative health professional working in a hospital; an individual who assumes responsibilities for the secretarial, clerical, communication, and other designated needs of a hospital unit. | clinical secretary (CS) / Ward Clerk |
| An electronic chart. | echart |
| Any release from a healthcare facility by doctor's orders. | discharge |
| Care for a client who is acutely ill, that is, very ill but with an illness expected to run a short course. Acute care is provided for clients with a variety of health problems. | acute care |
| Care for a person with a terminal illness who is in hospital to die, to have the condition stabilized or for pain control. | palliative care |
| Care for someone with a chronic illness, that is, one that typically progresses slowly but lasts for a long time, often lifelong. | chronic care |
| Centralizing certain services, particularly those that require specialized care, to one hospital region. | rationalization of services |
| Essential client information passed on to the next shift of nurses. | shift report |
| Commonly used proprietary name for a paper-based patient care document or health record. | kardex |
| Examination of a canal, such as the colon, with an endoscope: a thin tube with lenses to allow visualization. | endoscopy |
| Experiencing life-threatening problems; in medical crisis. | critically ill |
| Medical and nursing care less intensive than traditional acute-care hospital treatment. | subacute, traditional, step down care |
| Moving from one to another, or covering two units. | cross coverage |
| Nonemergency, planned surgery, booked in advance. | elective surgery |
| Surgery conducted with a hospital stay of less than 24 hours. | day surgery |
| The act of moving a client from one place to another within the same healthcare facility. | transfer |
| The bed and other furniture used by the client are thoroughly cleaned with a specifically selected disinfectant solution. | terminal cleaning |
| The process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented. | order entry |
| The relationship among hospitals that have entered into an agreement to form a partnership sharing clinical and administrative responsibilities. | collaborative partnership |
| The usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client. | bolus |
| To draw attention to a new entry by sticking a coloured marker in, placing a coloured sticker on the back, or using some other device to visually draw attention. | flag |
| Written or oral directions given by a physician to nursing staff and other health professionals regarding the care medications, treatment, and laboratory and diagnostic tests a patient is to receive while in hospital. | doctor's orders |
Created by:
Barbara Ross
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