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Clinical Secretary
Clinical secretary review
| Question | Answer |
|---|---|
| A device used to check hearing. | tuning fork |
| A device used to examine the ears. | otoscope |
| A device used to examine the eyes. | opthalmoscope |
| A device used to listen to the heart. | stethoscope |
| A device used to take blood pressure. | sphygmomanometer |
| A plastic bracelet used on every admission. | ID band |
| A specialist dictates his findings. | consultation report |
| A unique number assigned to each client. | hospital number |
| All equipment and supplies, other than those that must be sterilized, are obtained here. | stores/materials management |
| Any medication given to a client must be recorded and signed for. | MAR-medication administration records |
| Billing provincial territorial plans. | business office |
| Care for a client with an illness expected to run a short course. | acute care |
| Care for a person with a terminal illness. | palliative care unit |
| Care for someone with a chronic illness. | chronic care |
| Chart begins with this. | admission (face) sheet |
| Confidential room for doctors to dictate. | dictation room |
| Covering two units. | cross-coverage |
| Ensures that equipment is safe and operational. | maintenance-environmental engineer |
| Essential client information passed on to the next shift of nurses. | shift report |
| Gathers a basic health history. | admission interview/assessment form |
| Interconnecting tunnels that connect all units. | pneumatic tube |
| Internal communication systems | pa system/paging/intercom |
| Kept mostly by nurses. | nurses' notes |
| Medical crisis. | critically ill |
| Mini-elevator for small objects. | dumbwaiter |
| Must be dated and signed each time a new order is given. | doctors' orders sheet |
| Oversees infection control policies and procedures within the facility. | risk management/infection control |
| Physician's assessment of the client's response to treatment. | progress notes |
| Plastic card imprinted with essential client information. | hospital card |
| Preprinted with essential client information. | ID labels |
| Provides a method of tracking initials. | signature sheet |
| Provides all client meals. | nutritional services |
| Responsible for all charts generated within the hospital. | health information services/medical records |
| Responsible for all medication used in the hospital. | pharmacy |
| Responsible for communication systems within the hospital. | information services |
| Responsible for community liaison. | public relations |
| Responsible for employees' work-related medical needs. | employee health services |
| Responsible for recruiting and interviewing new employees. | human resources (HR) |
| Responsible for sterilizing and distributing sterile equipment. | sterile processing dept. (SPD)/central supply material management |
| Responsible for supplying client-care units with clean laundry. | laundry |
| Responsible for taking inventory. | purchasing department |
| Responsible for the cleanliness of the facility. | housekeeping/environmental services |
| Result that deviates from normal and causes concern. | critical value |
| Room for friends and relatives to visit. | waiting room/reception |
| Room used for teaching outpatients. | client teaching room |
| Stores frequently used supplies. | clean utility room |
| Stores medications and IV drug solutions. | medication room |
| Stores pails, mops, other cleaning supplies. | housekeeping supply room |
| Stores used equipment and supplies. | dirty utility room |
| Stores wheelchairs, IV poles, gurneys, etc. | storage room |
| Team conferences, meetings, client interviews | conference room |
| The boundaries of a person's responsibilities. | scope of practice |
| The head office. | nurse's station |
| "The hub of the wheel" | clinical secretary (CS)/ward clerk |
| Unpaid workers who visit patients. | auxiliary/volunteer services |
| Used to perform examinations and minor procedures. | treatment room |
| Usually the first point of contact; tracks all admissions and discharges; takes a daily census. | admitting/client registration dept. |
| Vital signs. | vital signs flow sheet |
| Clinical responsibilities of a Clinical Secretary | Prepare/update ID bands, labels Distribute client mail Transcribe orders accurately and promptly Notify nurses of stat orders and changes in client care Maintain staffing schedules Keep charts up to date Label charts with client info and dr's name |
| Communication responsibilities of a Clinical Secretary | Answer phone, direct calls, take msgs Notify drs/staff of death, discharge, transfers, admissions Educate clients and give info. Book appts/tests for clients Page/locate drs and other staff Direct/send reports, faxes, Xerox Keep co-workers informed |
| 9 Universal codes | RED, WHITE, GREEN, ORANGE, BROWN, BLUE, PINK, YELLOW, BLACK, GREY |
| Medical client care units | -nephrology -cardiology -neurology -oncology -palliative care -psychiatry (mental health) -rehabilitation -pediatrics -gynecology -maternal/child |
| Different healthcare facilities | -general hospital -federal hospital -convalescent hospital -nursing homes -rehabilitation facilities -drug/alcohol addiction treatment -psychiatric hospitals -chronic care facilities |
| Forms you would find in a patients chart ( Hospital Book) | -doctor's orders -multidisciplinary notes -progress notes -vital signs flow chart -signature sheet -admission (face) sheet -fluid balance sheet -lab/diagnostic test results -consultation reports |
| Forms from a surgical chart | -consent form -pre-anesthetic questionnaire -history/physical assessment -preop checklist -anesthetic record -fluid balance sheet -surgical sheets |
Created by:
Barbara Ross
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