Reverse Definitions Clinical Secretary
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| 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
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| 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
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| stethoscope | a device that amplifies sound, used by doctors and other health care professionals to listen to heart and take blood pressure
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| otoscope | a device used to examine the ears
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| opthalmoscope | a device used to examine the eyes
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| sphygmomanometer | a device used to take blood pressure
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| admitting (provisional) diagnosis | a diagnosis subject to change after an actual diagnosis has been established
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| prophyloctic | a measure taken to prevent a problem from developing
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| loading dose | a medication ordered as a single-order stat medication with a dose that is higher than the ususal or routine dose
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| P chart | a paper chart
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| credentialling | a process whereby a peer group judges an individual's qualifications to perform certain services
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| pre-admission | a process wherein clients who are booked for surgery recieve preoperative and postoperative teaching and fill in documents ahead of time
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| emesis basin/kidney basin/K basin | a small basin usually kidney shaped , used for clients to vomit into or cough up sputum or phlegm.
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| 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
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| 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
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| 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
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| ultrasongrapher | a technican who operates an ultrasound machine
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| critical value | a test result that so deviates from normal taht it causes concern for the client's immediate well being
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| terminal cleaning | a thorough wash with a disinfectant solution of all equipment used by a client upon discharge
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| laproscopy | a type of endoscope that allows surgeons to visualize internal structures.
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| hospital number | a unique number assigned to each client admitted to hospital
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| AMA | Acronym for "against medical advice" Refers to a patience discharging himself from hospital without physician approval
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| 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
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| E chart | electronic chart
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| discharge | any release from a healthcare facility by doctor's orders
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| 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
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| palliative care | care for a person with a terminal illness who is in hospital to die, or have condition stabilized or for pain control
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| 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
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| rationalization of services | centralizing certain services particularly those that require specialized care, to one hospital region
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| shift report | essential client information passed on to the next shift of nurses
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| Kardex | commonly used proprietary name for a paper based patient care document or health record
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| endoscopy | examination of a canal, such as the colon, with an endoscope: thin tube with lenses to allow visualization
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| subacute, transitional, step down | medical and nursing care less intensive than traditional acute-care hospital treatment
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| cross-coverage | moving from one area to another or covering two units
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| elective surgery | nonemergency, planned surgery, booked in advance
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| day surgery | surgery conducted with a hospital stay of less than 24 hours
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| transfer | the act of moving a client from one place to another within the same healthcare facility
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| order entry | process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented
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| collaborative partnership | the relationship among hospitals that have entered into a agreement to form a partnership sharing clinical and administrative responsibilities
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| bolus | the usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client
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| 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
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| 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.
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| tuning fork | device for checking hearing
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| ID wrist band | a plastic bracelet used on every admission
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| consultation report | specialist dictates his/her findings
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| Medication Administration Records (MAR) | where medication given to a client is recorded and signed for
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| Acute Care | care for client with an illness expected to run a short course
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| Palliative Care | care for a person with a terminal illness
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| Chronic Care | care for a person with a chronic/ long term illness
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| admission sheet | first sheet in client chart also known as "face chart"
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| critically ill | medical crisis
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| signature sheet | sheet in client chart that provides a method of tracking initials
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| Pharmacy | responsible for all medications used in the hospital
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| hospital number | a unique number assigned to each client when admitted to hospital
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| cross-coverage | covering two medical units
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| shift report | essential client information passed to the next shift of nurses
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| admission interview/assessment form | gathers basic health history
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| Risk Management | over sees infection control policies and procedures within facility
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| Nutritional Services | overs see all a client meals
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| Information Services | responsible for all communication/ computer systems within the hospital
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| Public Relations | responsible for community liaison
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| Employee Heath Services | responsible for employees work related medical needs
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| Sterile Processing Dept/Central Supply-Materials Management | responsible or sterilizing and distributing sterile equipment
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| Purchasing | responsible for taking inventory
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| Housekeeping/ Environmental Services | responsible for cleanliness of the facility
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| Maintenance | ensures all equipment is safe and operational
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| Doctor's order sheets | sheets in client chart that must be dated and signed each time a new order is given
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| Physician's Progress notes | assessment of client's response to treatment
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| Medical Records/Heath Information Services | responsible for all chart generated within the hospital
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Created by:
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