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ClinicalSec Wordlist

Clinical Secretary Word List

Acute Care Care for a client who is acutely ill,but the illness is expected to be short in duration.
Addressograph Device used to imprint client information contained on the hospital card onto the client documents.
Admission Sheet Face or front sheet at the beginning of a chart that contains patient demographic information.
Autopsy The examination of a body to determine the cause of death and/or identify diease processes.
Admitting/Client information Is the first point of contact for a patient. They take daily census and responsible for tracking all patients that are admitted and discharged.
Business Office Responsible for billing provincial or territorial plans.
Bolus The usually rapid infusion of additional IV fluids or an IV,IM or S/C medication in addition to the base amount ordered for a client.
Bone Mineral Density BMD, uses very small doses of radiation to check the density of bone in the spine and hip. Used to detect osteoporosis.
Cardiology A physician who specialized in the heart.
Chronic Care Care for someone with a chronic illness, that is, one that typically progresses slowly but lasts for a long time, often lifelong.
Clinical Secretary/Ward Clerk Health office professional working in a hospital;an individual who assumes responsibilities for the secretarial,clerical,communication,and other designated needs of a hospital unit or department.
CCU Coronary Care Unit or Critical Care Unit of a hospital.
Consultation Report Report dictated by a specialist to whom the paitent was referred.
Critical Value One that indicated a life-threatening situation and requires immediate attention. The results deviates from the normal and causes concern.
Critically ill Experiencing life-threatening problems;in medical crisis.
Cross-coverage Moving from one area to another, or covering two units.
Day Surgery Surgery conducted with a hospital stay of less than 24 hours.
Dietician Registered dieticians are university graduates. Responsible for designing a diet that meets the nutritional needs of a patient while considering any medical,lifestyle, and personal preferences.
Discharge Any release from a health-care facility by doctor's order.
Doctor's order Written or oral directions given by a physician to the nursing staff and other health care professional regarding the care,medications,treatment, and laboratory and diagnostic tests a client is to receive while in hospital.
Doctor's Order Sheet The hospital chart form that the doctor writes the order on for processing. This form must be dated and signed each time a new order is given.
Dumbwaiter Lift,mini-elevator for small objects.
Dictation Room Confidential room for doctors to dictate progress notes.
Elective Surgery Non emergency. Planned surgery,booked in advance.
Embolism Obstruction of a blood vessel by a blood clot,and air bubble, or foreign matter.
Emesis Basin A small basin,usually kidney shaped,used for clients to vomit into or cough up sputum or phlegm.
Endoscopy Examination of a canal,such as the colon,with an endoscope;a thin tube with lenses to allow visualization.
Enema The introduction of liquid into the rectum through the anus for cleansing the bowl and for stimulating evacuation of the bowels.
Employee Health Services Responsible for work related medical needs.
Encrypted Digital Signature Security for computers.
Flag (of a chart) 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.
Fractionalized Chart A portion of a patient's chart,seperate from the main chart.
Graphic Record A form that is a visual graph of a patient's vital signs.
Health Information Systems Responsible for all charts generated within the hospital.
Housekeeping Responsible for cleanliness of the facility.
Human Resources Responsible for recuiting,interviewing and hiring new employees.
Hospital Cards A plastic card imprinted with essential patient demographic information.
Heparin Lock Hep Lock, a device that provides IV access when needed,without continuous infusion. It sits in the vein and must be flushed at specific intervals with saline solution or heparin solution.
Hospital Number A unique number assigned to each client admitted to the hospital.
Identification Band ID band, a plastic bracelet bearing the client's name and hospital number that can be removed only by cutting.
IV Push IVP, a medication given into the vein or into an ongoing IV fusion, using a syringe and needle.
ID Stickers Preprinted stickers that have essential patient demographic information.
Information Services Responsible for maintaining communication systems within the hospital.
Kardex Commonly used proprietary name for a paper-based client care document or health record.
Laboratory Reports Results of lab tests, including pathology.
Laparoscope A type of endoscope that allows surgeons to visualize internal structures.
Lateral Side-lying, with top hip and knee flexed.
Laundry Falls under environmental services.
Loading Dose Medication ordered as a single-order stat medication with a dose that is higher than the usualy or routine dose.
Medical Administration Record A legal document in which all medication administered to a patient is documented. a.k.a MAR.
Material Management Responsible for all equipment and supplies that are not sterilized.
Medical Unit Includes patients who are on telemetry,nephrology, and pediatrics.
Medical Records A department in the hospital that maintains and files patient charts.
New Admission A client recently admitted to the hospital.
Nutritional Services Fills orders for special diets.
Order Transcription The process of interpreting,recording and generating the administrative steps required for a doctor's orders to be implemented.
Pneumatic Tube System Interconnecting tunnels connecting departments.
Pharmacy Responsible for all medication in the hospital.
PA System Communication tool that can be heard throughout the hospital.
Palliative Care Care for a person with terminal illness who is in hospital to die,to have the condition stabilized, or for pain.
Patient Intervention Screen A computer-based client care document containing the same information as a Kardex. This is an electronic Kardex.
Ophthalmoscope Used to examine eyes.
Otoscope Used to examine ears.
Purchasing Department Responsible for taking and maintaining inventory.
Public Relations Community liaison responsible for hospital news letter, public events, and spokesperson with the media.
Provisional Diagnosis The diagnosis is subject to change after actual diagnosis reached.
Pre-Admission A process wherein clients who are booked for surgery receive preoperative and postoperative teaching and fill documents ahead of time.
Prophylactic A measure taken to prevent a problem from developing.
Physician's progress Notes Physician's assessment of patient's response to treatment.
Range of motion ROM, join through their full range of motion.
Registered Nurse RN, has a university degree, may dispense medication, gives IV medication.
Registered Practical Nurse RPN, is a graduate of a college program and may give out medication in a nursing home.
Requisition An order form.
Resource Nurse The person who coordinates and manages a unit for a shift, sometimes referred to as the charge nurse.
Respiratory Therapists RT, provide inhalation treatments, set up and monitor oxygen therapy, manage clients on respirators or using spirometers, obtain blood gases, and monitor clients' respiratory progress.
Risk Management Oversees infection control policies and procedures.
Scope of Practice The limits or boundaries of a person's responsiblities.
Shift Report Essential client information passed on to the next shift of nurses.
Signature Sheet Method for tacking the initials of each health care team member that may write in a patients's chart.
Sphygmomanometer Used to take blood pressure.
Social Worker Helps family cope with hospitalization and make plans after discharge.
Step-down Care Medical and nursing care less intensive than traditional acute care hospital treatment.
Stethoscope Used to listen to the heart.
Supine Lying on the back.
Suture Removal Tray A specially prepared sterile tray similar to the dressing tray, but containing suture removal scissors or clip removers.
Terminal Cleaning A through wash with a disinfectant solution of all equipment used by a client upon her discharge.
Transfer The act of moving a client from one place to another.
Tuning Fork Used to check hearing.
Volunteer Services Unpaid workers in the hospital who visit with the patients, help patients find departments, and work in the gift shop.
Weight Bearing Putting body weght on the lower limbs.
Workload Analysis A software component that tracks types of care provided as a basis for billing the provinical health-care plan.
X-ray Visual test in which an image of a selected body part or region is created by using low doses of radiation reflected on film or fluorescent screens
Created by: zeldafan